Growth Hormone Therapy in Decompensated Cirrhosis: An Open-Label, Randomized Control Trial.

INTRODUCTION: Effect of long-term growth-hormone (GH) therapy in decompensated cirrhosis (DC) is unknown. We studied the safety and efficacy of GH therapy on malnutrition, nitrogen metabolism, and hormonal changes in patients with DC. METHODS: Patients with DC were randomized to standard medical therapy plus GH (group A; n = 38) or standard medical therapy alone (group B; n = 38). Body mass index, midarm muscle circumference (MAMC), hand grip strength (HGS), liver frailty index (LFI), skeletal muscle index (SMI), nitrogen balance, Child-Turcotte-Pugh, model for end-stage liver disease, quality of life (QOL), serum albumin, GH, insulin like growth factor-1, and acid labile subunit (ALS) were assessed at baseline and at 12 months. RESULTS: The mean difference between baseline and 12-months in SMI (-6.122 [-9.460 to -2.785] cm 2 /m 2 ), body mass index (-2.078 [-3.584 to -0.5718] kg/m 2 ), MAMC (-1.960 [-2.928 to -0.9908] cm), HGS (-5.595 [-7.159 to -4.031] kg), albumin (-0.3967 [-0.6876 to -0.1057] g/dL), LFI (0.3328 [0.07786-0.5878]), Child-Turcotte-Pugh (0.9624 [0.1435-1.781]), model for end-stage liver disease (1.401 [0.04698-2.75]), insulin-like growth factor-1 (-6.295 [-11.09 to -1.495] ng/dL), and ALS (-8.728 [-14.12 to -3.341] pg/mL) were statistically significantly better ( P < 0.05) in group A. There was no improvement in nutritional parameters, clinical scores, QOL scores, or nitrogen balance in group B. The mean difference between group A and B in SMI, HGS, MAMC, LFI, ALS, physical component summary, and mental component summary at 12 months was also statistically significant. Survival at 12 months was similar in both groups ( P = 0.35). No serious adverse events were observed. DISCUSSION: Long-term use of GH is safe in DC and leads to improvement in malnutrition and possibly QOL. However, there is no improvement in 12-month survival (NCT03420144).

Real-time loop-mediated isothermal amplification (real-time LAMP) assay for rapid diagnosis of amoebic liver abscess.

Among the parasitic diseases, amoebic liver abscess (ALA) ranks second to malaria in terms of mortality. Due to the poor sensitivity of conventional diagnostic methods, there is a need for the development of effective and rapid diagnostic methods for ALA. Thus, the purpose of this work was to develop a real-time loop-mediated isothermal amplification (RT-LAMP) assay specific to Entamoeba histolytica. Further, we compared the performance of real-time LAMP with conventional and real-time PCR (RT-PCR) targeting 18S small subunit ribosomal RNA (18S SSU rRNA) gene of E. histolytica in patients with ALA. A total of 126 liver samples were obtained for the study. Of these, 96 aspirated pus samples were obtained from patients suffering from an ALA (serology confirmed, anti-amoebic immunoglobulin IgG positive), 19 aspirated pus samples from patients with pyogenic liver abscess (PLA, 16S RNA gene positive) and 11 autopsy liver tissues. The results showed that the DNA of E. histolytica was detected in 81 samples by conventional PCR, 93 by RT-PCR and 95 by RT-LAMP. The analytical sensitivity of the RT-LAMP assay was much higher than the other two techniques. RT-LAMP assay was able to amplify up to one copy of the targeted gene of E. histolytica while conventional PCR and RT-PCR could amplify up to 103 and 102 copies of the targeted gene of E. histolytica, respectively. In conclusion, RT-LAMP proved to be a sensitive, specific and rapid test which can be utilised as an effective tool for the diagnosis of ALA.

Endoscopic Ultrasound-Guided Transgastric Shunt Obliteration for Recurrent Hepatic Encephalopathy.

