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Contrast-enhanced ultrasonography (CEUS) is a potential interesting method for assessing accurately Crohn’s disease (CD) activity. We compared the value of intestinal ultrasonography (US) coupled with contrast agent injection with that of magnetic resonance enterography (MRE) in the assessment of small bowel CD activity using surgical histopathology analysis as reference. Seventeen clinically active CD patients (14 women, mean age 33 years) requiring an ileal or ileocolonic resection were prospectively enrolled. All performed a MRE and a US coupled with contrast agent injection (CEUS) less than 8 weeks prior to surgery. Various imaging qualitative and quantitative parameters were recorded and their respective performance to detect disease activity, disease extension and presence of complications was compared to surgical histopathological analysis. The median wall thickness measured by US differed significantly between patients with non-severely active CD (n = 5) and those with severely active CD (n = 12) [7.0 mm, IQR (6.5–9.5) vs 10.0 mm, IQR (8.0–12.0), respectively; p = 0.03]. A non-significant trend was found with MRE with a median wall thickness in severe active CD of 10.0 mm, IQR (8.0–13.7) compared with 8.0 mm, IQR (7.5–10.5) in non-severely active CD (p = 0.07). The area under the ROC curve (AUROC) of the wall thickness assessed by US and MRE to identify patients with or without severely active CD on surgical specimens were 0.85, 95% CI (0.64–1.04), p = 0.03 and 0.80, 95% CI (0.56–1.01), p = 0.07, respectively. Among the parameters derived from the time-intensity curve during CEUS, time to peak and rise time were the two most accurate markers [AUROC = 0.88, 95% CI (0.70–1.04), p = 0.02 and 0.86, 95% CI (0.68–1.04), p = 0.03] to detect patients with severely active CD assessed on surgical specimens. The accuracy of intestinal CEUS is close to that of conventional US to detect disease activity. A thickened bowel and shortened time to peak and rise time were the most accurate to identify CD patients with severe histological disease activity.

Background Hepatic surgery is appropriate for selected patients with colorectal liver metastases (CRLM). Advances in chemotherapy have led to modification of management, particularly when metastases disappear. Treatment should address all initial CRLM sites based on pretherapeutic cross-sectional imaging. This study aimed to evaluate pretherapeutic fiducial marker placement to optimize CRLM treatment. Methods This pilot investigation included patients with CRLM who were considered for potentially curative treatment between 2009 and 2016. According to a multidisciplinary team decision, lesions smaller than 25 mm in diameter that were more than 10 mm deep in the hepatic parenchyma and located outside the field of a planned resection were marked. Complication rates and clinicopathological data were analysed. Results Some 76 metastases were marked in 43 patients among 217 patients with CRLM treated with curative intent. Of these, 23 marked CRLM (30 per cent), with a mean(s.d.) size of 11·0(3·4) mm, disappeared with preoperative chemotherapy. There were four complications associated with marking: two intrahepatic haematomas, one fiducial migration and one misplacement. After a median follow-up of 47·7 (range 18·1-144·9) months, no needle-track seeding was noted. Of four disappearing CRLM that were marked and resected, two presented with persistent active disease. Other missing lesions were treated with thermoablation. Conclusion Pretherapeutic fiducial marker placement appears useful for the curative management of CRLM.

Contrast-enhanced ultrasonography (CEUS) is a potential interesting method for assessing accurately Crohn's disease (CD) activity. We compared the value of intestinal ultrasonography (US) coupled with contrast agent injection with that of magnetic resonance enterography (MRE) in the assessment of small bowel CD activity using surgical histopathology analysis as reference.Seventeen clinically active CD patients (14 women, mean age 33 years) requiring an ileal or ileocolonic resection were prospectively enrolled. All performed a MRE and a US coupled with contrast agent injection (CEUS) less than 8 weeks prior to surgery. Various imaging qualitative and quantitative parameters were recorded and their respective performance to detect disease activity, disease extension and presence of complications was compared to surgical histopathological analysis.The median wall thickness measured by US differed significantly between patients with non-severely active CD (n = 5) and those with severely active CD (n = 12) [7.0 mm, IQR (6.5-9.5) vs 10.0 mm, IQR (8.0-12.0), respectively; p = 0.03]. A non-significant trend was found with MRE with a median wall thickness in severe active CD of 10.0 mm, IQR (8.0-13.7) compared with 8.0 mm, IQR (7.5-10.5) in non-severely active CD (p = 0.07). The area under the ROC curve (AUROC) of the wall thickness assessed by US and MRE to identify patients with or without severely active CD on surgical specimens were 0.85, 95% CI (0.64-1.04), p = 0.03 and 0.80, 95% CI (0.56-1.01), p = 0.07, respectively. Among the parameters derived from the time-intensity curve during CEUS, time to peak and rise time were the two most accurate markers [AUROC = 0.88, 95% CI (0.70-1.04), p = 0.02 and 0.86, 95% CI (0.68-1.04), p = 0.03] to detect patients with severely active CD assessed on surgical specimens.The accuracy of intestinal CEUS is close to that of conventional US to detect disease activity. A thickened bowel and shortened time to peak and rise time were the most accurate to identify CD patients with severe histological disease activity.

