Magnetic resonance imaging of degeneration of uterine adenomyosis during pregnancy and post-partum period.

Degeneration of adenomyosis during pregnancy and the post-partum period is very rare. A 42-year-old Japanese parous woman with four normal-term deliveries, who presented with abdominal pain and fever at 22 weeks of gestation with transient increases of the white blood cell count and C-reactive protein, demonstrated sustained inflammation after cesarean section at 29 weeks of gestation due to the occurrence of gestational hypertension with late deceleration. The noncontrast-enhanced magnetic resonance imaging (MRI) at 22 weeks demonstrated a poorly demarcated hypointense area at the posterior uterine wall on T1- and T2-weighted imaging. The 2nd MRI 2 weeks after the cesarean section showed hypointensity on a T1-weighted image and hyperintensity on a T2-weighted image, allowing confirmation of the diagnosis of degeneration of adenomyosis. Repeated MRIs were clinically useful to diagnose the degeneration of adenomyosis.

Subclinical growth of an arteriovenous fistula associated with renal biopsy: a case report.

BACKGROUND: Renal biopsy is not free from complications and patients who undergo this procedure are usually hospitalized to receive intensive care for several days after biopsy. In contrast, after this period, routine follow-up to detect biopsy-associated complications is rarely scheduled, unless the patient develops a clinical manifestation. We describe a case of marked enlargement of arteriovenous fistula in the kidney that occurred many years after renal biopsy. In contrast to the previous cases requiring interventional radiology, our patient showed subclinical growth of fistula over about nine years. CASE PRESENTATION: A 24-year-old man with a history of percutaneous renal biopsy was hospitalized for interventional radiology. Gross hematuria emerged shortly after biopsy, but completely disappeared with administration of hemostatic agents and bed rest. Subsequently, the patient had few symptoms for many years. A giant fistula (a gourd-shaped mass, size 26 × 22 and 12 × 11 mm) was unexpectedly detected by ultrasonography performed for examination of an unrelated disorder (slight elevation of serum transaminase) at 9 years after the original biopsy. The fistula was successfully treated with radiological intervention. Thus, subclinical development of complications associated with renal biopsy should be considered, even in an uneventful course. CONCLUSIONS: This case provides a platform to discuss the importance of long-term follow-up of patients after renal biopsy despite of its difficulty.

Spontaneous resolution of post-delivery or post-abortion uterine artery pseudoaneurysm: A report of three cases.

Post-delivery/-abortion uterine artery pseudoaneurysm (UAP) sometimes causes life-threatening bleeding, requiring transarterial embolization (TAE). It is unclear whether some UAP resolve spontaneously. In three patients, UAP resolved spontaneously without TAE. Case 1 was after vacuum delivery with slight bleeding: at day 5 post-partum, a yin-yang sign on Color Doppler and an enhanced intrauterine sac-like structure were observed, leading to the diagnosis of UAP, which disappeared at 4 weeks post-partum. Case 2 was after vacuum delivery with manual placental removal and was asymptomatic: a hypoechoic intrauterine mass with a yin-yang sign were observed during a post-partum routine check-up and the intrauterine flow disappeared at 4 weeks post-partum. Case 3 was after dilatation and curettage in the first trimester with slight bleeding: UAP was detected at 4 weeks post-abortion, which disappeared at 6 weeks post-abortion. All three cases had a small UAP (diameter: 10-15 mm) and low-level or no symptoms. Some UAP may resolve spontaneously and, thus, may not require TAE.

Intraductal papillary mucinous neoplasm penetrating to the stomach, duodenum, and jejunum demonstrated on MR cholangiopancreatography with an oral negative contrast agent.

A 65-year-old man was referred to our hospital due to epigastric pain. Abdominal enhanced computed tomography (CT) demonstrated marked dilatation of the main pancreatic duct (MPD) and communication to the gastric and duodenal lumen was suspected. Esophagogastroduodenoscopy (EGD) showed a villous tumor with white mucous discharge in the posterior wall of the gastric corpus and duodenal bulb. Pathological specimens showed mucin-producing epithelium with nuclear atypia that had developed in a papillary form. Based on these findings, we diagnosed intraductal papillary mucinous neoplasm (IPMN) arising in the MPD with penetration into the gastric and duodenal lumen. Magnetic resonance cholangiopancreatography (MRCP) with an oral negative contrast agent (manganese chloride tetrahydrate) showed a fistulous tract not only to the stomach and duodenum, but also to the jejunum. MRCP demonstrated mucous streaming with remarkably high intensity. In this case, an oral negative contrast agent was useful to distinguish mucous discharge from gastric fluid, facilitating the diagnosis of penetration to the jejunum. This finding was unobtainable by CT or EGD. When IPMN penetrating to other organs is suspected, MRCP with an oral negative contrast agent may provide important information.

