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ABSTRACT |
Tuesday, May 2, 1:30 PM–3:30 PM
Abstracts 144–153
Moderators: Benjamin Yeh, MD and Dina F. Caroline, MD
1:30 PM
Keynote Address: CT/MR Enterography
Benjamin Yeh, MD, University of California San Francisco, San Francisco, CA
1:50 PM
144. Radiographic Predictors of Outcome after Myotomy in Patients with Achalasia
Lucas L.1*; Canon C.1; Morgan D.1; Hawn M.2; Leeth R.2; Finan K.2; Johnson L.3; Koehler R.1; 1. Radiology, University of Alabama at Birmingham, Birmingham, AL; 2. Surgery, UAB, Birmingham, AL; 3. Medicine, Division of Gastroenterology and Hepatology, UAB, Birmingham, AL.
Address correspondence to L. Lucas (llucas{at}uabmc.edu)
Objective: Prediction of which patients with achalasia will benefit from surgical correction on the basis of barium swallow findings has been difficult. The timed barium esophagram (TBE) has been used to evaluate efficacy of myotomy, but has correlated poorly with pre- and postoperative symptoms in these patients.
Materials and Methods: Methods: Sixty-seven patients with achalasia underwent laparoscopic Heller myotomy with or without fundoplication over a twelve-month period. With consensus reading, two abdominal radiologists evaluated TBE for: height of contrast column at 1, 2, and 5 minutes; esophageal width; tortuosity of the esophagus; length, width and orientation of lower esophageal sphincter; presence of retained food, and visible contractions (vigorous achalasia). These independent variables were correlated with postoperative symptom survey evaluating chest pain/pressure; sensation of food or stomach contents in throat; difficulty swallowing; sour taste in mouth; and self reported "success" of surgery using student's t-test, chi-squared analysis, and univariate linear regression.
Results: Thirty-three patients had both preoperative TBE and postoperative symptom survey. Mean height of contrast column at 1, 2, and 5 minutes was 14.9 cm, 15.2 cm, and 14.4 cm, respectively; mean esophageal width was 4.1cm (range 1.7–9.1 cm); mean LES length was 2.4 cm (range 0.5–4.4 cm). There was no correlation with the preoperative radiographic findings of contrast column height, esophageal width, retained food, or degree of LES opening and persistent postoperative symptoms. However, patients with vigorous achalasia were statistically more likely to experience postoperative regurgitation (p < 0.017), and there was a trend for vigorous achalasia patients to experience persistent chest pressure (p < 0.057). Thirty-one (94%) of 33 patients responded that surgery "was successful" (N = 22) or resulted in "some improvement" (N = 9) in symptoms. With univariate linear regression analysis, increased LES length significantly correlated with reduced (improved) postoperative symptom scores for chest pain; sensation of food or stomach contents in throat; sour taste in mouth, and shortness of breath.
Conclusion: Patients with achalasia have significant improvement in symptoms following Heller myotomy, even those with "megaesophagus." However, patients with preoperative vigorous achalasia are more likely to experience persistent regurgitation and chest pressure despite improvement in dysphagia.
145. Can the Non Invasive Hydro-multidetector Row CT Replace the Endoscopic Ultrasound in the Preoperative Staging of Gastric Cancer?
Ba-Ssalamah A.1*; Pinker K.; Matzek W.; Poespueck A.; Zacherl J.; Schima W.; 1. Radiology, Medical University of Vienna, Vienna, Austria; 1. Pathology, Medical University of Vienna, Vienna, Austria; 3. Gastroenterology, Medical University of Vienna, Vienna, Austria; 1. Surgery, Medical University of Vienna, Vienna, Austria;
Address correspondence to A. Ba-Ssalamah (ahmed.ba-ssalamah{at}meduniwien.ac.at)
Objective: To compare the efficacy of Hydro-multidetector CT (HMCT) in the preoperative staging of gastric cancer with the endoscopic ultrasound (EUS) using the post-operative histopathological results as gold standard.
