Usefulness of Ultrasound in the Evaluation of Morphologic Change of a Cirrhotic Liver During Respiration

PURPOSE: This study was designed to determine whether transabdominal ultrasound can detect different hepatic stiffness between patients with cirrhosis and control subjects. MATERIALS AND METHODS: Sevent-three patients (Child-Pugh class A stage) with liver cirrhosis and 57 control subjects were included in this study. All patients were subdivided arbitrarily into two groups: early cirrhosis (n = 53) and overt cirrhosis (n = 20). Two sagittal images of the left lobe of the liver were obtained in the left hepatic vein level during the resting state and at full inspiration while pushing their belly out, by abdominal US (i.e., resting and stress image). The length between the inferior hepatic angle and the midpoint of the liver dome was measured in all images for the evaluation of liver distortion. The elongation was calculated by a formula: (L2-L1/L1) x 100(%); where L1 and L2 are the length of the liver for both the resting and stress image. The calculated elongated length (L2-L1, EL) and elongation rate were compared between cirrhotic patients and control subjects. RESULTS: For the control subjects, early cirrhosis, and overt cirrhosis groups, the mean ELs (elongation rate) were 2.34+/-0.98 cm (30.2+/-13.2%), 1.18+/-0.73 cm (14.9+/-9.5%) and 0.53+/-0.54 cm (6.3+/-6.6%), respectively. This difference among the three groups was statistically significant (p < 0.05). A possible best cut-off value of liver elongation rate is 17% for the prediction of cirrhosis (sensitivity: 90%, specificity: 75.3%). CONCLUSION: The liver of patients with liver cirrhosis is stiffer than that of control subjects. Calculation of the elongation rate in the left lobe of the liver during a respiratory maneuver may be used as an ancillary method of US for the evaluation of liver cirrhosis.

Assessment of Left Ventricular Function after Mitral Valvular Replacement Using Multidetector Row Computed Tomography: Initial Experience

PURPOSE: To assess the usefulness of cardiac MDCT for the evaluation of cardiac function and morphology of mitral valve replacement (MVR) with or without subvalvular preservation. MATERIALS AND METHODS: Sixteen patients with (n = 10) or without (n = 6) subvalvular sparing and control subjects (n = 6) were evaluated using 16-slice MDCT (Sensation 16, Siemens, Erlangen, Germany). Images of MDCT were reconstructed for the evaluation of cardiac morphology and ventricular function. Patients were compared with respect to variables such as ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and the diastolic-systolic left ventricular area ratio on a short-axis view at apical, mid-ventricular, and basal levels. RESULTS: The average values for cardiac function variables for control subjects and after MVR (with subvalvular preservation versus without subvalvular preservation) were, respectively, 54 +/- 8%, 54 +/- 7% and 44 +/- 6 %, for EF; 91 +/- 28 ml, 108 +/- 35 ml and 99 +/- 33 ml for EDV; 43 +/- 19 ml, 52 +/- 24 ml and, 56 +/- 21 ml for ESV. The area ratio was 2.56, 2.75, 2.09 at the apex; 2.20, 2.17, 1.56 at the mid-ventricular level; 1.90, 1.87, 1.76 at the basal level, respectively. Mid ventricular contraction for patients following subvalvular resection was significantly decreased (p < 0.05). CONCLUSION: MDCT is a useful diagnostic modality for functional and morphologic evaluation of MVR.

Duodenal Obstruction and Acquired Gastroduodenal Fistula Caused by Magnets: A Case Report

Foreign body ingestion in children is commonly encountered and this usually resolves spontaneously. Single magnet ingestion usually does not need additional medical treatment. However, multiple magnets can attract each other in intestinal loops and several complications can develop such as bowel obstruction and fistula formation. In this situation, endoscopic and/or surgical intervention is inevitably required. Therefore, making the correct diagnosis is needed for cases of magnets ingestion, and this should be done as soon as possible for children. We report here on a case of gastroduodenal fistula and duodenal obstruction caused by the interaction of four magnets.

