Causes of adverse outcomes in acute intestinal obstruction.

OBJECTIVES: The purpose of this study is to analyse the effectiveness of methods of diagnosis and treatment of patients with acute intestinal obstruction. METHODS: A total of 123 patients were examined, who were diagnosed based on history, an overview X-ray of the abdominal cavity, a contrast examination of the intestine, and contrast marks according to Yu. L. Shalkov and irrigoscopy. 57.4 % of patients had all typical aspects of the disease, 17.7 % - indolent aspects, and 4.8 % - atypical. In the case of colonic obstruction, the method of irrigoscopy is informative. To restore intestinal function, patients with acute intestinal obstruction of the small intestine are indicated with a Yu. L. Shalkov nasogastroenteral tube or a double-drainage nasointestinal tube. And with the colonic form of the disease, it is necessary to perform a Hartmann-type operation and establish a Maidl-type anastomosis. RESULTS: It was noted that with indolent or atypical aspects of the disease, patients received medical care late. It is shown that in the case of resection of necrotic areas of the intestine, it is informative to determine the resection boundary using the vasoscopy method using a 1 % aqueous solution of methylene blue. It was found that the optimal distance from the edge of the resection is 3 cm. CONCLUSIONS: The results of this study are of interest to clinicians who are engaged in the diagnosis and treatment of patients with acute intestinal obstruction.

Obscure gastrointestinal bleeding caused by congenital enteropathy in a Chinese young child-a case report.

BACKGROUND: SLCO2A1 was recently reported to cause nonspecific ulcers at small bowel, it was named as chronic enteropathy associated with SLCO2A1 (CEAS). It was rarely reported beyond the Japanese population. CASE PRESENTATION: A 4-year-5-month old girl presented with intractable anemia since 1-year-3-month. Her stool occult blood test was positive and the result of esophagogastroduodenoscopy and colonoscopy were normal. She was considered as obscure gastrointestinal bleeding. The magnetic resonance enterography and ultrasound of small intestinal revealed segmental thickening of small bowel. The capsule endoscopy detected ulcers, erosion and slightly stenosis near the site of junction of jejunum and ileum. She was considered chronic non-specific multiple ulcers of the small intestine and was advised to have whole exon sequencing. She was treated with exclusive enteral nutrition and iron supplement for two months. However, she was not responsive to this treatment, then she had three doses of infliximab. At the same time, the next-generation sequencing of this patient revealed two novel compound heterozygous mutations in SLCO2A1. She was diagnosed with CEAS and was treated with oral mercaptopurine. Her hemoglobin level was stable and the serum albumin level was slightly decreased during the follow up. CONCLUSION: CEAS may present as nonspecific small bowel ulcers, and misinterpret as small bowel Crohn's disease. Genetic tests may help with the precise diagnosis of small bowel ulcers.

Sending in the ViCE Squad: Evaluation and Management of Patients with Small Intestinal Bleeding.

Bleeding from the small intestine remains a clinically challenging diagnostic and therapeutic problem. It may be minor, requiring only supplemental iron treatment, to patients who have severe overt bleeding that requires multimodal intervention. This article provides an up-to-date review of the state-of-the-art of diagnosis and treatment of small intestinal bleeding.

Preliminary Investigation of the Diagnosis of Neonatal Congenital Small Bowel Atresia by Ultrasound.

PURPOSE: To assess the diagnostic value of ultrasonography (US) for congenital small bowel atresia (SBA) in neonates and their sonographic characteristics. METHODS: A retrospective analysis was performed of 20 neonates who were confirmed with SBA by operation from March 2014 to January 2019. All the neonates have been scanned by US before surgery, and no one underwent barium enema or upper gastrointestinal imaging prior to US. Preoperation ultrasound characteristics about intestinal morphology and intestinal contents were collected, further to summarize the typical ultrasonic features of SBA. RESULTS: Five cases were duodenal atresia, and 15 cases were jejuno-ileal atresia. Distended proximal intestines, liquid with tiny points in it, can be found in 20 neonates. The small intestine without any gas can be found in 20 neonates. Microcolon, no gas and other contents in it, can be found in 16 cases. CONCLUSIONS: The typical ultrasonic features of SBA include dilation in proximal intestines, small intestines, and microcolon. US is a promising modality in the clinical diagnosis of SBA.

Diagnosis and therapeutic strategies for small bowel vascular lesions.

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy's lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

Medicinal Sulphur Polypore Mushroom Laetiporus sulphureus (Agaricomycetes) Plus Tiny Amounts of Essential Oils Decrease the Activity of Crohn Disease.

A mixture of Laetiporus sulphureus (LS) and essential oils of Origanum vulgare, Cinnamomum verum, and Syzygium aromaticum (LOCS) was recommended for 24 patients with Crohn disease (CD). Patients were followed up for at least 24 months (median 32 months; range, 24-54 months). Nineteen patients were compliant with the treatment, although 3 stopped taking it, relapsed, began the LOCS regimen again, and recovered; 5 patients were not compliant at all. Compliant patients experienced flares of CD, with a CD Activity Index > 220, for 5.6% of the surveillance period (median 34 months). Noncompliant patients experienced flares of CD, with a CD Activity Index > 220, for 75.0% of the surveillance period (median 26 months; P < 10-6). Each case was then analyzed with a Bayesian approach that considered the probability of CD spontaneously disappearing within 2 weeks after intake of LOCS, the reappearance of CD within 2 weeks after stopping LOCS, and the disappearance of CD again after rechallenge. For the 19 compliant patients, the global posterior probability (probability that all the events observed were due to coincidence only) was equal to 10-6. Thus it can be concluded that LOCS decreases the CD Activity Index. Further investigations are necessary to unravel the mechanism of action of LOCS and to confirm its positive effect over periods as long as 5 to 10 years.

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction.

BACKGROUND/PURPOSE: We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO). METHODS: Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared. RESULTS: Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42. CONCLUSIONS: Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Antidiarrheal activity of a novel sulfated polysaccharide from the red seaweed Gracilaria cervicornis.

ETHNOPHARMACOLOGICAL RELEVANCE: The use of marine seaweeds as a source of natural compounds with medicinal purposes is increasing in Western countries in the last decades, becoming an important alternative in the traditional medicine of many developing countries, where diarrhea still remains a severe public health problem, with high rates of mortality and morbidity. Sulfated polysaccharides (PLS) extracted from red seaweeds can exhibit therapeutic effects for the treatment of gastrointestinal disorders. Thus, the pharmacological properties of the PLS from Gracilaria cervicornis, an endemic seaweed found in the Brazilian northeast coast, was evaluated as an alternative natural medication for diarrhea. AIM OF THE STUDY: This study aimed to evaluate the antidiarrheal activity of sulfated polysaccharides (PLS) extracted from the red seaweed G. cervicornis in Swiss mice pre-treated with castor oil or cholera toxin. MATERIALS AND METHODS: The seaweed Gracilaria cervicornis was collected at Flecheiras beach (city of Trairí, State of Ceará, Brazil) and the PLS was obtained through enzymatic extraction and administered in mice (25-30 g) before diarrhea induction with castor oil or cholera toxin. For the evaluation of the total number of fecal output and diarrheal feces, the animals were placed in cages lined with adsorbent material. The evaluation of intestinal fluid accumulation (enteropooling) on castor oil-induced diarrhea in mice occurred by dissecting the small intestine and measuring its volume. The determination of Na+/K+-ATPase activity was measured in the small intestine supernatants by colorimetry, using commercial biochemistry kits. The gastrointestinal motility was evaluated utilizing an activated charcoal as a food tracer. The intestinal fluid secretion and chloride ion concentration were evaluated in intestinal closed loops in mice with cholera toxin-induced secretory diarrhea. The binding ability of PLS with GM1 and/or cholera toxin was evaluated by an Enzyme-Linked Immunosorbent Assay (ELISA). RESULTS: The G. cervicornis PLS showed antidiarrheal effects in both acute and secretory diarrhea, reducing the total number of fecal output, diarrheic stools, intestinal fluid accumulation, and increasing small intestine Na+/K+-ATPase activity on castor oil-induced diarrhea. However, the PLS did not affect gastrointestinal motility, indicating that this compound has a different action mechanism than loperamide. In secretory diarrhea, the PLS decreased intestinal fluid secretion and small intestine chloride excretion, binding with GM1 and/or cholera toxin and blocking their attachment to the enterocyte cell surface. CONCLUSIONS: In conclusion, PLS has a significant antidiarrheal effect in acute and secretory diarrhea. Further investigation is needed towards its use as a natural medicine to treat diarrhea.

