Marko Kralik

Color Doppler ultrasonography is reliable in assessing the risk of esophageal variceal bleeding in patients with liver cirrhosis

SummaryPURPOSE: The aim of the study was to examine the role of Doppler ultrasonography of the portal vein in predicting esophageal variceal bleeding in patients with liver cirrhosis and portal hypertension by comparing the ultrasound data to the endoscopic findings. PATIENTS AND METHODS: 99 patients with liver cirrhosis and esophageal varices underwent color Doppler ultrasonography and esophagogastroduodenoscopy. The following portal hemodynamic parameters were analyzed: diameter and cross-sectional area, mean blood flow velocity, blood flow volume, perfusion pressure gradient, congestion index, and platelet count-to-spleen diameter ratio. Variceal characteristics, the size and the presence of red signs, were determined by endoscopic examination. RESULTS: Patients with variceal red signs had significantly higher values of portal diameter (1.538 ± 0.246 vs. 1.243 ± 0.167), cross-sectional area (1.286 ± 0.448 vs. 0.945 ± 0.256), blood flow volume (965.520 ± 432.728 vs. 625.117 ± 320.999) and congestion index (0.165 ± 0.068 vs. 0.126 ± 0.051) than patients without red signs, while the perfusion pressure gradient (0.260 ± 0.087 vs. 0.447 ± 0.271) and the platelet-to-spleen ratio (522.424 ± 222.823 vs. 708.921 ± 230.769) were lower. The same pattern of differences between the ultrasound parameters was found in patients with large varices comparing ones with red signs to the ones without them (diameter, 1.567 ± 0.234 vs. 1.258 ± 0.175; cross-section, 1.313 ± 0.455 vs. 1.061 ± 0.264; flow volume, 988.195 ± 443.353 vs. 739.423 ± 414.281; congestion index, 0.171 ± 0.067 vs. 0.130 ± 0.058; perfusion pressure gradient 0.247 ± 0.078 vs. 0.501 ± 0.379 and platelet-to-spleen ratio 479.930 ± 184.302 vs. 699.094 ± 316.171). Differences in values of ultrasonographic parameters were less obvious among groups of patients with different variceal sizes: only the diameter, cross-sectional area and blood flow volume were significantly different. The mean blood flow velocity did not depend on the variceal size or on the presence of red signs. The sensitivities and specificities of the analyzed parameters were 60–80% and 48.6–78.4%, respectively. CONCLUSIONS: Results suggest that color Doppler ultrasonography is a useful noninvasive method for evaluating the risk of esophageal variceal bleeding in patients with liver cirrhosis.ZusammenfassungZIEL: Untersuchung der Anwendbarkeit des Farb-Doppler-Ultraschalls in der Vorhersage von Ösophagusvarizen-Blutungen bei Patienten mit Leberzirrhose im Vergleich zur Endoskopie. PATIENTEN UND METHODEN: Farb-Doppler-Ultrasonographie und Ösophagogastroduodenoskopie wurden bei 99 Patienten mit Leberzirrhose und Ösophagusvarizen durchgeführt. Folgende hämodynamische Parameter der V. portae wurden mittels Doppler-Ultraschall gemessen: Durchmesser und Querschnittsfläche, mittlere Blutflussgeschwindigkeit, Blutflussvolumen, Perfusionsdruckgradient, Kongestions-Index und das Verhältnis von Thrombozytenzahl zu Milzdurchmesser. Die Charaktersitik der Varizen, ihre Größe und das Vorhandensein von Rötungszeichen wurden endoskopisch erhoben. ERGEBNISSE: Patienten mit Rötungszeichen der Varizen hatten signifikant höhere Werte der portalen Durchmesser (1,538 ± 0,246 vs 1,243 ± 0,167), der Querschnittsflächen (1,286 ± 0,448 vs. 0,945 ± 0,256), des Blutflussvolumens (965,520 ± 432,728 vs. 625,117 ± 320,999) und des Kongestions-Index (0,165 ± 0,068 vs. 0,126 ± 0,051). Der Perfusionsdruckgradient (0,260 ± 0,087 vs. 0,447 ± 0,271) und das Verhältnis Thrombozytenzahl/Milzdurchmesser (522,424 ± 222,823 vs. 708,921 ± 230,769) hingegen waren im Vergleich mit den Werten der Patienten ohne Rötungszeichen erniedrigt. Bei den Patienten mit großen Varizen wurden ähnliche Ergebnisse in den Ultraschall-Parametern erhoben. Die Durchmesser, Querschnittsflächen, Kongestionsindices, Perfusionsdruckgradienten und Thrombozyten/Milz-Quotienten waren bei den Patienten mit Rötungszeichen im Vergleich zu denen ohne wie folgt: 1,567 ± 0,234 vs. 1,258 ± 0,175; 1,313 ± 0,455 vs. 1,061 ± 0,264; 988,195 ± 443,353 vs. 739,423 ± 414,281; 0,171 ± 0,067 vs. 0,130 ± 0,058; 0,247 ± 0,078 vs. 0,501 ± 0,379 und 479,930 ± 184,302 vs. 699,094 ± 316,171. Die Unterschiede in den Ultraschall-Parametern waren weniger deutlich in den Patientengruppen mit unterschiedlicher Varizengröße. Nur der Durchmesser, die Querschnittsfläche und das Blutflussvolumen waren in diesen Gruppen signifikant unterschiedlich. Die mittlere Blutflussgeschwindigkeit war weder von der Varizengröße noch vom Vorhandensein von Rötungszeichen abhängig. Die Sensitivität der Ultraschallparameter lag zwischen 60 und 80 %, die Spezifität zwischen 49 und 78 %. SCHLUSSFOLGERUNG: Die Farb-Doppler-Ultrasonographie ist eine brauchbare, nicht-invasive Methode zur Risikoabschätzung für die Blutung von Ösophagusvarizen bei Patienten mit Leberzirrhose.

