Passage of "colonic cast" after colorectal surgery: report of four cases and review of the literature.

Anal passage of a full-thickness infarcted colonic segment (so-called "cast") not accompanied by any features of acute peritonitis is a very rare occurrence and may be the main advertising manifestation of acute colonic ischemia. Most of the reported cases of acute colonic ischemia are secondary to abdominal aortic aneurysms and ensuing inferior mesenteric artery thrombosis or to the repair of these aneurysms. The preceding events causing ischemia in other cases are Hartmann reversal, rectal resection and colonic J-pouch construction, and acute pancreatitis. In this article we present our experience on four cases of colonic cast passage, all of which developed subsequent to colorectal resection. Three of these casts are supposed to be mucosal and one is transmural. Generally, surgery is the rule and consists of the resection of the concerned ischemic segment. Every clinician should be aware of this form of presentation of bowel ischemia, not only following aneurysm surgery but also in the postoperative course of colorectal surgery.

The contributions of virtual colonoscopy to laparoscopic colorectal surgery.

BACKGROUND/AIMS: Operative tumor or polypectomy site localization and synchronous colonic lesions are challenging problems especially in laparoscopic surgery. We designed this prospective study to determine the contributions of virtual colonoscopy to laparoscopic colorectal surgery. METHODOLOGY: Virtual colonoscopy was performed in 40 consecutive patients who had undergone laparoscopic resection for colorectal neoplasm. Preoperative findings of optical colonoscopy and virtual colonoscopy, operative data, tumor localizations and histopathologic findings were assessed. RESULTS: Accuracy rates for virtual colonoscopy and optical colonoscopy were 97.5% and 55%, respectively (P<0.05). Polypectomy site was localized with virtual colonoscopy in five patients. There were nine partially obstructing tumors that did not allow optical endoscope passage. Four of six synchronous tumors (one tumor and three polyps) couldn't be shown with optical colonoscopy because of distal obstructing tumor. Histopathologic investigations revealed adenocarcinoma (n=34), adenoma demonstrating low-grade dysplasia (n=3) and high-grade dysplasia (n=2) and neuroendocrine carcinoma (n=1). Mean tumor size was 4 (1.5-10) cm. Mean proximal and distal surgical margins were 15 (5-36) cm and 7.3 (0.8-27) cm, respectively. Overall patient preference was 87.5% for virtual colonoscopy. CONCLUSIONS: Correct localization of colorectal neoplasm or polypectomy site is mandatory before laparoscopic colorectal surgery. Virtual colonoscopy is a safe, minimally invasive three-dimensional imaging method and may be an alternative localization technique.

Acute renal failure in a patient with severe hemolysis.

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disorder of bone marrow. It is characterized by blood cells lacking membrane proteins that are normally attached by the glycosylphosphatidylinositol (GPI) anchor. The cellular defect arises in a hematopoetic stem cell and is due to somatic mutation of the Phosphatidylinositol-glycan protein-A gene (PIG-A gene), encoding a protein needed for the biosynthesis of the anchor GPI. Paroxysmal nocturnal hemoglobinuria is presented by intravascular hemolysis, cytopenias, frequent infections, bone marrow hypoplasia, and a high incidence of life threatening venous thrombosis. Kidney involvement is usually benign and secondary to chronic tubular deposition of hemosiderin. Acute renal failure may occur in association with a hemolytic crisis. Here we report a case of 40-year-old woman with hematuria, pancytopenia, and acute renal failure due to PNH.

Comparison of virtual colonoscopy with conventional colonoscopy in detection of colorectal polyps.

BACKGROUND/AIMS: To determine the sensitivity and specificity of multidetector computed tomography-based virtual colonoscopy for colorectal polyp detection by using conventional colonoscopy as the reference standard. METHODS: 48 patients with high risk for colorectal cancer underwent virtual colonoscopy followed by conventional colonoscopy. Examination results were compared with conventional colonoscopy, which served as the gold standard. RESULTS: Virtual colonoscopy correctly depicted 19 of 22 polyps (sensitivity, 86%) that were detected in conventional colonoscopy. All 4 polyps that were greater than 10 mm in size (100%), 6 of 7 polyps 6-9 mm in size (85%), and 9 of 11 polyps 5 mm in size or smaller (81%) were correctly depicted with virtual colonoscopy. Virtual colonoscopy had an overall sensitivity of 86% and specificity of 98%. CONCLUSION: Multidetector computed tomography-based virtual colonoscopy has excellent sensitivity for the detection of clinically important colorectal polyps.

Radiological evaluation of internal abdominal hernias.

An internal abdominal herniation is the protrusion of a viscus through a normal or abnormal mesenteric or peritoneal aperture. Internal abdominal herniations can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. Paraduodenal hernias are the most common type of internal abdominal hernias, accounting for over one-half of reported cases, and thus are a significant clinical entity. Other internal hernias include pericecal, transmesenteric, transomental, intersigmoid, supravesical hernias and herniation through the foramen of Winslow. Because internal abdominal herniations are rare, their diagnosis remains a challenge for both the clinician and the radiologist. Symptoms of internal abdominal herniations are nonspecific. We present our experience with the radiological evaluation of internal abdominal herniations and review the main radiologic findings on barium as well as computed tomography studies.

