Barbara M. Kadell

Gray-scale ultrasonography of the jaundiced patient.

In 143 jaundiced patients, ultrasound demonstrated the extrahepatic biliary system in 38% of those with medical and 74% of those with surgical jaundice. The size of the extrahepatic biliary system indicated that surgical was best differentiated from medical jaundice when 5 mm served as the upper normal limit for the common hepatic or common bile duct in patients without prior biliary surgery. Half of those patients with prior biliary bypass surgery had nondiagnostic sonograms. In 22% of the jaundiced patients, no additional imaging procedures were performed before definitive therapy. The role of ultrasound in evaluating jaundiced patients is discussed.

Migration of Intrauterine Devices: Radiologic Findings and Implications for Patient Care

Intrauterine devices (IUDs) are a commonly used form of contraception worldwide. However, migration of the IUD from its normal position in the uterine fundus is a frequently encountered complication, varying from uterine expulsion to displacement into the endometrial canal to uterine perforation. Different sites of IUD translocation vary in terms of their clinical significance and subsequent management, and the urgency of communicating IUD migration to the clinician is likewise variable. Expulsion or intrauterine displacement of the IUD leads to decreased contraceptive efficacy and should be clearly communicated, since it warrants IUD replacement to prevent unplanned pregnancy. Embedment of the IUD into the myometrium can usually be managed in the outpatient clinical setting but occasionally requires hysteroscopic removal. Complete uterine perforation, in which the IUD is partially or completely within the peritoneal cavity, requires surgical management, and timely and direct communication with the clinician is essential in such cases. Careful evaluation for intraabdominal complications is also important, since they may warrant urgent or emergent surgical intervention. The radiologist plays an important role in the diagnosis of IUD migration and should be familiar with its appearance at multiple imaging modalities.

Esophageal motility in progressive systemic sclerosis (PSS)

The evaluation of structural and functional abnormalities of the esophagus by manometry (using perfused tubes) and cine-radiography were compared in 25 subjects with progressive systemic sclerosis (PSS). Motility by both procedures was definitely abnormal in 19 subjects and normal in 3. The remaining 3 subjects had abnormal motility on manometry, coupled with cine-esophagrams interpreted as normal. Many structural abnormalities not demonstrated by manometry were identified by cine-radiography. Therefore, the initial diagnostic examination of motility in PSS should be the cine-esophagram.

Performance of multidetector computed tomographic angiography in determining surgical resectability of pancreatic head adenocarcinoma.

Objective: To evaluate the performance of multidetector computed tomographic angiography (MDCTA) in assessing the surgical resectability of pancreatic head adenocarcinoma. Methods: With institutional review board approval, radiographic, surgical, and pathological records of 203 consecutive patients with adenocarcinoma of the pancreatic head were analyzed retrospectively. Patients were imaged with MDCT scanners using our institutions CTA pancreatic protocol. Images were compared with surgical outcomes to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MDCTA in determining resectability. Results: Data were analyzed twice, once with equivocal findings on MDCTA assumed as resectable and again with equivocal cases assumed as unresectable. All equivocal cases were ultimately unresectable; when this was assumed, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were determined to be 100%, 71%, 85%,100% and 89%. Twelve patients deemed resectable by preoperative MDCTA were found to be unresectable on surgical exploration owing to vascular involvement (n = 4), liver metastases (n = 4), and peritoneal involvement (n = 4). Conclusions: Multidetector CT angiography offers accurate and valuable preoperative assessment of surgical resectability of pancreatic ductal adenocarcinoma. Liver and peritoneal metastases and vascular invasion still remain important pitfalls in preoperative evaluation.

Congenital atypical benign chondroblastoma of a rib

Abstract Pathological examination of a congenital rib tumor showed a proliferating chondroid tumor with many features of a benign chondroblastoma. The site and occurrence in this age group was not described previously.

Angiographic demonstration of the ventricular septum. A new technic.

In the cardiac disease, idiopathic hypertrophic subaortic stenosis (IHSS) (1), there is hypertrophy of the myocardium which is often asymmetrically distributed. Although published descriptions appeared earlier, it was not until a clinical report by Brock (3) in 1957 and a pathologic report by Teare (10) in 1958 that the disease became well known. Since that time many other papers have appeared. The disease is much more common than was first realized. Most of the authors describing their cases emphasize that the often massive myocardial hypertrophy may primarily involve the ventricular septum (2, 4, 8, 10, 11), although usually the free wall of the left ventricle and sometimes the right ventricle are involved as well. Frequently the first manifestation of the disease is a heart murmur. The most common symptoms are dyspnea and angina. The patient is often asymptomatic, however. The electrocardiogram is almost always abnormal (2). At catheterization the demonstration of a pressure gradient within the left ve...

Use of MDCT to Differentiate Autoimmune Pancreatitis From Ductal Adenocarcinoma and Interstitial Pancreatitis.

