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ABSTRACT: Cholescintigraphy is significantly more accurate than ultrasonography in the diagnosis of acute calculous cholecystitis (ACC)
(strong evidence).There is no one highly accurate test for the diagnosis of acute acalculous cholecystitis (AAC) (moderate
evidence).Cholecystokinin stimulated cholescintigraphy is very helpful in the diagnosis of chronic acalculous cholecystitis
(CAC) and is predictive of symptom relief after cholecystectomy (strong evidence).Magnetic resonance cholangiopancreatography
(MRCP) and endoscopic ultrasonography (EUS) are superior to ultrasonography in visualizing the whole of the bile duct, and
establishing the level of bile duct obstruction (strong evidence).Patients with a high likelihood of choledocholithiasis based
on clinical, laboratory, and ultrasonography findings should proceed directly to therapeutic endoscopic retrograde cholangiopancreatography
(ERCP) without further cholangiographic studies (strong evidence).Magnetic resonance cholangiopancreatography is useful in
the diagnosis of bile duct obstruction and in directing further patient management (moderate evidence).Endoscopic ultrasound
and MRCP have a complementary role in the comprehensive evaluation of patients with bile duct stricture (moderate evidence).
12/2010: pages 527-551;
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ABSTRACT: State-of-the-art magnetic resonance imaging (MRI) may be superior to state-of-the-art multidetector computed tomography (CT)
for detection of liver metastases from colorectal cancer (insufficient and limited evidence). Fluorodeoxyglucose positron
emission tomography (FDG-PET) is the most sensitive noninvasive test for detecting liver metastases (limited to moderate evidence).
Periodic screening with imaging tests of patients with cirrhosis for early detection of hepatocellular carcinoma is beneficial
(limited evidence). Magnetic resonance imaging may be superior to CT for detecting hepatocellular carcinoma (limited evidence).
12/2010: pages 553-569;
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ABSTRACT: The purpose of this study is to evaluate how body habitus affects reader confidence in diagnosing acute appendicitis and appendiceal visualization using 64 MDCT technology with and without oral contrast. We conducted a HIPAA compliant, IRB approved study of adult patients presenting to the Emergency Department with nontraumatic abdominal pain. Subjects were randomized to two groups: 64 MDCT scans performed with oral and intravenous contrast or scans performed solely with intravenous contrast. Three radiologists established their confidence about the presence of appendicitis as well as recording whether the appendix was visualized. Reader confidence in diagnosing acute appendicitis was compared between the two groups for the three readers. The impact of patient BMI and estimated intra-abdominal fat on reader confidence in diagnosing appendicitis was determined. Finally, a comparison of the effect of BMI and intra-abdominal fat on appendiceal visualization between the two groups was carried out. Three hundred three patients were enrolled in this study. There was a statistically significant difference in confidence based on BMI for reader 2, group 1 in diagnosing appendicitis. No further statistically significant differences in reader confidence for diagnosing appendicitis based on BMI or intra-abdominal fat were identified. There was no influence of BMI or intra-abdominal fat on appendiceal visualization. Increasing BMI was seen to improve reader confidence for one of three readers in patients that received both oral and intravenous contrast. No further effects of BMI or intra-abdominal fat on confidence in diagnosing or excluding appendicitis were seen. Neither BMI nor intra-abdominal fat were seen to influence appendiceal visualization.
Emergency Radiology 05/2010; 17(6):445-53.
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Stephan W Anderson,
Jorge A Soto, Brian C Lucey,
Al Ozonoff,
Jacqueline D Jordan,
Jirair Ratevosian,
Andrew S Ulrich,
Niels K Rathlev,
Patricia M Mitchell,
Casey Rebholz,
James A Feldman,
James T Rhea
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ABSTRACT: The objective of our study was to compare the diagnostic accuracy of IV contrast-enhanced 64-MDCT with and without the use of oral contrast material in diagnosing appendicitis in patients with abdominal pain.
