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Purpose: To retrospectively evaluate the sensitivity and specificity of the number and location of bowel transition points at computed tomography (CT) in the diagnosis of small-bowel volvulus, with surgical findings as the reference standard., Materials and Methods: This HIPAA-compliant study had institutional review board approval; informed consent was waived. One hundred adult patients who had undergone preoperative CT and who had surgically proved non-abdominal wall hernia small-bowel obstruction (n=68) or small-bowel volvulus (n=32) were retrospectively identified. The patients included 61 women and 39 men with a mean age of 57 years (range, 18-96 years). One reader, blinded to the diagnoses, recorded the number of transition points at CT, the anteroposterior location of each transition point relative to the anterior edge of the spine, and the presence or absence of a whirl sign. Statistical analyses were performed with the Fisher exact test, unpaired t tests, and multiple logistic regression., Results: The frequency of the finding of multiple transition points was significantly higher in patients with volvulus (19 [59%] of 32) than in patients without volvulus (11 [16%] of 68) (P<.001). Transition points associated with volvulus were less likely to be located more than 7 cm anterior to the spine (four [12%] of 32 patients) than were transition points not associated with volvulus (31 [46%] of 68 patients) (P<.005). The whirl sign was an additional significant independent predictor of volvulus (P<.05). When all three of these predictors were present, the specificity for small-bowel volvulus was 100%., Conclusion: The presence of multiple transition points with a posterior location at CT in an adult with small-bowel obstruction is significantly associated with volvulus., (Copyright (c) RSNA, 2007.)

Purpose: To evaluate the performance of radiologists in the diagnosis of internal hernia with specific computed tomographic (CT) findings., Materials and Methods: Abdominal CT scans obtained in 42 patients were retrospectively reviewed by three radiologists. The case group consisted of 18 patients with internal hernias (two paraduodenal, 16 transmesenteric); the comparison group was 24 patients with no internal hernia. Images were reviewed in a random and blinded fashion. Individual and group performance was evaluated with receiver operating characteristic (ROC) analysis, and interobserver agreement was measured with Cronbach coefficient alpha. Individual CT signs relevant as predictors of transmesenteric hernia were identified with logistic regression analysis and ranked by their odds ratio and P values., Results: Both paraduodenal hernias were diagnosed by all readers on the basis of CT signs, including a retrogastric saclike mass of small-bowel loops. Diagnosis of transmesenteric hernia was more difficult and variable, with an average accuracy of area under the ROC curve (A(z)) of 77%, sensitivity of 63%, and specificity of 76%. CT signs of transmesenteric hernia were recognized consistently (Cronbach coefficient alpha >or= 0.80) and included a cluster of dilated small-bowel segments and stretching and displacement of mesenteric vessels. Coexisting volvulus and ischemia were diagnosed with low sensitivity (46% and 43%, respectively) but high specificity (96% and 98%, respectively)., Conclusion: Diagnosis of internal hernia with CT remains difficult. Special attention should be given to the clustering of bowel loops, the mesenteric vessels, and signs of small-bowel obstruction.

Purpose: To determine the role of radiographic assessment in patients who underwent an adjustable laparoscopic gastric banding (ALGB) for the treatment of morbid obesity, and to evaluate the frequency and type of postoperative complications., Materials and Methods: From September 1995 to March 1998, 98 consecutive patients (18 men, 80 women; mean age, 39 years; age range, 22-62 years) with morbid obesity (mean body weight, 132 kg; mean body mass index, 47.1 kg/m(2)) underwent ALGB. In all patients, fluoroscopy was performed postoperatively to confirm band position and to exclude perforation and at 6-8 weeks later to measure and adjust the stoma between the pouch and stomach for optimal weight loss. All patients underwent another examination 12 months postoperatively, whereas patients with unsatisfactory weight loss or patients suspected of having complications were examined earlier and on several occasions., Results: Port puncture was feasible in all cases, and stomal adjustments could easily be repeated. Absolute (ie, total) weight loss after 1 year ranged from 8.8% to 39.2% (mean, 18.3%). Twenty patients showed unsatisfactory weight loss. No early complications occurred. Late complications occurred in 34 patients and included pouch dilatation (concentric or eccentric with posterior slippage), eccentric band herniation, band penetration, disconnection, axial pouch herniation, and port-site infection., Conclusion: ALGB is an effective method in the treatment of morbid obesity. Radiographic assessments are crucial in the management of weight loss and detection of postoperative complications.

