[Rare diagnosis as the etiology of abdominal pain after cholecystectomy]. / Seltene Diagnose als Ursache von Abdominalschmerzen nach Cholezystektomie.

We report a case of a 77-year old female patient with abdominal pain in the upper right part. In the computertomography we had the suspicion of a rare small bowel diverticulitis which was confirmed in laparoscopic and histopathologic diagnostics. After surgical excision the patient was free of symptoms.

Comparison of the spectrum of radiologic and clinical manifestations of pulmonary disease caused by Mycobacterium avium complex and Mycobacterium xenopi.

AIM: Mycobacterium xenopi is described with upper lobe cavitation ("fibrocavitary" pattern), whereas the Mycobacterium avium complex (MAC) is described with bronchiectasis and centrilobular nodules ("nodular bronchiectasis"). We retrospectively described and compared computed tomography (CT) chest manifestations of disease caused by MAC and M xenopi. MATERIALS AND METHODS: We reviewed patients who had either MAC or M xenopi lung disease and who had CTs between January 2002 and December 2003. Clinical data were recorded, and the patterns on chest CTs were categorized as "fibrocavitary," "nodular bronchiectatic," and "unclassified." RESULTS: There were 74 patients; 50 with MAC and 24 with M xenopi. The patients with MAC were older (mean 69 vs 58 years; P = .007). Patients with M xenopi more often had emphysema (50% vs 20%; P = .02), cavities (46% vs 16%; P = .01), and nodules ≤5 mm (88% vs 58%; P = .02). M xenopi cases more commonly had a fibrocavitary radiologic pattern (33% vs 18%), with no statistically significant difference (P = .24). MAC was more often associated with a nodular bronchiectatic pattern (68% MAC vs 4% M xenopi; P < .0001). Sixty-three percent of patients with M xenopi had a pattern that was predominantly randomly distributed nodules (11/15 [73%]) or consolidation and/or ground-glass opacities (4/15 [27%]). CONCLUSION: Compared with MAC, patients with M xenopi infection develop more cavities and more nodules, and they less often have a predominant nodular bronchiectatic pattern. Although a predominantly cavitary pattern appears to be more common with M xenopi, the majority of patients with M xenopi had CT patterns of random nodules or consolidation and/or ground-glass opacities rather than classically described findings.

Restrictive allograft syndrome post lung transplantation is characterized by pleuroparenchymal fibroelastosis.

We previously described restrictive allograft syndrome as a form of chronic lung allograft dysfunction, demonstrating restrictive pulmonary function decline. However, the histopathological correlates of restrictive allograft syndrome have yet to be satisfactorily described. We hypothesized that pulmonary pleuroparenchymal fibroelastosis, as has recently been described in bone marrow transplant recipients, may also be present in the lungs of patients with restrictive allograft syndrome. Retrospective review of 493 patients who underwent lung transplantation between 1 January 1996 and 30 June 2009, was conducted. Out of 47 patients with clinical features of restrictive allograft syndrome, 16 had wedge biopsy, re-transplant lung explant, or autopsy lung specimens available for review. All lungs showed varying degrees of pleural fibrosis. Fifteen of 16 showed parenchymal fibroelastosis, characterized by hypocellular collagen deposition with preservation and thickening of the underlying alveolar septal elastic network. The fibroelastosis was predominantly subpleural in distribution, with some cases also showing centrilobular and paraseptal distribution. A sharp demarcation was often seen between areas of fibroelastosis and unaffected lung parenchyma, with fibroblastic foci often present at this interface. Concurrent features of obliterative bronchiolitis were present in 14 cases. Another common finding was the presence of diffuse alveolar damage (13 cases), usually in specimens obtained <1 year after clinical onset of restrictive allograft syndrome. The single specimen in which fibroelastosis was not identified was obtained before the clinical onset of chronic lung allograft dysfunction, and showed features of diffuse alveolar damage. In conclusion, pleuroparenchymal fibroelastosis is a major histopathologic correlate of restrictive allograft syndrome, and was often found concurrently with diffuse alveolar damage. Our findings support a temporal sequence of diffuse alveolar damage followed by the development of pleuroparenchymal fibroelastosis in the histopathologic evolution of restrictive allograft syndrome.

Chest computed tomography predicts microbiological burden and symptoms in pulmonary Mycobacterium xenopi.

