[Role of arterial embolization in the management of postpartum hemorrhage]. / Place de l'embolisation artérielle en cas d'hémorragie du post-partum.

OBJECTIVES: To provide recommendations regarding the use of arterial embolization in the management of post partum hemorrhage. METHODS: A literature search was conducted using the Pubmed, Medline and Embase databases and the Cochrane Library (study period 1979 to June 2014). RESULTS: Selective embolization of both uterine arteries without microcatheter is recommended (professional consensus). Embolization should be performed using gelatin sponge pledgets rather than gelatin sponge slurry or powder (grade C). Control of hemorrhage can be expected in 70 to 100% of cases after embolization (EL3). Control of hemorrhage is obtained in 85 to 100% of cases (EL3). Arterial embolization is recommended in case of uterine atony after failure of uterotonic drugs particularly after vaginal delivery, in case of cervical hemorrhage, vaginal thrombus of cervico-vaginal tear in case of failed surgical repair or if surgery is not feasible (grade C). Pseudoaneurysm of the uterine artery is a good indication for embolization. Major complications related to embolization are reported in 5% of cases (EL4). The presence of coagulation disorders is not a contraindication to embolization (professional consensus). Embolization remains feasible after failed arterial ligations (selective or proximal) or after hysterectomy even if technically more challenging (professional consensus). Embolization can be performed in case of post partum hemorrhage related to abnormal placentation (professional consensus). Prophylactic embolization with the placenta left in place is not routinely recommended (professional consensus). The systematic preoperative placement of arterial occlusion balloons is not recommended in the management of abnormal placentation (professional consensus). Secondary post partum hemorrhage is a good indication for arterial embolization (grade C). After embolization, fertility can be spared (EL3). The risk of recurrent post partum hemorrhage does not seem different after arterial ligations or arterial embolization (EL3).

The management of lower gastrointestinal bleeding.

Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2-4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient.

Mesenteric tumors: diagnosis and treatment.

Mesenteric tumors are rare and consist of a heterogeneous group of lesions. Masses may arise from any of the mesenteric components: peritoneum, lymphatic tissue, fat, and connective tissue. Cellular proliferation can also arise from infectious or inflammatory processes. They can be classified as solid or cystic, benign or malignant. Mesenteric tumors are usually discovered incidentally or during investigation of non-specific symptoms. While clinical examination and imagery may suffice to make the diagnosis, histopathology is often required by either needle percutaneous or surgical biopsy, or immediate excision. Therapeutic management options vary widely depending on the nature of the lesion; they range from simple observation or medical therapy to surgery. Benign well-delineated mesenteric masses that are symptomatic can often be treated by simple enucleation. But invasive malignant tumors require a carcinologic resection; a careful preoperative evaluation to assess the relationship between the mass and adjacent vascular and digestive structures is essential since they may dictate the need for extensive sacrifice of bowel with resultant intestinal insufficiency due to short bowel syndrome.

Imaging in infections of the left iliac fossa.

The main organs in the left iliac fossa are the descending colon, sigmoid colon and, in women, internal reproductive organs. An infection of the left iliac fossa must lead the clinician firstly to suspect diverticulitis of the sigmoid colon in older patients and salpingitis in women of childbearing age. Other less common aetiologies are possible (inflammatory or infectious colitis, epiploic appendagitis, abscess of the psoas, pyelonephritis, renal abscess, etc.). Sonography as a first-line investigation may lead to diagnosis (especially in gynaecological disease), but a CT scan with intravenous injection of an iodine-containing contrast medium will allow for a full assessment of disease spread, and complications of sigmoid colitis or its differential diagnoses (abscess, fistula, perforation) to be investigated. It can also be used to guide percutaneous drainage or fine-needle aspiration for microbiology investigations.

[Chronic coronary artery occlusion: questions from the cardiologist and surgeon, answers from the radiologist]. / Occlusions coronaires chroniques: les questions du cardiologue et du chirurgien, les réponses du radiologue.

