Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage.

AIM: To present our experience using intravenous sedoanalgesia for percutaneous biliary drainage. MATERIALS AND METHODS: This study comprised 100 patients, all of whom were continuously monitored [electrocardiogram (ECG), blood pressure, pulse oxymetry] and received an initial dose of 2mg midazolam followed by 0.02 mg fentanyl. Before every anticipated painful procedure, a maintenance dose of 0.01 mg fentanyl was administered. If the procedure continued and the patient became aware, another 1mg midazolam was given. This was repeated if patients felt pain. A total dose of 0.08 mg fentanyl and 7 mg midazolam was never exceeded. Immediately after the procedure, the nurse was asked to evaluate patients' pain score. The patients were asked 3h later to complete a visual 10-degree pain score scale. RESULTS: The average dose of fentanyl and midazolam was 0.042 mg (0.03-0.08 mg) and 4.28 mg (2-7 mg), respectively. Only one patient recorded the procedure as painful. The scores given by the attending nurse (1-7 points, mean 2.9) correlated well with those given by the patients (1-6 points, mean 2.72). No complications were noted. CONCLUSION: According to our experience, interventional radiologists practising biliary procedures can administer low doses of midazolam and minimize the doses of fentanyl, without loss of adequate sedation and analgesia.

Nitinol stents for palliative treatment of malignant obstructive jaundice: should we stent the sphincter of Oddi in every case?

PURPOSE: To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm from the papilla of Vater. METHODS: Sixty-seven self-expandable biliary stents were used in 60 patients with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and in another 30 with their distal part protruding into the duodenum (group B). RESULTS: The 30-day mortality was 15%, due to the underlying disease. The stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survived < or = 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival > 90 days, only two developed cholangitis. In group B, 13 patients who survived < or = 90 days had no episodes of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regarding the incidence of cholangitis in favor of group A. CONCLUSIONS: In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (< or = 3 months), due to more advanced disease or to a worse general condition, the sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity.

Vibrational angioplasty in the treatment of chronic femoropopliteal arterial occlusions: preliminary experience.

PURPOSE: To evaluate the safety and efficacy of vibrational angioplasty in chronic femoropopliteal arterial occlusions. METHODS: Six patients (5 men; ages 52 to 84 years) with peripheral arterial occlusive disease were treated percutaneously using vibrational angioplasty to recanalize the lesion. Three occlusions ranging from 10 to 15 cm long were in the superficial femoral artery (SFA), while 3 other diffusely diseased popliteal arteries were occluded distally (length from 3.5 to 4.5 cm). Vibrational angioplasty using coronary equipment was applied to assist passage of a coronary guidewire, which was followed by conventional angioplasty. Follow-up surveillance featured periodic physical examination, ankle brachial index measurements, and duplex scanning. RESULTS: In all 6 cases, recanalization of the occlusions was successful and without complications. The time to cross the occlusions with the wire ranged from 20 to 25 minutes for the SFA lesions and from 4 to 10 minutes for the popliteal occlusions. Two SFA occlusions were treated with stent implantation. Over a follow-up of 3 to 9 months, all treated vessels were patent. In 3 patients with skin ulcers, healing of the ulcers was observed. CONCLUSIONS: Vibrational angioplasty using coronary guidewires seems to be a promising ancillary technique in the management of chronic femoropopliteal arterial occlusions.

Late complication following percutaneous cholecystostomy: retained abdominal wall gallstone.

A case of recurrent abdominal wall abscess following percutaneous cholecystostomy (PC) is presented. Transperitoneal PC was performed in an 82-year-old female with calculous cholecystitis. Symptoms resolved and the catheter was removed 29 days later. The patient came back 5 months later with a superficial abscess that was drained and 8 months post PC with a fistula discharging clear fluid. Ultrasonography revealed the tract adjacent to an area of inflammation containing a calculus, whereas CT failed to depict the stone. Subsequent surgery confirmed US findings. To our knowledge, this is the first report of a dislodged bile stone following percutaneous cholecystostomy.

Q fever pneumonia: CT findings.

