The role of CT in decision for acute appendicitis treatment.

PURPOSE Acute appendicitis is the most common cause of the acute abdomen requiring surgery. Although standard treatment has been surgery, it has been seen in recent years that treatment is possible with antibiotics and non-operative observation. In this study, our aim is to determine whether the CT findings in patients diagnosed with acute appendicitis can be used for directing treatment. METHODS A retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 - 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared. Appendiceal wall thickness, appendiceal diameter, the severity of mural enhancement, intra-abdominal free fluid, the severity of periappendiceal fat stranding, size of pericecal lymph node, appendicolith, adjacent organ findings and the CT appendicitis score of groups were compared with Pearson Chi-square and Mann Whitney U tests. Multivariable logistic regression was used to identify predictors of surgical treatment, expressed as odds ratios (ORs) with 95% confidence intervals. Diagnostic efficacies of appendiceal diameter, the CT appendicitis score and developed model were quantified by ROC curves. RESULTS Appendiceal diameter (P < .001), adjacent organ findings (P = .041), the CT appendicitis score (P < .001), the severity of periappendiceal fat stranding (P = .002), appendicolith (P = .001) and intra-abdominal free fluid (P <0.001) showed statistically significant differences between the medical and surgical treatment groups. According to the logistic regression test, if the patients with appendiceal diameter ≥13mm (OR = 5.1, 95%CI 1.58 - 16.50), appendicolith (OR = 4, 95%CI 1.17 - 13.63) and intra-abdominal free fluid (OR = 3.04, 95%CI 1.28 - 7.20), surgeons should prefer surgical treatment. The AUCs for the CT appendicitis score, the appendiceal diameter and the model were 0.742 (95% CI 0,659 - 0,824), 0.699 (95% CI 0.613 - 0.786) and 0.745 (95% CI 0.671 - 0.819), respectively. As the successful and unsuccessful medical treatment groups were compared, the only significant parameter was the severity of mural enhancement (P = .005). CONCLUSION CT findings may be helpful in patients with uncomplicated acute appendicitis whose treatment surgeons are indecisive about. We can recommend surgical treatment in cases with appendix diameter ≥13mm, intraabdominal free fluid, appendicolith, high CT appendicitis score and severe mural enhancement.

The volumetric measurement of developing liver atrophy in patients with Chilaiditi's sign.

PURPOSE: The Chilaiditi's sign is a hepatodiaphragmatic interposition of the colon and is a rare diagnosed condition. This condition may cause a problem in liver transplantation applications which are progressively increasing in number. Although not reported in the literature, we observed that liver atrophy developed in the intestinal interposition region in patients with Chilaiditi's sign in computed tomography (CT) images. This study aimed to determine the amount of liver atrophy caused by the interposed colon, the factors that change the rate of atrophy, and the effects of this situation on the liver parenchyma. MATERIALS AND METHODS: A total of 30,000 patients who presented to radiology department with any reason between March 2012 and March 2013 and who underwent thoracoabdominal or abdominal CT imaging were retrospectively analyzed. The volumes of the liver right lobe and lateral/medial segments of the left lobe were estimated in cm3 using Volume Viewer application in 75 cases (20 females, 55 males) in which Chilaiditi's sign was observed in CT images. RESULTS: 17-27% of the lobes affected from the colon interposition were seen to develop atrophy. The ratio of right lobe volume to total liver volume was found to be higher in patients with left lobe atrophy (74%) than right lobe atrophy (55%) (p < 0.001). Similarly, the rate of the volume of the left lobe to the total liver volume was found to be higher in cases with right lobe atrophy (45%) compared to left lobe atrophy (26%) (p < 0.001). CONCLUSION: Hepatodiaphragmatic interposition of the colon can cause liver atrophy. This condition should especially be considered in the liver transplantation applications. Compensatory hypertrophy may develop in the unaffected liver lobe and CT is very useful for diagnostic imaging.

