Michele Galluzzo

Gallstone ileus is a rare cause of bowel obstruction, accounting for only 0.3–0.5% of patients with cholecystolithiasis, and it predominantly affects elderly women. This condition develops when gallstones migrate through a bilio-enteric fistula, typically resulting from repeated episodes of acute cholecystitis. Gallstones are the cause of bowel mechanical obstruction and the ileocecal valve represents the most common site of obstruction because it is the narrowest part of the bowel. For the same reasons, the incidence of gallstone ileus increases in patients that suffer bowel strictures, including those with Crohn’s disease or diverticulitis. Symptoms are non-specific and resemble those of other types of bowel obstruction, including abdominal pain, vomiting, and constipation. These symptoms may make initial diagnosis challenging. In fact, radiological imaging plays a crucial role in diagnosing this condition and contrast-enhanced computed tomography (CT) is the diagnostic method of choice. The Rigler triad is pathognomonic but not always present and it is represented by pneumobilia, sign of mechanical bowel obstruction and ectopic gallstones. Treatment options include enterolithotomy, a surgical procedure to remove obstructing gallstone, sometimes in conjunction with cholecystectomy and closure of the bilio-enteric fistula. Bowel resection may be needed in cases of complications. Early diagnosis and timely surgical intervention are critical to improving patient outcomes and preventing further complications.

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1–2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

Ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) have high diagnostic accuracy in the diagnosis of acute appendicitis. Nowadays imaging is part of the diagnostic algorithm of appendicitis and the advantages are demonstrated by the reduced negative appendectomies rates. US is the preferred first line imaging in acute appendicitis. The US diagnosis of complicated and uncomplicated appendicitis is well characterized by different signs but the paradigm of US to take in mind is that the non-visualization of the appendix cannot exclude acute appendicitis. In US, when the appendix is not visualized, or US is inconclusive, second-line imaging examination should be performed. The aims of this pictorial are 1. to illustrate the US signs of complicated and uncomplicated AA; 2. to describe the conditions in which other imaging modalities should be performed to reach a definitive diagnosis.

Traumatic vascular injuries consist in direct or indirect damage to arteries and/or veins and accounts for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Extremities vascular injuries can occur isolated or in association in major trauma with other organ injuries. They account for 1-2% of patients admitted to Emergency Department, for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than the upper ones in adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging notably in polytrauma because of the dilemma of which injury should be prioritized and treatment delay can cause disability or even death especially for limb vascular injury. Our purposes are to discuss the role of Computed Tomography Angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve the definitive diagnosis, and to assess the radiological signs of vascular injuries and the possible pitfalls.

Purpose To identify CT prognostic signs of poor outcomes in acute obstructive colonic cancer (AOCC). Methods Demographic, clinical, laboratory, radiological and surgical data of 65 consecutive patients with AOCC who underwent emergency surgery were analyzed. CT exams were reviewed to assess diameters of cecum, ascending, transverse, descending, and sigmoid proximal to the tumor; colon segments’ CD/L1-VD ratios, continence of the ileocecal valve, small bowel overdistension, presence of small bowel feces sign and cecal pneumatosis. Post Operative complications (PO), according to the Clavien–Dindo classification, were analyzed. Results Gender, age and location of the tumor were not predictive factors of complications. Among laboratory exams, CRP was the most important predictive value of PO (OR 8.23). A cecum distension ≥ 9 cm represented the critical diameter beyond which perforation and cecal necrosis were found at surgery. Cecal pneumatosis at CT was correlated with cecal necrosis at surgery in < 50% of patients. Pre-operative transverse colon CD/L1-VD ratio ≥ 1.43 and descending colon CD/L1-VD ratio ≥ 1.31 were associated with the development of PO (grade ≥ III-V). PO (grade ≥ III-V) occurred in 18/65 patients. Conclusion Postoperative complications in emergency surgery of AOCC were not related to the age, sex and tumor’s location. Preoperative PCR values (≥ 2.17) predict the development of postoperative complications. CT resulted a valid diagnostic tool to identify patients at higher risk of complications: a CD/L1-VD ratios with cut-off values of 1.43 (transverse) and 1.31 (descending) predicted major complications (grade ≥ III-V) and a cecum distension ≥ 9 cm represented the critical diameter beyond which perforation occurred in > 84% of patients.