Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel.

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging.

PURPOSE: To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR). METHODS: An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus. RESULTS: The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%. CONCLUSION: We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Use of a 3D-Printed Abdominal Compression Device to Facilitate CT Fluoroscopy-Guided Percutaneous Interventions.

OBJECTIVE: The purpose of this article is to describe a handheld external compression device used to facilitate CT fluoroscopy-guided percutaneous interventions in the abdomen. CONCLUSION: The device was designed with computer-aided design software to modify an existing gastrointestinal fluoroscopy compression device and was constructed by 3D printing. This abdominal compression device facilitates access to interventional targets, and its use minimizes radiation exposure of radiologists. Twenty-one procedures, including biopsies, drainage procedures, and an ablation, were performed with the device. Radiation dosimetry data were collected during two procedures.

Beyond moulage sign and TTG levels: the role of cross-sectional imaging in celiac sprue.

Celiac disease is an autoimmune disorder that causes inflammation and destruction in the small intestine of genetically susceptible individuals following ingestion of gluten. Awareness of the disease has increased; however, it remains a challenge to diagnose. This review summarizes the intestinal and extraintestinal cross-sectional imaging findings of celiac disease. Small intestine fold abnormalities are the most specific imaging findings for celiac disease, whereas most other imaging findings reflect a more generalized pattern seen with malabsorptive processes. Familiarity with the imaging pattern may allow the radiologist to suggest the diagnosis in patients with atypical presentations in whom it is not clinically suspected. Earlier detection allows earlier treatment initiation and may prevent significant morbidity and mortality that can occur with delayed diagnosis. Refractory celiac disease carries the greatest risk of mortality due to associated complications, including cavitating mesenteric lymph node syndrome, ulcerative jejunoileitis, enteropathy-associated T cell lymphoma, and adenocarcinoma, all of which are described and illustrated. Radiologic and endoscopic investigations are complimentary modalities in the setting of complicated celiac disease.

Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease.

OBJECTIVE: The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition. CONCLUSION: Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.

Computed tomography of miscellaneous regional and diffuse small bowel disorders.

This article reviews the computed tomography (CT) findings of miscellaneous regional and diffuse small bowel disorders. CT technique and potential pitfalls are discussed. Several categories of regional and diffuse small bowel conditions are reviewed, with representative CT images. These disorders often have relatively nonspecific CT appearances, and correlation with the history, clinical, and laboratory findings in each specific case is critical. In selected conditions, the CT findings are highly specific. The imaging literature of some of the common as well as some of the less common entities is reviewed, and clues to narrowing the differential diagnosis are provided.

CT findings in adult celiac disease.

Celiac disease is now recognized as a common disease, occurring in about one in every 200 Americans. However, less than 10% of cases are currently diagnosed, with a diagnostic delay of more than 10 years from onset of symptoms. In the past, barium examination of the small bowel demonstrated a pattern of abnormal findings caused by the pathophysiologic changes induced by malabsorption, thus leading to diagnosis of celiac disease and other diseases of malabsorption. Although not specific, that pattern prompted further patient evaluation. The number of barium examinations performed and the skill necessary to interpret their results are both in decline. Abdominal pain in celiac disease is a common early complaint that often leads to computed tomography (CT). Improved CT resolution now permits better depiction of the small bowel, colon, and mesenteric lymph nodes, all of which are affected by celiac disease. Detection of celiac disease with CT will allow treatment to be initiated to prevent the significant morbidity and increased mortality associated with a delay in diagnosis. The abnormal CT findings seen over the past decade during review of more than 200 cases of celiac disease demonstrate that CT depicts more features of celiac disease than did barium examination. Pattern recognition for the diagnosis of small bowel diseases that create structural changes in the bowel wall is well accepted. Because it demonstrates features of celiac disease not detected with barium examination, CT may be more sensitive than barium examination for diagnosis of this disease.

Angiotensin-converting enzyme inhibitor-induced small-bowel angioedema: clinical and imaging findings in 20 patients.