Clinical Utility of Capsule Endoscopy and Double-Balloon Enteroscopy in the Management of Obscure Gastrointestinal Bleeding.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a common but embarrassing problem for gastroenterologists. Most bleeding lesions associated with OGIB are present in the small intestine and sometimes cannot be identified due to the difficulty associated with physical accessibility. Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have enabled in the process of diagnosing and have evolved to become approaches to treating OGIB. SUMMARY: CE is a minimally invasive procedure and has a high diagnostic yield in patients with OGIB. DBE offers additional advantage of biopsy collection for pathological diagnosis and therapeutic intervention, but it should be noted that it sometimes causes severe adverse events such as acute pancreatitis, intestinal bleeding, and intestinal perforation. CE should be performed early in the workup course of OGIB. Positive CE findings enhance the diagnostic yield of subsequent DBE, and the effective therapeutic intervention improves the clinical outcomes of OGIB patients. On the contrary, there are no clear guidelines for further investigation of patients with negative CE findings at the present. Although patients in stable general condition may only require follow-up, repeated CE is useful to detect positive findings in patients with evidence of sustained bleeding and progressing anemia. We have revealed that repeated CE has higher positive finding rate than DBE in OGIB patients with negative CE findings in a preliminary study. Key Messages: CE and DBE have complementary roles in the management of OGIB, and the precise timing and proper sequence may be important for the approach to treating OGIB.

Acceleration of small bowel motility after oral administration of dai-kenchu-to (TJ-100) assessed by cine magnetic resonance imaging.

Dai-kenchu-to (TJ-100) is an herbal medicine used to shorten the duration of intestinal transit by accelerating intestinal movement. However, intestinal movement in itself has not been evaluated in healthy volunteers using radiography, fluoroscopy, and radioisotopes because of exposure to ionizing radiation. The purpose of this study was to evaluate the effect of TJ-100 on intestinal motility using cinematic magnetic resonance imaging (cine MRI) with a steady-state free precession sequence. Ten healthy male volunteers received 5 g of either TJ-100 or lactose without disclosure of the identity of the substance. Each volunteer underwent two MRI examinations after taking the substances (TJ-100 and lactose) on separate days. They drank 1200 mL of tap water and underwent cine MRI after 10 min. A steady-state free precession sequence was used for imaging, which was performed thrice at 0, 10, 20, 30, 40, and 50 min. The bowel contraction frequency and distention score were assessed. Wilcoxon signed-rank test was used, and differences were considered significant at a P-value <0.05. The bowel contraction frequency tended to be greater in the TJ-100 group and was significantly different in the ileum at 20 (TJ-100, 8.95 ± 2.88; lactose, 4.80 ± 2.92; P < 0.05) and 50 min (TJ-100, 9.45 ± 4.49; lactose, 4.45 ± 2.65; P < 0.05) between the groups. No significant differences were observed in the bowel distention scores. Cine MRI demonstrated that TJ-100 activated intestinal motility without dependence on ileum distention.

Current management of small bowel obstruction in the UK: results from the National Audit of Small Bowel Obstruction clinical practice survey.

AIM: Small bowel obstruction (SBO) is associated with high rates of morbidity and mortality. The National Audit of Small Bowel Obstruction (NASBO) is a collaboration between trainees and specialty associations to improve the care of patients with SBO through national clinical audit. The aim of this study was to define current consultant practice preferences in the management of SBO in the UK. METHOD: A survey was designed to assess practice preferences of consultant surgeons. The anonymous survey captured demographics, indications for surgery or conservative management, use of investigations including water-soluble contrast agents (WSCA), use of laparoscopy and nutritional support strategies. The questionnaire underwent two pilot rounds prior to dissemination via the NASBO network. RESULTS: A total of 384 responses were received from 131 NASBO participating units (overall response rate 29.2%). Abdominal CT and serum urea and electrolytes were considered essential initial investigations by more than 80% of consultants. Consensus was demonstrated on indications for early surgery and conservative management. Three hundred and thirty-eight (88%) respondents would consider use of WSCA; of these, 328 (97.1%) would use it in adhesive SBO. Two hundred (52.1%) consultants considered a laparoscopic approach when operating for SBO. Oral nutritional supplements were favoured in operatively managed patients by 259 (67.4%) respondents compared with conservatively managed patients (186 respondents, 48.4%). CONCLUSION: This survey demonstrates consensus on imaging requirements and indications for early surgery in the management of SBO. Significant variation exists around awareness of the need for nutritional support in patients with SBO, and on strategies to achieve this support.

A surgical solution to regain bowel continuity following an extended left colectomy-reviving and extending the indication for a "Flip-Flop" procedure.

