A simplified approach to virtual colonoscopy using different intestinal preparations: preliminary experience with regard to quality, accuracy and patient acceptability.

PURPOSE: The authors assessed the quality, diagnostic accuracy and patient acceptability of computed tomography (CT) colonography performed using a simplified bowel preparation and software for post-processing digital elimination of stool and fluid data from images compared with the examination obtained with conventional preparation. MATERIALS AND METHODS: Two groups of 40 consecutive asymptomatic patients aged between 48 and 72 years underwent CT colonography. In group A, the CT scan was performed with conventional bowel preparation (a full cathartic dose and oral contrast medium to tag any residue in the 3 days preceding the study). In the second group, CT colonography was performed after a reduced bowel preparation, with the oral contrast medium for residue tagging being administered only on the day of the investigation. Examination quality, diagnostic performance and patient acceptability (rated with a self-completed questionnaire) in the two groups of patients were compared by using the McNemar test. RESULTS: No significant difference was obtained with regard to examination quality (180 vs. 165 segments free from stools and fluid, p>0.05) and overall diagnostic accuracy (16/17 colonic polyps detected in group A and 12/13 in group B, p>0.05). The questionnaires revealed a greater acceptability of the reduced bowel preparation compared with the standard procedure (p=0.01). CONCLUSIONS: In asymptomatic patients, the use of software for post-processing digital elimination of residue from images in conjunction with reduced bowel preparation does not reduce examination quality or diagnostic performance when compared with the conventional CT colonography technique and is more acceptable to and better tolerated by the patient.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP.

PURPOSE: This study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP). MATERIALS AND METHODS: The MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the "duct-penetrating" sign was evaluated. RESULTS: MR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in 1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD. CONCLUSIONS: Delayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.

Increased D-dimer value and occult cancer in the absence of detectable thrombosis.

Fibrin formation and removal occurs continuously during the development of malignancy. Accordingly, hemostatic disorders in cancer patients are a rather frequent observation and range from asymptomatic laboratory changes to massive thromboembolism or haemorrhage. We document the case of an asymptomatic women, who was enrolled as a healthy control in a study and showed up with a substantially increased D- dimer value. After ruling out the most probable sources of D-dimer elevation, such as thrombosis, inflammation and trauma, she underwent laboratory and radiological investigations for malignancy, which were consistent with a colorectal metastatic adenocarcinoma. This case allow us to hypothesize that screening for occult malignancy in the presence of apparently inexplicable elevated D-dimer values may be taken into consideration.

Spiral computed tomography assessment of resectability of pancreatic ductal adenocarcinoma: analysis of results.

BACKGROUND: Despite more recent technical advances, single detector spiral computed tomography is still the most widely used imaging technique for the detection and staging of pancreatic adenocarcinoma. Many reports have recently focused on single detector spiral computed tomography imaging findings indicative of unresectability AIM: To evaluate the ability of single detector spiral computed tomography in the pre-operative staging of ductal adenocarcinoma of the pancreas in selecting surgically resectable versus unresectable cases, considering different parameters (vascular and local infiltration, liver metastases, lymphadenopathy, and peritoneal carcinomatosis). PATIENTS AND METHODS: A total of 100 patients diagnosed with ductal adenocarcinoma of the pancreas, pathologically verified, and examined with single detector spiral computed tomography were considered. Of these, 63 underwent surgery; 37 were excluded (imaging evidence of unresectability in biopsy-proven adenocarcinomas). Single detector spiral computed tomography studies, performed at the time of surgery, were retrospectively reviewed by two radiologists. The final results were reached by consensus, without being aware of the operation. All prospective clinical readings were also considered, and tabulated. RESULTS: In the patients undergoing surgery, 44 proved to be unresectable and 19 resectable. Considering the above-mentioned parameters, the prospective assessment of resectability demonstrated a rather low sensitivity (68%), with high specificity (95%). Accordingly, a high positive predictive value (97%) was achieved, while the negative predictive value was 56%. After the retrospective evaluation, the value of sensitivity increased (84%) to the expense of the specificity (84%). Moreover, a positive predictive value of 92.5%, and a negative predictive value of 69.5% were obtained. CONCLUSIONS: The demonstration of many signs of unresectability of pancreatic ductal adenocarcinoma reported in the literature yields a better sensitivity in the diagnosis, but unfortunately, is associated with an inevitable reduction in specificity.

