Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography.

BACKGROUND AND AIMS: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefits, but may be associated with cardiopulmonary complications. We analyzed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo) and cardiac and renal biomarkers. APPROACH: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6 hours of admission, at the time of starting terlipressin (48 h), and at 72 hours. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic cardiomyopathy (CCM) was defined per 2020 criteria. RESULTS: One hundred and forty patients were enrolled (84% men, 59% alcohol-associated disease, mean MELD-Na 25±SD 5.6). A median daily dose of infused terlipressin was 4.3 (interquartile range: 3.9-4.6) mg/day; mean duration 6.4 ± SD 1.9 days; the complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cutoffs for prediction of terlipressin nonresponse were cardiac variables [ratio of early mitral inflow velocity and mitral annular early diastolic tissue doppler velocity > 12.5 (indicating increased left filling pressures, C-statistic: 0.774), tissue doppler mitral velocity < 7 cm/s (indicating impaired relaxation; C-statistic: 0.791), > 20.5% reduction in cardiac index at 72 hours (C-statistic: 0.885); p < 0.001] and pretreatment biomarkers (CysC > 2.2 mg/l, C-statistic: 0.640 and N-terminal proBNP > 350 pg/mL, C-statistic: 0.655; p <0.050). About 6% of all patients with HRS-AKI and 26% of patients with CCM had pulmonary edema. The presence of CCM (adjusted HR 1.9; CI: 1.8-4.5, p = 0.009) and terlipressin nonresponse (adjusted HR 5.2; CI: 2.2-12.2, p <0.001) were predictors of mortality independent of age, sex, obesity, DM-2, etiology, and baseline creatinine. CONCLUSIONS: CCM and reduction in cardiac index, reliably predict terlipressin nonresponse. CCM is independently associated with poor survival in HRS-AKI.

The anatomy of the cystic duct and its association with cholelithiasis: MR cholangiopancreatographic study.

The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis-a-vis the main biliary duct. The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%), and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non-lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non-gallstone group (p = 0.02). The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.

Percutaneous transthoracic embolisation for massive haemoptysis secondary to peripheral pulmonary artery pseudoaneurysms.

OBJECTIVE: Pulmonary artery pseudoaneurysms (PAPs) are rare, but important and treatable cause of massive haemoptysis. Minimal data exists on their interventional radiology management due to their rarity, especially direct percutaneous injection. Here, we report our experience of direct percutaneous management of such pseudoaneurysms. METHODS: Data of patients presenting to our department from January 2014 to November 2019 was retrospectively analysed, who presented with massive haemoptysis, and CT angiography positive for pulmonary artery pseudoaneurysms. Only patients treated with direct percutaneous intervention were included. Twelve patients who were managed endovascularly were excluded from the study. Observations were tabulated under age, sex, underlying pathology, lobe involved, number and size of the pseudoaneurysm, imaging guidance and embolising agent. Technical and clinical success and complications were then analysed. RESULTS: Twenty-nine pseudoaneurysms were treated in 27 patients with a mean age of 41.4 years. The most common underlying aetiology was tuberculosis (85.1%), with the most common location being bilateral upper lobes (31% each). CT guidance was the most frequently used imaging guidance (26/29). N-butyl cyanoacrylate (NBCA) glue mixture was used in 79.3% and reconstituted thrombin in the remaining 20.7% pseudoaneurysms. Complete technical and clinical success rates were 93.1% and 88.9% respectively. No major complications were seen except for development of significant pneumothorax in one patient. CONCLUSION: Pulmonary pseudoaneurysms are rare but fatal cause for massive haemoptysis. Interventional radiology management via direct percutaneous embolisation is a safe and minimally invasive treatment measure in selective patients, with successful outcomes and minimal complication and recurrence rates. KEY POINTS: • Pulmonary artery pseudoaneurysms are rare but important and treatable cause of massive haemoptysis. • This study shows the advantages of percutaneous management of these pseudoaneurysms as an alternate to endovascular embolisation, in case endovascular embolisation is not feasible or practical. • It is a safe and minimally invasive treatment, with technical success of 93.1% and clinical success of 88.9% in this study.

Efficacy and safety of irreversible electroporation for malignant liver tumors: a systematic review and meta-analysis.