Resume Objectif Evaluer les resultats oncologiques et fonctionnels apres un traitement par cryoablation pour des tumeurs renales dans notre centre. Patients et methode Etude retrospective concernant 28 tumeurs pour 26 patients chez qui une cryoablation a ete realisee de novembre 2006 a juin 2011. Les caracteristiques des patients et des tumeurs ainsi que les donnees peri- et postprocedure ont ete repertoriees. Une biopsie a ete realisee systematiquement avant chaque procedure. Le protocole de suivi comprenait une imagerie de controle a 1 mois, puis tous les 3 mois pendant 1 an, puis tous les 6 mois pendant 2 ans, puis annuellement. Le succes a ete defini par l’absence de rehaussement dans la zone traitee, apres injection de produit de contraste, lors des differents controles d’imagerie. Resultats Les patients avaient un âge, un indice de comorbidite selon Charlson et un BMI moyens de 70,1 ans, 6 et 29 kg/m2 respectivement. Ont ete inclus onze reins uniques dont quatre transplants. Les tumeurs avaient une taille moyenne de 29,5 (± 9,8) mm et etaient representees majoritairement par des carcinomes renaux a cellules claires (16/28), endophytiques (17/28) et mediorenales (14/28). Vingt-cinq cryoablations ont ete realisees par voie percutanee, deux par lombotomie, parmi les complications nous avons note deux pneumothorax perprocedures et six complications mineures postprocedure (≤ Clavien 2). Il n’y a eu aucune complication majeure. Le suivi moyen etait de 27,5 mois (± 15,7). Il n’y a pas eu de modification significative de la fonction renale. La survie globale et la survie specifique etaient de 100 % tandis que la survie sans recidive etait de 78,6 % (5 recidives et un 1 echec de traitement). Conclusion La cryoablation percutanee offre une alternative mini-invasive, avec un controle oncologique satisfaisant, pour les patients porteurs de petites tumeurs renales qui ne peuvent pas beneficier d’une chirurgie d’exerese. Niveau de preuve 5.

Although Mayer-Rokitansky-Küster-Hauser syndrome is a rare condition with a reported incidence of 1/4500 female live births, it represents the second most common cause of primary amenorrhea and has psychologically devastating consequences. The radiologist plays a pivotal role in both making the accurate initial diagnosis of this condition and assessing findings that may contribute to treatment planning. The purpose of this article is to provide an overview of the capabilities of ultrasound and magnetic resonance imaging (MRI) for the diagnosis and management of this syndrome with emphasis on the relevant clinical and surgical findings and to describe potential associated abnormalities and differential diagnosis.

Spontaneous hemoperitoneum is not frequent. We report here a rare cause of spontaneous hemoperitoneum during the second trimester of pregnancy. A ruptured uterine artery aneurysm was revealed in a patient who came for important abdominal pain. A CT scan showed a large hemoperitoneum and an additional arterial image. The patient underwent rapidly an embolization, which allowed a complete closure of the aneurysm. The patient gave birth to a healthy child. The diagnosis of hemoperitoneum must be discussed without delay. Once imagery realised, a good management of the patient must be done depending on the origin of the hemoperitoneum.