OBJECTIVE The purposes of this study were to identify the most common imaging features of autoimmune pancreatitis and to evaluate the utility of MDCT for differentiating autoimmune pancreatitis from two more frequently encountered differential diagnoses--pancreatic ductal adenocarcinoma and acute interstitial pancreatitis. MATERIALS AND METHODS Dual-phase contrast-enhanced MDCT images of 91 patients (39 with autoimmune pancreatitis, 25 with pancreatic ductal adenocarcinoma, 27 with acute interstitial pancreatitis) were evaluated by two radiologists in consensus for distribution of pancreatic abnormality, sausage shape, low-attenuation halo, pancreatic duct dilatation, peripancreatic stranding, lymphadenopathy, biliary abnormality, vascular involvement, and renal lesions. Chi-square tests, multiple logistic regression analysis, and ROC analysis were performed. RESULTS The most common imaging features of autoimmune pancreatitis were sausage shape (25/39 [64%]) and low-attenuation halo (23/39 [59%]). Pancreatic duct dilatation (20/25 [80%]) and biliary dilatation (11/25 [44%]) were most frequent in pancreatic ductal adenocarcinoma. Peripancreatic stranding (22/27 [81%]) was most frequent in acute interstitial pancreatitis. Sausage shape, low-attenuation halo, and absence of a pancreatic duct or biliary dilatation differentiated autoimmune pancreatitis from pancreatic ductal adenocarcinoma with an accuracy of 0.88. Sausage shape and absence of peripancreatic stranding differentiated autoimmune pancreatitis from acute interstitial pancreatitis with an accuracy of 0.82. There was no significant difference in the frequency of vascular involvement or of lymphadenopathy among these diagnoses. CONCLUSION Typical cases of autoimmune pancreatitis can be accurately differentiated from pancreatic ductal adenocarcinoma and acute interstitial pancreatitis on the basis of characteristic MDCT features. However, autoimmune pancreatitis should be considered in the presence of atypical features.

Patient gender-related performance of nonfocused helical computed tomography in the diagnosis of acute appendicitis.

Objective To determine the impact of patient gender on the performance of helical computed tomography (CT) in the diagnosis of acute appendicitis. Materials and Methods From January 1, 1996 to December 31, 2000, 650 consecutive nonfocused helical abdominal CT scans were performed in adult patients presenting with acute lower abdominal pain. In general, most patients received both intravenous and oral contrast with 5-mm scan collimation through the lower abdomen and pelvis; details regarding technique and overall accuracy have been published previously. We subanalyzed results with respect to patient gender-related differences, especially in false-positive and false-negative cases. A &khgr;2 analysis was performed to determine if significant gender-related differences were present in major or minor CT diagnostic criteria for acute appendicitis, extra-appendiceal findings, sensitivity, specificity, and accuracy. Results Of the 650 patients, 552 had adequate clinical follow-up. The sensitivity for diagnosing acute appendicitis was 100% (65/65) in men and 93.6% (74/79) in women (P < 0.05); specificity was 96.2% (130/135) in men and 98.9% (272/275) in women (P > 0.05); and accuracy was 97.5% (193/198) in men and 97.6% in women (346/354) (P > 0.05). A thickened appendix and periappendiceal stranding were seen in 92.1% of men and 84.5% of women (P = 0.15) All 5 false-negative results were in thin women. In patients without acute appendicitis, CT was able to provide a relevant alternative diagnosis in 183 of 272 women (67.3%) and 81 of 130 men (62.3%) (P > 0.05). Conclusion Nonfocused helical CT was highly accurate for diagnosing acute appendicitis in both men and women, although there was a slight but significant decrease in sensitivity in thin women.

Hepatic metastases from breast carcinoma: comparison of noncontrast, arterial-dominant, and portal-dominant phase spiral CT.

PURPOSE The purpose of this work was to determine the relative value of noncontrast (NC), arterial-dominant (AD), and portal-dominant (PD) phase images in spiral CT of the liver for breast cancer metastases. METHOD Forty-four spiral CT scans in 18 patients with hepatic metastases from breast cancer were retrospectively reviewed by three radiologists. Subjective evaluations of overall lesion conspicuity and margination were graded on a 5 point scale for NC, AD, and PD phase images, and the three phases were also ranked for demonstration of overall tumor volume. Those scans with hypervascular lesions were separately analyzed, resulting in three groups (all, hypervascular, hypovascular). RESULTS For lesion conspicuity and margination for the entire study group, AD phase images showed the lowest grades (1.97 and 1.83), whereas the PD phase showed the highest grade (3.34 and 3.14; p < 0.0001) followed by NC (2.36 and 2.42; p < 0.0001). For the hypervascular subgroup, the AD phase also showed the lowest grades (2.39 and 2.24). In no case did the AD phase show more lesions than the combination of NC and PD phases. For depiction of overall tumor volume, the AD phase had the lowest ranking (2.51) compared with the NC and PD phases (1.71 and 1.78; p < 0.001). For the hypervascular subgroup, the AD phase had the lowest ranking (2.33) compared with the NC and PD phases (1.39 and 2.27; p < 0.0001). CONCLUSION The AD phase is not required for lesion detection in spiral CT for hepatic metastases from breast carcinoma. The NC phase depicts the maximal tumor volume.

Current Status of the Transjugular Approach for Direct Cholangiography

Excellent visualization of the biliary tree can be obtained by the transjugular technique of direct cholangiography as predictably as by the abdominal approach. However, serious complications related to biliary-venous communication have occurred. If more effective antibiotic coverage cannot be devised, the procedure would seem to be contraindicated in patients with a history of prior cholangitis.