Gallbladder Wall Thickening Research Articles

S2852 Tissue Invasive Cytomegalovirus Enteritis With Gastric Outlet Obstruction in an Immunocompetent Patient

INTRODUCTION: Cytomegalovirus (CMV) usually causes asymptomatic or mononucleosis-like syndrome in immunocompetent individuals. We present a case of severe tissue invasive gastrointestinal CMV in an immunocompetent individual complicated by gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 72-year-old man with a history of hypertension presented with vomiting, postprandial abdominal pain, and hematochezia for one week. He had also lost 40lbs in three months. Physical examination was normal except for epigastric tenderness. The previous colonoscopy done 5 years ago was normal. No personal or family history of inflammatory bowel disease, gastrointestinal malignancy, or lymphoma. He had never had immunosuppressive therapy, organ transplantation, or any other biological agent. Initial blood work revealed Hemoglobin 10.9 g/dl, AST 64 IU/l, ALT 83 IU/l, and ALP 350 IU/l. His HIV and Tuberculosis screening were negative. Ultrasound and CT scan of the abdomen and pelvis were normal except for increased gallbladder wall thickness (3mm). An Esophagogastroduodenoscopy (EGD) revealed esophagitis, pyloric channel ulcer, and duodenal ulcer. Colonoscopy revealed an ulcer at the ileocecal valve. The biopsy of all the ulcers revealed ulcerated mucosa, architectural distortion, and reactive epithelial atypia suspicious of CMV infection which was later confirmed by immunohistochemical staining (IHC) [Figure 1]. Quantitative CMV DNA PCR analysis showed levels of 1739 IU/ml. He was started on intravenous ganciclovir while inpatient and sent home on oral valganciclovir for 21 days. His symptoms improved significantly after treatment. CMV DNA levels decreased to 1230 IU/ml post-treatment. The patient returned with symptoms of gastric outlet obstruction a few months later which were getting worse. His barium X-ray revealed a delayed gastric emptying time with pyloric stenosis and partial malrotation of the small bowel [Figure 2]. A repeat EGD revealed pyloric stenosis with an inner diameter of 11 mm, which was dilated endoscopically. The biopsy taken from an antral ulcer was negative for CMV on IHC staining. There were no other signs of prior CMV infection on the EGD. DISCUSSION: The gastric outlet obstruction in the patient is likely a long term sequela of CMV. Due to the undertreatment and delay in diagnosis, CMV infections can lead to long term and potentially life-threatening complications. Therefore, gastrointestinal CMV should be considered in immunocompetent patients and aggressively treated.Figure 1.: Medium power (100×) Immunohistochemical staining for CMV with hematoxylin counter-stain. A representative high power view demonstrating strong focal CMV immunoreactivity.Figure 2.: Barium Xray reveals pyloric stenosis (black arrow) and malrotation with the first loop of jejunum to the right.

Incidence and Preoperative Predictor Factors of Gallbladder Cancer Before Laparoscopic Cholecystectomy: a Systematic Review

Many cases of gallbladder cancer (GBC) were made incidentally after cholecystectomy for presumed benign disease. The aim of this review is to assess the preoperative predictor factors of gallbladder cancer. This systematic review was conducted according to PRISMA guidelines when it was applicable. We conducted bibliographic researches on October 2nd, 2019, in the following sources: The National Library of Medicine through PubMed, Cochrane database, and Google scholar. We have assessed the univariate and multivariate analysis outcomes. We included ten studies. Incidence of incidental GBC was 0.36%. Seven studies reported age as a significant predictive factor of iGBC. Comorbidities were the second significant predictor. One study found that iGBC group was more likely to have elevated TB, DB, PAL, and ALT. Another study reported a significantly higher rate of TB, PAL, and AST. One study concluded that elevated CA19-9 combined with CEA or CA-125 was significantly more frequent in the group with iGBC. Polyps, porcelain GB, GB wall thickness, and CBD dilation were reported to be associated with iGBC. iGBC group were more likely to have solitary and larger GS and gallbladder wall thickening, essentially focal. Incidence of iGBC was 0.365% varying between 0.19 and 1.6% of laparoscopic cholecystectomy and about 50% of GBC cases. This highlights the deficiency of preoperative diagnostic features. Despite the efforts made, the rate of this condition is still high, underlining the need of new radiological technologies.

