Purpose Review imaging protocol and findings in postoperative oesophagogastrectomy patients with suspected complications. Methods and materials We undertook a retrospective study of 86 consecutive oesophagogastrectomy cases in a tertiary referral centre, with particular focus on postoperative patients with suspected complications, computed tomography (CT) imaging protocol and potential pitfalls. Results The study included 86 patients who underwent surgery: 40 gastrectomies and 46 oesophagectomies. Complications were suspected in 25 patients. Computed tomography pulmonary angiography (CTPA) was performed in two cases of suspected pulmonary emboli. The remaining 23 patients were imaged according to the departmental CT protocol for postoperative patients with suspected leak. Although fluoroscopy is used as firstline investigation in some centres, we routinely rely on CT imaging with non-contrast examination prior to oral contrast bolus on the CT table. With specific reconstruction and reformat protocols, we optimise delineation of leaks while excluding other postoperative complications. Recognition of common pitfalls is important in accurate image interpretation. Conclusion The high morbidity and mortality associated with postoperative leak highlights the importance of early detection and prompt treatment. As radiologists, we therefore have the responsibility of maximising detection of leaks, avoiding common pitfalls and excluding other complications. We have demonstrated accurate detection of anastomotic leaks using CT with refined protocols. Review imaging protocol and findings in postoperative oesophagogastrectomy patients with suspected complications. We undertook a retrospective study of 86 consecutive oesophagogastrectomy cases in a tertiary referral centre, with particular focus on postoperative patients with suspected complications, computed tomography (CT) imaging protocol and potential pitfalls. The study included 86 patients who underwent surgery: 40 gastrectomies and 46 oesophagectomies. Complications were suspected in 25 patients. Computed tomography pulmonary angiography (CTPA) was performed in two cases of suspected pulmonary emboli. The remaining 23 patients were imaged according to the departmental CT protocol for postoperative patients with suspected leak. Although fluoroscopy is used as firstline investigation in some centres, we routinely rely on CT imaging with non-contrast examination prior to oral contrast bolus on the CT table. With specific reconstruction and reformat protocols, we optimise delineation of leaks while excluding other postoperative complications. Recognition of common pitfalls is important in accurate image interpretation. The high morbidity and mortality associated with postoperative leak highlights the importance of early detection and prompt treatment. As radiologists, we therefore have the responsibility of maximising detection of leaks, avoiding common pitfalls and excluding other complications. We have demonstrated accurate detection of anastomotic leaks using CT with refined protocols.

•Absorbable surgical clips are increasingly being used in general and urological surgery.•Clips degrade by hydrolysis over a period of approximately 7 months.•During hydrolysis the structure of the clip is lost and foreign body reaction predominates.•This process can form soft tissue nodules that mimic recurrent malignant disease.•Radiologists must be aware of local surgical practise to avoid misinterpretation.

OBJECTIVE. The purpose of this article is to describe the diagnostic pitfalls caused by dropped gallstones left in situ after laparoscopic cholecystectomy.CONCLUSION. Dropped gallstones may rarely become symptomatic, causing recurrent abscesses. Diagnosis is challenging due to unusual clinical presentations, myriad locations, and radiologically occult calculi. Even asymptomatic dropped gallstones may cause diagnostic confusion by masquerading as intraperitoneal neoplastic deposits. Radiologists should be aware of techniques for identifying and retrieving dropped gallstones and be wary of their complications and imitations in patients who have undergone laparoscopic cholecystectomy.

As the life expectancy of cystic fibrosis (CF) patients continues to increase, abdominal manifestations of CF are increasingly being encountered by clinicians and radiologists. Imaging plays an important role in the evaluation of adult CF patients with abdominal pain as a cause is often not discernable clinically. Accurate diagnosis is crucial in these patients as some causes may be managed conservatively, whilst others may require surgical intervention. In this review, we describe clinical presentation, imaging findings, and management of adult CF patients presenting with abdominal pain.

