Emil J. Balthazar

Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates

Objective:The purposes of this study were to investigate the use of computed tomography (CT) imaging in patients with suspected acute appendicitis and to evaluate the impact of CT on negative appendectomy and perforation rates. In patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15–20%; 10% in men and 25–45% in women of childbearing age. This is associated with a perforation rate of 21–23%.Methods:This is a retrospective analysis of 146 consecutive patients presenting with clinical symptoms suspicious of appendicitis over a 2-yr period in whom CT examinations were performed before therapy was instituted. The overall negative appendectomy and perforation rates were calculated for the entire group, as well as for the 54 women aged 15–50 yr in the childbearing cohort.Results:The negative appendectomy rate was 4% in 122 patients operated on and the perforation rate was 22%. Among 36 women 15–50 yr of age operated on, the negative appendectomy rate was 8.3% and the perforation rate was 19%. Surgery was avoided in 24 patients, 18 of whom were women of childbearing age.Conclusions:The judicious use of CT imaging in patients with equivocal clinical presentation suspected of having appendicitis led to a significant improvement in the preoperative diagnosis. It resulted in a substantial decrease in the negative appendectomy rate compared to previously published reports, without incurring an increase in the perforation rate.

A Pattern Approach to the Abnormal Small Bowel: Observations at MDCT and CT Enterography

OBJECTIVE Imaging of the vast array of pathologic processes occurring in the small bowel has been facilitated by recent advances, including the use of MDCT scanners that acquire isotropic data and neutral oral contrast agents that improve small-bowel distention. CONCLUSION This review shows how a systematic pattern approach can be used to narrow the differential diagnosis when an abnormal small-bowel loop is detected on MDCT.

Ultrasound and CT evaluation of emergent gallbladder pathology.

Ultrasound is the initial imaging modality of choice for the evaluation of suspected acute gallbladder disorders, and is often sufficient for correct diagnosis. CT also plays a vital role, however, in the evaluation of acute gallbladder pathology. CT is particularly useful in situations where ultrasound findings are equivocal. CT is also extremely valuable in the assessment of suspected complications of acute cholecystitis, particularly emphysematous cholecystitis, hemorrhagic cholecystitis, and gallbladder perforation, which are often very difficult diagnoses to establish at sonography. If CT is the initial imaging test performed in a patient with abdominal pain of uncertain etiology, recognition of the various disorders described in this article may eliminate the need for further imaging and facilitate appropriate management.

Hemorrhagic Complications of Pancreatitis: Radiologic Evaluation with Emphasis on CT Imaging

Objective: To analyze and describe the incidence, pathophysiology, radiographic diagnosis and the initial management of hemorrhagic complications associated with pancreatitis. Material and Methods: Among 1,910 patients diagnosed of having pancreatitis in the last 10 years, 26 developed hemorrhagic complications (1.3%). These complications were detected from 2 months to 8 years after one or several episodes of pancreatitis with a mean of 2.3 years. Radiographic studies were reviewed and clinical management and outcome were recorded. Results: Ten patients had CT evidence of pancreatic necrosis, 12 patients chronic pancreatitis, and 17 patients pancreatic pseudocysts. The cause of hemorrhage was bleeding pseudoaneurysm in 16 patients (61%), diffuse bleeding with pancreatic necrosis in 5 patients (19.5%) and hemorrhagic pseudocysts in 5 patients (19.5%). Intra-abdominal hemorrhage developed in 21 patients and gastro-intestinal bleeding in 5 patients. Arterial embolization was attempted in 12 patients and was successful in 9 patients (75%). Surgery was used in 16 patients and the overall mortality rate was 11%. Conclusions: Hemorrhagic complications are rarely seen and are usually late sequelae of pancreatitis. They develop because of leaking or ruptured pseudoaneurysms, diffuse bleeding in pancreatic necrosis, and hemorrhagic pseudocysts. Early detection followed by angiography, embolization and/or surgery has decreased mortality rates.

A role for radiotherapy in the treatment of solid and papillary neoplasms of the pancreas.

Solid and papillary neoplasms of the pancreas are rare tumors that usually occur in young women as enlarging abdominal masses. These lesions almost never metastasize but may be locally destructive. Although the usual treatment is surgery, the authors herein report a case that was treated solely by radiotherapy. They conclude that solid and papillary neoplasms of the pancreas are radiosensitive and can be successfully treated by radiation therapy.

