Chang-Hsien Liu

Strangulated transmesosigmoid hernia: CT diagnosis

We present a rare case of strangulated closed loop small bowel obstruction secondary to a trans-mesosigmoid hernia to emphasize the diagnostic role of computed tomography in patients with no history of previous surgery. The characteristic computed tomographic features showed a cluster of dilated, fluid-filled, U- and C-shaped loops of small bowel entrapped the left posterior and lateral to the sigmoid colon through a defect in the mesosigmoid, which caused anterior and medial displacement of the sigmoid colon.

The value of multidetector-row computed tomography for localization of obscure acute gastrointestinal bleeding ☆

PURPOSE There are no simple guidelines on when to perform multidetector-row computed tomography (MDCT) for diagnosis of obscure acute gastrointestinal bleeding (AGIB). We used a risk scoring system to evaluate the diagnostic power of MDCT for patients with obscure AGIB. MATERIALS AND METHODS Ninety-two patients with obscure AGIB who were referred for an MDCT scan after unsuccessful endoscopic treatment at presentation were studied. We recorded clinical data and calculated Blatchford score for each patient. Patients who required transfusion more than 500mL of blood to maintain the vital signs were classified as high-risk patients. Two radiologists independently reviewed and categorized MDCT signs of obscure AGIB. Discordant findings were resolved by consensus. One-way ANOVA was used to compare clinical data between two groups; kappa statistics were used to estimate agreement on MDCT findings between radiologists. RESULTS Of the 92 patients, 62 (67.4%) were classified as high-risk patients. Blatchford scores of high-risk patients were significantly greater than those of low-risk patients. Sensitivity for MDCT diagnosing obscure AGIB was 81% in high-risk patients, as compared with 50% in the low-risk. When used in conjunction with selection of the cut-off value of 13 in Blatchford scoring system, the sensitivity and specificity of MDCT were 70.9% and 73.7%, respectively. Contrast extravasation was the most specific sign of AGIB (k=.87), recognition of which would have improved diagnostic accuracy. CONCLUSIONS With the aid of Blatchford scoring system for evaluating the disease severity, MDCT can localize the bleeders of obscure AGIB more efficiently.

Unusual Complication of Superior Mesenteric Artery Syndrome: Spontaneous Upper Gastrointestinal Bleeding with Hypovolemic Shock

Superior mesenteric artery (SMA) syndrome is an unusual form of duodenal obstruction. Complications of SMA syndrome may sometimes develop and are usually associated with marked gastric dilatation, although most complications can be corrected by supportive treatment. In this article, we report a case of severe SMA syndrome with hypovolemic shock in a 24-year-old man. Multidetector-row computed tomography with reconstructed images was performed to establish the diagnosis. Spontaneous gastrointestinal bleeding is an extremely uncommon complication of SMA syndrome, and emergent surgical intervention was unavoidable in our patient. To our knowledge, no other such case has been reported in the English-language literature.

Intra-Arterial Treatment in Patients with Acute Massive Gastrointestinal Bleeding after Endoscopic Failure: Comparisons between Positive versus Negative Contrast Extravasation Groups

Objective To determine whether treatment outcome is associated with visualization of contrast extravasation in patients with acute massive gastrointestinal bleeding after endoscopic failure. Materials and Methods From January 2007 to December 2009, patients that experienced a first attack of acute gastrointestinal bleeding after failure of initial endoscopy were referred to our interventional department for intra-arterial treatment. We enrolled 79 patients and divided them into two groups: positive and negative extravasation. For positive extravasation, patients were treated by coil embolization; and in negative extravasation, patients were treated with intra-arterial vasopressin infusion. The two groups were compared for clinical parameters, hemodynamics, laboratory findings, endoscopic characteristics, and mortality rates. Results Forty-eight patients had detectable contrast extravasation (positive extravasation), while 31 patients did not (negative extravasation). Fifty-six patients survived from this bleeding episode (overall clinical success rate, 71%). An elevation of hemoglobin level was observed in the both two groups; significantly greater in the positive extravasation group compared to the negative extravasation group. Although these patients were all at high risk of dying, the 90-day mortality rate was significantly lower in the positive extravasation than in the negative extravasation (20% versus 42%, p < 0.05). A multivariate analysis suggested that successful hemostasis (odds ratio [OR] = 28.66) is the most important predictor affecting the mortality in the two groups of patients. Conclusion Visualization of contrast extravasation on angiography usually can target the bleeding artery directly, resulting in a higher success rate to control of hemorrhage.

Amyand's hernia with scrotal abscess presenting as acute scrotum

Amyands hernia is a rare form of inguinal hernia in which an inflamed appendix is incarcerated in a hernial sac. The clinical presentation of Amyands hernia varies, depending on the extent of inflammation involved in the hernial sac and the presence or absence of a scrotal abscess. If a scrotal abscess is present, this usually indicates that the appendix in the hernial sac is perforated. However, without the availability of computed tomography (CT) scans, the condition is often preoperatively misdiagnosed as a strangulated inguinal hernia. We describe a rare case of a 64-year-old man who presented at our emergency room complaining of scrotal swelling and pain. Diagnosis of Amyands hernia with a scrotal abscess was confirmed preoperatively by CT scan.

