Choledocholithiasis: Diagnosis and Management Copelan, Alexander, MD; Kapoor, Baljendra S., MD, FSIR
Techniques in vascular and interventional radiology,
12/2015, Volume:
18, Issue:
4
Journal Article
Peer reviewed
Common bile duct stones constitute the main etiology of nonmalignant biliary obstruction. Endoscopic retrieval of common bile duct stones has been adopted as the primary treatment modality for ...extrahepatic biliary stones. However, endoscopic therapy may fail in patients who have had previous gastrointestinal tract surgeries, including partial gastrectomy with Billroth II reconstruction or bilioenteric anastomosis, or in patients with anatomical anomalies such as a duodenal periampullary diverticulum, which makes the biliary duct difficult to access via an endoscopic approach. Endoscopic therapy may also not be suitable for hepatolithiasis with large and impacted stones. In such situations, a percutaneous approach is generally the best option. A variety of percutaneous techniques are available for removal of intrahepatic and extrahepatic bile duct stones via transhepatic approach and T-tube tract. These techniques include extraction, fragmentation, and expulsion of stones into the duodenum. In this article, clinical presentations, imaging modalities, and different management options, particularly percutaneous techniques for the management of choledocholithiasis or hepatolithiasis, are reviewed.
Chylothorax is an uncommon but serious medical condition, which arises when intestinal lymphatic fluid leaks into the pleural space. Treatment strategies depend on the daily output and underlying ...etiology, which may be due to direct injury to lymphatic vessels or a nontraumatic disorder. Chest radiographs confirm the presence of pleural fluid and lateralize the process. In the setting of direct injury, lymphangiography can often be both diagnostic and facilitate a minimally invasive attempt at therapy. CT and MRI in this setting may be appropriate for cases when lymphangiography is not diagnostic. When the etiology is nontraumatic or unknown, CT or MRI can narrow the differential diagnosis, and lymphangiography is useful if a minimally invasive approach to treatment is desired. 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.
Mesenteric ischemia is a serious medical condition characterized by insufficient vascular supply to the small bowel. In the acute setting, endovascular interventions, including embolectomy, ...transcatheter thrombolysis, and angioplasty with or without stent placement, are recommended as initial therapeutic options. For nonocclusive mesenteric ischemia, transarterial infusion of vasodilators, such as papaverine or prostaglandin E1, is the recommended initial treatment. In the chronic setting, endovascular means of revascularization, including angioplasty and stent placement, are generally recommend, with surgical options, such as bypass or endarterectomy, considered alternative options. Although the diagnosis of median arcuate ligament syndrome remains controversial, diagnostic angiography can be helpful in rendering a diagnosis, with the preferred treatment option being a surgical release. Systemic anticoagulation is recommended as initial therapy for venous mesenteric ischemia with acceptable rates of recanalization. If anticoagulation fails, transcatheter thrombolytic infusion can be considered with possible adjunctive placement of a transjugular intrahepatic portosystemic shunt to augment antegrade flow. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower ...extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. 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.
Background
Small bowel transplant (SBT) is a surgical procedure that may be used in patients with pathology resulting in severe intestinal failure resistant to conventional forms of surgical and ...nonsurgical treatment. Intestinal failure is defined as the failure of enterocytes to absorb sufficient macronutrients, water, and/or electrolytes to sustain homeostasis and/or promote growth. With the advancement of surgical techniques and advancements in perioperative transplant management, SBT has become an increasingly common treatment for intestinal failure, with survival rates for SBT comparable to those for other solid organ transplants.
Materials and methods
This review provides background on SBT, its variations, and the associated preoperative and postoperative imaging studies with regard to surgical planning and anticipated complications.
Results and conclusions
With the increasing use of SBT, radiologists will be expected to be familiar with the diagnostic studies and available endovascular interventions associated with this procedure.
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