Free AccessCase of the monthAn African woman presenting with acalculous cholecystitis and sclerosing cholangiopathyS Y LIONG and S A SUKUMARS Y LIONGSouth Manchester University Hospitals, Southmoor Road, Manchester M23 9LT, UK and S A SUKUMARSouth Manchester University Hospitals, Southmoor Road, Manchester M23 9LT, UKPublished Online:5 Mar 2014https://doi.org/10.1259/bjr/69643252SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail AboutA 31-year-old woman of Zimbabwean origin was admitted with a protracted history of low-grade pyrexia, weight loss and right upper quadrant pain. Laboratory tests revealed an elevated white cell count (16.6 × 109 l−1; normal range, 3–13 × 109 l−1), lymphopaenia (0.8 × 109 l−1; normal range, 1–3.7 × 109 l−1), raised alkaline phosphatase (764 IU l−1; normal range, 0–140 IU l−1) and raised γ-glutamyl transferase (770 IU l−1; normal rage, 0–50 IU l−1). Bilirubin, amylase, alanine aminotransferase and aspartate aminotransferase levels were within normal limits.Abdominal ultrasound (Figure 1) and CT (Figure 2) were performed. Based on these images, what are your differential diagnoses?In view of the elevated alkaline phosphatase and γ-glutamyl transferase, biliary obstruction was considered and magnetic resonance cholangiography (MRCP; Figure 3a) was performed to assess the biliary tree. The patient continued to have pain and, because a definite cause had not been established on ultrasound, CT or MRCP, an endoscopic retrograde cholangiography (ERCP; Figure 3b) was subsequently performed by the clinical team.FindingsUltrasound revealed an acalculous thick-walled gallbladder (Figure 1a) and dilated thick-walled common bile duct (Figure 1b, white arrow).On CT (Figure 2), there was mild intrahepatic duct dilatation and periportal oedema. There was gallbladder wall thickening and dilatation of the extrahepatic ducts down to the level of the pancreas, with tapering of the subampullary common bile duct (white arrow).MRCP (Figure 3a) and ERCP (Figure 3b) images depicted a dilated extrahepatic duct with tapering of the subampullary common bile duct (white arrows). The common bile duct measured up to 1 cm in diameter on MRCP. Note the irregular "shaggy" wall of the common bile duct (black arrow) delineated on ERCP. There was also dilatation and beading of the intrahepatic central biliary tree.DiagnosisA diagnosis of AIDS cholangiopathy was considered, and the patient was subsequently tested for HIV. Validated serological testing in this patient returned positive for HIV with a low CD4 count of 28 per mm3. Ampullary biopsies (Figure 4) taken at the time of ERCP confirmed Cryptosporidium and cytomegalovirus infection.DiscussionAIDS cholangiopathy is a potentially severe debilitating illness characterised by intrahepatic and extrahepatic sclerosing cholangitis, often with gallbladder involvement. Opportunistic infections by Cryptosporidium parvum or cytomegalovirus are the most common causes of AIDS cholangiopathy [1]. Diagnosis can be challenging in patients with no known history of infection with HIV.In immunocompetent hosts, infection with C. parvum or cytomegalovirus is usually enteric and manifests as self-limiting diarrhoea. In the immunocompromised, infection with these organisms can coexist and cause severe gastrointestinal disease with involvement of the biliary system. Biliary tract involvement resulting in cholangiopathy is rare and has been reported in 23% of patients with HIV infection [2]. As seen in our case, a low CD4 count (≤50 per mm3) is recognised as a risk factor for biliary cryptosporidiosis [3].Patients with biliary involvement may be asymptomatic or present with right upper quadrant pain, fever, malaise and nausea [1–5]. Alkaline phosphatase is usually elevated and serum bilirubin is normal or only mildly elevated [1, 4–8]. The transaminases and amylase may be elevated in some patients [4, 5].Radiological studies play an important role in the diagnosis of AIDS cholangiopathy. Ultrasound scans and CT may reveal normal [6, 7] or thickened dilated common bile ducts [6–8] without gallstones. The gallbladder may be thick-walled [6] or small and irregular, probably secondary to prolonged inflammation leading to cicatrisation [8].MRCP and ERCP are useful for the diagnosis of AIDS cholangiopathy. ERCP is regarded as the gold standard, as biopsy specimens can be taken at the time of procedure and therapeutic sphincterotomy can be performed. Four patterns of AIDS cholangiopathy on cholangiography have been described in a series by Cello [5]:Papillary stenosis alone in 15% of patients, characterised by dilatation of the common bile duct with smooth tapering.Sclerosing cholangitis pattern characterised by focal strictures; dilatation of the intrahepatic and extrahepatic ducts was seen in 20% of patients.Combined patterns of papillary stenosis and sclerosing cholangitis were observed in 50% of patients.Long segment extrahepatic structures in 15% of patients.In another series (Vakil et al [3]), papillary stenosis was observed in all 10 patients with AIDS cholangiopathy undergoing ERCP. Associated dilatation of the pancreatic duct has also been reported [3, 8].AIDS cholangiopathy is difficult to treat. Clinical trials and case reports suggest a role for paramomycin [2, 3] and azithromycin [3], either as monotherapy or in combination [9], for the treatment of biliary cryptosporidiosis. However, the observed responses were incomplete in some subjects and, currently, no effective antimicrobial exists for biliary cryptosporidiosis. Medical