Central venous disease in hemodialysis patients

Central venous disease (CVD) is difficult to treat and often resistant to treatment. In CVD, hemodialysis vascular access should sometimes be abandoned, or in serious cases, the patient's life may be threatened. Therefore, prevention is ideal. However, as the prevalence of chronic kidney disease (CKD) has increased steadily with population aging, CKD patients with a peripherally inserted central catheter (PICC) are encountered frequently. PICCs can cause CVD, and the basilic vein, which is regarded as the important last option for native arteriovenous fistula (AVF) creation in end-stage renal disease (ESRD) patients, is destroyed frequently after its use as the entry site of PICC. The most well-established risk factors for CVD are a history of central venous catheter (CVC) insertion and its duration of use. Therefore, to reduce the incidence of CVD, catheterization in the central vein (CV) should be minimized, along with its duration of use. In this review, we will first explain the basic territories of the CV and introduce its pathophysiology, clinical features, and advanced treatment options. Finally, we will emphasize prevention of CVD.

Conversion of Percutaneous Endoscopic Gastrostomy to Gastrojejunostomy Under Fluoroscopic Guidance for Treatment of Gastrocutaneous Fistula

Persistent enterocutaneous fistula after the removal of a gastrostomy tube is an unusual complication of percutaneous endoscopic gastrostomy (PEG). The following case report describes an 81-year-old man diagnosed with stroke and dysphagia in May 2008. The patient had been using a PEG since 2008, and PEG site infection occurred in June 2013. The PEG tube was removed and a new PEG tube was inserted. Thereafter, formation of gastrocutaneous fistula around the previous infected PEG site was observed. The fistula was refractory to medical management, accompanied by long duration of fasting and peripheral alimentation. Therefore, gastrojejunostomy tube insertion via the previously inserted PEG tube was performed, under fluoroscopic guidance; this mode of management was successful. For patients who have a gastrocutaneous fistula, gastrojejunostomy tube insertion via the pre-existing PEG tube is a safe and effective alternative management for enteral feeding.

Isolated Spontaneous Dissection of Superior Mesenteric Artery: Treated by Percutaneous Endovascular Stent Placement / 대한소화기학회지

Isolated spontaneous dissection of the superior mesenteric artery (SMA) without aortic dissection is a rare cause of acute mesenteric ischemia. A sudden decrease of intestinal blood flow can lead to fatal complications such as ischemic necrosis, shock, and death. Therefore, early diagnosis and therapeutic approach before the occurrence of intestinal infarction are the most important factor to determine the patient's prognosis. A 52-year-old male presented with postprandial periumbilical pain, and isolated spontaneous dissection of the superior mesenteric artery with mural thrombus was detected by abdominal computed tomography with contrast enhancement. By the percutaneous implantation of vascular metallic stent via femoral artery, he was treated successfully. We report a case of isolated spontaneous dissection of the SMA treated by a percutaneous endovascular stent replacement with a review of literature.

Isolated Spontaneous Dissection of Superior Mesenteric Artery: Treated by Percutaneous Endovascular Stent Placement / 대한소화기학회지

Isolated spontaneous dissection of the superior mesenteric artery (SMA) without aortic dissection is a rare cause of acute mesenteric ischemia. A sudden decrease of intestinal blood flow can lead to fatal complications such as ischemic necrosis, shock, and death. Therefore, early diagnosis and therapeutic approach before the occurrence of intestinal infarction are the most important factor to determine the patient's prognosis. A 52-year-old male presented with postprandial periumbilical pain, and isolated spontaneous dissection of the superior mesenteric artery with mural thrombus was detected by abdominal computed tomography with contrast enhancement. By the percutaneous implantation of vascular metallic stent via femoral artery, he was treated successfully. We report a case of isolated spontaneous dissection of the SMA treated by a percutaneous endovascular stent replacement with a review of literature.

