[Autoimmune pancreatitis versus pancreatic cancer]. / Autoimmunpankreatitis versus Pankreaskarzinom.

CLINICAL ISSUE: Autoimmune pancreatitis (AIP) is classified as a distinct form of pancreatitis according to the guidelines. It is characterized by imaging morphologic and histologic features and is associated with extrapancreatic manifestations in type 1 IgG 4-associated disease. Symptoms and findings almost always improve with administration of steroids. Differentiation from pancreatic ductal adenocarcinoma is required, particularly in the presence of AIP with focal parenchymal involvement. STANDARD RADIOLOGIC PROCEDURES: If AIP is suspected, abdominal ultrasound and/or endosonography, computed tomography (CT), and preferably magnetic resonance imaging (MRI) are indicated. A distinction is made between parenchymal and ductal changes that specifically indicate the presence of AIP. METHODOLOGICAL INNOVATIONS AND EVALUATION: The diagnosis of autoimmune pancreatitis should be made based on the International Consensus Criteria (ICDC), in which the five main features (imaging, serology, histology, other organ involvement, response to steroid medication) are assessed. In type 1 AIP, typical imaging changes are sufficient to establish the diagnosis even with negative histology, whereas for type 2 AIP, histologic evidence is required. Imaging changes help in the differential diagnosis from pancreatic cancer. PRACTICAL RECOMMENDATIONS: The following article addresses and evaluates crucial imaging diagnostic CT and MRI criteria for correct classification of findings, description of results, and differentiation of autoimmune pancreatitis from pancreatic cancer.

[Incidental and leave me alone findings of abdominal organs-part 2 : Spleen, kidneys and adrenal glands and efferent urinary tracts]. / Inzidentelle und Leave-me-alone-Befunde der abdominellen Organe ­ Teil 2 : Milz, Niere und Nebennieren sowie ableitende Harnwege.

For masses of the spleen, which are mostly benign, accessory spleens, cysts and hemangiomas should be radiologically described; however, if confirmed further follow-up control is unnecessary. In the case of disseminated small masses, chronic inflammation and granulomatous diseases, such as tuberculosis and sarcoidosis should be considered in the differential diagnostics. Solid masses in the kidneys should always be further clarified, with the exception of a fat-rich angiomyolipoma. For cystic masses of the kidneys, the modified Bosniak classification for computed tomography or magnetic resonance imaging should be used. Masses of the adrenal glands greater than 10mm in size should be clarified further as well as those where fat is not detected, independent of the size and evidence of malignancy.

[Incidental and "leave me alone" findings of abdominal organs-part 1 : Liver, gall ducts and pancreas]. / Inzidentelle und Leave-me-alone-Befunde der abdominellen Organe ­ Teil 1 : Leber, Gallenwege und Pankreas.

Incidentalomas of the parenchymal organs of the abdomen, i.e. radiological findings in these organs that are not the primary focus of the clinical question, are frequent in this region of the body. In particular, findings presumed to be unimportant, such as cystic masses in the liver, the bile duct system or the pancreas, initially appear to be irrelevant in the diagnosis. For the liver we define the mostly clearly diagnosable simple cysts and hemangiomas as leave me alone lesions. Otherwise, we recommend a classification of incidentalomas into the three major categories (<0.5 cm, 0.5-1.5 cm and >1.5 cm) as well as an assessment with respect to clearly benign and suspect imaging characteristics in the context of a classification of patients into three different risk groups.

[Diagnostic Imaging of pancreatic carcinoma-Update of the new guideline]. / Diagnostik beim Pankreaskarzinom ­ Update in der neuen Leitlinie.

The new German S3 guidelines on ductal pancreatic adenocarcinoma were published for the first time on the homepage of the Association of the Scientific Medical Societies in Germany (AWMF) in December 2021 as a new update and thus the second update (first update 2013) and contain a large number of innovations in terms of diagnostics and treatment. The guidelines were organized and led by the German Society for Digestive and Metabolic Diseases (DGVS). In this article we would like to present the central content and innovations related to the radiological diagnostics of ductal pancreatic adenocarcinoma. The most important innovations are the highest recommendation strength in favor of computed tomography (CT) when assessing tumor spread as well as the adaptation of the European guidelines for cystic tumors by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) as the method of first choice. A further innovation is the implementation of a structured reporting of CT findings for describing the anatomical tumor resectability on the basis of the publication presented by the Abdominal Imaging Working Group and the Oncological Imaging Working Group of the German Radiological Society. There is no evidence for the implementation of radiological imaging in the field of aftercare or in the field of screening.

