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Purpose To assess the findings of recurrent Crohn's disease in the neoterminal ileum on small bowel follow through (SBFT) and computed tomography (CT) as well as the overall diagnostic performance of these imaging tests. Methods Our radiology database yielded 52 patients with an ileocolic anastomosis for Crohn's disease who underwent SBFT and CT. The images were reviewed to determine the sensitivity, specificity, PPV, and NPV for individual findings of recurrent Crohn's disease in the neoterminal ileum. The overall sensitivity, specificity, PPV, and NPV of these tests for recurrent Crohn's disease were determined by comparing imaging reports to endoscopic and surgical findings in 45 patients (87%) and clinical response to treatment in seven (13%). Results SBFT had a sensitivity of 90%, specificity of 85%, PPV of 95%, and NPV of 73% for detecting recurrent Crohn's disease, and CT had a sensitivity of 77%, specificity of 69%, PPV of 88%, and NPV of 50%. These tests combined had a sensitivity of 95%, specificity of 69%, PPV of 90%, and NPV of 82%. The most common findings were luminal narrowing, thickened folds, and ulcers (especially aphthoid lesions) on SBFT and bowel wall thickening on CT. CT also revealed extraenteric collections not visualized on SBFT in three patients (8%). Conclusions Our experience suggests that SBFT is more sensitive and specific than CT for detecting recurrent Crohn's disease in the neoterminal ileum, mainly because of the ability of barium studies to depict aphthoid lesions not visualized on CT. Conversely, CT is better for detecting extraenteric findings such as abscesses. When combined, these tests have a higher sensitivity for detecting recurrent Crohn's disease than either test alone.

Saline-infused sonohysterography (SIS) may help improve visualization of the endometrium and endometrial cavity and assess tubal patency. Although most SIS procedures are straightforward, a variety of pitfalls may lead to an unsuccessful procedure or incomplete evaluation. SIS should be scheduled between days 4 and 10 of the patient's menstrual cycle, when the endometrium is at its thinnest, and physiologic changes during the secretory phase are not present. Performing preprocedure imaging serves many purposes, such as depicting hydrosalpinx, causes of uterine and adnexal tenderness, and pelvic inflammatory disease, as well as assessing the size and position of the uterus and the orientation of the cervix. It is important not to presume that fibroids are the cause of bleeding when the endometrium is obscured at preprocedure imaging. Obstacles to a successful procedure include issues related to patient anxiety and discomfort, which may be prevented or minimized at almost every step of the procedure. Inability to obtain access to the cervix is the most common cause of unsuccessful SIS; proper patient positioning in a semi-upright lithotomy position is important. Injection of air during any US-guided procedure may lead to shadowing that obscures the region of interest. Adequate distention of the endometrial cavity is crucial for successful SIS, and optimal positioning of the distended balloon may improve the degree of distention. However, poor distention may be indicative of an underlying pathologic condition. Knowledge of these pitfalls and the strategies to overcome them may prevent premature or unnecessary termination of an otherwise successful study.

Uterine artery embolization (UAE) is an effective treatment for symptomatic uterine fibroids. Magnetic resonance (MR) imaging is typically employed to evaluate the uterus following UAE for fibroid infarction, size, location change, persistent enhancement, changes in adenomyosis, and uterine necrosis. Variable pattern of calcification on computed tomography (CT) can differentiate embolic particles and fibroid involution. CT following UAE may be requested because of acute pelvic pain or chest discomfort or pyrexia and/or for complications that may require treatment in acute phase. Visualization of gas in uterus and uterine vessels following UAE is an expected finding that should not be misinterpreted as a sign of infection. The MRI and CT appearances vary depending upon the time interval after UAE and success of the procedure. Radiologists should be familiar with the range of post-UAE appearances on MRI and CT to better aid clinicians in correct diagnosis and treatment. The main purpose of this pictorial review is to identify the spectrum of findings on MRI and CT performed after UAE, to illustrate UAE-associated common and uncommon MRI and CT appearances and discuss post-UAE complications that require urgent medical or surgical intervention.

This article examines the role of sonohysterography as an extension of the transvaginal ultrasound examination. This technique is used to improve visualization of the endometrial cavity and its relationship to the uterus. The authors find that it is well tolerated and causes few complications. The improved anatomic resolution increases diagnostic confidence and helps direct the patient to appropriate therapeutic options, potentially decreasing the need for more costly or invasive examinations. The addition of three-dimensional ultrasound makes the examination quicker and expands the utility of the procedure. The authors conclude that it will play a growing role in the evaluation of common gynecologic problems and in defining uterine pathology.

