Shuchi Bhatt

Spontaneous transmural migration of retained surgical textile into both small and large bowel: a rare cause of intestinal obstruction

Retained surgical textile is an infrequent but serious complication of abdominal surgery. Diagnosis is often delayed owing to non-specific clinical symptoms and inconclusive imaging features. Medicolegal implications further complicate the issue. We report a case of a 30-year-old woman who had previously undergone caesarean section and who presented with pain and features of intestinal obstruction. Contrast-enhanced CT revealed a heterogeneous ill-defined mass with mottled air densities lying within both the large and the small bowel. Barium study beautifully demonstrated the intraluminal mass in the transverse colon extending into the jejunum, with a fistulous communication between the two loops. To the best of our knowledge, this is the first reported case in which the gauze migrated simultaneously into the large and small bowel, and where the exact site of migration was clearly mapped out on pre-operative imaging studies.

Prospective randomized clinical trial comparing phytotherapy with potassium citrate in management of minimal burden (≤8 mm) nephrolithiasis

Aim: To compare efficacy and tolerability of phytotherapy (PT) vs. potassium citrate (KC) in patients with minimal nephrolithiasis. To compare and assess changes in value of certain serum (Ca2+, PO43-, uric acid [UA]) and urinary (24-hr Ca2+, PO43-, UA, citrate, oxalate, and urine pH) parameters in patients being treated with PT or KC. Materials and Methods: After clearance by the local institutional ethics committee, 60 patients of nephrolithiasis who had consented for the study, were enrolled (as per entry criteria) and randomized into citrate therapy (group-I) or PT (group-II). PT was administered as a nutritional supplement, using a lupeol-based extract (Tablet Calcury™, two tablets twice a day). They were monitored for the changes in the serum and urinary biochemical, radiological, and clinical parameters (efficacy and tolerability) as per protocol. Results: Group-I patients demonstrated favorable changes in certain biochemical parameters (decreased serum calcium, urinary UA/oxalate, increased urinary citrate and pH) along with significant symptomatic improvement (decrease in visual analogue pain score with increased stone clearance/reduction in stone size). Four (13.3%) patients of group-I had mild upper gastrointestinal discomfort which was controlled with antacids. Group-II patients had favorable changes in biochemical parameters (decreased serum UA and increased urinary citrate) along with significant symptomatic improvement (reduction/clearance in the stone size), but without any noticeable side effects. Conclusions: Medical therapies with both KC and PT (with lupeol extract using Calcury™) were effective in reducing the stone size and symptoms of nephrolithiasis. It appeared that KC was biochemically efficacious in producing some favorable biochemical changes with some side effects, whereas PT was probably clinically efficacious in hastening stone expulsion (<8 mm) without any observed adverse events. Although both the medical therapies were not effective in all aspects, we believe that PT using lupeol-based extract (Calcury™) may be used as an alternative form of medical therapy in select patients with minimal nephrolithiasis. Long-term randomized placebo-controlled trials are needed to better define the precise role of lupeol-based PT vs. citrate therapy in minimal nephrolithiasis.

Contrast Induced Nephropathy with Intravenous Iodinated Contrast Media in Routine Diagnostic Imaging: An Initial Experience in a Tertiary Care Hospital

Background. Contrast induced nephropathy (CIN) is common cause of hospital acquired renal failure, defined as iatrogenic deterioration of renal function following intravascular contrast administration in the absence of another nephrotoxic event. Objectives. Objectives were to calculate incidence of CIN with routine IV contrast usage and to identify its risk factors. Materials and Methods. Study was conducted on 250 patients (having eGFR ≥ 45 mL/min/1.73 m2) receiving intravenous contrast. Various clinical risk factors and details of contrast media were recorded. Patients showing 25% increase in postprocedural serum creatinine value or an absolute increase of 0.5 mg/dL (44.2 mmol/L) were diagnosed as having CIN. Results and Conclusions. Postprocedural serum creatinine showed significant increase from baseline levels. 25 patients (10%) developed CIN. CIN was transient in 21 (84%) patients developing CIN. One patient (4%) developed renal failure and another died due to unknown cause. Dehydration, preexisting renal disease, cardiac failure, previous contrast administration, and volume of contrast had significant correlation with development of CIN (p < 0.05); whereas demographic variables, baseline serum creatinine/eGFR, previous renal surgery, diabetes mellitus, hypertension, nephrotoxic drug intake, abnormal routine hematology, and contrast characteristics had no correlation with CIN. CIN is a matter of concern even in routine imaging requiring intravenous contrast media, in our set-up.

Radiography and sonography of clubfoot: A comparative study.

