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Inflammatory bowel diseases (IBD) are chronic disabling conditions with a complex and multifactorial etiology, which is still not completely understood. In the last 20 years, anti-TNF-α antagonists have revolutionized the treatment of IBD, but many patients still do not respond or experience adverse events. Therefore, new biological therapies and small molecules, targeting several different pathways of gut inflammation, have been developed of which some have already been introduced in clinical practice while many others are currently investigated. Moreover, therapeutic procedures such as leukocytapheresis, fecal microbiota transplant and stem cell transplantation are currently being investigated for treating IBD. Lastly, complementary and alternative medicine has become a field of interest for gastroenterologist to reduce symptom burden in IBD patients. In this comprehensive and updated review, a novel classification of current and developing drugs is provided.

Predicting clinical outcomes represents a major challenge in Crohn's disease (CD). Radiomics provides a method to extract quantitative features from medical images and may successfully predict clinical course.The aim of this pilot study is to evaluate the use of radiomics to predict 10-year surgery for CD patients.We selected a cohort of CD patients with CT scan enterographies and a 10-year follow up. The R library Moddicom was used to extract radiomic features from each lesion of CD, segmented in the CT scans. A logistic regression model based on selected radiomic features was developed to predict 10-year surgery. The model was evaluated by computing the area under the curve (AUC) of the receiver operating characteristic curve, sensitivity, specificity, positive and negative predictive values (PPV, NPV).We enroled 30 patients, with 44 CT scans and 93 lesions. We extracted 217 radiomic features from each lesion. The developed model was based on two radiomic features and presented an AUC (95% CI) of 0.83 (0.73-0.91) in predicting 10-year surgery. Sensitivity, specificity, PPV, NPV of the radiomic model were equal to 0.72, 0.90, 0.79, 0.86, respectively.Radiomics could be a helpful tool to identify patients with high risk for surgery and needing a stricter monitoring.

Acute colonic diverticulitis (ACD) is an acute episode of severe and prolonged lower abdominal pain due to diverticular inflammation, usually associated with change in bowel movements, fever, and leukocytosis. Worldwide, computed tomography (CT) of the abdomen and pelvis with intravenous contrast is accepted as the best imaging method for evaluating the diverticular inflammation, serving the following functions: confirming the presence of ACD; evaluation of the disease severity and degree; therapy planning guide in presence of complications (such as abscess or intestinal perforation); diagnosis of other diseases that may simulate diverticular inflammation. In the literature, we found values of CT sensitivity for diverticular inflammation from 79% to 99%; CT is useful in differentiating other diseases, which may cause abdominal pain, when diverticular inflammation is not the cause, such as neoplasm, inflammatory bowel disease, appendix inflammations, epiploic appendix inflammation and colon ischemia. The trick to differentiate diverticulitis from other inflammatory diseases that involve the colon is the identification of diverticula in the pathological intestinal loop. In the last years, a radiological classification was created in order to guide the management of ACD in patients treated conservatively or with interventional procedures. The new classification system divides ACD into two groups: complicated and uncomplicated. Uncomplicated ACD is defined if only thickening of the intestinal wall is present, with increase of the perivisceral fat density. Complicated ACD is divided into 4 stages, depending on presence of microperforation without abscess and/or peritoneum involvement (stage 1 A), presence of abscess with diameter ≤4 cm (stage 1 B), presence of abscess with diameter >4 cm (stage 2 A), presence of distant air >5 cm from the pathological loop (stage 2 B), presence of diffuse fluid in at least two distant abdominal quadrants without distant free air (stage 3), presence of diffuse fluid and distant free air (stage 4). In this pictorial essay, we describe CT findings of the ACD and explain classification of the disease and its common and uncommon complications.

We report the case of a 52-year-old woman with follicular lymphoma localized in the left inguinal region without any extranodal involvement and achieving a complete response after radiotherapy. After a 3-year disease-free interval, muscular recurrence at the left arm was shown by contrast-enhanced F-FDG PET/CT. Contrast-enhanced F-FDG PET/CT performed after immunochemotherapy documented complete disease remission. Lymphoid tissue is usually not present in the skeletal muscle, making muscular lymphomatous involvement quite unusual; muscular relapse of a primarily nodal lymphoma is even rarer.

