Mariano Scaglione

Safety and efficacy of anticoagulation therapy with low molecular weight heparin for portal vein thrombosis in patients with liver cirrhosis.

Background Treatment of portal vein thrombosis (PVT) in patients with liver cirrhosis is not well established. Aim We intended to assess the safety and efficacy of low molecular weight heparin (LMWH) to treat PVT in cirrhotic patients. Study All 39 patients diagnosed with non-neoplastic PVT and cirrhosis from June 2005 to December 2006 were evaluated for anticoagulation therapy (AT). PVT was occludent in 15.4%, partial in 64.1%, and portal cavernoma presented in 20.5%. Twenty-eight patients received 200 U/kg/d of enoxaparin for at least 6 months. In 39.3% of patients PVT was an occasional finding, in 10.7% presented with acute abdominal pain, in 50% with bleeding from gastroesophageal varices. In this last group LMWH was started after endoscopic eradication of varices by band ligation. Results Complete recanalization of portal vein occurred in 33.3%, partial recanalization in 50% and no response in 16.7% of patients. Further 12 patients who continued AT obtained complete recanalization at a median time of 11 months (range 7 to 17 mo). Overall, a complete response was obtained in 75% of patients. No significant side effects, particularly bleeding complications, were observed during the treatment. Conclusions LMWH demonstrated safe and effective in the treatment of PVT in patients with liver cirrhosis.

Prognostic factors in noncirrhotic patients with splanchnic vein thromboses.

OBJECTIVES AND METHODS:Splanchnic vein thrombosis (SVT), not associated with cancer or liver cirrhosis, is a rare event and scanty data are available on its natural history, long-term prognosis, and treatment. In this study 121 SVT patients consecutively seen from January 1998 to December 2005 were included and 95 of them were followed up for a median time of 41 months. Screening for thrombophilic factors was performed in 104 patients. New thrombotic or bleeding episodes were registered and anticoagulant therapy was performed according to preestablished criteria.RESULTS:SVT was an incidental finding in 34 (28.1%) patients; 34 (28.1%) presented with abdominal infarction; 39 (32.2%) had bowel ischemia or acute portal vein thrombosis; 14 (11.6%) had bleeding from portal hypertensive sources. Survival rates at 1, 3, and 7 yr were 95%, 93.3%, and 89.6%, respectively; 87.5% of deaths occurred at onset of SVT as complications of intestinal infarction. Patients with isolated portal vein thromboses had symptoms and intestinal infarction in 16/41 (39%) and 0/41 (0%) of the cases, respectively, whereas superior mesenteric vein thromboses, isolated or not, were associated with symptoms and intestinal infarction in 69/75 (92%) and 34/75 (45%), respectively.During the follow-up 14 (14.7%) suffered from 39 episodes of gastrointestinal bleeding with no deaths. A previous gastrointestinal bleed was associated with new hemorrhagic events during follow-up.New venous thrombotic episodes occurred in 10 of 95 patients (10.5%), of which 73% were in the splanchnic area. Seven out of these 10 patients had a chronic myeloproliferative disease (MPD) and none was on anticoagulation.CONCLUSIONS:Anticoagulant therapy was effective to obtain recanalization of acute SVT in 45.4% of patients and preserved patients from recurrent thrombosis when given lifelong.

Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography

Purpose.The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign–body aspiration.Materials and methods.During a 5–year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign–body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign–body aspiration had occurred 2–72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients.Results.Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball–point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign–body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge.Conclusions.Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign–body aspiration, MSCT—possibly integrated with virtual bronchoscopy—should be considered in order to avoid unnecessary bronchoscopy.

