Cholecystogastric fistula. A case report and literature review.

Cholecystogastric fistulas is a rare complication of gallstone. Even if well described in the literature, this condition still poses a debate on diagnosis and surgical treatment. We present a case of a 35 year's old female which unexpectedly presented a cholecystogastric fistula during a laparoscopic cholecystectomy, treated successfully with fistula transection and repair and cholecystectomy through an open access. The open access remains the preferable option in this cases but laparoscopic techniques are being used worldwide with increasing success. The preoperative diagnosis remains difficult for the unspecific symptoms. KEY WORDS: Biliodigestive Fistula, Gallstone Ileus, Gastric Fistula, Biliary Fistula, Cholecystitis.

MRI reveals different Crohn's disease phenotypes in children and adults.

OBJECTIVES: To identify differences between two cohorts of adult and pediatric patients affected by Crohn's disease (CD), with regard to lesion location in the small intestine and colon-rectum, lesion activity, and prevalence of perianal disease (PD), using MRI as the main diagnostic tool. METHODS: We retrospectively reviewed 350 consecutive MRI examinations performed between 2013 and 2016 in outpatients or inpatients with histologically proven CD, monitored by the Gastroenterology and Pediatric Units of our Hospital. The magnetic resonance enterography (MRE) protocol for adult and pediatric CD patients routinely includes evaluation of nine different intestinal segments (from jejunum to rectum) and of the anal canal. Intestinal activity was also calculated using a validated score. Perianal disease (PD) was staged. Fisher's exact test was used and the odds ratio (OR) was calculated. RESULTS: Two hundred and nineteen out of 350 MRI studies (118 adults and 101 children) were included. The prevalence of PD was 34.6% in children and 16.1% in adults (OR = 2.8; p = 0.0017). Pediatric patients showed more frequent rectal involvement (29.7% vs 13.5%, OR = 2.7; p = 0.0045) and higher risk of PD in the presence of rectal disease (p = 0.043; OR = 4.5). In pediatric patients with severe colorectal disease, the prevalence of PD was twofold (86.7% vs 40%; p = 0.072). Using the clinical Montreal classification for lesion location, no significant differences emerged between the two patient populations. CONCLUSIONS: MRI showed a significantly higher prevalence of rectal involvement and perianal disease in the pediatric population. These results may have a relevant clinical impact and deserve further investigation. KEY POINTS: • To our knowledge, this is the largest morphological comparative study available in the literature using MRI as the main diagnostic tool to compare adult patients and children with Crohn's disease. • Our study showed significant differences between adults and children: a higher prevalence of rectal and perianal fistulous disease (PD) in pediatric patients and an increased prevalence of PD in the presence of severe colon-rectum involvement. • The association of rectal and perianal disease implies a poorer clinical prognosis and a higher risk of disabling complications in pediatric patients.

Prospective Comparison between two different magnetic resonance defecography techniques for evaluating pelvic floor disorders: air-balloon versus gel for rectal filling.

PURPOSE: to prospectively compare two rectal filling techniques for dynamic MRI of pelvic floor disorders (PFD). METHODS AND MATERIALS: Twenty-six patients with PFD underwent the two techniques during the same procedure, one based on rectal placement of a balloon-catheter filled with saline and air insufflation (air-balloon technique or AB); another based on rectal filling with 180 cc of gel (gel-filling technique or GF). The examinations were compared for assessment and staging of PFD, including rectal-descent, rectocele, cystocele, colpocele, enterocele, rectal invagination. Surgery and clinical examinations were the gold standard. RESULTS: AB showed sensitivity of 96 % for rectal descent, 100 % for both rectocele and colpocele, 86 % for rectal invagination and 100 % for enterocele; understaged 11 % of rectal descents and 19 % of rectoceles. GF showed sensitivity of 100 % for rectal descent, 91 % for rectocele, 83 % for colpocele, 100 % for rectal invagination and 73 % for enterocele; understaged 3.8 % of rectal descent and 11.5 % of rectoceles. Both techniques showed 100 % of specificity. Agreement between air-balloon and gel filling was 84 % for rectal descent, 69 % for rectocele, 88 % for rectal invagination, 84 % for enterocele, 88 % for cystocele and 92 % for colpocele. CONCLUSION: Both techniques allowed a satisfactory evaluation of PFD. The gel filling was superior for rectal invagination, the air-balloon for rectocele and anterior/middle compartment disorders. KEY POINTS: • A standardized MRI technique for assessing pelvic floor disorders is not yet established. • This study compares two MRI techniques based on different rectal filling: air-balloon versus gel. • Both MRI techniques proved to be valuable in assessing PFD, with good agreement. • Air-balloon technique is more hygienic and better tolerated than the gel-filling technique. • Gel was superior for rectal invagination, air-balloon for rectocele and uro-genital prolapses.

