Superior Mesenteric Artery Syndrome: A Potentially Fatal but Reversible Gastrointestinal Manifestation of Systemic Sclerosis.

Superior mesenteric artery syndrome (SMAS) is a rare gastrointestinal disorder characterised by vascular compression of the third part of the duodenum, in the angle between the superior mesenteric artery (SMA) and the abdominal aorta. It presents as an uncommon cause of upper gastrointestinal obstruction. In patients with systemic sclerosis (SSc), gastrointestinal involvement may result in oesophageal dysmotility, gastroesophageal reflux disease (GERD), gastroparesis, small intestinal bacterial overgrowth (SIBO), chronic intestinal pseudoobstruction (CIPO), and fecal incontinence. Malnutrition may thus result in weight loss and reduced mesenteric and retroperitoneal adipose tissue, decreasing the angle between the SMA and aorta causing SMAS. Enteral or parenteral feeding can potentially reverse SMAS in SSc. We report a case of SMAS in an elderly female with SSc and concurrent gastrointestinal involvement, and discuss the important management considerations and potential adverse outcomes when untreated.

Analysis of comparative performance of CEUS and CECT/MR LI-RADS classification: Can CEUS dichotomize LI-RADS indeterminate lesions on CT or MRI?

PURPOSE: To study the comparative performance of contrast-enhanced ultrasound (CEUS) and contrast-enhanced CT or MRI (CECT/MR) in evaluating liver lesions using the LI-RADS guidelines. METHODS: Retrospective analysis of radiology database from July 2010 to April 2017 revealed 228 patients who had CECT/MR and CEUS. Patients at risk of hepatocellular carcinoma (HCC), had contemporaneous CEUS and CECT/CEMR studies within 3 months and adequate follow up were included; reviewed (2 reviewers) and graded according to the 2017 CEUS and 2018 CECT/MR LI-RADS guidelines. Reference standard was multidisciplinary clinical decisions, histology or follow-up imaging. RESULTS: The study cohort consisted of 45 patients with 46 lesions. HCC were significantly larger than non-malignant (mean sizes of 2.5 and 1.4 cm, respectively, p<0.001). Intraclass correlation coefficient for CEUS review (0.941) was higher than of CECT/MR review (0.643). Mean area-under-ROC curve (AUC) for CEUS (0.994) was significantly higher than of CECT/MR (0.760) for all lesions (p=0.01). For lesions scored LR-3 by CECT/MR, the AUC was significantly higher for CEUS (0.978) than CECT/MR (0.500) (p<0.001). Twenty-one (of 27) lesions, classified LR-3 or LR-4 by CECT/MR were upgraded by CEUS and 20 were found to be HCC. Six lesions that were LR-3 on both CECT/MR and CEUS were found to be non-malignant. There was good concordance for LR-5 lesions between both techniques. CONCLUSION: CEUS is useful for reassessment of lesions with intermediate probability (LR-3) or probable for HCC (LR-4) on CECT/MR. Lesions upgraded by CEUS tend to be HCC. Lesions that remain LR-3 on CEUS tend to be non-malignant.

Clinics in diagnostic imaging (198). Small bowel obstruction secondary to a bezoar.

A 60-year-old man presented with abdominal pain. He was later diagnosed on imaging to have high-grade small bowel obstruction. The patient underwent surgery, and a hard, rounded bezoar resembling the endosperm of Nypa fruticans, colloquially known as attap chee, was found at the point of obstruction. Small bowel obstruction is a common acute surgical condition with multiple causes, including bezoars. We discuss the typical imaging features of bezoars causing small bowel obstruction as well as potential pitfalls that can mimic the appearance of a bezoar.

Effectiveness of an algorithm in reducing the number of unnecessary ultrasound scans for deep vein thrombosis: an evaluation report.

INTRODUCTION: Patients with suspected deep vein thrombosis (DVT) pose a diagnostic dilemma to the Emergency Department (ED) clinician. This study aimed to implement a known algorithm incorporating the modified Wells criteria and D-dimer testing to guide the ED clinician, thus reducing unnecessary ultrasound scans (USS). METHODS: Patients who presented to the ED between August 2008 and April 2009 with suspected DVT underwent Wells scoring. Those with scores < 2 were deemed unlikely to have DVT and underwent D-dimer testing first. Patients with scores ≥ 2 were regarded as likely to have DVT and underwent urgent USS. USS findings were tabulated as positive or negative/indeterminate for DVT. The latter group was followed up for one year to check whether DVT was missed during the initial USS. RESULTS: 75 patients presented with suspected DVT and underwent USS. Of these, 14 results were positive and 61 were negative. 37 patients had Wells scores < 2, with three (8.1%) having DVT. Another 38 patients had Wells scores ≥ 2, with 11 (28.9%) having DVT. D-dimer testing was performed on 27 of the 75 patients. Those with DVT had higher average values compared to those without DVT (1.305 vs. 0.595 µg/ml). The majority of patients with raised D-dimer values had cellulitis, although three also had DVT (with values ≥ 0.99 µg/ml). CONCLUSION: We managed to reduce the number of unnecessary USS and increase the pick-up rate of DVT. A cut-off score ≥ 2 in our algorithm is suitable for use in the ED setting.

Contrast enhanced ultrasound of kidneys. Pictorial essay.

Contrast-enhanced ultrasound has entered the imaging mainstream in the last few years. It is a safe technique with exquisite temporal and spatial resolution and is especially useful for evaluating focal renal mass lesions in patients with renal impairment when iodinated or gadolinium contrast agents are contraindicated. The purpose of this manuscript is to briefly describe our technique, show the normal renal haemodynamics of ultrasound contrast agent and demonstrate a spectrum of renal masses and possible pitfalls.

Fasciola hepatica in a New Zealander traveler.

Fascioliasis is a reemerging zoonosis endemic in many parts of the world. Reports of imported fascioliasis by migrants into nonendemic countries are common, but tourists and business travelers are rarely afflicted. Here, we report a case of a New Zealander traveler who acquired the infection on a business trip.

Preauricular sinus: clinical course and associations.

OBJECTIVES: To evaluate the clinical course of congenital preauricular sinus (PAS) up until adulthood and to determine its association with congenital ear and renal abnormalities. DESIGN: Cohort survey. SETTING: Medical screening facility at a military base. PARTICIPANTS: All individuals in a cohort of male subjects who were medically assessed for conscription into the army between September 1, 2003, and March 31, 2004. INTERVENTIONS: Subjects identified as having PAS were further evaluated with pure-tone audiometry and renal ultrasonography. MAIN OUTCOME MEASURES: Presence of PAS and associated hearing and renal abnormalities. RESULTS: Of 10 734 male subjects (median age, 19 years; range, 16-26 years) screened, 121 (1.13%) were found to have PAS, all of which were isolated. The point prevalence of PAS in Chinese, Malay, and Indian subjects was 1.36%, 0.69%, and 0.17%, respectively. Of the 29 subjects (24.0%) who developed symptoms (mainly sinus discharge), most had recurrent symptoms, and 7 (24.1%) of the 29 had onset of symptoms after age 16 years. Only 1.7% and 2.6% of the subjects had associated hearing loss (sensorineural) and renal deformity (minor in nature), respectively. CONCLUSIONS: In a study of young adult males with PAS, associations with ear and renal abnormalities were found to be rare, although PAS had widely been acknowledged to be associated with these congenital defects. Up until adulthood, about one quarter of all lesions became symptomatic. Of those who developed symptoms, almost one third did so after age 16 years. The most common symptom was sinus discharge, which tended to be recurrent.