Multidetector CT Findings of Solid Organ Injury Based on 2018 Updated American Association for the Surgery of Trauma Organ Injury Scaling System

The newly revised 2018 Organ Injury Scale (OIS) has a similar format to the previous American Association for Surgery and Trauma (AAST) Emergency General Surgery Grading System, dividing the criteria for grading solid organ damage into three groups; imaging, operation, and pathology. The most significant alteration in the OIS system 2018 revision is the incorporation of multidetector CT (MDCT) findings of vascular injury including pseudoaneurysm and arteriovenous fistula. Similar to the previous OIS, the highest of the three criteria is assigned the final grade. In addition, if multiple grade I or II injuries are present, one grade is advanced for multiple injuries up to grade III. This pictorial essay demonstrates the MDCT findings of solid organ injury grades based on the 2018 OIS system.

Multidetector CT Findings of Solid Organ Injury Based on 2018 Updated American Association for the Surgery of Trauma Organ Injury Scaling System

The newly revised 2018 Organ Injury Scale (OIS) has a similar format to the previous American Association for Surgery and Trauma (AAST) Emergency General Surgery Grading System, dividing the criteria for grading solid organ damage into three groups; imaging, operation, and pathology. The most significant alteration in the OIS system 2018 revision is the incorporation of multidetector CT (MDCT) findings of vascular injury including pseudoaneurysm and arteriovenous fistula. Similar to the previous OIS, the highest of the three criteria is assigned the final grade. In addition, if multiple grade I or II injuries are present, one grade is advanced for multiple injuries up to grade III. This pictorial essay demonstrates the MDCT findings of solid organ injury grades based on the 2018 OIS system.

Lipiodol Pneumonitis Following Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

Transcatheter arterial chemoembolization (TACE) is a useful palliative therapeutic modality for hepatocellular carcinoma (HCC). Postembolization syndromes, such as fever, abdominal pain, and elevated liver enzyme levels are commonly known complications of TACE. One post-TACE pulmonary complication, lipiodol pneumonitis, is rarely reported. Lipiodol pneumonitis after TACE appears to be associated with chemical injury due to accidental perfusion of lipiodol to the lung vasculature, promoted by arteriovenous shunts within the hypervascular HCC. Here, we report a 42-year-old man with unresectable HCC and hepatic vein thrombosis. The patient was initially treated with TACE. The following day after TACE, acute respiratory symptoms such as dyspnea and cough developed with decreased oxygen saturation. Chest X-ray and computed tomography showed multiple patches and diffuse ground-glass opacities in both lung fields, suggesting of lipiodol pneumonitis. The patient’s condition and radiologic abnormalities subsequently improved after 2 weeks of conservative treatment alone.

Imaging Findings of Pancreatic Solid Pseudopapillary Neoplasm with High-Grade Malignant Transformation: Focusing on Diffusion-Weighted Imaging and Normalized Apparent Diffusion Coefficient Values

Solid pseudopapillary neoplasm (SPN) of the pancreas is an uncommon neoplasm characterized by low-grade malignant potential and uncertain histogenesis, and usually afflicts relatively young women. The tumors typically manifest as well-marginated, mixed density lesions consisting of a solid peripheral and central cystic component in conjunction with hemorrhagic foci. SPN with apparent high-grade malignant transformation is a rare histologic variant. Herein, we report a rare case of SPN with high-grade malignant transformation diagnosed in a 75-year-old female, with emphasis on differential diagnoses and role of normalized ADC values. SPN with malignant transformation should be included in the differential diagnosis in cases of mixed solid and cystic masses with hemorrhagic components, irregular margin and lower normalized apparent diffusion coefficient (ADC) values in an elderly female patient, as was the case discussed below.

