Hemangini Thakkar

Sonography in Budd-Chiari Syndrome

Objective. The objective of this presentation is to provide an overview of sonographic manifestations of Budd‐Chiari syndrome (BCS). Methods. Patients were scanned with ultrasound systems using mainly a 2‐ to 5‐MHz curvilinear transducer and in some patients a 5‐ to 12‐MHz linear transducer. The patients were asked to fast from the previous night or for at least 6 hours. Color and spectral Doppler sonography was performed in all patients. Results. Commonly seen findings in BCS include inferior vena cava (IVC) webs and thrombi, IVC narrowing, hepatic venous thrombosis, enlarged caudate lobes, ascites, intrahepatic or extrahepatic collaterals, monophasic to absent flow in the hepatic veins, and high flow velocities in areas of stenosis in the IVC or hepatic veins. Inferior vena cava stents used in the treatment of BCS could also be seen. Conclusions. Budd‐Chiari syndrome is an uncommon disorder; outcome is poor in many cases; and the condition is often misdiagnosed or underdiagnosed. Sonography is a noninvasive and effective modality for diagnosis of BCS.

Antenatal Detection of Idiopathic Arterial Calcification With Hydrops Fetalis

Idiopathic arterial calcification of infancy, or occlusive infantile arterial calcification, is a rare cause of arterial calcification. This condition is inherited as an autosomal recessive pattern, which is almost always fatal. In most of the 100 cases described in the literature, the diagnosis was made at autopsy; a few cases have been reported in which an antemortem diagnosis was made on the basis of radiographic or sonographic demonstration of arterial calcification. The clinical characteristics are extremely variable, and respiratory distress with cardiac failure is the most common finding. Hypertension that is refractory to treatment is present in most cases. Most infants die before the age of 6 months, and very few have survived for more than 1 year. Mortality in this condition is caused by myocardial ischemia due to coronary artery involvement or refractory cardiac failure. The purpose of this report is to describe the prenatal diagnosis of idiopathic arterial calcification. Fewer than 10 cases of antenatal detection of this condition have been reported in the literature. This case is 1 of 2 cases with the earliest diagnosis of this condition so far (Table 1).

Ovarian Cystic Teratoma Determined Phenotypic Response of Keratocytes and Uncommon Intracystic Floating Balls Appearance on Sonography and Computed Tomography

Ovarian cystic tumors (dermoid cysts), derived from totipotent cells, are composed mainly of a cyst lined entirely or partly by epithelium resembling keratinized epidermis with sebaceous and sweat glands. The term dermoid emphasizes the preponderance of ectodermal tissue, with the elements derived from other germ layers being inevitably present. 1,2 Sonography 3,4 and computed tomography (CT) 5,6 can easily facilitate diagnosis of these benign cystic fatty tumors. Generally, cystic teratomas are classified into 1 of 3 categories on the basis of their configuration and components. The first type shows layering of floating debris within a tumor 6,7 ; the second type has nodular or palm tree-like mural protrusions 3,7 ; and the third type shows a fat-fluid level. 3 We report a case of a dermoid cyst that had none of the classic sonographic features. Instead, multiple mobile fat balls were seen within the cyst, and no features of calcification, tooth, or bone were shown on sonography and CT. Also, the golden brown color of the hair in the dermoid was similar to that of the patients scalp hair. To our knowledge, that feature, showing the determined nature of keratocytes, has not been discussed before in the literature. We present unusual sonographic and CT features of a cystic ovarian teratoma with intracystic mobile spherical masses. The spherical fat balls, spme of which were admixed with hair, caused the striking feature of multiple floating masses in the cyst.

Radiological Illustration of Spontaneous Ovarian Hyperstimulation Syndrome

Summary Background The role of radiology is of utmost importance not only in diagnosing s-OHSS but also in ruling out other cystic ovarian diseases and to determine the underlying etiology and course of the disease. We presented a radiological algorithm for diagnosing the various causes of s-OHSS. Case Report A 26-year-old female, gravida one was referred to radiology department with history of lower abdominal pain, nausea and vomiting since 2 days which was gradual in onset and progression. The patient had no significant medical and surgical history. Conclusions This article illustrates and emphasizes that diagnosis of s-OHSS and its etiology can be completely evaluated radiologically. Biochemical markers will confirm the radiological diagnosis.

