Amit Nandan Dhar Dwivedi

Gall bladder carcinoma: Aggressive malignancy with protean loco-regional and distant spread

The most common malignancy of biliary tract is gallbladder cancer (GBC) which is the third most common cancer in gastrointestinal tract. It is a lethal disease for most patients in spite of growing awareness and improved diagnostic techniques. GBC has a very poor prognosis and the 5 year survival rate is < 10%. Although etiology of the carcinoma of the gallbladder is still obscure, various factors have been implicated, cholelithiasis being the most frequent. The incidence of GBC worldwide is based on the gender, geography and ethnicity which suggest that both genetic and environmental factors can cause GBC. The major route of spread of gallbladder cancer (GC) is loco-regional rather than distant. It spreads by lymphatic, vascular, neural, intraperitoneal, and intraductal routes. Sonography is usually the most common imaging test to evaluate symptoms of biliary tract disease including suspected GC. With recent advances in imaging modalities like multi-detector computed tomography (CT) scanners, magnetic resonance imaging-positron emission tomography/CT diagnosis of gallbladder cancer has improved. Studies have also targeted molecular and genetic pathways. Treatment options have included extended and radical surgeries and adjuvant chemotherapy. This review article deals in detail with important aspects of carcinoma gallbladder and its manifestations and challenges. Role of various imaging modalities in characterization and accurate staging has been discussed. The loco-regional spread of this aggressive malignancy is dealt explicitly.

Severity of Soft Tissue Injury Within the Temporomandibular Joint Following Condylar Fracture as Seen on Magnetic Resonance Imaging and Its Impact on Outcome of Functional Management

PURPOSE This study aimed to quantify articular soft tissue injury in condylar fractures based on magnetic resonance imaging (MRI) findings and investigate the impact of severity of articular soft tissue injury on the development of postoperative complications after functional reduction of a condylar fracture. PATIENTS AND METHODS Fifty-four patients 18 to 60 years old with unilateral undisplaced, deviated, or displaced condylar fractures were included in this prospective study. Articular soft tissue within the temporomandibular joint (TMJ) was evaluated using MRI within 7 days after the condylar fracture. Based on MRI findings, such injuries were classified as grade I (hemarthrosis only), grade II (hemarthrosis and disc displacement), grade III (hemarthrosis, disc displacement, and capsular tear), or grade IV (disc perforation in association with grade I, II, or III). All condylar fractures were treated conservatively using a standardized functional reduction method and patients were followed for 1 year. RESULTS In 37 of 54 TMJs, MRI diagnosis of disc displacement was established, and capsular tear was observed in 12 joints and hemarthrosis was present in 42 joints. Disc perforation was present in only 5 cases. Patients with hemarthrosis alone (grade I) had the best outcome after functional reduction, whereas patients with hemarthrosis and disc displacement (grade II) had comparatively poorer results. Fifty percent of patients with grade II injury and 66.6% of patients with associated capsular tear (grade III) had limited mouth opening and restricted movement at the end of the follow-up period. One hundred percent of patients with disc perforation (grade IV) had restricted joint movement and joint noise. CONCLUSION Results suggest that serious injury to the articular disc and capsule of the TMJ is a major contributing factor toward the development of complications after closed reduction of a condylar fracture.

Clinical and imaging perspective and unanswered questions in a case of metronidazole induced encephalopathy

We discuss the clinical and imaging perspective in a case of a 78-year-old male who developed slurring of speech and ataxia acute in onset for the last 3 days. During his hospital stay, he developed multiple episodes of focal seizures without secondary generalization involving the angle of mouth on the right side. The patient had ataxia and positive cerebellar signs. In the past, the patient was treated for amoebic liver abscess and had undergone percutaneous aspiration of abscess. The patient was prescribed oral metronidazole and was discharged. This time, the patient underwent magnetic resonance imaging examination, which revealed lesion highly suggestive of metronidazole-induced encephalopathy. The offending drug was discontinued immediately after which the patient improved clinically. A follow-up scan was performed after 12 days and showed complete resolution of lesions.

Transmural invasion of hepatic flexure of colon causing cholecystocolic fistula by aggressive gallbladder carcinoma

Spontaneous enterobiliary fistulae are a complication of biliary disease or a disease of adjacent structures. Cholecystocolic fistulae are rare in relation to gallbladder carcinoma (GBC). Previous reports have presented images showing subtle findings suggestive of cholecystocolic fistula. We report the unusual spread and rare images of a case of cholecystocolicfistula,to highlight the aggressive nature of GBC and findings of gross transmural invasion of the colonic wall. The images acquired in all three planes define the anatomical and pathological extent conclusively. There are a higher number of GBC cases across the geographic belt of North India compared to the West. In this case, the patient’s pathology was extensive and unresectable, and therefore palliative and supportive care wasadvised.

