First Choice For Diagnosis Research Articles

SPONTANEOUS RUPTURE OF HEPATOCELLULAR CARCINOMA IN A HEALTHY LIVER: A CASE REPORT

Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare and potentially fatal complication with a poor prognosis. Its occurrence is increasing due to the high incidence of hepatocellular carcinoma. The mechanism of rupture is poorly understood. The clinical diagnosis is polymorphous and non-specific, but above all difficult to evoke it in subjects who are not known to be cirrhotic or to have hepatocellular carcinoma. The computed tomography scan remains the first choice for diagnosis. Initial stabilization of the patient remains the priority of emergency therapeutic management. The challenge of this complication is twofold: diagnosis and treatment. In this article, we report a case of spontaneous rupture of a hepatocellular carcinoma in a healthy liver.

P397 AN UNUSUAL SYMPTOMATIC PERICARDIAL EFFUSION AT THE 24TH GESTATIONAL WEEK

Abstract Background pericardial diseases during pregnancy are rare. The most common are hydropericardium – typically in the third trimester, with spontaneous resolution – and pericarditis. Echocardiogram is the imaging method of first choice for diagnosis. Clinical case a 38–year–old woman, at gestational week 24, came to the Emergency Department due to anxiety, shortness of breath, cough, gastroesophageal reflux, inappetence, and sialorrhea, all of which started with the pregnancy and worsened overtime. She underwent cardiological evaluation because of troponin discovered via blood test. The evaluation highlighted mild pericardial effusion. Hence, she was admitted to the Cardiology Department, where a progressive increase of effusion – from mild to severe (in particular in front of apical and posterior segments) without hemodynamic impact – was noted. Corticosteroid therapy was started without clinical improvement and the patient displayed orthopnea, diaphoresis, and oliguria. Through an echographic re–evaluation an hypervascular mass was identified in parasternal view. After a multidisciplinary discussion, a CT scan of thorax and abdomen with contrast (MRI was impracticable due to orthopnea) was carried out with evidence of a mediastinal solid lesion (11,5 x 7 mm) compressing superior vena cava, trachea and principal bronchial branches suggestive of lymphoproliferative disease. A pericardiocentesis was perfomed with evacuation of 400 ml of bloody fluid. The worsening of blood gas test required a tracheal intubation. Therefore, an emergency Cesarean section was executed, and a surgical biopsy of mass was taken with detection of diffuse large B–cell non–Hodgkin‘s lymphoma. Hgh doses of corticosteroids and chemotherapeutic drugs were administered and the patient was extubated after two days. After four therapeutic cycles, a PET–CT scan confirmed remission of the disease. Conclusion pregnancy is not a predisposing condition for pericardial diseases. Although pericardial involvement is benign in most cases, the use of corticosteroid therapy after the 20th week of gestation is indicated in suspected pericarditis to avoid fetal complications from NSAIDs. If there is no response, the use of advanced imaging methods (even potentially dangerous to the fetus) should not be procrastinated.

Hydatid Disease: A Radiological Pictorial Review of a Great Neoplasms Mimicker

Hydatid cyst is a common name for the larval stage of a tapeworm species of Echinococcus granulosus, which is transmitted from animals to humans via the fecal-oral route. Hydatid cysts predominantly affect the liver (75%), followed by the lung (15%), and they can affect many organs in the human body. Medical imaging modalities are the keystone for the diagnosis of hydatid cysts with high sensitivity and specificity. Ultrasound imaging with high resolution is the first choice for diagnosis, differential diagnosis, staging, establishing a role in interventional management, and follow-up, and it can differentiate Type I hydatid cysts from simple liver cysts. Unenhanced computed tomography (CT) is indicated where or when an ultrasound is unsatisfactory, such as with chest or brain hydatid cysts, when detecting calcification, and in obese patients. Magnetic resonance imaging (MRI) is superior for demonstrating cyst wall defects, biliary communication, neural involvement, and differentiating hydatid cysts from simple cysts using diffusion-weighted imaging (DWI) sequences. According to the phase of growth, hydatid cysts occur in different sizes and shapes, which may mimic benign or malignant neoplasms and may create diagnostic challenges in some cases. Hydatid cysts can mimic simple cysts, choledochal cysts, Caroli's disease, or mesenchymal hamartomas of the liver. They can mimic lung cystic lesions, mycetoma, blood clots, Rasmussen aneurysms, and even lung carcinomas. Differential diagnosis can be difficult for arachnoid cysts, porencephalic cysts, pyogenic abscesses, and even cystic tumors of the brain, and can create diagnostic dilemmas in the musculoskeletal system.