OBJECTIVE: The data regarding overall survival (OS) and progression-free survival (PFS) following irreversible electroporation (IRE) is scarce. We performed a systematic review of the safety and efficacy of IRE for liver malignancies. METHODS: Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through September 1, 2019. Studies reporting the survival data (OS and PFS) and complications (graded according to the Society of interventional Radiology classification) were included. A generalized linear mixed method with a random-effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs). RESULTS: A total of 25 studies (n = 776, 15 prospective, 10 retrospective) were included. Metastasis, hepatocellular carcinoma, and cholangiocarcinoma were present in 354, 285, and 100 patients, respectively. The pooled OS at 6, 12, 24, and 36 months was 93.28% (95% CI: 63.23-99.12, I2= 67%), 81.29% (95% CI: 69.80-89.22, I2 = 73%), 61.47% (95% CI: 52.81-69.46, I2 = 0%), and 40.88% (95% CI: 28.43-54.61, I2 = 64%), respectively. The pooled PFS at 6, 12, and 24 months was 79.72% (95% CI: 67.88-87.97, I2 = 70%), 64.19% (95% CI: 56.68-71.06, I2 = 57%), 49.05% (95% CI: 11.47-87.73, I2 = 96%), respectively. Overall complication rate was 23.7%. Major complications (grade C-F) occurred in 6.9% patients. CONCLUSION: IRE is associated with favorable OS and PFS. Although the overall complication rate is high, most complications are graded as minor. KEY POINTS: • The pooled OS and PFS at 6, 12, and 24 months for all the tumor types was 93.28% and 79.72%, 81.29% and 64.19%, and 61.47% and 49.05%, respectively. • HCC was associated with a better OS at 12 and 36 months. • The overall complication rate was 23.7%, with major complications (SIR grade C-F) comprising 6.9%.

Overall survival and local recurrence following RFA, MWA, and cryoablation of very early and early HCC: a systematic review and Bayesian network meta-analysis.

OBJECTIVE: To compare overall survival (OS) and local recurrence (LR) following radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CA) for very early and early hepatocellular carcinoma (HCC). METHODS: This systematic review was performed according to the PRISMA guidelines. MEDLINE, Embase, and Cochrane databases were searched. Randomized controlled trials (RCTs) and observational studies were included. OS and LR at 1 year and 3 years were assessed. OS was reported as hazard ratio (HR) with 95% credible intervals (CrI) and LR as relative risk (RR) with 95% CrI, to summarize effect of each comparison. RESULTS: Nineteen studies (3043 patients), including six RCTs and 13 observational studies, met inclusion criteria. For OS at 1 year, as compared to RFA, CA had HR of 0.81 (95% CrI: 0.43-1.51), and MWA had HR of 1.01 (95% CrI: 0.71-1.43). For OS at 3 years, as compared to RFA, CA had HR of 0.90 (95% CrI: 0.48-1.64) and MWA had HR of 1.07 (95% CrI: 0.73-1.50). For LR at 1 year, CA and MWA had RR of 0.75 (95% CrI: 0.45-1.24) and 0.93 (95% CrI: 0.78-1.14), respectively, as compared to RFA. For LR at 3 years, CA and MWA had RR of 0.96 (0.74-1.23) and 0.98 (0.87-1.09), respectively, as compared to RFA. Overall, none of the comparisons was statistically significant. Age of patients and tumor size did not influence treatment effect. CONCLUSIONS: RFA, MWA, and CA are equally effective for locoregional treatment of very early and early HCC. KEY POINTS: • There is no significant difference in the OS and LR (at 1 year and 3 years) following ablation of very early and early HCC with RFA, MWA, and CA. • There was no effect of tumor size on the treatment efficacy. • More RCTs comparing CA with RFA and MWA should be performed.

Diagnostic accuracy of Liver Imaging Reporting and Data System locoregional treatment response criteria: a systematic review and meta-analysis.

