Tomografía computada y resonancia magnética en la patología de la vesícula biliar: más allá de la litiasis / Computed tomography and magnetic resonance in gallbladder patology: beyond lithiasis

Resumen La enfermedad de la vesícula biliar es una causa común de dolor abdominal. Si bien por lo general el dolor es secundario a la presencia de litiasis y colecistitis aguda, el espectro de la enfermedad es amplio e incluye anomalías congénitas, otros procesos inflamatorios y neoplasias. La tomografía computada (TC) y la resonancia magnética (RM) tienen un papel relevante en aquellos casos en los que la ecografía no es concluyente y en la planificación del tratamiento. Dentro de las anomalías congénitas, la forma en “gorro frigio” es la más frecuente. Los pólipos son en su mayoría lesiones benignas, siendo las características de malignidad un tamaño superior a 10 mm, solitario y sésil. La adenomiomatosis es reconocible por el engrosamiento de la pared vesicular y los componentes quísticos intramurales. Es importante reconocer el gas intramural e intraluminal en la colecistitis enfisematosa y los microabscesos y hemorragias intraluminales en la colecistitis gangrenosa debido a su alta morbilidad y mortalidad. La colecistitis xantogranulomatosa presenta nódulos intramurales que ocupan más del 60% del área de la pared engrosada y la conservación lineal del realce de la mucosa sin interrupción. El carcinoma vesicular se presenta como una lesión infiltrante que se extiende al hígado, un engrosamiento mural o una masa polipoide intraluminal.

Abstract Gallbladder disease is a common cause of abdominal pain. Although the pain is usually secondary to the presence of lithiasis and acute cholecystitis, the spectrum of the disease is broad and includes congenital anomalies, other inflammatory processes and neoplasms. Computed tomography (CT) and magnetic resonance (MRI) have a relevant role in those cases in which ultrasound is not conclusive and in treatment planning. Among the congenital anomalies, the “phrygian cap” shape is the most frequent. Polyps are mostly benign lesions, with the characteristics of malignancy being larger than 10 mm, solitary and sessile. Adenomyomatosis is recognizable by gallbladder wall thickening and intramural cystic components. It is important to recognize intramural and intraluminal gas in emphysematous cholecystitis and intraluminal microabscesses and hemorrhages in gangrenous cholecystitis because of its high morbidity and mortality. Xanthogranulomatous cholecystitis presents with intramural nodules occupying more than 60% of the thickened wall area and linear preservation of mucosal enhancement without interruption. Gallbladder carcinoma presents as an infiltrative lesion extending to the liver, a mural thickening or an intraluminal polypoid mass.

Follicular Cholecystitis Mimicking Xanthogranulomatous Cholecystitis and Malignancy: A Case Report.

Chronic follicular cholecystitis (CFC) is a rare pathology characterized by prominent lymphoid follicles in the lamina propria distributed throughout the gallbladder wall. It has also been mentioned in the literature as lymphoid hyperplasia and pseudolymphoma. CFC represents less than 2% of cholecystectomies. Its etiopathology is mostly unknown. Most reports are based on histopathological findings, with little or no imaging analysis. We describe a case involving a 66-year-old man radiologically diagnosed as xanthogranulomatous cholecystitis (XGC) versus malignancy, revealing CFC with surrounding inflammatory changes in the cholecystectomy specimen.

Expected and Unexpected Imaging Findings after 90Y Transarterial Radioembolization for Liver Tumors.

Transarterial radioembolization (TARE), also called radioembolization or selective internal radiation therapy, is an interventional radiology technique used to treat primary liver tumors and liver metastases. The aim of this therapy is to deliver tumoricidal doses of radiation to liver tumors while selecting a safe radiation dose limit for nontumoral liver and lung tissue. Hence, correct treatment planning is essential to obtaining good results. However, this treatment invariably results in some degree of irradiation of normal liver parenchyma, inducing different radiologic findings that may affect follow-up image interpretation. When evaluating treatment response, the treated area size, tumor necrosis, devascularization, and changes seen at functional MRI must be taken into account. Unlike with other interventional procedures, with TARE, it can take several months for the tumor response to become evident. Ideally, responding lesions will show reduced size and decreased enhancement 3-6 months after treatment. In addition, during follow-up, there are many imaging findings related to the procedure itself (eg, peritumoral edema, inflammation, ring enhancement, hepatic fibrosis, and capsular retraction) that can make image interpretation and response evaluation difficult. Possible complications, either hepatic or extrahepatic, also can occur and include biliary injuries, hepatic abscess, radioembolization-induced liver disease, and radiation pneumonitis or dermatitis. A complete understanding of these possible posttreatment changes is essential for correct radiologic interpretations during the follow-up of patients who have undergone TARE. ©RSNA, 2019.

Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature.

