Necrotizing soft tissue infection of the upper leg as first presentation of necrotizing pancreatitis: a case report.

Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis.

Prediction of exocrine and endocrine insufficiency after pancreaticoduodenectomy using volumetry.

Objectives: The aim of this study is to evaluate the use of pancreatic volumetric assessment to predict exocrine and endocrine insufficiency after pancreaticoduodenectomy.Methods: Thirty-seven patients who underwent pancreaticoduodenectomy were included in the study. Endocrine function was assessed in all patients without a history of diabetes using an oral glucose tolerance test. A 13C-labeled mixed triglyceride (MTG) breath test evaluated exocrine function before and after resection. Volumetric measurements were performed on CT or MRI.Results: The volumetric measurements could not predict pre- or postoperative diabetes. Moreover, the resected volume was significantly lower in patients who developed diabetes after resection. Comparing patients with a normal and disturbed postoperative MTG, postoperative volumes and parenchymal thickness were significantly different. The parenchymal thickness on postoperative imaging is withheld as a predictive factor (OR = .85 [95% CI .71-1.01], p = .049). The best cutoff value to predict exocrine insufficiency is a parenchymal thickness of less than 11.4 mm (AUC = .76, p = .025, sensitivity = 88.9%, specificity = 70.0%).Conclusions: Pancreatic remnant volumetry and parenchymal thickness measurement after pancreaticoduodenectomy are correlated with exocrine insufficiency, but with limited predictive value. None of the preoperative measurements are withheld to predict postoperative exocrine function. Pre- and postoperative volumetry appear to have no use in predicting postoperative diabetes.

Sarcopenia in patients with non-alcoholic fatty liver disease: is it a clinically significant entity?

Sarcopenia, described as the loss of muscle mass and/or strength, is gaining importance as it can be increasingly related to many chronic diseases. It is also associated with chronic liver disease, and recently it has been more frequently linked to non-alcoholic fatty liver disease (NAFLD) in particular. Both sarcopenia and NAFLD are subject to complex and intermingled pathophysiological processes, of which some are in common. Furthermore, it is presently unclear if sarcopenia directly contributes to NAFLD or vice versa. The mechanisms that are involved may include obesity, insulin resistance, vitamin D deficiency, aging, physical inactivity and certain cytokines. Current clinical evidence is subject to an important heterogeneity in methods and definitions, with additionally also a relative overrepresentation of evidence in Asian ethnicities. Nonetheless, all studies so far point towards the same association between sarcopenia and NAFLD, including an association with NAFLD-severity and NAFLD-related fibrosis. Since the field is in its infancy, clear definitions and further research are needed to aid to improve understanding of the association between NAFLD and sarcopenia. This can eventually lead to additional potential therapeutic interventions. This review attempts to give an overview of the current published literature that links sarcopenia to NAFLD, followed by a discussion of the presumably involved pathophysiological factors, and ends by discussing current unmet needs.

The Belgian Association for Study of the Liver Guidance Document on the Management of Adult and Paediatric Non-Alcoholic Fatty Liver Disease.

Non-Alcoholic Fatty Liver Disease (NAFLD) is highly prevalent and associated with considerable liver-related and non-liverrelated morbidity and mortality. There is, however, a lot of uncertainty on how to handle NAFLD in clinical practice. The current guidance document, compiled under the aegis of the Belgian Association for the Study of the Liver by a panel of experts in NAFLD, from a broad range of different specialties, covers many questions encountered in daily clinical practice regarding diagnosis, screening, therapy and follow-up in adult and paediatric patients. Guidance statements in this document are based on the available evidence whenever possible. In case of absence of evidence or inconsistency of the data, guidance statements were formulated based on consensus of the expert panel. This guidance document is intended as a help for clinicians (general practitioners and all involved specialties) to implement the most recent evidence and insights in the field of NAFLD within a Belgian perspective.

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores.

