Introduction: Abdominal pneumoperitoneum is often caused by perforated abdominal viscus. Other causes include bowel obstruction, appendicitis, neoplasm, vasculitis, and infection. Presentation varies from asymptomatic to life-threatening sepsis and may warrant emergent surgical intervention. Recurrent idiopathic pneumoperitoneum is a very rare disorder described in only a few case reports in literature. We present a case of asymptomatic recurrent idiopathic pneumoperitoneum. Case Description/Methods: A 56-year-old man with history of chronic pain, GERD, and constipation presented with hand and rib pain after a fall on a sidewalk. Abdominal x-ray showed massive pneumoperitoneum and dilated loops of small bowel. CT scan confirmed pneumoperitoneum and no evidence of bowel obstruction. Labs including CBC and CMP were within normal range. CRP was 9mg/L (normal < 8 mg/L). Repeat CT scan the next day showed stable findings. Patient had no abdominal pain or fever. Patient was discharged home, asymptomatic and hemodynamically stable. CT 1-month later showed persistent large amount of free intraperitoneal air (Figure 1A). Patient remained completely asymptomatic. Surgical consult obtained and no surgery was recommended. Leading diagnosis was pneumatosis cystoids intestinalis and patient treated empirically with antibiotics (metronidazole). Evaluation including upper GI small bowel follow through, colonoscopy, EGD, and gastrograffin enema did not reveal any pathology to explain pneumoperitoneum. Chest CT and serologic work-up (ANA, SSA, SSB, RNP, dsDNA, C3, C4, ANCA, MPO, PR3) ruled out pulmonary etiology, connection tissue disorder and vasculitis. CT enterography 1-month later showed resolution of pneumoperitoneum (Figure 1B). CT 3-months later showed recurrent large amount of free intraperitoneal air (Figure 1C). Patient was re-referred for surgical evaluation. After multidisciplinary discussion with surgery and radiology, he underwent laparoscopy, EGD and flexible sigmoidoscopy; no air leak, cyst or serosal defect was seen. Patient has continued to do well without additional intervention. Discussion: Asymptomatic, recurrent idiopathic pneumoperitoneum is a rare disorder and identifying the etiology can be challenging/anxiety provoking for the patient and provider. Data is very limited but suggests that patients may do well with conservative therapy. Given the rarity of this diagnosis, extensive evaluation and multidisciplinary approach is essential in the diagnosis and management of these patients.Figure 1.: Recurrent idiopathic pneumoperitoneum CT scans over the course of time showing interval resolution and then recurrence of free air (marked by red arrow) in the peritoneum.

The stomach is one of the most frequently imaged organs in the body with dedicated and incidental inclusion in chest imaging modalities. Gastric emergencies often present clinically with non-specific abdominal, nausea, and vomiting. As such, imaging plays a critical role in early identification and treatment of a myriad of gastric emergencies. The goal of this paper is to showcase gastric emergencies as they appear on multimodality imaging.

Introduction: Migration of plastic biliary stents at Endoscopic retrograde cholangiopancreatography (ERCP) is well described. However, proximal migration of the stent into the portal vein is rare and less frequently reported. This case series highlights the approach to successful management of this potentially life threatening complication of ERCP in collaboration with Interventional Radiology (IR). Case Description/Methods: Case 1: A 76-year-old male presented with gallstone pancreatitis to an outside center. An ERCP was performed, with difficult cannulation requiring a needle-knife sphincterotomy that resulted in significant bleeding. A CBD stent was placed and the patient was transferred to our center. Computed tomography (CT) showed placement of the CBD stent through the bile duct into the portal vein. Endoscopic removal of the CBD stent was performed with IR service and surgical back up in place. A percutaneous balloon catheter was introduced into the portal vein, and stent was removed with duodenoscope, with immediate bleeding noted. The balloon in the portal vein was then inflated with good hemostasis. The patient did well. Case 2: A 73-year-old male with a history of Bilroth II gastrectomy presented with abdominal pain, elevated liver tests, CBD stone and gallbladder perforation. ERCP was performed with needle knife sphincterotomy, CBD stone removal and placement of a plastic biliary stent. Two months later the patient presented with lethargy. A CT scan showed impingement of the proximal end of the CBD stent into the portal vein causing stricture of the portal vein. An ERCP was performed in conjunction with the IR service. The CBD stent was removed, a cholangiogram and portal venogram did not demonstrate any contrast leakage or fistulous tract between the biliary tree and the portal vein. The portal vein stricture was balloon dilated by IR and the patient did well. Discussion: Proximal migration of a plastic biliary stent placed at ERCP is a rare but potentially life threatening complication (portal venous bleeding, stricture). This case series highlights the importance of a multidisciplinary approach to management of this complication. Biliary stents at ERCP should be judiciously placed for appropriate indications. Once stent related portal vein injury is suspected or documented, then invoking a planned, multidisciplinary approach to management is critical to avoid catastrophic consequences and to ensure a good patient outcome.Figure 1.: A) CT image showing perforation of the CBD stent through the duodenum and terminating in portal vein in Case 1. B) Portal venogram demonstrating CBD placement into the portal vein from Case 1. C) CT image demonstrating migration of CBD stent with compression upon the portal venous system in Case 2. D) Portal venogram showing CBD stent impingement on the portal vein in Case 2.

