Conventional Radiology in the Evaluation of the Small Bowel

For many years, the small bowel has been considered as the “black box” of the gastrointestinal system because it could not be evaluated through endoscopy. For this reason, the conventional radiological methods, such as small bowel enteroclysis and small bowel follow-through, have been considered the standard approach for the evaluation of the small bowel in the diagnosis and management of Crohn’s disease for years. However, due to technological limits, the study of small bowel through conventional radiology has been focused mainly on its function than on its anatomy. To date, the conventional examination with the study of intestinal transit is now rarely used, if not obsolete, but it has st…

CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know.

AbstractAbdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest wit…

MR-imaging features of hepatocellular carcinoma capsule appearance in cirrhotic liver: comparison of gadoxetic acid and gadobenate dimeglumine.

Purpose: The purpose of the study is to compare the MR-imaging features of hepatocellular carcinoma (HCC) capsule appearance on gadoxetic acid and gadobenate dimeglumine-enhanced MR imaging, using imaging-based presumptive diagnosis of HCC as the reference standard. Methods: Gadoxetic acid and gadobenate dimeglumine-enhanced MR imaging of 51 patients with 71 HCCs were retrospectively reviewed. Three readers graded in consensus, using a five-point scale, the presence (score 4–5) of capsule appearance on images obtained during T1-weighted GRE portal venous phase (PVP), 3-min phase, and hepatobiliary phase (HBP). The Fisher's exact test and the t student unpaired test were performed. Results: …

DIFFERENT LOCATIONS OF ENDOMETRIOSIS IN 86 PATIENTS: A SINGLE- CENTRE STUDY.

Endometriosis is an important gynecologic disorder defined as the presence of functional endometrial glands and stroma outside the uterine cavity. Prevalence of endometriosis is 6-10% in the general population, but rises to 35-50% in women with pelvic pain or infertility or both. The aim of this study was to retrospectively review the different locations of pelvic and extrapelvic endometriosis occurred in our Department during last 3 years.

Occupational Diseases: Asbestosis and Mesothelioma in Forensic Practice

Diagnosis of occupational diseases, a strong collaboration between radiologic and clinical features with related occupational history and literature supporting, and an association between the exposure and the disease process are requested. Further pathological findings emerging at biopsy or autopsy, which are considered ancillary examination techniques, may assist in the judgment related to causal chain reconstruction.

Interpretation of Diagnostic Imaging for Medicolegal Issues

Forensic radiology is a relative recently emergent part of forensic medicine characterized by the application of radiological methods in criminal investigations, such as the forensic M.E’s radiological reports in civil or penal matters for judicial technical advice. The various imaging modalities like X-rays, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and ultrasonography can be used depending on various forms of cases and their requirements in routine investigations.

Detection of liver metastases in cancer patients with geographic fatty infiltration of the liver: the added value of contrast-enhanced sonography

Purpose The aim of this study is to assess the role of contrast-enhanced ultrasonography (CEUS) in the detection of liver metastases in cancer patients with geographic liver fatty deposition on greyscale ultrasonography (US). Methods Thirty-seven consecutive cancer patients (24 women and 13 men; age, 33 to 80 years; mean, 58.1 years) with geographic liver fatty deposition, but without any detectable focal liver lesion on greyscale US, underwent sulphur hexafluoride-enhanced US. Two readers reported by consensus the presence, size, and location of any detected lesion. All patients underwent magnetic resonance imaging (MRI) as a confirmatory study. Sensitivity, specificity, positive and negat…

Radiological Follow-Up of Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD) are chronic gastrointestinal diseases that typically affect the young working-age population. Patients with IBD, both asymptomatic and symptomatic, often develop complications during their clinical course. This is particularly true in patients with Crohn’s disease (CD) and biological signs of inflammation, despite being asymptomatic. In addition, it seems clear that the absence of symptoms does not imply an absence of inflammation. For all the above mentioned reasons, patients should be followed up and objectively evaluated. IBD are idiopathic diseases characterized by periods of remission and frequent exacerbations. To appreciate the impact of disease pr…