MRCP findings of biliary ascariasis before and after medical treatment.

A 53-year-old woman presented with the complaints of abdominal pain on right upper quadrant, nausea, vomiting, diarrhea, and loss of appetite. Her physical exam was unremarkable except for right upper quadrant tenderness. Abdominal ultrasound revealed a tubular, mobile, non-shadowing echogenic structure within the slightly dilated common bile duct. Examination of feces for ova suggested the diagnosis of ascariasis. In this report, ultrasonographic and magnetic resonance cholangiopancreatographic findings of the case are described before and after medical treatment.

Gamna-Gandy bodies: a sign of portal hypertension.

Gamna-Gandy bodies (siderotic nodules) represent organized foci of hemorrhage in the spleen that is caused by portal hypertension. Gamna-Gandy bodies contain hemosiderin, fibrous tissue, and calcium. Magnetic resonance imaging has been approved as the most sensitive imaging modality for the detection of these nodules due to their iron content. Computerized tomography and ultrasonography also help in the detection and characterization of these lesions. We report here a case of portal hypertension due to cryptogenic liver cirrhosis with Gamna-Gandy bodies, and characteristic features of ultrasonography, computerized tomography and magnetic resonance.

Diffusion-weighted MR imaging findings of acute necrotizing encephalopathy.

Multiple, symmetrical brain lesions affecting the bilateral thalami and cerebral white matter, which often show a concentric structure on CT and MR images, characterize acute necrotizing encephalopathy (ANE) of childhood. We describe the imaging findings of a 2-year-old child with ANE obtained with diffusion-weighted MR imaging. We discuss the significance of these findings, as well as the pathophysiology of ANE lesions, with reference to the appearance of the disease as revealed by diffusion-weighted MR imaging.

Enteroclysis in older children and teenagers.

BACKGROUND: Enteroclysis (EC) has been widely and successfully used for evaluation of the small bowel in adults for about 30 years. However, despite recently improved intubation and examination techniques, in many paediatric radiology centres it is still not the preferred conventional barium study for the evaluation of small bowel pathology in children. OBJECTIVE: To share our 10 years of experience and review the feasibility of EC in 83 older children and teenagers, in terms of both technique and pathological findings. MATERIALS AND METHODS: Between 1996 and 2006, EC was performed by the standard technique described by Herlinger to 83 children between 7 and 18 years of age. The indication for the study was jointly decided by the paediatric radiologist and the clinician. None of the examinations was converted to follow-through studies because of patient refusal or technical failure. Morphological changes, mucosal abnormalities, luminal abnormalities, perienteric structures, the location of the disease, indirect findings regarding the bowel wall and functional information were evaluated. RESULTS: All the children tolerated the procedure without difficulty. Out of 83 patients, 63 had abnormal findings. The spectrum of diagnoses were Crohn disease (n = 23), nonspecific enteritis (n = 10), malabsorption (n = 8), intestinal tuberculosis (n = 6), intestinal lymphoma (n = 5), Peutz-Jegher syndrome (n = 3), adhesions (n = 2), Behçet disease (n = 2), back-wash ileitis due to ulcerative colitis (n = 2), common-variable immune deficiency (n = 1) and lymphangiectasis (n = 1). CONCLUSION: EC can easily be performed in children over 7 years of age and when performed using a correct technique it shows high diagnostic performance without any complications in the evaluation of small bowel diseases in older children and teenagers.

Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose.

OBJECTIVE: The purpose of our study was to determine the breast radiation dose when performing routine thoracic multidetector computed tomography (MDCT). We also evaluated dose reduction and the effect on image quality of using a bismuth breast shield when performing thoracic MDCT. MATERIAL AND METHODS: The dose reduction achievable by shielding the adult (18 years or older) female breasts was studied in 50 women who underwent routine thoracic MDCT. All examinations were performed with a 16-MDCT scanner (Sensation Cardiac 16; Siemens Medical Solutions). To compare the shielded/unshielded breast dose, the examination was performed with (right breast) and without (left breast) breast shielding in all patients. With this technique, the superficial breast doses were calculated. To determine the average glandular breast radiation dose, we imaged an anthropomorphic dosimetric phantom into which calibrated dosimeters were placed to measure the dose to breast. The phantom was imaged using the same protocol. Radiation doses to the breasts with and without the breast shielding were measured and compared using the Student t test. RESULTS: In the qualitative evaluation of the MDCT scans, all were considered to be of diagnostic quality. We did not see any differences in quality between the shielded and unshielded lung. The mean radiation doses to the breasts with the shield and to those without the shield were 8.6 +/- 2.33 versus 14.46 +/- 3.94 mGy, respectively. The breast shield enabled a 40.53% decrease in radiation dose to the breast. The difference between the dose received by the breasts with and that received by the breasts without bismuth shielding was significant, with a P value of less than 0.001. CONCLUSIONS: Bismuth in-plane shielding for routine thoracic MDCT decreased radiation dose to the breast without qualitative changes in image quality. The other radiosensitive superficial organs (eg, testes and thyroid gland) specifically must be protected with shielding.