Inflammatory bowel diseases (IBD) are a group of chronic inflammatory intestinal conditions with unknown etiology. Crohn's disease (CD) and ulcerative colitis (UC) are the two main types of IBD and they have some interchangeable and some different clinical and pathological characteristics. When diagnosis is performed for the first time, the majority of CD patients have a predominant inflammatory condition. As the disease progresses most patients experience the development of complications, such as abscesses, fistulas, perforation, strictures, and others. Both computed tomography (CT) and Magnetic Resonance Imaging (MRI) allow great view of the whole length of the intestinal tract together with the eventual extra-and intra-intestinal complications. MR enterography (MRE) and CT enterography (CTE), performed after oral administrations of contrast medium, have similar diagnostic accuracy for the diagnosis of CD and its complications. Even though CT is still the most familiar diagnostic technique used for studying CD worldwide, MRE have several important benefits that are leading to rapid increase in its employment in the last years. In particular, MRE allows a superior soft tissue contrast resolution compared to CT, offering a better visualization of bowel wall and its inflammatory and fibrotic characteristics. Moreover, Pelvic Magnetic Resonance is the principal technique in patients with perianal disease due to its ability of providing precise and fine detail images of the sphincter complex, which are crucial for evaluating pelvic disease. In this paper we describe common and uncommon complications in patients with CD, and explain how to identify their findings in CT and MR exams.

Crohn's disease (CD) is a chronic inflammation of the gastro-intestinal system in which episodes of clinical worsening alternate with episodes of clinical regression. Monitoring of disease is mandatory to evaluate the efficacy of therapy and it is usually performed using a combination of clinical symptoms, laboratory tests, endoscopy and radiological exams, such as MR enterography or CT enterography. MR enterography should be preferred to CT enterography because of the absence of ionizing radiation, a very high soft tissue contrast, and a lower incidence of adverse events. In 2003, Maglinte introduced a radiological classification to identify patients in different stages of disease (active inflammatory, fibrostenotic and fistulising/perforating subtypes), based on following parameters: oedema, ulcers, stenosis, mural thickening, stratified contrast enhancement, engorged vasa recta, fistulae/abscess and mesenteric inflammation. In general, medical therapy is efficient in reducing inflammation while fibrotic disease and fistulising subtypes usually require surgery. Moreover, in patients with active CD it is important to quantify disease activity in order to adequately plan therapy and to monitor drug effects, by using some MR enterography indexes such as MaRIA score, Clermont index, and others. In this review we describe how to apply Maglinte's classification in MR enterography exams and how to quantify active disease.

Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates.This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients.Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.

Aim of this retrospective study is to evaluate the response to therapy in Crohn's disease (CD) patients studied by MR Enterography (MRE) in comparison with Harvey Bradshaw Index (HBI).One hundred and sixty patients with histological proved CD have undergone MRE in the last years. Forty-six patients who repeated MRE after medical therapy within six months were selected for the study. Magnetic Resonance Index of Activity (MaRIA) was evaluated for each patient and used to define the MR judgment. In MRE we also evaluated wall thickening, longitudinal extension of wall thickening, presence of stratified mural hyperenhancement and extraintestinal signs. The clinical response to therapy was judged based on HBI and classified as improved, worsened or stable disease. Clinical judgment was correlated with MRE findings and the agreement was analysed using the Cohen Kappa test.Among 46 enrolled patients, 18 (39%) improved clinically, 4 (10%) worsened, 24 (51%) remained stable. MR judgment was in agreement with clinical assessment in 33 patients (72%), showing moderate significant concordance (Kappa = 0.49; p 0.01). No agreement was observed in 13 (28%) patients. Moreover, clinical improvement was significantly correlated to reduction of wall thickening, reduction of longitudinal extension of the disease and reduction of engorged vasa recta (p 0.05). Worsening conditions were significantly correlated to increased wall thickening (p = 0.05).MRE is useful in evaluating the response to therapy in CD patients.