Our purpose was to assess the performance of CT colonography (CTC) in patients older than 60 years who were referred because colonoscopy was contraindicated or incomplete.Over a 2-year period, 61 patients underwent CTC at our institution, 42 of whom (26 women, 16 men) were 60 years old or older (range, 60-87 years; mean age, 71 years). After 24-48 hours of ingesting only clear liquids and after colonic cleansing, fecal tagging, and automated CO2 insufflation, patients were scanned using a 16-MDCT scanner. Images were obtained with the patient in the supine and prone positions and as needed in the right or left decubitus position. Axial 2D and 3D endoluminal views were evaluated on a dedicated workstation.Contraindications to colonoscopy in 12 (29%) of the 42 patients were as follows: anticoagulation (n = 8), increased anesthesia risk (n = 3), and poor tolerance for colonoscopy preparation (n = 1). Incomplete colonoscopy in the other 30 patients (71%) was due to diverticular disease (n = 10), colonic redundancy (n = 10), adhesions (n = 3), residual colonic content (n = 3), sigmoid stricture (n = 1), ventral hernia (n = 1), and unknown cause (n =2). No complications were observed. Optimal distention of the entire colon was achieved in 38 patients (90%). Thirty-nine (93%) of the 42 patients had abnormal findings: diverticular disease (n = 25), one or more polyps (n = 22), a mass lesion (n = 1), a lipoma (n = 1), and inflammatory stricture (n = 1). Extracolonic findings potentially requiring further evaluation or treatment were observed in 26 patients (62%).CTC using CO2 insufflation was well tolerated and successful in imaging the entire colon in most of the 42 patients, despite the presence of sigmoid diverticular disease or colonic redundancy.

Ultrasonographically (US) guided percutaneous biopsy of a neck lesion is a cost-effective, safe, and diagnostically effective procedure without radiation exposure. The benefit of real-time visualization of the needle location allows for instantaneous maneuvering of the needle trajectory for safe and accurate tissue sampling with short procedural time. Effective US-guided biopsy requires technical experience, strong clinical acumen, and skillful biopsy technique. A neuroradiologist's knowledge of head and neck anatomy and pathology allows correlation with cross-sectional imaging and enhances the understanding of US imaging evaluation. Familiarity with a spectrum of neck surgeries and reconstructions and expertise in imaging evaluation of the treated neck are invaluable in accurate identification of the target for biopsy in patients with treatment-related altered anatomy using US guidance. After thyroid nodules, the common adult neck masses are lymphadenopathy, head and neck cancer, salivary neoplasms, nerve sheath tumors, and inflammatory and infectious pseudomasses. Diagnostic expertise in the imaging characteristics of these individual pathologic conditions and their differential diagnoses also play an important role in choosing the biopsy technique and in procuring an adequate sample for diagnosis, including material for ancillary laboratory testing. Using an anatomic zone approach, this article illustrates the practical considerations in patient selection, the methodical analysis of preprocedure cross-sectional imaging and its correlation with real-time US evaluation, general principles for optimizing US instrumentation, and biopsy technique. In skillful hands, the versatility and portability of US make it the valuable modality for histologic sampling of superficial head and neck lesions. Online supplemental material is available for this article.

Objective The purpose of this study was to review the clinical, imaging, and pathologic findings associated with adnexal torsion. Methods A review of surgically proven cases of torsion between 1990 and 2006 included clinical, surgical, and pathologic data and preoperative sonographic, computed tomographic (CT), and magnetic resonance imaging (MRI) studies. Imaging reports were assessed to determine whether a correct preoperative diagnosis was made. Factors related to failure to make a correct diagnosis were evaluated. Results Fifty-eight cases of torsion were evaluated (patient ages, 12-85 years; 14 postmenopausal). There was a slight right-sided predominance (55%); in most cases (72%), both the ovary and fallopian tube were involved. Common symptoms/signs were pain (91%), leukocytosis (64%), nausea/vomiting (62%), and a palpable mass (41%). Twenty-eight patients (48%) had previous abdominal surgery; in 12 (46%) of these 28, pelvic adhesions were noted. At pathologic examination, underlying adnexal masses were found in 30 cases (52%); they were benign in 26 (87%) of 30 cases. Common imaging findings were an adnexal mass (65% on sonography, 87% on CT, and 75% on MRI), a displaced adnexal mass/enlarged ovary (53% on sonography, 87% on CT, and 75% on MRI), and ascites (53% on sonography, 73% on CT, and 50% on MRI). A correct preoperative diagnosis was made by initial sonography in 15 (71%) of 21 cases versus initial CT in 5 (38%) of 13. A correct imaging diagnosis was made more frequently in premenopausal than in menopausal patients (P = .02) and in patients without an underlying adnexal mass compared with those with a mass (P = .05). Conclusions Although CT shows features suggestive of torsion, in our study, the diagnostic value of initial CT was less than that of initial sonography. A correct preoperative diagnosis was made less often with an underlying adnexal mass and in postmenopausal women. Previous surgery and adhesions may be predisposing factors for adnexal torsion.

