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Intrauterine devices (IUDs) are a commonly used form of contraception worldwide. However, migration of the IUD from its normal position in the uterine fundus is a frequently encountered complication, varying from uterine expulsion to displacement into the endometrial canal to uterine perforation. Different sites of IUD translocation vary in terms of their clinical significance and subsequent management, and the urgency of communicating IUD migration to the clinician is likewise variable. Expulsion or intrauterine displacement of the IUD leads to decreased contraceptive efficacy and should be clearly communicated, since it warrants IUD replacement to prevent unplanned pregnancy. Embedment of the IUD into the myometrium can usually be managed in the outpatient clinical setting but occasionally requires hysteroscopic removal. Complete uterine perforation, in which the IUD is partially or completely within the peritoneal cavity, requires surgical management, and timely and direct communication with the clinician is essential in such cases. Careful evaluation for intraabdominal complications is also important, since they may warrant urgent or emergent surgical intervention. The radiologist plays an important role in the diagnosis of IUD migration and should be familiar with its appearance at multiple imaging modalities., (© RSNA, 2012.)

Objective: To evaluate the performance of multidetector computed tomographic angiography (MDCTA) in assessing the surgical resectability of pancreatic head adenocarcinoma., Methods: With institutional review board approval, radiographic, surgical, and pathological records of 203 consecutive patients with adenocarcinoma of the pancreatic head were analyzed retrospectively. Patients were imaged with MDCT scanners using our institution's CTA pancreatic protocol. Images were compared with surgical outcomes to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MDCTA in determining resectability., Results: Data were analyzed twice, once with equivocal findings on MDCTA assumed as resectable and again with equivocal cases assumed as unresectable. All equivocal cases were ultimately unresectable; when this was assumed, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were determined to be 100%, 71%, 85%,100% and 89%. Twelve patients deemed resectable by preoperative MDCTA were found to be unresectable on surgical exploration owing to vascular involvement (n = 4), liver metastases (n = 4), and peritoneal involvement (n = 4)., Conclusions: Multidetector CT angiography offers accurate and valuable preoperative assessment of surgical resectability of pancreatic ductal adenocarcinoma. Liver and peritoneal metastases and vascular invasion still remain important pitfalls in preoperative evaluation.

Portal vein aneurysms are a relatively uncommon entity and often an incidental, asymptomatic finding. Recognition of this finding can help to avoid potential confusion with abdominal masses of other etiologies. We would like to present four cases of portal vein aneurysms, and discuss the natural history, imaging findings, and treatment of this condition. One of the cases of portal vein aneurysm presented occurred after liver transplantation, which, to the best of our knowledge, has only been described once in the English-language literature.

A variety of anatomic variants and pathologic conditions in and around the pancreas may simulate primary pancreatic neoplasia at routine abdominal cross-sectional imaging. An ambiguous lesion whose appearance suggests a pancreatic origin requires a broad differential diagnosis that can subsequently be narrowed on the basis of both clinical history and features at optimal computed tomography (CT) and magnetic resonance (MR) imaging. Pancreas-specific multidetector CT and MR imaging techniques with thin collimation, multiplanar and multiphasic scans, and newly introduced curved planar reformation may help avoid potential diagnostic pitfalls. These techniques can help identify and characterize a mass in multiple viewing planes, thereby helping distinguish a true pancreatic neoplasm from peripancreatic adenopathy or from a tumor of the adjacent duodenum or small bowel. They can also help determine the cause of a tumor. It is important that the radiologist be familiar with the wide spectrum of anatomic variants and disease entities that can mimic primary pancreatic neoplasia in order to initiate the appropriate lesion-specific work-up and treatment and avoid unnecessary tests or procedures, including surgery.

