Conservative Treatment in Diverticulitis Patients with Pericolic Extraluminal Air and the Role of Antibiotic Treatment.

BACKGROUND: Recently published studies advocate a conservative approach with observation and antibiotic treatment in diverticulitis patients with pericolic air on computed tomography (CT). The primary aim of this study was to assess the clinical course of initially conservatively treated diverticulitis patients with isolated pericolic air and to identify risk factors for conservative treatment failure. The secondary aim was to assess the outcome of non-antibiotic treatment. METHODS: Patient data from a retrospective cohort study on risk factors for complicated diverticulitis were combined with data from the DIABOLO trial, a randomised controlled trial comparing non-antibiotic with antibiotic treatment in patients with uncomplicated diverticulitis. The present study identified all patients with Hinchey 1A diverticulitis with isolated pericolic air on CT. Pericolic air was defined as air located < 5 cm from the affected segment of colon. The primary outcome was failure of conservative management which was defined as need for percutaneous abscess drainage or emergency surgery within 30 days after presentation. A multivariable logistic regression of clinical, radiological and laboratorial parameters with respect to treatment failure was performed. RESULTS: A total of 109 patients were included in the study. Fifty-two (48%) patients were treated with antibiotics. Nine (8%) patients failed conservative management, seven (13%) in the antibiotic treatment group and two (4%) in the non-antibiotic group (p = 0.083). Only (increased) CRP level at presentation was an independent predictor for treatment failure. CONCLUSIONS: Conservative treatment in diverticulitis patients with isolated pericolic air is a suitable treatment strategy. Moreover, non-antibiotic treatment might be reasonable in selected patients.

Gouty arthritis: decision-making following dual-energy CT scan in clinical practice, a retrospective analysis.

To establish whether dual-energy CT (DECT) is a diagnostic tool, i.e., associated with initiation or discontinuation of a urate lowering drug (ULD). Secondly, to determine whether DECT results (gout deposition y/n) can be predicted by clinical and laboratory variables. Digital medical records of 147 consecutive patients with clinical suspicion of gout were analyzed retrospectively. Clinical data including medication before and after DECT, lab results, and results from diagnostic joint aspiration and DECT were collected. The relationship between DECT results and clinical and laboratory results was evaluated by univariate regression analyses; predictors showing a p < 0.10 were entered in a multivariate logistic regression model with the DECT result as outcome variable. A backward stepwise technique was applied. After the DECT, 104 of these patients had a clinical diagnosis of gout based on the clinical judgment of the rheumatologist, and in 84 of these patients, the diagnosis was confirmed by demonstration of monosodium urate (MSU) crystals in synovial fluid (SF) or by positive DECT. After DECT, the current ULD was modified in 33 (22.4%) of patients; in 29 of them, ULD was started and in 1 it was intensified. Following DECT, the current ULD was stopped in three patients. In the multivariable regression model, cardiovascular disease (OR 3.07, 95% CI 1.26-7.47), disease duration (OR 1.008, 95% CI 1.001-1.016), frequency of attack (OR 1.23, 95% CI 1.07-1.42), and creatinine clearance (OR 2.03, 95% CI 0.91-1.00) were independently associated with positive DECT results. We found that the DECT result increases the confidence of the prescribers in their decision to initiation or discontinuation of urate lowering therapy regimen in of mono- or oligoarthritis. It may be a useful imaging tool for patients who cannot undergo joint aspiration because of contraindications or with difficult to aspirate joints, or those who refuse joint aspiration. We also suggest the use of DECT in cases where a definitive diagnosis cannot be made from signs, symptoms, and MSU analysis alone.

Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse.

AIM: This study compared the diagnostic capabilities of dynamic magnetic resonance defaecography (D-MRI) with conventional defaecography (CD, reference standard) in patients with symptoms of prolapse of the posterior compartment of the pelvic floor. METHOD: Forty-five consecutive patients underwent CD and D-MRI. Outcome measures were the presence or absence of rectocele, enterocele, intussusception, rectal prolapse and the descent of the anorectal junction on straining, measured in millimetres. Cohen's Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the positive and negative likelihood ratio of D-MRI were compared with CD. Cohen's Kappa and Pearson's correlation coefficient were calculated and regression analysis was performed to determine inter-observer agreement. RESULTS: Forty-one patients were available for analysis. D-MRI underreported rectocele formation with a difference in prevalence (CD 77.8% vs D-MRI 55.6%), mean protrusion (26.4 vs 22.7 mm, P = 0.039) and 11 false negative results, giving a low sensitivity of 0.62 and a NPV of 0.31. For the diagnosis of enterocele, D-MRI was inferior to CD, with five false negative results, giving a low sensitivity of 0.17 and high specificity (1.0) and PPV (1.0). Nine false positive intussusceptions were seen on D-MRI with only two missed. CONCLUSION: The accuracy of D-MRI for diagnosing rectocele and enterocele is less than that of CD. D-MRI, however, appears superior to CD in identifying intussusception. D-MRI and CD are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.

[Intermittent flank pain]. / Intermitterende flankpijn.

Flank pain is a common problem that can be caused by a variety of abnormalities. In this case report we describe two patients with intermittent flank pain with an unusual cause: intermittent ureteropelvic junction obstruction due to crossing of accessory renal vessels. Instant imaging at the time when the symptoms occur seems the best way to prevent delays in diagnosis and treatment.

Neurofibromatosis presenting with a cherubism phenotype.

We report on a child who presented clinical manifestations of both neurofibromatosis type 1 (NF1) and cherubism. With genetic testing, we found a mutation in the NF-1 gene, confirming the neurocutaneous disorder. Histology when correlated with radiological evaluation of a mandibular biopsy was consistent with cherubism. This is the first report in the literature of a child with proven neurofibromatosis type 1 and cherubism without extragnathic lesions. This emphasises that cherubism is a clinical phenotype that can be associated with a number of germline mutations involving SH3BP2, PTPN11 and NF1.

[Diagnostic image (253). A man with a swollen penile base and scrotum]. / Diagnose in beeld (253). Een man met een gezwollen penisbasis en scrotum.

A 29-year-old man heard a snap during sexual intercourse followed by immediate detumescence and a swelling of the penile basis and scrotum, due to a penile fracture.

Postpartum ovarian vein thrombosis: report of a case and review of literature.

Postpartum ovarian vein thrombosis (POVT) is an uncommon disease and it may complicate streptococcal group B infection of the vagina and endometrium. Obstruction of the right ureter is an uncommon complication of POVT. We present a case of POVT complicated by thrombus extension in the inferior vena cava and ureteral obstruction with urinary leakage, and outline the clinical presentation, radiological investigations useful in diagnosis and treatment of the disease process.