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CT enterography in Crohn's disease. Learning

Objectives: To define the contribution of CT enterography (CTE) to the diagnosis, follow-up and prognosis of Crohn's disease, and to detail image acquisition. To compare CT enterography with other diagnostic methods used for the study of the small bowel, defining advantages and disadvantages.
Topic Review: Crohn's disease is a chronic inflammatory bowel disease that affects the entire gastrointestinal tract with a discontinuous and transmural compromise. The objectives are to determine small bowel involvement, diagnosis of active disease and its response to treatment. The course of disease, its complications (bleeding, obstruction, strangulation, abscesses and fistulas) and the severity of symptoms are variable. Initial diagnosis is based on a combination of clinical, endoscopic, biochemical and radiological findings.
Image Findings: The characteristic features in CTE are increased mural enhancement and enhanced lymph nodes after the administration of IV contrast (both signs of activity), wall thickening and halo sign (low attenuation ring in bowel due to deposit of submucosal fat), proliferation of mesenteric fat, prominence of the vasa recta, areas of stenosis, fistulas and abscesses.
Conclusion: CTE is readily available and easy to perform, being possible to determine the extent and stage of disease progression, extraintestinal involvement and potential complications. The combination of a short examination time, a single breath hold, accessibility and availability has made CTE an important tool in the diagnosis and follow-up of patients with Crohn’s disease.

Keywords: Tomography. Virtual colonoscopy. Ultrasound. Doppler. Crohn’s disease. Inflamatory bowel disease.

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Craniofacial and skull base findings in Langerhans cell histiocytosis in pediatric patients

Langerhans cell histiocytosis (CLH) is an uncommon entity, of unknown etiology, with an incidence of 2.6 at 5.4 per 1,000,000 children/year in the general population. It may have bone manifestations (solitary or multiple osteolytic lesions in flat, long and irregular bones) or multiorgan manifestations. We report the radiological findings in retrospective series of 17 pediatric patients aged 1 to 12 years old, with CLH in craniofacial and skull base. Radiological findings included osteolytic and soft tissue lesions occupying the orbit, sinuses, tympanic cavity and mastoid. In the mandible, reabsorption of the alveolar ridge with the appearance of floating teeth was observed. The anatomical complexity of the area studied required evaluation by CT and MRI with contrast. LCH disease should be considered in the differential diagnoses of craniofacial and skull base lesions, especially in pediatric patients.

Keywords: Histiocytosis. Pediatric. Craniofacial. Skull base.

Lymphomas are involved in a group of heterogeneous histology tumors derived from Immune System Cells. The term extranodal lymphoma is used to describe neoplastic proliferation in different sites from lymph nodes or lymphatic tissue. Lymphoma´s prevalence is rising and extra nodal manifestations are diagnosed frequently in every day practice. The 18 FDG PET / CT has been proven to be superior to computed tomography (CT) alone in staging, restaging and monitoring therapy response in patients with lymphoma. This article reviews the utility of PET / CT in the evaluation of extra nodal manifestation in Hodgkin (HL) and Non Hodgkin Lymphoma (NHL).

Key Words: Extranodal lymphoma, PET/CT.

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The liver is the largest solid organ in the normal abdomen that occupies the right hypochondrium. It weighs 1500 grams approximately and has a reddish brown coloring. The Anatomy of surface recognizes 4 lobes. The first anatomist to study liver division was James Cantlie. In 1957, Goldsmith and Woodburne proposed a liver segmentation system based on the suprahepatic veins. In 1957, Coinaud proposed another segmentation following the portal branches from the superior view, in clockwise and in spiral sequence matching the districts or "arrondissements" of Paris. That is to say the suprahepatic veins act as limits of independent biliary drainage and irrigation areas. For liver segmentation will make axial and longitudinal views using 3.5-5 Mhz convex probes in epigastrium, with angles toward right and left shoulder, allowing the visualization segments I, II, III, IVa and b, V and VIII respectively, while with sagittal view in axillary line display segments VI, VII and VIII. Finally parasagittal views will make possible to complement the visualization of segments I, II, III, V and VIII. Understanding the anatomy and making correct interpretations would bring a number of undeniable advantages for the surgeon. The segmental liver resection is the treatment of current choice for various diseases and tumor processes. While Ultrasound presents the disadvantage of being operator- dependent, it is a method that is simple and easy to use and, at the same time, it allows a significant correlation with the anatomy

Key Words: Liver segmentation – Ultrasound evaluation.