Urokinase Plasminogen Activator and Its Inhibitor Type-1 as Prognostic Factors in Differentiated Thyroid Carcinoma Patients:

Objective To investigate the prognostic value of urokinase-type plasminogen activator (uPA) and its inhibitor, type-1 plasminogen activator inhibitor (PAI-1), in differentiated thyroid cancer. Study Design Prospective cohort study. Setting University hospital. Subjects and Methods Cytosolic concentrations of uPA and PAI-1 were determined in 105 patients with differentiated thyroid carcinoma and normal matched tissues using an enzyme-linked immunoassay (ELISA). Results Both uPA and PAI-1 concentrations were significantly higher in differentiated thyroid tumors (uPA = 0.509 ± 0.767 and PAI-1 = 6.337 ± 6.415 ng/mg) compared to normal tissues (uPA = 0.237 ± 0.051, P < .001; PAI-1 = 2.368 ± 0.418 ng/mg, P < .001). uPA and PAI-1 were significantly higher if extrathyroidal invasion (uPA, P = .015; PAI-1, P < .001) or distant metastasis (PAI-1 P < .001) was present, as well as in tumors whose size exceeded 1 cm in diameter (uPA, P = .002; PAI-1, P = .001). Survival analysis revealed the significant impact of both uPA and PAI-1 on progression-free survival (PFS) (82.22 vs 49.478 months for patients with low and high uPA, respectively, P < .001; 87.068 vs 44.964 months for patients with low and high PAI-1, respectively, P < .001). Univariate analysis showed that gender, tumor size, tumor grade, extrathyroid invasion, local lymph node involvement, distant metastasis, uPA, and PAI-1 were significant predictors of PFS. However, multivariate analysis identified only distant metastasis and tumor tissue uPA and PAI-1 as independent prognostic factors. Conclusion These findings indicate that high uPA and PAI-1 levels represent independent unfavorable prognostic factors in patients with differentiated thyroid carcinoma.

Cross-sectional imaging of the pelvic tumors and tumor-like lesions in gynecologic patients—misinterpretation points and differential diagnosis

Computed tomography and/or magnetic resonance imaging were performed in 42 female patients with suspected pelvic mass. Surgical and histopathological reports were compared to the imaging findings, yielding mismatch in five (17.8%) patients. One benign cyst and one case of postirradiation fibrosis were characterized as recurrent tumors, one surgically transposed ovary as metastasis, and an ovarian torsion as ovarian tumor, and a pelvic hematoma was mistaken for abscess. The most common false-positive finding on a per-lesion basis was that of enlarged lymph nodes.