Purpose: To evaluate the use of simultaneous defecography and peritoneography (defecoperitoneography) in patients with an unexplained widening of the rectovaginal space noted at defecography., Materials and Methods: Twenty-two patients with unexplained widening of the rectovaginal space noted at defecography were studied with defecoperitoneography. Defecoperitoneography was a combination of defecography and peritoneography with water-soluble contrast medium administered intraperitoneally., Results: The outline and movements of the peritoneum and alterations in the pelvic peritoneal cavity could be visualized with defecoperitoneography during the dynamic act of defecation. Unexplained widening of the rectovaginal space was completely due to a peritoneocele in 14 patients and partially due to a peritoneocele in six patients. In two patients, there was no peritoneocele. Only nine of 22 patients had bowel in the unexplained widening (enterocele). Three patients had a rectal peritoneocele; six, a septal peritoneocele; one, a vaginal peritoneocele; and 10, a combination of these findings., Conclusion: Visualization of the pelvic floor with defecoperitoneography is improved compared with visualization with defecography alone.

Purpose: To determine the usefulness of a number of imaging features in the differentiation of patients with Graves ophthalmopathy who had optic neuropathy from those who did not. Intracranial herniation of orbital fat through the superior ophthalmic fissure and its clinical importance was also assessed., Materials and Methods: The computed tomographic (CT) appearance of the orbital apex was examined in 50 patients without and in 50 patients with Graves ophthalmopathy. The clinical diagnosis of optic neuropathy was made by an ophthalmologist who was unaware of the imaging appearances and was based on clinical features and abnormalities of visual evoked potentials or changes at automated perimetry., Results: Intracranial fat prolapse (P < .001) and optic nerve crowding (P < .05) were the only imaging features that were independently related to optic neuropathy. The presence of intracranial fat prolapse or optic nerve crowding on CT scans helped identify 16 of 17 patients with optic neuropathy. Sensitivity was 94%, specificity was 91%, positive predictive value was 69%, and negative predictive value was 98%., Conclusion: Intracranial fat prolapse correlates closely to the presence of optic neuropathy in Graves ophthalmopathy. This sign, in combination with optic nerve crowding, demonstrates a closer correlation to optic neuropathy than previously described imaging features.

Purpose: To document the proctographic features of anismus at evacuation proctography and determine the optimum radiologic measurements for diagnosis., Materials and Methods: Twenty-four patients with anismus according to clinical and multiple physiologic criteria were examined with evacuation proctography. Structural and functional measurements were compared with those of a group of 20 asymptomatic subjects., Results: No significant difference between patients and control subjects was found with respect to pelvic descent, rectocele, or any anorectal angle measurement. In patients with anismus, initiation of evacuation was prolonged (median, 9 vs 3 seconds for control subjects; P < .0001) and anal canal width was reduced (median, 0.6 vs 1.2 cm; P = .0075). Evacuation time was increased (median, 50 vs 10 seconds; P < .0001), and the percentage of contrast material evacuated was decreased (median, 60% vs 100%; P < .0001). Only four patients were able to evacuate more than 66% of the contrast material within 30 seconds, whereas all control subjects were able to do so., Conclusion: Measurement of the anorectal angle to diagnose anismus should be abandoned. Patients with anismus demonstrate delayed initiation of evacuation, which is also prolonged and incomplete. Incomplete evacuation after 30 seconds is highly suggestive of anismus.