Role of magnetic resonance imaging in the detection and characterization of solid pancreatic nodules: An update.

Pancreatic ductal adenocarcinoma is the most common malignant tumor of the pancreas. The remaining pancreatic tumors are a diverse group of pancreatic neoplasms that comprises cystic pancreatic neoplasms, endocrine tumors and other uncommon pancreatic tumors. Due to the excellent soft tissue contrast resolution, magnetic resonance imaging (MRI) is frequently able to readily separate cystic from noncystic tumors. Cystic tumors are often easy to diagnose with MRI; however, noncystic non-adenocarcinoma tumors may show a wide spectrum of imaging features, which can potentially mimic ductal adenocarcinoma. MRI is a reliable technique for the characterization of pancreatic lesions. The implementation of novel motion-resistant pulse sequences and respiratory gating techniques, as well as the recognized benefits of MR cholangiopancreatography, make MRI a very accurate examination for the evaluation of pancreatic masses. MRI has the distinctive ability of non-invasive assessment of the pancreatic ducts, pancreatic parenchyma, neighbouring soft tissues, and vascular network in one examination. MRI can identify different characteristics of various solid pancreatic lesions, potentially allowing the differentiation of adenocarcinoma from other benign and malignant entities. In this review we describe the MRI protocols and MRI characteristics of various solid pancreatic lesions. Recognition of these characteristics may establish the right diagnosis or at least narrow the differential diagnosis, thus avoiding unnecessary tests or procedures and permitting better management.

Primary colonic lymphoma: An incidental finding in a patient with a gallstone attack.

We report a case of primary colonic lymphoma incidentally diagnosed in a patient presenting a gallbladder attack making particular attention on the diagnostic findings at ultrasound (US) and total body computed tomography (CT) exams that allowed us to make the correct final diagnosis. A 85-year-old Caucasian male patient was referred to our department due to acute pain at the upper right quadrant, spreaded to the right shoulder blade. Patient had nausea and mild fever and Murphy's maneuver was positive. At physical examination a large bulky mass was found in the right flank. Patient underwent to US exam that detected a big stone in the lumen of the gallbladder and in correspondence of the palpable mass, an extended concentric thickening of the colic wall. CT scan was performed and confirmed a widespread and concentric thickening of the wall of the ascending colon and cecum. In addition, revealed signs of microperforation of the colic wall. Numerous large lymphadenopathies were found in the abdominal, pelvic and thoracic cavity and there was a condition of splenomegaly, with some ischemic outcomes in the context of the spleen. No metastasis in the parenchimatous organs were found. These imaging findings suggest us the diagnosis of lymphoma. Patient underwent to surgery, and right hemicolectomy and cholecystectomy was performed. Histological examination confirmed our diagnosis, revealing a diffuse large B-cell lymphoma. The patient underwent to Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone chemotherapy showing only a partial regression of the lymphadenopathies, being in advanced stage at the time of diagnosis.

Bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome: value of MRI in the differential diagnosis.

Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis.

Prostate cancer: 1HMRS-DCEMR at 3T versus [(18)F]choline PET/CT in the detection of local prostate cancer recurrence in men with biochemical progression after radical retropubic prostatectomy (RRP).

OBJECTIVES: This study compares proton magnetic resonancespectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) combined techniques at 3T magnet versus [(18)F]choline PET/computed tomography (CT) in the detection of local prostate cancer recurrence in patients with biochemical progression after radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: 84 consecutive patients at high risk of local recurrence underwent combined 1HMRSI-DCEMR and 18-Fcholine- PET/CT. MR scan protocol included turbo spin echo (TSE) T2-weighted sequences in the axial, sagittal and coronal planes; three-dimensional (3D) chemical shift imaging (CSI) sequences with spectral/spatial pulses optimized for quantitative detection of choline and citrate; dynamic contrast enhanced gradient-echo (GRE) T1-weighted sequence. The population was divided into two groups. Group A included 28 patients with a lesion size ranging between 5.00mm and 7.2mm and PSA reduction following radiation therapy. Group B included 56 patients with a lesion size between 7.6mm and 19.4mm. Sensitivity, specificity, positive predictive value (PPV) and accuracy were evaluated and receiver operating characteristic (ROC) curves were performed. RESULTS: In Group A combined 1H-MRSI and DCE-MRI showed a sensitivity of 92%, a specificity of 75% (PPV 96%) while PET-CT examination showed a sensitivity of 62% and a specificity of 50% (PPV 88%) in identifying local recurrence. The accuracy of MRI was 89% while PET-CT showed an accuracy of 60%. Areas under the ROC curve (AUC) values for MR and PET-CT were 0.833 and 0.562, respectively. In Group B combined 1H-MRSI and DCEMR showed a sensitivity of 94% and a specificity of 100% (PPV 100%) with accuracy of 94%. PET-CT had a sensitivity of 92% and a specificity of 33% (PPV 98%) with accuracy of 91%. The AUCs for MR and PET-CT values were 0.971 and 0.837, respectively. CONCLUSION: The diagnostic accuracy of combined 1HMRSI-DCEMR was higher than PET/CT to identify local prostate cancer recurrence, mostly in patients with low biochemical progression after RRP (0.2-2ng/mL).

