Submucosal fat accumulation in Crohn's disease: evaluation with sonography.

BACKGROUND/AIMS: The study objective is to investigate the ultrasound features that allow suspecting the presence of submucosal fat deposition, called the fat halo sign (FHS), in the intestinal wall of patients with Crohn's disease. METHODS: Computed tomography (CT) examinations over a period of 10 years were reviewed for the presence of the FHS in the bowel wall. A measurement of less than -10 Hounsfield units was regarded as indicative of fat. We included only patients who had undergone ultrasound examinations 3 months before or after CT. The study cohort group comprised 68 patients. Wall and submucosal thickness were measured on longitudinal ultrasound sections. A receiver operating characteristic curve was constructed to determine the best cutoff of ultrasound submucosal wall thickness value for predicting FHS in the bowel wall determined on CT. RESULTS: The FHS was present in 22 patients (31%) on CT. There were significant differences between submucosal thickness of patients with FHS and patients without FHS (4.19 mm vs. 2.41 mm). From the receiver operating characteristic curve, a threshold value of 3.1 mm of submucosal thickness had the best sensitivity and specificity to suspect FHS (95.5% and 89.1%, respectively; area under the curve, 0.962), with an odds ratio of 172. All of 16 patients with a submucosal thickness >3.9 mm had FHS. CONCLUSIONS: FHS in patients with Crohn's disease can be suspected on ultrasound in cases with marked thickening of the submucosa layer. In these cases, the activity of the disease should be measured by other parameters such as the color Doppler.

How to strengthen the management of acute diverticulitis: the utility of the WSES classification-a prospective single-center observational study.

PURPOSE: This study aimed to validate the World Society for Emergent Surgery (WSES) scale for the management of acute left-sided colonic diverticulitis (ALCD). METHODS: An observational study based on a prospective database of patients with ultrasound (US) and computerized tomography (CT) confirmed ALCD was conducted at our center from April 2018 to May 2019. The primary outcome was the success rate of outpatient management. Secondary outcomes were the association between different WSES stages, clinical and analytical parameters, treatments modalities, and outcomes, and the accuracy of US for management decisions. RESULTS: A total of 230 patients were included. Outpatient management was successful in 51/53 (96.23%) cases with ALCD stage 0 and 62/72 (86.11%) patients with stage 1A. There were no differences in age (p = 0.076) or the presence of pericolic air bubbles (p = 0.06) between patients who underwent admission or outpatient management. Clinical and analytical data, treatment decisions, and outcomes showed statistically significant differences between WSES stages. In 7/12 patients with stage 2A, percutaneous drainage or emergency surgery was required. All cases with stage 2B (distant air) underwent conservative management without the need for emergency or elective surgery. The accuracy of US WSES stages for management decisions, when compared with CT, was 96.96%. CONCLUSION: The WSES classification for ALCD seemed to be valid helping clinicians in the decision-making process to select between admission or outpatient management. Differences in clinical and analytical data, elected treatments, and outcomes were found between WSES stages. The US WSES stages showed high accuracy for management decisions.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the use of abdominal ultrasound in inflammatory bowel disease. / Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre el empleo de la ecografía abdominal en la enfermedad inflamatoria intestinal.

Ultrasound has an excellent diagnostic performance when Crohn's disease is suspected, when performing an activity assessment, or determining the extension and location of Crohn's disease, very similar to other examinations such as MRI or CT. It has a good correlation with endoscopic lesions and allows the detection of complications such as strictures, fistulas or abscesses. It complements colonoscopy in the diagnosis and, given its tolerance, cost and immediacy, it can be considered as a good tool for disease monitoring. In ulcerative colitis, its role is less relevant, being limited to assessing the extent and activity when it is not possible with other diagnostic techniques or if there are doubts with these. Despite its advantages, its use in inflammatory bowel disease (IBD) is not widespread in Spain. For this reason, this document reviews the advantages and disadvantages of the technique to promote knowledge about it and implementation of it in IBD Units.

The Role of Intravenous Contrast Agent in the Sonographic Assessment of Crohn's Disease Activity: Is Contrast Agent Injection Necessary?

BACKGROUND AND AIMS: Contrast-enhanced ultrasound [CEUS] is reported to be superior to wall thickness or colour Doppler imaging [CDI] in predicting disease activity using endoscopy as the reference standard. Our aims were to determine in patients with Crohn's disease [CD] whether the evaluation of wall thickness or CDI before CEUS examination could help to decide when the injection of contrast agent is justified as a means for detecting disease activity as determined at endoscopy, without reducing the accuracy of ultrasound. METHODS: In total, 180 patients with CD underwent both colonoscopy and ultrasound, including mural thickness, CDI and CEUS evaluation, prospectively as part of clinical care. A receiver operating characteristic curve was constructed to determine the area under the curve and the best cutoff of wall thickness and ultrasound enhancement value to discriminate between endoscopically active and inactive disease. Several analyses were carried out to determine which parameter or combination of parameters best detected endoscopic activity. RESULTS: Comparative evaluation of the different analysis showed that wall thickness alone classified 76.6% of patients correctly, CDI alone 72.7%, and thickness plus CDI 72.2%. The use of CEUS significantly improved the diagnosis of active disease: CEUS alone correctly classified 164 of 180 patients [91.1%], combined analysis of CDI and CEUS 165 of 180 [91.7%], and combined analysis of thickness, CDI and CEUS 164 of 180 [91.1%], without significant differences. Patients with CDI grade 2 or 3 showed a predictive positive value of 97% to detect disease activity, similar to CEUS [100%]. CONCLUSION: CEUS is the most reliable ultrasound criterion for endoscopic disease activity. However, the use of a contrast agent is probably not justified to assess disease activity for patients with CDI grade 2/3.

