[Pneumoperitoneum is not always caused by bowel perforation: a case report of vaginal cuff dehiscence].

Postcoital vaginal cuff dehiscence is a rare but well documented complication of hysterectomy. Common symptoms are vaginal bleeding and abdominopelvic pain with or without evisceration of the intraperitoneal contents through the separated vaginal cuff, which can lead to bowel injury, necrosis and sepsis. This potentially life-threatening condition usually occurs during the first postoperative act of intercourse or within the first few months of surgery. This case report presents the unusual case of vaginal cuff dehiscence in a 59-year-old woman 14 years after a total abdominal hysterectomy.

Influence of Genetics, Immunity and the Microbiome on the Prognosis of Inflammatory Bowel Disease (IBD Prognosis Study): the protocol for a Copenhagen IBD Inception Cohort Study.

INTRODUCTION: Inflammatory bowel diseases (IBD), encompassing Crohn's disease and ulcerative colitis, are chronic, inflammatory diseases of the gastrointestinal tract. We have initiated a Danish population-based inception cohort study aiming to investigate the underlying mechanisms for the heterogeneous course of IBD, including need for, and response to, treatment. METHODS AND ANALYSIS: IBD Prognosis Study is a prospective, population-based inception cohort study of unselected, newly diagnosed adult, adolescent and paediatric patients with IBD within the uptake area of Hvidovre University Hospital and Herlev University Hospital, Denmark, which covers approximately 1 050 000 inhabitants (~20% of the Danish population). The diagnosis of IBD will be according to the Porto diagnostic criteria in paediatric and adolescent patients or the Copenhagen diagnostic criteria in adult patients. All patients will be followed prospectively with regular clinical examinations including ileocolonoscopies, MRI of the small intestine, validated patient-reported measures and objective examinations with intestinal ultrasound. In addition, intestinal biopsies from ileocolonoscopies, stool, rectal swabs, saliva samples, swabs of the oral cavity and blood samples will be collected systematically for the analysis of biomarkers, microbiome and genetic profiles. Environmental factors and quality of life will be assessed using questionnaires and, when available, automatic registration of purchase data. The occurrence and course of extraintestinal manifestations will be evaluated by rheumatologists, dermatologists and dentists, and assessed by MR cholangiopancreatography, MR of the spine and sacroiliac joints, ultrasonography of peripheral joints and entheses, clinical oral examination, as well as panoramic radiograph of the jaws. Fibroscans and dual-energy X-ray absorptiometry scans will be performed to monitor occurrence and course of chronic liver diseases, osteopenia and osteoporosis. ETHICS AND DISSEMINATION: This study has been approved by Ethics Committee of the Capital Region of Denmark (approval number: H-20065831). Study results will be disseminated through publication in international scientific journals and presentation at (inter)national conferences.

Whole-body MR angiography in patients with peripheral arterial disease.

INTRODUCTION: Ph.D. project performed at Copenhagen University Hospital Herlev in the period 2007-2010. PURPOSE: To investigate whole-body magnetic resonance angiography (WB-MRA) as diagnostic method in patients with peripheral arterial disease (PAD). BACKGROUND: Due to the systemic nature of atherosclerosis patients with PAD often have concomitant arterial stenoses outside the peripheral arteries. In this respect, it seems desirable to perform whole-body angiography. Currently, WB-MRA is the only imaging modality allowing assessment of the total arterial system (excluding the coronary arteries) in one examination without limiting factors like invasiveness or ionizing radiation. MATERIAL AND METHODS: Four studies were performed (I-IV). Study I investigated the feasibility of performing WB-MRA in a 3T MRI system using body coil acquisition and a blood-pool contrast agent. Study II investigated the impact of a hybrid scan technique on the performance of 3T WB-MRA using body coil acquisition and an extracellular contrast agent. The aim of study III was to investigate if addition of infra-genicular steady-state MRA (SS-MRA) to first-pass imaging alone improves diagnostic performance in 3T WB-MRA. The last study (IV) was a questionnaire-based investigation of patient acceptance of WB-MRA compared to digital subtraction angiography (DSA). In all studies the inclusion criterium was referral to DSA due to PAD. Exclusion criteria were overweight exceeding the MRI system's limitations, inability to lie still due to rest pain, allergy to gadolinium-based contrast media, chronic renal insufficiency with an estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m², dialysis, inability to obtain informed consent, and contraindications for MRI (pacemaker, claustrophobia etc.). In total, 57 patients were investigated in the technical oriented studies (I: n = 11, II: n = 26, and III: n = 20). Seventy-nine patients were included in study IV. DSA served as method of reference for calculation of WB-MRA sensitivity and specificity for detection of significant (> 50% luminal narrowing or occlusion) arterial stenoses. RESULTS: The feasibility of body coil acquisition 3T WB-MRA using the blood-pool contrast agent gadofosveset trisodium was shown in study I. Overall sensitivity and specificity for detection of significant arterial stenoses with WB-MRA were 0.66/0.68 (observer 1/2) and 0.82/0.93, respectively. The low sensitivity was caused by poor sensitivity in the lower leg region. Study II showed that a hybrid scan protocol improves the performance of body coil acquisition 3T WB-MRA performed with the extracellular contrast agent gadoterate. Compared to a standard sequential WB-MRA protocol, the hybrid protocol resulted in statistically significant higher image quality scores, as well as lower venous contamination scores in the lower leg region. Overall sensitivities for detection of significant stenoses were 0.63/0.66 using the standard sequential WB-MRA protocol, and 0.75/0.70 using the hybrid WB-MRA protocol. Study III showed that addition of infra-genicular SS-MRA to first-pass imaging is an effective means of improving gadofosveset-enhanced WB-MRA. Combined analysis of steady-state and first-pass images showed infra-genicular sensitivitiy of 0.81, compared to 0.42 for first-pass imaging alone. In general, specificities for characterization of arterial stenoses with WB-MRA were high, with overall values ranging from 0.82 to 0.97 in studies I-III. Study IV showed that patient acceptance of WB-MRA was superior to that of DSA in patients with PAD, with the majority of patients (60%) preferring WB-MRA. Concomitant arterial stenoses outside the peripheral arteries were found in 28-32% of the investigated PAD patients. CONCLUSION: Body coil acquisition 3T WB-MRA is technically feasible using both a blood-pool and a standard non-specific extracellular contrast agent. However, the method is limited by low sensitivities for arterial stenoses. Hybrid examination technique and use of steady-state MRA are methods of improving WB-MRA. Patient acceptance of WB-MRA is superior to that of DSA. The rationale of using WB-MRA as diagnostic method in PAD patients is shown by the high prevalence of concomitant arterial stenosis outside the peripheral arteries.