Resume Le traitement des tumeurs par irradiation externe connait depuis quelques annees des evolutions majeures : d’une part, la diffusion de machines delivrant des rayonnements de haute energie permet d’irradier correctement les tumeurs profondes ; d’autre part, l’emergence de nouvelles techniques d’irradiation conformationnelle tridimensionnelle avec modulation d’intensite (RCMI) permettent de delivrer des doses importantes, cela toutefois sous reserve d’une parfaite delimitation du volume tumoral et des structures anatomiques a epargner. Parallelement, les progres de l’imagerie ameliorent la localisation et la visualisation precises de l’extension des tumeurs, ainsi que leur representation dans l’espace tridimensionnel. Le reperage des volumes cibles et la prediction de la dose absorbee en tout point du volume image deviennent donc une etape essentielle de la planification du traitement. Cette planification est le plus souvent pratiquee avec un scanographe. La technique la plus couramment utilisee est une scanographie de dosimetrie sans injection de produit de contraste permettant un reperage de la tumeur par son effet de masse ou par sa difference spontanee de densite d’avec les structures de voisinage. Toutefois, la visualisation du volume tumoral reste parfois difficile pour des lesions de petite taille ou manquant de contraste par rapport aux tissus environnants. Ce manque de contraste represente une source de variabilite importante pour la delimitation du volume cible qui a ete documentee dans de nombreuses etudes. Les tumeurs doivent alors etre localisees par correlation avec les images faites lors du bilan diagnostique par d’autres techniques d’imagerie, essentiellement l’imagerie par resonance magnetique (IRM) et la tomographie par emission de positons (TEP). Cette approche repond au concept de multimodalite diagnostique qui reprend le principe maintenant bien etabli de complementarite des differentes techniques d’imagerie. Chaque technique apporte en effet, selon son principe physique, une ou plusieurs informations specifiques. Il convient des lors de bien apprehender la contribution de chaque examen d’imagerie utilise, cela selon les maladies et leurs localisations.

The authors relate two cases of peritonitis secondary to jejunal perforation by a fish bone. Clinically, the first patient presented signs and symptoms of acute diverticulitis and the second had signs of duodenal perforation. In both cases, the diagnosis was made by the CT-scan revealing a linear radio-opaque object suggestive of a fish bone perforating the jejunum. At laparotomy of the first case, we found a perforation located above several loops of small bowel densely adhered to the nonabsorbable intra-abdominal mesh. Removal of the fish bone, suture of the jejunal perforation, washing and drainage of the abdominal cavity were performed. The mesh was removed and replaced by a polyglycolic acid mesh. In the second case, jejunal perforation occurred in an unaltered small bowel loop and a short intestinal resection was performed. The postoperative course was uneventful for both patients. These clinical cases allow us to discuss the several fish bone perforation site and our patients precipitating factors.

Les techniques d’imageric revelent des lesions focalisees solides ou kystiques du pancreas a un stade de plus en plus precoce, mais elles ne permettent pas toujours d’affirmer la malignite de ces lesions. La cytoponction percutanee presente une sensibilite de l’ordre de 80% a 90% pour le diagnostic d’adenocarcinome. Le diagnostic reste douteux en cas de resultat negatif, ce d’autant que la valeur predictive negative de la cytologie est faible en l’absence de cytopathologie specifique des lesions focalisees pancreatiques non tumorales (nodule de pancreatite). Dans ces conditions, si l’interet de la cytoponction percutanee n’est das discutable pour les lesions non resecables, il est en revanche plus limite en cas de nodule resecable, surtout si on ne retient pas la possibilite d’utiliser un resultat negatif (mais incertain) pour conforter une attitude conservatrice devant un tableau radioclinique rassurant. Des methode de prelevement plus precises des lesions pancreatiques de petite taille doivent donc etre developpees. Le reperage echoendoscopique apportera peut-etre la solution.

L’echographie Doppler, en permettant une exploration velocimetrique des structures vasculaires abdominales, devrait trouver sa place dans le bilan de la cirrhose et de l’hypertension portale. L’analyse quantitative des parametres Doppler s’avere decevante et seule la vitesse circulatoire portale semble presenter un interet pronostique. L’analyse qualitative identifie la presence et le sens du flux dans le systeme porte et recherche d’eventuelles voies de derivation. Le Doppler depiste ainsi des anomalies (inversion de flux, thrombus) qui confortent une impression clinique de gravite. Des que les etudes des facteurs pronostiques de la cirrhose et les estimations de la perfusion hepatique auront ete precisees, le bilan de l’hypertension portale passera probablement par une evaluation Doppler de premiere intention, du fait du caractere peu couteux et non invasif de cette methode.

Spontaneous hemoperitoneum is not frequent. We report here a rare cause of spontaneous hemoperitoneum during the second trimester of pregnancy. A ruptured uterine artery aneurysm was revealed in a patient who came for important abdominal pain. A CT scan showed a large hemoperitoneum and an additional arterial image. The patient underwent rapidly an embolization, which allowed a complete closure of the aneurysm. The patient gave birth to a healthy child. The diagnosis of hemoperitoneum must be discussed without delay. Once imagery realised, a good management of the patient must be done depending on the origin of the hemoperitoneum.

