Staging of portal hypertension and portosystemic shunts using dynamic nuclear medicine investigations.

AIM: To explore portal hypertension and portosystemic shunts and to stage chronic liver disease (CLD) based on the pathophysiology of portal hemodynamics. METHODS: Per-rectal portal scintigraphy (PRPS) was performed on 312 patients with CLD and liver angioscintigraphy (LAS) on 231 of them. The control group included 25 healthy subjects. We developed a new model of PRPS interpretation by introducing two new parameters, the liver transit time (LTT) and the circulation time between right heart and liver (RHLT). LTT for each lobe was used to evaluate the early portal hypertension. RHLT is useful in cirrhosis to detect liver areas missing portal inflow. We calculated the classical per-rectal portal shunt index (PRSI) at PRPS and the hepatic perfusion index (HPI) at LAS. RESULTS: The normal LTT value was 24 +/- 1 s. Abnormal LTT had PPV = 100% for CLD. 27 non-cirrhotic patients had LTT increased up to 35 s (median 27 s). RHLT (42 +/- 1 s) was not related to liver disease. Cirrhosis could be excluded in all patients with PRSI < 5% (P < 0.01). PRSI > 30% had PPV = 100% for cirrhosis. Based on PRPS and LAS we propose the classification of CLD in 5 hemodynamic stages. Stage 0 is normal (LTT = 24 s, PRSI < 5%). In stage 1, LTT is increased, while PRSI remains normal. In stage 2, LTT is decreased between 16 s and 23 s, whereas PRSI is increased between 5% and 10%. In stage 3, PRSI is increased to 10%-30%, and LTT becomes undetectable by PRPS due to the portosystemic shunts. Stage 4 includes the patients with PRSI > 30%. RHLT and HPI were used to subtype stage 4. In our study stage 0 had NPV = 100% for CLD, stage 1 had PPV = 100% for non-cirrhotic CLD, stages 2 and 3 represented the transition from chronic hepatitis to cirrhosis, stage 4 had PPV = 100% for cirrhosis. CONCLUSION: LTT allows the detection of early portal hypertension and of opening of transhepatic shunts. PRSI is useful in CLD with extrahepatic portosystemic shunts. Our hemodynamic model stages the evolution of portal hypertension and portosystemic shunts. It may be of use in the selection of patients for interferon therapy.

Acute Cholecystitis as a Complication after Colonoscopy: A Case Report and Literature Review.

Acute cholecystitis after colonoscopy is a rare event, with less than 10 cases described in the literature. We report the case of a male patient with silent gallstones who underwent colonoscopy for follow-up of his Crohn's disease. The colonoscopy revealed erosions in the terminal ileum, from which biopsies were taken. A sessile polyp 4 mm in diameter at the recto-sigmoid junction was also removed. Less than 24 h after the colonoscopy, the patient complained of upper right quadrant pain, nausea and vomiting. Based on the clinical findings, laboratory data and ultrasonography, we diagnosed acute cholecystitis and excluded any complication after the colonoscopy. Laparoscopic cholecystectomy was performed and the patient was discharged. LEARNING POINTS: Cholecystitis following colonoscopy can be a rare complication or a coincidence.Rarely, manoeuvres during colonoscopy may dislodge small gallstones which then obstruct the bile duct causing acute cholecystitis.Imaging and the clinical picture help to differentiate bowel perforation, a fairly common early event after colonoscopy, from other complications.

Ileo-colic intussusception by ileo-cecal valve lipoma - an infrequent ultrasonographic occurrence. A case report.

We present a rare cause of intestinal obstruction in an adult, due to ileo-colic intussusception by a lipoma of the ileo-cecal valve and its ultrasonographic presentation. The case presented in emergency for spontaneously appearing and disappearing palpable elastic mass in the right iliac fossa. The ultrasonographic examination raised the suspicion of an ileo-colic intussusception due to a polypoid tumor. The contrast-enhanced computed tomography confirmed the finding and suggested that the polypoid tumor was more likely a lipoma. Right hemicolectomy and cholecystectomy were performed and the pathological examination confirmed the lipoma. The evolution of the patient was favourable and uneventful.

Chyliform effusion without pleural thickening in a patient with rheumatoid arthritis: A case report.

Pseudochylothorax, also known as chyliform effusion rich in cholesterol crystals, is a rare entity that sometimes occurs in long-standing rheumatoid arthritis (RA) and is usually associated with thickened pleura. There have only been a few case reports in the literature on pseudochylothorax unassociated with pleural thickening and with a short duration of articular symptoms in patients with RA. We report the case of a 70-year-old male patient with a history of RA and heart failure due to severe aortic stenosis, who presented with signs and symptoms of decompensated heart failure due to a moderate right-sided pleural effusion that was consequently proved to be pseudochylothorax unassociated with pleural thickening on chest computed tomography (CT) scan. The patient's outcome was favorable after thoracocentesis was carried out and leflunomide was added to the standard heart failure treatment.

