Magnetic Resonance Visibility, Artifacts, and Overall Safety of the Self-Locating Peritoneal Dialysis Catheter with a Tungsten Tip.

Background: The self-locating peritoneal dialysis (PD) catheter, contains a tungsten tip. The effects of magnetic resonance (MR) on the catheter were evaluated, emphasizing its MR signal, artifacts, ferromagnetism, and possible heating production during the MR sequences. Methods: The catheter was studied in an ex vivo model using a 1.5T MR system and placed into a plastic box containing saline solution. Acquisitions on coronal and axial planes were obtained on fast gradient-echo T1-weighted and fast spin-echo T2-weighted. In vivo abdominal MR exams were also carried out. Results: Overall, the catheter had good visibility. In all sequences, an extensive paramagnetic blooming artifact was detected at the level of the tip tungsten ballast, with a circular artifact of 5 cm in diameter. The catheter showed no magnetic deflection, rotation, or movements during all MR sequences. After imaging, the temperature of the saline solution did not change compared to the basal measurement. Patients safely underwent abdominal MR. Conclusions: The results point to the possibility of safely performing MR in PD patients carrying the self-locating catheter. The self-locating PD catheter is stable when subjected to a 1.5T MR system. However, it creates some visual interference, preventing an accurate study of the tissues surrounding the tungsten tip.

Diagnostic significance of mesenteric lymph node involvement in proximal small bowel Crohn's disease.

Background: The diagnosis of proximal small bowel involvement in Crohn's disease (CD) can be challenging at magnetic resonance enterography (MRE). The inflammatory process in CD can be associated with peri-intestinal inflammatory reactions, including the presence of inflamed mesenteric lymph nodes. Objectives: To evaluate the significance of inflamed mesenteric lymph nodes adjacent to the jejunum at MRE in CD and the association with proximal bowel disease as detected by video capsule endoscopy (VCE). Design: This retrospective study was performed in two tertiary medical centres, and included 64 patients with CD who underwent MRE as well as VCE within 1 year. Methods: Data were collected for examinations performed between August 2013 and February 2021. MRE images were independently reviewed by radiologists who were blinded to the clinical data. Association between the presence of mesenteric lymph nodes adjacent to jejunum at MRE and disease activity according to VCE Lewis scores of proximal small bowel was examined. Results: VCE detected proximal disease in 24/64 patients (37.5%). Presence of regional lymph nodes in the jejunal mesentery was significantly associated with jejunal disease as seen on VCE (p < 0.001). Of the 20 patients who had proximal mesenteric lymph nodes at MRE, 15 (75%) had jejunal disease at VCE (sensitivity, 62.5%; specificity, 87.5%; and negative and positive predictive values, 79.5 and 75%, respectively). The number of regional lymph nodes was positively correlated with jejunal disease (mean: 2.63 ± 2.90 versus 0.78 ± 2.60, p = 0.01). Other MRE features of lymph nodes were not significantly predictive of jejunal CD. Conclusion: In patients with CD, inflamed regional lymph nodes in the jejunal mesentery at MRE can be valuable to suggest proximal small bowel disease, even when bowel wall features at imaging do not suggest disease involvement. Plain language summary: The diagnosis of proximal small bowel involvement in Crohn's disease (CD) can be challenging at magnetic resonance enterography (MRE). We analysed MRE examinations in patients with CD for the presence of lymph nodes adjacent to the proximal small bowel. We included 64 patients with CD who had MRE examinations and video capsule endoscopy (VCE) examinations within 1 year. Of 64 patients, 24 had proximal small bowel disease according to VCE. We found that of 20 patients who had regional mesenteric lymph nodes in the jejunal mesentery at MRE, 15 had proximal bowel disease involvement. We also found that patients with jejunal disease had a larger number of regional lymph nodes compared to patients without jejunal disease. All but one patient had normal appearing bowel at MRE. But, using regional mesenteric lymphadenopathy at MRE as an indicator for disease, 15/24 (62.5%) patients with proximal small bowel disease were detected. We therefore conclude that regional mesenteric lymph nodes assessment at MRE can aid diagnose proximal bowel disease, even when the proximal bowel looks normal at imaging. Presence of proximal mesenteric lymph nodes at MRE in patients with CD possibly warrant further investigation of the proximal small bowel by endoscopic measures.

