Abdominal Ultrasound Scan Research Articles

Validation of self-report of uterine fibroid diagnosis using a transvaginal ultrasound scan

Self-report of uterine fibroids (UF) has been used for epidemiologic research in different environments. Given the dearth of studies on the epidemiology of UF in Sub-Saharan Africa (SSA), it is valuable to evaluate its performance as a potential tool for much needed research on this common neoplasm in SSA women. We conducted a cross-sectional study of self-report of UF compared with transvaginal ultrasound diagnosis (TVUS) among 486 women who are members of the African Collaborative Center for Microbiome and Genomics Research (ACCME) Study Cohort in central Nigeria. We used log-binomial regression models to compute the classification, sensitivity, specificity, and predictive values of self-report compared to TVUS, adjusted for significant covariates. The prevalence of UF on TVUS was 45.1% (219/486) compared to 5.4% (26/486) based on self-report of abdominal ultrasound scan and 7.2% (35/486) based on report of healthcare practitioner’s diagnosis. Self-report correctly classified 39.5% of the women compared to TVUS in multivariable adjusted models. The multivariable adjusted sensitivity of self-report of healthcare worker diagnosis was 38.8%, specificity was 74.5%, positive predictive value (PPV) was 55.6%, and negative predictive value (NPV) was 59.8%. For self-reported abdominal ultrasound diagnosis, the multivariable adjusted sensitivity was 40.6%, specificity was 75.3%, PPV was 57.4%, and NPV was 60.6%. Self-report significantly underestimates the prevalence of UF and is not accurate enough for epidemiological research on UF. Future studies of UF should use population-based designs and more accurate diagnostic tools such as TVUS.

O020 Comparison of indices of deprivation and screening uptake within a local AAA screening programme

Abstract Introduction The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) was established nationally to reduce the number of deaths caused by ruptured AAA. NAAASP invites all men in their 65th year for a simple abdominal ultrasound scan. Across the country uptake to the programme varies greatly. The aim of this study is to determine the impact of deprivation on local screening programme attendance. Methods The attendance for patients invited to screening within the Leicester, Leicestershire and Rutland screening NAAASP programme between the years 2016 and 2021 was compared to indices of multiple deprivation (IMD) (derived from their Lower Layer Super Output Area (LSOA) for each patient). Multiple logistic regression was used to determine the most significant component contributing to the IMD score. Results 28,730 men in total were invited to attend. Mean IMD for those that attended screening was 15.6 versus 20.6 for non-attenders (P value <0.001). Multiple regression revealed the IMD domains most associated with non-attendance to screening to be; Health Deprivation and Disability domain (P<0.001), Outdoor living environment domain (P<0.001) and Adult skills and English language proficiency domain (P<0.001). Barriers to housing and service domain including ‘geographical barriers’ which relate to the physical proximity of local services and employment domains did not show any association with attendance. Conclusion In line with the contemporary medical literature, social deprivation affects the uptake of the local National Abdominal Aortic Aneurysm Screening Programme (NAAASP). Health deprivation and disability, Outdoor living environment and adult education domains are most contributory to non-attendance.

Protocolo diagnóstico de la enfermedad renal crónica

Chronic kidney disease requires early diagnosis, attempting to discover its cause and evaluating its consequences, so that the appropriate therapy can be applied to prevent it from progressing. Diagnosis is based on a fall in the glomerular filtration rate (GFR) to below 60ml/min/1.73m2 or kidney deterioration markers in the absence of a fall in the GFR, and these findings have to remain for longer than three months. It is fundamental to prepare an appropriate clinical history (personal and family antecedents, an exhaustive anamnesis and a complete physical examination), accompanied by obligatory complementary tests such as blood and urine studies and an abdominal ultrasound scan. Given the prevalence and impact of this disease and the absence of symptoms until it reaches a very advanced stage, screening is necessary, most especially in the population with risk factors.

