Intussusception Reduction

A "scout" radiograph before intussusception reduction procedure shows a soft tissue mass (arrows) in the right upper quadrant representing the intussusception. There is no free air.

Contrast enema for reduction shows the intussusception (arrows) in the right upper quadrant. It was successfully reduced.

Facts

• Image-guided liquid or air reduction of intussusception is the treatment of choice
• Contraindications for image-guided reduction = peritonitis, free intraperitoneal air due to perforation, in shock or sepsis
• Choice between air, liquid, contrast enema reduction of intussusception depends on radiologist experience and local preference/practice. Most radiologists prefer to use air and it is now generally accepted as the technique of choice
• Air pressure: between 80 and 120 mmHg
• Contrast: bag positioned approximately between 3 ft and 6 ft above the patient
• Reduction rate between 80% to 95%

Preparation for Reduction

• Notify the referring physician and surgeon
• Patient must be stable, well-hydrated and has no evidence of peritonitis
• IV line in place
• A large-bore needle at hand (if you use air reduction)

Complications

• Perforation rates with air enema less than 1%
• Recurrence 10% of cases

Reference:

1. Daldrup-Link HE, Gooding CA. Essentials of Pediatric Radiology: A Multimodality Approach, 2010.

2. Hodler J, Von Schulthess GK, Zollikofer CL. Diseases of the Abdomen and Pelvis 2010-2013: Diagnostic Imaging and Interventional Techniques, 2010.

Microcolon with Features of Low Intestinal Obstruction

Barium enema in a 2-day old boy shows diffuse small caliber of the colon (arrows). Retained barium is noted in the stomach from a recent upper GI study (which was normal). Note the presence of air in the rest of the small bowel (tubular lucent areas in the background) indicating that this is a low intestinal obstruction.

Differential Diagnosis: Microcolon with Features of Low Intestinal Obstruction

• Pathology of colon itself: colonic atresia, diffuse Hirschsprung's disease
• Pathology of distal small bowel (no bowel content can pass into colon resulting in small colon caliber): ileal atresia, meconium ileus

Approach: when seen evidence of bowel obstruction in a neonate, one needs to distinguish between high and low intestinal obstruction. High obstruction presents with little amount of gas in the bowel, dilated stomach and/or duodenum. If high obstruction due to midgut volvulus is suspected, upper GI study is the next step. If low obstruction is suspected, barium enema is performed. In this case, we see a lot of bowel gas in the neonate with clinical intestinal obstruction and a barium enema shows diffuse microcolon - the differential diagnoses are either diseases of distal small bowel or of the colon itself.

Our case: distal ileal volvulus with possible meconium ileus producing distal intestinal obstruction and microcolon

Reference:

Davies SG. Chapman & Nakielny's Aids to Radiological Differential Diagnosis, 5th edition, 2009.

Zenker's Diverticulum

Lateral view of barium esophagogram shows a large diverticulum (arrow) arising in the midline from the posterior wall of the cervical esophagus (arrowheads).

Facts:

• Most common form of esophageal diverticulum
• Protrusion of mucosa posteriorly just proximal to cricopharyngeus muscle
• Believed to be due to oropharyngeal discoordination and upper esophageal sphinctor dysfunction
• Many patients are asymptomatic, but can present with dysphagia, regurgitation, throat discomfort
• Usually in 5th to 8th decades of life

Diagnosis and Treatment

• Barium esophagogram is an optimal method to demonstrate the diverticulum
• Intradiverticular filling defects usually represent food, but carcinoma is in the differential diagnosis.
• Large diverticulum can present on chest radiograph as a superior mediastinal mass
• Endoscopy not required, but if it is to be done it should be done with caution because of a risk of inadvertent perforation
• Treatment: diverticulectomy with or without cricopharyngeal myotoma, endoscopic stapling and division of common wall between cervical esophagus and diverticulum

Reference:

Grendell JH, et al. Current Diagnosis & Treatment in Gastroenterology, 2nd edition, 2003.

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Autoimmune Pancreatitis

Fig. 1: Axial CT image of a 61-year-old man with abdominal pain shows mild diffuse enlargement of the pancreas, loss of pancreatic lobulation and minimal peripancreatic fat stranding (arrows).

Fig. 2: An ERCP image (injection of pancreatic duct) shows irregular narrowing of the pancreatic duct (arrowheads).