OBJECTIVE: There is increasing adoption of Liver Imaging Reporting and Data System (LI-RADS) treatment response (LR-TR) criteria. However, there is still a relative lack of evidence evaluating the performance of these criteria. We performed this study to assess the diagnostic accuracy of LI-RADS LR-TR criteria. METHODS: A thorough search of PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials for studies reporting diagnostic accuracy of LI-RADS LR-TR criteria was conducted through 30 June 2020. The meta-analytic summary of sensitivity, specificity, and diagnostic odds ratio of LI-RADS LR-TR criteria was computed using explant histopathology as the reference standard. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS: Four studies were found eligible for meta-analysis. The total number of LR-TR observations was 462 (240 patients, 82.5% males). Different locoregional therapies (LRTs), including bland embolization, chemoembolization, radiofrequency ablation, and microwave ablation, had been used. The mean time interval between LRT and liver transplantation ranged from 181 to 219 days. There was a moderate to good inter-reader agreement for LR-TR criteria. The pooled sensitivity and specificity of LR-TR criteria for viable disease were 62% (95% CI, 49-74%; I2 = 69%) and 87% (95% CI, 76-93%; I2 = 57%), respectively. The pooled diagnostic odds ratio and area under the curve were 9.83 (95% CI, 5.34-18.08; I2 = 19%) and 0.80. CONCLUSIONS: LI-RADS LR-TR criteria have acceptable diagnostic performance for the diagnosis of viable tumor after LRT. Well-designed prospective studies evaluating criteria of equivocal lesions and effect of different LRTs should be performed. KEY POINTS: • The pooled sensitivity and specificity of LI-RADS LR-TR criteria for the diagnosis of viable tumor were 62% and 87%, respectively. • The pooled diagnostic odds ratio and area under the curve were 9.83 and 0.80. • LR-TR criteria had a moderate to good inter-reader agreement.

Endoscopic Ultrasound Guided Radiofrequency Ablation for Caudate Lobe Hepatocellular Carcinoma: A New Paradigm in Endohepatology.

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a promising technique for treating small left hepatic lesions, particularly where ablation via percutaneous route is deemed to be technically difficult. Herein, we report a case of a 64-year-old cirrhotic patient with caudate lobe hepatocellular carcinoma (HCC) who underwent EUS-RFA, resulting in complete ablation of the tumor and also review the related literature.

Cytomorphologic diagnosis of adult granulosa cell tumors at the metastatic sites with an emphasis on the cytologic mimics.

INTRODUCTION: Adult granulosa cell tumor (AGCT) is a rare ovarian sex-cord malignancy notorious for late recurrences and metastases. The cytologic features of AGCT at the metastatic sites have been documented sporadically. Hence, knowledge of the characteristic cytomorphologic features is essential for an accurate diagnosis and distinguishing it from its pathologic mimics, especially at the metastatic sites. MATERIALS AND METHODS: This was a retrospective study conducted over six years. The cytopathology electronic database was searched for the fine needle aspirates (FNA) reported as metastatic AGCT. A detailed cytomorphologic assessment was done for multiple cytologic features, including overall cellularity, cellular arrangement of the tumor cells, cell size, cell shape, nuclear pleomorphism, nuclear grooving, chromatin pattern, nucleolar prominence, mitotic figures, amount and character of cytoplasm, and the extracellular background. RESULTS: There were 6 cases reported as metastatic AGCT on aspiration cytology. The smears in all the cases were cellular, with tumor cells arranged in loose aggregates, three-dimensional clusters, perivascular papillary fronds, and scattered singly. The most consistent cytologic features included microfollicular arrangement of monomorphic tumor cells with round-oval nuclei, fine chromatin, longitudinal nuclear grooving, and scant cytoplasm. Typical Call-Exner bodies and metachromatically stained extracellular hyaline material were noted sporadically. None of the smears showed anaplasia, prominent macronucleoli, atypical mitoses, or necrosis. CONCLUSIONS: The current study not only outlines the distinct cytologic attributes of AGCTs across various metastatic locations but also highlights its prevalent cytologic mimics. Additionally, it outlines key clinicopathologic traits that can aid in distinguishing and precisely diagnosing these tumors through cytological analysis.

Adnexal arteriovenous malformation presenting with spontaneous massive haemoperitoneum.

