Wavelet-Transformed Frequency Linked Attention with Selective Hierarchy for Abdominal Organ Segmentation.

To the Editor: Despite the frequency and variety of foreign bodies ingested, secondary intestinal perforation is a rare occurrence. Preoperative diagnosis using computed tomography (CT) scan is rarely made because of the lack of radiographic contrast of nonmetallic foreign objects. A case of jejunal perforation by a fish bone is reported. Diagnosis was made using abdominal helical CT scan, and surgery was immediately performed. This clinical case allows us to discuss the several fish bone perforation sites and the patient precipitating factors. Coloenteric perforation by foreign bodies is a rare occurrence and therefore a difficult preoperative diagnosis. A case of jejunal perforation by a fish bone in an old man with bad dentition is reported. Diagnosis was made using computed tomography (CT) scan before operating. An 81-year-old male patient suffering from lower left quadrant abdominal tenderness associated with fever (>38.5°C) and elevated white blood cell count (15,000/mm3) was admitted to the emergency service. His medical history included several laparotomies for cholecystectomy, obstruction of the bowel caused by adhesions, and incisional hernia. Plain abdominal x-ray showed gas shadows in the lower left quadrant without pneumoperitoneum. The CT scan revealed jejunal perforation by a nonmetallic foreign body suggestive of a fish bone (Figure 1). The laparotomy revealed lower left quadrant peritonitis and jejunal perforation by the fish bone, as seen on the CT scan. Removal of the fish bone, suture of the jejunal perforation, debridement, and washing and drainage of the abdominal cavity were performed. The postoperative course was uneventful, and the patient was discharged 12 days after his surgery. The patient was well at his 1-year follow-up. He reported retrospectively that he had eaten fresh fish 2 days before the surgical intervention and did not feel any pain during his lunch. Abdominal computed tomography scan (frontal view) showing the fishbone (white arrow) perforating the small bowel and the macroscopic view of the fishbone. This case is particularly interesting because the peritonitis was discovered preoperatively using a CT scan. The patient's bad dentition certainly contributed to this complication. Ingestion of nonmetallic foreign bodies leading to intestinal perforation is a rare occurrence because most foreign bodies pass spontaneously per anus.1 Perforation by foreign bodies can occur anywhere in the gastrointestinal tract. Fish bones are more often responsible for perforation of the esophagus, complicated by mediastinitis.1 Other parts of the upper digestive tract, such as the stomach or the duodenum, may be perforated.2 Fish bones may also pass through the gastrointestinal tract and enter other organs of the abdominal cavity such as the liver and the pancreas. One case of a fish bone totally integrated into the hepatic parenchyma has been recently reported.3 The small bowel4 or the large bowel5,6 may be perforated too, and cases of Meckel's diverticulum7 perforation have been described. The clinical manifestations of gastrointestinal perforation by foreign bodies are variable. Symptoms may be acute, showing signs of peritonitis associated with pneumoperitoneum visible on plain abdominal x-ray,7 although the patient may present more-indolent symptoms attributable to carcinoma or chronic disease. One study reported a clinical case of an 80-year-old woman presenting a painless, hard epigastric mass on physical examination 8 days after fish ingestion.5 She received an antibiotic treatment for abdominal pain secondary to the initially unsuspected perforation of the large bowel by a fish bone. Diagnosis was made at laparotomy. In the case of late diagnosis, a fish bone located inside the duodenum and pancreas was found several months after ingestion.2 As with the current patient, elderly persons are more at risk because of the bad quality of their dentition, which is responsible for a lack of mastication.5,8 Some cases of intestinal perforation by fish bone discovered using helical CT scan have been previously described.1,4,6 Ileal or jejunal perforation by fish bone is a rare occurrence of gastroenteric perforation. Preoperative diagnosis may be made using abdominal helical CT scan in an emergency. It is necessary to carefully remove the bones from fish that elderly persons eat because of the lack of mastication and the bad quality of dentition. Financial Disclosure: None. Author Contributions: Brice Dugas: preparation of manuscript. Bénédicte Bernard: preparation of manuscript. Pierre-Jean Valette: acquisition of subjects and data and analysis and interpretation of data. Emmanuel Odet: preparation of manuscript. Alain Naouri: preparation of manuscript. Pierre Bernard: acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: none.