5613357 ULTRASONOGRAPHIC SPLENIC INDICES AND AGE-RELATED CLINICAL AND LABORATORY PARAMETERS IN PATIENTS WITH SICKLE CELL DISEASE IN NORTH-EASTERN NIGERIA

Background: The spleen is one of the organs affected by sickle cell disease (SCD) early in life (1-3); repeated episodes of vaso-occlusion and infarction result in a reduction in both the spleen’s structure and function (4). The rate of progression of this process varies markedly among individuals with SCD. The aim of the current study was to evaluate spleen sizes using abdominal ultrasound in children and adults with SCD in an African setting and to explore baseline clinical and laboratory variables associated with the presence or absence of the spleen. This information could be used for early monitoring and aid management among these patients. Methods: Two hundred and four sickle cell disease patients (SCD) (101 males and 103 females; age range, 1.1 to 45 years) underwent abdominal ultrasound scans at the University of Maiduguri Teaching Hospital, Nigeria between October 2020 to November 2021. One hundred and eleven age-matched healthy persons were enrolled as controls (69 males and 42 females: age range 1.5 years to 34 years). Imaging was performed by a single radiologist who assessed and measured the spleen length, depth, and width, and calculated the volume. Results: The spleen was visualized in 107 SCD patients (52.4%; 95% CI, 46% - 59%; SE 0.035) on ultrasound and was absent in 97 patients. There was a progressive increase in spleen absence with increasing age; while the spleen was present in all the under-fives, it was present in less than 24% (n = 20/85) of those 15 years and above (Fig.1). The pattern of spleen size growth with age among the SCD patients is shown in Fig.2; the median spleen length remained relatively stable at 6.5cm throughout early childhood, increasing only slightly to 7.0 cm in the 10 -14 years before reaching the adulthood size of 8.8cm from 15 years and above. Factors that were significantly associated with the presence of the spleen on the univariate analysis included high HbF and haemoglobin, low levels of platelets, HbA2, red cells indices (MCH, MCHC), positive malaria parasitemia, and history of intake of hydroxyurea. Multivariable logistic regression analysis showed only high HbF (12.2% vs 7.5%; OR, 1.17; 95% CI, 1.05 -1.29. P = 0.003) and low mean corpuscular haemoglobin concentration (MCHC) (34.1pg vs 35.1pg; OR, 0.69; 95% CI, 0.47 – 0.99. P = 0.049) were significantly associated with persistence of the spleen among SCD patients (Table 1). Only 32 (15%) patients were on regular hydroxyurea therapy, however, the HbF% level was significantly higher among patients on hydroxyurea (median 12.7; IQR 9.4) compared to their counterparts not on hydroxyurea (median 7.4; IQR 8.0) (P = 0.000). Sex and clinical parameters including frequencies of hospitalization, painful crises, febrile episodes, and total lifetime transfusion had no association with the presence of spleen on ultrasound Conclusion: In patients with SCD, the spleen persisted up to five years before any evidence of autosplenectomy occurred. Patients with persistent spleens had a higher level of HbF compared to those with absent spleens. Early determination of HbF may be of value in identifying patients who will benefit from HbF-inducing therapy such as hydroxyurea. Table 1 - Adjusted odd ratios for associations with spleen present or absent on ultrasound Parameter OR (95% Confidence interval) P value Hb, g/dl 1.07 (0.78 - 1.46) 0.675 MCH, g/dl 0.86 (0.72 - 1.02) 0.077 MCHC, pg 0.69 (0.47 - 0.99) 0.049* Platelets, ×106/µL 0.99 (0.99 -1.00) 0.274 HbF, % 1.17 (1.05 -1.29) 0.003* HbA2, % 0.75 (0.35 - 1.58) 0.447 Malaria parasite positive 2.55 (0.96 - 6.75) 0.060 Regular intake of hydroxyurea 1.84 (0.42 - 7.99) 0.418 Hb haemoglobin; MCH mean corpuscular haemoglobin; MCHC mean corpuscular haemoglobin concentration; SD standard deviation. CI con

CHALLENGES IN DIAGNOSING SPLENIC ABSCESSES IN HIV-INFECTED PATIENTS

Objective: Improve the quality of treatment for HIV-infected patients with heart attacks and splenic abscesses by optimizing the diagnosis of these pathological processes. Material and Methods: From 2004 to 2019, 14,405 HIV-infected patients, including 34 patients with suspected splenic abscesses, were treated in the surgical department of the Infectious Clinical Hospital State Budgetary Healthcare Institution (ICH SBHI) No.2. The average age was 34.9 years, 22 males and 12 females. Three patients had stage 3, ten people had stage 4A, ten patiens had stage 4B, and eleven people had stage 4B HIV infection. Patient management followed the generally approved algorithms of the Ministry of Health of the Russian Federation for surgical patients (taking into account the HIV-infection co-morbidity). The following was done: complaints and anamnesis were collected, the duration of HIV-infection, adherence to ART, presence of opportunistic and concomitant diseases were carefully determined, an abdominal ultrasound imaging and an abdominal CT scan were performed. Four patients were diagnosed with splenic infarction; they were treated conservatively and discharged in a satisfactory condition. Surgical treatment was performed in 30 out of 34 patients in the period from 1 to 57 days from admission to the hospital, usually on day 9. 26 of them were discharged and 4 patients died. All 30 surgical patients received antibiotic therapy, surgical material was examined histologically, the cause of the splenic process was determined and therapy was adjusted (if tuberculosis had been diagnosed, patients were moved to an anti-TB hospital, if lymphoma had been diagnosed, patients were moved to an oncohematology department). Results: When examining HIV-infected patients with complaints of abdominal pain and hyperthermia, a detailed history of HIV infection, adherence to ART, viral load and immune status (if the patient knows these data), the presence of concomitant pathological conditions should always be clarified, as wells as abdominal ultrasound and abdominal CT scan should be performed as early as possible. All surgical materials should be examined histologically to verify the cause of the splenic process. Patients in stages 4B-4B, not adhering to ART, with a high viral load and low immune status, suffering from drug addiction and HCV infection, more often get complicated forms of the disease.

