A rare curious case of ureteric dissection in a patient with vaginal vault recurrence of endometrial carcinoma

We describe the rare case of a patient with ureteric rupture during systemic drug treatment for peritoneal metastases of gastric cancer, who underwent double-J stent placement. A 66-year-old man with gastric cancer was referred to the authors' hospital. Esophagogastroduodenoscopy showed an irregular elevated lesion with thickened gastric folds, and biopsy specimens revealed a poorly differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed extensive wall thickening with homogeneous enhancement of the stomach, enlarged lymph nodes in the perigastric area, and nodules in the peritoneal cavity, suggesting peritoneal metastases. The clinical diagnosis was cT4N2M1 with peritoneal metastases, and the patient received chemotherapy (S-1 plus oxaliplatin). After six courses of chemotherapy, the patient presented to the emergency outpatient department with a complaint of acute severe pain in the left lower back. Emergency abdominal contrast-enhanced CT showed extravasation of the contrast medium from the left upper ureter in the periureter area along with the retroperitoneum, and there was no mass lesion or stone in the kidney, ureter, or bladder. A double-J stent was placed under cystoscopic guidance, and no resistance was felt when the stent was inserted. The patient's postprocedural course was uneventful, and he received ramucirumab in combination with paclitaxel after double-J stent placement. However, 2months later, systemic drug treatment was discontinued because of loss of appetite and increased general fatigue and changed to the best supportive care. His general condition gradually deteriorated, and he died 3months after the ureteral rupture. Prompt interventions, including retrograde placement of ureteral stents with concurrent use of antibiotics, will reduce mortality and morbidity in this rare entity.

In preoperative contrast-enhanced computed tomography (CT) of the stomach, an effervescent agent is taken internally to stretch the wall of the stomach to allow evaluation of tumor depth. However, there are no reports on the effects of the effervescent agent on the contrast effects of arteries, veins, portal veins, and hepatic veins. The purpose of this study was to clarify the effects of an effervescent agent on the contrast effects of blood vessels in abdominal contrast-enhanced CT. The subjects were 60 preoperative gastric or pancreatic CT patients who underwent contrast-enhanced CT either with or without the effervescent agent. CT attenuations of the vessels were measured. CT attenuations of the left gastric artery, left gastroepiploic artery, right gastroepiploic artery, left gastric vein, left gastroepiploic vein, right gastroepiploic vein, portal vein, and hepatic vein were significantly higher (p<0.01) when the effervescent agent was taken. In abdominal contrast-enhancement CT, CT attenuations of the left gastric artery, left gastroepiploic artery, right gastroepiploic artery, left gastric vein, left gastroepiploic vein, right gastroepiploic vein, portal vein, and hepatic vein were found to be higher when the patient was administered the effervescent agent.

The Role of FDG-PET/CT in Ovarian Cancer Patients with High Tumor Markers or Suspicious Lesion on Contrast-Enhanced CT in Evaluation of Recurrence and/or in Determination of Intraabdominal Metastases

The Role of FDG-PET/CT in Ovarian Cancer Patients with High Tumor Markers or Suspicious Lesion on Contrast-Enhanced CT in Evaluation of Recurrence and/or in Determination of Intraabdominal Metastases