Aneurisma de septo interatrial associado a forame oval patente em cão - relato de caso

ABSTRACT Atrial septal aneurysm (ASA) is a rare congenital deformity of variable clinical relevance, often reported in association with patent foramen ovale (PFO). Transthoracic Doppler echocardiography (TTE) is the first choice for diagnosis, but complementary techniques, such as microbubble contrast, should be used. Despite its importance, in Veterinary Medicine, there is little information related to the subject, and the present study is the second report of this condition in dogs. The objective was to report a case of ASA type IV LR associated with PFO in a Shar Pei bitch, diagnosed by a combined approach of transthoracic echocardiography backed by agitated saline solution (microbubbles). During clinical care, the owners reported episodes of seizures as their main complaint. Echocardiographic examination revealed a type 4 LR atrial septal aneurysm and left ventricular systolic dysfunction. The use of microbubble contrast showed right-to-left shunt, confirming PFO. The recommended treatment was medication. It was concluded that the rarity of ASA in dogs may be due to incomplete diagnoses and the transthoracic echocardiographic examination allows its analysis and classification. Furthermore, ASA can be found in animals with or without evidence of heart disease and it should be investigated in patients with neurological alterations.

Assessment of cardiac dimensions in children diagnosed with hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is an inherited autosomal dominant heart disease, characterized by increased left ventricular wall thickness and abnormal loading conditions. Imaging modalities are the first choice for diagnosis and risk stratification. Although heart dimensions have been characterized widely in HCM adults from cardiac imaging, there is limited information about children affected by HCM. The aim of this study is to evaluate left ventricular function and left heart dimensions in a small population of children diagnosed with HCM. A total of 16 (seven male, nine female) pediatric patients with an average age of 14.0±2.5 years diagnosed with HCM at Great Ormond Street Hospital for Children were included in this study. Cardiac magnetic resonance (CMR) images were used to measure left and right ventricular dimensions, and septal and left ventricular free wall thicknesses in Simpleware ScanIP. The gender groups were compared using student t-test or non-parametric Mann-Whitney U-test depending on the sample distribution. Differences in heart rate, left ventricular end-diastolic volume and end-diastolic volume index, left ventricular stroke volume and stroke volume index, left ventricular end-systolic long axis length, left ventricular end-systolic long axis length index, left ventricular end-diastolic mid-cavity diameter, left ventricular end-diastolic free wall thickness, left ventricular end-diastolic free wall thickness index, right ventricular end-diastolic long axis length were statistically significant in males and females. Left ventricular wall and intraventricular septal thickness increase affecting left ventricle cavity dimensions and there may be differences in anatomical and physiological parameters in males and females affected by HCM.

Endoscopic ultrasound-guided fine needle aspiration for smooth benign appearing malignant esophageal stricture: a cross-sectional study.

BackgroundEndoscopic biopsy is standard for the diagnosis of esophageal malignancy. However, few cases are difficult to diagnose as they present with smooth esophageal stricture with negative biopsy results. We aimed to evaluate the effectiveness and safety of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis of biopsy-negative suspected malignant esophageal strictures.MethodsWe retrospectively analyzed cases of esophageal stricture with negative biopsies. From September 2016 to November 2021, 50 patients were enrolled. All the patients accepted the EUS-FNA examination. And histological and cytological specimens were obtained from all patients. Clinical, endoscopic, imaging, cytological, and histopathological results were noted and analyzed.ResultsA total of 50 patients (40 male and 10 female) were enrolled in this study. The 19G puncture needle was used in 6 cases and the 22G puncture needle was used in 44 cases; an average of 2.7 needles were used per case. Satisfactory specimens were obtained by EUS-FNA for all subjects. All patients were diagnosed as malignant tumor. The diagnosis was confirmed by EUS-FNA biopsies in 98% of patients. Based on the surgical pathology results, there were 16 cases of esophageal squamous cell carcinoma, 2 cases of esophageal metastatic carcinoma, 1 case of esophageal sarcoma, 22 cases of lung cancer, 6 cases of mediastinal lymph node metastasis, and 3 cases of mediastinal tumor. No obvious complications were observed. A total of 5 cases were treated with surgery, 28 with chemotherapy, 3 with chemotherapy + surgery, and 12 with radiotherapy; 2 patients ceased treatment. No obvious complications, such as bleeding and mediastinal infection, were observed.ConclusionsEUS-FNA is effective and safe for the diagnosis of malignant esophageal strictures with smooth overlying esophageal mucosa. EUS-FNA is effective and safe for patients with smooth esophagus stenosis for whom satisfactory cytological and histological specimens can be obtained, and the diagnosis can be confirmed by cytological, histological, and immunohistochemical examinations. It can be used as the first choice for diagnosis and treatment.

