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Mulé S, Brault B, Blain M, Neifar N, Touloupas C, Boulay-Coletta I, Reizine E, Luciani A, Zins M. Value of dual-energy computed tomography in the diagnosis of bowel ischemia in patients with mechanical small-bowel obstruction: a retrospective, dual-center study. Eur Radiol 2025:10.1007/s00330-025-11635-9. [PMID: 40328956 DOI: 10.1007/s00330-025-11635-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 03/12/2025] [Accepted: 03/23/2025] [Indexed: 05/08/2025]
Abstract
OBJECTIVES To investigate the diagnostic value of rapid-kV-switching dual-energy CT (DECT) for identifying bowel ischemia in patients with mechanical small-bowel obstruction (SBO), compared to 120 kVp-equivalent CT. MATERIALS AND METHODS This retrospective dual-center study included 112 patients with mechanical SBO. Clinical and surgical outcomes with histological findings were recorded as the reference standard. Three readers independently reviewed true unenhanced (TUE) and portal-venous 77-keV virtual monoenergetic images (VMI) (dataset#1), virtual unenhanced (VUE), iodine, and 50-keV VMI (dataset#2). Ischemia was defined as the presence of at least two CT features among reduced bowel-wall enhancement, diffuse mesenteric haziness, and a closed-loop mechanism. Unenhanced bowel-wall attenuation was also analysed. Bowel-wall attenuation and iodine concentration were measured in involved loops and proximal dilated loops. Sensitivity and specificity were calculated for each CT feature. Association between iodine concentration and bowel ischemia was analysed using ROC curves. RESULTS Forty-one (37%) patients underwent surgery. Twenty-four (21%) patients had findings of bowel ischemia, including 11 (10%) patients with irreversible ischemia (necrosis). Diagnostic performance for ischemia and necrosis was similar between both datasets for all readers (p > 0.49 for ischemia and p = 1 for necrosis). Increased bowel-wall attenuation on VUE or TUE images had a non-significantly different diagnostic value for all readers (p > 0.21 for ischemia and p > 0.78 for necrosis). Bowel-wall iodine concentration identified bowel necrosis with 82% sensitivity and 83% specificity (optimal cutoff value 1.82 mg/mL). CONCLUSION DECT performed similarly to 120 kVp-equivalent CT for the diagnosis of bowel ischemia in patients with mechanical SBO. VUE images offer a viable alternative to TUE images for the identification of increased bowel-wall attenuation. Bowel-wall iodine concentration accurately identifies bowel necrosis. KEY POINTS Question Dual-energy CT (DECT) could detect small-bowel ischemia caused by mechanical small-bowel obstruction (SBO), but its performance is unknown. Findings Reduced bowel-wall enhancement and increased unenhanced bowel-wall attenuation were not significantly different between DECT and 120 kVp-equivalent CT. Bowel-wall iodine concentration identified necrosis with 82% sensitivity and 83% specificity. Clinical relevance DECT performed similarly to 120 kVp-equivalent CT in depicting bowel ischemia in patients with mechanical SBO, while adding quantitative analysis of bowel-wall iodine concentration may further help identify patients requiring surgery.
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Affiliation(s)
- Sébastien Mulé
- Medical Imaging Department, AP-HP, Henri Mondor University Hospital, 1 rue Gustave Eiffel, 94000, Créteil, France.
- Faculty of Health, University of Paris Est Créteil, Créteil, France.
- INSERM IMRB, U 955, Team 18, Créteil, France.
| | - Baptiste Brault
- Medical Imaging Department, AP-HP, Henri Mondor University Hospital, 1 rue Gustave Eiffel, 94000, Créteil, France
| | - Maxime Blain
- Medical Imaging Department, AP-HP, Henri Mondor University Hospital, 1 rue Gustave Eiffel, 94000, Créteil, France
- Faculty of Health, University of Paris Est Créteil, Créteil, France
| | - Nada Neifar
- Department of Medical Imaging, Paris Saint Joseph Hospital, 185 rue Raymond Losserand, 75014, Paris, France
| | - Caroline Touloupas
- Department of Medical Imaging, Paris Saint Joseph Hospital, 185 rue Raymond Losserand, 75014, Paris, France
| | - Isabelle Boulay-Coletta
- Department of Medical Imaging, Paris Saint Joseph Hospital, 185 rue Raymond Losserand, 75014, Paris, France
| | - Edouard Reizine
- Medical Imaging Department, AP-HP, Henri Mondor University Hospital, 1 rue Gustave Eiffel, 94000, Créteil, France
- Faculty of Health, University of Paris Est Créteil, Créteil, France
- INSERM IMRB, U 955, Team 18, Créteil, France
| | - Alain Luciani
- Medical Imaging Department, AP-HP, Henri Mondor University Hospital, 1 rue Gustave Eiffel, 94000, Créteil, France
- Faculty of Health, University of Paris Est Créteil, Créteil, France
- INSERM IMRB, U 955, Team 18, Créteil, France
| | - Marc Zins
- Department of Medical Imaging, Paris Saint Joseph Hospital, 185 rue Raymond Losserand, 75014, Paris, France
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Lamant F, Simon G, Busse-Coté A, Hassoun Y, Roussel B, Verdot P, Doussot A, Lakkis Z, Delabrousse E, Calame P. Assessment of small bowel ischemia in mechanical small bowel obstruction: Diagnostic value of bowel wall iodine concentration using dual-energy CT. Diagn Interv Imaging 2025; 106:126-134. [PMID: 39550287 DOI: 10.1016/j.diii.2024.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 10/19/2024] [Accepted: 10/30/2024] [Indexed: 11/18/2024]
Abstract
PURPOSE The purpose of this study was to determine whether dual-energy computed tomography (DECT), specifically by measuring bowel wall iodine concentration (BWIC), is superior to monoenergetic reconstructions (MR) for the diagnosis and staging of small bowel ischemia in patients with mechanical small bowel obstruction (SBO). MATERIALS AND METHODS From November 2021 to December 2023, all patients with mechanical SBO who underwent contrast-enhanced DECT of the abdomen and pelvis were evaluated for inclusion. Demographic, clinical and biochemical data were collected. Two abdominal radiologists, blinded to all patient information, reviewed all DECT examinations. Conventional CT features (including a closed loop mechanism, mesenteric haziness, decreased bowel wall enhancement (DBE), and increased unenhanced attenuation of the bowel wall) were first reviewed on 70-keV-MR and 40-keV-MR, followed by BWIC measurements in five regions of interest in the walls of both normal and abnormal small bowel loops. The diagnostic performance of a simple CT score, which included a closed loop mechanism, mesenteric haziness and DBE, was compared to that of BWIC measurements made on dilated and/or abnormal small bowel segments for the diagnosis of small bowel ischemia. The diagnostic capabilities were compared using areas under the receiver operating characteristic curves (AUCs). RESULTS A total of 142 patients were included (80 men, 62 women; mean age, 67 ± 17 [standard deviation (SD)] years). Fifty-six patients underwent surgery; 22 of them had confirmed small bowel ischemia, including 12 patients with small bowel necrosis requiring surgical resection. Significant differences in mean BWIC were found between patients without small bowel ischemia (1.73 ± 0.44 [SD] mg/mL), those with small bowel ischemia without necrosis (0.79 ± 0.37 [SD] mg/mL), and those with small bowel ischemia and necrosis (0.48 ± 0.32 [SD] mg/mL) (P < 0.001). The overall AUC of the BWIC measurement for diagnosing small bowel ischemia was 0.98 (95 % confidence interval [CI]: 0.97-1.00), similar to the AUC of the simple CT score (0.97; 95 % CI: 0.92-1.00). However, using a cut off-value of 1.16 mgI/mL, BWIC outperformed subjective assessment of DBE at 70-keV-MR and 40-keV-MR (Youden index, 0.90 vs. 0.54 and vs. 0.71, respectively) (P < 0.001 for both). CONCLUSION BWIC measurement outperforms subjective assessment of DBE for the diagnosis of small bowel ischemia in patients with SBO and can allow stratification of ischemia. However, BWIC does not outperfomr a global comprehensive analysis of conventional CT images.
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Affiliation(s)
- Flora Lamant
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Gabriel Simon
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Andreas Busse-Coté
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Youness Hassoun
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Bastien Roussel
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Pierre Verdot
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Alexandre Doussot
- Department of Digestive Surgery, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France
| | - Eric Delabrousse
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France; EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, 25000 Besançon, France
| | - Paul Calame
- Department of Radiology, University of Franche-Comté, CHRU Besançon, 25000 Besançon, France; EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, 25000 Besançon, France.