INTRODUCTION: A pancreatic mass seen on cross-sectional imaging with liver lesions or lymphadenopathy is concerning for a pancreatic malignancy. Previous reports have discussed the utility of EUS-FNA for evaluation of pancreatic masses; this case series aims to reinforce the game-changing utility of EUS-FNA for the clarification of suspected pancreatic neoplasia. CASE DESCRIPTION/METHODS: Case #1: A 68-year-old woman undergoing evaluation for hematuria was found to have two enhancing liver lesions, two pulmonary nodules, and a low attenuation zone in the uncinate process of the pancreas on CT (Image 1). Physical exam and laboratory tests were unremarkable. A pancreas protocol CT at our center confirmed the above findings and the patient was referred for EUS-FNA. On EUS, pancreatic anatomy was completely normal and no mass was identified. Subsequent evaluation with a triphasic MRI (Image 2) concluded that the liver lesions were atypical hemangiomas and the pancreas had focal fatty replacement that can mimic a pancreatic tumor. A repeat EUS at 6 months was unremarkable and the patient is doing well. Case #2: A 56-year-old woman with history of melanoma presented with RUQ pain and +30lbs weight loss over the previous 5 months. Physical examination was unremarkable and laboratory tests were notable for elevated LFTs. CT (Image 3) revealed a homogeneously enhancing retroperitoneal mass arising between the pancreatic uncinate and D3 with several enlarged mesenteric lymph nodes, suspected to be pancreatic neoplasm. Further evaluation with EUS revealed a 3.5 cm heterogenous periduodenal mass abutting D2 and enlarged peri-gastric lymph nodes. FNA was performed and histopathology identified the mass as gastrointestinal stromal tumor (GIST) with reactive lymph nodes. The patient was started on neoadjuvant Imatinib with approximately 25% shrinkage of the mass appreciated in the first 2 months. Afterward, the patient underwent pancreaticoduodenectomy and surgical pathology revealed a mixed subtype duodenal GIST with a low mitotic rate. DISCUSSION: We report 2 cases of suspected metastatic pancreatic carcinoma whose diagnoses were elucidated as focal fatty replacement and duodenal GIST, respectively, with the help of EUS +/- FNA. Pancreatic lesions found on cross-sectional imaging that are thought to be primary pancreatic neoplasms should be further evaluated by EUS. EUS with/without FNA can be a game-changing imaging modality in such cases, providing an accurate diagnosis and helping guide appropriate management.

Gastropleural fistula is a relatively rare complication that can be seen as a result of traumatic, nontraumatic, benign, and neoplastic etiologies. Most commonly, these are found in patients with diaphragmatic herniation or prior thoracic surgery. Aortoenteric fistulas are rare communications typically between the abdominal aorta and bowel. We present a rare case of an 88-year-old male who developed a gastropleural fistula with erosions into the wall of the descending thoracic aorta. Computed tomography (CT) is a leading modality in evaluation of suspected gastropleural or aortoenteric fistulas given the quick scan time and widespread availability. Prompt diagnosis is essential and requires an understanding of appropriate CT protocols and CT imaging appearance.

A previously healthy 23-year-old man was admitted to an outside hospital with 2 years of intermittent right lower-quadrant pain, nausea, and vomiting. He acknowledged constipation and denied melena or hematochezia. An abdominal computed tomography (CT) showed a small-bowel obstruction in the right lower quadrant. This resolved spontaneously and he underwent an ileocolonoscopy, which was unremarkable. He then established care with our Gastroenterology Division 6 months later. His physical examination and laboratory work-up were normal.

1From the Department of Imaging Sciences (K.K.J., R.S., S.B., S.V., P.F., V.D., D.R.), University of Rochester, 601 Elmwood Ave, PO Box 648, Rochester, NY 14642. Received April 11, 2013; revision requested July 31 and received November 20; accepted March 14, 2014. All authors have disclosed no relevant relationships. Address correspondence to K.K.J. (e-mail: katherine_kaproth-joslin@urmc.rochester.edu). The full digital presentation is available online.