CASE PRESENTATION A 37-year-old woman presented to the emergency department with nonbilious vomiting and acute-onset right-sided abdominal pain. She had previously been diagnosed with haemolytic anaemia and gallstone disease. The patient was alert but appeared pale and jaundiced. The right side of her abdomen was tender. There was no guarding or rebound tenderness. She was afebrile and tachycardiac, with a blood pressure of 130/88 mmHg. Her white blood cell count and serum bilirubin levels were significantly elevated. Serum amylase and serum lipase were within normal limits. A chest radiograph was performed [Figure 1], followed by contrast-enhanced computed tomography (CT) of the abdomen [Figure 2a–c]. What do these images show? What is the diagnosis?Figure 1: Frontal chest radiograph.Figure 2: (a) Axial; and (b and c) reformatted coronal contrast-enhanced CT of the abdomen.IMAGE INTERPRETATION The chest radiograph shows no focal consolidation or pleural effusion. The cardio-mediastinal silhouette is normal. No free air is seen below the diaphragm. However, there are tubular branching lucencies (white arrows) in the right hypochondrium projected over the right paraspinal region, typical of pneumobilia. A partially imaged gastric shadow is seen with an air–fluid level [Figure 1]. Axial [Figure 2a] and reformatted coronal [Figure 2b, c] contrast-enhanced CT images show a grossly distended fluid-filled stomach. In the first part of the duodenum, there is a 3.1 cm × 2.5 cm, well-defined, isodense, ovoid structure in keeping with an ectopic impacted gallstone (large white arrowhead), which was the cause of gastric outlet obstruction. The gallstone is partially calcified with small central punctate calcification. There is surrounding fat stranding in the porta hepatis (black arrow). The gallbladder is partially distended, with no gallstone within. Pneumobilia is seen in the common bile duct and intrahepatic biliary branches (small black arrowheads). No free peritoneal air or ascites is seen, and the rest of the abdominal organs are normal. DIAGNOSIS Bouveret syndrome. CLINICAL COURSE The patient underwent diagnostic laparoscopy, which confirmed the CT findings and showed an impacted gallstone in the pyloroduodenal region that was adherent to the liver and the porta hepatis with dense omental adhesions [Figure 3a]. The initial attempt at the extraction of the impacted gallstone with laparoscopy was unsuccessful due to dense adhesions; hence, a decision was made to convert the laparoscopy to laparotomy. Piecemeal extraction of the impacted pigmented gallstone was then performed [Figure 3b]. The postoperative period was uneventful. The patient was well at discharge.Figure 3: (a) Photograph taken during exploratory laparoscopy and enterotomy shows adhesions and the impacted gallstone in the first part of the duodenum (black arrows). (b) Specimen photograph shows fragmented gallstones from piecemeal extraction from the first part of the duodenum.DISCUSSION Bouveret syndrome is an unusual form of gallstone ileus that arises secondary to an acquired fistula between the gallbladder and either the duodenum or stomach. The gallstone enters the bowel through the fistula and causes gastric outlet obstruction.[1] This syndrome was named after the French physician Leon Bouveret after he described two cases in 1896.[2] Long-standing history of cholelithiasis, recurrent episodes of acute cholecystitis, large calculus (>2.5 cm), female gender and advanced age of patients (>60 years) are all predisposing factors for the formation of a cholecystoenteric fistula, a passage through which an ectopic gallstone may lead to gastric obstruction in up to 3% of cases.[3,4,5] The underlying pathophysiology comprises chronic inflammation of the gallbladder and surrounding tissues, adhesions, pressure necrosis and wall erosion, resulting in the development of biliary-enteric fistula and gallstone migration. Passage of multiple smaller gallstones through the ampulla of Vater or gallstone migration resulting from manipulation of biliary interventions may occur in a smaller percentage of patients.[6] The clinical presentation is usually nonspecific and variable, with nausea, vomiting, right upper quadrant pain and fever being common. Haematemesis may be the first symptom in a small percentage of patients due to duodenal erosions or cystic artery erosion.[7] Bouveret syndrome frequently occurs in patients who are elderly and with multiple comorbidities; coupled with the rarity of the syndrome, nonspecific clinical manifestation, and delay in diagnosis and intervention, Bouuveret syndrome can cause mortality in up to 12%–30% of the patients, despite improved treatment strategies.[8] With the availability of noninvasive imaging methods, endoscopy is being used less frequently for diagnosis. In most cases of gallstone ileus, abdominal radiography is of limited diagnostic value and is relatively nonspecific. In 1941, Rigler described a triad of radiological signs for gallstone ileus on an abdominal radiograph, which consisted of air within the biliary tree (pneumobilia), signs of small bowel obstruction and radiopaque ectopic gallstone.[9] Although the Rigler triad is diagnostic of gallstone ileus, a diagnosis may be suggested even with the presence of two of the three signs as gallstones may not be seen, particularly if they are noncalcified [Figure 4]. Additional radiographic findings that have been reported include a shift in the location of a previously noted gallstone and two distinct air–fluid levels in the right upper quadrant, with the medial one corresponding to the duodenum and the lateral one corresponding to the gallbladder.[10]Figure 4: Gallstone ileus in a 50-year-old-woman who presented with abdominal pain. (a) Supine abdominal radiograph shows two signs of the Rigler triad, namely pneumobilia (white arrows) and grossly dilated small bowel loops. The ectopic gallstone impacted in the small bowel is not discernible on the radiograph. (b) Upright abdominal radiograph shows multiple tubular branching lucencies in the right upper quadrant due to pneumobilia (white arrows). (c) Reformatted coronal contrast-enhanced CT image of abdomen and pelvis shows an impacted, partially calcified ectopic gallstone in the jejunal loop (thin white arrows), in addition to other components of the Rigler triad, that is, pneumobilia (thick white arrow) and small bowel obstruction.Ultrasonography is superior to abdominal radiographs in detecting pneumobilia and gallstones, and the combination of radiography and ultrasonography has been reported to increase detection sensitivity to up to 74%.[11] By demonstrating gastric distention, pneumobilia and an ectopic gallstone, ultrasonography may aid in diagnosing Bouveret syndrome. The ectopic position of the gallstone may be viewed as orthotopic in the presence of a constricted or decompressed gallbladder.[12] Computed tomography is the investigation of choice in the diagnostic workup of the acute abdomen. In patients with acute small bowel obstruction, abdominal CT has a sensitivity of up to 93% in detecting gallstone ileus.[13] CT has high sensitivity in the detection of even minor degrees of pneumobilia and gallstones with varying proportions of calcification. The Rigler triad, a pathognomonic radiographical finding, is much more discernible on CT [Figure 4b]. As illustrated in our patient, the CT features of Bouveret syndrome — consisting of gastric outlet obstruction caused by a large, impacted gallstone in the duodenum and pneumobilia caused by a biliary–duodenal fistula — are well demonstrated [Figure 2a–c]. Apart from defining the size, location, structure of the ectopic calculus and the extent of bowel obstruction, CT also identifies potential complications, such as bowel oedema, inflammation and ischaemia.[14] Around 15%–25% of gallstones are isoattenuating relative to the bile or fluid and are not readily discernible on CT.[15] In such a scenario, dual-energy CT or the addition of an oral contrast agent can significantly increase the diagnostic sensitivity of the CT by outlining the stone within the gastrointestinal tract. Magnetic resonance cholangiopancreatography (MRCP) has a sensitivity of 97.7% in the diagnosis of gallstones.[16] However, compared to CT, it has a limited role in the acute setting due to the longer study duration and lack of ready availability. MRCP has a limited problem-solving role when an isoattenuating gallstone escapes CT detection or the patient cannot tolerate oral or intravenous contrast administration.[17] An ectopic calculus appears as a signal void within the gastrointestinal tract, distinguishing it from the surrounding T2-hyperintense fluid. In a collapsed fistulous tract, MRCP may show a small amount of fluid within the tract that may be impossible to appreciate on CT alone.[18] Bezoar can closely resemble an ectopic gallstone on ultrasonography. It is seen as an echogenic intraluminal mass casting a posterior acoustic shadow. The absence of pneumobilia and a normal gallbladder are useful distinguishing features from gallstone ileus. On CT, the bezoars present as a focal area of mottled gas lucency within the lumen, just proximal to the transition point [Figure 5]. Another differential diagnosis for gastric outlet obstruction is gastric malignancy, which is characterised by irregular thickening of the gastric wall and necessitates careful examination of the gastric mucosa [Figure 6].Figure 5: Small bowel bezoar in a 45-year-old man who presented with abdominal pain. Reformatted coronal contrast-enhanced CT image of abdomen and pelvis shows dilated small bowel loops, consistent with small bowel obstruction. Just proximal to the transition zone, there is an oval mass with mottled intraluminal lucency, highly suggestive of a bezoar (white arrows). This bezoar was proven to be a mushroom during the surgery.Figure 6: Gastric outlet obstruction in a 60-year-old woman with abdominal distention, early satiety and loss of weight. Axial contrast-enhanced CT image of the upper abdomen shows irregular enhancing wall thickening at the pylorus of the stomach (white arrow), causing gastric outlet obstruction. This was subsequently proven to be a poorly differentiated adenocarcinoma.The treatment options for Bouveret syndrome are endoscopy, with or without lithotripsy, and surgery. Due to the increased prevalence of Bouveret syndrome among the elderly, who are typically poor surgical candidates due to many comorbidities, endoscopic treatment should be attempted before surgical intervention. The size of the calculus has the most significant impact on the success of endoscopic retrieval, with gallstones >2.5 cm being difficult to extract.[19] The surgical method should be individualised for each patient based on their age, general health, comorbidities, local inflammatory condition and risk of secondary complications. Surgery options include enterolithotomy or gastrostomy, with or without cholecystectomy and repair of cholecystoenteric fistula.[20] In conclusion, Bouveret syndrome is a rare but potentially fatal condition in which a large ectopic gallstone causes gastric outlet obstruction. Due to the rarity and lack of distinctive clinical manifestations of the disease, it is possible for the diagnosis to be missed or delayed clinically. Imaging has an important role in the diagnosis of Bouveret syndrome, with CT being the modality of choice for evaluating gallstone ileus in the acute setting. Financial support and sponsorship Nil. Conflicts of interest Peh WC is a member of the SMJ Editorial Board, and was thus not involved in the peer review and publication decisions of this article. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 12 June 2023