The development of three-dimensional conformal radiotherapy (3DCRT) and intensity modulated therapy (IMRT) has enabled high dose radiation to be directed to tumors, this however subject to a perfect demarcation of the tumoral volume and the anatomical structures to be saved. At the same time, imaging modalities have improved their ability to demonstrate the location and the extension of tumors. The precise location of the target volume and the prediction of the dose absorbed by the tumor thus become an essential stage of the planning of the treatment. This planning is mostly determined on CT pictures. The technique usually used is a non enhanced CT allowing a location of the tumor by its mass effect mass or by its spontaneous difference of density from the adjacent structures. However, the clear visualization of the tumoral volume remains sometimes difficult for small-sized tumors or those with limited contrast with regard to surrounding tissues. This lack of contrast represents a source of variability for the demarcation of the target volume which has been highlighted in numerous papers. Tumors must be then localized by correlation with pictures made at the diagnosis time by other imaging modalities, essentially the MRI and the PET. This approach answers the concept of multimodality diagnosis which resumes the principle of complementarity of the various techniques. Every technique indeed brings, according to its physical principle, one or several specific information. It is advisable from then to clarify the contribution of every used imaging modality, this according to the pathologies and their localizations.

Feasibility study of contrast enhanced MR enterography without enteroclysis as a new diagnostic tool for children with known or suspected Crohn's disease.We prospectively included 15 children, 8-18 years old, with clinical suspicion of Crohn's disease. MR enterography without enteroclysis was performed on a 1,5 T clinical MR system. A total of 1000 ml of mannitol 5% was orally administered 60 minutes prior to MRI. Coronal and axial breath-hold sequences were acquired. The following sequences were obtained: True-FISP, FLASH T1 2D/3D with Fat saturation before and after gadolinium injection. Two radiologists, blinded to patient information, independently reviewed all examinations to record image quality, the degree of distension of the distal ileum, the presence of abnormal bowel segments and the presence of extra-intestinal complications. MRI findings were correlated to sonographic, endoscopic and biological results (sensitivity, specificity, Kappa test).The examinations were considered of satisfactory diagnostic quality in 93.3% of patients. Respiratory artifacts were present in one case. The entire GI tract could be identified on all sequences. Distention of the distal ileum was recorded as good to excellent in 89% of healthy subjects. Five MR examinations were considered abnormal with isolated ileal involvement in 2 cases, ileocolic involvement in 2 cases, and isolated colonic involvement in 1 case. The sensitivity and specificity of MR for the positive diagnosis of Crohn's disease were 100% and 83% respectively. Three extra-intestinal complications were detected: one case of ileo-ileal fistula, not identified on ultrasonography, an asymptomatic anal fistula and a symptomatic inflammatory stricture.MR enterography without enteroclysis is a well tolerated, effective non invasive method in the evaluation of known or suspected Crohn's disease. Because of the absence of ionizing radiation, MR enterography should become the gold standard in pediatric patients.

The authors relate two cases of peritonitis secondary to jejunal perforation by a fish bone. Clinically, the first patient presented signs and symptoms of acute diverticulitis and the second had signs of duodenal perforation. In both cases, the diagnosis was made by the CT-scan revealing a linear radio-opaque object suggestive of a fish bone perforating the jejunum. At laparotomy of the first case, we found a perforation located above several loops of small bowel densely adhered to the nonabsorbable intra-abdominal mesh. Removal of the fish bone, suture of the jejunal perforation, washing and drainage of the abdominal cavity were performed. The mesh was removed and replaced by a polyglycolic acid mesh. In the second case, jejunal perforation occurred in an unaltered small bowel loop and a short intestinal resection was performed. The postoperative course was uneventful for both patients. These clinical cases allow us to discuss the several fish bone perforation site and our patients precipitating factors.

The contrast-enhanced ultrasonography is a promising technique for the diagnosis of focal liver lesion with an increased sensitivity for the tumour detection and a direct visualization of the tumour vascularity. The future applications of this technique will probably depend on the clinical context: in case of suspicion of benign tumour, contrast injection should be able to facilitate the characterization of hemangiomas and focal nodular hyperplasia, when hepatic metastases are researched, it may improve the detection of small lesions in cirrhotic patients, it may facilitate the detection of small hepatocellular carcinomas and find a place in the systematic screening for these tumours. The recently published data are encouraging, but a confirmation of the clinical interest of this technique, and its place within the imaging diagnostic strategies still have to be performed.