Hands-On Ultrasound Training for Radiology Residents: The Impact of an Ultrasound Scanning Curriculum

Radiologists are responsible for interpreting ultrasound (US) images accurately, troubleshooting, aiding sonographers, and advancing technology and research. Despite this, most radiology residents do not feel confident performing US independently. The purpose of this study is to evaluate the impact of an abdominal US scanning rotation and digital curriculum on radiology residents' confidence and skills in performing US. All residents who were rotating in pediatric US at our institution for the first time were included (PGY 3-5). Those who agreed to participate were recruited sequentially from July 2018 to 2021 into (A) control and (B) intervention. B had a 1-week US scanning rotation and US digital course. Both groups completed a pre-and post-confidence self-assessment. Pre-and post-skills were objectively assessed by an expert technologist while participants scanned a volunteer. At completion, B completed an evaluation of the tutorial. Descriptive statistics summarized the demographics and closed questions. Pre-and post-test results were compared using paired-T tests, and effect size (ES) with Cohen's d. Open-ended questions were thematically analyzed. PGY-3 and 4 residents participated, and were enrolled in A (N=39) and B (N=30). Scanning confidence significantly improved in both groups, with a greater ES in B (p < 0.01). Scanning skills significantly improved in B (p < 0.01) but not A. Eighty per cent of questionnaire responders used the integrative US tutorial and found it helpful. Free text responses were grouped into themes: 1) Technical issues, 2) Didn't complete course, 3) Didn't understand project, 4) Course was detailed and thorough. Our scanning curriculum improved residents' confidence and skills in pediatric US and may encourage consistency in training, thus promoting stewardship of high-quality US.

Nonalcoholic fatty liver disease (NAFLD) detection and deep learning in a Chinese community-based population.

We aimed to develop and validate a deep learning system (DLS) by using an auxiliary section that extracts and outputs specific ultrasound diagnostic features to improve the explainable, clinical relevant utility of using DLS for detecting NAFLD. In a community-based study of 4144 participants with abdominal ultrasound scan in Hangzhou, China, we sampled 928 (617 [66.5%] females, mean age: 56years ± 13 [standard deviation]) participants (2 images per participant) to develop and validate DLS, a two-section neural network (2S-NNet). Radiologists' consensus diagnosis classified hepatic steatosis as none steatosis, mild, moderate, and severe. We also explored the NAFLD detection performance of six one-section neural network models and five fatty liver indices on our data set. We further evaluated the influence of participants' characteristics on the correctness of 2S-NNet by logistic regression. Area under the curve (AUROC) of 2S-NNet for hepatic steatosis was 0.90 for ≥ mild, 0.85 for ≥ moderate, and 0.93 for severe steatosis, and was 0.90 for NAFLD presence, 0.84 for moderate to severe NAFLD, and 0.93 for severe NAFLD. The AUROC of NAFLD severity was 0.88 for 2S-NNet, and 0.79-0.86 for one-section models. The AUROC of NAFLD presence was 0.90 for 2S-NNet, and 0.54-0.82 for fatty liver indices. Age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry had no significant impact on the correctness of 2S-NNet (p > 0.05). By using two-section design, 2S-NNet had improved the performance for detecting NAFLD with more explainable, clinical relevant utility than using one-section design. • Based on the consensus review derived from radiologists, our DLS (2S-NNet) had an AUROC of 0.88 by using two-section design and yielded better performance for detecting NAFLD than using one-section design with more explainable, clinical relevant utility. • The 2S-NNet outperformed five fatty liver indices with the highest AUROCs (0.84-0.93 vs. 0.54-0.82) for different NAFLD severity screening, indicating screening utility of deep learning-based radiology may perform better than blood biomarker panels in epidemiology. • The correctness of 2S-NNet was not significantly influenced by individual's characteristics, including age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry.

