Bronchobiliary Fistula Detected by Cholescintigraphy
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SAGES Clinical Spotlight Review: Intraoperative Cholangiography
SAGES Clinical Spotlight Review: Intraoperative cholangiography William W. Hope, MD, Robert Fanelli MD, Danielle S. Walsh MD, Ray Price MD, Dimitrios Stefanidis MD, William S. Richardson MD, and the SAGES Guidelines Committee Preamble The following clinical spotlight review regarding the intraoperative cholangiogram is intended for physicians who manage and treat gallbladder/biliary pathology and perform laparoscopic cholecystectomy. It is meant to critically review the technique of intraoperative cholangiography, alternatives for intraoperative biliary imaging, and the available evidence supporting their safety and efficacy. Based on the level of evidence, recommendations may or may not be given for their use in clinical practice. Disclaimer Guidelines for clinical practice and spotlight reviews are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Spotlight reviews are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to convey recommendations based on a focused topic; within the defined scope of review, they indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines and recommendations are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines, spotlight reviews, and recommendations are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. -
Impact of Preoperative Endoscopic Ultrasound in Surgical Oncology
REVIEW Impact of preoperative endoscopic ultrasound in surgical oncology Endoscopic ultrasound (EUS) has a strong impact on the imaging and staging of solid tumors within or in close proximity of the upper GI tract. Technological developments during the last two decades have increased the image quality and allowed very detailed visualization of local tumor spread and lymph node affection. Current indications for EUS of the upper GI tract encompass the differentiation between benign and malignant lesions, the staging of esophageal, gastric and pancreatic cancer, and the procurement of a biopsy specimen through fine-needle aspiration. Various technical innovations during the past two decades have increased the diagnostic quality and have simultaneously strengthened the role of EUS in the clinical setting. This article will give a compressed summary on the current state of EUS and possible further technical developments. 1 KEYWORDS: 3D imaging elastosonography endoscopic ultrasound miniprobes Sascha S Chopra & oncologic surgery Michael Hünerbein† 1Department of General & Transplantation Surgery, Charité Campus Virchow-Clinic, Berlin, Conventional endoscopic ultrasound the so-called ‘miniprobes’ into the biliary system Germany Linear versus radial systems or the pancreatic duct in order to obtain high-res- †Author for correspondence: Department of Surgery & Surgical Endoscopic ultrasound (EUS) with flex- olution radial ultrasound images locally. Present Oncology, Helios Hospital Berlin, ible endoscopes is an important diagnostic and mini probes show a diameter of 2–3 mm and oper- 13122 Berlin, Germany Tel.: +49 309 417 1480 therapeutic tool, especially for the local staging ate with frequencies between 12 and 30 MHz. Fax: +49 309 417 1404 of gastrointestinal (GI) cancers, the differen- The main drawbacks of these devices are the lim- michael.huenerbein@ tiation between benign and malignant tumors, ited durability and the decreased depth of penetra- helios-kliniken.de and interventional procedures, such as biopsies tion (~2 cm). -
ACR Appropriateness Criteria® Right Upper Quadrant Pain
