Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis.

BACKGROUND: Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT-proven acute diverticulitis. METHODS: PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT-proven left-sided acute diverticulitis. The prevalence was pooled using a random-effects model and, if possible, compared with that among asymptomatic controls. RESULTS: Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent. CONCLUSION: Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis.

BACKGROUND: The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world. PURPOSE: Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis. METHODS: PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs. RESULTS: A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I2 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%. CONCLUSION: Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

[No hocus POCUS: high standards should be set for point-of-care ultrasonography]. / Geen hocus POCUS.

Point-of-care ultrasonography (POCUS) was initially limited to simple applications such as diagnosing ascites, sampling pleural fluid and guiding venous access. Use of POCUS is currently on the rise. As radiologists, we endorse the use of ultrasonography as the stethoscope of the future, but we make some critical comments. The interpretation of ultrasonographic findings can have far-reaching therapeutic implications. The patient is therefore entitled to maximum ultrasonographic expertise. Intensive hands-on training starting in early medical school is mandatory and central archiving of ultrasonographic images and reports is essential.

Image-guided posterior transperineal drainage for presacral abscess: An analysis of 21 patients.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the safety and efficacy of posterior transperineal drainage in patients with presacral abscess. MATERIALS AND METHOD: The records of 21 patients (14 men, 7 women; mean age: 62.1±10 years) who underwent posterior transperineal drainage for the treatment of presacral abscess, either using fluoroscopy or computed tomography guidance, were retrospectively reviewed. Data were analysed with respect to technical success, tolerance, duration of drainage, complications and short-term outcome. RESULTS: A total of 28 posterior transperineal drainage procedures of presacral abscesses were performed in 21 patients, either using fluoroscopy (24/28; 86%) or computed tomography (4/28; 14%) guidance. Technical success rate was 89% (25/28 procedures) and clinical success rate 88% (22/25 technically successful procedures). Transperineal catheter drainage was maintained for 3-105 days (mean 31 days±26 [SD]). After three procedures (3/28; 11%) patients reported discomfort. No major complications were reported. CONCLUSION: This study suggests that posterior transperineal drainage is an effective, safe and well-tolerated procedure for the treatment of presacral abscess.

[Abdominal ultrasound: a task for the radiologist]. / Abdominale echografie: zaak van de radioloog.

In the Netherlands, ultrasound (US) as a primary, symptom-directed diagnostic tool, is used mainly by radiologists and not by internists; there are good reasons for this. It guarantees concentration of expertise in US as well as in CT and MRI, which makes integrated imaging possible. It also guarantees the continuous availability of expertise, optimal digital accessibility, clearly assigns the responsibility, and minimises the radiation risk. Symptom-directed US plays an important role in the triage of patients who are admitted by general practitioners or via the Emergency Ward, and in interdisciplinary and inter-observer assessment. Finally, the lack of self-referral helps to reduce the costs of medical care.

[Acute abdominal pain in the third trimester of pregnancy caused by adnexal torsion based on a small cystic adenoma]. / Acute buik in het derde trimester van de zwangerschap door torsie van het adnexum op basis van een klein cysteadenoom.

A 25-year-old woman presented in the third trimester of pregnancy with severe abdominal pain in the lower right abdominal quadrant. Differential diagnosis included urolithiasis, adnexal torsion and appendicitis. A definitive diagnosis could not be made based on clinical and laboratory examination. Ultrasonography revealed a 3-cm cyst in the lower right abdomen, which was considered unlikely to cause abdominal pain. During laparotomy, adnexal torsion was found, which was deemed to be the cause of the abdominal pain. The twisted portion was uncoiled and the dark-coloured cyst was extirpated. The cyst was determined to be a cystic adenoma. Adnexal torsion is rarely caused by cysts smaller than 5 cm, especially in the third trimester. Emergency laparoscopyllaparotomy should be performed if adnexal torsion is suspected to confirm the diagnosis and uncoil the twist to prevent ovarian damage. Adnexal torsion should be considered in the differential diagnosis of acute abdominal pain in the third trimester of pregnancy.