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Reintam Blaser A, Koitmäe M, Laisaar KT, Forbes A, Kase K, Kiisk E, Murruste M, Reim M, Starkopf J, Tamme K. Radiological diagnosis of acute mesenteric ischemia in adult patients: a systematic review and meta-analysis. Sci Rep 2025; 15:9875. [PMID: 40119151 PMCID: PMC11928508 DOI: 10.1038/s41598-025-94846-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Accepted: 03/17/2025] [Indexed: 03/24/2025] Open
Abstract
Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. Systematic literature search in PubMed, Cochrane Library, Web of Science and Scopus was conducted in May 2024. Studies including at least 10 adult patients and reporting radiological diagnosis of AMI versus no AMI or transmural ischemia versus no transmural ischemia were included. Meta-analyses on sensitivity and specificity of different radiological features in diagnosing AMI were conducted. From 2628 titles, 490 studies underwent full text review, and 81 were included in 14 meta-analyses. Diagnostic accuracy of CT angiography (CTA) was high - sensitivity of 92.0% and specificity of 98.8% (I2 45% and 79%, respectively), but lower for other CT protocols (sensitivity 75.8 and specificity 90.5; I2 83%). In most included studies, distinction of subtypes and severity of AMI (non-transmural or transmural) was not possible. Amongst the non-vascular features, absent/reduced bowel wall enhancement provided the best prognostic value (sensitivity 57.9 and specificity 90.1). CTA is the method of choice for diagnosing AMI with high diagnostic accuracy. None of the non-vascular features alone is sufficiently reliable to diagnose AMI or its progression to transmural necrosis, whereas a combination of different radiological features conveys a potential.
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Merli Koitmäe
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Kaja-Triin Laisaar
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of General and Plastic Surgery, Tartu University Hospital, Tartu, Estonia
| | - Ele Kiisk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of General and Plastic Surgery, Tartu University Hospital, Tartu, Estonia
| | - Martin Reim
- Department of Radiology, Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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Wang Z, Zhu L, Liu S, Li D, Liu J, Zhou X, Wang Y, Liu R. Development and validation of a CT-based radiomic nomogram for predicting surgical resection risk in patients with adhesive small bowel obstruction. BMC Med Imaging 2025; 25:46. [PMID: 39934668 PMCID: PMC11817561 DOI: 10.1186/s12880-025-01575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 01/28/2025] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND Adhesive small bowel obstruction (ASBO) is a common emergency that requires prompt medical attention, and the timing of surgical intervention poses a considerable challenge. Although computed tomography (CT) is widely used, its effectiveness in accurately identifying bowel strangulation is limited. The potential of radiomics models to predict the necessity for surgical resection in ASBO cases is not yet fully explored. OBJECTIVES The aim of this study is to identify risk factors for surgical resection in patients with ASBO and to develop a predictive model that integrates radiomic features with clinical data. This model designed to estimate the likelihood of surgical intervention and aid in clinical decision-making for acute ASBO cases. METHODS From January 2019 to February 2022, we enrolled 188 ASBO patients from our hospital, dividing them randomly into a training cohort (n = 131) and a test cohort (n = 57) using a 7:3 ratio. We collected baseline clinical data and extracted radiomic features from CT images to compute a radiomic score (Rad-score). A nomogram was developed that combines clinical characteristics and Rad-score. The performance of clinical, radiomic, and combined nomogram models was evaluated in both cohorts. RESULTS Of the 188 patients, 92 underwent surgical resection, while 96 did not. The nomogram integrated factors such as white blood cell count, duration of obstruction, and preoperative infection indicators (fever, tachycardia, peritonitis), along with CT findings (elevated wall density, thickened wall, mesenteric fluid, ascites, bowel wall gas, small bowel feces, and hyperdensity of mesenteric fat) (p < 0.1). This combined model accurately predicted the need for surgical resection, with area under the curve (AUC) values of 0.761 (95% CI, 0.628-0.893) for the test cohort. Calibration curves showed strong agreement between predicted and observed outcomes, and decision curve analysis validated the model's utility for acute ASBO cases. CONCLUSION We developed and validated a CT-based nomogram that combines radiomic features with clinical data to predict the risk of surgical resection in ASBO patients. This tool offers valuable support for treatment planning and decision-making in emergent situations.
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Affiliation(s)
- Zhibo Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
- Department of General Surgery, Weifang People's hospital, Weifang, 261000, China
| | - Ling Zhu
- Shandong Key Laboratory of Digital Medicine and Computer Assisted Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Shunli Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Dalue Li
- Emergency Department, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Jingnong Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Xiaoming Zhou
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Yuxi Wang
- Acute Abdomen Surgery Department, The second hospital of Dalian medical university, Dalian, 116027, China
| | - Ruiqing Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China.
- The Affiliated Hospital of Qingdao University, Wutaishan-road No.1677, Qingdao, 266071, Shandong, China.
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Eze VN, Parry T, Boone D, Mallett S, Halligan S. Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review. Eur Radiol 2024; 34:3861-3871. [PMID: 37938387 PMCID: PMC11166786 DOI: 10.1007/s00330-023-10421-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/06/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES To identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction. METHODS Two researchers systematically reviewed indexed literature 2001-2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies. RESULTS Thirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36). CONCLUSIONS Systematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery. CLINICAL RELEVANCE STATEMENT Via systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility. KEY POINTS • While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely. • Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery. • Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.
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Affiliation(s)
- Vivienne N Eze
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Tom Parry
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
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Li BQ, Qi WJ, Yuan M, Wang HY, Chen M, Lei JA, Meng M, Li Q, Li L, Jiang B, Ma ZL, Xiu DR, Yuan CH. Prediction of bowel necrosis by reduced bowel wall enhancement in closed-loop small bowel obstruction: Quantitative methods. Eur J Radiol 2024; 173:111363. [PMID: 38367415 DOI: 10.1016/j.ejrad.2024.111363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 02/08/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE To assess diagnostic performance and reproducibility of reduced bowel wall enhancement evaluated by quantitative methods using CT to identify bowel necrosis among closed-loop small bowel obstruction (CL-SBO) patients. METHODS This retrospective single-center study included patients who diagnosed with CL-SBO caused by adhesion or internal hernia during January 2016 and May 2022. Patients were divided into necrotic group (n = 41) and non-necrotic group (n = 67) according to surgical exploration and postoperative pathology. Two doctors independently measured the attenuation of bowel wall and consensus was reached through panel discussion with a third gastrointestinal radiologist. Reduced bowel wall enhancement was assessed by four quantitative methods. Univariate analyses were used to evaluate the association between each method and bowel necrosis, and kappa/intraclass correlation coefficient values were used to assess interobserver agreement. Diagnostic performance parameters were calculated for each method. RESULTS Reduced bowel wall enhancement in arterial phase (OR 8.98, P < 0.0001), reduced bowel wall enhancement in portal phase (OR 16.84, P < 0.001), adjusted reduced bowel wall enhancement in arterial phase (OR 29.48, P < 0.001), adjusted reduced bowel wall enhancement in portal phase (OR 145.69, P < 0.001) were significantly associated with bowel necrosis. Adjusted reduced bowel wall enhancement in portal phase had the best diagnostic performance (AUC: 0.92; Youden index: 0.84; specificity: 94.03 %) and interobserver agreement (kappa value of 0.59-0.73) to predict bowel necrosis. CONCLUSION When assessing reduced bowel enhancement to predict bowel necrosis among CL-SBO patients, using unenhanced CT images and proximal dilated loop as standard references in portal phase is the most accurate quantitative method among those tested.
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Affiliation(s)
- Bing-Qi Li
- Department of General Surgery, Peking University Third Hospital, Beijing, China; Department of General Surgery, Yan'an Hospital of Traditional Chinese Medicine, Shanxi, China
| | - Wei-Jun Qi
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Meng Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Hang-Yan Wang
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Ming Chen
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Ji-An Lei
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Meng Meng
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Qi Li
- Department of General Surgery, Yan'an Hospital of Traditional Chinese Medicine, Shanxi, China
| | - Lei Li
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Bin Jiang
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Zhao-Lai Ma
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Dian-Rong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Chun-Hui Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, China.