Objective: To determine the impact of patient gender on the performance of helical computed tomography (CT) in the diagnosis of acute appendicitis., Materials and Methods: From January 1, 1996 to December 31, 2000, 650 consecutive nonfocused helical abdominal CT scans were performed in adult patients presenting with acute lower abdominal pain. In general, most patients received both intravenous and oral contrast with 5-mm scan collimation through the lower abdomen and pelvis; details regarding technique and overall accuracy have been published previously. We subanalyzed results with respect to patient gender-related differences, especially in false-positive and false-negative cases. A chi2 analysis was performed to determine if significant gender-related differences were present in major or minor CT diagnostic criteria for acute appendicitis, extra-appendiceal findings, sensitivity, specificity, and accuracy., Results: Of the 650 patients, 552 had adequate clinical follow-up. The sensitivity for diagnosing acute appendicitis was 100% (65/65) in men and 93.6% (74/79) in women (P < 0.05); specificity was 96.2% (130/135) in men and 98.9% (272/275) in women (P > 0.05); and accuracy was 97.5% (193/198) in men and 97.6% in women (346/354) (P > 0.05). A thickened appendix and periappendiceal stranding were seen in 92.1% of men and 84.5% of women (P = 0.15) All 5 false-negative results were in thin women. In patients without acute appendicitis, CT was able to provide a relevant alternative diagnosis in 183 of 272 women (67.3%) and 81 of 130 men (62.3%) (P > 0.05)., Conclusion: Nonfocused helical CT was highly accurate for diagnosing acute appendicitis in both men and women, although there was a slight but significant decrease in sensitivity in thin women.

Objective: The clinical usefulness of routine, nonfocused helical CT was evaluated in diagnosing acute appendicitis or providing an alternative diagnosis in patients presenting to the emergency department with acute lower abdominal pain., Materials and Methods: We reviewed CT reports and clinical records of 650 consecutive adult patients who presented between January 1996 and December 2000 with right lower quadrant pain or lower abdominal pain and clinical findings suggestive of appendicitis. Helical CT was performed with oral contrast material in 610 cases (93.8%) and IV contrast in 572 cases (88.0%). Both vascular and enteric contrast media were administered in 544 cases (83.7%). Rectal contrast material was administered in 52 cases (8.0%). The abdomen was helically scanned from the dome of the diaphragm to the iliac crests with a collimation of 7 mm, from the iliac crests to the acetabular roof at a 5-mm collimation, from the acetabular roof to the symphysis pubis with a collimation of 5-10 mm. The surgical or clinical record was used for follow-up., Results: Of the 650 patients, 552 (84.9%) had adequate clinical follow-up. There were 137 true-positive, eight false-positive, five false-negative, and 402 true-negative cases. The sensitivity, specificity, and accuracy of nonfocused helical CT were 96.5%, 98.0%, 97.6%, respectively. The positive and negative predictive values were 94.5% and 98.8%, respectively. In patients without acute appendicitis, CT suggested an alternative diagnosis, which clinically explained the patient's acute abdominal pain in 266 patients (66.2%)., Conclusion: Nonfocused helical CT was highly accurate in diagnosing acute appendicitis or suggesting an alternative diagnosis in patients with acute lower abdominal pain or right lower quadrant pain.

Many radiologists are not familiar with the names of various instruments, surgical sponges, and needles that may be seen on intraoperative and postoperative radiographs. These devices may be intentionally placed for localization or therapeutic intervention, discovered on radiographs obtained to evaluate incorrect sponge or needle counts, or incidentally encountered on postoperative radiographs. These paraphernalia are usually described in vague nonspecific terms in radiology reports. In this article, photographs and radiographs of several instruments commonly used for intraoperative localization or therapy are presented, as well as examples of sponges, needles, and other devices that should not be found on postoperative radiographs. Familiarity with their appearances will allow a more precise and knowledgeable description in radiology reports.

