Appendicular endometriosis mimicking appendicitis

A 31-year-old woman presented to the emergency department with right lower quadrant pain. The pain had started three days earlier with increasing intensity postprandially, when walking and in right decubitus position. Completion of her last menstruation was one week before admission. Clinical examination confirmed the right fossa pain with a negative psoas sign. Laboratory findings revealed normal white blood cell count (6.4 x 109/L) and a mild elevation of the CRP (12.6 mg/L). Abdominal ultrasound and CT showed a pathological wall thickening of the appendix extending to the caecum and with infiltration of the peri-appendicular fat and a thickening of the adjacent peritoneal membrane (Fig. A, B). There was no free fluid. Based on the clinical and imaging findings, the tentative diagnosis of appendicitis was made, and a laparascopic appendectomy and a partial caecal resection was performed. Microscopic examination of the appendix showed only minor signs of inflammation, but the presence of fibrous tissue intermixed with endometrial glandular tissue. The latter was confirmed by CK-7 and CD-10 positive staining. Delayed second-look laparascopy showed adhesion of both ovaries towards the uterus and endometriosis sites in the rectovesical excavation and the recto-uterine pouch. Retrospective analysis of the CT-images depicts the close proximity of both ovaries to the uterine body (Fig. C)

Pressure flow analysis in the assessment of preswallow pharyngeal bolus presence in dysphagia

Objectives: Preswallow pharyngeal bolus presence is evident in patients with oropharyngeal dysphagia. Pressure flow analysis (PFA) using high resolution manometry with impedance (HRMI) with AIMplot software is a method for objective interpretation of pharyngeal and upper esophageal sphincter (UES) pressures and bolus flow patterns during swallowing. This study aimed to observe alterations in PFA metrics in the event of preswallow pharyngeal bolus presence as seen on videofluoroscopy (VFSS). Methods: Swallows from 40 broad dysphagia patients and 8 controls were recorded with a HRMI catheter during simultaneous VFSS. Evidence of bolus presence and level reached prior to pharyngeal swallow onset was recorded. AIMPlot software derived automated PFA functional metrics. Results: Patients with bolus movement to the pyriform sinuses had a higher SRI, indicating greater swallow dysfunction. Amongst individual metrics, TNadImp to PeakP was shorter and flow interval longer in patient groups compared to controls. A higher pharyngeal mean impedance and UES mean impedance differentiated the two patient groups. Conclusions: This pilot study identifies specific altered PFA metrics in patients demonstrating preswallow pharyngeal bolus presence to the pyriform sinuses. PFA metrics may be used to guide diagnosis and treatment of patients with oropharyngeal dysphagia and track changes in swallow function over time.Lara Ferris, Taher Omari, Margot Selleslagh, Eddy Dejaeger, Jan Tack, Dirk Vanbeckevoort and Nathalie Romme

Automatische Impedantie Manometrie (AIM): objectieve diagnostiek van oro-faryngale dysfagie

Dit overzichtsartikel wil het klinisch potentieel aantonen van Automatische Impedantie Manometrie (AIM) als nieuwe, nietradiologische techniek voor screening en diagnostiek van faryngale dysfagie, zijnde slikstoornissen in de mond, keelholte en bovenste slokdarm. Deze AIM-techniek maakt gebruik van een katheter met druksensoren en impedantie-elektroden om slikken kwantitatief te beschrijven. Een geïntegreerde – eerder dan afzonderlijke – analyse van de gemeten druk- en impedantiepatronen die ontstaan bij het doorslikken van een voedselbolus, kan een zinvolle aanvulling zijn op de dynamische beeldvormingsonderzoeken die vandaag de dag als gouden standaard worden gezien. Belangrijke voordelen zijn het objectieve karakter van de techniek en de geautomatiseerde berekening van diverse slikparameters. Een globale maat voor de slikfunctie kan worden bekomen (Slik Risico Index, SRI) en houdt verband met (de ernst van) het aspiratierisico van de patiënt en de aanwezigheid van bolusresidu. Zo kan een accurate detectie van aspiratie met een sensitiviteit van 0,88 en specificiteit van 0,96 niet via radiologisch onderzoek bereikt worden. Verschillende slikparameters zijn ook voldoende gevoelig om veranderingen in voedselconsistentie te detecteren en om de effecten van slikmanoeuvres objectief te beschrijven. Recent werd ook aangetoond dat deze AIM-analyse snel en betrouwbaar kan worden uitgevoerd door clinici met variërende ervaring en opleiding. Bovendien worden in verschillende patiëntengroepen andere patronen van afwijkende slikparameters aangetroffen. Of deze observatie aanleiding kan geven tot specifieke slikdiagnoses en dus meer gerichte behandelingen is momenteel onderwerp van onderzoek

Virtual colonoscopy: a new screening tool for colorectal cancer?