therapy for cytomegalovirus with ganciclovir and foscarnet has also failed to influence the course of the cholangitis [4].As low CD4 counts have been associated with biliary infection by Cryptosporidium [2, 3], reconstitution of immunity through the use of anti-retroviral therapy may have some effect on biliary cryptosporidiosis. In a study by Carr et al [10], which included two patients with biliary cryptosporidiosis, a response (decreasing alkaline phosphatase and improvement of pain) was observed with combination anti-retroviral therapy.Because of the disappointing results observed with pharmacological therapy, there is an important role for supportive and symptomatic treatment. Several series have evaluated the efficacy of sphincterotomy in patients with papillary stenosis. In series by Cello et al [5] and Hashmey et al [2], a significant reduction in pain was reported after sphincterotomy. However, in a series by Vakil et al [3], neither complete resolution of pain nor improvement in liver function tests was observed in any patient post-sphincterotomy. A sphincterotomy was not performed in our patient. There may be a role for cholecystectomy, as observed by Vakil et al [3] and Hashmey et al [2], with resolution of pain reported following surgery.It is important to recognise that cryptosporidiosis and cytomegaloviral infection are AIDS-defining illnesses, and are primary presentations of HIV infection in 5% and 9% of cases, respectively [11]. This case highlights the importance of considering the diagnosis of AIDS cholangiopathy in patients with acalculous cholecystitis and sclerosing cholangitis, particularly in high-risk patients. Correct diagnosis can lead to the detection of important underlying immunodeficient states and subsequent appropriate treatment.Figure 1. Sonographic images of the (a) liver and (b) common bile duct. Download Figure Figure 2. (a,b) Axial and (c) coronal reformatted CT images. Download Figure Figure 3. (a) Magnetic resonance cholangiography and (b) endoscopic retrograde cholangiography images. Download Figure Figure 4. High-power magnification images of tissue samples taken at the time of endoscopic retrograde cholangiography show (a) Cryptosoridium parvum protozoa and (b) intranuclear eosinophilic cytomegalovirus inclusion bodies (arrows). Download Figure The authors would like to acknowledge Professor D Martin, Consultant Radiologist at South Manchester University Hospitals Foundation Trust, Mr S Galloway, Consultant Surgeon at South Manchester University Hospitals Foundation Trust, and Dr V Howarth, Consultant Histopathologist at Stockport NHS Foundation Trust, for their input into this case report. References 1 Bonacini M. Hepatobiliary complications in patients with human immunodeficiency virus infection. Am J Med 1992;92:404–11. Crossref Medline ISI, Google Scholar2 Hashmey R, Smith NH, Cron S, Graviss EA, Chappell CL, White AC Jr. Cryptosporidiosis in Houston, Texas. A report of 95 cases. Medicine (Baltimore) 1997;76:118–39. Crossref Medline ISI, Google Scholar3 Vakil NB, Schwartz SM, Buggy BP, Brummitt CF, Kherellah M, Letzer DM, et al. Biliary cryptosporidiosis in HIV-infected people after the waterborne outbreak of cryptosporidiosis in Milwaukee. N Eng J Med 1996;334:19–23. Crossref Medline ISI, Google Scholar4 Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroent Clin North Am 1997;26:323–35. Crossref Medline ISI, Google Scholar5 Cello JP. Acquired immunodeficiency syndrome cholangiopathy: spectrum of disease. Am J Med 1989;86:539–46. Crossref Medline ISI, Google Scholar6 Teixidor HS, Godwin TA, Ramirez EA. Cryptosporidiosis of the biliary tract in AIDS. Radiology 1991;180:51–6. Crossref Medline ISI, Google Scholar7 Dolmatch BL, Laing FC, Federle MP, Jeffrey RB, Cello J. AIDS-related cholangitis: radiologic findings in nine patients. Radiology 1987;163:313–6. Crossref Medline ISI, Google Scholar8 Radin DR, Cohen H, Halls JM. Acalculous inflammatory disease of the biliary tree in acquired immunodeficiency syndrome: CT demonstration. J Comput Assist Tomogr 1987;11:775–8. Crossref Medline ISI, Google Scholar9 Smith NH, Cron S, Valdez LM, Chappell CL, White AC Jr. Combination drug therapy for cryptosporidiosis in AIDS. J Infect Dis 1998;178:900–3. Crossref Medline ISI, Google Scholar10 Carr A, Marriott D, Field A, Vasak E, Cooper DA. Treatment of HIV-1-associated microsporidiosis and cryptosporidiosis with combination antiretroviral therapy. Lancet 1998;351: 256–62. Crossref Medline ISI, Google Scholar11 Poznansky M, Coker R, Skinner C, Hill A, Bailey S, Whitaker L, et al. HIV positive patients first presenting with an AIDS defining illness: characteristics and survival. BMJ 1995;311:156–8. Crossref Medline, Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byCryptosporidium and cryptosporidiosis: the African perspective29 April 2016 | Environmental Science and Pollution Research, Vol. 23, No. 14Gallstones and Benign Biliary Diseases5 May 2011 Volume 82, Issue 980August 2009Pages: 617-e170 © The British Institute of Radiology History RevisedApril 09,2009ReceivedFebruary 08,2009AcceptedApril 22,2009Published onlineMarch 05,2014 Metrics The authors would like to acknowledge Professor D Martin, Consultant Radiologist at South Manchester University Hospitals Foundation Trust, Mr S Galloway, Consultant Surgeon at South Manchester University Hospitals Foundation Trust, and Dr V Howarth, Consultant Histopathologist at Stockport NHS Foundation Trust, for their input into this case report.Download PDF