Complete Remission with Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma Who Showed Early Recurrence following Surgical Resection

Although surgical resection is a curative treatment option for solitary hepatocellular carcinoma, high recurrence rate contributes to dismal long-term prognosis after curative resection. Early recurrence within 2 years after surgery is associated with intrahepatic metastasis of primary tumor. Liver regeneration after hepatic resection can accelerate tumorigenesis in remnant liver. Treatment strategies for intrahepatic recurrence after curative resection include salvage transplantation, repeated resection, local ablation, and transarterial chemoembolization (TACE). Here, we report a 51-year-old male who was presented with a single large tumor located at segment 4. The patient was initially treated with surgical resection, but intrahepatic recurrence occurred only 4 months after surgery. He achieved complete remission with repeated TACE and has survived without recurrence for 4 years so far.

MDCT Findings of Right Circumaortic Renal Vein with Ectopic Kidney

Anomalies of renal vasculature combined with ectopic kidneys were found on a multi-detector CT scan. Knowledge of renal vascular variation is very important for surgical exploration, radiologic intervention and staging for urologic cancer. We present an extremely rare case of a right circumaortic renal vein combined with a right ectopic kidney. The right kidney was located at the level between the third and fifth lumbar vertebra. The right circumaortic renal vein crossed the aorta and returned to the inferior vena cava behind the aorta.

Image Quality Improvement after Implementation of a CT Accreditation Program

OBJECTIVE: The purpose of this study was to evaluate any improvement in the quality of abdominal CTs after the utilization of the nationally based accreditation program. MATERIALS AND METHODS: Approval was obtained from the Institutional Review Board, and informed consent was waived. We retrospectively analyzed 1,011 outside abdominal CTs, from 2003 to 2007. We evaluated images using a fill-up sheet form of the national accreditation program, and subjectively by grading for the overall CT image quality. CT scans were divided into two categories according to time periods; before and after the implementation of the accreditation program. We compared CT scans between two periods according to parameters pertaining to the evaluation of images. We determined whether there was a correlation between the results of a subjective assessment of the image quality and the evaluation scores of the clinical image. RESULTS: The following parameters were significantly different after the implementation of the accreditation program: identifying data, display parameters, scan length, spatial and contrast resolution, window width and level, optimal contrast enhancement, slice thickness, and total score. The remaining parameters were not significantly different between scans obtained from the two different periods: scan parameters, film quality, and artifacts. CONCLUSION: After performing the CT accreditation program, the quality of the outside abdominal CTs show marked improvement, especially for the parameters related to the scanning protocol.

Eosinophilic Enteritis Involving the Entire Intestinal Wall Presenting as Small Bowel Obstruction and Acute Abdomen

Eosinophilic enteritis is an uncommon disease that rarely manifests as an acute abdomen. A 50-year-old man visited our hospital and complained of epigastric and periumbilical pain. He reported direct and rebound tenderness over the periumbilical area. Laboratory examinations showed leukocytosis without eosinophilia. Plain abdominal radiography revealed air-fluid levels in the small intestine and computed tomography revealed concentric wall thickening in the small bowel and ascites in the pelvic cavity. We conducted an emergency operation and segmental resection of the jejunum was performed. Histologically, transmural, eosinophilic infiltration was observed. In patients with intestinal obstruction, even when presenting with an acute abdomen with no peripheral eosinophilia, eosinophilic enteritis should be included in the differential diagnosis.

Small Bowel Volvulus Induced by Mesenteric Lymphangioma in an Adult: a Case Report

Mesenteric lymphangiomas are rare abdominal masses that are seldom associated with small bowel volvulus, and especially in adult patients. We report here on an unusual case of small bowel volvulus that was induced by a mesenteric lymphangioma in a 43-year-old man who suffered from repeated bouts of abdominal pain. At multidetector CT, we noticed whirling of the cystic mesenteric mass and the adjacent small bowel around the superior mesenteric artery. Small bowel volvulus induced by the rotation of the mesenteric lymphangioma was found on exploratory laparotomy. Lymphangioma should be considered as a rare cause of small bowel volvulus in adult patients.