A rare case of Balo concentric sclerosis showing unusual clinical improvement and response with oral prednisolone

The present report is a rare case of Balo Concentric Sclerosis. Most cases have either been diagnosed post mortem or have succumbed to the disease after being diagnosed ante mortem. In our case, the patient showed a dramatic response to treatment, and after a one-year follow-up, he was asymptomatic, with no relapses or residual effect of the illness.

Determinants of Intravascular Resistance in Indian Diabetic Nephropathy Patients: A Hospital-Based Study

Aims and Objectives. Metabolic dysregulation has failed to explain clinical variability of patients with diabetic nephropathy and hence a renewed interest emerged in haemodynamic factors as determinant of progression and development of diabetic nephropathy. We therefore studied for various factors which can correlate with raised renal vascular resistance in diabetic nephropathy. Material and Methods. Renal vascular resistance was measured in patients with established and incipient diabetic nephropathy and compared with controls using noninvasive color Doppler examinations of intrarenal vasculature. Results. Renal vascular resistance correlated with age, duration of disease, GFR, serum creatinine, and stage of retinopathy. Renal vascular resistance was significantly reduced in patients on treatment with RAAS inhibitors and insulin, than those on OHA and antihypertensives other than RAAS inhibitors. Conclusion. The study implies that renal vascular resistance may help identify diabetics at high risk of developing nephropathy, and these set of patients could be candidates for RAAS inhibition and early insulin therapy even in patients without albuminuria.

A CT-based comparative study of radiological patterns of pulmonary tuberculosis in patients with type 2 diabetes versus non-diabetics

The diabetic epidemic, although apparent across the world, has been most pronounced in non-European populations. Type II diabetes in children, teenagers and adolescents is a serious aspect to the epidemic and is an emerging public health problem. Patients with diabetes mellitus are also at higher risk of tuberculosis. We aim to study the differences in radiological pattern of pulmonary tuberculosis using high-resolution and contrast-enhanced CT scans in patients with concomitant diabetes mellitus as compared to those without diabetes and study the atypical radiological manifestations of pulmonary tuberculosis in diabetics. All the patients included in this study were scanned using VCT LIGHT SPEED 64-slice multidetector CT scanner of GE. A non-contrast scan was acquired followed by a contrast-enhanced scan. Brief history of patients was taken with regard to possibility of adverse reaction to the iodinated contrast media. Features like cavity, consolidation, centrilobular nodules, tree-in-bud pattern, pleural effusion and lymphadenopathy were noted. The patients of tuberculosis (50) with diabetes tended to be older than the patients without diabetes (50). No significant difference was seen in the frequency of upper lobe involvement between the two groups. Consolidation in lower lobes is more common in patients with diabetes. Cavitary lesions are also more common in lower lobes in patients with diabetes. No significant difference was seen in terms of bilateral involvement between the two groups. No significant difference was also seen in terms of pleural effusion and lymphadenopathy. Patients of tuberculosis with diabetes showed a significantly higher prevalence of endobronchial spread (51%) compared to non-diabetics (30%). Diabetes mellitus alters the radiological appearance of pulmonary tuberculosis. In a patient with tuberculosis, a radiological appearance of lower lobe consolidation and lower lobe cavitation should alert the clinician towards the presence of concomitant diabetes mellitus.

Visceral leishmaniasis or systemic lupus erythematosus flare

Systemic lupus erythematosus (SLE) is a multisystem disorder characterised by B-cell hyperactivity with production of multiple autoantibodies. Fever in SLE may be caused by disease exacerbation or by infection. We report a patient of SLE that was later complicated by fever, pancytopenia, and massive splenomegaly. Corticosteroid therapy for SLE might have masked the underlying infection at earlier stage. Despite negative results of rk-39 test and bone marrow biopsy, a very high suspicion for visceral leishmaniasis (VL) led us to go for direct agglutination test (DAT) and polymerase chain reaction (PCR) for leishmanial antigen that revealed positive results. Moreover, significant improvement in clinical and biochemical parameters was noted on starting the patient on antileishmanial therapy.