[Incidental and "leave me alone" findings in the GI tract-part 1 : Intestinal lumen and intestinal wall]. / Inzidentelle und Leave-me-alone-Befunde des GI-Trakts ­ Teil 1 : Darmlumen und Darmwand.

CLINICAL PROBLEM: Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) asymptomatic incidental findings of the gastrointestinal tract (GI) are increasingly being recognized. Incidental findings are frequently not part of the primary inquiry from referring physicians but it is obligatory to make a diagnosis and to stipulate the need for further clarification. RADIOLOGICAL STANDARD PROCEDURES: A multitude of incidental findings in the intestinal lumen, in the intestinal wall and in the adjacent mesenterium or subperitoneal space are shown in CT and MRI. METHODOLOGICAL INNOVATIONS AND ASSESSMENT: The first part of the two-part overview addresses the intestinal incidental findings in the lumen, such as coproliths, invaginations, mucoceles and chronic dilatations. In the intestinal wall, thickenings of neoplastic and nonneoplastic origins are discussed. Many of the findings can be classified as benign and as "leave me alone lesions" do not necessitate any further clarification but in contrast others need a definitive clarification. The most important incidental findings in the GI tract are systematically classified, illustrated and evaluated with respect to the clinical relevance, depending on the localization (e.g. stomach, small and large intestines).

[Incidental and "leave me alone" findings of the GI tract-part 2 : Intestinal wall and mesentery]. / Inzidentelle und Leave-me-alone-Befunde des GI-Trakts ­ Teil 2 : Darmwand und Mesenterium.

Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) asymptomatic incidental findings of the gastrointestinal (GI) tract are increasingly being recognized. Incidental findings are frequently not part of the primary inquiry from referring physicians but it is obligatory to make a diagnosis and to stipulate the need for further clarification. A multitude of incidental findings in the intestinal lumen, in the intestinal wall and in the adjacent mesentery or subperitoneal space are shown in CT and MRI of the GI tract. The last part of the two-part review addresses the gastrointestinal incidental findings in the intestinal wall and the adjacent sections. Extramural incidental findings occur as mesenteric inflammation, tumors and cysts. Many of the findings can be classified as benign and as "leave me alone lesions" do not necessitate any further clarification but in contrast others need a definitive clarification. The most important incidental findings in the GI tract are systematically classified, illustrated and evaluated with respect to the clinical relevance, depending on the localization (e.g. stomach, small and large intestines).

[Acute pancreatitis : Typical findings in computed tomography and magnetic resonance imaging]. / Akute Pankreatitis : Typische Befunde in Computer- und Magnetresonanztomographie.

CLINICAL PROBLEM: Imaging plays a major role to differentiate interstitial edematous from necrotic pancreatitis and to describe relevant local complications for proper patient management and decision-making in acute pancreatitis. STANDARD RADIOLOGICAL PROCEDURES: The revised Atlanta classification 2012 of acute pancreatitis divides patients into mild, moderately severe and severe groups. Computed tomography (CT) and magnetic resonance imaging (MRI) are well established for diagnosis and follow-up of acute pancreatitis and its complications METHODOLOGICAL INNOVATIONS AND ASSESSMENT: Based on the revised Atlanta classification, CT and MRI allow for adequate categorization of interstitial edematous and necrotic pancreatitis. Imaging and standardized reporting nomenclature enable confident differentiation of early and late complications in acute pancreatitis. RECOMMENDATIONS: The aim of this review article is to present an image-rich overview of different morphologic characteristics of acute pancreatitis and associated local complications by CT or MRI using case examples.

[Guideline-based diagnosis of pancreatitis]. / Leitliniengerechte Diagnostik der Pankreatitis.

BACKGROUND: There is currently no S3 guideline that contains statements on the diagnosis and treatment of acute, chronic and autoimmune pancreatitis in a single guideline. OBJECTIVES: This article presents the most relevant recommendations relating to radiological imaging from the new "S3 guideline for pancreatitis". MATERIALS AND METHODS: The guideline was developed by the DGVS (German Society for Digestive and Metabolic Diseases). After an online-based Delphi survey, the statements were discussed by an interdisciplinary expert team at a 3-day consensus conference and then agreed upon. The level of evidence scheme (version 2) of the Oxford Centre for Evidence-based Medicine was used. RESULTS: The new German "S3 guideline pancreatitis" comprises for the first time all entities of pancreatitis, acute, chronic and autoimmune pancreatitis and contains a large number of innovations with regard to diagnostic imaging and therapy. In addition to the evidence-based recommendations for diagnosis and therapy, a German-language glossary of the revised Atlanta classification on acute pancreatitis was adopted by consensus of the interdisciplinary guideline expert team. Furthermore, protocol recommendations for the performance of computed tomography (CT) are provided for the first time. In this article we introduce the key recommendations and innovations in the field of diagnostic radiologic imaging for acute, chronic and autoimmune pancreatitis. CONCLUSIONS: In the future, every radiologist should have deep knowledge of the recommended time intervals for radiological imaging in acute pancreatitis and know the German terms for the description of acute pancreatitis; furthermore they should be able to classify the morphologies to the appropriate stages.

