Rapidly growing sclerosing angiomatoid nodular transformation of the spleen.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a rare benign vascular lesion with unknown pathogenesis and no definitive pathognomonic radiological features. The majority of patients with SANT are asymptomatic, and the lesion is an incidental finding on cross-sectional imaging performed for unrelated reasons or during intra-abdominal surgery. However, in the symptomatic minority, abdominal pain is the most commonly reported symptom. SANT generally remains stable or has very slow growth, making it amenable to surveillance using serial cross-sectional imaging. Herein, we report the unusual case of SANT in a 30-year-old female with rapid growth from 6.0 × 5.6 × 4.4 cm to 8.0 × 6.6 × 7.2 cm over 21 months. Given the rapid growth, it was imperative to rule out malignancy. Thus, the patient underwent a laparoscopic total splenectomy. For SANT, splenectomy serves the dual purpose of diagnosis and definitive therapy.

Nonalcoholic Fatty Liver Diseases among Recently Diagnosed Patients with Diabetes Mellitus and Risk Factors.

AIM: Prevalence of obesity and type 2 diabetes mellitus (T2DM), both of which represent are related to nonalcoholic fatty liver disease (NAFLD), is an increasing trend among Asian people. The study aimed to assess the prevalence of NAFLD in T2DM with their risk factors in the Southern part of Pakistan. MATERIALS AND METHODS: A cross-sectional study was accomplished during 2008-2013 at The Aga Khan University Hospital, Karachi, Pakistan. Adult patients diagnosed with T2DM during last 6 months were enrolled in this study. NAFLD was identified using ultrasound of the liver. Clinical and biochemical relevant measurements were accomplished. RESULTS: Out of a total of 203 patients with T2DM, NAFLD was detected in 146 patients (71.9%). Multivariate analysis revealed that NAFLD was significantly associated with dyslipidemia (OR 2.38, 95% CI 1.06-5.34, p = 0.035), higher LDL (OR 1.02, 95%CI 1.01-1.03, p = 0.003), H bA1c (OR1.27, 95% CI 0.97-1.68, p = 0.045) and diastolic blood pressure (OR 1.05, 95% CI 1.01-1.10, p = 0.009). The highest odds of 10.8 for NAFLD (95% CI 4.9-24, p = 0.001) was found for the combination of hypertension, dyslipidemia, body mass index (BMI), waist circumference, lack of physical inactivity, triglycerides, lower HDL, LDL, HbA1c, and ALT (multiplicative analysis). CONCLUSION: High incidence of NAFLD with the association of different lifestyle-related factors has been analyzed. It unmasks the need for screening for NAFLD in newly diagnosed DM patients in Pakistan with the assessment of parameters of risk factors. HOW TO CITE THIS ARTICLE: Butt AS, Hamid S, et al. Nonalcoholic fatty Liver Diseases Among Recently Diagnosed Patients With Diabetes Mellitus and Risk Factors. Euroasian J Hepatogastroenterol 2019;9(1):9-13.

Diagnostic accuracy of CT scan in staging resectable esophageal cancer.

INTRODUCTION: CT scan is an important tool in staging of esophageal cancer. Survival can be improved by providing neoadjuvant treatment which depends on stage of esophageal cancer. So it is very important to stage the disease accurately. METHODS: The objective of this study is to determine diagnostic accuracy of CT scan to stage esophageal cancer. Ct scans of 62 patients included in the study were reviewed by a Consultant radiologist who was blinded to the final stage of tumour. Diagnostic accuracy measured by comparing with histopathological staging. RESULTS: Accuracy, sensitivity and specificity of CT for T2 and T3 are 66%, 61%, 68% and 63%, 67%, 56% respectively. Accuracy, sensitivity and specificity of CT for presence of nodal disease are 65%, 59% and 75%. CONCLUSIONS: Ct scan alone has low diagnostic accuracy for staging Esophageal Cancer.

Accuracy of 99mTechnetium-labeled RBC Scintigraphy and MDCT With Gastrointestinal Bleed Protocol for Detection and Localization of Source of Acute Lower Gastrointestinal Bleeding.