Prediction of esophageal varices in patients with hepatitis B-associated liver cirrhosis by non-invasive markers

AimsTo assess the non-invasive markers for diagnosing and grading esophageal varices(EV) in hepatitis B-associated liver cirrhosis by non-invasive method. MethodsA total of 209 treatment-naive patients with hepatitis B-associated liver cirrhosis were included in this study. These patients were divided into no EV, large grade EV and any grade EV groups according to electronic gastroscope (EGD) results. Blood tests, physical examination, and abdominal ultrasound scan (USS) were measured. The non-invasive indexes for predicting esophageal varices were screened, and non conditional logistic regression model was established. Performance was expressed as sensitivity, specificity, positive, and negative predictive values (PPV, NPV), accuracy, and area under the curve (AUC). ResultsIn the 209 patients, 155 (74.2%) EV and 106(50.7%) large EV were found. There were significant differences in spleen-length (SL), portal vein diameter (PVD), platelet blood cell (PLT) and white blood cell (WBC) between patients with any grade or large and without EV by univariate analysis. The logistic regression model was Y=-2.083-0.011∗PLT+0.101∗PVD+0.013∗SL with any grade EV, the prediction formula is Y= ​0.427-0.013∗PLT -0.861∗WBC+0.008∗SL with large EV. ConclusionsSpleen-length, portal vein diameter, platelet and white blood cell can predict esophageal varices and large esophageal varices in hepatitis B-associated liver cirrhosis.

Does Patient Weight, Age, or Gender Correlate With the Ability to Visualize the Distal Aorta on Bedside Aortic Ultrasounds in the Emergency Department?

Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound. Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans. Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded. Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019).Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization. There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Maternal Serum Alpha Feto Protein Level May Predict Morbidly Adherent Placenta in Women with Placenta Previa

Background: In situations of a morbidly adherent placenta, studies have shown that maternal serum alfa feto protein (AFP) is clinically high. Objective: To examine the association of morbidly adherent placenta (MAP) in pregnant women with placenta previa (PP) and their serum AFP biomarker. Methods: A prospective observational study that was conducted in the Department of Obstetrics and Gynecology at Azadi Teaching Hospital, Kirkuk, Iraq during the period from Feb. till Nov. 2019. It included 82 pregnant women those between 14-20 weeks of gestation with singleton pregnancy, viable fetus, and diagnosed with low lying placenta, with and without vaginal bleeding. A blood sample from all women was taken to investigate for serum AFP level after confirming the diagnosis of low-lying placenta by early abdominal ultrasound (U/S) scan. All the enrolled pregnant women were followed by Doppler U/S at gestational age 28-32 weeks, underwent targeted screening for MAP and were divided into two groups according to the status of placenta: MAP group included 11 pregnant women and PP group alone included 71 pregnant women. Results: In this study, MAP was diagnosed in 13.4% of cases. Mean of serum AFP biomarker in women with MAP was significantly higher than that in women with PP. Serum AFP biomarker in early pregnancy &gt;200 ng/ml is predictive for diagnosis of MAP in late pregnancy. Conclusion: Maternal serum AFP biomarker may play an important role at early pregnancy in prediction of placental adherence at late pregnancy in cases of early low-lying placenta. Keywords: Morbidly adherent placenta, alpha feto protein, previa, pregnancy, Iraq Citation: Hassan SS, Ghalib AK. Maternal serum alpha feto protein level may predict morbidly adherent placenta in women with placenta previa. Iraqi JMS. 2022; 20(2): 278-285. doi: 10.22578/IJMS.20.2.16

Splenic hamartoma in a patient with peripancreatic arterial arcades: A case report

AbstractSplenic hamartoma is a rare benign vascular lesion of the spleen. A splenic mass was incidentally detected in an asymptomatic 65-year-old male during an abdominal ultrasound scan. The workup of the splenic lesion included an abdominal CT angiography (CTA), contrast-enhanced ultrasound (CEUS), and microvascular flow imaging Doppler sonography. The CT scan confirmed that the splenic mass had benign characteristics, and its contrast enhancement was similar to the spleen. The CEUS was able to rule out the possibility of hemangioma. Meanwhile, chronic compression of the celiac trunk and the filling of the splenic artery from collaterals were also detected on CTA. The imaging studies suggested a splenic hamartoma, and the diagnosis was confirmed by the result of a fine needle aspiration biopsy.

