MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome.

PURPOSE: Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients. METHODS: From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy. RESULTS: Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores. CONCLUSION: It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Magnetic resonance-assisted imaging of slow flow in the pancreatic and common bile duct in healthy volunteers.

BACKGROUND: Magnetic resonance cholangiopancreaticography (MRCP) is commonly used to evaluate the pancreatic (PD) and common bile duct (CBD), and the addition of secretin is used to obtain functional information (S-MRCP). Neither method gives any information on flow velocities within the ducts. PURPOSE: To evaluate a new, MRI diffusion-based, slow-flow-sensitive sequence for the detection of slow flow changes in the PD and CBD. MATERIAL AND METHODS: Seven healthy volunteers were examined. A modified single-shot turbo spin-echo sequence was used to detect slow flow changes. Three b factors (0, 6, and 12 s/mm(2)) were used. The flow sensitivity was applied in two directions, vertically and horizontally. Scanning was performed before and after glucagon was given, and again after an intravenous injection of secretin. The sequence gives signal loss from a duct when flow increases, and such changes were recorded. RESULTS: All images showed the PD with b = 0 (no flow sensitization). After administration of glucagon, artifacts from bowel movements were reduced and visibility of the PD was improved at both b = 6 and b = 12. Significant reduction of the visibility of the PD, indicating increased flow, was recorded both at b = 6 and b = 12 after the administration of secretin. There were no changes in the visibility of the CBD. CONCLUSION: This study shows that MRI-based detection of slow flow changes inside the PD is possible. Due to the sequence's high sensitivity to any motion, further studies are required before adopting the method for clinical use.

Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract.

PURPOSE: To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT) MATERIAL AND METHODS: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated. RESULTS: In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT. CONCLUSION: S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.

Dynamic first pass 3D EPI of the prostate: accuracy in tumor location.

PURPOSE: To evaluate the potential of dynamic contrast enhanced (DCE) 3D EPI in the location of prostate cancer. MATERIAL AND METHODS: A DCE 3D EPI scan was included in the magnetic resonance imaging protocol for prostate examination. Twenty-eight patients who subsequently underwent radical prostatectomy were included in the study. T2-weighted (T2W) Turbo Spin Echo (TSE) images were initially evaluated by two radiologists. Parametric images reflecting contrast enhancement were added and new evaluations performed. The results were compared with histology from resected specimens. Accuracies and interobserver agreements were calculated. RESULTS: Interobserver agreement was Kw =49+/-3% for the T2W technique and Kw=30+/-3% for the combined techniques. No statistically significant advantages were found for location of tumor in the prostate or in the seminal vesicles by adding the DCE information. CONCLUSION: DCE 3D EPI did not improve tumor location compared with that of T2W TSE images. Further investigation is needed on how best to exploit the DCE technique.

A new pulse sequence to visualize slow flow.

The purpose of this paper is to present a new pulse sequence for visualizing slow flow. The new sequence consists of an initial Stejskal-Tanner flow sensitization part followed by a DEFT pulse and a spoiler gradient. A single-shot TSE readout train is then applied to sample the NMR signal. The sequence was initially tested using a simple flow phantom. To verify potential clinical use, both flow-sensitive MRCP and cerebrospinal fluid (CSF) images were produced. The phantom study proved the sequence sensitivity to flow in the range 0-1 cm/s. bVE-factors 1.5, 3, 6 and 12 were chosen. Within this flow velocity range, the signal dropped as predicted theoretically. This indicates that the method can be used to quantify flow. All anatomical features seen in a standard MRCP sequence were identified and the methods sensitivity to CSF flow was demonstrated by sagital images of the head. A new pulse sequence sensitive to slow flow has been developed.

Bowel MR imaging with oral Gastrografin: an experimental study with healthy volunteers.

Our objective was to evaluate Gastrografin for MR bowel imaging. Twenty-three healthy volunteers in two randomised groups received 300 or 400 ml 50% Gastrografin, drunk continuously during 2 and 3 h, respectively. Images were applied during breath-hold in three orthogonal orientations. The balanced fast-field echo (BFFE) and balanced turbo field-echo (BTFE) sequences, with acquisition times from 13 to 25 s, were used before gadolinium (Gd) DTPA implying 1- to 2-mm-thick slices locally or 6-mm-thick slices through the entire gastrointestinal tract. The Gd-enhanced images were performed using a 3D T1-weighted FFE sequence with water selective excitation (Proset). Image quality, including bowel distention, homogeneity of opacification and wall conspicuity, were evaluated by two experienced reviewers, and the adverse reactions were recorded. Very good or excellent distention, homogeneity and wall conspicuity were achieved in the central segments from the ileum to the left colon flexure in 83-96% of cases, due to the adequate contrast media supply in these regions. Distention, homogeneity and delineation were good in the central segments of the remaining bowels. Diarrhoea was a major problem affecting all participants, followed by nausea. Provided that there is modern fast sequential technology, excellent MR imaging of the bowel can be achieved by the oral administration 50% diluted Gastrografin. Further studies are needed to refine the technique and optimise the quantity and concentration of Gastrografin in order to avoid or reduce adverse reactions.