Ganglioneuroblastoma nodular quístico: Presentación de un caso / Cystic Nodular Ganglioneuroblastoma: Case Report

Presentamos el caso de un niño de 9 años de edad, en quien como hallazgo incidental en una radiografía de tórax se observa una calcificación en el hipocondrio izquierdo sugestiva de masa. Se amplía el estudio mediante ecografía y resonancia magnética (RM) abdominal para mejor caracterización: se visualiza una masa suprarrenal izquierda, predominantemente quística, con un nódulo sólido. Finalmente, se le practica una resección quirúrgica, en la cual se llega al diagnóstico de ganglioneuroblastoma nodular quístico, tras el análisis histopatológico. El ganglioneuroblastoma quístico es un tumor poco frecuente, originado en las células ganglionares del sistema nervioso simpático. El sitio de origen más frecuente son las glándulas suprarrenales. A pesar de que el diagnóstico definitivo se suele realizar tras la resección quirúrgica del tumor, con la ecografía y la RM se debe incluir entre los diagnósticos diferenciales de incidentalomas suprarrenales en un niño o un paciente joven. Los hallazgos en tomografía computarizada son variables.

We present the case of a child patient aged 9 years, in whom, as an incidental finding in chest X-rays, a calcified lesion was observed in the left hypochondrium. The study is extended by ultrasound and then MRI was performed to better characterize it. These showed a left adrenal, predominantly cystic mass with a solid nodule. The surgical team decided to perform resection of the mass and submit it for histopathological examination. A definitive diagnosis of cystic nodular ganglioneuroblastoma was made. Ganglioneuroblastoma is a rare tumour, originating in ganglion cells of the sympathetic nervous system. The site of more frequent origin is in the adrenal glands. Although the majority are diagnosed based on the postoperative histological analysis, with ultrasound and MRI we should include it among the differentials diagnoses of adrenal incidentalomas in a child or young patient. The findings on CT are variables.

Usefulness of contrast-enhanced US in the diagnosis of acute gangrenous cholecystitis: A comparative study with surgical and pathological findings.

OBJECTIVE: To prospectively determine the usefulness of contrast-enhanced ultrasound (CEUS) in the diagnostic assessment of acute gangrenous cholecystitis, using histopathology as the reference method. MATERIAL & METHODS: The local institutional review board approved the study protocol, and all patients at enrollment provided a written informed consent. From December 2011 to July 2014, all patients with a clinical-sonographic diagnosis of acute cholecystitis underwent a CEUS examination. We included only patients who underwent cholecystectomies within 24-h of CEUS. Radiologists in the course of routine clinical care interpreted the US and CEUS images at the end of the examination, filling out a questionnaire. Two radiologists, blinded to the final diagnosis, independently reviewed the video CEUS sequences for the presence of defects of the gallbladder wall enhancement. Associations between the sonographic findings and histological gangrenous cholecystitis were evaluated by using univariate and multivariate logistic regression analysis. RESULTS: A total of 150 patients were analyzed. The histological diagnoses were 41 (27%) nongangrenous cholecystitis and 109 acute gangrenous cholecystitis (73%). Multivariate analysis of the predictive parameters at univariate analysis revealed that only leukocytosis, diabetes mellitus, lithiasis and defects of wall enhancement on CEUS were independent variables related to gangrenous cholecystitis. The presence of enhancement defects on CEUS enabled the diagnosis of the gangrenous form with sensitivity between 85 and 91% and specificity of 67.5-84.8%. Interobserver agreement for CEUS interpretation was good (median k value: 0.664; range, 0.655-0.680). CONCLUSION: Local or widespread absence of gallbladder wall enhancement on CEUS is associated with the presence of gangrenous acute cholecystitis.

Sigmoid stenosis caused by diverticulitis vs. carcinoma: usefulness of sonographic features for their differentiation in the emergency setting.

