Ultrasonography in the Diagnosis of Appendicitis: Evaluation by Meta-analysis

OBJECTIVE: We wanted to review the usefulness of ultrasonography (US) for the diagnosis of appendicitis and to evaluate the diagnostic accuracy of US according to patients' and researchers' characteristics. MATERIALS AND METHODS: The relevant Korean articles published between 1985 and 2003 were included in this study if the patients had clinical symptoms of acute appendicitis. The histopathologic findings were the reference standard and the data were presented for 2x2 tables. Articles were excluded if patients had no sonographic signs of appendicitis according to graded-compression US. Two reviewers independently extracted the data on study characteristics. The Hasselblad method was used to obtain the combined estimates of sensitivity and specificity for the performance of US. RESULTS: Twenty-two articles (2, 643 patients) fulfilled all inclusion criteria. The estimate of d calculated by combining the sensitivity and specificity was 2.0054 (95% confidence interval [CI]: 1.8553, 2.1554) by a random effects model. The overall sensitivity and specificity (95% CI) were 86.7% (85.4 to 88.0), and 90.0% (88.9 to 91.2), respectively. According to the subgroup meta-analysis by patients' characteristics, the d estimate (95% CI) of dominantly younger age, male, and highly clinical suggestive group for US was 2.2388 (1.8758 to 2.6019), 2.7131 (2.2493 to 3.1770), and 2.4582 (1.7387 to 3.1777), respectively. Also, according to subgroup meta-analysis by researchers' characteristics, the d value (95% CI) for US done by diagnostic radiologists and gray-scale was 2.0195 (1.7942 to 2.2447) and 2.2630 (1.8444 to 2.6815). CONCLUSION: This evidence suggests that US may be useful for the diagnosis of acute appendicitis, especially when patients are younger age, male, and highly clinical suggestive.

Relationship of Hemodynamic Indices and Prognosis in Patients with Liver Cirrhosis

BACKGROUND: Hyperdynamic circulation due to reduced peripheral vascular resistance and increased cardiac output, and the development of portal hypertension are the hemodynamic changes observed in patients with liver cirrhosis. Such hemodynamic abnormalities appear in patients with late stage liver cirrhosis. Therefore, hemodynamic indices, which represent hyperdynamic circulation and portal hypertension, are significant for the prognosis of patients with liver cirrhosis. The aim of this study was to determine the hemodynamic indices associated with the prognosis of patients with liver cirrhosis. METHODS: A total of 103 patients diagnosed with liver cirrhosis between December 1999 and June 2003, with a mean follow-up period of 73 weeks, ranging from 7 to 168 weeks, were recruited. Using Child-Pugh classification, the mean arterial pressure, heart rate and hepatic venous pressure gradient (HVPG) were measured. The indices of Doppler ultrasonography, including the portal and splenic venous flows, and the resistance of the hepatic, splenic, and renal arteries were also measured using the arterial pulsatility index (PI). The prognostic values of these indices were determined by their comparison with the patient survivals. RESULTS: Significant hemodynamic indices for a bad prognosis were high HVPG (> or=15 mmHg) and renal arterial PI (> or=1.14) (p or=10 was important for a poor prognosis (p or=15 mmHg) and high renal arterial resistance (PI> or=1.14) were valuable hemodynamic indices for the prognosis of patients with liver cirrhosis. Therefore, it was concluded that the measurement of these hemodynamic indices, in addition to the Child-Pugh classification, is helpful in the prognosis of patients with liver cirrhosis.