Facts

• Relatively new, rare disease first described in 1995 by Yoshida et al.
• Chronic pancreatitis characterized by autoimmune inflammatory process (lymphocytic infiltrates) with associated fibrosis of pancreas
• Associated with immunologic abnormalities: hypergammaglobulinemia, elevated serum IgG4 levels and autoantibodies against carbonic anhydrase and lactoferrin
• Pathology shows diffusely indurated and firm pancreas, with periductal lymphocytic and plasma cell infiltrates
• Involvement of the gallbladder, bile ducts, kidney, lung and salivary glands has been described

Clinical

• 5-6% of all patients with chronic pancreatitis
• Men > women, most are > 50 years
• Mostly associated with other autoimmune disease e.g. rheumatoid arthritis, Sjogren's syndrome, inflammatory bowel disease
• Responsive to steroid

Imaging

• On CT, diffuse pancreatic enlargement, enhanced peripheral rim of hypoattenuation "halo", low attenuation "mass" in pancreatic head, homogeneous attenuation and loss of lobularity
• Minimal peripancreatic fat stranding
• Involution of pancreatic tail in long-standing disease
• On ERCP, focal, diffuse or segmental pancreatic ductal narrowing, disappearance of right-angled branches

Reference:

Finkelberg DL, Sahani D, Deshpande V, et al. Autoimmune pancreatitis. N Eng J Med 2006;355:2670-2676.

Fulminant Candida Esophagitis

Fig: Double contrast barium esophagography shows innumerable pseudomembranes and plaques (arrows) "shaggy esophagus" in a patient with AIDS.

Candida Esophagitis

• Most common cause of infectious esophagitis
• Usually opportunistic infection in immunocompromised hosts, particularly AIDS
• Can be seen in patients with esophageal stasis i.e. achalasia, scleroderma
• Absence of oral thrush does not exclude this condition! (50% of patients with Candida esophagitis do not have thrush)

Radiographic Findings

• Better with double-contrast barium esophagography (over single contrast)
• Plaque (95% of cases) > abnormal motility = thickened folds = ulcers > "shaggy" contour
• "When patients with esophageal symptoms are clinically immunosuppressed or have underlying obstructive disease of the esophagus, discrete plaque-like lesions should strongly suggest candidiasis on the double-contrast study"

Our case - fulminant Candida esophagitis.

References:

1. Levine MS, Macones AJ, Laufer I. Candida esophagitis: accuracy of radiographic diagnosis. Radiology 1985;154:581-587.

2. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology 2005;237:414-427.

Hepatic angiography: Accessory Left Gastric Artery

รูปที่ 1 Celiac angiography แสดงให้เห็น branches ของ celiac trunk ได้แก่ (1) splenic artery,(2) common hepatic artery และ (3) left gastric artery

รูปที่ 2 แสดงให้เห็นถึง branches ที่ไปเลี้ยง stomach ได้แก่ (1) Left gastric artery, (2) Right gastric artery ซึ่งทั้งสองเส้นนี้เลี้ยงบริเวณ lesser curvature ของ stomach ส่วน  greater curvature นั้นจะเลี้ยงด้วย (3) Right gastroepiploic artery และ Left gastric epiploic artery (มองไม่เห็นจากรูปนี้) ส่วนบริเวณ fundus นั้นได้เลือดมาจาก (4) Short gastric artery และ (1) Left gastric artery

รูปที่ 3 Common hepatic angiography (A) ในช่วง late arterial phase แสดง (1) Left hepatic artery และ (2) Right hepatic artery. (B) ในช่วง portovenous phase จะเห็นว่ามี   contrast blush อยู่บริเวณ ลูกศรสีน้ำเงิน 

รูปที่ 4 Superselective left hepatic angiography ในรูป A จะเห็น left hepatic branches ที่ไปเลี้ยง   hepatic segment 2, 3 และ 4 ส่วนในรูป B นั้น จะเห็นว่า branch ดังกล่าวมีให้ลักษณะของ branching pattern ของ gastric fundus สรุปคือ branch นี้คือ accessory left gastric artery

Accessory left gastric artery

•  พบในการตรวจ angiography ประมาณ 3-14% 
• เลี้ยงบริเวณ cardia และ fundus ของกระเพาะอาหาร
• วิ่งอยู่ใน fissure of ligamentum venosum
• อาจแปลผลผิดว่าเป็นเส้นเลือดที่ไปเลี้ยงตับได้
• มีความสำคัญในการทำ transarterial chemoembolization (TACE) ถ้าไม่สังเกตพบเสียก่อน อาจทำให้เกิด  complication ได้ เช่น เกิดแผลในกระเพาะอาหาร หรือผู้ป่วยมีคลื่นใส้ อาเจียนระหว่าง TACE ได้ 

Reference: 

1. Ishigami K, Yoshimitsu K, Irie H, Tajima T, Asayama Y, Hirakawa M, Honda H.Accessory left gastric artery from left hepatic artery shown on MDCT and conventional angiography: correlation with CT hepatic arteriography. AJR Am J Roentgenol. 2006 Oct;187(4):1002-9.
   
2. Lee KH, Sung KB, Lee DY, Park SJ, Kim KW, Yu JS.Transcatheter arterial chemoembolization for hepatocellular carcinoma: anatomic and hemodynamic considerations in the hepatic artery and portal vein.Radiographics. 2002 Sep-Oct;22(5):1077-91.