Renal Hypoperfusion Associated with Splenorenal Shunts in Liver Cirrhosis

PURPOSE: To determine whether spontaneous a splenorenal shunt can be used as an imaging predictor of early renal hemodynamic changes in patients with cirrhosis. MATERIALS AND METHODS: The study included 82 cirrhotic patients and 41 control subjects. Three-phase CT was performed and CT attenuation values (Hounsfield units) of the renal cortex in three phases were measured to evaluate renal perfusion. Likelihood ratio tests for trend were conducted for age, presence of ascites, and Child's grade. RESULTS: The mean CT attenuation values of the renal cortex in cirrhotic patients were significantly lower than the values of control subjects in three phases: 153.3 +/- 37.9 versus 173.3 +/-25.2 in the arterial phase, 172.6 +/- 41.0 versus 197.6 +/- 26.5 in the portal phase and 136.9 +/- 26.0 versus 152.7 +/- 20.0 in the delayed phase, respectively. The mean CT attenuation value of cortices in patients with renal hypoperfusion was 119.9 +/- 11.8 in the portal phase. Child's class C (aOR: 58.4, 95% CI: 3.6-956.2; p < 0.01) and the presence of a renal shunt (aOR: 7.5, 95% CI: 1.8-30.5; p < 0.01) were associated with renal hypoperfusion. The incidence of renal hypoperfusion was associated with Child's grade (trend: p < 0.01), and not with the grade of ascites or age. CONCLUSION: A dilated spontaneous splenorenal shunt may be a risk factor for renal hypoperfusion in cirrhosis.

Can the Splenic Artery Resistive Index Be an Ancillary Sign on Ultrasound for the Differentiation of Alcoholic Cirrhosis from Hepatitis B-virus Related Cirrhosis?

PURPOSE: We wanted to assess the usefulness of the splenic artery resistive index (RIS) for differentiating between alcoholic cirrhosis (AC) and hepatitis B-virus related cirrhosis (VC). MATERIALS AND METHODS: A total of 109 subjects (28 normal healthy controls, 38 patients with VC and 43 patients with AC) were included in this study. The spleen sizes, Child-Pugh scores and RISs were compared between the two cirrhotic groups. The receiver operating characteristic (ROC) curve was used to determine an RIS cutoff value for the differentiation of the two cirrhotic groups. RESULTS: The mean spleen size and mean RIS in the controls were less than those of the two cirrhotic groups (p 0.05; 6.6 +/- 1.9 vs. 5.9 +/- 1.6, p > 0.05, respectively). In contrast, the mean RIS of the AC patients was significantly higher than that of the VC patients (0.72 +/- 0.07 vs. 0.62 +/- 0.06, respectively, p < 0.01). The sensitivity, specificity and accuracy at an RIS cut-off value of 0.7 for differentiating the two cirrhotic groups were 76.7%, 68.4% and 72.8, respectively. CONCLUSION: The RIS is useful factor for differentiating the patients with AC from the patients with VC.

Collecting Duct Carcinoma of the Kidney Mimicking Invasive Transitional Cell Carcinoma: A Case Report

Approximately 100 cases of collecting duct carcinoma have been reported in the medical literature. We herein report on a case of collecting duct carcinoma of the kidney in a 75-year-old patient. The abdominal sonography depicted a relatively poorly defined 7X6 cm sized, isoechoic mass lesion, as compared to the normal parenchyma, at the left kidney lower pole and the affected kidney showed preservation of the reniform shape. CT revealed a heterogeneous poorly defined low-attenuation mass that was mainly located in the medulla with involvement of the cortex and the lower half of the renal pelvis. Retrograde ureteropyelography showed a filling defect at the lower renal pelvis and severe narrowing of the left proximal ureter. We initially thought this lesion was invasive transitional cell carcinoma. Subsequent surgery confirmed a collecting duct carcinoma.