Abdominal lymphatic malformations.

BACKGROUND: Abdominal lymphatic malformations (LM) are relatively rare findings in the differential diagnosis of focal abdominal lesions; however, they represent a challenge especially in younger patients. The aim of this review article is to provide up-to-date information about the different kinds of LM manifestations. In addition, related syndromes and typical imaging features to facilitate the diagnosis are discussed. RESULTS: The clinical presentation of abdominal LM is unspecific, whereby most are asymptomatic and comprise incidental findings of thin-walled cystic masses anywhere in the abdomen. The fluid in the cystic masses may be proteinaceous, contain blood, or be infected. Radiological imaging features overlap with other cystic diseases; hallmark in LM is a lack of a solid component and exclusive enhancement of the walls and septa. CONCLUSION: In cystic abdominal masses in early childhood or young adults, abdominal LM must be taken into account by the radiologist. Newly defined entities in this spectrum of diseases are central conducting lymphatic anomaly (CCLA) and generalized lymphatic anomaly (GLA).

[Diverticular disease : Complications and differential diagnosis]. / Divertikelerkrankung : Komplikationen und Differenzialdiagnosen.

BACKGROUND: Diverticular disease is becoming increasingly more common in the western world. It is clinically subdivided into uncomplicated diverticular disease and diverticular disease with a complicated course. In approximately 20% of cases the diverticula will become symptomatic during the lifetime of patients. RESULTS: In contrast to previous medical opinions, the occurrence of diverticula cannot be prevented by a diet rich in fiber; however, the development into complicated diverticulitis can be reduced by dietary measures. Complications include perforations, abscess and fistula formation or mechanical ileus. In addition, hemorrhage can occur as a complication, which can, however, occur in diverticulosis and also diverticulitis and especially in the chronic form. For the differential diagnostics a broad spectrum of inflammatory and noninflammatory diseases of the abdomen and pelvis must be taken into consideration. CONCLUSION: According to the new S2K guidelines the subdivision of diverticulitis should be implemented using the so-called classification of diverticular diseases (CDD). This enables a stratification of patients for outpatient or inhospital treatment.

[Inflammatory and infectious abdominal peritoneal and mesenterial processes]. / Inflammatorische und entzündlich-infektiöse abdominelle peritoneale und mesenteriale Prozesse.

BACKGROUND: Mesenterial and peritoneal inflammation represents a major clinical challenge regarding differential diagnosis. In this review article, a systematic overview of the most common causes such as autoimmune reaction, infarction with consecutive necrosis and infection caused by protozoa or bacteria is provided. RESULTS: The common clinical features of all inflammatory peritoneal and mesenterial diseases are the nonspecific abdominal symptoms. Even in radiological imaging an overlap of imaging features such as lymphadenopathy and nodular mesenteric structures is typical. Frequently the radiologist can narrow the differential diagnosis based on clinical information and anamnesis resulting in an optimized clinical outcome. CONCLUSION: Having a huge spectrum of etiologies for inflammatory peritoneal and mesenterial conditions the radiologist has to consider autoimmune diseases (IgG4-associated disease), acute infarction with necrosis and bacterial or protozoan infection.

[Misty mesentery : Mesenteric panniculitis and associated processes]. / "Misty mesentery" : Mesenteriale Pannikulitis und verwandte Prozesse.

BACKGROUND: Sclerosing mesenteritis (SM) and mesenteric panniculitis are rare processes of the mesentery which pose a major clinical and imaging challenge. This review article attempts to introduce a systematic nomenclature to address typical symptoms, imaging and major differential diagnoses. RESULTS: SM with its subtypes-mesenteric lipodystrophy, panniculitis and retractile mesenteritis-is a chronic process with a very diverse and heterogeneous clinical appearance. The typical radiological characteristics ("misty mesentery", increased lymph nodes, pseudocapsule and "fat halo") are also not very specific. A link between SM and malignant diseases is not proven, but there is controversial discussion. Therefore, if there are doubts about the diagnosis, further examinations and a biopsy are desired. CONCLUSION: When diagnosing SM, "red flags", i. e. characteristics that are atypical for SM in imaging, should be considered. In case of ambiguous imaging, differential diagnostics should also consider malignant diseases and exclude them.