To propose a comprehensive imaging algorithm of living donors for liver transplantation allowing virtual presurgical planning.Prospective CT and MRI evaluation of 20 patients selected as potential living donors for liver transplantation, between June 2001 and March 2003. For each patient, a virtual hepatectomy according to anatomical biliary and vascular variations, total liver Volume and residual liver Volume, were simulated. The imaging results were correlated to the surgical findings.CT and MRI demonstrated thirty-five vascular and biliary anatomical variations in 17 patients. Knowledge of these variations resulted in modification of the surgical planning in 6 cases. Four additional variations were described at surgery. The virtual graft Volumes correlated well to the surgical ones (p0.0001).CT and MRI are useful for the presurgical evaluation of living donors prior to liver transplantation. Estimation of the residual liver Volume allows a good prediction of the postsurgical outcome.

To compare MRI of the liver with mangafodipir trisodium (MnDPDP) and computed tomography with intravenous contrast media in the follow-up of liver metastases in patient on chemotherapy for colorectal carcinoma.This was a prospective study with patients on chemotherapy for liver metastases from colorectal cancer. Patients underwent both contrast-enhanced helical CT using 2 cc/kg contrast at 3 cc/sec and mangafodipir trisodium-enhanced MR imaging at 1.5 T using 2-3 cc/min contrast at 5 micro mol/kg within a two week interval. Two experienced radiologists independently reviewed all scans in a blinded fashion and recorded image quality as well as presence and number of liver lesions. Statistical analysis was performed using the wilcoxon signed rank test.All examinations were of good quality. A total of 71 lesions were detected at CT, with 69 lesions consistent with metastases and 2 lesions consistent with cysts. A total of 98 lesions were detected at MRI, with 97 consistent with metastases and 1 lesion consistent with a cyst. T1 weighted images with MnDPDP significantly detected two additional lesions compared to CT (p0.05). No significant difference was demonstrated between T1 weighted images without MnDPDP and CT or between T2 weighted images and CT.Magnetic resonance imaging with MnDPDP is significantly more sensitive than unenhanced MRI and helical CT for the follow-up of liver lesions.

Recent advances of cross sectional imaging allow optimal evaluation of the small bowel. This chapter will detail technical considerations and emphasize the role of imaging in the evaluation of the most common diseases of the small bowel.

To evaluate the accuracy of MR cholangiography to differentiate between the benign and malignant etiology of biliary strictures, excluding bilioenteric anastomoses.49 patients (26 males, 23 females) with suspected biliary stricture underwent MR cholangiography at 1.5T (Siemens Symphony). RARE and HASTE sequences were acquired in the coronal, oblique and axial planes. MR cholangiography findings were reviewed by two independent radiologists and correlated with the final histological diagnosis. Sensitivity, specificity, and agreement were calculated with a 95% confidence interval.Benign stenosis was identified in 23 patients (47%) and malignant stenosis in 26 (53%). The sensitivity of MR cholangiography was 64% and the specificity was 96%. The agreement between results at MR cholangiography and histology was moderate. The inter-observer agreement for MR cholangiography was good with a Kappa value of 0.61.MR cholangiography has the potential to replace diagnostic cholangiography in patients with suspected biliary stricture. Direct cholangiography could be reserved for patients where a therapeutic procedure is anticipated.

The authors report two uncommon cases of incidental superior mesenteric vein aneurysm in two asymptomatic women. Patients underwent ultrasonography, CT and MR angiography. The etiology, clinical features and treatment are discussed along with a review of to the literature.

Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up.Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied.Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications.Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

To evaluate the correlation between computed tomography (CT) and surgery, for the diagnosis of bezoar in small bowel obstruction. To analyze the predisposing etiologic factors in this population.We reviewed retrospectively between 1994 and 1999, 12 patients whose final diagnosis was small bowel obstruction with bezoar. All patients underwent helical CT scan before treatment. Eight patients were treated by surgery and 4 recovered with gastric aspiration.Small bowel obstruction was diagnosed by CT which always demonstrated a transition zone with ovoid intraluminal mass outlined by the bowel wall. The mass consisted of a mixture of soft tissue and internal gas bubbles like feces, suggesting bezoar. Surgery confirmed small bowel obstruction and presence of bezoar. Predisposing factors were: partial gastrectomy (2/12), post surgical adhesions (7/12), Meckel diverticulum (1/12) and dietary factors.We agree with the authors of the few prior CT reports and suggest that the characteristic CT appearance of mottled gas pattern is pathognomonic of bezoar with an excellent correlation in our population.

This paper is a review of the anatomy of the bile ducts and the vascular anatomy of the liver. This anatomy is subject of numerous variations which can be explained by the embryology of the liver and its vessels. The perfect knowledge of this anatomy is useful for an accurate interpretation of the conventional and slice imaging techniques of the liver. It is also of major importance for an appropriate management of all kinds of hepatic vascular and biliary percutaneous procedures.