The Value of Renal Artery Resistive Indices: Association with Esophageal Variceal Bleeding in Patients with Alcoholic Cirrhosis

PURPOSE: To determine whether resistive indices of the renal artery (RIR) or the splenic artery (RIS) can be used as predictors of bleeding in patients with alcoholic liver cirrhosis. MATERIALS AND METHODS: According to esophageal variceal bleeding episodes, 33 patients with cirrhosis were divided into two groups, a bleeder group (n=17) and a non-bleeder group (n=16). These two groups were compared with respect to five variables (age, spleen size, Child's score, RIS, and RIR). Sensitivity, specificity, and accuracy for the detection of bleeders were calculated using a cutoff value of 0.7 for RIR. RESULTS: The mean values of variables were higher for bleeders than for non-bleeders. With the exception of age, four variables were significantly correlated with bleeding (r=0.43 for spleen size; r=0.36 for Child's score; r=0.37 for RIS; p<0.05, respectively; r=0.63 for RIR, p<0.01). Only RIR was found to be significantly a predictive variable for bleeders (adjusted Odds ratio=19.9; 95% confidence interval: 1.3-306, p<0.05) when the RIR was more than 0.7. RIR had a sensitivity of 88.3% and a specificity of 75% with an accuracy of 81.8% at a cutoff value of 0.7 for identifying bleeders. CONCLUSION: A high RIR value will be useful in predicating esophageal variceal bleeding in patients with alcoholic liver cirrhosis.

Various Ocular MR Imagings in a Mouse Implanted with a New Cell Line of Retinoblastoma and the Correlation with the Pathology: Preliminary Study

PURPOSE: We wanted to show various MR and correlated pathologic images of retinoblastoma in nude mousewith a new human retinoblastom cell line (SNUOT-Rb1), which was inoculated into the intravitreous cavity. MATERIALS AND METHODS: The established cell line was inoculated into the intravitreous cavity of 36 eyeballs of 18 mice and the transplanted retinoblastoma was examined for 3 months. The T1-weighted (T1WI), T2-weighted (T2WI), and contrast enhanced (Gd-DTPA) T1-weighted images were obtained with using a small loop coil. After scanning, the mice's eyeballs were extracted and the hematoxylin & eosin stained specimens were examined with a microscope. We compared the MR imagings with pathologic findings and evaluated the character of the tumors. RESULTS: The innoculated cells in the eyeballs of the mice grew into retinoblastoma (23/36, 64%). The eyeballs with retinoblastoma protruded externally and showed focal hemorrhage. Most tumors showed iso-signal intensity on TIWI (13/23, 57%), high signal intensity on T2WI (17/23, 74%), and good enhancement (21/23, 91%) with contrast. Almost all of the tumors (n=21) were located in the retina and three extraretinal tumors were confirmed by pathology. Involvement of the optic nerve was suspected on MRI and this was confirmed by pathology in 6 cases and 5 cases, respectively. CONCLUSION: We could demonstrate various MR imagings of transplanted retinoblastoma by using the new tumor cell line in vivo.

Occlusive Myocardial Infarction: Cardiac CT Perfusion in a Rat Model

PURPOSE: To test whether cardiac multidetector CT (MDCT) perfusion imaging can accurately delineate an irreversibly damaged myocardium in animals with an occlusive myocardial infarction. MATERIALS AND METHODS: In 16 rats, the left anterior descending coronary arteries were ligated distal to its first diagonal artery after a thoracotomy. Thirty minutes after the procedure, 16-slice MDCT (Sensation 16, Siemens, Erlangen, Germany) was performed and delayed images were obtained up to 5 minutes after injecting the contrast agent (0.2 mL/100g, 0.5 mL/sec). Ten rats were re-examined one week later. After CT scanning, the rats were sacrificed and their hearts were extirpated for 2,3,5-triphenyltetrazolium chloride (TTC) histochemical staining. The stained slices were compared with the CT images. The CT number (HU) of the infarct and non-infarct areas were estimated from the contrast ratio (CR). RESULTS: The CT attenuation in the infarct area was significantly lower than that in the normal myocardium. Quantitative analysis of the CT attenuation revealed a significant difference in the CR and CT attenuation of the infarct and reference areas (0.48+/-0.12 vs 0.64+/-0.13, p<0.05, 163+/-46 HU vs 216+/-56 HU, p<0.05). However, there were no significant differences in the CT numbers between the infarct and non-infarct areas on the one-week follow-up. CONCLUSION: A perfusion defect on MDCT indicates the myocardial damage in an animal model with occlusive myocardial infarction.