INTRODUCTION: Occlusion of spontaneous portosystemic shunts (SPSSs) in patients with cirrhosis may be required in recurrent or refractory hepatic encephalopathy. We describe a novel method for occlusion of SPSS using endoscopic ultrasound (EUS). METHODS: EUS-guided transgastric shunt obliteration was performed by injecting glue and coils directly into SPSS. RESULTS: EUS-guided transgastric shunt obliteration was performed for 7 patients in 9 sessions. Complete cessation of Doppler flow was achieved in 6/7 cases. Adequate clinical response was observed in 6/7 patients. No procedure-related severe adverse events were seen. DISCUSSION: This novel technique is a potentially effective and efficient method for shunt obliteration.

Misdiagnosis of carcinoma gall bladder in endemic regions.

BACKGROUND: Incidental carcinoma gall bladder and benign disease in radical cholecystectomy specimen is the cause of concern. We attempted to find out the incidence and reasons thereof in the present study. METHODS: Present study is a retrospective analysis of a prospectively maintained database between July 2002 and July 2019. All patients with a diagnosis of carcinoma gall bladder admitted for surgery were included. RESULTS: Out of 148 patients, 110 patients had carcinoma gall bladder (CAGB), while 38 patients (25.7%) had incidental carcinoma (under-diagnosis). Radical resection was done in 61/110 (55.4%) patients with clinical CAGB, where 15 (24.6%) patients had benign pathology ("over-diagnosis"). Overdiagnosis was due to xanthogranulomatous cholecystitis (n = 9), chronic cholecystitis (n = 2), tuberculosis (n = 2) and IgG4 related cholecystitis (n = 2). Among 61 patients, a history of weight loss and anorexia were significantly associated with malignancy. Asymmetrical wall thickness was significantly more common in benign mimickers. Among patients with incidental carcinoma, preoperative ultrasonography reported normal wall thickness of gall bladder in 28 (73.7%), thickened gall bladder wall in 6, and polyp in 3 patients. The resectability rate among incidental carcinoma was 27/38 (71.05%). CONCLUSION: Over-diagnosis of the carcinoma gall bladder was present in 24.6%. On the other hand, incidental carcinoma comprised 25.7% of all admissions for carcinoma gall bladder with resectability of 71%.

The anatomy of the cystic duct and its association with cholelithiasis: MR cholangiopancreatographic study.

The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis-a-vis the main biliary duct. The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%), and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non-lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non-gallstone group (p = 0.02). The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.

Abbreviated MRI for hepatocellular carcinoma screening: A systematic review and meta-analysis.

BACKGROUND & AIMS: Biannual ultrasound has poor sensitivity for hepatocellular carcinoma (HCC) screening. MRI is accurate for the detection of HCC, but a complete MRI is not feasible as a screening tool. Abbreviated MRI (AMRI) is an acceptable alternative. The diagnostic performance of different AMRI protocols is not known. We performed a systematic review to determine the diagnostic accuracy of AMRI for HCC screening. METHODS: We searched the MEDLINE and EMBASE databases for studies reporting the diagnostic accuracy of AMRI for HCC screening. The pooled sensitivity and specificity of different AMRI protocols were calculated based on a random intercept logistic regression model. The diagnostic performance of AMRI was compared with ultrasound. Study quality was assessed using the QUADAS-2 tool. RESULTS: Of the 11,327 studies screened by titles, 15 studies (3 prospective and 12 retrospective: 2,807 patients, 917 with HCC) were included in the final analysis. The pooled per-patient sensitivity and specificity were 86% (95% CI 84-88%, I2 0%) and 94% (95% CI 91-96%, I2 83%), respectively. Pooled per-lesion sensitivity was 77% (95% CI 74-81%, I2 8%). There was no influence of study type, screening setting, reference standard, and presence and etiology of cirrhosis on the performance of AMRI. The sensitivity of AMRI for detection of HCC <2 cm was lower than that for HCC ≥2 cm (69% vs. 86%). The sensitivity and specificity of non-contrast AMRI were comparable to contrast-enhanced AMRI (86% and 94% vs. 87% and 94%, respectively). The diagnostic performance of different non-contrast AMRI and contrast-enhanced AMRI protocols was comparable. The sensitivity of ultrasound was lower than AMRI (53% vs. 82%). CONCLUSIONS: AMRI has high sensitivity and specificity for HCC screening. Different AMRI protocols have comparable diagnostic performance. LAY SUMMARY: Abbreviated MRI (AMRI) has been suggested as an alternative to ultrasound and complete MRI for hepatocellular carcinoma (HCC) screening. Our study results showed that AMRI has a high per-patient and per-lesion sensitivity for HCC. Although the sensitivity of AMRI for detection of HCC <2 cm is considerably lower than for HCC ≥2 cm, it is substantially higher than ultrasound, making it a potential alternative for HCC screening in high-risk populations.

