MyT3 13 - Abdominal and Gastrointestinal

Purpose:

Although acute appendicitis standard treatment has been performed surgically, it has been seen that treatment is possible with antibiotic and non-operative observation in recent years. In this study, we aimed to determine whether CT findings in patients diagnosed with acute appendicitis should be used for directing treatment.

Methods and materials:

A total of 60 patients, who underwent abdominal CT and antibiotic treatment for acute appendicitis were retrospectively evaluated. Patients who were treated with antibiotics were followed up for at least six months to determine the recurrent disease rate and CT findings of successful and unsuccessful medical treatment cases were compared. Appendiceal wall thickness, diameter, wall contrast enhancement, intraabdominal free fluid, periappendiceal fat stranding severity, perirectal lymph node, appendicolith and adjacent organ findings in CT of groups were compared with chi-square and Mann-Whitney-U tests.

Results:

A total of 60 patients were evaluated. Because of 6 of the 60 patients who received medical treatment didn’t complete the 6-month follow-up period, and 17 of them couldn’t be followed-up, 23 patients have not been included in the research. As a result, at the end of the 6-month follow-up, 23 of the 37 medical treatment patients were successful and 14 of them were unsuccessful. Comparing the CT findings of the successful and unsuccessful medical treatment groups, just the severity of appendix wall enhancement was found statistically significant (p=0.005). After at least 6 months follow-up, the recurrent disease rate of patients who received medical treatment was 38%.

Conclusion:

The likelihood of unsuccessful treatment increases when the severity of appendix wall contrast enhancement is evident in patients treated with medical therapy. The recurrent disease rate of medical treatment after at least 6 months follow-up was 38%.

Limitations:

Retrospective study.

Ethics committee approval

Ethics committee approval obtained.

Funding:

No funding was received.

Purpose:

The purpose of this study was to assess liver regeneration with CT volumetry in patients who have undergone liver transplantation and to evaluate factors impacting liver regeneration in these patients.

Methods and materials:

The study was done in the Department of Radiodiagnosis at Sir Ganga Ram Hospital. 34 patients were included in this study. Inclusion criteria: all adult patients who underwent living donor liver transplantation at our centre and gave consent for participation in our study. Exclusion criteria: paediatric liver transplant patients and acute liver failure patients. After taking valid consent, demographic, clinical and laboratory parameters, as well as pre-operative graft weight of these patients, were noted. CT was done on the 7th and 30th post-transplant day and The volume was calculated using CT volumetry software. Percentage and absolute growth of graft on these days were calculated. Correlation of various pre-transplant variables (age, sex, height, weight, BMI, BSA, MELD score, graft lobe, pre-transplant graft volume, graft to recipient weight ratio and indication for liver transplant) with graft regeneration was assessed.

Results:

Rapid regeneration of graft was noted with a mean absolute and percentage regeneration on the 30th day being 685.4 ± 200.3cc and 119.2 ± 44%. Significant (p value <0.05) and positive correlation was found between weight, BMI, BSA, graft volume, graft to recipient weight ratio (GRWR) and 30th-day graft volume.

Conclusion:

We concluded that graft regeneration in liver transplant recipients is a rapid and continuous process in the first thirty days. There is a positive and significant correlation between graft regeneration and pre-transplant variables as well as recipient’s weight, BMI, BSA, graft volume and GRWR.

Limitations:

The study is limited by the relatively small sample size of 34 patients and the fact that is was a time bound study.

Ethics committee approval

The study was approved by the institute's ethics committee.

Funding:

No funding was received for this work.

Purpose:

The purpose of this study is to assess the accuracy of MDCT findings as predictors for impending surgical intervention in patients with adhesive small bowel obstruction.

Methods and materials:

The study was done in the Department of Radiodiagnosis (CT) at Sir Ganga Ram Hospital. The study was done in two phases. In the first phase, 75 retrospective cases meeting the inclusion criteria were included in this study. 8 MDCT features: small bowel dilatation, bowel wall thickening, degree of obstruction, small bowel air-fluid level, small bowel faeces sign, mesenteric fatty stranding, the presence of transition point and the presence of intraperitoneal free fluid were assessed in these patients. Sensitivity, specificity, positive predictive value, negative predictive value and the accuracy of these features for the prediction of surgical outcome were evaluated. Correlations of these features individually and in combination were assessed with surgical management. In the second phase of our study, the validity of the results obtained in the retrospective group was tested by applying them to 25 prospective cases.