Materials and Methods: HMCT and EUS examinations were performed in 79 patients of gastric cancer diagnosed by biopsy prior to surgery on two different days. Distention of the stomach was achieved with 1 to 1.5 L of water. The HMTC- and EUS-findings were prospectively analyzed. Each case was staged according to the TNM classification and correlated with histopathological findings. HMCT scans were performed using 4-channel, 16-channel, or 64-channel scanner. EUS were performed using a fiber-optic endoscopy with a 5-10 MHz electronic array with a 360° scanning angle. Accuracy of TNM-staging was calculated for each modality and findings of EUS and HMCT were directly compared to each other were correlated with histopathological findings.
Results: The accuracy for T staging with HMCT was 84%, for N staging 72% and for M staging 97%. The results of EUS were 79%, 61%, and 43% respectively.
Conclusion: Accuracies for T- and N-Staging with CT can be substantially better achieved than with endosonography.
146. Plain Abdominal Films in Acute Small Bowel Obstruction
Thompson W.M.*; Smith B.B.; Kilani R.K.; Jaffe T.A.; Thomas J.; Paulson E.K.; Radiology, Duke University Medical Center, Durham, NC.
Address correspondence to W.M. Thompson (thomp132{at}mc.duke.edu)
Objective: To determine the sensitivity of plain abdominal radiographs in acute small bowel obstruction (SBO) and to three tests previously described predictive signs of SBO.
Materials and Methods: Ninety patients suspected of SBO who had abdominal films between January and December 2003 were evaluated by four attendings (3 - 30 years experience) and two radiology residents. Each film was evaluated for the presence or absence of SBO using a scale of 1 (definitely not present) to 5 (definitely present). The following three criteria for SBO were recorded for each case: (1) two or more air fluid levels, (2) air fluid levels at different heights (greater than 5 mm) in the same loop and (3) air fluid levels with a width greater than 25 mm.
Results: Thirty-one of the 90 patients were proven to have SBO by CT, surgery and/or clinical follow-up. Results form the evaluations of the presence of SBO show a range of accuracy 81 to 95%, sensitivity 61 to 97%, specificity 78 to 95%, positive predictive value 68 to 91% and negative predictive value 88 to 96%. The more experienced radiologists had significantly better results than the junior radiologists or residents. The most predictive of the three signs was (1) two or more air fluid levels, sensitivity 88% and specificity 94%, positive predictive value 63% and negative predictive value 94%. Second most predictive was (3) a width greater than 25 mm, sensitivity 76%, specificity 91%, positive predictive value 86% and negative predictive value 91%. Air fluid levels at different heights (2) was the least predictive, sensitivity 52%, specificity 98%, PPV 93% and NPV 84%.
Conclusion: The plain film of the abdomen is specific and sensitive for the detection of acute SBO. The most predictive signs are seeing two or more air fluid and air fluid levels with width greater than 25 mm.
147. Direct Comparison of Efficacy of Low Density (VoLumen) and High Density (Barium) Oral Contrast Medium in the Same Patients Studied on 16-MDCT of the Abdomen
Shah Z.K.*; Sahani D.; Blake M.; Uppot R.; Mathews M.; Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA.
Address correspondence to Z.K. Shah (zarineshah{at}partners.org)
Objective: To compare the performance of low attenuation oral contrast medium (VoLumen) with high attenuation oral contrast for bowel distension and bowel marking on 16 MDCT scans of the abdomen.
Materials and Methods: In this prospective study, 40 patients (28 male, 12 female) scanned with 16 MDCT using a high attenuation oral contrast and now scheduled for a follow up CT within 6 months were studied. For the follow up study, 900-1350 ml (2-3 bottles) of VoLumen (E-Z-EM Inc.), a low attenuation oral contrast was administered each patient over 40 minutes and then patient were scanned on a 16-MDCT scan (Light-Speed 16, GE) after intravenous injection of contrast (370 mgI/mL at 1.8ml/kg body wt. at 3 ml/sec) using a detector collimation = 0.625 mm, table speed = 18.75 mm/rotation and slice thickness = 5 mm. Two blinded readers reviewed both MDCT studies from each subject for qualitative assessment. A 5-point scale was used to grade small bowel distension and small bowel marking. Visualization of the terminal ileum was also rated. Average scores for bowel distension, bowel marking and overall visualization of small bowel with 16-MDCTs with VoLumen and high-density oral contrast were compared. If any bowel pathology discovered on CT was recorded and reader's confidence was also rated. Statistical analysis was performed using the Wilcoxon signed-rank test.