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Garzelli L, Felli E, Al-Taher M, Barberio M, Agnus V, Plaforet V, Bonvalet F, Baiocchini A, Nuzzo A, Paulatto L, Vilgrain V, Gallix B, Diana M, Ronot M. MRI for the Detection of Small Bowel Ischemic Injury in Arterial Acute Mesenteric Ischemia: Preclinical Study in a Porcine Model. J Magn Reson Imaging 2023; 57:918-927. [PMID: 35852296 DOI: 10.1002/jmri.28344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND MRI is the reference for the diagnosis of arterial cerebral ischemia, but its role in acute mesenteric ischemia (AMI) is poorly known. PURPOSE To assess MRI detection of early ischemic bowel lesions in a porcine model of arterial AMI. STUDY TYPE Prospective/cohort. ANIMAL MODEL Porcine model of arterial AMI obtained by embolization of the superior mesenteric artery (seven pigs). FIELD STRENGTH/SEQUENCE A 5-T. T1 gradient-echo-weighted-imaging (WI), half-Fourier-acquisition-single-shot-turbo-spin-echo, T2 turbo-spin-echo, true-fast-imaging-with-steady-precession (True-FISP), diffusion-weighted-echo-planar (DWI). ASSESSMENT T1-WI, T2-WI, and DWI were performed before and continuously after embolization for 6 hours. The signal intensity (SI) of the ischemic bowel was assessed visually and quantitatively on all sequences. The apparent diffusion coefficient (ADC) was assessed. STATISTICAL TESTS Paired Student's t-test or Mann-Whitney U-test, significance at P < 0.05. RESULTS One pig died from non-AMI-related causes. The remaining pigs underwent a median 5 h53 (range 1 h24-6 h01) of ischemia. Visually, the ischemic bowel showed signal hyperintensity on DWI-b800 after a median 85 (57-276) minutes compared to the nonischemic bowel. DWI-b800 SI significantly increased after 2 hours (+19%) and the ADC significant decrease within the first hour (-31%). The ischemic bowel was hyperintense on precontrast T1-WI after a median 87 (70-171) minutes with no significant quantitative changes over time (P = 0.46-0.93). The ischemic bowel was hyperintense on T2-WI in three pigs with a significant SI increase on True-FISP after 1 and 2 hours. DATA CONCLUSION Changes in SI and ADC can be seen early after the onset of arterial AMI with DWI. The value of T2-WI appears to be limited. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Lorenzo Garzelli
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France.,IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Eric Felli
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,Hepatology, Department of Biomedical Research, Inselspital, University of Bern, Bern, Switzerland
| | - Mahdi Al-Taher
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Manuel Barberio
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Agnus
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Vincent Plaforet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Fanny Bonvalet
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Andrea Baiocchini
- Department of Pathology, San Camillo Forlanini Hospital, Rome, Italy
| | - Alexandre Nuzzo
- Université Paris Cité, Paris, France & Structure d'Urgence Vasculaire Intestinales (SURVI), Nutritional support, Gastroenterology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Luisa Paulatto
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Valérie Vilgrain
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Benoit Gallix
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France
| | - Michele Diana
- IHU Strasbourg - Image Guided Surgery, Strasbourg University, Strasbourg, France.,IRCAD, Research Institute against Digestive Cancer, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, France.,ICube Lab, Photonics for Health, Strasbourg, France
| | - Maxime Ronot
- Université Paris Cité, Paris, France & Department of Radiology, Beaujon Hospital, APHP.Nord, Clichy, France
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Abstract
Acute mesenteric ischemia (AMI) is an uncommon yet highly lethal cause of acute abdomen in the emergency setting. Computed tomography (CT) imaging, in particular a biphasic protocol consisting of angiographic and venous phase scans, is widely used to corroborate non-specific clinical findings when suspicions of AMI are high. Techniques such as low kilovoltage peak scanning, dual energy acquisition, or a combined arterial/enteric phase can improve iodine conspicuity and evaluation of bowel enhancement. Biphasic CT with CT angiography is mandatory to directly assess for the 3 primary etiologies of AMI-arterial, venous, and non-occlusive mesenteric ischemia (NOMI), and the CT angiographic findings may be the first visible in the disease. In addition, numerous non-vascular CT findings have also been reported. Bowel wall thickening, mesenteric stranding, and ascites are common but non-specific findings that correlate poorly with disease severity. Pneumatosis intestinalis and portomesenteric venous gas, while not pathognomonic for ischemia, are highly specific in cases of high clinical suspicion. Bowel wall hypoenhancement is an early and specific sign but requires a protocol optimizing iodine conspicuity to confidently identify. Finally, intraperitoneal free air and solid organ infarcts are also highly specific ancillary findings in AMI. AMI occurs as a complication in 10% of small bowel obstruction (SBO) patients, and understanding imaging findings of ischemia in the context of SBO is necessary to aid in treatment planning and reduce over- and under-diagnosis of strangulation. Familiarity with the imaging features of ischemia by radiologists is vital to establish an early diagnosis before irreversible necrosis occurs.
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Affiliation(s)
- Hang Yu
- Department of Diagnostic Radiology, 8664University of Manitoba, Winnipeg, MB, Canada
| | - Iain D C Kirkpatrick
- Department of Diagnostic Radiology, 8664University of Manitoba, Winnipeg, MB, Canada
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9
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Dual-energy CT of acute bowel ischemia. Abdom Radiol (NY) 2022; 47:1660-1683. [PMID: 34191075 DOI: 10.1007/s00261-021-03188-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022]
Abstract
Acute bowel ischemia is a condition with high mortality and requires rapid intervention to avoid catastrophic outcomes. Swift and accurate imaging diagnosis is essential because clinical findings are commonly nonspecific. Conventional contrast enhanced CT of the abdomen has been the imaging modality of choice to evaluate suspected acute bowel ischemia. However, subtlety of image findings and lack of non-contrast or arterial phase images can make correct diagnosis challenging. Dual-energy CT provides valuable information toward assessing bowel ischemia. Dual-energy CT exploits the differential X-ray attenuation at two different photon energy levels to characterize the composition of tissues and reveal the presence or absence of faint intravenous iodinated contrast to improve reader confidence in detecting subtle bowel wall enhancement. With the same underlying technique, virtual non-contrast images can help to show non-enhancing hyperdense hemorrhage of the bowel wall in intravenous contrast-enhanced scans without the need to acquire actual non-contrast scans. Dual-energy CT derived low photon energy (keV) virtual monoenergetic images emphasize iodine contrast and provide CT angiography-like images from portal venous phase scans to better evaluate abdominal arterial patency. In Summary, dual-energy CT aids diagnosing acute bowel ischemia in multiple ways, including improving visualization of the bowel wall and mesenteric vasculature, revealing intramural hemorrhage in contrast enhanced scans, or possibly reducing intravenous contrast dose.
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10
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Chai Y, Xing J, Lv P, Liang P, Xu H, Yue S, Gao J. Evaluation of ischemia and necrosis in adhesive small bowel obstruction based on CT signs: Subjective visual evaluation and objective measurement. Eur J Radiol 2021; 147:110115. [PMID: 34990890 DOI: 10.1016/j.ejrad.2021.110115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/23/2021] [Accepted: 12/19/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the diagnostic performance of CT signs for detecting bowel ischemia and necrosis in adhesive small bowel obstruction(SBO) with subjective and objective methods. MATERIALS AND METHODS 113 adhesive SBO patients were enrolled and divided into ischemic group (49 cases in necrotic group and 35 cases in reversible ischemic group) and non-ischemic group (29 cases) according to the operation results. Subjective visual assessment of CT signs associated with ischemia and necrosis was performed by two radiologists independently. Elevated unenhanced attenuation and enhancement value of involved bowel wall were objectively measured and compared by single factor analysis of variance. Cut-off value and diagnostic performance were evaluated by receiver operating characteristic curve (ROC). RESULTS Closed-loop mechanism, reduced bowel wall enhancement, and mesenteric edema were associated with bowel ischemia, with sensitivity of 81.0%, 65.5%, 75.0%, and specificity of 86.2%, 96.6%, 89.7%, respectively. Increased unenhanced bowel wall attenuation was a specific sign for necrosis with 100.0% specificity and 51.0% sensitivity. The sensitivity and specificity for ischemia were 86.0% and 91.9% with cut-off enhancement value lower than 33.5 HU. The sensitivity and specificity for necrosis were 58.2% and 100.0% with cut-off elevated unenhanced attenuation higher than 16.5 HU, 86.7% and 83.3% with cut-off enhancement value lower than 21.5 HU. CONCLUSION Reduced bowel wall enhancement and increased unenhanced bowel wall attenuation were good indicators of bowel ischemia and necrosis. The objective measurement of elevated unenhanced attenuation and enhancement value can predict bowel ischemia and necrosis more accurately.
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Affiliation(s)
- Yaru Chai
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jingjing Xing
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Peijie Lv
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Pan Liang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Huanan Xu
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Songwei Yue
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jianbo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China.
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11
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Tang W, Zhang J, Kuang LQ, Yi KM, Li CX, Wang Y. Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia. Quant Imaging Med Surg 2021; 11:3120-3132. [PMID: 34249639 PMCID: PMC8250001 DOI: 10.21037/qims-20-604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 03/12/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism. METHODS In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis. RESULTS Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71). CONCLUSIONS In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.
