World Journal of · World Journal of Radiology World J Radiol 2013 July 28; 5(7): 253-266 ISSN 1949-8470 (online)

World Journal of RadiologyWorld J Radiol 2013 July 28; 5(7): 253-266

ISSN 1949-8470 (online)

www.wjgnet.com

EDITOR-IN-CHIEFFilippo Cademartiri, Monastier di Treviso

STRATEGY ASSOCIATE EDITORS-IN-CHIEFRitesh Agarwal, ChandigarhKenneth Coenegrachts, BrugesMannudeep K Kalra, BostonMeng Law, Lost AngelesEwald Moser, ViennaAytekin Oto, ChicagoAAK Abdel Razek, MansouraÀlex Rovira, BarcelonaYi-Xiang Wang, Hong KongHui-Xiong Xu, Guangzhou

GUEST EDITORIAL BOARD MEMBERSWing P Chan, TaipeiWen-Chen Huang, TaipeiShi-Long Lian, KaohsiungChao-Bao Luo, TaipeiShu-Hang Ng, TaoyuanPao-Sheng Yen, Haulien

MEMBERS OF THE EDITORIAL BOARD

Australia

Karol Miller, PerthTomas Kron, MelbourneZhonghua Sun, Perth

Austria

Herwig R Cerwenka, GrazDaniela Prayer,Vienna

Siegfried Trattnig, Vienna

Belgium

Piet R Dirix, LeuvenYicheng Ni, LeuvenPiet Vanhoenacker, AalstJean-Louis Vincent, Brussels

Brazil

Emerson L Gasparetto, Rio de JaneiroEdson Marchiori, PetrópolisWellington P Martins, São Paulo

Canada

Sriharsha Athreya, HamiltonMark Otto Baerlocher, TorontoMartin Charron, TorontoJames Chow, TorontoJohn Martin Kirby, HamiltonPiyush Kumar, EdmontonCatherine Limperpoulos, QuebecErnest K Osei, KitchenerWeiguang Yao, Sudbury

Chile

Masami Yamamoto, Santiago

China

Feng Chen, NanjingYing-Sheng Cheng, ShanghaiWoei-Chyn Chu, TaipeiGuo-Guang Fan, Shenyang

Shen Fu, ShanghaiGang Jin, BeijingTak Yeung Leung, Hong KongWen-Bin Li, ShanghaiRico Liu, Hong KongYi-Yao Liu, ChengduWei Lu, GuangdongFu-Hua Peng, GuangzhouLiang Wang, WuhanLi-Jun Wu, HefeiZhi-Gang Yang, ChengduXiao-Ming Zhang, NanchongChun-Jiu Zhong, Shanghai

Czech

Vlastimil Válek, Brno

Denmark

Poul Erik Andersen, Odense

Egypt

Mohamed Abou El-Ghar, MansouraMohamed Ragab Nouh, AlexandriaAhmed A Shokeir, Mansoura

Estonia

Tiina Talvik, Tartu

Finland

Tove J Grönroos, Turku

Editorial Board2009-2013

The World Journal of Radiology Editorial Board consists of 319 members, representing a team of worldwide experts in radiology. They are from 40 countries, including Australia (3), Austria (4), Belgium (5), Brazil (3), Canada (9), Chile (1), China (25), Czech (1), Denmark (1), Egypt (4), Estonia (1), Finland (1), France (6), Germany (17), Greece (8), Hungary (1), India (9), Iran (5), Ireland (1), Israel (4), Italy (28), Japan (14), Lebanon (1), Libya (1), Malaysia (2), Mexico (1), Netherlands (4), New Zealand (1), Norway (1), Saudi Arabia (3), Serbia (1), Singapore (2), Slovakia (1), South Korea (16), Spain (8), Switzerland (5), Thailand (1), Turkey (20), United Kingdom (16), and United States (82).

World Journal of RadiologyW J R

I January 28, 2013WJR|www.wjgnet.com

France

Alain Chapel, Fontenay-Aux-RosesNathalie Lassau, VillejuifYoulia M Kirova, ParisGéraldine Le Duc, Grenoble CedexLaurent Pierot, ReimsFrank Pilleul, LyonPascal Pommier, Lyon

Germany

Ambros J Beer, MünchenThomas Deserno, AachenFrederik L Giesel, HeidelbergUlf Jensen, KielMarkus Sebastian Juchems, UlmKai U Juergens, BremenMelanie Kettering, JenaJennifer Linn, MunichChristian Lohrmann, FreiburgDavid Maintz, MünsterHenrik J Michaely, MannheimOliver Micke, BielefeldThoralf Niendorf, Berlin-BuchSilvia Obenauer, DuesseldorfSteffen Rickes, HalberstadtLars V Baron von Engelhardt, BochumGoetz H Welsch, Erlangen

Greece

Panagiotis Antoniou, AlexandroupolisGeorge C Kagadis, RionDimitris Karacostas, ThessalonikiGeorge Panayiotakis, PatrasAlexander D Rapidis, AthensC Triantopoulou, AthensIoannis Tsalafoutas, AthensVirginia Tsapaki, AnixiIoannis Valais, Athens

Hungary

Peter Laszlo Lakatos, Budapest

India

Anil Kumar Anand, New DelhiSurendra Babu, TamilnaduSandip Basu, BombayKundan Singh Chufal, New DelhiShivanand Gamanagatti, New DelhiVimoj J Nair, HaryanaR Prabhakar, New DelhiSanjeeb Kumar Sahoo, Orissa

Iran

Vahid Reza Dabbagh Kakhki, MashhadMehran Karimi, ShirazFarideh Nejat, TehranAlireza Shirazi, TehranHadi Rokni Yazdi, Tehran

Ireland

Joseph Simon Butler, Dublin

Israel

Amit Gefen, Tel AvivEyal Sheiner, Be’er-ShevaJacob Sosna, JerusalemSimcha Yagel, Jerusalem

ItalyMohssen Ansarin, MilanStefano Arcangeli, RomeTommaso Bartalena, ImolaSergio Casciaro, LecceLaura Crocetti, PisaAlberto Cuocolo, NapoliMirko D’Onofrio, VeronaMassimo Filippi, MilanClaudio Fiorino, MilanoAlessandro Franchello, TurinRoberto Grassi, Naples Stefano Guerriero, CagliariFrancesco Lassandro, NapoliNicola Limbucci, L'AquilaRaffaele Lodi, BolognaFrancesca Maccioni, RomeLaura Martincich, CandioloMario Mascalchi, FlorenceRoberto Miraglia, PalermoEugenio Picano, PisaAntonio Pinto, NaplesStefania Romano, NaplesLuca Saba, CagliariSergio Sartori, FerraraMariano Scaglione, Castel VolturnoLidia Strigari, RomeVincenzo Valentini, Rome

JapanShigeru Ehara, MoriokaNobuyuki Hamada, ChibaTakao Hiraki, OkayamaAkio Hiwatashi, FukuokaMasahiro Jinzaki, TokyoHiroshi Matsuda, SaitamaYasunori Minami, OsakaJun-Ichi Nishizawa, TokyoTetsu Niwa, YokohamaKazushi Numata, KanagawaKazuhiko Ogawa, OkinawaHitoshi Shibuya, TokyoAkira Uchino, SaitamaHaiquan Yang, Kanagawa

Lebanon Aghiad Al-Kutoubi, Beirut

LibyaAnuj Mishra, Tripoli

MalaysiaR Logeswaran, CyberjayaKwan-Hoong Ng, Kuala Lumpur

Mexico

Heriberto Medina-Franco, Mexico City

Netherlands

Jurgen J Fütterer, NijmegenRaffaella Rossin, EindhovenPaul E Sijens, Groningen

New Zealand

W Howell Round, Hamilton

Norway

Arne Sigmund Borthne, Lørenskog

Saudi Arabia

Mohammed Al-Omran, RiyadhRagab Hani Donkol, AbhaVolker Rudat, Al Khobar

Serbia

Djordjije Saranovic, Belgrade

Singapore

Uei Pua, SingaporeLim CC Tchoyoson, Singapore

Slovakia

František Dubecký, Bratislava

South Korea

Bo-Young Choe, SeoulJoon Koo Han, SeoulSeung Jae Huh, SeoulChan Kyo Kim, SeoulMyeong-Jin Kim, SeoulSeung Hyup Kim, SeoulKyoung Ho Lee, Gyeonggi-doWon-Jin Moon, SeoulWazir Muhammad, DaeguJai Soung Park, BucheonNoh Hyuck Park, KyunggiSang-Hyun Park, DaejeonJoon Beom Seo, SeoulJi-Hoon Shin, SeoulJin-Suck Suh, SeoulHong-Gyun Wu, Seoul

II January 28, 2013WJR|www.wjgnet.com

Spain

Eduardo J Aguilar, ValenciaMiguel Alcaraz, MurciaJuan Luis Alcazar, PamplonaGorka Bastarrika, PamplonaRafael Martínez-Monge, PamplonaAlberto Muñoz, MadridJoan C Vilanova, Girona

Switzerland

Nicolau Beckmann, BaselSilke Grabherr, LausanneKarl-Olof Lövblad, GenevaTilo Niemann, BaselMartin A Walter, Basel

Thailand

Sudsriluk Sampatchalit, Bangkok

Turkey

Olus Api, IstanbulKubilay Aydin, İstanbulIşıl Bilgen, IzmirZulkif Bozgeyik, ElazigBarbaros E Çil, AnkaraGulgun Engin, IstanbulM Fatih Evcimik, MalatyaAhmet Kaan Gündüz, AnkaraTayfun Hakan, IstanbulAdnan Kabaalioglu, AntalyaFehmi Kaçmaz, AnkaraMusturay Karcaaltincaba, AnkaraOsman Kizilkilic, IstanbulZafer Koc, AdanaCem Onal, AdanaYahya Paksoy, KonyaBunyamin Sahin, SamsunErcument Unlu, EdirneAhmet Tuncay Turgut, AnkaraEnder Uysal, Istanbul

United Kingdom

K Faulkner, WallsendPeter Gaines, SheffieldBalaji Ganeshan, BrightonNagy Habib, LondonAlan Jackson, ManchesterPradesh Kumar, PortsmouthTarik F Massoud, CambridgeIgor Meglinski, BedfordshireRobert Morgan, LondonIan Negus, BristolGeorgios A Plataniotis, AberdeenN J Raine-Fenning, NottinghamManuchehr Soleimani, BathMY Tseng, NottinghamEdwin JR van Beek, EdinburghFeng Wu, Oxford

United States

Athanassios Argiris, PittsburghStephen R Baker, NewarkLia Bartella, New YorkCharles Bellows, New OrleansWalter L Biffl, DenverHomer S Black, HoustonWessam Bou-Assaly, Ann ArborOwen Carmichael, DavisShelton D Caruthers, St LouisYuhchyau Chen, RochesterMelvin E Clouse, BostonEzra Eddy Wyssam Cohen, ChicagoAaron Cohen-Gadol, IndianapolisPatrick M Colletti, Los AngelesKassa Darge, PhiladelphiaAbhijit P Datir, MiamiDelia C DeBuc, MiamiRussell L Deter, HoustonAdam P Dicker, PhilKhaled M Elsayes, Ann ArborSteven Feigenberg, BaltimoreChristopher G Filippi, BurlingtonVictor Frenkel, BethesdaThomas J George Jr, GainesvillePatrick K Ha, BaltimoreRobert I Haddad, BostonWalter A Hall, SyracuseMary S Hammes, Chicago

