[Rare cause of gastrointestinal bleeding]. / Seltene Ursache einer gastrointestinalen Blutung.

HISTOLOGY AND CLINICAL FINDINGS: We report on a 66-year-old-patient with plasmocytoma, who presented with melena since 3 days, dyspnea and dizzyness. INVESTIGATION AND DIAGNOSIS: Because of the laboratory and clinical examination the suspected diagnosis was an active gastrointestinal bleeding. The performed gastroduodenoscopy and sigmoidoscopy could not verify an active bleeding. Thus a contrast-enhanced computed tomography was performed additionally and showed abnormal enhancement as well as a ballooning of the proximal jejunum. Subsequently a jejunoscopy was performed where an actively bleeding mass was found. TREATMENT AND COURSE: Due to the known medical history of a plasmocytoma and in conjunction with the performed examinations the suspected diagnosis of an extramedullary metastasis of a plasmocytoma in the jejunum was made. Since only temporary control of the bleeding could be achieved, a segmental resection of the small bowel was performed. The following histological examination confirmed the diagnosis. CONCLUSION: The differential diagnosis for gastrointestinal bleeding includes also rarely neoplastic manifestations in the small bowel. Contrast-enhanced computed tomography can aide in the localization of the bleeding side and determination of the cause of hemorrhage.

The clinical role of multimodality imaging in the detection of prostate cancer recurrence after radical prostatectomy and radiation therapy: past, present, and future.

Detection of the recurrence sites in prostate cancer (PCa) patients affected by biochemical recurrence after radical prostatectomy (RP) and radiation therapy (RT) is still a challenge for clinicians, nuclear medicine physicians, and radiologists. In the era of personalised and precision care, this task requires the integration, amalgamation, and combined analysis of clinical and imaging data from multiple sources. At present, multiparametric Magnetic Resonance Imaging (mpMRI) and choline-positron emission tomography (PET) are giving encouraging results; their combination allows the effective detection of local, lymph nodal, and skeletal recurrences at low PSA levels. Future diagnostic perspectives include the clinical implementation of PET/MRI scanners, multimodal fusion imaging platforms for retrospective co-registration of PET and MR images, real-time transrectal ultrasound/mpMRI fusion imaging, and novel organ-specific PET radiotracers.

Multimodality fusion imaging in abdominal and pelvic malignancies: current applications and future perspectives.

Medicine is evolving toward personalized care and this development entails the integration, amalgamation, and synchronized analysis of data from multiple sources. Multimodality fusion imaging refers to the simultaneous visualization of spatially aligned and juxtaposed medical images obtained by two or more image modalities. PET/MRI scanners and MMFI platforms are able to improve the diagnostic workflow in oncologic patients and provide exquisite images that aid physicians in the molecular profiling and characterization of tissues. Advanced navigation platforms involving real-time ultrasound are promising tools for guiding personalized and tailored mini-invasive interventional procedures on technically challenging targets. The main objective of the present essay was to describe the current applications and future perspectives of multimodality fusion imaging for both diagnostic and interventional purposes in the field of abdominal and pelvic malignancies. We also outlined the technical differences between fusion imaging achieved by means of simultaneous bimodal acquisition (i.e., integrated PET/MRI scanners), retrospective co-registration, and multimodality fusion imaging involving ultrafast or real-time imaging modalities.

CT of the abdomen: degree and quality of enhancement obtained with two concentrations of the same iodinated contrast medium with fixed iodine delivery rate and total iodine load.

OBJECTIVES: to compare vascular and parenchymal enhancement in abdominal computed tomography (CT) using two iodine concentrations (370 vs 300mgI/mL) of the same contrast medium (CM) molecule (iopromide), using fixed iodine delivery rate (IDR, 1.2gI/s) and total iodine load (630mgI/kg). METHODS: 144 patients were randomized into two groups: group A receiving iopromide 370 and group B receiving iopromide 300. Attenuation values (AV) were measured in correspondence to key anatomical structures on different phases and compared between groups with parametrical tests. Qualitative analysis was also performed. Peak injection pressure and local discomfort at the site of injection (pain and warmth) were registered. RESULTS: mean AV of abdominal aorta in late arterial phase were 300.32±59.76 for group A and 298.2±59.14 for group B (p=0.8); mean AV of portal vein in portal phase were 190.5±29.92 for group A and 192.91±24.12 for group B (p=0.6). Mean AV of liver parenchyma in portal phase were 124.73±18.22 for group A and 125.11±15.7 for group B (p=0.9); mean AV of liver at equilibrium were 85.11±7.75 for group A and 85.41±8.09 for group B (p=0.8). Qualitative analysis did not show significant differences between groups (p>0.05). Median peak injection pressure was lower in group B (93psi, 76-172) than in group A (115psi, 88-288, p<0.0001), while discomfort at injection site was not significantly different (p>0.05). CONCLUSIONS: with fixed IDR and total iodine load, comparable quantitative and qualitative enhancement can be achieved with different concentrations of the same CM. Peak injection pressure increases using CM with higher iodine concentration.

