Long term follow up of ultrasound diagnosed bilateral testicular sarcoidosis: Case report and literature review.

Testicular sarcoidosis is a rare condition characterised by non-caseating granulomas located within the testicles. This case study reports a 44-year-old man who presented initially in 2011 with testicular pain and bilateral testicular sarcoidosis was confirmed on scrotal US. In 2019 he presented with erectile dysfunction. Scrotal ultrasound scan (US) showed bilateral testicular sarcoidosis that has not changed in size and nature when compared with US in 2011.

Trans-arterial chemoembolization (TACE) in patients with unresectable Hepatocellular carcinoma: Experience from a tertiary care centre in India.

AIMS: To evaluate the outcome following transarterial chemoembolization (TACE) and to identify the predictors of survival in patients with unresectable hepatocellular carcinoma (HCC). MATERIAL AND METHODS: HCC patients reporting to our hospital (2001-2007) were subjected to clinical, biochemical, and radiological examination. TACE was performed in those who fulfilled the inclusion criteria. Follow-up assessment was done with multiphase CT scan of the liver at 1, 3, and 6 months. Tumor response and survival rate were estimated. Univariate and multivariate analyses were done for determinants of survival. RESULTS: A total of 73 patients (69 males, 4 females; mean age 49±13.4 years) were subjected to 123 sessions of TACE. The Child's classification was: A - 56 patients and B - 17 patients. Barcelona Clinic staging was: A - 20 patients, B - 38 patients, and C - 15 patients. Tumor size was ≤5cm in 28 (38%) patients, >5-10 cm in 28 (38%) patients, and >10 cm in 17 (23%) patients. Median follow-up was for 12 months (range: 1-77 months). No significant postprocedure complications were encountered. Overall survival rate was 66%, 47%, and 36.4% at 1, 2, and 3 years, respectively. Tumor size emerged as an important predictor of survival. CONCLUSION: TACE offers a reasonable palliative therapy for HCC. Initial tumor size is an independent predictor of survival.

A pseudoaneurysm within a subperiosteal collection in a patient with sickle cell disease.

Sickle cell disease involves long bones in the form of infection or subperiosteal collections. Rare pseudoaneurysm/aneurysm formation is also known to occur in the intracranial and visceral territories. We report a small subperiosteal pseudoaneurysm that developed within a subperiosteal abscess in the tibia in a patient with sickle cell disease. This case adds to the known spectrum of musculoskeletal abnormalities resulting from this condition.

Endovascular management of grade V blunt renal trauma with associated splenic injury.

BACKGROUND: A 15-year-old boy presented to hospital with tenderness in his left loin and hypochondrium, and frank hematuria; he was hemodynamically stable. The patient was overweight and had fallen onto his left flank from his bicycle 2 h previously. INVESTIGATIONS: Physical examination, routine blood tests, contrast-enhanced CT of the abdomen and pelvis, renal MRI and percutaneous transfemoral angiography. DIAGNOSIS: Grade V blunt renal trauma, grade IV splenic injury and left renal vein thrombosis. MANAGEMENT: The patient received conservative management with supportive measures followed by percutaneous transfemoral angiography and embolization of the injured left kidney. He recovered well and was able to resume normal activities.

Isolated duodenal rupture due to go-karting accidents--braking news.

INTRODUCTION: Isolated duodenal injury due to blunt abdominal trauma is extremely rare. We present a series of three such injuries due to go-karting accidents, which presented to our hospital over 5 months. CASE REPORTS: Between October 2007 and February 2008, three cases of D3/D4 duodenal rupture presented to our hospital after go-karting accidents. Trauma occurred as a result of the steering wheel impacting on the abdomen. All patients presented similarly with symptoms of epigastric and right upper quadrant pain. In all cases, computed tomography scanning was highly suggestive of duodenal injury and, in particular, demonstrated presence of retroperitoneal air centred around the duodenum. Treatment required laparotomy and operative repair in all cases. CONCLUSIONS: Duodenal injury presents insidiously due to its retroperitoneal position. A low threshold for investigating patients presenting with epigastric and right upper quadrant pain should be adopted along with active clinical vigilance to exclude serious and life-threatening trauma after go-karting accidents.

Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment.

BACKGROUND & AIMS: Patients with carcinoma of the gallbladder (GBC) and obstructive jaundice are usually not amenable to curative resection. Effective palliation by biliary decompression is the goal of treatment. Endoscopic stenting (ES) and percutaneous transhepatic biliary drainage (PTBD) can provide biliary decompression. We compared unilateral PTBD and ES in patients with a hilar block caused by GBC and assessed their quality of life (QOL). METHODS: Consecutive patients with GBC not suitable for curative resection with Bismuth type 2 or 3 block were randomized to either PTBD or ES with a 10F plastic stent. Technical success, successful drainage, early cholangitis, complications, procedure-related mortality, 30-day mortality, survival, and QOL before and 1 and 3 months after stenting were compared between the 2 groups. All patients were followed up until death. RESULTS: Fifty-four patients were randomized to PTBD or ES (27 each). Successful drainage was better in the PTBD group (89% vs 41%; P < .001). Early cholangitis was significantly higher in the ES group (48% vs 11%; P = .002). Procedure-related (4% vs 8%) and 30-day mortality (4% vs 8%) and median survival were similar (60 days in both; P = .71). Although the World Health Organization-Quality of Life 1- and 3-month physical and psychological scores were better after PTBD, the difference was not significant. The European Organization for Research and Treatment of Cancer (EORTC)-Quality of Life Questionnaire 30 global health status at 3 months was significantly better after PTBD (75 vs 30.5, P = .02). The EORTC symptom scores improved in both groups, but only fatigue was significantly better after PTBD. CONCLUSIONS: PTBD provides better biliary drainage and has lower complication rates in patients with GBC and hilar block.

Randomised comparison of the FerX Ella antireflux stent and the ultraflex stent: proton pump inhibitor combination for prevention of post-stent reflux in patients with esophageal carcinoma involving the esophago-gastric junction.

BACKGROUND AND AIM: Metal stents placed across the gastroesophageal junction in patients with malignant dysphagia frequently present with reflux symptoms. We compared an antireflux stent with a standard open stent used in combination with proton pump inhibitor medication. METHODS: Forty-nine patients with dysphagia due to inoperable carcinoma in the lower third of the esophagus were randomly selected to receive either a antireflux valve stent (FerX-Ella) (n = 22) or a covered standard open stent (Ultraflex), which was combined with proton pump inhibitors such as omeprazole (n = 26). The technical success, the presence of reflux, and complications were recorded. RESULTS: Reflux was seen in 3/22 patients (13.6%) in the FerX-Ella group and in 2/26 patients (7.7%) in the Ultraflex and proton pump inhibitor combination group (P-value not significant). In both groups, a significant improvement in the dysphagia score was seen and no statistically significant difference was detected between the two groups (P = 0.84). The FerX-Ella stents migrated more frequently (32%) than the Ultraflex stents (23%). This also necessitated surgical intervention more frequently in the FerX-Ella group (2/22, 9.1%) compared to the Ultraflex group (1/26, 3.8%). CONCLUSION: The antireflux stent had no demonstrable advantages compared to the combination of standard open stent and proton pump inhibitor medication.

Economic evaluation of a surveillance program of hepatocellular carcinoma (HCC) in India.

PURPOSE: Surveillance of patients of cirrhosis of liver is practiced for early detection of HCC. No data from any developing country on cost-effectiveness of such a program are available. METHODS: Economic evaluation of HCC surveillance was embedded in a prospective study undertaken to estimate the incidence of HCC in 194 cirrhotics. The protocol consisted of 6 monthly abdominal ultrasound (US) and serum alphafetoprotein (AFP) estimation, and yearly triple phase CT. Cost was estimated from the hospital and patient perspectives. Cost-effectiveness ratios for detecting a case of HCC were estimated. Modeling was done to estimate cost effectiveness with different combinations of diagnostic tests. RESULTS: Cost-effectiveness ratios of HCC surveillance program per HCC case detected were estimated as US$ 280 from the hospital perspective. From patient perspective, these were US$ 9,965 for outstation and US$ 2,808 for local patients. Cost-effectiveness ratio for direct medical cost per case of HCC detected by 6 monthly US and AFP, the EASL protocol, was estimated to be US$ 1,510 in the private sector. CONCLUSION: The cost of HCC surveillance program is exorbitant for India (gross national income per capita US$ 620) and possibly other low/middle income countries.