OBJECTIVE: The purpose of this article is to retrospectively review the radiologic and clinical findings in patients with angiotensin-converting enzyme inhibitor (ACEI)-induced small-bowel angioedema, with an emphasis on CT findings. MATERIALS AND METHODS: Imaging findings, with an emphasis on CT, and clinical characteristics of 20 patients (23 presentations) presenting to two institutions' emergency departments from 1996 through 2010 with ACEI-induced small-bowel angioedema were retrospectively reviewed by two abdominal radiologists who were aware of the diagnosis. Examinations were reviewed in consensus to determine common radiographic findings. RESULTS: Patient age range was 23-83 years (mean, 56 years). Sixteen of the 20 patients were women, and 15 of 20 were obese. All had acute onset of severe abdominal pain. The date of the initial episode prompting CT evaluation ranged from 2 days to 10 years after the start of ACEI therapy (average, 3.3 years). All patients underwent abdominal CT examinations while symptomatic; five patients also underwent a small-bowel series. Three patients underwent urgent surgery for presumed small-bowel ischemia. All patients had resolution of symptoms within 4 days of hospitalization. CT findings included ascites in all patients, small-bowel wall thickening (mean, 1.3 cm), mild dilatation (mean, 2.9 cm), and straightening. There was no small-bowel obstruction. CONCLUSION: ACEI-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACEI therapy present with abdominal complaints and the following combination of findings on CT examination: ascites, small-bowel wall thickening, dilatation without obstruction, and straightening.

Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings.

Differentiation of direct inguinal hernias, indirect inguinal hernias, and femoral hernias is often difficult at clinical examination and presents challenges even at diagnostic imaging. With the advent of higher-resolution multidetector computed tomography (CT), the minute anatomic detail of the inguinal region can be better delineated. The authors examine the appearance of these hernias at axial CT, as the axial plane remains the diagnostic mainstay of evaluation of acute abdomen. They review and label key anatomic structures, present cases of direct and indirect inguinal hernias and femoral hernias, and demonstrate their anatomic differences on axial images. Direct inguinal hernias protrude anteromedial and inferior to the course of the inferior epigastric vessels, whereas indirect inguinal hernias protrude posterolateral and superior to the course of those vessels. The proposed lateral crescent sign may be useful in diagnosis of early direct inguinal hernias, as it represents lateral compression and stretching of the inguinal canal fat and contents by the hernia sac. Femoral hernias protrude inferior to the course of the inferior epigastric vessels and medial to the common femoral vein, often have a narrow funnel-shaped neck, and may compress the femoral vein, causing engorgement of distal collateral veins. Familiarity with these anatomic differences at axial CT, along with the lateral crescent sign of direct inguinal hernias, may help the radiologist better assist the clinician in accurate diagnosis of the major types of hernias of the inguinal region. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.312105129/-/DC1.

Colonic diverticulitis: does age predict severity of disease on CT imaging?

PURPOSE: The aim of our study was to determine whether young patients with diverticulitis were more likely to present with abdominal CT evidence of severe disease. METHODS: We analyzed the abdominal CT scans of 932 patients who presented to our institution with CT scan findings consistent with diverticulitis from January 2002 through June 2007. Radiologists retrospectively reviewed all abdominal scans for the presence of imaging findings consistent with diverticulitis (bowel wall thickness, extraluminal air, free perforation, abscess, or fistula). The cohort was divided into 2 groups; patients 51 years of age. RESULTS: Two hundred forty-three patients were 51 years. Young patients were more likely to be male (63% vs 42%, P < .0001). Young patients had a higher proportion of scans with extraluminal air than older patients (19.7% vs 12.6%, P < .008). Young patients were more likely to present with severe disease found by CT than older patients (19.3% vs 11.5%). When we adjusted for gender, young males had a higher proportion of scans with extraluminal air than older males (22.4% vs 13.1%, P = .014). Young males were also more likely to present with severe disease (22% vs 12%). CONCLUSION: Young patients were more likely to have extraluminal air and severe disease found by CT. Young male patients presented more commonly with evidence of severe disease. They did not differ from older patients in rates of free perforation, abscess, or fistula formation.