A Series of Congenital High Airway Obstruction Syndrome – Classic Imaging Findings

Congenital high airway obstruction syndrome (CHAOS) is a very rare entity with very poor prognosis in which upper airway is intrinsically obstructed, the most common reason being laryngeal atresia. In summary prenatal early diagnosis of patients with CHAOS is necessary so that perinatal management can be undertaken successfully or elective termination of pregnancy can be undertaken. The fetoscopic approach may be a life saving modality in a subset of CHAOS patients. Involving a multidisciplinary team comprising of paediatricians, radiologists, obstetricians and anaesthesiologists increases the efficiency of management.

Juvenile Granulosa Cell Tumour of the Ovary with Unilocular Pure Cystic Presentation: A Case Report and Review of Literature

Summary Background Granulosa cell tumours of the ovary are rare, hormonally active, oestrogen-secreting tumours of the ovary existing in two forms: the adult form and the even rarer juvenile form. These tumours present as predominantly solid lesions while the cystic, unilocular presentation is uncommon. Case Report We present an 18-year-old unmarried girl who presented with complaints of chronic pain, abdominal distension and presence of facial hair. Radiological examination revealed a large, purely cystic, unilocular lesion without any solid components, debris or septations. Histopathological diagnosis was of a juvenile granulosa cell tumour. Conclusions Radiological criteria suggestive of malignant ovarian masses include thick, irregular walls and septae; papillary projections and solid, echogenic foci. Nonetheless, we propose that a malignant ovarian lesion should be included in the differential diagnosis of a unilocular, purely cystic ovarian lesion.

Use of imaging in diagnosis of Herlyn–Werner–Wunderlich syndrome, a case report

Herlyn–Werner–Wunderlich (HWW) syndrome is a very rare congenital anomaly characterised by a triad of obstructed hemivagina, didelphys uterus and renal agenesis, which was first reported in 1922 by Purslow (Fedele et al. 2013). It is an anomaly of Mullerian duct that also involves the Wolffian duct. It is a combination of Type III Mullerian anomaly associated with mesonephric duct anomaly and vaginal septum (Buttram and Gibbons 1979). The incidence of Mullerian duct anomaly in the general population is 0.1–3.8% and the incidence of uterine didelphys in Mullerian duct anomalies is 11%. In cases of uterine didelphys, the incidence of accompanying transverse vaginal septum is 75% (Junqueira et al. 2009). The incidence of uterine didelphys in HWW syndrome varies from 1/200 to 1/28,000 and the incidence of accompanying unilateral renal agenesis is 43% (Zurawin et al. 2004). The triad of didelphic uterus, obstructed hemivagina and ipsilateral renal agenesis is a very rare presentation constituting 0.16–10% of all Mullerian duct abnormalities. (Cox and Ching 2012) HWW syndrome was classified into two distinct types and subtypes (completely or incompletely obstructed hemivagina) in the year 2015 (Zhu et al. 2015). This paper is written with an objective to report a very rare case with the description of typical imaging features.

Imaging in median arcuate ligament syndrome.

An 18-year-old man presented with a 7-month history of abdominal pain, particularly in the epigastrium, and weight loss of 14 pounds. Symptoms were aggravated post meals. An abdominal sonogram, upper gastroendoscopy and colonoscopy, were inconclusive. A contrast-enhanced CT of the abdomen revealed kinking of the proximal coeliac artery due to the median arcuate ligament, creating a hooked appearance with post-stenotic dilation (figure 1). A repeat sonography with Doppler revealed a normal calibre coeliac artery in inspiration with a peak systolic velocity (PSV) of 147 cm/s (figure 2 …

A Co-Presentation of Biliary Ascariasis and Hepatic Hydatidosis.