Results:

In the retrospective group, small bowel dilatation (>4cm) and high-grade obstruction were found to be statistically significant and a positive predictor of surgical outcome in patients of adhesive small bowel obstruction both individually and in combination. The model generated on the basis of the retrospective data showed an outstanding discrimination between surgical and conservative management when applied on prospective cases, thus validating our results.

Conclusion:

MDCT features of small bowel dilatation >4cm and high-grade obstruction can both independently and in combination predict surgical outcome in patients with adhesive small bowel obstruction.

Limitations:

There is no widely accepted definition for the grade of obstruction. The clinical status of the patient was not taken into consideration.

Ethics committee approval

Approved by the ethical committee of our institutuion.

Funding:

No funding was received for this work.

Purpose:

The purpose of this study was to determine the diagnostic accuracy of ultrasound in the detection of amoebic liver abscess in patients undergoing liver abscess aspiration at the Department of Radiology (Aga Khan University Hospital).

Methods and materials:

Setting: Department of Radiology, Aga Khan University Hospital, Karachi. Duration of the study with dates: The study was carried out over a period of six months from 22-01-2019 to 21-07-2019. Subjects and Methods: A total of 105 cases undergoing liver abscess aspiration were included in the study. Ultrasound was performed by a sonologist / radiologist with a minimum of 5 years experience of abdominal sonography. The same interpreted the images. Patient demographics and sonographic features were recorded on a proforma.

Results:

The mean age of the patients was 49.3±17.5; 74 (70.5%) male and 31 (29.5%) female patients. A single lesion was found in 98 patients (93.3%) and multiples lesions in 7 patients (6.7%). Out of 105 patients, the location of the lesion was right in 93 (88.6%) and left in 12 patients (11.4%). Ultrasound showed a sensitivity of 97.5%, specificity 82.6%, PPV 95.2%, NPV 90.4% and diagnostic accuracy 94.2%, in the detection of amoebic liver abscess. Stratification for age, gender, number of lesions and location of lesions was also carried out.

Conclusion:

In conclusion, ultrasonography is highly sensitive in diagnosing amoebic liver abscess. Ultrasound is an ideal, safe, sensitive, non-invasive and easily available imaging modality for the diagnosis. Ultrasound is an excellent imaging modality for the identification and location of the ALA, for the estimation of size and volume, and for the evaluation of complications.

Limitations:

The study does not enumerate how these features would help to differentiate from a pyogenic abscess.

Ethics committee approval

Ethical review committee exemption was obtained.

Funding:

No funding was received for this study.

Purpose:

To compare and determine the role of CEUS and DCE-MRI in the diagnostic evaluation of focal liver lesion and to qualitatively classify lesions using contrast washout patterns on CEUS (LI-RADS).

Methods and materials:

An observational cross-sectional study was performed on 102 patients. All patients with focal liver lesions on grayscale ultrasound were included in the study except for those with simple cysts, patients with COPD, CKD (GFR<30 ml/min/1.73 m²), IHD and patients with contraindications to MRI. First CEUS was done on our subject and a provisional classification of the lesion using LI-RADS was done using the washout pattern of the contrast followed by DCE-MRI on which the lesion was classified again using LI-RADS. The final diagnosis was confirmed by histopathology. Results of these non-invasive modalities were then compared to histopathology (gold standard).

Results:

For the contrast-enhanced ultrasound studies, sensitivity is 90% (95% CI 88-90), specificity is 82% (95% CI 80–84), and 41 for diagnostic odds ratio (DOR); for the CEMRI studies, sensitivity is 88% (95% CI 86-90), specificity is 83% (95% CI 81–85), and 35.80 for DOR.

Conclusion:

CEUS can be a promising and cost-effective modality for focal liver lesions as compared to DCE-MRI for an initial evaluation. It not only shows comparable results in identifying the final diagnosis but also makes use of a contrast agent which gets excreted through lungs (SF6) and hence can easily be used in patients with liver/renal disease.

Limitations:

The only limitation to our study is that CEUS is operator-dependent, so specificity of CEUS can further be increased when performed by the same and experienced sonologist.

Ethics committee approval

Approval taken.

Funding:

No funding for this study was received.

