Biomedical subjects
Publications and source records attributed to Dean D T Maglinte.
A patient who presented with acute abdominal pain secondary to small bowel angioedema is reported. Characteristic imaging features are highlighted with clarifying images. The importance of considering this diagnosis in patients presenting with acute abdominal pain correlated with the appropriate history is discussed.
The clinical management of patients with anorectal and pelvic floor dysfunction is often difficult. Evacuation proctography has evolved from a method to evaluate the anorectum for functional disorders to its current status as a practical method for evaluating anorectal dysfunction and pelvic floor prolapse. It has a high observer accuracy and yield of positive diagnosis. Clinicians find it of major benefit and has altered management from surgical to medical and vice versa in a significant number of cases.
There was a time when the small bowel follow-through (SBFT) was the primary method of diagnosing diseases of the small intestine. Enteroclysis was reinvented in the 70's and with the SBFT remained the dominant methods of investigating the mesenteric small intestine to the late 90's. Since the introduction of the first commercial computed tomography (CT) scanner in 1973, the ability of monoslice CT to diagnose different causes of intestinal obstruction and inflammatory bowel diseases emerged. The introduction of helical CT technology in 1989 and subsequently multichannel CT further changed small bowel imaging. Faster acquisition of a large volume of data with thinner collimation allowed multiplanar reformatting a distinct advantage in evaluating an organ which is longer than wide. The introduction of magnetic resonance (MR) imaging with its increased soft tissue contrast, lack of ionizing radiation, and the ability to acquire ultrafast sequences has made MR imaging an important tool in small bowel imaging (1).
SUMMARY: Endoscopy is frequently used as the reference standard in the evaluation of inflammation. However, endoscopy enables visualization of the mucosa only, has a limited reach, and has difficulty in anatomic orientation. Therefore, it is not a stand-alone diagnostic procedure. Imaging is needed if one is to visualize the entire intestinal wall, define the extent of disease, and categorize disease subtypes. Bodily et al in this issue of Radiology have described an objective, more reliable, and hopefully reproducible method of measuring active inflammation of a segment of bowel by quantifying mural enhancement in patients examined with CT enterography. Their results showed good correlation with ileoscopic and histologic findings of active inflammation.
OBJECTIVE: Our objective was to define the CT criteria for blind pouches formed after enteric anastomosis. CONCLUSION: Familiarity with the CT appearance of blind pouches avoids the mistaking of these entities for bowel obstruction or abscesses.
OBJECTIVE: Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction. CONCLUSION: Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.
BACKGROUND: Although complications involving leaking at the enteric anastomosis site, graft thrombosis, and intraabdominal abscess formation have been well documented after pancreas transplantation, the occurrence of small bowel obstruction in this setting has received scant attention. Although uncommon, intestinal obstruction after pancreas transplantation may have atypical etiologies. In this article, we will review three unusual cases of intestinal obstruction in pancreas transplant recipients. The value of computed tomographic (CT) enteroclysis in equivocal situations in the diagnosis of the obstruction is emphasized. METHODS: In this study, we reviewed the posttransplant course of all pancreas transplants performed between July 1, 2002 and June 1, 2004. We specifically focused on all patients that required reexploration for suspected small bowel obstruction at any time after transplantation. RESULTS: A total of 65 pancreas transplants were performed between July 1, 2002 and June 1, 2004. Pancreas graft survival was 97%, and patient survival was 98.5%. Five (7.7%) patients presented with mechanical small bowel obstruction, three of which were secondary to internal herniation of small intestine through a defect posterior to the pancreas allograft. All patients recovered well postsurgically. DISCUSSION: Small bowel obstruction is an uncommon complication after pancreas transplantation. CT enteroclysis in the evaluation of small bowel obstruction may assist the patient care decision-making process by providing information on the location and severity of the obstruction in the clinical situation where conventional abdominal CT and radiography are equivocal. Prompt detection of small bowel obstruction with early surgical intervention can minimize complications and preserve allograft function.
The aim of our study was to evaluate the reliability of MDCT-enteroclysis (MDCT-E), an emerging technique of small bowel examination that combines the advantages of MDCT examination of the abdomen and the enteral volume challenge of enteroclysis, in evaluation of small bowel neoplasms. In our institutions, MDCT-E was used to study 456 patients (age range 21-84 years, mean 53 years) admitted for suspicion of small bowel disease. All examinations were done on multichannel CT units, 129 on a 16-slice scanner and 327 on a four-slice scanner. Post-processing and multiplanar reformatting and interpretation were performed on dedicated workstations. After adequate gastrointestinal preparation and naso-enteric intubation, small bowel was distended by methylcellulose infused by a peristaltic pump. One volumetric MDCT acquisition was obtained after 120-130 ml of intravenous contrast medium. Multiplanar reformatting was based on the image reconstruction parameters from 3 to 4 mm. Forty-five small bowel neoplasms were found; in the remaining cases, 223 Crohn's diseases and 149 other abnormalities were detected. All findings were confirmed by surgery, endoscopy or clinical follow-up. In our experience, MDCT-E with neutral enteral and IV contrast seems to be a reliable method in the diagnosis of small bowel neoplasms.