Amyloidosis is a rare hereditary or acquired protein deposition disorder with different etiologies, characterized by pathological protein deposition essentially in nearly any organs or tissues. There are 2 major forms: primary and secondary amyloidosis. Moreover, it is possible to have systemic or localized disease. The localized form of amyloidosis affecting the small intestine is rare, and it is characterized by the formation of precursor proteins at the site of the lesion. We report a case of localized small bowel amyloidosis studied by F-choline and F-FDG-iodinated PET/CT performed for staging an aggressive prostatic cancer.

A 75-year-old man, who had been diagnosed with small lymphocytic lymphoma with cervical localization, underwent F-FDG PET/CT with iodinated contrast medium due to the appearance of cervical swelling suspected of illness relapse. PET/CT revealed intense F-FDG uptake in multiple cervical and subdiaphragmatic lymph nodes and in the left parotid. Moreover, diffuse uptake and wall thickening of the colon were evident; endoscopy with biopsy revealed a diffuse large B-cell lymphoma. Transformation into a more aggressive lymphoma occurs in 2% to 8% of small lymphocytic lymphoma, the so-called Richter syndrome. Extranodal localization in the sigmoid colon is an extremely rare site for transformed lymphoma.

Crohn’s disease (CD) is a chronic inflammatory condition characterized by continuous mucosal damage and ongoing wound healing of the intestines. The fibrinolytic system is involved in early parts of the wound healing process. Fibrin is a key mediator of primary blood clot formation and is formed by cross-linking of fibrinogen. To gain insights into the dynamics of wound healing in CD patients we investigated the conversion of fibrinogen into fibrin by the pro-peptide FPA, the amount of factor XIII cross-linked fibrin and total fibrin clot. Methods: Serum samples of 35 CD patients, 15 non-inflammatory bowel disease (non-IBD) patients and 39 age-matched healthy controls were analyzed for three novel neo-epitope markers: D-fragment and D-dimer, reflecting the degradation of total fibrin clot and factor XIII cross-linked fibrin, as well as FPA, reflecting synthesis of fibrin. Results: Crohn’s disease patients had a significantly lower D-dimer level (p=0.0001) compared to healthy controls. Crohn’s disease and non-IBD patients had a significantly higher level of FPA (p

Simple Summary Crohn’s disease (CD) is a chronic inflammatory bowel disease affecting both young and elderly patients, involving the entire gastrointestinal tract from the mouth to anus. The chronic transmural inflammation can lead to several complications, among which gastrointestinal cancers represent one of the most life-threatening, with a higher risk of onset as compared to the general population. Moreover, diagnostic and therapeutic strategies in this subset of patients still represent a significant challenge for physicians. Thus, the aim of this review is to provide a comprehensive overview of the current evidence for an adequate diagnostic pathway and medical and surgical management of CD patients after gastrointestinal cancer onset. Abstract Crohn’s disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra-intestinal cancer in patients with CD, due to long-standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case-by-case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset.

Aim: To evaluate if a single and/or combined (clinical, endoscopic and radiological) assessment could predict clinical outcomes in Crohn’s disease (CD). Methods: We prospectively evaluated 57 CD cases who underwent both a colonoscopy and a CT-enterography (CTE). Harvey-Bradshaw Index (HBi), SES-CD (and/or Rutgeerts score) and the radiological disease activity were defined to stratify patients according to clinical, endoscopic and radiological disease activity respectively. Hospitalizations, surgery, therapeutic changes and deaths were evaluated up to 36 months (time 1) for 53 patients. Results: CTE and endoscopy agreed in stratifying disease activity in 47% of cases (k = –0.05; p = 0.694), CTE and HBi in 35% (k = 0.09; p = 0.08), endoscopy and HBi in 39% (k = 0.13; p = 0.03). Taken together, CTE, endoscopy and HBi agreed only in 18% of cases (k = 0.01; p = 0.41). Among the 11 cases with mucosal healing, only 3 (27%) showed transmural healing. Patients with endoscopic activity needed significantly more changes of therapy compared to patients with endoscopic remission (p = 0.02). Patients with higher transmural or clinical activity at baseline required significantly more hospitalizations (p < 0.01). Hospitalization rate decreases with an increase in the number of parameters indicating remissions at baseline (p = 0.04). Conclusions: Clinical, endoscopic and radiological assessments offer complementary information and could predict different mid-term outcomes in CD.

