Ujjwal Gorsi

Pancreatic volvulus with wandering spleen and gastric volvulus: An unusual triad for acute abdomen in a surgical emergency

Wandering spleen is a rare clinical condition which occurs due to laxity or absence of the normal intraperitoneal ligaments that hold the spleen in place. Gastric volvulus and wandering spleen share a common etiology of absence or laxity of intraperitoneal ligaments. The occurrence of simultaneous pancreatic volvulus has never been described before in adolescence. Herein, we report a case having wandering spleen with torsion, and gastric and distal pancreatic volvulus, an unusual triad in acute abdomen in an emergency setting, which has never been described before to the best of our knowledge.

Imaging in pulmonary hydatid cysts

Hydatid disease is a zoonosis that can involve almost any organ in the human body. After the liver, the lungs are the most common site for hydatid disease in adults. Imaging plays a pivotal role in the diagnosis of the disease, as clinical features are often nonspecific. Classical radiological signs of pulmonary hydatid cysts have been described in the literature, aiding in the diagnosis of the disease. However, complicated hydatid cysts can prove to be a diagnostic challenge at times due to their atypical imaging features. Radiography is the initial imaging modality. Computed tomography can provide a specific diagnosis in complicated cases. Ultrasound is particularly useful in peripheral lung lesions. The role of magnetic resonance imaging largely remains unexplored.

Role of digital tomosynthesis and dual energy subtraction digital radiography in detection of parenchymal lesions in active pulmonary tuberculosis

OBJECTIVE To assess the role of digital tomosynthesis (DTS) and dual energy subtraction digital radiography (DES-DR) in detection of parenchymal lesions in active pulmonary tuberculosis (TB) and to compare them with digital radiography (DR). MATERIALS AND METHODS This prospective study was approved by our institutional review committee. DTS and DES-DR were performed in 62 patients with active pulmonary TB within one week of multidetector computed tomography (MDCT) study. Findings of active pulmonary TB, that is consolidation, cavitation and nodules were noted on digital radiography (DR), DTS and DES-DR in all patients. Sensitivity, specificity, positive and negative predictive values of all 3 modalities was calculated with MDCT as reference standard. In addition presence of centrilobular nodules was also noted on DTS. RESULTS Our study comprised of 62 patients (33 males, 29 females with age range 18-82 years). Sensitivity and specificity of DTS for detection of nodules and cavitation was better than DR and DES-DR. Sensitivity and specificity of DTS for detection of consolidation was comparable to DR and DES-DR. DES-DR performed better than DR in detection of nodules and cavitation. DTS was also able to detect centrilobular nodules with sensitivity and specificity of 57.4% and 86.5% respectively. CONCLUSION DTS and DES-DR perform better than DR in detection of nodules, consolidation and cavitation in pulmonary TB. DTS gives better results than DES-DR, particularly in detection of cavitation and has moderate sensitivity for detection of centrilobular nodules. Thus DTS can be used for evaluation of patients of suspected pulmonary TB, thereby giving a more confident diagnosis of active disease and also in follow up.

Congenital Uterine Arteriovenous Malformation Presenting as Postcoital bleeding: A Rare Presentation of a Rare Clinical Condition

Congenital uterine arteriovenous malformation (AVM) is an extremely rare condition with <100 cases documented in literature. We report multiparous women presenting to us with a history of postcoital bleed. Initial Doppler ultrasonography was consistent with features suggestive of AVM. Subsequently, computed tomography (CT) angiography confirmed the diagnosis. Embolization was chosen as the treatment because of the large extension of AVM and the risk of hemorrhage during hysterectomy. The patient was discharged in a stable condition with a plan of repeat embolization in the next setting. At 6 and 12 weeks of follow-up, she did not experience any further episodes of bleed. The purpose of this case report is to highlight the salient clinical features, diagnosis, and the management options available for this rare clinical condition.