Evaluating patients with cirrhosis for hepatocellular carcinoma: value of clinical symptomatology, imaging and alpha-fetoprotein.

OBJECTIVE: This study was undertaken to assess the value of clinical symptomatology, abdominal ultrasound (US), triple-phase CT (TPCT) and serum alpha-fetoprotein (AFP) estimation in predicting presence of hepatocellular carcinoma (HCC) among patients with cirrhosis. MATERIALS AND METHODS: In this cross-sectional study, Child's A/B cirrhosis patients were subjected to clinical evaluation, US, TPCT and serum AFP estimation. Sensitivity and specificity of clinical symptoms and of AFP at different cut-off levels were determined. Detection rate of HCC and agreement between US and TPCT was estimated. RESULTS: A high proportion of enrolled subjects had HCC at first presentation (40.7%). Significantly higher prevalence of abdominal pain, weight loss, and anorexia was seen in patients with cirrhosis with HCC compared to those without HCC. Sensitivity and specificity of any of these symptoms was 73 and 79%, respectively (positive and negative predictive values of 65 and 85%, respectively). A 100% agreement between TPCT and US was observed for diagnosing HCC cases. However, TPCT detected a greater number of smaller HCCs. Sensitivity of AFP at 400 ng/ml cut-off was only 25.7%, too low to be useful. Best mix of sensitivity (77.2%) and specificity (78.1%) of AFP was found to be at 10.7 ng/ml cut-off which falls within the conventional limits of normalcy. CONCLUSION: The study highlights the importance of symptomatology of weight loss, abdominal pain or anorexia as markers for HCC in patients with cirrhosis. AFP was not found to be a useful screening test. TPCT should be undertaken in all cirrhotics presenting to the hospital for the first time.

Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature.

BACKGROUND: Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone. CASE PRESENTATION: We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done. CONCLUSION: This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.

Fibrous dysplasia localized to spine: a diagnostic dilemma.

Fibrous dysplasia of the spine is uncommon, especially in monostotic form. Isolated vertebral involvement in polyostotic form is very rare. We report a case of polyostotic fibrous dysplasia with lesions localized to dorso-lumbar spine in a 45-year-old rheumatoid arthritis patient. No associated appendicular lesions, cutaneous manifestations or endocrinopathies were seen. The extreme rarity of this type of lesion can pose a diagnostic dilemma, and biopsy is required for diagnosis. The association with rheumatoid arthritis in our case seems to be a chance occurrence.

Incidence of hepatocellular carcinoma among Indian patients with cirrhosis of liver: an experience from a tertiary care center in northern India.

BACKGROUND/AIM: Despite bearing the main burden of HCC, prospective studies from developing countries are lacking. This prospective observational study was designed to estimate the incidence of HCC among Indian patients with hepatic cirrhosis. METHODS: Between April 2001 and November 2004, we enrolled 301 patients with liver cirrhosis. Patients found to be free of HCC using baseline abdominal ultrasound, triple-phase computed tomography (TPCT) and serum alpha-fetoprotein (AFP) levels were followed up prospectively for detection of HCC using ultrasound and AFP every 6 months, and TPCT annually. RESULTS: Among the 194 patients (mean age [SD] 45.1 [+/-13.1] years; male:female 6.1:1.0) followed up, 154 had Child's A and 40 had Child's B disease. The causes of cirrhosis were: hepatitis B-71 (36.6%), hepatitis C-54 (27.8%), dual infection with hepatitis B and C-12 (6.2%) and others including autoimmune, alcoholic and cryptogenic cirrhosis 57 (29.4%). During a cumulative follow up period of 563.4 person-years, 9 cases of HCC were detected, with an incidence rate of 1.60 per 100 person-years. CONCLUSION: In our study, the incidence of HCC among patients with liver cirrhosis was intermediate, being lower than that in Japan but higher than that reported from Europe.