Results: The bowel distension and bowel marking achieved with VoLumen were considered superior than with high density oral contrast (3.9 vs 3.6 and 4.3 vs 3.4, respectively). Terminal ileum was confidently visualized with VoLumen in all 40 patients. Due to better bowel distention both readers found it easier to trace the small bowel using Volumen. Good inter-observer agreement was achieved (k = 0.73).
Conclusion: Bowel distention and mucosal details are better visualized with low attenuation oral contrast. The better bowel distension and bowel marking achieved with VoLumen may potentially increase diagnostic performance of 16 MDCT for assessing small bowel pathology.
148. Utility of Low Density Oral Contrast Medium (VoLumen) as a Bowel-Marking Agent for 16-MDCT of the Abdomen and Pelvis
Shah Z.K.*; Sahani D.; Uppot R.; Blake M.; Mathews M.; Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA.
Address correspondence to Z.K. Shah (zarineshah{at}partners.org)
Objective: Assess efficacy, acceptability and utility of bowel distension and marking using low Hounsfield value oral contrast (VoLumen-E-Z-EM Inc.). Compare the results with barium suspension in 16-MDCT scans of the abdomen and pelvis. Evaluate the value of reformatted coronal images for tracing small bowel.
Materials and Methods: This prospective study includes 100 patients (73M: 27W), mean age 58.3 yrs. scheduled for routine 16-MDCT of the abdomen and pelvis. Patients were randomly administered equal volumes [900-1,350 ml] of either VoLumen or barium over 40 minutes. Palatability of VoLumen and barium were assessed, and adverse events if any were recorded. Patients were not known to have small bowel pathology before the scan. The 16-MDCTs (Lightspeed, GE) were performed in the portal venous phase with intravenous contrast (370 mgI/mL at 1.8ml/kg body wt. at 3ml/sec) using detector collimation = 0.625 mm, table speed = 18.75 mm/rotation and slice thickness = 5 mm. Coronal reformats were obtained at 2.5 mm slice thickness (using retro-reconstruction at 1.25 mm) at the CT console. Two blinded readers evaluated the axial and coronal images. Using a qualitative 5-point scale, readers graded each study for distension of the stomach and small bowel and for bowel mucosal pattern and mucosal detail. An overall assessment of small bowel labeling was made. Finally readers' ability to trace the entire small bowel on the coronal images was also graded using a 5-point scale. Quantitative measurement of small bowel distension was performed. Average scores with VoLumen and barium were compared using the Wilcoxon rank sum test.
Results: VoLumen provided a higher mean score than barium for distension and marking of the small bowel (4.0 vs. 3.6 and 4.3 vs. 3.2 respectively). The inter-observer agreement was excellent (k = 0.81). Using coronal images there was increased confidence among readers for VoLumen and barium in tracing the small bowel. Both readers considered VoLumen superior to barium (4.2 vs. 3.5) for overall visualization of the small bowel (< 0.01). Few patients complained of increased bowel movement following the scan with the use of VoLumen.
Conclusion: VoLumen affords better small bowel distension and provides better visualization of bowel mucosal detail as compared to high-density barium. Optimal quality coronal reformats on 16-MDCT improve the diagnostic confidence of the radiologist for small bowel pathology. However, incidence of increased bowel movements with Volumen in some patients is a concern.
149. Diagnostic Performance of 16-MDCT for Bowel Obstruction: Utility of Coronal Reformatted Images in Assessing Bowel Obstruction
Shah Z.K.1*; Wargo J.2; Uppot R.1; Sahani D.1; 1. Division of Abdominal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Boston, MA; 2. Department of Surgery, Massachusetts General Hospital, Boston, MA.
