Spontaneous Biliary-Enteric Fistulas and Associated Complications: An Overview.

Spontaneous biliary-enteric fistula (SBEF) is an abnormal communication between the biliary tree and the gastrointestinal tract which develops as a result of biliary or gastrointestinal disease. Iatrogenic fistulas, due to surgery or instrumental exploration, are not included in this definition. R. Colombo, in 1559, was the first to describe SBEF as an occasional finding during an autopsy. In almost 90% of cases the cause of SBEF is chronic recurrent cholelithiasis. Less common causes are penetrating peptic ulcers and neoplastic infiltration from the biliary or gastrointestinal tract. The most common type of SBEF is cholecystoduodenal fistula and the least common is choledochoduodenal fistula. There are various complications associated with SBEF but often these are not promptly recognized by patients or physicians and diagnosis and treatment may be delayed for years. The most important complication, which can be considered pathognomonic for SBEF, is gallstone ileus which manifests clinically as acute or chronic mechanical intestinal obstruction. Gallstone ileus, a rather rare complication of a rather common pathology, biliary lithiasis, is found in 0.000015% of hospitalized patients but in 0.0003% of surgical patients. It is mainly found in women over the age of 65, with a male to-female ratio of 1:5. There are various forms of occlusion, related to the sites of gallstone impaction, with various clinical characteristics and degrees of severity. These include Bouveret syndrome ( 10% of cases) with impaction in duodenum or pylorus, and the more common Barnard's syndrome (5-75% of cases) in which the site of impaction is in the terminal ileum right before Bauhin's valve. For diagnosis, the radiological signs which make up Riglerâ??s triad or tetrad, are essential, and are best visible on magnetic resonance. The the gold standard is contrast-enhanced computed tomography scan. Regarding the surgical management, one-stage simple enterolithotomy is reserved for the oldest patients and the most severe cases. Nowadays, is performed more and more frequently by laparoscopy. In more favorable cases radical treatment of the occlusion, the biliary lithiasis and the SBEF is recommended, either as a one-stage procedure or in two stages with the second procedure performed after few weeks.

Value of MRI of the hand and the wrist in evaluation of bone age: preliminary results.

PURPOSE: To evaluate bone age determination using MRI of the hand and wrist. MATERIALS AND METHODS: A total of 179 (78 female and 101 males, 11 to 16 years old) subjects of 252 normal volunteers met entrance criteria. A low field open magnet (0.2 Tesla) was used for this study; coronal T1-weighted images with a slice thickness of 1.3mm were acquired. Two blinded radiologists evaluated the studies and the following elements were considered: the appearance of cartilage, vacuolization of cartilage, provisional calcification, progression of ossification, and complete ossification. Correlation between chronologic age and MR bone age was determined by means of simple linear regression analysis. RESULTS: Strong correlation between MR skeletal age and chronological age was observed for both investigators, Pearson correlation R2 = 0.9 for each. CONCLUSION: Determination of bone age with MRI is feasible and shows good interobserver reproducibility. Data from this study may be useful to develop an atlas of skeletal development and bone age.

MR enterography: relationship between intestinal fold pattern and the clinical presentation of adult celiac disease.

PURPOSE: To correlate the clinical presentation of adult celiac disease with various intestinal fold patterns using MR-enterography. MATERIALS AND METHODS: Fifty-four consecutive adult celiac patients (34 female, 20 male, 18 to 62 years) were studied by MR-enterography. Two radiologists blinded to the patients' clinical history evaluated in consensus MR studies, classifying the intestinal fold pattern into four categories: (a) no fold abnormalities, (b) isolated loss of folds in the duodenum, (c) jejunization of ileum, and (d) jejuno-ileal fold pattern reversal. Patients presented with the varying clinical forms of Celiac disease, classified as: (i) typical disease, (ii) atypical disease, and (iii) silent form. RESULTS: Twenty-three patients showed no intestinal fold abnormalities; 11 patients had isolated loss of duodenal folds; 9 patients showed jejunization of ileum and 11 had jejuno-ileal fold pattern reversal. 18/23 (78%) patients with MRI normal fold pattern had the silent clinical form of Celiac disease (Sensitivity 78%; specificity 100%; PPV = 1, NPV = 0.78); 9/11 (82%) patients with the isolated loss of duodenal folds had the atypical clinical form (sensitivity 82%; and specificity 100%; PPV = 1; NPV = 0.82). All 20 patients with the jejunization of ileum and jejuno-ileal fold pattern reversal had typical celiac disease (sensitivity and specificity of 100%; PPV and NPV = 1). CONCLUSION: MR-enterography findings in patients with celiac disease, demonstrates good correlation between MR findings and clinical severity.