Purpose:

To optimise the IVIM imaging of the liver on a 3T scanner by assessing parameter reproducibility on free-breathing (FB) and respiratory-triggered (RT) sequences acquired with different numbers of signal averages (NSA).

Methods and materials:

20 subjects underwent IVIM MRI on a 3T scanner using four different echo-planar sequences, each with 10 b values: 0-900 s/mm2. Images were acquired with FB and RT with NSA = 1-4 (FBNSA1-4, RTNSA1-4) and with NSA = 3-6 (FBNSA3-6, RTNSA3-6). For the assessment of the reproducibility of IVIM-derived parameters (f, D, D*), each subject was scanned again with an identical protocol during the same session. IVIM parameters were calculated. The distribution of IVIM-parameters for each DWI sequence was given as the median value with first and third quartile. Inter-scan reproducibility for each IVIM parameter was evaluated using the coefficient of variance and Bland-Altman difference. Differences between FB sequence and RT sequence were tested using the non-parametric Wilcoxon signed-rank test.

Results:

The mean coefficient of variance (%) for f, D, and D* ranged from 60 to 64, from 58 to 84, and 99 for FBNSA1-4 sequence; from 50 to 69, from 41 to 97, and from 82 to 88 for RTNSA1-4 sequence; from 22 to 27, 15, and from 70 to 80 for FBNSA3-6 sequence; and from 21 to 32, from 12 to 17, and from 50 to 80 for RTNSA3-6 sequence, respectively.

Conclusion:

Increasing the NSA for IVIM acquisitions allows us to improve the reproducibility of IVIM-derived parameters. The sequence FBNSA= 3-6 was optimal in terms of reproducibility and acquisition time.

Limitations:

The number of studied subjects was limited to 20.

Ethics committee approval

The study was approved by the Institutional Review Board, and all volunteers signed an informed consent form.

Funding:

No funding was received for this work.

Purpose:

To study the correlation of liver (LIC) and myocardial (MIC) iron concentration using T2* MRI with serum ferritin in non-transfusion-dependent thalassemia patients.

Methods and materials:

In this prospective study done between September 2016 and 2018, thirty patients of non-transfusion-dependent thalassemia (17 males and 13 females) were studied. Serum ferritin was determined using the chemiluminescent method. T2* MRI was done using 1.5T Seimens Magentom Avanto. Post-processing: T2* analysis spreadsheet. Inclusion criteria: patients who were diagnosed with non-transfusion-dependent thalassemia (NTDT) - age: 5-50 years. Exclusion criteria: patients on chelation therapy, patients with fever or active infections and patients with contraindications to MR imaging.

Results:

Out of 30 patients, 24 had a liver iron overload and only 1 patient had a myocardial iron overload. There was a non-linear correlation between LIC and serum ferritin (P-value <0.01). The rate of change of serum ferritin was not proportional to LIC. No correlation was found between MIC and serum ferritin. A negative correlation was found between LIC and haemoglobin. Liver iron concentration increases as age increases, indicating the accumulation of iron over time. A significant positive correlation was found between LIC and liver size and spleen size (P-value <0.01).

Conclusion:

Since the serum ferritin level does not reflect the level of liver iron overload in non-transfusion-dependent thalassemia patients, the assessment of liver iron concentration using the T2* relaxometry method helps in the early detection of iron overload, the early initiation of chelation therapy and the prevention of complications.

Limitations:

Respiratory artifact can cause false interpretation.

Ethics committee approval

The Ethics committee approval was obtained.

Funding:

NIL

Purpose:

The Child-Pugh score is based on clinical indices and lab results and gives the idea about patient’s severity about liver disease. The Child-Pugh C score carries the grave prognosis. In emergency settings, all the values might not be known. Thus it becomes important to have a proxy for laboratory indices which can be promptly and non-invasively done. Thus, we looked at Doppler ultrasound as an alternative. Previous studies have shown that Colour Doppler is useful in prognosticating patients with liver disease. However, very few studies have used objective parameters like the damping index to assess the severity of liver failure objectively, to be used as a prognostication marker.

Methods and materials:

30 patients with portal hypertension underwent Doppler ultrasound. The damping index was calculated by a reader who was blinded to the patient’s Child-Pugh score. SPSS was used to calculate the ROC curve. Middle hepatic artery waveform was taken, then the damping index was calculated, dividing the minimum velocity by maximum velocity.

