Giuseppina Dell’aversano Orabona

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

Acute pyelonephritis (APN) is a bacterial infection causing inflammation of the kidneys. Diagnosis is usually based on clinical and laboratory findings. Imaging is required if a complication is suspected in acute pyelonephritis to assess the nature and extent of the lesions and to detect underlying causes. CT represents the current imaging modality of choice in clinical practice. CEUS is an alternative that has been proven to be equally accurate in the detection of acute pyelonephritis renal lesions. CEUS allows us to distinguish small simple nephritic involvement from abscess complications and to follow their evolution over time during antibiotic therapy. The absence of ionizing radiation and the lack of nephrotoxicity make CEUS an ideal tool in the study of pyelonephritis.

Bariatric surgery has demonstrated a higher rate of success than other nonsurgical treatments in selected patients with obesity; however, like all medical procedures, postoperative complications may occur, ranging between 2 and 10% and, although rare, they can be life threatening. Complications may be unspecific (any surgery-related complications) or specific (linked to the specific surgical procedure) and can be distinguished as common, less common, and unexpected. According to the onset, they may be acute, when occurring in the first 30 days after surgery, or chronic, with a presentation after 30 days from the procedure. The aim of this pictorial essay is to review the radiological aspects of surgical techniques usually performed and the possible complications, in order to make radiologists more confident with the postsurgical anatomy and with the normal and abnormal imaging findings.

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80–85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient’s haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

Pelvic pain in reproductive age often represents a diagnostic challenge due to the variety of potential causes characterized by overlapping clinical symptoms, including gynecological and other disorders (e.g., entero-colic or urological). It is also necessary to determine if there is a possibility of pregnancy to rule out any related complications, such as ectopic pregnancy. Although ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are strongly integrated, the choice of which is the ideal diagnostic tool should be guided both by clinical suspicion (gynecological vs. non-gynecological cause) and by the risk ratio–benefit (ionizing radiation and instrumental costs), too. The didactic objective proposed by this review consists in the diagnosis of the cause and differential of pelvic pain in reproductive age by describing and critically analyzing the US diagnostic clues of the most frequent adnexal, uterine, and vascular causes.

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.

Errors in emergency ultrasound (US) have been representing an increasing problem in recent years thanks to several unique features related to both the inherent characteristics of the discipline and to the latest developments, which every medical operator should be aware of. Because of the subjective nature of the interpretation of emergency US findings, it is more prone to errors than other diagnostic imaging modalities. The misinterpretation of US images should therefore be considered as a serious risk in diagnosis. The etiology of error is multi-factorial: it depends on environmental factors, patients and the technical skills of the operator; it is influenced by intrinsic US artifacts, poor clinical correlation, US-setting errors and anatomical variants; and it is conditioned by the lack of a methodologically correct clinical approach and excessive diagnostic confidence too. In this review, we evaluate the common and uncommon sources of diagnostic errors in emergency US during clinical practice, showing how to recognize and avoid them.

Trauma is one of the most common causes of death or permanent disability in young people, so a timely diagnostic approach is crucial. In polytrauma patients, CEUS (contrast enhanced ultrasound) has been shown to be more sensitive than US (ultrasound) for the detection of solid organ injuries, improving the identification and grading of traumatic abdominal lesions with levels of sensitivity and specificity similar to those seen with MDCT (multidetector tomography). CEUS is recommended for the diagnostic evaluation of hemodynamically stable patients with isolated blunt moderate-energy abdominal traumas and the diagnostic follow-up of conservatively managed abdominal traumas. In this pictorial review, we illustrate the advantages and disadvantages of CEUS and the procedure details with tips and tricks during the investigation of blunt moderate-energy abdominal trauma as well as during follow-up in non-operative management.

Background: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. Aim: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. Subjects and Methods: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists (with 5, 5, and 25 years of experience). The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. Results: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity (93% vs. 70%, respectively) and specificity (98% vs. 88%, respectively). Conclusion: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses.