Rectal Bleed in a Child With Abernathy Malformation- Endovascular Management.

Abernathy malformations are congenital extrahepatic porto-systemic shunts which allow splanchnic circulation to bypass the metabolic screen of the liver and drain directly into the systemic circulation. The resulting metabolic abnormalities have a multitude of implications ranging from hyperammonaemia, hepatic encephalopathy, to pulmonary hypoxemia. The shunt also causes anatomical implications in the form of varices. Interventional radiology plays the central role in this era of minimal invasive surgeries from establishing diagnosis to therapeutic interventional management. The holistic approach provided through interventional radiology reduces intraprocedural time as well as hospital stay. We describe a very rare case of peripheral congenital porto-systemic shunt communicating Inferior mesenteric vein and internal iliac vein with rectal bleed with complete management at the department of interventional radiology.

Magnetic Resonance Angiography and Multidetector CT Angiography in the Diagnosis of Takayasu's Arteritis: Assessment of Disease Extent and Correlation with Disease Activity.

BACKGROUND: Takayasu's Arteritis (TA) is a large vessel vasculitis with diverse clinical presentations and arterial vascular bed involvement.It is characterized by chronic, nonspecific inflammation of all layers of the vessel wall which results in stenosis, occlusion, dilatation, or aneurysm formation in the involved blood vessels. METHODS: The study included 36 patients of TA. All patients fulfilled the modified Ishikawa's diagnostic criteria for TA. All patients were evaluated for clinical presentation, angiographic findings, and severity of the disease. The disease activity was assessed based on Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) and also by CT Angiography (CTA)/Magnetic resonance angiography (MRA) imaging. The angiographic types were classified based on the International TA Conference in Tokyo 1994 angiographic classification. RESULTS: A total of 36 patients were included in the study, 86% were females and a mean age of 21.6 years. Hypertension (78%) was the most common clinical presentation. Type V was the most common angiographic type (42%) followed by type III (25%), type IV (14%), type IIb (11%), type I (5%) and type IIa (3%). Among the aortic arch branches the left subclavian artery (50%), right subclavian artery (38.8%), left vertebral artery (33.3%) and left common carotid artery (27.7%) were the most commonly involved arteries. Disease activity based on CT / MR imaging showed a significant statistical correlation with elevated ESR and positive CRP (p < 0.0001). Mediastinal lymphadenopathy was seen in 21 patients out of which 11 had active disease. However, no significant correlation was found between mediastinal lymphadenopathy and disease activity. CONCLUSION: TA presents with varied symptomatology and differing vascular involvement. CT/MR angiography is effective in diagnosis and accurately predicted the active stage of the disease.

How Useful is Extravascular Lung Water Measurement in Managing Lung Injury in Intensive Care Unit?

CONTEXT: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). AIMS: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. SETTINGS AND DESIGN: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. SUBJECTS AND METHODS: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. STATISTICAL ANALYSIS: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. RESULTS: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = -0.32, P = 0.0004; r = -0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = -0.71, P < 0.0001; r = -0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). CONCLUSIONS: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.

Bronchoesophageal Fistula Repair with Intercostal Muscle Flap Followed by Occlusion of Residual Diverticula with N-butyl Cyanoacrylate (NBCA) Glue: A Case Report.

The incidence of bronchoesophageal fistula in presence of benign pathology of tracheal tree or oesophagus is rare. It is encountered in thoracic diseases like tuberculosis, syphilis or histoplasmosis due to erosion by infected lymph node or abscess to adjoining structures. The source of primary pathology has to be eliminated followed by appropriate steps of fistula tract closure is essential for optimal result. We report a 25-year-old patient with left sided bronchoesophageal fistula. He had a past history of pulmonary tuberculosis. A left lower lobectomy followed by repair of oesophageal fistula opening was performed by primary closure and reinforcement with an intercostal muscle flap based on posterior intercostal artery. Postoperative oesophagogram showed short diverticula, which was occluded with n-butyl cyanoacrylate (NBCA) glue under radiological guidance. Feeding was started one week after application of glue without further complication. Reports on intercostals muscle flap repair and intervention of residual oesophageal diverticula with n-butyl cyanoacrylate (NBCA) glue under radiological guidance are scanty.

Transnasal tracheobronchial stenting for malignant airway narrowing under local anesthesia: Our experience of treating three cases using this technique.

PURPOSE: To study the technical feasibility of tracheobronchial stenting via transnasal route under bronchoscopy and fluoroscopic guidance in severe malignant airway strictures using self-expandable nitinol stents. MATERIALS AND METHODS: We describe three patients with malignant airway strictures, treated entirely via transnasal route under local anesthesia using bronchoscopic and fluoroscopic guidance. Nasal route allowed convenient access to the airway for the bronchoscope across the stricture and a guidewire was introduced through its working channel. The 18F tracheal stent and the 6F bronchial stent assembly could be easily introduced and deployed under bronchoscopic (reintroduced through the other nostril) and fluoroscopic guidance. RESULTS: We achieved technical success in all the three patients with immediate relief of dyspnea. CONCLUSION: Transnasal airway stenting with self-expandable nitinol stent using bronchoscopic and fluoroscopic guidance under local anesthesia is a safe and effective method with minimal patient discomfort.

