CT appearances of gastric injury due to caustic ingestion and associated findings (a study of 30 cases).

The mortality and morbidity of acute caustic gastric injuries are high. The spectrum of gastric injury due to caustic ingestion varies from hyperemia, erosion, and extensive ulcers to mucosal necrosis. Severe transmural necrosis can be associated with fistulous complications in the acute and subacute phases and stricture formation in the chronic phase. Due to these important clinical implications, timely diagnosis and appropriate management of gastric caustic injury are crucial, and endoscopy plays a pivotal role. However, critically ill patients or those with overt peritonitis and shock cannot undergo endoscopy. Thoraco-abdominal computed tomography (CT) is preferable to endoscopy as it avoids the risk of esophageal perforation and allows the evaluation of the entire gastrointestinal tract, as well as of the surrounding organs. With the advantage of not being invasive, CT scan has a promising role in the early evaluation of caustic injury. It has an increasing role in the emergency setting with good accuracy in identifying patients who are likely to benefit from surgery. In this pictorial essay, we present the CT spectrum of caustic injury of stomach and associated thoraco-abdominal injuries, with clinical follow-up.

Can lung ultrasound differentiate between bacterial and viral pneumonia in children?

PURPOSE: This study evaluates whether LUS can differentiate between bacterial and viral pneumonia in children and thus affect their management. METHODS: The prospective, cross-sectional, analytical study included 200 children under 12 years of age (excluding neonates) with clinical suspicion of pneumonia who had undergone a chest radiograph (CR). The CR and LUS findings were classified as bacterial or viral pneumonia. The final diagnosis was made on the basis of a combination of clinical profile, available routine laboratory investigations and CR diagnosis which was taken as the gold standard for the study and LUS was compared with the gold standard. RESULTS: LUS has a high sensitivity (91%; 95% CI [84-96]) and specificity (91.3%; 95% CI [84-96]) in diagnosing bacterial pneumonia with a high positive predictive value (91.9%; 95% CI [85-96]) and negative predictive value (90.3%; 95% CI [82-95]). For diagnosing viral pneumonia, the sensitivity of LUS was 78.4%; (95% CI [68-86]), specificity was high (90.4%; 95% CI [83-95]) and so was the positive predictive value (87.3%; 95% CI [78-94]) and negative predictive value (91.3%; 95% CI [84-96]). CONCLUSION: LUS has a high accuracy in differentiating between bacterial and viral pneumonia in children and can help in their management by avoiding an ill-advised use of antibiotic therapy.

Chest Sonography in the Diagnosis of Pneumothorax.

BACKGROUND: Few studies have assessed the utility of chest ultrasonography in the diagnosis of pneumothorax in India. METHODS: Chest ultrasonography was undertaken in 126 haemodynamically stable patients, followed by a chest radiograph within 30 minutes. If pneumothorax was not seen on the chest radiograph, a non-contrast computed tomography of the thorax was performed within 3 hours. The time taken to make or exclude a diagnosis of pneumothorax, by ultrasonography, was assessed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of chest ultrasonography was estimated. RESULTS: For the diagnosis of pneumothorax in any clinical situation, the average time taken on ultrasonography was less than 2 minutes. The sensitivity, specificity, accuracy, PPV and NPV of chest ultrasonography was 89%, 88.5%, 88.9%, 96.7% and 67.6%, respectively. CONCLUSIONS: Chest ultrasonography can be used as a primary imaging modality in the diagnosis of pneumothorax in a vast variety of clinical situations.

Carotid Intima-Media Thickness and Metabolic Complications in Children with HIV on Antiretroviral Therapy: A Cross-Sectional Study.