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Affiliation(s)
- Wei Tang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
- Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Lian-Qin Kuang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Kun-Ming Yi
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chun-Xue Li
- Department of Gastrointestinal Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yi Wang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China
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Hong W, Kim MJ, Lee SM, Ha HI, Park HC, Yeo SG. Computed Tomography Findings Associated with Treatment Failure after Antibiotic Therapy for Acute Appendicitis. Korean J Radiol 2021; 22:63-71. [PMID: 32783411 PMCID: PMC7772384 DOI: 10.3348/kjr.2019.0823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/14/2020] [Accepted: 05/24/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To identify the CT findings associated with treatment failure after antibiotic therapy for acute appendicitis. MATERIALS AND METHODS Altogether, 198 patients who received antibiotic therapy for appendicitis were identified by searching the hospital's surgery database. Selection criteria for antibiotic therapy were uncomplicated appendicitis with an appendiceal diameter equal to or less than 11 mm. The 86 patients included in the study were divided into a treatment success group and a treatment failure group. Treatment failure was defined as a resistance to antibiotic therapy or recurrent appendicitis during a 1-year follow-up period. Two radiologists independently evaluated the following CT findings: appendix-location, involved extent, maximal diameter, thickness, wall enhancement, focal wall defect, periappendiceal fat infiltration, and so on. For the quantitative analysis, two readers independently measured the CT values at the least attenuated wall of the appendix by drawing a round region of interest on the enhanced CT (HUpost) and non-enhanced CT (HUpre). The degree of appendiceal wall enhancement (HUsub) was calculated as the subtracted value between HUpost and HUpre. A logistic regression analysis was used to identify the CT findings associated with treatment failure. RESULTS Sixty-four of 86 (74.4%) patients were successfully treated with antibiotic therapy, with treatment failure occurring in the remaining 22 (25.5%). The treatment failure group showed a higher frequency of hypoenhancement of the appendiceal wall than the success group (31.8% vs. 7.8%; p = 0.005). Upon quantitative analysis, both HUpost (46.7 ± 21.3 HU vs. 58.9 ± 22.0 HU; p = 0.027) and HUsub (26.9 ± 17.3 HU vs. 35.4 ± 16.6 HU; p = 0.042) values were significantly lower in the treatment failure group than in the success group. CONCLUSION Hypoenhancement of the appendiceal wall was significantly associated with treatment failure after antibiotic therapy for acute appendicitis.
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Affiliation(s)
- Wonju Hong
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Min Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea.
| | - Sang Min Lee
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hong Il Ha
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyoung Chul Park
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Seung Gu Yeo
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Abstract
OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.
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14
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Chang KJ, Marin D, Kim DH, Fowler KJ, Camacho MA, Cash BD, Garcia EM, Hatten BW, Kambadakone AR, Levy AD, Liu PS, Moreno C, Peterson CM, Pietryga JA, Siegel A, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. J Am Coll Radiol 2020; 17:S305-S314. [PMID: 32370974 DOI: 10.1016/j.jacr.2020.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 01/29/2023]
Abstract
Small-bowel obstruction is a common cause of abdominal pain and accounts for a significant proportion of hospital admissions. Radiologic imaging plays the key role in the diagnosis and management of small-bowel obstruction as neither patient presentation, the clinical examination, nor laboratory testing are sufficiently sensitive or specific enough to diagnose or guide management. This document focuses on the imaging evaluation of the two most commonly encountered clinical scenarios related to small-bowel obstruction: the acute presentation and the more indolent, low-grade, or intermittent presentation. This document hopes to clarify the appropriate utilization of the many imaging procedures that are available and commonly employed in these clinical settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts.
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Benjamin W Hatten
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians
| | | | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | | | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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15
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Li Z, Zhang L, Liu X, Yuan F, Song B. Diagnostic utility of CT for small bowel obstruction: Systematic review and meta-analysis. PLoS One 2019; 14:e0226740. [PMID: 31887146 PMCID: PMC6936825 DOI: 10.1371/journal.pone.0226740] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To perform a systematic review and meta-analysis evaluating the diagnostic performance of computed tomography (CT) for small bowel obstruction (SBO), including diagnostic accuracy, ischemia, predicting surgical intervention, etiology and transition point. METHODS PubMed/MEDLINE and related databases were searched for research articles published from their inception through August 2018. Findings were pooled using bivariate random-effects and summary receiver operating characteristic curve models. Meta-regression and subgroup analyses were performed to evaluate whether publication year, patient age, enhanced CT, slice thickness and pathogenesis affected classification accuracy. RESULTS In total, 45 studies with a total of 4004 patients were included in the analysis. The pooled sensitivity and specificity of CT for SBO were 91% (95% confidence interval [CI]: 84%, 95%) and 89% (95% CI: 81%, 94%), respectively, and there were no differences in the subgroup analyses of age, publication year, enhanced CT and slice thickness. For ischemia, the pooled sensitivity and specificity was 82% (95% CI: 67%, 91%) and 92% (95% CI: 86%, 95%), respectively. No difference was found between enhanced and unenhanced CT based on subgroup analysis; however, high sensitivity was found in adhesive SBO compared with routine causes (96% vs. 78%, P = 0.03). The pooled sensitivity and specificity for predicting surgical intervention were 87% and 73%, respectively. The accuracy for etiology of adhesions, hernia and tumor was 95%, 70% and 82%, respectively. In addition, the pooled sensitivity and specificity for transition point was 92% and 77%, respectively. CONCLUSIONS CT has considerable accuracy in diagnosis of SBO, ischemia, predicting surgical intervention, etiology and transition point.
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Affiliation(s)
- Zhengyan Li
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ling Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xijiao Liu
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fang Yuan
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Bin Song
- Division of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Vassiliu P, Ntella V, Theodoroleas G, Mantanis Z, Pentara I, Papoutsi E, Mastoraki A, Arkadopoulos N. Successful management of adhesion related small bowel ischemia without intestinal resection: A case report and review of literature. World J Gastrointest Pathophysiol 2019; 10:29-35. [PMID: 31559107 PMCID: PMC6751506 DOI: 10.4291/wjgp.v10.i2.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intraabdominal adhesions develop spontaneously or after an inflammatory process or surgical procedure in the abdomen. They are the most common cause of small bowel obstruction (SBO). SBO occasionally leads to intestinal ischemia (InIs) which can be a life-threatening condition that requires management as soon as possible. We herein report a case of SBO with InIs presented in our institution and treated without intestinal resection.
CASE SUMMARY A 34-year-old man presented at the emergency department after a 12-h-onset diffuse abdominal pain, bloating and nausea. He had a history of traumatic right hepatectomy 11 years ago as well as adhesiolysis and resection of a long part of small bowel 2 years ago. An abdominal computed tomography (CT) showed dilated loops that led to the diagnosis of SBO. Due to deteriorating lactic acidosis, the patient was operated. Torsion of the small bowel around an adhesion led to 2.30 m of ischemic ileum. After the application of N/S 40 °C for 20 min, the intestine showed signs of improvement and it was decided to avoid resection and instead temporary close the abdomen with vacuum-pack technique. At the second-look laparotomy 48 h later, the intestine appeared normal. The patient was discharged on the 8th post-op day in excellent condition.
CONCLUSION In case of SBO caused by adhesions, extreme caution is needed if InIs is present, as the clinical signs are mild and you should rely for diagnosis in CT findings and lactate levels. Conservative surgical approach could reverse the effects of InIs, if performed quickly, so that intestinal resection is avoided and should be used even when minimum signs of viability are present.
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Affiliation(s)
- Pantelis Vassiliu
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Vasiliki Ntella
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - George Theodoroleas
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Zisis Mantanis
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Ioanna Pentara
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Eleni Papoutsi
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
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Copin P, Ronot M, Nuzzo A, Maggiori L, Bouhnik Y, Corcos O, Vilgrain V. Inter-reader agreement of CT features of acute mesenteric ischemia. Eur J Radiol 2018; 105:87-95. [PMID: 30017304 DOI: 10.1016/j.ejrad.2018.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 05/15/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the inter-reader agreement of the CT features of acute mesenteric ischemia (AMI). METHODS Between 2006 and 2014, 109 patients (57 men, 52%, mean age 50 years old [17-83]) admitted to our institution with a diagnosis of AMI were included. CT scans (42% were initially performed in our institution) were reviewed by two abdominal radiologists. Inter-observer agreement of the imaging features of vascular insufficiency and bowel ischemia was assessed by the percentage of agreement and the kappa value. RESULTS The final population included, Inter-observer agreement varied according to the different features (κ = 0.25-0.98). Inter-observer agreement for decreased/absent bowel wall enhancement was moderate (κ = 0.52), but was almost perfect (κ = 0.82) in the 47 patients (43%) with both unenhanced and arterial-phase images without positive oral contrast agent and excellent CT images quality. CONCLUSION Inter-reader agreement was moderate to substantial for most CT features of AMI. Multiphasic CT scan protocol, including unenhanced, arterial phase and venous phase images, without positive oral contrast agent, and excellent CT images quality improve inter-observer agreement of imaging features of AMI, especially for decreased/absent bowel wall enhancement, and should be performed in patients with suspected AMI.
