Joseph C. Veniero

LI-RADS: A Case-based Review of the New Categorization of Liver Findings in Patients with End-Stage Liver Disease

Hepatocellular carcinoma (HCC) is a global health problem, with the burden of disease expected to increase in the coming years. Patients who are at increased risk for developing HCC undergo routine imaging surveillance, and once a focal abnormality is detected, evaluation with multiphasic contrast material-enhanced computed tomography or magnetic resonance imaging is necessary for diagnosis and staging. Currently, findings at liver imaging are inconsistently interpreted and reported by most radiologists. The Liver Imaging-Reporting and Data System (LI-RADS) is an initiative supported by the American College of Radiology that aims to reduce variability in lesion interpretation by standardizing report content and structure; improving communication with clinicians; and facilitating decision making (eg, for transplantation, ablative therapy, or chemotherapy), outcome monitoring, performance auditing, quality assurance, and research. Five categories that follow the diagnostic thought process are used to stratify individual observations according to the level of concern for HCC, with the most worrisome imaging features including a masslike configuration, arterial phase hyperenhancement, portal venous phase or later phase hypoenhancement, an increase of 10 mm or more in diameter within 1 year, and tumor within the lumen of a vein. LI-RADS continues to evolve and is expected to integrate a series of improvements in future versions that will positively affect the care of at-risk patients.

Amyand’s hernia: a case report of prospective ct diagnosis in the emergency department

The diagnosis of Amyand’s hernia, the development of acute appendicits within an inguinal hernia, is rarely made preoperatively and is often confused clinically with an incarcerated right inguinal hernia. The use of CT to prospectively diagnose Amyand’s hernia and corresponding imaging findings are not well described in the literature. We report a case of Amyand’s hernia, which was correctly diagnosed by CT in a female patient presented to the emergency department with right lower quadrant pain and clinical suspicion of a strangulated omentocele.

Secretin-Enhanced MRCP: Review of Technique and Application With Proposal for Quantification of Exocrine Function

OBJECTIVE The purpose of this article is to present a proposal for quantification of exocrine function using secretin-enhanced MRCP for the diagnosis of chronic pancreatitis. The article also reviews the technique and application of secretin-enhanced MRCP in evaluating various pancreatic abnormalities. SUBJECTS AND METHODS One hundred thirty-four consecutive patients with chronic abdominal pain undergoing secretin-enhanced MRCP for suspected chronic pancreatitis were included. Patients were divided into four clinical groups (normal, equivocal, early chronic pancreatitis, established pancreatitis) on the basis of clinical symptoms and additional investigations, including CT (n=98), endoscopic pancreatic function test (n=65), endoscopic ultrasound (n=84), and ERCP (n=36). The volume of secretion was obtained by drawing a region of interest around T2 bright fluid secreted on postsecretin HASTE images. The maximal rate of secretion in response to secretin was obtained by plotting change in signal intensity on sequential postsecretin images. The analysis of variance test was used to compare the clinical groups with the volume and rate of secretion. RESULTS Significant volume differences were found between the normal and established pancreatitis groups (p<0.0001) as well as the equivocal and established pancreatitis groups (p<0.0005). Marginally significant differences were found between the normal and early pancreatitis groups (p=0.0150) as well as early and established pancreatitis groups (p=0.0351). Differences in the maximal rate of secretion were not statistically significant. CONCLUSION Secretory volume measurement of secretin-enhanced MRCP data is a simple method that brings out significant differences between normal, early, and established pancreatitis patients.

Mural attenuation in normal small bowel and active inflammatory Crohn's disease on CT enterography: location, absolute attenuation, relative attenuation, and the effect of wall thickness.