Multiple Cycles of Granulocyte Colony-Stimulating Factor Increase Survival Times of Patients With Decompensated Cirrhosis in a Randomized Trial.

BACKGROUND & AIMS: There is controversy regarding the inclusion of granulocyte colony stimulating factor (G-CSF) in the treatment of decompensated cirrhosis. Previous studies tested only a single cycle of G-CSF administration or were underpowered to detect changes in survival time. We performed an adequately powered study to determine whether multiple cycles of G-CSF increased the survival of patients 1 year after the start of therapy. METHODS: We conducted an open-label trial of 100 patients with decompensated cirrhosis without acute-on-chronic liver failure at a tertiary center from July 2016 through June 2018. The patients were assigned randomly to a group given 5 days of G-CSF every 3 months, with standard medical therapy, in 4 cycles (group A, n = 50), or standard medical therapy alone (group B, n = 50). The primary outcome was survival for 12 months after treatment began. Secondary outcomes were an increase in the number of CD34+ cells at day 6 compared with day 0, along with reductions in Child-Turcotte-Pugh and model for end-stage liver disease scores, increased control of ascites, reduced decompensation and episodes of infection, fewer hospitalizations, lower liver stiffness measurements, increased quality of life and nutrition, fulfilment of liver transplant criteria, and fewer adverse events at 12 months after the start of treatment. RESULTS: Groups A and B were comparable at baseline. Survival at 12 months after initiation of treatment was significantly higher in group A (74%) than in group B (42%) (P < .001). Blood samples from patients in group A had significantly more CD34+ cells on day 6 than on day 0 (P < .001); there was no significant change in group B. Compared with patients in group B, patients in group A had significant reductions in Child-Turcotte-Pugh and model for end-stage liver disease scores, increased ascites control, fewer infections and hospitalizations, lower liver stiffness measurements, an increased quality of life, and a lower number fulfilled the liver transplant criteria (P < .05). There was no improvement in nutrition in either group compared with baseline. G-CSF was safe and well tolerated. CONCLUSIONS: Administration of multiple cycles of G-CSF increases the numbers of hematopoietic stem cells and survival of patients with decompensated cirrhosis receiving standard medical treatment. The addition of G-CSF to medical treatment might provide a bridge to liver transplantation for these patients. ClincialTrials.gov no: NCT03415698.

Efficacy and safety of irreversible electroporation for malignant liver tumors: a systematic review and meta-analysis.