Placental Insertion into the Cervix with Cervical Shortening as a Clinical Sign to Suspect Cervico-Isthmic Pregnancy: A Case Report and Literature Review.

The clinical signs of cervico-isthmic pregnancy during pregnancy remain unknown. We herein report a case of cervico-isthmic pregnancy showing placental insertion into the cervix with cervical shortening, with a final diagnosis of placenta increta at the uterine body and cervix. A 33-year-old multiparous woman with a history of cesarean section was referred to our hospital at 7 weeks of gestation with suspected cesarean scar pregnancy. Cervical shortening with a cervical length of 14 mm was noted at 13 weeks of gestation. The placenta is gradually inserted into the cervix. An ultrasonographic examination and magnetic resonance imaging strongly suggested placenta accreta. We planned elective cesarean hysterectomy at 34 weeks of gestation. The pathological diagnosis was cervico-isthmic pregnancy with placenta increta at the uterine body and cervix. In conclusion, placental insertion into the cervix with cervical shortening in the early pregnancy period may be a clinical sign to suspect cervico-isthmic pregnancy.

Sonographic findings of Sister Mary Joseph's nodule from ovarian cancer.

Sister Mary Joseph's nodule (SMJN), which is known as a malignant tumor metastasized to the umbilicus, is a rare condition. We report ultrasonic findings of SMJN secondary to ovarian cancer in a 66-year-old woman. The umbilical tumor was observed as a hypoechoic mass with punctate hyperechoic foci. A pathological specimen obtained by needle biopsy confirmed adenocarcinoma with psammoma bodies. A comparison of the ultrasonographic findings with the pathological findings of the resected specimen suggested that the hyperechoic foci corresponded to psammoma bodies. When hyperechoic foci are observed inside SMJN by ultrasonography, adenocarcinoma from ovarian cancer should be included in the differential diagnosis.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography.

BACKGROUND: Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula. AIM: To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC. METHODS: This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed. RESULTS: Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001). CONCLUSION: The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

Successful control of portal hypertension-related complications after two embolization procedures for multiple and large spontaneous portosystemic shunts in a patient with liver cirrhosis.

Liver cirrhosis is frequently complicated by spontaneous portosystemic shunt (SPSS) due to portal hypertension. Shunt embolization is considered when symptoms related to SPSSs are refractory to endoscopic and/or medical therapies. However, little information is available on the treatment of patients with multiple and large SPSS. We report a successfully managed case in which patient with such SPSS received two embolization procedures within 6 months. A 57-year-old man with alcoholic liver cirrhosis was transferred to our hospital due to a ruptured gastric varix. CT examination showed gastrorenal and splenorenal shunts of 8 mm and 11 mm in diameter, respectively. In addition, multiple hepatocellular carcinomas (HCCs) were noted. First, balloon-occluded retrograde transvenous obliteration (BRTO) was performed for the gastrorenal shunt, resulting in the disappearance of the varix, followed by transcatheter arterial chemoembolization (TACE) for HCCs. However, the hepatic encephalopathy worsened after the BRTO and TACE, and the splenorenal shunt enlarged to 18 mm in diameter. Although the shunt was tortuous and had another drainage vein, we completed the embolization for the shunt using metallic coils without any events. The patient's hepatic encephalopathy and hepatic function were ameliorated after embolization for the splenorenal shunt, and the patient was free from hepatic encephalopathy.

Posterior Reversible Encephalopathy Syndrome with Stroke in Puerperal Woman with High Titer of Anti-Phospholipid IgM Antibody.