To retrospectively compare the accuracy in detection of hepatic metastases among contrast material-enhanced multi-detector row computed tomography (CT) alone, superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging alone, and a combination of contrast-enhanced CT and SPIO-enhanced MR imaging. The ethics committee did not require its approval or informed consent for this retrospective study, which was compliant with Declaration of Helsinki principles. Data in 38 patients (22 men, 16 women; mean age, 64.5 years; range, 35-78 years) suspected of having hepatic metastases who underwent both contrast-enhanced CT and SPIO-enhanced MR imaging were retrospectively analyzed. Twenty-one of the 38 patients had 61 metastases. Seventeen of the 61 metastases were confirmed histologically; the remaining 44 metastases were defined with imaging follow-up. At MR imaging, SPIO-enhanced heavily T1-weighted images, T2*-weighted gradient echo images, and T2-weighted fast spin-echo images were evaluated. Contrast-enhanced multi-detector row CT images obtained in the portal phase were evaluated. Four blinded observers independently reviewed CT images, MR images, and the combination of CT and MR images. Diagnostic accuracy was evaluated by using the alternative free-response receiver operating characteristic (AFROC) method. Sensitivities and positive predictive values were also analyzed with the Fisher protected least significant difference test and generalized estimating equations. The mean area under the AFROC curve for the combined approach (0.70) was significantly higher than that for SPIO-enhanced MR imaging alone (0.58, P < .05, Fisher protected least significant difference test), and there was no significant difference between each of them and that for contrast-enhanced CT alone (0.66). For all lesions, the mean sensitivity of combined imaging (0.59) was significantly higher than that of CT (0.48) or MR imaging (0.43) alone (P < .05, Fisher protected least significant difference test and generalized estimating equations). For all lesions, the mean positive predictive values were 0.82, 0.89, and 0.81, for combined MR and CT, CT alone, and MR alone, respectively. The addition of SPIO-enhanced MR imaging to contrast-enhanced multi-detector row CT (ie, combined analysis of SPIO-enhanced MR images and contrast-enhanced CT images) can improve sensitivity in the detection of hepatic metastases, although this improvement in sensitivity was not significant at AFROC analysis.