Arteriovenous malformations (AVMs) are vascular anomalies composed of a tangle of abnormal vessels in which one or more feeding arteries are directly connected to one or more draining veins via a nidus with no intervening capillary bed. The adnexa are particularly rare sites for the formation of such malformations. Here, we present the case of a middle-aged woman who presented with spontaneous massive haemoperitoneum occurring as a result of a ruptured adnexal AVM. The diagnosis was suspected on transabdominal sonography and confirmed on CT angiography. The patient was shifted to the interventional radiology suite for an urgent angioembolisation following which she improved haemodynamically and her symptoms resolved. The case highlights the fact that although exceedingly rare, gonadal AVMs are an important cause of spontaneous intraperitoneal bleeding. Diagnostic and interventional radiology play an important role in the early and accurate diagnosis of this entity, and angioembolisation can be lifesaving in such patients.

Endovascular management of traumatic renal artery-inferior vena cava fistula in a COVID patient.

A young teenage boy was referred to this tertiary care centre with a history of penetrating trauma to the flank. He had severe pain abdomen and gross haematuria on presentation. Imaging studies revealed a high flow direct fistulous communication between the renal artery and the inferior vena cava. On further work-up, the patient was also diagnosed with SARS-COV 2. Considering the young age of the patient, haemodynamic stability and the presence of a high flow arteriovenous fistula, endovascular management was opted. Diagnostic runs confirmed a high flow fistulous communication between the renal artery and the inferior vena cava. However, on account of logistic challenges at the time due to pandemic related restrictions, hardware accessibility was limited and hence simple coiling was contemplated. During the course of the procedure, the first coil which was deployed ran off via the fistulous communication into the inferior vena cava and got lodged in the right atrium. A separate venous access was obtained and the coil was retrieved with the help of a snare. The coil embolisation was next attempted again by starting distal to the pseudoaneurysm neck and proceeding proximally. In the end, successful coil embolisation of the fistula was done using slightly oversized coils.

Cytomorphologic and immunocytochemical diagnosis of primary hepatic angiosarcoma in a young adult: Challenging diagnosis of a rare, aggressive malignancy.

Primary hepatic angiosarcoma (PHA) is a rare, rapidly growing, highly aggressive hepatic malignancy, primarily seen in elderly males. Establishing an accurate clinical diagnosis is challenging owing to its rarity and nonspecific presentation. Rendering a cytologic diagnosis of PHA is extremely difficult, and immunocytochemistry(ICC) on cell block(CB) sections is essential to confirm the diagnosis. The characteristic cytomorphologic features of PHA have rarely been documented, further augmenting the diagnostic challenge. A 32-year-old male presented with abdominal pain, abdominal distension, and significant weight loss over the past 9 months. On examination, the abdomen was distended, with multiple spider angiomas and a large mass in the right hypochondrium. His renal function tests, liver function tests, and serum tumor markers were within normal limits. An abdominal triphasic computerized tomography revealed a large lobulated mass in the right lobe with central necrosis. An ultrasound-guided FNA was performed from the liver lesion. The cytologic smears showed singly scattered large, markedly pleomorphic, epithelioid-elongated tumor cells having oval-elongated nuclei, irregular nuclear contours, coarse chromatin, prominent macronucleoli, and abundant finely vacuolated cytoplasm in a background of blood. ICC on the CB demonstrated diffuse positivity for vimentin, CD31, and nuclear positivity for FLI-1, confirming a vascular origin. Hence, a final cytologic diagnosis of primary hepatic angiosarcoma was rendered. The index report describes the characteristic cytomorphologic and immunocytochemical features of a rare hepatic malignancy in a young male and reiterates the usefulness of FNAC coupled with CB-ICC in the quick and precise diagnosis of such challenging cases.

Radiological Imaging in Chest Diseases: Moving Away from Conventional Modes.

A chest radiograph is the most common and the initial radiological investigation for evaluating a child presenting with respiratory complaints. However, performing and interpreting chest radiography optimally requires training and skill. With the relatively easy availability of computed tomography (CT) scanning and more recently multidetector computed tomography (MDCT), these investigations are often performed. Although these can be the cross-sectional imaging modalities of choice in certain situations where detailed and exact anatomical and etiological information is required, both these investigations are associated with increased radiation exposure which has more detrimental effects on children, especially when repeated follow-up imaging is necessary to assess the disease status. Ultrasonography (USG) and magnetic resonance imaging (MRI) have evolved as radiation-free radiological investigations for evaluating the pediatric chest pathologies over the last few years. In the present review article, the utility and the current status, as well as the limitations of USG and MRI for evaluation of pediatric chest pathologies, are discussed. Radiology has grown beyond having just the diagnostic capabilities in managing children with chest disorders in the last two decades. Image-guided therapeutic procedures (percutaneous and endovascular) are routinely performed in children with pathologies in the mediastinum and lungs. The commonly performed image-guided pediatric chest interventions, including biopsies, fine needle aspiration, drainage procedures and therapeutic endovascular procedures, are also discussed in the current review.