Preoperative diagnoses and identification rates of unexpected gallbladder cancer.

Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC). We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan-Meier analysis for this retrospective case-control study. The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2-T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis. UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis.

Sonographically determined clues to the symptomatic or silent cholelithiasis.

To determine an association between sonographically determined contractility with the symptomatic or silent nature of gallstone. Designing: Comparative, cross-sectional study. Radiology Department, Dow University of Health Sciences (DUHS) and Civil Hospital, Karachi (CHK), from April 2004 to March 2005. Adult gallstone patients without (group I) and with biliary symptoms (group II) were compared with age and gender-matched controls. Demographic data, body mass index, risk factors, size, number and mobility of gallstone, gallbladder wall thickness (GBWT), volume and Ejection Fraction (EF) were determined on ultrasound before and after a standardized fatty meal (BFM and AFM). Demographic data, risk factors and gallstone characteristics were analyzed by Pearson Chi-square test and the gallbladder characteristics were analyzed by One-way ANOVA and Post Hoc tests by multiple comparisons on SPSS 11 with significance p=0.05. The gallbladder contractility as measured by changes in wall thickness and volume changes BFM and AFM, and ejection fraction was similar in controls and asymptomatic cholelithiasis groups and significantly reduced in symptomatic patients (p < .001). Multiparity (p=0.002), female gender (p=0.018), age less than 50 years (0.05), impacted calculi (p=0.001), multiple calculi (< .001) and calculi 5mm (p < 0.001) were associated with pain. A sluggishly emptying gallbladder was more significantly associated with symptomatic cholelithiasis compared to controls and asymptomatic cholelithiasis state in this series. Consideration of age, gender, impaction of calculi, number and size of calculi is important in causing symptom state and management options.

Computed tomographic features of confirmed gallbladder pathology in 34 dogs.

Gallbladder pathology is common in dogs, but published studies describing the computed tomographic (CT) appearance of many gallbladder pathologies are currently lacking. This retrospective, multicenter, cases series, descriptive study evaluated the CT features of confirmed gallbladder pathology in 34 dogs. In this subset of dogs, the most common pathologies included cystic mucosal hyperplasia (15/34, 44.1%), gallbladder wall edema (9/34, 26.5%), gallbladder mucocele (8/34, 23.5%), bactibilia (7/34, 20.6%), cholecystitis (6/34, 17.6%), white bile (6/34, 17.6%), and cholelithiasis (4/34, 11.8%). The presence of intraluminal nodules, gallbladder wall thickening, hyperattenuating material (35-100 HU), and mineral attenuating material (>100 HU) were the most common abnormalities detected. However, overlap of each of these findings with a variety of gallbladder pathologies showed that none of the findings were pathognomonic for any of these pathologies. The presence of any of these CT abnormalities should increase the suspicion of gallbladder pathology and prompt further evaluation of the gallbladder for definitive diagnosis.

Xanthogranulomatous cholecystitis: experience in 100 cases.

BackgroundXanthogranulomatous cholecystitis (XGC) is a rare presentation of chronic cholecystitis, characterized by xanthogranuloma, severe foam cells and fibrosis, and can be an inducement of difficulty in cholecystectomy. The purpose of this study was to review the clinical findings and imageology features of XGC and to optimize the treatment option.MethodsThis retrospective study collected clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications of 100 patients with XGC after evaluating 50005 cholecystectomy specimens between 2009 and 2018 in a single institute. heir clinical symptoms, demographics, imageology, operation records, histopathological findings, and postoperative complications were collected and analyzed.ResultsPatients showed various clinical symptoms, ultrasonography was performed in all patients, CT and MRI were further arranged selectively before the operation, but none of the patients were prediagnosed. Fifty-two patients received open cholecystectomy. Laparoscopic cholecystectomy (LC) was planned in 48 patients within whom 8 cases were converted to open cholecystectomy. No partial cholecystectomy was performed. The intraoperative findings included cholecystolithiasis, choledocholithiasis, thickened gallbladder wall, lesions infiltrating into adjacent tissues, disordered Calot’s triangle anatomy, enlarged regional lymph nodes, internal gallbladder fistula, and hepatic abscesses. Frozen-section analysis was performed in 48 patients under the suspicion of gallbladder carcinoma (GBCa), but only 2 cases were finally confirmed.ConclusionsThe preoperative diagnosis of XGC was challenging. Open cholecystectomy was the most preferred treatment, and conversion to open was often necessary after LC.

