A study of C-reactive protein and D-dimer in patients of appendicitis.

BACKGROUND: Acute appendicitis is the most common abdominal surgical emergencies across the world. OBJECTIVE: The aim of this study was to determine the value of C-reactive protein (CRP) and D-dimer as diagnostic markers of acute appendicitis. STUDY DESIGN: It was a Prospective observational clinical study. METHOD: The present study was carried out in General Surgical Unit of University Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi from September 2015 to July 2017. All data including patient's demography, clinical examination, laboratory test results, and appendix histology were summarized. Receiver operating characteristic (ROC) curve of TLC, CRP, and D-dimer was analyzed. RESULTS: Total 65 patients who presented with periumbilical pain or pain in right iliac fossa (RIF) were included in the study. The mean age of the patients was 31.18 ± 14.59 years (range: 15 to 65 years) with male : female ratio was 2.21:1. The most common symptom was pain in right iliac fossa (100%) followed by nausea/vomiting (69.2%). The mean leucocyte count, CRP, and D-dimer levels were significantly raised in appendicitis group as compared to negative appendicectomy group (P = 0.025, P = 0.036, and P = 0.025, respectively). The receiver operating characteristic (ROC) curve for TLC was not helpful for differentiating between appendicitis and negative appendicitis (P = 0.073). In addition, D-dimer was helpful for differentiating between appendicitis and negative appendicitis (P = 0.002). However, CRP was also found to be helpful for differentiating between appendicitis and negative appendicitis (P = 0.030). CONCLUSION: The diagnosis of appendicitis remains multifactorial and biochemical markers like CRP and D-dimer may help to guide the surgeon in the decision making.

Genetic mutational analysis of ß-catenin gene affecting GSK-3ß phosphorylation plays a role in gallbladder carcinogenesis: Results from a case control study.

This manuscript has reported different mutations of ß-catenin gene in gallbladder cancer patients which affect GSK-3ß phosphorylation site. PURPOSE: Gallbladder carcinoma (GBC) is a relatively rare and fatal cancer with poor prognosis. The molecular mechanism of gallbladder carcinogenesis is still not clear. Wnt signaling pathway is a highly conserved pathway that regulates proliferation, differentiation, migration, genetic stability, apoptosis, and stem cell renewal. ß-catenin plays major role in Wnt signaling and aberrations in ß-catenin has found to be involved in several cancers pathogenesis. This study was carried out to document the mutations of ß-catenin gene in gallbladder cancer and to evaluate its possible role in gallbladder carcinogenesis. METHODS: PCR-SSCP (Single Stranded Conformation Polymorphism) for ctnnb1 was performed in 50 patients each of gallbladder cancer, cholelithiasis and 50 healthy controls. Samples that showed variation in banding pattern were sequenced. RESULTS: Variation in banding pattern was observed in 9 (18%) samples of GBC, 4 (8%) of cholelithiasis and 2 (4%) of control. Sequencing analysis showed 9 novel mutations of ctnnb1 in exon 3 in 18% of gallbladder cancer (χ2 = 5.778; p < 0.05). Six point mutations, 1 deletion and 1 insertion mutation were found in 9 cases of gallbladder cancer. All point mutations were mis-sense mutation that affected highly conserved serine or threonine region that is important for GSK-3ß phosphorylation. CONCLUSION: Findings of the study suggests that high frequency of non synonymous mutations of ß-catenin gene (ctnnb1) occurs in patients with gallbladder cancer. As these mutations mainly effect GSK 3ß phosphorylation, it may be concluded that this might be an important step in gallbladder carcinogenesis. These ß-catenin mutations lead to Wnt pathway activation and appear to have a role in progression from inflammation to cancer in gallbladder.

Disseminated cystic nodal metastasis in renal cell carcinoma mimicking systemic hydatidosis on imaging.

Cystic metastases in renal cell carcinoma (RCC) are very rare. Very few case reports can be found in literature. Retroperitoneal cystic nodal metastases have been reported in head and neck tumors. We present a very interesting case of RCC that had disseminated intraperitoneal and retroperitoneal cystic metastases that mimicked systemic hydatidosis. A detailed color Doppler sonography was followed by plain and contrast-enhanced computed tomography on a 64-slice multi-detector scanner. Imaging features were more in favor of right RCC with cystic lymph nodal metastasis. However, rare possibility of incidental hydatid disease with RCC could not be ruled out. Biopsy from left inguinal lymph nodes was taken, which confirmed metastatic deposits from RCC.

Comparative Analysis of Mutational Profile of Sonic hedgehog Gene in Gallbladder Cancer.

