Der Ileus - ein Findling in der modernen Medizin?

Zusammenfassung: Kaum einem Krankheitsbild liegt ein so breites differenzialdiagnostisches Spektrum zugrunde wie dem Ileus. Insbesondere die hochgradige Obstruktion und der komplette Ileus können über eine bakterielle Translokation und Mikroperfusionsstörungen des dilatierten Darmes zu intestinalen Perforationen und einer Kreislaufinstabilität führen. Klare Algorithmen zur schnellen Kategorisierung des Ileus sind deshalb unabdingbar. Dabei sind insbesondere die Lokalisation des Kalibersprungs beim mechanischen Ileus als auch der Grad der Obstruktion wichtige Kriterien. Die Anamnese, klinische Untersuchung und das konventionelle Röntgenbild des Abdomens sind elementare Bestandteile der Basisdiagnostik. Als Goldstandard der erweiterten bildgebenden Diagnostik hat sich die Computertomographie etabliert. Während für die meisten hochgradigen mechanischen Obstruktionen des Dünndarms, die in drei Vierteln der Fälle durch Adhäsionen und Briden bedingt sind, eine explorative Laparotomie indiziert ist, stehen beim obstruierenden Dickdarmileus auch endoskopische Optionen zur Verfügung. Das Stenting von malignen kolorektalen Tumoren aboral der linken Flexur als überbrückende oder palliative Intervention hat sich ebenso wie die koloskopische Detorquierung des Volvulus etablier

Clinical Impact of Chronic Venous Changes Induced by Central Lines in Children: A Cohort with Abnormal Venograms

PURPOSE To explore the hypothesis that central venous stenosis/obstructions (CVS/O) in children are influenced by prior central venous access devices (CVADs) and are associated with future risk for thromboses. MATERIAL AND METHODS A convenience sample of 100 patients with abnormal venography (stenosis, collaterals, occlusions) documented during peripherally inserted central catheter (PICC) placements were identified from consecutive PICC placements (January 2008 to November 2012). The patients (41 males, 59 females, median age 2.7 years, median weight 11 kg) were categorized based on venographic presence (Group A, n = 53) or absence (Group B, n = 47) of visible connection to the superior vena cava. Each patient's CVAD history, before and after venography, was analyzed (until October 2016). RESULTS Before venogram, Group B patients were associated with a higher number of previous CVADs, larger diameter devices, greater incidence of malposition, and more use of polyurethane catheters than Group A patients (P < .001). An ipsilateral PICC was successfully placed in 98% of Group A, compared to 32% of Group B (P < .001). After venogram, significantly more Doppler ultrasounds (DUS) were performed and thromboses diagnosed in Group B (57% and 36%) compared to Group A (21% and 8%) (P < .003; P = .001), respectively. CONCLUSIONS Previous catheter characteristics influenced the severity of venographic changes of CVS/O (Group B). Group B was associated with more subsequent symptomatic thromboses. This information may assist parents and referring physicians to anticipate potential adverse sequelae from CVS/O on the child's venous health

Paediatric fractures of carpal bones other than the scaphoid

OBJECTIVES Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome. MATERIAL AND METHODS Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study. RESULTS In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good. CONCLUSION Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation

Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review

Background: Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological signs are described in the literature and which radilogical criteria are used to establish inclusion criteria in clincical studies evaluating different treatments in patients with lumbar spinal stenosis. Methods: A literature search was performed in Medline, Embase and the Cochrane library to identify papers reporting on radiological criteria to describe LSS and systematic reviews investigating the effects of different treatment modalities. Results: 25 studies reporting on radiological signs of LSS and four systematic reviews related to the evaluation of different treatments were found. Ten different parameters were identified to quantify lumbar spinal stenosis. Most often reported measures for central stenosis were antero-posterior diameter (< 10 mm) and cross-sectional area (< 70 mm2) of spinal canal. For lateral stenosis height and depth of the lateral recess, and for foraminal stenosis the foraminal diameter were typically used. Only four of 63 primary studies included in the systematic reviews reported on quantitative measures for defining inclusion criteria of patients in prognostic studies. Conclusions: There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies

Der Ileus – ein Findling in der modernen Medizin?