[Abdominal lymphatic malformations. German version]. / Abdominelle lymphatische Malformationen.

BACKGROUND: Abdominal lymphatic malformations (LM) are relatively rare findings in the differential diagnosis of focal abdominal lesions; however, they represent a challenge especially in younger patients. The aim of this review article is to provide up-to-date information about the different kinds of LM manifestations. In addition, related syndromes and typical imaging features to facilitate the diagnosis are discussed. RESULTS: The clinical presentation of abdominal LM is unspecific, whereby most are asymptomatic and comprise incidental findings of thin-walled cystic masses anywhere in the abdomen. The fluid in the cystic masses may be proteinaceous, contain blood, or be infected. Radiological imaging features overlap with other cystic diseases; hallmark in LM is a lack of a solid component and exclusive enhancement of the walls and septae. CONCLUSION: In cystic abdominal masses in early childhood or young adults, abdominal LM must be taken into account by the radiologist. Newly defined entities in this spectrum of diseases are central conducting lymphatic anomaly (CCLA) and generalized lymphatic anomaly (GLA).

[Acceptance of medical apps and e­books among German radiologists]. / Akzeptanz von Medizin-Apps und E­Books unter deutschen Radiologen.

PURPOSE: Smartphones, tablet PCs, mobile applications (apps) and electronic book files (e-books) affect our lives in private and job-related settings. The aim of this study was to analyze the behavior of radiologists on smartphones, tablet PCs and e­books and to investigate its effect on their daily work. MATERIALS AND METHODS: An online survey containing of 23 questions was conducted using Survey Monkey© ( www.surveymonkey.com ). The invitation to the survey was done using the newsletter of the German Radiological Society (DRG). The acquired data was automatically stored by the software and then analyzed using descriptive statistics. RESULTS: In total, 104 radiologists (29% female) participated in the online survey. Of these, 93% and 96.5% owned a smartphone or a tablet PC, respectively, and 72% and 67% used medical apps and e­books, respectively. Through their use, 31% found moderate and 41% found enormous improvement in their daily work. A majority of participating radiologists would be willing to pay an increased user fee for optimized apps or e­books. CONCLUSION: With currently only moderate individual benefit of mobile medical apps and e­books, there is a widespread need for optimally configured apps and e­books with a correspondingly high market potential. KEY POINTS: (1) Radiologists use smartphones (93%) or tablet PCs (96.5%); (2) 72% of radiologists use a smartphone or tablet PC for medical material; (3) 53% of radiologists report significant assistance from or a high value of the mobile medical applications used; (4) There is a willingness to pay a license fee for optimized mobile applications or e­books.

Impact of multidetector computed tomography on the diagnosis and treatment of patients with systemic inflammatory response syndrome or sepsis.

OBJECTIVES: To evaluate the impact of CT scans on diagnosis or change of therapy in patients with systemic inflammatory response syndrome (SIRS) or sepsis and obscure clinical infection. METHODS: CT records of patients with obscure clinical infection and SIRS or sepsis were retrospectively evaluated. Both confirmation of and changes in the diagnosis or therapy based on CT findings were analysed by means of the hospital information system and radiological information system. A sub-group analysis included differences with regard to anatomical region, medical history and referring department. RESULTS: Of 525 consecutive patients evaluated, 59% had been referred from internal medicine and 41% from surgery. CT examination had confirmed the suspected diagnosis in 26% and had resulted in a different diagnosis in 33% and a change of therapy in 32%. Abdominal scans yielded a significantly higher (p=0.013) change of therapy rate (42%) than thoracic scans (22%). Therapy was changed significantly more often (p=0.016) in surgical patients (38%) than in patients referred from internal medicine (28%). CONCLUSIONS: CT examination for detecting an unknown infection focus in patients with SIRS or sepsis is highly beneficial and should be conducted in patients with obscure clinical infection. KEY POINTS: • Evaluation of patients with obscure clinical infection is a challenging task. • CT examination of patients with SIRS or sepsis seems to be beneficial. • CT examination confirmed suspected diagnosis in 26% of patients. • CT examination yielded a new infection focus in 33% of patients. • CT examination changed therapy in up to 32% of patients.

[Cost and Income Analysis of the 10 Most Frequent Angiography Interventions at a German University Hospital]. / Analyse von Kosten und Erlösen der 10 häufigsten angiografischen Interventionen bei einem Krankenhaus der Maximalversorgung.