Posterior reversible encephalopathy syndrome with stroke is very rare in puerperal women. A 36-year-old nulliparous woman with both rheumatoid arthritis and recurrent pregnancy loss, probably due to a high titer of anti-phospholipid IgM antibody, was referred at 10 weeks of gestation. Low-dose aspirin at 100 mg/day and heparin calcium subcutaneous injection at 10,000 units/day were started before pregnancy and stopped at 35+6 and 40+2 weeks, respectively. She transabdominally delivered a male infant weighing 3,344 g at 40+5 weeks. A tonic-clonic seizure abruptly occurred without either hypertension or proteinuria 5 days after delivery. Intracerebral hemorrhage involving an area of 2 cm in diameter in the right frontal lobe and subarachnoid hemorrhage with PRES were confirmed. Seizure recurred 2 days after the initial episode. She showed severe headache and mild disturbance of consciousness but no neurological findings. We suggested that a high titer of anti-phospholipid IgM antibody might be associated with stroke.

Combined assessment using optical colonoscopy and computed tomographic colonography improves the determination of tumor location and invasion depth.

INTRODUCTION: An accurate assessment of the depth of tumor invasion in patients with colon cancer is an important part of the preoperative evaluation. Whether computed tomographic colonography (CTC) or optical colonoscopy (OC) is better to accurately determine tumor location and invasion depth has not been definitively determined. The aim of this study was to determine the diagnostic accuracy of tumor localization and tumor invasion depth of colon cancer by preoperative OC alone or combined with CTC. METHODS: Study participants include 143 patients who underwent both preoperative CTC using automated CO2 insufflation and OC from July 2012 to August 2013. RESULTS: The accuracy of tumor localization was significantly better with CTC than with OC (OC, 90%; CTC, 98%; P < 0.05). No tumor in the descending colon was localized accurately via OC alone. The accuracy of tumor invasion depth was better with CTC plus OC than with OC alone (OC, 55%; CTC, 73%; P < 0.05). CONCLUSIONS: OC combined with CTC provides a more accurate preoperative determination of tumor localization and invasion depth than OC alone.

CT prediction of the degree of ovarian torsion.

PURPOSE: Torsion angle determines the incidence of necrosis among patients with ovarian torsion. The purpose of this study was to evaluate the association between torsion angle and findings on CT scan. MATERIALS AND METHODS: We retrospectively reviewed CT scan findings obtained less than 36 h before surgery for 31 patients with ovarian torsion. Ovarian torsion angles measured intraoperatively ranged from 90° to 1260°. Ovaries with torsion angles less than 360° rarely develop necrosis. Patients were divided into two groups according to torsion angle: <360° (Group A) and ≥360° (Group B). A lesion corresponding to an enlarged fallopian tube and mesovarium containing dilated veins between the uterus and twisted ovary is referred to as a "mass-like swelling". RESULTS: A mass-like swelling occurred more often in Group B (p < 0.05) and had the highest correlation with torsion angles ≥360°. A mass-like swelling lacking enhancement or a high-density area was significantly different between the groups (p < 0.05) and was also indicative of torsion angles ≥360°. CONCLUSION: A mass-like swelling alone or with a high-density area or lack of enhancement suggests an ovarian torsion angle ≥360°. The presence of these findings predict ovarian necrosis and may allow ovary-sparing treatment.

A comparative study of degree of colorectal distention with manual air insufflation or automated CO(2) insufflation at CT colonography as a preoperative examination.

OBJECTIVES: The purpose of this study was to compare the degree of colorectal distention between manual insufflation using room air and automatic insufflation using carbon dioxide for computed tomography colonography performed as a preoperative examination for patients with colon cancer. MATERIALS AND METHODS: Participants comprised 200 patients who underwent computed tomography colonography immediately after colonoscopy from October 2011-2012. The first 100 patients were examined using manual insufflation, and the remaining 100 patients were examined using automated insufflation. Two radiologists independently assessed colorectal distention using a 4-point scale in six segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. Mean scores of the two radiologists were used to analyze whether any differences existed between techniques in terms of the degree of distention per segment. RESULTS: Mean distention values for the colonic lumen were better using the automated technique than with the manual technique in both positions (p < 0.05). In segments, distention was significantly better using the automated technique than using the manual technique in the sigmoid and descending colon for prone patients, and in all segments for supine patients. CONCLUSIONS: Automated carbon dioxide insufflation offered significantly improved colorectal distention scores compared to manual room air insufflation.

Preoperative evaluation of colorectal cancer using CT colonography, MRI, and PET/CT.