Revised 2018 American College of Radiology ACR Appropriateness Criteria® Right Upper Quadrant Pain Variant 1: Right upper quadrant pain. Suspected biliary disease. Initial imaging. Procedure Appropriateness Category Relative Radiation Level US abdomen Usually Appropriate O CT abdomen with IV contrast May Be Appropriate ☢☢☢ MRI abdomen without and with IV May Be Appropriate contrast with MRCP O MRI abdomen without IV contrast with May Be Appropriate MRCP O Nuclear medicine scan gallbladder May Be Appropriate ☢☢ CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ Variant 2: Right upper quadrant pain. No fever or high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound. Procedure Appropriateness Category Relative Radiation Level MRI abdomen without and with IV Usually Appropriate contrast with MRCP O CT abdomen with IV contrast Usually Appropriate ☢☢☢ MRI abdomen without IV contrast with Usually Appropriate MRCP O Nuclear medicine scan gallbladder May Be Appropriate ☢☢ CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ Variant 3: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound. Procedure Appropriateness Category Relative Radiation Level MRI abdomen without and with IV Usually Appropriate contrast with MRCP O CT abdomen with IV contrast Usually Appropriate ☢☢☢ Nuclear medicine scan gallbladder Usually Appropriate ☢☢ MRI abdomen without IV contrast with May Be Appropriate MRCP O CT abdomen without IV contrast May Be Appropriate ☢☢☢ CT abdomen without and with IV Usually Not Appropriate contrast ☢☢☢☢ ACR Appropriateness Criteria® 1 Right Upper Quadrant Pain Variant 4: Right upper quadrant pain. -
ACR Manual on Contrast Media
ACR Manual On Contrast Media 2021 ACR Committee on Drugs and Contrast Media Preface 2 ACR Manual on Contrast Media 2021 ACR Committee on Drugs and Contrast Media © Copyright 2021 American College of Radiology ISBN: 978-1-55903-012-0 TABLE OF CONTENTS Topic Page 1. Preface 1 2. Version History 2 3. Introduction 4 4. Patient Selection and Preparation Strategies Before Contrast 5 Medium Administration 5. Fasting Prior to Intravascular Contrast Media Administration 14 6. Safe Injection of Contrast Media 15 7. Extravasation of Contrast Media 18 8. Allergic-Like And Physiologic Reactions to Intravascular 22 Iodinated Contrast Media 9. Contrast Media Warming 29 10. Contrast-Associated Acute Kidney Injury and Contrast 33 Induced Acute Kidney Injury in Adults 11. Metformin 45 12. Contrast Media in Children 48 13. Gastrointestinal (GI) Contrast Media in Adults: Indications and 57 Guidelines 14. ACR–ASNR Position Statement On the Use of Gadolinium 78 Contrast Agents 15. Adverse Reactions To Gadolinium-Based Contrast Media 79 16. Nephrogenic Systemic Fibrosis (NSF) 83 17. Ultrasound Contrast Media 92 18. Treatment of Contrast Reactions 95 19. Administration of Contrast Media to Pregnant or Potentially 97 Pregnant Patients 20. Administration of Contrast Media to Women Who are Breast- 101 Feeding Table 1 – Categories Of Acute Reactions 103 Table 2 – Treatment Of Acute Reactions To Contrast Media In 105 Children Table 3 – Management Of Acute Reactions To Contrast Media In 114 Adults Table 4 – Equipment For Contrast Reaction Kits In Radiology 122 Appendix A – Contrast Media Specifications 124 PREFACE This edition of the ACR Manual on Contrast Media replaces all earlier editions. -
Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement
Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement Harvey A. Ziessman, MD; Douglas A. Jones, MD; Larry R. Muenz, PhD; and Anup K. Agarval, MS Department of Radiology, Georgetown University Hospital, Washington, DC Fatty meals have been used by investigators and clini- The purpose of this investigation was to evaluate the use of a cians over the years to evaluate gallbladder contraction in commercially available lactose-free fatty-meal food supple- conjunction with oral cholecystography, ultrasonography, ment, as an alternative to sincalide cholescintigraphy, to de- and cholescintigraphy. Proponents assert that fatty meals velop a standard methodology, and to determine normal gall- are physiologic and low in cost. Numerous different fatty bladder ejection fractions (GBEFs) for this supplement. meals have been used. Many are institution specific. Meth- Methods: Twenty healthy volunteers all had negative medical histories for hepatobiliary and gallbladder disease, had no per- odologies have differed, and few investigations have stud- sonal or family history of hepatobiliary disease, and were not ied a sufficient number of subjects to establish valid normal taking any medication known to affect gallbladder emptying. All GBEFs for the specific meal. Whole milk and half-and-half were prescreened with a complete blood cell count, compre- have the advantage of being simple to prepare and admin- hensive metabolic profile, gallbladder and liver ultrasonography, ister (4–7). Milk has been particularly well investigated. and conventional cholescintigraphy. Three of the 20 subjects Large numbers of healthy subjects have been studied, a were eliminated from the final analysis because of an abnormal- clear methodology described, and normal values determined ity in one of the above studies. -