A Case of Rupture of a Renal Artery Aneurysm in Polyarteritis Nodosa which is predicted early in Emergency Department

Polyarteritis nodosa (PAN) is a necrotizing angitis that predominantly affects small-and medium-sized arteries in which microaneurysm or occlusion of the visceral arteries can be seen by arteriography. Patients with PAN may have non-specific symptoms at the beginning of their illness, but progression can be sudden and result in severe, even life threatening, complications. These include central nervous system hemorrhages, gastrointestinal hemorrhages or perforation, acute appendicitis, liver infarcts, acute renal failure, renal perirenal hematomas, and cardiac failure. A diagnosis of PAN should be considered when multiple small-sized aneurysms are detected by angiography, even if a biopsy is negative. Involvement of gastrointestinal and renal arteries is frequent in polyarteritis nodosa. The most common complications of gastrointestinal involvement are mucosal ulceration, bowel infarction, perforation, cholecystitis and hepatitis. Another rare but potentially life-threatening complication is perirenal hematoma caused by spontaneous rupture of renal aneurysm. Because of this possibility, rapid evaluation of these patients is necessary to make early diagnosis and treatment possible. We describe an extremely rare case of polyarteritis nodosa with development of spontaneous perirenal hematoma due to rupture of renal aneurysm, which was evaluated with immediate angiography and treated by coil embolization.

Rupture of Popliteal Arterial Aneurysm due to Salmonella Infection

We report here on a case of popliteal aneurysm and rupture that occurred over a 10-day period and this was all secondary to salmonella infection. Computed tomography (CT) angiography of the extremity that was performed before and after aneurysmal rupture showed the aneurysm's rapid evolution to rupture over a short period of time. We also review the pathogenesis, clinical presentation, diagnostic approach and management of salmonella aneurysms.

Rupture of Popliteal Arterial Aneurysm due to Salmonella Infection

We report here on a case of popliteal aneurysm and rupture that occurred over a 10-day period and this was all secondary to salmonella infection. Computed tomography (CT) angiography of the extremity that was performed before and after aneurysmal rupture showed the aneurysm's rapid evolution to rupture over a short period of time. We also review the pathogenesis, clinical presentation, diagnostic approach and management of salmonella aneurysms.

Usefulness of Three Dimensional Reconstructive Images for Thoracic Trauma Induced Fractures

PURPOSE: We wanted to evaluate the usefulness of three-dimensional reconstructive images using multidetector computed tomography (MDCT) for thoracic traumatic patients visiting emergency room. MATERIALS AND METHODS: 76 patients with fractures of the 105 patients who visited our emergency room with complaints of thoracic trauma were analyzed retrospectively. All the patients had thoracic MDCT performed and the three-dimensional reconstructive images were taken. The fractures were confirmed by axial CT, the clinical information, whole body bone scanning and the multiplanar reformation images. Plain x-ray images were analyzed by the fractured sites in a blind comparison of two radiologists' readings, and then that finding was compared with the axial CT scans and the three-dimensional reconstructive images. RESULTS: The fracture sites were rib (n=68), sternum (n=14), clavicle (n=6), scapula (n=3), spine (n=5) and combined fractures (n=14). Plain x-ray and axial CT scans had a correspondency of 0.555 for the rib fractures. Axial CT scans and the three-dimensional reconstructive images had a correspondency of .952. For sternal fractures, those values were 0.692 and 0.928, respectively. The axial CT scans and three-dimensional reconstructive images showed sensitivities of 94% and 91% for rib and other fractures, respectively, and 93% and 100% for sternal fracture, respectively. Three-dimensional reconstructive image had an especially high sensitivity for the diagnosis of sternal fracture. CONCLUSION: While evaluating thoracic trauma at the emergency room, the three-dimensional reconstructive image was useful to easily diagnose the extent of fracture and it was very sensitive for detecting sternal fracture.