Chemical Ablation for Treating Anal Fistulas without Surgical Intervention: Long-Term Results.

Purposes. This study aimed to evaluate long-term outcomes after the application of a corrosive chemical agent for ablation of epithelial tissue as a non-surgical treatment of anal fistulas. Methods. Adult patients with symptomatic perianal fistula were prospectively included in the study. The fistula tract was irrigated with a 5% silver nitrate solution. The primary outcome measured in this study was the rate of clinical healing after long-term follow-up. Factors that may affect healing were also analysed. Results. A total of 186 patients with anal fistula were analysed. After irrigation with silver nitrate, 82 (44%) patients had complete clinical healing during a median follow-up time of 50 (7-64) months. Patients with intermittent discharge had a significantly higher rate of complete clinical healing than those with continuous discharge (P < .04). Fistulas without abscesses or secondary tracts had a significantly higher rate of complete clinical healing than the other types (P = .007). Conclusion. Chemical ablation of the epithelium of the anal fistula yields promising long-term outcomes in the management of anal fistulas without surgical intervention.

Annual contrast-enhanced magnetic resonance imaging is highly effective in the surveillance of hepatocellular carcinoma among cirrhotic patients.

OBJECTIVES: Biannual ultrasonography, a globally accepted surveillance method, has low sensitivity in detecting early-stage hepatocellular carcinoma (HCC). We aimed to investigate the effectiveness of a surveillance strategy using annual contrast-enhanced MRI to detect HCCs at early-stage. MATERIALS AND METHODS: We reviewed the data of 294 patients with consistent annual contrast-enhanced MRI and biannual alpha fetoprotein (AFP) surveillance between 2008 and 2017. Patients were stratified for HCC risk as low-intermediate-high risk group using Toronto risk score. HCCs were classified according to Barcelona Clinic Liver Cancer staging system. RESULTS: Thirty-five (11.9%) HCCs were detected with annual surveillance MRI. Of those, 30 (85.8%) were early-stage and 15 (42.9%) were very early-stage. The majority of patients (82.9%) with surveillance detected HCC were high risk at the entry. MRI had sensitivity of 83.3 and 80% with a specificity of 95.4 and 91.4%, for detecting early and very early-stage HCC, respectively. Addition of AFP to MRI displayed similar sensitivity and specificity rates to detect early and very early HCCs. The area under the curve of MRI alone and combination with AFP was not statistically different (Any-HCC: 0.905 vs. 0.924; Early-HCC: 0.853 vs. 0.885; Very early-HCC: 0.838 vs. 0.885, respectively, all P values >0.2). CONCLUSION: Annual MRI strategy demonstrated a satisfactory performance in the surveillance of HCC, in terms of detecting most of the lesions in earlier curable stages and indicating high sensitivity with no additional benefit of biannual AFP. New risk stratified screening algorithms may further increase the yield of HCC surveillance among cirrhotic patients.

Clinical significance of isolated abnormal intestinal findings in magnetic resonance enterography in patients with suspected small bowel disease.

PURPOSE: Magnetic resonance imaging (MRE) is a well-established adjunct diagnostic tool for the diagnosis of Crohn's Disease (CD), as ileocolonoscopy can sometimes be falsely reassuring when CD skips distal terminal ileum. We aimed to determine the frequency and clinical significance of isolated abnormal small bowel findings in MRE with normal ileal view in ileoscopy. METHODS: We retrospectively reviewed findings from 1611 MRE studies that were conducted between 2012 and 2018 to detect patients bearing abnormal intestinal findings and having full ileocolonoscopy. After exclusion of normal or repetitive MRE scans and previously known CD, 147 patients with abnormal MRE detected. MRE scans were categorized as suspicious of CD and non-specific findings. RESULTS: Out of 147 patients with abnormal MRE, 122 (83%) had terminal ileum involvement in MRE consistent with ileoscopy findings. Twenty-five (17%) patients were found to have solitarily abnormal intestinal findings in MRE with normal ileoscopy. Only 3 (12%) were diagnosed with CD initially, and all had MRE findings suspicious of CD. The remainder 40% (n = 10) were diagnosed with non-Crohn's small bowel disease after further investigation, while in the other 48% (n = 12) abnormal MRE findings could not be explained with any organic disease in the follow-up. CONCLUSION: The present study demonstrated that only a small portion of patients with isolated abnormal intestinal findings in MRE is CD, and more than that are non-crohn's small bowel diseases. These findings, even if they carry the suspicion of CD, do not transform to CD in the long-term follow-up.