[Treating physicians can perform simple ultrasounds; triage ultrasonography should be reserved for radiologists]. / Behandelend arts kan zelf eenvoudige echo's maken.

We feel that, in trained hands, point-of-care ultrasonography by non-radiologists is of value to patient care. However, more extensive ultrasonography, i.e., triage ultrasonography, requires a skill set and a clinical environment that can currently only be provided by radiologists.

A rare case of Waterhouse- Friderichsen syndrome during primary Varicella zoster infection.

Primary Varicella zoster virus infection in adults is associated with a higher risk of complications when compared with the benign disease course of primary infection during childhood. We present a rare complication of adult primary Varicella zoster in the form of acute, irreversible adrenal insufficiency due to bilateral adrenal haemorrhage, which is also known as the WaterhouseFriderichsensyndrome.

[Acute abdominal and back pain in a patient with an aortic aneurysm and a duodenum perforation on CT-scan]. / Acute buik- en rugpijn bij een aneurysma van de aorta, en een duodenumperforatie op de CT-scan.

An 82-year old man with a known aneurysm of the abdominal aorta (AAA) presented with a history of acute onset abdominal and back pain of a few hours. He was haemodynamically stable and had pain on pressure over the aneurysm. Ultrasound confirmed the AAA, but could not demonstrate or exclude rupture. Subsequent CT-scan confirmed a non-ruptured AAA and demonstrated a small, curvilinear, hyperdense structure thought to be a fish bone or chicken bone which had perforated the duodenum. On gastroduodenoscopy, a fish bone was found and removed. The patient's symptoms resolved completely within two days. In patients with a possible ruptured AAA, echographic or CT-scan investigations can confirm or exclude the condition thus avoiding unnecessary surgery. These investigations also gather preoperative data for potential endovascular reconstruction. Before the introduction of new visualization techniques a duodenum perforation resulting from the unnoticed swallowing of a sharp object could only be diagnosed by explorative laparotomy. Delay in diagnosis leads to high mortality.

[Diagnostic policy in patients with a suspected ruptured abdominal aortic aneurysm]. / Diagnostisch beleid bij klinische aanwijzingen voor een geruptureerd aneurysma van de aorta abdominalis.

The clinical diagnosis of a ruptured aortic aneurysm is unreliable, and in haemodynamically stable patients both ultrasound and CT are used to improve diagnostic accuracy. In any patient with a suspected ruptured aneurysm, ultrasound is done upon arrival of the patient in the hospital to confirm or exclude the presence of an aortic aneurysm. If facilities for endovascular reconstruction are available at the hospital, an immediate CT scan with intravenous contrast follows, to find out if and how endovascular treatment should be performed. If endovascular reconstruction is not available, a CT scan without using contrast is carried out. If the CT scan shows a ruptured aneurysm, the patient is transported to the Operating Department without further delay. If the CT scan does not show any signs of rupture, there is time for further investigation. If no alternative condition to explain the patient's symptoms is found, further diagnostic tests such as repeat ultrasound, CT with contrast material and laboratory tests can be performed. If no other serious condition emerges, the aortic aneurysm should be considered symptomatic. In this case, the patient should undergo a rapid, but thorough pre-operative work-up, and go for operation as soon as possible by a rested and experienced operating team as part of the regular day programme.

Ultrasound diagnosis of an intraneural ganglion cyst of the peroneal nerve. Case report.

The authors present the case of an intraneural ganglion cyst of the peroneal nerve. The cyst was diagnosed by means of ultrasound, which also gave an exact definition of its size and location, confirmed at operation. Some controversial aspects of these lesions are discussed.

Percutaneous gallbladder drainage in emphysematous cholecystitis.

Emphysematous cholecystitis is a serious disorder with a high mortality and morbidity. We report successful drainage of the gallbladder in a male diabetic patient with emphysematous cholecystitis in whom surgery was considered contraindicated because of his poor cardiac status.

Thyroid scintigraphy for the detection of radiation-induced thyroid cancer.

