Novel radiological technique to recognize acute liver failure caused by yellow phosphorous containing rodenticides.

Yellow phosphorous rodenticide (YPR) poisoning is the commonest cause for acute liver failure (ALF) in southern and western India. Due to medicolegal issues, history of YPR ingestion may not be available. As early recognition of YPR poisoning is important and there are no specific biochemical assays, other early predictors to identify this entity is necessary. We evaluated the diagnostic role of plain computed tomography (CT) in identifying YPR-induced ALF. All patients admitted to the liver unit with a diagnosis of ALF underwent a plain CT scan abdomen. Demographic details, clinical history, laboratory parameters, liver attenuation index (LAI) calculated on CT scan, treatment details, need for liver transplantation and clinical outcome were analyzed. Parameters for YPR-induced ALF (ALF-YPR) and other causes (ALF-OTH) were compared. Ability of LAI to distinguish ALF-YPR and ALF-OTH was analyzed using receiver operating characteristic (ROC) curve analysis. Twenty-four patients (15 female [62.5%]) were included in the study. Thirteen patients (54%) had YPR poisoning, while the rest formed the ALF-OTH group (11,46%). ALF-YPR patients had higher transaminase levels, lower peak serum bilirubin levels. ALF-YPR livers had significantly lower LAI as compared to ALF-OTH (- 30 vs. - 8, p = 0.001). On ROC curve analysis, an LAI greater than - 18 ruled out YPR as the cause for ALF with 91% sensitivity and 85% specificity. On regression analysis, LAI was the only independent factor predicting ALF-YPR (odds ratio - 0.86, [0.76, 0.96] p = 0.008). Our data shows that LAI on plain abdominal CT scan can be used to quickly recognize ALF-YPR in unclear cases so that necessary treatment protocol can be activated, or patient transfer arranged. Our analysis shows that an LAI greater than - 18 can reliably rule out YPR ingestion as the cause for ALF.

Newly proposed classification of celiac artery variations based on embryology and correlation with computed tomography angiography.

Purpose: We studied the prevalence of celiac trunk and its anatomical variations on diagnostic computed tomography angiography (CTA) studies and have proposed a new classification to define the celiac artery (CA) variations based on embryology. Material and methods: We retrospectively assessed the celiac trunk variations in 1113 patients who came to our department for diagnostic CTA for liver and renal donor workup. The patient data were acquired from the Picture Archiving and Communication System of our institutions. We analysed the celiac trunk's origin and branching pattern, including the superior mesenteric artery (SMA) and inferior phrenic artery (IPA). Results: We evaluated the CTA studies of 1050 patients. A normal trifurcation pattern, the most common type, was observed in 39% of cases. Variation with CA + left IPA was the most common subtype. Other variations noted in the study and their incidences are listed in the table below. We attempted to propose a new classification based on embryo-logy, which comprises 6 main types and their subtypes. We also analysed previous studies from the literature, including cadaveric, post-mortem, CTA, and digital subtraction angiography studies and compared them with the present study. Conclusions: Because variations of CA classifications reported to date do not encompass all CA branching pattern variants, we have proposed a new classification that incorporates most of the variants. We reiterate the clinical importance of anatomical variants of CA, IPA, and SMA in surgical and interventional radiology procedures.

Salmonella Bacteremia Causing Mycotic Pseudoaneurysm of Right Common Iliac Artery Complicated by Septic Caval Thrombosis.

Mycotic pseudoaneurysm (MPA) is a blind, saccular outpouching of the arterial lumen of infective origin. MPA is a rare life-threatening condition and if not treated early, has a 67% mortality rate due to sepsis and hemorrhage. Major predisposing factors are diabetes mellitus, chronic renal failure, malignancy, steroids, and intravenous drug use. Imaging modalities include Doppler ultrasound, contrast-enhanced computed tomography, and digital subtraction angiography. We report a unique case of Salmonella bacteremia-related MPA of the right common iliac artery complicated by septic inferior vena cava (IVC) thrombosis in a patient with uncontrolled diabetes. Such transcompartmental involvement of IVC has hitherto not been described in the literature and hence makes for interesting documentation. This case ponders upon the aggressiveness of the invasive nontyphoidal Salmonella infection pathogen and the need for early imaging of suspicious patients to reduce morbidity and mortality.

Wolman's Disease: A Rare Cause of Infantile Cholestasis and Cirrhosis.

Liver cirrhosis in infancy can be secondary to various etiologies such as biliary atresia, familial cholestatic and metabolic disorders. Wolman's disease (WD) is a lysosomal storage disorder caused by the absence of lysosomal acid lipase enzyme activity and a significant association with infantile cholestasis and cirrhosis. We encountered an infant presenting with advanced cirrhosis and decompensation having splenomegaly for which the underlying etiology was found to be WD and the diagnostic clue came from abdominal X-ray showing bilateral adrenal calcifications. The diagnosis was confirmed by genetic analysis. The outcome was poor and died before 6 months of age without enzyme replacement therapy or hematopoietic stem cell transplantation.

Unusual Presentations of Abdominal Melioidosis.

Melioidosis is an endemic bacterial infection caused by soil saprophyte, Burkholderia pseudomallei. It infects adults with risk factors or immunosuppressed and exposed to moist soil. Its significance lies in its varied clinical presentation and high mortality (40%). We present two cases of abdominal melioidosis with unusual clinical presentations. The first case presented with intractable hiccups and had isolated splenic melioidosis with contained rupture. The second case presented with fever and acute abdominal pain found to have pancreatic melioidosis and splenic vein thrombosis. Both the patients were treated with IV antibiotics and subsequently discharged after improvement in symptoms. The imaging findings of isolated type of melioidosis can mimic various other infections and granulomatous disease. Hence high index of clinical suspicion for patients presenting from endemic areas will narrow down the differential diagnosis.

Restoring one way traffic across the Roux loop: The Nakajo value.

Roux-en-Y (RY) hepaticojejunostomy (HJ) is a critical component of complex hepatobiliary operations, and it is the treatment of choice for post-cholecystectomy biliary strictures (PCBS). Complications related to the Roux limb, particularly those leading to cholangitis, can severely compromise outcomes. We present a case of a 54-year-old lady who had previously undergone two HJ procedures for recurrent PCBS. The same Roux limb had been used in each of the operations. Short Roux/Roux reflux syndrome led to recurrent cholangitis in this patient, as proven by the reflux of oral contrast into the biliary tree on imaging. This was effectively treated by lengthening the Roux limb (60 cm) with a redo-jejunojejunostomy, and creation of a Nakajo type valve. One-year post surgery, the patient remains well at follow-up. Enteric reflux into the biliary tree may lead to refractory cholangitis. We present the first ever case in an adult, where a simple and effective modification to the HJ obviated this complication.