Imaging of Gastrointestinal Stromal Tumors: From Diagnosis to Evaluation of Therapeutic Response

Once considered an obscure tumor entity with poor prognosis, gastrointestinal stromal tumors (GISTs) are nowadays recognized as the most common mesenchymal tumors of the alimentary tract. GISTs differ from other mesenchymal neoplasms at pathology since 90% of them exhibit strong immunohistochemical staining for KIT, a tyrosinase kinase growth factor receptor. In the early 2000s, the ability of imatinib mesylate, a tyrosine kinase inhibitor, to inhibit KIT established a new paradigm for cancer treatment. A reduction in lesion size may not be observed or may appear many months after therapy; thus, tumor response criteria alternative to the Response Evaluation Criteria in Solid Tumors were dev…

Radiological Features of Gastrointestinal Lymphoma.

Gastrointestinal lymphomas represent 5–20% of extranodal lymphomas and mainly occur in the stomach and small intestine. Clinical findings are not specific, thus often determining a delay in the diagnosis. Imaging features at conventional and cross-sectional imaging must be known by the radiologist since he/she plays a pivotal role in the diagnosis and disease assessment, thus assisting in the choice of the optimal treatment to patients. This review focuses on the wide variety of imaging presentation of esophageal, gastric, and small and large bowel lymphoma presenting their main imaging appearances at conventional and cross-sectional imaging, mainly focusing on computed tomography and magne…

Can 3D Digital Breast Tomosynthesis (DBT) improve breast malignant pathology detection? A case-to-case imaging comparison between 3D DBT and 2D Mammographic images

Learning objectives Background Findings and procedure details Conclusion Personal information References

Imaging features of pancreatic metastases: A comparison with pancreatic ductal adenocarcinoma

Purpose: To compare imaging features of pancreatic metastases (PM) with those of pancreatic ductal adenocarcinomas (PDAC). Methods: CT and MR scans of 24 patients with 54 PM and 30 patients with PDAC were reviewed to evaluate the imaging features, which were compared by using a Chi square test. Results: We found a statistically significant difference between PM and PDAC based on location (P < 0.001), margins (P < 0.001), arterial enhancement (P = 0.004), rim enhancement (P < 0.001), pancreatic duct dilatation (P = 0.01), common bile duct dilatation (P = 0.003), vascular involvement (P = 0.02), parenchymal atrophy (P < 0.001), peripancreatic fluid (P = 0.03). Conclusion: Imaging features mig…

Relationship between anxiety level and radiological investigation. Comparison among different diagnostic imaging exams in a prospective single-center study

Objective: Every patient could feel anxious when he waits in a radiological department to undergo diagnostic exams. The aim of our study is to evaluate the impact of the radiological exams on patient anxiety. Materials and methods: We evaluated 343 patients (mean age 54.83 years) who underwent different types of diagnostic exams in the Department of Diagnostic Imaging at our Hospital from April 2013 to August 2014. We administered to patients the State and Trait Anxiety Inventory Test, which detected with high sensitivity both state anxiety and trait anxiety. A team of clinical psychologists and radiologists evaluated the scores obtained. Results: 83 out of 343 patients were excluded becaus…

Swallowing impairment in neurologic disorders: The role of videofluorographic swallowing study

Patients with neurologic diseases almost inevitably develop various degrees of swallowing disorders during their life. Dysphagia is one of the main negative prognostic factors in this class of patients, leading to severe morbidity (i.e. aspiration pneumonia, dehydration, malnutrition, and life quality deterioration) and to a noticeable increase in public health spending. Videofluorographic swallowing study is considered the gold standard technique for swallowing impairment assessment. It is aimed at early identification of the risk of aspiration, definition of the kind and grade of dysphagia, and an indication to suspend oral nutrition and adopt other feeding strategies, and define when the…

The "serpent sign" in hydatid disease.

