Sonographic Journey for the detection of gastrointestinal masses from distal esophagus to rectum with histological correlation

Objective: To demonstrate the sonographic features of gut masses detected either incidentally or purposely through the gastrointestinal tract sonography with histological correlation to compare the detected abnormalities for their benign and malignant nature

Material and Methods: The study was conducted between September 2009 and February 2013. Ultrasound scanning was performed on 72 patients [20-75 years, mean age 46 years] presenting with clinical suspicion of underlying primary gastrointestinal pathology due to abdominal symptoms. The histological confirmation was done either through surgically resected specimen, trucut biopsy, flexible endoscopic biopsy or fine needle aspiration

Results: Out of 72 patients, upper GI tract masses included 2 distal esophageal and 7gastric cancers. Mid gut included 9 cases of primary small bowel lymphoma. Intussusception was found in 6 patients. Ileoceacal masses were found in 13 patients with one case of jejunal mass. 18 patients were diagnosed as acute appendicitis, 3 patients demonstrated appendicular mass. Large intestine revealed a single case of diverticulitis besides 15 cases of colorectal cancer. The masses were either lobulated or revealed a segmental wall thickening simulating appearance of kidney [Pseudokidney sign], or diffused wall thickening [Target sign]

Conclusion: In our experience, ultrasonography of the gastrointestinal tract is an extremely useful modality for evaluating gut masses from distal esophagus up to rectum. Sonographic appearance ofgut related masses helps to evaluate the clinical differential diagnosis. However, additional work-up may be needed in the form of contrast study, cross-sectional imaging or endoscopy for specifying the diagnosis with histological confirmation

Osteopoikilosis; a rare incidental spotted bone disease on CT

Osteopoikilosis is a benign, asymptomatic, sclerosing bone dysplasia with an autosomal dominant trait. The disease is characterized by diffuse symmetrical small round and ovoid radiopacities in the juxta-particular region of cancellous bone. We reported a rare case of a middle aged female presented with abdominal distension, whose radiological work up revealed an incidental osteopoikilosis

High resolution ultrasound guided needle aspirate of parathyroid lesion; a preliminary but accurate approach to preoperative identification and localization of parathyroid adenoma

Objective: to determine the sensitivity and specificity of high resolution ultrasound guided FNAC as a preliminary but accurate investigation for identification and localization of parathyroid adenoma for minimally invasive surgical road mapping to position the incision directly over the diseased gland

Material and Methods: this cross sectional study was conducted in Department of Radiology, Omer hospital, Lahore, between September 2012 and September 2013. The study included series of 13 patients, including 5 men and 8 women, ranging between 35 and 70 years [mean 48.5 +/- 13 years]. Neck ultrasound for parathyroid glands was performed in the patients presented with non-specific symptoms of hypercalcaemia. Serological analysis included serum calcium, serum PTH, alkaline phosphatase and creatinine. Exact size, location and number of parathyroid adenomas were assessed followed by US-guided FNA

Results: in 12 out of 13 patients, the position and size of the normal parathyroid gland as well as parathyroid lesions were adequately demonstrated on ultrasound. One patient had ectopic parathyroid adenoma which was confirmed on scintigraphy and excisional biopsy. Two patients had normal appearing parathyroid gland which turned out to be adenomatous on histology. One patient had indeterminate histology of an otherwise hypoechoic parathyroid region reported as adenoma on ultrasound. Remaining 9 patients had large parathyroid adenomas initially picked on ultrasound and later on confirmed on histology through US guided FNA. None of the patients had concomitant thyroid disease or involvement of more than one parathyroid gland. All patients had serum calcium of more than 11 mg/dl and elevated serum PTH. On histopathology of FNA, predominant cell type was chief cells arranged in sheets and occasionally small follicles with variably thick connective tissue capsule. Cells with a clearer cystoplasm and occasionally oncocytic cells were also seen

Conclusion: high resolution ultrasound is a preliminary but sensitive investigation in detecting parathyroid adenomas. When combined with US guided FNA, it becomes a highly specific and accurate modality for preoperative identification and localization of parathyroid adenoma. We highly recommend ultrasound for surgical road mapping of adenomas

Cystic adenomatoid malformation in a young male adult with recurrent respiratory tract infections

