Pancreatic Injury in Patients with SARS-Cov-2 (COVID-19) Infection: A Retrospective Analysis of CT Findings.

OBJECTIVE: To determine the association between COVID-19 infection and peripancreatic changes on CT as a sign of acute pancreatic injury. METHODS: Retrospective analysis of CT examinations in patients with confirmed COVID-19 infection yielded 103 instances. An age- and gender-matched cohort of patients without COVID-19 was found. CT examinations were evaluated for peripancreatic stranding or edema, fluid collection, or necrosis, without any other explanation. Depicted pulmonary parenchyma was evaluated for possible COVID-19-related changes. Clinical and laboratory data were retrieved from the clinical database. RESULTS: Peripancreatic fat stranding (n = 8) or fluid collection (n = 2) without any other cause was found in 10 (10%) patients. Abdominal complaints were reported in 4 (40%) patients. Elevated serum amylase or lipase levels were documented in 5 (50%) patients who also satisfied the diagnostic criteria for acute pancreatitis. From the study sample of 103 patients with COVID-19, pulmonary parenchyma was depicted in 102 (99%), and from these, 57 (55%) had an evidence of pulmonary changes compatible with COVID-19 pneumonia. This proportion was not significantly different between patients with and without peripancreatic changes (p = 0.35). In the matched cohort, we found peripancreatic changes in 2 (2%, p = 0.033) patients. Patients with pancreatic injury and elevated amylase levels were more likely to require orotracheal intubation (35% vs. 12%, p = 0.021). CONCLUSIONS: We showed that the prevalence of peripancreatic stranding or fluid collection is higher in patients diagnosed with COVID-19 infection compared to an age- and gender-matched cohort. Patients with pancreatic injury and elevated amylase levels are more likely to require orotracheal intubation. Our findings corroborate the link between COVID-19 infection and pancreatic injury from the perspective of imaging.

A bimodal pattern of the onset of COVID-19 related acute pancreatitis supports both the cytotoxic and immune-related pathogenesis - a systematic review.

OBJECTIVES: To review clinical and laboratory findings in patients with SARS-Cov-2 (COVID-19) related acute pancreatitis. METHODS: This systematic review was based on a database search for articles of COVID-19 related acute pancreatitis in adult patients with confirmed COVID-19 infection that included age, gender, presenting symptoms, the onset of symptoms, laboratory values, imaging findings and exclusion of common causes of pancreatitis. RESULTS: Altogether 35 articles comprising 37 patients were included. Acute pancreatitis was the first presentation of COVID-19 in 43% of patients, concurrent with general or respiratory symptoms in 14% of patients or delayed after general or pulmonary symptoms by an average of 10 ± 5 d (range, 1 - 19 d) in 43% of patients. Serum amylase and lipase levels were elevated in 87% and 100% of patients. In 50% and 84%, amylase and lipase levels exceeded three-fold the upper normal limit. Pancreatic necrosis was reported in 6% of patients and in 12% of patients, the pancreas appeared normal. Three patients died. CONCLUSIONS: We conclude that the bi-modal pattern of the onset of symptoms supports both the cytotoxic and the immune-related pathogenesis of the pancreatic injury. Acute pancreatitis may be the first symptom of COVID-19 infection. Necrosis of the pancreas is rare.

CT colonography has low sensitivity but high specificity in the detection of internal hemorrhoids.

