Radiologic Gastrointestinal Imaging

Contents

Foreword: Diagnostic Imaging: A Peephole into Many of the Body’s Dressing

Rooms xiii
Alan L. Buchman

Preface: Gastrointestinal Imaging: Rapid Advancements Leading to Improved

Patient Care xv
Perry J. Pickhardt

Ten Questions About Barium Esophagography and Dysphagia 449

Marc S. Levine
The barium esophagogram is a global test for patients with dysphagia that
can simultaneously detect morphologic abnormalities in the pharynx and
esophagus, pharyngeal swallowing dysfunction, esophageal dysmotility,
and gastroesophageal reflux. The barium esophagram is an inexpensive,
noninvasive, and widely available procedure that can serve as the initial
diagnostic test for dysphagia and facilitate selection of other diagnostic
studies such as endoscopy. This article addresses 10 questions about
barium esophagography and dysphagia that should help gastroenterolo-
gists gain a better perspective about the utility of barium studies in this
clinical setting.

Computed Tomography and Magnetic Resonance Small Bowel Enterography:

Current Status and Future Trends Focusing on Crohn’s Disease 475
Seong Ho Park, Byong Duk Ye, Tae Young Lee, and Joel G. Fletcher
Video content accompanies this article at http://www.gastro.
theclinics.com/.

Computed tomography enterography (CTE) and magnetic resonance en-

terography (MRE) are presently state-of-the-art radiologic tests used to
examine the small bowel for various indications. This article focuses on
CTE and MRE for the evaluation of Crohn’s disease. The article describes
recent efforts to achieve more standardized interpretation of CTE
and MRE, summarizes recent research studies investigating the role and
impact of CTE and MRE more directly for several different clinical and
research issues beyond general diagnostic accuracy, and provides an up-
date on progress in imaging techniques. Also addressed are areas that
need further exploration in the future.

Radiologic Assessment of Gastrointestinal Bleeding 501

Gene Kim, Jorge A. Soto, and Trevor Morrison
Gastrointestinal (GI) bleeding represents a broad differential of disease
throughout the GI tract. The proper diagnostic evaluation of patients pre-
senting with symptoms of GI bleeding depends on the overall clinical acu-
ity and suspected source locations. The radiologic assessment of these
viii Contents

patients is centered on computed tomography (CT) angiography, CT en-

terography, conventional angiography, and nuclear scintigraphy.

The Natural History of Colorectal Polyps: Overview of Predictive Static and

Dynamic Features 515
Perry J. Pickhardt, Bryan Dustin Pooler, David H. Kim, Cesare Hassan,
Kristina A. Matkowskyj, and Richard B. Halberg
For decades, colorectal screening strategies have been largely driven by
static features, particularly polyp size. Although cross-sectional features
of polyp size, morphology, and location are important determinants of
clinical relevance before histology, they lack any dynamic information on
polyp growth rates. Computed tomography colonography allows for
in vivo surveillance of colorectal polyps, providing volumetric growth rates
that are providing new insights into tumorigenesis. In this article, existing
cross-sectional and longitudinal data on colorectal polyps are reviewed,
with an emphasis on how these features may affect clinical relevance
and patient management.

Rectal MRI for Cancer Staging and Surveillance 537

Courtney C. Moreno, Patrick S. Sullivan, and Pardeep K. Mittal
MRI is an integral part of the multidisciplinary treatment of rectal adenocar-
cinoma. Staging MRI is performed to establish TNM stage and assess for
prognostic factors, including circumferential resection margin status and
presence of extramural vascular invasion. The results of staging MRI
determine which patients will undergo preoperative neoadjuvant chemora-
diation before resection. Restaging MRI is performed to evaluate for treat-
ment response and may identify patients with no residual visible tumor
who are candidates for a “watch and wait” strategy in lieu of resection.
In addition, the results of MRI in conjunction with endoscopy determine
the surgical technique used to remove the tumor.

Defecography: An Overview of Technique, Interpretation, and Impact on

Patient Care 553
Nathan Y. Kim, David H. Kim, Perry J. Pickhardt, Evie H. Carchman,
Arnold Wald, and Jessica B. Robbins
Pelvic floor and defecatory dysfunction are common in the female patient
population. When combined with physical examination, barium defecogra-
phy allows for accurate and expanded assessment of the underlying
pathology and helps to guide future intervention. Understanding the imag-
ing findings of barium defecography in the spectrum of pathology of the
anorectum and pelvic floor allows one to appropriately triage and treat pa-
tients presenting with defecatory dysfunction.

