Giuseppe D’Ippolito

Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings.

Tuberculosis is a disease whose incidence has increased principally as a consequence of HIV infection and use of immunosuppressive drugs. The abdomen is the most common site of extrapulmonary tuberculosis. It may be confused with several different conditions such as inflammatory bowel disease, cancer and other infectious diseases. Delay in the diagnosis may result in significantly increased morbidity, and therefore an early recognition of the condition is essential for proper treatment. In the present essay, cases with confirmed diagnosis of abdominal tuberculosis were assessed by means of computed tomography and magnetic resonance imaging, demonstrating the involvement of different organs and systems, and presentations which frequently lead radiologists to a diagnostic dilemma. A brief literature review was focused on imaging findings and their respective prevalence.

Differentiating Cirrhosis and Chronic Hepatosplenic Schistosomiasis Using MRI

OBJECTIVE The objective of our study was to identify which imaging features may be used to differentiate between cirrhosis and chronic hepatosplenic schistosomiasis and to assess image interpretation agreement for MRI findings. MATERIALS AND METHODS Retrospective review of 27 patients with alcoholic or virus-induced cirrhosis and 24 patients with chronic hepatosplenic schistosomiasis who underwent MRI (1.5 T) of the abdomen was performed. Images were interpreted independently by two radiologists evaluating the following MRI features: hepatic fissure widening, irregularity of hepatic contours, periportal fibrosis, hepatic parenchyma heterogeneity, and splenic siderotic nodules. Left, right, and caudate hepatic lobe measurements were obtained, and the splenic index was measured. The Fishers exact test, chi-square test, and Students t test were used to compare both groups, and regression analysis was performed. Observer agreement was measured using kappa and intraclass correlation tests. RESULTS Periportal fibrosis, heterogeneity of hepatic parenchyma, and splenic siderotic nodules were more frequent in the group with schistosomiasis (p < 0.05), with periportal fibrosis showing the largest difference in presence and distribution (peripheral greater than central). The transverse diameter of the right hepatic lobe, caudate lobe-right lobe ratio, and splenic index were larger in patients with chronic schistosomiasis (p < 0.001). At multiple regression analysis, splenic siderotic nodules, splenic index, and caudate lobe-right lobe ratio were predictive of schistosomiasis. Observer agreement was substantial or almost perfect for almost all variables analyzed (kappa or r = 0.81-1.00). CONCLUSION The presence of peripheral periportal fibrosis, heterogeneity of hepatic parenchyma, and splenic siderotic nodules, and the splenic index and caudate lobe-right lobe ratio are useful features for differentiating alcoholic or virus-induced cirrhosis from chronic schistosomiasis using MRI.

Anicteric cholangiopathy in schistosomiasis patients

UNLABELLED We previously reported that in anicteric patients with the isolated form of schistosomiasis (without co-morbidities) an ursodeoxycholic acid-sensitive increase in serum gamma-glutamyltransferase activity (gammaGT) occurs. We now describe the presence of cholangiopathy in these patients. METHODS Sixteen adult anicteric patients with the isolated form of schistosomiasis mansoni were carefully selected: nine with increased gammaGT and seven with normal gammaGT. High sensitive C-reactive protein (CRP), to exclude inflammatory status, hyaluronic acid (HA), and other laboratory parameters were determined. The ultrasonographic study measured spleen length, portal vein and splenic vein diameters, and the portal flow. Magnetic resonance cholangiopancreatography (MRCP) images were interpreted by a blind observer. MRCP was deemed abnormal when focal narrowing and/or paucity of second and third order biliary branches and/or irregularities in the contours of biliary pathways were identified. RESULTS Both groups (normal and elevated gammaGT) have preserved hepatic function tests (HA, serum albumin, prothrombin time) and clinical significant portal hypertension (low platelet count and ultrasonographic parameters). MRCP was abnormal in all patients with elevated gammaGT but in only 3 of the 7 patients with normal gammaGT (p=0.003). CONCLUSION Magnetic resonance cholangiopancreatography characterized a cholangiopatic disorder in anicteric patients with the isolated form of schistosomiasis, even preceding laboratory test alterations.

Transcatheter arterial embolization for unresectable symptomatic giant hepatic hemangiomas: single-center experience using a lipiodol-ethanol mixture.

Objective The present article is aimed at reporting the author’s experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas. Materials and Methods The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009–2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture. Results Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure. Conclusion Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.