Purpose: To document the possible association of segmental tracheomalacia in the thoracic inlet with the combination of a large thymus and normal innominate artery., Materials and Methods: Eight infants with symptoms of innominate artery compression of the trachea were studied. The diagnostic approach included observation of posterior tracheal displacement and focal tracheal collapse at fluoroscopy, ablation of the right radial pulse by rigid endoscopic pressure, and compression of the anterior tracheal wall by the innominate artery at magnetic resonance imaging., Results: Six patients had relief of symptoms with either thymectomy and innominate artery reimplantation (n = 4) or subtotal thymectomy and innominate artery suspension (n = 2). The ratio of the sagittal diameter of the thymus to the sagittal diameter of the thoracic inlet was significantly (P < .0009) higher in the symptomatic patients (0.58 +/- 0.03) than in age-matched control subjects (0.35 +/- 0.08)., Conclusion: Crowding of the thoracic inlet by cervical herniation of an enlarged but normal thymus may contribute to the development of tracheomalacia and the symptoms of innominate artery compression.

The contribution of evacuation proctography (EP) to the evaluation of pelvic prolapse was assessed in 74 consecutive patients. A rectocele was demonstrated in 73 patients (99%); large rectoceles frequently showed barium trapping, but there was no correlation between these findings and rectal symptoms. An enterocele was detected at evacuation proctography in 13 patients (18%) (including two enteroceles seen only retrospectively), and a sigmoidocele was shown in four patients (5%). Physical examination resulted in detection of only seven enteroceles and of none of the sigmoidoceles. In 48 patients (65%), additional findings were evident at EP, including excessive pelvic floor descent, anal incontinence, rectal intussusception, and spastic pelvic floor. These data suggest that EP is particularly useful in the preoperative evaluation of pelvic prolapse if the patient has anorectal symptoms or is at risk for an enterocele. EP contributes to surgical planning by enabling identification of clinically unsuspected enteroceles and sigmoidoceles and coexistent disorders of rectal evacuation.

Two cases of cardiac herniation and volvulus that occurred after right pneumonectomy are presented. Both asymptomatic patients demonstrated an unusual bulging contour to the right side of the heart on radiographs obtained in the recovery room, before complete herniation and volvulus occurred. In an autopsy preparation, a similar right contour was produced after partial cardiac herniation through a pericardial defect. The hemispheric contour from partial cardiac herniation resembles the shape of a snow cone. Clinical awareness of this sign of impending herniation is important, so risk factors known to produce herniation may be modified.

A transmesenteric herniation of bowel with subsequent bowel ischemia in a thirteen-year-old boy is reported. Radiographic findings were that of abdominal mass and branching radiolucencies secondary to gas within the mesenteric vasculature. The unusual distribution of vascular gas (mesenteric rather than portal) is thought to be secondary to obstruction of mesenteric veins by strangulation.

Four cases of herniation of the ureter are presented. A discussion of the various types of ureteral hernia is based on the roentgenographic features of each type as well as the anatomical considerations responsible for these radiographic signs. The use of erect and oblique projections in patients with hernias undergoing urography is urged. The sign of the curlicue ureter is felt to be pathognomonic for ureteral hernia.

Incarcerated obturator hernia is an uncommon entity that on occasion may produce specific radiographic findings and clinical signs (Howship-Romberg sign) that permit diagnosis prior to celiotomy. A case is reported in which the diagnosis was suggested when pain in the thigh was elicited during the course of a barium enema examination.

Computed tomography is the method of choice for initial evaluation of patients with potential suprasellar masses. In our experience, CT has proved completely reliable for detecting or ruling out the presence of a suprasellar mass, the direction and degree of parasellar extension, and the presence of any calcific or cystic component of the lesion. When multiple cut CT has been negative, further diagnostic studies have proved unrewarding. When CT has been positive, additional studies have been required in some cases to rule out aneurysm prior to craniotomy.

Pneumonectomy with partial pericardiectomy may result in herniation of the heart through the pericardial defect, leading to cardiovascular collapse and death. Awareness of this grave potential complication and familarity with its clinical and roentgenographic features should permit prompt diagnosis and facilitate lifesaving repeat thoracotomy.

Cardiac herniation with volvulus is a catastrophic complication of right intrapericardial pneumonectomy. This case illustrates diagnostic radiographic findings that may be essential for early diagnosis and survival, since the clinical signs are nonspecific.

A case of pericardial rupture with herniation of the heart through the pericardium into the left hemithorax is described. Chest radiographs showed the heart displaced to the left with slight or no displacement of the rest of the mediastinum. The patient's condition improved following operative reduction of the heart rate and repair of the pericardial tear.