Smiti Sripathi

Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review.

INTRODUCTION Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. METHODS A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. RESULTS 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h. CONCLUSIONS Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.

Case Report-Inguinoscrotal ureteral hernia diagnosed on micturating cystourethrography

The presence of a ureter within an inguinal hernia is an extremely rare entity, usually discovered incidentally during herniorrhaphy and may pose a surgical risk. Early preoperative diagnosis is crucial to guide proper surgical approach and to preserve renal function.

Idiopathic granulomatous mastitis: a diagnostic dilemma for the breast radiologist

BackgroundIdiopathic granulomatous mastitis is a chronic inflammatory disease of the breast, which is often difficult to differentiate both clinically and radiologically from infectious aetiologies such as tuberculosis, fungal infections, and also from malignancy, thus posing a diagnostic dilemma. We present a pictorial review of the commonly encountered imaging findings in idiopathic granulomatous mastitis on mammography and ultrasound.Materials and methodsMammographic and ultrasound findings of histopathologically proven cases of granulomatous mastitis are discussed.ConclusionIdiopathic granulomatous mastitis has varied and non-specific appearances on ultrasound and mammography. Histopathology is essential to establish diagnosis.Teaching Points• Idiopathic granulomatous mastitis often poses a diagnostic dilemma for the radiologist by mimicking malignancy.• It has varied and non-specific appearances on mammography and ultrasound.• Histopathology is mandatory to establish the diagnosis and decide management.

Spectrum of Imaging Findings in Paget's Disease of the Breast-A Pictorial Review.

AbstractPurposeWe aimed to demonstrate imaging features of Paget’s disease of breast, which is an extremely uncommon malignancy that presents with changes in the nipple-areolar region that may or may not be associated with an underlying in situ component or invasive cancer.Methods and ResultsMammography is the initial investigation of choice, having a high sensitivity especially in cases where a palpable mass is present. The addition of ultrasound improves the accuracy of mammography. When both mammography and ultrasound are negative, MRI may detect an underlying mass or ductal carcinoma in situ (DCIS).ConclusionThe surgical management of Paget’s disease includes mastectomy with or without axillary dissection, though breast conservation surgery in the form of wide local excision can also be done in a selected group of patients. Management should be based on both clinical and imaging findings, including mammography and ultrasound, with MRI playing a crucial role in defining the extent of involvement. Teaching Points • To differentiate Paget’s disease from other chronic skin conditions. • Mammographic and ultrasound findings of histopathologically established Paget’s disease. • When ultrasound and mammogram are negative, MRI may detect underlying malignancy.

CT features, mimics and atypical presentations of gastrointestinal stromal tumor (GIST)

The term stromal tumor was coined in 1983 by Clark and Mazur for smooth muscle neoplasm of the gastrointestinal tract (GIT). Gastrointestinal stromal tumors (GIST) are nonepithelial tumors arising from the interstitial cells of Cajal, which express KIT protein-CD117 on immunohistochemistry. GIST can arise anywhere in the GIT, including the mesentery, omentum, and retroperitoneum.

Low dose MDCT with tube current modulation: Role in detection of urolithiasis and patient effective dose reduction

INTRODUCTION Urolithiasis is one of the major, recurring problem in young individuals and CT being the commonest diagnostic modality used. In order to reduce the radiation dose to the patient who are young and as stone formation is a recurring process; one of the simplest way would be, low dose CT along with tube current modulation. AIM Aim of this study was to compare the sensitivity and specificity of low dose (70mAs) with standard dose (250mAs) protocol in detecting urolithiasis and to define the tube current and mean effective patient dose by these protocols. MATERIALS AND METHODS A prospective study was conducted in 200 patients over a period of 2 years with acute flank pain presentation. CT was performed in 100 cases with standard dose and another 100 with low dose protocol using tube current modulation. Sensitivity and specificity for calculus detection, percentage reduction of dose and tube current with low dose protocol was calculated. RESULTS Urolithiasis was detected in 138 patients, 67 were examined by high dose and 71 were by low dose protocol. Sensitivity and Specificity of low dose protocol was 97.1% and 96.4% with similar results found in high BMI patients. Tube current modulation resulted in reduction of effective tube current by 12.17%. The mean effective patient dose for standard dose was 10.33 mSv whereas 2.92 mSv for low dose with 51.13-53.8% reduction in low dose protocol. CONCLUSION The study has reinforced that low-dose CT with tube current modulation is appropriate for diagnosis of urolithiasis with significant reduction in tube current and patient effective dose.

Abdominal cocoon secondary to disseminated tuberculosis

Abdominal cocoon, also known as sclerosing encapsulating peritonitis, represents a rare entity where a variable length of the small bowel is enveloped by a fibrocollagenous membrane giving the appearance of a cocoon. It may be asymptomatic and is often diagnosed incidentally at laparotomy. We present a rare case of abdominal cocoon due to abdominal tuberculosis.

Bilateral sclerosing orbital pseudotumour in an adult

Sclerosing pseudotumour of the orbit is a rare idiopathic chronic inflammatory process, which greatly mimics neoplasms both clinically and on imaging studies. It is therefore important to differentiate this entity from true neoplasms and to rule out any systemic associations. We present a rare case of sclerosing orbital pseudotumour in an adult man with no systemic illnesses who presented with painless progressive proptosis of both eyes and showed a gradual initial response to steroid therapy but relapsed after a 2-year interval.

Role of Shear Wave Elastography in the Assessment of Fibrosis in Chronic Liver Disease

Objective: To evaluate the diagnostic performance of shear wave elastography in the estimation of fibrosis in patients with chronic liver disease by using biopsy and/or serum markers as reference standard. Materials and methods: 100 patients underwent point quantification-shear wave elastography, for whom noninvasive serum fibrosis indices like APRI, FIB-4, and King’s score were calculated. The receiver-operator characteristic (ROC) curve analysis was performed. Results: The shear wave elastography measurements showed moderate agreement with APRI, FIB-4, and fair agreement with King’s score. The AUROC for differentiating F0-F1, F2-F3, F2-F3, and F4 are 0.873 and 0.504 respectively using APRI as reference standard. The cutoff values derived for differentiating F0-F1 and F2-F3 was 7.07 and for differentiating F2-F3 and F4 was 11.94. Conclusion: The diagnostic performance of shear wave elastography is comparable with that of serum fibrosis indices APRI and FIB-4.

Gallbladder Adenomyomatosis Mimicking Carcinoma: A Diagnostic Dilemma

A69-year-oldmanpresentedwith right hypochondriac pain accompanied by postprandial nausea and vomiting for 2 months. Additional symptoms included fever and fatigue for 4 days. There was associated history of weight loss of approximately 6 kg over the past few months. Vital signs were normal, and he was febrile (38.3°C). His skin and sclerae weremildly icteric. He had no signs of liver failure. His abdomen was soft, with tenderness noted in the right hypochondriac region (Murphy sign positive); no tenderness was noted elsewhere, and there was no evidence of ascites. The tip of the gallbladder was palpable in the right 9th costal margin. Laboratory evaluation revealed mild conjugated hyperbilirubinemia (total bilirubin level, 2.1 mg/dL; direct bilirubin level, 1.1 mg/dL), with normal levels of transaminases and alkaline phosphatase. Mild hypoalbuminemia was present. Other investigations were unremarkable. On the basis of the clinical and laboratory findings, the patient was evaluated for obstructive jaundice, and ultrasonography (US) was performed.