INTRODUCTION: Recently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining 99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBSBSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBSBSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM. METHODS: Between 2012 and 2016, 140 patients underwent liver resection for CRLM following systemic therapy. HBSBSA, FLRV%, eFLRF and PBLS were calculated and compared for their value in predicting PHLF. RESULTS: eFLRF and FLRV% had a better predictive value for PHLF than HBSBSA alone and APRI and FIB-4 (AUC = 0.800, 0.843 versus 0.652, 0.635 and 0.658 respectively). In a subgroup analysis (Oxaliplatin all, Oxaliplatin ≥ 6 cycles, Irinotecan all and Irinotecan ≥ 6 cycles), eFLRF was the only factor predictive for PHLF in all subgroups (all: p ≤ 0.05). Prediction of HBSBSA for chemotherapy associated steato-hepatitis (CASH) reached almost significance (p = 0.06). FIB-4 was predictive for sinusoidal obstruction syndrome (SOS) (p = 0.011). Only weak correlation was found between HBSBSA and PBLS. CONCLUSION: eFLRF is a better predictor of PHLF than PBLS or HBSBSA alone. PBLS seem to measure other aspects of liver function or damage than HBSBSA.

ESGAR consensus statement on liver MR imaging and clinical use of liver-specific contrast agents.

OBJECTIVES: To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents. METHODS: The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) formed a multinational European panel of experts, selected on the basis of a literature review and their leadership in the field of liver MR imaging. A modified Delphi process was adopted to draft a list of statements. Descriptive and Cronbach's statistics were used to rate levels of agreement and internal reliability of the consensus. RESULTS: Three Delphi rounds were conducted and 76 statements composed on MR technique (n = 17), clinical application of liver-specific contrast agents in benign, focal liver lesions (n = 7), malignant liver lesions in non-cirrhotic (n = 9) and in cirrhotic patients (n = 18), diffuse and vascular liver diseases (n = 12), and bile ducts (n = 13). The overall mean score of agreement was 4.84 (SD ±0.17). Full consensus was reached in 22 % of all statements in all working groups, with no full consensus reached on diffuse and vascular diseases. CONCLUSIONS: The consensus provided updated recommendations on the methodology, and clinical indications, of MRI with liver specific contrast agents in the study of liver diseases. KEY POINTS: • Liver-specific contrast agents are recommended in MRI of the liver. • The hepatobiliary phase improves the detection and characterization of hepatocellular lesions. • Liver-specific contrast agents can improve the detection of HCC.

Septic Thrombophlebitis of the Right Ovarian Vein.

BACKGROUND: A 26-year-old woman presented at the emergency department with a painful abdomen and fever up to 39°C, despite antibiotics. She had given prematurely birth by caesarian section to a twin 8 days earlier. On clinical examination she had a diffuse painful and tender abdomen, especially on the right side and suprapubic region. Laboratory findings showed an increased c-reactive protein of 24 mg/dL (normal < 0,3) and increased white blood cell count of 13 Å~ 10E9/L (normal 4,3-10 Å~ 10E9/L). There was also a decreased hemoglobin level of 8,4 g/dL (normal 12-15 g/dL). An ultrasonography was performed by the gynecologist and revealed a large heterogeneous fluid collection anteriorly of the uterus.

Mucocele of the appendix: case report and review of literature.

Mucocele of the appendix is a descriptive term of a distended, mucus-filled appendix caused by various conditions, both benign and malignant. Computed tomography is the imaging modality of choice. Correct pre-operative diagnosis is important because of the possibility of peroperative rupture and subsequent development of pseudomyxoma) peritonei. It is the task of the radiologist to alert the clinician and surgeon to the presence of this entity, the potential associated complications and possible signs of malignancy.

Update in non small-cell lung cancer staging.

Significant progress has been made with the introduction of the TNM-7 staging system for non-small cell lung cancer (NSCLC). Constituting the first major revision in 12 years, the seventh edition of NSCLC TNM (TNM-7) is based on the recommendations from the International Association for the Study of Lung Cancer (IASLC) Lung Cancer Staging Project of 2007. This new TNM iteration includes a subset analysis on SCLC and carcinoid tumors. A thorough understanding of its principles by the radiologist is helpful to increase efficiency and to improve communication with the referring clinicians.