High-Resolution CT Findings of Re-Expansion Pulmonary Edema

OBJECTIVE: To describe the high-resolution CT (HRCT) findings of re-expansion pulmonary edema (REPE) following a thoracentesis for a spontaneous pneumothorax. MATERIALS AND METHODS: HRCT scans from 43 patients who developed REPE immediately after a thoracentesis for treatment of pneumothorax were retrospectively analyzed. The study group consisted of 41 men and two women with a mean age of 34 years. The average time interval between insertion of the drainage tube and HRCT was 8.5 hours (range, 1-24 hours). The patterns and distribution of the lung lesions were analyzed and were assigned one of the following classifications: consolidation, ground-glass opacity (GGO), intralobular interstitial thickening, interlobular septal thickening, thickening of bronchovascular bundles, and nodules. The presence of pleural effusion and contralateral lung involvement was also assessed. RESULTS: Patchy areas of GGO were observed in all 43 patients examined. Consolidation was noted in 22 patients (51%). The geographic distribution of GGO and consolidation was noted in 25 patients (58%). Interlobular septal thickening and intralobular interstitial thickening was noted in 28 patients (65%), respectively. Bronchovascular bundle thickening was seen in 13 patients (30%), whereas ill-defined centrilobular GGO nodules were observed in five patients (12%). The lesions were predominantly peripheral in 38 patients (88%). Of these lesions, gravity-dependent distribution was noted in 23 cases (53%). Bilateral lung involvement was noted in four patients (9%), and a small amount of pleural effusion was seen in seven patients (16%). CONCLUSION: The HRCT findings of REPE were peripheral patchy areas of GGO that were frequently combined with consolidation as well as interlobular septal and intralobular interstitial thickening.

Colon Ischemia Associated with Buerger's Disease: Case Report and Review of the Literature

Buerger's disease, or thromboangiitis obliterans, is a nonatherosclerotic inflammatory disease affecting the small- and medium-sized arteries and veins of the extremities (arms, hands, legs, and feet). It is most common in the Orient, Southeast Asia, India, and the Middle East, and usually affects men aged between 20 and 40 years, although it is becoming more common in women. It is well established that most such patients smoke heavily and experience an improvement in symptoms following smoking cessation. Mesenteric involvement in Buerger's disease is extremely rare; however, we describe herein two cases of colon ischemia in patients who were previously diagnosed with lower-extremity Buerger's disease. In one case, the patient developed colonic obstruction, and surgical resection was performed. Histopathologic findings were compatible with the chronic stage of Buerger's disease. In the other case, angiography revealed abrupt occlusion of the inferior mesenteric artery with numerous collateral vessels, just like the corkscrew appearance found in the extremities. If patients with established Buerger's disease of the extremities complain of gastrointestinal symptoms, early interventional diagnosis should be performed to prevent intestinal obstruction and gangrene.

Typical and Atypical Manifestations of Intrathoracic Sarcoidosis

Sarcoidosis is a systemic disorder of unknown cause that is characterized by the presence of noncaseating granulomas. The radiological findings associated with sarcoidosis have been well described. The findings include symmetric, bilateral hilar and paratracheal lymphadenopathy, with or without concomitant parenchymal abnormalities (multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium). However, in 25% to 30% of cases, the radiological findings are atypical and unfamiliar to most radiologists, which cause difficulty for making a correct diagnosis. Many atypical forms of intrathoracic sarcoidosis have been described sporadically. We have collected cases with unusual radiological findings associated with pulmonary sarcoidosis (unilateral or asymmetric lymphadenopathy, necrosis or cavitation, large opacity, ground glass opacity, an airway abnormality and pleural involvement) and describe the typical forms of the disorder as well. The understanding of a wide range of the radiological manifestations of sarcoidosis will be very helpful for making a proper diagnosis.