Elucidating vaginal fistulas on CT and MRI.

Vaginal fistulas (VF) represent abnormal communications between the vagina and either the distal portion of the digestive system or the lower urinary tract, but lack an accepted classification and standardised terminology. Regardless of the underlying cause, these uncommon disorders result in profound physical, psychological, sexual and social distress to the patients.Since diagnosis of VF is challenging at gynaecologic examination, ano-proctoscopy and urethro-cystoscopy, imaging is crucial to confirm the fistula, to visualise its site, course and involved organ, and to characterise the underlying disease. The traditional conventional radiographic studies provided limited cross-sectional information and are nowadays largely replaced by CT and MRI studies.Aiming to provide radiologists with an increased familiarity with VF, this pictorial paper summarises their clinical features, pathogenesis and therapeutic approach, and presents the appropriate CT and MRI acquisition and interpretation techniques that vary according to the anatomic site and termination of the fistula. The current role of state-of-the art CT and MRI is presented with examples regarding both entero- (involving the colon, rectum and anus) and urinary (connecting the bladder, distal ureter or urethra) VF. The resulting combined anatomic and functional cross-sectional information is crucial to allow a correct therapeutic choice and surgical planning.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion.

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease.

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

Endoscopic stenting of malignant, benign and iatrogenic colorectal disorders: a primer for radiologists.

In recent years, endoscopic placement of intraluminal stents is increasingly used to manage a widening range of colorectal disorders. Self-expanding metal stents represent an established alternative to surgery for the palliation of unresectable carcinomas and currently allow a "bridge-to-surgery" strategy to relieve large bowel obstruction and optimise the patients' clinical conditions before elective oncologic resection. Additionally, intraluminal stents represent an appealing option to manage obstructing extracolonic tumours and selected patients with benign conditions such as refractory anastomotic strictures and post-surgical leaks.This educational paper reviews the technical features and current indications of colorectal stenting and presents the expected and abnormal radiographic, CT and MRI appearances observed during the endoscopic management of malignant, benign and iatrogenic colonic disorders with stents. The aim is to provide radiologists with a thorough familiarity with stent-related issues, which is crucial for appropriate reconstruction of focused CT images, correct interpretation of early post-procedural studies and elucidation of stent-related complications such as misplacement, haemorrhage, perforation, migration and re-obstruction.

A closer look at the stoma: multimodal imaging of patients with ileostomies and colostomies.

Nowadays, large numbers of ileostomies and colostomies are created during surgical management of a variety of intestinal disorders. Depending on indication, surgical technique and emergency versus elective conditions, stomas may be either temporary or permanent. As a result, patients with ileostomies and colostomies are commonly encountered in Radiology departments, particularly during perioperative hospitalisation following stoma creation or before recanalisation, and when needing CT or MRI studies for follow-up of operated tumours or chronic inflammatory bowel diseases. However, the stoma site is commonly overlooked on cross-sectional imaging.Aiming to improve radiologists' familiarity with stoma-related issues, this pictorial essay concisely reviews indications and surgical techniques for ileostomies and colostomies, and presents state-of-the art multimodal imaging in patients living with a stoma, including water-soluble contrast stomal enema (WSC-SE), CT and MRI techniques, interpretation and expected findings. Afterwards, the clinical features and imaging appearances of early and late stoma-related complications are illustrated with imaging examples, including diversion colitis.When interpreting cross-sectional imaging studies, focused attention to the stoma site and awareness of expected appearances and of possible complications are required to avoid missing significant changes requiring clinical attention. Additionally, dedicated imaging techniques such as WSC-SE and combined CT plus WSC-SE may be helpful to provide surgeons the appropriate clinical information required to direct management.

