Transjugular intrahepatic cavoportal shunt for Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient's symptoms subsided and she was discharged and followed up for 6 months.

The evaluation of hepatocellular carcinoma with biphasic contrast enhanced helical CT scan.

OBJECTIVE: To evaluate the role of biphasic contrast-enhanced helical CT including Hepatic Arterial Phase (HAP) imaging with Portal Venous Phase (PVP) imaging, in the detection and characterization of hepatocellular carcinomas. METHODS: The study included 40 patients (M = 26, F = 14) with histopathologically proven HCC. Age range was between 30-85 years (mean = 55) by following consecutive patients with cirrhosis in whom Hepatocellular carcinoma was diagnosed or suspected either by raised serum a (alpha)-fetoprotein level or Ultrasound. RESULTS: Biphasic contrast-enhanced examination revealed a total of 85 lesions in these 40 patients, out of which 13 were unifocal, 12 showed a dominant mass with satellite lesions, 2 showed cluster of contiguous nodules and 13 were multifocal HCCs. Mean diameter was 3.1 cm, ranging from 0.8 to 14 cm. On HAP imaging 85% were detected. (hyperattenuating = 69, hypoattenuating = 3) while on PVP imaging detectibility was only 48% (hyperattenuating = 2, hypoattenuating = 39). Hence detectibility was significantly (p = 0.008) superior in HAP as compared to PVP imaging. In 7 patients (17%) tumor was visible only on HAP images. Venous invasion was present in 12 patients (30%) while arterio-portal shunting was seen in 5 patients (13%). CONCLUSION: Biphasic contrast enhanced helical CT is a useful method in detection and characterization of HCC.

The role of magnetic resonance cholangiopancreatography (MRCP) in obstructive jaundice.

OBJECTIVE: To evaluate the diagnostic value of MRCP in studying the sites and cause of obstructive jaundice in comparison with other imaging modalities at the Department of Radiology, Aga Khan University Hospital, from January 1999 to May 2001. METHODS: Forty nine consecutive patients included 19 men and 30 women, suspected of obstructive jaundice. Patients underwent ultrasound (n = 49), CT (n = 11), ERCP (n = 25) and biliary surgery (n = 17). Final diagnosis was established by surgical exploration, endoscopic sphincterectomy, cytology and clinical follow up. RESULTS: Of the 49 patients 17 had choledocholithiasis. Twenty five patients had malignant strictures, out of which 11 had non-specific malignant strictures, 7 had pancreatic carcinoma, 3 had Klatskin tumors, 3 had periampullary carcinoma and 1 had gallbladder carcinoma. Six patients had benign strictures and 1 patient had choledochal cyst. Overall, MRCP was sensitive (88%) and specific (96.8%) in detecting choledocholithiasis. MRCP sensitivity and specificity in detecting benign main bile duct stricture was equal to 83.3% and 97.6% respectively, and 92% and 100% for malignant stricture. CONCLUSION: Our prospective study confirms that MRCP, a noninvasive and well tolerated imaging technique is of value in the diagnosis of obstructive jaundice.

Unenhanced helical CT of ureterolithiasis: incidence of secondary urinary tract findings.

OBJECTIVE: To determine the incidence of secondary signs of obstruction in patients with ureteral stones on unenhanced helical CT scans. MATERIAL AND METHODS: Three hundred consecutive patients with suspected renal colic referred by the emergency department for an unenhanced helical CT scan were evaluated. One hundred and thirty two patients with ureteric calculi were viewed prospectively for the secondary signs of obstruction, which include hydronephrosis, hydroureter, perinephric stranding, nephromegaly, periureteral edema and difference in attenuation between acutely obstructed kidney and unobstructed kidney. RESULTS: In the evaluated 132 patients, calculi were present in the proximal, mid and distal ureter in 12, 18 and 112 patients respectively. Four patients had a contralateral ureteric calculus while none had more than one ureteric calculus on the same site. Concurrent renal parenchymal calculi were seen in 40 patients with ureteric stones, hydronephrosis in 69, hydroureter in 93 and perinephric strandings in 66 patients. Nephromegaly was seen in 15 and periureteral edema in 42 patients. In 87% patients with acute renal obstruction, the affected kidney was less dense than the unobstructed kidney. Only 5 of 132 patients had no associated findings. CONCLUSION: Unenhanced helical CT has rapidly become the imaging technique of choice in evaluating patients with acute ureteric colic. The secondary signs of obstruction provide supportive evidence of acute obstructive process.