The Role of Diffusion-Weighted Imaging and the Apparent Diffusion Coefficient (ADC) Values for Breast Tumors

OBJECTIVE: We wanted to evaluate the role of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) for detecting breast tumors, as compared with the T1- and T2-weighted images. MATERIALS AND METHODS: Forty-one female patients underwent breast MRI, and this included the T1-, T2-, DWI and dynamic contrast-enhanced images. Sixty-five enhancing lesions were detected on the dynamic contrast-enhanced images and we used this as a reference image for detecting tumor. Fifty-six breast lesions were detected on DWI and the histological diagnoses were as follows: 43 invasive ductal carcinomas, one mucinous carcinoma, one mixed infiltrative and mucinous carcinoma, seven ductal carcinomas in situ (DCIS), and four benign tumors. First, we compared the detectability of breast lesions on DWI with that of the T1- and T2-weighted images. We then compared the ADCs of the malignant and benign breast lesions to the ADCs of the normal fibroglandular tissue. RESULTS: Fifty-six lesions were detected via DWI (detectability of 86.2%). The detectabilities of breast lesions on the T1- and T2-weighted imaging were 61.5% (40/65) and 75.4% (49/65), respectively. The mean ADCs of the invasive ductal carcinoma (0.89 +/- 0.18x10(-3)mm2/second) and DCIS (1.17 +/- 0.18x10(-3)mm2/ second) are significantly lower than those of the benign lesions (1.41 +/- 0.56x10(-3)mm2/second) and the normal fibroglandular tissue (1.51 +/- 0.29x10(-3)mm2/ second). CONCLUSION: DWI has a high sensitivity for detecting breast tumors, and especially for detecting malignant breast tumors. DWI was an effective imaging technique for detecting breast lesions, as compared to using the T1- and T2-weighted images.

The Vascular Pedicle Width seen on Chest PA in Normal Korean Adults

PURPOSE: We wanted to measure the vascular pedicle width (VPW) in normal Korean adults and correlate the VPW with the body physique and we also wanted to establish the index for normal VPWs, which could be utilized in reading chest PAs. MATERIALS AND METHODS: The VPW was measured on the posteroanterior (PA) chest radiographs of 262 normal Korean adults (134 men and 128 women, age range: 22-88 years, mean age: 45.2 years), who visited the hospital for a general health examination. The relationship between the VPW and the height and the Body Mass Index (BMI) was evaluated. Correlations between height and the thoracic spine length (TSL) and between the BMI and the lateral chest wall thickness (CWT) were analyzed as well. RESULTS: The mean VPW was 47.4 (+/-6.4) mm. The VPW was positively correlated with the height (p<0.01) and the BMI (p<0.01) of the subject. The patient's height was well correlated with the TSL, and the BMI was correlated with the CWT (r=0.75, r=0.76). The table for the normal VPWs according to patient's TSL and CWT was established. CONCLUSION: By measuring the TSL and the CWT on chest PA, which reflect the height and BMI, respectively, and by utilizing the provided table for the normal VPW, we can determine the normality of a patient's VPW.

Percutaneous Radiologic Gastrostomy in a Locked-in Syndrome Patient : A case report

Since being introduced by Gauderer et al. in 1980, percutaneous endoscopic gastrostomy (PEG) has proved to be a safe and effective procedure that has become a popular way to establish long term enteral feeding in situations where oral intake is not possible. Indications of PEG are broad, with a few exceptions such as total obstruction of pharynx or esophagus and poor transillumination conditions. In those cases, percutaneous radiologic gastrostomy (PRG) or surgical gastrostomy is feasible. We reported a case of percutaneous radiologic gastrostomy (PRG) in locked-in syndrome patient.

Cerebral Fat Embolism as a Rare Complication of Postgastrectomy: Case Report

Cerebral fat embolism syndrome is a rare complication of trauma, and it particularly involves fractures of the long bones. This syndrome may occur in a diverse series of conditions such as diabetes mellitus, acute hemorrhagic pancreatitis, acute fatty cirrhosis, prolonged corticosteroid therapy, lymphography and liposuction. The author reports the CT and MRI findings in a patient with cerebral fat embolism that occurred as a rare complication of postgastrectomy.

