Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive ...SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes
an update on the best CT signs for predicting ischemia and a need for bowel resection;
a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and
a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.
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
.
Purpose To determine which computed tomography (CT) findings or combinations of findings can help to accurately identify strangulation in adhesive small bowel obstruction (SBO). Materials and Methods ...Contrast agent-enhanced CT findings in a cohort of 256 patients consecutively admitted for adhesive SBO, with a delay of less than 24 hours between CT and surgery for the operated patients, were reviewed independently by two radiologists, with consensus by a third, to assess CT findings commonly associated with strangulation. The reference standard for strangulation was surgery. Univariate and multivariate analyses were performed to identify predictors of strangulation in the entire cohort and to identify predictors of the need for surgical resection in the subgroup of patients with strangulation. A CT score was obtained and diagnostic performances of different combined CT findings were calculated. Results In this study, 105 patients (41.0%; 105 of 256) underwent a surgical procedure, 62 of whom were found to have strangulation (59.0%; 62 of 105), whereas 151 patients (59.0%; 151 of 256) improved with medical care. Three CT findings were significantly associated with strangulation in the multivariate analysis: reduced bowel wall enhancement (odds ratio, 7.8; 95% confidence interval CI: 2.6, 23.5), diffuse mesenteric haziness (odds ratio, 6.1; 95% CI: 2.5, 15.2), and a closed-loop mechanism (odds ratio, 6.5; 95% CI: 2.8, 15.5). The model combining these three features had an area under the curve of 0.91 (95% CI: 0.86, 0.96) and a high negative predictive value (97%; 95% CI: 93%, 99%). Positive likelihood ratios were high when two or three of these CT findings were combined (positive likelihood ratios, 14.7 95% CI: 7.1, 30.4 and 43.8 (95% CI: 14.2, 135.2, respectively). Among the strangulated cases, reduced bowel wall enhancement (odds ratio, 3.9; 95% CI: 1.3, 12) and mesenteric fluid (odds ratio, 3.6; 95% CI: 1.0, 12.8) were predictive of resection. Conclusion A score that combines three CT findings (reduced bowel wall enhancement, a closed-loop mechanism, and diffuse mesenteric haziness) can accurately predict strangulation in adhesive SBO.
RSNA, 2017 Online supplemental material is available for this article.
Objectives
To identify computed tomography (CT) findings associated with bowel necrosis in patients with surgically confirmed strangulating closed-loop small-bowel obstruction (CL-SBO) due to ...adhesions or internal hernia.
Methods
This retrospective study was approved by our institutional review board, and informed consent was waived. To identify CT signs of bowel necrosis, two gastrointestinal radiologists performed blinded, independent, retrospective reviews of 41 CT studies from consecutive patients who had CL-SBO due to adhesions or internal hernias and who underwent surgery within 48 h. On the basis of surgical and pathological findings, patients were classified as having reversible ischemia or histologically documented necrosis. Univariate statistical analyses were performed to assess associations between CT signs and bowel necrosis. Kappa statistics were computed to assess interobserver agreement.
Results
We included 25 (61%) women and 16 (39%) men with a median age of 79 years. Bowel necrosis was found in 25/41 (61%) patients and ischemic but viable bowel in 16/41 (39%) patients. Increased unenhanced bowel-wall attenuation was the only CT finding significantly associated with bowel necrosis (
p
= 0.0002). This sign had 58% (95% CI, 37–78) sensitivity and 100% (95% CI, 79–100) specificity for necrosis. Interobserver agreement was fair (0.59; 95% CI, 0.37–0.82).
Conclusion
Increased unenhanced bowel-wall attenuation is specific for bowel necrosis and should lead to prompt surgery for bowel resection.
Key Points
• Increased unenhanced bowel-wall attenuation is the only sign specific for necrosis
• Decreased bowel-wall enhancement is not relevant for differentiating reversible ischemia from necrosis
• Preoperative knowledge of bowel necrosis is helpful to plan adequate surgery
Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in ...that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.
Graphical Abstract
Critical relevance statement
This educational review provides an exhaustive overview of acute abdominal presentations of endometriosis along with illustrative examples, to facilitate their diagnosis in clinical practice.
Key points
This review addresses key imaging findings of acute abdominal complication of endometriosis.
Endometriosis must be considered in menstruating women presenting with acute abdominal pain.
Magnetic Resonance Imaging plays a key role in the diagnosis.
Approximately one-quarter of adnexal masses detected at ultrasonography are indeterminate for benignity or malignancy, posing a substantial clinical dilemma.
To validate the accuracy of a 5-point ...Ovarian-Adnexal Reporting Data System Magnetic Resonance Imaging (O-RADS MRI) score for risk stratification of adnexal masses.
This multicenter cohort study was conducted between March 1, 2013, and March 31, 2016. Among patients undergoing expectant management, 2-year follow-up data were completed by March 31, 2018. A routine pelvic MRI was performed among consecutive patients referred to characterize a sonographically indeterminate adnexal mass according to routine diagnostic practice at 15 referral centers. The MRI score was prospectively applied by 2 onsite readers and by 1 reader masked to clinical and ultrasonographic data. Data analysis was conducted between April and November 2018.
The primary end point was the joint analysis of true-negative and false-negative rates according to the MRI score compared with the reference standard (ie, histology or 2-year follow-up).