Hydrocele of the Canal of Nuck

In females, a small evagination of parietal peritoneum accompanies the round ligament through the inguinal ring into the inguinal canal and is called the canal of Nuck; it is homologous to the process vaginalis in males. If it fails to undergo complete obliteration, an indirect inguinal hernia or a hydrocele of the canal of Nuck can occur. We report three cases of this rare developmental disorder, discuss the CT findings and its use in the diagnosis of a hydrocele of the canal of Nuck.

Comparison of Prevalence of Visceral Obesity between Hemodialysis and Peritoneal Dialysis Patients / 대한신장학회지

PURPOSE: Visceral obesity is a more reliable indicator of cardiovascular risk factor than BMI. Our study was designed to compare the prevalence of visceral obesity in peritoneal dialysis (PD) patients to hemodialysis (HD) patients with abdominal fat CT in a single center. METHODS: In this cross sectional study, the result of abdominal fat CT of dialysis patients was investigated from January, 2007 to March, 2007 in Uijeongbu St. Mary s Hospital. To evaluate the risk factors related to visceral obesity, we analyzed patients medical records such as duration of dialysis, lipid profiles, anthropometric data and the presence of DM. RESULTS: We enrolled 65 HD patients and 67 PD patients. PD group had higher mean body weight, mean body mass index (BMI), and triglyceride level, compared to HD group. The PD group had higher visceral fat area, measured by abdominal fat CT than HD group. The prevalence of visceral obesity was higher in PD group than HD group. Visceral fat area showed positive co-relation with BMI in HD group, but did not in PD group. The age related prevalence of visceral obesity was significantly increased in the patients with older age group (>65). CONCLUSION: Our cross sectional study points to the fact that visceral obesity is more common in PD patients than HD patients. It is necessary to control weight and nutritional status, especially in PD patients for preventing metabolic complications.

A Case of Combined Hepatocellular Carcinoma-Cholangiocarcinoma with Pseudosarcomatous Features

Combine hepatocellular-cholangiocarcinoma with pseudosarcomatous features is a rare primary liver tumor. We report a 46-year-old man who is a carrier of HBV and has presented intermittent severe abdominal pain on right upper quadrant for 6 days. Tumor markers, alpha-fetoprotein, CEA and CA19-9 were within normal ranges. Abdominal computed tomogram revealed a large heterogeneous mass in the posteroinferior segment of right liver without associated biliary dilatation and conglomerated, enlarged portocaval and peripancreatic lymph nodes. Right hepatectomy was performed with local lymph node dissection. The tumor, measuring 7.5 x 5.5 cm showed an ill demarcated round to oval shape and a variegated whitish yellow solid cut surface with necrosis. Microscopically, the tumor consisted of three components, hepatocellular carcinoma, cholangiocarcinoma and undifferentiated sarcomatoid tumor cells. Immunohistochemically, hepatocellular carcinoma portion reacted positively with alpha-fetoprotein, cholangiocarcinoma portion reacted positively with bile duct-type cytokeratins (cytokeratin 7 and 19) and EMA. The pseudosarcomatous portion reacted with bile duct type cytokeratins and EMA. These findings suggested that pseudosarcomatous tumor cells may be with closely, associated primitive stem cells that can differentiate into the ductal epithelium.