We conducted a randomized trial of a convenience sample of adult patients presenting to an urban academic emergency department with acute nontraumatic abdominal pain and clinical suspicion of appendicitis, diverticulitis, or small-bowel obstruction. Patients were enrolled between 8 am and 11 pm when research assistants were present. Consenting subjects were randomized into one of two groups: Group 1 subjects underwent 64-MDCT performed with oral and IV contrast media and group 2 subjects underwent 64-MDCT performed solely with IV contrast material. Three expert radiologists independently reviewed the CT examinations, evaluating for the presence of appendicitis. Each radiologist interpreted 202 examinations, ensuring that each examination was interpreted by two radiologists. Individual reader performance and a combined interpretation performance of the two readers assigned to each case were calculated. In cases of disagreement, the third reader was asked to deliver a tiebreaker interpretation to be used to calculate the combined reader performance. Final outcome was based on operative, clinical, and follow-up data. We compared radiologic diagnoses with clinical outcomes to calculate the diagnostic accuracy of CT in both groups.
Of the 303 patients enrolled, 151 patients (50%) were randomized to group 1 and the remaining 152 (50%) were randomized to group 2. The combined reader performance for the diagnosis of appendicitis in group 1 was a sensitivity of 100% (95% CI, 76.8-100%) and specificity of 97.1% (95% CI, 92.7-99.2%). The performance in group 2 was a sensitivity of 100% (73.5-100%) and specificity of 97.1% (92.9-99.2%).
Patients presenting with nontraumatic abdominal pain imaged using 64-MDCT with isotropic reformations had similar characteristics for the diagnosis of appendicitis when IV contrast material alone was used and when oral and IV contrast media were used.
American Journal of Roentgenology 11/2009; 193(5):1282-8. · 2.78 Impact Factor
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ABSTRACT: The objective of our study was to determine whether there is an association between the grade of a traumatic renal injury and the subsequent development of renal parenchymal scars on CT.
We performed a retrospective study encompassing all acute trauma patients admitted to our institution over a 42-month period found to have renal parenchyma injuries on initial MDCT and also to have undergone a follow-up CT performed at least 1 month after trauma. We identified 54 patients who sustained blunt (n = 44) or penetrating (n = 10) abdominal trauma. The renal injuries were graded by two radiologists according to the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST), grades I through V. Follow-up CT was reviewed for the presence of parenchymal distortion, scarring, or perfusion defects.
Of the 54 patients, 12 had grade I injury, eight had grade II injury, 22 had grade III injury, 10 had grade IV injury, and two had grade V injury. Grades I and II traumatic renal injuries were undetectable on follow-up CT. Grade III injuries resulted in the development of renal scars in 14 of 22 (64%) patients. Scarring resulted in all patients with grades IV and V injuries.
Grades I and II renal injuries heal completely, whereas higher grades of renal trauma result in permanent parenchymal scarring. Hence, incidentally discovered renal scars in patients with a history of minor renal trauma should be attributed tentatively to other causes that may or may not require additional investigation.
American Journal of Roentgenology 06/2008; 190(5):1174-9. · 2.78 Impact Factor
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ABSTRACT: To retrospectively evaluate the integration of pelvic computed tomographic (CT) angiography into the thoracoabdominal CT examination of blunt trauma by using 64-detector row CT to differentiate active arterial from active venous hemorrhage.
This study was institutional review board approved and HIPAA compliant; the requirement for informed patient consent was waived. Fifty-three patients (30 male, 23 female; mean age, 42 years) with multiple blunt trauma underwent pelvic CT angiography with 64-detector row CT at admission. Arterial phase and portal venous phase pelvic CT angiograms were evaluated for evidence of vascular injury. In patients with active extravasation, the size of the hemorrhaging area was measured on arterial, portal venous, and delayed phase images. The Fisher exact test was used to correlate presence of vascular injury with subsequent clinical management. The Wilcoxon rank sum test was used to test the association between size of active hemorrhage during the vascular enhancement phases and subsequent clinical outcome. Finally, the Fisher exact test was used to correlate presence of vascular injury with severity of osseous injury.
At pelvic CT angiography, 21 of the 53 patients had evidence of vascular injury: 10 isolated active arterial extravasations, three isolated arterial occlusions, three cases of both arterial extravasation and occlusion, two cases of arterial and venous extravasations, and three isolated venous extravasations. Eleven of the 21 patients also underwent conventional angiography, with subsequent embolization performed in seven of these 11 patients. The remaining 10 patients were successfully treated conservatively. When the foci of active arterial extravasation were compared on arterial, portal venous, and delayed phase images, the mean areas of hemorrhage across all three phases were larger in patients who required conventional angiography than in those successfully treated with conservative management.
