A CT evaluation of the intraperitoneal fluid distribution.

Detection of hemoperitoneum in splenic trauma is as important as detection of the visceral injury itself. Observation of a consistent spectrum of fluid accumulation in patients with splenic trauma prompted us to investigate the patterns in more detail. Twenty-three computed tomographic (CT) scans in 20 patients were evaluated with respect to presence of fluid collections in various peritoneal and retroperitoneal compartments. These were correlated with severity of injury and operative and pathologic findings. Hemoperitoneum was detected in the pelvis (65%), paracolic gutters (52%), left subphrenic space (48%), perihepatic space (48%), Morison's pouch (17%) and in the lesser sac (9%). In addition to free fluid, pleural fluid (39%) and retroperitoneal hematoma in the left anterior pararenal space (13%) were also encountered. These ancillary findings may help to substantiate the diagnosis of splenic trauma in equivocal cases, particularly when the spleen itself is obscured by artifacts. Early detection may reduce mortality and morbidity associated with splenic trauma.

Objective To evaluate the uncertainty of the small bowel dose-volume and the normal tissue complication probability (NTCP) during intensity-modulated radiotherapy (IMRT) for rectal cancer, and to provide a reference for the dose limit and protection of the small bowel during IMRT for rectal cancer. Methods A total of 20 patients with rectal cancer who received postoperative adjuvant radiotherapy from March 2014 to August 2015 were enrolled in this study, including 10 patients receiving CT scan in the supine position and 10 patients in the prone position. All patients received computed tomography (CT) scan before the treatment and at weeks 1, 2, 3, and 4 of treatment, and they were defined as Plan, 1W, 2W, 3W, and 4W CT groups, respectively. The small bowel loop (BL) and peritoneal space (PS) were delineated on the images. The IMRT plan based on the Plan CT was copied to the 1W, 2W, 3W, and 4W CT groups, and then the small bowel dose-volume and NTCP were assessed for all CT groups. The paired t-test was used for comparison between groups. The Pearson method was used to analyze the correlation between NTCPC (chronic NTCP) and dose-volume. Results A total of 89 CT images of 20 patients were obtained. In all the patients, the volumes of BL and PS were 251.21 cm3 and 1324.16 cm3, respectively, and the shift% was 23.15% and 11.34%, respectively. The V15 of BL and PS was 184.86 cm3 and 792.45 cm3, respectively, and the shift% was 31.69% and 3.70%, respectively. The V30 of BL and PS was 88.01 cm3 and 645.73 cm3, respectively, and the shift% was 37.66% and 10.49%, respectively. The V15 of BL in 35% of patients and V15 of PS in 20% of patients, the Dmax of BL in 50% of patients, and the NTCP of 15% of patients in the course of treatment exceeded the safety limits. The 1-4W CT groups had a significantly higher NTCPC than the Plan CT group (4.02% vs. 3.20%, P=0.104), and their SD% was 41.68%. There was a significant correlation between NTCPC and V30-V50 of BL (R>0.400, P=0.000). The NTCPA (acute NTCP) and NTCPC in the supine position were significantly higher than those in the prone position (62.30% vs. 56.74%, P=0.061; 4.88% vs. 3.22%, P=0.145). Conclusions Small bowel motility leads to an uncertainty of the adverse event assessment during IMRT for rectal cancer. The change in BL is significantly larger than that in PS and the change in BL and PS in the supine position is significantly larger than that in the prone position. Using the prone position and minimizing V15 and V30 when designing the treatment plan can reduce the NTCPA and NTCPC in the small bowel. Key words: Rectal neoplasms/intensity-modulated radiotherapy; Small bowel; Normal tissue complication probability

Plain radiography (Fig. 9.1) has been superseded by cross-sectional imaging techniques and the peritoneal cavity is visualized only via contrast herniography (Fig. 9.2).