Percutaneous glue embolization of a visceral artery pseudoaneurysm in a case of sickle cell anemia.

Although aneurysmal complications of sickle cell anemia have been described in the intracranial circulation, visceral artery pseudoaneurysms in this disease entity have not previously been reported in the literature. Conventional treatment of visceral pseudoaneurysms has been surgical ligation or resection of the aneurysm. Transcatheter embolization has emerged as an attractive, minimally invasive alternative to surgery in the treatment of these lesions. In certain situations, however, due to the unfavorable angiographic anatomy precluding safe transcatheter embolization, direct percutaneous glue injection of the pseudoaneurysm sac may be considered to achieve successful occlusion of the sac. The procedure may be rendered safer by simultaneous balloon protection of the parent artery. We describe this novel treatment modality in a case of inferior pancreaticoduodenal artery pseudoaneurysm in a patient with sickle cell anemia. Although a complication in the form of glue reflux into the parent vessel occurred that necessitated surgery, this treatment modality may be used in very selected cases (where conventional endovascular embolization techniques are not applicable) after careful selection of the balloon diameter and appropriate concentration of the glue-lipiodol mixture.

Three-dimensional helical computed tomography cholangiography with minimum intensity projection in gallbladder carcinoma patients with obstructive jaundice: comparison with magnetic resonance cholangiography and percutaneous transhepatic cholangiography.

OBJECTIVE: Computed tomography (CT) is traditionally used for evaluation and staging of gallbladder carcinoma (GC). However, in the subgroup of patients with obstructive jaundice, magnetic resonance cholangiography (MRC) is generally required to assess the level of biliary obstruction. The present study was undertaken to evaluate the diagnostic potential of three-dimensional helical CT cholangiography (3-D CTC) with minimum intensity projection (minIP), to determine the presence and level of biliary obstruction. MATERIALS AND METHODS: Twenty-five consecutive patients with proven GC, presenting with clinical and biochemical features of obstructive jaundice, over a 1-year period were included in the study. Dual phase helical CT data was obtained in the arterial and venous phases, respectively, after intravenous contrast injection using a pressure injector. Axial CT data (both arterial and venous phase) was studied for staging and resectability of tumor. Three-dimensional helical CT cholangiography using minIP obtained from the venous phase data set, was used to assess the level of biliary obstruction and isolation of hepatic segmental ducts. Three-dimensional helical CT cholangiography findings were compared with MRC and percutaneous transhepatic cholangiography (PTC) (gold standard). None of the patients were operated on as they were all considered inoperable on axial CT images due to extensive local disease or distant metastasis. RESULTS: In all patients, 3-D CTC demonstrated dilated intrahepatic ducts up to tertiary branch level. The 3-D CTC correctly diagnosed the level of biliary obstruction and demonstrated isolated segmental ducts in all patients and correlated well in all cases with MRC and PTC findings in this regard. However, the 3-D CTC did not add any additional information over the axial source images. CONCLUSION: Three-dimensional helical CT cholangiography with minIP can correctly determine the level of biliary obstruction in patients with GC and may be a strong competitor with MRC, because it gives equivalent information with regard to the level of ductal obstruction even while being a part of an overall comprehensive CT staging study. Even though 3-D CTC did not provide additional information on top of the source images, the referring physicians found them very useful for conceptualization of the 3-D biliary anatomy.

Sarcoidosis manifesting as massive splenomegaly: a rare occurrence.

Sarcoidosis is a multisystemic granulomatous disease of unknown origin occurring worldwide and affecting people of all races and ages. This disease manifests most frequently with bilateral hilar lymphadenopathy, pulmonary infiltrates, and skin and ocular lesions. Granulomatous inflammation of the spleen is common in patients with sarcoidosis, but splenic enlargement is unusual and massive splenomegaly quite rare. Splenomegaly is usually homogeneous, but multiple low-attenuating nodular lesions are occasionally seen and easily mistaken for lymphoma, metastases, or infections such as tuberculosis. We describe an unusual case of sarcoidosis in a woman who presented with massive splenomegaly with extensive nodularity that cleared completely with corticosteroid therapy.