PURPOSE: To evaluate the computed tomographic (CT) features of Q fever pneumonia. MATERIALS AND METHODS: The authors retrospectively reviewed the chest radiographs and CT scans obtained in 12 patients, who were selected on the basis of chest CT availability from a group of patients with a definite diagnosis of acute Q fever infection during an 8.5-year period. RESULTS: In all cases, CT depicted lesions indicative of airspace involvement, which was expressed as lobar (n = 3), segmental (n = 3), patchy (n = 3), or a combination of these patterns (n = 3). Involvement of more than one lobe was observed in seven (58%) patients. In one patient with multiple patchy areas of consolidation, nodular lesions with a vascular connection and a halo of ground-glass opacity, which were suggestive of an angioinvasive process, were demonstrated. In addition, CT performed in a patient with acute Coxiella burnetii infection who abused alcohol revealed necrotizing pneumonia. Pleural effusions were seen at both CT and radiography in three patients, and mild lymph node enlargement in isolated regions was seen at CT in four patients. Chest radiography was less accurate than CT in the detection of segmental and patchy areas of consolidation. CONCLUSION: The typical CT findings of Q fever pneumonia consisted mainly of multilobar airspace consolidation. A nodular pattern accompanied by a halo of ground-glass opacification and vessel connection, and necrotizing pneumonia in the setting of impaired immunity were less frequent.

Percutaneous cholangioscopy in the management of biliary disease: experience in 25 patients.

PURPOSE: To present our experience performing percutaneous cholangioscopy in the management of 25 patients with biliary disease. METHODS: During the last 3 years, 26 percutaneous cholangioscopies were performed in 25 patients with common bile duct disease (n = 16), intrahepatic ducts disease (n = 6), and gallbladder disease (n = 4). Our patient population group included seven with common bile duct stones, three with intrahepatic lithiasis, and eight with benign strictures (six iatrogenic and two postinflammatory). In four patients malignancy was to be excluded, in two the tumor extent was to be evaluated, whereas in one case the correct placement of a metallic stent needed to be controlled. A 9.9 Fr flexible endoscope URF-P (Olympus, 1.2 mm working channel, 70-cm length) was used. RESULTS: In total, percutaneous cholangioscopy answered 30 diagnostic questions, was technically helpful in 19 cases (performing lithotripsy or biopsy or guiding a wire), and of therapeutic help in 12 (performing stone retrieval). In 24 of 26 cases the therapeutic decision and the patient management changed because of the findings or because of the help of the method. In two cases biliary intervention failed to treat the cause of the disease. No major complication due to the use of the endoscopy was noted. CONCLUSIONS: Percutaneous cholangioscopy is a very useful tool in the management of patients with biliary disease. The method can help in diagnosis, in performing complex interventional procedures, and in making or changing therapeutic decisions.

Assessment of nasal mucosa blood supply by quantitative endoscopic imaging of the back-scattered light.

In this article we present a method for the objective assessment and monitoring of tissue blood supply using a specially developed endoscopic imaging colorimeter that enables quantitative color modeling of the back-scattered light during endoscopic examination. Tissue blood volume changes in the nasal mucosa, induced by xylometazoline hydrochloride nasal spray, were evaluated with this method. It was found that quantitative imaging provides sensitive, reproducible, and reliable means for the monitoring and mapping of tissue blood supply and is easy to use routinely. The results showed that saturation decreases with time, being the most sensitive color parameter to the vasoconstriction procedure. It appears that objective indexes for optical tissue characterization and analysis may be promising in the understanding of the pathophysiology of tissue changes and in the objective evaluation of their response to different therapeutic schemes.

HRCT in miliary lung disease.

PURPOSE: To analyze high resolution CT (HRCT) features of a miliary pattern in different diseases. MATERIAL AND METHODS: Eight HRCT studies with a miliary lung pattern were retrospectively reviewed with the diagnoses tuberculosis (n=3), Candida albicans (n=1), sarcoidosis (n=3), and metastatic adenocarcinoma (n=1). RESULTS: In all cases, HRCT showed diffusely disseminated nodules up to 3 mm. In 2 cases of tuberculosis and 1 of sarcoidosis, the lesions predominated in the upper/middle lung zones. In the case of metastatic adenocarcinoma the nodules were more sparse in the lung periphery while in 1 case of sarcoidosis, HRCT revealed a predominance of the lesions in the outer third of the lungs. Cyst-like lesions of 12 mm were observed in 2/3 cases of tuberculosis and in metastatic adenocarcinoma. Notably thickened interlobular septa and interlobar fissures were each seen in 2/3 cases of sarcoidosis. In general, a random relationship of miliary nodules to secondary lobular structures and bronchovascular bundles was observed, despite the co-existence of centrilobular, subpleural and paraseptal nodules. CONCLUSION: HRCT features that potentially contribute in making a differential diagnosis are: a) A peripheral distribution of nodules, an increased number of thickened interlobular septae, and a notable thickening of interlobar fissures, all of which are indicative of sarcoidosis; and b) Multiple cyst-like lesions which should direct attention to tuberculous or metastatic origin. The predominance of miliary nodules in relation to cephalocaudal axis, their margin and size are not helpful features to the differential diagnosis of diseases presenting a miliary pattern.