Objectives CT is nowadays an examination routinely performed in Crohn’s disease (CD) patients. However, there are several ways to assess gastro-intestinal tract, in particular colonic segments. Aim of this study is to compare enterography-CT (E-CT), performed after oral administration of polyethylene-glycol solution (PEG-CT) versus enterography-CT performed also with water enema via rectum (ECT-WE) in patients with CD. Methods We have studied 79 patients with CD undergone to enterography-CT (42 evaluated with PEG-CT and 37 with ECT-WE) who have performed a lower endoscopy within 15 days before CT. CT results concerning large bowel were compared with endoscopic findings. Intestinal distension, discomfort of the patients, sensitivity, specificity and diagnostic accuracy were evaluated. Pearson test was used for statistical analysis. Results Degree of abdominal pain was significantly higher in patients underwent to ECT-WE compared to PEG-CT. Distension of the colon was significantly greater in patients studied with ECT-WE compared to those studied with PEG-CT. Values of sensitivity, specificity and diagnostic accuracy of PEG-CT and ECT-WE were respectively 77, 86.5 and 81%, and 89, 100 and 92% in comparison with endoscopy. Conclusions In patients with CD, ECT-WE allows the evaluation of large bowel in addition to small bowel better than PEG-CT.

The aim of this study was to evaluate clinical correlations of CT signs in proven Crohn's disease. Fifty patients were studied by means of multidetector CT. Clinical activity was assessed using Crohn's disease activity index (CDAI) score and some laboratory parameters. All patients with CDAI>150 had CT study scored as pathological. Seventy-nine percent of patients with CDAI

In recent years, CT enterography (CTE) has emerged as an important methodology to study patients with Crohn’s disease (CD). The aim of this study was to evaluate the correlation between clinical response to therapy and CTE findings in CD patients. Forty-five patients with proven CD underwent CTE before and after medical therapy. In CTE we evaluated bowel thickness, longitudinal extension of parietal thickening, presence of target signs and extraintestinal signs. The clinical response to therapy was judged based on clinical global assessment and classified as improved, worsened or stable disease. Radiological judgement was compared to clinical judgement. The Cohen kappa test, t test or Anova analysis and χ 2 test were used for comparisons. Among 45 enrolled patients, 21 (47 %) improved clinically, five (11 %) worsened, 19 (42 %) remained stable. Clinical improvement was significantly correlated to reduced intestinal thickness, reduced longitudinal extension of the disease, increased diameter of pathological bowel and reduced target signs (p

The purpose of this study was to evaluate the diagnostic accuracy of multidetector-CT enteroclysis (MDCT-E) versus barium enteroclysis with methylcellulose (BE) in clinically selected patients with suspected small bowel disease. We prospectively studied 52 patients who underwent unenhanced and contrast-enhanced multidetector CT (16 rows) after administration of 2-2.5 l of methylcellulose by naso-jejunal tube. BE was performed after administration of barium 60% w/v (200-250 ml) and methylcellulose (1-2 l). Patients with radiological signs of Crohn's disease were classified into the following subtypes: active, fibrostenotic, fistulising/perforating, reparative or regenerative subtypes. Twenty-eight patients also underwent endoscopy. The radiological prevalent subtype was the active subtype. The sensitivity, specificity and diagnostic accuracy of MDCT-E versus BE was 83%, 100% and 89%, respectively. BE showed five false negative CT cases due to early Crohn's disease; endoscopy confirmed positive cases of the CT and the BE, but showed one false negative case of the BE. Together, MDCT enteroclysis and BE permitted the diagnosis of Crohn's disease in 30 patients, adhesions in one patient, lymphoma in two patients and carcinoid tumours in two patients. In conclusion, MDCT-E permits good representation of pathological patterns. Early stages of Crohn's disease are better evaluated by BE.

A 24-year-old man with a recent onset of intermittent diarrhea, mild diffuse abdominal pain, as well as weight loss.