Post-traumatic hepatic arterial pseudoaneurysm and arterioportal shunt.

The authors report the case of a 21-year-old man who suffered from a blunt abdominal trauma. Initial imaging revealed a liver laceration at the right lobe, a perirenal hematoma of the right kidney and a hematoma of the right adrenal gland. Follow-up MDCT-scan on day 10 after admission showed at the arterial-phase contrast-enhanced study perfusion alterations and two hepatic pseudoaneurysms. The diagnosis of pseudoaneurysm was confirmed and treated angiographically with superselective coil embolization. A follow-up CT-scan on day 17 showed at a nontreated area an arterioportal shunt and a wedge-shaped transient hepatic parenchymal enhancement. This was confirmed angiographically and subsequently treated with coil embolization.

A solid pseudopapillary tumour of the pancreas presenting after an abdominal trauma.

We present the case of 12-year-old girl who was referred with persistent abdominal pain and a palpable mass after blunt trauma and whose final diagnosis was a solid pseudopapillary tumour of the pancreas. This is the second case in our hospital of a solid pseudopapillary tumour of the pancreas presenting after a blunt abdominal trauma. Solid pseudopapillary tumour of the pancreas is a rare neoplasm. It comprises 2 to 3% of primary pancreatic tumours occurring at all ages. It was first described in 1959 by Frantz. The presenting symptoms are usually a slow growing abdominal mass with vague abdominal discomfort. Sometimes they are discovered after a trauma. Solid pseudopapillary tumours of the pancreas have a fairly characteristic appearance on imaging but the final diagnosis depends on histological confirmation. After resection the prognosis is excellent.

Asymptomatic pneumatosis intestinalis in AIDS.

Pneumatosis intestinalis is an unusual entity in which subserosal or submucosal collections of gas occur in the bowel wall. We present a case of asymptomatic linear pneumatosis intestinalis and free abdominal air in a 67-year-old man with acquired immunodeficiency syndrome (AIDS) who improved spontaneously following conservative management. Pneumatosis intestinalis is a late-stage phenomenon in patients with AIDS that characteristically involves the cecum, ascending and transverse colon or the rectum with sparing of the descending colon and the sigmoid. For these patients, non-operative management is appropriate.

Indications for body MRI Part I. Upper abdomen and renal imaging.

The lack of ionizing radiation use in MRI makes the high spatial resolution technique very appealing. Also, the easy access to multiplanar imaging and the fact that gadolinium-DTPA is well tolerated and not nephrotoxic makes MRI a robust alternative in the healthy as well as the renal compromised patient. Furthermore, MRI adds advanced possibility for tissue characterization and pathology detection and dynamic imaging can be performed. Specific contrast agents specific to the hepatobiliary or the reticuloendothelial system can help with additional information in problem cases. The role of MRI for different organs is discussed and a review of the literature is given. We concluded that MRI is considered a useful and non-invasive diagnostic tool for the detection of hepatic iron concentration, to correct misdiagnosis (pseudolesions) from US and CT in focal steatosis and to help with focal lesion detection and characterization, in the healthy and especially in the cirrhotic liver, where MRI is superior to CT. Moreover, MRCP is excellent for identifying the presence and the level of biliary obstruction in malignant invasion and is considered in the literature as a non-invasive screening tool for common bile duct stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications. MRI is the first choice modality for adrenal evaluation in contemporary medical imaging. It is a useful examination in renal as well as splenic pathology and best assesses loco-regional staging, i.e. arterial involvement in pancreatic cancer.

Indications for body MRI Part II: retroperitoneum, intestines and pelvis.

In this article an overview is given of the present knowledge of whole body MRI, MRI of the retroperitoneum, intestines and pelvis. Recommendations are based on current literature and clinical applications in daily routine focusing on efficacy rather than cost considerations. The contribution and complementary role of MRI relative to those of its competing modalities was the most important endpoint assessed. Perfusion and functional information, as well as specific contrast agents in the area of the pelvis are still considered research indications.