To recognize and document the small bowel reactions following major abdominal surgery is an important key for a correct diagnosis. Usually, plain abdominal radiography is the initial imaging examination requested in the immediate postoperative period, whereas gastrointestinal contrast studies are used to look for specific complications. In some countries, especially in Europe, sonography is widely employed to evaluate any acute affection of the abdomen. CT is commonly used to assess postoperative abdominal complications; in our institution also CT enteroclysis is often performed, to provide additional important informations. Radiologist should be able to diagnose less common types of obstruction, such as afferent loop, closed loop, strangulating obstruction as well as internal hernia. This knowledge may assume a critical importance for surgeons to decide on therapy. In this article, we focus our attention on the imaging (particularly CT) in small bowel complications following abdominal surgery.
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During a double-contrast barium enema the radiologist interacts with the patient, the controls of the fluoroscope, and the image on the television monitor. The radiologist paints an image of the colon; the barium is the paint, the colon is the canvas. The radiologist manipulates the barium pool, the air column, and the patient to create images. Although the radiologist may have a plan going into the examination, the game plan is altered by the patient's ability to tolerate and perform the study, the length of the colon, and pathology encountered. If the radiologist understands the goals to be achieved, the studied can be tailored to fit what is happening in the fluoroscopic suite.
The diagnosis and treatment of small bowel obstruction continue to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the current concepts related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.
Currently, CT-E is not recommended as the first-line examination in patients when mucosal detail is required. Double-contrast barium air enteroclysis has advantages in demonstrating small mucosal abnormalities. The authors find CT-E of value in the work-up of patients with symptoms of intermittent small bowel obstruction, particularly those with a history of prior abdominal surgery; in the further work-up of selected patients with high-grade obstruction in whom general surgeons prefer initial conservative management (immediate postoperative small bowel obstruction, patients with history of prior abdominal surgery for malignant tumor, history of radiation treatment, and possible internal extraintestinal fistulae); in looking for complications of small bowel Crohn's disease; and in the patient with unexplained anemia or gastrointestinal bleeding. In a series of patients who had both abdominal CT and barium enteroclysis done, each examination provided unique and complimentary diagnostic information. Because CT-E combines the advantages of both methods of examination, is it the optimum imaging work-up in the investigation of small bowel disease? Further research and clinical experience will define the precise role of CT-E in the investigation of small bowel disease. Experience with this method of examination is limited to a few institutions, performed by investigators with interest in small bowel diseases. The addition of cross-sectional display and multiplanar reformatting made possible by multidetector-row helical CT to enteral volume change and the use of multifunctional nasointestinal catheters make CT-E an important tool in the investigation of small bowel disease. Experience has shown the increased reliability of any method of examining the small bowel that challenges intestinal wall distensibility by fluid enteral volume infusion.
This article has reviewed the imaging features that correspond to and support the classification of patients into clinical subtypes of Crohn's disease. One study showed that radiologic features on barium studies closely correlated with the Crohn's Disease Activity Index, and another study indicated that CT findings changed patient management in up to 29% of cases. Knowledge of the location, severity, and presence of complications assist in providing patients with appropriate treatment options. Reports of radiologic studies in Crohn's disease should include the presence or absence of imaging features that support these different subtypes. An additional advantage of the use of a reproducible imaging classification that emphasizes morphologic features would be improved comparison of the results of different investigators and treatment protocols. Whatever method of radiologic investigation is employed, it should be targeted to answer questions relevant to patient management. The imaging modalities used should be able to classify the small bowel Crohn's subtypes and should be reflected in the radiologists' reports.
More accurate preoperative assessment by DCP or MR imaging hopefully should reduce the incidence of operative failure. These techniques help the surgeon to plan the different components of pelvic reconstructive surgery and, importantly, whether a transvaginal or transabdominal approach will be required. The current trend is toward the transabdominal route. Available evidence suggests that the reoperative rate is halved when the abdominal approach is employed. Large enteroceles and marked vaginal vault prolapse, in particular, are much more amenable to correction by transabdominal surgery. It should be recognized that enteroceles and sigmoidoceles often escape preoperative detection unless radiologic evaluation is performed. Global assessment of pelvic organ prolapse is optimized by ensuring that competing organs are effectively emptied by virtue of a triphasic approach. As expressed succinctly by Halligan, "the global pelvic floor specialist has arrived, and his closest ally is the radiologist".
As the primary method of investigating the small bowel, enteroclysis remains a technique in evolution. Technical refinements have made the examination faster to perform, better tolerated by patients, and easier to interpret. More recently, its essential principle of volume challenge has been combined with the tremendous advantage of CT cross-sectional imaging with multiplanar reformatting to give rise to the exciting new techniques of CT enteroclysis and MR enteroclysis (see separate reviews in this issue). Through improvements in methodology and advancements in technology, the future of enteroclysis looks bright indeed.
Small bowel obstruction is a common clinical condition, often presenting with signs and symptoms similar to those seen in other acute abdominal disorders. The diagnosis and treatment of this dynamic process continues to evolve. The imaging approach in the work-up of patients with known or suspected small bowel obstruction and the timing of surgical intervention in this disease have undergone considerable changes over the past two decades. This article examines the changes related to the use of imaging technology in the diagnosis and management of patients with small bowel obstruction. The meaning of frequently used but poorly defined terms in describing intestinal obstruction is clarified and illustrated.