Cirrhotic cardiomyopathy influences clinical outcomes and enhances performance of conventional risk prediction models in acute-on-chronic liver failure with severe sepsis.

BACKGROUND: Point-of-care echocardiography (POC-Echo) is an essential intensive care hemodynamic monitoring tool. AIMS: To assess POC-Echo parameters [i.e., cardiac index (CI), systemic vascular resistance index (SVRI) and cirrhotic cardiomyopathy (CCM) markers] and serum biomarkers in predicting circulatory failure (need for vasopressors) and mortality in patients with acute-on-chronic liver failure (ACLF) having sepsis-induced hypotension. METHODS: We performed serial POC-Echo within 6 hours (h) of presentation and subsequently at 24, 48 and 72 h in patients with ACLF and sepsis-induced hypotension admitted to our liver intensive care unit. Clinical data, POC-Echo data and serum biomarkers were collected prospectively. RESULTS: We enrolled 120 patients [59% men, aged 49 ± 12 years, 56% alcohol-related disease and median MELDNa of 30 (27-32)], of whom 68 (56.6%) had circulatory failure, with overall mortality of 60%. CCM was present in 52.5%. The predictors of circulatory failure were CI (aHR -1.5; p = 0.021), N-terminal brain natriuretic peptide (aHR -1.1; p = 0.007) and CCM markers; e' septal mitral velocity (aHR -0.5; p = 0.039) and E/e' ratio (aHR -1.2; p = 0.045). Reduction in CI by 20% and SVRI by 15% at 72 h predicted mortality with a sensitivity of 84% and 72%, and specificity 76% and 65%, respectively (p < 0.001). The MELD-CCM model and CLIF-CCM model were computed as MELDNa + 1.815 × E/e' (septal) + 0.402 × e' (septal) and CLIF-C ACLF + 1.815 × E/e' (septal) + 0.402 × e' (septal), respectively, based on multivariable logistic regression. Both scores outperformed MELDNa (z-score = -2.073, p = 0.038) and CLIF-C ACLF score (z score = -2.683, p-value = 0.007), respectively, in predicting 90-day mortality. CONCLUSION: POC-Echo measurements such as CCM markers (E/e' and e' velocity) and change in CI reliably predict circulatory failure and mortality in ACLF with severe sepsis. CCM markers significantly enhanced the CLIF-C ACLF and MELDNa predictive performance.

Hepatic Angiosarcoma-Uncommon Presentation of a Rare Tumor and its Management by Interventional Radiology.

Hepatic angiosarcoma is an uncommon primary malignancy of the liver. It carries a poor prognosis because of very aggressive nature of the tumor. Clinical presentation of hepatic angiosarcoma is variable, most common being hepatomegaly or abdominal mass. Here we report a case of primary hepatic angiosarcoma presented with spontaneous rupture and hemoperitoneum, which was managed successfully by transarterial embolization.

Indian College of Radiology and Imaging Guidelines on Interventions in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is one of the most common malignancies and a significant cause of cancer-related death. Treatment of HCC depends on the stage of the tumor. As many patients with HCC are not deemed fit for surgical resection or liver transplantation, locoregional therapies play an essential role in the management. Image-guided locoregional treatments include percutaneous ablative therapies and endovascular therapies. The choice of an individual or a combination of therapies is guided by the tumor and patient characteristics. As the outcomes of image-guided locoregional treatments depend on the ability to achieve necrosis of the entire tumor along with a safety margin around it, it is mandatory to follow standard guidelines. In this manuscript, we discuss in detail the various aspects of image-guided locoregional therapies to guide interventional radiologists involved in the care of patients with HCC.

A case of amoebic liver abscess complicated by bilhaemia and venous thrombosis.