Feasibility of EBUS-TBNA for histopathological and molecular diagnostics of NSCLC-A retrospective single-center experience.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive bronchoscopic procedure, well established as a diagnostic modality of first choice for diagnosis and staging of non-small cell lung cancer (NSCLC). The therapeutic decisions for advanced NSCLC require comprehensive profiling of actionable mutations, which is currently considered to be an essential part of the diagnostic process. The purpose of this study was to evaluate the utility of EBUS-TBNA cytology specimen for histological subtyping, molecular profiling of NSCLC by massive parallel sequencing (MPS), as well as for PD-L1 analysis. A retrospective review of 806 EBUS bronchoscopies was performed, resulting in a cohort of 132 consecutive patients with EBUS-TBNA specimens showing NSCLC cells in lymph nodes. Data on patient demographics, radiology features of the suspected tumor and mediastinal engagement, lymph nodes sampled, the histopathological subtype of NSCLC, and performed molecular analysis were collected. The EBUS-TBNA specimen proved sufficient for subtyping NSCLC in 83% and analysis of treatment predictive biomarkers in 77% (MPS in 53%). The adequacy of the EBUS-TBNA specimen was 69% for EGFR gene mutation analysis, 49% for analysis of ALK rearrangement, 36% for ROS1 rearrangement, and 33% for analysis of PD-L1. The findings of our study confirm that EBUS-TBNA cytology aspirate is appropriate for diagnosis and subtyping of NSCLC and largely also for treatment predictive molecular testing, although more data is needed on the utility of EBUS cytology specimen for MPS and PD-L1 analysis.

TO FIND OUT THE THERAPEUTIC ROLE OF DIAGNOSTIC LAPAROSCOPY IN CHRONIC ABDOMINAL PAIN AND COMPARING ITS EFFECTIVENESS WITH OPEN PROCEDURES.

Background & Method: All the patients with chronic pain abdomen admitted in general surgery under the Department of surgery Index Medical College and Hospital, Indore. The patient is placed on the operating table with the legs straight or lithotomy position if female. The operating table is tilted head up or down by approximately 15 degree depends on the main area of examination. Compression bandage may be used on leg during the operation to prevent thromboembolism especially if patient is in lithotomy position.
 Result: Laparoscopy has been proved diagnostic as well as therapeutic in 82% of the cases enrolled in our study.
 Conclusion: Laparoscopy (diagnostic and therapeutic) is simple, safe, available and diagnostically accurate procedure but it is not non-invasive, non traumatic, nor the first choice for diagnosis. It should be reserved for those situations after non invasive methods fail to make a diagnosis.
 Keywords: laparoscopy, therapeutic, abdominal & diagnostic.

FDG-PET/CT images of COVID-19: a comprehensive review.

Following a lot of reports of coronavirus disease 2019 (COVID-19) CT images, the feature of FDG-PET/ CT imaging of COVID-19 was reported in several articles. Since FDG accumulates in activated inflammatory cells, FDG-PET/CT has huge potential for diagnosing and monitoring of inflammatory disease. However, FDG-PET/CT cannot be routinely used in an emergency setting and is not generally recommended as a first choice for diagnosis of infectious diseases. In this review, we demonstrate FDG-PET/CT imaging features of COVID-19, including our experience and current knowledge, and discuss the value of FDG-PET/CT in terms of estimating the pathologic mechanism.