The Diagnosis of Acute Cholecystitis: Sensitivity of Sonography
The Diagnosis of Acute Cholecystitis: Sensitivity of Sonography, Cholescintigraphy and Computed Tomography Patthisak Changphaisarnkul MD*, Supakajee Saengruang-Orn PhD*, Trirat Boonya-Asadorn MD* * Division of Radiology, Phramonkutklao Hospital, Bangkok, Thailand Objective: To compare the sensitivity of sonographic, cholescintigraphic, and computed tomographic examination of acute cholecystitis to the pathology result, which is considered the Gold Standard. Material and Method: A retrospective analytic study was conducted among 412 patients, aged between 15 and 98 years, who underwent cholecystectomy surgeries, and whose pathology results indicated acute cholecystitis between July 2004 and May 2013. The sensitivity and the differences between sensitivity of the three methods were calculated in all patients. Complicated acute cholecystitis cases were analyzed separately. Results: The three methods demonstrated statistically significant differences in sensitivity (p-value = 0.017), with the cholescintigraphy as the most sensitive method (84.2%), followed by computed tomography (67.3%), and sonography (59.8%). Concerning the samples with the pathology result indicating complicated acute cholecystitis, computed tomography was statistically significantly more sensitive than sonography in detecting acute cholecystitis, whether or not the complications were identified (100% and 63.6%, respectively, with p-value = 0.0055). None of the patients with the pathology result of complicated acute cholecystitis case was examined by cholescintigraphy, thus, no calculation was possible. Regarding the ability to detect the complications of acute cholecystitis, computed tomography had a sensitivity of 35.71% (5 in 14 patients), while sonographic examinations could not detect any of the complications. Conclusion: Cholescintigraphy is a more sensitive method than computed tomography and sonography, but the three methods have its own advantages, disadvantages, and limitations, which must be considered for each individual patient. -
MRCP Vs. ERCP
MRCPMRCP vs.vs. ERCPERCP SteveSteve Harrell,Harrell, MD,MD, MSPHMSPH AdvancedAdvanced TherapeuticTherapeutic EndoscopyEndoscopy DecemberDecember 6,6, 20072007 University of Louisville InitialInitial ThoughtsThoughts ““So,So, itit isis mymy predictionprediction thatthat MRCPMRCP willwill havehave aa hugehuge effecteffect onon ERCPERCP practicepractice inin thethe UnitedUnited States.States.”” ““IfIf II hadhad aa pancreaticpancreatic oror biliarybiliary problemproblem II wouldwould searchsearch outout …… aa centercenter withwith thethe mostmost sophisticatedsophisticated noninvasivenoninvasive techniquestechniques…… veryvery quickly.quickly.”” ““WeWe allall wantwant thethe bestbest forfor ourour patients;patients; shouldshould wewe treattreat themthem differentlydifferently thanthan wewe wouldwould ourselves?ourselves?”” 5/15/985/15/98 Peter B. Cotton, MD, FRCP Medical University of South Carolina Charleston, South Carolina Universityhttp://www.ddc.musc.edu/ddc_pro/pro_development of Louisville /hot_topics/impact_MRCP-cotton.htm LearningLearning GoalsGoals KnowKnow whatwhat ERCPERCP andand MRCPMRCP standstand forfor AdvantagesAdvantages andand disadvantagesdisadvantages ofof MRCPMRCP IndicationsIndications forfor ERCPERCP PoorPoor IndicationsIndications forfor ERCPERCP ClinicalClinical UseUse inin commoncommon disordersdisorders forfor MRCPMRCP EffectsEffects ofof MRCPMRCP onon ERCPERCP inin trainingtraining CasesCases University of Louisville ERCPERCP EndoscopicEndoscopic retrograderetrograde cholangiopancreatographycholangiopancreatography -