Minimally invasive treatment of cirrhotic secondary hypersplenism with high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has been reported to be a minimally invasive effective method for the treatment of secondary hypersplenism. However, neither the short-term efficacy nor the indications and/or contraindications have been described in patients with cirrhosis. From October 2019 to May 2021, eleven cases of patients with cirrhotic secondary hypersplenism were enrolled. The blood counts, liver function tests and abdominal ultrasound and/or MRI scans of all patients were closely evaluated. Among these 11 patients, eight (72.7%) patients were classified as Child–Pugh A, and the other 3 (27.3%) patients were Child–Pugh B; Five (45%) patients were diagnosed with gallstone, including multiple small stones in 2 patients and single stone in 3 patients. HIFU was performed successfully in all 11 patients. After HIFU, hematologic parameters and liver function were significantly improved in all 11 patients (p < 0.05). The HIFU ablated volume to spleen volume rate was 35–61%. Complications were ecchymosis of the waist in 7 (63.3%) patients, ablated area pain in 3 (27.3%) patients, and choledocholithiasis in 2 (18.2%) patients with multiple small gallstones. All of them recovered smoothly without additional treatment except for 2 patients with choledocholithiasis recovered with risky endoscopic retrograde cholangiopancreatography (ERCP) treatment. This series suggested that HIFU is an effective and safe treatment for cirrhotic secondary hypersplenism in patients classified as Child–Pugh A or B. However, multiple small gallstones could be a relative contraindication for it.

P-040 DIFFUSE LARGE CELL B LYMPHOMA TYPE ACTIVATED B CELL (MANTLE LYMPHOMA) AS A DIFFERENTIAL DIAGNOSIS OF INGUINAL HERNIA. A RARE FINDING

Abstract Introduction Mantle cell lymphoma is a rare type of B-cell non-Hodgkin lymphoma. It represents 7% of lymphomas in Europe, with an incidence of between 4 and 8 cases/year per million-hab. More frequent in men with a 4:1 ratio and middle-age. We present a diagnosed clinical case of MCL with an infrequent presentation. Material &amp; Methods A 70-year-old male affected by left inguinal tumor after physical exertion 6 months before the consultation. Abdominal ultrasound and CT scan describe an extra testicular 3cm lesion with irregular edges without extension to other structures with possible signs of malignancy. Surgery is performed with the lesion bloc excision including left test and elements of the spermatic cord. Results The analysis of Pathological Anatomy shows us as a result a diffuse large cell B Lymphoma type Polymorphic Mantle Cell Lymphoma. The postoperative extension study (PET) shows no residual tumor or medullary involvement, suggestive of stage I. Discussion MCL is a rare type of lymphoma, characterized by translocation (11;14) (q13; q32) leading to overexpression of cyclin D1. Most common presentation of MCL is B symptoms (up to 40%) fever, night sweats. Others include asthenia, nighttime pruritus, adenopathies, and hepatic or splenic enlargement. Finally, CML can present with extranodal disease, digestive system, respiratory system, nervous system, endocrine or salivary glands. It is a highly aggressive type of lymphoma that is usually diagnosed in advanced stages (90% cases), with poor prognosis with a life expectancy of 4 years despite optimal treatment. Current treatment consists of a combination of chemotherapy and immunotherapy.

S3231 Armillifer armillatus, Travel Token From Toga: Innumerable Asymptomatic Liver Calcifications

Introduction: Armillifer armillatus found in tropical Africa, typical hosts are pythons,rodents presumed to be intermediate hosts. Accidental infection reported in humans stemming from consumption of infected snakes sold as the bushmeat. Most infections are asymptomatic, but there exist rare reports of debilitating and rarely fatal infections. Case Description/Methods: 61 yo M with HTN, h/o malaria,chronic back pain presented for primary care visit. DX lumbar spine obtained and showed multiple calcifications,followed by CT abdomen pelvis with following findings: extensive subcentimeter calcifications throughout liver and mesentery. Laboratory data did not show LFT abnormality. CBC with elevated eosinophil count ranging 4.1-6.2%. Upon evaluation with EGD/colonoscopy, seven 5 to 10 mm submucosal polypoid lesions in the rectum, transverse colon,hepatic flexure, and cecum. One of the polypoid lesion was removed with a hot snare. Path showed completely calcified nodule in the submucosa. PAS stain failed to show any parasites, pathology, however, favoring infection such as parasite associated. Standard ova and parasite panel is negative for all organisms tested in the panel. (Figure) Discussion: The first documentation of human infection by Armifiller armilatus dates back to 1847,several cases were since documented with noted male predominance possibly attributed to more adventurous lifestyle and greater prevalence of certain activities. Most cases of Armillifer armillatus infestations are asymptomatic with only few with mild symptoms such as dry cough attributed to pneumonitis in a setting of parasitic infection. In patients with severe infestation, there could be associated pericarditis, pleuritis, acute abdominal conditions (intestinal obstruction,viscus perforation).These acute abdominal conditions have resulted in unnecessary laparotomy before true diagnosis was made. Close surveillance using abdominal ultrasound scan, liver function test and fecal occult blood test are advised in view of the radiologically confirmed severe hepatic affectation. Diagnosis usually is made incidentally as in our case when radiographic study obtained for unrelated reasons with findings of extensive crescentic calcific lesions in the lungs, peritoneum and liver. Some patients may have deranged LFTs. This is usually seen in those with severe liver affectation as noted by some authors. Our patient had normal liver function test parameters despite severe liver involvement. Liver biopsy is required as complementary investigation tool.Figure 1.: innumerable subcentimeter calcified liver inclusions.