Extension–contraction transformation network for pancreas segmentation in abdominal CT scans

Objective: Abdominal computed tomography has proven accurate for the detection of pediatric solid organ injuries following blunt abdominal trauma but is less reliable in detecting blunt bowel and mesenteric injuries (BBMI). The purpose of this study was to determine the significance of nonspecific findings on abdominal computed tomography (CT) scan in children at risk for BBMI. Design: Retrospective chart review. Setting: Regional pediatric trauma center. Patients: All patients who received an abdominal CT scan as part of their evaluation following blunt abdominal trauma over a 10-yr period (September 1991 to September 2001). Interventions: None. Measurements and Main Results: Individual records were reviewed by one of the authors and analyzed for age, gender, mechanism of injury, diagnostic studies and procedures, results of initial CT scan, treatment, surgical procedures, complications, and outcome. Patients were excluded if they suffered penetrating trauma, had an abdominal CT scan performed at another institution, had a surgical procedure before CT scan, or had incomplete records. A total of 2,114 patients met inclusion criteria. Sixty-five percent were male and ages ranged from 3 wks to 18 yrs. There were 178 patients who had at least one nonspecific finding on abdominal CT scan suggestive of BBMI; 151 patients had one finding, 24 patients had two findings, and three had three findings. The risk of BBMI increased with the number of nonspecific findings (positive predictive value = 11% with at least one finding and 44% with two or more findings). This increase in positive predictive value, however, was accompanied by a reduction in sensitivity (62% and 37%, respectively). A total of 32 patients had surgically proven BBMI. Of these, eight had a single nonspecific finding on CT scan, ten had two findings, and two had three findings (12 patients had no CT findings suggestive of BBMI). There were complications in four of the 32 patients with BBMI and one death (due to laceration of the superior mesenteric artery). The complications appeared to occur independent of the time to surgical intervention. Conclusions: The presence of multiple nonspecific findings on abdominal CT scan does not reliably predict BBMI in children. Children also appear to suffer complications from BBMI less frequently than adults, regardless of the time to surgery. Therefore, nonspecific findings alone do not warrant surgical exploration. The decision to operate should instead be based on clinical data that include serial physical examinations.

In modern medicine, a radiation scans is an very important examination tool for making a diagnosis and subsequent treatment plan. Among the range of medical examinations, Computed tomography (CT) is being performed in an increasing number of cases and a CT scan uses the most radiation of any diagnostic exam. On the other hand, radiation protection during scanning is not typical for bodily regions other than those designated for examination. Therefore, the aim of this study was to develop a lead-free fused radiation shielding fiber (RSF) and to evaluate its effectiveness with a view to reducing radiation exposure to only the effective dose or less in a CT scan by means of a multilayer structural coating. A GE High Speed Advantage Spiral CT was used to conduct measurements using a FH-40G (Eberline, USA) proportional digital counter survey meter. In a brain CT scan, abdominal CT scan, and knee CT scan, two-way ANOVA was used to analyze the changes in radiation dosage and to examine the correlation based on body parts and thickness of the RSF. In addition, when significant results were obtained, a Duncan post hoc test was used to examine the difference depending on each condition. In the brain CT scan, the highest exposure to secondary radiation was measured in the chest, which was closest in distance. The use of a 3mm shielding fiber resulted in a shielding effect of approximately 65% shielding effect compared to the initial exposure dose. In the abdominal CT scan, no exposure dose was detected in the head area, which had been shielded with the 3-mm shielding fiber. In a knee CT scan, 1-mm shielding fiber was sufficient to demonstrate a shielding effect. The RSF developed in this study may help reduce low-dose exposure to secondary X-rays, such as scattered rays.