One of the new forays into the field of medical imaging is the 3-D computer imaging. Thanks to new and more performant computer processing and 3-D rendering methods it is nowadays possible to generate high resolution images of the inner surface of the colon based on CT and MR images. This article reviews the current status and research directions of virtual colonoscopy and its possible eligibility of becoming a new tool for colorectal screenin

Upper esophageal sphincter impedance as a marker of sphincter opening diameter

The measurement of the physical extent of opening of the upper esophageal sphincter (UES) during bolus swallowing has to date relied on videofluoroscopy. Theoretically luminal impedance measured during bolus flow should be influenced by luminal diameter. In this study, we measured the UES nadir impedance (lowest value of impedance) during bolus swallowing and assessed it as a potential correlate of UES diameter that can be determined nonradiologically. In 40 patients with dysphagia, bolus swallowing of liquids, semisolids, and solids was recorded with manometry, impedance, and videofluoroscopy. During swallows, the UES opening diameter (in the lateral fluoroscopic view) was measured and compared with automated impedance manometry (AIM)-derived swallow function variables and UES nadir impedance as well as high-resolution manometry-derived UES relaxation pressure variables. Of all measured variables, UES nadir impedance was the most strongly correlated with UES opening diameter. Narrower diameter correlated with higher impedance (r = −0.478, P < 0.001). Patients with <10 mm, 10–14 mm (normal), and ≥15 mm UES diameter had average UES nadir impedances of 498 ± 39 Ohms, 369 ± 31 Ohms, and 293 ± 17 Ohms, respectively (ANOVA P = 0.005). A higher swallow risk index, indicative of poor pharyngeal swallow function, was associated with narrower UES diameter and higher UES nadir impedance during swallowing. In contrast, UES relaxation pressure variables were not significantly altered in relation to UES diameter. We concluded that the UES nadir impedance correlates with opening diameter of the UES during bolus flow. This variable, when combined with other pharyngeal AIM analysis variables, may allow characterization of the pathophysiology of swallowing dysfunction.Taher I. Omari, Lara Ferris, Eddy Dejaeger, Jan Tack, Dirk Vanbeckevoort and Nathalie Romme

Gastric Outlet Obtruction by a Donor Aortic Tube After En Bloc Liver Pancreas Transplantation : A Case Report

We present the case of a 30-years-old female suffering from a type five maturity onset diabetes of the young deficiency, resulting in type 1 diabetes and terminal renal inssufficiency. She also had chronic and refractory pruritis due to primary sclerosing cholangitis _like fibrosis. She underwent combined en bloc liver and pancreas transplantation and kidney transplantation.The postoperative course was complicated by a gastric outlet obstruction due to compression of the native gastroduodenal junction by the donor aortic tube . This was treated by construction of a roux-en-y gastrojejunostomy at posttransplant day 24. To our knowledge, compression of the gastroduodenal junction by a donor aortic tube after combined liver and pancreas (or multivisceral) transplantation has not been reported previously

The IDEAL study: MRI for suspected deep endometriosis assessment prior to laparoscopy is equally reliable as radiological imaging as a complement to transvaginal ultrasonography

OBJECTIVES: this prospective observational study compared the value of magnetic resonance imaging (MRI) complementary to transvaginal ultrasonography (TV-US) to our standard preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. Based on the extent to which endometriosis affects reproductive organs, bowel, ureters, bladder or other abdominal organs, the surgery will be carried out by gynecologists only or by a multidisciplinary team involving abdominal surgeons and/or urologists. METHODS: In 74 women with clinically suspected deep endometriosis (DE) the standard preoperative imaging, i.e. an expert transvaginal ultrasonography (TV-US), complemented by an intravenous urography (IVU) for the evaluation of the ureters, and a double contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and caecum was compared with an expert TV-US complemented by a 'one-stop' abdominal and pelvic magnetic resonance imaging (MRI). The findings of the laparoscopy were the reference standard to provide an answer to the question if a 'one-stop' abdominal/pelvic MRI is equally reliable as our standard radiological imaging as a complement to transvaginal ultrasonography for preoperative triaging of patients with suspected urological and intestinal involvement by DE in tertiary care centers. RESULTS: The standard preoperative imaging as well as the combined findings of the TV-US and the MRI allowed a correct stratification for a monodisciplinary approach by gynecologists or a multidisciplinary approach in 90.5% of the patients. Both TV-US and DCBE underestimated the severity of the rectal involvement in 2.7%, whereas TV-US and/or DCBE overestimated it in 6.8% of the patients. CONCLUSIONS: In conclusion, complementary to an expert transvaginal ultrasound (TV-US) a 'one-stop' magnetic resonance imaging (MRI) predicts the intra-operative findings equally well as the standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center