John Hart Jr, DallasRandall T Higashida, San FranciscoJuebin Huang, JacksonAndrei Iagaru, StanfordCraig Johnson, MilwaukeeElla F Jones, San FranciscoCsaba Juhasz, DetroitRiyad Karmy-Jones, VancouverDaniel J Kelley, MadisonAmir Khan, LongviewEuishin Edmund Kim, HoustonVikas Kundra, HoustonKennith F Layton, DallasRui Liao, PrincetonCM Charlie Ma, PhiladelphiaNina A Mayr, ColumbusThomas J Meade, EvanstonSteven R Messé, PhiladelphiaNathan Olivier Mewton, BaltimoreFeroze B Mohamed, PhiladelphiaKoenraad J Mortele, BostonMohan Natarajan, San AntonioJohn L Nosher, New BrunswickChong-Xian Pan, SacramentoDipanjan Pan, St LouisMartin R Prince, New YorkReza Rahbar, BostonCarlos S Restrepo, San AntonioVeronica Rooks, HonoluluMaythem Saeed, San FranciscoEdgar A Samaniego, Palo AltoKohkan Shamsi, DoylestownJason P Sheehan, CharlottesvilleWilliam P Sheehan, WillmarCharles Jeffrey Smith, ColumbiaMonvadi B Srichai-Parsia, New YorkDan Stoianovici, BaltimoreJanio Szklaruk, HoustonDian Wang, MilwaukeeJian Z Wang, ColumbusShougang Wang, Santa ClaraWenbao Wang, New YorkAaron H Wolfson, MiamiGayle E Woloschak, ChicagoYing Xiao, PhiladelphiaJuan Xu, PittsburghBenjamin M Yeh, San FranciscoTerry T Yoshizumi, DurhamJinxing Yu, RichmondJianhui Zhong, Rochester

III January 28, 2013WJR|www.wjgnet.com

253 Enteroclysis: Current clinical value

Maataoui A, Vogl TJ, Jacobi V, Khan MF

259 Prostate magnetic resonance imaging at 3 Tesla: Is administration of

hyoscine-N-butyl-bromide mandatory?

Roethke MC, Kuru TH, Radbruch A, Hadaschik B, Schlemmer HP

264 Choledochocele with pancreas divisum: A rare co-occurrence diagnosed on

magnetic resonance cholangiopancreatography

Patidar Y , Agarwal N, Gupta S, Arora A, Mukund A, Rajesh S


Contents

BRIEF ARTICLE

MonthlyVolume5Number7July28,2013

� July 28, 2013|Volume 5|�ssue 7|WJR|www.wjgnet.com

CASE REPORT

Contents

NAME OF JOURNAL World Journal of Radiology

ISSNISSN 1949-8470 (online)

LAUNCH DATEDecember 31, 2009

FREQUENCYMonthly

EDITOR-IN-CHIEFFilippo Cademartiri, MD, PhD, FESC, FSCCT, Professor, Cardio-Vascular Imaging Unit-Giovanni XXIII Hospital, Via Giovanni XXIII, 7-31050-Mo-nastier di Treviso (TV), Italy

EDITORIAL OFFICEJin-Lei Wang, DirectorXiu-Xia Song, Vice Director

FLYLEAF

APPENDIX

EDITORS FOR THIS ISSUE

Responsible Assistant Editor: Xin-Xin Che Responsible Science Editor: Xiu-Xia SongResponsible Electronic Editor: Ya-Jing Lu Proofing Editor-in-Chief: Lian-Sheng Ma

World Journal of RadiologyRoom 903, Building D, Ocean International Center, No. 62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, ChinaTelephone: +86-10-85381891Fax: +86-10-85381893E-mail: [email protected]://www.wjgnet.com

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PUBLICATION DATEJuly 28, 2013

COPYRIGHT© 2013 Baishideng. Articles published by this Open-Access journal are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and repro-duction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.

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ONLINE SUBMISSION http://www.wjgnet.com/esps/

ABOUT COVER

I-V Instructions to authors

Editorial Board Member of World Journal of Radiology , Feng Chen, MD, PhD, Professor, Department of Radiology, Zhong Da Hospital, Southeast University, 87 Ding Jiaqiao, Nanjing 210009, Jiangsu Province, China World Journal of Radiology (World J Radiol, WJR, online ISSN 1949-8470, DOI: 10.4329) is a peer-reviewed open access academic journal that aims to guide clinical practice and im-prove diagnostic and therapeutic skills of clinicians.

WJR covers topics concerning diagnostic radiology, radiation oncology, radiologic physics, neuroradiology, nuclear radiology, pediatric radiology, vascular/interventional radiology, medical imaging achieved by various modalities and related methods analysis. The current columns of WJR include editorial, frontier, diagnostic advances, therapeutics advances, field of vision, mini-reviews, review, topic highlight, medical ethics, original articles, case report, clinical case conference (clinicopathological conference), and autobi-ography.

We encourage authors to submit their manuscripts to WJR. We will give priority to manuscripts that are supported by major national and international foundations and those that are of great basic and clinical significance.

World Journal of Radiology is now indexed in PubMed Central, PubMed, Digital Object Iden-tifier, and Directory of Open Access Journals.

I-III Editorial Board

AIM AND SCOPE

�� July 28, 2013|Volume 5|�ssue 7|WJR|www.wjgnet.com

World Journal of RadiologyVolume5Number7July28,2013

INDEXING/ABSTRACTING

Enteroclysis: Current clinical value

Adel Maataoui, Thomas J Vogl, Volkmar Jacobi, M Fawad Khan

BRIEF ARTICLE


Online Submissions: http://www.wjgnet.com/esps/[email protected]:10.4329/wjr.v5.i7.253

World J Radiol 2013 July 28; 5(7): 253-258ISSN 1949-8470 (online)

© 2013 Baishideng. All rights reserved.

253 July 28, 2013|Volume 5|Issue 7|WJR|www.wjgnet.com

Adel Maataoui, Thomas J Vogl, Volkmar Jacobi, M Fawad Khan, Institute for Diagnostic and Interventional Radiology, Goethe University, 60590 Frankfurt am Main, GermanyAuthor contributions: Vogl TJ and Khan MF supervised the project; Maataoui A and Jacobi V designed the study and anal-ysed the data; Maataoui A and Khan MF wrote the main paper; all authors discussed and interpreted the results and implications and commented on the manuscript at all stages.Correspondence to: Adel Maataoui, MD, Institute for Diag-nostic and Interventional Radiology, Goethe University, Frank-furt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany. [email protected]: +49-69-63015534 Fax: +49-69-63014222Received: January 23, 2013 Revised: May 26, 2013Accepted: June 8, 2013Published online: July 28, 2013

AbstractAIM: To retrospectively analyze changes in clinical indi-cation, referring medical specialty and detected pathol-ogy for small bowel double-contrast examinations.

METHODS: Two hundred and forty-one (n = 143 fe-males; n = 98 males; 01.01.1990-31.12.1990) and 384 (n = 225 females; n = 159 males; 01.01.2004-31.12.2010) patients underwent enteroclysis, respectively. All exami-nations were performed in standardized double-contrast technique. After placement of a nasojejunal probe distal to the ligament of Treitz, radiopaque contrast media fol-lowed by X-ray negative distending contrast media were administered. Following this standardized projections in all four abdominal quadrants were acquired. Depending on the detected pathology further documentation was carried out by focused imaging. Examination protocols were reviewed and compared concerning requesting unit, indication and final report.

RESULTS: Two hundred and forty-one examinations in 1990 faced an average of 55 examinations per year from 2004-2010. There was an increase of examina-tions for gastroenterological (33.6% to 64.6%) and

pediatric (0.4% to 7.8%) indications while internal (29.0% to 6.0% for inpatients and from 16.6% to 9.1% for outpatients) and surgical (12.4% to 7.3%) referrals significantly decreased. “Follow-up of Crohn’s disease” (33.1%) and “bleeding/tumor search” (15.1%) repre-sented the most frequent clinical indications. A total of 34% (1990) and 53.4% (2004-2010) examinations yielded pathologic findings. In the period 01.01.2004 -31.12.2010 the largest proportion of pathological find-ings was found in patients with diagnosed Crohn’s dis-ease (73.5%), followed by patients with abdominal pain (67.6% with history of surgery and 52.6% without his-tory of surgery), chronic diarrhea (41.7%), suspected Crohn’s disease (39.5%) and search for gastrointestinal bleeding source/tumor (19.1%). The most common pathologies diagnosed by enteroclysis were “changes in Crohn’s disease” (25.0%) and “adhesions /strictures” (12.2%).

CONCLUSION: “Crohn’s disease” represents the main indication for enteroclysis. The relative increase of pathologic findings reflects today’s well directed use of enteroclysis.


Key words: Inflammatory bowel diseases; Fluoroscopy; Double-Balloon enteroscopy; Magnetic resonance imag-ing; Helical computed tomography

Core tip: The double contrast examination of the small intestine by enteroclysis is a well-established diagnostic tool for small bowel diagnostics. Comparing the number of performed investigations, it becomes obvious that modern endoscopic and radiological methods lead to an increased replacement of classical radiological methods such as enteroclysis. On the other hand the increas-ing proportion of pathological findings, as shown in the presented study, justifies the continued use of entero-clysis for dedicated clinical indications in a structured diagnostic chain.

Maataoui A et al . Enteroclysis: Current clinical value


Maataoui A, Vogl TJ, Jacobi V, Khan MF. Enteroclysis: Current clinical value. World J Radiol 2013; 5(7): 253-258 Available from: URL: http://www.wjgnet.com/1949-8470/full/v5/i7/253.htm DOI: http://dx.doi.org/10.4329/wjr.v5.i7.253

INTRODUCTION Due to the anatomical and physiological characteristics of the small bowel the diagnostic accessibility of conven-tional endoscopic procedures is limited to the duodenum and terminal ileum[1]. Although modern endoscopic tech-niques such as single-ballon enteroscopy, double-balloon enteroscopy, spiral enteroscopy or video capsule endos-copy allow an almost complete investigation of the small bowel they remain subject to technical and economic limitations[2].

The double contrast examination of the small intes-tine by enteroclysis is a well-established diagnostic tool for small bowel diagnostics[3], especially for infectious bowel diseases[3-5]. The increasing incidence of inflamma-tory bowel diseases in the industrialized world is leading to a rising interest in this modality[6,7]. Due to its indirect impression of mucosal structures the double contrast technique allows the detection of very small ulcers, ero-sions and aphtoid lesions as early signs of common pa-thologies[8]. The dynamic examination approach permits a functional small bowel assessment; this represents a ma-jor advantage over alternate diagnostic modalities. Since the rate of pathological findings is directly dependant on the degree of suspected small bowel disease enteroclysis is inappropriate as a screening procedure.