Diseases of the Colon & Rectum: July 2013 - Volume 56 - Issue 7 - p e343 doi: 10.1097/DCR.0b013e318293079a

HomeRadiologyVol. 209, No. 2 PreviousNext ReviewsComputed Body Tomography with MRI Correlation. 3rd edPatrick J. FultzPatrick J. FultzPatrick J. FultzPublished Online:Nov 1 1998https://doi.org/10.1148/radiology.209.2.476MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In Article HistoryPublished in print: Nov 1998 FiguresReferencesRelatedDetailsCited ByAutocorrection in MR Imaging: Adaptive Motion Correction without Navigator Echoes1Armando Manduca, , Kiaran P. McGee, , E. Brian Welch, , Joel P. Felmlee, , Roger C. Grimm, , and Richard L. Ehman, 1 June 2000 | Radiology, Vol. 215, No. 3Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 209, No. 2 Metrics Altmetric Score PDF download

An interstitial pregnancy complicated by rectal bleeding is described. Despite modern imaging modalities, confounding features made preoperative diagnosis difficult. The pregnancy ruptured into the ileum. Ossified fetal skull bones and degenerated placental tissue were the only remains from the pregnancy.

We report a case of hepatic cysticercosis in a 62-year-old man who had been diagnosed with a colonic adenocarcinoma 9 years previously. Additional clinical studies failed to show disease in the soft tissues, brain, orbit and heart. The patient was successfully treated with a course of praziquantel and prednisone and is alive and well 28 months after diagnosis. This is the first reported case of hepatic cysticercosis that has resulted in significant morbidity.

S Vol. 2, No. 12, December 1995 7-3 The Value of the Resistive Index in Screening for Renal Artery Stenosis Jeffrey Lieberman, M.D., Nasser Ghaed, M.D., Patrick Fultz, M.D., Deborah Rubens, M.D. University of Rochester Medical Center. 7-4 Cystic Renal Masses: Accuracy of the Bosniak Classification System Revisited Eric A. Docile, M.D., Todd Wilson, M.D., Richard H. Cohan, Kirk J. Wojno, M.D., Melyvn Korobkin, M.D. University of Michigan. Pnrpose: The resistive index (RI) is e~sily measured by Doppler ultrasound in most kidneys. The purpose of this study was to assess the accuracy of using the RI for the diagnosis of renal artery stenosis (RAS) with captupril renal scintigraphy as the gold standard. Methods: 19 patients with suspected renovaseular hypertension were prospectively studied with the captopril renal scan, using both Te 99m diethylenetriamine-pentacetin acid and l 131 hippuran, and Doppler ultrasound. Doppler ultrasound was performed simultaneously with all renal scans. Three KPs were averaged from the midpole intedobar arteries in each kidney. The difference between the average RI of each patient's two kidneys (A RI) was cainulated. Results: Doppler ultrasound and renal scan resalts were in agreemetu in 18 e l l9 patients (15 negative, 3 positive for RAS) using a cut off value for A RI post captupriI of > 0.1 as gnsitive for RAS. There was a significant difference (p < .0001) in A PA post eaptopril between patients with positive and negative renal scans for RAS. Conclusion: There was excellent correlation between using captupril renal seimigraphy and A RI in screening for renal artery stsnosis. Using the RI difference between kidneys has considerable potential in improving the accuracy of Doppler ultrasound in screening for renal artery stsnosis, Purpose: To evaluate the util i ty of the Bosniak sys tem for classifying cystic renal masses on CT. M e t h o d s : CT scans of 18 pat ients with 20 cystic renal mas se s t ha t were subsequent ly surgically removed or biopsled, were retrospectively reviewed. Masses were categorized us ing the Bosniak sys tem in a blinded fashion and resul ts correlated with the pathology reports. Resu l t s : The f'mal pathology of the cystic renal masses was as follows: category I lesions6 / 6 benign, category II2 / 3 benign, category III0 / 3 benign, and category IV0 / 6 benign. Neither of two unclassifiable cystic hisions tha t measured water a t tenuat ion prior to b u t soft t i ssue a t tenuat ion following contras t media adminis t ra t ion were benign. All 4 measured lesions t ha t enhanced by more than 10 HU were malignant ; however, so were 3 of 6 lesions t ha t did not enhance by more then 10 HU. Six of seven graded malignancies were Fuh rman Grade I or II lesions. C o n c l u s i o n : Our s tudy confirms the usefulness of the Bosniak classification system, since higher category lesions are more likely to be malignant . Enhancement e r a portion of a mass by more t h a n 10 HU suggests malignancy. Minimally complicated (Category I1) or nonenhaneing cystic lesions may contain mal ignant cells. 7-5 Voiding Cystourethrography in Female Stress Incontinence Retta E. Pelsang, M.D., William W. Bonney, M.D. University of Iowa Hospital. 8-1 Computer Assisted Peer Review in Abdominal CT Charles Siegler, M.D., S.M. Pomerantz, B.D. Daly, T.L. Krebs, J.J. Wong, M.J. Severson. University of Maryland Medical System. P U R P O S E . 1) To determine a) the sensitivity of the voiding cystourethrogram (VCUG) in detecting incontinence in women with a history of leakage, b) the positive and negative predictive value of VCUG for stress incontinence, and e) how ofteff a history of leakage is ac6ompaaied by urethrocele on VCUG. 2) To correlate posterior urethrovesieal (PUV) angle change and urethral descent with the presence of urethroceles on VCUG by Olesen's criteria. M E T H O D S . 159 women with incontinence or voiding dysfunction were evaluated by VCUG and urodynamic studies (UDS). R E S U L T S . VCUG detected stress incontinence in 76% of women with a history of leakage. Of 61 women with proven stress incontinence on UDS, only 37 (60%) were identified on VCUG giving a positive predictive value of 56%. VCUG had a negative predictive value of 74%. In 40 women with urethroeeles, 26 had stress incontinence on VCUG. Abnormal increase in the PUV angle and urethral descent were statistically, greater for women with urethroceins. Urethral inclination was statistically differen for women with urethrocele only with voiding. These anatomic measurements, however, did not eorrelate with the presence of stress incontinence. C O N C L U S I O N S . 1) In the evaluation of stress incontinence, VCUG is limited because of a significant number of false positives produced by detrusor instability and urge incontinence. 2) The anatomic measurements of PUV angle change, urethral descent, and urethral inclination as well as the presence of a urethrocele had limited ability in predicting stress incontinence. Purpose: Quality assurance (QA) is an important component in the management of a large academic radiology department where many radiologists interpret CT studies. We have devised and implemented a simple, rapidly performed computerized method for radiologist interpretation audit as part of a wider QA program in abdominal CT. Methods: In 707 CT scans over a 12 Week period, the attending radiologist recorded agreement or disagreement with interpretation of previous CT studies. A computer database/spreadsheet was created to record discrepant cases which were analyzed at a monthly QA conference of attending radiologists. Errors were classified as either observational or interpretive and were graded 1, 2, 3, or 4 in ascending order ofmageitude. Results: Analysis of results showed 23 errors of which 9 were observational (average grade 2.4) and 14 interpretational (average grade 1.3). Conclusions: Interpretive errors were more frequent but the observational errors were graded higher in magnitude. Recognition of specific error patterns by this rapidly performed QA program has facilitated adjustments in protocol and influenced in-service education programs.

