Novel anticancer agents have replaced conventional chemotherapy as first line agents for many cancers, with continued new and expanding indications. Small molecule inhibitors act on cell surface or intracellular targets and prevent the downstream signaling that would otherwise permit tumor growth and spread. Anticancer antibodies can be directed against growth factors or may be immunotherapeutic agents. The latter act by inhibiting mechanisms that cancer cells use to evade the immune system. Hormonal agents act by decreasing levels of hormones that are necessary for the growth of certain cancer cells. Cancer therapy protocols often include novel anticancer agents and conventional chemotherapy used successively or in combination, in order to maximize survival and minimize morbidity. A working knowledge of anti-cancer drug classification will aid the radiologist in assessing response on imaging.

Similar to the experiences of other radiology practices, our radiology staff members felt that scored peer review identified few errors/learning opportunities while undermining team collegiality. They desired a more effective way to promote team collegiality and foster lifelong learning. We describe the steps our department took to transition from a peer review system to a peer learning program.

Procedure Appropriateness Category Relative Radiation Level Fluoroscopy barium swallow modified Usually Appropriate ☢☢☢ Fluoroscopy pharynx dynamic and static imaging May Be Appropriate ☢☢☢ Fluoroscopy biphasic esophagram May Be Appropriate ☢☢☢ Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢ CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢ CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢ CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢ Esophageal transit nuclear medicine scan Usually Not Appropriate ☢☢☢

This review summarizes the relevant literature for the initial imaging of patients with symptoms of dysphagia. For patients with oropharyngeal dysphagia who have an underlying attributable cause, a modified barium swallow is usually appropriate for initial imaging but for those who have unexplained dysphagia a fluoroscopic biphasic esophagram is usually appropriate. Fluoroscopic biphasic esophagram is usually appropriate for initial imaging in both immunocompetent and immunocompromised patients who have retrosternal dysphagia. For postoperative patients with dysphagia, fluoroscopic single-contrast esophagram and CT neck and chest with intravenous (IV) contrast are usually appropriate for oropharyngeal or retrosternal dysphagia occurring in the early postoperative period where water-soluble contrast is usually preferred rather than barium sulfate. In the later postoperative period (greater than 1 month), CT neck and chest with IV contrast and fluoroscopic single-contrast esophagram are usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Procedure Appropriateness Category Relative Radiation Level Fluoroscopy barium swallow modified Usually Appropriate ☢☢☢ Fluoroscopy pharynx dynamic and static imaging May Be Appropriate ☢☢☢ Fluoroscopy biphasic esophagram May Be Appropriate ☢☢☢ Fluoroscopy single contrast esophagram May Be Appropriate ☢☢☢ CT neck and chest without IV contrast Usually Not Appropriate ☢☢☢☢ CT neck and chest with IV contrast Usually Not Appropriate ☢☢☢☢ CT neck and chest without and with IV contrast Usually Not Appropriate ☢☢☢☢ Esophageal transit nuclear medicine scan Usually Not Appropriate ☢☢☢

The range of pathology in adults that can produce abdominal pain is broad and necessitates an imaging approach to evaluate many different organ systems. Although localizing pain prompts directed imaging/management, clinical presentations may vary and result in nonlocalized symptoms. This review focuses on imaging the adult population with nonlocalized abdominal pain, including patients with fever, recent abdominal surgery, or neutropenia. Imaging of the entire abdomen and pelvis to evaluate for infectious or inflammatory processes of the abdominal viscera and solid organs, abdominal and pelvic neoplasms, and screen for ischemic or vascular etiologies is essential for prompt diagnosis and treatment. Often the first-line modality, CT quickly evaluates the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain. Ultrasound and tailored MRI protocols may be useful as first-line imaging studies, especially in pregnant patients. In the postoperative abdomen, fluoroscopy may help detect anastomotic leaks/abscesses. While often performed, abdominal radiographs may not alter management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ MRI abdomen and pelvis without and with IV contrast May Be Appropriate O US abdomen May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ MRI abdomen and pelvis without IV contrast May Be Appropriate O CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢ Radiography abdomen May Be Appropriate ☢☢ FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢ WBC scan abdomen and pelvis Usually Not Appropriate ☢☢☢☢ Nuclear medicine scan gallbladder Usually Not Appropriate ☢☢ Fluoroscopy contrast enema Usually Not Appropriate ☢☢☢ Fluoroscopy upper GI series with small bowel follow-through Usually Not Appropriate ☢☢☢

