A comparison of magnetic resonance elastography (MRE) to biomarker testing for staging fibrosis in non-alcoholic fatty liver disease (NAFLD).

Background: Non-alcoholic fatty liver disease (NAFLD) is the world's most prevalent chronic liver disease. In advanced stages, it is associated with significant morbidity and mortality. Magnetic resonance elastography (MRE) and scoring panels Fibrosis-4 (FIB-4) and NAFLD Fibrosis Score (NFS) are useful noninvasive alternatives to liver biopsy for fibrosis staging. Our study aimed to determine how well MRE corresponds with both FIB-4 and NFS at different stages of fibrosis. Methods: We performed a retrospective chart review of patients age ≥18 with NAFLD as their only known liver disease who underwent MRE within six months of a lab draw. MRE stratified patients into fibrosis stages using kPa values. FIB-4 categorized patients as Advanced Fibrosis Excluded, Further Investigation Needed or Advanced Fibrosis Likely. NFS categorized them as F0-2, Indeterminate or F3-4. MRE fibrosis staging was compared to FIB-4 and NFS for both ruling out advanced fibrosis and identifying advanced fibrosis/cirrhosis. Results: Overall, 193 patients met inclusion criteria. Our statistical analysis included calculating positive predictive values (PPVs) and negative predictive values (NPVs), which are the proportions of positive and negative fibrosis screening results that correspond to positive and negative MRE results respectively. NPV for FIB-4 (0.84) and NFS (0.89) in the 'rule out advanced fibrosis' category signify that 84% and 89% of respective biomarker scores correspond to MRE in early stage disease. The PPV for FIB-4 and NFS in the 'identify advanced fibrosis/cirrhosis' category signify 63% and 72% of respective biomarker scores correspond to MRE in late stage disease. Conclusions: FIB-4 and NFS scores indicating little to no fibrosis correspond extremely well with MRE, while scores suggesting advanced fibrosis/cirrhosis correspond less convincingly. MRE shows promise as an effective alternative to liver biopsy, however our study suggests FIB-4 and NFS alone may be sufficient for fibrosis staging, particularly in early stage NAFLD.

Pathogenesis to management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer whose incidence continues to rise in many parts of the world due to a concomitant rise in many associated risk factors, such as alcohol use and obesity. Although early-stage HCC can be potentially curable through liver resection, liver-directed therapies, or transplantation, patients usually present with intermediate to advanced disease, which continues to be associated with a poor prognosis. This is because HCC is a cancer with significant complexities, including substantial clinical, histopathologic, and genomic heterogeneity. However, the scientific community has made a major effort to better characterize HCC in those aspects via utilizing tissue sampling and histological classification, whole genome sequencing, and developing viable animal models. These efforts ultimately aim to develop clinically relevant biomarkers and discover molecular targets for new therapies. For example, until recently, there was only one approved systemic therapy for advanced or metastatic HCC in the form of sorafenib. Through these efforts, several additional targeted therapies have gained approval in the United States, although much progress remains to be desired. This review will focus on the link between characterizing the pathogenesis of HCC with current and future HCC management.

The patient-friendly radiology report: history, evolution, challenges and opportunities.

The past several decades have witnessed dramatic developments and improvements in the field of radiology, including technologic innovations and new imaging modalities, picture archiving and communication systems, and the rise of artificial intelligence. At the same time, an evolution has been occurring in a fundamental component of radiology practice - the radiologist's report. Initially, the radiology report was a private written communication between the radiologist and the referring physician 1,2. Today, the report is an electronic document, displayed on web portals, and visible to both physicians and the patients themselves.3 A provision in the 21st Century Cures Act, signed into law on December 13, 2016, ensures that radiology reports in the electronic health record are visible to patients without delay 4. To meet modern patient expectations and legal requirements, the structure and purpose of the radiologist report is changing. This article will provide an overview of the history of radiology reporting and the law, discuss the role of the radiologist report within the context of patient and family centered care, review current strategies and investigations in patient-friendly reporting, and summarize radiology reporting challenges and opportunities for the future.

EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography.

BACKGROUND AND AIMS: Guidelines recommend either EUS or magnetic resonance cholangiopancreatography (MRCP) for intermediate risk of choledocholithiasis. There is a lack of evidence that supports proceeding with EUS if the MRCP is negative and if clinical suspicion still exists. METHODS: This is a retrospective study of all patients who underwent EUS to assess for choledocholithiasis at a tertiary care referral center from July 2013 to October 2019. RESULTS: A total of 593 patients underwent EUS for evaluation for choledocholithiasis. Of the 593 patients, 35.2% (209/593) had an MRCP. 73.2% (153/209) had a negative MRCP while 26.8% (56/209) had a positive MRCP. Of the group of patients who underwent EUS with a negative MRCP, 15% (23/153) were positive for choledocholithiasis on EUS. Of these, 91% (21/23) were also positive for sludge or stones on endoscopic retrograde cholangiopancreatography and thus 14% (21/153) of the EUS were "true positives." There were no clinical or laboratory factors predictive of choledocholithiasis on univariate analysis in the EUS plus negative MRCP group. When further analyzing the MRCP negative group into MRCP-/EUS+ and MRCP-/EUS-subgroups, a total bilirubin >3 mg/dL predicted a bile duct stone (55% vs. 32%, P = 0.05). CONCLUSION: The diagnostic yield of EUS for suspected choledocholithiasis in the setting of a negative MRCP is 14% in our cohort. EUS should be considered in patients with intermediate risk of choledocholithiasis with a negative MRCP if the clinical suspicion is still present, and especially if the total bilirubin is above 3 mg/dL.

The utility of abdominopelvic CT in pregnant patients with abdominal pain and a negative or inconclusive abdominal MRI.

Pregnant women with abdominal pain can pose a diagnostic dilemma due to the nonspecific nature of symptoms and the desire to avoid radiation to the conceptus. Many algorithms will suggest ultrasound (US) or Magnetic Resonance Imaging (MRI) as the first-line imaging choice in pregnant women with abdominal pain due to the lack of ionizing radiation. However, these studies can have limitations as well. Abdominopelvic MRI is susceptible to respiratory motion that could cause a study to be nondiagnostic (Zaitsev et al., 2015 [1]). In the current case series, we present 8 pregnant patients with abdominal pain who underwent CT abdomen and pelvis after negative or inconclusive abdominal MRI exams. To our knowledge, this is the only case series that describes CT findings in the pregnant population after negative or inconclusive MRI.

Presentation and outcomes among inflammatory bowel disease patients with concurrent pneumatosis intestinalis: a case series and systematic review.

BACKGROUND/AIMS: Inflammatory bowel disease (IBD) involves chronic inflammation of the colon with ulcerative colitis (UC), and the colon and/or small intestine with Crohn's disease (CD). Pneumatosis intestinalis (PI), characterized by compromise of the intestinal wall with gas-filled cysts, has rarely been reported with IBD. The presentation, best management and outcomes of PI with IBD are poorly defined. METHODS: We conducted a search for PI in all abdominal computed tomography (CT) reports at 2 large tertiary care hospitals from January 1, 2010 to December 31, 2017, cross referenced to ICD codes for IBD. CT and chart review was performed to confirm PI and IBD respectively. A systematic review excluding case reports was performed for PI with IBD for comparison. RESULTS: Of 5,990 patients with a CT abdomen report mentioning PI, we identified 11 cases of PI with IBD, 4 UC, 6 CD, and 1 indeterminate colitis. PI was limited to the small bowel in 5 patients, the right colon in 5, and small bowel and colonic in 1. All 3 mortalities had CD, small intestinal PI and portal/mesenteric venous gas. The systematic literature search identified 9 articles describing 58 patients with IBD and PI. These cases were mostly included in larger cohorts of PI patients without extractable data on presentation or outcomes in the IBD subpopulation. CONCLUSIONS: Ours appears to be the first reporting of presentations and outcomes, outside of case reports, for those with PI and IBD. The high mortality for those with CD and PI of the small bowel appears to define a group requiring more than supportive medical care.

Ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration.

Dermoid cysts, or mature cystic teratomas, are complicated by malignant degeneration in only 1-2% of cases. Rarely, dermoid cysts result in complications of small bowel obstruction or entero-ovarian fistula formation. In the current report we present the case of a 59-year-old female with a known dermoid cyst who presented with leukocytosis and was discovered to have a small bowel obstruction at the level of an ileo-ovarian fistula. The patient was taken to the operating room and was treated with total abdominal hysterectomy, bilateral salpingo-oopherectomy, and short segment small bowel resection. Review of the surgical pathology revealed areas of malignant degeneration within the dermoid cyst to squamous cell carcinoma. To our knowledge, this is only the second reported case of an ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration.

Carotid Ultrasound Examinations: Indications Correlated With Abnormal Findings.

Our purpose was to evaluate the clinical indications for carotid duplex ultrasonography and determine for each indication how often carotid artery disease was identified.We retrospectively reviewed the consecutive reports for 3191 carotid ultrasound examinations. We tracked 14 indications to determine how often examinations were requested for each indication and correlated each indication with the finding of carotid artery disease.We found 26.5% of all examinations were abnormal; 17.5% of patients showed internal carotid artery disease; 10.9%, a moderate stenosis; 5.2%, a severe stenosis; and 1.4%, a total occlusion. For each of the 14 individual indications, with 1 exception, carotid ultrasound examination showed a 19.7% or greater chance of an abnormal result and an 11.6% or greater chance of finding a flow-limiting stenosis of an internal carotid artery.Our results validate the collaborative position of the American College of Radiology, the American Institute of Ultrasound in Medicine, the Society for Pediatric Radiology, and the Society of Radiologists in Ultrasound that, overall and for almost all indications they enumerate, carotid ultrasound examinations are a proven and useful procedure for evaluating extracranial carotid artery disease.

Incidental hepatic lesions detected on breast MRI: Rate of malignancy and implications for utilization.

OBJECTIVE: The objective of this study was to determine the rate of malignancy in incidentally detected T2 hyperintense hepatic lesions at breast MRI. METHODS: Incidental hepatic lesions identified during breast MRI, for which abdominal imaging was recommended, were retrospectively analyzed. RESULTS: Of the hepatic lesions, 97.3% were benign, and 2.7% were malignant, with a significant association between indication for the breast MRI and the malignancy status of the hepatic lesion (Fisher's Exact, P < 0.0142). CONCLUSION: Our initial experience suggests the benign nature of incidentally detected T2 hyperintense hepatic lesions at breast MRI in women without a newly diagnosed breast cancer.

Radiologic Imaging in Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis.

The article reviews the multimodality (ultrasound, computed tomography, and magnetic resonance [MR]) imaging appearance of nonalcoholic fatty liver disease (NAFLD) and discusses the radiologic diagnostic criteria as well as the sensitivity and specificity of these imaging methods. The authors review the role of both ultrasound and MR elastography for the diagnosis of fibrosis and for the longitudinal evaluation of patients following therapeutic intervention. Lastly, the authors briefly discuss the screening and diagnosis of hepatocellular carcinoma in patients with NAFLD, as there are special considerations in this population.

Appendiceal ganglioneuroma in neurofibromatosis type 2.