Imaging Indication Guidelines
IMAGING INDICATION GUIDELINES Your partner in outpatient radiology We are dedicated to achieving the highest levels of quality and safety in outpatient imaging. We developed these Imaging Indication Guidelines to help you choose imaging examinations that will answer your clinical questions for your patients. We hope they will assist you in the pre-authorization and Medicare Appropriate Use Criteria processes. Quality Convenience Affordability High quality reports Appointments when and Reduce your out-of-pocket and equipment where you need them imaging cost 2 | IMAGING INDICATION GUIDELINES Notes IMAGING INDICATION GUIDELINES | 3 Notes 4 | IMAGING INDICATION GUIDELINES We are dedicated to achieving the highest levels of quality and safety, and have developed these Imaging Indication Guidelines to provide information and guidance during the radiology ordering process. General Contrast Guidelines Choose “Radiologist Discretion” on the order and our board certified radiologists will select the contrast option suited to your patient’s history and condition. This will facilitate thepre -authorization process. Generally, contrast is indicated whenever you are concerned about: • Infection (except uncomplicated sinusitis) • Organ integrity • Tumor or cancer • Possible disc after lumbar surgery • Vascular abnormality (except stroke) Generally, contrasted MRI scans are performed with and without contrast. Generally, CT scans are performed either with or without contrast in order to limit the patient’s radiation dose. Without & with contrast CT scans are indicated for these conditions: • Thoracic aortic dissection • Kidney mass • Liver mass • Painless hematuria • Pancreas mass • Bladder mass • Adrenal gland mass Exams Commonly Confused: • Cervical CT or MRI (for vs. Soft tissue neck CT or MRI (for soft cervical spine) tissue, e.g. -
Ography C Virtual Colonoscopy for Screening
466 Gut 2004;53:466 Gut: first published as on 11 February 2004. Downloaded from Please visit the Gut website (www.gutjnl.com) for links possible to generate three dimensional ultrasound cholangiograms. to these articles – many to full text. The authors prospectively evaluated the ability of this technique, compared with direct cholangiography (endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous transhepatic cho- langiogram (PTC)) and MRCP, to detect and characterise biliary ....................................................................... obstruction in 40 patients. Experienced operators, who were blinded to the results of the other tests, evaluated images for Pseudo-pseudomembranous collagenous technical adequacy, presence and level of obstruction, and c suspected cause of any stricture. Compared with two dimensional colitis ultrasound, three dimensional analysis improved the assessment of m Yuan S, Reyes V, Bronner MP. Pseudomembranous collagenous colitis. Am J biliary anatomy in seven of 40 patients. Three dimensional Surg Pathol 2003;27:1375–9. ultrasound however visualised the peripapillary region less well Microscopic colitis has been divided into three types (Warren BF, et (80%) than MRCP (95%) and direct cholangiography (100%) but al. Histopathology 2002;40:374–6), all characterised by watery was superior at demonstrating the gall bladder and biliary tree diarrhoea and minimal mucosal changes at colonoscopy, asso- proximal to a stricture. All techniques were highly sensitive for ciated with an increase in lamina propria lymphocytes and minimal detection of biliary obstruction (100%) and each diagnosed the crypt architectural distortion. Of the three types, lymphocytic colitis likely cause in 90–95% of cases. Three dimensional ultrasound also has an increase in intraepithelial lymphocytes, collagenous detected the correct level of obstruction in 92% of cases compared colitis has a subepithelial collagen band, and microscopic colitis not with 95% for MRCP and 90% for ERCP/PTC. -
Magnetic Resonance Cholangio-Pancreatography in Patients with Acute Cholecystitis and Cholestatic Liver Pattern - What to Expect?