The effects of propranolol on portal pressure in cirrhotic patients with portal hypertension / 대한내과학회지

BACKGROUND: Propranolol is only known drug effective in preventing variceal bleeding by ameliorating portal hypertension. The optimal dose of propranolol is variable due to racial differences of cardiovascular receptor sensitivity. In this prospective study, we tried to evaluate the effect of propranolol on portal hypertension, required optimal dose and to find out factors that influence drug responses in Korean cirrhotic patients with portal hypertension. METHODS: This study included 25 patients with liver cirrhosis who had variceal bleeding episode. Propranolol was given orally at an initial dose of 20 mg twice daily. The dose was subsequently adjusted over a period of 2 days until the resting heart rate had been reduced by 25% or less than 55 beats per minute. The hemodynamic studies including measurements of heart rate (HR), mean blood pressure (MBP), hepatic venous pressure gradient (HVPG), portal venous flow (PVF) were evaluated both prior to and 3 months after commencing treatment. Patients who showed a reduction in HPVG of more than 20% of baseline or absolute value under 12 mmHg were defined as being responders. RESULTS: The mean required dose of propranolol to reach target heart rate was 165 mg (80~280 mg). Propranolol induced significant reduction in HVPG (-29.0+/-21.4%, p<0.01), PVF (-19.6+/-17.8%, p<0.01) and HR (-29.3+/-9.1%, p<0.01). Drug responders were 15 (60%) and non-responders were 10 (40%). There was no significant factor for drug responders in multivariate analysis. The main complication of propranolol was dizziness with incidence of 24%, but was not serious enough to stop the administration of the drug. CONCLUSION: Propranolol is effective in reducing portal pressure in Korean cirrhotic patient and considered as relatively safe, and might be useful in preventing variceal bleeding. To obtain effective improvement of portal hypertension, it is necessary to increase the dosage until the targeted heart rate is reached when the measurement of HVPG is not be available.

Comparison of Doppler Ultrasonography and Hepatic Venous Pressure Gradient in Assessing Portal Hypertension in Liver Cirrhosis / 대한간학회지

BACKGROUND/AIMS: This prospective study aimed to determine if Doppler ultrasonography can be representative of hepatic venous pressure gradient (HVPG) in assessing the severity of portal hypertension and response to drug reducing portal pressure. METHODS: The HVPG and the parameters of Doppler ultrasonography including portal venous velocity (PVV) and splenic venous velocity, the pulsatility and resistive index of hepatic, splenic and renal arteries were measured in 105 patients with liver cirrhosis. In 31 patients the changes of hepatic venous pressure gradient and portal venous velocity after administration of terlipressin were evaluated. The patients who showed a reduction in HVPG of more than 20% of the baseline were defined as responders to terlipressin. RESULTS: Any Doppler ultrasonographc parameters did not correlate with HVPG. Both HVPG and PVV showed a highly significant reduction after the administration of terlipressin(-28.3 +/- 3.9%, -31.2 +/- 2.2% respectively). However, PVV decreased significantly not only in responders(31.7 +/- 2.4%) but also in nonresponders(29.5 +/- 6.1%). CONCLUSION: Doppler ultrasonography can not be representative of HVPG in assessing the severity of portal hypertension and response to drug reducing portal pressure in liver cirrhosis.

Giant Serpentine Intracranial Aneurysm: A Case Report

The authors present a case of giant serpentine aneurysm (a partially thrombosed aneurysm containing tortuous vascular channels with a separate entrance and outflow pathway). Giant serpentine aneurysms form a subgroup of giant intracranial aneurysms, distinct from saccular and fusiform varieties, and in this case, too, the clinical presentation and radiographic features of CT, MR imaging and angiography were distinct.

The Role of Endoscopic Retrograde Pancreatography for Traumatic Pancreatic Duct Injury / 대한소화기내시경학회지