Splenic infarction, rare cause of acute abdomen, only seldom requires splenectomy. Case report and literature review.

Splenic infarction is a rare disorder, commonly without a characteristic symptomatology, that rarely requires surgical procedure; in fact it has the peculiar feature of an high tendency for complete healing after the only medical approach. Furthermore in order to prevent OPSI, only in case of clear, persistent symptoms or complications it may be necessary surgical laparoscopic or open approach. The Authors report on a recent case observed in emergency of splenic infarction with infectious complications that made the surgical procedure mandatory.

[Colon lesion for blunt trauma in the abdomen]. / Le lesioni del colon da trauma chiuso dell'addome.

Colon lesions resulting from blunt trauma in the abdomen can be defined as infrequent. Actually, they represent 3-5% of all hollow organ trauma. They present, however, serious social burden because of its prevalence in males with medium age ranging from 40 to 70 years. Study was conducted from 1971 to present at the University of Rome "La Sapienza" Institute of Clinical Emergency Surgery. 42 cases were observed in which 72% had motor vehicle accidents (with less than 1/4 of these resulting from seat belt). Numerous lesions were associated, especially in the abdomen (31), and the skull (20), both with Medium OIS 4.2. Most part of the cases was within the OIS-Class III category. The clinical parameters recorded upon admission revealed particular serious situations with average values of SAP-92 mm Hg, HR-114, RR-28, GCS-12, RTS-10.8. 17% had shock upon arrival with unsuccessful resuscitation. Ultrasound results at emergency indicated 62% with effusion/major parenchymal lesion, and 22% with severe peritonitis. 41% were treated with direct suture, 26% with resection-anastomosis, 19% with primary Hartman resection, and 14% with simple colostomy. 24% had abdominal complications including 14% sepsis, 5% hemorrhage, and 2 cases of post-surgical caval thrombus. The overall mortality was 26%. In general these lesions were frightening because of their uncertain manifestations. In most instances clinical signs related to associate lesions are overlooked, and these often present late symptoms from 24 to 48 hours. Delayed treatment for untimely diagnosis is one of the yet prevailing complications. The methods of surgical repair depend on the timing, the nature of associated lesions and, above all, eventual peritoneal contamination. The primary treatment involves surgical option actually recommended according to the EAST guideline with specific preference of reconstruction using the primary principle, and resorting to earlier interventions only in the presence of associated critical factors.

The use of high resolution magnetic resonance on 3.0-T system in solid/multicystic ameloblastoma surgical planning. Case report.

OBJECTIVES: The solid/multicystic ameloblastoma is a slowly growing, locally invasive epithelial odontogenic tumour. In 80% of cases this lesion occurs in the mandible, mainly in the posterior region, and it is characterized by the involvement of the inferior alveolar nerve. A panoramic radiograph of a 43-year-old man with chronic deep pain in the posterior area of the mandible showed a multilocular radiolucent lesion with scalloped borders in the left mandibular ramus. After the execution of a computed tomography of the jaws, to accurately determine the limits of the lesion and the relationship with the the inferior alveolar nerve, the magnetic resonance imaging was used. METHODS: The spatial relationship between the lesion and the inferior alveolar nerve was defined comparing different imaging methods: panoramic radiography, computed tomography and magnetic resonance imaging. T1-weighted fast spoiled gradient-recalled echo, T1-weighted fast imaging employing steady-state acquisition, T2-weighted interactive decomposition of water and fat with echo asymmetry least-squares estimation and Diffusion weighted imaging acquisition sequences were used on a 3.0 T unit. RESULTS: Regarding the inferior alveolar nerve course and its spatial relationship with the mandibular lesion, magnetic resonance imaging provided more detailed spatial and structural information than other imaging methods. CONCLUSION: The described acquisition sequences allowed us to highlight the diagnostic efficacy of the magnetic resonance in the morpho-structural characterization of a maxillofacial lesion and showed the importance of this imaging method as an additional technique to the computerized tomography in the maxillofacial surgical planning, resulting in a risk reduction of the inferior alveolar nerve surgical injury. KEY WORDS: Ameloblastoma, Mandibular Nerve, Magnetic Resonance Imaging, Tomography X-Ray Computed.