Sacroiliac joints: anatomical variants on CT.

The purpose of this work was to examine the type and prevalence of anatomical variants of the sacroiliac joints (SJs) in patients without SJ disease on CT examinations. The study comprised 534 consecutive patients undergoing pelvic CT with various indications not related to diseases that could involve the SJ. Images printed on bone window settings were evaluated with reference to any deviation from the usual appearance of the SJ. Physical data and history of low back pain were recorded in each patient. Six types of anatomical variants were observed: accessory joints in 102 patients (19.1%), "iliosacral complex" in 31 (5.8%), bipartite iliac bony plate in 22 (4.1%), crescent-like iliac bony plate in 20 (3.7%), semicircular defects at the sacral or iliac side in 16 (3%), and ossification centers in 3 patients (0.6%). Accessory joints were more common in obese than in normal-weight individuals (p < 0.05) and in older than younger (<60 years) patients (p < 0.001) and presented degenerative alterations especially in patients with episodes of low back pain. Three of these variants (iliosacral complex, bipartite iliac bony plate, and crescent-like iliac bony plate) had higher incidence in women than in men (p < 0.05) and were not associated with degenerative changes. Knowledge of the normal variations in the SJ appearance broadens the understanding of SJ anatomy, facilitating image interpretation.

Variation in the appearance of the normal sacroiliac joint on pelvic CT.

OBJECTIVE: To describe the CT appearance of the ageing sacroiliac joints (SJ) and correlate the radiological findings with patients' gender, body mass index (BMI) and, in women, parity. MATERIALS AND METHODS: The study population included 288 consecutive patients who underwent pelvic CT for various indications not related to SJ diseases. Patients were stratified by age, BMI and parity in women. The joint space and subchondral sclerosis were assessed and the presence of osteophytes, ankylosis, erosions, subchondral cysts and vacuum phenomena were noted on bone window settings. RESULTS: The widths of the SJ space and of the subchondral sclerosis on the iliac and sacral sides were 2.3+/-0.4mm, 2.5+/-1.6mm and 1.4+/-0.5mm, respectively, in patients younger than 40 years of age and 1.9+/-0.2 mm, 3.6+/-2.1 mm and 2.3+/-1.1 mm, respectively, in patients older than 40 years of age. The joint space tends to become narrow and less uniform with advancing age, while subchondral sclerosis appeared to be wider and less uniform in the elderly. Osteophytes were present even in younger patients and their prevalence increased with advancing age. Ankylosis and erosions were rare findings, observed only after the fifth decade of life. A higher prevalence of asymmetric non-uniform SJ space, ill-defined, non-uniform, extensive subchondral sclerosis and ankylosis was observed in women, obese and multiparous mothers than the age matched men, normal weighted individuals and non-multiparous women, respectively. CONCLUSION: Conventional pelvic CT can provide valuable information concerning the SJ, when reviewed on bone window settings. The CT appearance of the SJ is closely related to patients age, gender, BMI and, in women, parity. Knowledge of the spectrum of radiological findings observed in the normal population may be useful when interpreting examinations of patients with SJ disease.

Primary ilio-psoas abscess extending to the thigh in a neonate: US, CT and MR findings.

Psoas abscess in children, and especially in neonates, is an uncommon condition which is difficult to diagnose clinically. The US, CT and MR findings of a psoas abscess in a neonate, which extended to the thigh, are reported. Imaging was helpful in revealing the abnormality, in demonstrating its extension and in determining its nature. The child was treated conservatively and the abscess resolved, leaving atrophy of the psoas muscle.

A comparison between digital fluoroscopic hard copies and 105-mm spot films in evaluating vesicoureteric reflux in children.

OBJECTIVE: To compare fluoroscopic freeze-frame digital images with conventional 105-mm spot films during voiding cystourethrography (VCUG) with regard to diagnostic quality and radiation dose. MATERIALS AND METHODS: VCUG was performed on 57 consecutive children by a commercially available fluoroscopic digital system. Both freeze-frame digital images and conventional 105-mm spot films were obtained during 90 s of fluoroscopy. Skin radiation dose was assessed separately for spot films and for both fluoroscopy and spot films, employing thermoluminescent crystals on the anterior surface of the body. Patients were classified into three age groups: group A younger than 12 months, group B 1-5 years old and group C 5-12 years of age. RESULTS: Digital and conventional images provided diagnostically identical results in 108 out of 114 ureters examined (94.7%). Percentage reductions in skin radiation dose due to the fluoroscopic hard copies compared with the four 105-mm radiographs were 53.8%, 50.5% and 57.1% for groups A, B and C, respectively. CONCLUSION: Substitution of conventional 105-mm spot films during VCUG with digital fluoroscopic hard copies resulted in a substantial reduction in radiation dose. Digital images were as accurate as the conventional films in excluding vesicoureteric reflux (VUR). The two methods correlated well in diagnosing and grading VUR.