Intraductal papillary mucinous tumors of the pancreas: spectrum of CT and MR findings with pathologic correlation.

The reports of intraductal papillary mucinous tumors (IPMT) of the pancreas are increasingly more frequent in the literature. The diagnosis by means of cross-sectional imaging of these tumors is not easy, especially in the early stages, when they can mimic an inflammatory disease of the pancreas. Prompt identification of the disease is nevertheless extremely important, especially in the case of tumors originating from the collateral branches, since its recognition can modify the management of the patient, in some cases obviating recourse to surgery.

[Serous cystadenoma of the pancreas: imaging findings]. / Cistoadenoma sieroso del pancreas: i rilievi del'imaging.

PURPOSE: To present the imaging findings of serous cystadenoma (SCA) and discuss the main problems of differential diagnosis with other cystic pancreatic lesions. MATERIALS AND METHODS: 55 cases of SCA were reviewed; all the lesions proved to be benign at pathology. 35 tumors were evaluated with Ultrasonography (US), 49 with Computed Tomography (CT), and 15 with Magnetic Resonance Imaging (MRI). RESULTS: Among the patients who underwent either demolitive (47) or derivative (3) interventions, two different morpho-structural patterns were identified: microcystic (37), and oligocystic (13). The diagnosis of SCA, possible in the presence of microcystic pattern, was achieved in 63% of cases by US (22/35), in 63% of cases by CT (31/49), and in 73% of cases by MRI (11/15). In 12 patients evaluated with all the imaging modalities, the combined information allowed a correct diagnosis in 10 cases (83%). The 13 oligocystic tumors were almost always undistinguishable from other cystic masses of the pancreas. CONCLUSIONS: The diagnosis of SCA can be considered certain if a microcystic pattern is detected. A correct diagnosis is not achievable in the presence of oligocystic architecture. MRI is the best imaging modality in characterizing this tumor.

CT features of malignant mucinous cystic tumors of the pancreas.

This study is aimed at evaluating which pre-operative findings at CT are prevailingly associated with histologically malignant appearance of mucinous cystic tumor (MCT) of the pancreas. The CT examinations of 52 female patients affected with pathologically proved MCT were retrospectively evaluated by two radiologists, blinded to the histopathological assessment of the biologic behavior (either benign or malignant). A multivariate logistic regression analysis was performed in order to identify the most important features associated with the malignant nature of MCT. Calcifications in the wall and/or in the septa, thick wall, and septations resulted in the most important features associated with malignancy. The simultaneous presence of all these radiological signs constitutes an almost "certain" marker of malignancy, being the risk equal to 0.95, whereas the simultaneous presence of at least two of them entails a risk of malignancy ranging from 0.56 to 0.74, according to the type of morphological features. On the other hand, the absence of the mentioned radiological features entails a negligible risk of malignancy (0.02). Mucinous cystic tumors characterized by multilocular macrocystic architecture, with thick wall and calcifications in the wall and/or the septa, present the highest risk of malignancy, and advocate prompt surgical intervention. When those signs are absent, the probability of malignancy is lower. In this case a non-operative management is possible.

Nonfunctioning endocrine tumors of the pancreas: possibilities of spiral CT characterization.