Endovascular treatment of persistent epistaxis due to pseudoaneurysm formation of the ophthalmic artery secondary to nasogastric tube.

We present the case of a 60-year-old man with persistent epistaxis for 20 days that had started 2 weeks after removal of a nasogastric tube placed for an abdominal operation. There was no pathologic finding at selective facial and internal maxillary artery injections. An injury to the ethmoidal branches of the ophthalmic arteries or other arterial origins of bleeding was suspected. The internal carotid artery angiography revealed a pseudoaneurysm of an anterior ethmoidal branch of the left ophthalmic artery. The pseudoaneurysm was occluded with NBCA-histoacryl (25%) injection.

Primary hydatid cyst of the head and neck diagnosed with ultrasound and computed tomography: a report of two cases.

Hydatid cysts of the head and neck are rare, even in countries where echinococcal infestation is endemic. This report presents two patients with hydatid cyst, diagnosed using ultrasonography and computed tomography, in whom the cysts were located between the right cervical paravertebral muscles and below the superficial muscles of the right temporal region.

An unusual case of biliary obstruction caused by Dicrocoelium dentriticum.

Dicrocoelium dentriticum (D. dentriticum) is a liver fluke induced biliary obstruction. Infection usually occurs in herbivores such as sheep, goats and deer; human infection is very rarely encountered in clinical practice. We report on a 65-y-old female presenting with biliary obstruction caused by D. dentriticum. Following treatment with triclobendazole, her symptoms disappeared, and laboratory values returned to normal range within 6 months. Parasitosis is an important cause of biliary obstruction. We suggest that for patients presenting with biliary obstruction, D. dentriticum should be included in the differential diagnosis.

Effect of diffuse fatty infiltration of the liver on hepatic artery resistance index.

PURPOSE: This study was conducted to evaluate the effect of various degrees of diffuse fatty infiltration of the liver on the hepatic artery resistance index. METHODS: One-hundred forty subjects were examined using standard color and spectral Doppler sonography protocols. Fatty infiltration of the liver was identified and graded sonographically. The patients were grouped (n = 35 in each of 4 groups) according to the degree of diffuse fatty infiltration of the liver as follows: normal (group 1), mild (group 2), moderate (group 3), and severe (group 4). The resistance index calculated for each patient was the mean of 3 measurements. Mean resistance index of the hepatic artery was then calculated for each group. RESULTS: The mean resistance index was 0.81 +/- 0.04 for group 1, 0.79 +/- 0.06 for group 2, 0.75 +/- 0.05 for group 3, and 0.73 +/- 0.05 for group 4. We found a statistically significant (p < 0.05) decrease in resistance index when comparing groups 3 and 4 with groups 1 and 2 separately. CONCLUSIONS: Hepatic artery resistance index decreases as the severity of diffuse fatty infiltration increases.

Enteroclysis in obscure gastrointestinal system hemorrhage of small bowel origin.

BACKGROUND/AIMS: The diagnostic value of enteroclysis in patients with obscure gastrointestinal bleeding of small bowel origin was evaluated. Further diagnostic approaches in patients in whom enteroclysis did not yield a source for bleeding are discussed. METHODS: A total of 62 patients with gastrointestinal bleeding of obscure origin were retrospectively evaluated by enteroclysis. Patients in whom a specific pathology could not be identified on enteroclysis were further followed-up clinically and by laboratory examinations. Recurrent gastrointestinal bleeding had been considered an indication for further diagnostic evaluation. RESULTS: Accurate cause of the pathology which may explain the source of bleeding was achieved via enteroclysis in 29 of the patients. Of the pathologies, most were inflammatory bowel disease (n=18), followed by neoplasms (n=4), malabsorption (n=3) and miscellaneous disorders (n=4). Thirty-three patients had normal findings on enteroclysis. Six patients were diagnosed as angiodysplasia on angiography and nine patients had either gastritis or duodenitis. A final diagnosis to explain the source of bleeding could not be achieved in 18 cases. CONCLUSION: Enteroclysis provides essential information in gastrointestinal bleeding of obscure origin and its role in the diagnosis should not be undermined. Recurrent and consistent GI bleeding should be considered an indication for further diagnostic evaluation.

Endovascular treatment of a congenital dural caroticocavernous fistula.

Carotico-cavernous sinus fistula is a rare anomaly in infancy. We report a 3-month-old boy with progressive symptoms and threatened visual loss requiring urgent therapeutic intervention. Embolization using n-butyl 2-cyanoacrylate was performed with immediate and dramatic results.