OBJECTIVE: The data regarding overall survival (OS) and progression-free survival (PFS) following irreversible electroporation (IRE) is scarce. We performed a systematic review of the safety and efficacy of IRE for liver malignancies. METHODS: Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through September 1, 2019. Studies reporting the survival data (OS and PFS) and complications (graded according to the Society of interventional Radiology classification) were included. A generalized linear mixed method with a random-effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs). RESULTS: A total of 25 studies (n = 776, 15 prospective, 10 retrospective) were included. Metastasis, hepatocellular carcinoma, and cholangiocarcinoma were present in 354, 285, and 100 patients, respectively. The pooled OS at 6, 12, 24, and 36 months was 93.28% (95% CI: 63.23-99.12, I2= 67%), 81.29% (95% CI: 69.80-89.22, I2 = 73%), 61.47% (95% CI: 52.81-69.46, I2 = 0%), and 40.88% (95% CI: 28.43-54.61, I2 = 64%), respectively. The pooled PFS at 6, 12, and 24 months was 79.72% (95% CI: 67.88-87.97, I2 = 70%), 64.19% (95% CI: 56.68-71.06, I2 = 57%), 49.05% (95% CI: 11.47-87.73, I2 = 96%), respectively. Overall complication rate was 23.7%. Major complications (grade C-F) occurred in 6.9% patients. CONCLUSION: IRE is associated with favorable OS and PFS. Although the overall complication rate is high, most complications are graded as minor. KEY POINTS: • The pooled OS and PFS at 6, 12, and 24 months for all the tumor types was 93.28% and 79.72%, 81.29% and 64.19%, and 61.47% and 49.05%, respectively. • HCC was associated with a better OS at 12 and 36 months. • The overall complication rate was 23.7%, with major complications (SIR grade C-F) comprising 6.9%.

Overall survival and local recurrence following RFA, MWA, and cryoablation of very early and early HCC: a systematic review and Bayesian network meta-analysis.

OBJECTIVE: To compare overall survival (OS) and local recurrence (LR) following radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CA) for very early and early hepatocellular carcinoma (HCC). METHODS: This systematic review was performed according to the PRISMA guidelines. MEDLINE, Embase, and Cochrane databases were searched. Randomized controlled trials (RCTs) and observational studies were included. OS and LR at 1 year and 3 years were assessed. OS was reported as hazard ratio (HR) with 95% credible intervals (CrI) and LR as relative risk (RR) with 95% CrI, to summarize effect of each comparison. RESULTS: Nineteen studies (3043 patients), including six RCTs and 13 observational studies, met inclusion criteria. For OS at 1 year, as compared to RFA, CA had HR of 0.81 (95% CrI: 0.43-1.51), and MWA had HR of 1.01 (95% CrI: 0.71-1.43). For OS at 3 years, as compared to RFA, CA had HR of 0.90 (95% CrI: 0.48-1.64) and MWA had HR of 1.07 (95% CrI: 0.73-1.50). For LR at 1 year, CA and MWA had RR of 0.75 (95% CrI: 0.45-1.24) and 0.93 (95% CrI: 0.78-1.14), respectively, as compared to RFA. For LR at 3 years, CA and MWA had RR of 0.96 (0.74-1.23) and 0.98 (0.87-1.09), respectively, as compared to RFA. Overall, none of the comparisons was statistically significant. Age of patients and tumor size did not influence treatment effect. CONCLUSIONS: RFA, MWA, and CA are equally effective for locoregional treatment of very early and early HCC. KEY POINTS: • There is no significant difference in the OS and LR (at 1 year and 3 years) following ablation of very early and early HCC with RFA, MWA, and CA. • There was no effect of tumor size on the treatment efficacy. • More RCTs comparing CA with RFA and MWA should be performed.

Diagnostic accuracy of Liver Imaging Reporting and Data System locoregional treatment response criteria: a systematic review and meta-analysis.