Magnetic resonance imaging of the pelvic floor--possibilities and present status.

MRI has had both an increasing availability and fuctionality during the last 5-10 years. In diagnosing problems of the pelvic floor, it has been shown to have a potential, but is at present not to be considered a routine examination. Today's use of MRI of the pelvis includes anatomical/topographical images of high quality, but to make it a valuable diagnostic tool, functional imaging is mandatory. Functional MRI with a potential of simultaneously examining defecation, micturition, bladder motion and pelvic floor muscles, seems promising, but with having practical problems. The use of open MRI systems reduce the practical problems, but does not give the optimum image quality. In the future it is likely that MRI will have an increasing importance concerning diagnoses of the pelvic floor. However, clinical research is needed to evaluate the possible diagnostic gains, and maybe even open for more use of MRI.

Pancreatic carcinoma: MR, MR angiography and dynamic helical CT in the evaluation of vascular invasion.

OBJECTIVE: To assess the value of MR angiography in combination with contrast-enhanced MR imaging, and to compare MR imaging including MR angiography with dynamic contrast-enhanced dual phase helical CT in the preoperative assessment of vascular invasion in patients with suspected pancreatic carcinoma. METHODS AND MATERIAL: MR imaging only, MR imaging including MR angiography and dynamic contrast-enhanced dual phase helical CT images of 48 patients who were operated due to suspicion of pancreas cancer were correlated with the surgery results in terms of vascular invasion. Pathologic diagnosis were pancreatic adenocarcinoma in 31 patients of which nine had surgically confirmed vascular invasion. Sensitivity, specificity, predictive values (including 95% confidence intervals) and accuracy of MR imaging only, MR imaging including MR angiography and helical CT were calculated. RESULTS: Sensitivity, specificity, positive and negative predictive values and accuracy were 56, 100, 100, 85, 87%; 67, 100, 100, 88, 90% and 67, 100, 100, 88, 90%, respectively, for MR imaging only, MR imaging including MR angiography and helical CT in the adenocarcinoma group. The corresponding figures in the overall study group were 56, 97, 83, 90, 90%; 67, 97, 86, 93, 92% and 67, 97, 86, 93, 92%. Confidence intervals (95%) showed that the differences in the diagnostic efficacy of the techniques were not statistically significant in the overall study group, but the confidence intervals were undefined in the adenocarcinoma group due to the small sample size. CONCLUSION: Diagnostic efficacy of MR imaging when combined with MR angiography is equal to that of dynamic contrast-enhanced dual phase helical CT in the assessment of vascular invasion of pancreatic tumors.

Mucinous ductal ectasia of the biliary tree secondary to mucous metaplasia. A case report.

Mucinous ductal ectasia is an uncommon disorder, characterized by ductal dilatation and filling with thick, viscid mucus, described in the pancreas. We report a case of mucinous ductal ectasia of the biliary tree. The cause of the mucus production was mucous metaplasia in the biliary epithelium. The patient was followed for 16 years, treated with serial saline flushings of the biliary tree whenever he became symptomatic.

Pancreaticobiliary diseases. Comparison of 2D single-shot turbo spin-echo MR cholangiopancreatography with endoscopic retrograde cholangiopancreatography.

