C. Alili

Adhesive Small-Bowel Obstruction: Value of CT in Identifying Findings Associated with the Effectiveness of Nonsurgical Treatment

PURPOSE To identify computed tomographic (CT) findings that are associated with the effectiveness of nonsurgical treatment in patients with adhesive small-bowel obstruction ( SBO small-bowel obstruction ) that was initially treated medically. MATERIALS AND METHODS The local institutional review board approved this retrospective study; the informed consent requirement was waived. Multi-detector row CT studies in 159 patients (64 women, 95 men; median age, 69 years) with adhesive SBO small-bowel obstruction that was initially treated medically were reviewed retrospectively and independently by two emergency radiologists to identify numerous CT findings that could be associated with the effectiveness of nonsurgical treatment. Results were compared according to the success or failure of nonsurgical treatment. Univariate statistical analyses were performed for qualitative and quantitative data, as appropriate, and each significant parameter was entered in a multivariate logistic regression analysis. The κ statistic and correlation coefficients were used to assess interobserver agreement, as appropriate. RESULTS Nonsurgical treatment succeeded in 113 patients (71%) and failed in 46 patients (29%). At univariate analysis, an anterior parietal adhesion, a feces sign, and the lack of a beak sign were associated with successful nonsurgical treatment, whereas two beak signs or more, a whirl sign, a C- or U-shaped appearance of the bowel loop, and a high degree of obstruction were associated with nonsurgical treatment failure. At multivariate analysis, fewer than two beak signs and the presence of an anterior parietal adhesion were independent predictors of the effectiveness of nonsurgical treatment, with odds ratios of 0.27 and 0.11, respectively. CONCLUSION The number of beak signs and the location of the transition zone in relation to the anterior peritoneal layer are independent signs associated with the success or failure of nonsurgical treatment.

Mechanical occlusions: Diagnostic traps and key points of the report

Management of mechanical occlusion, particularly of the small intestine, has altered considerably over recent years, with a change of paradigm and the indication for surgery depending on the cause of the occlusion and any signs of entrapment or strangulation. It is therefore important today to make a positive diagnosis of mechanical occlusion, to assess its degree, its location and its cause, and to look for signs of entrapment and strangulation. Only computer tomography can provide the answers to these different questions. The aim of this paper is to provide a reminder of the CT signs that enable us to confirm diagnosis of the various aspects of mechanical occlusion of the stomach and duodenum, small intestine or colon, to emphasize and illustrate the diagnostic traps in CT and to set out the key points of a CT report of mechanical occlusion.

Infection of the right iliac fossa.

Febrile pain in the right iliac fossa is one of the most common reasons for consulting at an emergency service. Within this framework, the main diagnosis that is considered is appendicitis, the main complication of which is perforation. However, a certain number of other conditions can be responsible for this clinical picture, primarily including digestive tract and mesentery disorders including mesenteric lymphadenitis, Crohns disease, infectious enterocolitis, small intestine or colonic diverticulitis, ischaemic colitis or cancer of the caecum. This article illustrates the imaging semiology of the various right colonic, iliac, mesenteric and appendicular conditions that could potentially cause an infection of the right iliac fossa. It specifies the indications of ultrasound and CT scans, respectively, which depend on the age of the patient and the clinical signs and symptoms. Though the CT scan is commonly used in abdominal emergencies in general, and particularly in clinical pictures of infection of the right iliac fossa, ultrasound remains recommended as first line imaging when confronted with suspected appendicitis or lymphadenitis in a young subject or in the monitoring of Crohns disease.

Transient high density vertebral bone lesions

The contrast-enhanced CTexamination revealed sclerotic-like lesions associated with consecutive anterior and posterior elements from the fourth cervical vertebra to the fifth thoracic vertebra, without any lytic components, which could at first be considered as bony metastases (Fig. 1a–b). CT scan also highlighted significant collateral venous circulation secondary to a brachiocephalic left venous thrombosis. A PET-CT performed at the same time was negative. A non-contrast CT scan performed 10 days later did not reveal the initially noted bone lesions (Fig. 2a–b) and suggested diagnosis of intraosseous venous contrast media. The 1-year non-contrast CT follow-up did not show any progression of the disease. Given the lack of corresponding findings on the unenhanced CT, in the setting of central venous obstruction and collateral pathway formation, the high-attenuation lesions seen on the enhanced CTexamination can be explained by the presence of intraosseous venous collaterals. In fact, the left brachiocephalic vein obstruction was responsible for the development of an extensive collateral venous pathway (Fig. 2c–d) involving the mediastinum, anterior jugular veins, anterior, and basivertebral venous plexi. The venous pressure in the dilated capillaries allowed marrow enhancement through the anastomosis capillary sites: basivertebral veins bed (between the anterior external plexus and the posterior internal plexi) and pedicular sites (between the intervertebral veins and the vertebral plexi) (Fig. 3a–b). Our patient remained asymptomatic despite the huge collateral venous substitution. The rate of injection of contrast and the time of image acquisition following contrast injection might be factors influencing the appearance of these findings. Chest collateral veins usually occur in superior vena cava obstruction and then develop through four classic pathways: azygos and hemiazygos, internal thoracic and laterothoracic, superficial thoracoabdominal, and vertebral venous plexus (posterior way) [1, 2]. These patients usually present with a symptomatic superior vena cava syndrome [3]. Less frequently, chest collateral veins can develop secondary to unilateral thrombosis of the brachiocephalic venous trunk, as in our case where the posterior pathway was involved [4]. Several cases of visceral abnormalities related to superior vena cava syndrome, including pericardial and hepatic enhancement, have been described [5]. However, bone involvement is uncommon. Only, two cases of cervical vertebral bone high-density abnormalities have been described in the context of superior vena cava syndrome secondary to a mediastinal mass (epidermoid lung carcinoma and small-cell lung carcinoma) [6, 7]. To our knowledge, there are no reports of similar cases of vertebral marrow abnormalities in asymptomatic patients, without any mass syndrome or obstructed superior cava vein. In the case presented, the findings could be misinterpreted as lymphomatous bone marrow involvement because of the patient’s history even though bony features of osseous lymphoma are usually lytic and seldom sclerotic, with soft tissue involvement. In summary, the present case illustrates a benign lesion entity related to retrograde contrast filling in bone marrow. The case presentation can be found at doi: 10.1007/s00256-013-1619-2

Correlation between MR imaging – prognosis factors and molecular classification of breast cancers

The molecular classification of breast cancers defines subgroups of cancer with different prognoses and treatments. Each molecular type representing the intrinsic signature of the cancer corresponds to a histological profile incorporating hormone receptors, HER2 status and the proliferation index. This article describes the correlations between this molecular classification obtained in routine clinical practice using histological parameters and MRI. It shows that there is a specific MRI profile for triple-negative cancers: distinct demarcation, regular edges, hyperintensity on T2 weighted signals and, particularly, a crown enhancement. It is important for the radiologist to understand this molecular classification, firstly because of the relatively suggestive appearance of triple-negative basal-like cancers in the molecular classification, secondly, and particularly, as cancers in patients with the BRCA1 mutation are often triple-negative meaning that the criteria for reading the MRI needs to be tailored to this feature of the cancers, and finally because the efficacy of MRI in assessing response to neoadjuvant chemotherapy depends on the molecular class of cancer treated.