Because of the non-negligible radiation exposure[9] enteroclysis has to be enclosed in an overall diagnostic concept. In case of abdominal disorders, if clinical symp-toms do not suggest small bowel pathology, gastroduode-noscopy or colonoscopy should be preferred as an initial step in the diagnostic chain. In suspected small bowel disease enteroclysis is added to the diagnostic scheme in a stepwise diagnostic approach[4].

Today enteroclysis competes with modern endoscopic and radiological modalities with their specific advantages and disadvantages[4]. At the same time declining numbers of examinations result in a continuous lack of experience of young radiologists in terms of technical implementa-tion and diagnostic assessment. This development will hardly boost the value of enteroclysis and may lead to a declining number of referrals in the future. The aim of this study was to evaluate the currently changing clinical value of enteroclysis considering referring medical spe-cialties and detected pathologies.

MATERIALS AND METHODSThe data from 625 patients were retrospectively analyzed. A total of n = 241 (n = 143 females, n = 98 males; in-vestigation period 01.01.1990-31.12.1990) and n = 384 (n = 225 females, n = 159 males; investigation period

01.01.2004-31.12.2010) patients were evaluated for refer-ring physicians and percentage of pathological findings.

In addition, the data from the period 01.01.2004- 31.12.2010 were evaluated in terms of medical indication and detected pathology. This information was not avail-able for the first period of investigation in 1990.

Examination procedureAll examinations were performed in standardized double-contrast technique. Examiners were 4th year radiological residents directly supervised by a staff radiologist with more than 10 years of experience in gastrointestinal im-aging. After placement of a nasojejunal probe (Guerbet, Sulzbach, Germany) distal to the ligament of Treitz, radiopaque contrast media (Barium, Guerbet, Sulzbach, Germany) followed by X-ray negative distending contrast media (Methylcellulose, Guerbet, Sulzbach, Germany) were administered. All contrast media were applied with a contrast media pump (KMP 2000, Guerbet, Sulzbach, Germany) using standardized flow-rates of 80-120 mL/min. Following this standardized projections in all four abdominal quadrants were acquired. Depending on the detected pathology further documentation was carried out by focused imaging.

RESULTSExaminationThere was a decline of examinations from a total of 241 in the period 01.01.1990-31.12.1990 to an average of 55 examinations between 01.01.2004-31.12.2010.

Referring physicianIn the overall patient collective only in gastroenterology and in paediatrics a significant increase in patient refer-rals between both time periods was observed, i.e., 33.6% (81/241) to 64.6% (248/384) in gastroenterology and 0.4% (1/241) to 7.8% (30/384) in paediatrics. In contrast to these referrals from general medicine decreased from 29.0% (70/241) to 6.0% (23/384) for inpatients and from 16.6% (40/241) to 9.1% (35/384) for outpatients. Refer-rals for surgical inpatients decreased from 12.4% (30/241) to 7.3% (28/384). The number of referrals from all other departments including gynaecology and infectious dis-eases remained unchanged during the entire evaluation (Figure 1).

Pathological findingsThirty-four percent of studies in the period 01.01.1990-31.12.1990 and 53.4% of studies in the period 01.01.2004 -31.12.2010 showed a pathological finding. In the latter group, the vast majority of pathologies was diagnosed in patients with known Crohn’s disease (73.5%), followed by patients with abdominal pain (67.6% with history of surgery and 52.6% without history of surgery), chronic diarrhea (41.7%), suspected Crohn’s disease (39.5%) and search for gastrointestinal bleeding source/tumor (19.1%) (Table 1).


Indication (01.01.2004-31.12.2010)“Follow-up of Crohn’s disease” was the most frequent indication (33.1%, 127/384). It was followed by the “bleed-ing/tumor search (15.1%, 58/384)”, “suspected Crohn’s disease” (12.2%, 47/384), “abdominal discomfort after visceral surgery” (12.0%, 46/384), “recurrent diarrhea” (7.8%, 30/384), “abdominal discomfort without history of visceral surgery” (6.0%, 23/384) and “others” (13.8%, 53/384) (Figure 2).

Pathologies (01.01.2004-31.12.2010) The most common pathologies diagnosed by enterocly-sis were “changes in Crohn’s disease” (25.0%, 96/384), “adhesions/strictures” (12.2%, 47/384), “non-specific changes” (3.6%, 14/384), “diverticulum of small bowel” (2.9%, 11/384), “suspected malignancy” (1.6%, 6/384) and “other findings” (8.1%, 31/384) (Figure 3).

DISCUSSIONThe aim of this study was to evaluate the frequency of referrals from various medical specialties and to perform an assessment of the diagnostic value of enteroclysis.

Comparing the number of investigations shows a clear trend: While in 1990 the 241 examinations of the small bowel by enteroclysis were conducted, there was an average of only 55 investigations per year for the period of 2004-2010. The reasons are an increasing use of mod-ern endoscopic procedures[2] which allow a direct visual-ization of mucosal structures as well as the evolution of alternative imaging techniques such as ultrasound, com-puter tomography and magnetic resonance imaging[2].

We believe the shift in referral base from surgery to gastroenterology and pediatrics may have an influence on the number of examinations performed. While surgically referred examinations decreased, we found an increase of gastroenterologic and pediatric indications. The refer-rals, particularly for Crohns patients, may be a reflection of a change in attitude of treating physicians due to the emergence of novel immunomodulatory drug therapy in this disease. This was also established by the authors of the “European evidence based consensus on the diagnosis and management of Crohn’s disease: current management”[10]. They confirm that the surgical treat-ment strategies have lost significantly in importance in the last decade because of developments in drug therapy of chronic inflammatory bowel disease.

With regards to the increase in examinations for the pediatric patients the analysis of demographic data provides important information[11-13]. While in 1990 the youngest patient who underwent enteroclysis was 16 years old, in the years 2004-2010 already 4-year-old chil-dren were examined. In 1990 6.6% of patients were 0 to 20 years old, in 2004 to 2010 already 10.9% of patients were in this age group. These data are consistent with the epidemiological trend of chronic inflammatory bowel


19902001-10

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Figure 1 Comparison of referring medical specialties.

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Figure 2 Clinical indications for enteroclysis in the period 01.01.2004-31.12.2010.

Figure 3 Most common pathologies diagnosed by enteroclysis in the period 01.01.2004-31.12.2010.

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s

Pathologies


diseases, which shows that about one third of patients are younger than 20 years of age at the time of diagno-sis[14,15]. With the expected increase in number of young patients, alternative radiological modalities without radia-tion exposure such as ultrasound or magnetic resonance imaging are prefered[16]. The decreasing referrals from general medicine confirm the consistent trend for special-ization in internal medicine. General medicine physicians usually refer their patients with gastroenterological com-plaints to a gastroenterologic specialist to initiate further investigations. For the small bowel this is increasingly achieved with the improvement and further develop-ment of endoscopic procedures[2,17,18]. If necessary, at this point, enteroclysis is added to the diagnostic process. The described approach will ultimately lead to a selection of the patients referred to the radiologist in which a detailed diagnostic workup was performed already. This leads to a more efficient utilization of diagnostic resources and necessarily to an increasing proportion of pathologi-cal findings as shown in this study: While in 1990 34% of the investigations showed pathologic findings it was 53.4% between 2004-2010. Antes et al[19] confirmed an increase of pathological findings in the period of 1998- 2003 from 46% to 57%, respectively. Older data from the 80’s confirm a lower proportion of pathological findings which was between 34.4% and 40%[20-22].

The indications “suspected Crohn’s disease” and “follow-up of Crohn’s disease” were the most common indications in this patient population (2004-2010). At the same time, they are the patient group with the high-est percentage of pathological findings. The reason for that is an increasing incidence of chronic inflammatory bowel disease in western industrialized nations[6,7] and the high spatial resolution of enteroclysis. The latter allows the detection of early mucosal lesions with an excellent sensitivity and specificity[23]. The continuous technical development of modern imaging methods lead to an increased use in the investigation of Crohn’s disease. Magnetic resonance imaging (MRI), therefore, is gaining importance by providing direct visualization of mural and extramural changes as well as utilizing multiplanar imaging[2]. Because of the superior soft tissue contrast MRI imaging is superior to computed tomography (CT)

concerning enteral pathologies[2,24]. In addition, the ab-sence of radiation exposure, especially among young and very young patients who have to undergo multiple follow-ups for chronic disease monitoring, is of high value. Both modalities (MRI and CT) are limited by the visualization of mucosal details and cannot perform dy-namic studies[25]. Modern endoscopic procedures, such as double balloon endoscopy are important diagnostic and therapeutic procedures because they can obtain biopsies and dilate stenotic bowel sections.

The second most frequent indication was “tumor/bleeding”, which in a fifth of cases turned out to have pathological findings. Taking into account that in this patient population enteroclysis stands at the end of the diagnostic chain these are satisfactory results which are consistent with the data of other research groups and justify the use of enteroclysis[24-27]. None the less investi-gation of gastrointestinal bleeding remains the domain of endoscopy. Success rates of 54%[28] for the push-enteroscopy and 73%[17] for the double-ballon endoscopy are key arguments. Promising data is supplied by video capsule endoscopy, which achieved a sensitivity of 88.9% and a specificity of 95% in patients with negative gastros-copy and colonoscopy, respectively[29]. With an increas-ing availability and affordability this modality will be the future reference standard for the detection of otherwise undetectable gastrointestinal bleeding[30].

Studies done for the indication “recurrent diarrhea” yielded a pathological finding in 41.7% such as Crohn’s or Whipples disease (inflammatory), celiac disease (allergic) and diverticulums (functional).

In “unclear abdominal complaints” the double con-trast examination of the small bowel resulted in 48.6% (known prior surgery) and in 52.6% (no prior surgery) of cases in pathological findings. In particular the high number of detected pathologies in the latter group differs significantly from previous results. In patients with unclear abdominal complaints Lankisch et al[31] and Malik et al[27] detected 6% and 16.7% pathological findings by entero-clysis. The high percentage of detected pathologies in this study may be explained by the fact that 63.2% of the re-ferrals were with suspected small bowel obstruction. This illustrates impressively the correlation of an exact clinical indication and the efficiency of the used radiological pro-cedure. If the radiological findings stay inconspicuous, the use of video capsule endoscopy provides no diagnostic gain: In 20 patients with unexplained abdominal pain and normal upper gastrointestinal endoscopy, colonoscopy, push-enteroscopy and radiological workup, Bardan et al [27]

detected no pathology using video capsule endoscopy.In conclusion, modern endoscopic and radiological

methods lead to an increased replacement of classical radiological methods such as enteroclysis. The results presented in this paper justify the continued use of en-teroclysis for dedicated clinical indications in a structured diagnostic chain. However the diagnostic benefit rely on a sound clinical work up.