The diagnosis of Crohn’s disease is challenging as it combines clinical and laboratory clues with endoscopic, radiological and histological findings [1, 2]. Consequently, the diagnosis is often delayed or the disease is misdiagnosed, in particular in the case of mainly or exclusively ileal or jejunal involvement [3]. Enteroscopy enables deep intubation, with endoscopic visualization of the small bowel and otherwise complicated or unobtainable tissue sampling. In a secondarytertiary center, based on a strong clinical suspicion of inflammatory bowel disease (IBD) with laboratory findings consistent with Crohn’s disease, radiology could be the first step in making a diagnosis, followed directly by enteroscopy if there are clear signs of jejunal or ileal localization. This is a “top down” strategy in the diagnosis of Crohn’s disease, that might be effective in patients in whom the diagnosis is delayed.

This study was performed to assess the feasibility and possible advantages of bowel sonography after fluid filling of intestinal loops compared with conventional sonography. Forty-five consecutive patients with known or suspected coeliac disease (35 females, ten males; age range 11–65 years) prospectively underwent sonography before and after ingestion of 750 ml of an aqueous solution of polyethylene glycol. Results before and after fluid distension were compared to assess whether luminal filling improved small-bowel visualisation. Luminal filling improved visualisation of intestinal features (luminal diameter, mucosal folds, parietal layers) in 77.6% of cases (marked, moderate or mild improvement in 2, 16 and 17 patients; 4.4%, 35.5% and 37.7%), respectively, and showed no change or worsening in 20% and 2.2% nine and one patient), respectively. Baseline examination showed abnormal features in 13/25 celiac patients (dilated fluid-filled loops, increased peristalsis, transient intussusception, mesenteric lymph nodes, intraperitoneal fluid). Reexamination after luminal filling showed additional abnormalities in six of the previous 13 and in three further coeliac patients. There were no false positive signs due to fluid administration. Luminal filling can improve visualisation of bowel walls and fold pattern and may be helpful in selected cases.

A combination of different radiological techniques allows the correct evaluation of patients with suspected small-bowel disease, particularly Crohn’s disease and small-bowel neoplasms. Barium studies provide only indirect information on the intestinal wall and adjacent extraintestinal structures whereas with US, CT, and MRI direct visualization of the wall (thickness and structure) and adjacent extraintestinal structures (mesentery, perivisceral fibrofatty cells, lymph nodes, peritoneal spaces) is possible. In particular, CT-enteroclysis and MRI-enteroclysis show mucosal alterations and the morpho-functional characteristics of the small-bowel loops. CT findings have been shown to correlate with the clinical activity index of Crohn’s disease.

The aim of this study was to evaluate the accuracy of multidetector CT in patients with Crohn’s disease (CD) relapse after ileocolic resection compared with endoscopy. Thirty-four patients were studied by endoscopy and multidetector CT, after oral administration of polyethylene glycol solution (n = 21) or after administration of methylcellulose via nasojejunal tube (n = 13). In CT examinations we evaluated the presence of mural thickening, target sign, perienteric stranding, comb sign, fibrofatty proliferation and complications. Endoscopic results were classified in accordance with Rutgeerts score (from 0 to 4). The statistical evaluations were carried out by using Fisher’s exact text and χ2 testing (p < 0.05, statistically significant difference). Sensitivity, specificity and accuracy of the CT were 96.9%, 100% and 97%, respectively. We found a statistically significant correlation between an endoscopic score of 4 and the CT signs of target sign, perienteric stranding, comb sign and fibrofatty proliferation, and between scores 1 and 2 and mucosal hyperdensity without or with mural thickening, respectively (p < 0.05). Moreover, only CT identified the presence of jejunal and proximal ileum disease in two and three patients, respectively, and fistulas in three patients. CT is a reliable method in the diagnosis of CD relapse and shows agreement with the approved endoscopic Rutgeerts score.

