Alfonso Reginelli

Gastrointestinal Disorders in Elderly Patients

Gastrointestinal disorders are common in elderly patients, and the clinical presentation, complications, and management may differ from those in younger patient. Most impairment occurs in the proximal and distal tract of the gastrointestinal system. Swallowing abnormalities with a wide span of symptoms and pelvic floor pathologies involving all the pelvic compartments are common. Acute abdomen, often from small bowel obstruction or mesenteric ischemia, can pose a diagnostic challenge, because a mild clinical presentation may hide serious visceral involvement. In this setting, the radiologist often is asked to suggest the appropriate management options and to guide the management.

Errors in the radiological evaluation of the alimentary tract: part II.

Plain abdominal radiography and computed tomographic (CT) enteroclysis are 2 essential radiological investigations in the study of gastrointestinal tract. Errors in patient preparation, execution, and interpretation may lead to severe consequences in the diagnosis and thus in patient outcome. Abdominal radiography is one of the most frequently requested radiographic examinations, and has an established role in the assessment of the acute abdomen. CT enteroclysis has revolutionized the assessment of small-bowel pathology, especially in patients with inflammatory bowel. The purpose of this article is to describe the pitfalls in the execution and interpretation of plain abdominal film and CT enteroclysis.

Intestinal Ischemia: US-CT findings correlations

BackgroundIntestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.MethodsBasing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).ResultsTo make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.ConclusionAt present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Mesenteric ischemia: the importance of differential diagnosis for the surgeon

BackgroundIntestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.MethodsBasing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated, in particular trought the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).ResultsTo make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial, venous) and non occlusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.ConclusionThe radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment.

Gastrointestinal perforation: ultrasonographic diagnosis

Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women.

Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature

BackgroundTo evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.MethodsThe authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.ResultsSonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.ConclusionsUS is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.

Combined videofluoroscopy and manometry in the diagnosis of oropharyngeal dysphagia: examination technique and preliminary experience

PurposeDysphagia is a symptom of different pathological conditions characterised by alteration of the swallowing mechanism, which may manifest at different levels. We report our experience in the evaluation of the swallowing mechanism with combined videofluoroscopy and manometric recordings.Materials and methodsFor the combined study, we used a Dyno Compact computerised system (Menfis Biomedical s.r.l., Bologna, Italy) equipped with: (1) graphics card for the management of ultrasonographic or radiological images; (2) A.VI.U.S. dedicated software package, which enables digital-quality recording (PAL/NTSC, composite video or S-Video) of the videofluoroscopy study in AVI format with 320×240 resolution and 25 Hz acquisition frequency. The delay introduced by the process of image digitalisation is in the order of 200 ms, so for analysis purposes, the images can be considered synchronised with the manometric recordings. The videomanometry study was performed with the administration of contrast material either in bolus form or diluted. Data were collected on a specifically designed grid for the evaluation of 46 videofluoroscopic items, of which 34 are derived from the laterolateral view (seven in the oral preparatory phase, 15 in the oral transport phase and 12 in the pharyngeal phase) and 12 in the anteroposterior view (six in the oral preparatory phase and six in the oropharyngeal phase). A positive finding for the individual parameters is expressed in a binary fashion. Manometric evaluation was based on 11 items divided into four major and seven minor criteria.ResultsDynamic videofluoroscopy swallow study combined with concurrent manometry enabled the simultaneous recording of anatomical alterations and the functional data of oropharyngeal pressure, thus providing a picture of the anatomical, biomechanical and physiological conditions of swallowing and the manner of bolus propulsion and transit.ConclusionsAn early and effective diagnosis of oropharyngeal dysphagia means being able to effectively implement appropriate rehabilitation techniques, improve the patient’s quality of life, and minimise the complications associated with swallowing disorders (choking, aspiration pneumonia, malnourishment). Distinction of the anatomical level of dysphagia is not a matter of simple classification; rather, it is essential in that different clinical presentations require different diagnostic strategies, and a precise definition of the anatomical-functional substrate is required to implement the correct therapeutic approach. This study presents the authors’ experience with the use of combined videofluoroscopy and manometry with particular emphasis on the examination technique.RiassuntoObiettivoLa disfagia è un sintomo sotteso da differenti quadri patologici, in cui si verifica un’alterazione del meccanismo deglutitorio, che può estrinsecarsi a vari livelli. Gli autori riportano la loro esperienza nella valutazione del meccanismo della deglutizione mediante l’integrazione diagnostica combinata manometrica e videofluoroscopica.Materiali e metodiPer lo studio combinato è stato impiegato il sistema computerizzato “Dyno Compact” (Menfis Biomedical s.r.l., Bologna, Italia) dotato di: 1) scheda grafica per la gestione di immagini ecografiche o radiografiche; 2) A.VI.U.S. software dedicato, attraverso il quale è possibile registrare in qualità digitale (PAL/NTSC, video composito o S-Video) la videofluoroscopia, in filmati AVI con risoluzione 320×240 e con frequenza di acquisizione di 25 Hz; il ritardo introdotto dal processo di digitalizzazione dell’immagine è dell’ordine dei 200 ms, quindi, ai fini dell’analisi, l’immagine si può considerare sincronizzata con i tracciati pressori. Lo studio VFS è stato effettuato mediante somministrazione di boli adeguati di mezzo di contrasto opportunamente diluito. I dati vengono raccolti su una griglia precostituita per la valutazione di 46 items videofluoroscopici, di cui 34 derivano dallo studio in proiezione latero-laterale (7 in fase buccale, 15 in fase orale e 12 in fase faringea) e 12 dallo studio in proiezione antero-posteriore (6 in fase buccale e 6 in fase orofaringea); la positività ai singoli parametri è espressa in maniera binaria. La valutazione pressoria si basa su 11 sialoritems manometrici, a loro volta divisi in 4 criteri maggiori e 7 minoriRisultatiLa valutazione fluoroscopica dinamica della deglutizione con registrazione video abbinata alla manometria simultanea, ha permesso di registrare contemporaneamente le alterazioni anatomiche correlandole al dato funzionale della pressione orofaringea, consentendo durante la medesima registrazione di valutare la situazione anatomica, biomeccanica e fisiologica della deglutizione e le modalità di propulsione e transito del bolo.ConclusioniFare precocemente una buona diagnosi di disfagia orofaringea significa poter intervenire efficacemente con tecniche riabilitative logopediche, migliorare la qualità di vita del paziente, nonché ridurre al minimo le complicanze che questa comporta (soffocamento, polmonite ab ingestis, malnutrizione). La differenziazione del livello anatomico della disfagia non riveste una semplice categorizzazione, ma è indispensabile in quanto alla diversità di presentazione clinica corrisponde un differente approccio metodologico diagnostico, ed a una precisa definizione del substrato anatomo-funzionale responsabile del sintomo, corrisponde un diverso approccio terapeutico. Gli autori con il presente contributo presentano la loro esperienza nell’impiego della videofluoromanometria ed in particolare la metodologia di conduzione dell’esame.