Computed tomography (CT) has become established as an ideal form of imaging in small bowel obstruction (SBO), especially with modern day multiplanar imaging that is now widely available. CT can confirm the presence of SBO; show the site, level, and cause of obstruction accurately; and detect strangulation. It is important to recognize the common and unusual causes, but also conditions that mimic SBO. This review illustrates a spectrum of causes and discusses conditions that mimic SBO and their differentiation and the limitations of CT in the assessment of suspected SBO.

Clostridium difficile toxin (CDT) colitis is a form of colitis associated with an overgrowth of C. difficile. Almost all antibiotics and some anti-neoplastic agents have been implicated as factors leading to CDT colitis. 1 Bartlett J.G. Antibiotic associated diarrhoea. Clin Infect Dis. 1992; 15: 573-581 Crossref PubMed Scopus (371) Google Scholar The increasing use of these has led to an increase in the incidence of CDT colitis. By altering the normal colonic flora, antibiotic use allows C. difficile bacteria to proliferate. The bacteria produce an enterotoxin that is cytotoxic and causes colitis. 1 Bartlett J.G. Antibiotic associated diarrhoea. Clin Infect Dis. 1992; 15: 573-581 Crossref PubMed Scopus (371) Google Scholar CDT colitis occasionally occurs after intestinal obstruction or bowel surgery, and more frequently affects the elderly. 2 Ros P.R. Buetow P.C. Pantograg-Brown L. et al. Pseudomembranous colitis. Radiology. 1996; 198: 1-9 Crossref PubMed Scopus (67) Google Scholar The clinical features are often non-specific, the patients presenting with diarrhoea, abdominal pain, pyrexia and leucocytosis frequently diagnosed as appendicitis, diverticulitis, or intra-abdominal abscess. The symptoms can vary from mild diarrhoea to life-threatening colitis. Early recognition and management of C. difficile related colitis with appropriate antibiotic treatment decreases the incidence of fulminant colitis, although surgery is still occasionally required for patients with toxic megacolon or perforation.