Staging of acute pancreatitis

Management of patients with acute pancreatitis is based on the early assessment of severity of disease. Initial staging is established on clinical and laboratory grounds and on the findings of contrast-enhanced CT imaging. Individual clinical parameters and laboratory indices, although sometimes helpful, are not sufficiently accurate to reliable assess the severity of an acute attack. Numerical grading systems (Ransons, APACHE II) with sensitivities of about 70% are commonly used today as indicators of systemic failure and predictors of disease severity. Helical or MDCT scanning performed during the administration of a bolus of i.v. contrast material is performed to evaluate pancreatic morphology, detect pancreatic necrosis, and depict retroperitoneal complications. CT staging and the CT severity index have proved to be a reliable indicator of disease severity, having shown an excellent correlation with the risk of death and the development of local and systemic complications in this population.

Septic thrombophlebitis of the mesenteric and portal veins: CT imaging.

Pylephlebitis or septic thrombophlebitis of the portal vein and its tributaries is an acute ascending infection arising often from a primary gastrointestinal inflammatory lesion. Common primary sources of infection are diverticulitis, appendicitis, and infected pancreatic necrosis. CT imaging can diagnose this complication at an early stage and can significantly improve the previously reported high mortality and morbidity rates associated with this condition.

MDCT of Acute Mild (Nonnecrotizing) Pancreatitis: Abdominal Complications and Fate of Fluid Collections

OBJECTIVE The objective of our study was to describe the occurrence of local complications and the fate of fluid collections in milder forms of acute nonnecrotizing pancreatitis. MATERIALS AND METHODS Initial MDCT studies of 169 consecutive patients with mild acute pancreatitis and 203 follow-up CT examinations were reviewed. The fate of peripancreatic fluid collections was investigated, and the incidence and type of local complications were recorded and correlated to the CT grading system (A-E). RESULTS Complications developed in nine of 169 patients, for an incidence of 5.3%. All morbidity occurred in the subgroup of 73 patients with initial fluid collections, for an incidence of 12.3%. Follow-up CT examinations available in 51 of these 73 patients documented rapid fluid resolution in 35 cases (68.6%) and persistence of fluid more than 2 weeks from onset in seven asymptomatic patients (13.7%). Acute, life-threatening complications (hemorrhage, infection, perforation) occurred in five patients, for an incidence of 6.8% among the 73 patients with initial fluid collections, or 3.0% in the entire group of 169 patients. Five patients developed acute pseudocysts. Long-term follow-up studies discovered two patients with chronic pancreatitis and one with groove pancreatitis. CONCLUSION A small number of acute, life-threatening abdominal complications and chronic complications are expected to occur in patients with milder forms of acute nonnecrotizing pancreatitis presenting with fluid collections. In these patients, clinical monitoring and repeated imaging studies are recommended to document the resolution of fluid or the development of complications.

Pancreatitis Associated with Pancreatic Carcinoma

The combined occurrence of pancreatic carcinoma with acute or chronic pancreatitis is seldom seen in medical practice, but when present it is a challenging dilemma, plagued by confusing overlapping clinical findings and pitfalls in diagnostic imaging tests. This article reviews the presumptive pathophysiological aspects of this relationship, the perplexing clinical presentations and the advantages and limitations of the noninvasive imaging examinations. The role of state-of-the-art CT imaging in screening patients with acute and chronic pancreatitis is emphasized and the impute of additional more invasive tests in detecting pancreatic tumors in this cohort of patients is reviewed. The habitual use of CT imaging, followed when needed by complementary examinations, can improve on previously reported low detection rates and hopefully decrease the number of exploratory laparatomies and unnecessary major pancreatic surgical resections.

Left-sided omental infarction with associated omental abscess: CT diagnosis.

The CT findings of two patients with left-sided omental infarction associated with acute inflammation and abscess formation are described and illustrated. The patients presented with lower abdominal pain, fever, and leukocytosis, and they exhibited a poorly defined heterogeneous low-attenuated mass containing fat in the anterior left lower abdomen. Although segmental omental infarction is usually a self-limiting condition that may resolve spontaneously, necrosis associated with secondary infection and abscess formation may develop occasionally.