Role of Imaging in the Assessment of Impacted Foreign Bodies in the Hypopharynx and Cervical Esophagus

Impaction of foreign bodies in the upper digestive tract is a serious pathologic condition in ear, nose, and throat practice and is particularly common in children, prisoners, and psychiatric patients. Commonly found objects include fish bones, chicken bones, pieces of glass, dental prostheses, coins, and needles. The goals of the initial patient assessment are to identify the type of object, its location in the gastrointestinal tract, the presence of any associated complications, and the presence of any underlying esophageal conditions. Radiographic evaluation is helpful to confirm the location of foreign bodies and associated complications. Plain films of the neck and chest commonly will show the location of radiopaque objects, such as coins. Both anteroposterior and lateral views are necessary, as some radiopaque objects overlying the vertebral column may only be visible on the lateral view. Multidetector row computed tomography is superior to plain radiographs for the detection of pharyngoesophageal foreign bodies and provide additional crucial information for the management of complicated cases especially related to sharp or pointed ingested foreign bodies.

Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases

To determine the value of helical computed tomography (CT) in the diagnosis, management and outcome of patients suspected of having descending necrotizing mediastinitis (DNM). Thirty-two patients with suspected DNM were submitted to contrast-enhanced single detector-row helical CT, four detector-row CT and 16 detector-row CT of the neck and chest. In 10/32 patients (group 1) no abnormality was observed in the neck or in the chest spaces on CT scan. These patients were all treated non-operatively. In 12/32 patients (group 2) CT showed the presence in the neck spaces of fluid collections, fasciitis, cellulitis, myositis, jugular vein thrombosis and lymphadenopathy; in all these patients the chest was unaffected. A cervical drainage was performed in ten patients. In the remaining ten patients (group 3), the neck infection involved the mediastinal spaces in all the cases and the pleural and pericardial spaces; CT findings included mediastinal cellulitis and fluid collections, pleural and pericardial effusions, venous thrombosis and lymphadenopathy. In these patients, a cervico-mediastinal drainage was performed and antibiotics were administered. The CT provides a highly accurate depiction of the presence and the spread of DNM. The CT findings and the extension of disease are important factors in order to predict for patient management and outcome.

Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the ‘gold standard’ for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.

Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography

PurposeWe investigated the role of multidetector-row computed tomography (MDCT) in identifying active bleeding and its source in polytrauma patients with pelvic vascular injuries with or without associated fractures of the pelvis.Materials and methodsFrom January 2003 to December 2007, 28 patients (19 men and nine women, age range 16–80 years) with acute symptoms from blunt pelvic trauma and a drop in haematocrit underwent MDCT and angiography. Conventional radiography of the pelvis was performed in all patients at the time of admission to the emergency department. MDCT was performed with a four-row unit in 15 patients and a 16-row unit in the remaining 13 patients. The study included whole-body CT to identify craniocerebral, vertebral, thoracic, abdominal and pelvic injuries. CT was performed before and after rapid infusion (4–5 ml/s) of intravenous contrast material (120 ml) using a power injector. A triphasic contrast-enhanced study was performed in all patients. MDCT images were transferred to a workstation to assess pelvic fracture, site of haematoma and active extravasation of contrast material, visibility of possible vascular injuries and associated traumatic lesions. At angiography, an abdominal and pelvic aortogram was obtained in all cases before selective catheterisation of the internal iliac arteries and superselective catheterisation of their branches for embolisation purposes. Results related to identifying the source of bleeding at MDCT were compared with sites of bleeding or vascular injury identified by selective pelvic angiography. The sensitivity and positive predictive value (PPV) of MDCT were determined.ResultsMDCT allowed us to identify pelvic bleeding in 21/28 patients (75%), with most cases being detected in the delayed contrast-enhanced phase (13/21 cases, 61.9%). Injured arteries were identified on MDCT in 12/21 cases (57%): the obturator artery (n=9), internal iliac artery (n=6), internal pudendal artery (n=6) and superior gluteal artery (n=5) were most frequently injured. In 8/21 patients (28.6%), more than one artery was injured. Among the 12 patients in whom MDCT showed the presence of pelvic haemorrhage, there was agreement between MDCT and angiography in ten cases. Angiography confirmed the site of bleeding detected on MDCT and identified a second arterial haemorrhage in one patient. There was no agreement between MDCT and angiography in the last patient. MDCT showed a sensitivity of 42.85% and a PPV of 100% in identifying the injured arteries.ConclusionsArterial haemorrhage is one of the most serious problems associated with pelvic fracture, and it remains the leading cause of death attributable to such fractures. MDCT provides diagnostic information regarding the presence of small pelvic fractures and, thanks to the contrast-enhanced angiographic technique, it is capable of identifying pelvic bleeding, with the demonstration in some cases of it source. The presence of contrast material extravasation is an indicator of injury to a specific artery passing through the region of the pelvis where the extravasation is noted on MDCT. Urgent angiography and subsequent transcatheter embolisation are the most effective methods for controlling ongoing arterial bleeding in pelvic injuries.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo della tomografia computerizzata multidetettore (TCMD) nell’identificazione di sanguinamento attivo e della sua origine in pazienti politraumatizzati con trauma vascolare della pelvi associato o non associato a fratture dell’anello pelvico.Materiali e metodiTra gennaio 2003 e dicembre 2007, sono stati sottoposti ad esame TCMD e successivamente ad esame angiografico 28 pazienti politraumatizzati (19 maschi e 9 femmine, con età compresa tra 16 e 80 anni) affetti da specifico trauma della pelvi con calo dell’ematocrito. In tutti i pazienti era stato eseguito al ricovero in Pronto Soccorso l’esame radiografico del bacino. L’esame TCMD è stato condotto in 15 pazienti con apparecchiatura a quattro strati e nei rimanenti 13 pazienti con apparecchiatura a 16 strati ed ha previsto in tutti i pazienti uno studio total body per l’identificazione di lesioni traumatiche dell’encefalo, della colonna vertebrale, del bacino, del torace, dell’addome e della pelvi. È stata eseguita una fase precontrastografica seguita da uno studio contrastografico trifasico con somministrazione con iniettore automatico di un volume pari a 120–150 ml di mezzo di contrasto (MdC) con velocità di flusso di 4–5 ml/s, seguito da 40 ml di soluzione fisiologica con flusso pari a 2 ml/s. Le immagini TCMD acquisite sono state trasferite ad una stazione di lavoro per le ricostruzioni necessarie alle differenti valutazioni: tipologia della frattura del bacino quando presente, sede dell’ematoma e dello stravaso di MdC, eventuale visibilità del vaso lacerato nello scavo pelvico ed eventuali ulteriori lesioni traumatiche associate dello stesso scavo pelvico o di altri distretti anatomici. Il successivo studio angiografico è stata condotto effettuando prima un angiogramma panoramico della regione aortoiliaca, seguito da uno studio selettivo della regione di interesse mediante cateterismo delle arterie ipogastriche e cateterismo superselettivo delle branche di divisione delle stesse arterie ipogastriche ai fini dell’embolizzazione. I risultati relativi alla identificazione del vaso lacerato alla TCMD, sono stati confrontati con quelli dell’angiografia per valutare sensibilità e valore predittivo positivo (VPP) della TCMD.RisultatiL’esame TCMD ha consentito di evidenziare la presenza di sanguinamento attivo in 21/28 casi (75%) e la fase di studio postcontrastografico in cui più frequentemente è stato rilevato il sanguinamento attivo è risultata la fase tardiva (13/21 casi, 61,9%). Nell’ambito dei 21 pazienti in cui l’esame TCMD ha mostrato la presenza di sanguinamento attivo, il vaso leso è stato identificato in 12/21 casi (57%). Le arterie più frequentemente lese sono risultate l’otturatoria (9 casi), l’ipogastrica (6 casi), la pudenda interna (6 casi) e la glutea superiore (5 casi). In 8/28 pazienti (28,6%) sono state osservate lesioni a carico di più vasi arteriosi. Nell’ambito dei 12 pazienti in cui l’esame TCMD ha consentito l’identificazione del vaso leso, in 10 casi è stata riscontrata una concordanza tra esame TCMD ed esame angiografico, in un caso l’esame angiografico ha confermato la sede della lesione indicata all’indagine TCMD mostrando anche una seconda arteria lesa, ed in un caso si è verificata una discordanza tra indagine TCMD ed indagine angiografica. Nella identificazione del vaso lacerato la TCMD ha mostrato sensibilità e VPP pari rispettivamente a 42,85% e 100%.ConclusioniL’emorragia da lesione di un vaso arterioso rappresenta uno dei problemi più gravi associato a frattura del cingolo pelvico ed è la causa principale di mortalità. La TCMD permette di identificare anche piccole rime di frattura a carico del bacino e grazie all’utilizzo del MdC ev ed alla tecnica di studio di angiografia-TCMD consente di riconoscere la presenza del sanguinamento attivo con possibilità, in alcuni casi, di definire anche la sede della perdita ematica. Infatti la presenza di stravaso attivo di MdC ev rappresenta un indicatore della lesione che coinvolge un’arteria specifica localizzata nella regione dello scavo pelvico ove lo stravaso è visualizzato all’esame TCMD. L’angiografia eseguita in emergenza con embolizzazione della fonte emorragica è il trattamento più efficace delle emorragie di vasi arteriosi determinate da traumi pelvici.