The aim of this study was to assess the ability of spiral CT to adequately characterize the nonfunctioning endocrine tumors (NFETs) of the pancreas, distinguishing this lesion from the other pancreatic tumors. The spiral CT examinations of 21 cases of histologically proven NFETs, along with those of 29 cases of other pancreatic tumors and tumor-like lesions, were retrospectively reviewed in a blinded fashion by two radiologists, in order to correctly classify the lesions, highlighting the typical signs reported in the literature. Discordant cases were further analyzed in the presence of a third radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The histopathologic examination was considered the gold standard. The sensitivity, specificity, and positive and negative predictive values of CT were calculated. After the consensus evaluation, the correct diagnosis was reached in 72% of cases, with 10% of nonspecific diagnoses of solid pancreatic tumor and 18% of wrong diagnoses. The sensitivity and specificity of spiral CT in identifying NFETs were 66.6 and 82.7%, respectively. The positive and negative predictive values were 73.7 and 77.4%, respectively. In up to 70% of cases the NFET demonstrates a typical aspect of a mass hyperdense in the arterial contrastographic phase eventually associated with hyperdense hepatic metastases in more than half of the patients. This finding does allow the diagnosis of NFET but without certainty indeed, since other tumors can show a similar densitometric behavior and among them particularly the ductal adenocarcinoma. On the other hand, both the solid, hypovascularized NFETs, and the cystic form, cannot be differentiated from the other solid and cystic tumors of the pancreas.

Autoimmune pancreatitis: possibilities of CT characterization.

BACKGROUND: Pancreatitis is defined as an inflammatory disease of the pancreas, leading to morphological and pathological changes. Recently, an autoimmune pathogenesis of this disease has been proposed. This type of pancreatitis should be differentiated from other pancreatic diseases, since appropriate therapy is effective and morphological changes and pancreatic function can recover to normal levels. AIM OF THE STUDY: To assess the possibility of distinguishing autoimmune pancreatitis from other pancreatic diseases with an analogous clinical presentation on the basis of CT findings alone. METHODS: The CT images of 7 patients with proven autoimmune pancreatitis, along with those of 20 patients with other pancreatic diseases, but with an analogous clinical presentation, were retrospectively evaluated in a blinded fashion by 2 radiologists. In particular, the radiologists had to search for the typical signs of autoimmune pancreatitis. Discordant cases were further analyzed in the presence of a 3rd radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The sensitivity, specificity, positive and negative predictive values of CT were calculated against each of the diseases (autoimmune pancreatitis; other pancreatic diseases), in order to evaluate the diagnostic value of the scan. RESULTS: After the consensus evaluation, the correct diagnosis was reached in 25/27 (92.5%) cases, with only 2/27 wrong diagnoses (autoimmune pancreatitis diagnosed as another pancreatic disease and vice versa). The sensitivity and specificity of CT against autoimmune pancreatitis were 86 and 95%, respectively. The positive and negative predictive values were 89 and 93%, respectively. CONCLUSION: Patients with autoimmune pancreatitis demonstrate imaging findings that enable the correct diagnosis by dynamic CT, even in the presence of nonspecific clinical symptoms. The precise classification of the disease is extremely important, since simple steroid therapy then represents the correct treatment, and leads to complete recovery.

Duodenal duplication cyst identified with MRCP.

We report a case of a stalked cystic duodenal duplication. The lesion, hyperintense on T2-weighted GRE images, maintained the signal intensity after oral administration of a negative contrast agent (Lumirem, Guerbet, Aulnay-Sous-Bois, France), confirming its independence from the duodenal lumen. To our knowledge, this is the first demonstration of duodenal duplication by means of MR cholangiopancreatography.

Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report.

We present a rare late-onset (after 24 years) complication of gastric surgery with a combination of afferent loop syndrome associated with a large duodenal stone. The patient, who had undergone Billroth II partial gastrectomy for benign ulcer 24 years before, developed abdominal pain in the right upper quadrant, associated with nausea, vomiting, and high grade fever. Abnormal laboratory values included elevated liver function test, suggesting a pressure-related phenomenon. Leukocytosis and a high level of platelets were also found. Only computed tomography and endoscopy of the upper gastrointestinal tract confirmed the diagnosis of a huge stone in the dilated duodenal afferent loop. To our knowledge, a case like this has not been reported previously in the literature.

Characterization of cystic tumors of the pancreas: CT accuracy.