Natural History of Incidental Enhancing Nodules on Cone-Beam Computed Tomography during Transarterial Therapy of Hepatocellular Carcinoma

54-Year-Old Man With Dyspnea and Abdominal Wall Bruising

Grade 3, well-differentiated, gastric neuroendocrine tumors (NET G3) are extremely rare. Herein, we report the case of a 64-year-old man with a grade 3 neuroendocrine tumor of the stomach who experienced intra-abdominal bleeding during the course of drug treatment. The patient was referred to our hospital for examination of a gastric tumor that was initially diagnosed by a local medical doctor. Esophagogastroduodenoscopy revealed an elevated lesion with a central ulcer in the upper body of the stomach, and biopsy specimens confirmed the pathological diagnosis of NET G3. Abdominal contrast-enhanced computed tomography (CT) showed a 25-cm, well-defined mass lesion showing heterogeneous enhancement in the liver. A clinical diagnosis of NET G3 with multiple liver metastases was given, after which everolimus was administered in combination with a somatostatin analogue. However, the patient developed sudden-onset epigastric abdominal pain and general fatigue 2 months later, and emergency abdominal contrast-enhanced CT confirmed the presence of intra-abdominal hemorrhage. Following blood transfusion, the patient's symptoms and general condition improved. Although the patient was treated with streptozocin, abdominal CT indicated progression of the liver metastases. Unfortunately, despite receiving best supportive care, the patient died 8 months after the initial of the treatment. To the best of our knowledge, this is the first case of a patient who developed spontaneous hemoperitoneum during drug treatment for a NET G3 to be reported in the English literature. It is essential that additional data be obtained to determine the optimal treatment for this disease.