Address correspondence to Z.K. Shah (zarineshah{at}partners.org)
Objective: To assess the performance of 16-MDCT in evaluation of patients with bowel obstruction using surgery as a "gold standard". To assess the impact of axial and coronal reformatted images on reader confidence and localization of transition site.
Materials and Methods: Retrospective analysis of 16-MDCT scans of 30 patients op-erated for intestinal obstruction from Jan. 2003 to Aug 2005 was performed. The patients (19 male, 11 female) had a mean age of 58.3years. The 16-MDCTs (LightSpeed, GE) were performed in the portal venous phase with intravenous injection of contrast (300 mgI/mL at 2.0ml/kg body wt. at 3ml/sec) using a detector collimation = 0.625 mm, table speed = 18.75 mm/rotation and slice thickness = 5 mm. Reformatted coronal images were obtained at 2.5 mm slice thickness (using retro-reconstruction at 1.25 mm) at the CT console. Two readers, blinded to the surgical findings evaluated the MDCT data using a pre-designed template. The presence of intestinal obstruction, site of transition, cause of obstruction and associated complications was recorded. Axial images were evaluated first followed by addition of coronal images. The readers' confidence on axial and coronal images was graded on a 3-point scale (1 = low, 2 = moderate, 3 = high). The MDCT findings were correlated with the surgical findings.
Results: Presence of intestinal obstruction was detected in all 30 patients; post-operative adhesions (n = 11), tumor (n = 6), inflammatory bowel disease (n = 5), internal hernia (n = 3), anastomotic narrowing (n = 3), others (n = 2). The transition point was identified in 28/30 cases (93.33%), and the cause of obstruction was detected in 27/30 (90%). Both readers found that the addition of coronal reformatted images improved the diagnostic confidence for quick localization of the site of transition due to the orientation of the small bowel. The inter-observer agreement was excellent (k0.87).
Conclusion: The knowledge of the site of bowel obstruction, the etiology and associated complications plays a critical role in patient management. 16-MDCT is accurate in diagnosis of bowel obstruction and in detecting the cause and complications of the condition. The addition of coronal reformatted images enables the radiologist to trace small bowel and allows more rapid and confident assessment of the site of transition. This is of maximum benefit in complicated cases such as closed-loop obstruction, internal hernias and intussusceptions.
150. Can Independent Coronal Multiplanar Reformatted Images Using State-of-the-art MDCT Scanners Replace Axial Images in the Interpretation of the Gastrointestinal Tract? Initial Observations
Sebastian S.*; Kalra M.K.; Mittal P.K.; Torres W.E.; Saini S.; Small W.C.; Radiology, Emory University School of Medicine, Atlanta, GA.
Address correspondence to S. Sebastian (Sunit.Sebastian{at}emoryhealthcare.org)
Objective: To assess whether independent evaluation of multiplanar coronal reformats can replace conventionally used axial images for interpretation of MDCT performed for gastrointestinal tract indications.
Materials and Methods: Institutional review board approved the HIPAA-compliant study protocol; informed consent was waived. We have reviewed 50 patients out of the 100 patients referred for MDCT for gastrointestinal tract indications. All patients were scanned on a 64 slice-MDCT (Lightspeed VCT, GE Healthcare Technologies). Axial images were reconstructed at the CT console to obtain 0.625 mm batch MPR images. Two abdominal radiologists underwent a training session of 50 separate examinations to overcome the learning curve associated with viewing coronal images. Initially, each reader reviewed only the coronal reformats of all patients. After 3 weeks, axial images were reviewed. Each radiologist noted the number of lesions, their location, size of smallest lesion, and probable diagnosis. Image quality (5 point scale) and confidence for interpretation (3 point scale) was also noted. The total time required for interpretation was also noted. Statistical analysis was performed using paired t-test.
Results: Initial results show that average duration for interpretation of coronal reformats and axial images were not substantially different (5. 5 and 6 minutes, respectively) (p > 0.05). Both readers reported more findings on coronal evaluations (264 and 255) compared to axial images (232 and 227, respectively) (p < 0.001). Readers' confidence was also found to be higher on coronal evaluations as compared to axial images (p < 0.05). Retroperitoneal and mesenteric lymphadenopathy, cecal and terminal ileal pathologies and vascular anatomy variants were better delineated and identified on coronal reformats. There was good interobserver agreement between the two readers.