Multidetector Computed Tomography for Retrospective, Noninvasive Staging

of Liver Fibrosis 569
Meghan G. Lubner and Perry J. Pickhardt
Although not traditionally used to assess hepatic fibrosis, computed to-
mography (CT) is fast, accessible, robust, and commonly used for
 Contents ix

abdominal indications. CT metrics are often easily retrospectively obtained

without special equipment. Metrics such as liver segmental volume ratio,
which quantifies regional hepatic volume changes; splenic volume; and
liver surface nodularity scoring show diagnostic performance comparable
with elastography techniques for detecting significant and advanced
fibrosis. Other emerging CT tools, such as CT texture analysis and frac-
tional extracellular volume, have also shown promise in identifying fibrosis
and warrant further study.

Role of Imaging in Surveillance and Diagnosis of Hepatocellular Carcinoma 585

Mohit Gupta, Helena Gabriel, and Frank H. Miller
The prognosis for hepatocellular carcinoma (HCC) is dependent on
tumor stage at diagnosis, with curative treatment options more available
to early-detected HCCs. Professional organizations have produced
HCC screening guidelines in at-risk groups, with ultrasound imaging
the most commonly used screening tool and increased interest in MRI
in specific populations. HCC may be diagnosed by imaging features
alone and has been universally incorporated into management guide-
lines. The radiology community has standardized imaging criteria
for HCC with the development of the Liver Imaging Reporting and
Data System, which has expanded to incorporate computed tomogra-
phy, MR, and contrast-enhanced ultrasound imaging for diagnostic
purposes.

Imaging in Autoimmune Pancreatitis and Immunoglobulin G4–Related Disease

of the Abdomen 603
Kumaresan Sandrasegaran and Christine O. Menias
Autoimmune pancreatitis (AIP) is a steroid-responsive fibroinflammatory
disorder of the pancreas. There are 2 distinct subtypes of AIP, types 1
and 2. Type 1 is associated with systemic immunoglobulin (Ig)G4 disease
and may affect multiple organs in the body. Type 2 is confined to the
pancreas and shows an association with ulcerative colitis. This article de-
scribes the imaging findings of AIP and IgG4 disease in the liver, bile ducts,
kidneys, and retroperitoneal regions. The imaging differentiation of AIP
from pancreas cancer is discussed.

Percutaneous Biliary Interventions 621

Rocio Perez-Johnston, Amy R. Deipolyi, and Anne M. Covey
Biliary drainage is important in the care of patients with benign and malig-
nant biliary obstruction. Careful preprocedure evaluation of high-quality
cross-sectional imaging and inventory of symptoms are necessary to
determine whether a percutaneous, endoscopic, or surgical approach is
most appropriate. High bile duct obstruction is usually best managed
percutaneously; a specific duct can be targeted and enteric contamination
of isolated ducts can be avoided. Options for percutaneous biliary inter-
vention include external or internal/external biliary drainage, stent place-
ment, biliary stone retrieval, and bile duct biopsy. Preprocedure
evaluation, technique, and indications for percutaneous intervention in
benign and malignant diseases are summarized.
x Contents

Splenomegaly: A Combined Clinical and Radiologic Approach to the Differential

Diagnosis 643
Brett P. Sjoberg, Christine O. Menias, Meghan G. Lubner, Vincent M. Mellnick,
and Perry J. Pickhardt
An enlarged spleen (splenomegaly) is a common imaging finding and
may be related to a broad array of underlying conditions. The multifaceted
functions of the spleen make it susceptible to involvement by a variety of
pathophysiologic processes. Understanding these conditions and incor-
porating all relevant clinical and radiologic data allow narrowing the differ-
ential diagnosis.

MRI of the Nontraumatic Acute Abdomen: Description of Findings and

Multimodality Correlation 667
Bryan Dustin Pooler, Michael D. Repplinger, Scott B. Reeder, and
Perry J. Pickhardt
Obtaining a specific diagnosis in the nontraumatic acute abdomen can
be clinically challenging, because a wide range of disease processes
affecting a number of different organ systems may have very similar pre-
sentations. Although computed tomography and ultrasound examination
are the imaging tests most commonly used to evaluate the acute
abdomen, MRI can often offer comparable diagnostic performance and
may be considered when other modalities are equivocal, suboptimal, or
contraindicated. In some circumstances, MRI is emerging as an appro-
priate first-line imaging test.

PET/MRI for Gastrointestinal Imaging: Current Clinical Status and Future Prospects 691
Tyler J. Fraum, Daniel R. Ludwig, Thomas A. Hope, Kathryn J. Fowler
Positron emission tomography (PET)/computed tomography (CT) with
2-deoxy-2-[18F]fluoro-D-glucose (FDG) has become the standard of care
for the initial staging and subsequent treatment response assessment
for numerous gastrointestinal malignancies. However, it is often supple-
mented by magnetic resonance imaging (MRI) for local tumor staging.
Hybrid PET/MRI scanners, which acquire PET data and MRI data simulta-
neously, have the potential to provide accurate whole-body staging in a
single examination. Furthermore, to address certain limitations of FDG,
many new PET tracers have been developed to probe distinctive aspects
of tumor biology.