AML is a benign renal tumor composed of variable quantities of mature vascular, smooth muscle and fatty elements. They occur as an isolated finding, classically in middle-aged females, or in association with tuberous sclerosis. When symptomatic, they typically present with flank pain secondary to hemorrhage. CT is the diagnostic imaging modality of choice. The diagnosis can usually be made based on the recognition of fat within the lesion. When discovered, asymptomatic lesions are generally monitored by follow-up imaging studies, and if they remain stable, no intervention is required. Arterial embolization has become the recommended treatment of choice in some instances, particularly in cases with associated hemorrhage.

Previous reports of ultrasonographic and magnetic resonance imaging of placental site trophoblastic tumor have described a cystic appearance of this rare disease. We present the first case in which endovaginal ultrasonography and magnetic resonance imaging revealed a solid intramural mass.

Computed tomographic (CT) findings of 17 pyonephrotic and 20 uninfected hydronephrotic kidneys were reviewed. Parameters evaluated included: renal pelvic wall thickness (none; grade 1, ≤2 mm; grade 2, 3–5 mm; and grade 3, >5 mm), renal pelvic contents, parenchymal, and perirenal findings. All patients underwent subsequent percutaneous nephrostomy within 1 week of CT. Common CT findings suggesting pyonephrosis include increased pelvic wall thickness and more severe perirenal fat changes than are seen in uninfected hydronephrosis. However, for any one patient, these findings are often not diagnostic. The presence of clinical signs of infection with hydronephrosis on CT is a more sensitive indicator of pyonephrosis than most CT findings.

Computed tomographic (CT) scans of 11 patients with perforations of the stomach or duodenum were reviewed to determine the variety and relative conspicuity of findings. Five patients had de novo presentation due to perforation of peptic ulcers, two had perforations at ulcer repair sites, and the remaining four patients had ulcer perforations following unrelated surgery. CT allowed recognition of at least one component of bowel perforation, such as extragastroinestinal gas and/or contrast, in most patients. In only three patients (27%), however, could these findings be specifically related to a perforation of the stomach or duodenum from the CT scans alone.