Early Cross-sectional Imaging Research Articles

A CASE REPORT: SMALL BOWEL OBSTRUCTION DUE TO OBTURATOR HERNIA

Introduction: The obturator hernia is an uncommon cause for small bowel obstruction. It is classically described in thin elderly women. Delay to diagnosis may result in strangulation and gangrenous bowel at subsequent laparotomy The classically described signs, whilst useful when present, are absent in greater than 50% of cases, and preoperative diagnosis is made on radiological imaging. A 79-year-old female presented Case report: to hospital with a 2 – days history of vomiting, generalized dull aching abdominal pain and enable to pass stool for 2 days. Past medical history included scoliotic deformity in lumbar spine and previously operated for tubal ligation before 32 years. Laparotomy, bowel resection and suture hernia repair were undertaken. A subsequent presentation of small bowel obstruction was due to recurrence of the obturator hernia. However, resolved without operative management. A very high index of suspicion is required when Discussion: presented with the case of small bowel obstruction in an elderly female patient. One must therefore, also consider that any subsequent presentations of small bowel obstruction may be due to recurrence of the obturator hernia, the differential being adhesive bowel obstruction, and delay to denitive treatment is associated with poorer prognosis. A high index of suspicion is required to diagnose an obturator hernia clinicall Conclusion: y. Failure to do so results in greater mortality and morbidity. Early cross-sectional imaging can make the diagnosis and lead to earlier surgical repair. A diagnostic challenge, an obturator hernia is a rare cause of small bowel obstruction. Delay in diagnosis is associated with adverse outcome. Computed tomography scan has proved invaluable to early detection and repair.

LUNG CAVITATION: AN UNWANTED COMPLICATION OF COVID-19 LUNG DISEASE

Aim & objective: To assess the incidence of pulmonary cavitatory lesion in patients with COVID-19 and describe its characteristics and evolution. The present descriptive observational study Methodology: was conducted on 1105 RT-PCR Conrmed cases of SARS-COV-19 in Sri AUROBINDO MEDICAL COLLEGE AND PG INSTITUTE, INDORE, Madhya Pradesh january 2021 to june 2021. This study highlights t Conclusion: hat lung cavitatory lesion in patients with severe COVID-19 lung disease can occur, is associated with secondary complications of hemoptysis, pneumothorax, and confers a poor prognosis. Early cross sectional imaging should be considered if there is suspicion of cavitatory lesion on plain radiographs, and a more aggressive investigation and treatment of possible invasive fungal infection undertaken. Further studies are needed to determine whether treatment with tocilizumab, systemic glucocorticoids or a combination of both may increase the risk of developing lung cavitatory lesion in patients with COVID-19.

Renal mucormycosis presenting during the COVID-19 pandemic: A series of 11 cases from a tertiary care center in India.

Introduction:Renal mucormycosis has been documented to occur even in apparently immunocompetent individuals. Owing to the rarity of this disease, literature on its management is small. We present our experience of diagnosing and managing 11 cases of primary renal mucormycosis who presented during the second wave of the COVID-19 pandemic in India.Methods:We reviewed the records of all patients presenting to our institute with a diagnosis of acute pyelonephritis from March 2021 to September 2021. All patients with a radiological, microbiological, or histopathological diagnosis of renal mucormycosis were included in the analysis and all demographic and clinical details, including a history of COVID-19 disease and its treatment, were noted. All patients were treated by a combination of intravenous antifungal therapy and aggressive surgical debridement including nephrectomy and multivisceral resection as required. Predictors of mortality were evaluated by statistical analysis.Results:A total of 93 patients presented to our hospital with features of acute pyelonephritis of which 11 patients were suspected to have primary renal mucormycosis based on characteristic imaging features and confirmed on microbiological and histopathological examination. Of these, four patients had a history of COVID-19 infection. Only one patient had diabetes mellitus. Ten patients underwent nephrectomy and seven needed resections of surrounding organs. The colon was the most commonly involved organ. Five patients (45.5%) died of progressive sepsis. None of the predictors of mortality that were analyzed showed statistical significance.Conclusion:A high index of suspicion, early cross-sectional imaging, prompt institution of antifungal therapy, and aggressive surgical extirpation are very important for achieving good outcomes in patients of primary renal mucormycosis.

