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MDCT enteroclysis with split bolus technique provides additional information on the urinary tract in patients with suspected bowel endometriosis
No full textIntroduction: Multidetector computerized tomography enteroclysis (MDCTe) has been demonstrated to be accurate in the diagnosis of bowel endometriosis. In this study we present a modified protocol of MDCTe which allows to study the urinary tract without increasing the radiation dose imparted to the patients. Materials and methods: This prospective study included 103 women who underwent laparoscopy because of pain and gastrointestinal symptomssuggestive of pelvic and colorectal endometriosis. Women with a previous diagnosis of urolithiasis were excluded from the study. Colonic distension was achieved by introducing 2000–2300ml of water (378C). The same iodine load per patient body weight (7.4 mg/kg) was administered. The intra- venous contrast material (c.m.) was administered by using a split bolus technique. 20% of the c.m. was administered at a rate of 1 ml/s during colon distension (8 minutes before starting the volumetric acquisition). After injec- tion of the remaining quantity of the c.m, the volumetric acquisition was per- formed during the portal phase of the c.m. (40 s after the arterial peak). One volumetric acquisition was performed from the dome of the diaphragm to the pubic symphysis. Examinations were performed on a 16-row MDCT scanner (LightSpeed, GE Medical Systems, Waukesha, Wisconsin, USA). In addition to axial images, coronally and sagittally reformatted multiplanar reconstructions, maximum-intensity- projections, average-intensity-projections images were generated on an Advantage workstation (AW 4.2, GE Healthcare). Images were evaluated on a PACS workstation (Centricity, GE Healthcare) by two radiologists. The presence of bowel endometriotic nodules and the depth of infiltration of the nodules in the bowel wall were determined. The radiologists classified ureteral opacification as poor, sufficient, and good. When the ureter was opa- cified between the crossing of the iliac vessels and the bladder, the radiol- ogists determined whether ureteral compression was present. Radiological findings were compared with surgical and histological results. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (LRþ), and negative likelihood ratio (LR2) were calculated by using the CATmaker software (CEBM, Oxford, UK).
Results: Surgery revealed that 67 women (65.0%) had bowel endometriotic nodules. The sensitivity of MDCTe in identifying bowel nodules was 95.5%, the specificity 97.2%, the PPV 98.5%, the NPV 92.1%, the accuracy 96.1%, the LRþ 34.39, and the LR- 0.05. Three bowel nodules were not detected by MDCTe; they were all located on the rectum. The effectiveness of MDCTe was also determined for the diagnosis of bowel nodules infiltrating at least the muscular layer. In this analysis the sensibility of MDCTe was 93.3%, the specificity 96.6%, the PPV 95.5%, the NPV 94.9%, the accuracy 95.1%, the LRþ 27.07, and the LR- 0.07. One patient had a double ureter. Ureteral opacification was judged to be poor in 17 cases (8.2%), suf- ficient in 36 cases (17.4%), and good in 154 cases (74.4%). The renal cav- ities were well detected in all cases; no hydronephrosis was observed. Compression of the distal ureter was observed at MDCTe in 36 cases (17.4%); surgery confirmed the presence of ureteral compression in 34 cases (16.4%); therefore, there were two false positive at MDCTe. In 137 cases laparoscopic examination of the ureters revealed the presence of super- ficial endometriotic lesions involving the peritoneum overlying the ureters; however, no ureteral compression was observed. The sensitivity of MDCTe in identifying ureteral compression was 97.1%, the specificity 98.8%, the PPV 94.4%, the NPV 99.4%, the accuracy 99.0%, the LRþ 83.54, and the LR20.03.
Conclusions: Applying the split bolus technique to MDCTe allows diagnosing ureteral endometriosis and does not compromise the accuracy in the detection of bowel endometriosis
L'enteroclisi TC multistrato del colon (ETCMS) per lo studio della endometriosi intestinale: cosa è necessario sapere
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L'enteroclisi-TC multistrato del colon (E-TCMS) associata alla tecnica "split-bolus": metodica integrata per la valutazione degli ureteri in donne con endometriosi intestinale
No full textMultidetector computerised tomography enteroclysis versus magnetic resonance enteroclysis in the diagnosis of colorectal endometriosis
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Incidental physiological sliding hiatal hernia: a single center comparison study between CT with water enema and CT colonography
No full textPURPOSE:
Hiatal hernia is a well-known factor impacting on most mechanisms underlying gastroesophageal reflux, related with the risk of developing complications such as erosive esophagitis, Barrett's esophagus and ultimately, esophageal adenocarcinoma. It is our firm opinion that an erroneous reporting of hiatal hernia in CT exams performed with colonic distention may trigger a consecutive diagnostic process that is not only unnecessary, inducing a unmotivated anxiety in the patient, but also expensive and time-consuming for both the patient and the healthcare system. The purposes of our study were to determine whether colonic distention at CT with water enema and CT colonography can induce small sliding hiatal hernias and to detect whether hiatal hernias size modifications could be considered significant for both water and gas distention techniques.
METHODS:
We retrospectively evaluated 400 consecutive patients, 200 undergoing CT-WE and 200 undergoing CTC, including 59 subjects who also underwent a routine abdominal CT evaluation on a different time, used as internal control, while a separate group of 200 consecutive patients who underwent abdominal CT evaluation was used as external control. Two abdominal radiologists assessed the CT exams for the presence of a sliding hiatal hernia, grading the size as small, moderate, or large; the internal control groups were directly compared with the corresponding CT-WE or CTC study looking for a change in hernia size. We used the Student's t test applying a size-specific correction factor, in order to account for the effect of colonic distention: these "corrected" values were then individually compared with the external control group.
RESULTS:
A sliding hiatal hernia was present in 51 % (102/200) of the CT-WE patients and in 48.5 % (97/200) of the CTC patients. Internal control CT of the 31 patients with a hernia at CT-WE showed resolution of the hernia in 58.1 % (18/31) of patients, including 76.5 % (13/17) and 45.5 % (5/11) of small and moderate hernias. Comparison CT of the 28 patients with a hiatal hernia at CTC showed the absence of the hernia in 57.1 % (16/28) patients, including 68.8 % (11/16) and 50 % (5/10) of small and moderate hernias. The prevalence of sliding hiatal hernias in the external control group was 22 % (44/200), significantly lower than the CT-WE and CTC cohorts' prevalence of 51 % (p < 0.0001) and 48.5 % (p < 0.0001). After applying the correction factors for the CT-WE and the CTC groups, the estimated residual prevalences (16 and 18.5 %, respectively) were much closer to that of the external control patients (p = 0.160 for CT-WE and p = 0.455 for CTC).
CONCLUSIONS:
We believe that incidental findings at CT-WE and CTC should be considered according to the clinical background, and that small sliding hiatal hernias should not be reported in patients with symptoms not related to reflux disease undergoing CT-WE or CTC: When encountering these findings, accurate anamnesis and review of medical history looking for GERD-related symptoms are essential, in order to address these patients to a correct diagnostic iter, taking advantage from more appropriate techniques such as endoscopy or functional techniques
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