BACKGROUND: Acute lower gastrointestinal bleeding (LGIB) is a major cause of morbidity and mortality. Multidetector row computed tomography (CT) with gastrointestinal (GI) bleed protocol is a novel diagnostic technique for detecting and localizing LGIB. Being rapid and noninvasive, it may be useful as a first-line modality to investigate cases of acute LGIB. GOALS: To assess and compare diagnostic accuracy of (99M)Technetium (Tc)-labeled red blood cell (RBC) scintigraphy and multidetector row CT with GI bleed protocol for detection and localization of source of acute LGIB. STUDY: Requirement of informed consent was waived for this retrospective study. Seventy-six patients had undergone either RBC scintigraphy, CT with GI bleed protocol, or both, followed by conventional angiography for evaluation of acute persistent LGIB between January 2010 and February 2014 at our institution. Accuracy of both modalities was assessed using conventional angiography as reference standard and compared using the 2-tailed, Fisher exact test. A P-value of <0.05 was considered statistically significant. RESULTS: Fifty-one, 20, and 5 patients had undergone RBC scintigraphy only, CT with GI bleed protocol only, and both modalities, respectively. Fourteen of 25 patients in the CT group had angiographic evidence of active bleeding as compared with 32 of 56 patients in the scintigraphy group. CT with GI bleed protocol had higher accuracy (96%) than (99M)Tc-labeled RBC scintigraphy (55.4%, P<0.001). CONCLUSIONS: CT with GI bleed protocol was more accurate in detecting and localizing the source of acute LGIB as compared with (99M)Tc-labeled RBC scintigraphy.

Autoimmune pancreatitis mimicking Klatskin tumour on radiology.

Autoimmune pancreatitis (AIP) is categorised into two distinct types, AIP type 1 and 2. Although there can be multisystem involvement, rarely, the cholangitis associated with AIP can present radiologically in a manner similar to that of Klatskin tumour. We present the case of a 65-year-old man who was almost misdiagnosed with a Klatskin tumour because of the similarity in radiological features of the two aforementioned clinical entities. The patient presented with a history of jaundice, pruritus and abdominal pain, and work up showed deranged liver function tests, elevated cancer antigen 19-9 levels and positive antinuclear antibodies. CT scan of the abdomen showed findings suggestive of Klatskin tumour but due to diffuse enlargement of the pancreas and surrounding low-attenuation halo found on a closer review, a diagnosis of AIP was performed. The patient was started on standard corticosteroid therapy and responded well, with complete resolution of the radiological findings.

Intratumoral pseudoaneurysms in hepatocellular carcinoma: do they occur de novo without any prior intervention? A tertiary care center experience of 6 years.

BACKGROUND: Intratumoural pseudoaneurysms (ITPA) within hepatocellular carcinomas (HCC) usually arise as postprocedural complications of endovascular therapies or surgical procedures. Their de novo presence in HCC without any prior interventions has not been adequately described in medical literature. PURPOSE: To evaluate and quantify the presence of intratumoural pseudoaneurysms (ITPA) within hepatocellular carcinomas (HCC) prior to any intervention. MATERIAL AND METHODS: Retrospective cross-sectional review of 519 patients with HCC at a tertiary care university hospital with the purpose to evaluate and quantify the presence of ITPA present prior to any therapy. Patients' baseline data along with viral marker status, alpha fetoprotein (AFP) levels, imaging findings, and any prior treatment provided were recorded. Multi-detector computed tomography (MDCT) scans of selected patients were reviewed for presence of any ITPA and their incidence was calculated. RESULTS: ITPAs without any prior therapy were found in 5% (25/519) of patients with HCC. Seventeen of 25 (68%) patients had liver cirrhosis while eight of 25 (32%) patients were non-cirrhotic on imaging. Multiple ITPAs were seen in 44% (11/25) of patients. Eight percent (2/25) of patients had pseudoaneurysm-associated hemorrhage, 20% (5/25) had lung metastasis, 12% (3/25) had portal vein thrombosis, 8% (2/25) had hepatic vein thrombosis, and 16% (4/25) had peritumoral hematoma. The incidence of de novo ITPAs occurring in patients with HCC without any prior therapy or intervention was 0.24%. CONCLUSION: These cases provide a unique insight into an additional feature of HCC and usefulness of recognizing the ITPAs on imaging studies. Although de novo ITPAs in HCC are uncommon, occurring with an incidence rate of 0.24%, their presence in hypervascular hepatic lesion may point towards the diagnosis of HCC. Additionally, they should be accounted for in management planning as they can lead to complications of rupture and hemorrhage.