Pharyngeal dysphagia: what the radiologist needs to know.

Dysphagia is defined as difficulty in swallowing. Oropharyngeal dysphagia is defined as difficulty in moving the bolus from the mouth to the esophagus. The best initial evaluation of suspected oropharyngeal dysphagia is a barium study which can evaluate motility of the oropharynx and hypopharynx and provide double-contrast views that may identify structural or mucosal abnormalities. Pharyngeal diverticula, Zenker's and Killian-Jamieson diverticula, and pharyngeal pouches are readily identified on these studies. Zenker's diverticula are the commonest diverticulum implicated in pharyngeal dysphagia and typically occur in the setting of cricopharyngeal dysfunction. The radiologist must not only diagnose these diverticula but also understand the normal postoperative appearance after diverticulotomy, often confusing for the uninitiated imager. Cervical webs are a common finding in pharyngeal dysphagia and should not be mistaken for a normal postcricoid defect. Other potentially challenging diagnostic issues include correct identification of lingual hyperplasia, which mimics lymphoma, and detection of squamous carcinoma, which is more mass-like but sometimes difficult to see among the complex anatomic lines of the pharynx. All of the above abnormalities are easily differentiated from the retention cyst, the most common "mass" in the pharynx. Pathology extrinsic to the pharynx, such as tumor and cervical osteophytes, can result in secondary symptoms from mass effect. This article discusses the various radiographic findings in normal and abnormal states of the pharynx, an anatomically and functionally complicated segment of the gastrointestinal tract.

An update on biliary imaging.

This article provides an overview of the gamut of biliary imaging techniques currently available to the clinician. It provides a brief history of biliary imaging, particularly intravenous cholangiography, including most commonly used contrast agents. This history is followed by a detailed discussion of modern-day practice modalities, including fluoroscopic and barium cholangiography, CT cholangiography, and magnetic resonance cholangiopancreatography.

Intramural fat in the duodenum and proximal small intestine in patients with celiac disease.

OBJECTIVE: The purpose of this article is to describe and illustrate intramural fat in the duodenum and jejunum, to our knowledge a previously undescribed finding in celiac disease. CONCLUSION: Celiac disease is known to produce inflammation of the duodenum and jejunum. We propose that postinflammatory intramural fat deposition occurs in a distribution likely unique for celiac disease. CT scans of the chest and abdomen obtained for many indications include these portions of the bowel. Celiac disease is now recognized as a common disease, and the recognition of intramural fat in the duodenum and jejunum on CT may allow earlier diagnosis.

Radiology of the laparoscopic Roux-en-Y gastric bypass procedure: conceptualization and precise interpretation of results.

Obesity is an epidemic in the United States. The laparoscopic Roux-en-Y gastric bypass procedure is an effective surgical intervention that can produce dramatic weight loss in morbidly obese patients. Despite the inherent risks, the surgery is increasing in popularity. Radiology plays a crucial role in postoperative evaluation. Upper gastrointestinal (UGI) series and abdominal computed tomography (CT) are the primary radiologic tools used in assessment of possible complications. With knowledge of the normal postoperative appearance, performance of UGI studies and interpretation of the results should be easy. The 24-hour postoperative examination allows reliable detection of anastomotic leaks. Although strictures of the gastrojejunal anastomosis are a common complication, they are often diagnosed and treated with endoscopy. In a thorough examination, one also evaluates for degraded pouch restriction, including a patulous gastrojejunal anastomosis or gastrogastric fistula, as a late cause of weight gain. Knowledge of the postoperative anatomy also assists in detection of internal hernias. CT is invaluable in detection and characterization of small bowel obstructions and internal hernias. CT may allow diagnosis of anastomotic leaks, abscesses, gastrogastric fistulas, and intra-abdominal hematomas. CT-guided percutaneous procedures, such as placement of gastrostomy tubes or drainage of fluid collections, can obviate emergency exploration and may be the only procedural intervention necessary for a cure.