Early detection of extrahepatic bile-duct carcinomas in the nonicteric stage by using MRCP followed by EUS.

BACKGROUND: Most extrahepatic bile-duct carcinomas are usually diagnosed when they are already in an advanced stage, which is the main reason for the poor prognosis of this tumor. OBJECTIVE: To examine the usefulness of MRCP followed by EUS in the early diagnosis of extrahepatic bile-duct carcinoma in the nonicteric stage. PATIENTS: This study included patients who were nonicteric, who had abnormal serum concentrations of alkaline phosphatase and gamma glutamyl transpeptidase, and whose common hepatic duct was more than 8 mm in diameter on abdominal US because of unknown reasons. DESIGN: A single-center, prospective study. SETTING: An academic medical center. MAIN OUTCOME MEASUREMENTS: The sensitivity and specificity of MRCP followed by EUS for the early diagnosis of extrahepatic bile duct carcinoma in the nonicteric stage. RESULTS: A total of 142 patients who were nonicteric underwent prospective MRCP, and 26 of them underwent EUS. Ten patients (5 with stricture, 4 with filling defect, and 1 with no stricture or filling defect) had extrahepatic bile-duct carcinoma, including 5 patients with an incidentally diagnosed T1 stage tumor. The sensitivity and specificity of MRCP followed by EUS were 90% and 98%, respectively. LIMITATIONS: A single center and small number of patients. CONCLUSIONS: MRCP followed by EUS was highly sensitive and specific for the early diagnosis of extrahepatic bile-duct carcinoma in the nonicteric stage, including T1 stage tumors. Filling defects, as well as stenosis in the bile duct, are important MRCP findings of T1 stage carcinoma.

Rationale and design of the carotid plaque in human for all evaluations with aggressive rosuvastatin therapy (CHALLENGER trial): evaluation by magnetic resonance imaging.

BACKGROUND: Intensive lipid-lowering therapy with statins reduces levels of low-density lipoprotein (LDL)-cholesterol (C) and improves plaque volume and composition in patients with cardiovascular disease. Furthermore, rosuvastatin ameliorated carotid stenosis in the ASTEROID study, and altered the composition of plaques in a predominantly Caucasian study population in the ORION study. However, it is not known whether statin therapy achieves similar quantitative improvement in carotid artery plaque in other ethnic groups. METHODS AND RESULTS: Fifty patients with hypercholesterolemia (LDL-C >or=120 mg/dl) and a maximum carotid intima-media thickness >or=1.8 mm will be enrolled and treated with rosuvastatin at a dose of 5 mg/day for 96 weeks. The primary endpoints will be the percent change of carotid plaque volume and the change in plaque composition after 96 weeks of treatment, as evaluated by magnetic resonance imaging. CONCLUSIONS: The CHALLENGER study will provide a noninvasive assessment of the changes in carotid plaque volume and composition achieved by reduction of LDL levels in Japanese patients with carotid stenosis on long-term rosuvastatin therapy.

Pancreatic-duct-lavage cytology in candidates for surgical resection of branch-duct intraductal papillary mucinous neoplasm of the pancreas: should the International Consensus Guidelines be revised?

BACKGROUND: The International Consensus Guidelines are helpful for the management of branch-duct intraductal papillary mucinous neoplasms (IPMNs), because they allow us to exclude malignancy. However, it is not possible to predict malignancy with certainty, and further preoperative differentiation between benign and malignant IPMNs is required to avoid the false-positive results. OBJECTIVE: To examine the usefulness of pancreatic-duct-lavage cytology by using an originally designed double-lumen catheter for discriminating benign and malignant IPMNs of the branch-duct type in candidates for surgical resection based on the International Consensus Guidelines. PATIENTS: Pancreatic-duct-lavage cytology was investigated in 24 patients with branch-duct IPMNs who underwent surgical resection based on the International Consensus Guidelines, namely, they either had intramural nodules or the ectatic branch duct was >30 mm in diameter. DESIGN: Single-center retrospective study. SETTING: Academic medical center. MAIN OUTCOME MEASUREMENTS: The sensitivity and specificity of pancreatic-duct-lavage cytology for discriminating benign from malignant IPMNs. RESULTS: More than 30 mL of pancreatic-duct-lavage fluid was obtained from each patient, and there were no patients with noninformative results. The sensitivity, specificity, positive predictive value, and negative predictive value of the cytologic diagnosis were 78%, 93%, 88%, and 88%, respectively. LIMITATIONS: Single-center and small number of patients. CONCLUSIONS: Pancreatic-duct-lavage cytology can improve differentiation between benign and malignant IPMNs of the branch-duct type in candidates for surgical resection based on the International Consensus Guidelines.

