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To identify MRI features associated with appendicitis. Features expected to be associated with appendicitis were recorded in consensus by two expert radiologists on 223 abdominal MRIs in patients with suspected appendicitis. Nine MRI features were studied: appendix diameter >7 mm, appendicolith, peri-appendiceal fat infiltration, peri-appendiceal fluid, absence of gas in the appendix, appendiceal wall destruction, restricted diffusion of the appendiceal wall, lumen or focal fluid collections. Appendicitis was assigned as the final diagnosis in 117/223 patients. Associations between imaging features and appendicitis were evaluated with logistic regression analysis. All investigated features were significantly associated with appendicitis in univariate analysis. Combinations of two and three features were associated with a probability of appendicitis of 88 % and 92 %, respectively. In patients without any of the nine features, appendicitis was present in 2 % of cases. After multivariate analysis, only an appendix diameter >7 mm, peri-appendiceal fat infiltration and restricted diffusion of the appendiceal wall were significantly associated with appendicitis. The probability of appendicitis was 96 % in their presence and 2 % in their absence. An appendix diameter >7 mm, peri-appendiceal fat infiltration and restricted diffusion of the appendiceal wall have the strongest association with appendicitis on MRI. • An enlarged appendix, fat infiltration and restricted diffusion are associated with appendicitis. • One such feature on MRI gives an 88 % probability of appendicitis. • Two features in combination give a probability of appendicitis of 94 %. • Combinations of three features give a probability of appendicitis of 96 %. • The absence of these features almost rules out appendicitis (2 %).

To compare magnetic resonance imaging (MRI) and ultrasound in children with suspected appendicitis. In a single-centre diagnostic accuracy study, children with suspected appendicitis were prospectively identified at the emergency department. All underwent abdominal ultrasound and MRI within 2 h, with the reader blinded to other imaging findings. An expert panel established the final diagnosis after 3 months. We evaluated the diagnostic accuracy of three imaging strategies: ultrasound only, conditional MRI after negative or inconclusive ultrasound, and MRI only. Significance between sensitivity and specificity was calculated using McNemar's test statistic. Between April and December 2009 we included 104 consecutive children (47 male, mean age 12). According to the expert panel, 58 patients had appendicitis. The sensitivity of MRI only and conditional MRI was 100% (95% confidence interval 92-100), that of ultrasound was significantly lower (76%; 63-85, P

Background and Aim: We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). Methods: Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high-grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time. Results: From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0-78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high-grade stenosis. Ninety-five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon-assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre-study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon-assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon-assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre- and post-study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon-assisted enteroscopy. Conclusion: Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon-assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon-assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.

Objective: The aim of this study was to examine which factors influence guideline adherence and to determine the impact of non-adherence on survival. Materials and methods: Cohort of 606 patients (median age 65.3 years) newly diagnosed with head and neck cancer at Medical Centre Alkmaar between 1997 and 2009. Treatment was compared to guideline recommendations. Multivariable analyses were performed to determine factors associated with non-adherence and associated outcome. Results: Ninety-one percent of patients were treated in accordance with guidelines for head and neck cancer. Reasons for discordant treatment were comorbidity, lack of cooperation in patients aged

Purpose: To determine if training with direct feedback helps to improve the diagnostic performance of inexperienced readers in the detection of appendicitis on magnetic resonance (MR) images. Materials and Methods: The institutional review board approved this retrospective study and waived the requirement for informed consent. Nine radiologists and eight residents without experience in evaluating MR images for acute abdominal conditions evaluated a training set of images from 100 MR imaging examinations of patients suspected of having appendicitis and received direct feedback after each evaluation. An expert panel made a diagnosis of appendicitis in 45 patients and an alternative diagnosis in 55 patients on the basis of histopathologic examination and follow-up. Readers recorded two diagnoses: the first after viewing images from conventional MR sequences (half-Fourier rapid acquisition with relaxation enhancement and true fast imaging with steady-state precession) and the second after viewing diffusion-weighted (DW) MR images. Reader sensitivity and specificity were calculated per set of 25 cases. Results: The average reader sensitivity for detecting appendicitis improved significantly after training (0.82 vs 0.92, P = .003); the average specificity improved nonsignificantly (0.82 vs 0.88, P = .10). Sensitivity for radiologists increased from 0.81 in the first set of 25 cases to 0.91 in the last set, and specificity improved from 0.82 to 0.85. For residents, sensitivity increased from 0.82 to 0.94, and specificity increased from 0.82 to 0.91. Sensitivity improved from 0.80 to 0.87 (P