Imaging Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease (COVID-19).

BACKGROUND. A multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) has recently been described. OBJECTIVE. The purpose of our study was to evaluate the imaging findings of MIS-C associated with COVID-19. METHODS. Imaging studies and medical records of patients (age range, 0-20 years) admitted with MIS-C between April 22 and May 21, 2020, were retrospectively reviewed. Thoracic imaging studies were evaluated for parenchymal, mediastinal and hilar, and cardiovascular abnormalities. Abdominal imaging studies were evaluated for abnormalities of solid viscera, hollow viscera, and the peritoneum as well as the mesentery and retroperitoneum. Studies were reviewed independently by two radiologists, and disagreements were resolved by a third senior radiologist. RESULTS. Sixteen patients (10 male and six female patients; age range, 20 months-20 years) were included in this study. All 16 patients presented with fever. Other presenting signs and symptoms included the following: vomiting (12/16, 75%), abdominal pain (11/16, 69%), rash (10/16, 63%), conjunctivitis (8/16, 50%), diarrhea (7/16, 44%), headache (6/16, 38%), and sore throat (5/16, 31%). Shortness of breath and cough were each present in one patient. Chest radiography showed cardiomegaly (10/16, 63%), congestive heart failure or cardiogenic pulmonary edema (9/16, 56%), atelectasis (9/16, 56%), pleural effusions (7/16, 44%), acute respiratory distress syndrome (2/16, 13%), and pneumonia (1/16, 6%). Eight patients (50%) were evaluated for pulmonary embolism (PE) (six [75%] by CT angiography [CTA] and two [25%] by ventilation-perfusion scintigraphy). In two of the eight patients (25%), CTA showed a segmental PE. Abdominal imaging findings (ultrasound, CT, and radiography) included small-volume ascites (6/16, 38%), hepatomegaly (6/16, 38%), echogenic kidneys (5/16, 31%), bowel wall thickening (3/16, 19%), gallbladder wall thickening (3/16, 19%), mesenteric lymphadenopathy (2/16, 13%), splenomegaly (1/16, 6%), and bladder wall thickening (1/16, 6%). The frequencies of findings based on all the reviewed modalities were as follows: cardiomegaly (12/16, 75%), pleural effusion (10/16, 63%), and atelectasis (10/16, 63%). Absolute interobserver agreement was 0.69-1 for thoracic findings and 0.17-1 for abdominal findings. Fifteen patients (94%) were discharged from the hospital (length of hospital stay: range, 3-20 days), and one patient remained in the hospital at the end of the study period. There were no mortalities. CONCLUSION. MIS-C associated with COVID-19 is characterized predominantly by cardiovascular abnormalities, although solid visceral organ, gallbladder, and bowel abnormalities as well as ascites are also seen, reflecting a multisystemic inflammatory process. CLINICAL IMPACT. The constellation of imaging findings in the setting of COVID-19 may alert radiologists to the diagnosis of MIS-C before rapid deterioration of patients.

Small cell carcinoma of gall bladder: An uncommon histologic entity

Gall bladder small cell carcinoma (scc) comprises of 0.5% of all GB cancers. It carries a poor prognosis in view of its aggressive nature. We here report a case of small cell carcinoma GB 55-year old lady presented with features of obstructive jaundice with significant weight loss. Examination revealed hard lump in right upper abdomen with multiple scratch marks all over the body. Clinically she had jaundice. Blood investigations revealed hyperbilirubinemia. Tumour markers showed raised CA 19-9. Staging CECT thorax and Abdomen reported polypoidal enhancing wall thickening of gall bladder with multiple metastatic deposits close to pancreatic head encasing main portal vein and common bile duct. Histopathology was suggestive of small cell carcinoma. Patient was referred to Oncology department and is receiving palliative cisplatin-etoposide chemotherapy

Serum chymase levels correlate with severe dengue warning signs and clinical fluid accumulation in hospitalized pediatric patients

