María Jesús Martínez

Contrast-enhanced ultrasonography: Usefulness in the assessment of postoperative recurrence of Crohn's disease

AIM The aim of this study was to assess whether the contrast-enhanced ultrasonography (CEUS) can increase the value of the ultrasonography in the study of postoperative recurrence of Crohns disease (CD). MATERIALS AND METHODS 60 patients with CD who had previously undergone ileocolic resection underwent prospectively both CEUS and colonoscopy within a 3-day period. The sonographic examination included evaluation of bowel wall thickness, transmural complications, colour Doppler grade and contrast-enhanced US. In addition a sonographic score was established. The capacity of CEUS to diagnose endoscopic recurrence, as well as its severity, was assessed by calculating the sensitivity, specificity and positive and negative predictive values, accuracy and odds ratio, with their respective 95% confidence intervals. The areas under the receiver operating characteristic (ROC) curves were also calculated. RESULTS 49 out of 60 patients showed endoscopic postoperative recurrence. Severe endoscopic recurrence was present in 34 patients (57%). Classic ultrasound parameters (wall thickness >3mm and colour Doppler flow) revealed an accuracy of 88.3% for the diagnosis of recurrence. Sonographic score 2, including thickness >5mm or contrast enhancement >46%, improved the results with a sensitivity, specificity and accuracy of 98%, 100% and 98.3%, respectively, in the diagnosis of endoscopic recurrence. The area under the ROC curve was 0.99, in remarkable agreement with endoscopy (k: 0.946). Sonographic score 3, including thickness >5mm, contrast enhancement >70% or fistula identified 32 out of 34 (94.1%) severe endoscopic recurrences. The area under the ROC curve was 0.836, in good agreement with endoscopy (k: 0.688). CONCLUSION CEUS shows excellent sensitivity and specificity for the diagnosis of postoperative recurrence in CD and can also detect severe recurrences.

Usefulness of abdominal ultrasonography in the analysis of endoscopic activity in patients with Crohn's disease: Changes following treatment with immunomodulators and/or anti-TNF antibodies

OBJECTIVE The objective of this study was to analyze the accuracy of abdominal ultrasonography (AUS) in the assessment of mucosal healing in patients with Crohns disease (CD) receiving immunomodulators and/or biological treatment, with ileocolonoscopy as the reference standard. MATERIALS AND METHODS Thirty patients were included in a prospective longitudinal study. All patients underwent ileocolonoscopy and AUS before and after a minimum of one year of treatment. The Crohns Disease Endoscopic Inflammatory Index of Severity (CDEIS) was used for endoscopic assessment whereas AUS was analyzed by means of bowel wall thickness, color Doppler grade and percentage of increase of parietal enhancement after contrast injection. RESULTS In the segmental analysis, endoscopic healing was found in 71.2% of the segments and AUS findings were normalized in 62.8%, with a significant correlation between the two techniques (κ=0.76, p<0.001). In the overall assessment performed after treatment, 18 (60%) patients exhibited endoscopic remission (CDEIS <6 points); of these patients, 15 (83.3%) had normalized sonographic findings, with a good correlation between endoscopic remission and sonographic normalization (κ=0.73, p<0.001). Of the three variables assessed by AUS, parietal thickness was the best variable to predict mucosal healing in both analyses, segmental and global. CONCLUSION Abdominal ultrasonography is a useful and reliable technique for the assessment of the endoscopic response to treatment with immunomodulators and/or biological drugs in Crohns disease. AUS is a highly accurate technique for evaluating the healing of the intestinal mucosa.

Quadruple-Phase MDCT of the Liver in Patients with Suspected Hepatocellular Carcinoma: Effect of Contrast Material Flow Rate