Thyroid scintigraphy with Tc-99m pertechnetate was performed in 249 patients who received radiation therapy for abnormalities in the head or neck in order to determine the role of this examination in the detection of abnormal nodules arising from cancer. These patients received a mean total dose of about 10.1 Gy. The mean follow-up period was 39 years. All patients underwent physical examination without prior knowledge of the scintigram. Scintigrams were evaluated without prior knowledge of the physical examination. In 158 cases, both the physical examination and scintigraphy were negative. In 64 cases, both examinations were positive. In ten patients, the physical examination was positive and scintigraphy was negative and vice versa in 17 patients. Of 249 patients, 28 ultimately underwent thyroid surgery; a total of four had carcinoma. A cost-benefit relationship as to routine scintigraphy as a screening procedure is presented. If patients are first screened by palpation, a number of abnormal nodules will be missed. In addition, a considerable number with positive palpation would probably undergo surgery unnecessarily. From a clinical and financial point of view, it is believed that scintigraphy is the examination of choice for screening for radiation-induced thyroid malignancies.

[Spontaneous rupture of the bladder]. / Een spontane blaasruptuur.

A spontaneous bladder rupture was diagnosed using ultrasound and CT scan in 3 patients, 1 woman aged 62 and 2 men aged 77 and 42, presenting with abdominal pain, anuria and prior problems with urination. The younger man had suffered from this previously; he was now suffering from bacterial peritonitis due to infected urine. All 3 patients recovered after treatment with a transurethral catheter and antibiotics. A transurethral resection was performed on the benign enlarged prostate of the older man. The combination of non-specific symptoms, the absence of trauma history and its very rare occurrence mean that initially a spontaneous bladder rupture may not be suspected. However, an untreated bladder rupture can lead to life-threatening situations. Screening the abdomen with ultrasound, an ultrasound-guided puncture and CT scan may yield results that suggest a bladder rupture. In most cases, conservative treatment with a transurethral catheter will be sufficient. Sometimes surgical repair of a bladder rupture may be necessary.

[Abdominal aortic aneurysm as incidental finding in abdominal ultrasonography]. / Het aneurysma aortae abdominalis als nevenbevinding bij echografisch onderzoek van het abdomen.

Abdominal aortic aneurysm is a life-threatening condition, which usually remains without symptoms until rupture occurs. The only way to reduce the high mortality rate (estimated at over 80%) is elective surgery on suitable patients. Therefore the presence of such an aneurysm has to be detected. For this ultrasonography is the method of choice. We studied 4399 consecutive patients aged 50 years and older, who underwent abdominal ultrasonography for the first time. According to the recommendation of the Dutch Society for Radiodiagnostics the whole abdomen was screened. In 4026 patients (1717 men and 2309 women) the ultrasound examination was performed for non-vascular reasons. In 199 of these patients (4.9%) an abdominal aortic aneurysm was an adventitious finding (133 men (7.7%) and 66 women (2.9%)). In men aged 60 years and older it was even found in 10.2%. When abdominal ultrasonography is performed for the first time in a patient aged 50 years or older, the aorta has to be screened for presence of an aneurysm.

[A patient with Salmonella aortitis]. / Een patiënt met Salmonella-aortitis.

Bacterial aortitis is a rare but serious condition. Even when treated surgically, the prognosis is poor. Prompt diagnosis is mandatory. In the absence of specific clinical signs, radiological assessment by means of ultrasound and CT is most valuable. The treatment of choice is early surgical drainage, debridement and arterial reconstruction, preferably through uncontaminated tissue combined with antibiotic therapy. We report the case of a man aged 80 with Salmonella aortitis in whom the diagnosis of bacterial aortitis was made by means of ultrasound and CT, following which successful intervention was carried out.

[Bacterial ileocecitis, a "new" disease]. / Bacteriële ileocaecitis, een 'nieuwe' ziekte.