With use of 64-detector row scanning, pelvic CT angiography was successfully integrated into the authors' CT protocols and enabled differentiation between active arterial and active venous hemorrhage, which may influence clinical management.
Radiology 03/2008; 246(2):410-9. · 5.73 Impact Factor
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ABSTRACT: The finding of active hemorrhage on computed tomography (CT) in trauma patients has been shown to have significant clinical implications and has been incorporated into numerous CT grading schema. As CT technology has advanced, the sensitivity for detection of active hemorrhage in the trauma population has significantly improved. Currently, with the improved spatial and temporal resolution afforded by 64 multidetector computed tomography (64 MDCT) technology, the clinical implications of the CT findings of active extravasation may need to be reconsidered. This article illustrates the various imaging manifestations of active extravasation throughout the body using 64 MDCT. Additionally, protocol issues specific to the findings of active hemorrhage using 64 MDCT are detailed, including novel interpretation techniques, which offer aid in detecting and characterizing hemorrhage. Finally, the clinical implication of active extravasation using this new technology is discussed. Although more sensitive to the detection of small hemorrhagic foci and with clinical implications highly dependent upon location, active bleeding remains as a salient finding that affects subsequent clinical management of trauma patients.
Emergency Radiology 08/2007; 14(3):151-9.
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ABSTRACT: Spontaneous hemoperitoneum may be a life-threatening occurrence. It most frequently presents with acute abdominal pain. Computed tomography (CT) is the most commonly used modality in the initial work up of these patients, but sonography and magnetic resonance imaging (MRI) play a role in the diagnosis. The etiology is varied, yet may be broadly classified into gynecologic, hepatic, splenic, vascular, and coagulopathic causes. This review will describe the common imaging findings of spontaneous hemoperitoneum, as it presents through the emergency room, and will detail the underlying causes and significance of spontaneous hemoperitoneum.
Emergency Radiology 07/2007; 14(2):65-75.
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ABSTRACT: The purpose of this study was to evaluate the feasibility of performing CT-guided interventional procedures with a very low radiation dose.
We performed 291 CT-guided interventional procedures using a low dose of radiation. The subjects were 165 men and 126 women 22-89 years old with a mean age of 65 years. CT fluoroscopy was not used. The procedures were 201 percutaneous biopsies and 90 percutaneous aspiration or drainage procedures. Before the procedure, images were obtained with standard mAs of 175-250 mAs. All subsequent CT was performed at a reduced mAs. Technical success of catheter placement and biopsy was calculated, and the results were compared with those of procedures performed over the previous 12 months with standard radiation doses. Patient weight, lesion size, and number of CT acquisitions needed to complete the procedure were recorded.
All but three aspiration or drainage procedures performed at 30 mAs were successful, for a success rate of 96.7%. The technical success rate of biopsy performed at 30 mAs was 93.5%. In the cases of 13 patients undergoing biopsy, the masses were not identified with low-dose technique, and these procedures were completed at a higher dose. Results were independent of patient weight and lesion size. The technical success rate was 98% for percutaneous drainage performed at a standard radiation dose in the 12 months before introduction of the low-dose technique. The technical success rate was 87.5% for biopsy performed at a standard radiation dose in the 12 months before introduction of the low-dose technique. The complication rate of the low-dose technique was comparable to that of the standard-dose technique.
Low-dose radiation technique using 30 mAs results in technical success for both catheter placement and percutaneous biopsy comparable to standard radiation dose.
American Journal of Roentgenology 06/2007; 188(5):1187-94. · 2.78 Impact Factor
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ABSTRACT: To retrospectively evaluate delayed-phase computed tomography (CT) in the differentiation of active splenic hemorrhage requiring emergent treatment from contained vascular injuries (pseudoaneurysms or arteriovenous fistulas) that can be treated electively or managed conservatively.