Spigelian Hernia Including the Urinary Bladder: A Rare Potential Cause of Surgical Complication.

Spigelian hernia is a rare type of anterior abdominal wall hernia. While it is itself very rare, seeing urinary bladder in this hernia is even rarer. Here, in this case, we specifically illustrate a rare case of Spigelian hernia including the urinary bladder, diagnosed with computerized tomography.

Tuberculous peritonitis mimicking carcinomatosis peritonei: CT findings and histopathologic correlation.

The distinction between tuberculous peritonitis and peritoneal carcinomatosis is extremely difficult in patients with omental cake appearance on computed tomography and elevated CA-125 level. A 21-year-old female presented with abdominal distention, diarrhea, nausea, fever, weight loss, and night sweats. Serum CA-125 level was 563 U/L (normal range: <35 U/L) and other tumor markers were within normal range. Radiologic studies showed massive ascites, smooth minimal thickening and increased contrast enhancement of peritoneum, omental nodularities, hepatomegaly, and right pleural effusion. No underlying malignancy that could cause this condition was detected clinically and radiologically. Ultrasound-guided omental tru-cut biopsy was performed to exclude carcinomatosis peritonei. Histopathologic examination showed small-medium-sized granulomas with caseous necrosis. Molecular microbiology tests of biopsy specimens confirmed diagnosis of tuberculosis. In conclusion, tuberculous peritonitis should be in differential diagnosis of a patient with ascites, omental nodularities and elevated serum CA-125 levels.

De novo myeloid sarcoma as a rare cause of small bowel obstruction: CT findings and histopathologic correlation.

Small bowel obstruction caused by myeloid sarcoma in a patient with any hematological abnormality is very rare. Myeloid sarcoma occurs most commonly in patients with acute myelogenous leukemia (AML) and less with other hematological disorders. A 57-year-old female presented with abdominal pain, nausea, vomiting, and constipation. Radiological studies showed concentric bowel thickening in distal ileum that caused nearly total luminal compromise and signs of obstruction in proximal ileal bowel loops. She underwent laparotomic surgery and ileal resection was done. Diagnosis of myeloid sarcoma was made by histopathological examination of surgical specimens. Bone marrow biopsy was done to rule out systemic acute myelogenous leukemia (AML). Results of bone marrow biopsy were within normal limits. Finally, the patient was diagnosed as de novo myeloid sarcoma. Although the histopathological examination makes a definitive diagnosis, imaging allows to locate the lesion, evaluate its complications, and guide for correct biopsy. Accurate diagnosis of myeloid sarcoma has important prognostic value as transformation to AML can happen without chemotherapy or stem cell transplantation.

Computed tomography findings of primary epiploic appendagitis as an easily misdiagnosed entity: Case series and review of literature.

BACKGROUND: Primer epiploic appendagitis (PEA) is an uncommon condition. METHODS: We retrospectively reviewed the clinical records and computed tomography (CT) findings of 45 patients with PEA. RESULTS: On the basis of physical examination and pain localization, presumptive clinical diagnosis was acute appendicitis (n=13), acute cholecystitis (n=2), acute diverticulitis (n=19), renal colic (n=7) and ovarian pathology (n=4). CONCLUSION: Although it has no characteristic clinical and laboratory features, CT is the best modality for accurate diagnosis of PEA.

Comparison of Doppler ultrasound and transient elastography in the diagnosis of significant fibrosis in patients with nonalcoholic steatohepatitis.