Usefulness of Three Dimensional Reconstructive Images for Thoracic Trauma Induced Fractures

PURPOSE: We wanted to evaluate the usefulness of three-dimensional reconstructive images using multidetector computed tomography (MDCT) for thoracic traumatic patients visiting emergency room. MATERIALS AND METHODS: 76 patients with fractures of the 105 patients who visited our emergency room with complaints of thoracic trauma were analyzed retrospectively. All the patients had thoracic MDCT performed and the three-dimensional reconstructive images were taken. The fractures were confirmed by axial CT, the clinical information, whole body bone scanning and the multiplanar reformation images. Plain x-ray images were analyzed by the fractured sites in a blind comparison of two radiologists' readings, and then that finding was compared with the axial CT scans and the three-dimensional reconstructive images. RESULTS: The fracture sites were rib (n=68), sternum (n=14), clavicle (n=6), scapula (n=3), spine (n=5) and combined fractures (n=14). Plain x-ray and axial CT scans had a correspondency of 0.555 for the rib fractures. Axial CT scans and the three-dimensional reconstructive images had a correspondency of .952. For sternal fractures, those values were 0.692 and 0.928, respectively. The axial CT scans and three-dimensional reconstructive images showed sensitivities of 94% and 91% for rib and other fractures, respectively, and 93% and 100% for sternal fracture, respectively. Three-dimensional reconstructive image had an especially high sensitivity for the diagnosis of sternal fracture. CONCLUSION: While evaluating thoracic trauma at the emergency room, the three-dimensional reconstructive image was useful to easily diagnose the extent of fracture and it was very sensitive for detecting sternal fracture.

Catastrophic Primary Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome (CAPLS) was diagnosed in a 64-year-old male who was admitted to our hospital with dyspnea. The clinical and radiological examinations showed pulmonary thromboembolism, and so thromboembolectomy was performed. Abdominal distention rapidly developed several days later, and the abdominal computed tomography (CT) abdominal scan revealed thrombus within the superior mesenteric artery with small bowel and gall bladder distension. Cholecystectomy and jejunoileostomy were performed, and gall bladder necrosis and small bowel infarction were confirmed. The anticardiolipin antibody was positive. Anticoagulant agents and steroids were administered, but the patient expired 4 weeks after surgery due to acute respiratory distress syndrome (ARDS). We report here on a case of catastrophic APLS with manifestations of pulmonary thromboembolism, rapidly progressing GB necrosis and bowel infarction.

Catastrophic Primary Antiphospholipid Syndrome

Catastrophic antiphospholipid syndrome (CAPLS) was diagnosed in a 64-year-old male who was admitted to our hospital with dyspnea. The clinical and radiological examinations showed pulmonary thromboembolism, and so thromboembolectomy was performed. Abdominal distention rapidly developed several days later, and the abdominal computed tomography (CT) abdominal scan revealed thrombus within the superior mesenteric artery with small bowel and gall bladder distension. Cholecystectomy and jejunoileostomy were performed, and gall bladder necrosis and small bowel infarction were confirmed. The anticardiolipin antibody was positive. Anticoagulant agents and steroids were administered, but the patient expired 4 weeks after surgery due to acute respiratory distress syndrome (ARDS). We report here on a case of catastrophic APLS with manifestations of pulmonary thromboembolism, rapidly progressing GB necrosis and bowel infarction.

Cystic Lymphangioma Involving the Mesentery and the Retroperitoneum: A Case Report

Cystic lymphangioma is uncommon angiomatous tumor that mainly occurs in the neck. Less than 1% of these tumors affect the mesentery, retroperitoneum and greater omentum. In particular, the cystic lymphangioma involving the mesentery and the retroperitoneum is a rare lesion. We report here on an uncommon case of cystic lymphangioma that presented as a multilocular mass involving the mesentery and the retroperitoneum, and we also present a brief review of the relevant literature.

Endovascular Treatment of Arteriovenous Fistula with Pseudoaneurysm at Popliteal Fossa Using a PTFE Stent-graft: A Case Report

We report the successful treatment of a postoperative pseudoaneurysm of a popliteal artery, which was associated with an arteriovenous fistula to the popliteal vein using an endovascular placement of a PTFE-covered stent graft. After a one-month follow-up, there was an in-stent stenosis, which was managed by balloon angioplasty. The patient was well with mild leg discomfort after a 3-month follow-up.

