Howard Greenberg

A prospective comparison study of MRI versus small bowel follow-through in recurrent Crohn's disease.

BACKGROUND:We aimed to determine the utility of magnetic resonance imaging (MRI) compared with small bowel follow-through (SBFT) in the assessment of known Crohns disease.METHODS:Subjects, over age 18 yr who were to undergo SBFT investigations to assess for complications or extent of Crohns disease were eligible. SBFT was performed by a single radiologist (IB), and within 4 wk MRI was performed by a single radiologist (HG) who was blinded to the SBFT results. For MRI, oral contrast was 2% barium sulfate (1,350 mL). After unenhanced T1 weighted images and single shot fast spin echo T2 imaging, intravenous (IV) glucagon and gadolinium were given. Fast multiplanar spoiled-gradient recalled T1 coronal sequences were obtained followed by abdominal and pelvic axial images. MRI and SBFT were compared for extent of disease, presence of complications, and for identification of extraintestinal disease.RESULTS:Paired studies were undertaken within a mean of 22 days in 30 subjects. Ten studies were normal by both modalities and 8 studies showed similar extent of Crohns disease. SBFT revealed additional information in 4, including a stricture in 1 and ileosigmoid fistulas in 2. MRI provided enhanced information in 8, including identifying active inflammation in strictured areas based on wall enhancement patterns, vasa recta changes, and lymphadenopathy.CONCLUSIONS:On the basis of cost and accessibility, SBFT may still be a first line procedure of choice in some centers without MRI, but MRIs advantages of no radiation and the potential to identify active inflammation in strictured areas, extraintestinal, and colorectal disease make it an attractive alternative.

Primary Adrenal Lymphoma Associated with Adrenal Insufficiency: A Distinct Clinical Entity

We describe a case of a 42 year old male who presented with Addisons disease resulting from primary lymphoma of the adrenals. Our case and a review of the literature indicates that this distinct entity has some unique clinical and radiologic features. In this entity, the lymphoma tends to be extranodal and have a poor prognosis. In addition, the computed tomography (CT) images have the unique appearance of enlargement of the adrenal gland with maintenance of the adreniform shape. We suggest that primary adrenal lymphoma is a distinct clinical entity and should be considered in patients with an elevated serum lactate dehydrogenase, characteristic CT findings and Addisons disease.

Crohn's Disease Recurrence in a Small Bowel Transplant

This is a report of a patient with short-bowel syndrome secondary to recurrent surgeries for Crohns disease who ultimately required small bowel transplantation in 1994. Eight years posttransplantation he developed recurrent Crohns disease that was responsive to prednisone. From the perspective of advancing our understanding of Crohns disease pathogenesis this case suggests that intestine-specific antigens may be more important than the classical MHC antigens for the development of Crohns disease, since this man developed Crohns disease in both the native intestine and also in the engrafted one.

Multifocal gastric neoplasia after recurrent laser therapy for the watermelon stomach

Repeated laser therapy has become an accepted therapeutic approach in the treatment of watermelon stomach, and to date no important negative sequelae have been reported. The case of a patient who underwent repeated sessions of neodymium: yttrium aluminum garnet (Nd:YAG) laser therapy over a five-year period for the treatment of the watermelon stomach is presented. Postlaser therapy the patient developed deep ulcerations that would heal; however, he ultimately developed a nodular antrum. Random biopsies of antral nodules revealed carcinoma-in-situ. A Billroth I gastrectomy revealed two foci of carcinoma-in-situ/high grade dysplasia and multiple foci of lower grades of dysplasia. This case suggests a possible association between use of laser therapy and development of gastric neoplasia.

Detection and localization of bile duct leaks after cholecystectomy using Gd-EOB-DTPA-enhanced MR cholangiography: retrospective study of 16 patients.

Objective To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients. Material and Methods Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings. Results All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%. Conclusion Gadolinium-EOB-DTPA–enhanced MR can detect bile leaks with a high sensitivity and specificity.

Blastomycosis presenting as multiple splenic abscesses: Case report and review of the literature

A 31-year-old Canadian Aboriginal man from northwestern Ontario presented with left upper quadrant pain and a tender left upper quadrant mass. Evaluation with a computed tomography scan showed multiple lesions within the spleen, a collection between the splenic tip and splenic flexure of the colon, and several small adrenal lesions. Computed tomographic-guided needle biopsy showed necrotizing granulomatous inflammation and multinucleated giant cells. Gomoris methenamine silver stain showed broad-based budding yeast consistent with Blastomyces dermatitidis. Abdominal symptoms resolved after two months of oral itraconazole. Multiple splenic abscesses are a rare presentation of blastomycosis and should be considered in the differential diagnosis of left upper quadrant abdominal pain in a patient with a history of travel or residence in a region endemic for B dermatitidis.