Intraperitoneal Hemorrhage Due to Spontaneous Rupture of Hepatocellular Carcinoma: Comparisons of Tranarterial Oily Chemoembolization and Simple Embolization with Gelfoam

PURPOSE: To compare the safety and effectiveness of transarterial oily chemoembolization (TOCE) and transar-terial embolization (TAE) with Gelfoam in cases of ruptured hepatocellular carcinoma (HCC), and to describe the most important prognostic factors involved in emergency embolization. MATERIALS AND METHODS: Forty-two consecutive patients with spontaneously ruptured HCC underwent emergency TOCE (n = 22) or TGE (n = 20). In the TOCE group, Lipiodol (3 -10 cc), Adriamycin (20 -50 mg), and Mitomycin (2 -10 mg) were used, and these were followed by blockade of the hepatic arterial flow with gelatin sponge particles. In the TAE group, patients underwent only Gelfoam embolization. Using the Kaplan-Meier method, survival time from the time of embolization was estimated, and to analyze prognostic factors, Cox 's proportional hazard regression model was used. RESULTS: Successful hemostasis was achieved in 41 patients (97.6%). Mean survival time was 201 and 246 days in the TOCE and TAE group, respectively, but the difference was not tatistically significant (p > 0.05). Five of the TOCE group (22.7%) and three of the TAE group (15.0%) died of hepatic failure. Analysis of the prognostic factors showed that portal vein involvement by the tumor was the most important factor influencing survival. CONCLUSION: Although TOCE and TAE effectively controlled hemorrhaging from a ruptured HCC, the procedures involve a high risk of hepatic failure. Their goal should, therefore, be solely to achieve hemostasis, and thus decrease parenchymal injury.

Fluoroscopically Guided Biopsy of Intrathoracic Lesions: Diagnostic Accuracy of Combined Method Including Automated Gun Biopsy and Fine Needle Aspiration

PURPOSE: The purpose of this study was to evaluate the usefulness of combined automated gun biopsy (AGB) and fine needle aspiration (FNA) in the diagnosis of lung lesions. MATERIALS AND METHODS: Lung lesions in 102 patients were aspirated consecutively using a 21-gauge fine needle and biopsied with an 18-gauge automated gun at intervals of 3 -5 minutes. Final diagnosis was based on the findings of surgery or clinical follow-up. RESULTS: In 50 patients with malignant lesions, diagnostic accuracy was 80% with AGB and 76% with FNA, but using the combined modality, the figure was 94%. In 52 patients with benign lesions, diagnostic accuracy was 54% with AGB and 50% with FNA; using the combined modality, 69 percent accuracy was achieved. For all lesions, the diagnostic accuracy of the combined modality was thus significantly higher than that of a single method (p<.05). The complications which occurred were pneumothorax in six cases (5.9%), chest tubing in two (0.2%) and minor hemoptysis in nine (8.8%). CONCLUSION: In the diagnosis of lung lesions, the combined use of AGB and FNA is safe and can increase diag-nostic accuracy.

Excretory MR Urography Using Breathhold Three-dimensional FISP: Comparison with MR Urography Using HASTE Technique

PURPOSE: To compare the usefulness of gadolinium-enhanced excretory MR urography using breath-hold three-dimensional fast imaging with steady state precession (3-D FISP) with conventional MR urography using the half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence in the evaluation of obstructive uropathy. MATERIALS AND METHODS: Twenty-three patients in whom ultrasonography (US) and/or intravenous urography(IVU) revealed signs of urinary obstruction were enrolled in this study. Fifteen were men and eight were women, and their mean age was 54 (range, 21 -80) years. All MR images were obtained using a 1.5-T MR unit. MR urography using the HASTE technique (MRU) and gadolinium-enhanced excretory MR urography using the 3D-FISP technique were performed, and in all cases, reconstructions involved maximum intensity projection. For contrast-enhanced MR urography (CEMRU), images were obtained 3, 5, 20, and 30 minutes after the administration of intravenous contrast media, and for selected cases, additional images were obtained until 24 hours after contrast media injection. For qualitative analysis, two experienced radiologists compared CEMRU and MRU in terms of their diagnostic value as regards the level and cause of urinary obstruction, and morphologic accuracy. In addition, signal to noise ratio (SNR) and contrast to noise ratio (CNR) of the urinary tract at each anatomic level were quantitatively analysed. RESULTS: Quantitative analysis showed that in terms of SNR and CNR of the urinary tract at the level of the mid and distal ureter, CEMRU using 3-D FISP was better than MRU using HASTE (p<0.05). Qualitative analysis indicated that for the depiction of the whole length of normal ureter, and detection of the level of obstruction, anatomic anomalies and intrinsic tumors, 3-D FISP was superior to HASTE. There was, however, no difference between these two modalities in the diagnosis of ureteral stone and the degree of hydronephrosis. In addition, 3-D FISP was better than HASTE for the assessment of filling defect, but the difference was not statistically significant. CONCLUSION: Breath hold 3-D FISP is a very valuable tool in the evaluation of obstructive uropathy. It not only depicts very clearly the anatomy of the urinary tract system, but also provides qualitative information on renal function. We believe that CEMRU using 3-D FISP is a valuable diagnostic approach which can be added to those already available for the workup of obstructive uropathy.