OBJECTIVE The purpose of our study was to measure relative and absolute wall attenuations and wall thickness in normal small bowel on contrast-enhanced CT enterography and to study the efficacy of relative attenuation, absolute attenuation, and wall thickness in distinguishing normal from active inflammatory Crohns disease of the terminal ileum. MATERIALS AND METHODS Using a case-control study design, we reviewed 630 CT enterography examinations, of which 191 were normal and 36 had active inflammatory Crohns disease in the terminal ileum. In healthy individuals, wall thickness and attenuation in distended and collapsed loops were measured in the duodenum and four abdominal quadrants. Wall thickness and attenuation were also measured in the terminal ileum. All measurements of intraarterial attenuation were taken at the same slice level. In the examinations of patients with Crohns disease, only terminal ileum wall thickness and attenuation as well as arterial attenuation at the same slice level were measured. Normal segments were compared with a linear model. Terminal ileum data were fit to a multivariate logistic regression model. RESULTS Relative attenuation and absolute attenuation in the normal distended and collapsed duodenum and left upper quadrant were significantly greater than in all other segments (p < 0.001 and < 0.048 for relative attenuation and p < 0.001 and < 0.032 for absolute attenuation, respectively). Relative attenuation and wall thickness models and absolute attenuation and wall thickness models discriminated normal from active terminal ileum Crohns disease significantly better than the same measurements without wall thickness (p = 0.017 and 0.001, respectively). When the bowel wall is > 3 mm, a relative attenuation cutoff of 0.5 is 89% sensitive and 81% specific. CONCLUSION In normal small bowel, when wall measurement is taken into account, the duodenum and jejunum have a greater relative attenuation and absolute attenuation than other segments. Relative attenuation and absolute attenuation with wall thickness models discriminate normal from active terminal ileum Crohns disease better than the same measurements without wall thickness.

Focal liver lesion detection and characterization with GD-EOB-DTPA

Superior soft-tissue contrast affords magnetic resonance imaging (MRI) some advantages compared to computed tomography (CT) in both detection and characterization of focal liver lesions. Because of its relatively recently introduction into clinical practice, a growing number of articles in the literature have demonstrated the usefulness of the hepatobiliary-specific MRI contrast agent gadoxetic acid disodium (Gd-EOB-DTPA) in liver imaging. The purpose of this review is to demonstrate the typical enhancement patterns of the most common liver lesions using Gd-EOB-DTPA in daily clinical scenarios and briefly describe its mechanism of action. Radiologists interpreting liver MRI studies with this agent must be familiar with the appearance of focal lesions in the hepatocyte phase to avoid misinterpretation.

Computed Tomography Enterography and Magnetic Resonance Enterography: The Future of Small Bowel Imaging

In the last 5 years, computed tomography enterography (CTE) and to a lesser extent magnetic resonance enterography (MRE) have supplanted the routine small bowel series and enteroclysis in the evaluation of many small bowel diseases, especially Crohns disease. Both CTE and MRE use similar methods of bowel lumen opacification and distension and both have distinct advantages and disadvantages. Both have been most extensively studied in patients with Crohns disease. What is certain is that these cross-sectional examinations have largely replaced the historic fluoroscopic examinations in the evaluation of the small bowel.

Magnetic Resonance Imaging in the Management of Anal Fistula and Anorectal Sepsis

Complex perianal disease may be extremely debilitating for the patient with significant impingement on quality of life. The accurate identification of anatomical areas of involvement and subsequent appropriate management is crucial to achieving a successful outcome when treating anorectal sepsis and anal fistulae. Magnetic resonance imaging (MRI) has become a powerful tool in the evaluation of anal anatomy. In patients with complex disease MRI is an important adjunct in delineating disease location and extent, its relationship to sphincter muscles, and in planning management. MRI also plays an important role in evaluating the response to medical and surgical therapies.

Does secretin stimulation add to magnetic resonance cholangiopancreatography in characterising pancreatic cystic lesions as side-branch intraductal papillary mucinous neoplasm?

AbstractObjectivesTo assess the value of secretin during magnetic resonance cholangiopancreatography (MRCP) in demonstrating communication between cystic lesions and the pancreatic duct to help determine the diagnosis of side-branch intraductal papillary mucinous neoplasm (SB-IPMN).MethodsThis is an IRB-approved, HIPAA-compliant retrospective study of 29 SB-IPMN patients and 13 non-IPMN subjects (control) who underwent secretin-enhanced MRCP (s-MRCP). Two readers blinded to the final diagnosis reviewed three randomised image sets: (1) pre-secretin HASTE, (2) dynamic s-MRCP and (3) post-secretin HASTE. Logistic regression, generalised linear models and ROC analyses were used to compare pre- and post-secretin results.ResultsThere was no significant difference in median scores for the pre-secretin [reader 1: 1; reader 2: 2 (range -2 to 2)] and post-secretin HASTE [reader 1: 1; reader 2: 1 (range -2 to 2)] in the SB-IPMN group (P = 0.14), while the scores were lower for s-MRCP [reader 1: 0.5 (range -2 to 2); reader 2: 0 (range -1 to 2); P = 0.016]. There was no significant difference in mean maximum diameter of SB-IPMN on pre- and post-secretin HASTE, and s-MRCP (P > 0.05).ConclusionSecretin stimulation did not add to MRCP in characterising pancreatic cystic lesions as SB-IPMN.Key Points• Magnetic resonance cholangiopancreatography (MRCP) is used to evaluate pancreatic cystic lesions. • Intraductal papillary mucinous neoplasm (IPMN) is a type of pancreatic cystic neoplasm. • Secretin administration does not facilitate the diagnosis of IPMN on MRCP.