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ US abdomen May Be Appropriate O MRI abdomen and pelvis without and with IV contrast May Be Appropriate O US pelvis May Be Appropriate O MRI abdomen and pelvis without IV contrast May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ Radiography abdomen Usually Not Appropriate ☢☢ Fluoroscopy contrast enema Usually Not Appropriate ☢☢☢ WBC scan abdomen and pelvis Usually Not Appropriate ☢☢☢☢

This review summarizes the relevant literature regarding colorectal screening with imaging. For individuals at average or moderate risk for colorectal cancer, CT colonography is usually appropriate for colorectal cancer screening. After positive results on a fecal occult blood test or immunohistochemical test, CT colonography is usually appropriate for colorectal cancer detection. For individuals at high risk for colorectal cancer (eg, hereditary nonpolyposis colorectal cancer, ulcerative colitis, or Crohn colitis), optical colonoscopy is preferred because of its ability to obtain biopsies to detect dysplasia. After incomplete colonoscopy, CT colonography is usually appropriate for colorectal cancer screening for individuals at average, moderate, or high risk. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Colorectal cancers are common tumors in the United States and appropriate imaging is essential to direct appropriate care. Staging and treatment differs between tumors arising in the colon versus the rectum. Local staging for colon cancer is less integral to directing therapy given radical resection is often standard. Surgical options for rectal carcinoma are more varied and rely on accurate assessment of the sphincter, circumferential resection margins, and peritoneal reflection. These important anatomic landmarks are best appreciated on high-resolution imaging with transrectal ultrasound or MRI. When metastatic disease is suspected, imaging modalities that provide a global view of the body, such as CT with contrast or PET/CT may be indicated. Rectal cancer often metastasizes to the liver and so MRI of the liver with and without contrast provides accurate staging for liver metastases. This article focuses on local and distant staging and reviews the appropriateness of different imaging for both variants.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

CT abdomen and pelvis with IV contrast 5 May be appropriate if MRI cannot be performed and tumor is locally advanced. ☢☢☢ CT abdomen and pelvis without IV contrast 3 May be appropriate if MRI cannot be performed and tumor is locally advanced. ☢☢☢ CT abdomen and pelvis without and with IV contrast 3 May be appropriate if MRI cannot be performed and tumor is locally advanced. ☢☢☢☢ CT colonography 3 Low dose CTC without IV contrast. ☢☢☢

This article reviews the computed tomography (CT) findings of miscellaneous regional and diffuse small bowel disorders. CT technique and potential pitfalls are discussed. Several categories of regional and diffuse small bowel conditions are reviewed, with representative CT images. These disorders often have relatively nonspecific CT appearances, and correlation with the history, clinical, and laboratory findings in each specific case is critical. In selected conditions, the CT findings are highly specific. The imaging literature of some of the common as well as some of the less common entities is reviewed, and clues to narrowing the differential diagnosis are provided.

OBJECTIVE. The purpose of this article is to retrospectively review the radiologic and clinical findings in patients with angiotensin-converting enzyme inhibitor (ACEI)-induced small-bowel angioedema, with an emphasis on CT findings.MATERIALS AND METHODS. Imaging findings, with an emphasis on CT, and clinical characteristics of 20 patients (23 presentations) presenting to two institutions' emergency departments from 1996 through 2010 with ACEI-induced small-bowel angioedema were retrospectively reviewed by two abdominal radiologists who were aware of the diagnosis. Examinations were reviewed in consensus to determine common radiographic findings.RESULTS. Patient age range was 23-83 years (mean, 56 years). Sixteen of the 20 patients were women, and 15 of 20 were obese. All had acute onset of severe abdominal pain. The date of the initial episode prompting CT evaluation ranged from 2 days to 10 years after the start of ACEI therapy (average, 3.3 years). All patients underwent abdominal CT examinations while symptomatic; five patients also underwent a small-bowel series. Three patients underwent urgent surgery for presumed small-bowel ischemia. All patients had resolution of symptoms within 4 days of hospitalization. CT findings included ascites in all patients, small-bowel wall thickening (mean, 1.3 cm), mild dilatation (mean, 2.9 cm), and straightening. There was no small-bowel obstruction.CONCLUSION. ACEI-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACEI therapy present with abdominal complaints and the following combination of findings on CT examination: ascites, small-bowel wall thickening, dilatation without obstruction, and straightening.