BACKGROUND AND OBJECTIVE: The development of computed tomography (CT) findings usually precedes the diagnosis of pulmonary nontuberculous mycobacterial infection. The utility of specific CT scan features, although often available long before respiratory sample cultures, is not fully understood. We sought to assess associations among CT features, symptoms and microbiological disease criteria in pulmonary Mycobacterium xenopi isolation. METHODS: We reviewed 70 consecutive immunocompetent patients with pulmonary M. xenopi isolation and classified them according to the American Thoracic Society (ATS) diagnostic criteria for disease. 'Definite disease' patients (n = 16) met modified ATS criteria. 'Possible disease' patients (n = 10) met microbiological criteria, had abnormal CT scans, but data regarding symptoms were unavailable. 'No disease' patients (n = 44) had only one positive sputum culture, or were asymptomatic or had no relevant CT findings. Two radiologists, without knowledge of the clinical or microbiological information, independently reviewed the scans. RESULTS: The mean (standard deviation) age of all patients was 63 (16) years, and 39% were women. Patients with 'definite disease' usually had nodules (88%) and cavities (63%), but less often bronchiectasis (50%) and tree-in-bud (50%). Patients with 'possible' or 'no disease', respectively, had nodules (100% or 80%), bronchiectasis (40% or 18%) or tree-in-bud (40% or 11%). Cavitation (P ≤ 0.0001) and nodules ≥ 5 mm (P = 0.0002) were associated with fulfilled microbiological criteria for disease. Bronchiectasis (P = 0.02) and nodules <5 mm (P = 0.002) were associated with symptoms of infection. CONCLUSIONS: Among immunocompetent patients with pulmonary M. xenopi isolation, cavitation and large nodules predict fulfilling microbiological disease criteria, while bronchiectasis and small nodules predict symptoms.

CT screening for lung cancer: implication of lung biopsy recommendations.

OBJECTIVE: The purpose of this article is to address the implications of invasive diagnostic procedures recommended by a lung cancer screening protocol. In particular, we assess how many invasive procedures were recommended for benign nodules. MATERIALS AND METHODS: Between 2003 and 2009, 4782 high-risk current and former smokers were enrolled in a lung cancer screening study. A helical low-dose CT of the chest was performed. Morphologic features targeted were parenchymal nodules. The indication for biopsy was made according to the diagnostic algorithm provided by the International Early Lung Cancer Action Program. We recorded the time points of biopsy recommendation; shape, size, and growth of nodules; types of diagnostic procedures; complication rates; and final pathologic diagnosis. RESULTS: A total of 128 diagnostic biopsies were recommended for suspicious nodules, and 127 biopsies were performed, including 110 percutaneous CT-guided fine-needle aspiration biopsies (FNABs), nine video-assisted thoracoscopic surgery (VATS) resections, seven bronchoscopies, and one ultrasound-guided biopsy of a lymph node. Of 110 FNABs, 24 had unsatisfactory results, 13 of which were referred for secondary diagnostic VATS resection. The indication for biopsy was made on the basis of shape in 48% of cases (62/128), growth on follow-up in 40% of cases (51/128), and the appearance of new nodules in 12% of cases (15/128). In total, 104 of 124 biopsies (84%) were correctly indicated (true-positive recommendation) for malignancy, 20 were benign (false-positive) (16%), and final results are pending for four cases. The overall false-positive recommendation rate was 0.42% (20/4782); 11.6% of FNABs (16/128) and 3.6% of VATS (5/128) revealed benign nodules, corresponding to an overall false-positive rate of 0.33% for FNAB (16/4782) and 0.10% for VATS (5/4782). CONCLUSION: The recommended biopsy procedures for screen-detected suspicious pulmonary nodules resulted in a low intervention rate for benign nodules. This rate is minimal when we followed a research protocol that relies on shape and growth.

Restrictive allograft syndrome (RAS): a novel form of chronic lung allograft dysfunction.

BACKGROUND: Bronchiolitis obliterans syndrome (BOS) with small-airway pathology and obstructive pulmonary physiology may not be the only form of chronic lung allograft dysfunction (CLAD) after lung transplantation. Characteristics of a form of CLAD consisting of restrictive functional changes involving peripheral lung pathology were investigated. METHODS: Patients who received bilateral lung transplantation from 1996 to 2009 were retrospectively analyzed. Baseline pulmonary function was taken as the time of peak forced expiratory volume in 1 second (FEV(1)). CLAD was defined as irreversible decline in FEV(1) < 80% baseline. The most accurate threshold to predict irreversible decline in total lung capacity and thus restrictive functional change was at 90% baseline. Restrictive allograft syndrome (RAS) was defined as CLAD meeting this threshold. BOS was defined as CLAD without RAS. To estimate the effect on survival, Cox proportional hazards models and Kaplan-Meier analyses were used. RESULTS: Among 468 patients, CLAD developed in 156; of those, 47 (30%) showed the RAS phenotype. Compared with the 109 BOS patients, RAS patients showed significant computed tomography findings of interstitial lung disease (p < 0.0001). Prevalence of RAS was approximately 25% to 35% of all CLAD over time. Patient survival of RAS was significantly worse than BOS after CLAD onset (median survival, 541 vs 1,421 days; p = 0.0003). The RAS phenotype was the most significant risk factor of death among other variables after CLAD onset (hazard ratio, 1.60; confidential interval, 1.23-2.07). CONCLUSIONS: RAS is a novel form of CLAD that exhibits characteristics of peripheral lung fibrosis and significantly affects survival of lung transplant patients.

Intraoperative ultrasound of the liver in primary and secondary hepatic malignancies: comparison with preoperative 1.5-T MRI and 64-MDCT.