The main issue with chronic coronary artery occlusion relates to optimal treatment and cross sectional imaging is a valuable source of information. Cardiac MR imaging can identify candidates to revascularization by demonstrating viable myocardium. Coronary CTA allows evaluation of the entire coronary system and detection of factors predicting the success of revascularization, either percutaneous (angioplasty) or surgical.

[Pyogenic-liver abscess: diagnosis and management]. / Abcès à pyogènes du foie. Diagnostic et prise en charge.

Pyogenic-liver abscesses are due to bacteria mostly from the portal and biliary tracts. There is usually only one located in the right liver, but they may be found in the left liver, be multiple or multilocular. Diagnosis, based on ultrasound and/or computed tomography scan, is confirmed by percutaneous-needle aspiration to identify the bacteria causing the disease. Global management includes the treatment of sepsis and the aetiology of the liver abscess: biliary lithiasis, diverticular disease, colon cancer, appendicitis or other intra-abdominal infections. However, no cause is found in 20% of cases. Treatment is based on antibiotics and, sometimes, percutaneous drainage while the cause may be treated immediately or later if the sepsis is controlled. Interventional radiology is often used. Surgery may be performed in case of failure of initial treatment and to cure the cause of the abscess. Prognosis may be poor, especially if there are associated-risk factors, such as diabetes and immunodepression, even though the outcome has improved with a multidisciplinary approach.

[Hepatic cysts: diagnosis and management]. / Kystes hépatiques dits "kystes biliaires du foie."

Cystic lesions of the liver are common and usually benign. The most frequent lesion is simple hepatic cyst: typical imaging findings make their diagnosis easy and they require no treatment. Complicated hepatic cysts (i.e., compression, hemorrhage, infection) have more variable imaging findings making diagnosis more difficult; they may evoke other diagnoses. Asymptomatic hepatic cysts do not require any treatment or follow-up. Symptomatic cysts may benefit from simple follow-up or may be treated by laparoscopic fenestration or alcohol sclerotherapy. The differential diagnosis of complicated hepatic cysts includes cystadenoma, cystadenocarcinoma, hydatid cyst, or cystic metastasis; surgical resection is usually indicated for these lesions.

[Primitive metastasizing bronchial carcinoid with long survival]. / Carcinoïde bronchique d'emblée multimétastatique et survie prolongée. Une entité anatomo-clinique peu connue: place de l'imagerie fonctionnelle.

BACKGROUND: Metastatic bronchial carcinoid tumours are rare but some patients have a prolonged survival. A new functional imagery now makes it possible to supplement the assessment of the extent of disease. OBSERVATION: A 57 year old patient was referred for dyspnoea on exertion revealing an upper left lobar tumour, with carcinoid syndrome. The assessment enabled to find out a bronchial carcinoid tumour with liver and bone metastases, highlighted by positron-emission tomography and pentetreotide SPECT. A chemotherapy proved to be ineffective and upper left lobectomy was carried out because of the risk of pulmonary atelectasis. The patient was treated by somatostatin analogues then underwent liver transcatheter arterial chemo-embolization. The patient was alive 44 months after diagnosis (56 months after first computed tomography). CONCLUSION: Metastatic bronchial carcinoid tumours are rare. They keep a metastatic potential, the histological type remaining the major prognosis factor. Carcinoid syndrome is suggestive. The assessment of extra-thoracic disease extent benefits by contribution of new functional imagery techniques such as the pentetreotide SPECT and positron-emission tomography. The management is essentially symptomatic since there is no effective chemotherapy. However survival can be prolonged, even in multimetastatic patients.

[Esophageal disease: is cross sectional imaging contributive?]. / Pathologie de l'oesophage. L'imagerie en coupes a-t-elle un intérêt?

For a long time, esophagography and endoscopy were the major diagnostic tests used for evaluation of the esophagus. Now, the development of computed tomography, endosonography and MR imaging has permitted more comprehensive evaluation of esophageal diseases. Cross sectional imaging is essential to evaluate the relationship between esophageal lesions and adjacent mediastinal structures and to evaluate the thickness of the esophageal wall.