Useful Ultrasound Findings of Pediatric Patients with Equivocal Results of Appendicitis: Analysis Based on a Structured Report Form

Purpose@#To identify the features that can be used for differentiating appendicitis from non-appendicitis in pediatric patients with equivocal ultrasound (US) results. @*Materials and Methods@#A total of 53 pediatric patients (≤ 18 years old) with equivocal results on US examination for suspected appendicitis between November 2012 and October 2017 were included. US evaluation was conducted based on information retrieved from a predefined structured report form. Then, the likelihood of appendicitis was prospectively classified into five categories. The equivocal results were considered as grade 3 (indeterminate) and grade 4 (probably appendicitis). @*Results@#Of the 53 patients, 25 (47.2%) and 28 (52.8%) were classified into grade 3 and 4 groups, respectively. Among the individual US findings, increased vascularity of the appendiceal wall and peri-appendiceal fat infiltration were independent findings associated with the diagnosis of appendicitis (p = 0.005, p = 0.045, respectively) in the multivariate logistic regression analysis and showed the highest diagnostic accuracy (69.8% and 62.3%, respectively). @*Conclusion@#Increased vascularity within the appendiceal wall and peri-appendiceal fat infiltration were significant predictors of appendicitis in patients with equivocal US findings.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Using 2-mSv Appendiceal CT in Usual Practice for Adolescents and Young Adults: Willingness Survey of 579 Radiologists, Emergency Physicians, and Surgeons from 20 Hospitals

Synchronous Cancers of Hepatic Angiosarcoma and Gallbladder Adenocarcinoma, Mimicking Gallbladder Cancer with Hepatic Invasion: a Case Report

Synchronous primary cancers in the liver and gallbladder have been rarely reported.We report a case of synchronous cancers of hepatic angiosarcoma and gallbladder adenocarcinoma, mimicking gallbladder cancer with hepatic invasion. Additionally, the clinical implications, the radiologic features, and the diagnostic difficulties are further discussed.

Structured Reporting versus Free-Text Reporting for Appendiceal Computed Tomography in Adolescents and Young Adults: Preference Survey of 594 Referring Physicians, Surgeons, and Radiologists from 20 Hospitals

OBJECTIVE: To survey care providers' preference between structured reporting (SR) and free-text reporting (FTR) for appendiceal computed tomography (CT) in adolescents and young adults. MATERIALS AND METHODS: An ethical committee approved this prospective study. The requirement for participant consent was waived. We distributed the Likert scale-based SR form delivering the likelihood of appendicitis across 20 hospitals through a large clinical trial. In the final phase of the trial, we invited 706 potential care providers to participate in an online survey. The survey questions included usefulness in patient management, communicating the likelihood of appendicitis, convenience, style and format, and overall preference. Logistic regression analysis was performed for the overall preference. Three months after the completion of the trial, we checked if the use of the SR was sustained. RESULTS: Responses were analyzed from 594 participants (175 attendings and 419 trainees; 225 radiologists, 207 emergency physicians, and 162 surgeons). For each question, 47.3–64.8% of the participants preferred SR, 13.1–32.7% preferred FTR, and the remaining had no preference. The overall preference varied considerably across the hospitals, but slightly across the departments or job positions. The overall preference for SR over FTR was significantly associated with attendings, SR experience for appendiceal CT, hospitals with small appendectomy volume, and hospitals enrolling more patients in the trial. Five hospitals continued using the SR in usual care after the trial. CONCLUSION: Overall, the care providers preferred SR to FTR. Further investigation into the sustained use of the SR is needed.