Results:

The damping index of 0.56 has good sensitivity (94%) and specificity (84%) to identify the Child-Pugh C patients (p-value <0.001).

Conclusion:

The damping index can be used as an alternative to identify Child-Pugh score C patients who have severe liver disease and carry a bad prognosis. Kim et al have shown a 0.6 cut off of DI for a severe portal hypertension (hepatic venous pressure gradient >12 mm Hg) sensitivity of 75.9% and a specificity of 81.8%. Thus the findings of our study support the hypothesis that the damping index can be a useful parameter in evaluating patients with liver disease, especially for their prognostication.

Limitations:

The study sample size is small and it was done in one centre.

Ethics committee approval

Institutional ethic committee approval was obtained.

Funding:

No funding was received for this study.

Purpose:

To compare the liver stiffness (LS) values obtained by newly developed spin-echo echo-planar imaging (SE-EPI) MR elastography (MRE) with conventional gradient-recalled echo (GRE) MRE in the same condition. In addition, to assess the statistical correlation of the obtained LS values with those of transient elastography (TE).

Methods and materials:

From April 2018 to September 2019, we retrospectively included a study population who underwent liver MRE with both SE-EPI and GRE sequences in the same session. Among them, we excluded patients without TE within one year and finally enrolled 43 patients. LS measurements for MRE were performed using free-drawing region-of-interest and reliable TE measurements were defined as the median value of 10 measurements with interquartile range/median (IQR/M) ≤30%. We compared technical success rates, median LS values and areas of confidence for MRE measurements between SE-EPI and GRE sequences using paired t-test. We also evaluated the correlation co-efficient between LS values obtained by each MRE sequence and TE, respectively.

Results:

The technical success rate of MRE in SE-EPI was significantly higher than that of GRE (100% vs. 86.0%, p=0.03). LS values from SE-EPI and GRE MRE were not significantly different (SE-EPI; 3.78kPa vs. GRE; 3.54kPa, p=0.08). The areas of confidence for MRE measurements were significantly larger in SE-EPI than those of GRE MRE (8215.1981 vs. 2691.4759 mm2, p<0.001). The LS values from two MRE sequences were significantly correlated with those from TE (SE-EPI; r=0.64, p<0.001 vs. GRE; r=0.61, p<0.001).

Conclusion:

SE-EPI MRE is technically stable, and LS values obtained by this sequence would be reliable. LS values obtained by GRE and SE-EPI MREs are significantly correlated with those by TE.

Limitations:

The MRE examinations were performed using a single MR unit.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

The aim of this study was to retrospectively evaluate the accuracy of CT for preoperative determination of the site of surgically proven gastrointestinal (GI) perforation and to determinate the most predictive findings in this diagnosis.

Methods and materials:

We retrospectively reviewed the abdominal CT of 100 patients who had a surgically proven GI perforation (64 males; aged between 32-92 years) performed in our centre, from March 2017 to March 2019. IV contrast agent was used in 83 patients. Two observers, respectively with 25 and 4 years of radiological experience, blinded to the surgical diagnosis, reached a consensus prediction of the site of perforation using the presence of the following CT findings: extra-luminal air (grade and distribution), defect in the wall, wall thickening, abnormal wall enhancement, peritoneal fluid, fat-stranding and inflammatory masses. We also evaluated these signs in predicting perforation due to peptic ulcer disease vs diverticulitis, respectively the most common cause of upper and lower GI perforation. A Chi-Square test was used to analyse the results.

Results:

37 patients presented an upper GI perforation and 63 a lower GI perforation. Severe free air (p=0.04), free air in the supra-mesocolic compartment (p=0.00) and peritoneal fluid (p=0.00) resulted in strong predictors of upper GI perforation, while mild and moderate free air (p=0.04) and fat-stranding (p=0.00) indicated a lower GI perforation. 35 patients had a peptic ulcer disease and 28 patients had diverticulitis. Free air in the supra-mesocolic compartment (p=0.00) and peritoneal fluid (p=0.00) suggested a perforation due to peptic ulcers, while free air in pelvis and retroperitoneum (p=0.03), fat-stranding (p=0.00), abnormal wall enhancement (p=0.05) and inflammatory masses (p=0.05) indicated a perforation due to diverticulitis.