The institutional review board approved this HIPAA-compliant retrospective study; the informed consent requirement was waived. Forty-seven patients with blunt splenic injury diagnosed at CT after blunt abdominal trauma were evaluated. Abdominal and pelvic dual-phase CT was performed; images were obtained 60-70 seconds and 5 minutes after contrast material injection. Scans were reviewed in consensus by two radiologists. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale. Patients with intrasplenic hyperattenuating foci on portal venous phase images were classified as having active splenic hemorrhage (group 1) or a contained vascular injury (group 2) on the basis of delayed-phase imaging findings. Findings suggestive of active hemorrhage included areas that remained hyperattenuating or increased in size on delayed-phase images. The clinical outcome of these patients was determined by reviewing their medical records. Relationships between several factors were tested with the Fisher exact test, including (a) the presence or absence of hyperattenuating foci and management and (b) the presence of contained vascular injury or active extravasation and management.
Portal venous phase CT revealed a focal high-attenuation parenchymal contrast material collection in 19 patients: nine patients were classified as group 1 and 10 were classified as group 2. All patients in group 1 underwent emergent splenectomy, and all patients in group 2 were initially treated without surgery. Significant differences in management were noted on the basis of whether hyperattenuating foci were seen on portal venous phase images (P < .001) and whether hyperattenuating foci seen at portal venous phase imaging were further characterized as active splenic hemorrhage or a contained vascular injury at delayed-phase CT (P < .001).
In blunt splenic injury, delayed-phase CT helps differentiate patients with active splenic hemorrhage from those with contained vascular injuries.
Radiology 05/2007; 243(1):88-95. · 5.73 Impact Factor
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ABSTRACT: To retrospectively evaluate the accuracy of multidetector computed tomography (CT) in the diagnosis of perforated acute appendicitis by using surgery and pathologic examination combined as the reference standard.
The study was institutional review board approved and HIPAA compliant. Informed patient consent was waived. The authors retrospectively identified 244 patients (150 male, 94 female; mean age, 32.8 years; age range, 4-83 years) with pathologically proved acute appendicitis who underwent abdominopelvic multidetector CT. Two radiologists reviewed in consensus the multidetector CT images obtained in all patients for various findings that may be associated with appendiceal perforation. For continuous variables, a comparison of means between the perforated and nonperforated groups was performed by using the Wilcoxon rank sum test. For categorical variables, the sensitivity and specificity of each CT finding for the diagnosis of perforated appendicitis were determined.
The CT findings of abscess (99%), extraluminal gas (98%), and ileus (93%) had the highest specificities for appendiceal perforation; however, the sensitivities of these findings were low: 34%, 35%, and 53%, respectively. The appendix was larger in patients with perforated appendicitis: The mean diameter was 15.1 mm compared with a mean diameter of 11.7 mm in patients with nonperforated appendicitis (P < .001). Appendicolith, free fluid, enlarged abdominal lymph nodes, and enhancement defect in the appendiceal wall were neither highly sensitive nor highly specific for the detection of perforation.
Although certain multidetector CT findings are very specific for the diagnosis of perforated appendicitis, overall multidetector CT sensitivity is poor. Unless abscess or extraluminal gas is present, multidetector CT cannot enable the diagnosis of perforation.
Radiology 12/2006; 241(3):780-6. · 5.73 Impact Factor
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ABSTRACT: OBJECTIVE: The purpose of this study is to assess the ability of MRI to identify the presence of inflammation related to the pouch reservoir in symptomatic patients with an ileal pouch-anal anastomosis who present with clinically suspected complicated pouchitis. CONCLUSION: Initial results suggest that MRI should be considered in patients who have undergone ileal pouch-anal anastomosis and present a clinical impression of complicated pouchitis. MRI showed abnormalities consistent with complicated pouchitis in seven of nine examinations, with findings including pouch wall thickening, abnormal wall enhancement, peripouch fluid collection, sinus and fistula tract formation, lymphadenopathy, and peripouch stranding and fatty proliferation. MRI findings of complicated pouchitis should raise the suspicion of Crohn's disease and should prompt further investigation.
American Journal of Roentgenology 11/2006; 187(4):W386-91. · 2.78 Impact Factor
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ABSTRACT: OBJECTIVE: Our purpose was to evaluate the diagnostic performance of contrast-enhanced and unenhanced MDCT, performed for various indications, in detecting choledocholithiasis. CONCLUSION: Unenhanced and contrast-enhanced MDCT images, interpreted in PACS workstations with axial images, are moderately sensitive and specific for showing choledocholithiasis.
