Relationship of Arterial Changes in Acute Pancreatitis on CT Angiography with Modified CT Severity Index

Purpose To evaluate the prevalence of arterial changes in patients with acute pancreatitis (AP) on computed tomography angiography (CTA) and determine their association with etiology of AP, presence of necrosis, collections and severity of AP. Materials and Methods A total of 50 patients (20 women, 30 men; mean age: 43.04 ± 13.98; age range: 18–77 years) with AP underwent contrast-enhanced computed tomography (CECT) scan and CTA of abdomen, which was evaluated for necrosis and fluid collection (s). On CTA, splanchnic arterial structures were assessed for vascular complications. Association between vascular changes and presence of necrosis, fluid collections, etiology of AP and severity of AP (as assessed by modified computed tomography severity index CTSI) was determined. Results Arterial complications were seen in 28 percent (14/50). The most frequently involved artery was superior pancreaticoduodenal artery (12 percent), followed by splenic artery (8 percent) and right gastric artery (8 percent; Fig. 1). No significant association was seen between arterial changes and gallstone or alcohol-induced AP. Arterial changes showed a significant association with presence of acute necrotizing pancreatitis (ANP), presence of collections and severe AP (CTSI 8–10) (p < 0.05 for each). Conclusion Arterial changes on CTA are frequently seen in patients of AP having ANP. There is a significant association between arterial changes and presence of necrosis, collections and severe AP.

Cholecysto-pyloric fistula with submucosal impaction of gall stone causing gastric outlet obstruction masquerading as a gastric mass, Bouveret Syndrome: case report

Background Cholecysto-enteric fistula is a rare complication of cholelithiasis and cholecystitis. Another even rarer complication is proximal impaction of gallstone(s) in gastric pylorus leading to gastric outlet obstruction, known as the Bouveret Syndrome. Only a few cases have been reported in the available literature. It can be confused with a malignant thickening at the pylorus, knowledge of this syndrome helps in arriving at the right diagnosis. Case report A 52-year-old female patient, who was admitted to our hospital for evaluation of recurrent vomiting and abdominal pain. She was investigated with various imaging modalities including upper gastrointestinal (GI) endoscopy, abdominal ultrasonography as well as Contrast Enhanced Computerized Tomography (CECT) scan of the abdomen. On the outside scan, it was given as a malignant thickening at the pylorus. However, current radiologists felt that imaging findings were not of a typical malignant mass, and suspicion of Bouveret syndrome was given. Intraoperative findings confirmed the diagnosis of Bouveret syndrome. The patient has not experienced any postoperative complications till now. Conclusion Bouveret syndrome is associated with significant morbidity and mortality. Being familiar with the imaging appearance of this condition, and differentiating it with malignant thickening can help radiologists avoid unnecessary invasive procedures in such patients. Being a benign etiology, it also helps in a better prognosis.

CASE REPORT ON RARE DE-DIFFERENTIATED GIST OF STOMACH OCCURRING DENOVO

We present a rare case of de-differentiated GIST. GIST being the most common mesenchymal tumor of alimentary canal is commonly reported. However, de-defferentiation of GIST is a rare phenomenon which may occur denovo or with imatinib therapy. A 57 year old female patient presented with generalized weakness and anemia. On evaluation, a submucosal lesion on the body of stomach along the greater curvature was identied on UGI endoscopy. On CECT scan of abdomen, polypoidal intraluminal mass was seen. After sleeve gastrectomy histopathological examination showed dedifferentiated GIST, stomach which was conrmed on IHC. The patient had no prior history of Imatinib therapy/ any chemotherapy. We present this case as de-differentiated GIST occurring denovo without prior imatinib therapy is rare and not much is known about its clinical course and prognosis of such cases.

Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic–therapeutic algorithm

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

Yolk sac tumor in intraabdominal undescended testis in a child with normal serum alpha-fetoprotein: a rare case report

Background Intraabdominal testicular tumors are rare in prepubertal children, and most of the cases reported are intraabdominal testicular teratoma. The present study reports the first case of intraabdominal testicular yolk sac tumor (YST) with normal preoperative serum alpha-fetoprotein levels and diagnosis confirmed on histopathology and immunohistochemistry. Case Presentation A 2-year-old boy presented with bilateral nonpalpable undescended testes (UDT) and abdominal mass. Preoperative serum alpha-fetoprotein was normal. Contrast-enhanced computed tomography (CECT) scan of whole abdomen revealed a heterogeneous mildly enhancing space-occupying lesion in midline and left side of pelvis, left intraabdominal testis and nonvisualization of right testis. During surgery, the mass was found to involve right testis with one turn of torsion of its pedicle. Derotation of testis was performed, and right radical orchiectomy was performed. Left orchiopexy was also performed at the same time. Histopathology and immunohistochemistry confirmed diagnosis of intraabdominal testicular YST. There was no recurrence or distant metastasis at 12-month follow-up after surgery. Conclusion In a case of nonpalpable UDT and abdominal mass/pain, one should always consider possibility of intraabdominal testicular tumor and should investigate the case with serum tumor markers and ultrasound/CECT abdomen. Further, histology of tumor helps in guiding treatment of condition.