Background and study aims: New modalities are available for visualization of the small bowel in patients with possible obscure gastrointestinal bleeding (OGIB), but their performance requires further comparison. This study compared the diagnostic yield of magnetic resonance enteroclysis (MRE) and capsule endoscopy in patients with OGIB, using balloon-assisted enteroscopy (BAE) as the reference standard. Patients and methods: Consecutive consenting patients who were referred for evaluation of OGIB were prospectively included. Patients underwent MRE followed by capsule endoscopy and BAE. Patients with high grade stenosis at MRE did not undergo capsule endoscopy. The reference standard was BAE findings in visualized small-bowel segments and expert panel consensus for segments not visualized during BAE. Results: Over a period of 26 months, 38 patients were included (20 female [53 %]; mean age 58 years, range 28-75 years). Four patients (11 %) did not undergo capsule endoscopy due to high grade small-bowel stenosis at MRE (n=3; 8%) or timing issues (n=1; 3%). Capsule endoscopy was non-diagnostic in one patient. The reference standard identified abnormal findings in 20 patients (53 %). MRE had sensitivity, specificity, and positive and negative likelihood ratios of 21%, 100%, infinity, and 0.79, respectively. The corresponding values for capsule endoscopy were 61%, 85%, 4.1, and 0.46. The reference standard and capsule endoscopy did not differ in percent positive findings (P=0.34), but MRE differed significantly from the reference BAE (P

Purpose: This study aimed to determine the reliability of magnetic resonance imaging (MRI) without luminal contrast medium versus MR enteroclysis for evaluating small bowel pathology, to compare MRI and MRE findings per observer, and to compare these findings with those of an expert reader in order to determine the influence of luminal contrast medium on morphological evaluations. Conclusion: The use of luminal contrast medium bowel improves reliability for measuring bowel wall thickness and for the diagnosis and grading of obstruction when evaluating the small bowel. (C) 2009 Elsevier Inc. All rights reserved.

Objective: MR enteroclysis has become an important tool to visualize the complete small bowel wall and extramural structures. In many centers, this technique is rapidly becoming the first-line technique for small bowel visualization. MR enteroclysis yields a diagnosis of thickened jejunal loops in some patients. In this paper, we describe an MR enteroclysis protocol and review the literature on jejunum abnormalities with several sample cases. Conclusion: Jejunum abnormalities are not uncommon. These abnormalities can be self-limiting, but some patients suffer from infectious and other pathologic conditions of the small bowel necessitating intervention. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

