Amorino Vecchioli

Small-Bowel Neoplasms: Prospective Evaluation of MR Enteroclysis

PURPOSE To prospectively evaluate the accuracy of magnetic resonance (MR) enteroclysis in the detection of small-bowel neoplasms in symptomatic patients, with conventional endoscopy, tissue specimen, capsule endoscopy, conventional enteroclysis, and follow-up findings as reference standards. MATERIALS AND METHODS The study protocol was approved by the human research committee, and all patients gave written informed consent. One hundred fifty patients (83 male, 67 female; mean age, 42.6 years; age range, 17-84 years) who were clinically suspected of having small-bowel neoplasm and whose previous upper and lower gastrointestinal endoscopy findings were normal underwent MR enteroclysis. The MR enteroclysis findings were prospectively evaluated for the presence of focal bowel wall thickening, small-bowel masses, and small-bowel stenosis. Positive MR enteroclysis findings were compared with histopathologic examination results obtained after surgical (n = 19) or endoscopic (n = 2) procedures. Negative MR enteroclysis results were compared with the results of enteroscopy (n = 5), capsule endoscopy (n = 53), or conventional enteroclysis with subsequent clinical follow-up (n = 71). The diagnostic performance of MR enteroclysis was analyzed on a per-patient basis. RESULTS MR enteroclysis was successfully completed in all 150 patients and enabled correct detection of 19 small-bowel neoplasms, which were confirmed at histopathologic examination: three carcinoid neoplasms, two adenocarcinomas, two stromal tumors, five lymphomas, one angiomatous mass, three small-bowel metastases, one leiomyoma, one adenoma, and one lipoma. Overall sensitivity, specificity, and accuracy in identifying patients with small-bowel lesions were 86% (19 of 22), 98% (126 of 128), and 97% (145 of 150), respectively. Two MR enteroclysis examinations yielded false-positive findings, and three yielded false-negative findings. CONCLUSION MR enteroclysis is an accurate modality for detecting small-bowel neoplasms in symptomatic patients.

MR imaging and MRCP of hilar cholangiocarcinoma

Hilar cholangiocarcinoma, or Klatskin tumor, is a primary malignancy arising from the bile duct epithelium, at the confluence of the right and left hepatic ducts, within the porta hepatis [1]. The relative incidence of cholangiocarcinoma among primary liver cancers reported in autopsy series is relatively rare, ranging from 5% to 30% [2]; however, it is the most common primary malignancy of the biliary tree [3]. Hilar cholangiocarcinoma appears most frequently in the sixth and seventh decades of life [4], but most patients with risk factors may develop the neoplasm at younger ages; men are affected more frequently than women. Risk factors for cholangiocarcinoma are primary sclerosing cholangitis, choledochal cysts, familial polyposis, congenital hepatic fibrosis, infection with Clonorchis siniensis (Chinese liver fluke), and a history of chemical and thorium dioxide exposure (Thorotrast). The prognosis is poor, with an overall 5-year survival rate of 1% [5]. Because of this poor prognosis, many patients were treated with palliative drainage rather than with surgery. However, because of technical advances in diagnostic imaging that allow for better patient selection, and because of improved surgical techniques resulting in lower operative morbidity and mortality, more patients are being treated with surgical resection. This has improved overall 5-year survival rates after surgery to 20% [6, 7]. Surgical exploration should be undertaken only when preoperative examination has shown a potential for curative resection because the risks of palliative surgery for malignant obstructive jaundice are high, with surgical mortality rates of 20–30% [8]. Further, accurate preoperative assessment of hilar cholangiocarcinoma resectability has increased its importance because percutaneous and endoscopic palliative techniques for biliary drainage are now available. For these reasons, an accurate preoperative assessment of hilar cholangiocarcinoma is critical in choosing treatment planning.

MR imaging and MR cholangiopancreatography in the preoperative evaluation of hilar cholangiocarcinoma: correlation with surgical and pathologic findings

The primary aim was to evaluate delayed contrast-enhanced MRI in depicting perineural spread of hilar cholangiocarcinoma (CCC) and consequently to determine the capability of MRI/MRCP for staging CCC. Fifteen patients that underwent MRI/MRCP and surgical treatment were retrospectively included. Two radiologists evaluated MR images to assess delayed periductal enhancement, extent of bile duct stenosis, liver parenchymal and vascular involvement and presence of liver atrophy. An agreement between delayed enhancement of the bile duct walls and perineural neoplastic spread showed a very good correlation factor (0.93). The overall accuracy in detecting biliary neoplastic invasion was higher for delayed T1-weighted images (93.3%) than for the MRCP images (80%), and T1-delayed image increased the MR accuracy in assessing the neoplastic resectability (p < 0.05). MRI correctly predicted vascular involvement in 73% and liver involvement in 80% of the cases. The number of overall correctly assessed patients with regard to resectability was 11 true positive, 1 false positive and 3 true negative. The combination of MRI/MRCP is a reliable diagnostic method for staging hilar cholangiocarcinomas. Delayed periductal enhancement is accurate in the evaluation of neoplastic perineural spread, and it can improve diagnostic accuracy to identify resectable and unresectable tumours.

Crohn disease of the small bowel : MR enteroclysis versus conventional enteroclysis

Enteroclysis has been suggested as the technique of choice for the evaluation of Crohn disease of the small intestine. Adequate distention of the entire small bowel with barium suspension allows the radiologic demonstration of mucosal abnormalities and provides functional information by defining distensibility or fixation of the small bowel loops. The principal disadvantage of conventional enteroclysis is the limited indirect information on the state of the bowel wall and extramural extension of Crohn disease, and its effectiveness may be hindered owing to overlapping bowel loops. Moreover, the radiation dose administered to patients, mostly at a young age, should be considered. Magnetic resonance (MR) enteroclysis is an emerging technique for small bowel imaging and was introduced to overcome the limitations of conventional enteroclysis and MR cross-sectional imaging by combining the advantages of both into one technique. MR enteroclysis has the potential to change how the small bowel is assessed because of the functional information, soft tissue contrast, direct multiplanar imaging capabilities, and lack of ionizing radiation.

