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Resume La radiologie interventionnelle recouvre l'ensemble des techniques qui, au moyen de differents types de guidage (echographie, radiographie conventionnelle, tomodensitometrie, imagerie par resonance magnetique), permet un geste diagnostique ou therapeutique. Parallelement au developpement des techniques endoscopiques dans la prise en charge des hemorragies digestives, la radiologie interventionnelle est devenue l'un des elements-cles de l'arsenal diagnostique et therapeutique dans cette indication. L'amelioration des techniques de guidage, les perfectionnements des materiaux necessaires aux differentes procedures et leur diffusion dans les unites de radiologie permettent leur application dans le cadre de l'urgence, en particulier abdominale. La relative facilite de mise en œuvre de la radiologie interventionnelle et l'absence d'anesthesie generale en font a ce jour une methode de choix, notamment chez les patients fragilises ou lorsque la cause de l'hemorragie demeure inconnue malgre les explorations endoscopiques. Cette approche necessite une collaboration etroite entre hepato-gastro-enterologues, radiologues et chirurgiens. L'objectif de cette revue est de detailler la place de la radiologie interventionnelle dans la prise en charge des hemorragies digestives hautes et basses, liees ou non a une hypertension portale.

OBJECTIVE. Our aim was to compare the results of gadolinium-enhanced breath-hold MRangiographywiththoseofconventionalangiographyforthestudyofmesentericcirculation.SUBJECTS AND METHODS. MR angiography and digital subtraction angiography were prospectively performed in 33 patients referred for hepatic, pancreatic, or mesenteric disease. MR angiography was performed with four three-dimensional acquisitions at 0, 30, 60, and 90 sec after injection of 0.1 mmol/kg of gadolinium. Selective conventional angiography was used as the standard of reference.RESULTS. A pure arterial angiogram (one on which veins could not be visualized) was obtainedin 27 patients during the second or third acquisition. By subtracting the arterial phase from an arteriovenous phase (third or fourth acquisition) we obtained a pure venous angiogram (one on which arteries could not be visualized) in 28 patients. Agreement was good or excellent for the hepatic artery (κ = 0.78), the superior mesenteric artery (κ = 0.65), the splenic artery (...

To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks.Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect.In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma.Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.

The purpose of our study was to assess the efficacy of transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma using two different infusion schedules.Chemoembolization with lipiodol-mediated injection of doxorubicin was performed in 160 patients. In the first group of 80 patients, conventional chemoembolization was initially planned to be repeated at least three times at 2-month intervals. In the second group of 80 patients, chemoembolization was used selectively and repeated only when necessary on the basis of follow-up CT or MR imaging. According to the Okuda classification, 72 patients were stage 1, 33 belonging to group 1 (subgroup 1, Okuda 1) and 39 belonging to group 2 (subgroup 2, Okuda 1). Eighty-eight patients were stage 2, 47 belonging to group 1 (subgroup 1, Okuda 2) and 41 belonging to group 2 (subgroup 2, Okuda 2).Complications of transcatheter arterial chemoembolization occurred in 19 patients from group 1 and six patients from group 2 (p.001). The mean time between the first and the third courses was significantly different between group 1 (4 months) and group 2 (14 months) (p.001). The 1-year, 2-year, and 3-year survival rates were significantly different between subgroup 1, Okuda 1, (58%, 28%, 11%) and subgroup 2, Okuda 1 (89%, 68%, 39%) (p. 001), and between subgroup 1, Okuda 2 (19%, 0%, 0%), and subgroup 2, Okuda 2 (48%, 31%, 15%) (p.001).The efficacy and tolerability of chemoembolization increase when it is used selectively and repeated only when necessary. Such technical considerations might explain some of the discrepancies of the results of chemoembolization in published data.

OBJECTIVE: The purpose of this study was to evaluate the ability of MR cholangiography to reveal the characteristics of biliary abnormalities found in primary sclerosing cholangitis. CONCLUSION: Our results suggest that MR cholangiography could be useful in the diagnosis of primary sclerosing cholangitis. Slightly dilated peripheral bile ducts unconnected to the central ducts in several hepatic segments are a characteristic MR sign of primary sclerosing cholangitis. However, other studies are necessary to establish the usefulness of MR cholangiography in relation to other imaging techniques for evaluating primary sclerosing cholangitis.