Drug-induced Esophagitis

Esophageal injury could be caused by a various etiology, such as drug administration. Drug-induced esophagitis is a spectrum of esophageal lesions due to drugs that can cause complications of ulceration, perforation and stricture of the esophagus. More than one hundred drugs have been identified to cause damage to the esophageal wall, such as antibiotics, nonsteroidal anti inflammatory drugs (NSAID), alendronate, potassium chloride, anti-hypertension, quinidine, etc. Symptoms of drug induced esophagitis might appear as retrosternal pain, heartburn, odynophagia, dysphagia, weight loss, gastrointestinal bleeding, which also found in other cases of gastrointestinal lesions so they are often misdiagnosed in daily clinical practice. Endoscopic procedure is the first choice in diagnosis of drug-induced esophagitis. The lesion may appear as erosion, bleeding, ulcers, strictures, kissing ulcers, and residual drugs fragment on endoscopy. Management of drug-induced esophagitis are by stopping suspected drugs and educating about the proper drug administration. In severe cases, adequate fluid hydration and parenteral nutrition can be given. Sucralfat forms a protective layer in the area of the lesion, thus accelerates wound healing process. Acid-lowering agents can be considered in cases of reflux esophagitis. Therapeutic endoscopic may indicated in strictures cases, active bleeding due to esophageal ulcers, and retrieval remaining drug fragments that are lodged in the esophagus. While surgery should be reserved for patients with severe complications such as erosion of the mediastinal organs, heart and large blood vessels

Evaluation of the Diagnostic Performance of Recombinant Antigen B1 for Detection of Cystic Echinococcosis Using Lateral Flow Dipstick Test.

Background:Human echinococcosis is a neglected zoonotic disease distributed worldwide. It comprises cystic and alveolar forms, the former being the more prevalent disease. Imaging techniques are the first choice for diagnosis of cystic echinococcosis and serology is used as an additional diagnostic technique in doubtful cases or as the sole test in low-resource settings. Rapid diagnostic tests are useful and convenient for immunodiagnosis of cystic echinococcosis in endemic areas, where medical facilities often struggle with limited resources.Methods:Recently, we have developed Hyd Rapid™, an IgG4 lateral flow dipstick test using recombinant antigen B1 for detection of cystic echinococcosis. This study was performed between 2016 until 2018 at the Institute for Research in Molecular Medicine, Universiti Sains Malaysia. The diagnostic performance of Hyd Rapid™ was tested in-house and at two international laboratories in Switzerland and Iran.Results:The overall diagnostic sensitivity for detection of cystic and alveolar echinococcosis was 95% (56/59). Meanwhile, the diagnostic specificity, with and without exclusion of cysticercosis and fascioliasis, was 100% (n=48) and 88% (63/72), respectively.Conclusion:Hyd Rapid™ detected cystic echinococcosis as well as probable cases of alveolar echinococcosis. Therefore, Hyd Rapid™ showed good potential as a serological tool for echinococcosis, and merits further evaluation.

Nomogram for the diagnosis of suspected papillary thyroid carcinomas based on sonographic patterns: a retrospective study.

High resolution ultrasonography (US) is the first choice for diagnosis of thyroid cancer and is based on many sonographic features: composition, echogenicity, margins, calcifications, shape and vascularity. Here, we tried to develop a nomogram to evaluate papillary thyroid carcinoma (PTC) based on sonographic features. From Aug 2016 to Dec 2017, a primary cohort of 382 patients with suspicious thyroid nodules and accepted US examinations were included in Gansu Provincial Hospital. Sonographic features were used to develop a nomogram with Cox regression analysis. The nomogram was validated using prospective data from 162 patients as the validation group. The primary and validation cohort showed comparable clinical and US features in all aspects. Univariate and multivariate analyses showed solid composition [odds ratio (OR): 3.785; 95% confidence interval (CI): 1.504-9.528, P=0.005], hypoechoic (OR: 15.840; 95% CI: 5.754-43.602, P<0.001) and irregular margins (OR: 15.953; 95% CI: 5.897-43.160, P<0.001), microcalcifications (OR: 21.730; 95% CI: 7.119-66.329, P<0.001), taller than wide shape (OR: 5.153; 95% CI: 1.997-13.311, P=0.001), internal high vascularization (OR: 6.288; 95% CI: 2.175-18.181, P=0.001), and obscure borders (OR: 5.648; 95% CI: 2.118-15.065, P=0.001) as risk factors for PTC. Based on the seven risk factors, nomogram was developed and validated by a prospective group, and discrimination and calibration were measured using the concordance index (C-index). Our novel nomogram risk score model based on the US features accurately predicted PTC nodule diagnosis.