BACKGROUND: Gallbladder cancer has high incidence in northeastern India; mortality too is high as the disease is often diagnosed late. Numerous studies have shown the role of sonic hedgehog (shh) in different cancers, an important ligand of the hedgehog signaling pathway. AIM: This study was carried out to evaluate the shh gene mutations in gallbladder cancer patients. METHODS: PCR-SSCP was performed for shh gene in 50 samples each of gallbladder cancer, cholelithiasis, and control. The samples showing aberration in banding pattern were sequenced. RESULTS: Variation in banding pattern was observed in 20% gallbladder cancer cases, 10% in cholelithiasis, and none of the control (χ 2 = 11.111; p < 0.05). Sequencing results revealed seven novel point mutations in GBC cases. These novel mutations were found to be associated with histopathology (p < 0.05) and stage (p < 0.05) of gallbladder cancer. CONCLUSION: This study reveals several novel individual and repetitive mutations of shh gene in GBC and cholelithiasis samples that may be used as diagnostic markers for gallbladder carcinogenesis.

Multiple Mycotic Aneurysms of the Abdominal Aorta Illustrated on MDCT Scanner.

Infective mycotic aneurysm of the aorta is a rare and life-threatening disease. A patient presenting with constitutional symptoms and pulsatile abdominal mass should raise a suspicion of mycotic aneurysm. Early detection of aortic mycotic lesions in such patients should play a key role in the treatment of aortic aneurysms. Multiple mycotic aneurysms of abdominal aorta in a young male are a rare manifestation of the disease. Multidetector computerized tomography (CT) is an essential tool in identifying the etiology, pathogenesis, protean manifestations of systemic tuberculosis, and ultimately deciding the course of treatment.

Gall bladder carcinoma: Aggressive malignancy with protean loco-regional and distant spread.

The most common malignancy of biliary tract is gallbladder cancer (GBC) which is the third most common cancer in gastrointestinal tract. It is a lethal disease for most patients in spite of growing awareness and improved diagnostic techniques. GBC has a very poor prognosis and the 5 year survival rate is < 10%. Although etiology of the carcinoma of the gallbladder is still obscure, various factors have been implicated, cholelithiasis being the most frequent. The incidence of GBC worldwide is based on the gender, geography and ethnicity which suggest that both genetic and environmental factors can cause GBC. The major route of spread of gallbladder cancer (GC) is loco-regional rather than distant. It spreads by lymphatic, vascular, neural, intraperitoneal, and intraductal routes. Sonography is usually the most common imaging test to evaluate symptoms of biliary tract disease including suspected GC. With recent advances in imaging modalities like multi-detector computed tomography (CT) scanners, magnetic resonance imaging-positron emission tomography/CT diagnosis of gallbladder cancer has improved. Studies have also targeted molecular and genetic pathways. Treatment options have included extended and radical surgeries and adjuvant chemotherapy. This review article deals in detail with important aspects of carcinoma gallbladder and its manifestations and challenges. Role of various imaging modalities in characterization and accurate staging has been discussed. The loco-regional spread of this aggressive malignancy is dealt explicitly.

Mandibular arteriovenous malformation: A rare life-threatening condition depicted on multidetector CT angiography.

Arteriovenous malformation (AVM) of the mandible is a rare and potentially life-threatening condition which can lead to massive hemorrhage. The following is a description where a large mandibular AVM presented with torrential bleeding following tooth extraction for caries. An orthopantomogram (OPG) was performed which was suggestive of aneurysmal bone cyst or ameloblastoma. A computed tomography (CT) angiography revealed a large mandibular AVM with submandibular extension. It is important for both clinicians and radiologist to be aware of this type of lesion that can have life-threatening complications. It is important to define the anatomical location and the feeder vessels of the entity in detail preoperatively. This communication highlights the common differential and use of multidetector CT (MDCT) angiography along with other imaging modalities to prevent a fatal hemorrhage and arrive at a correct diagnosis.

Clinical and imaging perspective and unanswered questions in a case of metronidazole induced encephalopathy.

We discuss the clinical and imaging perspective in a case of a 78-year-old male who developed slurring of speech and ataxia acute in onset for the last 3 days. During his hospital stay, he developed multiple episodes of focal seizures without secondary generalization involving the angle of mouth on the right side. The patient had ataxia and positive cerebellar signs. In the past, the patient was treated for amoebic liver abscess and had undergone percutaneous aspiration of abscess. The patient was prescribed oral metronidazole and was discharged. This time, the patient underwent magnetic resonance imaging examination, which revealed lesion highly suggestive of metronidazole-induced encephalopathy. The offending drug was discontinued immediately after which the patient improved clinically. A follow-up scan was performed after 12 days and showed complete resolution of lesions.