[Role of neuroendocrine cells in prostate cancer progression]. / Ruolo delle cellule neuroendocrine nella progressionedel carcinoma prostatico.

Neuroendocrine (NE) cells represent the third epithelial cell type on normal prostatic tissue (in addition to basal and secretory cells). They are localized in all regions of the human prostate at birth but rapidly decrease in the peripheral prostate after birth, and then reappear at puberty. After puberty, their number seems to increase until an apparently optimum level is reached, which persists between the age of 25 and 54. NE cells were defined by Pearse as APUD to refer to chemical characteristics of amine precursor uptake and decarboxylation, common to the cells of this system. The most predominant product of prostatic NE cells is Chromogranin A, but they also produce serotonin, CgB, secretogranin or CgC, thyroid-stimulating hormone-like peptide, calcitonin, katacalcin, PTHrP and a-human chorionic gonadotropin-like peptide. NE cells in normal and neoplastic prostates are devoid of androgen receptors, but they express epidermal growth factor (EGF) receptor and c-erbB-2. For these reason NE cells are androgen-insensitive. The NE component of prostate adenocarcinoma is resistant to hormone therapy; some studies showed that the number of NE tumor cells and CgA serum levels increase with the recovery of human prostate tumor from hormonal therapy. Currently there are no clinical data available to support an active role of radiotherapy in NE differentiation.

[Current diagnostic procedure on neuroendocrine differentiation of prostate cancer]. / Attuale iter diagnostico sulla differenziazione neuroendocrina del carcinoma prostatico.

Chromogranin A (CgA) is considered as a major specific neuroendocrine tumor marker. It belongs to the secretogranin family, which is present in the gastrointestinal tract, respiratory system, endocrine glands and in a group of endocrine cells such us pancreas and thyroid. Serum levels of CgA could reflect the neuroendocrine activity and could be used when evaluating advance prostate carcinoma. Moreover, there are also several factors that may increase the serum level of CgA: treatment with proton-pump inhibitors or H2-receptor blockers, chronic atrophic gastritis, rheumatoid arthritis, liver and renal failure. Another method to evaluate NE differentiation is scintigraphy with the 111In-labeled somatostatin analogue (DTPA-D-Phe)-octrotide, (Octreoscan). This method takes advantage of the overexpression of type II somatostatin receptors on the cell surface of NE tumors. With this technique the presence of NE differentiation can be detected both at the primary (prostate) and the metastatic sites. A more specific system to detect NE cell activity is obtained by analyzing CgA gene expression in prostate tissue by a semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR).

PCA3 urinary test versus 1H-MRSI and DCEMR in the detection of prostate cancer foci in patients with biochemical alterations.

AIM: To compare the prostate antigen 3 (PCA3) test with (1)H-magnetic resonance spectroscopic imaging ((1)H-MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCEMR) combined examination in the detection of prostate tumor foci in patients with persistently elevated prostate-specific antigen (PSA) levels and prior negative random transrectal ultrasound (TRUS)-guided biopsy. PATIENTS AND METHODS: Forty-three patients with a first random biopsy negative for prostate adenocarcinoma, persistent elevated PSA and negative digital rectal examination were recruited. All the patients were submitted to MRSI examination (MRSI-DCEMR) and were submitted to an attentive prostate massage in order to perform PCA3 assay. Afterwards, 10-core laterally-directed random TRUS-guided prostate biopsy was performed. RESULTS: The overall sensitivity and specificity of a PCA3 score ≥35 for positive biopsy were 76.9% and 66.6%, respectively, with a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 62.5%; as for MRSI sensitivity and specificity were, respectively, 92.8% and 86.6% with a PPV of 92.8% and a NPV of 86.6%. Receiver operating characteristic (ROC) analysis rates were 0.755 for PCA3 and 0.864 for MRSI. CONCLUSION: Combined MRSI/DCEMR can better improve the cancer detection rate in patients with prior negative TRUS-guided biopsy and altered PSA serum levels than PCA3. Optimization of MRSI will allow more precise diagnosis of local invasion and improved bioptical procedures.