Clinical value of B-mode ultrasonography in the diagnosis of hepatic cystic hydatid disease

Objective To study the clinical application value of B-ultrasound in the diagnosis of hepatic cystic hydatid disease. Methods From June 2017 to July 2017, 400 suspected patients with hepatic cystic hydatid disease in the Traditional Chinese Medicine Hospital of Zhoushan were screened in Tibet.All the patients were examined by CT and B-ultrasound.Two CT diagnostics experienced in CT diagnosis and two ultrasound doctors experienced in ultrasound diagnosis were selected to analyze the CT images, B-ultrasound images of the patients, and make the diagnosis.The results of operation or serological examination(clinical diagnosis) were used as the reference.The sensitivity, specificity and accuracy of CT, B-ultrasound in the diagnosis of hepatic cystic hydatid disease were calculated and compared.The consistency between CT, B-ultrasound diagnosis and clinical diagnosis of hepatic cystic hydatid disease was analyzed by consistency test.According to the results of clinical diagnosis, the patients with hepatic cystic hydatid disease were divided into simple cyst type, multiple cyst type, daughter cyst cysts type, cyst calcification type and cyst solid type.The diagnostic coincidence rate of CT, B-ultrasound for different types of hepatic cystic hydatid disease was compared. Results A total of 358 cases were confirmed as hepatic cystic echinococcosis by operation and serological examination, and the remaining 42 cases were confirmed as hepatic bubble echinococcosis.The sensitivity, specificity and accuracy of CT in the diagnosis of liver cystic echinococcosis were 94.13%, 83.33%, 93.00%, respectively, which were lower than those of B-ultrasound (98.88%, 97.62% and 98.75%) (χ2=11.978, 4.974, 16.720, all P 0.05). Conclusion B-ultrasound can accurately diagnose hepatic cystic hydatid disease and can be used as the first choice for diagnosis of hepatic cystic hydatid disease, and B-ultrasound can also differentiate different types of hepatic cystic hydatid disease.The diagnostic value is significant. Key words: Echinococcosis, hepatic; Liver disease, parasitic; Ulerasonograpny; Tomography, x-raycomputed; Diagnosis differential

Thyroid function reference ranges during pregnancy in a large Chinese population and comparison with current guidelines.

Background:A correct thyroid function reference range is important for the accurate diagnosis of thyroid disease during pregnancy. However, there is no consensus on whether thyroid function reference ranges in Chinese population should follow the America Thyroid Association (ATA) guidelines. This study aimed to establish a thyroid function reference range more suited to the Chinese population by evaluating the current thyroid function reference range in pregnant Chinese women and comparing it to the ATA guidelines.Methods:A total of 52,027 pregnant women were enrolled from January 2013 to December 2016. Thyroid stimulating hormone (TSH), free thyroxine (FT4), and thyroid peroxidase antibody (TPOAb) levels were tested during the first and third trimesters of pregnancy. Reference ranges of TSH and FT4 were established from the 2.5th and 97.5th percentiles of the TPOAb-negative population of women. The Mann-Whitney U test was used to compare thyroid hormones between the TPOAb-positive and TPOAb-negative groups.Results:We obtained that the TSH reference ranges were 0.03 to 3.52 mU/L and 0.39 to 3.67 mU/L, and the FT4 reference ranges were 11.7 to 19.7 pmol/L and 9.1 to 14.4 pmol/L, in the first and third trimester, respectively. If we used the 2011 ATA criteria about 7.0% and 4.0% pregnant women would be over diagnosed in first and third trimester, respectively, compared with local population thyroid hormone reference. When we compared our local criteria with the new 2017 ATA criteria, about 1.2% and 0.8% pregnant women would have a missed diagnosis in first and third trimester, respectively.Conclusions:Based on our data, which is in line with the current ATA guidelines, a population-based thyroid function reference range would be the first choice for diagnosis of thyroid disease during pregnancy in China. In case such population-based thyroid function reference ranges are unavailable in the east of China, our reference ranges can be adopted, if the same assay is used.Trial Registration:www.chictr.org.cn (No. ChiCTR1800014394).