Acute mesenteric ischaemia with infective endocarditis: is there a role for anticoagulation?

A case of a 30-year-old woman with an end-stage renal disease and recently diagnosed with infective endocarditis, who presented with acute abdominal pain. An initial assessment of acute appendicitis was made. A CT scan of the abdomen showed a partially occluded superior mesenteric artery with radiographic evidence of ischaemia in an ileal loop. Intraoperatively, a 5-6 cm segment of the distal ileum was found to be non-viable. The segment was resected with the creation of a double-barrel ileostomy. This case report draws attention to the question of a need for anticoagulation for a septic embolus in the superior mesenteric artery. We could not find evidence on the use of postoperative anticoagulation in this scenario. In this case, the patient was started on oral anticoagulation.

An incidentally discovered asymptomatic para-aortic paraganglioma with Peutz-Jeghers syndrome.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant inherited disorder characterized by mucocutaneous melanin pigmentation and gastrointestinal (GI) tract hamartomatous polyps and an increased risk of malignancy. In addition to polyposis, previous studies have reported increased risk of GI and extraGI malignancies in PJS patients, compared with that of the general population. The most common extraintestinal malignancies reported in previous studies are pancreatic, breast, ovarian and testicular cancers.We report the case of a 17-year-old boy who presented with generalized weakness, recurrent sharp abdominal pain and melena, had exploratory laparotomy and ileal resection for ileo-ileal intussusception. Pigmentation of the buccal mucosa was noted. An abdominal computed tomography scan (CT) revealed multiple polyps in small bowel loops. Gastroscopy revealed multiple dimunitive polyps in stomach and pedunculated polyp in duodenum. Colonoscopy revealed multiple colonic polyps. Pathological examination of the polyps confirmed hamartomas with smooth muscle arborization, compatible with Peutz-Jeghers polyps. CT scan guided left para-aortic lymph node biopsy revealed the characteristic features of extra-adrenal para-aortic paraganglioma. Although cases of various GI and extra GI malignancies in PJS patients has been reported, the present case appears to be the first in literature in which the PJS syndrome was associated with asymptomatic extraadrenal para-aortic paraganglioma. Patients with PJS should be treated by endoscopic or surgical resection and need whole-body screening.

Portal biliopathy.

Portal biliopathy (PB) is a rare disorder, which mostly presents as sub-clinically. It occurs most commonly due to idiopathic extrahepatic portal vein obstruction. We present three cases having features of portal biliopathy secondary to portal hypertension. Our first case did not have a prior history of chronic liver disease while next two patients had previous history of chronic liver disease resulting in portal hypertension. Cavernous transformation of the portal vein due to extrahepatic portal vein obstruction is not infrequent but biliary obstruction in association with this disorder is distinctly uncommon. Proper case management is very important as prolonged biliary duct obstruction can lead to the development of ascending cholangitis or later on secondary biliary cirrhosis.

Comparison of radioguided occult lesion localization (ROLL) and wire localization for non-palpable breast cancers: a meta-analysis.

Four randomized trials encompassing 449 patients of non-palpable breast cancer undergoing with radio-guided occult lesion localization (ROLL) or wire guided localization (WGL). In the fixed effects model, accurate localization, peri-procedural complications, and reoperation rate were comparable between two techniques. Risk of having positive resection margins following WGL was higher. Duration of localization and surgical excision was shorter for ROLL. Volume and weight of the excised occult breast lesion was similar in WGL and ROLL groups.

Accuracy of 64-slice multidetector computed tomography scan in detection of the point of transition of small bowel obstruction.

PURPOSE: To determine the accuracy of 64-slice multidetector computed tomography scans in detecting the point of transition of small bowel obstruction by using surgical findings as the gold standard. MATERIALS AND METHODS: Cross-sectional study of 59 patients with SBO who underwent 64-slice MDCT scans of the abdomen followed by surgery from 1 June 2008 to 31 January 2010 at a tertiary care center. Point of transition between distended and collapsed small bowel loops were precisely determined on 64-slice MDCT and subsequently correlated with surgical findings. Data analysis was done on SPSS version 16. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of MDCT in detection of the point of transition were calculated. RESULTS: Out of 59 patients, 64-slice MDCT was able to detect the point of transition of SBO in 90% (53/59) of patients, while in 10% (6/59) of these patients the point of transition was not found on MDCT. Overall for detection of the point of transition of small bowel obstruction 64-slice MDCT has 93% sensitivity, 67% specificity, 98% positive predictive value, 33% negative predictive value and 92% accuracy, respectively. CONCLUSION: Sixty-four-slice MDCT is highly accurate in diagnosing the point of transition of small bowel obstruction with an accuracy of 92%. It can be used as a localizing tool before surgery for small bowel obstruction.