The goal of this study was to evaluate the clinical and functional consequences of anal sphincter echographic lesions in patients with fecal incontinence.From January 1997 to April 2001, 100 patients with fecal incontinence (90 women, 10 men) were prospectively explored by transanal ultrasound and vectormanometry. Internal and external sphincter defects, as well as their extension, were analyzed with regard to their clinical and functional expressions (resting and squeeze anal sphincter pressures, anal sphincter asymmetry index).Among the 100 patients, 42 had no echographic lesions, 58 had a defect: 26 had an isolated defect (internal sphincter (n = 3), external sphincter (n = 23) and 32 had combined internal and external sphincter defects. Squeeze anal pressures were significantly lower in the group of patients with combined defects, compared to the group with isolated defect or without defect. Anal asymmetry index was higher in the group of patients with combined defects, compared to the other groups. There was a positive correlation between the radial extension of the defect and the importance of clinical complaints.Echographic anal sphincter lesions are frequent in fecal incontinence and are clinically and functionally significant.

Background: Small bowel Crohn’s disease (CD) can be challenging to diagnose. The Montreal classification suggests that ileal disease will be recognised more frequently with the advent of better small bowel imaging. Isolated small bowel disease has been reported in up-to one third of CD patients. The presence or absence of inflammation in the terminal ileum at ileo-colonoscopy is often considered the gold-standard for CD assessment. Our aim was to evaluate the accuracy of terminal ileal (TI) inflammation/ulceration in predicting active small bowel CD. Methods: A retrospective review was carried out utilising our IBD database of patients referred for investigation of potential active small bowel CD over two years. Patients with both established and suspected CD who had undergone ileocolonoscopy with biopsy and capsule endoscopy (CE) were included. Small bowel CD was defined by either positive histology or CE with clinical response. Exclusion criteria included less than 12 months follow up, a documented history of NSAID exposure and incomplete CE studies. Correlation of TI findings with small bowel Crohn’s disease was performed using SPSS 19. Results: In total, 142 patients were identified, 57% were female with a mean age of 45 (range 19 70) and a mean follow up of 18 months (range 12 36). In all, 62 (44%) had active small bowel CD. TI inflammation/ulceration was seen in 44 (30%) patients and histology correlated with positive TI findings in only 13 (30%) patients. In total, 98 patients had normal TI findings and within this group 30 (30%) had active small bowel CD on CE or follow up. The sensitivity and specificity of TI inflammation/ulceration in diagnosing active small bowel CD are 51% and 85% respectively with a PPV of 71% and a NPV of 30%. Table 1. Of interest, both the PPV and NPV increased to 96% and 71% in the known CD cohort but was not as accurate in patients with suspected CD (PPV 45%, NPV 88%). Of interest, the correlation between visually reported TI inflammation/ ulceration with ultimate histology or diagnosis was very poor with r values of 0.4 and 0.1.

There appears to be an increasing number of patients with aneurysm of the hepatic artery. We report a retrospective analysis of management schemes used in a single hospital unit over the last 14 years.Clinical data on all patients with aneurysm of the hepatic artery, treated in Edouard-Herriot hospital (Lyon, France) from 1985 to 1999, were reviewed.There were 15 patients with 16 aneurysms. Mean patient age was 56 years with no gender predominance. The aneurysm was a fortuitous discovery in 8 of the patients. There were 10 cases of pseudoaneurysm and 6 cases of true aneurysm. Treatment was adapted to the local anatomy and the patient's status. Surgery was used for 5 patients and radiologic embolization for 4. Observation was indicated in 5 patients and spontaneous thrombosis occurred in 1. Mean duration of observation was 24 months. Six patients were lost to follow-up and 2 died from their primary disease.Surgery is the treatment of choice for aneurysms situated in an extrahepatic localization while radiologic embolization is appropriate for intrahepatic localizations. Close cooperation between the surgery and radiology teams was most contributive to proper management in our series, providing favorable outcome.