Analysis of the clinical characteristics and efficacy of 20 cases of extranodal Rosai-Dorfman disease in head and neck

Objective: To analyze the clinical characteristics and efficacy of extranodal Rosai-Dorfman disease in head and neck. Methods: Clinical and pathological features and follow-up of patients who were diagnosed as RDD at Beijing Tongren Hospital of Capital Medical University between May 2008 and November 2016 were analyzed retrospectively. Results: There were a total of 20 extranodal RDD patients in head and neck including 14 females and 6 males, aged from 27 to 86 years (mean 52.5 years). Nose (14 cases) and throat (5 cases) were most commonly involved organs and 5 patients had 2 or more organs involved. Diagnosis depends on biopsy. Histopathologically, the lesions of RDD were characterized by the presence of large histiocytes with emperipolesis. The large sinus histiocytes were positive for S-100 and CD68 protein staining. Diagnostic Errors in 13 patients and operations in all patients were happened. More than 1 operation was performed in 9 recurrence patients. Eight patients were treated by Glucocorticoids and immunosuppressive agents. All the patients were alive until Feb 2017. Conclusion: Extranodal RDD in head and neck is known as a rare benign idiopathic proliferative disease. Nose is the most common site involved, and recurrence easily. It is diagnosis depending on histopathological report. Operation is first choice in diagnosis and treatment now. Glucocorticoids and immunosuppressive agents are effective in recurrence patients.

Sleeping Cupid by Caravaggio: What Diagnosis?

The Sleeping Cupid, by Italian painter Caravaggio is a masterpiece painted in 1608. Signs of an endocrine disease are hidden among the shadows of the painting. We decided to conduct a survey among endocrinologists practicing in Italy and asked them if they could identify a specific disease condition in Caravaggio's Sleeping Cupid. A total of 86 members from 2 Italian endocrine societies completed the survey: 67 from the Society of Endocrinology and 19 from the Society of Paediatric Endocrinology and Diabetology. Altogether 21 (24.4%) endocrinologists agreed the Sleeping Cupid was affected by hypopituitarism, 30 (34.9%) diagnosed rickets, 15 (17.4%) identified a SHOX gene defect, 16 (18.6%) did not agree on any of the suggested hypotheses, and 4 (4.6%) endocrinologists could not identify any disease. The perception looking at a painting can never be entirely similar to that of another person, even though a commonality of features may instead indicate the opposite. That must be the reason why, within a group of Italian endocrinologists who analyzed Caravaggio's Sleeping Cupid, pediatric endocrinologists (who see in their clinical practice exclusively children and teenagers) considered rickets as their first choice of diagnosis, whereas the majority of adult endocrinologists suggested hypopituitarism. In conclusion, as Walter Benjamin said "to arrive at the purity of the gaze is not difficult, it is impossible."

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report.

Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported. To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it. A literature search for 'duodenal lipoma' was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery. Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery. Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour.

Glycosaminoglycan measured from synovial fluid serves as a useful indicator for progression of Osteoarthritis and complements Kellgren–Lawrence Score

BackgroundPlain radiography is the first choice for diagnosis and monitoring of knee-osteoarthritis (OA) while, Kellgren–Lawrence score (KL) is most widely used to grade OA severity. However, incompetency for reproducibility of joint space measurement in longitudinal assessment and non-linearity of KL-score system, limits radiography-based early diagnosis of the disease. Glycosaminoglycan (GAG) is direct cartilage-degradation product, which can be measured biochemically. We strived to correlate KL-score and GAG from OA patients to compliment KL-system. MethodsWe obtained 34 synovial-fluid (SF) samples from 28 OA patients (few bilateral) with different disease severity using arthrocetesis. All patients were categorised using radiographic KL-score-system. SFs were further analysed for GAG estimation using 1,2-dimethylmethylene blue (DMMB) assay. ResultsA substantial increase in GAG was noted in KL-grade-II and III, comparing grade-I patients, indicating amplified cartilage-degradation. KL-grade-IV patients revealed further rise in GAG reflecting more cartilage-loss. Another category of grade-IV patients with lower GAG were also detected, indicating close to total cartilage-loss. ConclusionsAccurate diagnosis of cartilage-loss remains a challenge with OA due to limitations of KL-system; thus no target intervention is available to arrest active cartilage-loss. We propose, GAG-estimation in OA patients, characterizes accurate biochemical depiction of cartilage degeneration. General Significance: Radiology often fails to reveal an accurate cartilage loss, associated with OA. GAG levels from the SFs of OA patients' serve as a useful marker, which parallels cartilage degeneration and strengthen radiographic grading system, ultimately

