Role of CT imaging in discriminating internal hernia from aspecific abdominal pain following Roux-en-Y gastric bypass: a single high-volume centre experience.

Internal hernia (IH) represents a delayed complication of the laparoscopic Roux-en-Y gastric bypass (LRYGB) and it is historically difficult to identify preoperatively. Numerous CT signs were considered suggestive of IH but none of them is pathognomonic. In this study, we aim to evaluate the accuracy of CT in diagnosing IH, differentiating from non-specific abdominal pain. This can lead to a way of personalized medicine and improve the outcome of anti-obesity treatments. We retrospectively reviewed CT scans of 50 patients previously subjected to LRYGB procedure, with a clinical suspicion of IH. 3 groups of patients were identified: IH group (21 patients with a surgical confirmed IH), negative group (12 patients in whom IH was not confirmed at surgery), and control group (17 patients who were not surgically explored because of low/no suspicion of IH). We divided CT signs into three groups: "bowel loop signs", "vessel signs", and "venous congestion/stasis signs". The accuracy of CT in detecting IH was tested by comparing each sign, either individually or in combination, with the surgical findings. Statistical analysis showed that "vessel signs" (swirl sign, superior mesenteric vein beaking, mesenteric arteries, and veins branches inversion) present the highest distribution in patients with IH demonstrated at surgery, with a higher accuracy in case of simultaneous presence of two or three signs. CT imaging is highly accurate in diagnosing IH. Despite no single sign being pathognomonic, the combination of two or more signs, especially among the "vessels signs", can suggest the IH, even in pauci-symptomatic patients.

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings.

Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.

Bowel and mesenteric injuries from blunt abdominal trauma: a review.

The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.

Long-term efficacy of B cell depletion therapy on lung and skin involvement in diffuse systemic sclerosis.

OBJECTIVES: To assess the long-term efficacy and safety of single and multiple courses of rituximab therapy in systemic sclerosis (SSc) patients with and without lung disease. METHODS: A total of 20 SSc patients with a diffuse disease were treated with rituximab. At baseline and during follow-up the lung involvement was evaluated with pulmonary function tests (FVC and DLCO) and with lung high-resolution computed tomography (HRCT). RESULTS: The skin score, activity, and severity indices improved significantly after 12 months and at final follow-up compared to baseline. After 12 months, there was a significant increase of FVC and TLC compared to baseline (p = 0.024 and p = 0.005, respectively), while the mean DLCO value remained stable. Considering the last available follow-up in six patients with restrictive lung disease at baseline, two patients (33.3%) experienced an increase of more than 10% of FVC, one patient had a decrease of FVC >10%, while in three patients FVC remained stable (50%). After the mean follow-up of 48.5 ± 20.4 months, among the patients with normal lung parameters at baseline, FVC remained stable in 12 (85.7%) and in one patient (14.3%) it increased by more than 10%. At the final follow-up, the alveolar and interstitial HRCT scores remained stable in more than 80% of patients, both in patients with and without restrictive lung disease at baseline. CONCLUSIONS: Anti-CD20 B cell depletion therapy is effective on skin involvement but seems also to preserve the pulmonary function, as supported by a stable or improved FVC and stable interstitial score, suggesting a possible role of rituximab as a modifying therapy overall in early diffuse SSc.

Evaluation of the dentoskeletal characteristics of an Egyptian mummy with three-dimensional computer analysis.

BACKGROUND: Since the introduction of Roentgen rays in medical diagnostics, mummies have been subjected to radiographic and cephalometric studies. These have, among others, the advantage of providing details that are not directly visible for inspection without the need to tamper with the relics. The acquisition of three-dimensional imaging techniques has also extended the possibility of noninvasive investigation, so that many famous mummies, such as those of Tutankhamun and Ramses II, underwent three-dimensional computed tomography (CT). METHODS: Computed tomography scan of Egyptian mummy of a 20- to 30-year-old woman found in Fayum and dating from the second century B.C. has been performed. DICOM data of the CT scan have been processed by means of a software for three-dimensional CT imaging processing. The purpose of this report was to present the somatic and skeletal characteristics of the mummy. RESULTS: Thanks to the image processing, a "virtual reconstruction" of the original facial features of the mummy has been obtained, and a reliable cephalometric tracing could be performed. The data derived from cephalometric tracings were similar to those published on other studies on a group of Egyptian mummies and on a sample of Iowa adult males. CONCLUSIONS: In our opinion, three-dimensional image processing of CT scan is useful to perform noninvasive morphologic investigations on archeological find, to allow virtual correction of postmortem artifact and to perform reliable cephalometric tracings.