(CHEST 2003; 124:2010 –2013) A 60-year-old woman was evaluated for a mass lesion shown on a radiograph of the thorax. The patient had been well until 6 weeks before, when progressive shortness of breath, coughing and leftsided chest pain, and pain between her shoulders developed. Her medical history revealed rheumatoid arthritis for 30 years, for which she received prednisolone, 10 mg/d. In 1994, breast-conserving surgery was performed because of a metaplastic carcinoma of the right breast. After surgery, she received adjuvant radiotherapy. No lymph node metastases were found. During follow-up, no signs of metastasis or relapse were observed. There was no history of smoking. Physical examination showed normal vital signs. The right breast showed a scar, but there were no palpable abnormalities in either breast. There was no lymphadenopathy. Percussion and auscultation of the chest were normal. Her extremities showed malformations matching her rheumatoid arthritis. Laboratory examination revealed an erythrocyte sedimentation rate of 52 mm/h, and a microcytic and hypochromic anemia (hemoglobin, 11,4 g/dL; hematocrit, 36%). The alkaline phosphatase level was 1,494 U/L (normal range, 70 to 150 U/L), with an elevated bone fraction. The other liver function test results were normal. The calcium and albumin levels were normal, and the parathyroid hormone was slightly raised (110 pg/L; normal range, 0 to 100 pg/L). Chest radiography showed a widened mediastinal silhouette, especially around the aortic arch, and a shadow at the posterobasal side of the left lung (Fig 1, top, and bottom). A CT scan revealed an abnormal calcified mass in the mediastinum and left lower lobe. The calcified mass in the mediastinum showed encasement of the descending aorta, with displacement of the trachea toward the left hemithorax (Fig 2, top). The calcified consolidated left lower lobe was continuous with the mediastinal mass. Left-sided pleural fluid was also present (Fig 2, bottom). A radionuclide bone scan showed pathologic uptake in the soft tissue of the left hemithorax. There were no signs of any bone metastases. Fiberoptic bronchoscopy revealed a stenotic left main bronchus, narrowed by pathologic tissue. Eventually, CT-guided biopsy was performed to obtain sufficient material for histologic examination.

ObjectiveTo compare accuracy and interobserver agreement between radiologists with limited experience in the evaluation of abdominal MRI (non-experts), and radiologists with longer MR reading experience (experts), in reading MRI in patients with suspected appendicitis.MethodsMR imaging was performed in 223 adult patients with suspected appendicitis and read independently by two members of a team of eight MR-inexperienced radiologists, who were trained with 100 MR examinations previous to this study (non-expert reading). Expert reading was performed by two radiologists with a larger abdominal MR experience (>500 examinations) in consensus. A final diagnosis was assigned after three months based on all available information, except MRI findings. We estimated MRI sensitivity and specificity for appendicitis and for all urgent diagnoses separately. Interobserver agreement was evaluated using kappa statistics.ResultsUrgent diagnoses were assigned to 147 of 223 patients; 117 had appendicitis. Sensitivity for appendicitis was 0.89 by MR-non-expert radiologists and 0.97 in MR-expert reading (p=0.01). Specificity was 0.83 for MR-non-experts versus 0.93 for MR-expert reading (p=0.002). MR-experts and MR-non-experts agreed on appendicitis in 89% of cases (kappa 0.78). Accuracy in detecting urgent diagnoses was significantly lower in MR-non-experts compared to MR-expert reading: sensitivity 0.84 versus 0.95 (p

To compare the diagnostic performance of imaging strategies with magnetic resonance (MR) imaging and computed tomographic (CT) imaging in adult patients suspected of having appendicitis. Institutional review board approval was obtained prior to study initiation, and patients gave written informed consent. In a multicenter diagnostic performance study, adults suspected of having appendicitis were prospectively identified in the emergency department. Consenting patients underwent ultrasonography (US) and subsequent contrast-enhanced CT if US imaging yielded negative or inconclusive results. Additionally, all patients underwent unenhanced MR imaging, with the reader blinded to other findings. An expert panel assigned final diagnosis after 3 months. Diagnostic performance of three imaging strategies was evaluated: conditional CT after US, conditional MR imaging after US, and immediate MR imaging. Sensitivity and specificity were calculated by comparing findings with final diagnosis. Between March and September 2010, 229 US, 115 CT, and 223 MR examinations were performed in 230 patients (median age, 35 years; 40% men). Appendicitis was the final diagnosis in 118 cases. Conditional and immediate MR imaging had sensitivity and specificity comparable to that of conditional CT, which resulted in 3% (three of 118; 95% confidence interval [CI]: 1%, 7%) missed appendicitis, and 8% (10 of 125; 95% CI: 4%, 14%) false-positives. Conditional MR missed appendicitis in 2% (two of 118; 95% CI: 0%, 6%) and generated 10% (13 of 129; 95% CI: 6%, 16%) false-positives. Immediate MR missed 3% (four of 117; 95% CI: 1%, 8%) appendicitis with 6% (seven of 120; 95% CI: 3%, 12%) false-positives. Conditional strategies resulted in more false-positives in women than in men (conditional CT, 17% vs 0%; P = .03; conditional MR, 19% vs 1%; P = .04), wherease immediate MR imaging did not. The accuracy of conditional or immediate MR imaging was similar to that of conditional CT in patients suspected of having appendicitis, which implied that strategies with MR imaging may replace conditional CT for appendicitis detection