PURPOSE: To compare the diagnostic value of MR cholangiopancreatography (MRCP) to that of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of various obstructive and nonobstructive pancreaticobiliary diseases. MATERIAL AND METHODS: We retrospectively reviewed 153 patients who had undergone both MRCP and ERCP Breath-hold, heavily T2-weighted images using 2D single-shot turbo spin-echo technique were obtained. MRCP and ERCP results were correlated with the final clinical diagnoses. Accuracy of MRCP and ERCP in the diagnosis of pancreaticobiliary diseases, detecting the cause and site of biliary obstruction, if present, and distinguishing malignant from benign cause of obstruction were compared. RESULTS: Success rates of MRCP and ERCP were 98.7% and 89.5%, respectively. The accuracy of MRCP and ERCP in detecting the site of biliary obstruction was 89.7% and 96.2%, and in detecting the cause of biliary obstruction 69.2% and 71.8%, respectively. The sensitivity, specificity and likelihood ratios for positive and negative tests for MRCP and ERCP in distinguishing malignant biliary obstruction from benign causes were 86.4%, 82.4%, 4.9, 0.2 and 88.6%, 94.1%, 15.1, 0.1, respectively. Concordance between the two tests was 91% (kappa coefficient 0.82, standard error of kappa 0.113, p<0.001). In the group of nonobstructive biliary diseases, accuracy of MRCP and ERCP in detecting cholecystolithiasis were 100% and 73.7%, and in detecting pancreatitis 57% and 14%, respectively. CONCLUSION: 2D single-shot turbo spin-echo MRCP can be performed as a complement to ERCP and can replace ERCP in high-risk patients and in case of unsuccessful cannulation.

Relationships between radiologists and clinicians: results from three surveys.

AIM: To analyse reasons for and the nature of clinico-radiological contacts and their clinical impact. MATERIALS AND METHODS: Three different surveys were performed. (1) Data concerning contacts between staff radiologists (n = 20) and clinicians during 10 consecutive working days were collected; (2) staff clinicians (n = 174) filled in a questionnaire asking for their opinions about relationships with radiologists; (3) staff radiologists collected data about contacts with clinicians related to more urgent/complicated cases. Radiologists assessed the clinical impact of the radiological procedure and of the consultation. RESULTS: (1) During 220 working days 20 radiologists had a mean of 3.95 contacts per day (48.2% personal contacts, 51.8% telephone contacts), amounting to a personal total of 21.65 min per day. These contacts amounted to a total of 7.08 h per day, roughly one whole-time equivalent radiologist. (2) These consultations helped to refine the diagnostic strategy often (12.6%) or sometimes (71.4%) and to alter therapeutic decisions often (10.4%) or sometimes (56.6%). (3) The initial clinical diagnosis was changed in 50% of cases and the therapy was substantially changed on the basis of further radiological investigations and clinical-radiological discussion in 60% of cases. CONCLUSION: Clinical-radiological consultations are time consuming but have a beneficial diagnostic and therapeutic impact.

[Use of magnetic resonance tomography in the diagnosis of gastrointestinal diseases]. / Bruk av magnetisk resonanstomografi innen gastrointestinal diagnostikk.

BACKGROUND: Magnetic resonance imaging (MRI) is a promising method for examination of the gastrointestinal tract. In this article we present the present status and potential of MRI. MATERIAL AND METHODS: The review is based on personal experience and selected published, international papers. RESULTS: Magnetic resonance cholangio-pancreatography (MRCP) and MRI of the liver are well documented examinations which are widely performed. These examinations partly replace existing modalities such as CT and ERCP and represent additional possibilities for examining this anatomic area. MRI is not as yet accepted as the standard examination of the pancreas, but it is regarded as comparable to CT. The adrenals may be examined even more accurately with MRI than with CT. MRI examinations of the oesophagus and gastric ventricle seem promising, but it should be said that they are in an early and not well documented phase. MRI of the small and large bowels is not common. With the exception of preoperative staging of rectal cancers, it is still experimental. MR angiography, functional MRI studies and perfusion studies are not yet in common abdominal diseases. We may, however, believe that they will become important diagnostic tools. INTERPRETATION: MRI is rapidly increasing its share of gastrointestinal imaging examinations. This is mainly due to the increased speed of newer machines. The diagnostic quality has improved, and will improve more. It is thus likely that MRI will, in a large amount of abdominal imaging, replace CT, and to some extent other diagnostic modalities. It is, however, not possible to replace CT for emergencies, and we will probably look forward to more and better imaging with more diagnostic modalities in the future.

MR urography: the future gold standard in paediatric urogenital imaging?

