Abhishek Jha

Diagnostic value of ultrasonography in evaluation and management of acute abdominal conditions in the paediatric age group.

BACKGROUND The aims of this study have been elaborated below: (1) to enumerate the common causes of acute abdominal emergencies by ultrasonography in paediatric patients; (2) to establish the diagnostic efficacy of ultrasonography in evaluation of acute abdominal conditions in children and to illustrate the associated ultrasonographic findings; (3) and, to discuss the role of ultrasonography in guiding the mode of intervention in these cases. PATIENTS AND METHODS This prospective study of ultrasonographic examination in 146 paediatric patients presenting with acute onset abdominal pain at the emergency/paediatric outpatient department section of Jawaharlal Nehru Medical College & Hospital, Aligarh, between June 2006 and December 2007, using 3.75 MHz and 8 MHz transducers of the ADARA (Siemens) machine. RESULTS Common causes of acute abdominal emergencies in pediatric patients as noted on ultrasonography included nonspecific pain (28%), abdominal abscess (21%), acute appendicitis (7%) and intussusception (7%). Ultrasonography was diagnostic in 45.2% cases and supportive in 12.3% of the cases. As for as the final outcome, ultrasonography prevented surgery in almost 20% cases and laparotomy was avoided in 7% of the patients as ultrasound guided interventions in the form of abscess aspiration were carried out. CONCLUSION Ultrasonography evaluation of children with acute abdominal pain, helps in making significant changes in the management plan of the patients, and also reveals various clinically unsuspected diseases.

Sonographic diagnosis of primary hydatid disease in the breast: the scroll sign.

Primary hydatid disease of breast is a rare entity and is caused by the larval stage of Echinococcus granulosus. The disease is more commonly seen in sheep‐rearing populations and imaging plays a pivotal role in its diagnosis. Several imaging signs have been described in relation to hydatid cysts. However, the “scroll sign,” due to the infolding of the endocyst, has rarely been encountered, with only one similar case in literature, in which the imaging findings were inconclusive. We present a case of primary hydatid disease of breast in a young Asian woman, with the sonographic scroll sign.

A rare case of partial diaphragmatic agenesis with thoracic liver herniation and anteriorly displaced intrathoracic kidney in an adult diagnosed by displaced diaphragmatic crus

Diaphragmatic agenesis is a rare anomaly and usually occurs in the early neonatal period. Its exact pathogenesis from the embryologic viewpoint is still unknown. Its presentation in adulthood is extremely rare, with only 7 cases of hemidiaphragmatic agenesis reported in adults. They are usually associated with herniation of abdominal contents and are predominantly left sided. We present a case of right hemidiaphragmatic agenesis with anteriorly displaced crus and intrathoracic herniation of kidney, which is anterior and rotated along the horizontal plane, with herniation of liver and colon. The position of the crus was instrumental in making a diagnosis of diaphragmatic agenesis and for which the patient was operated upon and the defect was repaired.

Diagnostic efficacies of computed tomography and ultrasonography in pediatric blunt abdominal trauma

Background: Blunt abdominal trauma is a common cause of morbidity and mortality in children. The objectives of the study are to evaluate the specific patterns of organ injury in pediatric patients as illustrated by ultrasonography and computed tomographic (CT) scan and assess the role of nonoperative management in such cases depending upon the severity of injury and the organ injured. Materials and Methods: This prospective study was conducted on pediatric patients with blunt abdominal trauma that presented to the casualty of Jawaharlal Nehru Medical College over a period of 2 years. A total of 45 patients were examined. The ultrasonographic evaluation of the patients was performed and thereafter CT scan of the patients were performed within 24 h of hospital admission if on ultrasonography any evidence of intraperitoneal free fluid was detected with or without any detectable visceral organ injury. Results: Ultrasonography detected hemoperitoneum in 15 patients (51.72%) as compared to CT which detected it in 23 cases (79.31%). Spleen was the most common solid organ injured, encountered in 10 cases (34.48%) on ultrasonography and 15 cases (51.72%) on CT scan. Liver was the second most common injured organ which was demonstrated by ultrasonography in five cases (17.24%), while CT detected hepatic parenchymal injuries in nine cases (31.03%). CT was also significantly more sensitive than ultrasonography in the detection of renal injuries which were illustrated by ultrasound in only one case (3.44%), while CT showed renal injuries in three cases (10.34%). Pancreatic injuries were least common and were seen in two cases and were detected equally by ultrasound and CT scan. Conclusion: Ultrasonography is a very useful and sensitive investigation for the detection of hemoperitoneum and visceral injuries. However, CT better delineates the solid organs injuries and grades the injury as well, thus guiding the management protocol. Nonoperative management is the rule in hemodynamically stable patients in correlation with radiological and clinical scenario.

Isolated crural hematoma mimicking retroperitoneal lymphadenopathy, a unique sign of traumatic diaphragmatic rupture: a case report.

Diaphragmatic injury following blunt thoracoabdominal trauma is rare and is usually associated with key radiological features like dependent viscera sign, collar sign, diaphragmatic thickening and defects. It may also be associated with secondary signs like intrathoracic herniation of abdominal viscera. Diaphragmatic crura, which are attached to the upper lumbar vertebra represent prominently thickened folds along the posterior diaphragm, are usually inconspicuous on routine Computed Tomography (CT) scans. We present a case of a young patient who sustained a motor vehicle accident and developed difficulty in breathing. CT scan of the patient revealed bilateral crural hematomas, with splenic and renal lacerations and no other sign of diaphragmatic injury. The patient was operated and blunt diaphragmatic rupture was confirmed at surgery.