PURPOSE: We aimed to evaluate the diagnostic performance of computed tomography colonography (CTC) in the detection of internal hemorrhoids. METHODS: Three gastroenterologists systematically reported on the presence of internal hemorrhoids in patients with incomplete colonoscopy, for whom they considered a subsequent CTC. For 44 patients with internal hemorrhoids revealed by optical colonoscopy, an age- and gender-matched cohort of 66 patients with normal findings in the rectum was selected. Endoluminal and transaxial CTC views of the rectum were evaluated for the presence of internal hemorrhoids, the anal verge prominence, asymmetry, and cushion-like appearance on a Likert scale by two experienced radiologists and two gastroenterologists. RESULTS: The sensitivity, specificity, and AUC for identification of internal hemorrhoids were 0.61 (95% CI, 0.53-0.68), 0.69 (95% CI, 0.63-0.75) and 0.66 (95% CI, 0.62-0.70), respectively. The radiologists showed a better specificity, the gastroenterologists a slightly better sensitivity. When only the rating "very likely" was considered as positive, the specificity rose to 0.89 (95% CI, 0.81-0.94) with a sensitivity of 0.50 (95% CI, 0.38-0.62). The interobserver agreement was fair. The best predictor of the presence of hemorrhoids was a prominent anal verge in the supine position (OR=1.789, 95% CI, 1.267-2.525). The difference between supine and prone positions in the evaluated features in patients with internal hemorrhoids was not significant. CONCLUSION: CTC has low sensitivity but high specificity in the detection of internal hemorrhoids, if the rater is confident in detecting them. Internal hemorrhoids do not substantially change their shape between prone and supine positions.

Intraoperative measurement of pressure gradient in median arcuate ligament syndrome as a rationale for radical surgical approach.

BACKGROUND: Median arcuate ligament syndrome (MALS) describes clinical symptoms in patients with stenosis of the celiac artery due to external compression by the ligament. There is an ongoing debate, whether sole release of the median arcuate ligament warrants long-term relief of the symptoms. MATERIALS AND METHODS: Eight patients diagnosed with MALS underwent open surgical treatment beginning with the release of the ligament. Systemic pressure and pressure in the left gastric artery were measured before and after division of the median arcuate ligament and release of the celiac artery. In patients with persistent gradient above 15 mm Hg after the release a PTFE bypass was performed. RESULTS: After the release, the pressure gradient decreased from 66 ± 19 to 48 ± 14 mm Hg (p = .001) and therefore in all patients either an aorto-celiac bypass (n = 6) or aorto-hepatic bypass (n = 2) was created. Consequently, the gradient decreased to 7 ± 2 mm Hg (p = .0001). One month postoperatively, three patients were free of symptoms and the rest reported relief of symptoms. CONCLUSIONS: Release of the celiac artery resulted in insufficient decrease of pressure gradient, which was achieved by bypassing the segment with favorable mid-term outcome. We believe that the effect of the release should always be assessed to decide on subsequent treatment.

The predictive value of computed tomography in the detection of reflux esophagitis in patients undergoing upper endoscopy.

BACKGROUND: Reflux esophagitis (RE) may mimic symptoms requiring cross-sectional imaging. METHODS: From 565 patients who had CT and esophagogastroduodenoscopy within four days apart, CT scans of 72 patients with RE confirmed by esophagogastroduodenoscopy and 108 matched patients without RE were evaluated for distal esophageal wall characteristics. RESULTS: In RE patients the distal esophageal wall thickness was greater (5.2±2.0mm) compared to patients without RE (3.5±1.2mm, p<0.0001) with AUC of 0.78 and 56% sensitivity, 88% specificity for a 5.0mm cut-off. CONCLUSIONS: There is a moderate association between distal esophageal wall thickness on CT and RE diagnosed by esophagogastroduodenoscopy as the reference standard.

Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is a rare disease with an incidence of 0.1 to 10 per million inhabitants a year caused by impaired venous outflow from the liver mostly at the level of hepatic veins and inferior vena cava. Etiological factors include hypercoagulable conditions, myeloprolipherative diseases, anatomical variability of the inferior vena cava, and environmental conditions. Survival rates in treated patients range from 42 to 100% depending on the etiology and the presence of risk factors including parameters of Child-Pugh score, sodium and creatinine plasma levels, and the choice of treatment. Without treatment, 90% of patients die within 3 years, mostly due to complications of liver cirrhosis. BCS can be classified according to etiology (primary, secondary), clinical course (acute, chronic, acute or chronic lesion), and morphology (truncal, radicular, and venooclusive type). The diagnosis is established by demonstrating obstruction of the venous outflow and structural changes of the liver, portal venous system, or a secondary pathology by ultrasound, computed tomography, or magnetic resonance. Laboratory and hematological tests are an integral part of the comprehensive workup and are invaluable in recognizing hematological and coagulation disorders that may be identified in up to 75% of patients with BCS. The recommended therapeutic approach to BCS is based on a stepwise algorithm beginning with medical treatment (a consensus of expert opinion recommends anticoagulation in all patients), endovascular treatment to restore vessel patency (angioplasty, stenting, and local thrombolysis), placement of transjugular portosystemic shunt (TIPS), and orthotopic liver transplantation as a last resort rescue treatment.