While sudden onset of severe pelvic pain in an afebrile woman of reproductive age is considered the classic presentation of a patient with adnexal torsion, this constellation of findings occurs in the minority of patients with adnexal torsion. In fact, many patients with adnexal torsion present with mild or intermittent symptoms and adnexal torsion likely occurs more frequently than originally thought in post menopausal women. Thus, the clinical presentation is often non-specific and may mimic other gynecologic pathology and even renal or gastrointestinal causes of lower quadrant pain. Duplex Doppler ultrasound (US) is typically the initial imaging study performed in female patients with suspected gynecological pathology. Findings of an enlarged amorphous, heterogenous ovary with an underlying mass or peripheral small follicles in an abnormal midline location are suggestive of ovarian torsion on ultrasound examination. Color Doppler interrogation may demonstrate the twisted blood vessels in the adnexal pedicle. Absence of Doppler detected blood flow suggest torsion and/or infarction but the documentation of blood flow should not exclude the diagnosis of torsion in a painful ovary with suspicious morphologic features. Since computed tomography (CT) may be the first imaging study obtained in patients suspected of harboring gastrointestinal or renal pathology, the radiologist should be familiar with the CT findings or ovarian torsion such as the presence of an enlarged, non-enhancing midline ovary/mass with an adjacent thickened or beak shaped tube or hematoma. Magnetic resonance imaging (MRI) has a role in the work-up of pelvic pain when CT or US findings are non-specific. Findings of adnexal torsion on MR are similar to findings observed on CT. However, the presence of high signal intensity stromal edema and numerous peripheral foillicles as well as lack of stromal enhancement are more easily detected on MRI.

Objective. The purpose of this presentation is to show the imaging findings of the common and uncommon variants of adenomyosis as seen on sonography and magnetic resonance imaging (MRI). Methods. A 3-year database search was performed to identify women who had pelvic sonography and pelvic MRI within a 6-month interval. Images of these cases were retrospectively reviewed. Results. Eighty women were identified. Adenomyosis was diagnosed on MRI, which was used as the reference standard, in 45 of these women. The correct diagnosis was made on sonography in 73% of the cases. Conclusions. Awareness of the spectrum of imaging features of adenomyosis is important to use sonography effectively for diagnosing this entity and to help avoid misdiagnosis.

Objective. To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision. Methods. A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature. Results. Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature. Conclusion. Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision.

Purpose To review the clinical indications, pathologic results, and success rate of all our sonographically guided solid renal mass biopsies over a 5-year period. Methods Between 1993 and 1998, 44 consecutive patients underwent sonographically guided percutaneous biopsy of a solid renal mass. Indications included prior history of nonrenal malignancy, metastatic disease of unknown primary origin, previous contralateral nephrectomy for a renal cell neoplasm, a renal transplant mass, suspected renal lymphoma, history of tuberous sclerosis, and poor surgical candidacy. Aspiration biopsies were initially performed with 22- to 18-gauge spinal needles. If the initial cytologic evaluation findings were nondiagnostic, core biopsies were then performed with 20- to 18-gauge core biopsy guns. Dictated sonographic reports of the biopsies were reviewed to determine the following: indication for biopsy, location and size of the renal mass, needle gauge and type, number of needle passes, and complications. Final cytologic and surgical pathologic records were reviewed. Results Thirty-six (82%) of the 44 biopsy specimens were diagnostic. Aspirated smears were diagnostic in 24 (67%) of these cases, with the diagnosis made on the basis of cell block alone in an additional 2 (6%). A definitive diagnosis came from core biopsy alone in 10 cases (28%). The 18-gauge core needle yielded diagnostic results more reliably than the 20-gauge core needle, and a significant correlation was seen between core biopsy needle size and the rate of diagnostic core samples (P = .017). Pathologic diagnoses included renal cell carcinoma (n = 18), lymphoma (n = 4), oncocytic neoplasm (n = 4), transitional cell carcinoma (n = 2), angiomyolipoma (n = 1), papillary cortical neoplasm (n = 1), and metastatic carcinoma (n = 6). Complications were seen in 4 (9%) of 44 cases; all were treated conservatively. Conclusions For specific clinical indications, sonographically guided fine-needle aspiration and core biopsy of a solid renal mass can be performed safely. In many cases, a definitive diagnosis can be made on the basis of fine-needle aspiration alone. However, diagnosis may ultimately require core biopsy, for which 18-gauge core needles would be more reliably diagnostic than 20-gauge needles.

