Ian Zealley

MR Enterographic Manifestations of Small Bowel Crohn Disease

Magnetic resonance (MR) enterography is a clinically useful technique for the evaluation of both intraluminal and extraluminal small bowel disease, particularly in younger patients with Crohn disease. MR enterography offers the advantages of multiplanar capability and lack of ionizing radiation. It allows evaluation of bowel wall contrast enhancement, wall thickening, and edema, findings useful for the assessment of Crohn disease activity. MR enterography can also depict other pathologic findings such as lymphadenopathy, fistula and sinus formation, abscesses, and abnormal fold patterns. Even subtle disease manifestations may be detected when adequate distention of the small bowel is achieved, although endoscopic and double-contrast barium small bowel techniques remain superior in the depiction of changes in early Crohn disease (eg, aphthoid ulceration). Further research will be needed to determine whether MR imaging enhancement patterns may reliably help discriminate between active and inactive disease.

Utility of a single early warning score in patients with sepsis in the emergency department

Background An important element in improving the care of patients with sepsis is early identification and early intervention. Early warning score (EWS) systems allow earlier identification of physiological deterioration. A standardised national EWS (NEWS) has been proposed for use across the National Health Service in the UK. Aim To determine whether a single NEWS on emergency department (ED) arrival is a predictor of outcome, either in-hospital death within 30 days or intensive care unit (ICU) admission within 2 days, in patients with sepsis. Methods Data were collected over a 3-month period as part of a national audit in 20 EDs in Scotland. All adult patients who were admitted for at least 2 days or who died within 2 days were screened for sepsis criteria. Patients with systemic inflammatory response syndrome criteria were included. An EWS was calculated based on initial physiological observations made in the ED using the NEWS. Results Complete data were available for 2003 patients. Each rise in NEWS category was associated with an increased risk of mortality when compared to the lowest category (5–6: OR 1.95, 95% CI 1.21 to 3.14), (7–8: OR 2.26, 95% CI 1.42 to 3.61), (9–20: OR 5.64, 95% CI 3.70 to 8.60). This was also the case for the combined outcome (ICU and/or mortality). Conclusions An increased NEWS on arrival at ED is associated with higher odds of adverse outcome among patients with sepsis. The use of NEWS could facilitate patient pathways to ensure triage to a high acuity area of the ED and senior clinician involvement at an early stage.

The role of interventional radiology in trauma.

#### Summary points Most preventable deaths from trauma are caused by unrecognised and therefore untreated haemorrhage, particularly in the abdomen. Haemorrhage causes early deaths, and the associated hypovolaemic shock leads to secondary brain injury and contributes to late death from multiorgan failure.1 Early management is focused on resuscitation and the diagnosis and treatment of life threatening bleeding to prevent the lethal metabolic disturbance triad of acidosis, hypothermia, and coagulopathy.2 Many aspects of immediate trauma care suffer from a lack of high quality prospective research. This review is based predominantly on evidence from retrospective cohort series and is subject to the limitations inherent in this type of level 2 research.3 There are no prospective randomised controlled trials of interventional radiology in major trauma. Although the volume of level 2 evidence is substantial and contains few contradictory findings, no robust level 1 evidence yet exists. This review aims to summarise the evidence supporting the use of interventional radiological techniques in the management of haemorrhage caused by blunt abdominal trauma. Interventional radiology uses minimally invasive endovascular techniques to stem haemorrhage. Endovascular haemostasic techniques are established in non-trauma clinical scenarios. In trauma, the main application is to control endovascular haemorrhage by blocking bleeding vessels (transcatheter arterial embolisation (fig 1⇓) or relining …

Spontaneous subclavian artery dissection causing ischemia of the arm: diagnosis and endovascular management.

Spontaneous subclavian artery dissections are rare, with very few cases described in the literature. We report an unusual case of a 62-year-old female who presented with ischemia of the left arm secondary to spontaneous dissection of the first part of the left subclavian artery. We describe the imaging findings on both aortic arch angiogram and CT angiogram and discuss management by endovascular means.