OBJECTIVES: To evaluate carotid intima media thickness (CIMT) in children with Human immunodeficiency virus (HIV) on anti-retroviral therapy (ART) and in controls. Also, to compare body mass index (BMI), body fat percentage, skin-fold thickness (SFT), waist-to-height ratio (WHtR), lipid profile, blood pressure, lipodystrophy syndrome (LDS), non-alcoholic fatty liver disease (NAFLD) in children with HIV and in controls and to determine association between lipid profile, LDS, liver amino-transferases, NAFLD, BMI, body fat percentage, SFT, WHtR and CIMT. METHODS: This cross-sectional study was done in 7 to 12 y old children attending the ART clinic and receiving ART for ≥6 mo according to 2018 National Aids Control Organization (NACO) guidelines. Thirty age and gender matched controls were enrolled from the pediatrics OPD. Weight, height, BMI, waist circumference, skin fold thickness and blood pressure were recorded. Lipid profile, liver amino-transferases, USG abdomen and CIMT were done with prior appointment. RESULTS: The present study had 43% females and 57% males (mean age of 9.33 ± 1.65 y). All cases were on combination ART (mean treatment duration: 59.1 mo). CIMT was significantly increased in cases as compared to controls 0.481 ± 0.087 mm vs. 0.418 ± 0.072 mm (p = 0.003). However, CIMT did not correlate with any other parameter. Cases had significantly higher body fat percentage (17% vs. 13.15%), systolic blood pressure (SBP), SFT, total cholesterol (TC) and low density lipoprotein- cholesterol (LDL-C) as compared to controls. NAFLD was seen in 3 cases (1%), lipohypertrophy in 7 (23%) cases and 5 (16%) controls. CONCLUSIONS: Children with HIV on ART have significantly higher CIMT and increased metabolic abnormalities.

Simultaneous non-traumatic perforation of the right hepatic duct and gallbladder: an atypical occurrence.

Simultaneous non-traumatic perforation of the extrahepatic bile duct and the gallbladder is an uncommon occurrence that has been infrequently reported. We describe a patient with a spontaneous perforation of both the extrahepatic bile duct and the gallbladder. A contrast-enhanced computed tomography (CECT) scan of the abdomen and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a perforation of the gallbladder and a free leak from the right hepatic duct, respectively. Endoscopic biliary drainage following a sphincterotomy and biliary stent placement led to a dramatic improvement in the patient's general condition. He was subsequently scheduled to undergo an elective cholecystectomy. Repeat ERCP performed at 4 weeks after the initial stenting showed a normal cholangiogram and a distally migrated stent, which was there after removed. However, early stent removal led to re-perforation of hepatic duct and gallbladder. A repeat endoscopic biliary drainage did not help, and the patient developed biliary peritonitis. Surgical exploration revealed a perforation at the fundus of the gallbladder, 400 ml of biliopurulent collection and a frozen Calot's triangle. A subtotal cholecystectomy, gall stone removal, and a thorough peritoneal lavage were undertaken. The patient improved postoperatively. The second biliary stent was removed after 4 months. This case report highlights the role of endoscopic biliary drainage in the management of an extrahepatic bile duct perforation and warns against the early removal of a biliary stent.

Lipoma at an unusual site - an intrinsic laryngeal lipoma involving the aryepiglottic fold.

Lipomas are common tumours. However they are a rare occurrence in the larynx. They are an unusual cause for hoarseness of voice and may at times present acutely with respiratory distress due to significant airway compromise. The characteristic imaging features help to differentiate it from laryngeal malignancy and other common pathologies. We present a case of a laryngeal lipoma arising from the aryepiglottic fold, which was diagnosed on imaging and confirmed on histopathological examination after surgical excision. We also briefly discuss the differential diagnoses of this entity.

Bronchial carcinoid with bronchocele masquerading as Scimitar syndrome on chest radiograph.

Bronchial carcinoid tumors occur predominantly in the perihilar location and can be asymptomatic. They may present in early stages with only obstructive features such as mucus plugging of airways resulting in bronchocele formation. We report the case of a 44-year lady with no chest complaints, who underwent chest radiograph for a routine preanesthetic checkup. A vertically oriented, tubular, soft tissue density lesion was observed in the right lower lung, which mimicked a Scimitar vein. Scimitar syndrome is a congenital disorder in which an anomalous vein drains the middle and lower lobes of right lung and enters into the IVC most commonly. It may present asymptomatically in adults and on chest radiograph appears as a vertical tubular opacity paralleling the right cardiac border. However, CT angiography revealed the lung lesion to be a bronchocele, distal to a central intensely enhancing spherical mass, completely occluding the right lower lobe bronchus. This perihilar mass had been missed on the chest radiograph. Bronchoscopic biopsy revealed a carcinoid tumor. As the patient was asymptomatic, she refused surgery in the ongoing COVID-19 pandemic.

Incidentalomas of the female genital tract on 64-slice MDCT: a clinico-radiological pictorial review.