Diagnosis of hepatoma using grayscale and Doppler ultrasound in patients with chronic liver disease.

OBJECTIVE: To determine the diagnostic accuracy of liver ultrasound for the detection of hepatoma in chronic liver disease (CLD) patients by either taking histopathology or serum α-fetoprotein levels or a biphasic computed tomography (CT) scan (whichever is available) as the gold standard. STUDY DESIGN: Cross-sectional. PLACE AND DURATION OF STUDY: Radiology Department, The Aga Khan University Hospital, Karachi, Pakistan, from January 2007 to January 2010. METHODS: A total of 239 patients (156 males and 83 females) with clinical suspicion or surveillance of hepatoma in CLD referred to the radiology department for ultrasound evaluation followed by either liver biopsy and histopathology or serum α-fetoprotein level or biphasic CT scan. RESULTS: The sensitivity of ultrasound for hepatoma detection in CLD was 65%, specificity was 85%, and accuracy was 70%, and positive predictive value and negative predictive value were 92% and 45%, respectively. CONCLUSION: Ultrasound is a relatively quick, safe, reasonably accurate, and noninvasive imaging modality for the detection of hepatoma in CLD and can be complemented with clinical assessment of screening high-risk patients.

Can computer assisted diagnosis (CAD) be used as a screening tool in the detection of pulmonary nodules when using 64-slice multidetector computed tomography?

OBJECTIVES: To evaluate (1) whether or not the addition of computer-assisted diagnosis (CAD) to 64-slice multidetector computed tomography (CT) can be used as a screening tool for detection of pulmonary nodules in routine CT chest examinations and (2) whether or not to advocate the incorporation of CAD as a screening tool into our daily practice. MATERIALS AND METHODS: A retrospective cross-sectional analysis of 109 consecutive patients who had all undergone routine contrast-enhanced CT chest examinations for indications other than lung cancer at the Radiology Department of Aga Khan University Hospital, Karachi, between November 2010 and January 2011. All examinations were evaluated in terms of the detection of pulmonary nodules by a consultant radiologist and CAD (ImageChecker CT Algorithm R2 Technology) software. The ability of CAD software to detect pulmonary nodules was evaluated against the reference standard. In addition, a chest radiologist also calculated the number of pulmonary nodules. The sensitivity and specificity of the CAD software were calculated against the reference standard by using a 2 × 2 table. The Mann-Whitney U test was applied to compare the performances of CAD and the radiologist. RESULTS: CAD detected 610 pulmonary nodules while the radiologist detected only 113. The reference standard declared 198 pulmonary nodules to be true nodules. CAD detected 95% of all true nodules (189/198), whereas the radiologist detected only 57% (113/198). In the detection of true pulmonary nodules, CAD had 98% sensitivity compared with the radiologist who had 57% sensitivity; the statistical difference between their performances had a P value <0.001. CONCLUSION: Considering the high sensitivity of CAD to detect nearly all true pulmonary nodules, we advocate its application as a screening tool in all CT chest examinations for the early detection of pulmonary nodules and lung carcinoma.

A paradigm shift in imaging for renal colic - Is it time to say good bye to an old trusted friend?

OBJECTIVES: To study the changing pattern in the use of intravenous urogram (IVU) and non-contrast enhanced CT (CTKUB) for evaluation of flank pain at a single centre. METHODS: All patients who underwent either an IVU or CTKUB at a single, tertiary care center from January 2002 to December 2007 were retrospectively identified from the radiology database. Study samples were-divided into two groups: Pediatric (14 years or less) and Adult (greater than 14 years). For each group, overall trends as well as trends across referral setting and gender were explored by plotting line graphs using SPSS version 15. RESULTS: During the study period a total of 11245 uro-radiological examinations were performed using either IVU (43.7%, n=4915) or CTKUB (56.3%, n=6330). A remarkable majority of procedures (95.5%, n=10741) was performed in adult patients. Overall, the respective proportions of IVU and CTKUB were 87.9% (n=43) and 12.1% (n=61) in the pediatric group whereas 41.6% (n=4472) and 58.4% (n=6269) in adults. Majority in both groups were ambulatory patients (Pediatrics 83.7%, Adults 76.7%). During 2002-20007, the yearly proportion of CTKUB increased from 27% to 80% in adults and from 3% to 27% in children. CONCLUSIONS: There is major shift in the choice of imaging in adults from IVU to CTKUB during years 2002-2007. In pediatric patients, IVU referrals still comprise the greater proportion of uro-radiological exams.

Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair: a systematic review.

OBJECTIVE: The objective of this meta-analysis was to evaluate the effectiveness of endovascular abdominal aortic aneurysm repair (EVAR) in reducing inhospital mortality against open graft replacement for aortic aneurysm. METHODS: Generic terms including EVAR, endovascular aneurysm repair and aortic endografting were used to search a variety of electronic databases. Based on selection criteria, decisions regarding inclusion and exclusion of primary studies were made. RESULTS: A total of three randomized controlled trials on 1,468 patients were included. In the EVAR group, 12 of 759 (1.5%) patients died, compared to 33 of 709 (4.6%) patients who died in the open surgery group. In both the fixed and random effect models, EVAR was associated with statistically significantly lower perioperative mortality when compared to open surgical repair of aortic aneurysm. The risk ratio of 0.33 indicates that mortality is 3.3 times more likely in the open surgery group compared to the EVAR group. CONCLUSION: EVAR carries a threefold lower risk of perioperative death in comparison to open repair of abdominal aortic aneurysm. This early advantage must be offset against the increased need for later re-intervention and probable equivalence of long-term outcome. In older and high operative risk patients, EVAR should be the treatment of choice.

Percutaneous radiologic gastrostomy: results and complications.

BACKGROUND: Percutaneous endoscopic gastrostomy is usually difficult in patients with malignant involvement of oral cavity, pharynx and esophagus. Flouroscopic guided insertion of Gastrostomy catheter with Gastropexy have gained acceptance because it is easy and less time consuming as well as less invasive as compare to surgical procedure. This study was done to evaluate the safety and efficacy of percutaneous placement of gastrostomy with gastropexy using imaging guidance in patients with oropharyngeal and esophageal cancers. METHODS: Over five years, 105 patients were referred to our department for percutaneous radiologic gastrostomy. In five patients the procedure was not performed because of overlying viscera and high position of stomach. We performed 100 gastrostomies with gastropexy procedures using seldinger technique. RESULTS: Success rate for percutaneous radiologic gastrostomy was 100%. No major complication had occurred. There were 11 minor complications occurred including 4 stomal infection, 3 catheter obstruction, one peritonism and three were extensive pneumoperitoneum. Stomal infection and catheter obstruction were not related to procedure. So, our true minor complications were only 4 (4%) which is comparable to literature. CONCLUSION: Percutaneous radiologic gastrostomy is an effective and safe procedure for enteric access of nutrition in patients with oral, pharyngeal and esophageal cancer where percutaneous endoscopic gastrostomy is difficult.

Role of computed tomography in acute pancreatitis and its complications among age groups.

OBJECTIVE: To determine value of CT scan in diagnosis of acute pancreatitis, its complications and to correlate with severity among different age groups. METHODS: The study was carried out from August 2001 to August 2002 at the Radiology Department, Aga Khan University Hospital. A total of 40 patients (33 male and 7 female) with age range from 16-71 years were divided in three groups. Group I was less than 40 years (12 patients), Group II was between 40-60 years (17 patients), and Group III was more than 60 years (11 patients). CT scans were assessed for pancreatic necrosis and its complications. CT Severity Index (CTSI) was calculated according to Balthazar's method. RESULTS: In 17 patients with mild pancreatitis, 5 had necrosis involving one-third of pancreas. In 13 patients with severe pancreatitis, 8 had necrosis involving more than half of the pancreas and 5 had necrosis involving half of the pancreas. No significant correlation was demonstrated between moderate pancreatitis and degree of necrosis. Thirty patients had complications, 8 had mild CTSI, 9 had moderate CTSI and 13 patients had severe CTSI. CONCLUSION: The study demonstrated a relationship between CTSI and severity of pancreatic damage and incidence of complications.