Spinal cord compression caused by multiple spinal osteochondromas

A 15-year-old boy with positive family history of osteochondromatosis presented with a three-month history of progressive paraparesis and a month history of urinary incontinence. The patient underwent irradiation of the whole neuroaxis for meduloblastoma at the age of 18 months. The CT and MRI showed multilevel osteochondromas of the spine with irregularly narrowed spinal canal to the level of complete obliteration, and spinal cord compression and displacement (Fig. 1A and 1B). MRI delineated the extent of the osteochondromas, particularly the cartilage cap, more accurately than CT. MRI was also superior in visualizing spinal cord compression. CT, however, was performing better in analysis of the bony structures of the tumors, calcifications, and in assessment of the spinal canal deformity (Fig. 1C). After laminectomy and partial resection of the tumor masses, neurological deficits remained, despite achieved decompression of the neural structures. Postoperative CT and MRI of the spine revealed residual exostosis that caused displacement of the spinal cord and postischemic changes of the spinal cord at the level Th2 (Fig. 2). Histological analysis of the removed specimens confirmed the benign nature of the tumors. Osteochondroma is a cartilaginous tumor, the most common benign tumor of the bone. It may be solitary, or multiple (osteochondromatosis, usually with autosomal dominant inheritance) [1, 2]. We believe that the osteochondromatosis in our patient was hereditary with possible acceleration of progression of the tumor growth caused by irradiation since it may be induced by radiation exposure [3].

Resistance index in mural arteries of thickened bowel wall: predictive value for Crohn disease activity assessment in pediatric patients

SummaryObjectiveTo define reliable Doppler parameters in mural arteries of affected bowel loops for quantitative assessment of Crohn disease (CD) activity in pediatric population and compare Doppler parameters with Pediatric Crohn Disease Activity Index (PCDAI).Patients and methodsThirty-four pediatric patients (7 with inactive, 27 with active disease of different severity; 13 male and 21 female; mean age 13; range 7–18) with CD were prospectively evaluated by Doppler ultrasound (DUS) of affected bowel segments. Using semiquantitative color and power Doppler assessment of vascularization of thickened bowel wall and mesentery, patients were divided in four grades. Spectral measurements (peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI)) of mural arteries were compared with PCDAI.ResultsThere was a significant difference in distribution of semiquantitative color values between inactive and active group. PSV and EDV values showed no significant difference between inactive and active group, while mean RI was significantly higher in the inactive group. RI was also significantly negatively correlated with PCDAI.ConclusionIntensity of color and power Doppler signals and RI measurement of mural arteries in thickened bowel wall is linked to CD activity and therefore might be of use in pediatric patients.ZusammenfassungZielDas Ziel dieser Studie war es, die zuverlässigen Doppler-Parameter in den intramularen Arterien der betroffenen Darmschlingen zur quantitativen Bewertung der Aktivität des Morbus Crohn (CD) bei der pädiatrischen Population zu definieren und die Doppler-Parameter mit dem pädiatrischem Morbus Crohn Aktivitätsindex (PCDAI) zu vergleichen.Patienten und MethodenDer Zustand von 34 pädiatrischen Patienten (7 mit inaktiver, 27 mit aktiver Erkrankung unterschiedlichen Schweregrades, 13 männliche und 21 weibliche, Alter 7–18, Durschnittsalter 13) mit M. Crohn wurde prospektiv anhand des Doppler-Ultraschall (DUS) betroffener Darmsegmente ausgewertet. Anhand der semi-quantitativen Farb- und Power-Doppler-Beurteilung der Vaskularisation der verdickten Darmwand und des Mesenteriums wurden die Patienten in 4 Gruppen unterteilt. Die spektrale Messungen (die maximale systolische Strömungsgeschwindigkeit – PSV, die enddiastolische Strömungsgeschwindigkeit – EDV, der Resistance-Index – RI) intramuraler Arterien wurden mit PCDAI verglichen.ErgebnisseEs bestand ein signifikanter Unterschied in der Verteilung der semi-quantitativen Farbwerte zwischen der inaktiven und aktiven Gruppe. PSV und EDV-Werte zeigten keinen signifikanten Unterschied zwischen der inaktiven und der aktiven Gruppe, während der mittlere RI in der inaktiven Gruppe signifikant höher war. Der RI war ebenfalls signifikant negativ mit dem PCDAI korreliert.SchlussfolgerungDie Intensität der Farb- und Power-Doppler-Signale und die RI-Messung in den intramuralen Arterien der verdickten Darmwand stehen im Zusammenhang mit der Aktivität des Morbus Crohn und können daher bei pädiatrischen Patienten von Nutzen sein.