To report on the frequency and treatment of arterial complications due to percutaneous transhepatic biliary drainage (PTBD).Lesions of the intrahepatic artery were encountered in 10 of 525 patients treated by PTBD (2%). Hemobilia followed in 9 patients and subcapsular hematoma in 1. Seven patients had a benign biliary stenosis and 3 had a malignant stenosis.The bleeding resolved spontaneously in 3 patients. In 7 it required arterial embolization, which was successfully achieved either through the percutaneous catheter (n = 3) or by arteriography (n = 4).Arterial bleeding is a relatively rare complication of PTBD that can easily be treated by selective arterial embolization when it does not resolve spontaneously. In this series its frequency was much higher (16%) when the stenosis was benign than when it was malignant (0.6%).

To evaluate the specificity of spiral CT for early diagnosis of small hepato-cellular carcinoma.One or several hepatic hypervascular nodules, with a diameter smaller than or equal to 3cm and suspected of corresponding to small hepato-cellular carcinoma, were detected during the arterial phase of spiral CT in 55 patients. The diagnosis of the main nodule could be established in 31 patients by pathologic examination, elevated alpha-foeto-protein level or follow-up examination.Among the 31 studied nodules, 19 were hepato-cellular carcinomas (61%) and 12 were benign (39%). Seven (78%) of the 9 nodules20mm and 12 (54%) of the 22 nodules=20mmm were hepato-cellular carcinomas. Three benign lesions (2 angiomas and 1 pseudo-nodule of hemodynamic origin) were showing typical radiological characteristics which retrospectively allowed their identification. On the other hand, the appearance of the 9 other benign nodules (29%) was exactly the same as the one of the hepato-cellular carcinoma.Although, in cirrhotic patients, hepato-cellular carcinoma is the most frequent cause of detected nodules during the arterial phase of the spiral CT, 29% of hypervascular lesions=3cm were benign in this study. In some cases, only follow-up examinations are able to confirm the diagnosis.

A tumor of the head of pancreas was an incidental finding on US of two patients aged 52 and 61 years presenting with abdominal pain. The tumor was studied by computed tomography, MRI and endoscopic ultrasonography. Surgical biopsy of a liver lesion was performed in one case and partial duodenopancreatectomy was performed in the other case. Histological evaluation, including immunohistochemistry, showed leiomyosarcoma and stromal tumor respectively. Whatever the site of origin, most mesenchymal pancreatic tumors are hypervascular, heterogeneous and have a necrotic center.

Our aim was to compare the results of gadolinium-enhanced breath-hold MR angiography with those of conventional angiography for the study of mesenteric circulation.MR angiography and digital subtraction angiography were prospectively performed in 33 patients referred for hepatic, pancreatic, or mesenteric disease. MR angiography was performed with four three-dimensional acquisitions at 0, 30, 60, and 90 sec after injection of 0.1 mmol/kg of gadolinium. Selective conventional angiography was used as the standard of reference.A pure arterial angiogram (one on which veins could not be visualized) was obtained in 27 patients during the second or third acquisition. By subtracting the arterial phase from an arteriovenous phase (third or fourth acquisition) we obtained a pure venous angiogram (one on which arteries could not be visualized) in 28 patients. Agreement was good or excellent for the hepatic artery (kappa = 0.78), the superior mesenteric artery (kappa = 0.65), the splenic artery (kappa = 0.70), the portal vein (kappa = 1.0), the superior mesenteric vein (kappa = 0.88), and the splenic vein (kappa = 0.75). Agreement was poor, and vessels were better shown by conventional angiography, for the intrahepatic arteries (kappa = 0.006) and the branches of the superior mesenteric artery (kappa = 0.14). MR angiography and conventional angiography revealed 29 and 27 portosystemic collaterals, respectively.Dynamic breath-hold contrast-enhanced MR angiography compared favorably with conventional angiography in preoperative assessment of the proximal mesenteric arteries and in the evaluation of portal hypertension; however, conventional angiography is still necessary to evaluate distal arteries.