The objective of this study was to assess the value of combining transvaginal sonohysterography with three-dimensional multiplanar ultrasonography to optimize assessment of the uterus. To make this assessment, we compared findings on three-dimensional sonohysterography with those on two-dimensional sonohysterography and X-ray hysterosalpingography. Of 20 women who underwent three-dimensional sonohysterography for various indications, 13 also underwent two-dimensional sonohysterography, and 12 had X-ray hysterosalpingography. We reviewed the 3 types of examinations separately and compared the standard techniques with three-dimensional sonohysterography to determine whether three-dimensional sonohysterography provided additional information. In 9 (69%) of 13 comparisons between three-dimensional sonohysterography and two-dimensional sonohysterography and in 11 (92%) of 12 comparisons between three-dimensional sonohysterography and X-ray hysterosalpingography, three-dimensional sonohysterography was advantageous. The coronal plane was most useful for displaying the relationship between lesions and the uterine cavity. Three-dimensional sonohysterography provided additional information compared with standard accepted techniques in the vast majority of women.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren ‘s-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

The purposes of this study were to determine splenic volumes using three-dimensional ultrasonography and to compare these measurements with two-dimensional splenic indices. Fifty-two healthy volunteers were studied. Two-dimensional volume measurements were based on length, width, and thickness, and the splenic index was calculated using the standard prolated ellipsoid formula (length x width x thickness x 0.523). Three-dimensional volume planar measurements were obtained with a slice by slice technique by manually drawing a region of interest around the spleen from one end of the sweep to the opposite end. These measurements were recorded three times by two observers. In addition, in vitro determination of splenic volume was performed using three cadaveric human spleens in a water bath. No statistically significant interobserver or intraobserver variability was present for either two-dimensional or three dimensional ultrasonography. Three-dimensional sonographic estimations of planar splenic volumes and ellipsoid splenic volumes were consistently smaller than two-dimensional sonographic estimations of splenic volumes. Three-dimensional sonographic splenic volumes calculated in vitro using the planar method were accurate to within 2% of in vitro water displacement volumes. Three-dimensional ultrasonography is potentially superior to two-dimensional sonography for evaluation of irregularly shaped objects, such as the spleen, and can provide improved accuracy over that of traditional two-dimensional techniques.

Female reproductive tract anomalies are difficult to number in the general population but are often discovered in evaluations of menstrual complications or fertility disorders. Traditionally, assessment of the reproductive tract entailed hysterosalpingography to image the uterine cavity with the final diagnosis provided by combined hysteroscopy/laparoscopy. These approaches, while providing important information, were uncomfortable and invasive and for HSG, involved radiation exposure. Magnetic resonance imaging (MIR) allowed for the avoidance of these issues while offering accuracy, thus becoming the gold standard diagnostic imaging modality but entailing cost, patient discomfort, and inconvenience. Current advances in ultrasound technology, specifically 3-dimensional ultrasound, achieve the same benefits of MRI in being accurate and noninvasive but also offer the following advantages: they are available in the office, they are cost-effective, and they provide immediate results. As 3-dimensional technology continues to become more accessible and more providers become proficient in using it, ultrasound may replace MRI as the new gold imaging standard in diagnosing mullerian anomalies.

An esophageal stricture is a narrowing of the lumen due to inflammation or tumor. Lack of distensibility is characteristic of stricture, which may be diffuse or localized and which may have abrupt or tapered margins. The purpose of this essay is to illustrate the imaging features of various types of strictures, focusing on their value in differential diagnosis.

The purpose of our study was to correlate the spectrum of radiologic and pathologic findings in a series of patients with biliary hamartomas and known extrahepatic malignancy.Biliary hamartomas were diagnosed in 18 patients with a primary malignant lesion who had liver biopsy for evaluation of possible metastatic disease. Prebiopsy imaging studies included CT in 16 patients and sonography in 11. Imaging studies were reviewed retrospectively and correlated with findings at surgery and on pathologic examination. The hamartomas were classified histologically by the degree of cystic dilatation of bile ducts within the lesion.Radiologically, biliary hamartomas presented a spectrum of findings including one or two circumscribed lesions (5-10 mm in diameter) in four patients; multiple (about five) lesions (approximately 5 mm each) in one patient; innumerable tiny, nearly uniform (2-5 mm) lesions in two patients; and innumerable lesions of varying size (2-15 mm) in three patients. Among the patients with innumerable lesions, the nodules were either uniformly or nonuniformly distributed throughout the liver. In all cases, the lesions were hypodense on contrast-enhanced CT scans and hypoechoic on sonograms. In eight patients, the lesions were not visible by imaging but biopsies were done at surgery when single or multiple tiny nodules were noted on the liver surface. The diagnosis was made by either wedge or core-needle biopsy; fine-needle aspirations were nondiagnostic. Pathologic examination revealed single or multiple hamartomas of varying sizes ranging from solid to largely cystic lesions; the degree of cystic dilatation did not correlate with imaging findings. Visibility on imaging correlated with larger lesion size; small surface lesions were usually occult.Biliary hamartomas cause single or multiple nonspecific hepatic lesions that may mimic metastases. This diagnosis should be considered in patients with a primary malignant tumor when single or multiple small hepatic lesions are seen, regardless of uniformity of size or distribution.

