Vivek Virmani

Ultrasound, Computed Tomography, and Magnetic Resonance Imaging of Ovarian Vein Thrombosis in Obstetrical and Nonobstetrical Patients

Ovarian vein thrombosis is an uncommon clinical entity, most familiar to radiologists as a source of postpartum sepsis, which, if unrecognized and left untreated, has the potential for septic shock, pulmonary thromboembolism, and death. Ovarian vein thrombosis also occurs with other common inflammatory and malignant conditions in the nonobstetrical patient. This article reviews the pathophysiology, predisposing conditions, clinical findings, imaging features on ultrasonography, computed tomography, and magnetic resonance imaging of acute and chronic ovarian vein thrombosis and its appropriate clinical management.

Current updates on the molecular genetics and magnetic resonance imaging of focal nodular hyperplasia and hepatocellular adenoma

Focal nodular hyperplasia (FNH) and hepatocellular adenomas (HCAs) constitute benign hepatic neoplasms in adults. HCAs are monoclonal neoplasms characterised by an increased predilection to haemorrhage and also malignant transformation. On the other hand, FNH is a polyclonal tumour-like lesion that occurs in response to increased perfusion and has an uneventful clinical course. Recent advances in molecular genetics and genotype-phenotype correlation in these hepatocellular neoplasms have enabled a new classification system. FNHs are classified into the typical and atypical types based on histomorphological and imaging features. HCAs have been categorised into four subtypes: (1) HCAs with HNF-1α mutations are diffusely steatotic, do not undergo malignant transformation, and are associated with familial diabetes or adenomatosis. (2) Inflammatory HCAs are hypervascular with marked peliosis and a tendency to bleed. They are associated with obesity, alcohol and hepatic steatosis. (3) HCAs with β-catenin mutations are associated with male hormone administration and glycogen storage disease, frequently undergo malignant transformation and may simulate hepatocellular carcinoma on imaging. (4) The final type is unclassified HCAs. Each of these except the unclassified subtype has a few distinct imaging features, often enabling reasonably accurate diagnosis. Biopsy with immunohistochemical analysis is helpful in difficult cases and has strong implications for patient management.Teaching points• FNHs are benign polyclonal neoplasms with no risk of haemorrhage or malignancy.• HCAs are benign monoclonal neoplasms classified into four subtypes based on immunohistochemistry.• Inflammatory HCAs show an atoll sign with a risk of bleeding and malignant transformation.• HNF-1α HCAs are steatotic HCAs with minimal complications and the best prognosis.• β-Catenin HCA shows variable MRI features and a high risk of malignancy.

Spectrum of medication-induced complications in the abdomen: Role of cross-sectional imaging

OBJECTIVE This article provides a comprehensive review of the role of MDCT and MRI in the diagnosis of drug-induced complications in the abdomen and pelvis in adults. A systematic organ-based review of these complications is presented, including but not limited to hepatic changes after chemotherapy, renal complications such as tumor lysis syndrome and lithium nephropathy, gastrointestinal manifestations, various opportunistic infections and secondary neoplasms, mycotic aortic aneurysm from intravesical bacille Calmette-Guérin, complications of anticoagulant therapy, and oral contraceptives. CONCLUSION Advancements in imaging have led to recognition of radiologic features of previously unsuspected diseases. Occasionally, imaging may also identify effects of treatments instituted for these diseases. Consequently, imaging plays a critical role in the accurate diagnosis of a broad spectrum of drug-induced complications in the abdomen, both in emergent and nonemergent settings. Knowledge of the natural history, clinical manifestations, and salient imaging features of these entities is crucial to facilitate accurate clinical diagnosis in a timely fashion.

Radiologist's perspective for the Meckel's diverticulum and its complications

The Meckels diverticulum is the commonest congenital anomaly of the gastrointestinal tract, often presenting with complications such as gastrointestinal bleeding, intussusception, bowel obstruction and diverticulitis, which are often misdiagnosed. Imaging plays an important role in the early diagnosis and characterization of these conditions and is very helpful in decision making. The Meckels diverticulum and its complications have myriad presentations and appearances on various imaging modalities. Thus, sound knowledge of the anatomy, embryology, clinical presentation, imaging characteristics and complications is crucial to the practice of abdominal imaging. We present a review of the literature and current radiological practices in the diagnosis and management of the Meckels diverticulum and its various complications with special emphasis on the imaging of various complications, mimickers and pathological correlation.

Small-Bowel and Mesenteric Injuries in Blunt Trauma of the Abdomen

Bowel and mesentery are injured in an estimated 1%-5% of cases after blunt trauma [1e3] and is the third most common type of injury from blunt trauma to abdominal organs [4e7]. There are 3 basic mechanisms that govern injury to bowel and mesentery, and include direct crushing force, shearing force, and a sudden increase in intraluminal pressure that results in burst injuries [8]. Missed or delayed diagnosis is multifactorial. Symptoms may be absent on initial presentation and, when present, may be nonspecific. Furthermore, clinical assessment of some patients may not be reliable in the presence of concomitant injuries. The result of these undiagnosed injuries is increased morbidity and mortality [2,9e13]. Diagnostic tests in patients with suspected abdominal injury include peritoneal lavage, ultrasonography, and computed tomography (CT). Although sensitivity of peritoneal lavage for detection of hemoperitoneum is higher than 90% [14e16], it is neither specific nor sensitive, with undetected bowel perforation seen in up to 10% of cases [17]. Focused ultrasound assessment in trauma has a sensitivity of 86% for detection of free intra-abdominal fluid but is nonspecific with regard to organ injury [18]. In comparison, multidetector CT is more sensitive and specific than diagnostic peritoneal lavage, abdominal ultrasound, and clinical examination for the diagnosis of bowel and mesenteric injuries [19], with improved diagnostic accuracy making it the imaging modality of choice for evaluation of abdominal and pelvic trauma [20e29].

Multi-modality imaging review of congenital abnormalities of kidney and upper urinary tract

Congenital abnormalities of the kidney and urinary tract (CAKUT) include a wide range of abnormalities ranging from asymptomatic ectopic kidneys to life threatening renal agenesis (bilateral). Many of them are detected in the antenatal or immediate postnatal with a significant proportion identified in the adult population with varying degree of severity. CAKUT can be classified on embryological basis in to abnormalities in the renal parenchymal development, aberrant embryonic migration and abnormalities of the collecting system. Renal parenchymal abnormalities include multi cystic dysplastic kidneys, renal hypoplasia, number (agenesis or supernumerary), shape and cystic renal diseases. Aberrant embryonic migration encompasses abnormal location and fusion anomalies. Collecting system abnormalities include duplex kidneys and Pelvi ureteric junction obstruction. Ultrasonography (US) is typically the first imaging performed as it is easily available, non-invasive and radiation free used both antenatally and postnatally. Computed tomography (CT) and magnetic resonance imaging (MRI) are useful to confirm the ultrasound detected abnormality, detection of complex malformations, demonstration of collecting system and vascular anatomy and more importantly for early detection of complications like renal calculi, infection and malignancies. As CAKUT are one of the leading causes of end stage renal disease, it is important for the radiologists to be familiar with the varying imaging appearances of CAKUT on US, CT and MRI, thereby helping in prompt diagnosis and optimal management.

Is a Picture Worth a Thousand Words? The Effect of Viewing Patient Photographs on Radiologist Interpretation of CT Studies

DESCRIPTION OF THE PROBLEM The past decade has seen sweeping changes to radiologic practice. Year-onyear increases in CT utilization [1,2] and the introduction of teleradiology [3] have inexorably shifted practice toward rapid reporting of cross-sectional imaging. An unintended effect of these changes has been a perceptible reduction in patient contact, with radiologists becoming increasingly remote from patient care [4,5] and feeling personally detached from patients [6]. To “personalize” the reporting process, the idea of presenting patient photographs to reporting radiologists was investigated in an unpublished study [7]. The authors suggested that radiologists produced longer reports containing more incidental findings, and subjectively reported more meticulously and empathetically, when presented with patients’ photographs. The study attracted considerable media attention and was even included in a published nonfiction book [8]. However, its significance remains unclear, because the incidental abnormalities were not classified in terms of clinical importance, and the findings have not been reproduced elsewhere. The purpose of this study was to assess whether presenting patients’

Non-neoplastic hepatic vascular diseases: Spectrum of CT and MRI appearances

The unique dual blood supply of the liver makes it one of the common sites for various vascular neoplastic and non-neoplastic diseases. Increasing use of multiphase contrast-enhanced computed tomography (CT) and dynamic magnetic resonance imaging (MRI) has led to increased identification of numerous non-neoplastic vascular entities apart from already well-known neoplastic lesions. The objective of this review is to describe the causes and clinical features and to familiarize the reader with the key imaging features of various non-neoplastic vascular diseases affecting the liver. Non-neoplastic vascular diseases are classified broadly as those affecting the hepatic veins, portal veins, hepatic artery, intrahepatic shunts, and other miscellaneous conditions.

Radiology-pathology conference: malignant solitary fibrous tumor of the seminal vesicle

Mesenchymal neoplasms are rarely encountered in the seminal vesicle. Only four cases of the seminal vesicle solitary fibrous tumor have been reported in English literature, all of which were benign in nature. We are describing the clinicoradiological and pathological features of a locally aggressive malignant solitary fibrous tumor arising from the seminal vesicle, which posed the therapeutic challenge for the surgical management in a 52-year-old male patient. To our knowledge, this is the first reported case of the malignant solitary fibrous tumor arising from the seminal vesicle.

The Abdominal Wall Lumps and Bumps: Cross-Sectional Imaging Spectrum

This article focuses on the cross-sectional imaging spectrum of abnormalities that affect the abdominal wall, with emphasis on magnetic resonance imaging (MRI). Cross-sectional imaging is valuable for diagnosing and evaluating the extent of abdominal-wall masses. With the increasing use of MRI, it is often possible to reach a diagnosis or narrow the differential diagnosis, thereby guiding effective management. Neoplastic and non-neoplastic pathologies will be illustrated, and the distinctive imaging characteristics of these entities will be highlighted.