OBJECTIVE: This study describes the MR imaging features of congenital hepatic fibrosis in four children who were examined with MR cholangiopancreatography. CONCLUSION: MR cholangiopancreatography effectively reveals biliary cysts, dilatation of intrahepatic bile ducts, and polycystic kidney disease, findings often associated with congenital hepatic fibrosis. This diagnosis should be suspected when these biliary and renal abnormalities are associated with hepatosplenomegaly in a patient with normal liver function.

Magnetic resonance cholangiopancreatography (MRCP) has received much attention in the recent literature as a noninvasive alternative to endoscopic retrograde cholangiography, primarily for biliary calculus disease, but also for the less common indication of evaluation of biliary anomalies. We present a case of Caroli's disease in which the diagnosis can be clearly inferred by MRCP. The findings of MRCP and endoscopic retrograde cholangiopancreatography are similar. This new procedure could be a noninvasive alternative to direct cholangiography and perhaps will become the first-choice imaging technique for diagnosing Caroli's disease.

A 15-month-old girl, who presented with biliary cirrhosis secondary to cystic fibrosis with refractory ascites and recurrent intestinal bleeding, underwent percutaneous transjugular intrahepatic portosystemic shunting. Immediately following the procedure the ascites disappeared and no further bleeding occurred. The stent shunt was patent on Doppler ultrasound until the 22nd day. The patient died on day 22 because of liver failure due to a low-flow syndrome with severe hepatic ischaemia, but with no recurrence of bleeding or ascites.

A low cost, well tolerated, and effective gastrointestinal contrast agent is needed for abdominal MRI. The authors tested, in vitro and in routine practice, a mixture of 192 g of barium sulfate (Micropaque HD oral, Guerbet, France) diluted in 500 ml of gastric antacid (Maalox, Rohrer, Fort Washington, PA). Its T1 and T2 relaxation times were 324 and 14 msec, respectively (.2 T). This contrast agent was used in routine practice in 789 patients (.5 T). It had a low signal intensity in 86% and 82% of the cases on T1- and T2-weighted sequences, respectively. No side effect due to magnetic susceptibility was seen, even with gradient-echo sequences. The dilution of barium sulfate in gastric antacid, instead of water, causes a low signal intensity on all sequences for a low barium sulfate concentration (38% w/v). This product is an effective and low cost contrast agent in routine practice.

The aim of this study was to assess the sensitivity of MR imaging in the diagnosis of liver hemochromatosis and its ability to quantify hepatic iron concentration (HIC).MR images were prospectively obtained in 58 patients suspected to have hemochromatosis. We used a scanner with a 0.5-T magnet and two sequences: gradient-echo T1-weighted (400/12 [TR/TE], 90 degrees flip angle) and gradient-echo T2*-weighted (700/30, 30 degrees flip angle) sequences. Measurement of the liver-to-muscle signal-intensity ratio was compared with the HIC value measured at biopsy for each patient.Both MR sequences showed significant correlation between decreased signal-intensity ratios and increased HIC (r = -.87 for T1-weighted sequences and r = -.74 for T2*-weighted sequences). The sensitivity and specificity of the T2*-weighted sequence (signal-intensity ratio0.8) to detect iron overload (HIC36 mumol/g) were 91% and 88%, respectively. The best correlation was obtained with T2*-weighted sequences, when patients had an HIC less than 100 mumol/g (r = -.71); with T1-weighted sequences, the best correlation was obtained when patients had an HIC of 100-324 mumol/g (r = -.67). We found a significant correlation between the HIC revealed on MR images, calculated from both sequences, and that measured at biopsy when patients had an HIC of less than 300 mumol/g (r = -.93, p.01).MR imaging shows promise in differentiating normal from abnormal hepatic iron concentration and in grossly quantifying moderate degrees of hepatic iron overload.

MR cholangiopancreatography (MRCP) is a new technique allowing noninvasive investigation of the bile ducts and pancreatic duct. Due to the extremely intense signal of water on T2-weighting, MR sequences can be obtained only demonstrating liquids. The bile and pancreatic ducts can therefore be studied spontaneously even in the case of major cholestasis. The contraindications of MR cholangiography are exclusively those of MR. MRCP can visualize the level of a bile duct obstruction and often the nature of this obstruction (stone, tumour). Complementary axial T1- and T2-weighted sequences can also visualize the parenchyma around the ducts. MR cholangiography therefore appears to be a technique of the future for noninvasive investigation of the bile ducts.

