Dietary pattern associated with non-alcoholic fatty liver disease (NAFLD) in non-diabetic adult patients: A case control study.

BACKGROUND: Dietary intake is an important factor in the development and management of non-alcoholic fatty liver disease (NAFLD) however, optimal food group composition remains unclear. Data on detailed food group intake of NAFLD patients from India is scarce. METHODS & MATERIALS: In this study with 320 participants (160 NAFLD cases and 160 controls), dietary habits were assessed using a 24-h dietary recall for two days and a validated 142-item food frequency questionnaire over the past year. Principal component analysis identified dietary patterns associated with NAFLD among the participants. RESULTS: Cases were having a significantly higher intake of edible oils and fats along with nuts and oilseeds as compared to controls (p < 0.05). There was a positive and significant association with edible oils and fats with NAFLD [OR (95 % CI):1.7 (1.11-2.49) p = 0.013). In dietary pattern analysis western dietary pattern was found to be a risk for NAFLD whereas protective dietary pattern was associated with the decreased risk of NAFLD. CONCLUSION: The overall food groups intake in NAFLD cases and controls was low suggesting lower diet quality. Protective dietary pattern found to be beneficial for NAFLD. High intake of sugars and edible oils associated with western dietary pattern increases the risk of NAFLD.

Acinar cystic transformation of the pancreatic body and tail in an elderly male patient: A case report.

Acinar cystic transformation (ACT) is a rare benign cystic lesion of the pancreas reported in elderly women. ACT can be easily confused with other cystic lesions of the pancreas, such as intraductal papillary neoplasm and serous and mucinous neoplasms, on imaging, especially when detected radiologically in a male patient as the index case. A preoperative histological examination can establish a diagnosis and avoid extensive surgical resection. We hereby report a case of ACT in a 69-year-old male patient that affected the body and tail region of the pancreas.

Benign Hepatic Nodules in Patients With Primary Extrahepatic Portal Vein Obstruction: Clinical and Magnetic Resonance Imaging Features.

Background/objective: To retrospectively evaluate the magnetic resonance imaging (MRI) features of benign hepatic nodules in patients with extrahepatic portal vein obstruction (EHPVO) and assess predictable features for their development. Methods: This retrospective observational study included 18 diagnosed patients of EHPVO who underwent contrast enhanced abdominal MRI at our Institute between June 2016 and May 2017, and who could be followed up for at least two years. The patients with liver nodules formed the study group (n = 8; 4 males, 4 females; mean age: 26.1 ± 10.9 years) and patients without liver nodules were controls (n = 10; 3 males, 7 females; mean age: 24.2 ± 15.1 years). Liver nodules were confirmed as benign by either biopsy or stability on follow up imaging. MRI features of liver nodules were assessed. Clinical details and imaging data of the study group were compared with controls to assess predictable features. Results: There was no statistically significant difference in age, gender, clinical characteristics and upper gastrointestinal endoscopic findings between the study and control groups. The size of the lienorenal collateral, left renal vein and superior mesenteric vein were significantly larger in the study group (P < 0.05). In the study group, the majority had multiple hepatic nodules with most of them being isointense on T1 (18/35; 51.4%) and T2-weighted images (16/35; 45.7%) and showing restriction of diffusion (21/35; 60%). All (n = 35) lesions showed arterial phase hyperenhancement and none showed washout in the venous phase. The patients in the control group did not develop any liver nodules during the follow-up period. Conclusion: Liver nodules in patients with EHPVO are likely to be benign and have characteristic MRI features. Significantly larger lienorenal collateral, left renal vein and superior mesenteric vein were associated with the development of these nodules.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis.

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Spectrum of Neuroimaging Abnormalities in Brain in Patients of Acute-on-Chronic Liver Failure.