Correcting trunk muscle geometry obtained from MRI and CT scans of supine postures for use in standing postures

ImageA 38-year-old man presented to the emergency department after a horse kicked him in the left flank. He denied chest and abdominal pain. His heart rate was 85 bpm, blood pressure was 139/93 mm Hg, and oxygen saturation was 99%. He had tenderness over a 4 cm contusion on his left flank at the 10th posterior rib. His abdomen was not tender. The assessment was otherwise unremarkable. The initial focused assessment for sonography in trauma (FAST) scan was negative. (Image 1: Right upper quadrant.) A computed tomography (CT) scan illustrated a grade 3 splenic laceration without active extravasation, perisplenic hematoma, small hemoperitoneum, and left 9th and 10th rib fractures. (Image 2.) A repeat FAST scan 10 minutes later was positive in the right upper quadrant only. (Image 3: Right upper quadrant.) The patient was admitted to the intensive care unit where his hematocrit fell to a nadir of 36.4 % (normal 35.0-47.0%). He was discharged on hospital day three. Patients can present after blunt torso trauma with solid organ injury without abdominal tenderness or hypotension. The spleen is the most commonly injured organ, comprising one-third of such injuries. Splenic injury management includes observation, angiography and embolization, or laparotomy depending on the degree of injury and hemodynamic stability. The FAST scan is an accepted screening tool for trauma evaluation. (Curr Opin Crit Care 2007;13[4]:399.) The right upper quadrant view is the most sensitive in a supine patient no matter the location of injury due to the anatominal attachment of the posterior mesentery. In experienced hands, 250 ml of fluid can be detected with an overall sensitivity and specificity of 86% and 98%, respectively. (J Trauma 2001;50[1]: 108.) As this case illustrates, it is imperative to perform repeat FAST scans to increase sensitivity. (J Trauma 2004;57[5]:934; J Emerg Med 2000;18[1]:79.) In hemodynamically stable patients with a positive FAST, CT can diagnose the specific injury and evaluate the retroperitoneal space because FAST scans only evaluate the intraperitoneal space. When the physician has a high degree of suspicion for intra-abdominal injury but does not have access to CT or surgical services, the FAST scan should be repeated as to avoid missing life-threatening injury.Initial ultrasound of Morrison's pouch, right upper quadrantComputed tomography of abdomen. Arrow indicates a grade 3 splenic laceration without active extravasation. Asterisks indicate large perisplenic hematoma.Repeat ultrasound of Morrison's pouch demonstrating intraperitoneal fluid (arrow).Drs. Rossi and Gharahbaghian are emergency physicians in the department of surgery, division of emergency medicine, at Stanford University Medical Center. Dr. Gharahbaghian is also the associate director of Emergency Ultrasound and a director of the Emergency Ultrasound Fellowship at Stanford. Return to EM-News.com

Background:Malignant ascites is an accumulation of fluid in the peritoneal cavity due to the manifestation of terminal metastatic malignancies. Accumulation of ascitic fluid could cause abdominal distention, early satiety, and shortness of breath. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life. Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months. Therapeutic paracentesis is the mainstay of palliation for malignant ascites. It only provides a temporary relief of symptoms, ascites re-accumulates, and paracentesis has to be repeated.Objectives:The aim of this case series was to evaluate our experiences when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events.Methods:Five patients with advanced disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port Central venous catheter in the peritoneal cavity. Maximum fluids that can be tapped were removed in ward. Patients and their relatives were assessed for satisfaction with the procedure.Results:Out of 5 patients, 3 were female and 2 male (age between 46 and 62 years). Two patients had carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement. Patients and their relatives were well satisfied in terms of frequent hospital visit for paracentesis.Conclusion:In summary, we suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital admissions.

Objective To explore the effects of different body positions at the expiratory phase thin-section multi-slice spiral CT on the diagnosis of pulmonary air trapping after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methods Thirty-one allo-HSCT patients underwent the expiratory phase low-dose MSCT lung scanning at supine and prone positions to detect whether they have air trapping lesion,the volume percent of air trapping region (CT value≤-700 HU at expiratory phase) against the whole lung was measured by using GE workstation after grading.Statistical analysis on lesion detection rate was performed with Mc Nemar test and volume percent with rank sum test. Results Air trapping regions were observed in 8 patients (25.8%,8/31) who performed CT scan at the supine position,while 15 cases (48.4%,15/31) were positive for prone position CT scan.Seven cases showed positive results at both body positions.Statistical significance in the positive detection rate at supine and prone positions was found (χ2=4.00,P=0.039).The volume fraction of the two positions was 13 for supine position and 21 for prone position with statistical significance (Z=-3.37,P=0.001).Sensitivity at prone position CT scan to detect air trapping was much higher than that at supine position CT scan. Conclusion For allo-HSCT patients with chronic rejection reaction,performing expiratory phase thin-section CT scan and prone position scan can not only improve the detection rate of lung forepart lesions,but also preliminarily evaluate the severity of the air trapping,which can provide a basis for the early diagnosis and treatment in clinics. Key words: Lung diseases; Stem cell transplantation; Graft rejection; Tomography,Xray computed