A 9-year-old female presented to the emergency department complaining of intense peri-umbilical pain with nausea and vomiting after a road accident. Physical examination revealed abdominal tenderness with a painful well-circumscribed mass in the lower abdomen. The haemodynamic state was stable. Ultrasonography showed a mobile hypoechoic mass with a moderate amount of free intraperitoneal fluid. An abdominal CT scan was performed. Axial images before and after intravenously administered contrast material are shown. What are the abnormalities seen in Figure 1? Figure 1 Abdominal CT scans obtained before and after intravenously administered contrast material. What do you notice in Figure 2? Figure 2 Abdominal CT scan with intravenously administered contrast material at a higher level. What is your diagnosis?

Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients. Clinical and radiologic data from 106 consecutive blunt trauma patients were reviewed. Diagnoses revealed by conventional work-up of the chest, abdomen, pelvis, and thoracolumbar spine were compared with that detected by CT scan of the chest and abdomen. Unexpected findings by CT scan and rejected diagnoses by CT scan were collected. Therapeutic consequences of these diagnoses were determined both theoretically and collected from the medical records. In 74% (95% confidence interval [CI] 65-82) of the 106 patients, 1 or more diagnoses were demonstrated by chest or abdominal CT scan, whereas they had not been revealed by preceding conventional work-up. This resulted in an actual change of treatment in 34% (95% CI 25-43) of the patients. CT scan of the chest resulted in a change of treatment in 33% (95% CI 23-44) and abdominal CT scan in 16% (95% CI 9-24). CT scan of the chest and abdomen has a high diagnostic value in the evaluation of blunt trauma patients, when it is selectively performed in addition to the early conventional radiologic work-up. Unexpected pathologic findings are detected by CT scan in the majority of the patients. These findings result in an adaptation of treatment in a substantial number of the patients.

CT scan and the pediatric trauma patient—are we overdoing it?

Abdominal computed tomography (CT) was performed as part of the initial staging evaluation in 77 patients with small cell carcinoma (SCC) of the lung. CT scans revealed mass lesions in 26 patients (34%). Abnormalities were confined to the liver in 15 patients and to retroperitoneal structures (lymph nodes, adrenal glands, psoas muscle region masses) in eight, and occurred in both areas in three. However, only three of 29 patients otherwise staged as having limited disease (confined to one hemithorax and regional nodes) had evidence of abdominal metastases on CT scan. Most (23/26) positive studies were in patients already known to have more extensive tumor dissemination. In 71 patients with pathologic confirmation of liver status, CT had a sensitivity of 63%, specificity of 91%, and overall accuracy of 85% in assessing the liver. Comparison of radionuclide liver scan findings with hepatic biopsies gave similar results. During therapy, 65 follow-up CT scans were obtained in 46 patients. Scan abnormalities improved or disappeared in 11/12 cases with tumor response documented in other ways, appeared or worsened in 5/13 cases of tumor progression that was diagnosed by other tests, and only rarely (2/65 scans) improved at the time of documented tumor progression, or vice versa. In only three patients, however, did CT scan provide the sole site of evaluable disease during treatment or detect either the only area of residual disease in a patient in otherwise complete remission or the initial evidence of tumor progression. Although abdominal CT scans in SCC can demonstrate metastatic dissemination not evaluable by other means, they provide relatively little therapeutically relevant information beyond that obtained with standard staging procedures.