OBJECTIVE: There is increasing adoption of Liver Imaging Reporting and Data System (LI-RADS) treatment response (LR-TR) criteria. However, there is still a relative lack of evidence evaluating the performance of these criteria. We performed this study to assess the diagnostic accuracy of LI-RADS LR-TR criteria. METHODS: A thorough search of PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials for studies reporting diagnostic accuracy of LI-RADS LR-TR criteria was conducted through 30 June 2020. The meta-analytic summary of sensitivity, specificity, and diagnostic odds ratio of LI-RADS LR-TR criteria was computed using explant histopathology as the reference standard. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS: Four studies were found eligible for meta-analysis. The total number of LR-TR observations was 462 (240 patients, 82.5% males). Different locoregional therapies (LRTs), including bland embolization, chemoembolization, radiofrequency ablation, and microwave ablation, had been used. The mean time interval between LRT and liver transplantation ranged from 181 to 219 days. There was a moderate to good inter-reader agreement for LR-TR criteria. The pooled sensitivity and specificity of LR-TR criteria for viable disease were 62% (95% CI, 49-74%; I2 = 69%) and 87% (95% CI, 76-93%; I2 = 57%), respectively. The pooled diagnostic odds ratio and area under the curve were 9.83 (95% CI, 5.34-18.08; I2 = 19%) and 0.80. CONCLUSIONS: LI-RADS LR-TR criteria have acceptable diagnostic performance for the diagnosis of viable tumor after LRT. Well-designed prospective studies evaluating criteria of equivocal lesions and effect of different LRTs should be performed. KEY POINTS: • The pooled sensitivity and specificity of LI-RADS LR-TR criteria for the diagnosis of viable tumor were 62% and 87%, respectively. • The pooled diagnostic odds ratio and area under the curve were 9.83 and 0.80. • LR-TR criteria had a moderate to good inter-reader agreement.

Comparison of virtual computed tomography enteroscopy using carbon dioxide with small-bowel enteroclysis and capsule endoscopy in patients with small-bowel tuberculosis.

OBJECTIVE: Comparison of virtual CT enteroscopy (VCTE) using carbon dioxide with small-bowel enteroclysis (SBE) and capsule endoscopy (CE) in small-bowel tuberculosis (SBTB). METHODS: This prospective study comprised consecutive patients suspected to have SBTB. VCTE and SBE were performed on the same day and evaluated by independent radiologists. CE was performed within 2 weeks. VCTE was performed following insufflation of carbon dioxide via catheters in the jejunum and anorectum. A contrast-enhanced CT was followed by a delayed non-contrast CT. Image processing was done using virtual colonoscopy software. Findings on VCTE, SBE, and CE were compared. The final diagnosis of SBTB was based on either histopathological or cytological findings, response to antitubercular treatment, or a combination of these. RESULTS: Of the 55 patients in whom VCTE was performed, complete data was available in 52 patients. A final diagnosis of SBTB was established in 37 patients. All patients had VCTE and SBE. CE was performed in 34 patients. Adequate luminal distension was achieved in all patients with SBE and 35 patients with VCTE. SBE showed more strictures in jejunum (10.8%) and ileum (75.7%) compared with VCTE (jejunum, 8.1%, and ileum, 64.9%) and CE (jejunum, 5.9%, and ileum, 61.8%). However, difference was not statistically significant. VCTE revealed a greater length of strictures in both the jejunum and ileum compared with SBE and CE. CONCLUSION: VCTE allows adequate evaluation of the bowel in most patients with SBTB. It allows detection of greater length of abnormality in jejunum and ileum compared with SBE and CE. KEY POINTS: • The use of VCTE using CO2 bowel insufflation in patients with SBTB should be considered. • VCTE allows detection of a greater length of abnormality in the jejunum and ileum.

Utility of percutaneous thrombin injection for treating visceral pseudoaneurysms.

PURPOSE: To assess the efficacy and outcome of percutaneous thrombin injection in treatment of visceral arterial pseudoaneurysms (PAs) in a selective group of patients. MATERIAL AND METHODS: Retrospective review of the institutional database showed 19 cases of visceral arterial pseudoaneurysms that were treated with percutaneous ultrasound-guided thrombin injection between January 2014 and December 2019 (13 men and 6 women). Of the pseudoaneurysms, 36% were due to pancreatitis, 35% were iatrogenic, 21% were infective and 8% traumatic. Most of the pseudoaneurysms arose from the hepatic artery (27%) followed by the splenic artery (26%) and renal artery (21%). Mean sac size of the pseudoaneurysms was 23 mm (range, 8 -40 mm). Technical success was defined as absence of flow within the PAs on follow-up ultrasonography (USG) 24 h and 3 days after thrombin injection. RESULTS: Overall technical success was seen in 10/19 patients. Technical success of thrombin injection was higher in cases of distal branch PAs as compared to main vessel PAs (9/13 vs. 1/6). Success rates were higher with smaller (<23mm) pseudoaneurysms (7/12) as compared to larger ones (3/7). There were no procedure-related complications. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is a novel method of treating visceral pseudoaneurysms as a painless, cheap and radiation-free procedure. However, further large-scale studies are needed to prove the efficacy in treating visceral pseudoaneurysms.