Three-dimensional anal endosonography in depicting anal-canal anatomy.

PurposeThis report describes the advantages of 3D anal endosonography in depicting the normal anatomy of the anal canal in relation to sex and age.Materials and methodsA retrospective study was performed of 85 patients, 33 men and 52 women, previously examined with 3D anal ultrasound (US) for clinically suspected anorectal disease but found to be negative. The examinations were performed with a Bruel and Kjaer US system with a 2050 transducer, scanning from the anorectal junction to the subcutaneous portion of the external anal sphincter (EAS). The 3D reconstructions provided an estimation of sphincter length in the anterior and posterior planes, and axial 2D images enabled calculation of the thickness of the internal anal sphincter (IAS) and EAS in the anterior, posterior and lateral transverse planes.ResultsDistribution of the sphincter complex is asymmetric in both sexes: the EAS and IAS are significantly shorter in females, especially in the anterior longitudinal plane (p=0.005 and p<0.001, respectively). EAS and IAS thickness increases with age, especially the lateral IAS (R2=0.37, p<0.001) and the posterior EAS (R2=0.29, p=0.01).ConclusionsA good knowledge of anal-canal anatomy is essential to detect sphincter abnormalities when assessing pelvic floor dysfunction.RiassuntoObiettivoScopo del presente lavoro è stato documentare la rappresentazione anatomica normale del canale anale attraverso l’ultrasonografia (US) endoanale 3D, in relazione al sesso e all’età.Materiali e metodiIn uno studio retrospettivo sono stati selezionati 85 soggetti, di cui 33 maschi e 52 femmine, sottoposti precedentemente ad US endoanale 3D per sospetto clinico di patologia dell’ano-retto distale ma risultati essere tutti negativi all’esame ultrasonografico. Gli esami sono stati eseguiti con apparecchio dedicato Bruel e Kjaer, con trasduttore tipo 2050 e scansioni dalla giunzione ano-rettale alla porzione più superficiale dello sfintere anale esterno (SAE). Nell’immediato postprocessing sono stati stimati la lunghezza degli sfinteri nei piani anteriore e posteriore e lo spessore anteriore, laterale e posteriore dello sfintere anale interno (SAI) e del SAE.RisultatiLa distribuzione della muscolatura del canale anale risulta asimmetrica in entrambi i sessi: la lunghezza di SAI e SAE è significativamente più breve nelle donne, specie lungo il piano longitudinale mediano anteriore (p=0,005 e p<0,001, rispettivamente). Inoltre, lo spessore di entrambi gli sfinteri presenta una tendenza all’accrescimento proporzionale all’età del paziente, soprattutto nella porzione laterale per il SAI (R2=0,37, p<0,001) e posteriore per il SAE (R2=0,29, p=0,01).ConclusioniLa conoscenza precisa delle componenti anatomiche muscolo-legamentose del canale anale è alla base della identificazione delle alterazioni sfinteriali utili alla comprensione dei disturbi del pavimento pelvico.