A case report of spontaneous appendicocutaneous fistula is presented. This represents the rarest form of enterocutaneous fistula. To our knowledge, this is the first report published in the radiological literature where the diagnosis has been made using multi-slice CT.

Picture quizPicture quizR Razzaq, S A Sukumar, H E Woodley, J Ward, P J A Robinson, C Messiou, A G Chalmers and J A GuthrieR Razzaq1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, S A Sukumar1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, H E Woodley1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, J Ward1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, P J A Robinson1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, C Messiou1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author, A G Chalmers1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this author and J A Guthrie1Department of Radiology, Royal Bolton Hospitals NHS Trust, Minerva Road, Farnworth, Bolton, 2University Hospitals of South Manchester, Southmoor Road, Wythenshawe, Manchester, 3St. James' University Hospital, Beckett Street, Leeds, 4Clinical Radiology Department, St James's University Hospital, Leeds LS9 7TF and 5CT Unit, Department of Radiology, The General Infirmary at Leeds, Leeds, UKSearch for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/imaging/22503988SectionsPDF/EPUBFull Text ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About Previous article Next article FiguresReferencesRelatedDetails Volume 16, Issue 4September 2004Pages: 287-iv © The British Institute of Radiology History Published onlineJanuary 28,2014 Metrics Download PDF

•. Cross‐sectional imaging has the benefit of extraluminal assessment. •. Ultrasound or CT are the methods of choice in assessing small bowel obstruction where the plain film gives uncertain information. •. Ultrasound is a useful radiological first test to evaluate possible inflammatory bowel disease.

Spontaneous aortocaval fistula is an unusual but well recognized complication of abdominal aortic aneurysm. Reports of aortocaval fistula as the source of pulmonary embolism are rare. We report a case of paradoxical pulmonary embolism secondary to an aortocaval fistula. The abdominal aortic aneurysm and the associated aortocaval fistula were well demonstrated on helical CT, leading to early diagnosis and prompt surgical treatment with good clinical outcome.

Hanging stones.P Robinson and S A SukumarP RobinsonSearch for more papers by this author and S A SukumarSearch for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/bjr.71.852.10319012SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail About"Hanging stones.." The British Journal of Radiology, 71(852), pp. 1331–1332 Previous article Next article FiguresReferencesRelatedDetails Volume 71, Issue 852December 1998Pages: 1225-1334 History Published onlineJanuary 28,2014 Metrics Download PDF