Dengue induces a spectrum of severity in humans from the milder dengue fever to severe disease, or dengue hemorrhagic fever (DHF). Chymase is a candidate biomarker that may aid dengue prognosis. This prospective study aimed to identify whether warning signs of severe dengue, including hypovolemia and fluid accumulation, were associated with elevated chymase. Serum chymase levels were quantified prospectively and longitudinally in hospitalized pediatric dengue patients in Sri Lanka. Warning signs were determined based on daily clinical assessments, laboratory tests and ultrasound findings. Chymase was significantly elevated during the acute phase of disease in DHF or Severe dengue, defined by either the 1997 or 2009 WHO diagnosis guidelines, and persisted longer in the most severe patients. Chymase levels were higher in patients with narrow pulse pressure and clinical warning signs such as severe leakage, fluid accumulation, pleural effusion, gall-bladder wall thickening and rapid haematocrit rise concurrent with thrombocytopenia. No association between chymase and liver enlargement was observed. This study confirms that serum chymase levels are associated with DHF/Severe dengue disease in hospitalized pediatric patients. Chymase levels correlate with warning signs of vascular dysfunction highlighting the possible functional role of chymase in vascular leakage during dengue.

Incidence of Different Sonographic Findings in Dengue Fever- A Study of 60 Patients

Dengue fever and dengue hemorrhagic fever emerged as major health problem in South East Asia and Bangladesh as well. The purpose of this study is to determine the use of ultrasound as an important adjunct to clinical and laboratory profile in diagnosing dengue fever and in predicting the severity of the disease. Sixty serologically diagnosed dengue fever patients between August and October 2019 referred for ultrasound scanning of the abdomen and thorax were selected for the study and the findings were analyzed. Out of the 60 patients, 19 (31.67%) had hepatomegaly, thick walled gall bladder, ascites with bilateral pleural effusion; 15 (25%) had hepatomegaly, thick walled gall bladder, ascites and only right sided pleural effusion; 6 (10%) had hepatomegaly and right sided pleural effusion; 5 (8.35%) had hepatomegaly and ascites; 3 (5%) had thick walled gall bladder; 1 (1.66%) patient had left sided pleural effusion and hepatomegaly; 1 (1.66%) patient had only hepatosplenomegaly; 1 (1.66%) had ascites with pericardial effusion and no abnormal sonographic findings was found in 9 individuals (15%). Ultrasound findings should strongly favor the diagnosis of dengue fever in patients presenting with fever and associated symptoms, particularly during an endemic. A simple ultrasound examination will effectively expedite the diagnosis and justifies initiation of specific treatment for dengue fever pending serological confirmation. Ultrasound also helps substantially in estimating the severity of the disease. Faridpur Med. Coll. J. Jul 2019;14(2): 90-92

Biliary hyperkinesia: an indication for cholecystectomy?

The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2weeks and 10-16months after surgeries. Over 7years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

A Study on Role of Ultrasonography in the Diagnosis of Dengue Fever

Background: Dengue Fever is an acute mosquito transmitted viral infection caused by one of the 4 serotypes of the genus flavivirus which has become a major international public health problem. The diagnosis of DF is often delayed owing to time taken for availability of serology test results. Moreover, this test is expensive and not widely available. Ultrasonography (USG) is a cheap, rapid and widely available non-invasive imaging method. In recent years several studies concluded that Ultrasonography of the chest and abdomen can be an important adjunct to clinical profile in diagnosis of DF and diagnosis can be made early in the course of the disease compared with other modes of diagnosis. The aim of the study is to demonstrate the ultrasound findings of dengue fever and also evaluate the specificity of gall bladder findings in dengue fever. Subjects and Methods: We conducted a prospective study in Govt Medical College&amp; Hospital, Srikakulam and Konaseema Institute of Medical Sciences, Amalapuram, A.P. Study included 50 patients referred to the department of Radio-Diagnosis and Imaging for Ultrasonography with clinical suspicion of dengue fever, during a period of July 2018 to December 2019. USG of the abdomen, pelvis and chest was performed in all cases and findings were noted. Dengue serology was performed later and all the ultrasound findings were correlated with dengue serology. Results: In our study of 50 patients all the patients studied were diagnosed with dengue fever based on dengue serology. In our study, 100% of our patients diagnosed with DF (by dengue serology) showed gall bladder wall thickening, 88% showed splenomegaly, 44% showed ascites. Pleural effusion was present in 30% of which 66.66% of pleural effusion was bilateral and the rest 33.33% was right sided. Isolated left sided pleural effusion was not found in our study. Hepatomegaly was present in 28% of our patients. In our study mortality and complications from dengue fever were not seen. Conclusion: Ultrasound findings in dengue fever are gall bladder wall thickening, splenomegaly, ascites, pleural effusion and hepatomegaly. In an area where DF is an epidemic, when Ultrasonography shows gall bladder wall thickening in a febrile patient with thrombocytopenia DF should be suggested On Ultrasonography, when there is gall bladder wall thickening, splenomegaly, ascites, and pleural effusion in a febrile patient with thrombocytopenia in a DF epidemic area a diagnosis of DF should be considered in a differential diagnosis until proved otherwise.