In helical CT, there are 4 mains factors of quality: The in-plane spatial resolution that is the same in conventional CT; The spatial resolution on the Z axis, which is the slice thickness. The increase factor of the slice thickness between a conventional and a helical CT depends on the pitch and the reconstruction algorithm. The value of the increase factor can be easily calculated; The signal to noise ratio which depends on the collimation, the mA, the KV and the reconstruction algorithm. The signal to noise ratio is not depending on the table speed; The reconstruction interval which can be less than the slice thickness. Then the contrast of small lesion is improved and stair-step artifacts are reduced in 3D reformations.

During a 7-year period, bleeding esophageal varices were treated by means of percutaneous transhepatic embolization in 400 cirrhotic patients, including 258 patients with Child's class C cirrhosis (65%) and 142 patients with Child's class B cirrhosis (35%). Embolization was performed either with bucrylate or with absolute ethanol and stainless-steel coils. Variceal hemorrhage was controlled in 245 (83%) of the 297 patients in whom percutaneous transhepatic embolization was performed as an emergency treatment. The 10-day survival rate in the series was 76%, with 97 deaths occurring shortly after the procedure as a result of recurrent bleeding or liver failure. The actuarial rate of recurrent bleeding was 55% at 6 months (38% Child's class B, 70% Child's class C) and 81% at 2 years (71% Child's class B, 90% Child's class C). One-half the cases of recurrent bleeding were easily controlled by medical treatment; 56% of these patients were still alive at 6 months (79% Child's class B, 42% Child's class C), 48% were alive at 1 year, and 26% were alive at 5 years. Results indicated that the survival rate was significantly higher (p less than .01) in Child's class B patients than in Child's class C patients during the 5-year follow-up period. The overall technical failure and complication rates were 9% and 7%, respectively, but these rates declined progressively as we gained more experience with the procedure. In this large series, transhepatic embolization was a safe, easy-to-perform, and effective treatment for the control of variceal bleeding and was somewhat more efficacious than previously reported.

Pancreatic pseudocysts were observed to simulate a mass in the upper pole of the left kidney in 4 patients. Urographic investigation of these pseudocysts revealed deformities similar in all respects to those produced by a cyst, though in two cases the mass was surrounded by a thick wall. A better definition of the parenchymatous deformity was obtained by the use of true trunk profile nephrotomograms. The value of ultrasonography, using the grey scale, and of transparietal puncture with measurement of amylase levels, is stressed. The authors discuss the problem of establishing the precise location--anterior to, surrounding, or within the kidney--of these pseudocysts.

Seventy three patients with malignant obstruction of the extrahepatic bile ducts were submitted to palliative drainage through percutaneous transhepatic endoprosthesis (P.T.E.). Complications occurred within the first month following the procedure in 13 patients (18%) and 8 of them died (10%). Cholangitis was the main complication resulting, from dysfunction of the endoprosthesis due to an incorrect placement of the stent in most cases. On the other hand, not any significant vascular complication such as previously reported following P.T.E., was encountered in our series. Late complications are mainly due to endoprosthesis obstruction (5 cases) or dislodgement (2 cases). The mortality rate within the first month following P.T.E. is 19%, resulting from either a complication of the procedure (11%) or the underlying disease (8%). The mean survival of these 73 patients, is 4, 7 months. When considering only the 59 patients who are alive one month following the procedure, the mean survival (post-operative deaths excluded) is 6 months. According to our experience P.T.E. remains a valuable palliative procedure when other endoscopic or surgical methods either have failed or cannot be resorted to provided a correct placement of the stent allowing for a good bile drainage can be achieved. Thus P.T.E. is able to provide in many cases the same long-term survival as palliative surgery, allowing the patients to resume their normal daily activity.

Winslow's lobe, the postero-inferior lobe of the head of the pancreas, gives rise to special angiographic appearances owing to its posterior position in relation to the axis of the superior mesenteric artery. It displaces the superior mesenteric artery laterally and forwards, and may also obstruct the vein. In 12 cases of pancreatitis, these signs were usually due to a pseudo-cyst of this lobe of the pancreas, the angiographic discovery of which provided greater accuracy in diagnosis. In 4 cases of carcinoma of the pancreas, there was also irregular stenosis of the first few jejunal arteries, the diagnostic interest of which is important.