Advanced endoscopic interventions on the pancreas and pancreatic ductal system: a primer for radiologists.

In recent years, technological advancements including endoscopic ultrasound (EUS) guidance and availability of specifically designed stents further expanded the indications and possibilities of interventional endoscopy. Although technically demanding and associated with non-negligible morbidity, advanced pancreatic endoscopic techniques now provide an effective minimally invasive treatment for complications of acute and chronic pancreatitis.Aiming to provide radiologists with an adequate familiarity, this pictorial essay reviews the indications, techniques, results and pre- and post-procedural cross-sectional imaging appearances of advanced endoscopic interventions on the pancreas and pancreatic ductal system. Most of the emphasis is placed on multidetector CT and MRI findings before and after internal drainage of pseudocysts and walled-off necrosis via EUS-guided endoscopic cystostomy, and on stent placement to relieve strictures or disruption of the main pancreatic duct, respectively in patients with chronic pancreatitis and disconnected pancreatic duct syndrome.

Early cross-sectional imaging following open and laparoscopic cholecystectomy: a primer for radiologists.

Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the "workhorse" modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract. TEACHING POINTS: • Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis. • Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage. • Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the "workhorse" modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen. • Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected. • Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage.

Totally laparoscopic, multi-stage, restorative proctocolectomy for inflammatory bowel diseases. A prospective study on safety, efficacy and long-term results.

BACKGROUND: Laparoscopic ileo-pouch-anal anastomosis (IPAA) has been reported as having low morbidity and several advantages. AIMS: To evaluate safety, efficacy and long-term results of laparoscopic IPAA, performed in elective or emergency settings, in consecutive unselected IBD patients. METHODS: All the patients received totally laparoscopic 2-stage (proctocolectomy and IPAA - stoma closure) or 3-stage (colectomy - proctectomy and IPAA - stoma closure) procedure according to their presentation. RESULTS: From July 2007 to July 2016, 160 patients entered the study. 50.6% underwent a 3-stage procedure and 49.4% a 2-stage procedure. Mortality and morbidity were 0.6% and 24.6%. Conversion rate was 3.75%. 8.7% septic complications were associated with steroids and Infliximab treatment (p = 0.0001). 3-stage patients were younger (p = 0.0001), with shorter disease duration (p = 0.0001), minor ASA scores of 2 and 3 (p = 0.0007), lower inflammatory index and better nutritional status (p = 0.003 and 0.0001), fewer Clavien-Dindo's grade II complications (p = .0001), reduced rates of readmission and reoperation at 90 days (p = 0.03), and shorter hospitalization (p = .0001), but with similar pouch and IPAA leakage, compared to 2-stage patients. 8 years pouch failure and definitive ileostomy were 5.1% and 3.7%. CONCLUSION: A totally laparoscopic approach is safe and feasible, with very low mortality and morbidity rates and very low conversion rate, even in multi-stage procedures and high-risk patients.

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study.

PURPOSE: To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma. MATERIALS AND METHODS: This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student's t, chi-squared, and Cohen's kappa tests. RESULTS: Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k = 0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p < 0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30 h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p < 0.05). CONCLUSION: Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.

Imaging the operated colon using water-enema multidetector CT, with emphasis on surgical anastomoses.

Water-enema multidetector CT (WE-MDCT) provides a detailed multiplanar visualisation of mural, intra- and extraluminal abnormalities of the large bowel, relying on preliminary bowel cleansing, retrograde luminal distension, pharmacological hypotonisation and intravenous contrast enhancement. In patients with a history of colorectal surgery for either carcinoma or Crohn's disease (CD), WE-MDCT may also be performed via a colostomy, which allows depicting the anatomy and position of the residual large bowel and evaluates the calibre, length, mural and extraluminal features of luminal strictures. Therefore, WE-MDCT may prove useful as a complementary technique after incomplete or inconclusive colonoscopy to assess features and suspected abnormalities of the surgical anastomosis, particularly when endoscopic or surgical interventions are being planned. This pictorial essay presents the WE-MDCT technique and pitfalls, the expected appearances after different colic surgeries and the imaging features of benign anastomotic disorders (fibrotic stricture, kinking, inflammatory ulcer) and of locally recurrent tumours and CD. TEACHING POINTS: • Water-enema multidetector CT (WE-MDCT) effectively visualises the operated colon • Complementary to endoscopy, WE-MDCT may helpfully depict abnormalities of surgical anastomoses • WE-MDCT allows assessment of strictures' features and abnormalities of the upstream bowel • Technical pitfalls, normal postsurgical findings and benign anastomotic disorders are presented • WE-MDCT allows detecting relapsing Crohn's disease, recurrent and metachronous tumours.