Eiternde Osteomyelitis mit Epiduralabszess bei einem Erwachsenen mehr als ein Jahrzehnt nach zervikaler Wirbelsäulenverletzung@@@Purulent osteomyelitis with epidural abcess in an adult over a decade after cervical spine injury

Cervical osteomyelitis and epidural abscess are rare and potentially fatal conditions with severe neurological manifestations. Changes on plain radiography and computed tomography are non-specific, while contrast enhanced magnetic resonance imaging shows high sensitivity and specificity in establishing early diagnosis.ZusammenfassungZervikale Osteomyelitiden und epidurale Abszesse sind seltene und potenziell tödlich verlaufende Störungen mit schweren neurologischen Manifestationen. Die Veränderungen im konventionellen Röntgenbild und in der Computertomographie (CT) sind unspezifisch, während die kontrastverstärkte Magnetresonanztomographie (MRT) eine frühzeitige Diagnose mit hoher Sensitivität und Spezifität ermöglicht.AbstractCervical osteomyelitis and epidural abscess are rare and potentially fatal conditions with severe neurological manifestations. Changes on plain radiography and computed tomography are non-specific, while contrast enhanced magnetic resonance imaging shows high sensitivity and specificity in establishing early diagnosis.

Eiternde Osteomyelitis mit Epiduralabszess bei einem Erwachsenen mehr als ein Jahrzehnt nach zervikaler Wirbelsäulenverletzung

Cervical osteomyelitis and epidural abscess are rare and potentially fatal conditions with severe neurological manifestations. Changes on plain radiography and computed tomography are non-specific, while contrast enhanced magnetic resonance imaging shows high sensitivity and specificity in establishing early diagnosis.ZusammenfassungZervikale Osteomyelitiden und epidurale Abszesse sind seltene und potenziell tödlich verlaufende Störungen mit schweren neurologischen Manifestationen. Die Veränderungen im konventionellen Röntgenbild und in der Computertomographie (CT) sind unspezifisch, während die kontrastverstärkte Magnetresonanztomographie (MRT) eine frühzeitige Diagnose mit hoher Sensitivität und Spezifität ermöglicht.AbstractCervical osteomyelitis and epidural abscess are rare and potentially fatal conditions with severe neurological manifestations. Changes on plain radiography and computed tomography are non-specific, while contrast enhanced magnetic resonance imaging shows high sensitivity and specificity in establishing early diagnosis.

EWING’S SARCOMA OF THE THIRD METATARSAL: A CASE REPORT AND REVIEW OF THE LITERATURE

We report a rare case of Ewings sarcoma involving the third metatarsal bone and spreading into adjacent bone in a 23-year-old man, with special emphasis on imaging characteristics. On radiographs the tumor presented as a permeative lytic lesion with aggressive periosteal reaction and cortical destruction. Computed tomography and magnetic resonance imaging delineated the osseous and soft tissue extent of the tumor. A large soft-tissue mass around the involved bone was highly indicative of Ewings sarcoma. Cortical invasion of the neighboring second metatarsal was seen only on magnetic resonance imaging. Increased up-take of technetium 99m methylene diphosphonate was noticed on bone scintigraphy. An early diagnosis of Ewings sarcoma, even when it occurs in unusual locations, is necessary for adequate treatment and is of particular importance in terms of prognosis. The optimal imaging modality for the diagnosis of Ewings sarcoma is magnetic resonance imaging since it allows accurate analysis of the soft-tissue component and visualization of possible local invasion of adjacent structures.

Multidetector computed tomography of iatrogenic urinary trauma – pictorial review

Abdomino-pelvic interventional and surgical procedures can result in iatrogenic urinary tract injury. Radiological diagnosis can be difficult to establish because findings are caused by iatrogenic trauma, and by underlying disease and therapeutical procedures. We performed multidetector computed tomography (MDCT) in patients with suspected urinary tract trauma with scanning protocol selected according to the suspected type of injury: non-enhanced scanning for detection of fluid collections, MDCT angiography for renal parenchymal and vascular changes, MDCT urography for pelvicalyceal and ureteric injuries, and MDCT cystography for bladder and urethral lesions. The injuries were found after urologic, general surgical and gynaecological/obstetric procedures. Renal parenchymal injuries were caused by blunt (extracorporeal shock-wave lithotripsy) or penetrating trauma (renal biopsy), with formation of subcapsular, perinephric and/or paranephric haematomas. Renal vascular pedicle changes after kidney transplantation were precisely defined using MDCT angiography. MDCT urography depicted leakage of contrast material from the pelvicalyceal system after nephron-sparing surgery, from the ureter after kidney transplantation, and from bladder tear after caesarean section, while urethral injury after bladder catheterization was diagnosed using MDCT cystography. MDCT angiography and/or MDCT urography present methods for evaluation of iatrogenic urinary tract trauma because they enable fast and accurate diagnosis and planning of surgical and interventional procedures.