Amoebic liver abscess is the most common extra-intestinal manifestation of amoebiasis. It usually responds well to treatment with metronidazole together with drainage, if indicated. Uncommonly, the abscess may rupture into the pleura, peritoneum or pericardium, bile duct at its hilum, or produce septic emboli. We present a patient with two rare complications: venous thrombosis and jaundice secondary to bilhaemia.

Interventional radiology and COVID-19: How to face the challenge?

With the sudden outbreak of Coronavirus disease-19 (COVID-19) in China, and its rapid spread across the continents over a short period of time, healthcare workers are posed with the challenge of managing these patients as well protecting themselves from getting infected. Since interventional radiology deals with both elective and emergency services, wherein close patient contact is a norm, there is a substantial risk of acquiring and transmitting infection. Given the circumstances, it is imperative to develop broadly applicable guidelines to utilize the available resources in an optimal fashion and limit transmission of disease. This brief review deals with infection control measures within the Interventional Radiology department or section and possible recommendations that can be adopted at the institutional level.

Point-of-Care Thoracic Ultrasonography in Patients With Cirrhosis and Liver Failure.

Point-of-care ultrasonography (POCUS) helps determine liver-related pathologies like an abscess, portal vein or hepatic vein thromboses, presence of ascites, site for pleural or ascitic paracentesis, and guiding biopsies. POCUS is revolutionizing the management of critically ill patients presenting with pneumonia, acute respiratory distress syndrome, acute-on-chronic liver failure, and in the emergency. The objectives of thoracic ultrasonography (TUS) are to aid the clinician in differentiating between pneumonia, effusions, interstitial edema and collections, and in estimating the volume status of patients with liver disease using inferior vena cava dynamic indices. The use of POCUS in patients with cirrhosis has since evolved. It is now widely used to help diagnose volume status, left ventricular diastolic dysfunction, myocardial infarction, and right ventricular dilation due to pulmonary embolism and to determine the causes for weaning failures such as effusions, lung collapse, and pneumothorax. During the Coronavirus Disease 2019 (COVID-19) pandemic, moving patients for computed tomography can be difficult. Therefore, TUS is now essential in liver transplantation and intensive care practice to assess ventilatory pressures, cardiac function, and fluid management. This review indicates the current and optimized use of TUS, offers a practical guide on TUS in the liver intensive care unit (ICU), and presents a diagnostic pathway for determining lung and pleural pathology, resolution of respiratory failure, and aid weaning from mechanical ventilation.

Liver Abscess in Children-experience From a Single Tertiary Care Center of North India: Etiology, Clinical Profile and Predictors of Complications.

BACKGROUND: Liver abscess (LA), a common problem in children in the tropics, is believed to be mostly pyogenic (PLA), sometimes amebic (ALA). We aimed to analyze the clinical profile, etiology, risk factors for complications, management and outcomes of LA in children. METHODS: The details of 81 children with LA managed in a tertiary set up over a period of 3 years were analyzed. A comparison of different parameters was performed with respect to etiology and complications. RESULTS: ALA, PLA and mixed infection LA were diagnosed in 40 (49.4%), 32 (39.5%) and 9 (11.1%) children. The triad of fever, hepatomegaly and right upper quadrant tenderness was seen in 65 (80.2%). Coagulopathy was observed in 60 (77%) and jaundice in 12 (14.8%). Majority (71.6%) had a single LA in the right lobe (69%). Conservative, percutaneous needle aspiration, percutaneous catheter drainage and surgical drainage were done in 11.1%, 3.7%, 82.7% and 2.5%, respectively. Forty-three (53.1%) had complicated LA with rupture in 55.8% and vascular thrombosis in 16.2%. Children with complicated LA had higher alanine transaminase, prolonged prothrombin time/international normalized ratio, low serum protein and albumin levels (P < 0.05). Median duration of follow-up was 2 months and mean time to resolution of LA was 48.5 ± 18 days. CONCLUSIONS: ALA is the commonest cause of pediatric LA in endemic regions and is difficult to differentiate from PLA clinically. Percutaneous catheter drainage is safe and effective modality for the management of LA in children. A higher alanine transaminase, prolonged prothrombin time/international normalized ratio and low serum albumin levels (<3 g/dL) at presentation identify complicated LA.