Background and aims: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality. There is a paucity of data about the spectrum of neuroimaging abnormalities in the brain in ACLF patients. The present study was aimed to study the prevalence of cerebral edema and other parenchymal changes in MR imaging of the brain in patients with ACLF. Methods: In this prospective observational study, MR imaging was done in patients with ACLF (n = 41), and findings were compared with age and sex-matched patients with acute decompensation (AD) (n = 13) and those with cirrhosis but without any decompensation at recruitment (n = 21). Results: Forty-one patients with ACLF (24.4% Grade 1 and Grade 2, 51.2% Grade 3) with 14 (34.1%) having cerebral failure were included in the study. T2-weighted (T2W) diffuse white matter hyperintensities (WMHs) and focal WMHs were seen in 17 (41.4%) and 7 (17%) patients, respectively. T1W basal ganglia hyperintensities in 20 (48.7%), cerebral microbleeds (CMBs) in 6 (14.6%), and 2 (4.8%) patients had cerebral edema. In patients with AD, T2W diffuse WMHs were seen in 3 (23%), T2W focal WMHs in 3 (23%) patients. None of the patients with AD had cerebral edema or CMBs. In compensated cirrhosis patients, T2W diffuse WMHs were present in 7 (33.3%), T2W focal WMHs in 5 (23.8%), while 3 (14.2%) patients had CMBs. T1 weighted hyperintensities in basal ganglia were more common in AD [9 (69.2%)] and compensated cirrhosis [15 (71.4%)] as compared to ACLF patients [20 (48.7%)], P = 0.174. The survival time of 30 and 90 days for patients with diffuse T2W WMHs was significantly lesser than patients without T2W WMHs (P = 0.007). Conclusion: Cerebral edema is uncommon in ACLF patients, and T2-weighted diffuse white matter hyperintensities may be associated with worse outcomes. However, due to the limited scope of the present study, the same needs to be explored further in larger cohorts.

Alterations in Autophagy and Mammalian Target of Rapamycin (mTOR) Pathways Mediate Sarcopenia in Patients with Cirrhosis.

Background and aims: The pathophysiology of sarcopenia in cirrhosis is poorly understood. We aimed to evaluate the histological alterations in the muscle tissue of patients with cirrhosis and sarcopenia, and identify the regulators of muscle homeostasis. Methods: Computed tomography images at third lumbar vertebral level were used to assess skeletal muscle index (SMI) in 180 patients. Sarcopenia was diagnosed based on the SMI cut-offs from a population of similar ethnicity. Muscle biopsy was obtained from the vastus lateralis in 10 sarcopenic patients with cirrhosis, and the external oblique in five controls (voluntary kidney donors during nephrectomy). Histological changes were assessed by hematoxylin and eosin staining and immunohistochemistry for phospho-FOXO3, phospho-AKT, phospho-mTOR, and apoptosis markers (annexin V and caspase 3). The messenger ribonucleic acid (mRNA) expressions for MSTN, FoxO3, markers of ubiquitin-proteasome pathway (FBXO32, TRIM63), and markers of autophagy (Beclin-1 and LC3) were also quantified. Results: The prevalence of sarcopenia was 14.4%. Muscle histology in sarcopenics showed atrophic angulated fibers (P = 0.002) compared to controls. Immunohistochemistry showed a significant loss of expression of phospho-mTOR (P = 0.026) and an unaltered phospho-AKT (P = 0.089) in sarcopenic patients. There were no differences in the immunostaining for annexin-V, caspase-3, and phospho-FoxO3 between the two groups. The mRNA expressions of MSTN and Beclin-1 were higher in sarcopenics (P = 0.04 and P = 0.04, respectively). The two groups did not differ in the mRNA levels for TRIM63, FBXO32, and LC3. Conclusions: Significant muscle atrophy, increase in autophagy, MSTN gene expression, and an impaired mTOR signaling were seen in patients with sarcopenia and cirrhosis.

European Working Group on Sarcopenia in Older People (EWGSOP2) Criteria With Population-Based Skeletal Muscle Index Best Predicts Mortality in Asians With Cirrhosis.

BACKGROUND/AIMS: Multiple definitions of sarcopenia exist and the acceptable criterion that best predicts outcome is lacking. We estimated the prevalence of sarcopenia based on four criteria and assessed their utility in predicting mortality in cirrhotics. METHODS: In a prospective observational study, consecutive Asian patients with cirrhosis underwent testing for handgrip strength (HGS) and estimation of skeletal muscle index (SMI) using computed tomography at the third lumbar vertebra. Sarcopenia was defined based on the Western cut-off (WC; SMI < 50 cm2/m2 for men and <39 cm2/m2 for women), Asian cut-off (AC; SMI < 36.5 cm2/m2 for men and 30.2 cm2/m2 for women), European Working Group on Sarcopenia in Older People-2nd meeting (EWGSOP2) definition incorporating low HGS (<27 kg for men and <16 kg for women) with low SMI (defined by the WC), and EWGSOP2 definition with low HGS and low SMI (defined by AC). Risk factors for mortality were assessed using multivariate Cox-proportional hazards. RESULTS: We included 219 patients with cirrhosis (168 men; mean age 42.6 years) with 50.2% patients having decompensation. Alcohol was the commonest aetiology (33.3%). The prevalence of sarcopenia was highest with the WC (men: 82.1%; women: 62.7%). There was a weak concordance among all criteria (Fleiss' kappa 0.23, 95% confidence interval [CI] 0.10-0.37). Overall, 12-month survival was 86.1% (81.1-91.3%) over a median (interquartile range) follow-up of 12 (6-15) months. Ascites (hazards ratio [HR] 6.27 [95% CI 1.6-24.1]; P < 0.007) and SMI (HR 0.92 [0.85-0.98]; P = 0.021) were independent predictors of mortality. The 12-month mortality rate was higher in patients with sarcopenia, irrespective of criteria (log rank P < 0.05). Low HGS and low SMI (defined by AC) was the best for predicting mortality (HR 3.04 [1.43-6.43]; P = 0.004). CONCLUSION: A weak concordance exists amongst various diagnostic definitions of sarcopenia. Sarcopenia diagnosed by a combination of low HGS and population-specific SMI cut-off (AC) best predicts mortality.