OBJECTIVE: To retrospectively evaluate the accuracy of ultrasound as a diagnostic method for differentiating acute diverticulitis from colon cancer in patients with sigmoid colon stenosis. MATERIALS AND METHODS: Ultrasound examinations of 91 consecutive patients with sigmoid stenosis (50 diverticulitis and 41 colon cancers) were reviewed by two trained radiologists. Sixty-five (71%) patients presented with acute abdominal symptoms. Thirteen sonographic criteria retrieved from the literature were evaluated to differentiate benign from malignant strictures. A score including all parameters which showed significant differences between benign vs. malignant was built. Sensitivity, specificity, accuracy, and positive or negative predictive values of each sonographic sign, the overall diagnosis, and sonographic score were calculated. RESULTS: Loss of the bowel wall stratification was the most reliable criteria for the diagnosis of malignancy (92% and 94% of sensitivity and specificity, respectively), and the best inter-radiologist agreement (κ = 0.848). Adjacent lymph nodes were the most specific feature (98%) for colon cancer, but its sensitivity was low. Global assessment could differentiate both diseases with high sensitivity (92-94.9%) and specificity (98-100%). Sonographic score >3 enabled differentiation of carcinoma from diverticulitis with 95% sensitivity and 92-94% specificity, with an area under the ROC curve of 0.98-0.987. There were no significant differences in the results between patients with acute and nonacute abdominal symptoms. CONCLUSION: The combination of several morphological sonographic findings using a score can differentiate most cases of diverticulitis from colon carcinoma in sigmoid strictures.

Sonographic findings in ischemic colitis in 58 patients.

OBJECTIVE: The purpose of this study was to describe the sonographic findings of 58 patients with proven ischemic colitis and to evaluate whether any of the findings are related to the presence or development of transmural necrosis. MATERIALS AND METHODS: We reviewed the histories of patients diagnosed with ischemic colitis over a period of 5.5 years. Sixty-two patients had undergone sonographic examinations. The spectrum of sonographic findings in ischemic colitis was based on the original imaging report, with an analysis of the presence of colonic abnormalities and their associated alterations. In the second part of the study, we divided the patients into two groups according to the presence or absence of transmural necrosis, and the sonographic findings of each group were compared. Ten patients had sonographic follow-up studies during their hospital stay. RESULTS: The prospective sensitivity of sonography for the characterization of colonic abnormalities was 93.5% (58/62 patients). Segmental involvement was detected in 57 of the 58 patients, with left-sided colitis in 47 (81%). The mean length of bowel involved was 19 cm, with a mean wall thickness of 7.6 mm. Colon wall stratification was preserved in 38 patients (66%). Altered pericolic fat was observed in 16 patients (28%). Absence of or barely visible color Doppler flow in the thickened bowel wall was recorded in 80% of patients. Altered pericolic fat was the only sonographic variable significantly associated with the presence of transmural necrosis (p = 0.004). Improvement as assessed on sonography was observed in all patients with a good clinical course. In patients with transmural necrosis, sonography did not show improvement. CONCLUSION: Sonography is a valuable technique for the detection of colonic abnormalities resulting from ischemic colitis. In this study, altered pericolic fat or the absence of improvement in sonographic follow-up studies were factors associated with transmural necrosis.

Small bowel obstruction caused by snail's shell: radiographic and CT findings.

We report a case of small bowel obstruction in a 74-year-old woman presenting with abdominal pain due to the accidental swallowing of a snail shell. A diagnosis of obstruction was made by abdominal radiograph, and its etiology was found after abdominal CT was performed. This is an unusual case of small bowel obstruction due to a foreign body that was preoperatively diagnosed with imaging.

Colitis isquémica: hallazgos en TC / Ischemic colitis: computed tomography findings

Objetivo: describir los hallazgos en tomografía computarizada (TC) de 28 pacientes con colitis isquémica, analizando su valor pronóstico. Material y método: estudio retrospectivo de 28 pacientes con diagnóstico confirmado de colitis isquémica. Revisamos historia clínica y hallazgos en TC. Valoramos en la TC: localización del segmento afectado, longitud y grosor, apariencia del límite externo de la pared colónica, presencia de ascitis, aire en pared intestinal o porta y patrón de atenuación de la pared tras inyectar contraste intravenoso. Análisis estadístico: test de Chi-cuadrado y test de Anova. Resultados: 24 pacientes (86 por ciento) presentaron afectación del colon izquierdo y 4 (14 por ciento) del derecho. Ningún paciente tuvo afectación pancolónica. La longitud de los segmentos afectados osciló entre 7 y 35 cm (media: 20 cm). El grosor medio fue de 8 mm. El segmento isquémico presentaba contorno liso en 22 pacientes (79 por ciento) y borroso en 6. Tras inyectar contraste intravenoso se observó captación en anillos concéntricos en 12 pacientes (43 por ciento) y ausencia de capas en los otros 16 pacientes. Se vio ascitis en 8 pacientes (31 por ciento). Se observó un solo caso de aire en vena porta, aire intramural o neumoperitoneo. No encontramos asociación estadísticamente significativa entre los signos valorados en la TC y la evolución del paciente. Conclusión: Aunque los hallazgos de la TC son inespecíficos pueden ser útiles para el diagnóstico de colitis isquémica en el contexto clínico adecuado, sobre todo en pacientes mayores con factores predisponentes y una distribución segmentaria del proceso. Los hallazgos en la TC inicial no tienen valor pronóstico. (AU)