To determine the frequency of stability in malignant microcalcifications and its relationship to specific histologic diagnoses.During a 34-month period, microcalcifications were proved malignant in 182 patients referred for needle-guided biopsy. In 105 patients, the mammograms were compared with one or more than one previous mammogram. These patients were classified on the basis of interval change in two groups: those with stable and those with increasing or new microcalcifications. The histologic diagnoses were reviewed.Microcalcifications were stable for 8-63 months (mean, 25.4 months) in 26 patients (24.8%), only three (12%) of whom had invasive ductal carcinoma, which was found in 29 (37%) of the 79 patients with increasing or new microcalcifications.The odds for presence of invasive ductal carcinoma are statistically significantly lower (P.025) among patients with stable microcalcifications than among those with increasing or new microcalcifications. Stability of indeterminate or suspicious microcalcifications is unreliable for exclusion of a diagnosis of malignancy.

Background: To determine whether intravenous contrast improves the ability of radiologists to establish the cause of acute abdominal pain after nondiagnostic or normal unenhanced CT. Methods: Out of 164 consecutive emergency department patients presenting with less than 48 h of nontraumatic, acute abdominal pain, a confident diagnosis for cause of pain was made prospectively in 71/164 (43%) patients on these unenhanced scans by the monitoring radiologist. In the other 93 patients, our study sample, intravenous contrast-enhanced CT was obtained. At a later date, retrospectively, two experienced abdominal CT radiologists independently evaluated unenhanced CT scans alone for potential causes of pain and diagnostic confidence level on a 1–3 scale. At least 2 weeks later, intravenous enhanced and unenhanced scans were read side-by-side for the same assessment. Results: There was no significant difference in diagnostic confidence levels comparing unenhanced CT alone (2.59) vs. intravenous enhanced and unenhanced CT together (2.64). Chi-square analysis found no significant difference in finding a cause for pain when intravenous contrast was added compared to the initial unenhanced scan alone. Conclusions: Intravenous contrast did not significantly improve the ability of CT to establish a cause of abdominal pain after a negative or nondiagnostic unenhanced CT.

Advances in the medical and surgical treatment of uterine leiomyomas have stimulated interest in the imaging of these common tumors. The purpose of this essay is to illustrate the appearance of leiomyomas on images obtained with various techniques. The advantages of each technique in particular clinical circumstances are discussed.

OBJECTIVE. The purpose of this study was to describe the sonohysterographic features of adenomyosis with MRI correlation.CONCLUSION. In this study, when the sonohysterographic findings suggested adenomyosis, MRI findings confirmed the diagnosis in 96% of cases. Myometrial cracks are, to our knowledge, a previously undescribed sonohysterographic sign of adenomyosis.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

The purpose of our study was to assess the relationship between the endometrium and submucosal fibroids before and after uterine artery embolization (UAE).Contrast-enhanced pelvic 1.5-T MRI was performed in 49 women before and after UAE over a 2-year period. Dominant (largest diameter) fibroids in intramural, submucosal, subserosal, pedunculated subserosal, and endocavitary locations were assessed on pre- (baseline) and postembolization MRI. Size, locations of dominant fibroids relative to endometrium and serosa before and after embolization were compared. The ratio between the largest endometrial interface and the maximum dimension of the dominant submucosal fibroid (interface-dimension ratio) was determined on baseline MRI. The infarction rate for dominant fibroids was estimated after UAE.One hundred forty dominant fibroids were identified on baseline MRI. Forty-nine (35%) were intramural, 39 (28%) were submucosal, 34 (24%) were subserosal, eight (6%) were pedunculated subserosal, and 10 (6%) were endocavitary in location on preembolization MRI. After UAE, of 39 dominant submucosal fibroids, 13 (33%) became endocavitary: complete (n = 4), partial (n = 9) on the basis of European Society of Gynaecological Endoscopy (ESGE) classification. The preembolization mean interface-dimension ratio and mean diameters for dominant fibroids that became endocavitary were significantly greater than for those that did not become endocavitary after embolization (0.65 vs 0.32, p0.005; 8 vs 5.4 cm, p0.05, respectively). All dominant submucosal fibroids showed 100% infarction after UAE.Submucosal fibroids with an interface-dimension ratio of greater than 0.55 are more likely to migrate into the endometrial cavity after UAE. The majority of these are expelled spontaneously without significant symptoms. Rarely, submucosal fibroids greater than 6 cm in size that become endocavitary may cause postprocedural complications requiring further intervention and medical treatment.

Intravenous urography and retrograde pyelography are the primary radiologic studies for detecting ureteral carcinoma but give limited information regarding stage of disease. Computed tomography (CT) and magnetic resonance imaging (MRI) delineate the extent of ureteral carcinomas with a high degree of accuracy by depicting the periureteral fat and presence or absence of lymphadenopathy. In selected cases, CT and MRI are valuable for assessing the presence or absence of tumor in a ureteral stump and for the differential diagnosis of ureteral obstruction. Five cases of ureteral carcinoma and 2 cases of stump carcinoma are presented with preoperative CT and/or MRI evaluation and staging.