Computed Tomography Colonography Phantom: Construction, Validation and Literature Review.

BACKGROUND: Several dedicated computed tomography (CT) colonography phantoms have been described previously. OBJECTIVES: To compare their pros and cons and describe the construction of a dedicated phantom that can be easily manufactured. MATERIALS AND METHODS: We found 15 different phantom designs by literature search and compared their advantages and disadvantages based on their description and images. We tested various materials for density and mechanical properties and constructed a phantom from polypropylene pipes (30 mm and 50 mm in diameter, 52 cm in length). Haustral folds were created by heat shaping and 39 intermediate sessile polyps with a target size of 6-10 mm and two flat lesions were created from silicone. Nine polyps were attached to a fold. The model was placed in a 30-cm barrel filled with water to simulate attenuation of human body. Attenuation of polyps was compared to intermediate polyps found in patients. RESULTS: None of the earlier colonic phantoms found in the literature incorporated all the properties that would ensure both reproducibility and validity of the model (including a rigid wall, density of the wall and polyps similar to human colon, at least two levels of distension and durability). In the present phantom, the average size of sessile polyps was 8.6 ± 0.9 mm and their density was 53 ± 24 HU. We found no significant difference in polyp density between simulated polyps in the phantom and polyps in human subjects (P = 0.70). All polyps, with the exception of one flat lesion, were detected by computer aided detection. CONCLUSION: We constructed and validated a CT colonography phantom with correct density allowing performance of reproducible experiments.

Intercondylar Route of Prosthetic Infragenicular Femoropopliteal Bypass Has Better Primary, Assisted, and Secondary Patency but Not Limb Salvage Rate Compared to the Medial Route.

Aim. To compare the differences between medial and intercondylar infragenicular femoropopliteal prosthetic bypasses in terms of their midterm patency and limb salvage rates. Methods. Ninety-three consecutive patients with peripheral arterial disease who underwent a simple distal femoropopliteal bypass using a reinforced polytetrafluorethylene graft were included in this retrospective study. The bypass was constructed in the intercondylar route in 52 of the patients (group A) and in 41 in the medial route (group B). Results. Median observation time of the patients was 12.7 (IQR 4.6-18.5) months. There were 22 and 24 interventional or surgical procedures (angioplasty, stenting, thrombolysis, thrombectomy, or correction of the anastomosis) performed to restore patency of the reconstruction in groups A and B, respectively (p = 0.14). The 20-month primary, assisted, and secondary patency rates and limb salvage rates were 57%, 57%, 81%, and 80% in group A compared to 21%, 23%, 55%, and 82% in group B (p = 0.0012, 0.0052, 0.022, and 0.44, resp.). Conclusion. Despite better primary, assisted, and secondary patency rates in patients with a prosthetic infragenicular femoropopliteal bypass embedded in the intercondylar fossa compared to patients with the medial approach, there is no benefit in terms of the limb salvage rate and the number of interventions required to maintain patency of the reconstruction.

Juxtarenal Mycotic Aneurysm as a Complication of Acute Exacerbation of Chronic Cholecystitis Treated by Resection and Replacement by a Fresh Allograft.

We present a case of a female patient with infectious (mycotic) juxtarenal abdominal aneurysm with atypical symptoms beginning as acute exacerbation of chronic cholecystitis. Apart from common antibiotic treatment, the patient successfully underwent resection of the diseased segment and replacement by a fresh allograft in order to reduce the risk of infection of the graft, but with the need of subsequent life-long immunosuppressive therapy. Perioperative monitoring of the spinal cord by near infrared spectroscopy was used to identify possible spinal ischemia. The choice of the fresh allograft was based on our experience supported by review of the literature.