Conclusion: Our initial results suggest that coronal multiplanar reformatted images alone can replace conventionally used axial images for interpretation in the MDCT evaluation of the gastrointestinal tract.
151. CT Evaluation of Patients with Acute Abdominal Pain: is the Small Bowel Feces Sign Predictive of Small Bowel Obstruction?
Jacobs S.L.; Rozenblit A.; Milikow D.; Ricci Z.; Roberts J.; Chernyak V.; Wolf E.*; Radiology, Montefiore Medical Center, Bronx, NY.
Address correspondence to E. Wolf (ewolf{at}montefiore.org)
Objective: To evaluate frequency and clinical relevance of "small bowel feces" sign (SBFS) on CT in patients with and without small bowel obstruction (SBO) presenting with acute abdominal pain.
Materials and Methods: Abdominal CTs of consecutive patients presenting to the emergency department with abdominal pain over a 6 month period were retrospectively reviewed by six radiologists, independently, for the presence of the SBFS. Examinations with positive SBFS were further evaluated in consensus by three radiologists, blinded to the final diagnosis. We graded the small bowel (SB) as nondilated (< 2.5 cm) and mildly (2.5-2.9 cm), moderately (3.0-3.5 cm) or severely (> 3.5 cm) dilated. The presence of distal SB collapse indicative of SBO was recorded. Imaging findings were subsequently correlated with the final diagnosis via chart review and compared between patients with and without small bowel obstruction.
Results: Of 1642 CT examinations, a positive SBFS was found in 100 (6%) studies. Of 100 patients with a positive SBF sign, 32 (32%) had documented small bowel obstruction. Of the remaining 68 patients, 32 (47%) had no specific diagnosis, 26 (38.2%) had miscellaneous diagnoses including ovarian cyst, pancreatitis, appendicitis, and diverticulitis, 10 (14.7%) had nephrolithiasis and 7 (10.3%) patients had acute cholecystitis. SB was nondilated and mildly, moderately or severely dilated in 61(90%), 7 (10%), 0 (%) and 0 (0%) patients without SBO, and in 1 (3%), 5 (16%), 20 (62%) and 6 (19%) in patients with SBO. Normal or mildly dilated SB was seen in all (100%) patients without SBO, but only in 6 (19%) of 32 patients with SBO (p < 0.0001). Moderate or severe SB dilatation was present in 0 (0%) patient without SBO, while it was seen in 26 (81%) patients with SBO (p < 0.0001). Distal SB collapse was found in 0 (0%) patients without SBO and in 30 (94%) patients with SBO (p < 0.0001). A SBFS associated with normal or mildly dilated SB and lack of distal collapse was seen in 68 (100%) patients without SBO and in 0 (0%) patients with SBO (p < 0.0001). A combination of SBFS, moderate or severe SB distension and distal collapse was found in 0 (0%) patients without SBO and in 24 (75%) patients with SBO (p < 0.0001).
Conclusion: A SBFS combined with normal or mildly dilated small bowel is significantly more common in patients without SBO. When associated with moderate or severe small bowel dilatation, a SBFS is significantly more common in patients with SBO.
152. Transient Small Bowel Intussusception: An Incidental Finding on Ultrasound
Mateen M.A.1,2; Saleem S.1,3; Rao C.1; Gangadhar V.1; Reddy D.N.2; 1. Radiology, Nitya Diagnostic Centre, Hyderabad, AP, India; 2. Radiology, Asian Institute of Gastroenterology, Hyderabad, AP, India; 3. Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, AP, India.
Address correspondence to S. Saleem (sheenasaleem{at}gmail.com)
Objective: To study the ultrasound findings and clinical significance of transient small bowel intussusceptions in adults and children
Materials and Methods: The US findings and clinical outcome of 108 patients of intestinal intussusception diagnosed on US between August 1995 and August 2004 were reviewed. US examinations were performed with a convex transducer of frequency 3.5 to 5 MHz, a linear transducer of frequency 7 to 12 MHz and a transvaginal transducer of frequency 5 to 7.5 MHz. In all cases the length, diameter, wall thickness and color doppler study of the bowel segment involved in intussusception were evaluated. Subsequent follow up scans were performed at 30 minutes, three days and two weeks. Patients were clinically followed up for six months.