Ankle impingement: a review of multimodality imaging approach

Ankle impingement is defined as entrapment of an anatomic structure that leads to pain and decreased range of motion of the ankle and can be classified as either soft tissue or osseous (Bassett et al. in J Bone Joint Surg Am 72:55–59, 1990). The impingement syndromes of the ankle are a group of painful disorders that limit full range of movement. Symptoms are due to compression of soft-tissues or osseous structures during particular movements (Ogilvie-Harris et al. in Arthroscopy 13:564–574, 1997). Osseous impingement can result from spur formation along the anterior margin of the distal tibia and talus or as a result of a prominent posterolateral talar process, the os trigonum. Soft-tissue impingement usually results from scarring and fibrosis associated with synovial, capsular, or ligamentous injury. Soft-tissue impingement most often occurs in the anterolateral gutter, the medial ankle, or in the region of the syndesmosis (Van den Bekerom and Raven in Knee Surg Sports Traumatol Arthrosc 15:465–471, 2007). The main impingement syndromes are anterolateral, anterior, anteromedial, posterior, and posteromedial impingement. These conditions arise from initial ankle injuries, which, in the subacute or chronic situation, lead to development of abnormal osseous and soft-tissue thickening within the ankle joint. The relative contributions of the osseous and soft-tissue abnormalities are variable, but whatever component is dominant there is physical impingement and painful limitation of ankle movement. Conventional radiography is usually the first imaging technique performer and allows assessment of any potential bone abnormality, particularly in anterior and posterior impingement. Computed tomography (CT) and isotope bone scanning have been largely superseded by magnetic resonance (MR) imaging. MR imaging can demonstrate osseous and soft-tissue edema in anterior or posterior impingement. MR imaging is the most useful imaging modality in evaluating suspected soft-tissue impingement or in excluding other ankle pathology such as an osteochondral lesion of the talus. MR imaging can reveal evidence of previous ligamentous injury and also can demonstrate thickened synovium, fibrosis, or adjacent reactive soft-tissue edema. Studies of conventional MR imaging have produced conflicting sensitivities and specificities in assessment of anterolateral impingement. CT and MR arthrographic techniques allow the most accurate assessment of the capsular recesses, albeit with important limitations in diagnosis of clinical impingement syndromes. In the majority of cases, ankle impingement is treated with conservative measures, with surgical debridement via arthroscopy or an open procedure reserved for patients who have refractory symptoms. In this article, we describe the clinical and potential imaging features, for the four main impingement syndromes of the ankle: anterolateral, anterior, anteromedial, posterior, and posteromedial impingement.

Magnetic resonance imaging in the evaluation of anatomical risk factors for pediatric obstructive sleep apnoea–hypopnoea: A pilot study

OBJECTIVE Aim of our study was to identify anatomical risk factors involved in the development of pediatric OSAHS through a MRI-based case-control pilot study. METHODS MRI exams of the head and neck of 40 children affected by OSAHS were retrospectively evaluated. 25 indices referring to the air lumen, soft tissues and craniofacial skeleton were measured. Subsequently, the same process of measurement of indices was performed on MRI exams of 40 controls. For each index, then, we calculated in both groups mean, standard deviation, standard error and t value. Comparing the two series we finally calculated the degree of significance of each difference between children with OSAHS and controls through the Students t-test. RESULTS Besides the expected and previously described differences of minimum retropharyngeal cross-sectional area (CSA), nasopharyngeal airway, combined upper airway volume, tonsillar and adenoid cross-sectional and volumetric indices, we found a higher midsagittal CSA of the soft palate and lower position of the hyoid bone, SNB angle and mandibular volume. CONCLUSIONS Results from our study population, certainly limited in terms of number of patients and considered age range, showed that not only adeno-tonsillar hypertrophy is important in determining the clinical syndrome: soft palate enlargement and certain skeletal pattern can even assume greater importance in the genesis and in the progression of the obstruction. MRI proved to be an accurate technique in the evaluation of the prevalent risk factor in children affected by OSAHS, leading to the most appropriate surgical approach.