The aim of this study was to assess the diagnostic potential of multidetector computed tomography (MDCT) in the evaluation of small-bowel neoplasms. We studied 120 patients with suspected small-bowel disease by 16-slice MDCT after oral administration of a polyethylene glycol solution (n=56) or methylcellulose via a nasojejunal tube (n=64). Unenhanced and contrast-enhanced CT was performed. Contrast-enhanced CT images were acquired 40 s after IV injection of 130 ml of iodinated contrast agent at a rate of 3 ml/s. Multiplanar reconstructions were performed at the end of the examinations. Fifteen patients were found to be affected by small-bowel neoplasm (six had non-Hodgkin’s lymphoma, three had carcinoid tumour, two had Peutz-Jeghers syndrome, two had adenocarcinoma, two had melanoma metastases, one had lipoma). In the remaining patients, 58 cases of Crohn’s disease and seven miscellaneous diseases were detected. All findings were confirmed by barium studies, surgery or endoscopy. MDCT performed after bowel-loop distension with low-density contrast material and IV administration of iodinated contrast agent is a reliable method for diagnosing and staging small-bowel neoplasms.

To verify the diagnostic accuracy of per oral pneumocolon in the identification of both normal and pathological patterns in patients with suspected or proven small bowel disease.Per oral pneumocolon was performed after small bowel follow-through examinations in a series of 42 selected patients. The terminal ileum visibility, the loop location and possible pathological patterns were evaluated separately before and after insufflation. In post-insufflation images the presence/absence of reflux and grade of reflux were evaluated.The diagnostic quality of per oral pneumocolon as compared with per oral small bowel examination was superior in 23 of the 42 patients (54.8%; group 1), similar in nine of the 42 (21.4%; group 2), and inferior in 10 of the 42 (23.8%; group 3). Transvalvular reflux was present in 22 of 23 (95.6%) patients from group 1 and only in one of 10 patients (10%) from group 3 (p0.001: statistically significant difference). Among the 24 of 42 (57.1%) patients with suspected or proven Crohn's disease, per oral pneumocolon increased the confidence with which the ileum was considered normal in 12 patients and it allowed a better evaluation of the disease extent and the differentiation between prolonged spasms and stenosis in five patients.In conclusion per oral pneumocolon should be performed after a small bowel follow-through examination in selected patients.

The diagnostic approach to a patient with a complex pelvic cyst incidentally found on CT and come to the Emergency Department for lumbar pain, is discussed. To better define the location and nature of the cyst MRI was performed. It supported the diagnostic hypothesis of cystic endosalpingiosis, confirmed at the histological examination of the surgical specimen.

The case of a 73-year-old male patient come to the Emergency Department for epigastric pain, vomiting and blocked bowel movement is presented. Plain abdominal X-ray performed on emergency showed marked small bowel distention, and air-fluid levels suggestive of intestinal obstruction. CT was indicated to establish its precise site and cause. The presence of a gallstone was evidenced: gallstone ileus was diagnosed. Interestingly enough, at surgery the gallstone was not found; most likely it was expelled spontaneuously during the time elapsed between CT and surgery. Based on imaging findings and a review of the literature it was concluded that the study patient had a rare association of intestinal volvulus and gallstone ileus.

The case of a female patient with abdominal pain, fever and dyspnea appeared abruptly, is reported. Two days previously the patient underwent endoscopic colic polypectomy. Preliminary abdominal and chest X-ray showed colic and tenual air-fluid levels, a modest amount of pneumomediastinum and soft tissue emphysema of the neck. The cause of the latter finding was referable to five sites of origin: the lung parenchyma, mediastinal airways, the esophagus, the neck and the abdominal cavity. For symptom worsening thoracoabdominal CT was performed. It confirmed the pneumomediastinum and soft tissue emphysema of the neck and presence of intra and retroperitoneal free air as for perforation. Colonoscopy is a routine procedure in the diagnosis and therapy of colonopathies, but colic iatrogenic perforation is a dangerous complication not to be underestimated.