CT-Guided Transgluteal Biopsy for Systematic Random Sampling of the Prostate in Patients Without Rectal Access.

OBJECTIVE The objective of our study was to review our experience with CT-guided transgluteal prostate biopsy in patients without rectal access. MATERIALS AND METHODS Twenty-one CT-guided transgluteal prostate biopsy procedures were performed in 16 men (mean age, 68 years; age range, 60-78 years) who were under conscious sedation. The mean prostate-specific antigen (PSA) value was 11.4 ng/mL (range, 2.3-39.4 ng/mL). Six had seven prior unsuccessful transperineal or transurethral biopsies. Biopsy results, complications, sedation time, and radiation dose were recorded. The mean PSA values and number of core specimens were compared between patients with malignant results and patients with nonmalignant results using the Student t test. RESULTS The average procedural sedation time was 50.6 minutes (range, 15-90 minutes) (n = 20), and the mean effective radiation dose was 8.2 mSv (median, 6.6 mSv; range 3.6-19.3 mSv) (n = 13). Twenty of the 21 (95%) procedures were technically successful. The only complication was a single episode of gross hematuria and penile pain in one patient, which resolved spontaneously. Of 20 successful biopsies, 8 (40%) yielded adenocarcinoma (Gleason score: mean, 8; range, 7-9). Twelve biopsies yielded nonmalignant results (60%): high-grade prostatic intraepithelial neoplasia (n = 3) or benign prostatic tissue with or without inflammation (n = 9). Three patients had carcinoma diagnosed on subsequent biopsies (second biopsy, n = 2 patients; third biopsy, n = 1 patient). A malignant biopsy result was not significantly associated with the number of core specimens (p = 0.3) or the mean PSA value (p = 0.1). CONCLUSION CT-guided transgluteal prostate biopsy is a safe and reliable technique for the systematic random sampling of the prostate in patients without a rectal access. In patients with initial negative biopsy results, repeat biopsy should be considered if there is a persistent rise in the PSA value.

Computed tomography-guided endoscopic sinusotomy for an ileal pouch presacral sinus

Endoscopic sinusotomy for ileal pouch sinus, a detrimental complication caused by chronic anastomotic leak, is an effective and safe treatment option [1]. Endoscopic sinusotomy requires access to the sinus from the pouch lumen and has been considered infeasible in patients with a sealed sinus. We describe herein the first endoscopic sinusotomy for a sealed sinus using computed tomography (CT)-guided wire placement. The patient was a 28-year-old man diagnosed with ulcerative colitis in 2002, who underwent restorative proctocolectomy with an ileal pouch–anal anastomosis (IPAA). He was later diagnosed with Crohn’s disease based on the presence of inflammation in the pouch body and afferent limb and was started on adalimumab. He was referred for the management of a 2.7 ×1.6-cm presacral sinus that had been found on magnetic resonance imaging (MRI) in 2017 (▶Fig. 1 a). He had symptoms of failure to thrive, tailbone pain, and night sweats. Pouchoscopy was performed which failed to detect a sinus opening. We then decided to use CT-guided wire placement to gain access to the sinus through the side of the pouch. An experienced radiologist advanced a 17-Fr trocar needle cutaneously, through the collection and into the pouch, and this was followed by wire placement (▶Fig. 1b). The patient was subsequently brought to the endoscopy suite, where he received conscious sedation. After the area had been tattooed, partial endoscopic sinusotomy was performed along the path of the wire using an IT needle-knife (▶Fig. 1 c, d), and this was followed by placement of five endoclips to maintain the patency of the orifice (▶Video1). Complete endoscopic sinusotomy was performed 1 month later, followed by placement of endoclips to maintain pa-