Backgroud/Aims: Because the status of the main pancreatic duct (MPD) is the most important determinant for pancreatic trauma associated morbidity and mortality, early diagnosis and optimal treatment are critical, especially in MPD injury. METHODS: Twenty-three pancreatic trauma patients were divided into two groups according to the interval between trauma and endoscopic retrograde pancreatography (ERP). The clinical and laboratory findings, CT and ERP results were described. The treatment modality and its clinical outcome were assessed according to ERP findings. RESULTS: The pancreatic duct was injured in 14 of the 23 trauma patients: 11 MPD injuries and 3 branching duct injuries. CT scan correctly predicted the MPD injury in only 6 (54.5%) of the 11 patients, whereas ERP correctly demonstrated the origin and the degree of pancreatic duct injury in all patients. Through contrast leakage from the MPD into peritoneal cavity, ERP confirmed an MPD injury in 8 patients and they underwent surgical exploration. Three patients who showed parenchymal leakage from branching duct recovered with conservative treatment. Transpapillary pancreatic stents were successfully inserted into the distrupted MPD in 3 patients who showed that the contrast leakage was confined to the pancreatic parenchyme and they achieved complete resolution of the pancreatic leaks after a 3-month follow-up period. The late ERP group (>72 hours after trauma) had a significantly higher pancreas associated complication rate and a tendency to a longer hospital stay than the early ERP group. CONCLUSIONS: Early ERP is the most useful tool for demonstrating the presence of MPD injury as well as planning the optimal treatment modality according to the degree of pancreatic duct injury.

The Role of Endoscopic Retrograde Pancreatography for Traumatic Pancreatic Duct Injury / 대한소화기내시경학회지

Backgroud/Aims: Because the status of the main pancreatic duct (MPD) is the most important determinant for pancreatic trauma associated morbidity and mortality, early diagnosis and optimal treatment are critical, especially in MPD injury. METHODS: Twenty-three pancreatic trauma patients were divided into two groups according to the interval between trauma and endoscopic retrograde pancreatography (ERP). The clinical and laboratory findings, CT and ERP results were described. The treatment modality and its clinical outcome were assessed according to ERP findings. RESULTS: The pancreatic duct was injured in 14 of the 23 trauma patients: 11 MPD injuries and 3 branching duct injuries. CT scan correctly predicted the MPD injury in only 6 (54.5%) of the 11 patients, whereas ERP correctly demonstrated the origin and the degree of pancreatic duct injury in all patients. Through contrast leakage from the MPD into peritoneal cavity, ERP confirmed an MPD injury in 8 patients and they underwent surgical exploration. Three patients who showed parenchymal leakage from branching duct recovered with conservative treatment. Transpapillary pancreatic stents were successfully inserted into the distrupted MPD in 3 patients who showed that the contrast leakage was confined to the pancreatic parenchyme and they achieved complete resolution of the pancreatic leaks after a 3-month follow-up period. The late ERP group (>72 hours after trauma) had a significantly higher pancreas associated complication rate and a tendency to a longer hospital stay than the early ERP group. CONCLUSIONS: Early ERP is the most useful tool for demonstrating the presence of MPD injury as well as planning the optimal treatment modality according to the degree of pancreatic duct injury.

Effectiveness of Embolization for Management of Hemoptysis in Pulmonary Tuberculosis: Comparison of Chest Radiographic Study and Angiography

PURPOSE: To compare the effectiveness of embolization of the bronchial artery embolization for the management of hemoptysis in pulmonary tuberculosis cases with the severity of lung parenchymal injury and pleural infiltration, as seen on plain chest radiographs, and with the findings of angiography of the bronchial artery. MATERIALS AND METHODS: Among 265 patients with hemoptysis due to pulmonary tuberculosis, the findings of plain chest radiography and angiography of the bronchial artery were comparatively analyzed in the 206 for whom the results of follow up were available. The chest radiographic findings were lassified as follows: Type I refers to simple pulmonary tuberculosis; Type II includes cases in which pulmonary tuberculosis is complicated by bronchiectasis, aspergillosis, or cavitation; Type III is either Types I or II accompanied by pleural infiltrates limited to the lung apex, and Type IV includes cases in which pleural infiltrates have extended beyond the apex in the whole of the lung. Bronchial angiographic findings were divided into four groups : Group I consists of cases which show abnormalities of only the bronchial artery; Group II includes those in which abnormalities are seen in the bronchial artery and either the internal mammary or an ntercostal artery; Group III comprises cases which belong to Group I or II and in which a branch of the subclavian artery is abnormal, and Group IV includes those in which abnormalities occur in at least two branches of the subclavian artery, or there is direct visualization of hypervascularity of this vessel. The initial post-embolic hemostatic effect and the results of follow up were studied over a six-month period. RESULTS: As compared with simple pulmonary tuberculosis (Type I), we found that as the severity of pleural infiltration and complications revealed by plain chest radiographs increased (Type II, III, IV), so did the severity of the manifestation of systemic collateral arteries other than the bronchial artery, as depicted by increase on bronchial angiography. Early post-embolic hemostasis occurred in 96% of Type-I cases (47/49), 82% of Type II (36/44), 70% of Type III (28/40), and 55% of Type IV (40/73). The average success rate was 74% (151/205). During the six month follow-up period, continued hemostasis was found in 80% of Type-I patients (36/45), 75% of Type II (30/40), 59% of Type III (20/34), and 48% of Type IV (20/42). The average long-term hemostasis rate was 66% (106/161). CONCLUSION: Bronchial angiography shows that in systemic collateral arteries circulation increases very substantially, and in cases in which plain chest radiographs depict extensive pleural infiltration or complications associated with pulmonary tuberculosis, it is therefore difficult to expect good hemostatic results after embolization. In such instances we thus recommend aggressive treatment such as surgical intervention.