We present a case of 26-year-old male with congenital cystic adenomatoid malformation. His medical history started after birth as recurrent respiratory tract infections and breathlessness during his infancy which persisted even after continued medical treatment. Cystic bronchiectasis of right lower lobe was suspected. On cross-sectional imaging at our hospital, congenital cystic adenomatoid malformation of right lower lobe was diagnosed. The clinical features, radiological characteristics, differential diagnosis and prognosis of the disease are discussed

Prevalence of incidental sinonasal diseases on brain imaging by computed tomography scan

Objective: the purpose of this study was to investigate the prevalence of incidental sinonasal diseases on CT scan in Pakistani population presenting with neurological signs and symptoms for brain imaging

Material and Methods: this cross sectional study was conducted in Department of Radiology, Services Institute of Medical Sciences/ Services Hospital, Lahore, between August 2009 and June 2010. All the cases undergoing CT head referred by physicians and neurophysicians presenting with neurological symptoms and signs besides exclusion of the cases of head trauma were included. The study population consisted of 507 patients, including 311 men and 196 women, who were 2-75 years old [mean age, 42 years]. Frontal, ethmoid, sphenoid, left and right maxillary sinuses were separately evaluated. The pathological processes included were mucosal thickening, opacification, air-fluid level, retention cysts and polyps

Results: out of 507, there were 199 patients [39.25%] in whom sinus pathology was documented. There were no significant gender differences amongst the study population. Most of the patients were adults; pediatric age group consisted 11 %. The incidental sinonasal disease was more common in the patients above 30 years of age, with slight predilection toward females [56%]. Mucosal thickening was the most common pathology [71.8%]; categorization including normal [no mucosal thickening], mucosal thickness of 1 mm [34.6%], 2 mm [24.6%], 3 mm [27.7%], and 4 mm or above [13.1 %] was done accordingly. Other abnormalities including sinus opacification [14%], air-fluid level [5.0%], retention cyst [5.5%] and polyp [3.5%] were found uncommon

Conclusion: the high prevalence of sinonasal disease in general population emphasizes the necessity of clinical correlation, if picked incidentally on cross-sectional brain imaging. Subtle mucosa! Thickening, in particular to ethmoidal air cells, is a normal variant, most likely due to the physiologic nasal cycle. Incidental findings of paranasal sinus disease without clinical signs and symptoms do not define a diagnosis of sinusitis or a sinonasal disease; adequate clinical information is mandatory prior to starting the treatment. The possible reason of high prevalence of sinonasal disease in Pakistani population could be dust allergy and pollution besides respiratory tract infections and smoking. Future studies are recommended to a larger population to evaluate the significance of these incidental findings

Accident and emergency neuroimaging: is an optimization needed in ordered non-enhanced CT scans for brain imaging?

To determine and characterize ordering of computed tomography scans for neuroimaging and to identify the frequency of negative non-enhanced computed tomography [NECT] in a prospective series of patients presenting to medical, surgical and pediatric floors of Accident and Emergency Department, so as to manipulate ordering practice by the referring physicians. This study was conducted in Department of Radiology, Services Institute of Medical Sciences/ Services Hospital, Lahore, between January and June 2010. The study consecutively included all the cases from Accident and Emergency Department with neurological symptoms and signs undergoing CT head referred from medical, surgical and pediatric floors. The patients' medical records were reviewed. The study population consisted of 2570 patients, including 1611 men and 959 women, who were 1-75 years old [mean 42 years]. Interpretation of NECT heads was done for positive as well as negative cases. Of 2570 cases, 1155 cases [44.9%] were positive. The overall percentage of negative CT scans was high for medical emergencies, with only 481 cases [29.2%] out of 1647 revealing positive findings. The percentage of negative CT scans referred from surgical emergency was not as high as for medical emergencies, but the major head trauma was only productive for extra-axial bleed/ hematoma revealing 403 cases [44.6%]. Minor head trauma was more commonly scanned with most of the CT scans head remarkable only for skull vault non-depressed fractures. Pediatric referrals positive percentage was again low with only 6 [28.5%] out of 21 cases positive for any underlying pathology. Optimization in the neuroimaging should be encouraged for more thoughtful use of imaging modalities in Accidents and Emergency departments to ensure patients' benefit from continued imaging innovation. An urgent CT head scan is deemed appropriate if it leads to an immediate change in a patient's management. Unnecessary use of neuroimaging, in particular to CT scan, has long-term effects of accumulated diagnostic radiation. Appropriateness of the requests should be evaluated according to the various guidelines.