Table 1 Percentage of pathological findings depending on the clinical question

Clinical question Percentage of pathological findings

Control of Crohn’s disease 73.5Suspected Crohn’s disease 39.5Search for GI bleeding source 19.1Abdominal pain (positive history of surgery) 67.6Abdominal pain (without history of surgery) 52.6Chronic diarrhea 41.7Overall percentage of pathological findings 53.4

GI: Gastrointestinal.


COMMENTSBackgroundThe double contrast examination of the small intestine by enteroclysis is a well-established diagnostic tool for small bowel diagnostics. Especially the increas-ing incidence of inflammatory bowel diseases in the western world is leading to a regaining interest in this modality. Today enteroclysis competes with modern endoscopic and radiological modalities, such as single-balloon enteroscopy, double-balloon enteroscopy and magnetic resonance imaging. The aim of the presented study was to evaluate the currently changing clinical value of entero-clysis.Innovations and breakthroughsModern endoscopic and radiological methods lead to an increased replacement of classical radiological methods such as enteroclysis. “Crohn’s disease” repre-sents the main indication for enteroclysis. The relative increase of pathological findings reflects today’s well directed use of enteroclysis. However the diagnos-tic benefit relies on a sound clinical work up.ApplicationsDespite modern endoscopic and radiological modalities the study results justify the use of enteroclysis for dedicated clinical indications in a structured diagnos-tic chain.TerminologyEnteroclysis: Enteroclysis is a fluoroscopic X-ray of the small intestine. After placement of a nasojejunal probe, radiopaque contrast media followed by X-ray negative distending radiocontrast are infused. Images are taken in real-time as the contrast moves through the small intestine. Due to its indirect impression of mucosal structures the double contrast technique allows the detection of early signs of common pathologies.Peer reviewIn the retrospective study “Enteroclysis: current clinical value” the authors report on enteroclysis as diagnostic option in small bowel disease. The well elaborated study shows that enteroclysis has its diagnostic value for dedicated clinical indications.

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P- Reviewer Domagk D S- Editor Song XX L- Editor A E- Editor Lu YJ


Prostate magnetic resonance imaging at 3 Tesla: Is administration of hyoscine-N-butyl-bromide mandatory?

Matthias C Roethke, Timur H Kuru, Alexander Radbruch, Boris Hadaschik, Heinz-Peter Schlemmer

BRIEF ARTICLE






Matthias C Roethke, Alexander Radbruch, Heinz-Peter Sch-lemmer, Department of Radiology, German Cancer Research Center Heidelberg (DKFZ), 69120 Heidelberg, GermanyTimur H Kuru, Boris Hadaschik, Department of Urology, Uni-versityhospital Heidelberg, 69120 Heidelberg, GermanyAuthor contributions: Roethke MC, Radbruch A and Kuru TH designed the study; Roethke MC, Kuru TH and Schlemmer HP were responsible for acquisition and evaluation of the scans; Ro-ethke MC, Hadaschik B and Schlemmer HP critically revised the manuscript; Roethke MC and Schlemmer HP wrote the paper; all authors contributed to supportive work.Correspondence to: Dr. Matthias C Roethke, MD, Depart-ment of Radiology, German Cancer Research Center Heidelberg (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany. [email protected]: +49-6221-422520 Fax: +49-6221-422531Received: April 3, 2013 Revised: May 23, 2013 Accepted: July 4, 2013Published online: July 28, 2013

AbstractAIM: To evaluate the value of administration of hyo-scine-N-butyl-bromide (HBB) for image quality mag-netic resonance imaging (MRI) of the prostate.

METHODS: Seventy patients were retrospectively in-cluded in the study. Thirty-five patients were examined with administration of 40 milligrams of HBB (Buscopan®; Boehringer, Ingelheim, Germany); 35 patients were examined without HBB. A multiparametric MRI protocol was performed on a 3.0 Tesla scanner without using an endorectal coil. The following criteria were evalu-ated independently by two experienced radiologists on a five-point Likert scale: anatomical details (delinea-tion between peripheral and transitional zone of the prostate, visualisation of the capsule, depiction of the neurovascular bundles); visualisation of lymph nodes; motion related artefacts; and overall image quality.

RESULTS: Comparison of anatomical details between the two cohorts showed no statistically significant dif-ference (3.9 ± 0.7 vs 4.0 ± 0.9, P = 0.54, and 3.8 ± 0.7 vs 4.2 ± 0.6, P = 0.07) for both readers. There was no significant advantage regarding depiction of local and iliac lymph nodes (3.9 ± 0.6 vs 4.2 ± 0.6, P = 0.07, and 3.8 ± 0.9 vs 4.1 ± 0.8, P = 0.19). Motion arte-facts were rated as “none” to “few” in both groups and showed no statistical difference (2.3 ± 1.0 vs 1.9 ± 0.9, P = 0.19, and 2.3 ± 1.1 vs 1.9 ± 0.7, P = 0.22). Over-all image quality was rated “good” in average for both cohorts without significant difference (4.0 ± 0.6 vs 4.0 ± 0.9, P = 0.78, and 3.8 ± 0.8 vs 4.2 ± 0.6, P = 0.09).

CONCLUSION: The results demonstrated no signifi-cant effect of HBB administration on image quality. The study suggests that use of HBB is not mandatory for MRI of the prostate at 3.0 Tesla.


Key words: Butylscopolamine; Buscopan; Motion artefacts; Magnetic resonance imaging; Prostate cancer; 3 Tesla

Core tip: The study demonstrated no significant effect of hyoscine-N-butyl-bromide (HBB) (butylscopolamine) administration on image quality of prostate magnetic resonance imaging (MRI) at 3.0 Tesla without using an endorectal coil. The results suggest that the use of HBB is not generally mandatory for MRI of the prostate.

Roethke MC, Kuru TH, Radbruch A, Hadaschik B, Schlemmer HP. Prostate magnetic resonance imaging at 3 Tesla: Is adminis-tration of hyoscine-N-butyl-bromide mandatory? World J Radiol 2013; 5(7): 259-263 Available from: URL: http://www.wjgnet.com/1949-8470/full/v5/i7/259.htm DOI: http://dx.doi.org/10.4329/wjr.v5.i7.259

Roethke MC et al . 3 Tesla prostate MRI


INTRODUCTIONMagnetic resonance imaging (MRI) is an emerging mo-dality for detection and staging of prostate cancer. To date, multiparametric imaging protocols for MRI of the prostate apply morphological high-spatial resolution T2-weighted sequences complemented by functional imag-ing techniques: diffusion weighted imaging, dynamic contrast-enhanced imaging, and MR-spectroscopy. A mandatory next step for further acceptance of this tech-nique is to simplify and to standardize the MR-protocols for prostate MRI.

A majority of MR-studies of the prostate are per-formed with glucagon or hyoscine-N-butyl-bromide (HBB, butylscopolamine) because administration of an anti-peristaltic drug is recommended for many oncologic MR-examinations of the pelvis[1,2]. The rationale behind it consists of motion reduction of prostate surrounding structures (bladder, rectum, and small bowels) that may cause motion related artefacts which potentially degrade signal-to-noise ratio (SNR) and image quality. However, a recent study by Wagner et al[3] found no benefit for HBB in prostate MRI at 1.5 Tesla. The authors contended that the prostate is located in the lower pelvis, between pelvic floor muscles, bladder and rectum, distant to small bowel structures, and thus it is not affected by peristaltic arte-facts. Consequently, they suggested waiving of spasmo-lytic drug administration. At present, MRI of the prostate at 3.0 Tesla is becoming the state-of-the art examination, because the increased field strength at 3.0 Tesla poten-tially improves image quality by increased SNR[4,5]. Never-theless, non-significant artefacts due to peristaltic bowel motion on 1.5 Tesla MR imaging may become more ex-aggerated on 3.0 Tesla MR imaging and result in reduced image quality.

Hence, purpose of the study was to evaluate the value of administration of HBB for image quality in prostate MRI at 3.0 Tesla.

maTeRIals aND meThODsPatientsThis retrospective, single institutional study was approved by local ethics committee. Patients were included into the study from October 2010 to June 2011. All patients were referred for prostate MRI from the university hospital by the department of urology with clinical suspicion of prostate cancer. Patients with prior radiation therapy or adjuvant hormone ablative therapy were not included into the study. The standard MR-protocol provided ad-ministration of HBB. HBB was not administered in the presence of contraindications such as glaucoma, cardiac arrhythmia and/or ischemic heart disease, myasthenia gravis, and apparent benign prostatic hyperplasia with potential urinary retention[6]. Patients who used their car after the examination did not receive HBB for safety rea-sons. The data of the included patients were transferred into pseudonymous data and allocated to a database into

a HBB-group and into a non-HBB-group. Then, the pa-tients in both groups were sorted according to age in an ascending sequence and into 5-year intervals. To avoid a selection bias, a random number generator software func-tion was used (Excel; Microsoft, Redmond, WA, United States): first, a patient was selected out of the HBB-group. Then, a patient from the non-HBB-group was randomly drawn out of the corresponding age-interval. In total, two datasets with 35 patients from each group were generated (Figure 1). Finally, the resulting groups were tested for statistically significant age difference.

Imaging techniquePatients in the HBB group were administered 40 mg of drug approved HBB (Buscopan®; Boehringer, Ingelheim, Germany) by a venous access directly before the exami-nation. All examinations were performed on a 3.0 Tesla scanner (Siemens Magnetom Trio; Siemens Healthcare, Erlangen, Germany) using the manufacturer standard multi-channel body coil and integrated spine phased-array coil. The MR-protocol started with T2-weighted half-fourier acquisition turbo spin echo localizer sequences. An transverse T1-weighted 3-dimensional gradient echo sequence (FLASH-3D) was obtained for lymph node staging and detection of haemorrhage with the following imaging parameters: repetition time (TR): 6.66 ms, echo time (TE): 2.55 ms, echo train length: 1, averages: 1, sec-tion thickness: 3 mm, no intersection gap, matrix: 317 × 512, field of view: 24 cm × 35 cm, acquisition time: 1:40 min. Sequences included high-spatial resolution T2-weighted turbo spin echo MR imaging in the transverse and coronal plane with the following imaging parameters: TR: 5120 ms, TE: 143 ms, echo train length: 13, averages: 4, section thickness: 3 mm, no intersection gap, matrix: 254 × 448, field of view: 21.2 cm × 30.0 cm, acquisition time: 4:14 min. Axial diffusion-weighted images were ac-quired using a single-shot echo-planar imaging pulse se-quence: TR 12500 ms, TE 65 ms; averages, 4; matrix size, 176 × 176; FOV 450 × 306 mm2; slice thickness, 5 mm; parallel imaging GRAPPA factor 2; b-values: 0, 50, 100, 150, 200, 250, and 800 s/mm2). Three orthogonal diffu-sion directions were acquired. ADC maps were implicitly calculated on the scanner with the standard software pro-vided by the manufacturer using all measured b-values.