Multidetector CT of expected findings and complications after hysterectomy.

Indicated to manage a variety of disorders affecting the female genital tract, hysterectomy represents the second most common gynaecological operation after caesarean section. Performed via an open, laparoscopic or vaginal approach, hysterectomy is associated with non-negligible morbidity and occasional mortality. Iatrogenic complications represent a growing concern for gynaecologists and may result in prolonged hospitalisation, need for interventional procedures or repeated surgery, renal impairment and malpractice claims. As a result, radiologists are increasingly requested to investigate patients with suspected complications after hysterectomy. In the vast majority of early postoperative situations, multidetector CT represents the ideal modality to comprehensively visualise the surgically altered pelvic anatomy and to consistently triage the varied spectrum of possible injuries. This pictorial review provides an overview of current indications and surgical techniques, illustrates the expected CT appearances after recent hysterectomy, the clinical and imaging features of specific complications such as lymphoceles, surgical site infections, haemorrhages, urinary tract lesions and fistulas, bowel injury and obstruction. Our aim is to increase radiologists' familiarity with normal post-hysterectomy findings and with post-surgical complications, which is crucial for an appropriate choice between conservative, interventional and surgical management. TEACHING POINTS: • Hysterectomy via open, laparoscopic or vaginal route is associated with non-negligible morbidity. • Multiplanar CT imaging optimally visualises the surgically altered pelvic anatomy. • Familiarity with early post-hysterectomy CT and expected findings is warranted. • Complications encompass surgical site infections, haemorrhages, bowel injury and obstruction. • Urological complications include ureteral leakage, bladder injury, urinomas and urinary fistulas.

Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists.

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40-50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis. TEACHING POINTS: • Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40-50%). • Multidetector CT is the mainstay technique to investigate suspected complications following PD. • Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings. • CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula. • Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

Multidetector CT of iatrogenic and self-inflicted vascular lesions and infections at the groin.

The number and complexity of endovascular procedures performed via either arterial or venous access are steadily increasing. Albeit associated with higher morbidity compared to the radial approach, the traditional common femoral artery remains the preferred access site in a variety of cardiac, aortic, oncologic and peripheral vascular procedures. Both transarterial and venous cannulation (for electrophysiology, intravenous laser ablation and central catheterisation) at the groin may result in potentially severe vascular access site complications (VASC). Furthermore, vascular and soft-tissue groin infections may develop after untreated VASC or secondarily to non-sterile injections for recreational drug use. VASC and groin infections require rapid diagnosis and appropriate treatment to avoid further, potentially devastating harm. Whereas in the past colour Doppler ultrasound was generally used, in recent years cardiologists, vascular surgeons and interventional radiologists increasingly rely on pelvic and femoral CT angiography. Despite drawbacks of ionising radiation and the need for intravenous contrast, multidetector CT rapidly and consistently provides a panoramic, comprehensive visualisation, which is crucial for correct choice between conservative, endovascular and surgical management. This paper aims to provide radiologists with an increased familiarity with iatrogenic and self-inflicted VASC and infections at the groin by presenting examples of haematomas, active bleeding, pseudoaneurysms, arterial occlusion, arterio-venous fistula, endovenous heat-induced thrombosis, septic thrombophlebitis, soft-tissue infections at the groin, and late sequelae of venous injuries. TEACHING POINTS: • Complications may develop after femoral arterial or venous access for interventional procedures. • Arterial injuries include bleeding, pseudoaneurysm, occlusion, arteriovenous fistula, dissection. • Endovenous heat-induced thrombosis is a specific form of iatrogenic venous complication. • Iatrogenic infections include groin cellulitis, abscesses and septic thrombophlebitis. • CT angiography reliably triages vascular access site complications and groin infections.

Radiation overexposure from repeated CT scans in young adults with acute abdominal pain.

PURPOSE: The purpose of this study is to assess the dose of ionizing radiation caused by repeated CT scans performed to investigate non-traumatic acute abdominal conditions in young adults. METHODS: Over 26 months, we collected a cohort of patients aged 18 to 45 years who were subject to at least one urgent contrast-enhanced abdomen/pelvis CT. Patients affected with urolithiasis, HIV infection, tumors, and vascular and chronic inflammatory bowel diseases were excluded. All abdomen/pelvis CT scans carried out at our institution for over 6 years were retrospectively tallied, and the effective doses (EDs) were computed by multiplying the total dose-length product by the appropriate anatomic conversion factor. Examples of age- and gender-adjusted lifetime attributable cancer risks were estimated using the online calculator Radiation Risk Assessment Tool. RESULTS: Sixty-one patients (average age 34.2 years) received multiple CT scans (average 2.7 scans per patient). ED largely varied among single- and multi-phase acquisitions. Cumulative ED ranged from 14.1 mSv to a maximum of 436.6 mSv (average 70.1 mSv per person). Twenty-five patients (40.9%) received more than 50 mSv, 84% of them within year; 12 (19.7%) and 4 (6.6%) patients received more than 100 and 200 mSv, respectively. CONCLUSION: Young adults are subject to repetitive CT imaging to monitor urogenital, intestinal, hepatobiliary, and pancreatic disorders during non-operative management to detect and follow up abdominal emergencies requiring surgical intervention and to assess post-surgical complications. In this population, the risk of accruing high cumulative radiation exposure should be considered.

Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI.

Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn's disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists' familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success. TEACHING POINTS: • Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn's disease and tumours. • The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance. • The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice. • Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time. • Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.

Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis.

Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented. TEACHING POINTS: • Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs • Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis • CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs • Currently the commonest complication, haemorrhage may be treated with transarterial embolisation • Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation.

Early postoperative imaging after non-bariatric gastric resection: a primer for radiologists.

Surgical resection represents the mainstay treatment and only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Furthermore, other tumours and selected cases of non-malignant disorders of the stomach may require partial or total gastrectomy. Often performed in elderly patients, gastric resection remains a challenging procedure, with significant morbidity (14-43% complication rate) and non-negligible postoperative mortality (approximately 3%). This paper provides an overview of contemporary surgical techniques for non-bariatric gastric resection, reviews and illustrates the expected postoperative imaging appearances, common and unusual complications after partial and total gastrectomy. Albeit cumbersome or unfeasible in severely ill or uncooperative patients, contrast fluoroscopy remains useful to rapidly check for anastomotic patency and integrity. Currently, emphasis is placed on multidetector CT, which comprehensively visualizes the surgically altered anatomy and consistently detects complications such as anastomotic leaks and fistulas, duodenal stump leakage, afferent loop syndrome, haemorrhages, pancreatic fistulas and porto-mesenteric venous thrombosis. Our aim is to help radiologists become familiar with early postoperative imaging, in order to understand the surgically altered anatomy and to differentiate between expected imaging appearances and abnormal changes heralding iatrogenic complications, thus providing a consistent basis for correct choice between conservative, interventional or surgical treatment. TEACHING POINTS: • Radical gastrectomy is associated with frequent postoperative morbidity and non-negligible mortality. • In cooperative patients fluoroscopy allows checking for anastomotic patency and leaks. • Multidetector CT with / without oral contrast comprehensively visualizes the operated abdomen. • Awareness of surgically altered anatomy and expected postoperative appearances is warranted. • Main complications include anastomotic and duodenal leaks, haemorrhages and pancreatic fistulas.