Imaging studies are a major component in the evaluation of patients for the screening, staging and surveillance of colorectal cancer. This review presents commonly encountered findings in the diagnosis and staging of patients with colorectal cancer using computed tomography (CT) colonography, magnetic resonance imaging (MRI), and positron emission tomography (PET)/CT colonography. CT colonography provides important information for the preoperative assessment of T staging. Wall deformities are associated with muscular or subserosal invasion. Lymph node metastases from colorectal cancer often present with calcifications. CT is superior to detect calcified metastases. Three-dimensional CT to image the vascular anatomy facilitates laparoscopic surgery. T staging of rectal cancer by MRI is an established modality because MRI can diagnose rectal wall laminar structure. N staging in patients with colorectal cancer is still challenging using any imaging modality. MRI is more accurate than CT for the evaluation of liver metastases. PET/CT colonography is valuable in the evaluation of extra-colonic and hepatic disease. PET/CT colonography is useful for obstructing colorectal cancers that cannot be traversed colonoscopically. PET/CT colonography is able to localize synchronous colon cancers proximal to the obstruction precisely. However, there is no definite evidence to support the routine clinical use of PET/CT colonography.

Laterally spreading tumors: limitations of computed tomography colonography.

AIM: To prospectively investigate the detection rate of laterally spreading tumors (LSTs) of the colorectum by computed tomography (CT) colonography (CTC). METHODS: Patients with LSTs measuring ≥ 20 mm detected during colonoscopy were prospectively enrolled in the study. All patients underwent colonoscopy and subsequent CTC on the same day. CTC was performed using multi-detector CT without contrast in the prone and supine positions. Two radiologists blinded to the existence of LSTs read the virtual endoscopic images as well as 2-D images. LSTs were classified into granular and non-granular types based on colonoscopic appearance. RESULTS: Forty-seven pathologically proven LSTs were evaluated prospectively. Histology included adenomas in 19, mucosal cancers in 19 and T1 cancers in 9. The mean diameter of the LSTs was 35.1 mm. Twenty-eight (60%) LSTs were correctly identified by CTC, and the configuration was similar to the colonoscopic appearance in most cases. Detection rate for the granular type was significantly higher than that for the non-granular type (71% vs 31%, P = 0.013). Detection rate of adenomas was significantly lower than mucosal cancers (32% vs 79%, P = 0.008) and T1 cancers (32% vs 78%, P = 0.042). CONCLUSION: The detection rate of LSTs by CTC, particularly the non-granular type was not acceptable. Practitioners should be aware of the relatively low detection rate when using CTC.

Routine use of dual time ¹8F-FDG PET for staging of preoperative lung cancer: does it affect clinical management?

OBJECTIVE: The objective of this study was to compare the diagnostic accuracy of dual-time-point 18F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) to single-time-point (18)F-FDG PET for staging of preoperative lung cancer. METHODS: Between November 2008 and December 2009, 107 patients who were diagnosed as having lung cancer or strongly suspected of having lung cancer were enrolled. They underwent dual-time-point (18)F-FDG PET following conventional imaging. Dual-time-point (18)F-FDG PET imaging (whole body) was performed at 1-h (early) post-FDG injection and repeated (2 h delayed) after injection. The diagnostic accuracy of pre-PET staging and post-PET staging was retrospectively evaluated, and the diagnostic accuracy of dual-time-point (18)F-FDG PET was compared to that of single-time-point (18)F-FDG PET. RESULTS: In 100 patients, the early (18)F-FDG PET scan resulted in upstaging of the tumor in ten (10 %) and down-staging of the tumor in five (5 %) compared to the conventional scan. The delayed phase of (18)F-FDG PET provided no additional information on staging for lung cancer patients. The remaining seven patients were diagnosed as not having lung cancer. CONCLUSION: This study confirmed that dual-time-point (18)F-FDG PET is useful for differential diagnosis between benign and malignant lesions, but has no major impact on staging and therapeutic management of patients with pathologically proven lung cancer.

Flank pain, nausea, vomiting and hypotension in a chronic hemodialysis patient with a spontaneous perirenal hemorrhage.

Decreases in blood pressure develop in response to a wide range of clinical disorders. Various factors have been implicated in the development of hemodialysis-associated hypotension, including an impairment of the compensatory processes, an autonomic dysfunction or cardiac failure. The additional presence of concomitant acute abdomen may result in a diagnostically challenging situation. We herein report our experience with a chronic hemodialysis patient who developed severe hypotension with acute flank pain due to spontaneous bleeding around the kidney. Concerns regarding the management of the disease are also discussed.