Intraductal papillary mucinous neoplasia--a challenging diagnosis in a patient with paraneoplastic rheumatoid arthritis. Case report.

Intraductal papillary mucinous neoplasias (IPMNs) of the pancreas are potentially malignant tumors, and associated also with extrapancreatic carcinomas. We present the case of a 80 year old man with IPMN and late onset of rheumatoid arthritis. The particularity of this case is the discordance between the clinical picture and the imaging worrisome features, together with the surgery-requiring mixed-type of IPMN, despite the late possible paraneoplastic onset of rheumatoid arthritis.

Spontaneous and antiviral-induced cutaneous lesions in chronic hepatitis B virus infection.

AIM: To describe spontaneous, or interferon (IFN)- or immunization-induced skin lesions in hepatitis B virus (HBV) infection. METHODS: A comprehensive literature search of all the papers presenting case reports of dermatological lesions in patients with chronic HBV infection was carried out. We included only patients with histologically proven skin lesions that appeared in the normal course of hepatitis B infection, or after immunization for hepatitis B or antiviral treatment. RESULTS: We found 44 papers on this topic, reporting 151 cases. About 2% of patients with hepatitis B infection, mainly men, presented with skin lesions. Among patients with chronic hepatitis B, vasculitis and essential mixed cryoglobulinemia seemed to be the most frequent skin lesion (53.3%), followed by papular changes, rashes and Gianotti-Crosti syndrome, skin carcinoma and Henoch-Schönlein purpura were rare. IFN treatment seemed to be effective against HBV-associated and immunoglobulin-complex-mediated disease (vasculitis). Two cutaneous lesions (lichen planus and granuloma annulare) were described after hepatitis B vaccination. Systemic lupus and lupus-like lesions were the most frequently encountered lesions after antiviral treatment. Immunosuppressive and steroid therapy ameliorates lichen planus lesions in 50% of cases. CONCLUSION: Vasculitis was the most frequent spontaneous skin lesion found in chronic hepatitis B. Lichen planus was most frequent after immunization and lupus/lupus-like lesions after IFN.

Pseudoaneurysma of the external jugular vein communicating with the internal jugular vein. Case report.

True and false aneurysmas (pseudoaneurysmas) of veins are very rare conditions. We present the case of a 58 year old woman with a progressive spheric enlargement with pusatile character of the right laterocervical area. Ultrasonography established the diagnosis showing the vascular mass with turbulent flow belonging to the external jugular vein and the communication with the internal jugular vein.. The particularities of this case are the absence of an obvious etiology and the particular variant of flow direction from internal towards the external jugular vein. To the best of our knowledge, this is the first case of pseudoaneurysma of the external jugular vein reported in literature.

The non-conventional use of 99mTc-Tetrofosmine for dynamic hepatobiliary scintigraphy.

BACKGROUND: Classic dynamic hepatobiliary scintigraphy (DHBS) is commonly performed with 99mTc-Iminodiacetic Acid (IDA) derivatives and represents a non-invasive diagnosis method for biliary dyskinesia, fistulas, surgical anastomosis, etc (1). This study assesses the possibility of performing DHBS with 99mTc-Tetrofosmine (TF), a radiopharmaceutical (RF) dedicated to myocardial perfusion scintigraphy (MPS), but being excreted through the liver. The possibility to use 99mTc-TF for DHBS may be important in situations when the standardized RF for this procedure (IDA derivatives) is not available. MATERIAL AND METHODS: We performed DHBS for 30 patients referred for investigation by internal medicine and surgery departments. The patients had been fasting for 12 hours. The dynamic investigation started simultaneously with the intravenous (IV) administration of 37-110 MBq (1-3 mCi) 99mTc-TF. Dynamic images were recorded for 30-45 minutes, one image per minute, followed by static scintigraphy at 1 h, 1.5 h, 2 h, and 3 h after IV injection. RESULTS: The quality of scintigraphic images of the liver and biliary tree obtained at DHBS with 99mTc-TF ensured the correct diagnosis of biliary dyskinesia, stasis, stenosis, and fistulas. CONCLUSIONS: DHBS using 99mTc-TF is justified by the image quality and by the good cost/benefits ratio. Because the IDA derivatives are not always available, this finding may be important for medical practice. 99mTc-TF evacuated through the bile duct allows DHBS interpretation, while the necessary dose is approximately 8 to 20 times smaller than that used for myocardial perfusion scintigraphy.

Usefulness of contrast enhanced ultrasound guidance in percutaneous biopsies of liver tumors.

The performance of percutaneous echoguided biopsy in hepatic tumor diagnosis is limited by several factors, among which tumor characteristics such as tumor type, size and location play an important role. With all the advantages offered by ultrasound guidance, the overall sensitivity of this method in the tumor diagnosis has remained around 90%. Contrast enhanced ultrasound (CEUS) guided percutaneous biopsy is a new developed technique aimed at increasing the accuracy of percutaneous biopsies. With new ultrasound devices comprising the split-screen mode, which displays both the CEUS and background B-mode US image simultaneously on a single monitor, the procedure is now technically feasible. CEUS guided percutaneous liver biopsy should be applied in large tumors with consistent necrosis, in hypovascular tumors or in those invisible or poorly visible to conventional ultrasound. An increased accuracy was demonstrated in poorly visible or invisible hepatic lesions and when CEUS was used before biopsy.