Sonography is the imaging modality of choice for diagnosing diseases of the female genital tract due to its high resolution, easy availability, low cost and lack of radiation. CT is not advocated for the primary evaluation of the female pelvis. However, with the advent of Multidetector CT (MDCT), females of all ages undergo CT scan of the abdomen and pelvis for myriad non-gynaecological diseases, e.g. subacute intestinal obstruction, abdominal lump, abdominal tuberculosis, appendicitis, ureteric colic, pancreatitis, oncological staging, follow-up, etc. Incidental female genital tract disorders were seen on these scans that are a dilemma for both, the radiologists and the clinicians. The objective of this pictorial review is to characterise the incidentally detected lesions of the female genital tract observed on 64-slice MDCT by correlating with sonography, if necessary, and establishing a clinico-radiological diagnosis. Our aim is to emphasise that the radiologist may be the first person to recognise a gynaecologic disorder and hence can play a significant role in patient management.

Characteristic patterns of segmental infantile hemangiomas in Indian children: A descriptive study.

BACKGROUND: Approximately 18% of infantile hemangiomas are segmental. These are larger than other infantile hemangiomas, associated with higher rate of complications and developmental anomalies, and often require treatment. They follow nonrandom patterns on the head and neck as well as extremities which are probably related to embryologic development. AIMS: Our study aimed to describe segmental patterns of infantile hemangiomas in Indian children, with associated anatomical abnormalities if any. METHODS: Over a 9-year period, 59 infants presenting with lesions classified as segmental infantile hemangiomas were evaluated and analyzed. Associated developmental anomalies were assessed and recorded. In addition, patterns of "indeterminate" infantile hemangiomas in another 43 patients were analyzed. RESULTS: There were 14 male and 45 female infants with an average birth weight of 2.7 ± 0.726 kg in our study; the average age at onset was 1 ± 1.25 months with most (50.8%) lesions localized to the head and neck area. Mapping of lesions showed that the most common facial segments involved were mandibular (33%) and maxillary (30%). However, additional repetitive patterns not previously described (such as an "inverted comma" pattern on the chest, bilateral neck involvement and unilateral labium involvement) were seen in our patients. Common local complications were ulceration (27%), amblyopia and nasal obstruction (3% each). Mapping of the additional 43 patients with indeterminate infantile hemangiomas also showed repetitive though incomplete patterns. LIMITATIONS: Relatively small number of patients. CONCLUSION: Segmental infantile hemangiomas present as large, distinctively patterned lesions, even on the trunk and genitalia. These patterns are probably based on embryologic developmental patterns. In addition, indeterminate lesions also showed distinctive repetitive patterns. Our study suggests that additional segments may need to be defined, particularly on the trunk and genital area.

Diffuse pancreatic serous cystadenoma associated with neuroendocrine carcinoma: a case report and review of literature.

CONTEXT: Diffuse serous cystadenomas of the pancreas are extremely rare, with only 8 cases reported previously, and have been associated with neuroendocrine tumors in only two patients. Some have been seen in von Hippel-Lindau disease. The management of these tumors poses a challenge due to their rarity and uncertain malignant potential. We report a case of diffuse serous cystadenoma associated with neuroendocrine carcinoma in a 35-year-old woman. CASE REPORT: A 35-year-old woman with mild abdominal pain was diagnosed as having a cystic pancreatic mass on ultrasonography. On contrast-enhanced CT scan, MRI and MRCP imaging, a spongy lesion was found to replace the entire pancreas, and was diagnosed as diffuse serous cystadenoma. Serum biochemistry for amylase, lipase, CA 19-9 and CEA was normal. Screening for retinal and CNS lesions was also unremarkable. A total pancreatectomy was performed, and the patient recovered well. Histopathological examination of the specimen revealed microcysts and macrocysts replacing the entire pancreas, the largest being 3.5 cm. The cysts were lined with a single layer of cuboidal to flattened cells. An endocrine tumor abutting the cystic component was found, having neoplastic cells in a trabecular pattern. Metastasis of the neuroendocrine component was seen in the adherent lymph nodes. A diagnosis of diffuse serous cystadenoma associated with neuroendocrine carcinoma was made. CONCLUSION: Diffuse serous cystadenomas of the pancreas are extremely rare tumors. In young patients, they may harbour associated malignancy, and may be the first presentation of von Hippel-Lindau disease. Aggressive surgical resection with long-term follow-up may be worthwhile in this group of patients.