We report MR and sonographic imaging features of an incidentally detected paraovarian adrenal rest in a 44-year-old woman who was being evaluated for menorrhagia. This is the first report of chemical shift imaging identifying the presence of lipid within an adrenal rest as well as rapid washout of contrast. Both of these MR characteristics are typically seen with an adrenal adenoma.

3Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107. s the use of colonoscopy has increased greatly in recent years, awareness of its complications has become more important. Hemorrhage is the most common complication, with an incidence of 1–2% [1]. Perforation is the next most common complication, with an incidence of 0.1–0.2% [1]. Unusual complications of colonoscopy include pneumothorax, septicemia, mesenteric tears, and colonic volvulus. Splenic trauma is a rare complication of colonoscopy and was first reported by Wherry and Zehner in 1974 [2]. Two early studies that included nearly 13,000 patients reported no cases of splenic rupture [3, 4]. Since then, at least 26 cases of splenic rupture after colonoscopy have been reported in the English-language surgical and medical literature [5, 6]. To our knowledge, there is only one such report in the English-language radiology literature [7]. Given the increasing use of colonoscopy, it is important that radiologists are aware of this rare but potentially fatal complication of colonoscopy. We present two cases of splenic injury secondary to colonoscopy that were diagnosed by sonography and CT and managed conservatively by clinical observation and follow-up CT scans.

To assess whether sonohysterography provides added diagnostic value over transvaginal sonography in patients with suspected or known myomas by comparing diagnostic confidence, interobserver agreement, accuracy, and change in diagnoses when 2 independent observers interpreted transvaginal sonography alone and later interpreted transvaginal sonography and sonohysterography together.Hard copy images from 72 women were interpreted independently by 2 sonologists on separate occasions, rating parameters (abnormal uterus, myoma in any location, submucous myoma, classification of location of a submucous myoma with respect to the uterine cavity, myoma remote from the cavity, adenomyosis, and focal and diffuse endometrial lesions) on a scale of 1 to 5 (1 indicated definitely no; 2, probably no; 3, uncertain; 4, probably yes; and 5, definitely yes). Correlation was made with clinical and imaging follow-up, surgery, and pathologic examination.The added information provided by sonohysterography resulted in improved diagnostic confidence for most parameters. Interobserver agreement was markedly improved for the diagnosis and location of submucous myomas and focal endometrial lesions. Sensitivity values for submucous myomas and focal endometrial lesions were 100% and 90% for transvaginal sonography and sonohysterography together and 100% and 70% for transvaginal sonography alone.We found that sonohysterography does provide additional information over transvaginal sonography alone and is an important adjunct to transvaginal sonography in symptomatic women with known or suspected myomas, particularly before surgical or medical therapy.

Objective. To evaluate the feasibility of performing three-dimensional ultrasonographic studies that meet American Institute of Ultrasound in Medicine and American College of Radiology ultrasonographic examination guidelines with review off-line and at remote locations. Methods. One hundred patients were studied at 2 institutions using high-end two-dimensional clinical ultrasonographic scanners and commercially available three-dimensional ultrasonography for a variety of organ systems (first- and second-trimester fetus, abdomen, and female pelvis) We evaluated several parameters, including measurements, completeness of organ visualization, abnormalities identified, image quality, number of volumes required, and discrepancies between interpretations. Results. Overall, three-dimensional ultrasonography could produce diagnostic-quality results comparable with those of two-dimensional ultrasonography. Three-dimensional ultrasonographic image quality was lower than that of two-dimensional ultrasonography. Two- and three-dimensional ultrasonographic measurements were comparable (

Rationale and Objectives The purpose of this study was to determine whether the interval change in hepatic colorectal metastases as assessed with serial computed tomographic (CT) scans without contrast material enhancement differs from that as assessed using serial, portal dominant phase, contrast-enhanced CT scans. Materials and Methods Unenhanced and contrast-enhanced abdominal CT scans were obtained in 28 patients. Three radiologists separately reviewed serial unenhanced and contrast-enhanced studies to assess the interval change in liver metastases. These radiologists recorded total number of lesions, bidimensional measurements of the largest lesions (as many as three), and overall impressions regarding the interval change (none, worse, or better). Results Among the 84 judgments (28 patients × 3 radiologists), comparisons of unenhanced and contrast-enhanced CT studies were concordant in 60 assessments (71%). Nineteen (23%) showed mild disagreement. Of these, contrast-enhanced CT studies demonstrated disease stability when unenhanced CT studies demonstrated otherwise in 11 judgments, whereas unenhanced CT studies demonstrated stability when contrast-enhanced CT studies demonstrated otherwise in eight assessments. Furthermore, of the five marked disagreements, two resulted from a conclusion of interval improvement on unenhanced CT studies and a conclusion of interval worsening on contrast-enhanced CT studies, whereas three demonstrated the opposite. Neither set of serial CT studies systematically resulted in under- or overestimation of disease progression (McNemar Q test, P Conclusion The authors found no consistent pattern to demonstrate that serial unenhanced or contrast-enhanced CT studies resulted in over- or underestimation of disease progression.