SP9.1.4 Management of Small Bowel Obstruction: A Comparison to NASBO

Abstract Aim Prompt diagnosis and proactive decisions in management of small bowel obstruction (SBO) can reduce the associated morbidity, in-hospital stay and mortality. Following recommendations of National Audit of Small Bowel Obstruction (NASBO) and Bologna (2017), the “agreed pathway” of The Association of Surgeons of Great Britain and Ireland (ASGBI, 2018) sets clear guidelines to aid timely management of SBO. We aimed to audit our practice to these guidelines and compared outcomes to NASBO. Methods Data was collected retrospectively on patients admitted with SBO from July 2019 - December 2019 and presented as percentage, median or interquartile range (IQR). Results Median age of 76 included patients was 62.0 years, 53.9% were female. Aetiologies were; adhesions (59.2%), hernia (27.6%), malignancy (10.5%) and others (2.6%). Admission CTs were performed in 92.1% vs. 80.0% (NASBO), with a median time of 3.3 hours vs. 2.2 days (NASBO). Median time to surgery in those managed operatively (n = 35) was 10 hours vs. 1 day (NASBO), while in 72.0% vs. 21.0% (NASBO) of non-settling SBO, water soluble contrast study (WSCS) was performed in a median (IQR) time of 39.0 (20.0-45.4) hours. Adhesional SBO resolved in 85.7% of cases suitable for non-operative approach. Objective nutritional assessment was performed in 94.7% vs. 90.0% (NASBO). In-hospital stay, 30-day morbidity and mortality compared to NASBO were 5.0 vs. 10.7 days, 31.6% vs. 23.0% and 5.3% vs. 8.0% respectively. Conclusion ASGBI guidelines provide multi-faceted proactive approach in managing SBO; including early cross-sectional imaging, prompt WSCS use and timely nutritional interventions, promoting improved outcomes.

S3076 Early Cross-Sectional Imaging in Acute Pancreatitis Does Not Change Clinical Outcomes

INTRODUCTION: Acute pancreatitis (AP) accounts for $2.6 billion in costs annually. The American College of Gastroenterology recommends cross-sectional imaging should be reserved for patients in whom the diagnosis is unclear, who fail to clinically improve within 48-72 hours after admission, or to evaluate for complications. Studies have shown that the majority of patients with mild AP have normal CT scans and the imaging results do not change management. We aim to compare the outcomes of patients admitted with AP who had early cross-sectional imaging (within 72 hours of admission) versus those who did not. METHODS: This was a retrospective study of patients who presented to the emergency department of a tertiary care center with acute pancreatitis from January 1, 2009 to December 31, 2019. Patients were identified based on diagnosis code for acute pancreatitis and were included if they presented with abdominal pain and had a lipase level greater than three times the upper limit of normal. Patients were excluded if they were less than 18 years of age, pregnant, or had trauma as the reason for the abdominal pain. RESULTS: Over the 11-year study period, 993 patients presented with abdominal pain and elevated lipase, meeting criteria for acute pancreatitis. Approximately half of the patients were female (49.3%) and overall average age was 53.8 years (Table 1). The most common etiologies of AP were biliary followed by alcohol. Early cross-sectional imaging was utilized in 60.9% of patients. There were no differences in incidence of bacteremia, need for ICU care, mortality, or readmission rate in patients who received cross-sectional imaging compared to those who did not. (Table 2). These findings remain consistent among patients with higher BISAP scores. Longer length of stay was associated with those who had cross-sectional imaging (P < 0.01). CONCLUSION: Despite meeting diagnostic criteria for acute pancreatitis, 61% of our patients had early cross-sectional imaging. No difference in meaningful clinical outcomes were noted between the cohort that received early imaging versus no imaging, regardless of the severity of presentation. All stakeholders including gastroenterologists, emergency room physicians, and primary care teams should work in concert to generate institutional policies to eliminate the use of unnecessary imaging in AP, with hopes that future guidelines may reflect these findings and emphasize against the use of early cross-sectional imaging in the diagnosis of acute pancreatitis.Table 1.: Demographics and clinical characteristics of patients with acute pancreatitisTable 2.: Outcomes of patients undergoing early cross-sectional imaging versus those who did not