Zusammenfassung: Kaum einem Krankheitsbild liegt ein so breites differenzialdiagnostisches Spektrum zugrunde wie dem Ileus. Insbesondere die hochgradige Obstruktion und der komplette Ileus können über eine bakterielle Translokation und Mikroperfusionsstörungen des dilatierten Darmes zu intestinalen Perforationen und einer Kreislaufinstabilität führen. Klare Algorithmen zur schnellen Kategorisierung des Ileus sind deshalb unabdingbar. Dabei sind insbesondere die Lokalisation des Kalibersprungs beim mechanischen Ileus als auch der Grad der Obstruktion wichtige Kriterien. Die Anamnese, klinische Untersuchung und das konventionelle Röntgenbild des Abdomens sind elementare Bestandteile der Basisdiagnostik. Als Goldstandard der erweiterten bildgebenden Diagnostik hat sich die Computertomographie etabliert. Während für die meisten hochgradigen mechanischen Obstruktionen des Dünndarms, die in drei Vierteln der Fälle durch Adhäsionen und Briden bedingt sind, eine explorative Laparotomie indiziert ist, stehen beim obstruierenden Dickdarmileus auch endoskopische Optionen zur Verfügung. Das Stenting von malignen kolorektalen Tumoren aboral der linken Flexur als überbrückende oder palliative Intervention hat sich ebenso wie die koloskopische Detorquierung des Volvulus etablier

Dual-energy CT for characterization of the incidental adrenal mass: Preliminary observations

OBJECTIVE: The purpose of our study was to evaluate the accuracy of virtual unenhanced images reconstructed from contrast-enhanced dual-energy CT for the differentiation of incidental adrenal masses in comparison with standard unenhanced CT. MATERIALS AND METHODS: One hundred-forty patients (mean age, 74 ± 9 years) underwent unenhanced and contrast-enhanced CT of the abdomen, the latter acquired with dual-energy for reconstruction of virtual unenhanced images. Two blinded and independent readers (R1 and R2) measured attenuation of each incidental adrenal mass on standard unenhanced and virtual unenhanced images using an optimized dual-energy three-material decomposition algorithm. RESULTS: Fifty-one incidental adrenal masses were found in 42 of 135 patients (31%); 39 incidental adrenal masses were ≥ 1 cm. On the basis of unenhanced CT, 29 of 51 incidental adrenal masses and 22 of 39 incidental adrenal masses ≥ 1 cm were classified as benign (HU < 10). Virtual unenhanced image quality was rated as good or with mild impairment (2.45 ± 0.83 for R1, 2.45 ± 0.99 for R2). Image noise was 12.7 ± 3.6 HU in unenhanced images and 8.8 ± 2.0 HU in virtual unenhanced images (p < 0.001). There was no significant difference in incidental adrenal mass attenuation between unenhanced and virtual unenhanced images for all incidental adrenal masses (5.9 ± 21.0 HU vs 7.0 ± 20.6 HU, p = 0.48) and for those ≥ 1 cm (6.6 ± 18.5 HU vs 7.9 ± 18.3 HU, p = 0.87). Sensitivity, specificity, and accuracy of virtual unenhanced images for the characterization of incidental adrenal masses as probably benign were 76%, 82%, and 78% for R1 and 79%, 95%, and 86% for R2, respectively. For incidental adrenal masses ≥ 1 cm, sensitivity, specificity, and accuracy increased to 95%, 100%, and 97% for R1 and 91%, 100%, and 95% for R2 CONCLUSION: Reconstruction of virtual unenhanced images from contrast-enhanced dual-energy CT of the abdomen allows the characterization of the incidental adrenal masses with a good accuracy compared with standard unenhanced CT, with the most favorable results in incidental adrenal masses measuring ≥ 1 cm