DCE was performed with a high-spatial resolution T1-weighted 3-dimensional gradient echo sequence with a temporal resolution of 9.9 s: TR 4.42 ms, TE 2.2 ms; flip angle 15°; matrix size 176 × 265, FOV 400 × 275 mm2; slice thickness 1.5 mm. As contrast agent, weight-adjusted (0.1 mmol/kg) gadobutrol (Gadovist®; Bayer Healthcare, Leverkusen, Germany) was administered.

Imaging analysis The acquired datasets were analysed by two board-certi-fied radiologists with 5 and 12 years of experience in read-ing prostate MRI studies. Both radiologists were blinded to administration of HBB. The readers scored the cases independently and in random order on Likert five-point


scales. First, anatomical details (delineation between pe-ripheral and transitional zone of the prostate, visualisation of the capsule, depiction of neurovascular bundles) and visualisation of local and iliac lymph nodes were assigned on a five-point scale referring to imaging criteria described by Wagner et al[3]: (1) non-diagnostic: structures cannot be evaluated; (2) poor visualization: heavily blurred appear-ance of structures; (3) moderate visualization: moderate blurring; (4) good delineation: slight blurring; and (5) excellent visualization: sharp delineation. Motion related artefacts in the prostatic area were scored on the follow-ing five-point scale: (1) no artefacts; (2) few artefacts; (3) moderate artefacts; (4) considerable artefacts; and (5) severely affected. Finally, the readers documented their perception of overall image quality: (1) non-diagnostic; (2) poor; (3) satisfactory; (4) good; and (5) excellent.

Statistical analysisA two-tailed Wilcoxon rank-sum test was used to deter-mine significant difference between the two cohorts. Ad-ditionally, Bonferroni correction was applied. Weighted kappa (κ) statistics were used for evaluation of interob-server agreement. The following intervals were defined for interpretation of the kappa values: 0.0-0.2 = poor, 0.21-0.4 = fair, 0.41-0.6 = moderate, 0.61-0.8 = substan-tial, 0.81-1.00 high to almost perfect agreement. A P-value of 0.05 or less was considered as statistically significant. All analyses were performed with SAS/STAT software (SAS Institute, Cary, NC, United States).

ResUlTsPatients305 patients matched the predefined criteria. Out of this cohort 82 patients were eligible for administration of HBB and 223 patients did not receive HBB. The two resulting groups of 35 patients each showed no statisti-cal difference regarding age distribution (P = 0.26) with an average age in the HBB-group of 64.9 [95%CI: 62.4- 67.4] and 67.0 years [95%CI: 64.7-68.6] in the non-HBB group, respectively.

Imaging analysisQualitative analysis demonstrated good results regarding the scored criteria for both groups (Figure 2, Table 1). Comparison of anatomical details between the two co-horts showed no statistical significant difference (P = 0.54 and P = 0.07) for both readers. There was no statistically significant advantage regarding depiction of local and iliac lymph nodes (P = 0.07 and P = 0.19). Motion arte-facts were rated as “no” to “few” in both groups. Analy-sis showed no statistical difference (P = 0.19 and P = 0.22) between the two groups. Two examples of the evaluated patient sets are demonstrated in Figure 3A and B. Scoring of overall image quality showed no significant difference (P = 0.78 and P = 0.09).

Inter-reader evaluationEvaluation of inter-observer agreement was moderate for all criteria (range: κ = 0.44-0.53) except for a fair re-sult with κ = 0.37 for assessment of overall image qual-ity. However, a difference of more than one scale interval between the two readers occurred in only 3 of 280 scores (1.07%).

DIsCUssIONThe results demonstrated no significant effect of ad-ministration of HBB on visualisation of the prostate, iliac lymph nodes, periprostatic artefacts, and overall im-age quality. The findings correspond to the results of a study by Wagner et al[3] at 1.5 Tesla with ERC that found no significant effect of intravenous or intramuscular administration of HBB for visualisation of the prostate, neurovascular bundles, pelvic lymph nodes, and overall image quality. Studies promoting the use of HBB for pel-vic MRI emphasize the advantage of suppressing bowel peristalsis to reduce motion artefacts[4,7,8], which is par-ticularly the case in MR-sequences with long acquisition times such as T2w TSE sequences[9]. Nevertheless, mo-tion artefacts were comparably low in both of our assessed


Total MRI examinations (n = 305)

No HBB administered (n = 223)

Administration of (n = 82)

pat. selected with random algorithm

(n = 35)

pat. selected with random algorithm

(n = 35)

Figure 1 Flowchart of patient inclusion. Total of 70 patients were selected randomly out of the hyoscine-N-butyl-bromide (HBB) and the corresponding control group. MRI: Magnetic resonance imaging.

HBBNo HBB

Anatomy Lymph nodes Artefacts Overall quality

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Figure 2 Average scores of the obtained imaging categories in both groups. No statistical significant difference could be obtained. HBB: Hyoscine-N-butyl-bromide.


groups, which could be explained by the anatomical distance between the prostate and small bowel. Thus, the prostate is not directly affected by small bowel motion artefacts (Figure 3A and B). Choosing a posteroanterior phase-encoding direction, which sufficiently suppresses peristaltic artefacts caused by small and larger intestine, is an explanation for visualisation of iliac lymph nodes be-ing marginally affected by administration of HBB[10]. In contrast to this study, an initial study by Johnson et al[11] found improved visualisation of the prostate in about 40% of the patients after HBB administration. However, the number of patients was considerably small with 23 men and there was no dedicated MR-protocol for pros-tate imaging at a 1.0 Tesla system.

In opposite to this study, Wagner et al[3] used an ERC for prostate imaging at 1.5 Tesla. To date, after introduc-tion of 3.0 Tesla scanners, the increased SNR is frequent-ly used to exclude the ERC from prostate examinations, mainly in order to prevent discomfort from patients and to avoid the additional costs for the ERC[12-17]. The use of an ERC provides a wide-ranging immobilization of the prostate in the lower pelvis, which contributes to reduc-tion of motion related artefacts in that specific area[3]. On the other hand, the inflated ERC provides a mechanical stimulus for rectal motion artefacts that can hardly be suppressed by HBB. That is further the case for air that processes through the rectum during the examination. Nevertheless, studies at 1.5 Tesla found that image qual-ity of prostate MRI without ERC to be equal to those with ERC without increased motion artefacts[5,12,13]. A few studies assessed the additional value of the use of an ERC for prostate MRI at 3.0 Tesla. These studies dem-onstrated an incremental benefit for image quality using an ERC[4,7,8]. However, it remains unclear if further im-proved SNR at 3.0 Tesla by an ERC improves diagnostic performance[9].

Although there was no significant effect of HBB ad-ministration on image in our study, the authors believe that there are indications for administration of an anti-peristaltic drug in MR of the prostate, e.g., for patients with hyper-motile intestine or flatulence. In these cases, an anti-peristaltic drug can be administered subsequently after detection on initial T1- or T2-weighted sequences. Furthermore, it would be interesting to investigate the ef-fect of an anti-peristaltic agent on spectral noise in MR-spectroscopy.

The study has some limitations. First, the study was

performed in a retrospective design. A larger prospective study would substantiate the findings of this study. Sec-ondly, there was no intra-individual comparison between HBB and no HBB administration. This methodical draw-back was compensated by a sufficient number of patients and adjustment of the age characteristics in both patient groups. At present, there is no evidence for a difference between the HBB and the non-HBB group caused by a methodical bias.

In conclusion, the results of the study demonstrated no significant effect of HBB administration on image quality of prostate MRI at 3.0 Tesla without ERC. The results of the study suggest that the use of HBB is not mandatory for MRI of the prostate.

COmmeNTsBackgroundA mandatory next step for further acceptance for prostate magnetic resonance imaging (MRI) is to simplify and to standardize MR-protocols. Like many other oncologic MR-examinations of the pelvis, a majority of MR-studies of the


Figure 3 The results demonstrated no significant effect of administration of hyoscine-N-butyl-bromide on visualisation of the prostate, iliac lymph nodes, periprostatic artefacts, and overall image quality. A: 54-year-old patient. Coronal T2w-TSE sequence after administration of hyoscine-N-butyl-bromide (HBB): Prostate capsule (arrows) and neurovascular bundles are well visualized. Central gland and peripheral zone can be differentiated. Bowel wall structures are sharply depicted without artefacts (arrowheads); B: 72-year-old patient after coronal T2w-TSE sequence without administration of hyoscine-N-butyl-bromide (HBB): Qualitative rating showed no significant difference in visu-alisation of prostate capsule (white arrow), differentiation between central and peripheral gland, and neurovascular bundle structures (black arrow). However, ill-defined and blurred small bowel loops with surrounding artefacts occurred (arrowheads) without affecting the prostate or periprostatic space.

A

B

Table 1 Qualitative evaluation using a five-point-scale

Non-HBB group HBB group

A B A B

Prostate anatomy 3.9 ± 0.7 3.8 ± 0.7 4.0 ± 0.9 4.2 ± 0.6Iliac lymph nodes 3.9 ± 0.6 3.8 ± 0.9 4.2 ± 0.6 4.1 ± 0.8Related artefacts 2.3 ± 1.0 2.3 ± 1.1 1.9 ± 0.9 1.9 ± 0.7Overall quality 4.0 ± 0.6 3.8 ± 0.8 4.0 ± 0.9 4.2 ± 0.6

Data are expressed as mean ± SD. HBB: Hyoscine-N-butyl-bromide.

COmmeNTs


prostate are performed using an anti-peristaltic drug. However, recent studies indicate that the additional value of bowel motion suppressing agents is limited. Thus, purpose of this study was to evaluate the value of administration of an anti-peristaltic agent for prostate MRI at 3.0 Tesla. Research frontiersA current topic of research consists of standardizing reading, reporting, and conduction of multiparametric MRI of the prostate. At present, for prostate MRI, there are different recommendations regarding the use of an anti-peristaltic agent for bowel motion suppression.Innovations and breakthroughsA recent study by Wagner et al. found no benefit for administration of an anti-peristaltic agent for prostate MRI at 1.5 Tesla. However, a contrary study by Johnson et al. found improved visualisation of the prostate at 1.0 Tesla in about 40% of the patients after administration of an anti-peristaltic agent. Further-more, the use of an endorectal coil may have an influence on prostate MRI. Currently, a major number of examinations at state-of-the-art 3.0 Tesla scan-ners are carried out without using an endorectal coil. ApplicationsThe study demonstrated no significant effect of hyoscine-N-butyl-bromide (HBB) (butylscopolamine) administration on image quality of prostate MRI at 3.0 Tesla. The results suggest that the use of HBB is not generally mandatory for MRI of the prostate. This may help to further facilitate and to simplify prostate MRI. TerminologyHBB, an anti-peristaltic agent commonly used for suppression of bowel motion, e.g., for pelvic imaging. Endorectal coils are used to gain increased signal from the prostate. However, modern pelvic phased-array surface coils deliver excel-lent signal, especially at higher field strengths. Therefore, many sites perform prostate MRI without using an endorectal coil. Peer reviewThe authors evaluated the role of administration of HBB in improving the image quality of MRI of the prostate at 3.0 Tesla. The results demonstrated no signifi-cant effect of HBB administration on image quality, and suggest that the use of HBB is not mandatory for MRI of the prostate at 3.0 Tesla. This is a direct and carefully-designed study with relatively large number of patients. The conclu-sion drew from the study is clear and convincing. The study was carried out thoroughly and the paper is written nicely.