Identification of risk factors for open conversion from laparoscopic cholecystectomy for acute cholecystitis based on computed tomography findings.

Laparoscopic cholecystectomy (LC) is performed widely for acute cholecystitis (AC). This study was conducted to identify the predictors for conversion cholecystectomy (CC) for AC. The subjects of this study were 395 patients who underwent emergency surgery for AC between 2011 and 2019. Univariate and multivariate analyses were performed to establish the significance of the risk factors for CC in patients with grades II and III AC. There were 162 TG18 GII and GIII patients in the LC group and 31 in the CC group. Univariate analysis revealed significant differences in performance status (p = 0.039), C-reactive protein levels (p = 0.016), albumin levels (p = 0.002), gallbladder (GB) wall thickness (p = 0.045), poor contrast of the GB wall (p = 0.035), severe inflammation around the GB (p < 0.001), enhancement of the liver bed (p = 0.048), and duodenal edema (p < 0.001) between the groups. Multivariate analysis identified hypoalbuminemia (p = 0.043) and duodenal edema (p = 0.014) as independent risk factors for CC. Most patients with grade I AC underwent LC and had better surgical outcomes than those with grades II and III AC. The most appropriate surgical procedure should be selected based on preoperative imaging of the GB and the neighboring organs and by the presence of hypoalbuminemia.

Does difficulty assessment of laparoscopic cholecystectomy using currently available preoperative scores need revision

Introduction Risk factors used for preoperative anticipation of a difficult laparoscopic cholecystectomy should be identified to prevent complications beforehand. The aim of this study was to evaluate factors predicting difficulty and the possibility of conversion to open cholecystectomy before surgery. Patients and methods Patients diagnosed with symptomatic cholelithiasis and scheduled for elective laparoscopic cholecystectomy were enrolled in the study. Patient’s age and sex, previous hospital admissions, BMI, previous abdominal scar, a palpable gall bladder, gall bladder wall thickness, the presence of pericholecystic fluid collection, and impacted stone are considered risk factors that were used to calculate preoperative scores. Surgical procedure was categorized intraoperative as easy, difficult, or very difficult on the basis of duration of surgery or conversion to open cholecystectomy. Results There was no significant difference between intraoperative difficulty regarding age, sex, BMI, and the presence of either abdominal scar or impacted stone. The absence of previous history of hospitalization and the presence of nonpalpable gall bladder were significantly associated with intraoperative categorization as easy cases (P=0.002). Discussion and conclusion The evaluated scoring system requires meticulous revision for the factors included. Insensitive factors could be removed without negative effect on the outcome. Focus should be directed toward significant items regarding sonography findings. It could be applied as a useful tool to predict easy cases but needs adjustment for the factors considered in case of predicting difficult and very difficult cases. The experience of the surgeon is an important factor in assessing difficulty intraoperative.

A case of non-dilated pancreaticobiliary maljunction with branch-type IPMN

A woman in her 60's visited our hospital complaining abnormality in medical examination. Pancreatic cysts, adenomyomatosis, a gallbladder stone, and thickened gallbladder wall were detected using abdominal ultrasonography. Detailed investigations, including ERCP, revealed a non-dilated pancreaticobiliary maljunction, with branch-type IPMN and cholecystectomy was performed. Pathological examination revealed adenomyomatosis of the gallbladder at the bottom and cholesterosis in the gallbladder wall. Biliary carcinoma occurs in 42.4% of non-dilated bile duct-pancreatic-biliary junction abnormalities, and 88.1% of these cases are gallbladder carcinoma; therefore, prophylactic cholecystectomy is recommended. However, because this case was diagnosed in an elderly patient, surgery was performed immediately after confirming the absence of malignancy in the biliary system by using EUS and biliary cytology. In addition, the patient also has IPMN, which is considered to be a high risk for pancreatic cancer development. Frequent follow-up of the patient's pancreatic-biliary system function is required.