Fusion imaging is an emerging technique that combines real-time ultrasound examination with images acquired previously using other modalities, such as computed tomography (CT), magnetic resonance imaging and positron emission tomography. The primary aim of this study was to evaluate the feasibility of fusion imaging in patients with suspicion of ovarian or peritoneal cancer. Secondary aims were: to compare the agreement of findings on fusion imaging, CT alone and ultrasound imaging alone with laparoscopic findings, in the assessment of extent of intra-abdominal disease; and to evaluate the time required for the fusion imaging technique. Patients with clinical and/or radiographic suspicion of advanced ovarian or peritoneal cancer who were candidates for surgery were enrolled prospectively between December 2019 and September 2020. All patients underwent a CT scan and ultrasound and fusion imaging to evaluate the presence or absence of the following abdominal-cancer features according to the laparoscopy-based scoring model (predictive index value (PIV)): supracolic omental disease, visceral carcinomatosis on the liver, lesser omental carcinomatosis and/or visceral carcinomatosis on the lesser curvature of the stomach and/or spleen, involvement of the paracolic gutter(s) and/or anterior abdominal wall, involvement of the diaphragm and visceral carcinomatosis on the small and/or large bowel (regardless of rectosigmoid involvement). The feasibility of the fusion examination in these patients was evaluated. Agreement of each imaging method (ultrasound, CT and fusion imaging) with laparoscopy (considered as reference standard) was calculated using Cohen's kappa coefficient. Fifty-two patients were enrolled into the study. Fusion imaging was feasible in 51 (98%) of these patients (in one patient, it was not possible for technical reasons). Two patients were excluded because laparoscopy was not performed, leaving 49 women in the final analysis. Kappa values for CT, ultrasound and fusion imaging, using laparoscopy as the reference standard, in assessing the PIV parameters were, respectively: 0.781, 0.845 and 0.896 for the great omentum; 0.329, 0.608 and 0.847 for the liver surface; 0.472, 0.549 and 0.756 for the lesser omentum and/or stomach and/or spleen; 0.385, 0.588 and 0.795 for the paracolic gutter(s) and/or anterior abdominal wall; 0.385, 0.497 and 0.657 for the diaphragm; and 0.336, 0.410 and 0.469 for the bowel. The median time needed to perform the fusion examination was 20 (range, 10-40) min. Fusion of CT images and real-time ultrasound imaging is feasible in patients with suspicion of ovarian or peritoneal cancer and improves the agreement with surgical findings when compared with ultrasound or CT scan alone. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Differences in Lung and Lobe Volumes between Supine and Standing Positions Scanned with Conventional and Newly Developed 320-Detector-Row Upright CT: Intra-Individual Comparison

Understanding respiratory motions of liver and its surrogate organs is crucial for precise dose delivery in liver cancer radiotherapy. Although these motions have been studied for respiratory motion management in the supine posture, few studies have quantified them and evaluated their correlations in the upright posture. This study quantified the respiratory motions of liver and surrogate organs and evaluated the correlations between the liver motions and surrogate signals for respiratory motion monitoring in both the supine and upright postures. 4D dynamic volume computed tomography (CT) images were acquired from 13 asymptomatic volunteers in both supine and upright postures while free breathing. The 4D liver motions were calculated by performing deformable image registration. Subsequently, superior-inferior (SI) motion at the right diaphragm apex and anterior-posterior (AP) motion at the abdominal skin surface were obtained as surrogate signals from the 4D CT images. The average displacements and maximum magnitudes of liver motions and surrogate signals were compared between the postures. Moreover, the correlations between the liver motions and surrogate signals were evaluated based on correlation models. The average liver displacements from the end-exhalation along the SI, AP, and left-right directions were -6.1, 2.1, and -0.4 mm in the supine posture and -4.6, 2.5, and 0.1 mm in the upright posture, respectively. The maximum motion range along the SI direction significantly decreased from 16.3 ± 6.6 mm in the supine posture to 11.0 ± 2.7 mm in the upright posture. Similar to the supine posture, the correlation models also reproduced the liver motions with high fitting accuracy in the upright posture. Compared to the conventional supine posture, the liver SI motion became smaller in the upright posture while keeping evident correlations with the surrogate signals, which suggests the upright posture will allow precise dose delivery with reduced internal target margins.