Contrast enhanced ultrasound guidance: a new tool to improve accuracy in percutaneous biopsies.

The performance of percutaneous echoguided biopsy in the tumoral diagnosis is limited by several factors, among which tumor characteristics such as tumor type, size and location play an important role. With all the advantages offered by the ultrasound guidance, the overall sensitivity of this method in the tumoral diagnosis of tumor has remained around 90%. Contrast enhanced ultrasound guided percutaneous biopsy is a new developed technique aimed to increase the acurracy of percutaneous biopsies. With new ultrasound devices with split-screen mode, which displays both the CEUS and background B-mode US image simultaneously, on a single monitor, the procedure is technically feasible. CEUS guided percutaneous biopsy should be applied in large tumors with consistent necrosis, in hypovascular tumors or in those invisible or poorly visible to conventional ultrasound. The increased accuracy was demonstrated in liver tumors and in prostate adenocarcinoma.

B-mode and contrast enhanced ultrasound guided biopsy of portal vein thrombosis. Value in the diagnosis of occult hepatocellular carcinoma in liver cirrhosis.

AIM: The ultrasonographic (US) detection of hepatocellular carcinoma (HCC) in patients with liver cirrhosis is based on the visualization of focal lesions. However, in some cases HCC cannot be clearly identified at US, the only sign being a portal vein thrombosis (PVT). Contrast enhanced ultrasound (CEUS) is an excellent method to characterise focal lesions and portal thrombosis in patients with liver cirrhosis. The aim of the study was to assess the value of US and CEUS -guided PVT core biopsy in the diagnosis of an occult HCC in patients with cirrhosis. MATERIAL AND METHODS: Twenty patients with cirrhosis, PVT and no focal lesion on high-resolution US were studied. In 17 cases the thrombus was interpreted as malignant at US. All patients had normal coagulation parameters. The biopsies of an intrahepatic PVT were performed using an 18G Bard needle coupled on "Biopty Gun".US and CEUS guidance was used in16 respectively 4 patients. In 10 cases with a very inhomogeneous hepatic echostructure near the PVT (coarse echo pattern) a liver biopsy from that area was performed. RESULTS: Adequate histological specimens were obtained in all cases, requiring 1 to 2 passes (mean 1.5 per patient). Only 1 patient had severe pain. No major complications were detected. The overall sensitivity of core biopsy in the diagnosis of malignant PVT was 94.4 % (17/18). The sensitivities of US and CEUS guided PVT biopsy were 92.8% (13/14) and 100% (4/4) respectively. In 6 of 10 cases with coarse echo pattern the same type of HCC was found in the surrounding parenchyma. No false positive results were noted. CONCLUSIONS: US-guided core biopsy of PVT is a safe and useful technique in the diagnosis of occult HCC in cirrhosis and should be performed in all cases with PVT with malignant US features and no evidence of focal lesions. The "coarse echo pattern" found in the vicinity of a malignant thrombus is frequently the expression of an inapparent, occult HCC. CEUS guided PVT biopsy is a new, promising method with excellent results in establishing the nature of a portal thrombus.

A simplified 2-D electrophoresis protocol with the aid of an organic disulfide.

2-DE is still a relatively cumbersome and labor intensive method. Given the successful cysteinyl protection concept with hydroxyethyl disulfide (specific oxidation) during the first dimension separation, the possibility for a simplified equilibration procedure was investigated. This was achieved by maintaining the S-mercaptoethanol modified cysteinyls throughout the 2-D workflow including second dimension separation, spot handling, protein digestion, and protein identification. The traditional equilibration protocol encompassing thiol reduction and alkylation was compared with a one-step protocol employing continuous exposure to hydroxyethyl disulfide. Both equilibration protocols gave equally well-resolved spot maps with analytical protein loads regardless of IPG strip pH range. Using preparative protein loads, narrow range IPG strips gave comparable results for the two protocols while preparative load on wide range IPG strips was the only condition where classical reduction/alkylation outperformed hydroxyethyl disulfide equilibration. Moreover, with analytical protein loads, the hydroxyethyl disulfide equilibration time could be significantly reduced without apparent loss of spot map quality or quantitative protein transfer from the first- to the second dimension gel. MALDI-TOF mass spectrometric protein identification was successfully performed with either iodoacetamide or hydroxyethyl disulfide as the cysteine modifier, yielding comparable identification results with high confidence in protein assignment, sequence coverage, and detection of cysteine-containing peptides. The results provide a novel and simplified protocol for 2-DE where the concept of hydroxyethyl disulfide as the cysteinyl protecting agent is extended to cover the entire 2-D work flow.