OBJECTIVE The purposes of this study were to evaluate the effect of contrast material flow rate (3 mL/sec vs 5 mL/sec) on the detection and visualization of hepatocellular carcinoma (HCC) with MDCT and the safety profile of iodixanol at different injection rates. SUBJECTS AND METHODS In a prospective, randomized multicenter trial, 97 patients (83 men and 14 women, with a mean age of 64 years) suspected of having HCC underwent quadruple-phase (double arterial, portal venous, delayed phase) 4-16-MDCT. Patients were randomized to receive iodixanol, 320 mg I/mL (1.5 mL/kg body weight), at a flow rate of 3 mL/sec (48 patients) or 5 mL/sec (49 patients). Qualitative (lesion detection, image quality) and quantitative (liver and aortic enhancement, tumor-liver contrast) analyses and safety assessment were performed. RESULTS Overall, 145 HCCs were detected in the 5 mL/sec group and 100 HCCs in the 3 mL/sec group (p < 0.05). More lesions equal to or less than 1 cm were detected at 5 mL/sec (33 vs 16 lesions). The late arterial phase showed significantly more lesions than the early, arterial phase (133 vs 100 and 96 vs 67 lesions, respectively, p < 0.0001). Hyperattenuating HCCs were better visualized in the late arterial phase at 5 mL/sec (excellent visualization: 54% vs 27%). Using a flow of 5 mL/sec did not increase the rate of patient discomfort or contrast media-related adverse events. Most discomfort in both groups was of mild intensity and there was no severe discomfort. CONCLUSION For detection of HCC with MDCT, a higher flow rate of 5 mL/sec is recommended. Visualization of hyperattenuating HCC is improved with no greater discomfort or adverse events.

Non-invasive diagnosis and grading of postsurgical endoscopic recurrence in Crohn's disease Usefulness of abdominal ultrasonography and 99m Tc-hexamethylpropylene amineoxime-labelled leucocyte scintigraphy

UNLABELLED Non-invasive techniques aim to be an alternative to endoscopy in the assessment of postsurgical recurrence of Crohns disease (CD). The object of this study was to evaluate the accuracy of abdominal ultrasonography (AUS) and (99m)Tc-hexamethylpropylene amineoxime ((99m)Tc-HMPAO)-labelled leucocyte scintigraphy (LLS) compared with endoscopy in the diagnosis and grading of postsurgical recurrence of CD. Between January 2006 and May 2007, all patients with CD and resection with ileocolic anastomosis were included prospectively. Within three days they underwent an ileocolonoscopy, AUS with evaluation of bowel wall thickness and the presence of Doppler flow, and LLS. Forty patients who met the study conditions were included; 5 patients did not agree to have the ileocolonoscopy and it was not possible to assess the anastomosis in 2 patients. Endoscopic recurrence was detected in 26 patients (78.8%), in 15 of whom it was moderate-severe. For the diagnosis of recurrence, both AUS and LLS showed acceptable sensitivity and positive predictive value, with an accuracy of 72.7% and 78.1%, respectively. The results of the AUS and LLS for diagnosing moderate-severe recurrence were better, with an accuracy of 78.8% and 81.3%, respectively. The best assessment of the severity of the recurrence was obtained with the combination of both techniques (sensitivity, specificity, positive and negative predictive values, accuracy and kappa index were, respectively: 93.3%, 72.2%, 73.7%, 92.9%, 81.8% and 0.64). The variables evaluated, both sonographic and scintigraphic, had areas under the curve that were similar and significantly different from 0.5. CONCLUSION Abdominal ultrasonography and (99m)Tc-HMPAO-labelled leucocyte scintigraphy are two useful non-invasive techniques for the assessment of postsurgical recurrence of Crohns disease.

99mTc-hexamethylpropylene amineoxime leukocyte scintigraphy in acute pancreatitis : An alternative to contrast-enhanced computed tomography?

OBJECTIVES:Contrast-enhanced computed tomography (CECT) is the most efficient imaging technique for the diagnosis and staging of acute pancreatitis (AP); its use, however, may be unfeasible in some patients as a consequence of the drawbacks of intravenous (IV) contrast material. The aim of this study was to test the utility of labeled leukocyte scintigraphy (LLS) as an alternative imaging technique to CECT for the staging of AP.METHODS:Sixty-six patients with AP were prospectively studied. All patients underwent CECT and pancreatic LLS using 99mTc-hexamethylpropylene amineoxime as leukocyte label within a time interval of 2 days, in the early phase of AP. In addition, all patients had their serum C-reactive protein (CRP) concentration measured within 48–72 h after admission. CECT images were analyzed for Balthazars grade of pancreatitis and for the presence or absence of pancreatic necrosis. Scintigraphic activity of 3–4 h planar images was scored on a 0–2 scale in relation to physiological liver uptake.RESULTS:LLS score was significantly related (p < 0.001) to both components of CECT (grade of pancreatitis and pancreatic necrosis). LLS and serum CRP showed similar results for detecting the most severe pancreatic damage as showed by their respective receiver operating characteristic (ROC) curves. Sensitivities and specificities of LLS score of 2 were, respectively, 62% and 96% for the detection of grade D-E pancreatitis and 90% and 89% for the detection of pancreatic necrosis. Scintigraphic score of 2 increased the likelihood of grade D-E pancreatitis from 32% (pretest probability) to 87% (posttest probability) (likelihood ratio: 13.9) and that of pancreatic necrosis from 16% to 60% (likelihood ratio: 8.4).CONCLUSION:Our results show that leukocytes are related to the severity of local pancreatic damage in AP. Thus, LLS is a potential alternative technique to CECT for staging AP.