RefeReNCes1 Dosdá R, Martí-Bonmatí L, Ronchera-Oms CL, Mollá E,

Arana E. Effect of subcutaneous butylscopolamine admin-istration in the reduction of peristaltic artifacts in 1.5-T MR fast abdominal examinations. Eur Radiol 2003; 13: 294-298 [PMID: 12598993 DOI: 10.1007/s00330-002-1500-5]

2 Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G, Rouviere O, Logager V, Fütterer JJ. ESUR pros-tate MR guidelines 2012. Eur Radiol 2012; 22: 746-757 [PMID: 22322308 DOI: 10.1007/s00330-011-2377-y]

3 Wagner M, Rief M, Busch J, Scheurig C, Taupitz M, Hamm B, Franiel T. Effect of butylscopolamine on image quality in MRI of the prostate. Clin Radiol 2010; 65: 460-464 [PMID: 20451013]

4 Bloch BN, Rofsky NM, Baroni RH, Marquis RP, Pedrosa I, Lenkinski RE. 3 Tesla magnetic resonance imaging of the prostate with combined pelvic phased-array and endorec-tal coils; Initial experience(1). Acad Radiol 2004; 11: 863-867

[PMID: 15288036 DOI: 10.1016/j.acra.2004.04.017]5 Sosna J, Pedrosa I, Dewolf WC, Mahallati H, Lenkinski RE,

Rofsky NM. MR imaging of the prostate at 3 Tesla: compari-son of an external phased-array coil to imaging with an en-dorectal coil at 1.5 Tesla. Acad Radiol 2004; 11: 857-862 [PMID: 15354305 DOI: 10.1016/j.acra.2004.04.013]

6 Dyde R, Chapman AH, Gale R, Mackintosh A, Tolan DJ. Precautions to be taken by radiologists and radiographers when prescribing hyoscine-N-butylbromide. Clin Radiol 2008; 63: 739-743 [PMID: 18555031]

7 Heijmink SW, Fütterer JJ, Hambrock T, Takahashi S, Scheenen TW, Huisman HJ, Hulsbergen-Van de Kaa CA, Knipscheer BC, Kiemeney LA, Witjes JA, Barentsz JO. Pros-tate cancer: body-array versus endorectal coil MR imag-ing at 3 T--comparison of image quality, localization, and staging performance. Radiology 2007; 244: 184-195 [PMID: 17495178]

8 Hambrock T , Somford DM, Hoeks C, Bouwense SA, Huisman H, Yakar D, van Oort IM, Witjes JA, Fütterer JJ, Barentsz JO. Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen. J Urol 2010; 183: 520-527 [PMID: 20006859]

9 Seitz M, Shukla-Dave A, Bjartell A, Touijer K, Sciarra A, Bastian PJ, Stief C, Hricak H, Graser A. Functional magnetic resonance imaging in prostate cancer. Eur Urol 2009; 55: 801-814 [PMID: 19185981]

10 Wood ML, Runge VM, Henkelman RM. Overcoming mo-tion in abdominal MR imaging. AJR Am J Roentgenol 1988; 150: 513-522 [PMID: 3257601]

11 Johnson W, Taylor MB, Carrington BM, Bonington SC, Swindell R. The value of hyoscine butylbromide in pelvic MRI. Clin Radiol 2007; 62: 1087-1093 [PMID: 17920868]

12 Park BK, Kim B, Kim CK, Lee HM, Kwon GY. Comparison of phased-array 3.0-T and endorectal 1.5-T magnetic reso-nance imaging in the evaluation of local staging accuracy for prostate cancer. J Comput Assist Tomogr 2007; 31: 534-538 [PMID: 17882027 DOI: 10.1097/01.rct.0000250108.85799.e1]

13 Torricelli P, Cinquantini F, Ligabue G, Bianchi G, Sighinolfi P, Romagnoli R. Comparative evaluation between external phased array coil at 3 T and endorectal coil at 1.5 T: prelimi-nary results. J Comput Assist Tomogr 2006; 30: 355-361 [PMID: 16778606]

14 Beyersdorff D, Winkel A, Hamm B, Lenk S, Loening SA, Taupitz M. MR imaging-guided prostate biopsy with a closed MR unit at 1.5 T: initial results. Radiology 2005; 234: 576-581 [PMID: 15616117]

15 Liu X, Zhou L, Peng W, Qian M. Effect of intravenous gad-olinium-DTPA on diffusion-weighted imaging for prostate lesions and normal tissue at 3.0-Tesla magnetic resonance imaging. Acta Radiol 2011; 52: 575-580 [PMID: 21498291]

16 Kim CK, Park BK. Update of prostate magnetic resonance imaging at 3 T. J Comput Assist Tomogr 2008; 32: 163-172 [PMID: 18379296 DOI: 10.1097/RCT.0b013e3180683b99]

17 Augustin H, Fritz GA, Ehammer T, Auprich M, Pummer K. Accuracy of 3-Tesla magnetic resonance imaging for the staging of prostate cancer in comparison to the Partin tables. Acta Radiol 2009; 50: 562-569 [PMID: 19455449]

P- Reviewers Chen F, El-Ghar MA, Maintz DS- Editor Gou SX L- Editor A E- Editor Lu YJ


Choledochocele with pancreas divisum: A rare co-occurrence diagnosed on magnetic resonance cholangiopancreatography

Yashwant Patidar, Nitesh Agarwal, Shailesh Gupta, Ankur Arora, Amar Mukund, S Rajesh

CASE REPORT






Yashwant Patidar, Nitesh Agarwal, Shailesh Gupta, Ankur Arora, Amar Mukund, S Rajesh, Department of Radiology, In-stitute of Liver and Biliary Sciences, New Delhi 110070, IndiaAuthor contributions: Patidar Y and Agarwal N designed re-search; Gupta S and Rajesh S performed research; Arora A and Mukund A contributed new reagents or analytic tools; Patidar Y and Rajesh S wrote the paper. Correspondence to: Yashwant Patidar, MD, Department of Radiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi 110070, India. [email protected]: +91-95-40950980 Fax: +91-11-26123504Received: April 16, 2013 Revised: June 5, 2013 Accepted: July 4, 2013Published online: July 28, 2013

AbstractWe report a case of a 42-year-old male with symptom-atic choledochocele and incidental pancreas divisum diagnosed with magnetic resonance cholangiopancreatography (MRCP). Small choledochocele is rare congenital malformation associated with non-specific symptoms and a delay in diagnosis. The coexistence of choledochocele and pancreas divisum is extremely rare with only two case reports published in literature. In both cases MRCP failed to diagnose any biliary or pancreatic abnormality. This case suggests that the patients with recurrent abdominal pain and pancreas divisum should not be presumed to be suffering from pancreatitis. Careful evaluated for additional anomalies in the biliary tree should be sought for refractory symp-toms. MRCP is a useful one-stop-shop for diagnosing pancreatic and biliary ductal anomalies.


Key words: Choledochocele; Pancreas divisum; Mag-netic resonance cholangiopan-creatography; Pancreatic

and biliary ductal anomalies; Pancreatitis

Core tip: Small choledochocele is a rare congenital mal-formation associated with non-specific symptoms and a delay in diagnosis. The coexistence of choledochocele and pancreas divisum is extremely rare with only two cases reported in literature. In both cases magnetic resonance cholangiopancreatography (MRCP) failed to diagnose any biliary or pancreatic abnormality. We report a case of a 42-year-old male with symptomatic choledochocele and incidental pancreas divisum diag-nosed with MRCP.

Patidar Y , Agarwal N, Gupta S, Arora A, Mukund A, Rajesh S. Choledochocele with pancreas divisum: A rare co-occurrence diagnosed on magnetic resonance cholangiopancreatography. World J Radiol 2013; 5(7): 264-266 Available from: URL: http://www.wjgnet.com/1949-8470/full/v5/i7/264.htm DOI: http://dx.doi.org/10.4329/wjr.v5.i7.264

INTRODUCTIONCholedochocele is a rare congenital malformation associ-ated with non-specific symptoms which may result in a delay in diagnosis. The coexistence of choledochocele and pancreas divisum is extremely rare with only two cases reported in literature. In both cases magnetic resonance cholangiopancreatography (MRCP) failed to diagnose any biliary or pancreatic abnormality. We report a case of a 42-year-old male with symptomatic choledochocele and incidental pancreas divisum diagnosed with MRCP.

CASE REPORTA 42-year-old male presented with recurrent upper ab-dominal pain following an uneventful cholecystectomy

Patidar Y et al . Choledochocele with pancreas divisum


one year ago. Epigastric pain typically developed after a meal and gradually abated within a few hours. The blood count was within normal limits. The liver function tests revealed slight elevation of gamma-glutamyl transferase. The serum amylase and lipase levels were not elevated and upper gastrointestinal tract endoscopy was normal. A MRCP study revealed cystic dilatation of the terminal portion of the distal common bile duct. In addition, the pancreas was seen to drain predominantly through the duct of Santorini into the minor papilla (Figure 1). A diagnosis of choledochocele (type Ⅲb) with pancreas divisum was made. In our case, pancreas divisum was an incidental finding and not the cause of abdominal pain, as the patient had no documented laboratory or radiological evidence of pancreatitis during any of the previous epi-sodes or the present hospital stay. The patient was advised intervention but he refused and was lost to follow-up.

DISCUSSIONAlthough the co-existence of choledochal cysts and pan-creas divisum has been described in a few case reports[1,2], association of choledochocele with pancreas divisum is extremely rare with only two published case report[3,4]. Pancreas divisum occurs due to failure of the ventral and dorsal pancreatic ducts to fuse during embryogenesis[5]. The exocrine secretions are preferentially drained into the minor papilla through the dorsal duct and duct of Santorini. Impedance to the flow of pancreatic secre-tions through a relatively narrow minor papilla results in increased intraductal pressure which is hypothesised to cause recurrent pancreatitis[5]. On the other hand, one of the causes of choledochal cysts is suggested to be the reflux of pancreatic enzymes into the proximal biliary system because of the anomalous arrangement of the pancreaticobiliary ductal system[6]. Although the fusion of pancreatic buds and development of the pancreaticobili-ary system occurs during the same period of embryologi-cal development, a choledochocele is usually not associ-ated with anomalies of the pancreaticobiliary system[7]. A choledochocele is believed to represent a simple divertic-ulum occurring between the ampullary and common duct components of the sphincter or a congenital duodenal duplication that arises in that region[7]. Also, the pathol-ogy of choledochocele is different from other forms of

choledochal cyst, and its lining is most commonly the duodenal mucosa which suggests that choledochoceles not only have features of the pancreaticobiliarysystem, but also those of the duodenum[3].

