[How to choose a radiological examination for a gastroenterological patient in 2016?] / Quelles imageries prescrire en gastroentérologie en 2016 ?

During the two last decades, medical imaging showed considerable changes in technology and in knowledge of abdominal diseases. This review illustrates the consequences of this evolution on the prescription of a radiological examination for a gastroenterological patient, in 15 selected and illustrative topics.

L'imagerie radiologique a connu des développements considérables au cours des deux dernières décennies. Ces nouveaux développements modifient la prescription raisonnée et raisonnable en imagerie médicale en pathologie gastrointestinale. Cet article de revue il lustre ces changements en 15 tableaux représentatifs de cette évolution.

Wegener's granulomatosis masquerading as a renal cancer: a case report and review of the literature.

A 32 year-old man presented with sinusitis, proteinuria, mononeuritis multiplex, very increased acute phase proteins. Anti-PR3 ANCA were detected and Wegener's granulomatosis (WG) was diagnosed. As abdominal tomodensitometry detected a tumoral process of the left kidney, a paraneoplastic vasculitis associated with a renal cancer was suspected. Biopsy of the mass showed fibrosis, inflammatory infiltrates and necrotizing granulomas. No malignant cells were detected. The outcome was favourable after administration of methylprednisolone and cyclophosphamide. Characteristics of the nine previously reported renal inflammatory pseudotumors associated with WG are discussed.

Primary Sjögren's syndrome associated with pneumatosis cystoides coli.

We report the case of a 43-year-old woman with primary Sjögren's syndrome, according to Americano-European criteria. Eighteen months after the diagnosis, the patient presented pneumatosis cystoides coli (PCC), which resolved with medical treatment consisting of diet and cisapride. Four years after this episode, the patient has not developed clinical features of another systemic inflammatory rheumatic disease and PCC has not relapsed. To the best of our knowledge, the association between primary Sjögren' syndrome and PCC has never been reported. Physiopathology and treatment of PCC are discussed.

Local ablative treatments for liver metastases: the current situation.

Surgical resection is the optimal treatment for liver metastases. However, due to their multifocality and/or insufficient remnant liver volume, the majority of liver metastases are unresectable. For this reason, several local ablative techniques have been developed, aiming to produce selective tumour destruction and thus increase the rate of patients amenable to curative-intent treatments. Among these techniques, cryoablation and radiofrequency ablation only have proven to have a curative potential, while transarterial chemoembolization and alcohol injection should be considered as palliative options only. The local recurrences after cryoablation and radiofrequency are equivalent, inferior to 10%, highly dependent of selection criteria. In contrast, morbidity is significantly increased after cryoablation, leading most of the teams to prefer the radiofrequency approach. Two major limitations for radiofrequency are, first, the risk to provoke heat biliary lesion in case of metastases located proximally to hilar plate, and second, the risk of insufficient ablation due to a cooling effect in case of metastases near to major vessels. Keeping in mind these limitations, selective use of radiofrequency may offer a significant benefit by allowing complete tumour clearance in patients with unresectable liver metastases.

[Multidisciplinary approach of hepatic metastasis of colorectal origin]. / Approche multidisciplinaire des métastases hépatiques d'origine colorectale.

Surgery remains the only potentially curative treatment for liver metastases. After margin free resection, approximately 30% of the patients present long-term survival. Due to the metastases number and/or volume, only 10 to 15% of the patients are candidates for curative-intent surgery. Thus, the objectives of the diagnostic and therapeutic management are to select adequately the patients for surgery and to improve resection rate by the use of neoadjuvants methods. Positron emission tomography could improve the preoperative detection of hepatic and extrahepatic metastases leading to the exclusion of some patients from useless surgical exploration. For patients with initially resectable tumors, no benefit has been demonstrated for adjuvant chemotherapy. For non resectable metastases, two neoadjuvants methods should be evaluated, chemotherapy to reduce tumor volume and portal vein embolization of the tumor side to improve the hepatic functional reserve and allow larger resection. For non-accessible lesion, selective tumor destruction using radiofrequency offers promising perspectives. In conclusion, the multiplication of the diagnostic and therapeutic methods certainly improve the global management of patients with liver metastases but also makes more difficult the individual choice for the best treatment. For this reason, a multimodal approach is absolutely mandatory.

[The medical imaging and radiology department]. / Le Service d'Imagerie Médicale et de Radiologie Interventionnelle.