GFRs Measured by Gates' Method According to 5 Background Sites: Comparison with GFR Measured by I-125-Iothalamate Method / 대한핵의학회잡지

PURPOSE: The aim was to assess how the background site affects the Gates' glomerular filtration rate (GFR) measurement using Tc-99m-DTPA in correlation with GFR by I-125-iothalamate method. MATERIAL AND METHODS: The study populations were 63 adults with 39 men and 24 women aged from 20 to 59 yrs (mean = 37.9 yrs). The following five background regions of interest were used in measurement of GFR using Gates' method: 1) lower side of each kidney (subrenal), 2) around each kidney (circumferential), 3) upper side of each kidney (suprarenal), 4) lateral side of each kidney (lateral), 5) between the two kidneys (inter-renal). We also measured GFR using I-125-iothalamate in each subject. The two studies were separated by 1 to 3 weeks. The subjects were divided into two groups by renal depth. Group 1 with renal depth> or=7cm and group 2 with renal depth or=7cm. CONCLUSION: GFRs measured with Gates' method showed higher correlation with the GFR measured by I-125-iothalamate when the regions of interest were placed over the suprarenal and inter-renal backgrounds. And GFRs measured with Gates method showed statistically significant correlation with the GFR measured by I-125-iothalamate in the group with renal depth < 7cm.

The Usefulness of Diffusion Weighted Imaging in the Differential Diagnosis of Various Intracranial Cystic Lesions

PURPOSE: The purpose of this study was to evaluate the usefulness of diffusion-weighted imaging (DWI) for the differential diagnosis of various intracranial cystic lesions. MATERIALS AND METHODS: This study included 19 patients (13 males, 6 females) with a mean age of 42.5 years. The final histopathological diagnoses for 14 patients were pyogenic brain abscess (n=3), glioblastoma (n=3), ependymoma (n=1), anaplastic astrocytoma (n=1), pilocytic astrocytoma (n=1), hemangioblastoma (n=2), arachnoid cyst (n=1), epidermoid (n=1) and schwannoma (n=1). The other cases of metastasis (n=4) and arachnoid cyst (n=2) were diagnosed on the basis of clinical, laboratory and imaging data. DWI imaging studies were performed with a 1.5 T MR system. A single shot spin echo EPI pulse sequence was applied. B values were set at 0 and 1000 sec/mm2. The apparent diffusion coefficient (ADC) were calculated from the ADC map of 10 different cystic brain lesions. Conventional MR imaging included T2WI, T1WI, FLAIR and contrast enhanced T1WI. We analyzed the location, nature, signal intensity on DWI, and the enhancement pattern of the lesions. RESULTS: All of the 3 cases of brain abscess, 1 of 4 cases of metastasis and 1 case of epidermoid showed hyperintensity on DWI. The mean ADC value of brain abscess (2 cases) was less than 1.15 (0.13x10-3 mm2/s). The mean ADC values of the other cystic lesions (8 cases) were variable, ranging from 2.840.66 to 3.100.16 (10-3 mm2/sec). CONCLUSION: DWI and ADC values were useful in the differential diagnosis of various intracranial cystic lesions, but some metastatic tumors may mimic a brain abscess on DWI. Therefore, a clinical correlation is mandatory.

Expanding Hematoma of the Abdominal Wall Caused by Spontaneous Rupture of a Deep Circumflex Iliac Artery:Report of A Case Treated by Coil Embolization

Abdominal wall hematoma is a rare but well-known disease, usually caused by trauma or, on rare occasions, occurring spontaneously. Hematomas of the rectus sheath and the anterolateral abdominal wall are commonly associated with injury to the inferior epigastric artery and the deep circumflex iliac artery, respectively. The diagnosis of spontaneously developed abdominal wall hematoma is sometimes delayed, due its clinical manifestations being similar to those of other causes of the acute abdomen. CT and angiography can be helpful in the diagnosis of the hematoma and the injured vessel. Herein, we report on a rare case of a spontaneously developed anterolateral abdominal wall hematoma treated with microcoil embolization of the left deep circumflex iliac artery.