S0073 Over-Utilization of Early Cross-Sectional Imaging in the Diagnosis of Acute Pancreatitis

INTRODUCTION: Acute pancreatitis (AP) accounts for $2.6 billion in costs annually. The American College of Gastroenterology recommends that cross-sectional imaging in acute pancreatitis should be reserved for patients in whom the diagnosis is unclear, who fail to clinically improve within 48–72 hours after admission, or to evaluate for complications. We aim to assess the use of early cross-sectional imaging (within 72 hours of admission) among those admitted with AP. METHODS: This was a retrospective study of patients who presented at a tertiary care center emergency department with acute pancreatitis from January 1, 2009 to December 31, 2019. Patients were identified by diagnosis codes for acute pancreatitis and were included if they presented with abdominal pain and had a lipase level greater than or equal to three times the upper limit of normal. Exclusion criteria included age less than 18 years, pregnancy, or abdominal pain due to trauma. Variables that were not available from the center’s database were manually extracted from electronic medical records. RESULTS: Over the 11-year study period, 993 patients met the study inclusion criteria. Approximately half of the patients were female (49.3%) and overall average age was 53.8 years (Table 1). Average Charlson comorbidity index was 3.29. The most common etiology of AP was biliary followed by alcohol. Among this cohort, 60.9% of patients had early cross-sectional imaging. Among those who underwent imaging, 97.2% of the radiology readings revealed either normal (33.6%) or uncomplicated acute pancreatitis (63.6%) (Figure 1). Patients who received imaging were older (55 vs. 51 years, P < 0.01), had higher mean lipase levels (4781 vs. 3490, P = 0.02), and higher mean BISAP scores (1.16 vs. 1.01, P = 0.03). CONCLUSION: The majority of patients who met non-imaging diagnostic criteria for AP received early cross-sectional imaging. Over 97% of the imaging demonstrated normal or uncomplicated acute pancreatitis which does not affect clinical management in the first 5–7 days of presentation. Efforts should be made at the institutional level to reduce unnecessary cross-sectional imaging in patients admitted with AP in order to limit radiation exposure for patients and reduce health care costs.Table 1.: Demographics and clinical characteristics of patients with acute pancreatitisFigure 1.: Results of imaging performed in the first 72 hours of presentation.

Paediatric abdominal pain in the time of COVID-19: a new diagnostic dilemma

The diagnostic uncertainty for children with abdominal pain has increased during the COVID-19 pandemic with the additional consideration of both COVID-19 and paediatric inflammatory multisystem syndrome—temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) alongside appendicitis, mesenteric adenitis and other less common causes of abdominal pain. We describe the cases of two children who presented with severe abdominal pain, non-bilious vomiting and high temperatures during the UK’s first peak of the COVID-19 pandemic. Laboratory and abdominal ultrasound features were similar for both children but symptom progression in combination with cross-sectional abdominal imaging enabled differentiation between PIMS-TS and appendicitis with concurrent COVID-19. These cases highlight the importance of regular clinical review, multidisciplinary working and the utility of early cross-sectional imaging to determine the underlying condition.