Empyema necessities in a 17 years male with long standing pneumonia

Empyema necessitans is a spontaneous discharge of an empyema that has burrowed through the parietal pleural, usually in the chest wall, to form a subcutaneous abscess. We present a case of 17 year old adult male presented to us for cross-sectional imaging and was diagnosed to be a case of Empyema necessitans besides bilateral empyema associated with right hydro/ hemopneumothorax and multiple thick walled cavitations of variable sizes with multiple air fluid levels in non-segmental distribution involving all lobes bilaterally placed peripherally

Radiological feature of hepatic cirrhosis hepatitis "c" in Pakistan our experience at department of radiology, services institute of medical sciences

Objects: to evaluate the accuracy of liver fibrosis stage by utilizing the techniques of advanced ultrasound performance in patients with chronic liver disease with Hepatitis C

Material and Method: this cross-sectional study was prospectively designed by including 101 consecutive patients with a diagnosis of chronic liver disease including liver cirrhosis between January and December 2010. The ultrasound score was determined from both hepatic lobes and the average scoring was calculated for liver edge, liver surface and liver parenchymal texture. A score of O was given when no abnormality was observed; score 1 for mild abnormality; score of 2 for moderate abnormality; and a score of 3 for severe abnormality. Scoring was given for a blunted edge and severe irregular surface or a highly coarse texture only when these characteristics were clearly confirmed by the low frequency probe

Results: out of 101 subjects, 63.4 % were male and 36.6 % were female with age range of.23-70 years [mean age 50.73 years SD+/- 10]. 17.8 % subjects were between age group 20-40 years, 67 .3 % between age group 41- 60 years and 14.9 % between 61 years and above. Mean duration of illness was 2.86 years [minimum 1 year and maximum 15 years]. Mean liver size was 12.261 with SD+ 2.7145. Mean portal vein size was 1.662 SD+ 2.3247. Mean spleen size was 71.71 SD+ 32.226. 62.4 % had splenomegaly, 66.3 % had ascites, 56.4 % had bruising and bleeding, 62.4% had varices. 20.8 % had sharp edge 48.5 % had mildly blunted edge and 30.7 % had blunt edge, '11.9% had smooth edge. 33.7% had mildly irregular edge, 39.6 % had irregular edge and 14.9 % had highly irregular edge. Regarding liver parenchymal structure 13.9 % had fine, 22.8 % had mildly coarse, 48.5 had coarse and 14.9 % had highly coarse liver parenchymal. structure.15.8 % of subjects had mild fibrosis [score 0-2], 55.4 % had moderate fibrosis [score 3-5], 28.7 % had severe fibrosis [score 6-8]

Conclusion: US scoring system is clinically useful for differentiating patients with minimal or no fibrosis from those with mild to severe fibrosis. This is also useful for prognostic information and determining the optimal therapeutic options during the follow-up of chronic liver disease

Mesentro-axial gastric volvulus in a Morgagni diaphragmatic hernia in an old female

A Morgagni diaphragmatic hernia is a rare congenital anteromedial defect in adults [5%]. Symptoms of visceral herniation are attributable to the organs involved. Imaging is the mainstay of diagnosis either in an asymptomatic person or in a person with respiratory and/or gastrointestinal symptoms, ultimately requiring surgical intervention because of the risk of incarceration. We present a rare case of 80 years old female with vague upper abdominal pain and recurrent vomiting. An anteromedial parasternal defect was established on conventional as well as on cross-sectional imaging in right hemidiaphragm through which the upper abdominal contents were protruding in the right hemithorax, all enclosed in a peritoneal sac. The herniation resulted in mesentro-axial gastric volvulus. Due to age and anaesthesia risk, patient was conservatively managed

Gender differences among suspected pulmonary tuberculosis patients undergoing sputum smear microscopy attending the department of chest medicine and tuberculosis, Nishtar hospital, Multan