S3022 Hepatic Cerebrospinal Fluid Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunt

Introduction: Ventriculoperitoneal shunts (VPS) are commonly used in the management of hydrocephalus to drain cerebrospinal fluid (CSF) into the peritoneal cavity. The placement of VPS has prolonged the survival of patients with hydrocephalus. Abdominal pseudocysts are long-term complication of VPS that are identified later in life. Hepatic CSF pseudocyst is a rare long-term complication of VPS that should be differentiated from other cystic lesions of liver. Case Description/Methods: A 49-year-old man with intellectual disability from congenital hydrocephalus s/p placement of right and left-sided VPS at age of 3 months and 7 years respectively presented with exertional dyspnea and abdominal distension. On presentation his vitals were unremarkable except tachycardic (115/min)., He had abdominal distention, hepatomegaly but no tenderness. Initial labs showed D-dimer 2.20 mcg/mL, AST 27 u/L, ALT 38 u/L, alkaline phosphate 126 u/L and total bilirubin 0.5 mg/dL. Chest CT with IV contrast was negative for pulmonary embolism, however revealed a large 18x13x13.5 cm cyst in right hepatic lobe. CT abdomen and pelvis demonstrated a 17.5x12.6x12.7 cm cystic lesion in the right hepatic lobe with the tip of VP shunt catheter within cyst cavity. Hepatobiliary nuclear scan was unremarkable for any biliary leak or sphincter of oddi dysfunction. CT head was negative for any acute abnormalities. Shunt series x-rays were negative for disruption of VPS catheter. Robotic laparoscopic cyst fenestration with partial hepatectomy was performed and catheter was repositioned to the right lower quadrant of abdomen. Patient was discharged home two days later with significant reduction of cyst size on follow up imaging. (Figure) Discussion: This case illustrates a rare complication of VPS that result in hepatic CSF pseudocyst. If hydrocephalus is absent, patients with hepatic CSF pseudocyst are asymptomatic at earlier stages., or they may present with abdominal pain, distention, or palpable right upper quadrant abdominal mass. A subset of patients with hepatic CSF pseudocyst are complicated with bacterial or parasitic infection and present with abdominal pain, distention, or right upper quadrant mass. Abdominal ultrasound and CT scan assist in diagnosis by identifying the tip of VPS catheter in the pseudocyst cavity. Asymptomatic patients are managed conservatively while surgical repositioning of VPS catheter with or without cyst fenestration or surgical excision of cyst may be required for complete resolution of symptoms.Figure 1.: CT of abdomen showing a large right hepatic lobe cyst with evidence of tip of right VPS catheter within the cavity of the cyst (arrows) on transverse (A), axial (B) and lateral (C) views. CT scan of the head (D) showing VPS catheters both in right and left lateral ventricles without evidence of ventricular dilation. Shunt series x-ray (E) shows now distortion of VPS catheter. Robotic laparoscopic cyst fenestration (F) shows VPS catheter within cyst cavity containing CSF.