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Affiliation(s)
- Pauline Copin
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France
| | - Maxime Ronot
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; INSERM U1149, centre de recherche biomédicale Bichat-Beaujon, CRB3, Paris, France.
| | - Alexandre Nuzzo
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Léon Maggiori
- University Paris Diderot, Sorbonne Paris Cité, Paris, France; Department of Surgery, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France
| | - Yoram Bouhnik
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Olivier Corcos
- Department of Gastroenterology, IBD and Intestinal Failure, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; SURVI - Structure d'URgences Vasculaires Intestinales (Intestinal Stroke), France
| | - Valérie Vilgrain
- Department of Radiology, APHP, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France; INSERM U1149, centre de recherche biomédicale Bichat-Beaujon, CRB3, Paris, France
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Copin P, Zins M, Nuzzo A, Purcell Y, Beranger-Gibert S, Maggiori L, Corcos O, Vilgrain V, Ronot M. Acute mesenteric ischemia: A critical role for the radiologist. Diagn Interv Imaging 2018; 99:123-134. [DOI: 10.1016/j.diii.2018.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 12/13/2022]
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19
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Abdominal Multidetector Computed Tomography for Suspected Small-Bowel Obstruction. J Comput Assist Tomogr 2017; 41:388-393. [DOI: 10.1097/rct.0000000000000529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Matsushima K, Inaba K, Dollbaum R, Cheng V, Khan M, Herr K, Strumwasser A, Asturias S, Dilektasli E, Demetriades D. High-Density Free Fluid on Computed Tomography: a Predictor of Surgical Intervention in Patients with Adhesive Small Bowel Obstruction. J Gastrointest Surg 2016; 20:1861-1866. [PMID: 27613731 DOI: 10.1007/s11605-016-3244-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/08/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with adhesive small bowel obstruction (ASBO) often develop intraabdominal free fluid (IFF). While IFF is a finding on abdominopelvic computed tomography (CT) associated with the need for surgical intervention, many patients with IFF can be still managed non-operatively. A previous study suggested that a higher red blood cell count of IFF is highly predictive of strangulated ASBO. We hypothesized that radiodensity in IFF (Hounsfield unit (HU)) on CT would predict the need for surgical intervention. STUDY DESIGN Patients with clinicoradiological evidence of ASBO between January 2009 and December 2013 were identified. In patients with IFF > 3 cm2 identified on CT, the HU was measured in the largest pocket of IFF. A sensitivity analysis was performed to determine a high-density HU threshold. The HU of patients who underwent therapeutic laparotomy was compared with those successfully discharged with non-operative management. RESULTS A total of 318 patients with ASBO (median age 52 years, 56.0 % male) were identified. Of 111 patients who had IFF on CT, 55.9 % underwent therapeutic laparotomy and 15.3 % required bowel resection. Radiodensity of IFF in the operative group was significantly higher than that in the non-operative group (18.2 vs. 7.0 HU, p < 0.01). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of high-density IFF (>10 HU) to predict the need for surgical intervention were 83.9, 65.3, 75.4, 76.2, and 75.6 %, respectively. CONCLUSIONS High-density IFF on CT was significantly associated with the need for surgical intervention in patients with ASBO. Prospective study to validate the predictive value of high-density IFF on CT will be warranted.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA.
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ryan Dollbaum
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Vincent Cheng
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Moazzam Khan
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Keith Herr
- Department of Radiology, University of Southern California, Los Angeles, CA, USA
| | - Aaron Strumwasser
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Sabrina Asturias
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Evren Dilektasli
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
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Makar RA, Bashir MR, Haystead CM, Iseman C, Mayes N, Hebert S, Allen BC, Bhattacharya SD, Choudhury KR, Jaffe TA. Diagnostic performance of MDCT in identifying closed loop small bowel obstruction. Abdom Radiol (NY) 2016; 41:1253-60. [PMID: 26830421 DOI: 10.1007/s00261-016-0656-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE To assess the diagnostic performance of MDCT in the diagnosis of closed loop small bowel obstruction. MATERIALS AND METHODS One hundred fifty patients with CT reports including "small bowel obstruction (SBO)" between 1/30/2011 and 12/4/2012 were included (65 men, 85 women, mean age 63 years). CT examinations were independently and blindly reviewed by five radiologists to determine the presence of closed loop obstruction (CL-SBO) and to assess findings of bowel ischemia. Clinical records were reviewed to determine management and operative findings. Using operative findings as a gold standard, reader agreement for the diagnosis of and the CT findings associated with CLO was analyzed using Pearson's correlation (r). Positive predictive value (PPV) and negative predictive value for the diagnosis of CL-SBO and CT signs of bowel ischemia were analyzed. RESULTS Eighty-eight of 150 patients underwent operative intervention for SBO and 24/88 were considered CL-SBO operatively. Average reader sensitivity and specificity for CL-SBO was 53 % (95 % CI 44-63 %) and 83 % (95 % CI 79-87 %). Reader agreement on CL-SBO was poor to moderate (K = 0.39-0.63). Reader agreement for CT signs of bowel ischemia resulting in a diagnosis of CL-SBO was weak (r = 0.19-0.32). CONCLUSION The CT diagnosis of CL-SBO is complex and associated imaging findings have variable sensitivity for predicting a closed loop operative diagnosis. CT can be helpful in excluding a closed loop component in patients with SBO.
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Chen YC, Huang TY, Chen RC, Tsai SH, Chang WC, Fan HL, Huang GS, Ko KH, Chou YC, Hsu HH. Comparison of Ischemic and Nonischemic Bowel Segments in Patients With Mesenteric Ischemia: Multidetector Row Computed Tomography Findings and Measurement of Bowel Wall Attenuation Changes. Mayo Clin Proc 2016; 91:316-28. [PMID: 26809547 DOI: 10.1016/j.mayocp.2015.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe multidetector row computed tomography (MDCT) findings and to compare the enhancing ratio of ischemic and nonischemic bowel wall segments in patients with mesenteric ischemia. PATIENTS AND METHODS We performed a retrospective review of 69 patients with pathologically proven mesenteric ischemia who underwent a preoperative MDCT evaluation from January 1, 2010, through December 31, 2014. Two reviewers performed quantitative MDCT measurements of the bowel wall attenuation of the ischemic and nonischemic bowel segments on the unenhanced phase, arterial phase, and portal venous phase. Receiver operating characteristic curves for the enhancing ratios on the arterial phase and portal venous phase (ERv) were calculated to discriminate the 2 segments. A concordance correlation coefficient was used to assess interobserver variability. RESULTS The most common origin of ischemia was the mesenteric artery (45 of the 69 patients [65.2%]), but only 5 patients (7.2%) had evidence of arterial thrombus on MDCT. The quantitative MDCT measurements indicated that the ischemic bowel segments had significantly less bowel wall attenuation than the nonischemic bowel segments on the arterial phase (28.58±9.28 vs 58.97±12.50; P<.001) and the portal venous phase (33.93±11.16 vs 76.25±13.56; P<.001). The enhancing ratio on the arterial phase (cutoff, 0.32 or less; sensitivity, 89.9%; specificity, 98.6%) and the ERv (cutoff, 0.81 or less; sensitivity, 95.7%; specificity, 98.6%) predicted bowel ischemia. The most common MDCT findings in ischemic bowel were thickened bowel wall in 59 patients (85.5%), mesenteric fatty stranding in 57 (82.6%), and decreased bowel wall enhancement in 56 (81.2%). All quantitative measurements reached moderate to substantial agreement (0.399-0.601). CONCLUSION Without oral contrast administration and at a constant 120-peak kilovolt setting, MDCT findings of decreased enhancement of the thickened bowel wall together with a low ERv value predicted the presence of an ischemic bowel segment.
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Affiliation(s)
- Ya-Cheng Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tien-Yu Huang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ran-Chou Chen
- Department of Radiology, Taipei City Hospital, Taiwan, Republic of China; Department of Biochemical Imaging and Radiological Sciences, National Yang-Ming University, Taiwan, Republic of China
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China; Department of Biochemical Imaging and Radiological Sciences, National Yang-Ming University, Taiwan, Republic of China.