Rationale and Objectives The authors performed this study to compare the cost and diagnostic abilities of ultrasound (US) performed with and without the use of an oral contrast material recently approved by the U.S. Food and Drug Administration. Materials and Methods An interactive decision-analytic model was constructed to compare US performed with and without contrast material (SonoRx; Bracco Diagnostics) for the evaluation of patients with abdominal pain who were suspected of having pancreatic disease. The model considered all resources that might be used to evaluate a patient suspected of having pancreatic disease (eg, US, computed tomography [CT], endoscopic retrograde cholangiopancreatography, fine-needle aspiration biopsy, and open biopsy). The literature and an expert panel were the clinical data sources. Cost estimates were based on Medicare and non-Medicare reimbursements. The primary cost-effectiveness measure was the cost to achieve a diagnosis. Results SonoRx-enhanced US was less expensive than unenhanced US ($714 vs $808, respectively, with Medicare costs; $1,612 vs $1,878, respectively, with non-Medicare costs) and as effective (0.785 vs 0.782, respectively). SonoRx-enhanced US was more cost-effective than unenhanced US ($909 vs $1,034, respectively, with Medicare costs; $2,052 vs $2,401, respectively, with non-Medicare costs). This relationship was maintained throughout extensive sensitivity analyses. Conclusion SonoRx-enhanced US is more cost-effective than unenhanced US, primarily because it avoids the need for CT. CT may be avoided owing to the higher probability of obtaining optimal US scans with oral contrast material.

Sonographic guidance is commonly used in the biopsy of focal hepatic lesions, but biopsy for diffuse disease is often non-image-guided. We evaluated the safety and efficacy of real-time sonographically guided random core biopsy in the assessment of diffuse liver disease in 210 patients. The two most common indications for biopsy were viral hepatitis (in 113 patients) and elevated liver function test results of unknown cause (in 54 patients). Ultrasonography and pathology reports were reviewed retrospectively to determine number of needle passes and final diagnoses. Adequate tissue was obtained in all 210 patients, with 259 of 269 (96%) passes having been successful. Specimens were submitted for light microscopy and other tests as indicated. No difference in success rates was found for right and left lobe biopsies. No major complications occurred. Minor complications occurred in 10 of 210 (4.8%) patients and were self-limited. Sonographically guided core liver biopsy is a safe and effective method for the diagnosis of liver disease.

To investigate whether measurements of hepatic metastases from colorectal carcinoma before contrast material administration are significantly different statistically from measurements after contrast material administration.Twenty-four patients with hepatic metastases from colorectal carcinoma underwent spiral computed tomography (CT) with 7-mm collimation. The liver was imaged before and in the portal-dominant phase after intravenous contrast material administration. For each scan, one to three discrete liver lesions were selected for measurement (n = 49). Three experienced radiologists performed independent measurements of the selected lesions on both pre- and postcontrast images at a computer workstation. A three-way analysis of variance (ANOVA) was performed: subjects by raters (the three independent radiologists) by pre- or postcontrast status. The dependent variable was the product of bidimensional measurements.Sixty-seven percent (33 of 49) of the lesions were measured as larger on precontrast images; 33% (16 of 49), as smaller. There was high interrater reliability, with an intraclass correlation coefficient greater than 0.9 ANOVA showed significant subject, rater, and contrast material effects (P.001) for the largest lesions in each liver. Contrast material status was a significant factor for all lesion sizes (P.003).On average, hepatic metastases from colorectal carcinoma are significantly smaller after contrast material administration.

Our purpose was to study the safety and efficacy of a new orally administered sonographic contrast agent in patients with suspected upper abdominal disorders.Ninety-nine patients with signs or symptoms suggestive of upper abdominal disorders were enrolled in a prospective range-of-dose phase II clinical trial at six sites; sonograms of 93 patients were evaluated for efficacy. Patients underwent upper abdominal sonography before and after receiving a randomized dose of the contrast agent (200, 400, 600, 800, or 1000 ml). Safety was monitored by physical examination and laboratory testing. The primary efficacy parameter was additional information provided by the contrast agent when comparing unenhanced and contrast-enhanced sonography.Of the 14 adverse events in 11 patients, only five, which included mild diarrhea and nausea, were considered related to the contrast agent. In 83 of 93 patients, additional information was obtained from the contrast-enhanced images. Visualization of anatomy was improved as follows: the stomach, in 82% of patients; the duodenum, in 63% of patients; the pancreatic head and body, in 61% of patients; and the pancreatic tail, in 67% of patients.SonoRx is a safe and well-tolerated contrast agent that improves the sonographic evaluation of the upper abdomen, with significant improvement in imaging the stomach, duodenum, and pancreas.