Objective: The purpose of this study was to evaluate the effectiveness of CT colonography when patients were imaged in both the supine and prone positions. We evaluated whether imaging in two positions decreased the number of collapsed colonic segments and increased sensitivity for polyp detection., Materials and Methods: Twenty-three patients underwent CT colonography in both the supine and prone positions. Colonic distention for each of the 46 scans was graded. Adequacy of distention for either position alone was compared with that of the combination of the two positions. Polyp data revealed by colonoscopy were reviewed, and the CT data were then retrospectively reviewed for polyp detection., Results: When each scan was considered alone without benefit of the scan obtained in the opposite position, 27 (58.7%) of 46 scans showed inadequate distention. When scans obtained in both positions were considered together, 20 (87.0%) of 23 patients had adequate distention with the grading system used. However, this value increased to 23 (100%) of 23 patients when the reasons for inadequate distention in the three patients were considered. Of the 27 polyps detected with colonoscopy, 21 (77.8%) were also detected retrospectively with CT colonography. Colonoscopy showed 20 polyps that were 5 mm or larger; nineteen (95.0%) of these 20 polyps were also detected retrospectively with CT colonography, nine (47.4%) of which were seen in only one position., Conclusion: Use of both the supine and prone positions for patients undergoing CT colonography improves evaluation of the colon and increases sensitivity for polyp detection.

Computed tomographic (CT) peritoneography involves CT of the abdomen and pelvis after administration of a mixture of contrast material and dialysate. CT peritoneography can demonstrate a variety of complications of continuous ambulatory peritoneal dialysis. In patients with symptoms of peritonitis, CT peritoneography is better than conventional CT in demonstrating loculated fluid collections and indicates adhesions by means of uneven distribution of the contrast material-dialysate mixture. In patients with edema or abdominal bulging, CT peritoneography reliably shows the site of dialysate leakage and allows differentiation of a leak from a hernia. In patients with problems of fluid return, catheter malposition and its effect on dialysate distribution can be determined with CT peritoneography. In patients with poor ultrafiltration, demonstration of restricted space in the pelvis or poor distribution of fluid with CT peritoneography suggests adhesions. CT peritoneography also provides anatomic information for referring physicians that may determine whether treatment is medical or surgical.

Objective: This study was conducted to determine the criteria for unresectability of major peripancreatic vessels in patients with pancreatic carcinoma as revealed by optimally enhanced, pancreatic-phase thin-section helical CT., Subjects and Methods: Twenty-five patients with pancreatic adenocarcinoma who underwent local dissection during curative or palliative surgery also underwent preoperative pancreatic-phase thin-section helical CT (40- to 70-sec delay, 2.5- to 3-mm collimation). Tumor involvement of the portal and superior mesenteric veins and the celiac, hepatic, and superior mesenteric arteries was prospectively graded on a 0-4 scale based on circumferential contiguity of tumor to vessel. Subsequent surgical results were then correlated with the CT grades., Results: At surgery, definitive evaluation was possible for 80 vessels. Forty-eight of 48 vessels graded 0 and three of three vessels graded 1 were resectable. Four of seven vessels graded 2, seven of eight vessels graded 3, and 14 of 14 vessels graded 4 were unresectable. A threshold of between grades 2 and 3, which corresponded to tumor involvement of one-half circumference of the vessel, yielded the lowest number of false-negatives and an acceptable number of false-positives for unresectability. Such a threshold would have yielded a sensitivity of 84%, a specificity of 98%, a positive predictive value of 95%, and a negative predictive value of 93% for unresectability of the vessels studied., Conclusion: A grading system for tumor involvement of the major vessels in patients with pancreatic adenocarcinoma can be based on the degree of circumferential contiguity of tumor to vessel. Involvement of vessel to tumor that exceeds one-half circumference of the vessel is highly specific for unresectable tumor.

Objective: Five CT studies in three patients with congenital or idiopathic hepatic vascular malformations were reviewed., Conclusion: Consistent findings included direct visualization of the abnormal vessels, hepatomegaly, and changes of fibrosis. Dual-phase helical CT in two patients also revealed arteriovenous shunting. One patient had growth of the malformation over 7 years.