Colonic complications of pancreatitis are not infrequent occurrences, as illustrated by the fact that the authors have personally treated 39 such cases. Lesions are found in the colon at sites which correspond perfectly to diffusion of pancreatic necrotic lesions along mesenteric pathways as described by Meyers. They occur mainly in the left colic flexure (17 cases) and transverse colon (10 cases) but may affect the ascending (6 cases) and descending (4 cases) colon by diffusion of the pancreatitis into the anterior extrarenal space. These topographical characteristics, associated with the extrinsic and inflammatory nature of the lesions, produce a very specific and typical radiological syndrome which should assist diagnosis.

The extension of infiltrating stomach cancer through the gastrocolic ligament into the transverse colon appears to be relatively common. The radiological appearance is characteristic, with more or less widespread, but shallow, extrinsic prints with irregular contours typical of malignant tumours. Its gastric origin is strongly suggested by its position of the superior border of the transverse colon. The authors report 6 observations in which the value of this very characteristic radiological abnormality of the colon to diagnose primary stomach cancer was confirmed. Radiological appearances are not very specific in primary stomach cancer and interpretation is often difficult; endoscopy or even biopsies are often inconclusive.

Apart from special types encountered in neonates and during pregnancy, spontaneous sub-capsular haematoma (SCH) of the liver is a rare condition which is usually not recognized before operation. The diagnostic value of arteriography is emphasized by this case of SCH in a 29 year old man which presented spontaneously with the appearance of a large mass in the right hypochondrium with fever and pain. Angiographic changes identical to those seen with a traumatic SCH were found and, in this case, were accompanied by a local reversal in intra-hepatic portal flow related to a tumoural Budd-Chiari phenomenon (compression of the hepatic veins by the haematoma). Despite histological study of the liver, no tumoural, vascular, infective or parasitic aetiology could be found to explain this apparently idiopathic spontaneous SCH.

Results obtained in 66 cases emphasize the value of lateral imaging to increase sensibility of radiculography in the diagnosis of narrow lumbar canal. In all cases, in fact, the anteroposterior diameter of the opacified canal diminished in the standing position in proportions varying from 20 to 50%, and furthermore, in 20% of patients diagnosis was only possible from this image. Narrowing of the canal was considered as being present in patients with an anteroposterior canal diameter in the standing position that was less than 11 mm in corrected values. This image appears therefore to be an essential one, particularly as clinical symptomatology of narrow lumbar canal is very often atypical (62% of cases). Moreover, contrary to widespread opinions, computed tomography is sometimes less sensitive than radiculography in this type of disorder.

Hepatic tumours may, in the course of their development, compress or invade the hepatic veins, causing in a certain way a secondary Budd-Chiari syndrome of neoplastic origin. This results in reversal of the intrahepatic portal flow in the corresponding area, easily seen at arteriography. Hepatic arteriography shows retrograde opacification of intra-hepatic portal branches (arterio-portal reflux) which is the direct sign. Return ileoportography shows the functional absence of those portal branches in which current is reversed which is the indirect sign. This haemodynamic anomaly seen at arteriography is particularly interesting when the responsible tumour is an invasive and avascular carcinoma of the liver, as was the case with our two patients, since it represents the only angiographic sign from which the diagnosis may be made, there being neither hypervascularisation nor evidence of a mass.

Inversion of the intrahepatic flow is a phenomenon commonly observed during the initial days of a liver contusion. Its symptomatology combines one direct sign: segmentary, peripheral arterioportal reflux; and two indirect signs: arteriolar hypervascularization and a functional amputation of portal flow on selective arteriography of the superior mesenteric artery in the same territory. The direct sign may be absent, and may not be visualized in the absence of a selective injection. Both indirect signs are always present and enable the diagnosis. In most cases it is a question of a transient phenomenon secondary to a inflammatory reaction released by the contusion of the liver parenchyma; it may be the only sign of liver trauma. It may be a sign of a benign contusion and is not alone an indication for surgery. This concerns a hemodynamic phenomenon which must be clearly differentiated from arterioportal fistulas with which it is often confused.