Breast Paraffinoma Coexisting Breast Cancer / 한국유방암학회지

A paraffin injection is regarded as to be a simple and effective method of breast augmentation. However, there are few reports on the long-term complication of a paraffin injected breast. The generation of breast cancer from a paraffinoma of the breast is rare, even though there is no clear evidence to suggest any relationship between a paraffin injection and breast cancer. We encountered a case of infiltrative ductal carcinoma arising from paraffinoma tissues. A 49-year-old woman had undergone bilateral breast augmentation by paraffin injection 20 years earlier. She presented with bilateral diffuse painless palpable masses with reddish discoloration and painful swelling in her left breast. She had been managed with a bilateral simple mastectomy including the mass. After discharge, the pathology report showed infiltrative ductal carcinoma of the left breast mass. The patient was readmitted for additional surgery, and she underwent a modified radical mastectomy. Ultrasonography is a useful diagnostic tool for detecting a breast mass, particularly in a dense breast. However, ultrasonography has a limitation in the case of a paraffinoma. Through this case, it is necessary to review the radiological (mammography, ultrasonography, magnetic resonance imaging, plain film) appearances and the histopathological feature to help make an accurate diagnosis and to differentiate between a carcinoma and a paraffinoma. In rare cases, a breast ductal carcinoma can be combined with a paraffinoma. Therefore, a paraffinoma must be carefully managed due to the potential risk of a carcinoma.

Breast Paraffinoma Coexisting Breast Cancer / 한국유방암학회지

A paraffin injection is regarded as to be a simple and effective method of breast augmentation. However, there are few reports on the long-term complication of a paraffin injected breast. The generation of breast cancer from a paraffinoma of the breast is rare, even though there is no clear evidence to suggest any relationship between a paraffin injection and breast cancer. We encountered a case of infiltrative ductal carcinoma arising from paraffinoma tissues. A 49-year-old woman had undergone bilateral breast augmentation by paraffin injection 20 years earlier. She presented with bilateral diffuse painless palpable masses with reddish discoloration and painful swelling in her left breast. She had been managed with a bilateral simple mastectomy including the mass. After discharge, the pathology report showed infiltrative ductal carcinoma of the left breast mass. The patient was readmitted for additional surgery, and she underwent a modified radical mastectomy. Ultrasonography is a useful diagnostic tool for detecting a breast mass, particularly in a dense breast. However, ultrasonography has a limitation in the case of a paraffinoma. Through this case, it is necessary to review the radiological (mammography, ultrasonography, magnetic resonance imaging, plain film) appearances and the histopathological feature to help make an accurate diagnosis and to differentiate between a carcinoma and a paraffinoma. In rare cases, a breast ductal carcinoma can be combined with a paraffinoma. Therefore, a paraffinoma must be carefully managed due to the potential risk of a carcinoma.

Gastrojejunocolic Fistula Occurring after Billroth-II Subtotal Gastrectomy

Gastrojejunocolic fistula (GJCF) is mainly thought to be a late complication of inadequate gastric surgery such as insufficient gastric resection or inappropriate vagotomy. The pathogenesis of fistula formation has been accounted to the perforation of a retained jejunal marginal ulcer into the transverse colon. Most patients with GJCF present a common symptom triad of faecal vomiting, chronic diarrhea and weight loss. We recently experienced a patient with GJCF who had been suffering from diarrhea for a long period of time. He had undergone gastric surgery 8 years previously for peptic ulcer disease at another hospital. After detailed preoperative evaluation with duodenoscopy, upper gastrointestinal series, colonofiberscopy, barium enema and abdominal CT, he underwent surgery-resection of the gastric stump and segmental resection of the jejunum and transverse colon with Roux-en-Y gastrojejunostomy. Recent advances in surgical technique such as vagotomy, and medical therapy have remarkably decreased the incidence of both stomal ulcer and GJCF in peptic ulcer disease. However, gastrojejunocolic fistula should be recognized as one of the late severe complications observed after a gastrectomy with Billroth-II reconstruction, since this disease may occur even 20 years after the first operation. We report the case of a 52-year old man with gastrojejunocolic fistula with review of the literature.