BACKGROUND: Examination of the paediatric urogenital tract is traditionally performed using methods that utilise ionising radiation, such as intravenous urography (IVU), computerised tomography (CT), voiding cystourethrography (VCU), and scintigraphy, in addition to ultrasound (US). OBJECTIVE: To determine the potential and effectiveness of MR urography (MRU) in infants and children. Materials and methods. 44 MRU examinations were prospectively performed in 39 patients (21 infants, mean age 3.5 months, and 18 children, mean age 6 years 2 months) with known or suspected pathology of the urinary tract. Non-enhanced, fast spin-echo sequences (TSE) were performed in all patients. In 70 % of the patients a contrast-enhanced, fast gradient-echo sequence (TFE) was included. The dynamic sequence was prolonged and supplemented with furosemide provocation in some patients with suspected urinary-tract obstruction. RESULTS: Nine percent of examinations were non-diagnostic or interrupted due to movement. MRU contributed additional information in 66 %. Nine patients with suspected urinary-tract obstruction were examined with both contrast-enhanced MRU and scintigraphy. Three MRU examinations were less informative and one equal to scintigraphy when obstruction was the diagnosis. When using a technique with a prolonged dynamic sequence, including frusemide provocation, four MRU examinations were equal and one was superior to scintigraphy. CONCLUSIONS: MRU has the potential to replace traditional diagnostic methods which use ionising radiation in paediatric patients. Further studies are needed before definite conclusions can be drawn.

Clinical utility of chest roentgenograms.

Because chest roentgenograms are the most common radiological procedure, they represent a considerable use of resources. Because the usefulness of chest radiography is frequently disputed, it is mandatory to investigate whether or not this use of resources can be defended in terms of clinical utility. The current study was performed as an outcome analysis to assess the clinical utility of chest radiography for monitoring patients in general practice (GP). One year of chest radiography referrals from a municipality practice, comprising a total of 55 patients, were prospectively studied. Prior to the referrals, questionnaires were filled in with indications and expected results. After the examination, the radiological results were assessed regarding clinical utility. All 55 patients were carefully monitored by the same GP. The most frequent reason for referral was infectious disease. Only in 5 patients was the radiology report without value. In the 29 patients with a negative report, it was considered of value. In 7 of these 29 patients the ongoing treatment was altered. The subjective value of the radiology reports were considered to be high. The clinical utility was good, both when receiving positive and negative answers. Of special interest was the negative answers as 7 patients actually changed treatment. The clinical utility was considered high enough to justify the costs. Good access to radiology for GPs is both cost-saving and cost-effective.

[Urogenital tuberculosis]. / Urogenital tuberkulose.

Urogenital tuberculosis has unspecific clinical symptomatology. This is often a result of the complications of the disease. Clinical symptoms, X-ray examinations, urinary microscopy, cultures and cytological and histological examinations may reveal the diagnosis. Initial treatment is medical therapy, but surgery will often be a necessary supplement. Follow-up during the treatment period is important to avoid unnecessary complications. With appropriate treatment and follow-up, the prognosis will be good.

Cost-effectiveness of ultrasonographic screening for congenital hip dysplasia in new-borns.

OBJECTIVE: Screening for congenital dysplasia of the hips (CDH) of new-borns, mostly by Ortolani's of Barlow's tests, is widely performed, but nevertheless dysplasias are still discovered late. Ultrasonographic screening has been reported to reduce the number of these cases. The present investigation is intended to evaluate the cost-effectiveness of such as screening programme. MATERIALS AND METHODS: The cost of performing ultrasound investigations at Haukeland Hospital and the treatment costs of late-discovered CDH were calculated on the basis of 26 cases of late-discovered CDH at Hagavik Orthopaedic Hospital. Figures for sensitivity and specificity were taken from the literature. RESULTS: General ultrasonographic screening programmes for CDH will not be cost-effective because the population screened will be too large and the demands upon sensitivity too high. However, investigating babies at risk is probably cost-effective. CONCLUSION: A CDH screening programme requires high sensitivity and one should preferably aim at screening babies at risk. In Norway a centralisation to larger hospitals may therefore be necessary.

Cost-effectiveness of colour duplex sonography compared with angiography of the pelvis and lower limb.

The present investigation was performed to assess the clinical consequences, utility and efficacy of colour duplex sonography (CDS) compared with angiography as a preoperative examination in aorta, pelvis and lower limb, and thus to estimate the cost-effectiveness of CDS. CDS was additionally performed in 53 consecutive patients referred for preoperative angiography of the lower limb. The results for 49 patients were reviewed and compared to assess the technique's clinical utility. The costs of the two methods and the consequences of inappropriate treatment were assessed. In 15 patients inadequate diagnoses were obtained at CDS. If surgery had been performed solely on the basis of the ultrasonographic diagnosis, repeat surgery would have been necessary in 9 patients. In a further 3 patients necessary surgery would not have been performed. Two patients would have been overtreated (unnecessary surgery instead of percutaneous transluminal balloon angioplasty). To correct the initial incorrect diagnosis the estimated yearly cost would be approximately 1.3 million Swedish crowns. In addition, complications and discomfort could be anticipated for the patients. Because of its low sensitivity CDS ist not cost-effective as a preoperative investigation of arteries of the pelvis and lower limb.