Abdominal compartment syndrome and intra-abdominal hypertension in critically ill patients: diagnostic value of computed tomography.

AIMS: The aims of the present work were to reevaluate, prospectively, the diagnostic value of already-described computed tomography (CT) landmarks of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) and to study the diagnostic value of some undescribed CT signs for the diagnosis of IAH and ACS. MATERIALS AND METHODS: Consecutive patients admitted to the intensive care unit (ICU) in shock for whom an abdominal CT was clinically indicated were included. CT examinations were reviewed and scored by two reviewers for the 12 proposed CT features of IAH and ACS. Intravesical pressure (IVP) was measured for each patient. Imaging features and clinical data of patients with IAH (IVP ≥ 12 mmHg) were compared to those of patients with normal intra-abdominal pressure (IVP < 12 mmHg). RESULTS: Forty-one patients were included. Twenty-one patients (51%) presented IAH with an IVP value ≥ 12 mmHg. Four patients (10%) were considered to have ACS (10%). Only an increased peritoneal-to-abdominal height ratio (PAR) was associated with the presence of IAH (PAR = 0.45 [0.40-0.49] in patients with IVP < 12 mmHg and PAR = 0.52 [0.48-0.53] in patients with IVP ≥ 12 mmHg; p < 0.001). Increased PAR ≥ 0.52 had a specificity of 85% for IAH diagnosis. CONCLUSION: The present study suggests that a PAR ≥ 0.52 could help radiologists to identify IAH on abdominal CT scan and could lead to adequate identification and/or treatment, even at early stages of IAH. KEY POINTS: • CT is an efficient first-intention procedure to evaluate and follow up underlying conditions in critically ill patients at risk of IAH and ACS overcome. • Raising the possibility of an IAH on a CT examination is relevant information for the clinician. • The only factors associated with intra-abdominal hypertension were the peritoneal-to-abdominal height ratio (PAR) and the ratio of maximal anteroposterior to transverse abdominal diameter (which define the round belly sign when > 0.8).

Multiphase whole-body CT angiography before multiorgan retrieval in clinically brain dead patients: Role and influence on clinical practice.

GOALS: To evaluate the contribution of multiphase whole-body CT angiography (CTA) for identifying the contra-indications to multiorgan retrieval (MOR) and improving the preoperative organ harvesting strategy. PATIENTS AND METHODS: One hundred and eleven consecutive patients who were clinically brain dead underwent multiphase whole-body CTA to confirm the diagnosis of brain death and for assessment of MOR. The CTA protocol included volumetric acquisitions of the brain and abdominopelvic cavity without IV administration of iodinated contrast material, then images of the thorax-abdomen-pelvis 25s after IV contrast administration, of the brain at 60s and finally an abdominopelvic CT acquisition at 90s. The diagnosis of brain death was based on well-established criteria. The assessment of thorax, abdomen and pelvis was based on a systematic checklist. Post-processing imaging techniques were used in all patients. RESULTS: No organs were retrieved from 21 patients due to patient refusal (19%). Twenty-two potential MOR were denied because of general contra-indications including 12/22 (54%) based on CTA criteria alone. Finally, 68 patients were eligible for MOR and 160 organs were harvested. The exclusion of specific organs was based on CTA alone for 2/16 livers, 4/70 kidneys and 5/55 lungs. Fifty hearts and 58 pancreases were not harvested, none based on CTA results alone. Hepatic abnormalities and vascular anatomical variants were identified in 10% of patients. At least one renal artery variant was found in 28% of patients, 13% presented with a double renal vein and 8% with a hepato-mesenteric artery. CONCLUSION: Multiphase whole-body CTA for MOR is based on the simultaneous association of cerebral CTA to determine brain death with CTA of the thorax, abdomen and pelvis. This rapid, standardized and easily accessible procedure has no harmful effects on harvested kidneys. It makes it possible to select the donors and the organs to be harvested and allows the retrieving surgeon to identify and anticipate technical difficulties.

Mesenteric panniculitis: still an ambiguous condition.

PURPOSE: To study the possible relationship between mesenteric panniculitis (MP) visible on computed tomography (CT) and the presence of an underlying neoplastic disease. PATIENTS AND METHODS: A retrospective analysis of 158 patients with CT examinations that revealed the presence of MP was performed. CT images were analyzed by two different radiologists using morphological criteria validated in the radiological literature. The presence, frequency and type of neoplastic lesions associated with MP were assessed. RESULTS: MP was asymptomatic in 96/158 patients (61%). Fat halo sign and pseudocapsule were visible on CT in 89/158 (56%) and 93/158 (59%) patients, respectively. Underlying neoplastic disease was present in 88/158 patients (56%). The neoplastic diseases most often associated with MP were lymphoma (28%), melanoma (18%), colorectal cancer (15%) and prostate cancer (13%). CONCLUSION: MP has typical CT appearance and is associated with underlying neoplastic disease in 56% of patients. Such levels of association might suggest that MP may be considered as a paraneoplastic condition. Hence, incidental depiction of MP on CT in a patient without known neoplastic disease should incite radiologists to further scrutinize CT examination for presence of synchronous neoplastic lesions.