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Congenital upper urinary tract abnormalities imply a variable clinical spectrum of morphofunctional changes ranging from asymptomatic conditions to renal failure and incompatibility with life. Computed tomography, which has overcome excretory urography imaging, has been playing a key role in the diagnosis of congenital anomalies, serving as a better guidance in the therapeutic and surgical decision-making process, besides acting as an essential tool in the identification of associated complications and aiding in the performance of minimally invasive surgery techniques.

Keywords: Congenital abnormalities; Urinary tract; Multislice computed tomography.

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Objective: To evaluate sonographic features associated with morbidity in patients with chronic clinical presentations of schistosomiasis mansoni, according to the protocol proposed by the World Health Organization (WHO).
Materials and Methods: Two distinctive populations were evaluated: a) patients from an endemic area, and b) patients from a tertiary institution, with histopathologically confirmed periportal fibrosis. Inclusion criteria: diagnosis confirmed by parasitological stool examination for Schistosoma mansoni (Kato-Katz method). Exclusion criteria: positive serology for HIV, HTLV-1, HBV or HCV. The Niamey protocol on ultrasonography proposed by the WHO was utilized.
Results: As the measures of periportal spaces were isolatedly evaluated, no alteration was observed in 21% of the tertiary institution patients with advanced disease. As all parameters of the Niamey protocol were considered, 100% of patients from the tertiary institution, with severe disease, presented advanced periportal fibrosis. In hepatosplenic patients from endemic areas, fibrosis was not identified at ultrasonography.
Conclusion: The sonographic protocol proposed by the WHO can detect advanced periportal fibrosis in patients with severe form of disease with higher sensitivity than the isolated measurement of periportal space. The complexity involved in the sonographic identification of early stages of periportal fibrosis in endemic areas may give rise to the field of diagnostic supplementation and to a continued improvement of sonographic protocols in these areas.

Keywords: Schistosomiasis mansoni; Morbidity; Periportal fibrosis; Ultrasonography.

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TSitus Ambiguous abnormalities in adults. A study of four cases

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Anomalies Situs (ASIT) has been described mainly in the pediatric population and there is little information on this in adults. These are very rare abnormalities; in the case of Situs Ambiguous (SAMB) in adults, there have only been a few published case series. SAMB, also called heterotaxy or heterotaxy Syndrome, is defined as the abnormal or ambiguous positioning of organs and vessels, that could also be associated with morphological alterations characteristic of each organ. There are two main groups within SAMB: polysplenia and asplenia. This publication present a specific literature review, with emphasis on the classification of adult ASIT and abdominal findings in cases of SAMB. It will be complemented clinically and radiologically with four cases of abdominal tomographic imaging studies.

Keywords: Heterotaxy, Polysplenia, Situs ambiguus.

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Purpose. To describe metastatic disease detected by PET/CT in breast cancer (BC), and to evaluate the relative contribution of PET and CT analyzed separately. Patients and Method. We defined two groups of patients with BC: 1) recently diagnosed with no treatment, 2) with relapse after treatment. We described findings which are visible exclusively with CT and exclusively with PET. Results. In recently diagnosed patients (n=17) 88% show lymphadenopathies, 29% bone metastases (BM), 17% lung metastases, 17% hepatic metastases, and 11% other localizations. For relapsed patients (n=35) these percentages were 54%, 62%, 34%, 31% and 28%, respectively. CT detected more lung nodules and sclerotic bone lesions than PET. PET detected more lymphadenopathies, medullary bone and hepatic lesions than CT. There were synchronous cancers in 6% of recently diagnosed patients and in 11% of relapsed patients. Conclusion. BC patients show mainly lymph nodal and bone metastasis. The PET/CT hybrid study detected more lesions than PET and CT analyzed separately.

Key words: Cancer, Breast, Metastases, PET, Relapse.