Hepatobiliary cystic tumors are rare, but must be correctly diagnosed because of their potential malignancy. We report the clinical, radiological, pathological and evolutive characteristics of 7 cases of hepatobiliary cystic tumors.Complete clinical charts were available. Radiological and pathological documents were reviewed.There were 4 females and 3 males (median age, 58.7 yrs). In 3 cases, the presenting symptom was the palpation of a mass in the right upper abdominal quadrant. In 6 cases, pre-operative imaging studies showed a cystic intra-hepatic mass, containing vegetations and/or septa in 5 cases. In the remaining case, the radiological appearance showed a heterogeneous liver mass. Two patients were treated by pericystectomy and 5 by radical hepatectomy. At macroscopic examination, tumors were usually large (range: 2-24 cm) and multilocular. Histological diagnosis was: cystadenoma with mesenchymous stroma (2 cases), mucinous cystadenoma (2 cases), mucinous cystadenocarcinoma (2 cases), giant cell cystadenocarcinoma (1 case). The mean duration of follow up was 60 months. Two patients, both with cystadenocarcinomas, died after respectively, 21 and 34 months with metastatic dissemination. Five patients are alive without evidence of disease after a delay ranging from 14 to 144 months.Radical surgical treatment of cystic hepatobiliary tumors is necessary to obtain histopathological examination of the complete specimen, which is essential for a correct evaluation of the malignant potential of the lesion, and for prolonged survival, even in cases of locally invasive tumors.

To assess the incidence of endosonographic anal sphincter defects in a population of patients complaining of anal incontinence.Seventy two consecutive patients (10 men, 62 women, mean age: 55 years) with anal incontinence underwent transanal sonography. In this series, 22 patients had a history of anal surgery (group I), while 50 patients (46 parous women, 4 men) had not been previously operated (group II).Fifty patients (69.4%) had an anal sphincter defect identified on transanal sonography: 6 isolated internal sphincter defects (12%), 18 isolated external sphincter defects (36%) and 26 combined sphincter defects (52%). The incidence of sphincter defects was similar in the surgical and medical group (81.8% vs 64%, p0.05). All but one of the isolated internal sphincter defects were observed in group I. Among the 46 parous women of group II, the use of forceps was not associated with a significantly higher frequency of anal sphincter defects (72% vs 64%, p0.05).This study confirms the high incidence of endosonographic anal sphincter defects in patients with anal incontinence. Isolated lesions of the internal sphincter are mainly seen after anal surgery. In our group of parous women, the use of forceps did not increase the incidence of anal sphincter lesions.

Two patients have been diagnosed preoperatively with ectopic pancreas located within the small bowel using CT-enteroclysis. This technique, combining helical CT and small bowel opacification through a naso-jejunal tube, allows detection of small tumors.

Solid pseudopapillary tumors of the pancreas are exceptional. The aims of our study were to reevaluate the mode of presentation of these tumors and to analyze the role of pathological examination in diagnostic assessment and prognostic evaluation.We report the clinical, radiological and pathological findings in a retrospective series of 13 patients in whom a diagnosis of solid pseudopapillary tumor of the pancreas was made between 1983 and 1997. There were 12 females (median age: 22.5 years) and one male, aged 73.The tumor was discovered incidentally (3 cases) or because of nonspecific digestive symptoms (10 cases). Biological data were uninformative. The tumor was pancreatic in 12 cases and duodenal in 1. In all cases, imaging techniques showed an heterogeneous lesion with no or poor vascularization. A cystic component was identified in 4 cases. Surgical resection was performed in all cases. Pathological examination showed an encapsulated tumor in 8 cases, a non-encapsulated but well-limited lesion in 3 cases and an infiltrative tumor in 2 cases. At the time of diagnosis, multiple liver metastases were present in 1 case. Mean duration of follow-up was 24 months (range: 3-168). At last follow-up, all patients, including the patient with synchronous metastatic disease, were alive, without local recurrence.Our study confirms that most cases of solid pseudopapillary tumors of the pancreas present with a suggestive clinical picture, including their occurrence in young women and their good prognosis after surgical resection. However, our results also underline the occurrence of cases presenting with unusual features, including old age, male sex, extra-pancreatic localization and malignant evolution. Histopathological examination is essential for the establishment of the diagnosis but morphological data are of little prognostic value.

EARLY DIAGNOSIS: The Budd-Chiari syndrome results from an obstruction of the suprahepatic venous drainage. The condition spontaneously evolves towards liver fibrosis and death. Early diagnosis is thus of prime importance to initiate adapted treatment promptly.Color-coded and pulsed Doppler coupled with ultrasonography is the key to positive diagnosis. Magnetic resonance imaging may provide further precision. DECONGESTION OF THE LIVER: As the hepatic lesions are reversible, satisfactory drainage must be achieved as rapidly as possible, either by percutaneous puncture or surgery. The problem is to control the underlying hematology disease to prevent recurrent venous thrombosis, generally the cause of treatment failure. PREVENTIVE ANTICOAGULATION: Effective anticoagulation using low-molecular-weight heparin, which appears to be more adapted than standard heparin, must be achieved prior to any decongestion procedure. Long-term management requires anti-vitamin K therapy if the risk of thrombosis persists.

