Splanchnic Inflammatory System. The first description of the imaging findings of a disease affecting > 50 million Americans. Seeing things that have always been there, but never appreciated before.
This is the most important paper ever written in abdominal imaging:
Hepatic steatosis: additional findings in the splanchnic system on magnetic resonance imaging.
Why Dr Richard Semelka do you say it is the most important? It is the first paper to tie together multiple findings in multiple different organ systems to provide a global picture of an extremely common medical condition, which has wide occurrence (> 50 million), significant potential for severe disease development (cancer) and in may stages fundamentally readily treatable...
and never before understood and hence never before described. The most importantpaper.
Splanchnic Inflammatory Syndrome(SIS) is the term we have given to it. . I have just made postings and shown other examples on MRI on TikTok. Like many things, once they have been discovered and pointed out, the findings are straightforward, and once you see them (and are trained to read body MRI) you cannot avoid seeing them again in future cases... They were always present and there before, but never seen, and therefore never looked for. With Dr Semelka now pointing them out, it is impossible to overlook them... provided ofcourse the reader is astute, Everyone who interprets abdominal imaging studies and certainly abdominal MR should see my presentations. They should feel it imperative to read these cases properly.
It is reasonable and hence appropriate to ask: 'why should I believe Dr Richard Semelka about something that is so profoundly game-changing to everything we thought we knew about the digestive tract, the pancreas, the mesentery, the gallbladder, the biliary tree, and the liver?
Well, the reason you should,is readily discoverable. Dr Semelka has not just blown out of the seat of his pants that he knows more about the military than the generals, with no evidence other than he said it. In modern medicine these things are discoverable by reading a physician's curiculum vitae (cv). Dr Semelka has: i) written 6 editions of the world-wide dominant textbook on abdominal MRI, ii) has pioneered abdominal MRI,iii) is the leading author in the peer-reviewed literature (peer-reviewed is the gold standard for credibility of articles) on abdominal MRI, having written > 200 peer-reviewed articles (of > 350 peer-reviewed articles) just on this subject, and has written the first and second generation descriptions of essentially all common and uncommon diseases of the abdomen on MRI. So unmatched and formidable accomplishments. Maybe not the Novak Djokovic, but certainly the Roger Federer of Radiology. For confirmation read my cv. An important addition, which is also discoverable, but with difficulty, I have read more than 100,000 studies of MR of the abdomen (comparable number of CTs of the abdomen) and have done so with clarity, profound knowledge, and decisiveness. So I know the findings of abdominal MRI, like Roger knows a top spin forehand up the line... Also important to understand, yes maybe extremely good, maybe bettter than anyone else, but also not perfect.
It is the interesting observation that the findings have always been there, but no one previously (including myself) 'saw' them, and hence did not recognize them for what they are. The study population is limited to 100, but my expanded real world experience post being aware of this entity is well over 1,000, in whom all these additional patient studies have been consistent with the findings reported in this article. In fact, my expanded base of real world experience allows for more confidence and greater breadth of observation of findings and additional findings than I described in the paper. Such as all cases of small pancreatic cysts show duodenal or jejunal, or both, increased enhancement. Acalculous acute cholecystitis is actually inflammation of the duodenum with sympathetic inflammation of adjacent gallbladder. This explains why cholecystectomy does not resolve symptoms. Most / all biliary dyskinesias are also biliary inflammation extension from the primary inflammation of the duodenum. Mesenteric panniculitis represents tracking of jejunal inflammation into the mesentery. Likely many benign lesions of the various organs are secondary to SIS, and many malignancies.
We describe for the first time the comprehensive disease processes involving all organs in the splanchnic system: digestive (AKA GI) tract, pancreas, gallbladder, biliary tree, liver. This essentially describes the interaction between underlying inflammation and the effects on all these organs and tissues in the Splanchnic System. We opine the digestive tract, the one organ of the group in direct contact with the outside world, is the entry point, and liver the exit point - inflammation essentially along the digestive tract - liver axis. Recent studies have shown the strong cause and effect relationship between Splanchnic (digestive tract) diseases (eg: microbiome dysbiosis) and other organ systems, presently reported on the neurological system (the relationship between digestive conditions and dementia as one example) and the digestive-tract - skin relationship.
This article touches on many of the entities, and looks at the association with others. GI - liver inflammation is the root cause for many/most diseases of the system. These disturbances have profound effect on the entire body as well.
I also read recently, and I forget the source, where some physician/researcher observed that a great loss in advancement of knowledge in medicine is that many studies written by unrecognized researchers and published in minor journals go unnoticed..
Interesting this probably reflects simply that novel, game-changing discoveries are generally initially rejected by the organized group (whichever group it is, in this case western medicine) because it challenges everything/ most things. As the leading author in abdominal MRI I am hardly an unrecognized researcher, however none-the-less the first description of complete game-changing medical understandings is met with skepticism.... and in truth, they should be..
Actually though, regarding many of the authors who write about integrative abdominal health, this actually provides the missing imaging evidence of what they describe for diet, and that diet influences all aspects of health. Miracle stories that allopathic physicians (including myself) were incredulous of: individuals with diabetes, hypertension, chronic illness of all kinds, adopt a healthy diet (no pharmaceutical drugs) and become perfectly healthy. Our imaging findings actually then demonstrate why: the digestive tract is the entry point to inflammation of the entire system, resolve that inflammation and everything else can improve. This study documents all those findings. We have also observed (not yet reported in the peer-reviewed literature) that change in lifestyle and diet on followup MRI shows improvement of fat content in liver and diminished inflammatory enhancement of bowel..