CT colonography with rectal iodine tagging: Feasibility and comparison with oral tagging in a colorectal cancer screening population

PURPOSE To evaluate feasibility, diagnostic performance, patient acceptance, and overall examination time of CT colonography (CTC) performed through rectal administration of iodinated contrast material. MATERIALS AND METHODS Six-hundred asymptomatic subjects (male:female=270:330; mean 63 years) undergoing CTC for colorectal cancer screening on an individual basis were consecutively enrolled in the study. Out of them, 503 patients (group 1) underwent CTC with rectal tagging, of which 55 had a total of 77 colonic lesions. The remaining 97 patients (group 2) were randomly selected to receive CTC with oral tagging of which 15 had a total of 20 colonic lesions. CTC findings were compared with optical colonoscopy, and per-segment image quality was visually assessed using a semi-quantitative score (1=poor, 2=adequate, 3=excellent). In 70/600 patients (11.7%), CTC was performed twice with both types of tagging over a 5-year follow-up cancer screening program. In this subgroup, patient acceptance was rated via phone interview two weeks after CTC using a semi-quantitative scale (1=poor, 2=fair, 3=average, 4=good, 5=excellent). RESULTS Mean per-polyp sensitivity, specificity, positive and negative predictive values of CTC with rectal vs oral tagging were 96.1% (CI95% 85.4÷99.3%) vs 89.4% (CI95% 65.4÷98.1%), 95.3% (CI95% 90.7÷97.8%) vs 95.8% (CI95% 87.6÷98.9%), 86.0% (CI95% 73.6÷93.3) vs 85.0% (CI95% 61.1÷96.0%), and 98.8% (CI95% 95.3÷99.8%) vs 97.2% (CI95% 89.4÷99.5%), respectively (p>0.05). Polyp detection rates were not statistically different between groups 1 and 2 (p>0.05). Overall examination time was significantly shorter with rectal than with oral tagging (18.3±3.5 vs 215.6±10.3 minutes, respectively; p<0.0001). CONCLUSIONS Rectal iodine tagging can be an effective alternative to oral tagging for CTC with the advantages of greater patient acceptance and lower overall examination time.

Mapeamento dos métodos adotados para o ensino de diagnóstico por imagem nas escolas médicas brasileiras

Objective To map the different methods for diagnostic imaging instruction at medical schools in Brazil. Materials and Methods In this cross-sectional study, a questionnaire was sent to each of the coordinators of 178 Brazilian medical schools. The following characteristics were assessed: teaching model; total course hours; infrastructure; numbers of students and professionals involved; themes addressed; diagnostic imaging modalities covered; and education policies related to diagnostic imaging. Results Of the 178 questionnaires sent, 45 (25.3%) were completed and returned. Of those 45 responses, 17 (37.8%) were from public medical schools, whereas 28 (62.2%) were from private medical schools. Among the 45 medical schools evaluated, the method of diagnostic imaging instruction was modular at 21 (46.7%), classic (independent discipline) at 13 (28.9%), hybrid (classical and modular) at 9 (20.0%), and none of the preceding at 3 (6.7%). Diagnostic imaging is part of the formal curriculum at 36 (80.0%) of the schools, an elective course at 3 (6.7%), and included within another modality at 6 (13.3%). Professors involved in diagnostic imaging teaching are radiologists at 43 (95.5%) of the institutions. Conclusion The survey showed that medical courses in Brazil tend to offer diagnostic imaging instruction in courses that include other content and at different time points during the course. Radiologists are extensively involved in undergraduate medical education, regardless of the teaching methodology employed at the institution.

Müllerian Duct Anomalies

Mullerian duct anomalies (MDAs) represent one of the uterine causes of infertility. In the propaedeutics of the evaluation of MDAs, various images procedures have been used, especially the two ones that will be our focus, magnetic resonance imaging (RM) and 3D ultrasonography. In this chapter a didactic compilation of the diagnostic criteria used for the MDAs cathegories as recomended by American Fertility Socliety will be shown. We will bring morphology and morphometry concepts that are used for the correct classification of MDAs, and aply them in a series of clinical cases. What we write is what we do in clinical pratice, and we try to translate this experience into words. We wish to make this chapter a source for quick consultation, with accessible information that may enable greater precision in diagnoses.

Analysis of the effect of renal excretory system cooling during thermal radiofrequency ablation in an animal model

OBJECTIVE Analysis of renal excretory system integrity and efficacy of radiofrequency ablation with and without irrigation with saline at 2°C (SF2). MATERIALS AND METHODS The median third of sixteen kidneys were submitted to radiofrequency (exposition of 1 cm) controlled by intra-surgical ultrasound, with eight minutes cycles and median temperature of 90°C in eight female pigs. One excretory renal system was cooled with SF2, at a 30mL/min rate, and the other kidney was not. After 14 days of post-operatory, the biggest diameters of the lesions and the radiological aspects of the excretory system were compared by bilateral ascending pyelogram and the animals were sacrificed in order to perform histological analysis. RESULTS There were no significant differences between the diameters of the kidney lesions whether or not exposed to cooling of the excretory system. Median diameter of the cooled kidneys and not cooled kidneys were respectively (in mm): anteroposterior: 11.46 vs. 12.5 (p = 0.23); longitudinal: 17.94 vs. 18.84 (p = 0.62); depth: 11.38 vs. 12.25 (p = 0.47). There was no lesion of the excretory system or signs of leakage of contrast media or hydronephrosis at ascending pyelogram. CONCLUSION Cooling of excretory system during radiofrequency ablation does not sig¬nificantly alter generated coagulation necrosis or affect the integrity of the excretory system in the studied model.