Phlebosclerotic colitis.

Phlebosclerotic colitis (PC) is a rare form of ischemic colitis that usually affects the right hemicolon. It is due to ischemia induced by phlebosclerosis in the branches of the superior mesenteric vein that disturb venous return from the colon. The clinical course is different from that of the more common type of ischemic colitis caused by arterial disease. We encountered a 73-year-old woman with PC who had the characteristic computed tomographic finding of fine linear venous calcification that was mainly perpendicular to the long axis of the colon.

Effects of diet-induced moderate weight reduction on intrahepatic and intramyocellular triglycerides and glucose metabolism in obese subjects.

CONTEXT: Although moderate weight reduction is recommended as primary therapy of metabolic syndrome, little information is known regarding metabolic changes associated with moderate weight reduction in nondiabetic obese subjects. OBJECTIVE: The aim of this study was to determine the effects of a moderate weight reduction program on intracellular lipid and glucose metabolism in muscle and liver. PARTICIPANTS: Data for 13 nondiabetic obese subjects were evaluated. INTERVENTION: Subjects were put on a 3-month mildly hypocaloric diet therapy (approximately 35 kcal/kg of ideal body weight). MAIN OUTCOME MEASURES: Intrahepatic lipid (IHL) and intramyocellular lipid were measured by using (1)H magnetic resonance spectroscopy. Peripheral insulin sensitivity and splanchnic glucose uptake were evaluated by euglycemic-hyperinsulinemic clamp with oral glucose load. RESULTS: Diet therapy for 3 months resulted in 6% reduction in body weight (from 99.9 +/- 7.3 to 93.8 +/- 6.6 kg, P < 0.0001). This change was accompanied by reduction of plasma glucose and insulin excursions during 75-g oral glucose tolerance tests, decrease in diastolic blood pressure, glycated hemoglobin, serum low-density lipoprotein cholesterol, and triglyceride. These changes were also accompanied by a decrease in IHL (from 12.9 to 8.2%, P < 0.01) and increase in splanchnic glucose uptake (from 13.5 to 35.0%, P < 0.03). On the other hand, the diet program did not affect intramyocellular lipid or glucose infusion rate during euglycemic hyperinsulinemic clamp. CONCLUSIONS: Our results suggest that moderate weight reduction in obese subjects decreased IHL and augmented splanchnic glucose uptake. This mechanism is at least in part involved in improvement of glucose metabolism by moderate weight reduction in obese subjects.

Effects of diet and exercise on muscle and liver intracellular lipid contents and insulin sensitivity in type 2 diabetic patients.

Insulin resistance is associated with the circulating free fatty acid (FFA) level and intracellular lipid content in muscle and liver. We investigated the effect of 2-wk diet and exercise therapy on total adiposity, circulating FFA, intracellular lipid content in muscle and liver, and peripheral insulin sensitivity. Type 2 diabetic patients were divided into a diet group (n = 7) and a diet plus exercise group (n = 7). We performed a hyperinsulinemic-euglycemic clamp study before and after treatment. Intramyocellular lipid (IMCL) in the tibialis anterior muscle and intrahepatic lipid (IHL) were evaluated by (1)H-magnetic resonance spectroscopy. Fasting FFA were not altered, and total body fat showed a slight, but significant, decrease in both groups after treatment. IMCL was decreased by 19%, and the glucose infusion rate was increased by 57% in the diet plus exercise group, whereas neither IMCL nor glucose infusion rate was significantly altered in the diet group. However, IHL showed a significant decrease in both groups. In summary, we found that 2 wk of diet and exercise decreased IMCL and increased muscle insulin-mediated glucose uptake, whereas diet with or without exercise decreased IHL. These effects were evident despite a small decrease in body fat and were observed independently of fasting FFA levels.