BACKGROUND AND AIMS: Extended left hemicolectomy might be necessary for several indications. Once the resection is completed, it would be difficult or impossible to anastomose the transverse colon to the rectum due to the difficulty in mobilizing the transverse colon to reach for a tension-free rectal anastomosis. The aim of this report is to present the "Flip-Flop" technique to overcome this challenging situation. The procedure is based on a surgical technique published in the early 1960s to avoid permanent stoma after proctectomy and consists of changing the location of the right colon to reach the rectum. METHODS: Clinical parameters, surgical aspects, and postoperative outcome of patients that underwent the flip-flop procedure following an extended left colectomy in our medical service was reviewed. RESULTS: Three patients underwent a flip-flop procedure after an extended left colectomy performed for various reasons. The surgical technique is detailed in a step by step manner. Patients had uneventful postoperative recovery with an adequate functional outcome. CONCLUSIONS: We believe that this approach should be revived and be considered also in cases when the full length of the rectum is preserved to avoid ileo-rectal anastomosis or a high-tension colocolonic anastomosis. Popularization of this surgical solution among surgeons is highly important.

Clinical Effect of Water-Soluble Contrast Agents for Small Bowel Obstruction in the Virgin Abdomen.

BACKGROUND: Several studies have investigated the diagnostic and therapeutic role of water-soluble contrast agents (WSCAs) in adhesive small bowel obstruction (SBO). However, the clinical effect of WSCA for SBO without previous intraabdominal operation (i.e., virgin abdomen, VA) is unclear. The aim of this study was to clarify the clinical effect of WSCA for SBO in the VA. METHODS: Between January 2008 and December 2015, 838 consecutive patients with SBO were initially managed with WSCA and were included in the study. Abdominal X-rays were taken 5 h after administration of 100 ml WSCA and classified into complete/incomplete obstruction groups. The medical records of the patients with SBO were retrospectively analyzed and divided into two groups of patients with VA or non-VA. RESULTS: A total of 44 and 794 VA and non-VA patients were identified, respectively. Six VA patients (13%) and 121 non-VA patients (15%) were classified with complete obstruction (p = 1.000) and subjected to operative exploration on the same day. There were no significant differences in the duration of nasogastric tube decompression (2.2 versus 2.5 days, p = 0.400) and intervals until the initiation of oral intake (2.4 versus 2.6 days, p = 0.553) between the VA and non-VA groups. The overall operative rate was 16% in the VA and 17% in the non-VA groups (p = 1.000). Compared with non-VA, VA was associated with shorter hospital stays (9.6 versus 11.3 days, p = 0.006). CONCLUSIONS: WSCA for SBO in the VA is as effective as in non-VA patients in terms of a therapeutic strategy.

Prenatal magnetic resonance and ultrasonographic findings in small-bowel obstruction: imaging clues and postnatal outcomes.

BACKGROUND: Prenatal small-bowel obstruction can result from single or multiple atresias, and it can be an isolated abnormality or part of a syndrome. It is sometimes the first manifestation of cystic fibrosis. Accurate prediction of the level of obstruction and length of bowel affected can be difficult, presenting a challenge for counseling families and planning perinatal management. OBJECTIVE: To review the prenatal US and MRI findings of small-bowel obstruction and to assess whether fetal MRI adds information that could improve prenatal counseling and perinatal management. MATERIALS AND METHODS: We retrospectively reviewed 12 prenatally diagnosed cases of small-bowel obstruction evaluated by both US and MRI from 2005 to 2015. We analyzed gestational age at evaluation, US and MRI findings, gestational age at delivery and postnatal outcomes. RESULTS: The final diagnoses were jejunal atresia (7), ileal atresia (1), cystic fibrosis (3) and combined jejunal and anal atresia (1). Four of the eight with jejunal atresia were found to have multiple small-bowel atresias. Prenatal perforation was noted in three. We identified a trend of increasing complexity of bowel contents corresponding to progressively distal level of obstruction, as indicated by increasing US echogenicity and high T1 signal on MRI. Seven cases of jejunal atresia and one case of ileal atresia demonstrated small ascending, transverse and descending colon (microcolon) with filling of a normal-diameter rectum. In contrast, all three fetuses with cystic fibrosis and the fetus with jejunal-anal atresia demonstrated microcolon as well as abnormal paucity or absence of rectal meconium. Polyhydramnios was present in nine. Eight were delivered prematurely, of whom seven had polyhydramnios. The fetus with jejunal and anal atresia died in utero. Postnatally, three had short gut syndrome, all resulting from multiple jejunal atresias; these three were among a subset of four fetuses whose bowel diameter measured more than 3 cm. Eight infants had no further gastrointestinal complications. The presence of multiple atresias was not predicted by prenatal US or MRI. CONCLUSION: MR provides useful additional information regarding meconium distribution in the small bowel, which helps to clarify the level of obstruction. MR was additionally useful in the assessment of colon and rectal contents, serving as a fetal enema. Abnormally diminished meconium in the rectum suggests cystic fibrosis or combined small-bowel and colonic obstruction, information that is useful in counseling and preparing for postnatal care.