Computed tomographic-guided percutaneous radiofrequency ablation with hydrodissection of hepatic malignancies in the subcapsular location: Evaluation of safety and technical efficacy.

Background Image‐guided percutaneous radiofrequency ablation (RFA) has been the most commonly used modality in the treatment of nonresectable hepatic malignancies. However, tumors in the subcapsular location are still technically challenging. This study was undertaken to evaluate the feasibility, safety, and efficacy of computed tomographic‐guided percutaneous RFA with hydrodissection for hepatic malignancies in the subcapsular location. Methods A total of 103 patients with 253 hepatic lesions were treated with computed tomographic‐guided percutaneous RFA. Computed tomographic‐guided percutaneous RFA with hydrodissection was performed in 15 patients with 15 hepatic nodules. All tumors located in the hepatic subcapsular location were considered difficult to treat on planning sonography. Hydrodissection was performed with 5% dextrose in water or saline solution in displacing adjacent structures ≥ 10 mm away from the liver capsule. Two RFA systems with multitined expandable electrodes or straight internally cooled single electrodes were used for treatment of hepatic malignancies. The feasibility, safety, and efficacy of this technique were analyzed on follow‐up contrast‐enhanced computed tomography or magnetic resonance imaging. Results Hydrodissection was successfully achieved in 15 (100%) patients, displacing the adjacent structures ≥ 10 mm that were originally < 10 mm away from the liver capsule with administration of a mean of 376 mL of dextrose in water or saline solution. The average distance between an adjacent structure and the liver capsule after hydrodissection was 1.50 ± 0.40 cm and 0.11 ± 0.15 cm prior to hydrodissection, which was statistically significant (p < 0.001). No complication related to hydrodissection occurred during the follow‐up period. The primary technical success rate of percutaneous RFA for tumor was 100% (15/15) at 1‐month follow‐up imaging. There were three minor complications (20%, 3/15) related to the RFA procedure. Conclusion Computed tomographic‐guided percutaneous RFA with hydrodissection is a feasible, safe, and effective technique in the treatment of hepatic malignancies in the subcapsular location.

Clinical features and computed tomography characteristics of non-Klebsiella pneumoniae liver abscesses in elderly (>65 years) and nonelderly patients.

Purpose To compare the clinical and computed tomography (CT) appearances of liver abscesses caused by non-Klebsiella pneumoniae bacterial pathogens in elderly and nonelderly patients. Materials and Methods Eighty patients with confirmed non-Klebsiella pneumoniae liver abscesses (non-KPLAs) were enrolled and divided into two age groups: elderly (age ≥65 years, n=42) and nonelderly (age <65 years, n=38). Diagnosis of non-KPLA was established by pus and/or blood culture. We compared clinical presentations, outcomes, and CT characteristics of the two groups, and performed multivariate analysis for significant variables and receiver-operating-characteristic analysis to determine the cutoff value of abscess diameter for predicting non-KPLA. Results Elderly patients with non-KPLA were associated with a longer hospital stay (p<0.01). Regarding etiology, biliary sources had a strong association in the elderly group (p<0.01), and chronic liver diseases were related to the nonelderly group (p<0.01). Non-KPLAs (52.5%) tended to show a large, multiloculated appearance in the elderly group and were associated with bile duct dilatation (p<0.01), compared with the nonelderly group. The abscess diameter (cutoff value, 5.2 cm; area under the curve, 0.78) between the two groups was predicted. In multivariate analysis, underlying biliary tract disease [odds ratio (OR), 3.58, p<0.05], abscess diameter (OR, 2.40, p<0.05), and multiloculated abscess (OR, 1.19, p<0.01) independently predicted elderly patients with non-KPLA. Conclusion In the elderly patients with non-KPLA, a large, multiloculated abscess with a diameter greater than 5.2 cm was the predominant imaging feature.

An unusual case of pulmonary hypertension with multiple osteosclerotic lesions

A 47-year-old married woman with underlying sensorimotor polyneuropathy presented to our emergency department with a 2-week history of fatigue, legs edema and exertional dyspnea. On physical examination, elevated jugular vein pressure, a grade III pansystolic murmur at the left lower sternal border and peripheral edema were noted. Chest radiography revealed cardiomegaly, enlargement of the central pulmonary vessels and bilateral pleural effusions (Figure 1). Electrocardiograms showed right axis deviation. An echocardiogram demonstrated pericardial effusion, severe tricuspid regurgitation, pulmonary hypertension (pulmonary artery pressure was 78 mmHg) and normal left ventricular systolic function (the estimated ejection fraction was 77%). Contrast-enhance chest CT showed no evidence of intraluminal thrombi in the pulmonary arteries but central pulmonary artery dilatation (Figure 2). Chest CT image in a bone window setting showed osteosclerotic lesions in the vertebral body of the thoracic spine (arrow head) and sternum (white arrow), as well as proliferative new bone formation over the right transverse process (black arrow) (Figure 3). She was admitted and initially treated as having pulmonary hypertension with right heart failure. Figure 1. Chest radiograph demonstrates cardiomegaly, enlargement of the central pulmonary vessels and bilateral pleural effusions with more on …