Hepatic Pseudolymphoma Mimicking a Hypervascular Tumor: A Case Report

Hepatic pseudolymphoma is a rare benign liver mass that is characterized by proliferation of non-neoplastic lymphocytes extranodally. To the best of our knowledge, only 46 cases have been reported in the English literature. We described the case of a 75-year-old woman with hepatic pseudolymphoma mimicking a hypervascular tumor. After the histological confirmation of the rectal neuroendocrine tumor, CT scan revealed a 1.0 cm-sized, poorly-defined and low-density nodule in the liver. On MRI, the hepatic nodule showed an arterial enhancement and a low-signal intensity on the hepatobiliary phase. On diffusion-weighted imaging, the hepatic nodule showed a high signal intensity on a high b-value. On fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, it revealed a high standardized uptake value nodule. The US showed the hypoechoic nodule and the US-guided biopsy confirmed the hepatic pseudolymphoma.

Impact of high-grade obstruction on outcomes in patients with appendiceal inflammatory masses managed by nonoperative treatment

PURPOSE: To retrospectively assess the impact of high-grade obstructions identified on initial CT on outcomes of patients with appendiceal inflammatory masses managed by nonoperative treatment. METHODS: Institutional Review Boards approved this retrospective study and informed consent was waived. Included were 52 consecutive patients diagnosed with appendiceal inflammatory masses by CT scan and managed by nonoperative treatment. The main outcome measure was treatment failure and secondary outcomes were complications and initial and total hospital stay. Patient demographics, inflammatory markers, and CT findings for presence of an appendiceal inflammatory mass and high-grade obstruction were assessed. Patients with and without high-grade obstruction were compared for patient characteristics and outcomes using Fisher exact test and Student t-test. RESULTS: Among 52 patients, 14 (27%) had high-grade obstruction on CT examination at presentation. No significant differences were observed in patient characteristics (P > 0.05), treatment failure (P = 0.33), complications (P = 0.29), or initial (P = 0.73) or total (P = 0.72) hospitalization between patients with and without high-grade obstruction. CONCLUSION: For patients who were managed by nonoperative treatment for appendiceal inflammatory masses, the presence of high-grade obstruction identified on initial CT scan did not significantly affect outcomes of treatment failure, complications, and initial and total hospitalization.

Meaningful standard of reference for appendiceal perforation: pathology, surgery, or both?

PURPOSE: This retrospective study was aimed to determine if appendiceal perforation identified pathologically but not surgically is clinically meaningful. METHODS: The study consists of 2 parts. First, we reviewed 74 studies addressing appendiceal perforation published in 2012 and 2013. Second, in a cross-sectional study, we classified 1,438 adolescents and adults (mean age, 29.3 ± 8.4 years; 785 men) with confirmed appendicitis as “nonperforation” (n = 1,083, group 1), “pathologically-identified perforation” (n = 55, group 2), “surgically-identified perforation” (n = 202, group 3), or “pathologically- and surgically-identified perforation” (n = 98, group 4). The 4 groups were compared for the frequency of laparoscopic appendectomy and the length of hospital stay using multivariable logistic regression analyses. RESULTS: The reference standard for appendiceal perforation was frequently missing or inconsistent in the previous studies. Laparoscopic appendectomies were less frequent in groups 3 (52.5%, P = 0.001) and 4 (65%, P = 0.040) than in group 1 (70.7%), while group 2 (73%, P = 0.125) did not significantly differ from group 1. Median hospital stays were 2.9, 3.0, 5.1, and 6.0 days for groups 1–4, respectively. Prolonged hospital stay (≥3.7 days) was more frequent in groups 3 (77.7%, P < 0.001) and 4 (89%, P < 0.001) than in group 1 (23.4%), while group 2 (35%, P = 0.070) did not significantly differ from group 1. CONCLUSION: We recommend using surgical rather than pathologic findings as the reference standard for the presence of appendiceal perforation in future investigations.