Objective: To present five cases of the rare solid and papillary neoplasm of the pancreas with pathological correlation and review of the literature., Patients and Methods: Five patients (all female, two Caucasian, one Philipino and two Hispanic) with solid and papillary neoplasm of the pancreas were reviewed. Four patients were under 28 years of age but one patient was 44 years old at presentation. Review consisted of imaging (CT in all and ultrasound in three patients), gross pathological and histological appearance (5/5 specimens), immunohistochemistry (4/5 specimens) and clinical follow-up., Results: All five tumours were successfully resected without recurrence. All tumours were well-encapsulated but showed a wide spectrum of solid peripheral tumour with central cystic degeneration on imaging. Cystic spaces corresponded to haemorrhagic necrosis on histology. One tumour showed rim calcification. Immunohistological staining showed variable expression of both exocrine and endocrine markers., Conclusion: Although non-specific, solid and papillary neoplasm of the pancreas is characteristically a benign, well-encapsulated solid tumor with varying degree of central necrosis in young female patients. No racial predilection was demonstrated in this small series.

Neuromuscular dysfunction of the cricopharyngeus muscle is becoming increasingly recognized as a cause of dysphagia, particularly in the growing geriatric population. The disorder may occur primarily, or as part of a generalized neurologic syndrome. This debilitating and potentially lethal type of dysphagia, formerly managed by nasogastric tube or gastrostomy feeding, is usually correctable by simple section of the cricopharyngeus muscle. We report a series of six successfully managed patients to illustrate important aspects of diagnosis and treatment.

We studied the clinical, roentgenographic, and pathologic features of what is, to our knowledge, the seventh reported case of cholangiocarcinoma associated with Caroli's disease. Review of the literature reveals that the incidence of carcinoma in patients with this condition is higher than that previously reported for other forms of biliary-tract ectasia. Bile stasis, cholangitis, and the presence of carcinogens and promoters in bile may combine to produce the high incidence of carcinoma in these patients.

Gray-scale ultrasonography (GSU) and thin-needle cholangiography (TNC) were performed in 35 consecutive patients with unexplained jaundice. The status of the biliary tree was correctly assessed by GSU in 33 of 35 cases (94%); in two patients technical difficulty prevented definitive assessment. Neither false-positive nor false-negative results were encountered. There were no discrepancies between the results of GSU and TNC. We conclude that GSU provides a safe, highly reliable method of assessing the jaundiced patient and should be the preferred initial procedure in the diagnostic evaluation of patients with jaundice when the major differential lies between the medical and surgical types. If GSU does not demonstrate a dilated biliary system, TNC is unnecessary, and other diagnostic studies should be undertaken.

Thin needle cholangiography (TNC) was performed in 50 patients with obstructive jaundice or jaundice of obscure origin. The purpose of this study was to assess the diagnostic accuracy and safety of this procedure. TNC was performed by the technique described by Redeker et al. using the Chiba needle (JAMA 231:386, 1975). Obstructed ducts were successfully demonstrated in 100% of cases (29/29). Non-obstructed ducts were opacified in 12/21 (57%). Overall success was 82% (41/50). Two septic complications occurred. It is concluded that 1) TNC is a highly reliable, easy to perform and safe procedure in the evaluation of the jaundiced patient; 2) Accurate demonstration of the biliary anatomy by TNC provided important information which often in (10/50 = 20%) led to a change in diagnosis, avoidance of unnecessary procedures, and shortening of hospitalization; 3) Failure to visualize patients with non-dilated biliary ducts occurred with advanced chronic liver disease or fatty liver.

Sigmoid volvulus was diagnosed in two patients with progressive system sclerosis. In one case, this was initially confused with a high fecal impaction. Both cases responded to early surgical intervention. Sigmoid volvulus should be considered in the differential diagnosis of intestinal obstruction associated with progressive systemic sclerosis.

In 143 jaundiced patients, ultrasound demonstrated the extrahepatic biliary system in 38% of those with medical and 74% of those with surgical jaundice. The size of the extrahepatic biliary system indicated that surgical was best differentiated from medical jaundice when 5 mm served as the upper normal limit for the common hepatic or common bile duct in patients without prior biliary surgery. Half of those patients with prior biliary bypass surgery had nondiagnostic sonograms. In 22% of the jaundiced patients, no additional imaging procedures were performed before definitive therapy. The role of ultrasound in evaluating jaundiced patients is discussed.