Hernia Through the Foramen of Winslow: a Rare Form of Internal Hernia and a Diagnostic Dilemma

Internal hernia through the foramen of Winslow is extremely rare. Since its first description by Blandin in 1834, not many cases have been reported. They often have vague symptoms, but intestinal obstruction is inevitable. Delayed diagnosis results in strangulation of bowel and high mortality. We present a case of 24-year-old male who presented with acute, severe, diffuse abdominal pain and vomiting for 1 day, and on evaluation diagnosed to have closed loop obstruction with internal hernia through the foramen of Winslow. Emergency exploratory laparotomy done, contents reduced, and repair of hernia done. The foramen of Winslow hernia constitutes less than 0.1% of all abdominal hernias. It is difficult to diagnose in view of nonspecific presentation often resulting in bowel ischemia and mandating the need of bowel resection. Early cross-sectional imaging and surgical intervention are advised in order to reduce morbidity and mortality.

Tumor thrombus in the large veins draining primary pelvic osteosarcoma on cross sectional imaging

PurposeTo evaluate the frequency of tumor thrombus in the large veins draining primary pelvic osteosarcoma on early cross-sectional imaging studies and its effect on patient survival. Materials and methodsOur retrospective study included all patients with primary pelvic osteosarcoma treated at our facility between January 2000 and May 2014, who were ≤ 45 years of age, and had adequate imaging studies and clinical follow up. Four radiologists evaluated for tumor in the large draining veins on initial CT, MRI and PET/CTs. A consensus evaluation by the four radiologists together with findings on operative reports, pathology reports or follow-up imaging was used as the reference standard. ResultsThirty-nine patients with primary pelvic osteosarcoma met final inclusion criteria. Tumor thrombus was identified in the large draining veins in 10 of the 22 (45%) patients who underwent tumor resection and 10 of the 17 (59%) who did not. In the 22 patients who underwent tumor resection, tumor thrombus was significantly associated with worse overall survival (p = 0.03). ConclusionsTumor thrombus in the large draining veins is identified in a significant proportion of initial imaging studies in patients with pelvic osteosarcoma, and is associated with worse overall survival in patients who undergo tumor resection.

Catheter, MRI and CT Imaging in Newborns with Pulmonary Atresia with Ventricular Septal Defect and Aortopulmonary Collaterals: Quantifying the Risks of Radiation Dose and Anaesthetic Time

A comprehensive understanding of the native pulmonary blood supply is crucial in newborns with pulmonary atresia with ventricular septal defect and aortopulmonary collaterals (PA/VSD/MAPCA). We sought to describe the accuracy in terms of identifying native pulmonary arteries, radiation dose and anaesthetic time associated with multi-modality imaging in these patients, prior to their first therapeutic intervention. Furthermore, we wanted to evaluate the cumulative radiations dose and anaesthetic time over the study period. Patients with PA/VSD/MAPCA diagnosed at < 100 days between 2004 and 2014 were identified. Cumulative radiation dose and anaesthetic times were calculated, with imaging results compared with intraoperative findings. We then calculated the cumulative risks to date for all surviving children. Of 19 eligible patients, 2 had echocardiography only prior to first intervention. The remaining 17 patients underwent 13 MRIs, 4 CT scans and 13 cardiac catheterization procedures. The mean radiation dose was 169 mGy cm2 (47–461 mGy cm2), and mean anaesthetic time was 111 min (33–185 min). 3 children had MRI only with no radiation exposure, and one child had CT only with no anaesthetic. Early cross-sectional imaging allowed for delayed catheterisation, but without significantly reducing radiation burden or anaesthetic time. The maximum cumulative radiation dose was 8022 mGy cm2 in a 6-year-old patient and 1263 min of anaesthetic at 5 years. There is the potential to generate very high radiation doses and anaesthetic times from diagnostic imaging alone in these patients. As survival continues to improve in many congenital heart defects, the important risks of serial diagnostic imaging must be considered when planning long-term management.

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis.