Prospective morphologic and dynamic assessment of deep flexor tendon healing in zone II by high-frequency ultrasound: Preliminary experience

Preliminary data of this study indicate a better clinical outcome if a sutured tendon maintains a spindlelike shape and increased power Doppler signal. This might indicate a predominantly intrinsic healing pattern with reduced adhesion formation. Ultrasound morphology, power Doppler signal, and tendon excursion may be helpful tools to rate tendon healing and to establish individually modified rehabilitation protocols

Low kilovoltage CT of the neck with 70 kVp: comparison with a standard protocol

BACKGROUND AND PURPOSE: CT protocols should aim for radiation doses being as low as reasonably achievable. The purpose of our study was to assess the image quality and radiation dose of neck CT at a tube potential of 70 kVp. MATERIALS AND METHODS: Twenty patients (7 female, mean age 51.4 years, age range 19-81 years) underwent contrast-enhanced 64-section CT of the neck at 70 kVp (ATCM, effective tube current-time product 614 eff.mAs, range 467-713 eff.mAs). All 20 patients had a previous neck CT at 120 kVp on the same scanner. Two radiologists assessed image quality and artifacts in the upper, middle, and lower neck. Image noise and attenuation were measured, and the CNR was calculated. Effective radiation dose was calculated. RESULTS: Interobserver agreement regarding image quality of soft tissue for 70-kVp and 120-kVp scans was good to excellent. At 70 kVp, soft tissues were of diagnostic image quality in all scans, whereas the lower cervical spine was not of diagnostic quality in 3 and 4 scans per both readers. No difference was found among 70-kVp and 120-kVp scans for soft tissue image quality in the upper neck, while image quality was significantly better in the middle at 70 kVp (P < .05) and better in the lower third at 120 kVp (P < .05). CNR was significantly higher at 70 kVp in all levels for both readers (P < .001). Effective radiation dose at 70 kVp was significantly lower (0.88 ± 0.2 mSv) than at 120 kVp (1.33 ± 0.2 mSv, P < .001). CONCLUSIONS: CT of the cervical soft tissues at 70 kVp is feasible, provides diagnostic image quality with improved CNR, and reduces radiation dose by approximately 34% compared with a standard protocol at 120 kVp. In contrast, low kVp CT of the lower cervical spine suffers from compromised image quality

Whole-body CT in polytrauma patients: effect of arm positioning on thoracic and abdominal image quality

The purpose of this study is to assess the influence of different arm positioning techniques on thoracic and abdominal image quality and radiation dose of whole-body trauma CT (wbCT). One hundred and fifty polytrauma patients (104 male, mean age 47 ± 19) underwent wbCT with arms elevated above the head (group A, n=50), alongside the abdomen (group B, n=50), and on a pillow ventrally to the chest with both arms flexed (group C, n=50). Two blinded, independent observers measured image noise and rated image quality (scores 1-3) of the liver, aorta, spleen, spine, and lower lungs. Radiation dose parameters were noted, and the abdomens' anterior-posterior diameter and scan lengths were measured. Interreader agreements for image noise (r=0.86; p<0.001) and subjective image quality (k=0.71-0.84) were good. Noise was lower (p<0.05), image quality of the liver, aorta, spleen, and spine was higher, and radiation dose lower in group A than in groups B and C (p<0.001, each). Image quality of the spleen, liver, and aorta were higher in group C than in group B (p<0.05, each). No significant differences in scan length (p=0.61) were found among groups. Abdominal anterior-posterior diameter correlated significantly with noise (r=0.82; p<0.01) and dose (r=0.47; p<0.001). Estimated effective radiation doses were significantly (p<0.001) higher in groups B (21.2 mSv) and C (21.9 mSv) as compared to A (16.1 mSv). In wbCT for polytrauma patients, positioning of the arms above the head results in better image quality and lower radiation dose. Placing the flexed arms on a large pillow ventrally to the chest significantly improves image quality as compared to positioning alongside the abdomen