The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations

Computed tomography (CT) is the imaging method of choice in the assessment of multiple trauma patients. However, in patients who suffered from low-energy abdominal trauma, the use of CT is controversial, since the probability of injury is low and therefore most of the studies are normal. Thus, conventional US imaging has increasingly been employed as the initial imaging modality in the work-up of minor traumatic emergency condition. More recently, the introduction of a new contrast-enhanced ultrasound (CEUS) technique, using second-generation ultrasound contrast agents, has led to a notable increase in the diagnostic accuracy of US in many organs. Therefore, in trauma patients, following assessment with conventional US imaging, a CEUS exam can be performed, to provide a more reliable assessment of solid organ injuries. CEUS has the potential to detect active bleeding from a variety of traumatic origins. Similar to CT, active extravasation is considered when there is evidence of contrast agent collection with echogenicity similar to that of an adjacent vessel. On the other hand, at least some drawbacks have to be addressed, including operator competence and reduced panoramic view. Moreover, CEUS, like conventional US imaging, cannot depict some lesions, such as diaphragmatic ruptures, bowel, and mesenteric traumatic injuries. This technique represents a non-invasive and repeatable method that can be performed at patient’s bedside and is therefore extremely helpful for the follow-up of solid organs traumas managed conservatively, especially in pediatric patients and women of fertile age. Moreover, it may reduce the number of CT scans and expedite patient discharge.

Acute portal and mesenteric thrombosis: unusual presentation of cytomegalovirus infection.

Cytomegalovirus infection is a benign disease in immunocompetent patients. In-vitro and in-vivo studies show that cytomegalovirus may cause arterial and venous thrombosis through different mechanisms. We describe two cases of acute cytomegalovirus infection complicated by portal and mesenteric vein thrombosis leading to intestinal ischemia. Both patients carried the heterozygous prothrombin G20210A mutation. The presence of this unusual complication should be searched for in patients with acute cytomegalovirus infection and abdominal symptoms in order to start early anticoagulation. The necessity for full thrombophilic screening is also pointed out.

CT features of descending necrotizing mediastinitis--a pictorial essay.

Descending necrotizing mediastinitis (DNM) is a relatively rare condition caused by downward spread of neck infections into the mediastinum. This infection previously had a much worse prognosis. In recent years, prompt computer topography (CT) diagnosis has been recommended. CT scan provides the earliest means of detecting DNM for optimal management and early surgical intervention. This paper provides an illustrated summary of our extensive clinical experience with DNM, involving 36 documented cases with CT over a 5-year period.