Ann S. Fulcher

Liver regeneration and function in donor and recipient after right lobe adult to adult living donor liver transplantation

BACKGROUND Regeneration of the liver to a predetermined size after resection or transplantation is a well described phenomenon, but the time course over which these events occur has not been well defined. It is not clear how initial liver mass, reperfusion, immunosuppression, or steatosis influence this process. METHODS Liver regeneration was assessed prospectively by volumetric magnetic resonance imaging (MRI) in living right lobe liver donors and the recipients of these grafts. Imaging was performed at regular intervals through 60 days after resection/transplantation, and liver mass was determined. Liver function tests and synthetic function were monitored throughout the study period in donors and recipients of these grafts as well as recipients of cadaveric grafts. RESULTS MRI consistently overestimated liver mass by a mean of 45 g (+/-65) (range 10-123). Donor liver mass increased by 101%, 110%, 115%, and 144% at 7, 14, 30, and 60 days after resection, respectively. Recipient liver mass increased by 87,101, 119, and 99% at 7, 14, 30, and 60 days after transplantation, respectively. Steatosis did not influence the degree of regeneration or graft function, nor was there a functional difference between grafts of >1% graft to recipient body weight ratio or <1%. CONCLUSIONS MRI accurately determines right lobe mass. Most liver regeneration occurs in the 1st week after resection or transplantation, and the time course does not differ significantly in donors or recipients. The mass of the graft or remnant segment affects the duration of the regeneration process, with a smaller initial liver mass prolonging the course. Steatosis of <30% had no bearing on liver function or regeneration and, therefore, should not be an absolute criterion for exclusion of donors. A calculated graft to recipient body weight ratio of 0.8% is adequate for right lobe living donor liver transplantation.

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings.

BACKGROUND The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications. METHODS Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10). RESULTS Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients. CONCLUSIONS MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.

Aneurysms of the portal vein and superior mesenteric vein

Abstract. Only scattered reports of portal vein and superior mesenteric vein aneurysms appear in the literature. Case reports of three patients with portal vein and superior mesenteric vein aneurysms diagnosed by computed tomography (CT) and gray-scale, color Doppler, and duplex Doppler sonography are presented. In one case, an isolated portal vein aneurysm was demonstrated. In the second case, an aneurysm of the portal vein and superior mesenteric vein resulting in biliary ductal dilatation was observed. In the third case, an isolated superior mesenteric vein aneurysm was found. None of the patients had a history or clinical evidence of underlying liver disease, pancreatitis, or other disease states that would predispose them to the development of aneurysms. The clinical presentations, possible etiologies, and imaging features of portal vein and superior mesenteric vein aneurysms are reviewed. The value of CT and sonography in the detection and characterization of these rare aneurysms is discussed.

Thoracopancreatic fistula: clinical and imaging findings.

PURPOSE The goal of this work was to describe the clinical and imaging features of thoracopancreatic fistula, a rare complication of pancreatitis. METHOD Nine cases of thoracopancreatic fistula proved by thoracentesis, endoscopic retrograde cholangiopancreatography (ERCP), or surgery were retrospectively and independently reviewed by two abdominal radiologists. All available imaging examinations [chest radiographs = 9, CT = 9, MR and MR cholangiopancreatography (MRCP) = 2, and ERCP = 6] were analyzed, and findings were recorded on a standardized datasheet. Available medical records (n = 7) were reviewed to determine the clinical presentation of the patients and thoracentesis results. RESULTS Seven of the nine patients presented with pulmonary symptoms such as dyspnea or cough. Of the seven patients with pleural fluid analysis, all demonstrated elevated amylase levels (mean 13,007 U/L). Imaging examinations revealed pancreaticopleural fistulas in six patients, a mediastinal pseudocyst in one patient, and both a pancreaticopleural fistula and a mediastinal pseudocyst in two patients. Chest radiography showed pleural fluid collections in eight patients. CT demonstrated a fluid-containing fistula in all nine patients. MR and MRCP depicted a fistula extending from the abdomen to the pleural space in the two patients with MR correlation. ERCP showed pancreatic ductal changes characteristic of chronic pancreatitis in the six patients with ERCP correlation but failed to demonstrate the fistula in two of the six patients. CONCLUSION The CT, MR, MRCP, or ERCP finding of a fluid-filled tract extending from the pancreas to the thorax is characteristic of a thoracopancreatic fistula, particularly when identified in a patient who presents with pulmonary symptoms and a history of chronic pancreatitis.

Congenital Anomalies and Normal Variants of the Pancreaticobiliary Tract and the Pancreas in Adults: Part 2, Pancreatic Duct and Pancreas

OBJECTIVE The purpose of this article is to highlight the imaging features of congenital anomalies and normal variants of the pancreatic duct and the pancreas using contemporary imaging techniques such as MR cholangiopancreatography (MRCP), MRI, and helical CT. CONCLUSION Congenital anomalies and normal variants of the pancreatic duct and the pancreas may be clinically significant and may create a diagnostic challenge. Recognition of the updated imaging features of these entities is important in clinical management and for avoiding misdiagnosis.