Jemds.com Original Research Article Magnetic Resonance Cholangio-Pancreatography in Patients with Acute Cholecystitis and Cholestatic Liver Pattern - What to Expect? Ali Al Orf1, Khawaja Bilal Waheed2, Ali Salman Alshehri3, Mushref Ali Algarni4, Bilal Altaf5, Muhammad Amjad6, Ayman Abdullah Alhumaid7, Zechariah Jebakumar Arulanantham8 1Department of Radiology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 2Department of Radiology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 3Department of Radiology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 4Department of Radiology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 5Department of General Surgery, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 6Department of Internal Medicine, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 7Department of Radiology, King Fahad Military Medical Complex, Dhahran, Saudi Arabia. 8Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia. ABSTRACT BACKGROUND Acute cholecystitis is a potentially serious condition and usually needs to be treated Corresponding Author: in the hospital. Identification of a common bile duct (CBD) stone before Khawaja Bilal Waheed, Consultant General Radiologist, cholecystectomy is of concern for the treating physicians as management may King Fahad Military Medical Complex, change. Magnetic Resonance Cholangiopancreatography (MRCP) can help in Dhahran, Saudi Arabia. identifying causes of biliary obstruction (if present) and adequately delineate biliary E-mail: [email protected] tree in selected patients with limited or abnormal ultrasounds and cholestatic liver DOI: 10.14260/jemds/2020/530 pattern. Therefore, we aim to demonstrate imaging findings of MRCP in such patients of acute cholecystitis, and highlight the diagnostic ability of MRCP in biliary ductal How to Cite This Article: evaluation as well. -
Diagnosis and Management of Primary Sclerosing Cholangitis
AASLD PRACTICE GUIDELINES Diagnosis and Management of Primary Sclerosing Cholangitis Roger Chapman,1 Johan Fevery,2 Anthony Kalloo,3 David M. Nagorney,4 Kirsten Muri Boberg,5 Benjamin Shneider,6 and Gregory J. Gores7 Preamble classification used by the Grading of Recommendation This guideline has been approved by the American Asso- Assessment, Development, and Evaluation (GRADE) ciation for the Study of Liver Diseases and represents the workgroup with minor modifications (Table 1).3 The position of the Association. These recommendations pro- strength of recommendations in the GRADE system are vide a data-supported approach. They are based on the classified as strong (class 1) or weak (class 2). The quality following: (1) formal review and analysis of the recently- of evidence supporting strong or weak recommendations published world literature on the topic (Medline search); is designated by one of three levels: high (level A), mod- (2) American College of Physicians Manual for Assessing erate (level B), or low-quality (level C). Health Practices and Designing Practice Guidelines1; (3) guideline policies, including the AASLD Policy on the Definition and Diagnosis Development and Use of Practice Guidelines and the Definitions. Primary sclerosing cholangitis (PSC) is a American Gastroenterological Association Policy State- chronic, cholestatic liver disease characterized by inflam- ment on Guidelines2; and (4) the experience of the au- mation and fibrosis of both intrahepatic and extrahepatic thors in the specified topic. bile ducts,4 leading to the formation of multifocal bile Intended for use by physicians, these recommenda- duct strictures. PSC is likely an immune mediated, pro- tions suggest preferred approaches to the diagnostic, ther- gressive disorder that eventually develops into cirrhosis, apeutic and preventative aspects of care. -
Table 1. Summary of Criterion Evidence
SUMMARY TABLE Table 1: Summary of Criterion Evidence Domain 1: Criteria Related to the Underlying Health Condition Criterion Synthesized Information 1 Size of the affected No estimates of point prevalence of acute cholecystitis were found in the literature. An Ontario population hospital-based study29 estimated the annual incidence of acute cholecystitis from 1992 to 2000 to be 0.88 people per 1,000 population. The size of affected population is more than 1 in 10,000 (0.01%) and less than or equal 1 in 1,000 (0.1%) 2 Timeliness and Saskatchewan hospital guidelines indicate that cholescintigraphy for diagnosis of suspected acute urgency of test cholecystitis should be conducted within 24 hours (Patrick Au, Acute and Emergency Services results in planning Branch, Saskatchewan Ministry of Health: unpublished data, 2011) patient management The target time frame for performing the test is in 24 hours or less and obtaining the 99mTc-based test results in the appropriate timely manner for the underlying condition has significant impact on the management of the condition or the effective use of health care resources. 3 Impact of not If a test for diagnosing acute cholecystitis is not available, treatment might be delayed and performing a complications associated with high mortality rates might be more likely to develop. Complications diagnostic imaging from acute cholecystitis occur in around 20% of patients and complicated acute cholecystitis is test on mortality associated with a mortality rate of around 25%.33 Perforation of the gallbladder, which occurs in related to the 3% to 15% of patients with cholecystitis, has a 60% mortality rate.34 Acute acalculous cholecystitis underlying condition has a mortality rate of around 30%.35 Diagnostic imaging test results can have minimal impact on mortality.