To assess how computed tomography (CT) affected clinical management in coagulopathic patients with suspected spontaneous abdominal hemorrhage.Fifty-four patients with coagulopathy underwent CT for possible abdominal hemorrhage. Medical records were reviewed retrospectively for pre-CT management strategy, degree of clinical suspicion for abdominal hemorrhage, CT findings, and post-CT management strategy.Abdominopelvic CT demonstrated hemorrhage in 31/54 (57%) of patients; 20/54 (37%) of patients had retroperitoneal hemorrhage, 2/54 (4%) had hemoperitoneum, and 9/54 (17%) had hemorrhage confined to the thigh, groin, and/or abdominal wall. CT directly affected clinical management in 28/54 (54%) cases; 17/31 (55%) CT scans that were positive for hemorrhage had a clinical impact versus 11/23 (48%) negative CT scans. This difference was not statistically significant (p = 0.61). CT scans with a higher pretest suspicion for abdominal hemorrhage were more likely to have hemorrhage detected (p = 0.0046) but not more likely to have a clinical impact (p = 0.73).CT to assess for abdominal hemorrhage had a direct impact on clinical management in about one-half of coagulopathic patients. Positive and negative CT studies were equally likely to affect management.

This study evaluated the ability of laparoscopic ultrasonography to detect, localize, and characterize focal liver masses. Laparoscopic ultrasonography and CT portography of the liver were performed in 13 patients with known or suspected malignancy. Laparoscopic ultrasonography directly influenced surgical management in four (31%) cases ; three by detection of small focal masses and one by exclusion of masses suspected on CT portography. Laparoscopic ultrasonography provide guidance for biopsy or added important anatomic information in three cases. Laparoscopic ultrasonography was complementary to CT portography but added no additional information in three cases, and it failed to provide any information in two cases. Laparoscopic ultrasonography was falsely negative in one case. In this preliminary series, laparoscopic ultrasonography assisted surgeons in critical decision-making by either providing important new information, clarifying questionable areas, or complementing CT pornography.

The mammographic, sonographic, and MR appearances of both normal and abnormal breast implants have been described. Breast implants are occasionally seen on chest CT scans obtained for other reasons; however, we know of no published reports on the CT findings in a series of patients with breast implants. We present a retrospective review of CT findings in 18 patients with 27 breast implants that illustrates the spectrum of findings that can be seen in asymptomatic patients.

Magnetic resonance imaging (MRI) and transrectal sonography of 27 patients with biopsy-proved carcinoma of the prostate were performed to compare the sensitivity of these modalities each other for diagnosis and to computed tomography (CT) for staging. Sonography was superior to MRI for the detection of intraglandular carcinoma and capsular disruption. MRI was superior to both sonography and CT for evaluating seminal vesicle invasion, and slightly better than CT for detecting lymphadenopathy.

A case of venous intravasation mimicking coloureteral fistula in a patient with sigmoid diverticulitis is reported. Venous intravasation is a rare but serious complication of barium examination of the colon.

Twenty-six patients with possible esophageal disruption who were also at risk for aspiration or direct communication of the esophagus with the tracheobronchial tree were examined with iohexol esophagography. Fifteen patients had normal studies confirmed by findings at a barium examination performed immediately after. In 11 patients abnormalities were diagnosed on the basis of iohexol esophagograms; the abnormalities included extraluminal extravasation of contrast material (n = 7), aspiration (n = 1), esophageal stricture with intramural diverticulosis (n = 1), edema of the gastroesophageal junction (n = 1), and epiphrenic diverticulum (n = 1). Eight of these patients were immediately reexamined with barium esophagography, which yielded no additional information. Low-osmolality, water-soluble contrast agents are a safe alternative for patients in whom barium esophagography poses a risk of mediastinitis and esophagography with diatrizoate meglumine and diatrizoate sodium (Gastrografin) poses a risk of pulmonary edema.

The computed tomographic (CT) appearance of urachal carcinoma in ten patients was studied and compared with the pathologic findings. Magnetic resonance images were available in one case. All tumors were mucinous adenocarcinomas; four were solid, three were cystic, and three were mixed. The tumor had a characteristic location along the expected midline course of the urachus directly behind the anterior abdominal wall. The main tumor mass was supravesical in eight patients. Seven tumors contained calcification. CT correctly depicted bladder wall involvement and supravesical extent of tumor in all cases. CT provided incorrect information about invasion of the perivesical fat in three patients and about bladder mucosal invasion in two patients.