Osteoporotic Vertebral Fractures: SPECT findings / 대한핵의학회잡지

PURPOSE: The purpose of this study was to evaluate the usefulness of single photon emission computed tomography (SPECT) of bone using Tc-99m MDP in the diagnosis of osteoporotic vertebral fractures. MATERIALS AND METHODS: Thirty two patients with osteoporotic vertebral fracture were included in this study (mean age: 67 +/- 8, male: 5, female: 27). Seventy nine vertebral fractures were detected (38 thoracic/thoracolumbar lesions and 41 lumbar lesions), which were classified by type of deformity (wedge, biconcave or compression). The patterns and locations of increased uptakes were examined and analyzed. RESULTS: Forty seven wedge fractures, 20 biconcave fractures and 12 compression fractures were found. Diffuse and asymmetric uptakes were common in fractured bodies. More than one uptake were examined in 69 posterior elements of fractured vertebrae (87.3%) including 40 of 47 wedge fractures (85.1%), 17 of 20 biconcave fractures (85.0%) and 12 of 12 compression fractures (100%). Wedge fractures were predominant fracture in thoracic/thoracolumbar spine whereas incidence of biconcave or compression type was similar to that of wedge fracture in lumbar spine (p=0.04). Spinous process uptake was more frequently seen in lumbar lesions than thoracic/thoracolumbar lesions (p=0.009). Facet joint uptake in biconcave fracture was more common in lumbar spine (92.3%) than thoracic/thoracolumbar spine (57.1%). Spinous process uptake in biconcave fracture was also more frequently detected in lumbar spine (p=0.043). CONCLUSION: Bone SPECT was useful in the evaluation of osteoporotic vertebral fracture, especially posterior elements of vertebrae.

Predictive Factors of Renal Scarring in Children with Acute Urinary Tract Infection / 대한핵의학회잡지

PURPOSE: The purpose of this study was to evaluate the usefulness of 99mTc DMSA scintigraphy on the dignosis of a renal scar in children with urinary tract infections. MATERIALS AND METHODS: Eighty three patients were included in this study, who were diagnosed as the urinary tract infection on the basis of symptom, urinalysis and urine culture. 99mTc DMSA scintigraphy and voiding cystoureterography were performed within 7days before the treatment in all patients. We classified the scintigraphic findings as follows: 1; a large hypoactive upper or lower pole. 2; a small hypoactive area. 3; single defect resulting in localized deformity of the outlines. 4; deformed outlines in a small or normal sized kidney. 5; multiple defects. 6; diffuse hypoactive kidney without regional impairment. Follow-up scintigraphy was done at least 6 months after the initial study. When the abnormality on the initial scintigraphy was not completely resolved on the follow-up scan, the lesion was defined as containing a scar. RESULTS: One hundred and fifteen renal units of 166 units (69.3%) showed abnormal findings on the DMSA scintigraphy. 65 units (56.5%) was diagnosed as containing renal scars on follow-up scintigraphies. Incidences of renal scar among renal units showing pattern 3, 4 and 5 on the initial scan was 75%, 78% and 78%, respectively. Whereas many of renal units showing 1, 2 and 6 pattern were recovered (65%, 76%, 50%). Sensitivity, specificity and accuracy of pattern-based DMSA scintigraphic findings on the diagnosis of renal scar was 76.9%, 85.1% and 81.9%, respectively. VUR was significantly associated with the renal scar when the initial DMSA shows unrecoverable findings (pattern 3, 4, 5). Odds ratio of the renal scar in a kidney showing unrecoverable initial scintigraphic findings was 19.1. Odds ratio in a kidney with mild or moderate-to-severe VUR was 3.5 and 14.4 respectively. CONCLUSION: In the urinary tract infection, renal scar was significantly developed in a kidney showing unrecoverable findings on the initial DMSA scan and VUR on voiding cystoureterography.