PREOPERATIVE ASSESSMENT OF RECTAL CANCER: AN ACCURATE MRI PROTOCOL A RADIOLOGICAL TEMPLATE

Learning objectives Background Findings and procedure details Conclusion Personal information References

The Videofluorographic Swallowing Study in Rheumatologic Diseases: A Comprehensive Review

Autoimmune connective tissue diseases are a heterogeneous group of pathologies that affect about 10% of world population with chronic evolution in 20%–80%. Inflammation in autoimmune diseases may lead to serious damage to other organs including the gastrointestinal tract. Gastrointestinal tract involvement in these patients may also due to both a direct action of antibodies against organs and pharmacological therapies. Dysphagia is one of the most important symptom, and it is caused by failure of the swallowing function and may lead to aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The videofluorographic swallowing study is a key diagnostic tool in the…

Diffuse Liver Diseases: Role of imaging

Nowadays, the most common imaging techniques allow to study focal liver lesions with high diagnostic accuracy but a relatively recent emerging field of interest is represented by diffuse liver disease. They include a variegated series of storage and metabolic pathologies (ie, iron overload disorders and steatosis) requiring a precise diagnosis not always possible at imaging due to the overlapping of findings at conventional ultrasound, CT, or MR studies. In recent years, several imaging tecniques and specific softwares have been developed, especially for ultrasound and MR imaging, in order to identify different parameters useful in the noninvasive recognition and follow-up of these diffuse …

MRI Enteroclysis and Enterography

Magnetic Resonance is actually the most complete and less invasive imaging technique in the evaluation of Crohn’s disease. Compared to Computed Tomography and Ultrasound, Magnetic Resonance allows both a morphological and qualitative evaluation of the disease at the same time, thus allowing an evaluation of its extension in the gastrointestinal tract and of its grade of activity, obtaining an accurate relation with the clinical status of the patient. This is possible thanks to its intrinsic characteristics, as multiplanarity, high contrast resolution, and the possibility to make a functional assessment; moreover, there is no use of ionizing radiation. For all these reasons, this technique h…

MR Imaging of Perianal Crohn Disease: The Role of Contrast-enhanced Sequences

The MR imaging protocol described by the authors includes contrast-enhanced T1-weighted imaging with fat saturation in all patients except those with poor renal function. Horsthuis et al demonstrated in 2009 the usefulness of contrast-enhanced MR imaging for determining disease activity. Contrast agent administration is also required in case of suspicion of neoplastic tissue complicating fistulas. The joint European Crohn’s and Colitis Organisation–European Society of Gastointestinal and Abdominal Radiology guidelines report that T2-weighted images and contrast-enhanced T1-weighted images are included in the MR imaging protocol for the evaluation of perianal CD. However, as we have demonstr…

Comparison of US Strain Elastography and Entero-MRI to Typify the Mesenteric and Bowel Wall Changes during Crohn’s Disease: A Pilot Study

Purpose. To evaluate and compare the mesenteric and bowel wall changes during Crohn’s disease (CD) on ultrasonography (US) Strain Elastography (SE) and Enterography Magnetic Resonance Imaging (E-MRI). Methods. From July 2014 to September 2016, 35 patients with ileocolonoscopy diagnosis of CD were prospectively examined with E-MRI and in the same time with US and SE. Results. A total of 41 affected bowel segments and 35 unaffected bowel segments in 35 patients were evaluated. US-SE color-scale coding showed a blue color pattern in the fibrotic mesentery and bowel wall in 15 patients and a green color pattern in the edematous ones in 20 patients. The signal of the bowel wall and mesenteric fa…

Role of virtopsy in the post-mortem diagnosis of drowning.

Purpose: Due to admitted limits of autopsy-based studies in the diagnosis of drowning, virtopsy is considered the new imaging horizon in these post-mortem studies. The aim of our study was to evaluate the role of virtopsy performed through computed tomography (CT) in the forensic diagnosis of drowning. Materials and methods: We retrospectively examined the CT data of four cadavers recovered from sea water and suspected to have died by drowning. Each patient underwent a full-body post-mortem CT scan, and then a traditional autopsy. Conclusion: To date, there are no autopsy findings pathognomonic of drowning. This study proves that virtopsy is a useful tool in the diagnosis of drowning in tha…

Anatomic variants of the biliary tree at MRCP: still too rarely reported!