786 patients with suspected acute appendicitis or appendiceal mass were examined by ultrasonography to distinguish appendicitis from bacterial enteritis. 533 of these patients were described before. In 91 (11.6%) ultrasonography revealed the characteristic picture associated with bacterial enteritis of the ileocaecal region-enlarged mesenteric lymph nodes and mural thickening of the terminal ileum and caecum--but no image of an inflamed appendix. In 64 of these a bacterial infection was confirmed (Yersinia enterocolitica in 28, Campylobacter jejuni in 24, Salmonella enteritidis in 11, Yersinia pseudotuberculosis in one). In the other 27, bacteriological tests were negative (17) or not performed (10). Only 34 of 91 had diarrhoea. Six of the 91 patients underwent surgery, in all of them the removed appendix was normal. The other 85 patients recovered with conservative treatment. In 38 a planned appendicectomy was cancelled because of the sonographic findings. Bacterial enteritis limited to the ileocaecal region (bacterial ileocecitis) appears to be responsible for an appreciable number of unnecessary appendicectomies. It has characteristic sonographic features which distinguish it from appendicitis.

[Epiploic appendagitis: an underestimated self-limiting acute abdominal condition]. / Appendagitis epiploica: een onderbelichte zelflimiterende acute buikaandoening.

OBJECTIVE: To describe the clinical findings in patients with epiploic appendagitis and to evaluate its natural course. DESIGN: Retrospective. METHOD: A review of the medical records was carried out for all patients who were diagnosed with epiploic appendagitis using ultrasonography and computed tomography (CT), during the period June 1988-October 2001, at the Haaglanden Medical Centre (Westeinde site), The Hague, the Netherlands. RESULTS: The study group consisted of 49 patients, 38 men and 11 women, with a median age of 41 years. The main symptom was focal abdominal pain, with a median diagnostic delay in the patients of 2 days, located in the left lower quadrant (n = 34), right lower quadrant (n = 8), right upper quadrant (n = 6) or left upper quadrant (n = 1) of the abdomen. No other complaints were present with the exception of nausea and vomiting in two patients. Leucocytosis was found in 21% of patients, the erythrocyte sedimentation rate was elevated in 26% of the patients, and signs of peritoneal irritation were found in 53% of the patients. Epiploic appendagitis was correctly included in the clinical differential diagnosis of 2 patients. All of the patients made a complete and uncomplicated recovery under conservative treatment; the majority were symptom-free within 9 days. CONCLUSION: Due to the increased use of diagnostic imaging in patients with acute abdominal symptoms, epiploic appendagitis is much more frequently diagnosed than before. Presenting symptoms of epiploic appendagitis are non-specific, leading to misdiagnosis in most cases. Epiploic appendagitis has a benign natural course and if patients are correctly diagnosed using ultrasonography and CT, unnecessary surgery and medical treatment may be avoided.

[Enterovesical fistula in diverticulitis]. / Enterovesicale fistel bij diverticulitis.

Three men aged 52, 60, and 38 years, complained of dysuria and recurrent cystitis. One patient mentioned pneumaturia, a feature which later appeared to be present in all three. Ultrasound examination showed air in the bladder, and demonstrated the fistulous tract in two cases. Computed tomography identified the third fistula. In all 3 the enterovesical fistula was a complication of sigmoid diverticulitis. After sigmoid resection they recovered well. The key to the diagnosis of enterovesical fistula is to think of it. Pneumaturia and faecaluria are pathognomonic symptoms. Both ultrasound and computed tomography may be helpful in the diagnosis.

[Ovarian vein thrombosis]. / Vena-ovaricatrombose.

A 44 year-old woman was admitted with fever and lower abdominal pain at the right side suggestive of appendicitis. Ovarian vein thrombosis was diagnosed by sonography and confirmed by contrast-enhanced CT scan. After heparinisation the complaints disappeared and fever resolved in less than 72 hours. Repeated radiological investigation showed regression of the thrombus. Ovarian vein thrombosis is an uncommon, potentially fatal disorder that can be adequately treated with medication. The cornerstone of the diagnosis consists in non-invasive radiological investigation.