OBJECTIVE: The purpose of this study is to compare intraoperative ultrasound and preoperative contrast-enhanced MRI or 64-MDCT for the depiction of malignant lesions and for prediction of hepatic segments positive and negative for malignancy in patients undergoing partial hepatic resection. MATERIALS AND METHODS: In this retrospective study, 292 patients undergoing hepatic resection for metastatic colorectal cancer (n = 168), hepatocellular carcinoma (n = 70), or other hepatic malignancies (n = 54) were included. The sensitivity and negative predictive value of intraoperative ultrasound and preoperative cross-sectional imaging were calculated. The mean (± SD) time intervals to surgery were 37.6 ± 26 days for 64-MDCT and 48.1 ± 34 days for MRI. Surgical histopathologic examination was the reference standard. Changes in surgical management were recorded. Logistic regression models were used to estimate and compare proportions. RESULTS: For all 561 malignant lesions, the sensitivity of intraoperative ultrasound was 95.1%, compared with 96.8% for 64-MDCT (p = 0.025) and 94.4% for MRI (p = 0.960); 64-MDCT was also more sensitive than intraoperative ultrasound in identifying positive liver segments (p = 0.013). After controlling for patient group and time interval between imaging and surgery, the negative predictive value of 64-MDCT and MRI was higher than that of intraoperative ultrasound (p < 0.001 and p = 0.040, respectively). In only eight cases (2.7%) was surgical management changed after intraoperative ultrasound. CONCLUSION: For patients undergoing partial liver resection for hepatic malignancies, 64-MDCT and MRI have an equivalent or higher sensitivity in identifying hepatic segments with malignancy, and both 64-MDCT and MRI appear to have a higher predictive value for identifying disease-free segments than does intraoperative ultrasound.

Acute ischemic cholecystitis after transarterial chemoembolization of hepatocellular carcinoma: incidence and clinical outcome.

PURPOSE: To determine the incidence and clinical outcome of acute ischemic cholecystitis after transarterial chemoembolization (TACE) of hepatocellular carcinoma. MATERIALS AND METHODS: In this ethics board-approved study, a retrospective review of 355 TACE procedures performed in 246 patients during a 5-year period was performed. The review of postintervention computed tomography (CT) reports for findings indicative of acute cholecystitis identified 12 patients (4.9%). In these patients, all CT scans, laboratory results (white blood cell count, alkaline phosphatase level, total bilirubin level), and clinical reports were analyzed to assess imaging findings and outcomes at the following time points: before TACE, within the first week after the procedure, as well as 1 and 6 months post-TACE. RESULTS: In 11 of 12 cases, the dominant finding on CT was new gallbladder wall thickening of up to 12 mm, which developed within 24 hours in 10 patients and within the first month after TACE in 1 patient. Gallbladder wall thickening persisted in 1 patient for at least 6 months. Eleven of 12 patients showed deposition of Lipiodol in the gallbladder wall. In 1 patient, the dominant finding on CT was pericholecystic stranding that resolved on follow-up CT after 1 month. None of the patients demonstrated gas in the gallbladder wall, significant pericholecystic fluid, abdominal or liver abscesses. Blood work results revealed transient increase in white blood cell count, alkaline phosphatase level, and total bilirubin level, not different from that seen after TACE in patients without CT evidence of cholecystitis. Clinical reports documented transient right upper quadrant pain for a few days and up to 1 month in 1 case with eventual symptom relief. None of the cases required surgical or radiological intervention. All but 1 case demonstrated normal gallbladder wall thickness after 6 months. CONCLUSIONS: Acute ischemic cholecystitis is not an uncommon complication after TACE. However, it is self-limiting and does not seem to require any intervention or surgery.

Dynamic airway evaluation with volume CT: initial experience.

PURPOSE: The purpose of the study was to prospectively establish the use of a novel multidetector computed tomography unit (MDCT) with 320 x 0.5 detector rows for the evaluation of tracheomalacia by using a dynamic expiratory low-dose technique. METHODS: Six adult patients (5 men, 1 woman; mean age, 53.7 years [37-70 years]) referred for a clinical suspicion of tracheomalacia were studied on a 320-row MDCT unit by using the following parameters: 120 kVp, 40-50 mA, 0.5-second gantry rotation, and z-axis coverage of 160 mm sufficient to cover the thoracic trachea to the proximal bronchi. Image acquisition occurred during a forceful exhalation. The image data set was subject to the following analyses: cross-sectional area of airway lumen at 4 predefined locations (thoracic inlet, aortic arch, carina, and bronchus intermedius) and measurement of airway volume. RESULTS: All 6 patients had evidence of tracheomalacia, the proximal trachea collapsed at a later phase of expiration (3-4 seconds) than the distal trachea (2-3 seconds). The most common region of airway collapse occurred at the level of the aortic arch (5/6 [83%]), Three patients (50%) had diffuse segmental luminal narrowing that involved the tracheobronchial tree. The radiation dose (estimated dose length product, computed tomography console) measured 293.9 mGy in 1 subject and 483.5 mGy in 5 patients. CONCLUSIONS: Four-dimensional true isophasic and isovolumetric imaging of the central airways by using 320-row MDCT is a viable technique for the diagnosis of tracheomalacia; it provides a comprehensive assessment of airways dynamic.