An Unusual Presentation of Crohn's Disease Diagnosed Following Accidental Ingestion of Fruit Pits: Report of Two Cases and Review of the Literature.

The clinical course of Crohn's disease (CD) is often complicated by intestinal strictures, which can be fibrotic, inflammatory, or mixed, therefore leading to stenosis and eventually symptomatic obstruction. We report two cases of subclinical CD diagnosed after fruit pit ingestion, causing bowel obstruction; additionally, we conducted a narrative review of the scientific literature on cases of intestinal obstruction secondary to impacted bezoars due to fruit pits. Symptoms of gastrointestinal bezoars in CD patients are not diagnostic; and the diagnosis should be based on a combined assessment of history, clinical presentation, imaging examination and endoscopy findings. This report corroborates the concept that CD patients are at a greater risk of bowel obstruction with bezoars generally and shows that accidental ingestion of fruit pits may lead to an unusual presentation of the disease. Therapeutic options in this group of patients differ from the usual approaches implemented in other patients with strictures secondary to CD.

Quantification of Pancreas Surface Lobularity on CT: A Feasibility Study in the Normal Pancreas.

OBJECTIVE: To assess the feasibility and reproducibility of pancreatic surface lobularity (PSL) quantification derived from abdominal computed tomography (CT) in a population of patients free from pancreatic disease. MATERIALS AND METHODS: This retrospective study included 265 patients free from pancreatic disease who underwent contrast-enhanced abdominal CT between 2017 and 2019. A maximum of 11 individual PSL measurements were performed by two abdominal radiologists (head [5 measurements], body, and tail [3 measurements each]) using dedicated software. The influence of age, body mass index (BMI), and sex on PSL was assessed using the Pearson correlation and repeated measurements. Inter-reader agreement was assessed using the intraclass correlation coefficient (ICC) and Bland Altman (BA) plots. RESULTS: CT images of 15 (6%) patients could not be analyzed. A total of 2750 measurements were performed in the remaining 250 patients (143 male [57%], mean age 45 years [range, 18-91]), and 2237 (81%) values were obtained in the head 951/1250 (76%), body 609/750 (81%), and tail 677/750 (90%). The mean ± standard deviation PSL was 6.53 ± 1.37. The mean PSL was significantly higher in male than in female (6.89 ± 1.30 vs. 6.06 ± 1.31, respectively, p < 0.001). PSL gradually increased with age (r = 0.32, p < 0.001) and BMI (r = 0.32, p < 0.001). Inter-reader agreement was excellent (ICC 0.82 [95% confidence interval 0.72-0.85], with a BA bias of 0.30 and 95% limits of agreement of -1.29 and 1.89). CONCLUSION: CT-based PSL quantification is feasible with a high success rate and inter-reader agreement in subjects free from pancreatic disease. Significant variations were observed according to sex, age, and BMI. This study provides a reference for future studies.

Hyperintense nodule-in-nodule on hepatobiliary phase arising within hypovascular hypointense nodule: Outcome and rate of hypervascular transformation.

PURPOSE: To investigate the clinical implications and natural history of observations showing a "nodule-in-nodule" architecture on hepatobiliary phase (HBP) in a cirrhotic population. METHOD: This is an IRB-approved retrospective study conducted in a single institution. We identified 20 patients (11 men and 9 women, mean age 71 years, range 51-83 years) who had a hyperintense nodule on HBP arising within a larger HBP-hypointense nodule without arterial phase hyperenhancement (APHE) at gadoxetate disodium-enhanced MRI. Size and signal intensity of the nodules were evaluated in all sequences, along with the evolution of the nodules at serial MRI studies. RESULTS: Twenty-four nodules were analyzed in 20 patients. Mean diameter of the inner hyperintense nodule on HBP was 1.1 cm (range 0.6-1.8 cm) and that of the outer hypovascular hypointense nodule was 2.1 cm (range 1.2-4.1 cm). All intranodular foci were hyperintense on HBP and showed a typical pattern for hepatocellular carcinoma (HCC) with APHE and washout on portal venous phase (PVP) (n = 11, 46%), washout only (n = 7, 29%) or APHE with no washout (n = 6, 25%). The hyperintensity on 3-, 5- and 10-minute phases was seen in 21%, 58% and 83% of the nodules, respectively. In twelve out of sixteen (75%) nodules with subsequent imaging available the hyperintensity on HBP occurred before either the appearance of APHE or washout on PVP. CONCLUSIONS: HBP-hypointense nodules without APHE may contain a hyperintense smaller nodule-in-nodule on HBP that can precede the appearance of either APHE or washout on PVP.

Uncommon imaging evolutions of focal liver lesions in cirrhosis.

OBJECTIVE: The purpose of this article is to describe and illustrate uncommon imaging evolutions of benign (i.e., cyst, hemangioma, focal nodular hyperplasia-like nodules, and hepatic angiomyolipoma) and malignant (i.e., HCC and non HCC malignancies) lesions in a cirrhotic liver. The content highlights relevant pathogenesis and imaging clues for proper differential diagnosis. Revision of prior imaging and knowledge of these scenarios may help the abdominal radiologist to reach a noninvasive diagnosis and direct the patient to the most appropriate clinical management. CONCLUSION: Uncommon imaging evolutions of focal liver lesions in cirrhosis may represent a challenge for the abdominal radiologist, with atypical changes in size, and internal vascularization changes that may lead to misdiagnoses.

Hepatic sinusoidal dilatation.

Hepatic sinusoidal dilatation refers to the enlargement of the hepatic capillaries. Most of the time this condition is caused by hepatic venous outflow obstruction, which results in vascular stasis and congestion of hepatic parenchyma. In this setting, hepatic sinusoidal dilatation can be related to pericardial disease, heart failure, compression or thrombosis of the hepatic veins or inferior vena cava (i.e., Budd-Chiari syndrome) or central veins/sinusoids involvement (i.e., sinusoidal obstruction syndrome). Nevertheless, some extrahepatic inflammatory conditions (such as pyelonephritis, cholecystitis, pneumonia, pancreatitis, intestinal bowel disease, and others) may be associated with hepatic sinusoidal dilatation without concurrent venous outflow obstruction. On contrast-enhanced cross-sectional imaging, hepatic sinusoidal dilatation is typically characterized by a mottled, reticular enhancement of the liver, usually referred to as "mosaic" pattern. Other hepatic and extrahepatic imaging features, such us the dilatation of the hepatic veins or the presence of ascites, can help in identifying the cause of sinusoidal dilatation.