Pitfalls of Mr Cholangiopancreatography (mrcp)

MR cholangiopancreatography (MRCP) represents a relatively new development in MR technology that provides a noninvasive alternative to endoscopic retrograde cholangiopancreatography for evaluating pancreaticobiliary tract disease. Although the accuracy of MRCP has been documented in the diagnosis of a variety of diseases including choledocholithiasis and malignancy, pitfalls associated with this technique may result in diagnostic errors. This essay illustrates both technical and interpretive pitfalls of MRCP and suggests strategies for their recognition and avoidance.

Leiomyomatosis peritonealis disseminata complicated by sarcomatous transformation and ovarian torsion: presentation of two cases and review of the literature

Abstract. Leiomyomatosis peritonealis disseminata (LPD) is a rare disorder usually discovered incidentally in women of child-bearing age and is characterized by multiple subperitoneal smooth muscle nodules. Case reports of two patients with complications related to LPD and a review of the literature are presented. In one case, the patient carried the diagnosis of LPD for 11 years and experienced sarcomatous transformation; this is the first report of the magnetic resonance appearance of this entity. In the second case, LPD was diagnosed after an LPD implant on the ovary-induced ovarian torsion. We also present a patient in whom large, pedunculated uterine leiomyomas mimicked LPD. The clinical presentation, possible pathogenesis, imaging features, and therapeutic options of LPD are reviewed. Because this uncommon condition is being reported with increasing frequency, familiarity with its imaging features and pitfalls is important to suggest the diagnosis in the appropriate clinical setting.

Abdominal Imaging Features of HELLP Syndrome: A 10-Year Retrospective Review

OBJECTIVE The purpose of this study was to describe the abdominal imaging features associated with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, a complication of pregnancy. CONCLUSION The abdominal imaging features of HELLP syndrome include intraparenchymal and perihepatic hematomas and hemoperitoneum as noted on sonography, CT, and angiography.

Non‐Resective Ablation and Liver Transplantation in Patients with Cirrhosis and Hepatocellular Carcinoma (HCC): Safety and Efficacy

We investigated the efficacy of nonresective ablation techniques and the tumor‐free survival of cirrhotic patients undergoing liver transplantation for hepatocellular carcinoma (HCC). In group 1, 11 HCC patients were treated with these techniques and transplanted. On the waiting list, patients were treated to complete ablation, judged by gadolinium‐enhanced MRI and alpha‐fetoprotein (AFP) levels. Group 1 was compared with a concurrent group of 10 liver transplant patients (group 2) with incidental HCC (stages T1  three patients, T2  seven patients). The group 1 patients received 36 procedures (4 alcohol ablations, 14 trans ‐hepatic artery chemo‐embolizations, 15 trans ‐hepatic chemo‐infusions, and 3 radio frequency ablations) for treatment of 13 liver masses. Tumor‐node‐metastasis (TNM) stage was reduced in eight patients (72.7%), unchanged in two patients and increased in one patient before transplantation. The mean waiting time for transplantation was 12.9  7.6 months. Both groups had a tumor‐free survival of 100%, at 30  12 months post transplant. On pathology, 54.5% of explanted livers had residual viable HCC after tumor treatment, and 36.4% (4/11) explants had synchronous lesions. Non‐resective ablation therapy is safe and effective in reducing the HCC progression in cirrhotic patients awaiting liver transplantation. The cancer‐free survival rate in this treatment group is equal to that for incidental T1–T2 HCCs.

Blunt bowel and mesenteric injury: MDCT diagnosis.

Multidetector computed tomography (MDCT) has emerged as the imaging modality of choice for evaluating the abdomen and pelvis in trauma patients. MDCT readily detects injury of the solid organs as well as direct and indirect features of bowel and/or mesenteric injury—an important advance given that unrecognized bowel and mesenteric injuries may result in high morbidity and mortality. Nonetheless, challenges persist in the interpretation of abdominal and pelvic CT images in trauma patients. Difficulty in interpretation may result from lack of familiarity with or misunderstanding of CT features of bowel and/or mesenteric injury. Moreover, due to major technical advances afforded by MDCT, new CT features of bowel and/or mesenteric injuries have been recognized. Beading and termination of mesenteric vessels indicating surgically important mesenteric injury is an example of one of these new features. MDCT also allows for the detection of small or trace amounts of isolated intraperitoneal fluid in trauma patients, although the clinical management of these patients is still controversial. This pictorial essay illustrates the spectrum of typical, atypical, and newly reported MDCT features of bowel and mesenteric injuries due to blunt trauma. The features that help to differentiate these injuries from pitfalls are emphasized in these proven cases.