Cross-Sectional Abdominal Imaging Findings in Patients With COVID-19.

Objective We aimed to review and analyze cross-sectional abdominal imaging findings in a cohort of 10 patients who had tested positive for coronavirus disease 2019 (COVID-19). Methods This retrospective study conducted from April 1, 2020, to May 13, 2020, involved two institutions that comprised a central tertiary academic institution and multiple smaller community hospitals. We reviewed and examined cross-sectional imaging studies of patients who tested positive for COVID-19 either during the emergency room (ER) visit or hospital admission. Salient imaging findings and medical records were reviewed. Results A total of 10 COVID-19-positive patients (seven males and three females) of ages ranging from 21-75 years underwent cross-sectional abdominopelvic imaging. Nine of the 10 patients demonstrated typical lung base findings associated with COVID-19 on both CT and MRI. Twelve CT abdominopelvic examinations, one MRI abdomen, and one right upper quadrant ultrasound (RUQ US) were performed, with three patients undergoing two CT scans during the course of hospitalization. Gastric and bowel wall abnormalities were found on 25% (n=3/12) of abdominal CT scans. Acute interstitial pancreatitis and acute cholecystitis were both found on one CT exam. The remaining (n=7/12, 58%) CT studies demonstrated no acute intraabdominal pathology with incidental findings including fatty liver disease, cirrhosis, and splenomegaly. Conclusion A spectrum of abdominal imaging findings ranging from colitis to pancreatitis may be correlated with COVID-19 infection, even though the majority of our patients with gastrointestinal (GI) symptoms did not have identifiable GI pathology on imaging.

Correlating computed tomography pulmonary angiography signs of right ventricular strain in pulmonary embolisms to clinical outcomes.

INTRODUCTION: Right ventricular strain (RVS) in pulmonary embolism (PE) can be used to stratify risk and direct intervention. The clinical significance of computed tomography pulmonary angiogram (CTPA)-derived radiologic signs of RVS, however, remains incompletely characterized. We retrospectively analyzed a cohort of persons with acute PE to determine which, if any, findings of RVS on CTPA correlate with clinical outcomes. METHODS: All patients with PE diagnosed on CTPA from March 2013 through February 2015 at Lyndon B. Johnson Hospital were identified. Their records were retrospectively reviewed to identify length of stay, intensive care unit (ICU) placement, hemodynamic failure, use of thrombolytics, vasopressor requirement, mechanical ventilation, and attributable mortality. Three radiologists, blinded to clinical outcomes, separately reviewed the cohort's CTPAs to identify signs of RVS - pulmonary trunk size, internal size of the right and left ventricles, paradoxical interventricular septal bowing, inferior vena cava (IVC) contrast reflux, and hepatic vein contrast reflux. RESULTS: In our cohort of 102 persons, 12 demonstrated hemodynamic failure, 13 required ICU placement, 3 received thrombolysis, and 5 had death attributable to PE. The greatest interobserver agreement among radiologists existed for the presence of increased pulmonary trunk size (0.76 kappa by %agreement) and hepatic vein contrast reflux (0.92 kappa by %agreement). A multiple regression analysis found that when 100% radiologist agreement existed, presence of paradoxical intravenous septal bowing predicted thrombolytic usage (P = 0.02), and the presence of IVC reflux predicted attributable mortality (P = 0.03). CONCLUSION: Only IVC contrast reflux was associated with increased mortality, and no other sign of RVS on CTPA correlated with clinical outcomes. This suggests that most signs of RVS on CTPA do not reliably predict PE severity. Therefore, RVS seen by CTPA should be used cautiously in weighing the decision to initiate thrombolytics.

Computed tomography in ventral hernia diagnosis: have we improved? A quality improvement initiative.

BACKGROUND: Previous studies suggest that agreement between readers of computed tomography (CT) scans for the diagnosis of a ventral hernia (VH) is poor (32% agreement, κ = 0.21). Recommendations were developed by surgeons and radiologists after determining common reasons for disagreement among CT reviewers; however, the long-term effect of adoption of these recommendations has not been assessed. The aim of this quality improvement (QI) project was to determine whether the incorporation of recommendations developed by surgeons and radiologists improves agreement among reviewers of CT scans in diagnosing a VH. METHODS: A prospective cohort of patients, with a CT scan of the abdomen and pelvis in the past 1 y, attending a surgery clinic at a single institution was enrolled. Enrolled subjects underwent a standardized physical examination by a trained hernia surgeon to determine the likelihood of a clinical VH (no, indeterminate, or yes). The QI intervention was the distribution and implementation of previously described recommendations. After a year of intervention, independent radiologists assessed patients' CT scans for the presence or absence of a VH. Percent agreement and kappa were calculated to determine interobserver reliability. In-person discussion on scans with disagreement was held, and the results were used as a "gold standard" to calculate sensitivity, specificity, positive, and negative predictive values for CT scan diagnosis of a VH. RESULTS: A total of 79 patients were included in the study. After QI intervention, seven radiologists agreed on 43% of the scans, and κ was 0.50 (P < 0.001). Agreement was highest among patients with a high clinical likelihood of a VH and lowest among patients with an indeterminate clinical likelihood. Sensitivity and specificity were 0.369 and 0.833, respectively. CONCLUSIONS: After the implementation of recommendations, there is improved agreement among radiologists reading CT scans for the diagnosis of a VH. However, there is substantial room for improvement, and CT scans for the diagnosis of VH is not ready for widespread use.

Improved method for calculating hepatic steatosis using the hepatorenal index.

OBJECTIVES: Marshall et al (AJR Am J Roentgenol 2012; 199:997-1002) initially demonstrated that the hepatorenal index is an effective and noninvasive tool to screen patients for hepatic steatosis. The aim of this study was to determine whether the hepatorenal index can be accurately calculated directly from a picture archiving and communication system (PACS) quickly and efficiently without the need for the multiple steps and specialized software used to calculate hepatorenal index in the study by Marshall et al. METHODS: We evaluated 99 of the 101 patients included in the study by Marshall et al: patients being followed by hepatologists with plans for liver biopsy. The hepatorenal index was calculated by using Digital Imaging and Communications in Medicine (DICOM) images from a PACS and a markup region-of-interest tool. We compared this value to the value that Marshall et al derived by using specialized software and to standard histologic estimates. We created similar subgroups: patients with steatosis based on histologically estimated intracellular fat exceeding 5% and patients without steatosis. RESULTS: The mean hepatorenal index ± SD for those with steatosis according to histologic findings was 1.87 ± 0.6, and for those without, it was 1.14 ± 0.2. A hepatorenal index of 1.34 or higher had 92% sensitivity for identifying fat exceeding 5%, 85% specificity, a 94% negative predictive value, and a 79% positive predictive value. Substantial agreement was found between the hepatorenal index calculated from DICOM images and macrovesicular fat categorized at the cut point of 1.34 or higher (κ = 0.76; 95% confidence interval, 0.62-0.88; P < .001). CONCLUSIONS: The hepatorenal index can be quickly and accurately calculated from DICOM images directly on a PACS without supplementary software.