Technological developments arising from research have affected the whole wide spectrum of medical endeavor and have made a very significant impact on clinical practice and especially on imaging sciences. Ultrasonography brought spectacular advances, but CT and MRI became important landmark techniques. A further important development, which greatly increased the involvement of radiologists in direct patient management, was the growth of interventional and therapeutic techniques, called interventional radiology. Some statistics: approximately 155,000 patients per year including 19,000 CT Scans, 10,000 MRI exams, 21,000 ultrasound examinations and 1,000 therapeutic procedures. Some research activities: CT quantification of pulmonary emphysema, respiratory mechanics, MR and CT angiography, antenatal diagnosis of congenital and genetic diseases of the fetus, quantification of portal haemodynamics, MR imaging of bile and pancreatic ducts, morphologic and functional imaging of the brain, radiology of bone trauma, MR characterization in hepatic lesions.

Retrospective analysis of 29 patients surgically treated for hepatocellular adenoma or focal nodular hyperplasia.

BACKGROUND/AIMS: Hepatocellular adenoma resection and focal nodular hyperplasia supervision are widely recognized as the best management when these benign liver tumors are diagnosed. Differential diagnosis is thus mandatory. METHODOLOGY: Twenty-nine patients with a presumed benign liver tumor were retrospectively analyzed. RESULTS: Histopathological analysis of these resected liver tumors demonstrated hepatocellular adenoma in 16 patients and focal nodular hyperplasia in 13. One hepatocellular carcinoma was disclosed into a hepatocellular adenoma and 2 hepatocellular adenoma showed foci of liver-cell dysplasia. Seven patients with hepatocellular adenoma (43%) had evidence of intratumoral hemorrhage, among which 3 patients were admitted with intraperitoneal tumoral rupture. Computed tomography, performed in 26 patients, was the most reliable examination to characterize these presumed benign liver tumors. Magnetic resonance imaging concerned only 5 patients but 3 hepatocellular adenoma and 1 focal nodular hyperplasia were diagnosed. The indications of focal nodular hyperplasia surgical resection were chronic pain (4 pts), hepatocellular adenoma diagnosis (4 pts), undeterminate liver mass (2 pts), a liver mass of unknown origin in patients with a neoplastic history (3 pts). A diagnosis of focal nodular hyperplasia assumed by the imaging work-up was always histologically confirmed. All the patients underwent hepatic resection with no mortality. CONCLUSIONS: This report underlines the risk of hemorrhage or malignant transformation of hepatocellular adenoma that justifies a safety surgical resection. An imaging work-up in favor of focal nodular hyperplasia allows radiological observation.

Acute radiation-induced hepatic injury: evaluation by triphasic contrast enhanced helical CT.

We report a case of radiation-induced hepatic injury as a complication of localized abdominal radiotherapy for epidural spread of non-Hodgkin's lymphoma. The liver was evaluated by triphasic contrast enhanced helical CT scan. Hepatic biopsy demonstrated changes typical of veno-occlusive disease. The pattern of hepatic enhancement resulting from the radiation-induced veno-occlusive process is discussed.

A pilot study for identifying at risk thyroid lesions by means of a decision tree run on clinicocytological variables.

Fine-needle aspiration biopsy (FNAB) is safe, inexpensive, minimally invasive, and highly accurate in the diagnosis of nodular diseases of the thyroid. However, FNAB does not provide a reliable benign versus malignant diagnosis for 100% of the cases analysed. It is possible to increase the accuracy of the cytological diagnosis by means of information contributed by different clinical variables. In the present study we evaluate the diagnostic value of 10 variables in addition to FNAB on a series of 218 specimens for which we obtained histological diagnoses including 37 cancers (17%). The diagnostic information contributed by these variables was analyzed by means of the Decision Tree technique, an artificial intelligence-related method which forms part of the Supervised Learning algorithms. The results show that Decision Trees enable some subpopulations of patients with uncertain FNAB results to be characterized.

Right diaphragmatic rupture and hepatic hernia: an indirect sign on computed tomography.

We report a case of blunt traumatic right diaphragm rupture with hepatic hernia. The diagnosis was first suggested by an abnormal hepatic location depicted on axial CT. This finding can be considered as a potentially new indirect sign of right diaphragm rupture in patients with blunt trauma. The diagnosis was then confirmed by reformatted CT and MR images.