We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high-grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time.From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0-78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high-grade stenosis. Ninety-five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon-assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre-study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon-assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon-assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre- and post-study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon-assisted enteroscopy.Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon-assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon-assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.

New modalities are available to visualize the small bowel in patients with Crohn’s disease (CD). The aim of this study was to compare the diagnostic yield of magnetic resonance enteroclysis (MRE) and capsule endoscopy (CE) to balloon-assisted enteroscopy (BAE) in patients with suspected or established CD of the small bowel. Consecutive, consenting patients first underwent MRE followed by CE and BAE. Patients with high-grade stenosis at MRE did not undergo CE. Reference standard for small bowel CD activity was a combination of BAE and an expert panel consensus diagnosis. Analysis included 38 patients, 27 (71%) females, mean age 36 (20–74) years, with suspected (n = 20) or established (n = 18) small bowel CD: 16 (42%) were diagnosed with active CD, and 13 (34%) by MRE with suspected high-grade stenosis, who consequently did not undergo CE. The reference standard defined high-grade stenosis in 10 (26%) patients. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value of MRE and CE for small bowel CD activity were 73 and 57%, 90 and 89%, 88 and 67%, and 78 and 84%, respectively. CE was complicated by capsule retention in one patient. MRE has a higher sensitivity and PPV than CE in small bowel CD. The use of CE is considerably limited by the high prevalence of stenotic lesions in these patients.

A 15-year-old girl presented with bouts of diffuse abdominal pain that had existed for the past year. During these bouts of pain, she had no preferred posture. Her clinical history included cystic fibrosis (CFTR mutation. ∇F308 homozygote), which was diagnosed at 6 months of age, and cystic fibrosis-related diabetes mellitus. which was diagnosed at 1 year of age. She weighed 54 kg, which was normal for her age, and her forced expiratory volume in 1 second was 2.90 L (greater than the 100th percentile). There was no history of trauma. When this patient visited the outpatient clinic, her disease was being optimally treated. As part of the clinical work-up, ultrasonography (US) was performed. The US findings prompted subsequent. contrast material-enhanced (Ultravist 300; Schering, Berlin, Germany) abdominal computed tomography (CT) and magnetic resonance (MR) imaging.

OBJECTIVE. MR enteroclysis has been introduced in the workup of small-bowel diseases. The major advantage of this technique over others is the combined visualization of luminal, mural, and extramural abnormalities. In this article we propose an MR enteroclysis protocol, present a stepwise approach for evaluation of these examinations, and discuss the different inflammatory conditions that can be detected. CONCLUSION. MR enteroclysis can be considered the current first-line imaging technique for inflammatory small-bowel disorders.

MR enteroclysis is becoming a very important imaging modality in the workup and follow-up of small bowel diseases. The technique has many advantages, including the absence of ionizing radiation, ability to control luminal distension, superior tissue characterization, multiplanar capabilities, and mural and extramural visualization. These capabilities can be obtained with a simple protocol showing excellent agreement with conventional enteroclysis. In 29 (18 with new or known Crohn's disease) of the 50 patients pathology was detected, with a very good clinical correlation. In 14 patients MR enteroclysis data altered the therapeutic strategy. This contributes to the acceptance of this modality as a primary tool in small bowel diseases.