Recent concerns about the lifetime cancer risk associated computed tomography (CT) caused us to reevaluate the utility of this test in traumatized children. In addition, little is known regarding the utility of abdominal CT in children who have been emergently intubated. We sought to describe the injuries identified by abdominal CTs in intubated pediatric trauma patients and create a derivation set of predictors of intra-abdominal injury in this patient population. A review was conducted of patients cared for at a Level I pediatric trauma center. Patients were included if they were emergently intubated after blunt trauma and had an emergent abdominal CT performed. Outcome measures included the presence of an intra-abdominal injury on CT, the need for exploratory laparotomy (ELAP), the findings of the ELAP, and death. Logistic regression was used to determine which variables were associated with an abnormal abdominal CT scan. In all, 118 met inclusion criteria; the median age was 7.2 years. Thirty- two patients (27.1%) were found to have at least one abdominal injury on CT scan. One ELAP was performed and 12 patients died. Of the variables analyzed, abdominal examination abnormalities and elevated liver function tests (LFTs) were significantly associated with injuries. When both were abnormal, 75% of patients (12/16) had abnormal scans (sensitivity = 71%, specificity = 92%, positive predictive value = 75%, negative predictive value = 91%). In this series, a significant number of intubated pediatric trauma victims had intra-abdominal injuries identified by CT scan. The presence of abnormal abdominal examination findings and elevated LFTs appear to predict an abnormal CT scan.

Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique

Loss of muscle mass is a known feature of sarcopenia and predicts poor clinical outcomes. Although muscle metrics can be derived from routine computed tomography (CT) images, sex-specific reference values at multiple vertebral levels over a wide age range are lacking. The aim of this study was to provide reference values for skeletal muscle mass and attenuation on thoracic and abdominal CT scans in the community-based Framingham Heart Study cohort to aid in the identification of sarcopenia. This secondary analysis of a prospective trial describes muscle metrics by age and sex for participants from the Framingham Heart Study without prior history of cancer who underwent at least 1 CT scan between 2002 and 2011. Using 2 previously validated machine learning algorithms followed by human quality assurance, skeletal muscle was analyzed on a single axial CT image per level at the 5th, 8th, 10th thoracic, and 3rd lumbar vertebral body (T5, T8, T10, L3). Cross-sectional muscle area (cm 2 ), mean skeletal muscle radioattenuation (SMRA, in Hounsfield units), skeletal muscle index (SMI, in cm 2 /m 2 ), and skeletal muscle gauge (SMRA·SMI) were calculated. Measurements were summarized by age group (<45, 45-54, 55-64, 65-74, ≥75 years), sex, and vertebral level. Models enabling the calculation of age-, sex-, and vertebral-level-specific reference values were created and embedded into an open access online Web application. The cohort consisted of 3804 participants (1917 [50.4%] males; mean age, 55.6 ± 11.8 years; range, 33-92 years) and 7162 CT scans. Muscle metrics qualitatively decreased with increasing age and female sex. This study established age- and sex-specific reference values for CT-based muscle metrics at thoracic and lumbar vertebral levels. These values may be used in future research investigating the role of muscle mass and attenuation in health and disease, and to identify sarcopenia.