Dual phase helical CT of a primary malignant fibrous histiocytoma of the right renal vein.

A case is reported of primary malignant fibrous histiocytoma of the right renal vein involving the ipsilateral kidney which showed early enhancement on dual phase helical CT. The correct diagnosis of a primary tumour of the renal vein involving the kidney was not made but in retrospect could have been achieved pre-operatively by considering several CT features.

Role of the double-contrast barium enema in rectal stenosis due to suppositories containing paracetamol and acetylsalicylic acid.

Self-treatment of chronic headache with suppositories containing paracetamol and acetylsalicylic acid may lead to serious complications. We report the radiological features of five cases of rectal stenosis following the use of such suppositories. The role of the double-contrast barium enema in suggesting the diagnosis of this complication of a chronic and often unrecognized self-treatment is emphasized.

Contribution of computed tomography to decision making in the management of adhesive small bowel obstruction.

BACKGROUND: In adhesive small bowel obstruction, the early recognition of complications such as strangulation or volvulus is essential to choose between surgical or conservative initial treatment. The objective of this study was to determine prospectively the contribution of computed tomography (CT) to decision making in the management of these patients. METHODS: Patients with suspected adhesive small bowel obstruction had CT at admission. Patients with CT signs of volvulus or strangulation and/or clinical signs of peritoneal irritation underwent urgent surgery; other patients had conservative initial treatment. RESULTS: Fifty-four patients were evaluated. CT demonstrated signs of strangulation or volvulus in 19 patients, including three with signs of peritoneal irritation. Within this group, urgent laparotomy was performed in 17 patients and confirmed the CT diagnosis in 16. Thirty-seven patients without clinical or CT signs of complications had initial conservative treatment; among them, seven of 12 with a distal obstruction determined by CT required a delayed operation for persisting obstruction, compared with two of 25 patients with a proximal obstruction (P < 0.01). CONCLUSION: CT is useful for the evaluation of adhesive small bowel obstruction, to detect accurately patients with complications who require urgent operation and to determine the location of the adhesion, which represents a significant prognostic factor for success of conservative treatment.

Helical CT of aorta after endoluminal stent-graft therapy: value of biphasic acquisition.

OBJECTIVE: We report our prospective study evaluating biphasic helical CT of the aorta after endoluminal stent-graft placement. SUBJECTS AND METHODS: Biphasic helical CT scans in 95 patients with abdominal and thoracic aortic aneurysms who had undergone endoluminal stent-graft placement were reviewed. After a test bolus injection of 15 ml of contrast media at a rate of 3.5 ml/sec for the measurement of the optimal start delay, the aorta was scanned using the following parameters: collimation of 5 mm, table speed of 7 mm per rotation, tube rotation time of 0.75 sec, 120 kV, and 295 mA. A delayed helical CT scan was obtained 15 sec after the initial acquisition using the same parameters. RESULTS: Biphasic helical CT scans showed perigraft leakage in 45 (47%) of 95 patients. Leakage was shown only on arterial phase CT in eight patients and only on the delayed scans in three patients. In two patients, leakage shown on the delayed acquisition was retrospectively seen on the first scan. Leakage and outflow vessels were most visible on the arterial phase acquisition in 17 patients and on the second acquisition in six patients. Overall, biphasic acquisition was superior to arterial phase acquisition alone in 15 (16%) of 95 patients. CONCLUSION: The diagnostic value of biphasic helical CT is superior to arterial phase acquisition alone for the evaluation of the aorta after endoluminal stent-graft therapy.

[Mucosecretory and papillary intraductal tumors of the pancreas: clinicopathological considerations and radiological aspects including computed tomography symptomatology]. / Tumeurs intracanalaires mucosecretantes et papillaires du pancreas: considerations clinico-pathologiques et aspects radiologiques comprenant la semiologie tomodensitometrique.

Intraductal papillary-mucinous tumor of the pancreas (IPMT) is an uncommon entity, defined as an intraductal papillary proliferation of mucin-producing epithelial cells. Since the original description of the disease by Ohhashi in 1982, the definition and the classification of the disease has remained confused until the recently published classification of the World Health Organisation (WHO). The purpose of this article is therefore to report the clinico-pathological features of IPMT according to the WHO classification, to illustrate the radiological features especially the computed tomographic signs and to discute of the treatment.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series.

BACKGROUND: Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. METHODS: Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. RESULTS: Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). CONCLUSIONS: This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.