Mammographic criteria for determining the diagnostic value of microcalcifications in the detection of early breast cancer.

OBJECTIVE: To evaluate the importance of microcalcifications in the detection of breast carcinoma in conventional mammography. METHODS: This prospective study was carried out at Aga Khan University Hospital (AKUH). Mammograms of 68 patients with microcalcifications were evaluated. Craniocaudal and oblique views of both breasts were acquired on routine basis with cone compression and magnified views when required. RESULTS: Among 68 patients with microcalcifications, 61 (89%) had clustered microcalcifications while 7 patients (10.29%) had scattered microcalcifications. Microcalcifications can occur in benign and malignant diseases. While evaluating clustered microcalcifications, few criteria have been established to determine malignant clustered microcalcifications, these include specific and nonspecific criteria. Among specific and statistically significant criteria for malignant microcalcifications, which were identified in this study, were irregularity of size, irregularity of density, linear or branched shape and Le Gal's type V distribution. In a cluster total number of >30 microcalcifications and at least 10 microcalcifications/cm2 of a cluster are also important in diagnosing a malignant cluster, but are included in nonspecific criteria because they can be present in benign diseases also. Scattered bilateral microcalcifications are usually present in benign breast diseases, but in this study, two patients with breast cancer had profuse bilateral scattered microcalcifications. CONCLUSION: This study shows that specific and statistically significant criteria for malignant microcalcifications, are irregularity of size, irregularity of density, linear or branched shape and Le Gal's type V distribution. Scattered bilateral microcalcifications are usually present in benign breast diseases, but irregular shape and development of new calcifications among diffusely scattered bilateral calcifications, on follow up study, should also raise suspicion for being malignant.

Diagnosis of pulmonary embolism with helical C.T. scan.

OBJECTIVE: To determine the role of helical C.T. scan in the diagnosis of pulmonary embolism. SETTING: Radiology department, Aga Khan University Hospital. One year prospective study May 2001 to May 2002. METHODS: Sixty patients suspected of having pulmonary embolism were included in this study. Helical C.T. scan chest was performed from aortic arch to lung bases with intravenous contrast medium. Images were acquired in mediastinal and lung windows. Image interpretation was performed on the console and hard copies for main branch and segmental thrombus. RESULTS: Fifteen patients were diagnosed of having pulmonary embolism on C.T. scan. Clinical correlation and follow up with pulmonary angiography and Doppler ultrasound of leg was carried out. Pulmonary angiography was performed in one patient with embolectomy done after confirmation of diagnosis. 8 patients had associated DVT confirmed on Doppler sonography. Sensitivity of helical C.T. is 93.75%, specificity 100% and positive predictive value 95.65%. CONCLUSION: Helical CT scan is a quick, easy and accurate imaging modality for diagnosing pulmonary embolism.

Radiologic feeding gastrostomy placement: experience in 23 patients.

OBJECTIVE: To evaluate the safety, efficacy and complications of percutaneous gastrostomy catheter placementunder flouro guidance for long-term enteral feeding. MATERIALS AND METHODS: Between April 1998 to May 2002, 23 patients who had percutaneous gastrostomy catheter placement were retrospectively reviewed. Clinical indications for catheter placement included patients with neurologic disease, head and neck malignancy, and pulmonary disease patients. Placement of 12 - 14 Fr gastrostomy catheter was then accomplished with the Seldinger technique. The technical success, procedural complications were recorded. RESULTS: Twenty seven procedures, including revisions, were performed. The success rate for catheter placement was 100%. Revision was necessary in 7 (30%) instances in 7 patients. There was one (3.8%) major and 4 (14.8%) minor complications. CONCLUSION: Fluoroscopically directed percutaneous placement of gastrostomy catheters is a safe and effective procedure.