Radiology report: what is the opinion of the referring physician?

Objective To evaluate the opinion and perception of referring physicians regarding the radiology report, in order to develop tools that promote an improvement in its quality. Materials and Methods We prepared a questionnaire containing ten multiple choice questions about the radiology report, administering it to 70 physicians (35 specialists and 35 residents working in specialties other than radiology). Results Referring physicians (specialists and residents) showed a preference for structured reports, with a description explained in universal medical language and a complete conclusion listing the diagnostic possibilities with the degree of certainty. The examination technique should be described, and the final report is best presented when it contains the final chart, together with images, as hard copies and in digital format. The respondents also reported having confidence in the opinion of the radiologist and expressed the need for a direct channel of communication with the same. Conclusion Referring physicians seek detailed reports (including a description of the examination technique), preferably structured, with objective language and relevant conclusions (the position of the radiologist on the case is important). It is necessary to discuss the differential diagnoses and provide a form of contact between the parties. Although referring physicians consider the radiologist opinion relevant, they also want to analyze the images on their own.

Practical Considerations of Real Life of Hepatocellular Carcinoma in a Tertiary Center of Brazil.

BACKGROUND Hepatocellular carcinoma (HCC) is the most common malignancy that develops in cirrhotic livers. Its clinical and epidemiological characteristics and mortality rates vary according to geographical region. The objective of this study was to evaluate the clinical profile, epidemiological characteristics, laboratory parameters, treatment and survival of patients with HCC. MATERIAL AND METHODS Patients with HCC seen between 2000 and 2012 were studied. The Kaplan-Meier method was used for survival analysis according to variables in question. RESULTS The study included 247 patients with a mean age of 60 ± 10 years. There was a predominance of males (74%). The main etiologies of HCC were HCV infection (55%), excessive alcohol consumption (12%), and HBV infection (8%). Liver cirrhosis was present in 92% of cases. The mean tumor number and diameter were 2 and 5 cm, respectively. Patients meeting the Milan criteria corresponded to 43% of the sample. Liver transplantation was performed in 22.4% of patients of the Milan subset and in 10% of the whole sample. The overall mean survival was 60 months, with a 1-, 3- and 5-year survival probability of 74%, 40% and 29%, respectively. Lower survival was observed among patients with alcoholic etiology. Survival was higher among patients submitted to liver transplantation (P < 0.001), TACE (P < 0.001), or any kind of treatment (P < 0.001). However, no difference was found for surgical resection (P = 0.1) or sorafenib (P = 0.1). CONCLUSION Patients with HCC were mainly older men diagnosed at an advanced stage. Treatment was associated with better overall survival, but few patients survived to be treated.INTRODUCTION To identify the impact of portal vein thrombosis (PVT) and associated medical and surgical factors on outcomes post liver transplant (LT). MATERIAL AND METHODS Two analyses were performed. Analysis One: cohort study of 505 consecutive patients who underwent LT (Alberta) between 01/2002-12/2012. PVT was identified in 61 (14%) patients. Analysis Two: cohort study of 144 consecutive PVT patients from two sites (Alberta and London) during the same period. Cox multivariable survival analysis was used to identify independent associations with post-LT mortality. RESULTS In Analysis One (Alberta), PVT was not associated with post-LT mortality (log rank p = 0.99). On adjusted analysis, complete/occlusive PVT was associated with increased mortality (Hazard Ratio (HR) 8.4, p < 0.001). In Analysis Two (Alberta and London), complete/occlusive PVT was associated with increased mortality only on unadjusted analysis (HR 3.7, p = 0.02). On adjusted analysis, Hepatitis C (HR 2.1, p = 0.03) and post-LT portal vein re-occlusion (HR 3.2, p = 0.01) were independently associated with increased mortality. CONCLUSION Well-selected LT patients who had PVT prior to LT had similar post-LT outcomes to non-PVT LT recipients. Subgroups of PVT patients who did worse post-LT (complete/occlusive thrombosis pre-LT, Hepatitis C or post-LT portal vein re-occlusion) warrant closer evaluation in listing and management post-LT.