Omental torsion with right-sided inguinal hernia.

Omental torsion is a rare cause of acute abdomen. The diagnosis is usually not established before surgery, but recently some reports have described the usefulness of computed tomography (CT) for the detection of this condition. We encountered a 58-year-old man with torsion of the greater omentum secondary to right-sided inguinal hernia, and present the characteristic CT findings of a whirl-like mass with hyperattenuated fatty tissue.

Unexpected accumulation of thallium-201 in bilateral thalamic venous infarction induced by arteriovenous fistula in the posterior fossa: report of a case.

We encountered unexpected accumulation of thallium-201 in a patient with thalamic dementia resulting from bithalamic venous infarction induced by arteriovenous fistula in the posterior fossa The site and degree of abnormal accumulation varied between early and delayed thallium-201 SPECT images. This unexpected and complicated accumulation of thallium-201 appeared to depend on not only breakdown of the blood-brain barrier but also on the hemodynamics of this type of venous infarction.

Occult pancreatobiliary reflux in patients with a normal pancreaticobiliary junction.

BACKGROUND: The aim of this study was to investigate pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction. METHODS: Seventy-four patients with a normal pancreaticobiliary junction, as determined by ERCP, underwent secretin injection MRCP before cholecystectomy. Based on changes in the diameter of the biliary system after secretin injection, patients were categorized into enhanced or nonenhanced groups. RESULTS: Biliary amylase was measured in the 4 patients allocated to the enhanced group and 60 in the nonenhanced group. The mean (SD) biliary amylase level in the gallbladder was 123,723 (115,125) IU/L in the enhanced group and 238 (507) IU/L in the nonenhanced group (p < 0.0001). The mean (SD) biliary amylase level in gallbladders with carcinoma (n = 7) was 68,281 (106,500) IU/L, which was significantly higher than that in gallbladders without carcinoma (p < 0.01). CONCLUSION: Pancreatobiliary reflux similar to that seen in patients with pancreaticobiliary maljunction can occur in individuals with a normal pancreaticobiliary junction and may be associated with carcinoma of the gallbladder. Secretin injection MRCP is useful for identifying these individuals.

Extension of ductal carcinoma in situ: histopathological association with MR imaging and mammography.

The purpose of this study is to evaluate the capability of breast MRI (magnetic resonance imaging) and mammography in determining tumor extent and the detectability of ductal carcinoma in situ (DCIS) in association with histopathological features. Thirty women with breast cancer underwent 3D dynamic MRI. Twelve women had pure DCIS and 18 women had DCIS with microinvasion. We analyzed the results of preoperative MRI and mammography with histopathologic results, retrospectively. The mean lesion size was 55.1 mm from the histopathologic results. Twenty-six lesions were detected through the MRI (a sensitivity of 86.7%). MRI depicted eight lesions without mammographically detected microcalcification. In seven cases, MRI showed tumor extent accurately compared with mammography, and the combined diagnosis improved the accuracy of evaluating tumor extent. MRI can complement mammography in guiding surgical treatment of DCIS by providing better assessment of the extent of the lesion.

A case of incarcerated lesser sac hernia protruding simultaneously through both the gastrocolic and gastrohepatic omenta.

Small bowel obstruction due to lesser sac herniation through both the gastrocolic and gastrohepatic omenta is extremely rare, and only a few reported cases have been concerned with imaging diagnosis. CT images showed distended bowel loops at the level of the cephalad part of the stomach, collapsed triangular loops and attached mesentery were depicted just behind the caudal part of the stomach. These findings provided clues to the diagnosis of this type of lesser sac hernia.

Small bowel intussusception caused by intestinal angiosarcomatosis: usefulness of MR enteroclysis with infusion of water through a nasojejunal catheter.

We report a case of intestinal angiosarcomatosis manifesting as jejuno-jejunal intussusception.