Oral distension methods for small bowel MRI: comparison of different agents to optimize bowel distension.

Background Different methods for bowel distension prior to magnetic resonance imaging (MRI) examinations were described in recent years. Purpose To compare orally administered psyllium or locust bean gum / mannitol (LBM) with tylose administered through a duodenal catheter for bowel distension in patients undergoing MRI examination of the small bowel. Material and Methods Three different methods of bowel distension prior to MRI were compared: tylose applied through a duodenal catheter and orally administered psyllium and LBM in three groups with 15 patients each. Datasets were blinded and reviewed independently by two experienced radiologists, who assessed the diagnostic value and the maximum luminal diameter. Results Tylose was superior to psyllium and LBM in the examination of the duodenum and proximal jejunum. LBM was superior to the other methods for distension of the ileum and terminal ileum. The greatest luminal diameter of the duodenum was achieved after tylose and distension of the terminal ileum was the best in patients receiving LBM. The psyllium group was inferior to the other two groups in all segments. Conclusion By using LBM as an oral method of bowel distension, many patients can avoid the unpleasant placement of a duodenal catheter without compromising the diagnostic value of the examination.

Routine contrast enema is not required for all infants prior to ostomy reversal: A 10-year single-center experience.

INTRODUCTION: The incidence of intestinal stricture is low for most conditions requiring a primary small bowel stoma in infants. Routine performance of contrast enemas (CE) prior to stoma closure adds cost and radiation exposure. We hypothesized that routine CE prior to ostomy reversal is not necessary in all infants, and sought to identify a subset of patients who may benefit from preoperative CE. METHODS: Medical records of infants under age 1 (N=161) undergoing small bowel stoma reversal at a single institution between 2003 and 2013 were retrospectively reviewed. Student's T-test was used to compare groups. RESULTS: Contrast enemas were performed on 80% of all infants undergoing small bowel ostomy reversal during the study period. Infants with necrotizing enterocolitis (NEC) were more likely to have a CE than those with intestinal atresia (p=0.03) or those with all other diagnoses combined (p=0.03). Nine strictures were identified on CE. Of those, 8 (89%) were in patients with NEC, and only 4 were clinically significant and required operative resection. The overall relevant stricture rate was 2.5%. No patient that underwent ostomy takedown without CE had a stricture diagnosed intraoperatively or an unrecognized stricture that presented clinically after stoma takedown. CONCLUSIONS: Routine CE is not required prior to small bowel ostomy reversal in infants. We recommend judicious use of enema studies in patients with NEC and high likelihood of stricture.

Enterography CT without and with water enema in patients with Crohn's disease: Results from a comparative observational study in comparison with endoscopy.

OBJECTIVES: CT is nowadays an examination routinely performed in Crohn's disease (CD) patients. However, there are several ways to assess gastro-intestinal tract, in particular colonic segments. Aim of this study is to compare enterography-CT (E-CT), performed after oral administration of polyethylene-glycol solution (PEG-CT) versus enterography-CT performed also with water enema via rectum (ECT-WE) in patients with CD. METHODS: We have studied 79 patients with CD undergone to enterography-CT (42 evaluated with PEG-CT and 37 with ECT-WE) who have performed a lower endoscopy within 15 days before CT. CT results concerning large bowel were compared with endoscopic findings. Intestinal distension, discomfort of the patients, sensitivity, specificity and diagnostic accuracy were evaluated. Pearson test was used for statistical analysis. RESULTS: Degree of abdominal pain was significantly higher in patients underwent to ECT-WE compared to PEG-CT. Distension of the colon was significantly greater in patients studied with ECT-WE compared to those studied with PEG-CT. Values of sensitivity, specificity and diagnostic accuracy of PEG-CT and ECT-WE were respectively 77, 86.5 and 81%, and 89, 100 and 92% in comparison with endoscopy. CONCLUSIONS: In patients with CD, ECT-WE allows the evaluation of large bowel in addition to small bowel better than PEG-CT.

Diagnosis of pediatric gastric, small-bowel and colonic volvulus.

Digestive volvulus affects the stomach, small bowel and mobile segments of the colon and often has a developmental cause. Reference radiologic examinations include upper gastrointestinal contrast series for gastric volvulus, possibly with ultrasonography for small-bowel volvulus, and contrast enema for colonic volvulus. Treatment is usually surgical. This pictorial essay describes the embryological development and discusses the clinical and radiologic presentation of volvulus, depending on location, and details the appropriate radiologic examinations.