Hepatic Subcapsular Steatosis in a Diabetic CAPD Patient Receiving Intraperitoneal Insulin

Hepatic subcapsular steatosis is a rare and specific form of fatty change in the liver. It is a unique finding in diabetic patients receiving continuous ambulatory peritoneal dialysis (CAPD) and intraperitoneal insulin treatment. Intraperitoneal administration of insulin causes a unique pattern of fatty infiltration in the subcapsular location of the liver. Here we report a case of hepatic subcapsular steatosis in a diabetic CAPD patient who received intraperitoneal insulin. A 46-year-old diabetic woman on CAPD presented with general weakness. The patient received a total amount of 110 units of regular insulin via intraperitoneal and subcutaneous injection. Her initial blood chemistry showed increased serum lipid and liver enzyme profiles. Abdominal CT scan images and MRI revealed characteristic findings consistent with hepatic subcapsular steatosis. We assumed that the cause was CAPD and concomitant intraperitoneal insulin treatment; therefore, the patient was switched from CAPD to hemodialysis (HD) and began to receive insulin subcutaneously. Two months after the beginning of HD, the hepatic subcapsular steatosis completely resolved.

Clinical Significance of Routine Fistulography at Postoperative 1 Month in Patients Receiving Native Arteriovenous Fistula / 대한신장학회잡지

BACKGROUND: Fistulography is simple and accurate method detecting vascular access dysfunction. This study was performed to evaluate clinical significance of routine fistulography at postoperative 1 month in hemodialysis (HD) patients receiving native arteriovenous fistula (AVF). METHODS: This study enrolled 28 HD patients receiving native AVF operation who performed routine fistulography at postoperative 1 month before the first needling through the AVF. We investigated fistulographic findings and performed percutaneous angioplasty (PTA) in patients having severe stenosis more than 50 % of normal internal diameter. RESULTS: Of the total 28 patients, 8 patients showed normal findings and 20 patients showed stenosis in which 8 patients had severe stenosis requiring radiological or surgical correction. Of the 20 patients with stenosis, 12 patients had multiple lesions. Stenotic lesions were observed in AVF anastomosis site (n=6), proximal vein (n=5), artery near the AVF anastomosis site, and mixed lesions (n=6). PTA was performed in 5 of the 8 patients with severe stenosis and all stenostic lesions were completely corrected. CONCLUSION: Routine fistulography performed at postoperative 1 month is effective in detecting early native AVF and deciding treatment modalities.

Splenic Lymphangioma of the Spleen in an Elderly Patient

A splenic cystic lymphangioma is a very rare benign condition, and is classified as one of the cystic proliferations of the spleen. They are considered to result from developmental malformation of the lymphatic system and can be divided roughly into two types according to the extent of the disease: the isolated type, where only the spleen is involved, and the widespread type, where splenic involvement is an expression of multiple organ involvement. Thery are usually seen in children and often found incidentally. Herein, a case of cystic lymphangioma of the spleen in an elderly woman is presented, with emphasis on the rarity of cases in old age and on the problems of differential diagnosis in relation to other cystic proliferations of the spleen.

Epidermoid Cyst in Hepatoduodenal Ligament

A 39-year-old man was admitted to our hospital because of an intermittent, epigastric, abdominal pain and abdominal bloating. Magnetic resonance Cholangiopancreatography (MRCP) showed a 4x6 cm sized heterogenous cystic mass in the hilum of the liver. The mass seemed not to have originated from the liver, but was rather located at the anterior portion of the inferior vena cava and the caudate lobe, and superior to the head of the pancreas. The common bile duct (CBD) was displaced laterally by the mass, but the other biliary tree was normal. A presumptively diagnosed hematoma or high- protein mucous component filled cystic mass was later proved to be a large mass located in the hepatoduodenal ligament on laparotomy, and was completely removed by meticulous dissection. The histopathological diagnosis confirmed an epidermoid cyst.

Aggressive Angiomyxoma in the Vulva: A Case Report

Aggressive angiomyxoma is a rare benign tumor that originates in the pelvic or perineal organs of women. We report a case of an aggressive angiomyxoma as a huge vulvar mass, and present its clinical and image characteristics with a review of the literatures.