| | - Hsiu-Lung Fan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Kai-Hsiung Ko
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Chuong AM, Corno L, Beaussier H, Boulay-Coletta I, Millet I, Hodel J, Taourel P, Chatellier G, Zins M. Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT. Radiology 2016; 280:98-107. [PMID: 26866378 DOI: 10.1148/radiol.2016151029] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose To determine whether adding unenhanced computed tomography (CT) to contrast material-enhanced CT improves the diagnostic performance of decreased bowel wall enhancement as a sign of ischemia complicating mechanical small bowel obstruction (SBO). Materials and Methods This retrospective study was approved by the institutional review board, which waived the requirement for informed consent. Two gastrointestinal radiologists independently performed retrospective assessments of 164 unenhanced and contrast-enhanced CT studies from 158 consecutive patients (mean age, 71.2 years) with mechanical SBO. The reference standard was the intraoperative and/or histologic diagnosis (in 80 cases) or results from clinical follow-up in patients who did not undergo surgery (84 cases). Decreased bowel wall enhancement was evaluated with contrast-enhanced images then and both unenhanced and contrast-enhanced images 1 month later. Diagnostic performance of decreased bowel wall enhancement and confidence in the diagnosis were compared between the two readings by using McNemar and Wilcoxon signed rank tests. Interobserver agreement was assessed by using κ statistics and compared with bootstrapping. Results Ischemia was diagnosed in 41 of 164 (25%) episodes of SBO. For both observers, adding unenhanced images improved decreased bowel wall enhancement sensitivity (observer 1: 46.3% [19 of 41] vs 65.8% [27 of 41], P = .02; observer 2: 56.1% [23 of 41] vs 63.4% [26 of 41], P = .45), Youden index (from 0.41 to 0.58 for observer 1 and from 0.42 to 0.61 for observer 2), and confidence score (P < .001 for both). Specificity significantly increased for observer 2 (84.5% [104 of 123] vs 94.3% [116 of 123], P = .002), and interobserver agreement significantly increased, from moderate (κ = 0.48) to excellent (κ = 0.89; P < .0001). Conclusion Adding unenhanced CT to contrast-enhanced CT improved the sensitivity, diagnostic confidence, and interobserver agreement of the diagnosis of ischemia, a complication of mechanical SBO, on the basis of decreased bowel wall enhancement. (©) RSNA, 2016.
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Affiliation(s)
- Anh Minh Chuong
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Lucie Corno
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Hélène Beaussier
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Isabelle Boulay-Coletta
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Ingrid Millet
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Jérôme Hodel
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Patrice Taourel
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Gilles Chatellier
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
| | - Marc Zins
- From the Department of Radiology (A.M.C., L.C., I.B.C., J.H., M.Z.) and Clinical Research Unit (H.B., G.C.), Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France; Department of Medical Imaging, CHU Lapeyronie, Montpellier, France (I.M., P.T.); Department of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, Faculty of Medicine, Université Paris Est Créteil, Créteil, France (J.H.), and Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Paris, France (G.C.)
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Perry H, Foley KG, Witherspoon J, Powell-Chandler A, Abdelrahman T, Roberts A, Lewis WG. Relative accuracy of emergency CT in adults with non-traumatic abdominal pain. Br J Radiol 2016; 89:20150416. [PMID: 26790835 DOI: 10.1259/bjr.20150416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE CT examination prior to emergency laparotomy has become ubiquitous in contemporary clinical practice, but the relative accuracy of CT in this context has not been widely reported. The aim of this study was to determine the accuracy and strength of agreement between the perceived pre-operative CT diagnosis and operative findings. METHODS Data from patients undergoing pre-operative CT prior to emergency laparotomy from January 2013 to June 2014 in a large teaching hospital were analysed. The CT diagnosis was compared with operative findings using the χ(2) test and weighted kappa statistic (Kw). Results were further analysed related to the time of day the CT was reported, anatomical location and grade of the reporting radiologist. RESULTS 361 patients [median age 67 years (18-98 years); 180 males] underwent CT prior to emergency laparotomy. CT reports were deemed accurate in 318 (88.1%) cases and inaccurate in 43 (11.9%) cases, which resulted in 5 negative laparotomies in this latter cohort (11.6%, χ(2) 37.50, df 1; p < 0.0001). Accuracy and strength of agreement varied with anatomical location of the pathology; upper gastrointestinal (UGI) 75.5%, Kw 0.673 (0.531-0.815; p < 0.001); small bowel 89.9%, Kw 0.781 (0.687-0.875, p < 0.001); lower gastrointestinal (LGI) 90.4%, Kw 0.821 (0.749-0.893; p < 0.001). CT examinations reported within normal working hours had higher strength of agreement [Kw 0.832 (0.768-0.896), p < 0.001] than CTs reported out of hours [Kw 0.789 (0.721-0.857), p < 0.001], but there was no significant difference in overall accuracy (89.9 vs 86.0%; χ(2) 1.306, df 1, p = 0.253). Reporter seniority was not associated with improved diagnostic accuracy (χ(2) 1.825, df 1; p = 0.177). CONCLUSION CT agreement with emergency operative pathology was good to excellent, but the strength of agreement varied in relation to anatomical location of pathology. ADVANCES IN KNOWLEDGE Overall accuracy was 88.1% with good to excellent agreement between pre-operative CT and emergency laparotomy findings in adult patients with non-traumatic abdominal pain in the acute setting. Diagnostic accuracy of CT reporting varies with anatomical location of pathology.
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Affiliation(s)
- Helen Perry
- 1 Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Jolene Witherspoon
- 1 Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Tarig Abdelrahman
- 1 Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Ashley Roberts
- 2 Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Wyn G Lewis
- 1 Department of General Surgery, University Hospital of Wales, Cardiff, UK
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25
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Nishida T, Tsujimoto M, Takahashi T, Hirota S, Blay JY, Wataya-Kaneda M. Gastrointestinal stromal tumors in Japanese patients with neurofibromatosis type I. J Gastroenterol 2016; 51:571-8. [PMID: 26511941 PMCID: PMC4880630 DOI: 10.1007/s00535-015-1132-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/06/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Neurofibromatosis type I (NF1) predisposes patients to various neoplasias, including gastrointestinal stromal tumors (GISTs). Little is known about the risk of developing GISTs for NF1 patients or the clinicopathologic features and prognosis of NF1-GIST. METHODS We conducted a multi-detector computed tomography screen for adult NF1 patients between 2003 and 2012. Clinicopathologic data of sporadic GISTs from patients who underwent surgery between 2001 and 2010 were retrospectively collected from 32 hospitals in Japan. RESULTS CT screening identified 6 GIST patients from the 95 NF1 patients screened, suggesting that the prevalence rate of GISTs was approximately 6.3/100 in NF1 patients. All 6 NF1 patients exhibited hyperplasia of the interstitial cells of Cajal in the adjoining small intestine. NF1-GISTs may account for 1.1-1.3 % of primary sporadic GISTs and present as multiple tumors in the small intestine, with low mitotic activity and no KIT or PDGFRA mutations. The risk of recurrence and mortality is very similar between NF1 and non-NF1 patients after surgical resection of GISTs. CONCLUSIONS NF1 patients may be predisposed to developing small intestinal GISTs, which may appear as multiple GISTs without KIT and PDGFRA mutations. The prognosis of patients with NF1-GISTs is similar to patients with conventional GISTs.
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Affiliation(s)
- Toshirou Nishida
- />Department of Surgery, Osaka Police Hospital, Osaka, Japan , />Department of Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577 Japan
| | | | - Tsuyoshi Takahashi
- />Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seiichi Hirota
- />Department of Surgical Pathology, Hyogo College of Medicine, Nishinomiya, Hyogo Japan
| | - Jean-Yves Blay
- />Centre Leon Bernard of the Université Claude Bernard, Lyon, France
| | - Mari Wataya-Kaneda
- />Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, Japan
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26
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Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology 2015; 275:332-42. [PMID: 25906301 DOI: 10.1148/radiol.15131519] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a review of small-bowel obstruction written primarily for residents. The review focuses on radiography and computed tomography (CT) for diagnosing small-bowel obstruction and CT for determining complications. (©) RSNA, 2015.
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Affiliation(s)
- Erik K Paulson
- From the Department of Radiology, Duke University Medical Center, Durham, NC (E.K.P.); and Department of Radiology, University of New Mexico and New Mexico VA Health Care System, 1501 San Pedro Dr SE, Albuquerque, NM 87108-5128 (W.M.T.)
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27
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Millet I, Taourel P, Ruyer A, Molinari N. Value of CT findings to predict surgical ischemia in small bowel obstruction: A systematic review and meta-analysis. Eur Radiol 2015; 25:1823-35. [PMID: 25850889 DOI: 10.1007/s00330-014-3440-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 09/09/2014] [Accepted: 09/09/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE Our aim was to assess the diagnostic performance in determining strangulation in small bowel obstruction (SBO) for five CT findings commonly considered in published small bowel obstruction (SBO) management guidelines. MATERIALS AND METHODS Medical databases were searched for "bowel obstruction", "computed tomography", "strangulation", and related terms. Two reviewers independently selected articles for CT findings investigated with surgical or histological reference standards for strangulation. Bivariate random-effects meta-analytical methods were used. RESULTS A total of 768 patients, including 205 with strangulation from nine studies, were evaluated. The reduced bowel wall enhancement CT sign had the highest specificity (95 %, CI 75-99), with a positive LR of 11.07 (2.27-53.88) and DOR of 22.86 (4.99-104.61). The mesenteric fluid sign had the highest sensitivity (89 %, CI 75-96) with a negative LR of 0.16 (0.07-0.39) and a DOR of 13.9 (5.73-33.75). The bowel wall thickness had a sensitivity of 48 % (CI 41-54), a specificity of 83 % (CI 74-89), a positive LR of 2.84 (1.83-4.41) and a negative LR of 0.62 (0.53-0.72). The other CT findings had lower diagnostic performance. CONCLUSION Two CT findings should be used in clinical practice: reduced enhanced bowel wall is highly predictive of ischemia, and absence of mesenteric fluid is a reliable finding to rule out strangulation. KEY POINTS • Reduced bowel wall enhancement on CT increases the probability of strangulation 11-fold. • Absence of mesenteric fluid on CT decreases the probability of strangulation 6-fold. • The clinical reliability of other CT signs is doubtful for predicting strangulation.