BackgroundThere are roughly 300,000 hospitalizations for acute pancreatitis annually in the United States. Many of the affected patients at our institution undergo computed tomography (CT) or magnetic resonance imaging (MRI) unnecessarily early during their admissions. We hypothesize that cross-sectional imaging within 48 h of admission in patients meeting the criteria for acute, mild pancreatitis is over-utilized and does not change management.MethodsWe performed a retrospective analysis of patients with a discharge diagnosis of acute pancreatitis from our tertiary care institution from January 1, 2010 to December 31, 2015. Inclusion criteria were a lipase more than three times the upper limit of normal and clinical suspicion of pancreatitis. Exclusion criteria were an etiology of pancreatitis following endoscopic retrograde cholangiopancreatography, recurrent or chronic pancreatitis, severe pancreatitis, and ultrasound findings being the reason for imaging.ResultsOf the 166 patients who met the criteria for analysis, 105 (63.3%) underwent cross-sectional imaging within 48 h of presentation (CT: 104, MRI: 1). Of the examined CTs, 27 (26.0%) showed no abnormality and 55 (52.9%) revealed uncomplicated pancreatitis. The remaining 22 (21.2%) demonstrated at least one of the following: local complications, biliary ductal dilatation or other findings. On thorough chart review, only two patients received a beneficial change in management as a result of the early imaging.ConclusionsThis analysis supports current guidelines that early cross-sectional abdominal imaging (CT or MRI) in patients with suspected acute mild pancreatitis does not alter medical management. Early imaging may lead to unnecessary resource use and patient irradiation.

Painful lymphadenopathy due to silicone breast implant rupture following extensive global air travel

A 25-year-old Caucasian flight attendant with an extensive travel history presented with night sweats, fevers, weight loss and axillary and supraclavicular lymphadenopathy. Apart from surgical breast augmentation, she had no past medical or surgical history. She was anaemic, leucopenic and lymphopenic, and a broad infection screen was negative. Cross-sectional imaging revealed ipsilateral silicone breast implant rupture, with leaking of implant contents into the surrounding tissue. Histological examination of an axillary lymph node core biopsy confirmed the diagnosis of silicone lymphadenopathy. This case illustrates the broad differential for acute painful lymphadenopathy in the context of global travel, and the use of targeted infection testing, early cross-sectional imaging and biopsy to arrive at an unexpected diagnosis.

Utility of Early Cross-sectional Imaging to Evaluate Suspected Acute Mild Pancreatitis

Introduction: There are an estimated 300,000 hospitalizations for acute pancreatitis annually in the United States. It is our observation that many of the affected patients at our institution receive computed tomography (CT) or magnetic resonance (MR) imaging early in their admissions, despite current recommendations from the American College of Gastroenterology that cross-sectional imaging be reserved for patients with an unclear diagnosis or who fail to improve within 48-72 hours of medical management. We hypothesize that cross-sectional imaging (CT or MR) within 48 hours of admission in patients meeting criteria for acute mild pancreatitis is over-utilized and does not change management.Table: Table. Characteristics of Patients Admitted with Acute Mild Pancreatitis, Jan. 1, 2010-Dec. 31, 2015 (n=166)Methods: We performed a retrospective analysis of patients with a discharge diagnosis of acute pancreatitis from our tertiary care institution from Jan. 1, 2010 to Dec. 31, 2015. Inclusion criteria were a lipase more than three times the upper limit of normal and clinical suspicion for pancreatitis. Exclusion criteria were an etiology of post-ERCP pancreatitis, recurrent or chronic pancreatitis, organ failure on admission, bedside index of severity in acute pancreatitis (BISAP) score of more than two on admission, or who had imaging performed explicitly to evaluate other processes or abnormalities found on abdominal ultrasound. 166 patients met criteria for analysis. Results: Of the 166 patients, 105 (63.3%) received cross-sectional imaging within 48 hours (CT: 104, MR: 1). Of the examined CTs, 27 (26.0%) showed no abnormality, and 55 (52.9%) revealed uncomplicated pancreatitis. The remaining 22 (21.2%) demonstrated at least one of the following: local complications (organized fluid collection [4], necrosis [5], pseudocyst [1]), biliary ductal dilatation (7), or other findings (9). The CTs were redundant in 5 of the 7 patients with bile duct dilatation. The single MRI showed no pathology. Two patients (one diagnosed with a non-pancreatic malignancy, one diagnosed with Crohn's disease) benefited from the CTs obtained. On thorough chart review, no other patients had a beneficial change in management during index or subsequent hospitalizations due to the early imaging.Table: Table. Findings in the 105 Patients Who Received Cross-Sectional ImagingConclusion: This analysis supports current guidelines that early cross-sectional abdominal imaging (CT or MR) in patients with suspected acute mild pancreatitis does not alter medical management. The continued high prevalence of early imaging in these situations leads to unnecessary resource use and radiation exposure to patients.