Inflammatory appendix mass in patients with acute appendicitis: CT diagnosis and clinical relevance.

The purpose of our study was to analyze the clinical relevance of computerized tomography (CT) in providing the diagnosis of inflammatory appendix mass (IAM) in patients with acute appendicitis. The CT images of 134 patients were reviewed. Two groups of patients were made according to the presence (group 1; n = 21) or the absence (group 2; n = 113) of IAM. Clinical signs of patients, CT features, complications at surgery, and histological examinations were noted. Inter-observer agreement was assessed by using kappa statistics. Twenty-one patients presenting with CT features of IAM were diagnosed. An excellent inter-observer agreement (κ = 0.94) was assessed for the diagnosis of IAM. No significant statistical difference in the age distribution was observed between patients with IAM (mean age 55) and patients without (mean age 45) (p = 0.2232). No clinical sign showed a statistically significant association with the presence of IAM (p = 0.707) or with complication encountered at surgery (p = 0.180). Delay to CT examination was 5.4 days in patients presenting with CT features of IAM and of 1.7 days for patients presenting without (p = 0.0001). Conversely to acute appendicitis complicated by simple perforation (p = 0.153) or peri-appendicular abscess (p = 0.501), acute appendicitis presenting with IAM showed a statistically significant association with complications encountered at surgery (p = 0.0003) and the need for conversion to open surgery (p = 0.001). Performing CT in complicated acute appendicitis provides the diagnosis of IAM. Distinction of IAM appeared to be of clinical relevance, since immediate surgery in IAM was statistically associated with surgical complications and conversion to open surgery in our study.

Acute colitis: differential diagnosis using multidetector CT.

AIM: To investigate the utility of multidetector CT (MDCT) in helping to establish the underlying cause of acute colitis. METHODS AND MATERIALS: All patients who had acute colitis with a well-identified cause and underwent abdomen 64-MDCT were included in the study. MDCT images were retrospectively analysed in a blinded fashion and the CT findings were correlated with the eventual aetiological diagnosis. RESULTS: The study population included 105 patients. Acute colitis was related to inflammatory bowel disease in 43 cases. MDCT was used to identify six relevant signs of inflammatory colitis: the "comb" sign (p < 0.001), enlarged lymph nodes (p < 0.001), abscess (p = 0.026), fibro-fatty infiltration (p = 0.007), small bowel involvement (p < 0.001), and the absence of an "empty colon" sign (p = 0.045). Multivariate logistic regression analysis identified three independent signs of inflammatory colitis: the "comb" sign, small bowel involvement, and enlarged lymph nodes. Acute colitis was related to bacterial infection in 35 cases. Five signs were significantly associated with infectious colitis: continuous distribution (p = 0.020), an "empty colon" sign (p = 0.002), absence of fat stranding (p = 0.013), and absence of a "comb" sign (p = 0.010) and absence of enlarged lymph nodes (p = 0.035). Multivariate analysis identified three independent signs: the "empty colon" sign and absence of fat stranding and of a "comb" sign. The remaining causes were ischaemic colitis (n = 21) and drug-related colitis (n = 6). MDCT examination provided five relevant signs of ischaemic colitis: fat stranding (p = 0.002), discontinuous distribution (p < 0.001), and absence of enlarged lymph node (p < 0.001), a "comb" sign (p = 0.006) and small bowel involvement (p = 0.037). CONCLUSIONS: MDCT provides certain suggestive signs that may be helpful in distinguishing the underlying aetiological cause of acute colitis.

Coping with the problems of diagnosis of acute colitis.

Acute colitis is an acute condition of the colon. For the radiologist, it is mainly diagnosed during differential diagnosis of acute abdominal conditions. There are many causes of colitis and the degree of its severity varies. A CT scan is the best imaging examination for diagnosing it and also for analysing and characterising colitis. The topography, type of lesion and associated factors can often suggest a precise diagnosis but it is nevertheless essential to integrate these findings into the clinical context and take laboratory values into account. The use of endoscopy is still the rule where a doubt remains, or to obtain necessary histological evidence.