The following is worth repeating from above, these are some of the important features of the Splanchnic Inflammatory System:
1. mesenteric panniculitis is present in atleast 10% of sufferers, and in general it is a much more common occurrence than previously understood. We show that it is secondary to jejunal inflammation in the great majority (? all) of cases. It is not a reflection of cancer or lymphoma.
2. acute acalculous cholecystitis, which to the present day is still often erroneously treated with cholecystectomy. Symptoms usually persist post-cholecystectomy, and physicians are puzzled why. This is because this entity represents sympathetic inflammation of the gallbladder to the actual disease, which is duodenal inflammation. So to this day numerous cholecystectomies are performed, and the wrong thing is being treated, that is why this surgery does not work. The primary disease is duodenal inflammation..
3. This also applies to all biliary dyskinesia..
4. All/ most cases of liver steatosis due to NASH and other causes are secondary to upper GI tract inflammation. This is actually the central point of this paper.
5. Small pancreatic cysts are observed in the setting of duodenal and jejunal inflammation and they likely arise from inflammation tracking in the mesentery.
and by extension, on and on for benign lesions in the splanchnic system and many malignant lesions.
6. We suspect many benign liver lesions are also secondary to SIS, certainly FNHs, likely biliary hamartomas and adenomas.
7. A number of cancers are due to sustained long term inflammation: Hepatocellular carcinoma (liver cancer), and possibly some cases of pancreatic cancer and gallbladder cancer.
8. Irritable bowel syndrome routinely is shown as increased enhancement of segments of the upper GI tract. Conventional thinking is that Irritable Bowel Syndrome does not show findings on imaging. This is true for CT but not true for Gadolinium enhanced MRI.
One could ask: if SIS is so common and important imaging findings, then what are the clinical diseases that result in these findings, certainly this did not come out of nowhere. SIS is essentially the description of the clinical disease Metabolic Syndrome (I prefer calling it Splanchnic Metabolic Syndrome), and its precursor conditions Irritable Bowel Syndrome and leaky gut. Note leaky gut and irritable bowel syndrome do not inevitably progress into the Splanchnic Metabolic Syndrome. SIS shows the full range of imaging findings of the Metabolic Syndrome, beyond what to the present time has been understood to be present; partly because they may be clinically silent/ minor (eg: small pancreatic cysts) or unexpected (acute acalculous cholecystitis)..
Imaging. MRI with gadolinium enhancement demonstrates SIS extremely well, once one learns how to interpret the findings. In individuals who should not get Gadolinium, or do not want to get it, MRI with DWI shows many of the findings, and can low B0DWI can see many of the digestive tract findings (not all). Ultrasound is very poor and cannot identify important components of the condition: it shows most bowel findings poorly, and usually is unable to see the pancreas, especially in overweight individuals, which most people with SIS are.. CT also misses the GI inflammation, since CT with iodine is much less sensitive to show enhancement than MR with gadolinium. Although CT can show a number of the morphological findings. CT has not been able to show the important finding of upper GI tract inflammation, which is essential to make the diagnosis of Splanchnic Inflammatory Syndrome.
Years back, my team and I made the first description of imaging of fibrosis and and other features in chronic liver disease on MRI - this was similar in that we simply saw and understood what was there the whole time. This was similar, but simpler, than what we have done here: what we have seen and identified here are the importance of findings that were always there, but others (including myself for 30 years) never made the connection. I think for example, radiologists saw the increased enhancement of upper GI segments but passed it off as nothing, because no one ever reported before that it was abnormal.. I myself did not make that connection for some 30 years and having interpreted more abdominal MRI studies than anyone else in the world (over 100, 000). It was only with careful reflection, reviewing on my mental hard disc, that although abnormal enhancement of the upper GI tract was very common. But this is the thing, it was not very common as a reflection of being normal, but was very common because upper GI tract is a common cause of abdominal pain that was the reason for doing the MR study to begin with. Since people get MRI of the abdomen for an abdominal complaint, then radiologists would not have the experience to know what 'normals' look like, normal people do not get MRI of the abdomen with GBCA enhancement. It turns out, normal upper GI enhances the same as abdominal muscles in the same images: that is intermediate 'gray' signal, and not 'bright white' enhancement. The psoas and paraspinal muscles are the best comparators, as they are present in the same images.
We want to be careful not to say that everyone with abdominal pain needs MRI with Gd, but the starting point is if patients are getting MRI of the abdomen it is imperative to describe everything that is there. Know what mesenteric panniculitis looks like, and report it. Know what sympathetic increased enhancement of the gallbladder to adjacent duodenal disease looks like, and describe it. Know what abnormal jejunal enhancement looks like, and describe it, etc, Know what increased enhancement of the distal esophagus (which is the easiest to call) looks like, and describe it.. Infact as I think back, scan back on my cognitive hard disc,, how much trouble I had distinguishing varices from ileum in MR studies of cirrhotic patients, the reason that it was challenging is that the ileum was abnormal : it showed tubular featureless moderately increased enhancement. This is part of the Splanchnic Inflammatory Syndrome.
The bottom line may simply be, what so many integrative health authors have written, if you are overweight and have abdominal pain, start with changing your diet to a Mediterranean/ South Beach / autoimmune diet, or however you want to call a diet which avoids too much refined sugar, chemicals, processed meats, and emphasizes 'organic' vegetables, fruits and clean meats. You don't need MRI of the abdomen with GBCA to make that call. However, getting a noncontrast MR of the abdomen to rule-out malignant causes may be important, and if findings are present on that study that suggest malignancy may be present, get MRI with GBCA at that time.
Richard Semelka, MD
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