Introduction: Iliopsoas Abscess is a rare condition with non - specific presenting complaints. The disease symptoms are subtle, the etiology is variable and its presentation is atypical in a lot of cases. Only 30% of cases present with the clinical triad of fever, flank pain and limited range of movement of hip, often causing delay in diagnosis. Case Presentation: This case describes atypical and unusual manifestation of psoas abscess when an 80 year old female patient was admitted with suspected bloodstream infection from the GI tract and acute small bowel obstruction. Patient also had non - specific right hip and limb pain, UTIs and episodes of fever over the last two years. On preliminary investigations, no definite cause of intestinal obstruction was found and conservative management proved unsuccessful. A CT scan on the second day of admission confirmed a right psoas abscess and an abrupt transition from dilated to collapsed bowel loops in the right peri - umbilical region, suggesting a dynamic small bowel obstruction. An emergency Laparotomy revealed turbid abdominal fluid and peritonitis and small bowel loops adherent to the right posterior abdominal wall as well as to each other. Bowel loops were inflamed but there were no fistulas or perforation. Adhesionolysis was done, thorough TPL was done, and an ADK drain was placed in the right psoas. Successful treatment of SBO and psoas abscess was achieved through open surgery, the patients condition gradually improved and was discharged with a psoas drain on 13th day post surgery. Conclusion: For patients with Iliopsoas abscess, initial symptoms can be vague and atypical. They can present as functional bowel obstruction and septic shock. Consideration of psoas abscess is warranted if patient has suggestive symptoms like hip pain, limping, fever. Because of its atypial presentation, early diagnosis through imaging can significantly improve the prognosis.

Introduction. Ventral hernias are quite common, but liver herniation is an extremely rare case. This type of abdominal protrusion of part of the liver usually occurs through incisional weak spots on the abdominal wall. Incisional herniation of the liver usually occurs 2 to 3 years after an abdominal operation consequently leading to focal weakness of the abdominal wall. Case report. We present an extremely rare case of incisional herniation of part of the left and smaller part of the right liver lobe in a woman aged 64 years, as a consequence of a previous open cholecystectomy, creating a focal abdominal wall weakness. Abdominal CT scan was performed. Analysis of the CT scans, as well as of the reconstruction made in the coronal and sagittal plane was performed. Herniation of the left and the smaller part of the right liver lobe through an incisive focal weakness of the right upper quadrant of the abdominal wall was detected. Discussion. Incisional hernias are delayed complications of abdominal surgery. They can occur anywhere on the abdominal wall and are more frequently encountered in a vertical than in a transverse incision. Typically, incisional hernias occur during the first months following surgery, but later occurrence has been reported as well. Herniation of the liver through the anterior abdominal wall is an extremely rare condition and usually related to previous surgery on the upper abdomen. Due to its rarity it is both a diagnostic and therapeutic challenge. Conclusion. We can conclude that there is a connection between liver herniation through the upper abdominal wall and a previously performed open abdominal surgery. CT is the method of choice for diagnosis of liver herniation through the anterior abdominal wall.