Aim of the studyThe purpose of this study was to investigate the clinical manifestations and outcomes of patients with adult mixed-type Henoch-Schönlein purpura (HSP) and imaging characteristics of the disease, and to evaluate the efficacy of combined therapy in treating symptoms of HSP.Material and methodsFrom January 2008 to October 2015, 23 patients with adult mixed-type HSP were enrolled. Abdominal contrast-enhanced computed tomography (CT) examination and small intestinal enteroscopy were performed for all the patients. For patients with positive urine protein, ultrasonic guided renal needle biopsy with 18G biopsy needle was performed; immunofluorescence and pathologic examinations were performed. Combined therapy with antihistamine drugs, gastric acid suppressants and glucocorticoids was used to relieve abdominal pain, gastrointestinal tract bleeding and urine protein.ResultsThe typical skin manifestation of HSP is distributed purpura in dependent areas. Abdominal contrast-enhanced CT examination exhibited the intestinal canal wall thickening and edema. Small intestinal endoscopy showed diffused hyperemia, dropsy, and erosion. All the patients with positive urine protein showed significantly higher IgA levels. With the use of combined therapy, abdominal pain and gastrointestinal tract bleeding disappeared, and urine protein decreased gradually.ConclusionsHigher IgA levels with multiorgan involvement (gastrointestinal, kidney and skin) should make one consider the diagnosis. The combined examination of abdominal contrast-enhanced CT, small intestinal endoscopy and renal needle biopsy is a valuable method for the early diagnosis of adult mixed-type HSP.

Objective: This study aimed to investigate the relationship between computed tomography (CT)-derived Hounsfield Unit (HU) measurements and dual-energy X-ray absorptiometry (DXA) and to evaluate the feasibility of using contrast-enhanced abdominal CT as a complementary tool in the assessment of bone health in liver transplant recipients. Methods: This retrospective descriptive and analytical study included adult liver transplant recipients who underwent both contrast-enhanced abdominal CT and DXA within a three-month interval. HU measurements were obtained from sagittal and axial reformatted images at the lumbar spine (L1–L4) and femoral neck. All CT examinations were performed using a standardized venous-phase protocol. DXA-derived T-scores from the lumbar spine and femur served as the reference standard. Correlation analyses and receiver operating characteristic (ROC) curves were used to evaluate associations between HU values and BMD, as well as the diagnostic performance of HU in identifying low bone density. Results: A total of 259 recipients (mean age 55.7 ± 14.4 years; 62.9% male) were included. Based on lumbar spine DXA, 17.8% had normal BMD, 36.7% were osteopenic, and 45.5% were osteoporotic. CT-derived HU values at both the lumbar spine and femoral neck were significantly lower in patients with reduced BMD and showed a graded decline across worsening DXA categories. HU values demonstrated positive correlations with corresponding T-scores. Diagnostic performance for detecting osteoporosis was fair, with AUCs of 0.700 (sagittal), 0.698 (axial), and 0.751 (femoral). Conclusion: Contrast-enhanced abdominal CT provides useful ancillary information for opportunistic bone health assessment. CT-derived HU values offer a rapid and cost-effective complementary tool but should not replace DXA in the diagnostic evaluation of osteoporosis

Contrast-Enhanced Abdominal CT with Clinical Photon-Counting Detector CT: Assessment of Image Quality and Comparison with Energy-Integrating Detector CT

Targeted Training Reduces Search Errors but Not Classification Errors for Hepatic Metastasis Detection at Contrast-Enhanced CT

BackgroundUndifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum.Case presentationA 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann’s operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient’s age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed.ConclusionsWe reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS.

Liver Transplantation for Liver Malignancies in Wilson’s Disease