Diagnostic imaging and minimally invasive interventions

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Nelson Ernest Heath
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1 Diagnostic imaging and minimally invasive interventions 2018

2 Old and new Different questions to be answered, new tasks Specific, focused examinationsfókuszált, specifikus vizsgálatok Ionic radiation Cost/benefit analysis Accessibility, trained specialists, routine Local preferencies

3 Additional examinations Gold standard of diagnostics is endoscopy (+endosonography) Except small bowel X-ray alikes Oral and rectal CM examinations Fluoroscopy CT or MR or with US Functional Fthr studies, NM (PET-CT/MR, SPECT/CT)

4 Modern and cool CT MDCT, many slices with high resolution Fistulography, CTA, CTP Ultrasound Intussusception/invagination Wall-thickening Bowel movements CEUS MR Entero, colono, CE PET-CT Staging, looking for primary, secondary, and treatment FU

5 CT-examinations Good, generally CT-colono, CAD, screening Colitis, CRC diagnostics, ischaemia, diverticulitis Mesenterial, omental Enterography Staging, restaging, therapy FU Trying to lower radiation exposure and the same time increasing the resolution

6 Complications Abscess Perforations Fistule Obstruction Hinchey I. pericolic abscess II. Pelvic or retroperitoneal (larger) abscess III. Focal peritonitis IV. Diffuse fecal peritonitis Diagnosis/staging therapy decision making and FU: CT

7 CT in colitis (side effect) In cases of acut colitis First imaging method should be CT Plain film radiography Out of date, limited sensitivity Ultrasound is good Usual problems with machines and experience MR very good, but not to be used in acute situations

8 CT-diagnostics Wall thickening Dilated bowel Infiltrated fat Ascites Incerased enhancement of the bowel wall Pneumatosis, gas in portal vein

9 CT-colonography A CT-colono better than abdominal CT and much better than barium enema DC 99% complete examinations Sensitivity similar to endoscopy No real complication reported Needs preparations, lik for colonoscopy Incomplete colonoscopy can and should be followed with CT-C Screening potential

10 CT-colonography Contraindocations Hernias (pressure) IBD active phase Colon-surgery within 3 months Fluid based dietary for preparation within 24 hours, additionally tagged with oral contrast media CO2 pressure-controlled inflation Fast absorption Supine and prone position

11 MR in staging for rectal cancer Importance of circumferential resection margin predictor of recurrence MR is the best method to measure the distance between tumor an mesorectum This leads to correct T(NM) staging And is reproducible

12 screening/diagnosis - HCC In risk groups US examinations in every 6 months Preferably in centers, bay trained examiners Preferably on good quality US equipments Not in risk group? No screening Incidental finding Atipical signs or complains

13 EASL-EORTC c.p.g.

14 Examinations with CM pragmatic accessible Cheap? Optimal Fast and certain diagnosis Accessible? Local variations

15 CT 4 phase CE dynamic examinations Widely accessible But Ionising radiation Iodinated CM Allergy CIN

16 CT, CTA Helical/spiral 1-2 slices CT slices Multi-detector-rows 2D-3D reconstruction possibilities Checking the dynamic of contrast enhancement Power injector

17 CT 3-4 phases For CE dynamics Arterial (8-20sec) Portal (30-60sec) Vebous/late portal (60-90sec) Late(90sec-) MSCT/MDCT Very quick, high resolution (raw data min. 0,65-2,5mm), multiplanar and 3D (VR, SSD, MIP, MinIP, VIP)

18 MDCT in the liver Precise differentiating between CE patterns Different types of hystologies Precise measurements Isometric reconstructions 3D models Vascular anatomy Volumetry

19 Availability? MR Best soft-tissue resolution For the liver Hepatocyte-specific, double-pahes CM recommended Dynamic informations Struvtural informations Many and fast sequencies

20 MR DWI Diffusion of water molecules in the tissue Benign-malignant differs Non-contrast method Measurable Apparent diffusion coefficient Sensitive Less specific Part of the examination

21 Final diagnosis Biopsy, FNAC UH, CT, MR guidance 16G-25G needles Cutting, Menghini, Chiba Indications Preparations Be able to target is Communication Patient, relatives, pathologist, clinician

22 Biopsy surgical Core/tissue/cutting FN core (20G) FNAC

23 Additional diagnostic methods CEUS Intravascular microbubble based CM Dynamic examination Guiding of treatment/biopsy Evaluating response

24 IR Attempted non surgical invasive therapy with good results (sometimes as good as surgery), tolerated better by the patients. Sometimes the only way of treatment, palliative or curative.

25 Non-vascular interventions Invasive diagnostics Biopsy, aspiration, cytology, cholangiography, fistulography etc. Intervention=therapy Palliative Curative Biliary Ureter Fluid collections, abscesses Tumor ablation

26 Thermoablation Size, location and vessels around

27 GI-stents GI occlusion, when surgery not performed, due to the patient s condition, or technical factors Palliative stent placement mm diameter OTW or endoscopic route Min. 10F shaft working channel

28 Pecutanous feeding Can not drink and est paresis chronic malnutrition SMA sy Cancer pt Neurodegenerative disease

29 Types Short term less than 8 weeks Nasogastric Nasojejunal Long term Percutan gastrostomy Percutan gastrojejunostomy And their management

30 Nasojejunal catheter 6-8F JB-1 catheter Bentson gw 16/12F-es gastric tube

31 Percutan gastrostomy (PGS) Alternative of surgical PEG (endoscopic)

32 And so on...

Colorectal Pathway Board (Clinical Subgroup): Imaging Guidelines September 2015

Colorectal Pathway Board (Clinical Subgroup): Imaging Guidelines September 2015 1 Contents Page No. 1. Objective 3 2. Imaging Techniques 3 3. Staging of Colorectal Cancer 5 4. Radiological Reporting 6