Aims and objectives Methods and materials Results Conclusion Personal information References

Extrabiliary and extrapancreatic incidental findings at MRCP: a 4 years’ Italian experience

Aims and objectives Methods and materials Results Conclusion Personal information References

Imaging assessment of paediatric Crohn's disease: A literature review

Owing to the frequent absence of specific symptoms, diagnosis of Crohn's disease may be delayed, potentially leading to important patient morbidity, growth failure, pubertal delay, or a complicated form of the disease. In paediatric patients with Crohn's disease, radiation protection requires special consideration, and choosing the most appropriate imaging modality is crucial. All radiologists should be familiar with the main imaging characteristics of Crohn's disease. Therefore, the present study reviews the current literature on imaging modalities and main imaging characteristics of Crohn's disease. Magnetic resonance imaging is recommended for diagnosis of Crohn's disease in paediatric p…

Swallowing disorders after thyroidectomy: What we know and where we are. A systematic review.

Abstract Introduction Dysphagia and hoarseness are possible complications that can be observed in patients undergoing thyroidectomy or other neck surgery procedures. These complaints are usually related to superior and inferior laryngeal nerves dysfunction, but these can appear even after uncomplicated surgical procedure. Methods We reviewed the current literature available on MEDLINE database, concerning the swallowing disorders appearing after the thyroidectomy. The articles included in the review reported pathophysiology and diagnostic concerns. Results Twenty articles were selected for inclusion in the review. Depends on the possible causes of the difficulty swallowing (related to nerve…

Intravenous Contrast Agent in Abdominal CT: Is It Really Needed to Identify the Cause of Bowel Obstruction? Proof of Concept

Background. To compare sensitivity of unenhanced computed tomography (CT) and contrast-enhanced CT for the identification of the etiology of bowel obstruction.Materials and Methods. We retrospectively evaluated abdominal CT scans of patients operated for bowel obstruction from March 2013 to October 2017. Two radiologists evaluated CT scans before and after contrast agent in two reading sessions. Then, we calculated sensitivity of CT in the diagnosis of bowel obstruction and determined in which cases the etiology of bowel obstruction was detected on both unenhanced and enhanced CT or on enhanced CT only. The reference standard was defined as the final diagnosis obtained after surgery.Results…

Extrabiliary and extrapancreatic incidental findings on magnetic resonance cholangio-pancreatography: A single centre experience in 1000 patients.

Small Bowel Perforations: What the Radiologist Needs to Know

The incidence of small bowel perforation is low but can develop from a variety of causes including Crohn disease, ischemic or bacterial enteritis, diverticulitis, bowel obstruction, volvulus, intussusception, trauma, and ingested foreign bodies. In contrast to gastroduodenal perforation, the amount of extraluminal air in small bowel perforation is small or absent in most cases. This article will illustrate the main aspects of small bowel perforation, focusing on anatomical reasons of radiological findings and in the evaluation of the site of perforation using plain film, ultrasound, and multidetector computed tomography equipments. In particular, the authors highlight the anatomic key notes…

EVALUATION OF RESPONSE IN MALIGNANT TUMORS TREATED WITH TARGETED AGENTS.

Learning objectives Background Findings and procedure details Conclusion Personal information References

The “caput medusae” sign in portal hypertension

Magnetic resonance imaging of the cirrhotic liver in the era of gadoxetic acid.

Gadoxetic acid improves detection and characterization of focal liver lesions in cirrhotic patients and can estimate liver function in patients undergoing liver resection. The purpose of this article is to describe the optimal gadoxetic acid study protocol for the liver, the unique characteristics of gadoxetic acid, the differences between gadoxetic acid and extra-cellular gadolium chelates, and the differences in phases of enhancement between cirrhotic and normal liver using gadoxetic acid. We also discuss how to obtain and recognize an adequate hepatobiliary phase.

Hyaline fibromatosis syndrome (juvenile hyaline fibromatosis): whole-body MR findings in two siblings with different subcutaneous nodules distribution.

Abstract: Hyaline fibromatosis syndrome (juvenile hyaline fibromatosis) is a rare, progressive, autosomal recessive disorder whose main hallmark is the deposition of amorphous hyaline material in soft tissues, with an evolutionary course and health impairment. It may present involvement of subcutaneous or periskeletal soft tissue, or may develop as a visceral infiltration entity with poor prognosis. Very few radiological data about this inherited condition have been reported, due to the extreme rarity of disease. We herein present a case of two siblings, affected by different severity of the disease, with different clinical features. They were examined by whole-body MR (WBMR) in order to as…

An Osirix based plug-in for the study of dimensional and densitometric changes of hepatic metastases on CT images

Aims and objectives Methods and materials Results Conclusion Personal information References

Imaging for Ballistic Trauma: Other Applications of Forensic Imaging in the Living

Firearms are mechanical instruments that allow launching remote specific bodies with mass (bullets) exploiting burst gas energy. The role of imaging for ballistic trauma is crucial in order to define the main characteristics for both judiciary and nonjudiciary purpose, which are the intracorporeal trajectory, the entrance and exit wounds, and the general characteristics of gunshot injuries.

RUOLO DELL’ELASTOSONOGRAFIA E DELL’ENTERO-RM PER LA VALUTAZIONE DEL MESENTERE E DELLA PARETE INTESTINALE NEI PAZIENTI CON MORBO DI CROHN

Purpose. To evaluate and compare the mesenteric and bowel wall changes during Crohn’s disease (CD) on ultrasonography (US) Strain Elastography (SE) and Enterography Magnetic Resonance Imaging (E-MRI). Methods. From July 2014 to September 2016, 35 patients with ileocolonoscopy diagnosis of CD were prospectively examined with E-MRI and in the same time with US and SE. Results. A total of 41 affected bowel segments and 35 unaffected bowel segments in 35 patients were evaluated. US-SE color-scale coding showed a blue color pattern in the fibrotic mesentery and bowel wall in 15 patients and a green color pattern in the edematous ones in 20 patients. The signal of the bowel wall and mesenteric fa…

Glypican-3 and Hep Par-1 are Useful Biomarkers in the Cytologic Assessment of Ascites.

Till date, the utility of cytologic assessment of ascites for the identification of hepatocellular carcinoma (HCC) cells is still debated and the usefulness of immunocytochemistry for glypican-3 (GPC3) and Hep Par-1 in this setting has not been reported. Liquid-based cytology of ascitic fluid of 28 cirrhotic patients was performed and the spots obtained were stained with hematoxylin and eosin, papanicolau, and with GPC3 and Hep Par-1 antibodies. GPC3 and Hep Par-1 antibodies stained positively the atypical cells in the ascites of 2 patients with HCC showing an exophytic growth pattern. The specimens of the patients with nonexophytic HCC, other non-HCC cancers, or cirrhosis stained negativel…

Role of apparent diffusion coefficient values in prostate diseases characterization on diffusion-weighted magnetic resonance imaging.

BACKGROUND: To evaluate if normal and pathological prostate tissue can be distinguished by using apparent diffusion coefficient (ADC) values on magnetic resonance imaging (MRI) and to understand if it is possible to differentiate among pathological prostate tissues using ADC values.METHODS:Our population consisted in 81 patients (mean age 65.4 years) in which 84 suspicious areas were identified. Regions of interest were placed over suspicious areas, detected on MRI, and over areas with normal appearance, and ADC values were recorded. Statistical differences between ADC values of suspicious and normal areas were evaluated. Histopathological diagnosis, obtained from targeted biopsy using MRI-…

Anal Fistula in Crohn’s Disease

Transmural bowel inflammation in Crohn’s disease (CD) is associated with the development of fistulas, which are tracts or communications that connect two epithelial-lined organs. Common sites for fistulas connect the intestine to bladder (enterovesical), to skin (enterocutaneous), to bowel (enteroenteric), and to the vagina (enterovaginal).