Role of Colonoscopy in Patients with Hematochezia

Although colonoscopy is not indicated in patients with hematochezia, many surgeons, internists, and physicians are recommending colonoscopy for these patients in Korea. The aim of this study is to evaluate the diagnostic value of colonoscopy for patients with hematochezia. We retrospectively reviewed the data of colonoscopy between January 2010 and December 2010. A total of 321 patients among 3,038 colonoscopies (10.6%) underwent colonoscopy to evaluate the cause of hematochezia. The patients with previous colorectal surgery (2) or polypectomy (5) were excluded. We analyzed endoscopic diagnoses. Advanced neoplastic polyps were defined as adenomas with villous histology or high grade dysplasia, or adenomas more than 10 mm in diameter. Hemorrhoid was the most common diagnosis (217 cases, 67.6%). Polyps were detected in 93 patients (29.0%), but advanced neoplastic polyps were found in only 14 cases (4.4%). Colorectal cancers were diagnosed in 18 patients (5.6%) including 14 rectal cancers. There was no cancer located above sigmoid-descending junction. Diverticuli were detected in 41 patients (12.8%) but there was only one case of suspected diverticular bleeding. Colitis was diagnosed in 24 patients (7.5%). Other lesions included acute anal fissure, rectal tumor, stercoral ulcer, and radiation proctitis. The colonoscopy had little value in patients with hematochezia because the most pathologic lesions were located below sigmoid colon. The first choice of diagnosis in patients with hematochezia is sigmoidoscopy.

Pulmonary hypertension secondary to hyperviscosity in a patient with rheumatoid arthritis and acquired von Willebrand disease: a case report

IntroductionAcquired von Willebrand disease is initiated by autoantibodies and hyperviscosity syndrome caused by a massive polyclonal hypergammaglobulinemia. Acquired von Willebrand disease associated with autoimmune disease in addition to pulmonary hypertension during emergency room presentation is a rare condition. To the best of our knowledge, this is the second case reported in the literature treated with success; the first one was reported in 1987.Case presentationA 28-year-old mestizo man with a 3-year history of inflammatory arthritis was admitted to our hospital. An overlap of rheumatoid arthritis with systemic lupus erythematosus was suspected; therefore methotrexate was initiated, and later changed to leflunomide because of liver toxicity. Prothrombin time, international normalized ratio and activated partial thromboplastin times were normal (11/10.4 seconds; 1.2; 31.1/26.9 seconds, respectively), von Willebrand factor activity was observed with low ristocetin cofactor at 33.6UI/dL, high von Willebrand factor antigen >200UI/dL, and a low von Willebrand factor: ristocetin cofactor to von Willebrand factor antigen ratio. He was admitted to the emergency room with a 24-hour evolution of progressive dyspnea, cough, thoracic pain, and palpitations, 104 beats/min, 60/40 mmHg, temperature of 38°C, pulse oximetric saturation 88% and 30 breaths/minute. Cold, pale and mottled skin was also observed. He was then transferred to the intensive care unit. The placement of a pulmonary artery catheter was made. The initial patterns showed a precapillary pulmonary hypertension; acute pulmonary embolism was the first choice for diagnosis. Pulmonary angiography was conducted, and when no clot was discovered, pulmonary artery hypertension associated with connective tissue disease was considered. Serum protein electrophoresis confirmed the presence of a massive polyclonal hypergammaglobulinemia, and no paraproteinemia or monoclonal cell population was found from the electrophoretic pattern of the patient’s plasma. Hypergammaglobulinemia was the cause of hyperviscosity syndrome associated with autoantibodies. Three sessions of plasma exchange therapy were made, and clinical improvement was observed. He was then discharged from the intensive care unit and hospital, respectively. He is now attended by an external consult and has no respiratory symptomatology.ConclusionsHyperviscosity syndrome with pulmonary arterial hypertension presentation in a patient with acquired von Willebrand disease in an autoimmune context is a rare condition that can be treated successfully with plasmapheresis and critical care support.