Surface Modification of Stent Material: Experimental Study of Adhesion and Migration of Human AorticEndothelial Cells on Stent Material

PURPOSE: To evaluate the relative adhesion and migration rate of cultured human aortic endothelial cells onto modified stent material in vitro. MATERIALS AND METHODS: Flat 1 x 1cm square, stainless steel 316 L pieces(600 micrometer thick) were initially glow dis-charged to increase the polarity of the metal and were coated with 1 %polyhydroxyethylmethacrylate to which two different amino acid peptide sequences (GRGDY, GREDVY) were covalentlylinked via an amide to an amino-terminus, thus providing a known orientation of these covalently bound peptides.To stimulate implantation of a stent onto the intact arterial wall, human aortic endothelial cells were seeded andgrown to confluence on thick, firm collagen gel. The peptide coated steel pieces were then implanted on thisendothe-lialized surface and migration of HAEC to the surface was monitored and measured for ten days. The contactangle of steel was measured before and after glow-discharge treatment. RESULTS: Our results indicate that themigration and adhesion rate of HAEC to surfaces bearing either GRGDY or GREDVY adhesive peptide sequences wassignificantly higher than that of uncoated stainless steel. The contact angles of glow-discharged steel (eitherpositive or negative charge) were significantly lower, and this in-dicates the increased wettability of steel. Furthermore, migration to a GREDVY-coated surface was greater than to one coated with GRGDY. CONCLUSION: Theseresults indicate that a specific peptide sequence (GREDVY), together with positive glow-discharge treatment ofsteel can selectively enhance endothelial cell migration to metallic stent material.

Arterial Embolization for Management of Hemoptysis in Pulmonary Tuberculosis: Factors of Rebleeding

PURPOSE: To evaluate the effectiveness of arterial embolization in reducing hemoptysis in pulmonary tuberculosis, and rebleeding factors after embolization. MATERIALS AND METHODS: Fifty-nine patients with massiveor recurrent hemoptysis from pulmonary tuberculosis were underwent percutaneous transcatheter embolotherapy and thirteen were subsequentyly operated on. In 46 patients, we retrospectively analyzed on plain chest PA the extent of pulmonary tuberculosis lesions, the period from initial diagnosis to embolization, and angiographic findings. the extent of lesions shown on plain chest PA were classified into minimal, moderately advanced, and far advanced. If there was no evidence of rebleeding after the first embolization, this was regarded as initial success in thecontrol of hemoptysis. Angiographic findings were classified into hypervascularity, shunt, aneurysmal dilatation,and extravasation. Using the chi-square test, differences in these findings between rebleeding and non-rebleeding cases were analysed. RESULTS: Immediate control of hemoptysis was achieved in 27 (58.7%) of 46 patients. Hemoptysis recurred in 19 (41.3%) of 46 patients followed up. Rebleeding cases showed more nonbronchial systemiccollateral vessels and shunt than non-rebleeding cases (p<0.05). More advanced lesions of pulmonary tuberculosison plain chest PA showed an increased rebleeding rate after embolization, but this was not statistically significant There was no correlation between the period from initial diabnosis of pulmonary tuberculosis to embolization and the rate of rebleeding. But the longer the period, the greater the number of nonbronchial systemic collateral vessels. CONCLUSION: In cases with more advanced lesions of pulmonary tuberculosis on plainchest PA and a long period from initial diagnosis of pulmonary tuberculosis to embolization, angiographic findings showed numerous nonbronchial systemic collateral vessels but increases in the rebleeding rate were statistically not significant. The greater the number of nonbronchial systemic collateral vessels and shunt, the higher there bleeding rate after embolization.