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Affiliation(s)
- Ingrid Millet
- From Department of Medical Imaging, CHU Lapeyronie, 371 avenue Gaston Giraud, 34295, Montpellier Cedex 5, France,
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Tsunoyama T, Pham TD, Fujita T, Sakamoto T. Identification of intestinal wall abnormalities and ischemia by modeling spatial uncertainty in computed tomography imaging findings. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2014; 117:30-39. [PMID: 24938748 DOI: 10.1016/j.cmpb.2014.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 06/03/2023]
Abstract
Intestinal abnormalities and ischemia are medical conditions in which inflammation and injury of the intestine are caused by inadequate blood supply. Acute ischemia of the small bowel can be life-threatening. Computed tomography (CT) is currently a gold standard for the diagnosis of acute intestinal ischemia in the emergency department. However, the assessment of the diagnostic performance of CT findings in the detection of intestinal abnormalities and ischemia has been a difficult task for both radiologists and surgeons. Little effort has been found in developing computerized systems for the automated identification of these types of complex gastrointestinal disorders. In this paper, a geostatistical mapping of spatial uncertainty in CT scans is introduced for medical image feature extraction, which can be effectively applied for diagnostic detection of intestinal abnormalities and ischemia from control patterns. Experimental results obtained from the analysis of clinical data suggest the usefulness of the proposed uncertainty mapping model.
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Affiliation(s)
- Taichiro Tsunoyama
- School of Medicine, Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University, Tokyo 173-8606, Japan.
| | - Tuan D Pham
- Aizu Research Cluster for Medical Engineering and Informatics, Research Center for Advanced Information Science and Technology, The University of Aizu, Aizu-Wakamatsu, Fukushima 965-8580, Japan.
| | - Takashi Fujita
- School of Medicine, Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University, Tokyo 173-8606, Japan.
| | - Tetsuya Sakamoto
- School of Medicine, Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University, Tokyo 173-8606, Japan.
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Tsunoyama T, Pham TD, Fujita T, Sakamoto T. Automated CT detection of intestinal abnormalities and ischemia for decision making in emergency medicine. Biomed Eng Online 2014; 13 Suppl 1:S3. [PMID: 25077973 PMCID: PMC4108921 DOI: 10.1186/1475-925x-13-s1-s3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Evaluation of computed tomography (CT) for the diagnosis of intestinal wall abnormalities and ischemia is important for clinical decision making in patients with acute abdominal pain to which if surgery should be performed in the emergency department. Interpretation of such information on CT is usually based on visual assessment by medical professionals and still remains a challenge in a variety of settings of the medical emergency care. This paper reports a pilot study in the implementation of image processing methods for automated detection of intestinal wall abnormalities and bowel ischemia, which can be of a potential application for CT-based detection of the intestinal disease. Methods CT scans of 3 patients of ischemia, one benign and one control subjects were used in this study. Statistical and geometrical features of the CT scans were extracted for pattern classification using two distance measures and the k-nearest neighbor algorithm. The automated detection of intestinal abnormalities and ischemia was carried out using labeled data from the training process with various proportions of training and testing samples to validate the results. Results Detection rates of intestinal ischemia and abnormalities are promising in terms of sensitivity and specificity, where the sensitivity is higher than the specificity in all test cases. The overall classification accuracy between the diseased and control subjects can be as high as 100% when all CT scans were included for measuring the difference between a cohort of three patients of ischemia and a single control subject. Conclusion The proposed approach can be utilized as a computer-aided tool for decision making in the emergency department, where the availability of expert knowledge of the radiologist and surgeon about this complex bowel disease is limited.
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KANZAKI T, HATA J, IMAMURA H, MANABE N, OKEI K, KUSUNOKI H, KAMADA T, SHIOTANI A, HARUMA K. Contrast-enhanced ultrasonography with Sonazoid^|^reg; for the evaluation of bowel ischemia. CHOONPA IGAKU 2014; 41:845-851. [DOI: 10.3179/jjmu.jjmu.k.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
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Geffroy Y, Boulay-Coletta I, Jullès MC, Nakache S, Taourel P, Zins M. Increased unenhanced bowel-wall attenuation at multidetector CT is highly specific of ischemia complicating small-bowel obstruction. Radiology 2013; 270:159-67. [PMID: 24029649 DOI: 10.1148/radiol.13122654] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate performance of increased bowel-wall attenuation on unenhanced 64-section multidetector computed tomographic (CT) images for diagnosing bowel-wall ischemia in patients with mechanical small-bowel obstruction (SBO) and to evaluate the diagnostic accuracy of multidetector CT in detecting small-bowel ischemia complicating SBO, with surgical and histopathologic findings as reference standard. MATERIALS AND METHODS The local institutional review board approved this retrospective study; informed consent requirement was waived. In 44 patients (10 men, 34 women; age range, 30-100 years) who were admitted because they were suspected of having SBO and treated surgically within the next 7 days, 45 multidetector CT scans were retrospectively reviewed. Two gastrointestinal radiologists performed independent blinded reviews of images to identify specific signs of ischemia; disagreements were resolved in consensus with a third gastrointestinal radiologist. Results were compared with both findings in prospective radiology reports and surgical and histopathologic findings. Fisher exact and χ(2) tests were used to assess associations between CT signs and ischemia, and the κ statistic was used to assess interobserver agreement. RESULTS In 19 of 45 (42%) multidetector CT scans, ischemia was confirmed at surgery and/or histopathologic examination. Increased bowel-wall attenuation on unenhanced images was significantly associated with ischemia (P < .0001); in this highly selected population, this sign had a 100% (24 of 24) specificity and a 56% (10 of 18) sensitivity. Sensitivity and specificity of multidetector CT for ischemia were 63% (12 of 19) and 92% (24 of 26), respectively, for the prospective reports and 84% (16 of 19) and 96% (25 of 26), respectively, for the consensus review. Decreased segmental bowel-wall enhancement was the most accurate 64-section multidetector CT sign for diagnosing ischemia (sensitivity, 78% [14 of 18]; specificity, 96% [24 of 25]; P < .0001). The small-bowel feces sign was significantly associated with ischemia (P = .0308). CONCLUSION Increased bowel-wall attenuation on unenhanced 64-section multidetector CT images is a specific sign for ischemia complicating SBO. Diagnostic accuracy of 64-section multidetector CT for ischemia associated with SBO was excellent.
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Affiliation(s)
- Yann Geffroy
- From the Department of Radiology, Fondation Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France (Y.G., I.B., M.C.J., S.N., M.Z.); Department of Radiology, Hôpital d'Instruction des Armées Laveran (Marseille), Marseille, France (Y.G.); and Department of Radiology, CHU Lapeyronie, Montpellier, France (P.T.)
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Nonneoplastic Diseases of the Small Intestine: Clinical, Pathophysiologic, and Imaging Characteristics. AJR Am J Roentgenol 2013; 201:W382-90. [DOI: 10.2214/ajr.12.8496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Firetto MC, Lemos AA, Marini A, Avesani EC, Biondetti PR. Acute bowel ischemia: analysis of diagnostic error by overlooked findings at MDCT angiography. Emerg Radiol 2013; 20:139-147. [PMID: 23053162 DOI: 10.1007/s10140-012-1078-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/12/2012] [Indexed: 01/17/2023]
Abstract
To retrospectively evaluate the frequency and type of findings that were missed in the original reports of multi-detector CT angiography (MDCTA) in patients with suspected acute bowel ischemia. From January 2007 to March 2011, a series of 35 patients who underwent MDCTA of the abdomen and pelvis and had surgery were included. The reports of the initial CT were retrospectively compared with the discharge diagnosis and surgical reports. Discrepant or missing findings were re-evaluated and divided into relevant or not relevant regarding the diagnosis. In 23 of the 35 patients (66 %), all findings were correctly diagnosed in the initial MDCTA report. In the remaining 12 of the 35 patients (34 %), lesions that were not reported were present at surgery. In 10 of the 12 (83 %) patients, the overlooked findings were relevant and subtle: gas in the portal vein (n = 3), gas in the bowel wall (n = 3), gas in the portal vein and bowel wall (n = 2), thrombotic occlusion of the superior mesenteric artery (n = 1), and thrombotic occlusion of the inferior mesenteric artery (n = 1). In 2 of the 12 (17 %) patients in whom the MDCTA-overlooked findings were classified as non-relevant, bowel ischemia was found at surgery. With retrospective image interpretation, 83 % of the patients with occlusive mesenteric ischemia at surgery were correctly identified, whereas the remaining 17 % with non-occlusive mesenteric ischemia at surgery showed non-relevant findings at MDCTA. About 33 % of relevant findings of bowel ischemia were overlooked by the initial MDCTA interpretation, most were subtle findings. However, secondary reading revealed most of these findings and can serve to improve diagnostic performance.