Background: Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot. Materials and Methods: Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades. Results: MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity. Conclusion: All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Pseudoachondroplasia: A rare cause of rhizomelic dwarfism

Pseudoachondroplasia is a rare rhizomelic short-limbed skeletal dysplasia. Its inheritance is varied; autosomal dominant pattern and germline or somatic mutations can occur. Children at 2–3 years of age present with short height, gait disturbances, or limb deformities. Characteristic skeletal changes include shortening of long bones, predominantly of femur and humerus with irregular, flared metaphysis and fragmented epiphysis. Platyspondyly is also present, but the interpedicular distance is normal. The diagnosis is essentially based on imaging, and thus, it is important to be aware of the radiological features. Here, we report a case of two brothers where the elder sibling had classical radiological features of pseudoachondroplasia, whereas the younger one had early changes of this disorder.

Extraskeletal juxtaarticular chondroma of the knee.

Extraskeletal chondromas are atypical lesions and their recognition is important to avoid invasive treatment methods like marginal excision. The diagnosis must be confirmed with correlating clinical, radiological and histopathological examination. We report a 40-year-old woman with an extraskeletal chondroma around the knee joint. The radiological and histopathological aspects of the patient are presented along with a review of the literature.

Pancreatic laceration and portal vein thrombosis in blunt trauma abdomen.

Injuries to the pancreas by blunt trauma are uncommon. The association of pancreatic injury with acute portal vein thrombosis secondary to blunt trauma abdomen is furthermore rare. The early diagnosis of the pancreas with injury to the portal vein is challenging and difficult. These injuries are associated with high morbidity and mortality, particularly if the diagnosis is delayed. Accurate and early diagnosis is therefore imperative and computed tomography plays a key role in detection. We present a case of child with a rare combination of pancreatic laceration and acute portal vein thrombosis following a blunt trauma to the abdomen. With extensive literature search we found no such cases has been described previously.

Outcome of low level lasers versus ultrasonic therapy in de Quervain's tenosynovitis.

Background: de Quervains tenosynovitis is an inflammation of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle tendon sheaths at the level of radial styloid process. Its conservative management includes nonsteroidal anti-inflammatory drugs, wrist and thumb immobilization, ultrasonic therapy (US Th.) and low level laser therapy (LLLT). Literature is scanty on comparative efficacy of US Th. and LLLT for its management. This prospective study evaluates outcome of US Th. versus LLLT in de Quervains disease. Materials and Methods: Thirty patients clinically diagnosed de Quervains tenosynovitis were included in the study and randomly assigned to two groups. The average age was 36 years (range: 21-45 years). One group was given LLLT and the other US Th. for a total of 7 exposures on alternate days. The clinical criteria used were Finkelsteins test, tenderness over radial styloid (Ritchies tenderness scale), grip strength, pain (visual analog scale [VAS]) and radiological criteria was ultrasonographic assessment of change in thickness of APL and EPB tendon sheath. They were measured before commencement and at the end of seven sessions of therapy, as per standard procedure. Results: Significant improvement was seen within both groups in the following outcome measures assessed: Ritchies tenderness scale, grip strength and VAS. Finkelsteins test was not significantly improved in either groups. Ultrasonographic measurement of tendon sheath diameters, the mediolateral (ML), and anteroposterior (AP) diameters was not found to be significantly different in the US Th. group and the laser therapy group after treatment. On comparing both the groups, no statistically significant difference was found. However, looking at the mean values, the grip strength and VAS showed better improvement in the US Th. group as compared to the laser therapy group.

Mesenteric Liposarcoma: Report of Two Cases with Review of Literature

Liposarcomas are the most common sarcomas of adulthood [1]. They usually arise in the deep soft tissues of the extremities and retroperitoneum. There are five histopathological types of liposarcoma: well differentiated, myxoid, round cell, dedifferentiated, and pleomorphic [2]. They are notorious to grow relentlessly into largesized tumors when they become clinically symptomatic in view of sheer size or compression on adjacent organs. Though liposarcoma are the most common tumors of the retroperitoneum, bowel mesentery is an uncommon site for them. There are a few case reports of mesenteric liposarcoma (ML) in the English literature. There are no standard guidelines for the management of mesenteric liposarcomas in view of rarity of tumor. We present our experience of two cases of dedifferentiated mesenteric liposarcoma and discuss the reported clinicopathological features and employed management strategies. Case Presentations

Fat poor angiomyolipoma with lymphadenopathy: Diagnostic dilemma

A 24-year-old lady presented with left flank pain of 3 months duration. She had stigmata of tuberous sclerosis complex in the form of angiofibromas on face, ash-leaf macules on back and right upper limb and shagreen patches over back. Computed tomography scan of the abdomen showed 6.5 cm × 5.0 cm × 4.4 cm lobulated intensely enhancing exophytic mass lesion in mid pole of left kidney with significant para-aortic lymphadenopathy with no evidence of fat in the mass. She underwent radical left nephrectomy with a provisional diagnosis of renal cell carcinoma. Histopathological examination showed multicenteric angiomyolipoma involving kidney and para-aortic lymph nodes. This case report underscores the need for further research to differentiate fat-poor angiomyolipoma and lymphadenopathy from renal cell carcinoma.