Contrast Enhancement Patterns of Hepatic Masses using Three Phase Spiral CT

PURPOSE: To compare the contrast enhancement patterns of hepatocellular carcinomas(HCCs), hemangiomas, and metastases on three-phase images with spiral CT for differential diagnosis. MATERIALS AND METHODS: Three-phasespiral CT scan was performed in 73 patients with hepatic masses. CT scanning was performed with a table speed of 10mm/sec, section thickness of 10mm, and a reconstruction interval of 5mm, 100-150ml of contrast medium was injected intravenously with an automatic injector at a rate of 2-3mL/sec. CT scans were obtained at 30, 70 and 180 seconds after the start of contrast material injection. RESULTS: The enhancement patterns of 136 lesions in 53 patients with HCCs were as follows : 47 lesions(35%) were totally high and 55(40%) were mixed in the early phase ;30 lesions(22%) were mixed and 66(49%) were totally low in the portal phase ; and 105 lesions(78%) were totally low in the delayed phase. In hemangiomas of 23 lesions in 15 patients, 7 lesions(30%) were peripherally high and11(48%) were totally low in the arterial phase ; 4 lesions(17%) were totally high and 12(53%) were peripherally high in the portal phase ; 10 lesions(42%) were totally high and 4(18%) were peripherally high in the deayed phase. In metastatic liver mali gnancies of 42 lesions in 5 patients, 13 lesions(31%) were peripherally high and 22(52%) were totally low in the arterial phase ; 32 lesions(77%) were totally low in the portal phase, and 35(83%)were totally low in the delayed phase. CONCLUSION: Three-phase spiral CT scanning is a useful diagnostic methodin the differential diagnosis of hepatic masses including HCCs, hemangiomas, and hepatic metastases.

CT Findings of Small Bowel Rupture after Abdominal Trauma

PURPOSE: The accuracy of CT in the detection of injuries of the solid visceral organ is well established, but the value of CT in diagnosing small bowel rupture after abdominal trauma is controversal. This study was conducted to ascertain CT finding of small bowel rupture result from abdominal trauma. MATERIALS AND METHODS: A retrospective analysis of preoperative abdominal CT findings in 40 patients was performed. Small bowel rupture was confirmed by surgery. Precontrast and postcontrast enhanced CT images were obtained in all patients. RESULTS: Diagnostic findings of small bowel rupture including pneumoperitoneum or retroperitoneal air, discontinuity of the bowel wall and extravasation of oral contrast materials were observed in 33 cases(83%). Intraperitoneal or retroperitoneal free air was seen in 31 cases(78%) and intraperitoneal or retroperitoneal free fluid collection was seen in 38 patients(95%). Small bowel wall was thickened in 31 cases(78%), bowel wall was enhanced in 12 cases(30%) and bowel wall discontinuity and extravasation of oral contrast material was seen in 5 cases, respectively. CONCLUSION: The CT scan is sensitive and effective modality for evaluation of small bowel rupture after abdominal trauma, because of high detectability of diagnostic and suggestive CT findings.