S3020 Hepatitis From a Sexually Transmitted Bacterial Infection

Introduction: Syphilis is a multisystemic, sexually transmitted infection (STI) that is caused by the spirochete Treponema pallidum. Hepatic involvement is rare. We present a patient who was diagnosed with syphilitic hepatitis (SH). Case Description/Methods: A 54-year-old male presented to the hospital with one week of sharp upper abdominal pain, jaundice, poor appetite, and a 25-lb. weight loss. He also reported multiple sexual partners and a rash that developed 2 months ago. Vital signs were within normal range. Physical examination revealed scleral icterus, a soft, non-tender abdomen, a plaque-like penile lesion and small, circular lesions on his palms and soles of feet. Laboratory studies revealed aspartate aminotransferase (AST) 164 U/L, alanine aminotransferase (ALT) 207 U/L, alkaline phosphatase (ALP) 1395 U/L, total bilirubin 5.6 mg/dL, gamma-glutamyl transferase 782 U/L. Hepatitis panel, acetaminophen and alcohol levels were negative. Chronic liver disease work-up was unremarkable. Treponemal antibody and rapid plasma reagin test were both positive. HIV test and cerebrospinal fluid venereal disease research laboratory (VDRL) test were negative. Abdominal ultrasound and CT scan of the abdomen were unremarkable. Magnetic resonance cholangiopancreatography was notable for hepatomegaly and hepatitis. Patient received 1 dose of penicillin G 2.4 million units intramuscularly with remarkable improvement in his symptoms and liver function tests. He was discharged home with close follow-up with gastroenterology and infectious disease. Discussion: SH occurs in 0.2-9.7% of patients with syphilis and is most commonly seen in the primary and secondary disease stages. Clinical manifestations include a maculopapular rash (involving the trunk, palms and/or soles of feet), fatigue, poor appetite, hepatomegaly and icterus. Liver function tests (LFTs) may reveal a marked increase in ALP and GGT in comparison to ALT and AST. SH is diagnosed with abnormal LFTs, serological evidence of syphilis, exclusion of other liver diseases and LFTs returning to normal after antibiotic therapy as in our patient. The histological features of SH include inflammatory infiltration of the bile duct and hepatic granulomas. Spirochetes are often difficult to identify in liver tissue. Penicillin is the mainstay of treatment. Clinicians should consider syphilitic hepatitis in a patient with abnormal LFTs (especially ALP) and a rash involving the palms and soles of feet in the appropriate clinical context.

S3072 Liver Injury Caused by a Weight Loss Supplement Containing Green Tea Extract and Garcinia Cambogia

Introduction: Herbal-induced liver injury (HILI) is a growing topic worldwide, and herbal and dietary supplements (HDS) are the second leading class of compounds after antimicrobials causing liver injury in the United States. It is thought that many cases go unrecognized, as patients fail to mention their use of HDS. This is a case of mild liver injury in a young woman after taking a short course of a weight loss supplement containing a garcinia cambogia (GC) and green tea extract (GTE). Case Description/Methods: A 45-year-old female with a history of obesity presented to clinic with elevated liver enzymes identified on routine labs from two weeks prior. Medication reconciliation revealed that one month prior, she started a 15-day course of Revert 10.0 by Natureal for weight loss. She stopped taking the supplement on her own as she felt it was not helpful. Her only prescription medication was her oral contraceptive pill. She was born in the United States and denied any prior history of liver disease. She was asymptomatic with no nausea, abdominal pain, or jaundice. Her physical exam was unremarkable. Baseline laboratory values from six months prior showed AST 18 U/L (normal < 40), ALT 14 U/L (normal < 32), ALP 76 U/L (normal 39-117), TBili 0.4 mg/dL (normal < 1.2). Her liver tests after one week of using Revert 10.0 revealed elevations of AST to 49 and ALT to 83, with normal ALP 61, and TBili 0.2. LFTs after two weeks showed further rises in AST to 66, and ALT to 112, with normal ALP 66, and TBili 0.2. Her viral hepatitis panel was non-reactive. An abdominal ultrasound and CT scan of the abdomen/pelvis showed no abnormalities with normal echogenicity and liver morphology. Two weeks after withdrawing the supplement, her LFTs had returned to normal, AST 24, ALT 26, ALP 72, and TBili 0.2. (Figure) Discussion: This is the first report of liver injury from Revert 10.0. We encourage clinicians to consider HILI in patients with even mild laboratory abnormalities, and to conduct thorough history-taking. While GC and GTE are both known hepatotoxins, there are no cases reported of the two agents working in conjunction to cause HILI. Furthermore, the Roussel Uclaf Causality Assessment Method, the gold standard for HILI diagnosis does not consider the potential for synergy between multiple known hepatotoxic agents. Our case highlights that further research should explore how synergy of multiple supplements can affect presentation of HILI.Figure 1.: Liver Enzyme Trend Over Time