Role of Diffusion-Weighted Magnetic Resonance Imaging in the Diagnosis and Grading of Hepatic Steatosis in Patients With Non-alcoholic Fatty Liver Disease: Comparison With Ultrasonography and Magnetic Resonance Spectroscopy.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is becoming the most common cause of cirrhosis. Although magnetic resonance spectroscopy (MRS) is considered the gold standard, it has a few limitations. The role of diffusion-weighted imaging (DWI), which is a simpler sequence, in the diagnosis and grading of fatty liver is not well studied. The aim of the study was to investigate the value of DWI in the diagnosis and grading of hepatic steatosis in patients with NAFLD. MATERIALS AND METHODS: Fifty-one adults (mean age: 38 years; 28 men, 23 women) with NAFLD, diagnosed clinically and by ultrasonography (USG), were included in the study after obtaining informed consent and approval from the institute ethics committee. USG was performed for grading of hepatic steatosis in all patients, followed by magnetic resonance imaging with DWI and MRS, on a 1.5T scanner. The mean apparent diffusion coefficient (ADC) values and proton density fat fraction (PDFF) were calculated, and MRS was used as the gold standard. The mean ADC values were compared with the PDFF and USG grades. RESULTS: There was a weak correlation between ADC values and PDFF (r = -0.36; P < 0.05). In addition, there was a weak correlation between the ADC values of the liver and USG grade (r = -0.34; P < 0.05). However, an overall increase in USG grades and PDFF was associated with decrease in the mean ADC value (P < 0.001). CONCLUSION: DWI is not accurate in the diagnosis and grading of hepatic steatosis in patients with NAFLD. However, a significant increase in fat deposition in the liver lowers the ADC values.

Hemorrhage and Rupture of an Unusual Benign Liver Lesion in Pregnancy: A Case Report.

Liver rupture in pregnancy is an acute condition with significant risk to the mother and fetus. It is known to occur with tumors such as hepatic adenoma, infective causes such as abscess, granulomatous diseases, and parasitic infections, and rarely spontaneously. Most of these conditions have overlapping clinicoradiological findings, almost always requiring histopathological confirmation. We report a case of a ruptured hepatic lesion, with an unusual diagnosis of Bartonella henselae infection causing cat-scratch disease, in a 24-year-old pregnant lady.

Sepsis Following Liver Biopsy in a Liver Transplant Recipient: Case Report and Review of Literature.

Percutaneous liver biopsy is a relatively safe procedure with low complication rates. Infections following liver biopsy are uncommon and can lead to a poor outcome. There are limited data on liver biopsy-related infections among liver transplant (LT) recipients. Also, there is a paucity of data regarding the use of prophylactic antibiotics in LT patients undergoing percutaneous liver biopsy. We report a case of systemic sepsis following percutaneous liver biopsy in a LT recipient with choledochojejunal anastomosis. This was followed by severe rejection and deterioration of liver function and recurrence of primary sclerosing cholangitis (PSC) to the extent that he has been listed for retransplantation. This case report emphasizes the potential risk of sepsis in LT recipients with bilioenteric anastomosis undergoing percutaneous liver biopsy. This increased risk may warrant periprocedural broad spectrum antibiotic prophylaxis, in this subgroup of patients.

CT-Guided Lumbar Sympathectomy as a Last Option for Chronic Limb-Threatening Ischemia of the Lower Limbs: Evaluation of Technical Factors and Long-Term Outcomes.

OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors on the long-term outcome of CT-guided lumbar sympathectomy in patients with chronic limb-threatening ischemia. SUBJECTS AND METHODS. Thirty patients (28 men, two women; mean age, 45.8 years) with chronic limb-threatening ischemia and diffuse tibial arterial disease not amenable to revascularization were included. CT-guided lumbar sympathectomy was performed at the L2-L3 level with a 22-gauge Chiba needle and absolute alcohol. Any periprocedural complication was noted. Numeric pain score (1-10 scale) and skin ulcers were assessed before the procedure and 3 weeks, 3 months, and 1 and 2 years after the procedure. According to spread of alcohol, patients were categorized into those with medial spread and those without medial spread (lateral spread group) with the lateral edge of the vertebral body as the reference point. Treatment results were categorized as improved, unchanged, or worsened on the basis of clinical response. RESULTS. There were 22 (73.3%) patients in the medial spread group and eight (26.7%) in the lateral spread group. The mean volumes of alcohol injected per side were not significantly different (p = .50). One major complication occurred in the group with medial spread. Mean numeric pain scores before the procedure and 3 weeks, 3 months, and 1 and 2 years afterward were 7.31, 2.95, 2.47, 2.10, and 2.04 in the medial spread group and 6.25, 4.13, 4.50, 4.35 and 4.32 in the lateral spread group (p < .001). At 2 years, 16 patients in the medial spread group and two patients in the lateral spread group showed clinical improvement (p < .001), and the limb salvage rates were 100% and 87.5%, respectively. Multivariate analysis showed a trend in improvement with smoking cessation, but the difference was not statistically significant (p = .15). The direction of spread of the neurolytic agent, however, was a major determinant of outcome. CONCLUSION. CT-guided lumbar sympathectomy is a simple, safe, and effective procedure. Ensuring medial spread of the neurolytic agent significantly improves long-term results.

The rare case of a cystic pancreatic neuroendocrine tumor.

The pancreatic neuroendocrine tumors (PanNETs) most commonly present as solid neoplasms; however, very rarely, they may present primarily as cystic neoplasms. Most of the cystic PanNETs are non-secreting tumors, and the radiological features are not well defined. Hence pre-operative diagnosis is usually challenging and the tumors are misdiagnosed as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, serous cystic neoplasms, solid pseudopapillary neoplasms, and non-neoplastic cysts. However, the management depends on the accurate diagnosis of these cystic lesions, which poses a dilemma. Herein, we report the case of a cystic PanNET in the tail of the pancreas, which was clinically and radiologically misdiagnosed as a mucinous cystic neoplasm. This case is reported to highlight this issue to the medical community regarding the diagnostic difficulty in such rare non-functioning pancreatic neuroendocrine tumors.

Role of Magnetic Resonance Imaging in the Monitoring of Patients with Nonalcoholic Fatty Liver Disease: Comparison with Ultrasonography, Lipid Profile, and Body Mass Index.

AIM: The aim of this study was to study the role of magnetic resonance imaging (MRI) in monitoring hepatic fat content in cases of nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS: 41 adults (mean age: 39 years, 22 males; 19 females) with NAFLD were included after obtaining approval from the institutional ethics committee. The baseline clinical (weight, body mass index [BMI]) and biochemical parameters, fatty liver grade on ultrasonography (USG), and hepatic fat signal fraction (FSF) using dual-echo chemical shift imaging and proton density fat fraction on magnetic resonance spectroscopy (MRS-PDFF) were assessed, before and after intervention (dietary and lifestyle changes and oral vitamin E for six months). They were categorized into Group A (good compliance to intervention) and Group B (poor compliance), and the clinical and imaging parameters were compared between them. RESULTS: After intervention, Group A (n = 30) showed significant reduction in BMI (28.35 ± 3.25 to 27.14 ± 3.24 kg/m2; P < 0.001), hepatic FSF (19.30 ± 9.09% to 11.18 ± 7.61%; P < 0.05), and MRS-PDFF (18.79 ± 8.53% to 10.64 ± 6.66%). In Group B (n = 11), there was significant increase in BMI (28.85 ± 2.41 to 29.31 ± 2.57 kg/m2; P < 0.001), hepatic FSF (18.96 ± 9.79% to 21.48 ± 11.80%; P < 0.05), and reduction in high-density lipoproteins (P < 0.05). Although there was good correlation between USG and MRS in quantifying liver fat (r = 0.84-0.87; P < 0.001), USG was unable to detect <5.3% change in hepatic fat. There was poor correlation between lipid profile and MRS-PDFF. Change in body weight significantly correlated with change in hepatic fat content (r = 0.76; P < 0.001). CONCLUSION: MRI is useful in accurately quantifying and in monitoring hepatic fat content and is better than clinical and biochemical parameters and USG.