Osteomyelitis of the ribs: a strategy for prompt diagnosis and effective management.

Seven patients were treated for osteomyelitis rib (OR). Discharging sinuses and painful swellings were the presenting symptoms. An initial chest X-ray was unremarkable in all patients. Fine needle aspiration cytology and microscopy of pus did not reveal acid-fast bacillus in any patient. Computerized tomography (CT) of thorax was consistent with the diagnosis of OR in five patients. The patients underwent a subperiosteal excision of the affected part of the ribs or an excision biopsy of the unhealthy granulation tissue. Histopathological diagnosis was consistent with the diagnosis of tuberculosis (TB) OR in six patients. The patients received anti-TB drugs or appropriate antibiotics following surgery. All responded to treatment except one with a non-TB OR, who required further excision of the unhealthy rib ends. Inclusion of a CT of the thorax and an excision biopsy in the diagnostic process facilitates prompt diagnosis and effective management of OR.

Giant exophytic renal angiomyolipoma masquerading as a retroperitoneal liposarcoma: A case report and review of literature.

A 42-years-old lady, presented with a large retroperitoneal mass which was preoperatively diagnosed as a retroperitoneal liposarcoma following an image guided core biopsy. She underwent a margin-negative resection of the retroperitoneal mass (multi visceral resection - enbloc excision of the retroperitoneal mass with a left nephrectomy and a segmental descending colectomy). The final histopathological examination of the resected specimen confirmed an exophytic renal angiomyolipoma (AML) which was extending into the retroperitoneum. AML is a rare benign tumor arising most commonly from the kidney. It can sometimes present as a diagnostic challenge as it mimics a retroperitoneal liposarcoma or a fat-containing renal cell carcinomas closely. We present this case to share our experience of managing a case of giant exophytic AML which resembled retroperitoneal liposarcoma closely and resulted into an aggressive surgery.

Delayed Tension Pneumothorax - Identification and Treatment in Traumatic Bronchial Injury: An Interesting Presentation.

A 13-year-old girl, who did not receive any treatment for few hours following Road Traffic Injury (RTI), reported to the Casualty Department and found to have patent airway with clinically normal C spine, air-hunger (RR 42/minute), trachea deviated to left, distended neck veins and absent breath sounds on the right side. The chest X-ray she carried, done immediately after the injury, showed right sided tension pneumothorax. She was put on oxygen at 11 L/minute and an Intercostal chest tube drainage (ICD) was inserted on right side. Her oxygen saturation (40%) failed to improve. ICD bag showed continuous bubbling and air entry remained absent on the right side. An urgent right thoracotomy was done which revealed right main bronchus tear; the tear was repaired using interrupted Prolene® sutures. Patient recovered well and was discharged 10 days later in a stable condition.

Selective Non-operative Management of Patients with Abdominal Trauma-Is CECT Scan Mandatory?

CECT scan is considered essential for selective non-operative management (SNOM) of patients with abdominal trauma. However, CECT has its own hazards and limitations. We evaluated the safety and efficacy of selective non-operative management of patients with abdominal trauma without the mandatory use of CECT scan in a prospective study. Patients with peritonitis and ongoing intra-abdominal bleed were excluded. Consenting FAST positive, hemodynamically stable patients with blunt and penetrating abdominal trauma between 18 and 60 years of age were included and admitted for SNOM and detailed ultrasonography of the abdomen (in all) with or without CECT abdomen (selectively). Eighty-four patients with abdominal trauma were admitted during the study period. Twenty-two patients did not satisfy the inclusion criteria and 18 required immediate laparotomy based on primary survey. Remaining 44 patients were admitted for SNOM: mean ± SD age of these patients was 27 ± 8.7 years; 40 (89 %) were males. Thirty-five patients (79.54 %) sustained blunt trauma (RTI = 16, Fall = 16, others = 3) while nine patients (20.45 %) sustained penetrating trauma. SNOM without CECT was successful in 36 (81.82 %) patients. Five (11.36 %) patients underwent delayed emergency laparotomy based on clinical and detailed USG evaluation. CECT was not done in these patients. Three patients underwent CECT for various reasons; however, they were managed with SNOM. Thus, SNOM without abdominal CECT was successful in 36 (81.82 %) patients. SNOM failed in five patients but abdominal USG was sufficient. SNOM can be practised safely in patients of abdominal trauma with limited use of CECT scan.