Failed Retrieval of Potentially Retrievable IVC Filters: A Report of Two Cases

Retrievable inferior vena cava filters are being increasingly used for the prevention of life-threatening pulmonary emboli in patients who have temporary contraindications to anticoagulation therapy. We report two cases of failure to remove these devices.

The ophthalmo-meningeal foramen masquerading as an intraocular foreign body.

Although the diagnosis of intraocular foreign body is primarily a clinical one, radiographic imaging is often used to clarify the diagnosis and to localise the foreign body. For this case the radiographic findings served to confuse the diagnosis.

Removal of a Permanent IVC Filter

Inferior vena cava (IVC) filters are increasingly used for prevention of life-threatening pulmonary emboli in patients who have contraindications to anticoagulation therapy. We report a case of the removal of a permanent IVC filter, which was inadvertently inserted due to an incorrect ultrasound report.

Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial

Summary Background Magnetic resonance enterography (MRE) and ultrasound are used to image Crohns disease, but their comparative accuracy for assessing disease extent and activity is not known with certainty. Therefore, we did a multicentre trial to address this issue. Methods We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohns disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in per-patient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed. Findings 284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohns disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72–86]) and presence (97% [91–99]) were significantly greater than that of ultrasound (70% [62–78] for disease extent, 92% [84–96] for disease presence); a 10% (95% CI 1–18; p=0·027) difference for extent, and 5% (1–9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85–98]) was significantly greater than that of ultrasound (81% [64–91]); a difference of 14% (1–27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86–99) with MRE and 84% (65–94) with ultrasound (difference 12% [0–25]; p=0·054). There were no serious adverse events. Interpretation Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly. Funding National Institute of Health and Research Health Technology Assessment.

Acute pancreatitis: a comparison of intervention rates precipitated by early vs guideline CT scan timing

AIM To assess whether computed tomography (CT) examination earlier in acute pancreatitis (AP) precipitates any surgical or radiological intervention. MATERIALS AND METHODS A single-centre retrospective cohort study comparing intervention rates in AP precipitated by early (<6 day of admission, n=100) and UK guideline (≥6 day of admission, n=103) CT examinations. RESULTS No intervention was precipitated by performing CT before the sixth day of admission in AP. A statistically significant larger number of interventions were precipitated when CT was performed on the sixth day or later (p<0.05). Of note, this study was conducted using day of admission, rather than day of symptom onset. Six patients underwent repeat CT examination in the same admission after an early CT examination. CONCLUSION Performing CT before the sixth day of admission does not lead to earlier intervention. Such early examinations waste resources and may offer false reassurance to clinicians.

Provision of out-of-hours interventional radiology services in Scotland.

AIM To evaluate the availability of out-of-hours (OOH) interventional radiology (IR) services in Scotland and discuss implications for service redesign. MATERIALS AND METHODS Data were gathered via a survey conducted by telephone/e-mail interview. The setting was hospitals in Scotland with acute medical and/or surgical beds. The interviewees were consultant interventional radiologists representing each of the 14 geographical Health Boards in Scotland. RESULTS Three of the 14 geographical Health Boards provided a formal, prospectively planned OOH IR service in at least one hospital. Fourteen of the 34 acute hospitals provided an in-hours IR service, which includes endovascular haemorrhage control. Eight of the 34 acute hospitals had formal, prospectively planned on-call IR arrangements, 12 had an ad-hoc service, and 20 transferred patients to other facilities. Thirty-eight of the 223 consultant radiologists in Scotland were able to perform endovascular haemorrhage control procedures: only 18 of these 38 (47%) were included in on-call rotas. A further 42 radiologists were able to perform nephrostomy and a further 61 were able to perform abscess drainage. Eighty-two radiologists did not perform any interventional procedures. CONCLUSIONS The provision of OOH IR services in Scotland is limited and available resources, both skills and equipment, are being underutilized. These data will be used to inform a process of OOH IR service redesign in Scotland.