Rapunzel syndrome with cholangitis and pancreatitis – A rare case report

Rapunzel syndrome, defined by the presence of a trichobezoar extending from the stomach to the small intestine, is a rare cause of intestinal obstruction. It usually presents with vague symptoms; however, it can also present with complications such as perforation, peritonitis and obstructive jaundice. We report a rare case of a 37-year-old woman with Rapunzel syndrome complicated by acute cholangitis and pancreatitis and analyse the diagnosis and management of this complicated pathology. Although she reported a history of trichotillomania and trichophagia, she had been asymptomatic for ten years. We review the steps of diagnosis, highlighting the importance of a thorough clinical history and detailed examination, with supporting evidence from the contrast-enhanced computed tomography (CECT) scan. She was successfully managed with gastrotomy and trichobezoar removal. She had an uneventful postoperative recovery and was discharged after psychiatric counselling. To our knowledge, this is the first case of Rapunzel syndrome in a young female presenting with both cholangitis and pancreatitis.

Intramural Gas: Would it be Life-threatening?

The CECT scan of the abdomen at axial and coronal views show gas bubbles tracking along the inner wall of the ascending colon and hepatic flexure, which is separated from the intraluminal gas within the bowel. These intramural gas bubbles appear to be outlining the bowel wall circumferentially. The bowel wall appears to be thickened however the inner mucosa is not enhanced. There are no ascites in the images provided. The colon of the hepatic flexure and transverse colon appears dilated. No significant atherosclerotic plaque in the visualised arteries. Based on the clinical presentations and CECT features in Figure 1 and Figure 2, the best diagnosis for him is benign pneumatosis intestinalis (PI) secondary to obstructed low rectal cancer. He was subjected for a trephine transverse colostomy to relieve the obstruction with simultaneous transanal rectal mass biopsy. Once the histology is available, he subsequently will be referred for concurrent chemo-radiotherapy as neoadjuvant treatment and later for a low anterior resection, provided that it is a localized disease.

THE CLINICAL PRESENTATION AND SURGICAL MANAGEMENT OF PATIENTS WITH CARCINOMA STOMACH

Carcinoma stomach is a condition that occurs due to various causes. In order to diagnose a case ofcarcinoma stomach, a high index of suspicion is required. A detailed history and a thorough clinicalexamination must be done. Patients may have various complaints such as vomiting, abdominal painand anemia. Diet has also been shown to play a role in the occurrence of carcinoma stomach. Thepatient’s socio-economic status also plays a very important role in the incidence of carcinomastomach. Various investigations are available today in order to diagnose a case of carcinomastomach. Investigations such as upper GI endoscopy are very useful to visualize a growth in thestomach and to take tissue for biopsy. A contrast enhanced CT (CECT) scan of the abdomen is alsovery useful to diagnose the stomach neoplasia as well as to find out if any metastatic lesions arepresent. On histopathology, adenocarcinoma is the most common type of carcinoma that may befound. Other tumors such as GI stromal tumors and lymphomas may also be found. Treatment ofcarcinoma involves surgery as well as chemotherapy. Our study was carried out from March 2015to February 2019. The study was carried out at SRM Medical College Hospital and Research Center,Kattankulathur, Tamil Nadu, India. The total number of patients studied was 75. The results obtainedwere tabulated and compared with other studies.

Utility of triple tumor markers CA19-9, CA125 and CEA in predicting advanced stage of carcinoma gallbladder: a retrospective study

Background: A combination of serum tumor markers are used in the evaluation and prognosis of carcinoma gallbladder (GBC). Aim of the study was to find the significance of combined use of CA19-9, CA125 and CEA in advanced stage of GBC and to find the cut-off value of each of these tumor markers in metastatic GBC. Methods: This was a retrospective observational cohort study over 1 year, which was carried out in 42 cases of advanced GBC. The patients were grouped in to locally advanced and metastatic stage on the basis of CECT scan findings. CA19-9, CA125 and CEA were assayed in all patients. These tumor markers were analysed with these two groups of GBCs. Statistical analysis was performed using R statistical software v3.6.2.Results: Out of 42 cases CA19-9 was elevated in 18 (78%), CA125 in 16 (70%) and CEA in 9 (39%) patients with metastatic disease. The cut-off value of CA19-9, CA125 and CEA was determined by ROC curve were >109 U/ml, 55.4 U/ml and 2.56 μg/l respectively. CA19-9 had the highest sensitivity 78.3% followed by CA125 69.6% and CEA has the highest specificity 68.4% for the diagnosis of metastatic stage of the disease. Specificity of these tumor markers were highest when used in combination.Conclusions: Combined use of triple tumor markers increases its specificity in the diagnosis of advanced stage of GBC but their cut-off level is statistically not significant in predicting metastatic GBC.

Dural Metastases of Advanced Prostate Cancer Detected by 18F-Fluorocholine

Prostate cancer with extensive dural metastases is very rare, with only few cases described in the literature. We report one such case of a 74-year-old man with advanced prostate cancer, and in relatively good clinical condition. The patient returned with complaints of headache and diplopia. Fluorocholine (18F) chloride (18F-FCH) is an analog of choline in which a hydrogen atom has been replaced by fluorine (18F). After crossing the cell membrane by a carrier-mediated mechanism, choline is phosphorylated by choline kinase to produce phosphorylcholine. 18F-FCH positron emission tomography–computed tomography (PET/CT) is widely used to stage and restage patients affected by prostate cancer with good sensitivity. 18F-FCH PET/CT showed disease progression with the onset of multiple skull lesions. Numerous suspicious dural hypermetabolic lesions indicating neoplastic involvement were detected along the fronto-parietal convexities, in the left fronto-orbital region and right lateral wall of the orbit, concerning for metastases in these regions. A contrast-enhanced computed tomography (CECT) scan was performed which showed corresponding enhancing tissue which correlated with the PET findings. The final imaging diagnosis was osteo-dural metastases from prostate cancer associated with poor outcome. Awareness of this pattern of metastases may be of clinical relevance in order to avoid unnecessary invasive diagnostic procedures in groups of patients with a dismal prognosis.