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy.
We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, realtime procedures, such as fine-needle aspiration.

Hernia pulmonar post-traumática / Post-traumatic pulmonary hernia

Paciente femenina de 65 años consulta por tumoración en región lateral izquierda del tórax, no dolorosa, que fluctúa con los movimientos respiratorios y la tos. Cumple tratamiento por bronquitis aguda hace una semana. Presenta antecedente de traumatismo en parrilla costal izquierda debido a caída desde altura hace 6 meses. Al examen físico se palpa masa de consistencia elástica, que aumenta ante maniobra de Valsalva. Se solicita radiografía de tórax (RxTx) (Figura 1a) donde se evidencia imagen radiolúcida de contornos bien definidos, que sobrepasa los límites del seno costo-frénico y parrilla costal izquierda ("Signo del pulmón más allá de la costilla")1 , asociado a fracturas de los arcos costales anteriores (10 y 11). En la tomografía computada de tórax (TCTx) se confirma el diagnóstico de hernia pulmonar (Figura 1b). Debido a persistir asintomática y la ausencia de complicaciones, se realizan controles con TCTx y tratamiento conservador

[Bilateral pneumothorax complicating cavitary pulmonary metastases in angiosarcoma]. / Neumotórax bilateral como complicación de metástasis pulmonar cavitaria de un angiosarcoma.

Metastatic pulmonary angiosarcomas are a common complication of a rare condition. Generally, they are presented as peripheral solid nodules, infiltrates, and pleural effusions. We report the case of a 65 year-old man with bilateral recurrent pneumothorax secondary to metastatic cavitary lesions from angiosarcoma of the scalp. In this case, videothoracoscopy allowed tumor resection, inspection, and pleurodesis. There weren't complications or tumor recurrence at six months follow up.

Neumotórax bilateral como complicación de metástasis pulmonar cavitaria de un angiosarcoma / Bilateral pneumothorax complicating cavitary pulmonary metastases in angiosarcoma

Las metástasis pulmonares de angiosarcoma constituyen una complicación común de una neoplasia maligna poco frecuente. Habitualmente se presentan como nódulos solidos periféricos y derrame pleural. Presentamos el caso de un hombre de 65 años de edad con neumotórax bilateral recurrente, secundario a metástasis cavitadas de un angiosarcoma primitivo de cuero cabelludo. La videotoracoscopia permitió la inspección, la resección de las metástasis y la pleurodesis. No ocurrieron complicaciones ni recurrencia tumoral a los seis meses de seguimiento.

Metastatic pulmonary angiosarcomas are a common complication of a rare condition. Generally, they are presented as peripheral solid nodules, infiltrates, and pleural effusions. We report the case of a 65 year-old man with bilateral recurrent pneumothorax secondary to metastatic cavitary lesions from angiosarcoma of the scalp. In this case, videothoracoscopy allowed tumor resection, inspection, and pleurodesis. There weren't complications or tumor recurrence at six months follow up.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature.

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

Caso: hombre de 43 años con diagnóstico de AR y disnea de 6 meses de evolución / Case: 43-year-old man diagnosed with RA and dyspnea of 6 months of evolution

Un hombre de 42 años de edad, no fumador, fue evaluado en la consulta externa de Neumonología por tos y disnea que en los últimos seis meses había progresado hasta hacerse evidente en reposo. Aproximadamente un año antes, el paciente había notado un descenso en su tolerancia a las actividades diarias. En los últimos seis meses desarrolló disnea de esfuerzo que progresa al reposo y se acompaña de tos con expectoración hialina escasa, y sibilancias. Un mes antes de esta evaluación, el paciente había consultado a un especialista en otro centro. En la auscultación pulmonar se encontraron sibilancias 4/6 difusas, y una espirometría reveló una alteración ventilatoria obstructiva en grado muy severo. Por este motivo inició tratamiento con broncodilatadores de acción prolongada asociados a corticoides inhalados en dosis altas, así como broncodilatadores de acción corta en nebulización a demanda, pero no encontró cambios en su condición clínica

New surgical strategy to induce liver hypertrophy: role of MDCT-volumetry to monitor and predict liver growth.