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Introduction: The functional Magnetic Resonance (fMRI) is important in the evaluation of language and memory of patients with temporal lobe epilepsy. The fMRI has also enabled to observe how the structures in the medial temporal cortex have functional laterality according to the dominance of language, with a hemisphere which is specialized in the expressive and receptive aspects of language and the encoding of verbal material.
Objective: To relate the left hippocampus integrity with the degree of asymmetry of the language dominance seen by fMRI.
Materials and methods: Images with T1 volumetric information and EPI with T2 information are obtained using a 1.5T magnetic resonator, during the execution of complex scenes encoding paradigms, as well as during the generation of words and a semantic decision in a set of 12 control subjects and different patients who are potential candidates for epilepsy surgery.
Results: The automatized volumetric properties of the control group hippocampus do not show significant asymmetry. Indifferent patients with hippocampal sclerosis, numerical indexes are obtained, which are in accordance with the implication of the integrity of the left hippocampus with the asymmetry indexes in the language paradigms.
Conclusions: Among the results of the implementation of the memory and language protocol, using fMRI for patients with temporal lobe epilepsy, one can emphasize the evidences obtained using fMRI regarding the implications of the left hippocampus in the language network and the effects of its dysfunction in the migration patterns of language towards the contralateral hemisphere.

Keywords: Temporal lobe epilepsy, Functional magnetic resonance imaging Language

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Summary: Dementia is a syndrome which includes cognitive and neuropsychiatric alterations which affect at least two domains, such as memory, language, visual-spatial abilities, executive functions, personality and behavior. Regarding dementia, all these alterations represent a decrease in the prior functional level of the patient, which interferes with social tasks and daily activities. Neuroimaging techniques, especially MRI, are part of the initial study of a patient with dementia, because it serves to identify potentially reversible causes of dementia, as well as recognize vascular lesions or focal atrophy. It can also differentiate among the different types of dementia, according to the findings. Advances in the field of neuroimaging, and the use of functional neuroimaging techniques and nuclear medicine have enabled to find anatomical and functional substrates, both in the normal aging process and in advanced dementia, which has contributed to the development of new therapeutic options.

Keywords Magnetic resonance imaging Alzheimer disease, Frontotemporal dementia, Vascular dementia

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Patients with oncologic disease require frequent imaging tests (predominantly computed tomography) for follow-up. These patients may have thoracic vascular disease that can influence the diagnosis, treatment, and prognosis of their cancer. Primary vascular tumors can involve the thoracic vessels, like the pulmonary arteries (pulmonary artery sarcoma), and the neoplastic disease can extend locally (lung tumor) or remotely to the thoracic vessels (pulmonary tumor embolism and pulmonary tumor thrombotic microangiopathy). Oncologic treatment results in multiple complications that involve the thoracic vessels and can even compromise the patient’s life in certain cases. CT, and especially multislice CT, makes it possible to evaluate neoplastic disease and associated thoracic vascular disease in oncologic patients.

Keywords: Thoracic diseases; Vascular diseases; Clinical oncology; Multidetector CT

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In 2008, CT colonography was approved by the American Cancer Society as a technique for screening for colorectal cancer. This approval should be considered an important step in the recognition of the technique, which although still relatively new is already changing some diagnostic algorithms. This update about CT colonography reports the quality parameters necessary for a CT colonographic study to be diagnostic and reviews the technical innovations and colonic preparation for the study. We provide a brief review of the signs and close with a discussion of the current indications for and controversies about the technique.

Key Words: Polyp; CT-Colonography; Colo-rectal cancer; CT; Colon

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This article describes and illustrates a case of hepatic abscess secondary to fish bone that pierced the wall of the gastric antrum, which was diagnosed by CT. We performed percutaneous drainage of the abscess. Watchful waiting is taking over the foreign body, which in evolution again penetrates into the gastric lumen confirmed their expulsion in faeces. The preoperative diagnosis of liver abscess due to penetration of foreign bodies in the gastrointestinal tract is rare with conventional imaging methods. The value of computed tomography in the preoperative diagnosis in such cases becomes very important, so that before a patient with known risk factors for foreign body ingestion should be studied by this method.

Key Words: liver abscess, foreign bodies, penetration, perforation, computed tomography.

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This review offers insight into the possible role of vasa vasorum in the development of intracranial vascular disease. Unique structural features of intracranial vessels and nourishment from the surrounding cerebrospinal fluid environment may account for the relative lack of intracranial vasa vasorum early in life. However, with advancing age and with the development of vascular disease, vasa vasorum are known to develop. Advanced contrast material– enhanced imaging techniques are capable of helping detect and even grade intracranial vasa vasorum, and this may provide new insights into our ability to diagnose and assess the risk of intracranial vascular lesions such as atherosclerosis, aneurysms, dissections, and vasculitis.