To evaluate the use of Magnetic Resonance Imaging (MRI) for the treatment of problematical anal fistulas and follow-up of cases treated by long-term seton drainage with two or three-stage fistulotomy.prospective study on 24 patients with surgical treatment between July 1993 and March 1995 selected for MRI among 100 anal suppurations according to following criteria: high trans-sphincteric or supra-sphincteric fistula with one or more previous definitive attempts at treatment (15), and/or severe anal or rectal fibrosis (11). Patients with Crohn's disease were not included. For 14 of these patients who had a long-term seton drainage, MRI tried to assess the quality of the surgical drainage and the course of residual abscess.the overall accuracy of MRI for visualization of internal opening, primary and secondary tract was 84% when compared with surgical data. The sensitivity and specificity were 100% for the detection of horse shoe fistulous tracts (8). For the 14 patients followed by MRI, only one false positive was noted and in 5 cases the results of MRI modified the previous staged procedure (prolonged seton drainage or new excision). For the 20 patients treated for more than 6 months, the mean follow-up was 18 months and median was 14 months. Only one recurrence was noted with no loss of follow-up.this study confirms the high degree of accuracy of MRI for mapping of high complex fistula in ano. MRI is very helpful for the survey of healing in cases treated with seton drainage and two or three stage fistulotomy to preserve continence.

Anal fistulae are pathological conditions observed in infections of the Hermann and Defosses' glands or related to Crohn's diseases. The success and the lack of complication of surgical treatment depends on how accurately the tracks are assessed. The contribution of MRI in anal fistulas is now well established but the imaging appearance is not well discribed. The purpose of this work was to discribe the different patterns of lesions.Eighteen patients with anal fistulas were examined with MRI before operation (mean delay: 14 days. range: 1-56). SE T2 sequences, in coronal and axial planes referred to the anal canal were performed. The examinations were reviewed and compared with the results of surgical assessment to correlate imaging and surgical findings.Lesions were hyperintense on T2-weighted sequences but were also iso- or poorly hyper-intense when they did not contain fluids but only inflammatory tissue. When involving the supra-levator space, lesions were nodular. They were well limited if they occurred in the supra-levator space itself. On the contrary, the rectal wall was thickened and hyper-intense when the fistulous tract reached it. Lesions were similar in Crohn's disease, except for anal fissures which were seen as a tubular hypersignal in contact with the anal lumen. On T2 sequences, healed fistulas were not visible.The simple SE T2 sequences can discriminate between different patterns of lesions, especially for supra-levator extensions, fissures in Crohn's disease and chronic inflammatory lesions without fluid. The use of more recent machines or fat suppression sequences may improve the detectability of lesions, especially the more chronic ones.

Perendoscopic ultrasound (PERUS) relies on the complex combination of an ultrasonic probe and a flexible endoscope. The endoscope is made up of optic fibers, which enable the operator to zero in on the lesion to be ultrasonically scanned; a mechanical device aids the focusing of the probe on the lesion; and an operative canal enables air to be aspirated or water to be injected in order to improve the acoustic coupling. The probe emits high-frequency ultrasound of 7–12 MHz. Two types of echoendoscope (EE) are currently employed (Fig. 27.1 a, b). With mechanical EEs, the transducer rotates in a plane perpendicular to the axis of the endoscope, covering a circular field of 360 ° around the probe; this yields circumferential sections of the digestive tract. The transducer is attached to the distal end of the endoscope. Rotation takes place around a flexible mechanical axis.

Twelve cases of pancreatectomy for intraductal papillary-mucinous tumor of the pancreas operated between August 1985 and February 1996 are reported. Mean age of the patients was 57.6 years (range: 25 to 77 years). Two of them were female and 10 were male. Ten patients underwent a pylorus preserving pancreaticoduodenectomy, one patient a segmental isthmic pancreatectomy and one other a left pancreatectomy. Histologic examination of the operative specimen showed benign ademomatosis with severe dysplasia in 3 cases, intramucosal or microinvasive carcinoma in 7 cases and invasive carcinoma in 2 cases. Two patients died during the period of follow-up, one at 20 months from metastases, the other one at 33 months accidentally. The 10 remaining patients were alive and disease-free with a follow-up of 3 to 93 months (mean time of follow-up: 38 months). Pancreatectomy is indicated without delay as soon as the diagnosis of this uncommon tumor is obtained.

In four cases, angiomyolipoma of the liver was discovered incidentally by ultrasound investigation. Based on a review of 26 other previously reported cases and as was borne out in our series, the diagnosis is suggested by the demonstration of fatty material on CT-scan and confirmed by needle aspiration biopsy. Magnetic resonance may be contributive as well.