A choledochocele have been classified as a subtype (type Ⅲ) of choledochal cysts by Todani et al[6]. They are characterized by cystic ectasia of the intraduodenal portion of the common bile duct. Choledochoceles are further classified as type ⅢA (cystic dilatation of the common channel), type ⅢB (cystic dilatation of the intramural bile duct with a common pancreaticobiliary channel) and type ⅢC (cystic dilatation of the intramural bile duct opening into the duodenum separately from the pancreatic duct[8].

Intermittent episodes of upper abdominal pain rep-resent the most common clinical presentation of cho-ledochocele[6]. Acute pancreatitis with hyperamylasemia is occasionally present, as is obstructive jaundice. The diagnosis is easily missed unless a high index of suspicion of the entity exists and full investigation is carried out.

Unlike the present case, all previously reported cases had clinical and laboratory evidence of pancreatitis. Al-though endoscopic retrograde cholangiopancreatography (ERCP) has long been regarded as the gold standard for diagnosing choledochal cysts and evaluating anomalous pancreatobiliary junction, over the past ten years multiple studies have shown MRCP to be just as sensitive, if not more, than conventional cholangiography[9].

Complications include secondary biliary cirrhosis, spontaneous rupture of the cyst and cholangiocarci-noma[10,11]. Choledochoceles may be drained or resected endoscopically. Surveillance for dysplasia should be con-sidered for lesions that are not resected.

In conclusion, patients with recurrent abdominal pain and pancreas divisum should not be presumed to be suf-fering from pancreatitis. Careful evaluation for additional anomalies in the biliary tree should be sought for refrac-tory symptoms. MRCP is a useful one-stop-shop for diag-nosing pancreatic and biliary ductal anomalies as demon-strated in this case report.

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A BFigure 1 Choledochocele and associated pancreas di-visum. A: Magnetic resonance cholangiopancreatography showing the cystic dilatation of the terminal portion of the common bile duct (white arrow) in the setting of pancreas divisum (dashed arrow); B: Transverse view, white arrow indi-cates the common bile duct.


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10 Kagawa Y, Kashihara S, Kuramoto S, Maetani S. Carcinoma arising in a congenitally dilated biliary tract. Report of a case and review of the literature. Gastroenterology 1978; 74: 1286-1294 [PMID: 348554]

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P- Reviewers Bradley EL, Kamisawa T, Kozarek R, Souza JLS, Sperti C S- Editor Gou SX L- Editor A

E- Editor Lu YJ

Patidar Y et al . Choledochocele with pancreas divisum

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Sample wording: [Name of individual] has received fees for serv-ing as a speaker, a consultant and an advisory board member for [names of organizations], and has received research funding from [names of organization]. [Name of individual] is an employee of [name of or-ganization]. [Name of individual] owns stocks and shares in [name of organization]. [Name of individual] owns patent [patent identification and brief description].

Statement of informed consentManuscripts should contain a statement to the effect that all human studies have been reviewed by the appropriate ethics committee or it should be stated clearly in the text that all persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study should be omitted. Authors should also draw attention to the Code of Ethics of the World Med-ical Association (Declaration of Helsinki, 1964, as revised in 2004).

Statement of human and animal rightsWhen reporting the results from experiments, authors should follow the highest standards and the trial should conform to Good Clini-cal Practice (for example, US Food and Drug Administration Good Clinical Practice in FDA-Regulated Clinical Trials; UK Medicines Research Council Guidelines for Good Clinical Practice in Clinical Trials) and/or the World Medical Association Declaration of Hel-sinki. Generally, we suggest authors follow the lead investigator’s na-tional standard. If doubt exists whether the research was conducted in accordance with the above standards, the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study.

Before submitting, authors should make their study approved by the relevant research ethics committee or institutional review board. If human participants were involved, manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and appropriate informed consent of each. Any personal item or information will not be published without ex-plicit consents from the involved patients. If experimental animals were used, the materials and methods (experimental procedures) section must clearly indicate that appropriate measures were taken to minimize pain or discomfort, and details of animal care should be provided.

SUBMISSION OF MANUSCRIPTSManuscripts should be typed in 1.5 line spacing and 12 pt. Book Antiqua with ample margins. Number all pages consecutively, and start each of the following sections on a new page: Title Page, Ab-stract, Introduction, Materials and Methods, Results, Discussion, Acknowledgements, References, Tables, Figures, and Figure Leg-ends. Neither the editors nor the publisher are responsible for the opinions expressed by contributors. Manuscripts formally accepted for publication become the permanent property of Baishideng Publishing Group Co., Limited, and may not be reproduced by any means, in whole or in part, without the written permission of both the authors and the publisher. We reserve the right to copy-edit and put onto our website accepted manuscripts. Authors should follow the relevant guidelines for the care and use of laboratory animals of their institution or national animal welfare committee. For the sake of transparency in regard to the performance and reporting of clinical trials, we endorse the policy of the ICMJE to refuse to pub-lish papers on clinical trial results if the trial was not recorded in a publicly-accessible registry at its outset. The only register now avail-able, to our knowledge, is http://www.clinicaltrials.gov sponsored by the United States National Library of Medicine and we encour-

WJR|www.wjgnet.com II July 28, 2013|Volume 5|Issue 7|


age all potential contributors to register with it. However, in the case that other registers become available you will be duly notified. A letter of recommendation from each author’s organization should be provided with the contributed article to ensure the privacy and secrecy of research is protected.

Authors should retain one copy of the text, tables, photographs and illustrations because rejected manuscripts will not be returned to the author(s) and the editors will not be responsible for loss or damage to photographs and illustrations sustained during mailing.

Online submissionsManuscripts should be submitted through the Online Submission System at: http://www.wjgnet.com/esps/. Authors are highly recom-mended to consult the ONLINE INSTRUCTIONS TO AUTHORS (http://www.wjgnet.com/1948-5204/g_info_20100312180518.htm) before attempting to submit online. For assistance, authors encoun-tering problems with the Online Submission System may send an email describing the problem to [email protected], or by telephone: +86-10-85381891. If you submit your manuscript online, do not make a postal contribution. Repeated online submission for the same manuscript is strictly prohibited.

MANUSCRIPT PREPARATIONAll contributions should be written in English. All articles must be submitted using word-processing software. All submissions must be typed in 1.5 line spacing and 12 pt. Book Antiqua with ample mar-gins. Style should conform to our house format. Required informa-tion for each of the manuscript sections is as follows:

Title pageTitle: Title should be less than 12 words.

Running title: A short running title of less than 6 words should be provided.

Authorship: Authorship credit should be in accordance with the standard proposed by International Committee of Medical Journal Editors, based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published. Au-thors should meet conditions 1, 2, and 3.

Institution: Author names should be given first, then the complete name of institution, city, province and postcode. For example, Xu-Chen Zhang, Li-Xin Mei, Department of Pathology, Chengde Medi-cal College, Chengde 067000, Hebei Province, China. One author may be represented from two institutions, for example, George Sgourakis, Department of General, Visceral, and Transplantation Surgery, Es-sen 45122, Germany; George Sgourakis, 2nd Surgical Department, Korgialenio-Benakio Red Cross Hospital, Athens 15451, Greece

Author contributions: The format of this section should be: Author contributions: Wang CL and Liang L contributed equally to this work; Wang CL, Liang L, Fu JF, Zou CC, Hong F and Wu XM designed the research; Wang CL, Zou CC, Hong F and Wu XM performed the research; Xue JZ and Lu JR contributed new reagents/analytic tools; Wang CL, Liang L and Fu JF analyzed the data; and Wang CL, Liang L and Fu JF wrote the paper.

Supportive foundations: The complete name and number of sup-portive foundations should be provided, e.g. Supported by National Natural Science Foundation of China, No. 30224801

Correspondence to: Only one corresponding address should be provided. Author names should be given first, then author title, af-filiation, the complete name of institution, city, postcode, province, country, and email. All the letters in the email should be in lower case. A space interval should be inserted between country name and email address. For example, Montgomery Bissell, MD, Professor of Medi-

cine, Chief, Liver Center, Gastroenterology Division, University of California, Box 0538, San Francisco, CA 94143, United States. [email protected]

Telephone and fax: Telephone and fax should consist of +, country number, district number and telephone or fax number, e.g. Tele-phone: +86-10-85381891 Fax: +86-10-85381893

Peer reviewers: All articles received are subject to peer review. Nor-mally, three experts are invited for each article. Decision on accept-ance is made only when at least two experts recommend publication of an article. All peer-reviewers are acknowledged on Express Sub-mission and Peer-review System website.

AbstractThere are unstructured abstracts (no less than 200 words) and struc-tured abstracts. The specific requirements for structured abstracts are as follows:

An informative, structured abstract should accompany each manuscript. Abstracts of original contributions should be struc-tured into the following sections: AIM (no more than 20 words; Only the purpose of the study should be included. Please write the Aim in the form of “To investigate/study/…”), METHODS (no less than 140 words for Original Articles; and no less than 80 words for Brief Articles), RESULTS (no less than 150 words for Original Articles and no less than 120 words for Brief Articles; You should present P values where appropriate and must provide relevant data to illustrate how they were obtained, e.g. 6.92 ± 3.86 vs 3.61 ± 1.67, P < 0.001), and CONCLUSION (no more than 26 words).

Key wordsPlease list 5-10 key words, selected mainly from Index Medicus, which reflect the content of the study.

Core tipPlease write a summary of less than 100 words to outline the most innovative and important arguments and core contents in your paper to attract readers.

TextFor articles of these sections, original articles and brief articles, the main text should be structured into the following sections: INTRO-DUCTION, MATERIALS AND METHODS, RESULTS and DIS-CUSSION, and should include appropriate Figures and Tables. Data should be presented in the main text or in Figures and Tables, but not in both. The main text format of these sections, editorial, topic high-light, case report, letters to the editors, can be found at: http://www.wjgnet.com/1948-5204/g_info_list.htm.

IllustrationsFigures should be numbered as 1, 2, 3, etc., and mentioned clearly in the main text. Provide a brief title for each figure on a separate page. Detailed legends should not be provided under the figures. This part should be added into the text where the figures are applicable. Keep-ing all elements compiled is necessary in line-art image. Scale bars should be used rather than magnification factors, with the length of the bar defined in the legend rather than on the bar itself. File names should identify the figure and panel. Avoid layering type directly over shaded or textured areas. Please use uniform legends for the same subjects. For example: Figure 1 Pathological changes in atrophic gas-tritis after treatment. A: ...; B: ...; C: ...; D: ...; E: ...; F: ...; G: …etc. It is our principle to publish high resolution-figures for the E-versions.

TablesThree-line tables should be numbered 1, 2, 3, etc., and mentioned clearly in the main text. Provide a brief title for each table. Detailed legends should not be included under tables, but rather added into the text where applicable. The information should complement, but not duplicate the text. Use one horizontal line under the title, a second under column heads, and a third below the Table, above any footnotes. Vertical and italic lines should be omitted.