To prospectively assess contrast material-enhanced voiding ultrasonography (US) for grading of vesicoureteral reflux (VUR) and to compare results with those of voiding cystourethrography (VCUG) in adult patients undergoing antireflux ureteral implantation.Thirty-seven consecutive adult patients who had undergone renal transplantation with Politano-Leadbetter (18 patients) or Lich-Gregoire (19 patients) technique were included on the basis of previous urinary tract infections (UTIs) and time elapsed after renal transplantation. Exclusion criterion was current UTI. US was performed by one of two sonologists with injection of saline and microbubble suspension and was recorded on videotape. Sonologists assigned VUR diagnosis in consensus after videotape review. VCUG was performed by one of two radiologists immediately after US. Radiologists were blinded to US findings and assigned VCUG diagnoses in consensus. Contingency table was used to compare US and VCUG. Agreement between US and VCUG was determined with kappa statistics.With VCUG, VUR was diagnosed in 15 patients and not diagnosed in 22 patients. US and VCUG results were in agreement in 14 patients with VUR and 21 patients without VUR. US sensitivity and specificity for detection of VUR were 93% (14 true-positive results in 15 abnormal cases) and 95% (21 true-negative results in 22 normal cases), respectively. Agreement between US and VCUG was 95% (kappa = 0.89, P.001). In 11 of 14 patients, VUR grades were in agreement for US and VCUG. In three of 14 patients, US indicated a higher grade than did VCUG. VUR was diagnosed in seven of 18 Politano-Leadbetter cases and eight of 19 Lich-Gregoire cases.A high rate of agreement was seen between voiding US and VCUG.

A case of a male patient with occult gastrointestinal bleeding and negative gastroscopy and colonoscopy is presented and discussed. Oral small bowel barium follow-through was performed upon the patient request. It documented a jejunal neoformation. The analysis of radiologic findings directed towards a probably extramucosal origin. Subsequent CT evaluation confirmed a neoformation inseparable from a jejunal loop with inhomogeneous contrast enhancement, therefore of suspected malignant nature. The histological examination on the surgical specimen documented the presence of a stromal tumor of indeterminate malignancy.

The case of a 79-year-old female patient with chest pain, palpitations and dysphagia is presented. The patient was sent to the Diagnostic Imaging department for barium study of the upper digestive tract. From the analysis of findings of fast digital imaging the various disorders and diseases that could be responsible for them, were considered. All alternative situations (pharyngeal venous plexus, cricopharyngeal muscle, vertebral osteophytosis, thyroid struma etc) were excluded and the diagnostic suspicion led to the diagnosis of esophageal web (thin mucous membrane within the lumen). For diagnostic completion esophagoscopy was performed. It confirmed the diagnostic suspicion and allowed treatment by dilatation that resulted in a marked benefit to the patient.

The case of a 39-year-old male patient with symptoms of persistent abdominal pain and melena, affected by Henoch-Schönlein purpura, is reported. Abdominal CT was requested. The examination was justified by the fact that symptoms could be correlated with other pathological conditions (volvulus, neoplasms, Chron's disease, etc.) which had to be excluded. For optimum study of the abdominal wall, correct preparation and the use of oral contrast agents were required. From the analysis of CT findings, in particular loop thickening with stratified density, the increased density of mesenteric fat and the presence of fluid among loops led to the radiological diagnosis of intestinal involvement in Henoch-Schönlein purpura. Other imaging procedures (double contrast enema, sonography, Doppler US, MRI) now used in the study of intestinal loops, are examined.

Primary megaureter is visualized as a typical dilatation on urography. Adequate oblique projections should be added to depict the juxtavesical tract of normal caliber. In even the most severe forms pyelocaliectasis is absent or mild and the ureter is not tortuous. Sonography as well as fluoroscopy during urography shows hyperperistalsis in the dilated tract and aperistalsis in the juxtavesical tract. Cystography rules out vesicoureteral reflux. In prune-belly syndrome the megaureter is bilateral and massive with no evidence of obstructions. The sonographic finding of hydronephrosis or hydroureteronephrosis and the absence of vesicoureteral reflux on voiding cystography lead to the suspicion of ureteral valves, directly documented on urography as sharp and transverse filling defects. Retrograde pyelography can better define the obstructing area and documents the normality of the underlying tract. With this procedure, the valvular flaps appear with a superior convexity (like a small umbrella). MR-urography still to be validated clinically, will be able to provide novel perspectives.