Spectrum of computed tomography findings in gall bladder carcinoma patients: a retrospective observational study from tertiary care oncology setup

Background: Gallbladder carcinoma (CA) is the most common primary biliary carcinoma and fifth most common malignancy of the gastrointestinal tract. Patients are usually asymptomatic early in the course of the disease and as a result, therapeutic window is usually missed. Authors discuss spectrum of imaging findings in CA gall bladder with multidetector computed tomography (CT) as modality of choice.Methods: Retrospective cross-sectional study conducted at Shaukat Khanum memorial hospital and research centre. Data from January 2019 to January 2020 which included 70 patients was collected from HIS. Patients with imaging findings of CA gall bladder were examined who had undergone contrast enhanced CT. Institutional review board approved this study.Results: Out of 70 cases in this study, cholelithiasis was present in 60%. The commonest MDCT finding was mass replacing GB (78.6%), followed by eccentric/diffuse gall bladder wall thickening. Extension to porta hepatis was noted in 25 (35.7%) cases. Antroduodenal involvement was noted in 11 (15.8%), hepatic flexure involvement in 8 (11.4%). Vascular encasement/thrombosis of the portal vein noted in 6 (8.6%). Metastasis at presentation was seen in 16 patients i.e., 22.9%. Majority patients presented with stage III and IV disease.Conclusions: Single-center tertiary care oncology hospital study gives insight about imaging findings of carcinoma gallbladder. Authors conclude that multidetector CT is the diagnostic tool of choice in detection of gall bladder carcinoma, locoregional disease, distant metastasis and hence operability and non-operability of the disease.

Kırım Kongo Kanamalı Ateşinin Abdominal Ultrasonografi Bulguları

Introduction:&#x0D; Crimean-Congo hemorrhagic fever (CCHF) is one of the deadly diseases, clinically causing viral hemorrhagic fever outbreaks. It is especially transmitted through tick bite and body secretions and accepted as an indigenous disease in certain regions in the world and in our country. Many of the organs, especially the lungs, are affected by this disease. However, current studies are not sufficiently relate the disease and abdominal organ involvement. Therefore, we aim to discuss the ultrasonography (US) findings of the CCHF disease in the context of the literature. &#x0D; Material and Method:&#x0D; The retrospective analysis of the hospital records of 283 patients, who were serologically diagnosed as CCHF between 2012-2016 was performed. Abdominal ultrasonography examination revealed that, 20 of those patients had findings in the womb. US findings of these 20 patients were analyzed. &#x0D; Results &#x0D; Nine patients (45%) were male, and 11 patients (55%) were female. The most common findings of abdominal US examinations were; the hepatomegalia and the intra-abdominal free fluid. Gallbladder wall thickening and splenomegalia were also commonly found in these patients. Periportal hyperechogenicity, intramuscular hemorrhage, colon wall thickening, sludge in gallbladder, renal hyperechogenicity, renal ectasia and ureter dilatation were rarely observed. &#x0D; Conclusion &#x0D; Our study is among the exceptional studies on the analysis of abdominal US findings of CCHF. The most commonly observed findings in our patients were the hepatomegalia and the intra-abdominal free fluid. Intra-abdominal findings of the disease were extremely variable. This study will shed light to the future comprehensive studies.

Benign gallbladder diseases: Imaging techniques and tips for differentiating with malignant gallbladder diseases.