Successful intrauterine transfusion of the fetus with erythroblastosis fetalis has been reported by Liley (1) and McCrostie (2). The purpose of this paper is to familiarize the radiologist with the technic involved in performing the procedure. Hematology Intrauterine intraperitoneal transfusion can be of value to a limited number of fetuses which are not hydropic at twenty-six weeks gestation, but are expected to be severely affected by thirty-four weeks. Establishing the severity of the erythroblastotic process in a fetus is possible not only by measurement of the rising maternal antibody, but also by spectrophotometric analysis of amniotic fluid. In the face of expected severe erythroblastosis, red cells have been infused into the peritoneal cavity of the fetus (1, 2). Absorption of intact red cells from the peritoneal cavity has been well established by Mellish and Wolman (3). It is unlikely that the technic to be described can be adapted to fetuses smaller than those of twenty-six weeks gestation. Technic Thirteen intrauterine fetal infusions have been performed in the Department of Radiology, Boston City Hospital. The patient is premedicated with morphine sulfate (20 mg) and phenobarbital (100 mg). Preliminary films are not necessary, as on two occasions movement of the fetus was found to invalidate the position described on radiography. With the patient supine, the abdomen is viewed with television monitoring for delineation of the fetus. It should be stressed that sharpness is needed; therefore, prior to exposure of the fetus, we have used a pelvic phantom for quality control check of the television image (see below.) The abdomen is then prepared and draped, and the site of injection in the abdominal wall is anesthetized with 1 per cent Xylocaine. An 8-in. No. 16 Tuohy needle is introduced into the amniotic sac at a point approximating the anterior abdominal wall of the fetus. After its position is checked by television monitoring, the needle is inserted into the peritoneal cavity of the fetus. We attempt to approximate the low fetal abdomen with caudad angulation of the needle to avoid liver or kidney puncture. When the needle enters the peritoneal cavity, and the stylet is withdrawn, one can frequently hear a characteristic “whistle.” Five cc of methylglucamine diatrizoate6 is injected to check the needle position. If its end is free, the opaque medium will outline the diaphragm, giving a crescent shape which is easily visualized fluoroscopically (Fig. 1). Occasionally, the injected opaque medium puddles in the low or mid abdomen. In this situation, contrasted bowel loops of the fetus may be seen, indicating the intraperitoneal location of the needle tip. Once the needle end is free, 50 to 100 cc of packed red cells are injected into the peritoneal cavity of the fetus. An anteroposterior or lateral exposure was at one time obtained at the termination of the procedure as a record of the location of the medium.

A VARIETY of pancreatic lesions may result in the accumulation of fluid in the peritoneal cavity. Although approximately 10% to 20% of patients with carcinoma of the pancreas develop ascites, this occurrence usually indicates wide peritoneal metastases. It is not unusual to find accumulation of peritoneal fluid in patients who succumb from severe forms of chronic pancreatitis. Generally, however, ascites is unusual with reversible chronic pancreatic disease. A pseudocyst of the pancreas is seldom considered in the differential diagnosis of massive ascites, and this association has received little attention in the surgical literature. In the few cases that have been reported with the association of a pancreatic pseudocyst and massive ascites, the majority of cases have been in patients with chronic alcoholism. Our recent experience with two patients having abdominal ascites and pancreatic pseudocyst, following blunt abdominal trauma, prompted this report. <h3>Report of Cases</h3><h3>Case 1.</h3> —This 28-year-old Negro woman

Dermatofibrosarcoma protuberans is a rare soft tissue sarcoma of low to intermediate malignant potential. Incidence is estimated to be 0.8 to 4.5 cases per million persons per year. The tumor is highly aggressive locally and is known to recur. Punch biopsy or excisional biopsy (in case of small tumors) are diagnostic. Computer tomography (CT) and magnetic resonance imaging (MRI) are useful in determining the size and extent of the tumor’s treatment is primarily surgical, with a wide local excision with at 2 cm margin. However, local recurrence after apparently adequate surgical excision is common. Mohs micrographic surgery has been recommended as it enables maximum preservation of tissue. When surgery is insufficient, imatinib mesylate is shown as a safe and effective treatment in dermatofibrosarcoma protuberans (DFSP), especially in cases of locally advanced or metastatic disease. Here, we report a case of a giant fibrosarcoma on the anterior abdominal wall, measuring 27×18×9 cm, which occurred in a recurrent dermatofibrosarcoma protuberans. Diagnosis was done by histopathological examination (HPE) of the previously excised tumor and CT was done. The tumor was excised with a 3 cm margin and extensive reconstruction of the anterior abdominal wall defect was done using synthetic mesh, myocutaneous flaps and split skin grafting. Keeping in view the recurrent nature of our case, large tumor size, DFSP-fibrosarcomatous (FS) transformation and close negative margins in the HPE of the postoperative specimen, the patient was planned for adjuvant radiotherapy.