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Affiliation(s)
- Maria Cristina Firetto
- Department of Radiology, Foundation Cà Granda, IRCCS Policlinico Hospital, Via F. Sforza 35, 20122 Milan, Italy
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Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2013; 73:S362-9. [PMID: 23114494 DOI: 10.1097/ta.0b013e31827019de] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO. METHODS A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011. RESULTS The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting. CONCLUSION Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.
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Wang Q, Chavhan GB, Babyn PS, Tomlinson G, Langer JC. Utility of CT in the diagnosis and management of small-bowel obstruction in children. Pediatr Radiol 2012; 42:1441-8. [PMID: 23052726 DOI: 10.1007/s00247-012-2497-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND CT is often used in the diagnosis and management of small-bowel obstruction in children. OBJECTIVE To determine sensitivity of CT in delineating presence, site and cause of small-bowel obstruction in children. MATERIALS AND METHODS We retrospectively reviewed the CT scans of 47 children with surgically proven small-bowel obstruction. We noted any findings of obstruction and the site and cause of obstruction. Presence, absence or equivocal findings of bowel obstruction on abdominal radiographs performed prior to CT were also noted. We reviewed patient charts for clinical details and surgical findings, including bowel resection. Statistical analysis was performed using Fisher exact test to determine which CT findings might predict bowel resection. RESULTS CT correctly diagnosed small-bowel obstruction in 43/47 (91.5%) cases. CT correctly indicated site of obstruction in 37/47 (78.7%) cases and cause of obstruction in 32/47 (68.1%) cases. Small-bowel feces sign was significantly associated with bowel resection at surgery (P = 0.0091). No other CT finding was predictive of bowel resection. Out of 41 children who had abdominal radiographs before CT, 29 (70.7%) showed unequivocal obstruction, six (14.6%) showed equivocal findings and six (14.6%) were unremarkable. CONCLUSION CT is highly sensitive in diagnosing small-bowel obstruction in children and is helpful in determining the presence of small-bowel obstruction in many clinically suspected cases with equivocal or normal plain radiographs. CT also helps to determine the site and cause of the obstruction with good sensitivity.
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Affiliation(s)
- Qiuyan Wang
- Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, 555 University Ave., Toronto, Canada, M5G 1X8
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CT findings of small bowel strangulation: the importance of contrast enhancement. Emerg Radiol 2012; 20:3-9. [PMID: 22910982 DOI: 10.1007/s10140-012-1070-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 08/08/2012] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.
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Kanzaki T, Hata J, Imamura H, Manabe N, Okei K, Kusunoki H, Kamada T, Shiotani A, Haruma K. Contrast-enhanced ultrasonography with Sonazoid™ for the evaluation of bowel ischemia. J Med Ultrason (2001) 2012; 39:161-167. [DOI: 10.1007/s10396-012-0346-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 12/19/2011] [Indexed: 01/16/2023]
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Vettoretto N, Carrara A, Corradi A, De Vivo G, Lazzaro L, Ricciardelli L, Agresta F, Amodio C, Bergamini C, Borzellino G, Catani M, Cavaliere D, Cirocchi R, Gemini S, Mirabella A, Palasciano N, Piazza D, Piccoli M, Rigamonti M, Scatizzi M, Tamborrino E, Zago M. Laparoscopic adhesiolysis: consensus conference guidelines. Colorectal Dis 2012; 14:e208-15. [PMID: 22309304 DOI: 10.1111/j.1463-1318.2012.02968.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. METHODS A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. RESULTS Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. CONCLUSION Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.
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Affiliation(s)
- N Vettoretto
- Laparoscopic Surgery Unit, M. Mellini Hospital, Chiari, Italy.
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Kim HC, Yang DM, Kim SW, Park SJ. Reassessment of CT images to improve diagnostic accuracy in patients with suspected acute appendicitis and an equivocal preoperative CT interpretation. Eur Radiol 2011; 22:1178-85. [PMID: 22193372 DOI: 10.1007/s00330-011-2362-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 11/15/2011] [Accepted: 11/24/2011] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify CT features that discriminate individuals with and without acute appendicitis in patients with equivocal CT findings, and to assess whether knowledge of these findings improves diagnostic accuracy. METHODS 53 patients that underwent appendectomy with an indeterminate preoperative CT interpretation were selected and allocated to an acute appendicitis group or a non-appendicitis group. The 53 CT examinations were reviewed by two radiologists in consensus to identify CT findings that could aid in the discrimination of those with and without appendicitis. In addition, two additional radiologists were then requested to evaluate independently the 53 CT examinations using a 4-point scale, both before and after being informed of the potentially discriminating criteria. RESULTS CT findings found to be significantly different in the two groups were; the presence of appendiceal wall enhancement, intraluminal air in appendix, a coexistent inflammatory lesion, and appendiceal wall thickening (P < 0.05). Areas under the curves of reviewers 1 and 2 significantly increased from 0.516 and 0.706 to 0.677 and 0.841, respectively, when reviewers were told which CT variables were significant (P = 0.0193 and P = 0.0397, respectively). CONCLUSIONS Knowledge of the identified CT findings was found to improve diagnostic accuracy for acute appendicitis in patients with equivocal CT findings. KEY POINTS • Numerous patients with clinically equivocal appendicitis do not have acute appendicitis • Computed tomography (CT) helps to reduce the negative appendectomy rate • CT is not always infallible and may also demonstrate indeterminate findings • However knowledge of significant CT variables can further reduce negative appendectomy rate • An equivocal CT interpretation of appendicitis should be reassessed with this knowledge.
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Affiliation(s)
- Hyun Cheol Kim
- Department of Radiology, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 149 Sangil-dong, Gangdong-gu, Seoul 134-727, Republic of Korea.
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La tomografía computarizada multidetector en el abdomen agudo. RADIOLOGIA 2011; 53 Suppl 1:60-9. [PMID: 21742357 DOI: 10.1016/j.rx.2011.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 03/17/2011] [Accepted: 03/26/2011] [Indexed: 11/21/2022]
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Radiologists' performance in the diagnosis of acute intestinal ischemia, using MDCT and specific CT findings, using a variety of CT protocols. Emerg Radiol 2011; 18:385-94. [PMID: 21655965 DOI: 10.1007/s10140-011-0965-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/23/2011] [Indexed: 10/18/2022]
Abstract
The aim of this study was to evaluate the performance of radiologists in the diagnosis of acute intestinal ischemia using specific multi-detector CT findings. The abdominal CT scans of 90 patients were retrospectively reviewed by three radiologists: an abdominal imaging specialist, an experienced general radiologist, and a senior resident. Forty-seven patients had surgically proven intestinal ischemia and comprised the case group, while 43 patients had no evidence of intestinal ischemia at surgery and comprised the control group. Images were reviewed in a random and blinded fashion. Radiologists' performance in diagnosing bowel ischemia from other bowel pathologies was evaluated. The sensitivity, specificity, and accuracy for diagnosing bowel ischemia were 89%, 67%, and 79% for the abdominal imager; 83%, 67%, and 76% for the general radiologist; and 66%, 83%, and 74% for the senior resident, respectively. The calculated kappa value for inter-observer agreement regarding the presence of bowel ischemia was 0.79. CT findings that significantly distinguished bowel ischemia from other bowel pathologies were decreased or absent bowel wall enhancement, filling defect in the superior mesenteric artery, small bowel pneumatosis, and gas in the portal veins or superior mesenteric vein. For most of these signs, there was good inter-observer agreement. Radiologists' performance in diagnosing bowel ischemia is good, but lower than previously reported since a significant amount of cases are evaluated using a suboptimal CT technique. Radiologists' experience and expertise have an important impact on their performance.
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Chen HQ, Lv B. Strategies for diagnosis and treatment of small bowel obstruction. Shijie Huaren Xiaohua Zazhi 2011; 19:551-556. [DOI: 10.11569/wcjd.v19.i6.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Small bowel obstruction, which is caused by a variety of etiological factors and mainly manifests as abdominal pain, vomiting and distension, is one of the most common acute abdomens. A rapid and accurate diagnosis of small bowel obstruction is needed to give reasonable and effective treatment to avoid its rapid deterioration. In this paper we discuss the strategies for diagnosis and treatment of small bowel obstruction through comparing different imaging methods for diagnosis of small bowel obstruction and reviewing the current situation of diagnosis and treatment of the disease in terms of pharmacotherapy, gastrointestinal decompression, and surgical intervention.
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