Results: 41 patients were diagnosed as transient small bowel intussusception. 36 intussusceptions were incidentally detected during US performed for some unrelated disease or vague abdominal symptom. Two patients had two adjacent intussusceptions. All the 36 intussusceptions showed spontaneous reduction and would have gone undetected had it not been for the US performed at that particular time. Five patients presented with signs of obstruction at the time of the initial US diagnosis; however the intussusceptions resolved without any treatment and were not detected on follow up scans. 67 symptomatic patients required surgical intervention.
Conclusion: Incidentally detected, small bowel intussusceptions without an identifiable pathological lead point, with a normal wall thickness, a length of less than 3.5 cm, normal non-dilated proximal bowel and normal vascularity on color doppler reduce spontaneously and are of no clinical significance.
3:20 PM
153. Comparison of Magnetic Resonance Enteroclysis (MRE) versus Indium111-labeled Octreotide Scintigraphy in the Detection of Gastrointestinal Carcinoid Tumors: Preliminary Results
Herrmann K.A.1*; Berger F.1; Knesewitsch P.2; Zech C.J.1; Reiser M.F.1; Schoenberg S.O.1; 1. Ludwig-Maximilians-University, University Hospitals Munich-Grosshadern, Institute of Clinical Radiology, Munich, Germany; 2. Ludwig-Maximilians-University, University Hospitals Munich-Grosshadern, Department of Nuclear Medicine, Munich, Germany.
Address correspondence to K.A. Herrmann (Karin.Herrmann{at}med.uni-muenchen.de)
Objective: To determine the diagnostic efficacy of magnetic resonance enteroclysis (MRE) versus somatostatin receptor scintigraphy (SRS) with 200 MBcq Indium111-labeled octreotide in the detection of gastrointestinal carcinoid tumors (GICT).
Materials and Methods: Seven patients (m:f=4:3, aged 58.3+11.5 years) with suspicion of a carcinoid tumor based on clinical and laboratory findings underwent preoperative MRE and SRS for the detection of abdominal tumor manifestation. All patients underwent surgery to confirm the diagnosis. 7 gastrointestinal carcinoid tumors (GICT) were found in 6 patients, located in the proximal (2), middle (2) and terminal ileum (3). One patient had bronchial carcinoid. Hepatic metastases were present in 4/7 patients, lymphatic metastases in 5/7. MRE was performed on a 1.5T MR-scanner (Magnetom Sonata, Siemens) using integrated parallel imaging techniques and MR-fluoroscopically monitored bowel filling with 2.5l of methylcellulose solution after naso-jejunal intubation. MRE included steady-state free precession (TrueFISP), half-Fourier-acquired single shot turbo-spin-echo (HASTE) and 3D-contrast enhanced T1 weighted gradient echo sequences. For SRS, 200 MBcq Indium111-labeled octreotide was applied. Whole-body scans were acquired 6 and 24 hours after tracer injection followed by SPECT imaging of the abdomen. All imaging data were retrospectively analyzed by two independent experienced radiologists and two nuclear physicians blinded to the surgical results to determine the primary tumor site and presence of lymphatic and hepatic metastases.
Results: All GICT were correctly identified with MRE. MRE was true negative in one patient with bronchial carcinoid (sensitivity 100%). Mean tumor size was 2.2cm (0.8-4.0cm). SRS did not exhibit tracer uptake and missed the primary tumor site in 6/7 GICT (sensitivity 14.8%). Lymphatic and hepatic metastases were correctly identified with MRE in all cases (100%). SRS indicated lymphatic metastases in 1/5 patients (20%) and hepatic metastases in 4/4.
Conclusion: MRE can be considered superior to octreotide-based SRS for detection of primary location of GICT and their loco-regional metastases.
* Will present paper
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