Thrombophilia in Budd-Chiari syndrome patient

A 27-years old female patient presented with a severe general condition of generalized edema and hypotension. Two months earlier computed tomography imaged thrombosis of the inferior vena cava and the three hepatic veins, or Budd-Chiari syndrome (BCS). Additional findings were thrombosis of the right common iliac vein and thrombosis of the renal veins bilaterally. Genetic testing proved congenital thrombophilia. Anticoagulation therapy did not affect thrombotic occlusions. In another cardiovascular center, an unsuccessful attempt for interventional treatment of the inferior vena cava with a jugular approach was made. The patient was admitted to our hospital for further evaluation and decision on treatment strategy. Laboratory and non-invasive imaging at admission rejected hepatic cirrhosis. An abdominal ultrasound scan demonstrated complete occlusion of the three hepatic veins and post hepatic portal hypertension. When thrombosis of all hepatic veins was detected transjugular intrahepatic portosystemic shunt (TIPS) was an option. An endovascular strategy for inferior vena cava was undertaken and complete revascularization was achieved with the right femoral approach as a bridge to TIPS shunt procedure, since the patient didn&amp;rsquo;t meet the criteria for liver transplantation. In diagnosing disease, the main contributors were the gastroenterologist, diagnostic imaging specialist, and hematologist, while the multidisciplinary team included also cardiologist, interventional cardiologist, and angiologist. In this case the multidisciplinary decisions played a major role in diagnosing and building an appropriate therapeutic strategy for systemic illnesses and conditions for which medical guidance does not yet have clear guidelines.

Thanatophoric dysplasia: a case report at Federal Medical Centre Yenagoa, Bayelsa state Nigeria

Thanatophoric dysplasia is a rare congenital severe skeletal disorder previously considered lethal but some survivals beyond the neonatal period have been reported due to extensive medical interventions. There have been a few studies on thanatophoric dysplasia in Africa and specifically in Nigeria hence this case report of an 8-day old female who was born with clinical features that were consistent with thanatophoric dysplasia creating awareness in this region. An eight-day old female term neonate who was seen in the special care baby unit with respiratory distress and limb abnormalities from birth. Two obstetric ultrasound scans had revealed a fetus with severe limb deformity. At presentation, she was in respiratory distress, with dysmorphic features, small chest wall with chest hypertelorism. The limbs were short having marks of amniotic bands with lymphoedema affecting both lower limbs. There were no palmar creases. Skeletal survey done revealed marked hypoplasia of the chest cavity, and widening of both proximal and distal epiphyses of all long bones showing telephone receiving appearance. Echocardiography and abdominal ultrasound scans were normal. It was documented that thanatophoric dysplasia was inherited in an autosomal dominant fashion however sporadic mutations do occur as seen in this patient who had no family history. Facility for genetic testing to analyse the fibroblast growth factor receptor (FGFR3) for typing and determining possible mutations was not available to confirm the diagnosis however, her clinical features and radiological findings were suggestive of thanotophoric dysplasia type 1.

Primary sclerosing cholangitis - an insidious enemy of the liver - case report

Background and introduction&#x0D; Primary sclerosing cholangitis (PSC) is a chronic liver disease with features of cholestasis as a result of inflammation and damage to the bile ducts, which can eventually lead to liver fibrosis and parenchymal failure at an advanced stage.&#x0D; Case Report&#x0D; A 22-year-old man was admitted urgently to the Department of Gastroenterology for complaints of abdominal pain, weakness and tarry stools. A panel of detailed examinations was performed to establish the diagnosis. An abdominal ultrasound scan showed significant enlargement of the liver and spleen. Gastroscopy revealed variceal columns of II degree in the lower esophagus, which were cauterized. Laboratory tests confirmed anemia, reduced platelet and white blood cell counts, increased activity of ALT, ASP, GTP, ALP and slight elevation of total bilirubin in the blood. Based on the clinical disease manifestation and the results of diagnostic tests, cirrhosis of unknown origin was suspected. Subsequent magnetic resonance cholangiopancreatography (MRCP) revealed the presence of multiple strictures in the intra- and extrahepatic bile ducts and gave rise to the diagnosis of PSC. Pharmacological treatment was administered. Currently, the patient remains under the close care of the Transplant Clinic, where he undergoes regular checks of liver function, and endoscopic variceal ligation (EVL) as required.&#x0D; Discussion with conclusions&#x0D; The case presented here shows that the course of PSC can be insidious and asymptomatic. Despite the absence of clinical symptoms, the disease can lead to the development of advanced cirrhosis even in patients of young age and be diagnosed as late as at the decompensated stage, when the only treatment option remains organ transplantation.