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Notes in tables and illustrationsData that are not statistically significant should not be noted. aP < 0.05, bP < 0.01 should be noted (P > 0.05 should not be noted). If there are other series of P values, cP < 0.05 and dP < 0.01 are used. A third series of P values can be expressed as eP < 0.05 and fP < 0.01. Other notes in tables or under illustrations should be expressed as 1F, 2F, 3F; or sometimes as other symbols with a superscript (Arabic numer-als) in the upper left corner. In a multi-curve illustration, each curve should be labeled with ●, ○, ■, □, ▲, △, etc., in a certain sequence.

AcknowledgmentsBrief acknowledgments of persons who have made genuine contri-butions to the manuscript and who endorse the data and conclusions should be included. Authors are responsible for obtaining written permission to use any copyrighted text and/or illustrations.

REFERENCESCoding systemThe author should number the references in Arabic numerals ac-cording to the citation order in the text. Put reference numbers in square brackets in superscript at the end of citation content or after the cited author’s name. For citation content which is part of the narration, the coding number and square brackets should be typeset normally. For example, “Crohn’s disease (CD) is associated with increased intestinal permeability[1,2]”. If references are cited directly in the text, they should be put together within the text, for example, “From references[19,22-24], we know that...”

When the authors write the references, please ensure that the order in text is the same as in the references section, and also ensure the spelling accuracy of the first author’s name. Do not list the same citation twice.

PMID and DOIPleased provide PubMed citation numbers to the reference list, e.g. PMID and DOI, which can be found at http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed and http://www.crossref.org/Simple-TextQuery/, respectively. The numbers will be used in E-version of this journal.

Style for journal referencesAuthors: the name of the first author should be typed in bold-faced letters. The family name of all authors should be typed with the initial letter capitalized, followed by their abbreviated first and middle ini-tials. (For example, Lian-Sheng Ma is abbreviated as Ma LS, Bo-Rong Pan as Pan BR). The title of the cited article and italicized journal title (journal title should be in its abbreviated form as shown in PubMed), publication date, volume number (in black), start page, and end page [PMID: 11819634 DOI: 10.3748/wjg.13.5396].

Style for book referencesAuthors: the name of the first author should be typed in bold-faced letters. The surname of all authors should be typed with the initial let-ter capitalized, followed by their abbreviated middle and first initials. (For example, Lian-Sheng Ma is abbreviated as Ma LS, Bo-Rong Pan as Pan BR) Book title. Publication number. Publication place: Publica-tion press, Year: start page and end page.

FormatJournals English journal article (list all authors and include the PMID where applicable)1 Jung EM, Clevert DA, Schreyer AG, Schmitt S, Rennert J,

Kubale R, Feuerbach S, Jung F. Evaluation of quantitative con-trast harmonic imaging to assess malignancy of liver tumors: A prospective controlled two-center study. World J Gastroenterol 2007; 13: 6356-6364 [PMID: 18081224 DOI: 10.3748/wjg.13. 6356]

Chinese journal article (list all authors and include the PMID where applicable)2 Lin GZ, Wang XZ, Wang P, Lin J, Yang FD. Immunologic ef-

fect of Jianpi Yishen decoction in treatment of Pixu-diarrhoea. Shijie Huaren Xiaohua Zazhi 1999; 7: 285-287

In press3 Tian D, Araki H, Stahl E, Bergelson J, Kreitman M. Signature

of balancing selection in Arabidopsis. Proc Natl Acad Sci USA 2006; In press

Organization as author4 Diabetes Prevention Program Research Group. Hyperten-

sion, insulin, and proinsulin in participants with impaired glu-cose tolerance. Hypertension 2002; 40: 679-686 [PMID: 12411462 DOI:10.1161/01.HYP.0000035706.28494.09]

Both personal authors and an organization as author 5 Vallancien G, Emberton M, Harving N, van Moorselaar RJ;

Alf-One Study Group. Sexual dysfunction in 1, 274 Euro-pean men suffering from lower urinary tract symptoms. J Urol 2003; 169: 2257-2261 [PMID: 12771764 DOI:10.1097/01.ju. 0000067940.76090.73]

No author given6 21st century heart solution may have a sting in the tail. BMJ

2002; 325: 184 [PMID: 12142303 DOI:10.1136/bmj.325. 7357.184]

Volume with supplement7 Geraud G, Spierings EL, Keywood C. Tolerability and safety

of frovatriptan with short- and long-term use for treatment of migraine and in comparison with sumatriptan. Headache 2002; 42 Suppl 2: S93-99 [PMID: 12028325 DOI:10.1046/j.1526- 4610.42.s2.7.x]

Issue with no volume8 Banit DM, Kaufer H, Hartford JM. Intraoperative frozen sec-

tion analysis in revision total joint arthroplasty. Clin Orthop Relat Res 2002; (401): 230-238 [PMID: 12151900 DOI:10.1097/00003086-200208000-00026]

No volume or issue9 Outreach: Bringing HIV-positive individuals into care. HRSA

Careaction 2002; 1-6 [PMID: 12154804]

BooksPersonal author(s)10 Sherlock S, Dooley J. Diseases of the liver and billiary system.

9th ed. Oxford: Blackwell Sci Pub, 1993: 258-296Chapter in a book (list all authors)11 Lam SK. Academic investigator’s perspectives of medical treat-

ment for peptic ulcer. In: Swabb EA, Azabo S. Ulcer disease: investigation and basis for therapy. New York: Marcel Dekker, 1991: 431-450

Author(s) and editor(s)12 Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd

ed. Wieczorek RR, editor. White Plains (NY): March of Dimes Education Services, 2001: 20-34

Conference proceedings13 Harnden P, Joffe JK, Jones WG, editors. Germ cell tumours

V. Proceedings of the 5th Germ cell tumours Conference; 2001 Sep 13-15; Leeds, UK. New York: Springer, 2002: 30-56

Conference paper14 Christensen S, Oppacher F. An analysis of Koza's computa-

tional effort statistic for genetic programming. In: Foster JA, Lutton E, Miller J, Ryan C, Tettamanzi AG, editors. Genetic programming. EuroGP 2002: Proceedings of the 5th European Conference on Genetic Programming; 2002 Apr 3-5; Kinsdale, Ireland. Berlin: Springer, 2002: 182-191

Electronic journal (list all authors)15 Morse SS. Factors in the emergence of infectious diseases.

Emerg Infect Dis serial online, 1995-01-03, cited 1996-06-05; 1(1): 24 screens. Available from: URL: http://www.cdc.gov/ncidod/eid/index.htm

Patent (list all authors)16 Pagedas AC, inventor; Ancel Surgical R&D Inc., assignee.

Flexible endoscopic grasping and cutting device and position-ing tool assembly. United States patent US 20020103498. 2002 Aug 1

Statistical dataWrite as mean ± SD or mean ± SE.

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Statistical expressionExpress t test as t (in italics), F test as F (in italics), chi square test as χ2 (in Greek), related coefficient as r (in italics), degree of freedom as υ (in Greek), sample number as n (in italics), and probability as P (in italics).

UnitsUse SI units. For example: body mass, m (B) = 78 kg; blood pressure, p (B) = 16.2/12.3 kPa; incubation time, t (incubation) = 96 h, blood glucose concentration, c (glucose) 6.4 ± 2.1 mmol/L; blood CEA mass concentration, p (CEA) = 8.6 24.5 mg/L; CO2 volume fraction, 50 mL/L CO2, not 5% CO2; likewise for 40 g/L formaldehyde, not 10% formalin; and mass fraction, 8 ng/g, etc. Arabic numerals such as 23, 243, 641 should be read 23 243 641.

The format for how to accurately write common units and quan-tums can be found at: http://www.wjgnet.com/1948-5204/g_info_ 20100312183048.htm.

AbbreviationsStandard abbreviations should be defined in the abstract and on first mention in the text. In general, terms should not be abbrevi-ated unless they are used repeatedly and the abbreviation is helpful to the reader. Permissible abbreviations are listed in Units, Symbols and Abbreviations: A Guide for Biological and Medical Editors and Authors (Ed. Baron DN, 1988) published by The Royal Society of Medicine, London. Certain commonly used abbreviations, such as DNA, RNA, HIV, LD50, PCR, HBV, ECG, WBC, RBC, CT, ESR, CSF, IgG, ELISA, PBS, ATP, EDTA, mAb, can be used directly without further explanation.

ItalicsQuantities: t time or temperature, c concentration, A area, l length, m mass, V volume.Genotypes: gyrA, arg 1, c myc, c fos, etc.Restriction enzymes: EcoRI, HindI, BamHI, Kbo I, Kpn I, etc.Biology: H. pylori, E coli, etc.

Examples for paper writingAll types of articles’ writing style and requirement will be found in the link: http://www.wjgnet.com/esps/NavigationInfo.aspx?id=15

SUBMISSION OF THE REVISED MANUSCRIPTS AFTER ACCEPTEDAuthors must revise their manuscript carefully according to the revision policies of Baishideng Publishing Group Co., Limited. The revised version, along with the signed copyright transfer agreement,

responses to the reviewers, and English language Grade B certificate (for non-native speakers of English), should be submitted to the online system via the link contained in the e-mail sent by the editor. If you have any questions about the revision, please send e-mail to [email protected].

Language evaluation The language of a manuscript will be graded before it is sent for revision. (1) Grade A: priority publishing; (2) Grade B: minor lan-guage polishing; (3) Grade C: a great deal of language polishing needed; and (4) Grade D: rejected. Revised articles should reach Grade A or B.

Copyright assignment formPlease download a Copyright assignment form from http://www.wjgnet.com/1948-5204/g_info_20100312182928.htm.

Responses to reviewersPlease revise your article according to the comments/suggestions provided by the reviewers. The format for responses to the reviewers’ comments can be found at: http://www.wjgnet.com/1948-5204/g_info_20100312182841.htm.

Proof of financial supportFor papers supported by a foundation, authors should provide a copy of the approval document and serial number of the foundation.

STATEMENT ABOUT ANONYMOUS PUBLICATION OF THE PEER REVIEWERS' COMMENTSIn order to increase the quality of peer review, push authors to carefully revise their manuscripts based on the peer reviewers' com-ments, and promote academic interactions among peer reviewers, authors and readers, we decide to anonymously publish the review-ers’ comments and author’s responses at the same time the manu-script is published online.

PUBLICATION FEEWJR is an international, peer-reviewed, OA online journal. Articles published by this journal are distributed under the terms of the Cre-ative Commons Attribution Non-commercial License, which per-mits use, distribution, and reproduction in any medium and format, provided the original work is properly cited. The use is non-com-mercial and is otherwise in compliance with the license. Authors of accepted articles must pay a publication fee. Publication fee: 600 USD per article. All invited articles are published free of charge.

WJR|www.wjgnet.com V July 28, 2013|Volume 5|Issue 7|

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Documents

World Journal of · World Journal of Radiology World J Radiol 2013 July 28; 5(7): 253-266 ISSN 1949-8470 (online)