Conclusion:

CT is highly accurate for distinguishing upper from lower GI perforation.

Limitations:

17 patients performed unenhanced CT.

Ethics committee approval

n/a

Funding:

n/a

Purpose:

To analyse the value of CT enterography (CTE) in predicting the incidence in patients of perianal fistulising disease and the risk of surgical treatment within one year, to provide the evidence for guiding clinical evaluation and rational selection of treatment options.

Methods and materials:

279 cases of newly diagnosed Crohn's disease patients were analysed retrospectively. All patients were followed-up for one year. CTE imaging parameters were recorded and pelvic MR images were evaluated with regard to the presence of anal fistulas.

Results:

204 patients were eligible for the analysis. The presence of colonic involvement was seen in 47/88 (53.41%) cases in the anal fistula group (Group 1) and in 38/116 (32.76%) cases in the non-anal fistula group (Group 2) (P=0.006). The bowel wall enhancement in Group 1 mainly manifested as type 1 and type 2 as 69/88 (78.41%) compared with type 3 and type 4 in Group 2 as 78/116 (67.25%)(P＜0.001). Rectal involvement was present in 12/18 (69.62%) cases of the surgical group (Group 3) vs 22/53 (41.51%) of the non-surgical group (Group 4), luminal stenosis in 15/18 cases (83.33%) of Group 3 vs 4/18 cases (22.22) in Group 4, intra-abdominal fistula in 33/53 (62.27%) of Group 3 vs 2/53 (3.77%) of Group 4. In the multivariate analysis, rectal involvement (OR 1.911 (1.102 to 4.185), P＜0.001), luminal stenosis (OR 2.627 (1.760 to 6.024), P=0.028) and intra-abdominal (OR 1.337 (1.093 to 3.585), P=0.006) increased the risk of surgery.

Conclusion:

Colonic involvement and bowel wall enhancement can predict the onset of perianal fistulising disease. Rectal involvement, luminal stenosis, and intra-abdominal fistula increase the risk of short-term surgery for perianal fistulising disease.

Limitations:

Limitations were: 1. Single-centre, selection bias; 2. Very few patients did not use enema; 3. Few patients' drug treatment was not standardised.

Ethics committee approval

n/a

Funding:

No funding was received for this study.

Purpose:

To determine the radiologic findings of ampullary cancer on contrast-enhanced MRI (CE-MRI) with a liver-specific contrast agent.

Methods and materials:

This retrospective study included 120 patients (65 male and 55 female; mean age: 70.62 years) who were suspected to have ampullary cancer and who performed CE-MRI with a liver-specific contrast agent from January 2015 to January 2019. We collected data including the presence of the bulging ampulla, size, T1/T2-signal intensity, enhancement patterns, diffusion restriction of the ampulla, the extent of common bile duct (CBD) and pancreatic duct dilatation, the change of shape in distal CBD, CBD wall thickening and asymmetry, the contrast secretion to duodenum on a 20-min and a 30-min delayed scan. We also reviewed the pathologic and clinical diagnostic information. In addition, we performed a subgroup analysis according to the presence of the bulging ampulla. Univariate and multivariate analysis was performed to determine the malignancy-associated factor.

Results:

54 patients had ampullary cancer and 66 patients had a benign condition. On the multivariate analysis, diffusion restriction (p=0.028) and heterogeneous enhancement (p=0.045) of the ampulla, no change of shape in distal CBD (p=0.010), and no contrast secretion to duodenum 30-min delayed scan (p=0.001) were significantly associated with ampullary cancer. On the subgroup analysis, the presence of diffusion restriction and the extent of CBD dilatation, no contrast secretion to duodenum 30-min delayed scan was significantly associated with ampullary cancer in the group with the bulging ampulla. In the group without the bulging ampulla, no contrast secretion to duodenum 30-min delayed scan is the only significant factor for ampullary cancer.

Conclusion:

Diffusion restriction and heterogeneous enhancement of the ampulla, no change of shape in distal CBD, and no contrast secretion to duodenum 30-min delayed scan were significantly associated with ampullary cancer. Among them, no contrast secretion to duodenum 30-min delayed scan is the only significant factor regardless of the presence of the bulging ampulla.

Limitations:

Single centre, retrospective study with a small number of subjects.

Ethics committee approval

n/a

Funding:

No funding was received for this work.