CT findings and clinical activity in Crohn's disease

The aim of this study was to evaluate clinical correlations of CT signs in proven Crohns disease. Fifty patients were studied by means of multidetector CT. Clinical activity was assessed using Crohns disease activity index (CDAI) score and some laboratory parameters. All patients with CDAI>150 had CT study scored as pathological. Seventy-nine percent of patients with CDAI<150 showed abnormalities in CT exam. CT findings correlate with some parameters of disease activity, thus underlining the usefulness of performing CT enteroclysis in Crohns disease patients.

Multidetector CT in small-bowel neoplasms

PurposeThe aim of this study was to assess the diagnostic potential of multidetector computed tomography (MDCT) in the evaluation of small-bowel neoplasms.Materials and methodsWe studied 120 patients with suspected small-bowel disease by 16-slice MDCT after oral administration of a polyethylene glycol solution (n=56) or methylcellulose via a nasojejunal tube (n=64). Unenhanced and contrast-enhanced CT was performed. Contrast-enhanced CT images were acquired 40 s after IV injection of 130 ml of iodinated contrast agent at a rate of 3 ml/s. Multiplanar reconstructions were performed at the end of the examinations.ResultsFifteen patients were found to be affected by small-bowel neoplasm (six had non-Hodgkin’s lymphoma, three had carcinoid tumour, two had Peutz-Jeghers syndrome, two had adenocarcinoma, two had melanoma metastases, one had lipoma). In the remaining patients, 58 cases of Crohn’s disease and seven miscellaneous diseases were detected. All findings were confirmed by barium studies, surgery or endoscopy.ConclusionsMDCT performed after bowel-loop distension with low-density contrast material and IV administration of iodinated contrast agent is a reliable method for diagnosing and staging small-bowel neoplasms.RiassuntoObiettivoValutare le potenzialità diagnostiche della TC multidetettore nello studio delle neoplasie dell’intestino tenue.Materiali e metodiSono stati studiati 120 pazienti con sospetta patologia tenuale mediante TC multidetettore (16 strati) previa somministrazione di polietilenglicole per via orale (n=56) o di metilcellulosa attraverso sondino naso-digiunale (n=64). L’esame TC è stato eseguito prima e durante infusione di 130 ml di MdC iodato con flusso di 3 ml/s ed inizio delle scansioni dopo 40 secondi dall’inizio della somministrazione. Al termine dell’esame sono state effettuate ricostruzioni multiplanari.RisultatiQuindici pazienti sono risultati affetti da neoplasia dell’intestino tenue (6 pazienti con linfoma non Hodgking, 3 con carcinoide, 2 con sindrome di Peutz Jeghers, 2 con adenocarcinoma, 1 con metastasi da melanoma e 1 con lipoma). In 58 pazienti la diagnosi era di morbo di Crohn, in 7 pazienti erano presenti patologie varie. Tutti i quadri venivano confermati con studi baritati, intervento chirurgico o endoscopia.ConclusioniLa TC multidetettore effettuata previa distensione delle anse con MdC ipodenso ed infusione ev di MdC iodato è una metodica utile nella diagnosi e stadiazione delle neoplasie tenuali.

Enterography CT without and with water enema in patients with Crohn’s disease: Results from a comparative observational study in comparison with endoscopy

OBJECTIVES CT is nowadays an examination routinely performed in Crohns disease (CD) patients. However, there are several ways to assess gastro-intestinal tract, in particular colonic segments. Aim of this study is to compare enterography-CT (E-CT), performed after oral administration of polyethylene-glycol solution (PEG-CT) versus enterography-CT performed also with water enema via rectum (ECT-WE) in patients with CD. METHODS We have studied 79 patients with CD undergone to enterography-CT (42 evaluated with PEG-CT and 37 with ECT-WE) who have performed a lower endoscopy within 15 days before CT. CT results concerning large bowel were compared with endoscopic findings. Intestinal distension, discomfort of the patients, sensitivity, specificity and diagnostic accuracy were evaluated. Pearson test was used for statistical analysis. RESULTS Degree of abdominal pain was significantly higher in patients underwent to ECT-WE compared to PEG-CT. Distension of the colon was significantly greater in patients studied with ECT-WE compared to those studied with PEG-CT. Values of sensitivity, specificity and diagnostic accuracy of PEG-CT and ECT-WE were respectively 77, 86.5 and 81%, and 89, 100 and 92% in comparison with endoscopy. CONCLUSIONS In patients with CD, ECT-WE allows the evaluation of large bowel in addition to small bowel better than PEG-CT.

A Collection of Clinical Cases

A 24-year-old man with a recent onset of intermittent diarrhea, mild diffuse abdominal pain, as well as weight loss.

Radiological Diagnosis of Small-Bowel Diseases

A combination of different radiological techniques allows the correct evaluation of patients with suspected small-bowel disease, particularly Crohn’s disease and small-bowel neoplasms. Barium studies provide only indirect information on the intestinal wall and adjacent extraintestinal structures whereas with US, CT, and MRI direct visualization of the wall (thickness and structure) and adjacent extraintestinal structures (mesentery, perivisceral fibrofatty cells, lymph nodes, peritoneal spaces) is possible. In particular, CT-enteroclysis and MRI-enteroclysis show mucosal alterations and the morpho-functional characteristics of the small-bowel loops. CT findings have been shown to correlate with the clinical activity index of Crohn’s disease.