Adult choledochal cysts: current update on classification, pathogenesis, and cross-sectional imaging findings.

Approximately 20% of choledochal cysts (CC) present in adult patients and they are commonly associated with a high risk of complications, including malignancy. Additionally, children who underwent internal drainage procedures for CCs can develop complications during adulthood despite treatment. Concepts regarding classification and pathogenesis of the CCs have been evolving. While new subtypes are being added to the widely accepted Todani classification system, simplified classification schemes have also been proposed to guide appropriate management. The exact etiology of CCs is currently unknown. The two leading theories involve either the presence of an anomalous pancreatico-biliary junction with associated reflux of pancreatic juice into the biliary system or, more recently, some form of antenatal biliary obstruction with resulting proximal bile duct dilation. Imaging studies play an important role in the initial diagnosis, surgical planning, and long-term surveillance of CCs.

Intraluminal air within an obstructed appendix: a CT sign of perforated or necrotic appendicitis.

RATIONALE AND OBJECTIVES: The aim of this study was to evaluate the predictive value of intraluminal air for appendiceal necrosis and/or perforation when not apparent on imaging. Additional factors of intraluminal appendicoliths, age, and gender were also assessed. MATERIALS AND METHODS: Patients with pathologically proven appendicitis who underwent multidetector computed tomographic imaging over a 3-year period (n = 487) were retrospectively reviewed. Those with imaging evidence for perforation were excluded to create a study population of apparent uncomplicated acute appendicitis (n = 374). Each scan was assessed for intraluminal appendiceal air and appendicoliths on multidetector computed tomography and compared against surgical and pathologic results for appendiceal necrosis and/or perforation. RESULTS: Image-occult necrosis or perforation was present in 17.4% (65 or 374) of the study cohort. Intraluminal air and appendicoliths were predictive variables by univariate logistic regression (P = .001 and P ≤ .001, respectively), with odds ratios of 2.64 (95% confidence interval, 1.48-4.73) for intraluminal air and 2.67 (95% confidence interval, 1.55-4.61) for appendicoliths. Both remained independent variables on multivariate modeling despite multicollinearity. Increasing age was also predictive (odds ratio, 1.25; 95% confidence interval, 1.09-1.44; P = .002), whereas gender was not (P = .472). CONCLUSIONS: Intraluminal appendiceal air in the setting of acute appendicitis is a marker of perforated or necrotic appendicitis. Recognition of this finding in otherwise uncomplicated appendicitis at imaging should raise suspicion for image-occult perforation or necrosis.

Coexisting MS and Lhermitte-Duclos Disease.

We report the case of a patient with pre-existing multiple sclerosis, who presented with horizontal diplopia, and a prior episode of progressive ataxia and dizziness lasting one week. While initially attributed to multiple sclerosis, subsequent imaging demonstrated a concurrent left cerebellar gangliocytoma, also known as Lhermitte-Duclos disease.