Primary Diffuse Large B-Cell Lymphoma of the Seminal Vesicle: a Case Report

Primary diffuse large B-cell lymphoma of the seminal vesicle is an extremely rare disorder, with only two cases reported in the English literature. Here, we present imaging findings of a case of primary diffuse large B-cell lymphoma of the seminal vesicle. On transrectal ultrasonography, the mass presented as a 3.0-cm-sized heterogeneous, hypoechoic lesion in the right seminal vesicle. Computed tomography (CT) revealed a mass with rim-like enhancement in the right seminal vesicle. On magnetic resonance imaging (MRI), the tumor showed iso-signal intensity on T1-weighted images and heterogeneously intermediate-high signal intensity on T2-weighted images. The tumor showed rim-like and progressive enhancement with non-enhancing portion on dynamic scanning. Diffusion restriction was observed in the mass. On fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET/CT) imaging, a high standardized uptake value (maxSUV, 23.5) by the tumor was noted exclusively in the right seminal vesicle.

Signet-ring cell carcinoma of the appendix: a case report with an emphasis on sonographic findings

In this report, we present a rare case of primary signet-ring cell carcinoma of the appendix in a 51-year-old woman with right lower quadrant pain. Since non-specific concentric appendiceal wall thickening was found in a radiologic evaluation, it was misdiagnosed as non-tumorous appendicitis. An in-depth examination of the correlation between sonographic and histopathologic findings demonstrated that a single markedly thickened hypoechoic layer was well correlated with the diffuse infiltration of tumor cells in both the submucosal and muscle layers. If this sonographic finding is observed in certain clinical settings, such as potential ovarian and peritoneal metastasis, submucosal infiltrative tumors, including signet-ring cell carcinoma, should be considered in the differential diagnosis.

Supradiaphragmatic Liver Confirmed by a Hepatocyte-specific Contrast Agent (Gd-EOB-DTPA): A Case Report

Supradiaphragmatic liver is a rare condition. Establishing an accurate preoperative diagnosis is difficult. Operative exploration is necessary to differentiate this lesion from intrathoracic masses, such as a pleural based tumor, diaphragmatic tumor and peripheral lung tumor. However, with the aid of the hepatocyte-specific magnetic resonance imaging contrast agent, gadoxetic acid (Gd-EOB-DTPA), functional hepatocytes in the lesion can be identified in the hepatobiliary phase, potentially allowing an accurate and non-invasive diagnosis. We report a case of supradiaphragmatic liver diagnosed by Gd-EOB-DTPA-enhanced magnetic resonance imaging.

The Efficacy and Safety of Cordyceps militaris in Korean Adults Who Have Mild Liver Dysfunction

PURPOSE: The aim of this study is to determine the efficacy and safety of Cordyceps militaris in Korean adults with mild liver dysfunction. C. militaris is a mushroom traditionally used for several clinical purposes in East Asian territory, including China, and has been found to be effective in improving liver function through animal studies. METHODS: The C. militaris group was administered 1.5 g/day of C. militaris (2 capsules per dose, twice per day) and the placebo group was administered the same volume of placebo. Laboratory test (white blood cell, hemoglobin, platelet, aspartate aminotransferase, alanine aminotransferase, gamma glutamyltranspeptidase, lactic dehydrogenase, alkaline phosphatase, total bilirubin, blood urea nitrogen, creatinine), liver computed tomography (CT) were performed, and visual analogue scale score for subjective symptoms and fatigue severity scale were measured. RESULTS: In analysis of the liver CT scan at 8 weeks after administration compared to baseline, the mean ratio of change of Hounsfield unit of 8 segments of liver increased by an average of 21.43%+/-45.11% in the C. militaris group and 9.64%+/-11.41% in the placebo group. Others showed no statistically significant inter-group difference. CONCLUSION: C. militaris extract was used safely as a functional food in patients with mild liver dysfunction, and is expected to protect against progression of fatty liver or cirrhosis caused by suppression of lipid accumulation in hepatocytes.

A Case of an Abdominal Wall Abscess Associated with Spilled Gallstones: Imaging Findings and Clinical Significance

Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gall stones for the last 20 years. The spillage of stones is reported in up to one-third of all LCs but clinical squeals caused by dropped gallstones are uncommon. We recently observed a patient with late abdominal wall abscess formation as a result of dropped gall stones after LC, who in the end, underwent open surgery because the medical therapy including antibiotics and percutaneous catheter drainage was not fully effective.