Crohn's disease: value of diagnostic imaging in the evaluation of anastomotic recurrence.

UNLABELLED: In patients who had previously undergone ileocolic resection due to Crohn's disease (CD) complications, anastomotic recurrence is a frequent event, which may lead to further surgical interventions. Optical colonoscopy with retrograde ileoscopy is currently the reference standard technique to confirm the clinical suspicion of anastomotic recurrence; however, the ileal side of ileocolic anastomoses may not be assessed due to technical complexities in approximately 1/3 of cases. Moreover, endoscopy allows for an investigation limited to the mucosal surface without demonstrating trans-mural involvement and/or penetrating complications (i.e. fistulas and abscesses). Imaging plays an important role in the assessment of both ileocolic and entero-enteric anastomoses in patients with CD. Conventional radiological methods (i.e. small bowel enteroclysis and small bowel follow through) can effectively depict the presence of aphthous ulcers and other mild and subtle mucosal abnormalities, but they are not precise for the diagnosis of transmural and extramural disease. CT - and MR- enterography accurately demonstrate both the extent of bowel wall involvement and the presence of penetrating complications. The main cross-sectional imaging findings observed in CD (including anastomotic recurrence) are small bowel wall thickening with bilaminar or trilaminar stratification, hyperdensity and oedema of the mesenteric fat, engorged mesenteric vasa recta ("comb sign"), sub-mucosal fibro-fatty infiltration and mesenteric adenopathy. Ultrasonography performed after distension of small bowel loops with anechoic contrast agents (Small Intestine Contrast Ultrasonography - SICUS -) is a non-invasive imaging technique which can detect early inflammatory alterations of the anastomosis. On the other hand ultrasonography is an operator-dependent technique and it lacks of a large anatomic field of view. KEY WORDS: Computed Tomography enterography, Crohn's disease, Ileocolic anastomosis, Magnetic Resonance Imaging.

Crohn's disease recurrence in patients with ileocolic anastomosis: value of computed tomography enterography with water enema.

OBJECTIVES: The main objective of the present work was to determine the diagnostic value of CT-enterography with water enema (CTe-WE) in the assessment of the ileocolic anastomosis in patients with Crohn's disease (CD). The prevalence of synchronous inflammatory lesions (SILs) involving gastrointestinal segments distinct from the anastomosis was also determined. Further, the association between the type of ileocolic anastomosis and the behavior (i.e. inflammatory, stricturing, penetrating) of CD recurrence was evaluated. METHODS: 51 patients were retrospectively included (26 [51%] male and 25 [49%] female; mean age: 52.88 years ± 13.35). Ileocolic anastomoses were: 18 (35.3%) stapled side-to-side, 17 (33.3%) end-to-side, and 16 (31.4%) end-to-end. CTe-WEs were reviewed in consensus by two gastrointestinal radiologists. Endoscopy and medical records were used as reference standards. RESULTS: CTe-WE yielded 95.35% sensitivity (CI 95%: 84.19-99.43%), 75.00% specificity (CI 95%: 34.91-96.81%), and 92.15% diagnostic accuracy (CI 95%: 81.31-98.02%). Anastomotic recurrence was found in 41/51 (80.4%) patients, including 30/41 (73.2%) cases of isolated anastomotic recurrence, and 11/41 (26.8%) cases of anastomotic recurrence with a SIL. A significant lower prevalence of stricturing recurrence was observed in patients with stapled side-to-side anastomoses (p=0.033). CONCLUSIONS: CTe-WE provides a good distension of both sides of ileocolic anastomoses allowing the detection of SILs.