Jesus R. Diaz

Spontaneous perirenal hemorrhage: what radiologists need to know

Spontaneous perirenal hemorrhage (SPH), also known as Wünderlich’s syndrome, is a rare urological emergency. This article reviews the most common causes of SPH and the role of imaging in establishing the correct diagnosis and in guiding the appropriate therapy. A thorough understanding of underlying etiologies, imaging appearances, optimal imaging techniques, and follow-up protocols are crucial to recognize patients with SPH due to benign disease and avoid unnecessary nephrectomies.

Zygomycosis involving lungs, heart and brain, superimposed on pulmonary edema

Zygomycosis is an uncommon but frequently fatal infection and occurs mostly in immunosuppressed hosts, whereas approximately 50% of zygomycosis occurs in diabetic patients. The current patient initially presented with persistent pulmonary edema secondary to renal failure. This was the last of four admissions within 1 year for this 68‐year‐old woman, for whom the chief complaints were shortness of breath and chest pain. Her past medical history included insulin‐requiring type 2 diabetes and hypertension for 10 years, and chronic heart and renal failure. She was previously admitted to the hospital for what appeared to be pulmonary edema secondary to renal failure. In the last admission the patient developed pulmonary hemorrhage and metabolic acidosis. Transbronchial biopsy was performed, showing irregular fungal hyphae in the blood vessels, morphologically consistent with zygomycosis. Central nervous system computed tomography also revealed a large infarct in the cerebral hemisphere. The patient died on the seventh hospital day. At autopsy three organs were extensively involved by zygomycosis: (i) lungs were diffusely hemorrhagic with acute infarcts; (ii) pericardium had fibrotic inflammation; and (iii) the left cerebral hemisphere, cerebellum and pons had large hemorrhagic infarct by zygomycosis infection. Corticosteroid medication and hemodialysis triggered increasing hyperglycemia, metabolic acidosis and iron overload, which contributed to zygomycosis infection that subsequently spread to the heart and brain as a rare consequence.

Intragastric Meal Distribution during Gastric Emptying Scintigraphy for Assessment of Fundic Accommodation: Correlation with Symptoms of Gastroparesis

Impaired fundic accommodation (FA) limits fundic relaxation and the ability to act as a reservoir for food. Assessing intragastric meal distribution (IMD) during gastric emptying scintigraphy (GES) allows for a simple measure of FA. The 3 goals of this study were to evaluate trained readers’ (nuclear medicine and radiology physicians) visual assessments of FA from solid-meal GES; develop software to quantify GES IMD; and correlate symptoms of gastroparesis with IMD and gastric emptying. Methods: After training to achieve a consensus interpretation of GES FA, 4 readers interpreted FA in 148 GES studies from normal volunteers and patients. Mixture distribution and κ-agreement analyses were used to assess reader consistency and agreement of scoring of FA. Semiautomated software was used to quantify IMD (ratio of gastric counts in the proximal stomach to those in the total stomach) at 0, 1, 2, 3, and 4 h after ingestion of a meal. Receiver-operating-characteristic analysis was performed to optimize the diagnosis of abnormal IMD at 0 min (IMD0) with impaired FA. IMD0, GES, water load testing, and symptoms were then compared in 177 patients with symptoms of gastroparesis. Results: Reader pairwise weighted κ-values for the visual assessment of FA averaged 0.43 (moderate agreement) for normal FA versus impaired FA. Readers achieved 84.0% consensus and 85.8% reproducibility in assessing impaired FA. IMD0 based on the division of the stomach into proximal and distal halves averaged 0.809 (SD, 0.083) for normal FA and 0.447 (SD, 0.132) (P < 0.01) for impaired FA. On the basis of receiver-operating-characteristic analysis, the optimal cutoff for IMD0 discrimination of normal FA from impaired FA was 0.568 (sensitivity, 86.7%; specificity, 91.7%). Of 177 patients with symptoms of gastroparesis, 129 (72.9%) had delayed gastric emptying; 25 (14.1%) had abnormal IMD0. Low IMD0 (impaired FA) was associated with increased early satiety (P = 0.02). Conclusion: FA can be assessed visually during routine GES with moderate agreement and high reader consistency. Visual and quantitative assessments of FA during GES can yield additional information on gastric motility to help explain patients’ symptoms.

Su1451 Dynamic Antral Scintigraphy Identifies Patterns of Gastric Contractility in Patients With Upper GI Motility Disorders: Comparison to Conventional Gastric Emptying Scintigraphy Data

Introduction. Diabetic gastroparesis is defined as delayed gastric emptying not caused by obstruction or structural abnormality. Normal function of the gastric and intestinal mechanical activity is mediated by slow wave electrical activity in the stomach and small bowel. Previous studies using both electrogastrogram and magnetogastrogram have shown gastric slowwave dysrhythmias associated with gastroparesis, but no study has yet examined possible effects of gastroparesis on the intestinal slow wave. Methods. We recorded intestinal slow waves in diabetic patients with gastroparesis (N=7) and healthy controls (N=7) using the magnetoenterogram (MENG), which uses a Superconducting QUantum Interference Device (SQUID) to convert magnetic fields associated with intestinal slow waves into voltage signals. Second Order Blind Identification (SOBI) was used to reduce noise and isolate the intestinal slow wave signal from confounding magnetic artifact, and we computed the power spectrum of the intestinal slow wave using a Fast Fourier Transform technique. We analyzed dominant frequency, amplitude and percentage of power distributed (PPD) in brady, normo and tachyarrhythmic frequency ranges. Results. In gastroparesis patients, we found a significant decrease in postprandial dominant intestinal slow wave frequency from 10.2 ± 0.4 cpm to 8.8 ± 0.5 cpm (p<0.05) whereas the dominant frequency for control subjects increased from 9.9 ± 0.5 cpm to 10.8 ± 0.4 cpm (p<0.05). We did not observe significant differences in preand postprandial PPDs computed from controls or patients. Conclusions. Diabetic gastroparesis is associated with bradyarrhythmia, but not uncoupling, of the intestinal slow wave. Biomagnetic measurements of the MENG can assess intestinal slow wave activity in healthy and diseased tissue noninvasively.