Introduction: Familial Mediterranean fever (FMF) is a hereditary autoimmune disease in which patients present with periodic, self-limited episodes of fever and serositis. It is prevalent in individuals of Middle Eastern origin. Since no definitive diagnostic test is available, FMF is suspected based on clinical symptoms; there are major and minor criteria to aid in making the diagnosis. Imaging modalities are not included in these criteria. We present a patient whose only symptom was recurrent abdominal with no family history of FMF. At the time he was diagnosed with Functional Abdominal Pain. FMF was suspected based on unexplained focal peritonitis on computerized tomography (CT). Case Description/Methods: A 45-year-old male of Middle Eastern descent was seen in clinic complaining of episodic right upper quadrant (RUQ) abdominal pain since he was 17 years old. The pain occurred once or twice per month. Over the years he had multiple visits to the emergency department and extensive work up including endoscopic evaluation and imaging studies. He underwent cholecystectomy, and bilateral inguinal hernia repair without benefit. He was diagnosed with Functional Abdominal Pain then. When evaluated in our clinic, lab work showed mild iron deficiency anemia; otherwise, unremarkable. Upper endoscopy, colonoscopy, small bowel series and capsule endoscopy were normal. 3 months later he presented to our ER with an acute episode of severe RUQ pain. He was afebrile; abdominal exam was remarkable for localized tenderness in the RUQ. Lab work was remarkable for an elevated erythrocyte sedimentation rate of 31. Abdominal CT was only remarkable for fat stranding around the hepatic flexure and the proximal half of the transverse colon. Colonoscopy was normal with no evidence for segmental colitis to explain the inflammatory changes. Given the history of recurrent abdominal pain, ethnicity, and focal unexplained peritonitis on CT scan, FMF was suspected, and treatment with colchicine was initiated without recurrence of symptoms for now several years since the diagnosis, meeting diagnostic criteria for FMF. Discussion: If not considered, FMF can remain misdiagnosed for many years leading to unnecessary procedures and surgeries. This was an unusual presentation with afebrile episodes of intermittent RUQ pain with the diagnosis ultimately suspected by CT imaging and confirmed by response to colchicine. Clinicians should consider FMF in patients of high-risk ethnic origin presenting with unexplained focal peritonitis on CT scan.

An unrecognized, or occult, injury is particularly dangerous in trauma patients, who often have multiple life-threatening injuries. We sought to determine the frequency and quantify the utility of the abdominal computed tomographic (CT) scan in detecting occult pneumothoraces. Charts of all trauma patients diagnosed with a pneumothorax over a 7-year period were retrospectively reviewed for findings on admission chest radiograph, abdominal CT scan, and other demographic data. A total of 312 charts were reviewed, with 230 patients identified as having a pneumothorax at admission. Of the 230 patients, 126 (54.8%) had an occult pneumothorax identified on abdominal CT scan. In these patients, the mean Trauma Score was 14.1 +/- 2.9 and the mean Injury Severity Score was 24.1 +/- 11.2. In the group of occult pneumothoraces, 84 (66.7%) underwent chest tube placement. Abdominal CT scanning provided important information about thoracic trauma often missed on initial evaluation in the trauma bay. This information frequently affected the patient's clinical management.

BackgroundTo develop and test the performance of a fully automated system for classifying renal tumor subtypes via deep machine learning for automated segmentation and classification.Materials and methodsThe model was developed using computed tomography (CT) images of pathologically proven renal tumors collected from a prospective cohort at a medical center between March 2016 and December 2020. A total of 561 renal tumors were included: 233 clear cell renal cell carcinomas (RCCs), 82 papillary RCCs, 74 chromophobe RCCs, and 172 angiomyolipomas. Renal tumor masks manually drawn on contrast-enhanced CT images were used to develop a 3D U-Net-based deep learning model for fully automated tumor segmentation. After segmentation, the entire classification pipeline, including feature extraction and subtype classification, was conducted without any manual intervention. Both conventional radiological features (Hounsfield units, HUs) and radiomic features extracted from areas predicted by the deep learning models were used to develop an algorithm for classifying renal tumor subtypes via a random forest classifier. The performance of the segmentation model was evaluated using the Dice similarity coefficient, while the classification model was assessed based on accuracy, sensitivity, and specificity.ResultsFor tumors larger than 4 cm, the Dice similarity coefficient (DSC) for automated segmentation was 0.83, while for tumors smaller than 4 cm, the DSC was 0.65. The classification accuracy (ACC) for distinguishing RCC subtypes was 0.77 for tumors larger than 4 cm and 0.68 for tumors smaller than 4 cm. Additionally, the accuracy for benign versus malignant classification was 0.85.ConclusionsOur automatic segmentation and classifier model showed promising results for renal tumor segmentation and classification.

Could surgery be the gold standard in moderate and severe ischaemic colitis? Atypical case description and review of literature.