BACKGROUND: Liver fibrosis is an important prognostic determinant in patients with nonalcoholic steatohepatitis (NASH). Hepatic artery resistivity index (HARI) is a doppler ultrasonography (US) parameter that is used to follow up microcirculatory resistance in fatty liver. We aimed to asses whether it is possible to demonstrate significant fibrosis by means of doppler US in comparison with transient elastography (TE) and liver biopsy in NASH patients. PATIENTS AND METHODS: A total of 63 (mean age 47.1 ± 8.4 years, 39 male, 24 female) biopsy-proven NASH patients were enrolled in this prospective study. The study population was classified into two groups: significant and no-significant fibrosis patients. Doppler US and TE were performed in two groups. RESULTS: HARI and TE values were significantly higher in significant fibrosis group (0.81 ± 0.05 vs. 0.63 ± 0.14, p < 0.0005; 15.9 ± 4.8 vs. 6.2 ± 2.6 kilopascals, p < 0.0005; respectively). Based on the ROC curve, the optimal cut-off value of HARI for a significant fibrosis was >0.75, which yielded a sensitivity of 78% and a specificity of 75%, with the area under the curve at 0.90. The optimal cut-off value of TE for a significant fibrosis was >9.8 kilopascals, which yielded a sensitivity of 90% and a specificity of 91%, with the area under the curve at 0.95. HARI values were moderately correlated with TE values (r = 0.53, p < 0.001). CONCLUSION: Doppler US has moderate % sensitivity and % specificity, which is lower compared with TE for the diagnosis significant fibrosis. However, it may be used as an alternative method for the assessment of fibrosis in patients with NASH who are not good candidates for TE evaluation.

A rare case mimicking positron emission tomography/computed tomography mismatch: Hepatic subcapsular hematoma.

Subcapsular collections of bile, air or blood in the liver have been described following transhepatic procedures due to the leakage of bile and blood from the percutaneous puncture at the surface of the liver. Herein we presented the subcapsular collection led to a mismatch between functional and anatomical boundaries of the liver.

A Simple Method to Evaluate Whether Pancreas Texture Can Be Used to Predict Pancreatic Fistula Risk After Pancreatoduodenectomy.

INTRODUCTION: Soft pancreas is one of the most important risk factor for postoperative pancreatic fistula after pancreatoduodenectomy. The aim of this study is to investigate whether pancreatic attenuation index utilized to assess the pancreatic texture with computed tomography can be used to predict the risk of developing a clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy. METHODS: We reviewed 76 consecutive patients undergoing pancreatoduodenectomy between 2012 and 2014. The pancreatic attenuation index is found by dividing the pancreas density by the spleen density achieved with non-enhanced computed tomography. The independent predictors of clinically relevant postoperative pancreatic fistula were investigated. RESULTS: Clinically relevant postoperative pancreatic fistula occurred in 13 patients (17.1%). The group of patients with postoperative pancreatic fistula is compared with the group of patients without postoperative pancreatic fistula in terms of age, gender, body mass index, the American Society of Anesthesiologists (ASA) score, smoking, alcohol consumption, medical comorbidities, preoperative biliary drainage, type of anastomosis, and pancreatic duct size and pancreatic attenuation index. Univariate analyses have shown a significant difference in relation to chronic obstructive pulmonary disease and pancreatic attenuation index. The multivariate analyses showed that only pancreatic attenuation index was associated with a high postoperative pancreatic fistula rate (P = 0.012). CONCLUSION: A preoperative non-contrast computed tomography scan evaluating pancreatic attenuation index could help to predict the occurrence of clinically significant postoperative pancreatic fistula after pancreatoduodenectomy.

Quantitative assessment of liver fibrosis by digital image analysis: Relationship to Ishak staging and elasticity by shear-wave elastography.