Transmural invasion of hepatic flexure of colon causing cholecystocolic fistula by aggressive gallbladder carcinoma.

Spontaneous enterobiliary fistulae are a complication of biliary disease or a disease of adjacent structures. Cholecystocolic fistulae are rare in relation to gallbladder carcinoma (GBC). Previous reports have presented images showing subtle findings suggestive of cholecystocolic fistula. We report the unusual spread and rare images of a case of cholecystocolicfistula,to highlight the aggressive nature of GBC and findings of gross transmural invasion of the colonic wall. The images acquired in all three planes define the anatomical and pathological extent conclusively. There are a higher number of GBC cases across the geographic belt of North India compared to the West. In this case, the patient's pathology was extensive and unresectable, and therefore palliative and supportive care wasadvised.

Magnetic resonance imaging evaluation of temporomandibular joint and associated soft tissue changes following acute condylar injury.

PURPOSE: This study evaluated the role of magnetic resonance imaging (MRI) in cases of acute condylar injury and assessed soft tissue damage such as disc displacement, capsular tear, and hemarthrosis within the temporomandibular joint (TMJ). PATIENTS AND METHODS: This prospective study was conducted in 15 patients who presented with unilateral or bilateral condylar fracture or contusion with a unilateral or bilateral diagnosis of TMJ sprain/strain. Patients with trauma of less than 7 days previously with a unilateral or bilateral condylar fracture or contusion with a diagnosis of TMJ sprain/strain were included in the present study. The clinical diagnosis of TMJ sprain was made and further classified and graded according to the severity and type of injury. On confirmation of the diagnosis of condylar injury, patients underwent evaluation by MRI. All patients were treated by closed reduction of the condylar fracture and intermaxillary fixation for 14 to 21 days. RESULTS: Of the 15 patients, 5 were children and 10 were adults. Of all 17 TMJ cases (2 bilateral, 13 unilateral), 2 condylar fractures were of the high variety and 13 were of the low variety. MRI diagnosis of disc displacement was established in 8 of 17 TMJ cases. There was a significant association between degrees of condylar injury and the MRI diagnosis of displaced disc and hemarthrosis. However, an MRI finding of capsular tear was not significantly associated with the degree of condylar injury. CONCLUSIONS: Soft tissue changes of the TMJ can be predicted accurately by MRI and are in direct proportion to the severity of the condylar injury of the mandible. Among the soft tissue changes, disc displacement and hemarthrosis seem to affect the outcome of functional treatment.

Visceral leishmaniasis or systemic lupus erythematosus flare?

Systemic lupus erythematosus (SLE) is a multisystem disorder characterised by B-cell hyperactivity with production of multiple autoantibodies. Fever in SLE may be caused by disease exacerbation or by infection. We report a patient of SLE that was later complicated by fever, pancytopenia, and massive splenomegaly. Corticosteroid therapy for SLE might have masked the underlying infection at earlier stage. Despite negative results of rk-39 test and bone marrow biopsy, a very high suspicion for visceral leishmaniasis (VL) led us to go for direct agglutination test (DAT) and polymerase chain reaction (PCR) for leishmanial antigen that revealed positive results. Moreover, significant improvement in clinical and biochemical parameters was noted on starting the patient on antileishmanial therapy.

Determinants of intravascular resistance in Indian diabetic nephropathy patients: a hospital-based study.

Aims and Objectives. Metabolic dysregulation has failed to explain clinical variability of patients with diabetic nephropathy and hence a renewed interest emerged in haemodynamic factors as determinant of progression and development of diabetic nephropathy. We therefore studied for various factors which can correlate with raised renal vascular resistance in diabetic nephropathy. Material and Methods. Renal vascular resistance was measured in patients with established and incipient diabetic nephropathy and compared with controls using noninvasive color Doppler examinations of intrarenal vasculature. Results. Renal vascular resistance correlated with age, duration of disease, GFR, serum creatinine, and stage of retinopathy. Renal vascular resistance was significantly reduced in patients on treatment with RAAS inhibitors and insulin, than those on OHA and antihypertensives other than RAAS inhibitors. Conclusion. The study implies that renal vascular resistance may help identify diabetics at high risk of developing nephropathy, and these set of patients could be candidates for RAAS inhibition and early insulin therapy even in patients without albuminuria.