Sonographic images of hepato-pancreatico-biliary and intestinal ascariasis: A pictorial review.

UNLABELLED: Despite advancement in the diagnosis and treatment of intestinal helminthiasis, ascariasis remains the most common cause of helminthic infections in the developing countries. Ultrasound offers a rapid, safe, and noninvasive approach to the diagnosis of intestinal ascariasis. Ultrasound is also the modality of choice for diagnosis of hepatobiliary ascariasis, which is relatively rare and is due to migration of intestinal worms through the papilla of Vater. We present an imaging spectrum of hepato-pancreatico-biliary and intestinal ascariasis. MAIN MESSAGES: • Ascariasis refer to infestation by the round worm ascaris lumbricoides. • Ascaris eggs are excreted in faeces and are infective to humans. • Eggs hatch to larva, travel to the lungs and mature to adult worms. • Intestinal obstruction can be caused by multiple ascariasis forming bag of worms.

Locally Advanced Askin's Tumour in a Child-a Rare Case Report and Review of the Literature.

Askin's tumor is a primitive neuroectodermal tumor (PNET) developing from the soft tissues of the chest wall and mainly occur in children and adolescents. The management approach is complex and requires a multidisciplinary team. We report a case of locally advanced Askin's tumour in a child because of its rarity and also to highlight the importance of keeping the possibility of PNET tumours in mind while dealing with cases of chest wall tumour in children.

Endovascular treatment in spinal perimedullary arteriovenous fistula.

This study includes 20 patients with 21 spinal perimedullary fistulae. There were nine Type IVa (42.8%) lesions, ten Type IVb (47.6%) and two Type IVc (9.5%) lesions. The dominant arterial supply was from the anterior spinal artery (47.6%), posterior spinal artery (19%) and directly from the radiculomedullary artery (28.5%). Sixteen lesions in 15 patients were treated by endovascular route using n-butyl-2-cyanoacrylate. Endovascular treatment was not feasible in five patients. Of the ten patients with microfistulae, catheterization failed/was not attempted in 40%, complete obliteration of the lesion was seen in 60% but clinical improvement was seen in 40% of patients. Catheterization was feasible in all ten patients with macrofistulae (nine type IVb and two type IVc lesions). Complete obliteration of the lesions was seen in 60% and residue in 30%. Clinical improvement was seen in 80% and clinical deterioration in 10%. In conclusion, endovascular glue embolization is safe and efficacious in type IVb and IVc spinal perimedullary fistulae and should be considered the first option of treatment. It is also feasible in many of the type IVa lesions.

Symmetrical Chorioretinal Colobomata with Craniovertebral Junction Anomalies in CHARGE Syndrome - A Case Report with Review of Literature.

CHARGE syndrome is a common cause of congenital anomalies. Its rate of incidence is about 1:10,000. It is phenotypically heterogeneous, usually a sporadic or autosomal dominant disorder resulting from a mutation in the CHD7 (chromodomain helicase DNA-binding protein) gene. Since the time it was first described by Hall,[1] the knowledge of the clinical characteristics of CHARGE syndrome has increased over the years. Recently, basiocciput hypoplasia and basilar invagination in patients with CHARGE syndrome have been reported. We report here a case of CHARGE syndrome where there is involvement of symmetrical chorioretinal colobomata with craniovertebral junction anomalies. The patient had symmetrical chorioretinal colobomata, external and inner ear anomalies, sensorineural deafness, characteristic facial appearance, retarded growth and development, history of patent ductus arteriosus, and craniovertebral junction anomalies. Craniovertebral junction anomalies may be an under-diagnosed phenotypic expression of CHARGE syndrome. The diagnostic criteria of CHARGE syndrome may require further revision to include the addition of craniovertebral junction anomalies.

Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus.

Despite advances in imaging techniques, the detection of vegetative foreign bodies in soft tissues remains a difficult and sometimes even a challenging task. Clinical evaluation of such patient may present several months or even years after the initial injury and clinician may fail to elicit an antecedent skin puncture. X-ray examination will miss radiolucent foreign bodies. A 15-year-old boy presented with a draining non-healing sinus at the lateral aspect of his right thigh for 9 months. Musculoskeletal ultrasonography was ordered after ruling out chronic osteomyelitis to detect possible lesions around the thigh. High-frequency linear ultrasonic probe readily detected an elongated foreign body within the vastus lateralis muscle. A long piece of wood was confirmed at surgery. Non-healing sinus with normal finding in radiograph following old trauma should raise the suspicion of implanted radiolucent foreign body/bodies. The role of diagnostic ultrasound as a valuable screening tool for the detection of foreign body is briefly reviewed.