Neural vulnerability factors that increase risk for future weight gain.

Theorists have proposed several neural vulnerability factors that may increase overeating and consequent weight gain. Early cross-sectional imaging studies could not determine whether aberrant neural responsivity was a precursor or consequence of overeating. However, recent prospective imaging studies examining predictors of future weight gain and response to obesity treatment, and repeated-measures imaging studies before and after weight gain and loss have advanced knowledge of etiologic processes and neural plasticity resulting from weight change. The present article reviews evidence from prospective studies using imaging and behavioral measures reflecting neural function, as well as randomized experiments with humans and animals that are consistent or inconsistent with 5 neural vulnerability theories for excessive weight gain. Extant data provide strong support for the incentive sensitization theory of obesity and moderate support for the reward surfeit theory, inhibitory control deficit theory, and dynamic vulnerability model of obesity, which attempted to synthesize the former theories into a single etiologic model. However, existing data provide only minimal support for the reward deficit theory. Findings are synthesized into a new working etiologic model that is based on current scientific knowledge. Important directions for future studies, which have the potential to support or refute this working etiologic model, are delineated. (PsycINFO Database Record

Renal and Urologic Disorders in Antiretroviral-Treated Patients with HIV Infection or AIDS: Spectrum of Cross-Sectional Imaging Findings

In the aging human immunodeficiency virus (HIV)-infected population with improved immune function under antiretroviral treatment, many different opportunistic disorders may be encountered, along with rare presentations or complicated forms of common diseases. Renal and urologic abnormalities observed in the setting of HIV infection or acquired immunodeficiency syndrome are reviewed with their imaging appearances, including renal dysfunction, urolithiasis, urinary tract infections and related complications, genitourinary tuberculosis, vascular lesions, urogenital tumors, and bladder abnormalities, with emphasis on characterization. In HIV-positive patients, early cross-sectional imaging is warranted to detect uncommon disorders and complications, with the aim to preserve renal function.

Prospective audit of cross-sectional imaging and radiation exposure in general surgical patients

Most patients admitted with an acute surgical problem undergo some imaging during their in-patient stay. As computed tomography (CT) scanning becomes more readily available, it is becoming the mainstay of assessment. Recent studies have commented on the potential adverse effects of early cross-sectional imaging. This audit aimed to determine the use of early cross-sectional imaging and associated radiation dose in an acute surgical cohort. Data from 500 acute surgical patients were prospectively collected over a 3-month period. CT scans were undertaken, the effect on subsequent diagnostic and management decisions and the potential associated risks were evaluated. Almost 40% of subjects underwent CT scanning. Of these, 20% did not alter management and could be deemed unnecessary. The radiation exposure equated to an age- and gender-specific risk of fatal cancer induction between 1 in 1675 and 1 in 7130. Early-cross sectional imaging provides a valuable diagnostic adjunct. Decisions to expose patients to potentially hazardous radiation need to acknowledge the anticipated benefits versus risks.