Here we report the case of a 30-year-old woman with a history of neurofibromatosis type 2 (NF2) who presented with an incidentally discovered pelvic mass on an ultrasound. The identity of the mass remained indeterminate following a CT and MRI, although appendiceal pathology was suspected. An elective laparoscopy and appendectomy were performed without complication and pathology on the specimen demonstrated an appendiceal ganglioneuroma. To our knowledge, there has been no prior documented case of an appendiceal ganglioneuroma in a patient with NF2. Furthermore, the current case is the first to report the MR characteristics of appendiceal ganglioneuromas.

Nontraumatic large bowel perforation: spectrum of etiologies and CT findings.

Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis.

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.

Small bowel volvulus in pregnancy with associated superior mesenteric artery occlusion.

Here we report the case of a pregnant 28-year-old who presented with acute upper abdominal pain. CT demonstrated midgut volvulus with short segment occlusion of the superior mesenteric artery (SMA). Emergent detorsion of the small bowel was performed, at which time underlying intestinal malrotation was discovered. Following detorsion, the SMA had a bounding pulse and did not require thrombectomy or revascularization. Fewer than 25 cases of midgut volvulus during pregnancy have been reported over the past 20years. To our knowledge, this is the first report of maternal midgut volvulus in which imaging captures the resultant occlusion of the SMA.

Abdominal and pelvic manifestations of Rosai-Dorfman disease: a review of four cases.

Rosai-Dorfman disease is a rare disorder of unknown etiology caused by the proliferation of histiocytes within lymph nodes, predominantly in the cervical chain. Extranodal sites may be involved as well, with involvement of nearly every organ system described in the literature. Abdominal and pelvic manifestations of Rosai-Dorfman disease are extremely rare. We present four cases of abdominal and pelvic involvement by Rosai-Dorfman disease, specifically within the biliary tract, pancreas, spleen, and presacral space. Of note, a presacral mass was present in three of the four patients, and although not previously reported in Rosai-Dorfman disease, may suggest the diagnosis in the proper clinical scenario.

Adenocarcinoma arising at ileostomy sites: Two cases and a review of the literature.

Total colectomy with ileostomy placement is a treatment for patients with inflammatory bowel disease or familial adenomatous polyposis (FAP). A rare and late complication of this treatment is carcinoma arising at the ileostomy site. We describe two such cases: a 78-year-old male 30 years after subtotal colectomy and ileostomy for FAP, and an 85-year-old male 50 years after colectomy and ileostomy for ulcerative colitis. The long latency period between creation of the ileostomies and development of carcinoma suggests a chronic metaplasia due to an irritating/inflammatory causative factor. Surgical excision of the mass and relocation of the stoma is the mainstay of therapy, with possible benefits from adjuvant chemotherapy. Newly developed lesions at stoma sites should be biopsied to rule out the possibility of this rare ileostomy complication.

A program director's guide to the Medical Student Performance Evaluation (former dean's letter) with a database.

PURPOSE: The value of the Medical Student Performance Evaluation (MSPE) for a program director is in the information it contains comparing how a student performed in medical school relative to his or her classmates. The Association of American Medical Colleges has recommended that a student's class ranking be included in the summary paragraph of the MSPE and that this information be repeated in a supplementary appendix. METHODS: The authors reviewed the MSPEs from 1,479 applications for residency training positions. The aim was to determine to what extent and in what manner individual schools reveal how their students perform relative to their peers. The authors then set out to create a database containing this information. RESULTS: Working from a list of 141 US members of the Association of American Medical Colleges, complete information for 107 schools (76%) and partial information for the remaining 34 schools (24%) was gathered. Only 12 schools (9%) included complete comparative information in the summary section in accordance with the guidelines of the Association of American Medical Colleges. Other schools were in partial compliance or did not comply at all. The database the authors constructed will inform users if comparative information is available, guide users to its location in the MSPE, and explain the meaning of the language different schools use to rank or classify their students. CONCLUSIONS: The authors recognize that this database is incomplete and that the individual institutions will alter their ranking system from time to time. But this database is offered in an open format so that it can be continuously updated by users.