Maturation of the tract after percutaneous cholecystostomy with regard to the access route.

PURPOSE: To assess the shortest time for catheter removal with regard to the transhepatic or transperitoneal approach in patients undergoing percutaneous cholecystostomy (PC). METHODS: In this prospective study, 40 consecutive high-risk patients with acute cholecystitis (calculous, n = 22; acalculous, n = 18) underwent PC by means of a transhepatic (n = 20) or transperitoneal (n = 20) access route. In 28 patients (70%) computed tomography was used for puncture guidance, while in the remaining 12 (30%) the procedures were formed under ultrasound control. A fistulography was performed on the 14th postprocedural day in al patients and was repeated weekly if the tract was found to be immature. The catheter was removed only if a mature tract without evidence of leakage was delineated. RESULTS: In 36 of 40 patients the procedure was technically successful (90%). Three of the unsuccessful punctures were attempted transperitoneally and one transhepatically. Thirty-five of 36 patients showed rapid improvement within the first 48 hr following the procedure (96%). Three of them died of their severe underlying disease (7.5%) and in another three the catheter was accidentally removed prior to the first fistulography (7.5%) A total of 30 patients could be fully evaluated after the procedure: 15 with a transhepatic, and 15 with a transperitoneal PC. Whereas 14 of 15 patients (93%) with transhepatic gallbladder access developed a mature tract after 14 days and the remaining patient after 3 weeks, only 2 of 15 patients (13%) with a transperitoneal route presented a mature tract after 2 weeks (p < 0.0001; chi2 test with Yates' correction). Eleven patients (73%) with transperitoneal access required 3 weeks and two patients (13%) 4 weeks for complete tract formation. CONCLUSION: A period of 2 weeks suffices for the majority of patients to develop a mature tract when the transhepatic access route is used; when using the transperitoneal route at least 3 weeks are required. We suggest that the transhepatic route is preferable since it allows earlier removal of the catheter and reduces the incidence of complications and discomfort for the patients.

Uncommon locations of hydatid disease: CT appearances.

Hydatid disease (HD), already known by Hippocrates, is prevalent and widespread in most sheep-raising countries in Asia, Australia, South America, Near East, and southern Europe. The disease is most commonly due to Echinococcus granulosus and may occur in any organ or tissue. The location is mostly hepatic (75 %) and pulmonary (15 %), and only 10 % occur in the rest of the body [1]. Imaging modalities such as US, CT, and MR imaging are helpful in diagnosing the disease. The reliability of each method depends on the cyst's location in the body [2-5]. The purpose of this essay is to illustrate the use of CT in depicting some unusual locations of HD besides the liver and lung.

Crescentic and ring-shaped opacities. CT features in two cases of bronchiolitis obliterans organizing pneumonia (BOOP).

Two cases of idiopathic bronchiolitis obliterans organizing pneumonia (BOOP) with unusual CT findings are presented. On CT both cases exhibited crescentic and ring-shaped opacities, surrounding areas of groundglass attenuation, and associated with a nodular pattern in one patient and airspace consolidations in the second patient. CT-pathologic correlation disclosed that the central areas of groundglass attenuation corresponded to alveolar septal inflammation, in contrast to the denser periphery where granulomatous tissue in peripheral airspaces predominated. In the broad spectrum of CT findings, BOOP can exhibit specific CT features with regard to the crescentic or ring-shaped opacities with a central groundglass attenuation area. Since these features have not been described in any other disease, they might be characteristic features for the diagnosis of BOOP.

Hepatodiaphragmatic interposition of the colon in the upright and supine position.

OBJECTIVE: Hepatodiaphragmatic interposition of the colon (HDIC) has been previously evaluated with chest radiography (CR) of patients examined in an erect position. In this work the presence of HDIC was assessed in patients who underwent CT in the supine position. MATERIALS AND METHODS: In 1,440 patients, 806 men and 634 women, 19-83 years old subjected to CR and abdominal CT for various indications, HDIC was retrospectively evaluated. RESULTS: In 2.4% of the patients HDIC was found using CT in the supine position but in only 0.3% on CR. The variation appeared more frequently in men than in women and in older adults and individuals with an increased amount of intraabdominal fat. This latter finding may represent an additional factor favoring malposition of the colon. CONCLUSION: The results of this study indicate that HDIC has a significantly greater incidence in the supine position of patients, and it can not be excluded on the basis of negative CR.