Flow Mediated Dilatation, Carotid Intima Media Thickness, Ankle Brachial Pressure Index and Pulse Pressure in Young Male Post Myocardial Infarction Patients in India.

INTRODUCTION: Due to increase in Coronary Artery Disease (CAD) at a younger age, we should try to diagnose atherosclerotic process and population at risk, at the earliest. Flow Mediated Dilatation (FMD), Carotid Intima-Media Thickness (CIMT) and Ankle-Brachial Pressure Index (ABI) are probable markers for early atherosclerosis and may be useful in coronary risk stratification. AIM: To compare and correlate the FMD, CIMT, ABI and Pulse Pressure (PP) in young male patients of Myocardial Infarction (MI) with age and sex matched healthy controls. MATERIALS AND METHODS: Eighty male patients of MI aged ≤45 years, who presented to the Cardiac Care Unit and Department of Medicine of Guru Teg Bahadur Hospital, Delhi, India, from November 2010 to April 2012 were recruited consecutively for this case control study and same number of age and sex matched healthy controls were also analyzed. Six weeks after MI, FMD of the brachial artery, intima media thickness of carotid artery, ABPI and PP were measured in the cases and compared with healthy controls. RESULTS: The FMD was lower among young patients of MI than controls (p<0.001). CIMT was higher among cases than controls (p=0.001). ABI was lower among cases than controls (p<0.001). Compared to controls, PP was higher among cases (p=0.001). In all subjects, a negative correlation between FMD and CIMT (r=-0.220, p=0.005) and a positive correlation between FMD and ABPI (r=0.304, p<0.001) was found. A statistically significant negative correlation was found between endothelial dependent FMD and PP among cases and control groups (r=-0.209, p=0.007). CONCLUSION: Biophysical parameters were deranged in young post MI patients. Majority of our young male patients fell in low risk Framingham risk score but still they manifested with CAD. Despite six weeks of treatment among young male patients of MI, various biophysical parameters were still deranged.

Relationship of levels of Vitamin D with flow-mediated dilatation of brachial artery in patients of myocardial infarction and healthy control: A case-control study.

BACKGROUND: Cardiovascular diseases (CVD) remain the leading cause of death worldwide. Vitamin D deficiency has been linked to increased risk of adverse CV events. Vitamin D deficiency may be responsible for endothelial dysfunction which in turn affects the onset and progression of coronary artery disease and its risk factors, directly or indirectly through various mechanisms. MATERIALS AND METHODS: It was case-control study. A total of 50 cases of acute myocardial infarction (AMI) (aged 40-60 years), admitted to medicine emergency/CCU, were taken as per ACC/AHA 2007 guidelines. An equal number of age- and sex-matched controls were also taken. Risk factors of AMI, flow-mediated dilatation (FMD), and 25(OH)D levels were studied in all cases and controls. Correlation was also studied between FMD and 25(OH)D. RESULTS: The mean values of FMD were 18.86 ± 5.39% and 10.35 ± 4.90% in controls and cases, respectively (P < 0.05). The endothelial dilatation after glyceryl trinitrate (GTN) was also studied and was found to be 26.175 ± 4.25% and 18.80 ± 5.72% in controls and cases, respectively (P < 0.05). The mean levels of 25(OH)D in controls and cases were 25.45 ± 12.17 and 14.53 ± 8.28 ng/ml, respectively. In this study, 56% of subjects were Vitamin D deficient, 25% were Vitamin D insufficient, and only 19% had Vitamin D in normal range. A positive correlation coefficient was found between FMD and 25(OH) Vitamin D levels (r = 0.841, P < 0.01). In this study, a positive correlation coefficient was also found between endothelial dilatation after GTN and 25(OH)D levels (r = 0.743, P < 0.01). CONCLUSION: In this study, it was found that FMD was markedly impaired in patients of AMI when compared to controls. It was also found that majority of the study population was Vitamin D deficient; however, the deficiency was more severe in patients of AMI. We also found out that FMD was positively correlated (r = 0.841) to the deficiency state of Vitamin D in all the study subjects.