Kenneth M. Vitellas

Detection of bile duct leaks using MR cholangiography with Mangfodipir trisodium (teslascan)

Mangafodipir trisodium (Teslascan), a hepatobiliary contrast agent, has the potential of providing functional biliary imaging similar to hepatobiliary scintigraphy. To our knowledge. the potential role of this biliary contrast agent in the detection of bile duct leaks has not been reported. In this case report, we report the first case of a bile duct leak diagnosed with enhanced MRI with mangafodipir trisodium in a patient following laparoscopic cholecystectomy. Our case illustrates that functional MR cholangiography images can be successfully acquired by using a post-mangafodipir fat-suppressed GRE technique and that bile duct leaks can be detected.

Radiographic manifestations of eosinophilic gastroenteritis

Eosinophilic gastroenteritis (EG) is a rare inflammatory disease of unknown etiology, characterized by focal or diffuse eosinophilic infiltration of the gastrointestinal tract. Although little over 250 cases of EG have been reported in the literature, EG is probably more common than reports in the literature would indicate. A retrospective review of 25 patients with EG along with a review of the literature was done to identify clinical, laboratory, radiographic, and therapeutic features. An allergic disorder was present in 14 (56%) and a peripheral eosinophilia was present in 24 (96%) of our patients. The most common radiographic manifestations of the stomach and small bowel included stenosis and fold thickening, respectively. Thirteen patients had esophageal involvement, with the esophageal stricture being the most common abnormality found in these patients. Steroids produced a good therapeutic result in most patients; the remaining patients responded to cromolyn and/or surgery.

Biliary imaging: A review

For practitioners of endoscopic retrograde cholangiopancreatography (ERCP), the times are certainly “achangin.” Until recently, ERCP was the gold standard for imaging the bile ducts. Noninvasive imaging was confined to transcutaneous ultrasound (TUS), computed tomography (CT) scanning, and radionuclide gallbladder and biliary scans, with percutaneous transhepatic cholangiography (PTC) and IOC (formerly T-tube cholangiography) being the other invasive options. In the last decade, however, “young pretenders” to the ERCP “throne” have emerged: specifically, magnetic resonance imaging (MRI), multidetector helical CT (MDCT) cholangiography, and endoscopic ultrasound (EUS). It is not so long ago that MRI was considered to have no future in the abdominal cavity. However, the abdominal MRI naysayers failed to anticipate the exponential growth of this fledgling technology. Magnetic resonance cholangiopancreatography (MRCP) now rivals ERCP in sensitivity and specificity in many situations. ERCP remains the principal nonsurgical therapeutic approach for mechanical obstruction of the biliary and pancreatic ducts, with PTC and allied techniques (e.g., percutaneous biliary drainage [PBD]) being reserved for ERCP failures and situations in which ERCP is not attempted (e.g., after Roux-en-Y biliary diversion). In most endoscopy units, ERCP has evolved into a mainly therapeutic modality, with a variety of noninvasive (or less invasive) imaging techniques being used for diagnosis. This review will explore the changing face of biliary imaging, with particular emphasis on ERCP, MRCP, and MDCT cholangiography.

Cystic Schwannoma of the Pancreas

Intrapancreatic schwannoma is a rare neoplasm. We report a case of a 46-year-old man with a cystic schwannoma in the head of the pancreas. This tumor, based on clinical manifestations and radiologic features, was initially suspected to be a cystic mucinous tumor of the pancreas or a pseudocyst. Histologically, the tumor was a typical schwannoma with cyst formation caused by degenerative changes. Immunostaining showed the tumor cells to be strongly and diffusely positive for S-100 protein, vimentin, and CD56, and negative for cytokeratin AE1/AE3, desmin, smooth muscle myosin specific, CD34, and CD117, which support the diagnosis of schwannoma. Cystic schwannoma is a rare neoplasm occurring in the pancreas and should be considered in the differential diagnoses for patients presenting with pancreatic cystic lesions.

Pancreatitis complicated by gland necrosis: evolution of findings on contrast-enhanced CT.

PURPOSE The purpose of this work was to investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively. METHOD A computer-based radiology information search revealed 32 patients with pancreatic necrosis who had had serial contrast-enhanced CT scans and were managed nonoperatively. There were 23 men and 9 women with a mean age of 51 years. One hundred forty-five contrast-enhanced CT scans were retrospectively reviewed for the location and extent of necrosis. The medical records of all patients were reviewed. RESULTS The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). Eighteen of these 32 patients were managed nonoperatively, and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0-25% (9), 26-50% (6), 51-75% (6), and 76-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in six (60%) patients in whom there was an increase in necrosis and eight (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were five patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. Five of the 32 patients died. CONCLUSION Pancreatic necrosis as demonstrated by CT tends to remain stable in most patients treated nonoperatively. If the extent of necrosis increases, patients are more likely to require a necrosectomy. In some patients managed nonoperatively, the pancreatic necrosis will resorb, resulting in a fat-replaced cleft reminiscent of a scar.

Biliary cystadenocarcinoma: seven year follow-up and the role of MRI and MRCP

Biliary cystadenomas and their malignant counterparts, biliary cystadenocarcinomas, are rare cystic tumors that arise from hepatobiliary epithelium. Ultrasound (US) and computed tomography (CT) are the initial imaging modalities used for the evaluation of biliary cystic tumors, but are not specific. MRI and MRCP, because of increased contrast and spatial resolution, may be a more specific imaging modality in the detection of biliary cystic neoplasms. We present a case of biliary cystadenocarcinoma imaged by MRI and MRCP in a 65 year-old man managed conservatively for 7 years.

Castleman disease mimicking a hepatic neoplasm

Castleman disease, or angiofollicullar hyperplasia, is a rare cause of lymph node enlargement. This most commonly occurs within the thorax, although rare extrathoracic presentations have been described. Only two cases with hepatic localization have been reported. We present a case of Castleman disease within the porta hepatis masquerading as a hepatic neoplasm.

The Calcaneus: Applications of Magnetic Resonance Imaging

The calcaneus is the largest bone in the foot and is an important primary weightbearing structure. Pathologic processes that affect this bone may manifest in a variety of clinical presentations, including pain, abnormal motion, instability, or fracture. The purpose of this article is to present a pictorial essay of the wide spectrum of pathologic entities that may affect the calcaneus, emphasizing applications of magnetic resonance imaging and characteristic magnetic resonance features of these processes.

Magnetic resonance cholangiography with mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after T-tube removal in Liver transplantation

Liver transplant patients who present with abdominal pain after removal of the T-tube can be initially evaluated by contrast-enhanced magnetic resonance cholangiography (CEMRC) instead of abdominal computed tomography and hepatobiliary scintigraphy. In this article, 3 liver transplant patients who were evaluated by CEMRC after removal of the T-tube. CEMRC successfully identified the presence, location and extent of bile duct leaks, and can be performed as a diagnostic study in patients with suspected bile duct leaks.

THE ANKLE JOINT : IMAGING STRATEGIES IN THE EVALUATION OF LIGAMENTOUS INJURIES

(1998). The Ankle Joint: Imaging Strategies in the Evaluation of Ligamentous Injuries. Critical Reviews in Diagnostic Imaging: Vol. 39, No. 6, pp. 393-445.