OBJECTIVE: To analyze the relationship between fibrosis staged by Ishak stage and quantified by digital image analysis (DIA), and to reveal the optimum performance of shear-wave elastography (SWE) using quantitative DIA measurements as a comparative histological standard. METHODS: The proportionate area (PA) of fibrosis was measured by DIA from images of the PA of trichrome-stain (TPA) of 168 chronic hepatitis patients. SWE was performed in 105 patients. The accuracy of SWE for predicting the fibrosis defined by quantitative PA thresholds (≥ 2.5%, ≥ 5%, ≥ 10% and ≥ 20%, respectively) and by Ishak stages was measured using the area under the receiver operating characteristic curve (AUROC). RESULTS: DIA was proven to be highly reproducible (interclass correlation coefficient 0.926). The TPA range corresponding to each Ishak stage was large, widened as stages progressed, and reached its greatest extent in cirrhosis. TPA magnified at ×50 ranges 11.9-56% for Ishak stage F5-6. A good correlation between TPA and elasticity was presented for more advanced fibrosis (TPA ≥10%, rs = 0.732, P = 0.000) than milder fibrosis (TPA <10%, rs = 0.308, P = 0.006). With the advance of fibrosis either by stages or PA thresholds the discriminative accuracy of SWE gradually increased, but was less satisfactory for milder fibrosis. CONCLUSIONS: DIA may serve as a reproducible and reliable quantitative standard for surrogate tests for liver fibrosis. The performance and correlation of SWE with the fibrotic extent were better for advanced fibrosis, but less satisfactory for milder fibrosis.

Can MRI related patient anxiety be prevented?

PURPOSE: To evaluate the effectivity of a combined intervention of information and communication to reduce magnetic resonance imaging (MRI) anxiety using prolactin and cortisol as biochemical markers and State Trait Anxiety Inventory (STAI). MATERIALS AND METHODS: This study is a randomized prospective research. Sample size was 33 patients. Fourteen patients were enrolled as study group, compared to 19 patients as control group. Blood samples were collected by venous sampling, and STAI was filled before and after scan. State anxiety inventory was used twice. Study group received a standard information about MRI scans and were communicated with 2 minute intervals via intercom; control group had no intervention. Blood samples were carried in ice to be centrifuged and stored as soon as they were taken to study prolactin and cortisol. Data were stored and analyzed by SPSS 17.0. P value for significance was accepted as 0.05. RESULTS: Prolactin-pre, prolactin-post, cortisol-pre, cortisol-post, cortisol percent increase, Trait Anxiety Inventory (TAI), SAI (State Anxiety Inventory) pre-scan and post-scan levels were similar between demographic groups. Cortisol-pre levels were similar between study and control, however prolactin-pre levels were significantly higher in control group. Study group had 6% lower cortisol level post-scan, whereas control group had 18% increase. Study and control groups had similar Trait Anxiety and SAI-pre scores. SAI-post scores were lower in study group when compared with control group. Study group also had lower SAI-post scores than SAI-pre, whereas control group had higher. CONCLUSION: MRI anxiety can be reduced by information and communication. This combined method is shown to be effective and should be used during daily radiology routine.

Magnetic resonance enterography in refractory iron deficiency anemia: a pictorial overview.