Benign gallbladder diseases usually present with intraluminal lesions and localized or diffuse wall thickening. Intraluminal lesions of the gallbladder include gallstones, cholesterol polyps, adenomas, or sludge and polypoid type of gallbladder cancer must subsequently be excluded. Polyp size, stalk width, and enhancement intensity on contrast-enhanced ultrasound and degree of diffusion restriction may help differentiate cholesterol polyps and adenomas from gallbladder cancer. Localized gallbladder wall thickening is largely due to segmental or focal gallbladder adenomyomatosis, although infiltrative cancer may present similarly. Identification of Rokitansky-Aschoff sinuses is pivotal in diagnosing adenomyomatosis. The layered pattern, degree of enhancement, and integrity of the wall are imaging clues that help discriminate innocuous thickening from gallbladder cancer. High-resolution ultrasound is especially useful for analyzing the layering of gallbladder wall. A diffusely thickened wall is frequently seen in inflammatory processes of the gallbladder. Nevertheless, it is important to check for coexistent cancer in instances of acute cholecystitis. Ultrasound used alone is limited in evaluating complicated cholecystitis and often requires complementary computed tomography. In chronic cholecystitis, preservation of a two-layered wall and weak wall enhancement are diagnostic clues for excluding malignancy. Magnetic resonance imaging in conjunction with diffusion-weighted imaging helps to differentiate xathogranulomatous cholecystitis from gallbladder cancer by identifying the presence of fat and degree of diffusion restriction. Such distinctions require a familiarity with typical imaging features of various gallbladder diseases and an understanding of the roles that assorted imaging modalities play in gallbladder evaluations.

Validation of a Preoperative Scoring System to Predict Difficult Laparoscopic Cholecystectomy: A Nepalese Perspective

Introduction: Preoperative prediction of the factors leading to difficulty or conversion in cholecystectomy could help plan the surgical strategies and possible outcomes beforehand. The present study aimed to predict and analyze risk factors using a scoring system deemed responsible for surgical difficulties in patients undergoing cholecystectomy for symptomatic cholelithiasis. Methods: This hospital based prospective study was conducted at Department of Surgery, Lumbini Medical College and Teaching Hospital, Nepal. Various factors considered preoperatively were gender, age, previous history of hospitalization, impacted stone, obesity, gall bladder wall thickness, pericholecystic collection, previous abdominal scar and palpable gall bladder. Results: Among 177 cases operated, the mean age ±SD of the patients was 47.72±17.54 years. Conversion rate was 7.9 %. At preoperative score of 5; sensitivity, specificity, positive predictive value and negative predictive value were 89.40% (CI: 83.36%-93.82%), 69.23% (CI: 48.21 %-85.67%), 94.41%(CI: 90.44%-96.79%) and 52.94% (CI: 39.85%-65.64%) respectively{Area under curve– 0.74, p=0.0001, CI (0.637-0.846)}. Multivariate analysis showed abdominal scar {p=0.02, OR (CI): 5.2 (1.2-21.8)}, previous hospitalization {p=0.001, OR(CI): 6.8(2.2-20.8)} and thickened gall bladder wall {p= 0.03, OR(CI): 3.6(1.1-11.5)} to be statistically significant risk factors. Conclusion: With possible prediction beforehand, high risk group of patients can be identified and dealt accordingly to generate good surgical outcome avoiding complications.

Gd-EOB-DTPA-enhanced MR findings in chemotherapy-induced sinusoidal obstruction syndrome in colorectal liver metastases.

BackgroundWe assessed the clinical presentations, biomarkers, and Gd-EOB-DTPA-enhanced MRI features that were associated with oxaliplatin-induced sinusoidal obstruction syndrome (SOS) to detect chemotherapy-associated SOS in a timely manner.MethodsFifty-seven patients who underwent oxaliplatin-based chemotherapy and Gd-EOB-DTPA-enhanced MRI were included. Post-oxaliplatin heterogeneity in liver parenchyma was scored on a grading scale of 0 to 3. Abnormal clinical findings, including splenomegaly, hepatomegaly, gall bladder wall thickening, and hepatic vein narrowing, were also assessed. Additionally, alanine transaminase (ALT) levels, aspartate aminotransferase (AST) levels, and platelet counts were measured.ResultsFor SOS, 21 patients were scored grade 0, 24 were grade 1, seven were grade 2, and five were grade 3. Hepatomegaly, splenomegaly, gall bladder wall thickening, and hepatic vein narrowing were significantly correlated with the grade for non-tumorous hepatic parenchymal heterogeneity. For laboratory findings, ALT and AST levels, the AST-to-platelet ratio index score, and platelet counts were significantly associated with a high grade (≥2) of non-tumorous hepatic parenchymal heterogeneity.ConclusionsWe assessed the clinical presentations, biomarkers, and Gd-EOB-DTPA-enhanced MRI features that were associated with oxaliplatin-induced sinusoidal obstruction syndrome (SOS) to detect chemotherapy-associated SOS in a timely manner. Additionally, specific laboratory findings were significantly associated with a high grade (≥2).