American Journal of Roentgenology 08/2006; 187(1):174-80. · 2.78 Impact Factor
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ABSTRACT: The application of 64MDCT technology offers a significant evolution in imaging of patients with multiple trauma. Technological advances have allowed the integration of novel protocols into the initial assessment of the critically injured patient. This article details current trauma protocols using 64MDCT and discusses considerations in applying 64MDCT to trauma imaging, including multiplanar and three-dimensional image analysis, as well as radiation issues.
Contemporary Diagnostic Radiology. 04/2006; 29(9):1–5.
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ABSTRACT: The aim of this study was to evaluate the impact of bile leaks on patient morbidity and hospital course following blunt and penetrating liver trauma. Forty patients who underwent hepatobiliary scintigraphy after trauma were included. Scintigraphic results were classified as follows: free intraperitoneal bile leak, contained bile leak, and no bile leak. Outcomes measured were length of hospital stay, number of procedures required, and number of subsequent imaging studies. Bile leaks were identified in 25% of patients. Eight percent had free intraperitoneal leaks, 18% contained bile leaks, and 73% had no bile leak. One study was nondiagnostic due to poor hepatic function. Mean hospitalization was as follows: free bile leak group, 53 days; contained bile leak group, 10 days; no bile leak group, 14 days. Patients with free intraperitoneal bile leak had more imaging studies and procedures than patients without free bile leak. Patients with liver injury and free intraperitoneal bile leak have longer hospitalizations and undergo more therapeutic procedures than those without, who respond to conservative management.
Emergency Radiology 04/2006; 12(3):103-7.
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ABSTRACT: To retrospectively evaluate the accuracy of precontrast attenuation, relative percentage washout (RPW), and absolute percentage washout (APW) in distinguishing benign from malignant adrenal masses at multi-detector row computed tomography (CT).
This HIPAA-compliant retrospective study had institutional review board approval; the need for informed consent was waived. One hundred twenty-two adrenal masses were evaluated in 99 patients (51 men, 48 women; age range, 37-86 years) who had undergone CT performed according to the study protocol and who either were given a pathologic diagnosis or underwent follow-up imaging. Unenhanced images were obtained before administration of 120 mL of an intravenous contrast agent with a 75-second scan delay. Delayed images were obtained after 10 minutes. RPW and APW were computed. Receiver operating characteristic (ROC) analysis was performed to compare mean attenuation and both RPW and APW. Analysis was first performed with the exclusion of pheochromocytomas, myelolipomas, and cysts. Precontrast attenuation criteria specific for benignity or malignancy were determined, and ROC analysis of results for the entire nonpheochromocytoma group was then performed.
By using an RPW of 37.5% and excluding cysts and myelolipomas, all malignant lesions were detected with a sensitivity of 100% (17 of 17 lesions) and a specificity of 95% (90 of 95 lesions). Area under the binomial ROC curve (A(z)) values were 0.912, 0.985, and 0.892 for precontrast attenuation, RPW, and APW, respectively. Precontrast attenuation of less than 0 or more than 43 HU indicated benign and malignant entities, respectively. Incorporation of these criteria into the APW analysis yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (93 of 95 lesions) for a threshold washout value of 52.0%. This attenuation-corrected APW generated the greatest A(z) value (ie, 0.988). Combining all the information available from the protocol yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (98 of 100 lesions) for differentiating benign from malignant masses.
Precontrast attenuation of less than 0 HU supercedes the washout profile in the evaluation of an individual adrenal mass. Noncalcified, nonhemorrhagic adrenal lesions with precontrast attenuation of more than 43 HU should be considered suspicious for malignancy.
Radiology 03/2006; 238(2):578-85. · 5.73 Impact Factor
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ABSTRACT: OBJECTIVE: Few abdominal or pelvic cystic lesions come to the attention of the interventional radiologist, and those that do are symptomatic. Differentiation of cysts from cystic-appearing masses is not difficult when a multitechnique imaging approach is used. Our objective is to summarize the principles and specifics for management of symptomatic cysts through percutaneous catheter techniques. CONCLUSION: Percutaneous aspiration of cysts can relieve symptoms without the need for surgery. A sound knowledge of the various types of cysts that may be found in the abdomen and pelvis enables the radiologist to select those patients who will benefit the most from percutaneous management.