Radiologic team performance index: A new paradigm in KPI evaluating radiology examination volumes department performance: Results of Sicilian regional healthcare system survey

Background: Efficient management of Radiologic Operative Units (ROU) because population health needs increase while healthcare systems provide less resources expendable in technologies and employee. Purpose: Create a Key Performance Indicator (KPI) defined Radiologic Team Performance Index (RTPI) able to compare the activity and efficiency of ROU operating under different environments and with different resources. Methodology/Approach: A survey was conducted in Sicilian Public Healthcare System on behalf of Sicilian Group of Italian Society of Medical Radiology (SIRM) for a total of 63 investigated ROU. Obtained informations concern workforce, emergency care organization, technologies avail…

Role of virtopsy in the postmortem diagnosis of drowning

Aims and objectives Methods and materials Results Conclusion Personal information References

Swallowing evaluation with videofluoroscopy in the paediatric population

Valutazione della funzione deglutitoria in videofluoroscopia nei pazienti pediatrici.I disturbi della deglutizione in età pediatrica possono essere dovuti a diverse cause, dalla condizione di prematurità e patologie malformative sino al reflusso gastro-esofageo o a patologie infettive od infiammatorie del primo tratto gastroenterico. Nei neonati il processo della deglutizione è involontario e basato su meccanismi riflessi. In seguito, nell’ infanzia, la fase orale diventa volontaria , mentre le fasi faringea ed esofagea rimangono involontarie. I disordini della deglutizione possono severamente compromettere le capacità respiratorie e l’apporto nutrizionale dei pazienti pediatrici. La videof…

MR imaging of perianal fistulas in Crohn's disease: Sensitivity and specificity of STIR sequences

Introduction Although some studies proved the role of STIR sequences in the evaluation of perianal fistulas in Crohn's Disease (CD), contrast medium is still injected in many institutions since there is not a validated reference MR protocol. Our purpose was to evaluate the role of the STIR sequence in the detection and characterization of perianal fistulae comparing it to the post-contrast T1 sequence and correlating it with rectal examination under anesthesia. Materials and methods We retrospectively reviewed all clinical records of 31 CD patients, suspected of having perianal fistulas, who had been submitted to an MR study before and after contrast medium injection and surgical exploratio…

The “bouquet of flowers” appearance in medullary sponge kidney

The “bouquet of flowers” appearance is a radiological finding described for the intravenous pyelography (IVP) diagnosis of medullary sponge kidney (MSK). It refers to contrast pooling in dilated tubular structures in renal papillae, giving a striated pattern to the renal medulla, which resembles a “bouquet of flowers”

Gadoxetic acid-enhanced MRI of transient hepatic enhancement differences: Another cause of hypointense observation on hepatobiliary phase

Purpose: To retrospectively determine the frequency, natural history and factors associated with the presence of transient hepatic enhancement difference showing hypointensity on hepatobiliary phase images of gadoxetic acid-enhanced MRI. Materials and methods: Gadoxetic acid-enhanced MRI of 125 patients (91 men; 34 women) with transient hepatic enhancement difference were retrospectively reviewed. Three readers qualitatively and quantitatively evaluated MR imaging features and evolution at follow up. The Chi-square test, Fisher's exact test and Kruskall-Wallis rank test were used for statistical analysis. Results: Transient hepatic enhancement difference were hypointense on hepatobiliary ph…

Imaging Assessment of Gastroduodenal Perforations.

Gastroduodenal perforation is an emergency situation that usually requires early recognition and well-timed surgical treatment. It can arise from different natural, iatrogenic, or traumatic causes, and it can present with various symptoms especially in the early phase. This article reviews the role of the different imaging techniques in the diagnosis of gastroduodenal perforation, focusing on the direct and indirect signs that are encountered in conventional radiography and computed tomography; our personal experience is also provided.