PURPOSE: The aim of our study was to determine whether young patients with diverticulitis were more likely to present with abdominal CT evidence of severe disease.METHODS: We analyzed the abdominal CT scans of 932 patients who presented to our institution with CT scan findings consistent with diverticulitis from January 2002 through June 2007. Radiologists retrospectively reviewed all abdominal scans for the presence of imaging findings consistent with diverticulitis (bowel wall thickness, extraluminal air, free perforation, abscess, or fistula). The cohort was divided into 2 groups; patients <= 50 years of age and patients >51 years of age.RESULTS: Two hundred forty-three patients were <= 50 years and 689 patients were >51 years. Young patients were more likely to be male (63% vs 42%, P < .0001). Young patients had a higher proportion of scans with extraluminal air than older patients (19.7% vs 12.6%, P < .008). Young patients were more likely to present with severe disease found by CT than older patients (19.3% vs 11.5%). When we adjusted for gender, young males had a higher proportion of scans with extraluminal air than older males (22.4% vs 13.1%, P = .014). Young males were also more likely to present with severe disease (22% vs 12%).CONCLUSION: Young patients were more likely to have extraluminal air and severe disease found by CT. Young male patients presented more commonly with evidence of severe disease. They did not differ from older patients in rates of free perforation, abscess, or fistula formation.

Degos disease is a rare idiopathic vasculopathy with multisystem involvement. We present a previously healthy 40-year-old woman who developed spontaneous small bowel infarctions and perforations 17 months after presentation with characteristic skin lesions. The abdominal CT findings of Degos disease, which have not been previously depicted in the radiology literature, are discussed.

The ileal-pouch anal anastomosis is a means of preserving fecal continence in those patients undergoing total colectomy, primarily for treatment of ulcerative colitis and familial adenomatous polyposis. There are a variety of complications associated with the procedure, ranging from acute leaks to nonspecific pouchitis, and small bowel obstructions. Radiographic evaluation, primarily using conventional barium enemas and contrast-enhanced computed tomography, is crucial in guiding clinical management of these patients. Recent technical advancements in magnetic resonance imaging render this modality a potentially viable imaging alternative, while avoiding ionizing radiation. This article reviews the normal postoperative appearance and depicts a variety of radiographic complications associated with pouch creation.

OBJECTIVE:The purpose of this article is to describe and illustrate intramural fat in the duodenum and jejunum, to our knowledge a previously undescribed finding in celiac disease.CONCLUSION:Celiac disease is known to produce inflammation of the duodenum and jejunum. We propose that postinflammatory intramural fat deposition occurs in a distribution likely unique for celiac disease. CT scans of the chest and abdomen obtained for many indications include these portions of the bowel. Celiac disease is now recognized as a common disease, and the recognition of intramural fat in the duodenum and jejunum on CT may allow earlier diagnosis.

Screening of asymptomatic average-risk patients for the presence of colon cancer and early detection in precursor stages is of great interest to the general population. Comprehensive evaluation of symptomatic or high-risk patients represents another important clinical focus. Available techniques for total colon imaging, rectal cancer staging and the role of positron emission, tomography are discussed.

Obesity is an epidemic in the United States. The laparoscopic Roux-en-Y gastric bypass procedure is an effective surgical intervention that can produce dramatic weight loss in morbidly obese patients. Despite the inherent risks, the surgery is increasing in popularity. Radiology plays a crucial role in postoperative evaluation. Upper gastrointestinal (UGI) series and abdominal computed tomography (CT) are the primary radiologic tools used in assessment of possible complications. With knowledge of the normal postoperative appearance, performance of UGI studies and interpretation of the results should be easy. The 24-hour postoperative examination allows reliable detection of anastomotic leaks. Although strictures of the gastrojejunal anastomosis are a common complication, they are often diagnosed and treated with endoscopy. In a thorough examination, one also evaluates for degraded pouch restriction, including a patulous gastrojejunal anastomosis or gastrogastric fistula, as a late cause of weight gain. Knowledge of the postoperative anatomy also assists in detection of internal hernias. CT is invaluable in detection and characterization of small bowel obstructions and internal hernias. CT may allow diagnosis of anastomotic leaks, abscesses, gastrogastric fistulas, and intraabdominal hematomas. CT-guided percutaneous procedures, such as placement of gastrostomy tubes or drainage of fluid collections, can obviate emergency exploration and may be the only procedural intervention necessary for a cure.