Reassessment of Size Criteria on Lymph Node Metastasis of Gastric Carcinoma

PURPOSE: To reassess the usefulness of criteria for lymph node size in predicting metastatic lymph node ofgastric adenocarcinoma and to determine appropriate size criteria. MATERIALS AND METHODS: We reviewed the pathology of 1669 lymph nodes from 105 gastric adenocarcinoma patients and measured their long and short axis diameters. To determine the degree of lymph node shrinkage during fixation for pathologic examination, we measured the size of 105 lymph nodes both in the fresh state and on pathology slides after fixation and obtained their correlation equation ; this was used to determine the fresh-state size of the 1669 nodes. We analysed the distribution of metastatic and nonmetastatic lymph nodes according to their long and short axis and plotted a sensitivity-specificity curve to determine the appropriate size criteria for metastatic lymph nodes. RESULTS: There were 535 metastatic lymph nodes and their mean diameter was 8.2+/-4.9mm on the long axis and 5.7+/-3.8mm on the short axis. The mean diameter of nonmetastatic lymph nodes was 4.9+/-2.8mm, 3.0+/-1.7mm on the long and short axis, respectively. There difference in size between metastatic and nonmetastatic lymph nodes was not statistically significant. The (P>0.05) distribution curve of metastatic and nonmetastatic lymph nodesoverlapped over wide range of lymph node size. We determined appropriate size criteria at the point where sensitivity and specificity curves crossed, but the form of the curves was such that this was difficult. CONCLUSION: Appropriate size criteria on lymph node metastasis were 6.2mm for #1-6 lymph node group and 8.1mm for #7-12 lymph node group on long axis diameter and 4.0mm, 5.3mm on short axis diameter. But, even with this size criteria the expected accuracy was low(67-70%). This results showed limitation of size criteria to diagnose metastatic lymph node.

Radiological Findings of Primary Abdominal Malignant Fibrous Histiocytoma: Emphasis on CT Findings

PURPOSE: To evaluate the radiological findings of abdominal malignant fibrous histiocytomas. MATERIALS AND METHODS: We retrospectively reviewed the radiological findings of 13 masses in seven patients including two patients with multiple masses. The masses were located at the mesentery and omentum in three patients and at theretroperitoneum in four. Gastrointestinal examination using barium was performed in four patients, ultrasonographyin five and computed tomography in all. RESULTS: The average diameter of masses was 7.8cm(range : 1-20cm); plain abdominal films revealed soft tissue masses in all patients. Three of four barium studies demonstrated only displacement of bowel loops and the other showed findings of submucosal tumor. Eight of 11 masses were detected on ultrasonography and all were round or lobulated and had well defined margins. Four of these masses were greater than 8cm in diameter and showed homogeneous echogenicity with central hypo or anechoic area ; the remaining wereless than 8cm and showed relatively homogeneous echogenicity. On computed tomography, all 13 masses were seen as highly enhanced and well circumscribed. Seven were greater than 5cm in diameter and had internal low-densityareas. Peritumoral vessel-like structures were seen in eight masses and on plain abdominal radiograph and computed tomogram, calcification was seen in one patient. In no patient was combined retroperitoneal or intraperitoneal lymphadenopathy noted. CONCLUSION: Abdominal malignant fibrous histiocytomas are well-circumscribed, round orlobulated bulky masses with frequent necrosis and occasional calcification. Characteristically, there is nocombined lymphadenopathy and multiple masses are a rare manifestation. These findings may be helpful in the diagnosis of malignant fibrous histiocytoma.

Radiation Fibrosis : Differentiation from True Hilar Mass on Plain Chest Film

PURPOSE: Radiation-induced fibrotic mass might masquerade as a true hilar tumor mass on a plain chest radiograph. We attempted to differentiate radiation fibrosis from a true hilar tumor using only a plain radiograph. MATERIALS AND METHODS: Plain chest radiographs were obtained from seven patients who had developed radiation fibrosis simulating hilar mass after radiation therapy for lung cancer, and from 19 patients with lung cancer, a comparison group, who had not received radiation therapy. They were reviewed for the obliteration of the overlapped mediastinal and hilar anatomical silhouettes by the mass : pulmonary artery, heart or aorta border, and paraspinal line. RESULTS: All seven patients with radiation-induced fibrotic mass(bilateral lesion in twopatients) showed obliteration of all three overlapped anatomical silhouettes of the mediastinum and hilum on chestradiographs. in the comparison group of 19 patients with a true hilar mass, there was, however, no case which demonstrated obliteration of all landmarks. CONCLUSION: Obliteration of all anatomical landmarks at the hilum and mediastinum may be a helpful clue in the differential diagnosis of radiation-induced fibrotic mass from true hilarmass on a plain radiograph, particularly when clinical information on previous radiation therapy is unavailable.