Vanishing lung disease in an adult misdiagnosed as pneumothorax.

A previously healthy 34-year-old man attended the medical outpatient ward with a 6-month history of shortness of breath, which was worse on exertion. The patient was a chronic smoker but there was no additional history of cough, sputum production, haemoptysis, fever or chest pain. On examination,

Posttraumatic bifid and trifid mandibular condyle with bilateral temporomandibular joint ankylosis.

Trifid mandibular condyle is an exceedingly rare entity with only 5 cases reported to date. The etiology of the disorder is unknown, though like bifid mandibular condyle, a correlation with prior trauma is usually seen. We present a case of a 6-year-old child who presented with severe restriction of movements at the temporomandibular joint, with a history of trauma 2 years back. Imaging revealed bilateral temporomandibular joint ankylosis with trifid and bifid mandibular condyles.

Intrahepatic portal vein aneurysm—a rare entity

A20-year-old man was referred for abdominal ultrasound (US) examination as a part of diagnostic workup for anemia. The patient was nondiabetic and nonhypertensive and reported no history of any other chronic illness. There was no history of hemetemesis, jaundice, liver disease, trauma, or surgical intervention. Physical examination of the patient was unremarkable except for pallor. No sign of portal hypertension was found. Routine hematologic investigations were within normal limits except for anemia with a hemoglobin level of 9 g/dl. Grayscale and color Doppler US examination revealed a well-defined fusiform dilatation of the left branch of the portal vein (Figure 1), with nonpulsatile, monophasic venous flow (Figure 2). The size of the lesion was 21 3 17 3 22 mm and there was no evidence of thrombosis or calcification. CT scan was performed to rule out any other associated abnormality and confirmed the US findings with no evidence of thrombosis (Figure 3). There was no associated portal vein branching variation. As the condition was asymptomatic and discovered incidentally, routine follow-up was recommended. The lesion was stable after 6 months. As there are no standard protocols for follow-up of such lesions, we recommended continued follow-up every 6 months. The patient’s anemia was apparently unrelated and of nutritional origin, as his hemoglobin level returned to normal after 6 months of iron and folic acid administration. Intrahepatic portal venous aneurysm is an extremely uncommon entity with unknown etiology, although portal hypertension, trauma, pancreatitis, and interventional procedures have been reported as possible causative factors. Portal vein aneurysms account for 3% of all venous aneurysms with a prevalence of 0.43%. As none of the above-mentioned conditions were present in our case, this aneurysm was likely congenital. This condition has no gender predilection and is usually seen in the fifth to sixth decades of life. Aneurysms have been reported in all parts of the portal vein; however, extrahepatic aneurysms are by far more common than intrahepatic aneurysms. Grayscale and color Doppler US examination is a reliable modality to detect and monitor the growth of such aneurysms. On grayscale US, they appear as well-defined anechoic masses, usually near the porta hepatis. Color Doppler imaging can help differentiate these images from simple hepatic cysts and other FIGURE 1. Grayscale transabdominal US shows a well-defined anechoic structure near the porta hepatis, involving the left branch of the portal vein, without any visible calcifications or thrombus.

Presacral Epidermoid Cyst in an Elderly Female, Mistaken for Ovarian Cystadenoma

Epidermoid cyst is of common occurrence in other parts of the body, but has rarely been described in the presacral space [1]. It is a benign congenital lesion, mostly seen in middle-aged females and is usually asymptomatic. Pathologically, it contains a thin wall lined by stratified squamous epithelium with a mixture of desquamated debris, keratin, cholesterol, and water. From the development aspect, it arises from the sequestration of the ectoderm following the closure of the neurenteric canal, proctodeal membrane, or post-anal gut [2]. The major complications of epidermoid cysts include infection and fistulization, where they may cause rectal pain.

Role of ultrasonography in detection of renal artery pseudoaneurysm caused by retroperitoneal malignant peripheral nerve sheath tumor in a patient with neurofibromatosis type 1

Malignant peripheral nerve sheath tumors (MPNSTs) are extremely uncommon neoplasms, predominantly seen within the deep soft tissues of the extremities, in close proximity to the nerve trunks. Retroperitoneal MPNSTs are exceedingly rare, usually seen in association with neurofibromatosis type 1 (NF-1), and often result from malignant degeneration of a plexiform neurofibroma. These tumors are highly malignant and the prognosis is worsened if they occur in association with NF-1. Metastasis is not uncommon, but local invasion by these tumors is rarely reported. Renal artery pseudoaneurysms are mostly iatrogenic and rarely result from invasion by retroperitoneal neoplasms. Ultrasonography is a valuable tool in early diagnosis of these neoplasms and vascular complications, particularly in emergency cases requiring immediate operative intervention. To the best of our knowledge, no case of renal artery pseudoaneurysm caused by retroperitoneal MPNST has been reported to date. We present a case of a middle-aged female with Von Recklinghausen disease, complaining of sudden onset of severe abdominal pain, where ultrasound accurately diagnosed renal artery pseudoaneurysm caused by a large retroperitoneal MPNST, and who was later treated by radical excision of the tumor and nephrectomy.