Value of CT to predict surgically important bowel and/or mesenteric injury in blunt trauma: performance of a preliminary scoring system.

OBJECTIVES: To evaluate the performance of a computed tomography (CT) diagnostic score to predict surgical treatment for blunt bowel and/or mesentery injury (BBMI) in consecutive abdominal trauma. METHODS: This was a retrospective observational study of 805 consecutive abdominal traumas with 556 patients included and screened by an abdominal radiologist blinded to the patient outcome, to evaluate numerous CT findings and calculate their diagnostic performances. These CT findings were compared using univariate and multivariate analysis between patients who had a laparotomy-confirmed BBMI requiring surgical repair, and those without BBMI requiring surgery. A CT score was obtained with an internal bootstrap validation. RESULTS: Fifty-six patients (10.1 %) had BBMI requiring surgery. Nine CT signs were independently associated with BBMI requiring surgery and were used to develop a CT diagnostic score. The AUC of our model was 0.98 (95 % CI 0.96-100), with a ≥5 cut-off. Its diagnostic performance was determined by internal validation: sensitivity 91.1-100 %, specificity 85.7-97.6 %, positive predictive value 41.4-82.3 % and negative predictive value 98.9-100 %. Bowel wall discontinuity and mesenteric pneumoperitoneum had the strongest association with BBMI requiring surgery (OR = 128.9 and 140.5, respectively). CONCLUSION: We developed a reliable CT scoring system which is easy to implement and highly predictive of BBMI requiring surgery. KEY POINTS: • Finding of bowel wall discontinuity or mesenteric pneumoperitoneum indicates BBMI requiring surgery. • Arterial mesenteric vessel extravasation requires surgery when in association with other CT findings. • Our CT scoring system has excellent diagnostic performance in predicting BBMI requiring surgery.

Computed tomography findings of acute gastric volvulus.

PURPOSE: To assess the diagnostic performance of CT signs of gastric volvulus in both confirmed cases and control subjects. MATERIALS AND METHODS: We retrospectively reviewed CT findings in 10 patients with surgically confirmed acute gastric volvulus and 20 control subjects with gastric distension. Two radiologists independently evaluated CT images for risk factors of gastric volvulus, direct findings of gastric volvulus by assessing gastric dilatation, the presence of an antropyloric transition point, the respective position of the different stomach segments and of the greater and lesser curvatures, stenosis of the gastric segments through the oesophageal hiatus and for findings of gastric ischemia. The sensitivity and specificity of each finding were calculated. RESULTS: The most sensitive direct signs of gastric volvulus were an antropyloric transition point without any abnormality at the transition zone and the antrum at the same level or higher than the fundus. The presence of both these two findings as diagnostic criteria of gastric volvulus had 100% sensitivity and specificity for the diagnosis of gastric volvulus. There was no association between CT signs of ischemia and final bowel ischemia at pathology. CONCLUSION: CT is both highly sensitive and specific for diagnosing acute gastric volvulus. KEY POINTS: CT is highly reliable for diagnosing acute gastric volvulus with two findings. The two signs are gastropyloric transition zone and abnormal location of the antrum. This allows fast surgical management of this emergency.

Adhesive small-bowel obstruction: value of CT in identifying findings associated with the effectiveness of nonsurgical treatment.

PURPOSE: To identify computed tomographic (CT) findings that are associated with the effectiveness of nonsurgical treatment in patients with adhesive small-bowel obstruction ( SBO small-bowel obstruction ) that was initially treated medically. MATERIALS AND METHODS: The local institutional review board approved this retrospective study; the informed consent requirement was waived. Multi-detector row CT studies in 159 patients (64 women, 95 men; median age, 69 years) with adhesive SBO small-bowel obstruction that was initially treated medically were reviewed retrospectively and independently by two emergency radiologists to identify numerous CT findings that could be associated with the effectiveness of nonsurgical treatment. Results were compared according to the success or failure of nonsurgical treatment. Univariate statistical analyses were performed for qualitative and quantitative data, as appropriate, and each significant parameter was entered in a multivariate logistic regression analysis. The κ statistic and correlation coefficients were used to assess interobserver agreement, as appropriate. RESULTS: Nonsurgical treatment succeeded in 113 patients (71%) and failed in 46 patients (29%). At univariate analysis, an anterior parietal adhesion, a feces sign, and the lack of a beak sign were associated with successful nonsurgical treatment, whereas two beak signs or more, a whirl sign, a C- or U-shaped appearance of the bowel loop, and a high degree of obstruction were associated with nonsurgical treatment failure. At multivariate analysis, fewer than two beak signs and the presence of an anterior parietal adhesion were independent predictors of the effectiveness of nonsurgical treatment, with odds ratios of 0.27 and 0.11, respectively. CONCLUSION: The number of beak signs and the location of the transition zone in relation to the anterior peritoneal layer are independent signs associated with the success or failure of nonsurgical treatment.

Invasive breast carcinoma: influence of prognosis and patient-related factors on kinetic MR imaging characteristics.

PURPOSE: To retrospectively compare the kinetic magnetic resonance (MR) imaging characteristics of invasive breast carcinomas with both prognostic tumoral and patient-related parameters. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by the institutional review board, and informed consent was waived. From January 2008 to January 2011, 273 consecutive women (mean age, 55 years; range, 23-83 years) with invasive breast cancers who had undergone MR imaging were selected. The kinetic curves were retrospectively classified according to the Breast Imaging Reporting and Data System lexicon. Initial enhancement and maximal enhancement percentages, time to peak enhancement, and the signal enhancement ratio were calculated for each lesion. Kinetic characteristics were compared according to tumoral parameters (size, pathologic type, grade, hormone receptor status, and c-erbB-2 status) and patient parameters (menopausal status, personal history of breast carcinoma) by means of univariate and then multivariate analysis by using false-discovery-rate statistics. RESULTS: Lesions in menopausal patients exhibited less suspicious quantitative and qualitative characteristics than lesions in nonmenopausal patients. There was an independent association between the kinetic characteristics and menopausal status, with an odds ratio of 2.94 for the lack of rapid initial contrast material uptake and of 2.38 for the lack of washout in menopausal patients as compared with nonmenopausal patients. The odds ratio was 4.00 for not having rapid initial contrast material uptake in patients with a personal history of ipsilateral breast cancer. CONCLUSION: Kinetic data in invasive breast cancer are associated with the patient's menopausal status, with a typical kinetic pattern of malignancy being less common in menopausal patients.

Journal club: Acute abdominal pain in elderly patients: effect of radiologist awareness of clinicobiologic information on CT accuracy.

OBJECTIVE: The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic acute abdominal pain. MATERIALS AND METHODS: The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics. RESULTS: In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings. CONCLUSION: In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.