American Journal of Roentgenology 03/2006; 186(2):562-73. · 2.78 Impact Factor
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ABSTRACT: To retrospectively evaluate the utility of 5-minute delayed computed tomography (CT) of the abdomen and pelvis by using a reduced radiation dose in patients with blunt abdominal trauma.
Institutional review board consent was obtained, and written informed consent was waived. The study was HIPAA compliant. A total of 662 patients (497 men, 165 women; mean age, 40.5 years; range, 18-94 years) were identified who were evaluated with CT after blunt abdominal trauma during a 1-year period. Delayed CT scans were acquired 5 minutes after intravenous contrast material injection by using a decreased tube current of 100 mAs. Injury was identified in 106 patients. Two radiologists blinded to initial CT scan interpretation reviewed these cases to determine the quality and utility of delayed scans. Disagreement was settled by consensus. Delayed scans were considered useful when they aided in (a) characterizing initial CT findings, (b) identifying findings not present at initial CT, (c) excluding injury suggested at initial CT, and (d) increasing reader confidence with regard to initial CT findings.
All delayed scans were diagnostic. Delayed scans were useful in 27% (12 of 44) of patients with solid organ injury, 5.9% (one of 17) of patients with bowel or mesenteric injury, 4.5% (one of 22) of patients with pelvic fractures, and in none of the patients with free fluid only. Overall, delayed CT was useful in 2.1% (14 of 662) of all patients (95% confidence interval: 1.0, 3.2) referred for evaluation following blunt abdominal trauma. Utility increased to 13.2% (14 of 106) (95% confidence interval: 6.8, 19.7) in the group of patients with injury or suspected of having injury after initial CT.
If delayed CT scans are acquired when patients with blunt abdominal trauma are evaluated, selective, rather than routine, acquisition is recommended and a reduced radiation dose seems adequate.
Radiology 03/2006; 238(2):473-9. · 5.73 Impact Factor
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ABSTRACT: The purpose of this study was to show the value of 2D and 3D reformations of CT data from abdominal and pelvic CT performed immediately at the workstation using a PACS-based software program to evaluate the lumbar spine and pelvis in patients with blunt abdominal trauma.
We reviewed the abdominopelvic CT scans and conventional radiographs of the lumbar spine or pelvis of 156 consecutive patients with blunt abdominal trauma. The CT data were compared with the radiographic findings and also with the findings of dedicated repeat CT of the spine or pelvis, when performed.
CT depicted 80 fractures of the lumbar spine and 178 pelvic fractures. Radiography showed 40 fractures of the lumbar spine and 138 pelvic fractures. No additional fractures were identified on dedicated repeat CT.
Conventional radiographs to clear the lumbar spine are no longer required when abdominopelvic CT data are available. CT and reformatted CT data show more fractures than radiography and miss no fractures compared with dedicated CT of the lumbar spine or pelvis. Having these images immediately available through the PACS workstation saves time for the trauma team in the management of critically ill patients.
American Journal of Roentgenology 01/2006; 185(6):1435-40. · 2.78 Impact Factor
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ABSTRACT: Spontaneous hemoperitoneum may be extremely difficult to diagnose and may have a catastrophic outcome. It most commonly presents as acute abdominal pain, which may be accompanied by abdominal distention, hypotension, and tachycardia. There are few physical signs that point specifically to hemoperitoneum. Hematologic parameters suggesting the diagnosis include an unexplained drop in hematocrit in a patient presenting with acute abdominal pain; however, in the acute setting, the hematocrit may not drop in tandem with the intraperitoneal hemorrhage. As a result, imaging is the most reliable examination for diagnosing spontaneous hemoperitoneum, and its role is three-fold: (1) to make the diagnosis of hemoperitoneum; (2) to identify ongoing active bleeding; and (3) to identify an underlying cause of the hemorrhage. The possible etiologies of spontaneous hemoperitoneum are varied, with causes including visceral rupture, vascular rupture, coagulopathy, and gynecologic pathology.
Contemporary Diagnostic Radiology. 09/2005; 28(20):1–6.