A 50-year-old lady came with the complaints of vague abdominal pain and jaundice since 2 months. On examination she was afebrile and she had mild tenderness in right upper quadrant of the abdomen. Her direct bilirubin was 2.5 mg/dl, white blood count was 11,800. Rest of the laboratory values were within normal limits. On Ultrasonography there was hepatomegaly, measuring 17 cm in cranio-caudal dimension. There was a hypoechoic lesion in the liver with peripheral hypoechoic halos in segment III of liver. There were internal hyperechoic irregular membranes inside the lesion without internal vascularity. These findings were highly suggestive of hydatid cyst of liver [Table/Fig-1a]. Common bile duct was dilated up to 1.4 cm and there were multiple tubular structures seen in the Common bile duct [Table/Fig-1b]. These were also reaching up to the gall bladder via cystic duct [Table/Fig-1c]. These tubular structures were suggestive of worms. This was highly unlikely for both pathologies to occur simultaneously in the same patient. ERCP was done to remove worms after a dose of anti-helminthic medications. The tubular parallel hyperechoic structures seen in the common bile duct were multiple Ascaris worms which were removed on ERCP. After that, pericystectomy was done to remove the hydatid cyst. Histo-pathological evaluation from the resected specimen shows 3 layers of hydatid cyst with scolices [Table/Fig-1d]. Possible co-infestations for other geo-helminths were found to be negative. Also, serologies for HIV and hepatitis virus were done which was negative. Patient was asymptomatic on routine follow up. [Table/Fig-1a]: Abdominal ultrasound at right intercostal space shows a well-defined predominantly hypoechoic lesion with shaggy irregular outer walls in segment VIII of the liver. There is peripheral hypoechoic halo present around the lesion. There are few hyperechoic ... [Table/Fig-1b]: Abdominal ultrasound at right subcostal space shows dilated common bile duct up to 1.4 cm and few compacted tubular parallel hyperechoic structures in it. [Table/Fig-1c]: Abdominal ultrasound at right subcostal space shows distended gall bladder with curled up worms in the dependent part of the gall bladder. [Table/Fig-1d]: Histo pathological evaluation from the resected specimen shows 3 layers of hydatid cyst with scolices. The distribution of hydatid cysts in human is upto 50 to 75% with the rest occurring in the lungs and arterial system [1]. Rupture of hydatid cyst in to the biliary duct is the most common complication which may result in blockage of the duct [2]. USG and CT are the modalities of choice in identifying rupture of the hydatid cyst [2]. Common presentation of biliary ascariasis includes biliary colic, obstructive jaundice, choledocholithiasis, acute cholecystitis and acute cholangitis [3]. Common presentation of biliary ascariasis includes biliary colic, obstructive jaundice, choledocholithiasis, acute cholecystitis and acute cholangitis. Abdominal ultrasonography is the modality of choice with typical imaging findings of long, linear, parallel echogenic strip, usually without acoustic shadowing in the common bile duct [3]. ERCP can be used as therapeutic method for removal of the worm where as in hydatid cyst a combination of surgical intervention and chemotherapy is the treatment of choice [3,4]. There have been reports of Echinococcus co-infection with HIV, Hepatitis C and B virus [5]. In a similar of way co-infection of ascaris with other geo-helminths like Trichuris and Strongyloides have been reported [6]. How immune response against one of the infection is mutually beneficial against the other infection is yet to be studied. Also co-infection can point out areas endemic to both the infection. Also, it is difficult to diagnose both of them due to common presentations. Abdominal USG is a very important investigation for biliary ascariasis and hepatic hydatidosis. However, hydatid disease may give variable appearance on USG but biliary ascariasis is typically diagnosed on USG as compared to CT. The implication of Ascaris co-infection is yet to be studied on other life threatening disease. Co-existent infections may also, under some circumstances, suppress disease symptoms in places where polyparasitism is a rule.

Disseminated gestational choriocarcinoma presenting with hepatic and uveal metastases, hook effect, and choriocarcinoma syndrome

Choriocarcinoma is a human chorionic gonadotrophin (HCG)-secreting tumor that comprises vascular channels. It has a tendency for widespread metastasis, common sites for which include the lung, vagina, brain, liver, bone, intestine, and kidney. We describe a 30-year-old female who presented with hepatitis-like features and bilateral diminution of vision, and subsequently developed hemothorax and hemoperitoneum—all rare and seemingly unrelated manifestations which were finally attributable to metastases from gestational choriocarcinoma. To further complicate the clinical scenario, the serum HCG of the patient was mildly raised (due to a phenomenon called hook effect). Subsequently, the patient developed disseminated intravascular coagulation and succumbed to her illness. In this report, we discuss the imaging findings of choriocarcinoma, its potential sites of metastases, and the hook effect.