Iatrogenic Esophageal Submucosal Dissection: A Case Report / 대한소화기내시경학회지

Nasogastric tube insertion is a routine clinical procedure for nutritional support, gastric aspiration and decompression. Although it is generally a safe procedure, complication rates range from 0.3~8%. Submucosal esophageal dissection is a rare disorder caused by mucosal tearing and bleeding between the mucosal and muscular layers of the esophagus, leading to their separation. We report a case of submucosal esophageal dissection secondary to the accidental iatrogenic intramural insertion of a nasogastric tube.

Clinical Experiences of Fitz-Hugh-Curtis Syndrome

PURPOSE: Fitz-Hugh-Curtis (FHC) syndrome has been described as perihepatitis associated with pelvic inflammatory disease during surgery. Recently, on computerized tomography a linear enhancement of the liver capsule was detected in a patient with FHC syndrome. We studied to evaluate the clinical course of the disease. METHODS: Sixteen patients diagnosed with FHC syndrome from CT findings were retrospectively studied from April, 2006 to June, 2008. RESULTS: The mean age of the patients was 25.9 (19~35) years and mean duration of abdominal pain was 3.9 (1~14) days. The most common complaint was right upper quadrant area pain (11 cases, 68.8%). 12 patients showed leukocytosis and all the patients had elevated serum C-reative protein levels. All the patients had normal liver function. Among the 9 patients which had polymerase chain reaction test for sexually transmitted disease (Chlamydia trachomatis, Ureaplasma urealyticum, Neisseria gonorrheae, Mycoplasma hominis), all showed more than one positive results (Chlamydia trachomatis 6 cases, Ureaplasma urealyticum 6 cases, Mycoplasma hominis 2 cases). On simple abdomen X-ray, 7 cases (43.8%) showed paralytic ileus. 14 cases received only antibiotic treatment, but 1 case had to take operation (laparoscopic-assisted adhesiolysis) due to constant abdominal pain and prolonged ileus. CONCLUSION: It is important to rule out FHC syndrome by using CT findings, especially young women with right upper abdominal pain and PID. Usually, FHC syndrome can be treated easily with proper antibiotics.

Percutaneous Vertebroplasty in Osteoporotic Vertebral Body Compression Fracture

PURPOSE: To determine the clinical efficacy of percutaneous vertebroplasty in cases of painful and medically intractable osteoporotic vertebral compression fracture. MATERIALS AND METHODS: Ninety-eight patients (20 men and 78 women; mean age, 69 years) underwent 122 per-cutaneous vertebroplasty procedures for the treatment of osteoporotic vertical compression fracture. For the evaluation of bone mass, bone densitometry was performed in 45 patients, and to assess the recent evolution of the fracture, all 98 underwent MRI. Percutaneous vertebroplasty involves percutaneous transpedicular puncture of the involved vertebrae followed by the injection of a Polymethylmethacrylate(PMMA)-Barium mixture into the vertebral body. To assess leakage of the mixture into the epidural tissue, neural foramina, venous plexus and paravertebral tissue, we then immediately obtained a computerized tomographic (CT) scan, assessing the clinical efficacy of the procedure on the basis of time required for pain relief (defined as more than 60% reduction of initial pain), and time required for ambulation without significant pain. RESULTS: Percutaneous vertebroplasty was successful in all patients. Pain relief was accomplished within 1-5(mean, 1.8) days and early ambulation without significant pain was possible within 2 -15 (mean, 3.3) days. Post-procedural CT scanning revealed leakage of the PMMA-barium mixture into Paravertebral tissue(n=41), the paravertebral venous plexus (n=34) and epidural tissue (n=4). No neural foraminal leakage was identified, and no procedure-related complication requiring surgical treatment occurred. CONCLUSION: Percutaneous vertebroplasty is an effective new interventional procedure for the treatment of osteoporotic vertebral compression fracture. It relieves pain, provides early mobilization, and strengthens involved vertebral bodies.