Radiofrequency Ablation of the Gastrointestinal Tract with a Stent-Like Electrode: Experimental Study

OBJECTIVE: To assess the technical feasibility of a newly designed stent-like electrode in rabbits. MATERIALS AND METHODS: A stent-like electrode was knitted from a single thread of nitinol wire and interconnected to a generator using similar wire. In order to gauge the extent of radiofrequency ablation (RFA), we measured the depth of the ablated area in cow liver using a combination of 180-sec time intervals and 20-watt power increments. For data processing, Cox regression analysis was used. RFA was also applied to the small intestine of rabbits using this stent-like electrode under six different sets of conditions: 10 watts for 1 min, 10 watts for 2 mins, 20 watts for 1 min, 20 watts for 2 mins, 30 watts for 1 min, and 30 watts for 2 mins. To determine the gross and microscopic findings, six animals were sacrificed immediately after the procedure and the results obtained under the different sets of conditions were correlated. Eight rabbits were monitored for 4 weeks prior to sacrifice. RESULTS: For both ex-vivo and in-vivo ablations, the depth of the thermal lesion showed linear correlation with both the duration of RFA and the power applied. RFA of the duodenum was technically successful in all 14 rabbits. The acute changes occurring in the rabbits' small intestine included color change, cytoplasmic denaturation, fibrin deposition and hemorrhage, among which hemorrhage of the mucosal layer was the earliest finding. RF ablation for 2 mins at 30 watts caused serosal hemorrhage. The gross and histologic changes occurring showed close correlation under all six sets of conditions. CONCLUSION: Use of the stent-like electrode proves technically feasible but to determine the nature of the chronic change occurring in the gastrointestinal tract after RF ablation, further investigation and long-term follow-up in animals are required.

Evaluation of the Pedal Artery: Comparison of Three-dimensional Gadolinium-Enhanced MR Angiography with Digital Subtraction Angiography

PURPOSE: To compare the three-dimensional gadolinium-enhanced MR angiography with digital subtraction angiography (DSA) for evaluation of the pedal artery. MATERIALS AND METHODS: In 12 extremities of 11 patients, both digital subtraction angiography (DSA) and contrast-enhanced MR angiography (CE-MR angiography) were performed during the same week. Among ten of the 11 patients, the following conditions were present: atherosclerosis (n=4), diabetic foot (n=3), Buerger's disease (n=1), calciphylactic arteriopathy (n=1) and arteriovenous malformation of the foot (n=1). The remaining patient underwent angiography prior to flap surgery. For MR angiography, a 1.5T system using an extremity or head coil was used. A three-dimensional FISP (fast imaging with steady state precession) sequence was obtained before enhancement, followed by four sequential acquisitions (scan time, 20 secs; scan interval time, 10 secs) 10 seconds after intravenous bolus injection of normal saline (total 10 cc), following intravenous adminstration of gadolinium (0.02 mmol/kg, 3 ml/sec). Arterial segments of the ankle and foot were classified as the anterior or posterior tibial artery, the distal peroneal artery, the medial or lateral plantar artery, the pedal arch, and the dorsalis pedis artery. Two radiologists independently analysed visualization of each arteraial segment and the mean of visible arterial segments in one extreminty using CE-MR angiography and DSA. RESULTS: Among 84 arterial segments, 16 were invisible at both CE-MR angiography and DSA, while 39 were demonstrated by both modalities. Twenty-six segments were visible only at CE-MR angiography and three only at DSA. CE-MR angiography displayed a higher number of arterial segments than DSA (mean, 5.42 vs. mean 3.50, respectively), a difference which was statistically significant (p<0.000). The difference between each arterial segment was not statistically significant, except for the dorsalis pedis artery (t test, p<0.000). CONCLUSION: In that it provides additional information for the planning of treatment of lower-extremity arterial disease, three-dimensional CE-MR angiography is superior to DSA for evaluation of the pedal artery.