PURPOSE: The purpose of this work was to evaluate the capabilities of CT to accurately characterize cystic tumors of the pancreas. METHOD: Two observers retrospectively evaluated the CT exams of 100 cystic masses of the pancreas, with pathological confirmation. The two observers, blinded about clinical information and the final diagnosis, tried to categorize the lesions according to well established morphologic features. Statistical analysis was performed to measure the agreement between each radiologist and the consensus diagnosis and to evaluate the usefulness of certain CT findings in differentiating one type of cystic pancreatic neoplasm from another. RESULTS: Serous cystadenoma was better diagnosed by CT [Youden misclassification index (Ymi) = 0.72] than mucinous cystic tumor (Ymi = 0.44) and solid pseudopapillary tumor (cystic variant) (Ymi = 0.47). CONCLUSION: As patients with previous history of pancreatitis were excluded from the study, CT findings allowed correct characterization of only 60% of cystic pancreatic masses. Among the remaining 40%, 15-20% of the wrong diagnoses could not be corrected by means of CT, given the patterns shown by the tumors. In 20-25% of the cases, a nonspecific diagnosis of cystic mass was made.

Intraductal papillary mucinous tumor of the pancreas: a pictorial essay.

Intraductal papillary mucinous tumor (IPMT) of the pancreas was identified and classified only recently. IPMT has a primarily intraductal, papillomatous growth pattern, which is associated with excessive mucin secretion and results in progressive ductal dilatation or cyst formation. The tumor occurs in four forms: segmental or diffuse involvement of the main pancreatic duct and macrocystic or microcystic involvement of a branch duct. In the past, many IPMTs may have been misdiagnosed as chronic pancreatitis because of their generally benign behavior. The correct diagnosis, once achieved only with endoscopic retrograde cholangiopancreatography (ERCP), can now be made with noninvasive imaging modalities, particularly computed tomography (CT) and magnetic resonance (MR) imaging. ERCP remains the imaging modality of choice for diagnosis of IPMT. With ERCP, the communication between the cystically dilated ductal segment or branch duct and the main pancreatic duct is easily demonstrated. However, reflux of contrast material due to an excess of mucin or an enlarged papillary orifice hinders filling of the ductal tree. Filling defects due to mucin globs or mural nodules are also important clues to the diagnosis. Bulging of the papilla into the duodenal lumen is virtually pathognomonic of IPMT and is well demonstrated with CT or MR imaging.

Cystic dystrophy of the duodenal wall: radiologic findings.

PURPOSE: To determine the radiologic characteristics of cystic dystrophy of the duodenal wall. MATERIALS AND METHODS: Ten patients with cystic dystrophy of the duodenal wall and chronic pancreatitis underwent ultrasonography (US) (n = 10), computed tomography (CT) (n = 10), endoscopic US (n = 5), and endoscopic retrograde cholangiopancreatography (ERCP) (n = 9). Cystic dystrophy of the duodenal wall was classified as either cystic or solid. The imaging findings were retrospectively analyzed and compared with findings at pancreatoduodenectomy (n = 10). RESULTS: The more frequent cystic type (n = 7) of cystic dystrophy of the duodenal wall was characterized by the presence of easily recognizable cystic lesions (diameter, more than 1 cm), located within the thickened wall of the second portion of the duodenum. The solid type (n = 3) of cystic dystrophy of the duodenal wall demonstrated fibrous thickening of the duodenal wall within which small cysts (diameter, less than 1 cm) were present. The intraduodenal cysts were usually elongated or bilobate with a thick wall. The thickening of the duodenal wall appeared as a solid layer between the duodenal lumen and the pancreas, hypoechoic at US, isoattenuating at unenhanced CT, and hypoattenuating in the early phase (after initiation of infusion of contrast material) and isoattenuating in the late phase (after completion of infusion) at contrast material-enhanced CT. Findings at retrospective analysis of CT and endoscopic US images were characteristic. CONCLUSION: Imaging modalities, notably CT and endoscopic US, helped establish the diagnosis of cystic dystrophy of the duodenal wall.

Percutaneous transhepatic sphincterotomy of the major papilla and stone extraction without endoscopic control.

Obstructive jaundice due to an impacted stone in the common bile duct (CBD) was seen in a patient who had previously undergone Billroth II gastric resection and cholecystectomy. Surgical and endoscopic approaches to the common bile duct failed owing to pericholedochal adhesions and the excessive length of the duodenal loop. The patient was therefore treated percutaneously (sphincterotomy and stone extraction) without endoscopic control.