Ecografía y TC del mucocele apendicular: hallazgos que sugieren etiología maligna

Objetivo Describir los hallazgos del mucocele apendicular en ecografia y tomografia computarizada (TC), valorando los signos que ayu-den a predecir el origen maligno del mismo. Material y metodos Se revisaron los hallazgos clinicos y radiolo-gicos de 17 pacientes diagnosticados de mucocele apendicular en nuestro hospital en los ultimos 10 anos (seis cistoadenocarcinomas, ocho mucoceles de retencion, dos cistoadenomas y un adenoma vello-so). Resultados La ecografia mostro masas quisticas en la teorica loca-lizacion del apendice, con estructura de capas en la pared, de ecogeni-cidad interna variable, mostrando en siete casos calcificacion parietal. La TC mostro tumoraciones quisticas de baja atenuacion en el area pericecal, con realce parietal, siendo nodular en cuatro casos (tres cis-toadenocarcinomas y un adenoma velloso). Ninguno de los cistoade-nocarcinomas presento calcio en la pared. En cuatro pacientes se ob-servo la presencia de seudomixoma peritoneal (tres cistoadenocarcino-mas y un mucocele de retencion). Conclusiones El mucocele apendicular tiene unos hallazgos eco-graficos y en TC caracteristicos. La presencia en la TC de un realce nodular en la pared del mucocele es un hallazgo que sugiere un origen maligno. La ausencia de calcio parietal y la existencia de seudomixo-ma peritoneal asociado tambien sugieren malignidad, aunque ambos signos pueden aparecer en mucoceles benignos.

Usefulness of Technetium-99m Hexamethylpropylene Amine Oxime-Labeled Leukocyte Scintigraphy to Detect Pancreatic Necrosis in Patients with Acute Pancreatitis

Background: In acute pancreatitis (AP), pancreatic necrosis (PN) is an important local complication that can be identified by means of contrast-enhanced computed tomography (CECT). Pancreatic leukocyte infiltration is a significant pathogenic event in the development of PN that can be detected by labeled leukocyte scintigraphy (LLS). The aim of this study was to evaluate the utility of LLS with technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) to detect the presence of PN in patients with AP. Methods: Prospective cohort study of 84 patients with AP. Patients underwent LLS and the activity of images was scored on a 0–3 scale. CETC was performed to assess PN. Ranson, Glasgow and APACHE-II scores were calculated. Serum C-reactive protein (CRP) was measured. Sensitivity (Sn), specificity (Sp), positive predictive values (PPV), negative predictive values (NPV), areas under receiver operating characteristic (ROC) curves, likelihood ratios, odds ratios, analysis of variances between groups and correlation coefficients between tests were calculated. Results: PN was present in 11 (13%) patients. Pancreatic labeled leukocyte uptake was present in 38 patients (45%). Sn, Sp, PPV and NPV of LLS grade 2–3 for PN diagnosis were the highest (91, 88, 53 and 98%, respectively) of all tests. Patients with LLS grade 2–3 were 71 times more likely to be at risk of PN compared to those with LLS grade 0–1. The area under ROC curve of the LLS was the largest. A significant correlation was obtained between LLS and CRP (p < 0.001). Conclusion: In patients with AP, LLS with 99mTc-HMPAO detects PN with an acceptable level of confidence and therefore could be considered an alternative technique to CECT in detecting PN.