Superparamagnetic Iron Oxide Enhanced MR Imaging: Influence of Hepatic Dysfunction in Cirrhotic Patients

PURPOSE: To determine the influence of liver dysfunction on the detection of focal hepatic nodules, and to investigate the loss of signal intensity of hepatic parenchyma occurring after superparamagnetic iron oxide (S-PIO)-induced contrast enhancement in patients with liver cirrhosis. MATERIALS AND METHODS: In 68 patients with liver cirrhosis, we evaluated MR images before and after the administration of SPIO. Clinical information and laboratory data indicated that the liver was normal in ten patients (nine hemangiomas and one hepatic cyst), while Child's A was diagnosed in 25 cases [22 of which were hepatocellular carcinomas (HCCs)], Child's B in 15 (11 HCCs), and Child's C in 18 (10 HCCs). Before and after SPIO administration, conventional T2-weighted spin-echo, respiratory-triggered T2-weighted turbo spin-echo, and breathhold T2-weighted turbo spin-echo images were obtained. After the administration of SPIO, degrees of liver dysfunction and laboratory data were correlated with reductions in signal intensity of the liver, and, in addition, the state of hepatic dysfunction was corelated with inhomogeneous parenchymal change and lesion conspicuity. RESULTS: After the administration of SPIO, percentage signal loss in liver parenchyma was significantly higher on conventional T2-weighted spin-echo images than on T2-weighted turbo spin-echo and breathhold T2-weighted turbo spin-echo (p 0.05). CONCLUSION: SPIO uptake by hepatic parenchyma correlated closely with Child's degree of liver cirrhosis and laboratory data such as albumin and total bilirubin levels, and prothrombin time. In the Child's B and Child's C group, SPIO-enhanced MR imaging revealed inhomogeneous hepatic parenchyma, but the pattern observed did not affect the detection of hepatic nodules.

Diagnosis of Acute Appendicitis in the Community Hospital: Validity and Usefulness of Sonography

PURPOSE: To compare the accuracy of initial clinical diagnosis with that of ultrasonography(US) in diagnosingappendicitis and to determine its effect on the care of patients in a community hospital. MATERIALS AND METHODS: One hundred and fifty patients with suspected appendicitis were prospectively examined with US. Prior to this,they had been divided into three groups on the basis of clinical judgement regarding diagnosis and their treatmentplan: Group I : high suspicion (probability > 75%) - urgent surgery indicated ; Group II : equivocal (probability25 - 75%) - in hospital for observation, Group III : very unlikely (probability < 25%)- discharge without furthertesting. In order to determine the validity of these groupings, we calculated the sensitivity, specificity, andaccuracy of sonographic examination, and the likelihood ratios of initial clinical diagnosis. RESULTS: USrevealed a sensitivity of 92%, specificity of 90%, positive predictive value of 95%, negative predictive value of85% and overall accuracy of 91%. The initial clinical impression showed a sensitivity of 70%, specificity of 82%,positive predictive value of 89%, negative predictive value of 58%, and overall accuracy of 74%. Among 79 patientsin the high clinical risk category (Group I), the sensitivity, specificity and accuracy of US were 96%, 89%, and95%, respectively. Among 71 patients in the low- and intermediate- clinical categories (Groups II and III), thesensitivity, specificity, and accuracy of US were 83%, 90%, and 87%. The likelihood ratios were 3.9 in Group I,0.52 in Group II, and 0.15 in Group III. In 32 of 150 patients (21%), the findings of US led to changes in theproposed management plan. CONCLUSION: The overall accuracy of US in the diagnosis of appendicitis wasstatistically superior to that of the clinician's initial impression (p<0.05). In addition, US played an importantrole in making decisions regarding the treatment plan.