Bronchoalveolar lavage fluid and progression of scleroderma interstitial lung disease.

INTRODUCTION: So far no clinical or experimental evidences clearly explain how and which systemic sclerosis (SSc) patients will experience a functional and radiological progression of interstitial lung disease (ILD). OBJECTIVES: The aim of the study was to investigate whether any bronchoalveolar lavage fluid (BALF) characteristic, compared with clinical, functional and radiological parameters, is associated with the risk of progression of ILD and worse survival in SSc patients. METHODS: Lung involvement was evaluated in 110 consecutively examined SSc patients with pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT); 73 patients with evidence of ILD on HRCT underwent BAL. The progression of ILD was evaluated with PFTs and HRCT after 1-year follow-up. A 36-month survival analysis was assessed. RESULTS: ILD patients with alveolitis had a higher risk to have restrictive lung disease and honeycombing, to experience a worsening in honeycombing score or to develop honeycombing. ILD progression was associated with the evidence of honeycombing on HRCT, with the presence of eosinophils, with an inverted CD4/CD8 ratio and with a higher CD19 percentage count in the BALF or with a positive BALF microbiological culture. The patients with ILD had a worse overall survival. The diffuse disease was the only independent risk factor of overall mortality, and the extent of honeycombing on HRCT was the only independent risk factor of lung disease-related mortality. CONCLUSION: Our study suggests the importance of evaluating ILD with HRCT and BAL in order to characterize the risk factors of SSc lung involvement progression.

Functional, radiological and biological markers of alveolitis and infections of the lower respiratory tract in patients with systemic sclerosis.

BACKGROUND: A progressive lung disease and a worse survival have been observed in patients with systemic sclerosis and alveolitis. The objective of this study was to define the functional, radiological and biological markers of alveolitis in SSc patients. METHODS: 100 SSc patients (76 with limited and 24 with diffuse disease) underwent a multistep assessment of cardiopulmonary system: pulmonary function tests (PFTs) every 6-12 months, echocardiography, high resolution computed tomography (HRCT) and bronchoalveolar lavage (BAL), if clinically advisable. Alveolar and interstitial scores on HRCT and IL-6 plasma levels were also assessed as lung disease activity indices. RESULTS: 90 SSc patients with abnormal PFTs and 3 with signs and/or symptoms of lung involvement and normal PFTs underwent HRCT and echocardiography. HRCT revealed evidence of fibrosis in 87 (93.5%) patients, with 55 (59.1%) showing both ground glass attenuation and fibrosis. In 42 patients who had exhibited ground glass on HRCT and consented to undergo BAL, 16 (38.1%) revealed alveolitis. 12 (75%) of these patients had restrictive lung disease (p < 0.0001) and presented diffuse skin involvement (p = 0.0009). IL-6 plasma levels were higher in patients with alveolitis than in patients without (p = 0.041). On logistic regression model the best independent predictors of alveolitis were diffuse skin involvement (OR(95%CIs):12.80(2.54-64.37)) and skin score > 14 (OR(95%CIs):7.03(1.40-34.33)). The alveolar score showed a significant correlation with IL-6 plasma levels (r = 0.36, p = 0.001) and with the skin score (r = 0.33, p = 0.001). Cultures of BAL fluid resulted positive in 10 (23.8%) of the 42 patients that underwent BAL and after one year a deterioration in PFTs occurred in 8 (80%) of these patients (p = 0.01). Pulmonary artery systolic pressure > or = 40 mmHg was found in 6 (37.5%) patients with alveolitis. CONCLUSION: We found alveolitis only in 38.1% of the patients who had exhibited ground glass on HRCT and then underwent BAL, probably because the concomitant fibrosis influenced results. A diffuse skin involvement and a restrictive pattern on PFTs together with ground glass on HRCT were judged possible markers of alveolitis, a BAL examination being indicated as the next step. Nevertheless BAL would be necessary to detect any infections of the lower respiratory tract that may cause further deterioration in lung function.