Gallbladder carcinoma: Regional lymph nodes metastases on CT scan

CT scans of 23 patients with gallbladder carcinoma were retropectively reviewed to determine the incidence of lymphatic spread and to access the pattern of regional lymph node metastases. The lymphatic spread were noted in 74%(17/23). The involved patterns of regional lymph node metastases were nodes of porta hepatis 65%, portocaval nodes 41%, superior pancreaticoduodenal nodes 47%, posterior pancreaticoduodenal nodes 59%, nodes around the celiac trunk 35%, nodes around the superior mesenteric artery 29% and paraaortic nodes 35%. The findings suggested that the pattern of regional lumph node metastases in gallbladder carcinoma occurred along the normal lymphatic pathway of the gallbladder.

Gallbladder carcinoma: Regional lymph nodes metastases on CT scan

CT scans of 23 patients with gallbladder carcinoma were retropectively reviewed to determine the incidence of lymphatic spread and to access the pattern of regional lymph node metastases. The lymphatic spread were noted in 74%(17/23). The involved patterns of regional lymph node metastases were nodes of porta hepatis 65%, portocaval nodes 41%, superior pancreaticoduodenal nodes 47%, posterior pancreaticoduodenal nodes 59%, nodes around the celiac trunk 35%, nodes around the superior mesenteric artery 29% and paraaortic nodes 35%. The findings suggested that the pattern of regional lumph node metastases in gallbladder carcinoma occurred along the normal lymphatic pathway of the gallbladder.

MRI findings of castleman disease (Giant lymph node hyperplasia): case report

Castleman disease is a relatively rare disease of differential diagnostic interest in patients with lymphadenophathy. The etiology and pathogenesis of the Castleman disease are still not elucidated and the MRI findings of disease has not yet been reported. Two patients with Castleman disease studied by MRI are presented: one case presented with a localized anterior mediastinal mass and the other case, with a neck mass. The lesions were characterized by relatively high signal intensities on both T1 and T2 weighted images in both cases, and significant degree of enhancement was seen in the cervical Castleman disease.

MRI features of right atrial angiosarcoma: a case report

Primary tumors of the heart are rare, and one-third of them are malignant. The most common malignant intracardiac tumor is angiosarcoma, which usually involves right atrium. MR features in one patients with right atrial angiosarcoma is presented and the literature briefly reviewed. Angiosarcoma demonstrated slightly heterogeneous intermediate signal intensity on T1-weighted images, high signal intensity on T2-weighted images and higher signal intensity on Gd-DTPA enhanced images. MRI provided more information regarding the extent of the tumor than 2D echocardiography or CT.

Two cases of Wilson disease: MRI findings

Wilson disease is a rare genetic disorder of copper metabolism. Although CT findings suggest the disease when CNS pathologic changes are advanced, characteristic brain MR findings are reported to manifest early in the disease. The authors experienced two cases of Wilson disease of the brain and report the MR findings.

Radiological evaluation of G-I tract diverticulum in Korean

We reviewed 887 cases of esohagogram, 8863 cases of UGI series, 174 cases of small bowel series and 1926 casesof double contrast barium enema performed at the department of Radiology, Wonju College of Medicine from Jan. 1982 to Dec. 1984 to analyzed diverticula disease pattern of the GI tract in Korean. The results were as follows: 1.Esophageal diverticula The incidence was 3.27% and the sex ratio of male to female was 2.22:1 Age distribution wasrelatively even and most common in 5th decade. Most of them showed single in number, above 6mm sized and common inmiddle one third of both lateral side of esophagus. 2. Stomach diverticula The incidence was 0.07% and the sexratio of male to female was equal. Multiplicity was single in all cases. Most of them were above 11mm sized andcommon in gastric fundic area of greater curvature site of stomach. 3. Duodenal diverticula The incidence was1.51% and relatively even distribution in sex and age and common in after 5th decade. Most of them showed singlein number, 11-30mm sized and common in medial margin of 2nd portion of duodenum. 4. Colonic diverticula Theincidence was 2.34% and predominant in male and common in 5th. and 6th. decade. Most of them showed single innumber, below 5mm sized and common in right sided colon.