Intracavitary Urokinase in the Treatment of Multiloculated Liver Abscess: A case report

Radiologically-guided percutaneous abscess drainage has been preferred as a therapeutic modality for hepatic abscesses, though where these have been septated or multilocular, its success rate has often been low. The results of several clinical and in vitro studies have recently suggested that in difficult cases, where abscesses occur in the peritoneal cavity and retroperitoneum, or multiloculated empyema of the thorax, urokinase may be useful. To our knowledge, however, there has been only one report of a case of liver abscess in which intracavitary urokinase was administered. The authors therefore report a case of multiseptated hepatic abscess occuring in a 53-year-man. Conventional percutaneous tube drainage failed, but the use of transcatheter intracavitary urokinase was successful. Diagnosis and continuing assessment involved a combination of ultrasound and CT scanning.

Percutaneous Cholecystostomy at the Community Hospital: Value Evaluation

PURPOSE: To assess the role of percutaneous cholecystostomy as a therapeutic maneuver in patients critically ill with acute cholecystitis in community hospitals. MATERIALS AND METHODS: Eighteen patients, 11 with suspected acute calculous cholecystits and seven with acute acalculous cholecystitis underwent emergency percutaneous cholecystostomy. All demonstrated a variety of high risk factors for cholecystectomy: liver cirrhosis (n=2), diabetes mellitus (n=3), cardiac disease (n=3), underlying malignancy (n=2), pulmonary dysfunction (n=1), septic cholangitis (n=5), and old age (n=2). All percutaneous cholecystostomies were performed with ultrasound guidance and preferably using the transhepatic route. RESULTS: All procedures but one were successful, and most cholecystostomies were performed within 5-20 minutes. Technical problems were as follows: guide-wire buckling during catheter insertion (n=2) and procedure failure (n=1). The only major problem was a case of localized bile peritonitis due to procedural failure, but a few minor complications were encountered: catheter dislodgment (n=3), and significant abdominal pain during the procedure (2). After successful cholecystostomy, a dramatic improvement in clinical condition was observed in 16 of 17 patients (94%) within 48 hours. Ten of 16 patients who responded to percutaneous cholecystostomy underwent elective cholecystectomy after the improvement of clinical symptoms, and the remaining six patients improved without other gallbladder interventions. CONCLUSION: Percutaneous cholecystostomy is not only an effective procedure for acute cholecystitis, but also has a definite role in the management of these high-risk patients in community hospitals.

CT Guided Celiac Plexus and Splanchnic Nerve Neurolysis: The Modified Anterior Approach

Since it was first described by Kappis, celiac plexus neurolysis (CPN) has been performed under fluoroscopic guidance by anesthetists or surgeons for the relief of intractable pain caused by upper abdominal malignancy. Recently, however, several groups have reported a computed tomography (CT)-guided technique that increased the safety of the blocking procedure and improved its results. The authors present a new technique CT-guided celiac plexus and splanchic nerve block, to be used simultaneously with a modified anterior approach. Using CT to guide needle tip placement, an anterior approach that permitted direct neurolysis of the celiac ganglia and splanchnic nerve was developed.

CT-Guided Celiac Plexus Block with Absolute Alcohol: the Anterior Approach

PURPOSE: To evaluate the safety and efficacy of CT-guided celiac plexus block (CPB) using an anterior approach, and to determine the role of CT in this procedure. MATERIALS AND METHODS: CPB was attempted in 15 patients (10 men and 5 women; mean age, 62.3 years) with intractable upper abdominal pain due to terminal malignancy of the pancreas, liver, bowel, and kidney. To permit an anterior approach, patients lied supine on the CT scan table during the procedure. One or two 21-guage needles were placed just anterior to the diaphragmatic crus at or between the levels of the celiac and superior mesenteric arteries and 10-40 ml of 99.9% alcohol was injected. Pain relief following the procedure was assessed and pain was graded on a visual analogue scale (VAS) from 0 to 10. RESULTS: There were no technical failures and no neurologic or hemorrhagic complications. Abdominal pain during alcohol injection occurred in all patients, and transient hypotension in three. One patient with recurrent cancer of the pancreatic head died of sepsis five days after the procedure; the cause of sepsis was difficult to determine, but there was thought to be a biliary source of infection. Two days after block, 13 of 15 procedures (86.7%) had produced at least partial pain relief ; in 12 patients, relief was good. With CT guidance, more directed positioning of the needle is possible, allowing alcohol to be deposited in specific ganglion areas. CONCLUSION: CT-guided celiac plexus block using an anterior approach was an easy and effective way of reducing intractable upper abdominal pain due to terminal malignancies. CT guidance allowed precise needle placement and a safer procedure.