A total of 1340 women (mean range age, 49 18-96 years) were enrolled. Of 1194 evaluable women, 1130 (94.6%) had a pelvic mass on MRI with a reference standard (surgery, 768 67.9%; 2-year follow-up, 362 32.1%). A total of 203 patients (18.0%) had at least 1 malignant adnexal or nonadnexal pelvic mass. No invasive cancer was assigned a score of 2. Positive likelihood ratios were 0.01 for score 2, 0.27 for score 3, 4.42 for score 4, and 38.81 for score 5. Area under the receiver operating characteristic curve was 0.961 (95% CI, 0.948-0.971) among experienced readers, with a sensitivity of 0.93 (95% CI, 0.89-0.96; 189 of 203 patients) and a specificity of 0.91 (95% CI, 0.89-0.93; 848 of 927 patients). There was good interrater agreement among both experienced and junior readers (κ = 0.784; 95% CI, 0.743-0824). Of 580 of 1130 women (51.3%) with a mass on MRI and no specific gynecological symptoms, 362 (62.4%) underwent surgery. Of them, 244 (67.4%) had benign lesions and a score of 3 or less. The MRI score correctly reclassified the mass origin as nonadnexal with a sensitivity of 0.99 (95% CI, 0.98-0.99; 1360 of 1372 patients) and a specificity of 0.78 (95% CI, 0.71-0.85; 102 of 130 patients).
In this study, the O-RADS MRI score was accurate when stratifying the risk of malignancy in adnexal masses.
Objectives
To assess the added-value of systematic unenhanced abdominal computed tomography (CT) on emergency department (ED) diagnosis and management accuracy compared to current practice, in ...elderly patients with non-traumatic acute abdominal symptoms.
Methods
Institutional review board approval and informed consent were obtained. This prospective study included 401 consecutive patients 75 years of age or older, admitted to the ED with acute abdominal symptoms, and investigated by early systematic unenhanced abdominal CT scan. ED diagnosis and intended management before CT, after unenhanced CT, and after contrast CT if requested, were recorded. Diagnosis and management accuracies were evaluated and compared before CT (clinical strategy) and for two conditional strategies (current practice and systematic unenhanced CT). An expert clinical panel assigned a final diagnosis and management after a 3-month follow-up.
Results
Systematic unenhanced CT significantly improved the accurate diagnosis (76.8% to 85%,
p
=1.1x10
-6
) and management (88.5% to 95.8%,
p
=2.6x10
-6
) rates compared to current practice. It allowed diagnosing 30.3% of acute unsuspected pathologies, 3.4% of which were unexpected surgical procedure requirement.
Conclusions
Systematic unenhanced abdominal CT improves ED diagnosis accuracy and appropriate management in elderly patients presenting with acute abdominal symptoms compared to current practice.
Key Points
•
Systematic unenhanced CT improves significantly diagnosis accuracy compared to current practice.
•
Systematic unenhanced CT optimizes appropriate hospitalization by increasing the number of discharged patients.
•
Systematic unenhanced CT allows detection of about one-third of acute unsuspected abdominal conditions.
•
It should allow boosting emergency department management decision-making confidence in old patients.
Purpose
To assess the diagnostic performance of CT signs of gastric volvulus in both confirmed cases and control subjects.
Materials and methods
We retrospectively reviewed CT findings in 10 patients ...with surgically confirmed acute gastric volvulus and 20 control subjects with gastric distension. Two radiologists independently evaluated CT images for risk factors of gastric volvulus, direct findings of gastric volvulus by assessing gastric dilatation, the presence of an antropyloric transition point, the respective position of the different stomach segments and of the greater and lesser curvatures, stenosis of the gastric segments through the oesophageal hiatus and for findings of gastric ischemia. The sensitivity and specificity of each finding were calculated.
Results
The most sensitive direct signs of gastric volvulus were an antropyloric transition point without any abnormality at the transition zone and the antrum at the same level or higher than the fundus. The presence of both these two findings as diagnostic criteria of gastric volvulus had 100 % sensitivity and specificity for the diagnosis of gastric volvulus. There was no association between CT signs of ischemia and final bowel ischemia at pathology.
Conclusion
CT is both highly sensitive and specific for diagnosing acute gastric volvulus.
Key Points
•
CT is highly reliable for diagnosing acute gastric volvulus with two findings.
•
The two signs are gastropyloric transition zone and abnormal location of the antrum.
•
This allows fast surgical management of this emergency.
Mastitis frequently affects women of childbearing age. Of all the pathological breast conditions requiring specific management, autoimmune mastitis is in the third position after infection and breast ...cancer. The aim of this literature review was to make a comprehensive description of autoimmune diseases targeting the mammary gland. Four main histological patterns of autoimmune mastitis are described: (i) lymphocytic infiltrates; (ii) ductal ectasia; (iii) granulomatous mastitis; and (iv) vasculitis. Our literature search found that all types of autoimmune disease may target the mammary gland: organ-specific diseases (diabetes, thyroiditis); connective tissue diseases (such as systemic erythematosus lupus or Sjögren's syndrome); vasculitides (granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, giant cell arteritis, polyarteritis nodosa, Behçet's disease); granulomatous diseases (sarcoidosis, Crohn's disease); and IgG4-related disease. Cases of breast-specific autoimmune diseases have also been reported, including idiopathic granulomatous mastitis. These breast-limited inflammatory diseases are sometimes the first symptom of a systemic autoimmune disease. Although autoimmune mastitis is rare, it is probably underdiagnosed or misdiagnosed. Early diagnosis may allow us to detect systemic diseases at an earlier stage, which could help to initiate a prompt, appropriate therapeutic strategy. In case of suspected autoimmune mastitis, we hereby propose a diagnostic pathway and discuss the potential pathophysiological pathways leading to autoimmune breast damage.
The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic ...acute abdominal pain.
The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics.
In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings.
In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.
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