BACKGROUND/AIMS: To describe the role of MDCT-volumetry to monitor and predict liver hypertrophy in a recently introduced surgical technique in patients needing hepatectomy. METHODOLOGY: This prospective study was approved by the local research and ethics committee and patient informed consent was obtained. Twelve consecutive patients were selected for associating liver partition and portal vein ligation for staged-hepatectomy procedure. The mean absolute the future-liver-remnant (FLR) and FLR/total liver volume (TLV) ratio was calculated before and after surgery to determine the degree of hypertrophy. Six days after surgery a new CT-examination was performed to determine the FLR-volume and FLR/TLV. If the enlargement of the FLR was the expected a second-step surgery was performed. Continuous variables are expressed as mean (range). A p<0.05 was considered significant. RESULTS: The mean pre-operative FLR-volume was 402 mL and the FLR/TLV was 27%. The mean post-operative FLR-volume 6 days after the first step was 702 mL (range 521-1030 mL) being the mean difference between preoperative and postoperative FLR volume 303 mL (p<0.0001). The mean volume increase was 80% ranged from 21-139%. At day six, FLR/TLV was 46.5% (range 33.5-67.7), morbidity was 41% and mortality 0%. CONCLUSIONS: MDCT-volumetry has a key role in decision-making, monitoring and predicting liver hypertrophy pre- and postoperatively.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature / Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature.

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

[Multiple rib fractures associated with cough]. / Fracturas costales múltiples asociadas a tos.

Cough is a common symptom in ambulatory practice and in general does not require specific treatment. When the cough is chronic it can provoke complications such as syncope, pneumothorax or, rarely, rib fractures. We report a case of a patient with multiple rib fractures caused by cough. The diagnosis was performed by scintigraphy but fractures were not found in the x-rays. Five months later, a scintigraphy showed disappearance of the increased uptake areas. Multiple rib fractures are a cough complication which should be considered when the patient's pain is persistent even if there is no x-ray evidence.

Fracturas costales múltiples asociadas a tos

La tos es un frecuente motivo de consulta en la práctica ambulatoria. Aunque generalmente es autolimitada, cuando es crónica e intensa puede ser causa de complicaciones como síncope, neumotórax o más raramente fracturas costales. Presentamos un paciente con fracturas costales múltiples inducidas por la tos. El diagnóstico fue confirmado por un centellograma solicitado luego de la sospecha clínica debida a la intensidad y persistencia del dolor y a pesar de no mostrar alteraciones en las radiografías convencionales. Un centellograma de control a los 5 meses mostró desaparición de los focos hipercaptantes. Las fracturas costales múltiples son una complicación infrecuente de la tos que debería considerarse cuando el dolor torácico es intenso y persistente aun con radiografía de tórax o parrilla costal normal.

Multiple rib fractures associated with cough.

Cough is a common symptom in ambulatory practice and in general does not require specific treatment. When the cough is chronic it can provoke complications such as syncope, neumothorax or, rarely, rib fractures. We report a case of a patient with multiple rib fractures caused by cough. The diagnosis was performed by scintigraphy but fractures were not found in the x-rays. Five months later, a scintigraphy showed disappearance of the increased uptake areas. Multiple rib fractures are a cough complication which should be considered when the patient’s pain is persistent even if there is no x-ray evidence.

Adenocarcinoma mucinoso de uraco / Urachal adenocarcinoma: sonographic and CT findings

Se presenta el caso de una paciente de 43 años cuyo motivo de consulta consistió en dolor hipogástrico, incontinencia urinaria, mucosuria y hematuria. La ecografía y la tomografía axial computada (TC) con y sin contraste endovenoso de la región abdominopelviana demostraron una voluminosa masa heterogénea en contacto con la cúpula vesical. Se realizó cistectomía radical, histerectomía y plástica de pared abdominal. La anatomía patológica reveló un adenocarcinoma mucinoso de uraco

Lesiones quísticas pancreáticas, su evaluación por RM, enfatizando el estudio del conducto de Wirsung / Primary cystic pancreatic neoplasms and tumor-like conditions. MR cholangiopancreatographic evaluation of lesions and Wirsung's duct

Propósito. Resaltar e ilustrar el aporte y los avances del single shot fast spin echo (SSFSE) en la investigación de las lesiones quísticas del páncreas, y su vinculación con el conducto de Wirsung, se evaluaron retrospectivamente. Material y métodos. Sesenta y seis pacientes, 33 mujeres y 33 hombres (edad promedio de 66 años), con diagnóstico imagenológico de lesión quística pancreática. Se utilizó la técnica de SSFSE, ponderando el estudio del conducto de Wirsung. Se adicionaron las secuencias convencionales para páncreas. Se evaluó: ubicación, número, tamaño, relación con el conducto Wirsung, estructura y señal. Resultados. Las lesiones quísticas investigadas se dividieron en dos grupos: A. Vinculadas al conducto Wirsung (30 pacientes): 8 del conducto principal, 10 únicas de conductos periféricos y 12 múltiples de conductos periféricos. Todas fueron menores de 30 mm, con septos y 3 presentaron defectos de relleno en su interior. En base a estos hallazgos se realizó diagnóstico de tumor mucinoso papilífero intraductal. En este grupo el 7 por ciento fueron operados. B. No vinculadas al conducto Wirsung (36 pacientes): 7 cistadenomas serosos, 7 adenocarcinomas con componente quístico...