Does spatial heterogeneity of landscape explain the process of plant invasion? A case study of Hyptis suaveolens from Indian Western Himalaya.

Biological invasion is probably one of the most serious threats to biodiversity after climate change. Landscape distinguished by the heterogeneity of structure, forms, human interferences, and environmental settings plays an important role in the establishment and spread of invasive species. We investigated the effect of the spatial heterogeneity for a selected landscape upon the invasion process through a case study of Hyptis (Hyptis suaveolens) in the Indian Western Himalayan region. The selected study site constitutes a heterogeneous landscape of 32,300 ha in the state of Uttarakhand, placed at the lower elevation of the Indian Himalaya. The landscape has varying levels and patterns of Hyptis invasion. We quantified the spatial heterogeneity in terms of elevation; distance from the canal, river, road, and settlement; and 18 landscape metrics (at the patch and land use class level) to investigate their influence on the invasion; for this purpose, a logistic regression model was developed. The invasion of Hyptis was found to be governed by spatial heterogeneity. The highest probability of invasion was found in the areas adjacent to rivers and roads. The analysis at patch level revealed that the invasion is largely governed by the perimeter-area ratio of patches and is positively correlated. This suggests for greater invasion chances in smaller patches as compared with larger ones. The analysis for the land use class metrics indicated a higher influence of edge density expressed as total edge length of patches per unit area, followed by patch density expresses as a total number of patches per unit area. Hence, the landscapes with larger edges and more number of patches are supposed to be more prone to invasion risks. The results of the study can be used by forest managers in designing a landscape-level system to control invasion.

Percutaneous glue embolization as a primary treatment for visceral pseudoaneurysms.

Aim: To evaluate the feasibility and outcome of percutaneous glue embolisation as primary treatment for pseudoaneurysms in selective patients.Material and methods: A review of the pseudoaneurysm cases managed with percutaneous glue at our institute was analyzed in this study. A total of 21 patients over a period of last one year who were treated for pseudoaneurysm at varied sites primarily with percutaneous n-butyl cynoacrylate were retrospectively evaluated. Site of pseudoaneurysm was Pulmonary (seven cases), renal (four cases), pelvic (4four cases) and miscellaneous abdomen (six cases). Combined ultrasound and fluoroscopy approach was used in 17 cases, CT guidance in three cases and combined ultrasound and CT guidance in one case. Patients were evaluated for therapeutic response (radiological and clinical) and procedure related complications.Results: Complete occlusion of the pseudoaneurysm was seen in all patients. Two patients showed mild pneumothorax and one patient showed reflux into the intercostal artery. All the patients showed symptomatic improvement and discharged in stable condition.Conclusions: Percutaneous glue embolisation of the pseudoaneurysms as a primary treatment is feasible and can be safely carried out in select group of patients with good therapeutic response and minimal complications.

Content-Based Image Retrieval System for Pulmonary Nodules Using Optimal Feature Sets and Class Membership-Based Retrieval.