Crohn's disease is an inflammatory disease of the mucosa and bowel wall layers involving peritoneal, mesenteric structures and lymph nodes. The combination of the various imaging procedures plays a major role in the evaluation of Crohn's disease patients, based on which an optimal definition of the disease stage is achieved. This is required for a correct therapeutic strategy that can be exclusively medical, surgical or elective in complications. In the combined approach, the follow-through study of the small bowel and enteroclysis in particular, represents the examination of choice to document the early disease, early signs of recurrence with the demonstration of all mucosal alterations, including fistulous tracts. Sonography, CT and MRI allow the evaluation of Crohn's location in the wall and adjacent region. Preliminary results of CT-enteroclysis and MR-enteroclysis seem able to document mucosal alterations and morphofunctional characteristics In the near future these new examinations could become a real one-stop-shop coupled with wireless endoscopy in the study of Crohn's disease.

The primary objective of this review was to assess the diagnostic accuracy of voiding urosonography (VUS) in detecting reflux (VUR). As a secondary objective, the reported technical suggestions and diagnostic mistakes were shown to improve the examination protocol and provide the most accurate results. Using a Medline Database search, the published articles comparing the grey-scale (GS) or colour-Doppler (CD) VUS with voiding cystourethrography (VCUG) as the gold standard were selected. Articles were excluded when data were not sufficient to construct 2×2 tables or when the gold standard was different from VCUG. For the analyses of diagnostic accuracy values, 95% confidence intervals were given. Agreements in the results of GSVUS and VCUG and in those of CDVUS and VCUG were determined by Kappa statistics. GSVUS and CDVUS were compared for diagnostic accuracy by the McNemar test. Results showed that the range of GSVUS sensitivity and specificity in detecting VUR was 69%–100% and 86%–97%, respectively. The agreement between GSVUS and VCUG diagnoses ranged from 90% to 97% (K score range 0.61–0.92; P

P184 Mucosal healing does not correspond to histological healing in ulcerative colitis L. Laterza1 *, I. Scoleri1, S. Bibbo1, E. Gaetani1, G. Bruno1, L. Larosa2, A. Poscia3, A. Amato4, L.M. Minordi2, L. Bonomo2, G. Cammarota1, A. Gasbarrini1, V. Gerardi1. 1Gastroenterology Division, Catholic University of the Sacred Hearth, Rome, Italy, 2Radiology Department, Catholic University of the Sacred Hearth, Rome, Italy, 3Institute of Hygiene, Catholic University of the Sacred Hearth, Rome, Italy, 4Institute of Anestesiology, Catholic University of the Sacred Hearth, Rome, Italy

Results: Among 887 patients, a subgroup of 439 CD and 173 UC were included with a mean follow-up of 19 and 15 years respectively. One year after the diagnosis 147 CD patients had NS CD. At 5 years and at the maximum follow-up respectively, 83/147 (56%) and 15/147 (10%) patients still had NS CD. Complications were strictures (29%), fistulizing disease (18%), perianal disease (37%). Immunomodulators and antiTNF were required in 79% and 54% of patients respectively. Prognostic factors for persistent NS CD were older age at diagnosis (38 vs 26 years, p = 0.005), no corticosteroid during the first year (p = 0.036). In UC, 142 patients had NS disease one year after the diagnosis. 102/142 (72%) and 62 patients (44%) had NS UC after 5 years and at the maximum follow-up respectively. Surgery occurred in 19 patients (13%) after a mean time a 164 months. Immunomodulators were needed in 66 patients (47%) and anti-TNF in 37 patients (26%). NS UC was associated with absence of hospitalization for active UC over the first 5 years (p = 0.009) and during the total course of UC (p < 0.0001), no intake of corticosteroid during the first year (p = 0.03). Conclusions: In our cohort representing referall centre recruitment, nearly all CD patients and 2/3 of UC with NS disease at diagnosis became severe with time. Old age at diagnosis was associated with NS CD outcome while absence of hospitalisation during the first year was associated with NS UC outcome. Absence of steroid use during the first year was associated with NS outcome in both diseases.