To assess the gender differences among pulmonary tuberculosis suspects undergoing diagnostic sputum smear microscopy. This retrospective study was carried out in the Department of Physiology Nishtar Hospital Multan in collaboration with Department of Chest Medicine and Tuberculosis. Data from January 2005 and October 2007 were analyzed. The hospital records of newly diagnosed patients of pulmonary tuberculosis were selected. The patients were classified into various groups according to gender and age. Female/Male ratio of more than one [1.05/1] was found among pulmonary tuberculosis aspects undergoing sputum examination attending the Out Patient Department of Chest Medicine, however, AFB sputum smear positive cases were less among female patients, and female/male ratio was less than one [0.84/1.0]. The overall AFB sputum smear positive cases were significantly higher in male patients. Gender and age are both traditionally known variables in terms of incidence and prevalence of pulmonary tuberculosis. The existing gender disparity and pattern of gender specific treatment seeking is one of such indicators, which call for more attention to both males and females, especially productive age group

CT findings of a giant retroperitoneal liposarcoma; our experience at services hospital, Lahore

Liposarcoma is the most common primary neoplasm of mesodermal origin derived from adipose tissue. It is a slow-growing tumor with a propensity to displace rather than invade adjacent structures. This article reports the CT findings of retroperitoneal liposarcoma in one patient. CT scan revealed a huge hypodense expansile mass lesion with multiple hyperdense septation inside it, giving a whorly appearance to the mass. The mass was having mainly fat [attenuation. The mass appeared to be extending from the under surface of right hemidiaphragm to the right iliac fossa. The mass displaced all the abdominal viscerae and major vessels to the left side of the abdominal cavity, origin being retroperitoneum with most probable epicenter in right renal fossa

Severe parathyroid bone disease simulating metastatic bone disease

Osteitis fibrosa cystica is the classical bone disease of primary hyperparathyroidism. Occasionally, osteitis fibrosa cystica can be mistaken for a malignant lesion, even though it is reactive and clearly not neoplastic. Radiologically, the multiple, osteolytic lesions may be indistinguishable from metastatic bone disease. The features of parathyroid bone disease should be correlated with biochemical analysis and nuclear medicine imaging. · We recently encountered two cases of parathyroid bone disease with nephrolithiasis resulting from persistent hyperparathyroidism. In both cases, the preliminary diagnosis made by the clinicians was malignant bone lesion; however on review of both cases in our department, bone disease due to primary hyperparathyroidism was made, as these findings were consistent with biochemical analysis

Incidence of AFB sputum smears positive patients of pulmonary tuberculosis attending out patient department of chest medicine, Nishtar hospital, Multan

To find out the incidence of AFB smear positive patients of pulmonary tuberculosis who presented to out - patient department of chest medicine from January 2005 to October 2007. This retrospective study was carried out in the Department of Physiology in collaboration with Department of Chest Medicine and Tuberculosis Nishtar Hospital Multan. In this study, the hospital records of newly diagnosed patients of pulmonary tuberculosis were analyezd. The patients were classified into, various groups according to age and gender. The incidence of AFB smear positive patients and frequency of the presentation was calculated. The overall percentage of AFB smear positive cases between January 2005 and October 2007 in region of Multan was 22.16%, but it has dropped gradually from 2005 to 2007 both in male and female patients. A higher incidence was seen in population ranging in age between 10-30 years. Sputum smear examination for AFB is simple and cost-effective method to provide a fairly realistic estimate of the incidence or prevalence of tuberculosis. Although there was a decreasing trend in the incidence of AFB smear positive cases from 2005 to 2007, the high burden of tuberculosis among Pakistani population still warrants renewed and enhanced efforts to control TB. The higher prevalence of persistent cough and AFB-positive sputum smears need further exploration

Carcinoid tumor of small intestine; a radiological diagnosis

Carcinoid tumors are most common primary tumors of small-bowel and appendix. These are characteristically slowly growing tumors that may go unrecognized for many years. The diagnosis is typically not made until the patient undergoes imaging and exploratory surgery. We reported the CT findings of a carcinoid tumor of small intestine [ileum] in our patient. CT showed focal non-calcified mesenteric mass surrounded by thickened mesentery with stellate radiating pattern [desmoplastic reaction]; retraction/ shortening of small bowel mesentery was also noted resulting into the kinking of ileal loops with segmental thickening of adjacent loops. A low density lymphadenopathy was also noted; however no liver metastases were seen. These findings were classically suggestive of carcinoid tumor of the ileal loops