Lung cancer manifests itself in the form of lung nodules, the diagnosis of which is essential to plan the treatment. Automated retrieval of nodule cases will assist the budding radiologists in self-learning and differential diagnosis. This paper presents a content-based image retrieval (CBIR) system for lung nodules using optimal feature sets and learning to enhance the performance of retrieval. The classifiers with more features suffer from the curse of dimensionality. Like classification schemes, we found that the optimal feature set selected using the minimal-redundancy-maximal-relevance (mRMR) feature selection technique improves the precision performance of simple distance-based retrieval (SDR). The performance of the classifier is always superior to SDR, which leans researchers towards conventional classifier-based retrieval (CCBR). While CCBR improves the average precision and provides 100% precision for correct classification, it fails for misclassification leading to zero retrieval precision. The class membership-based retrieval (CMR) is found to bridge this gap for texture-based retrieval. Here, CMR is proposed for nodule retrieval using shape-, margin-, and texture-based features. It is found again that optimal feature set is important for the classifier used in CMR as well as for the feature set used for retrieval, which may lead to different feature sets. The proposed system is evaluated using two independent databases from two continents: a public database LIDC/IDRI and a private database PGIMER-IITKGP, using three distance metrics, i.e., Canberra, City block, and Euclidean. The proposed CMR-based retrieval system with optimal feature sets performs better than CCBR and SDR with optimal features in terms of average precision. Apart from average precision and standard deviation of precision, the fraction of queries with zero precision retrieval is also measured.

Outcome of Acute Pancreatic and Peripancreatic Collections Occurring in Patients With Acute Pancreatitis.

OBJECTIVE: To study the outcome of acute collections occurring in patients with acute pancreatitis BACKGROUND:: There are limited data on natural history of acute collections arising after acute pancreatitis (AP). METHODS: Consecutive patients of AP admitted between July 2011 and December 2012 were evaluated by imaging for development of acute collections as defined by revised Atlanta classification. Imaging was repeated at 1 and 3 months. Spontaneous resolution, evolution, and need for intervention were assessed. RESULTS: Of the 189 patients, 151 patients (79.9%) had acute collections with severe disease and delayed hospitalization being predictors of acute collections. Thirty-six patients had acute interstitial edematous pancreatitis, 8 of whom developed acute peripancreatic fluid collections, of which 1 evolved into pseudocyst. Among the 153 patients with acute necrotizing pancreatitis, 143 (93.4%) developed acute necrotic collection (ANC). Twenty-three of 143 ANC patients died, 21 had resolved collections, whereas 84 developed walled-off necrosis (WON), with necrosis >30% (P = 0.010) and Computed Tomographic Severity Index score ≥7 (P = 0.048) predicting development of WON. Of the 84 patients with WON, 8 expired, 53 patients required an intervention, and 23 were managed conservatively. Independent predictors of any intervention among all patients were Computed Tomographic Severity Index score ≥7 (P < 0.001) and interval between onset of pain to hospitalization >7 days (P = 0.04). CONCLUSIONS: Patients with severe AP and delayed hospitalization more often develop acute collections. Pancreatic pseudocysts are a rarity in acute interstitial pancreatitis. A majority of patients with necrotising pancreatitis will develop ANC, more than half of whom will develop WON. Delay in hospitalization and higher baseline necrosis score predict need for intervention.

Comparison of radiofrequency ablation alone & in combination with percutaneous ethanol injection for management of hepatocellular carcinoma.

Background & objective: It has been shown that the combined use of alcohol before radiofrequency ablation (RFA) helps to augment the therapeutic advantage of RFA. The present study was conducted to compare the outcome of treatment with RFA alone and RFA with alcohol as ablative technique in patients with small hepatocellular carcinomas (HCCs), who were not candidates for surgery. Methods: Fifty patients with chronic liver disease and concurrent HCC were enrolled in this prospective study. The patients were treated with either RFA alone (n=25) or RFA combined with alcohol (n=25). Patient outcome was evaluated, and the tumour recurrence and survival of the patients were assessed in the two groups. Results: The survival rates at six months in patients who completed at least six months of follow up were 84 and 80 per cent in patients treated with RFA alone and combination therapy, respectively. During the follow up period, 11 and four patients treated with RFA alone showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at one to 18 months of the follow up period. The distant recurrences occurred at 6-36 months of the follow up period. During the follow up period, eight and six patients treated with combination therapy showed local and distant intrahepatic tumour recurrence, respectively. All local recurrences were at 1.5-15 months during the follow up period. The distant intrahepatic recurrences occurred at 6-72 months during the follow up period. Interpretation & conclusions: No significant difference was seen between the survival time of the patients treated with RFA alone and RFA with alcohol as well as in the local recurrences and distant intrahepatic recurrences in RFA compared to RFA and alcohol group patients. Combined use of RFA and alcohol did not improve the local tumour control and survival in patients with HCC compared to RFA alone.

