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A blinded retrospective study was performed to determine the sensitivity and specificity of computed tomography (CT) in detecting perigraft infection (PGI) and aortoenteric fistula (AEF), rare but devastating complications of aortic reconstructive surgery. Two observers independently reviewed CT scans in 55 cases including AEF (n = 23); PGI (n = 12); and normal, noninfected grafts (n = 20). Each scan was assessed for ectopic gas, focal bowel wall thickening, perigraft fluid, perigraft soft tissue, pseudoaneurysm formation, disruption of the aneurysmal wrap, and increased soft tissue between the graft and surrounding wrap. Comparison of CT findings with operative results revealed that each observer correctly identified as abnormal 33 of 35 cases of PGI either with or without AEF (sensitivity, 94%) and that results were falsely positive in three cases (specificity, 85%). CT findings ranged from large amounts of perigraft soft tissue and ectopic gas to subtle findings of minimal or no abnormalities; thus, strict criteria must be applied to the interpretation of CT scans after aortic surgery. Although CT is not 100% sensitive or specific, the authors conclude that it will continue to be valuable for diagnosing PGI and AEF.

n engl j med 350;6 www.nejm.org february 5, 2004The new england journal of medicine 599 clinical problem-solvingIn this Journal feature, information about a real patient is presented in stages (boldface type)to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows.A 60-year-old woman with a history of radiologically confirmed seronegative rheumatoid arthritis presented to the emergency department with a 10-day history of worsening dyspnea on exertion, nonproductive cough, and subjective fever and a 7-day history of pain in the right leg and buttock, which limited her mobility. There was no sputum production, orthopnea, paroxysmal nocturnal dyspnea, or pleuritic chest pain.

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