AIM: To highlight magnetic resonance enterography (MRE) for diagnosis of patients with refractory iron deficiency anemia and normal endoscopy results. METHODS: Fifty-three patients diagnosed with iron deficiency anemia refractory to treatment and normal gastroscopy and colonoscopy results were admitted to this prospective study between June 2013 and December 2013. All patients underwent a standardized MRE examination with a 1.5 Tesla magnetic resonance imaging system using two six-channel phased-array abdominal coils. Adequate bowel distention and fast imaging sequences were utilized to achieve diagnostic accuracy. All segments of the small bowel, duodenum, jejunum, and ileum were examined in detail. All cases were examined independently by two radiologists with > 5 years of experience in abdominal magnetic resonance imaging. A consensus reading was performed for each patient following image examination. Both radiologists were blinded to patient history, laboratory findings, and endoscopy results. RESULTS: Twenty (37.7%) male and 33 (62.3%) female patients were included in the study. The mean age of the patients was 52.2 ± 13.6 years (range: 19-81 years, median 51.0). The age difference between the male and female patient groups was not statistically significant (54.8 ± 16.3 years vs 50.7 ± 11.7 years). MRE results were normal for 49 patients (92.5%). Four patients had abnormal MRE results. One patient with antral thickening was diagnosed with antral gastritis in the second-look gastroscopy. One patient had focal wall thickening in the 3(rd) and 4(th) portions of the duodenum. The affected areas were biopsied in a subsequent duodenoscopy, and adenocarcinoma was diagnosed. One patient had a fistula and focal contrast enhancement in the distal ileal segments, consistent with Crohn's disease. One patient had focal wall thickening with luminal narrowing in the mid-jejunum that was later biopsied during a double-balloon enteroscopy, and lymphoma was diagnosed. CONCLUSION: MRE is a non-invasive and effective alternative for evaluating possible malignancies of the small intestines and can serve as a guide for a second-look endoscopy.

Should we consider topical silver nitrate irrigation as a definitive nonsurgical treatment for perianal fistula?

BACKGROUND: Surgery is currently the sole treatment modality for anal fistulas. However, surgery is associated with complications such as permanent incontinence, which reduces quality of life. OBJECTIVE: To determine the rate of complete clinical healing of anal fistulas after irrigation of the fistula tract with silver nitrate solution as a nonsurgical treatment. DESIGN: Prospective single arm study. SETTING: Tertiary university hospital PATIENTS: : Adult patients with symptomatic perianal fistula presenting between June 2012 and January 2013. INTERVENTION: Irrigation of the fistula tract with 1% silver nitrate solution. Irrigation was repeated every 2 weeks when necessary. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of complete clinical healing. RESULTS: Fifty-six consecutive patients with anal fistula were analyzed. Of those, 29 (52%) had complete clinical healing without recurrence for a median of 10 months. The median number of irrigations needed for complete clinical healing was 4 (1-10). The level of satisfaction was excellent in patients with complete clinical healing. The frequency of complaints was the only independent factor that had an impact on healing; patients with intermittent discharge had a significantly higher rate of complete clinical healing (67%) than those with continuous discharge (40%). There were no notable complications. LIMITATIONS: Short follow-up, small sample size, and no comparisons. CONCLUSION: This study demonstrates that the application of silver nitrate solution often produces a favorable outcome in the treatment of anal fistula. This method may be considered as a first-line treatment for the disease because it is simple, performed on an outpatient basis, minimally invasive, and lacks the complications encountered with current conventional surgical modalities.

The retroaortic left renal vein abnormalities in cross-sectional imaging.

OBJECTIVE: The normal anatomic course of the left renal vein (LRV) from the kidney to inferior vena cava (IVC) is usually preaortic. It is called retroaortic left renal vein (RLRV) when located between the aorta and vertebra; the circumaortic left renal vein (CLRV) has both a preaortic and retroaortic course. In this study, we aimed to find the incidence and characteristics of LRV abnormalities in routine abdominal CT and MR examinations conducted in our clinic. MATERIALS AND METHODS: A total of 2189 abdominal CT and MR examinations, performed between April 2007 and June 2009, were reviewed retrospectively for retroaortic and circumaortic LRV abnormalities. RESULTS: LRV abnormalities were detected in 50 (2.3%) examinations. Forty-four of these (2%) were RLRV and 6 (0.3%) were circumaortic LRV abnormalities. CONCLUSIONS: Preoperative knowledge of LRV abnormalities facilitates the safe performance of surgery and reveals the clinical symptoms. It is easy to see LRV and its drainage way on routine CT and MR imagings.

Bouveret's syndrome on FDG PET/CT: A rare life-threatening complication of gallstone disease / El síndrome de Bouveret en FDG PET/TC: Una complicación rara y potencialmente mortal de la enfermedad de cálculos biliares

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