Small-Bowel Tuberculosis: A Comparative Study of MR Enterography and Small-Bowel Follow-Through.

OBJECTIVE: The purpose of this article is to describe the MR enterographic findings of small-bowel tuberculosis (TB) and to compare the imaging findings of small-bowel follow-through (SBFT) with those of MR enterography. SUBJECTS AND METHODS: Thirty patients (20 male and 10 female) presenting with suspected intestinal TB were enrolled in this prospective study. MR enterography and SBFT were performed within 2 weeks of each other. RESULTS: Nineteen of the 30 patients were confirmed to have TB. Of these 19 patients, MR enterography depicted ileocecal involvement in nine patients (47%), mural thickening in any other segment of the small bowel in 11 patients (58%), lymphadenopathy in 17 patients (89%), ascites in five patients (26%), and peritoneal enhancement in six patients (32%). In addition, MRI also depicted a splenic granuloma, spondylodiscitis with prevertebral abscess, and small-bowel perforation with collections in one patient each. There was good correlation between MR enterography and SBFT in the depiction of ileocecal involvement and small-bowel mural thickening. However, MR enterography was able to show a higher number of strictures than was SBFT. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of TB were 100%, 73%, 86%, and 100%, respectively, for MR enterography and 88%, 70%, 83%, and 78%, respectively, for SBFT. The difference was not statistically significant (p = 0.24). CONCLUSION: MR enterography depicts intestinal as well as extraintestinal manifestations of TB. The intestinal manifestations correlate well with SBFT findings. MR enterography has the potential to become the one-stop radiation-free tool in the evaluation of small-bowel TB.

Multidetector computed tomography evaluation of post cholecystectomy complications: A tertiary care center experience.

OBJECTIVE: To evaluate the role of multidetector computed tomography (CT) and CT angiography (CTA) in post cholecystectomy complications. METHODS: A retrospective analysis of data from December 2012 to August 2014 was performed. Eight hundred sixty consecutive patients with history of cholecystectomy (laparoscopic or open) were evaluated. After exclusion of 645 patients with normal imaging, analysis for post cholecystectomy complications was performed in 215 patients. A contrast enhanced CT/CTA was performed. Mean interval to imaging was 10 months (range 3 days to 15 months). RESULTS: A complication rate of 25% was noted in patients undergoing imaging following cholecystectomy. Gallbladder bed or perihepatic collections were seen in 11.9% cases (n = 103). Intrahepatic biliary radicle dilatation (IHBRD) was seen in 7% patients (n = 60). Isolated right or left ductal dilatation was seen in 9 patients; rest of the patients had bilateral IHBRD. Cholangitic abscesses and mild acute pancreatitis were seen in 11 (1.2%) and 12 (1.3%) patients respectively. These comprised biliary complications. Venous thrombosis involving the portal vein was the most frequently encountered vascular complication (n = 12). Right hepatic artery pseudoaneurysm was seen in two patients. Less common complications were abdominal wall hematoma (n = 2), incisional hernia (n = 6), port site hernia (n = 2), large bowel injury (n = 1), biliocutaneous fistula (n = 1) and enterocutaneous fistula (n = 1). CONCLUSION: CT allows classification of post cholecystectomy complications and guides further management. CTA provides an efficient road map for management of vascular complications.