Aim: Our aim was to make a detailed evaluation and cost analysis of the 10 most frequent angiography interventions in outpatients and inpatients at a university hospital. Material and Methods: Based on a detailed process-oriented model we calculated the cost and income for port and dialysis catheter implantation, PTA at the upper (UL) and lower leg (LL), TACE, SIRT, stent angioplasty (pelvis, visceral and supra-aortal vessels) and cerebral coil embolisation for the situations mentioned above. Various income models (DRG, GOÄ) were considered. A comprehensive evaluation of the overhead and personnel costs was performed. Results: The calculated data (in €) were as follows (overall, material, personnel costs, DRG income, GOÄ income inpatients, outpatients): port catheter: 375, 266, 59, 328, 260, 612; dialysis catheter: 456, 349, 59, 272, 343, 807; PTA UL: 595, 445, 99, 1 240, 425, 1 077; PTA LL: 732, 552, 129, 1 082, 425, 1 184; stent pelvis: 1 523, 1 338, 135, 1 323, 815, n/a; stent visceral: 2 124, 1 875, 199, 1 326, 912, n/a; stent supra-aortal: 1 901, 1 713, 138, 6 705, 1 138, n/a; TACE: 1 359, 1 120, 188, 2 588, 598, n/a; SIRT: 1 251, 1 054, 147, 2 289, 1 107, n/a; intracranial embolisation: 6 684, 6 367, 266, 6 531, n/a, n/a. Conclusion: Depending on the income model applied, most procedures caused a deficit, especially using GOÄ calculations. Outpatients covered by the private health insurance caused earnings for the procedures applied. Only TACE, SIRT and stent angioplasty of supra-aortal vessels caused profits in inpatients using InEK calculations.

[Pancreatitis: An update]. / Pankreatitis : Ein Update.

BACKGROUND: Acute and chronic pancreatitis are becoming increasingly more severe diseases in the western world with far-reaching consequences for the individual patient as well as the socioeconomic situation. This article gives an overview of the contribution of radiological imaging to the diagnostics and therapy of both forms of the disease. RESULTS: Acute pancreatitis can be subdivided into severe (20%) and mild manifestations. The diagnostics should be performed with computed tomography (CT) or magnetic resonance imaging (MRI) for assessing necrosis or potential infections only in severe forms of pancreatitis. In chronic pancreatitis transabdominal ultrasound should initially be adequate for assessment of the pancreas. For the differential diagnosis between pancreatic carcinoma and chronic pancreatitis, MRI with magnetic resonance cholangiopancreatography (MRCP) followed by an endoscopic ultrasound-guided fine needle aspiration is the method of choice. CONCLUSION: For the primary diagnosis for acute and chronic pancreatitis ultrasound examination is the modality of first choice followed by radiological CT and MRI with MRCP examinations.

Current Practice vs. Guideline Based Imaging in Abdominal Radiology in the German Speaking Area: Results of an Online Survey.

PURPOSE: The working group for abdominal imaging within the German Roentgen Society (DRG) performed an online survey amongst radiologist concerning the current status of techniques for abdominal imaging. The results of this survey were compared with the most recent guidelines. MATERIALS AND METHODS: We performed an online survey open for all members of the DRG during a 76-day period with 65 questions and an overall estimated time for finishing the questionnaire of 15 minutes concerning technical specifications for abdominal radiological imaging. The results were evaluated using descriptive statistics. RESULTS: 90 of all participants, who filled out the survey covering more than 80% of the questions, were included in the statistical evaluation. 27% of all participants were registered radiologists while 73% represented radiologists working in a hospital. Most participants worked in a managerial position. The participants gave detailed information regarding the radiological techniques used in dedicated organ systems (esophagus, stomach, pancreas, liver, small intestines, colon) regarding acquired contrast phases and oral and intravenous administration of contrast medium. CONCLUSION: The results confirm that most radiologists participating in this survey perform their examinations and choose their modalities in conformity with the current existing clinical guidelines. Because most clinical guidelines do not specify radiological examinations in detail, there is a noteworthy heterogeneity of the acquired contrast phases and major divergence in terms of technical parameters. Therefore a joint radiological effort should be initiated for developing and publishing updated radiological parameters for abdominal imaging. KEY POINTS: • In German speaking countries indications for abdominal radiological examinations are performed with a high compliance to published guidelines. • There is a significant heterogeneity regarding the acquisition of different contrast phases for parenchymal abdominal organs. • There is an urgent need to publish radiological recommendations and guidelines based on current radiological literature for radiological abdominal imaging.