Mounier-Kuhn syndrome masquerading pulmonary thromboembolism in an elderly male

Mounier-Kuhn syndrome, also referred to as tracheobronchomegaly, is a rare idiopathic clinical and radiologic disorder characterized by significant tracheobronchial dilation. It results in recurrent lower respiratory tract infections and bronchiectasis. In severe cases, patients may present with acute respiratory distress requiring hospital admission and ventilatory support. Clinical examination and chest radiography may be misleading in these patients as tracheobronchomegaly is easily overlooked on radiographs. We present an interesting report of our patient who presented with acute shortness of breath. A diagnosis of acute pulmonary thromboembolism was suggested by initial evaluation. Computed tomography pulmonary angiography was negative for thromboembolism; however, it revealed diagnosis of this rare disorder.

Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy for treatment of infected pancreatic necrosis in early phase of illness

Background and Objectives: Infected pancreatic necrosis (IPN) in the early phase is treated with “step up approach” involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is a paucity of data on a combined approach of initial PCD followed by endoscopic drainage and necrosectomy. A retrospectively study on safety and efficacy of initial PCD followed by endoscopic transluminal drainage and necrosectomy in IPN. Methods: Retrospective analysis of data of 23 patients with IPN who were treated with a combined approach. Patients were divided into two groups as follows: patients with central necrosis in whom PCD and endoscopic drainage were done in the same collection (n = 11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis, and endoscopic drainage was done for central necrosis (n = 12). Results: Endoscopic drainage could be done successfully in all 23 patients with mean time for the resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while direct endoscopic necrosectomy (DEN) was needed in 8 (34.8%) patients and fully covered self-expanding metal stent was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%), and 7 in 3 (13%) patients, respectively. Patients of central walled-off pancreatic necrosis (WOPN) with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter. Conclusion: The combined approach of initial PCD followed by endoscopic drainage and necrosectomy is safe and effective treatment alternative for patients with IPN.

Pneumoperitoneum in treated abdominal tuberculosis: Not always paradoxical worsening

Sir, We read with keen interest the report of pneumoperitoneum during the treatment of abdominal tuberculosis in a non‐HIV patient.[1] We had a similar scenario of A 48‐year‐old male who presented with a 3‐year history of recurrent episodes of abdominal pain and subacute intestinal obstruction. He was HIV nonreactive. In 2017, he underwent colonoscopy that revealed multiple ulcers in the cecum and ascending colon with widely open and deformed ileocecal valve. The computed tomography (CT) abdomen showed mural thickening and enhancement of the terminal ileum and ascending colon with gaping ileocecal valve; contracted, pulled, and deformed cecum [Figure 1]. The histopathology showed noncaseating epithelioid granulomas in the submucosa. His Mantoux was positive. He was started on standard four drugs antitubercular therapy (ATT) and had improvement with weight gain. His repeat colon after 2 months showed evidence of early mucosal response. However, 15 days after the end of therapy at 6 months, he had an episode of abdominal pain that subsided on its own. His X‐ray abdomen revealed gas under the diaphragm and a repeat CT abdomen revealed pneumoperitoneum with evidence of pneumatosis in ileal loops [Figure 2a and b]. The patient, however, had no signs of peritonitis and remained well. Pneumoperitoneum disappeared by 3 days, and the patient has remained well after 2 months of this episode.

Infected double graft explantation in graft enteric erosion

Aortoenteric fistula (AEF) is an uncommon entity with high morbidity and mortality associated with it. Primary AEF can occur in the presence of aortic aneurysm but it is less common as compared to the secondary type, which is associated with the presence of prosthetic graft used for repair of aortic aneurysm or aortic bypass for occlusive disease. Multiple strategies have been described in the literature which needs to be individualized to each patient. This patient had undergone aortobifemoral bypass twice in the past, which makes anatomy hostile, followed by graft infection and graft enteric (jejunum) erosion leading to very challenging case to treat. The patient was managed in two stages, first axillobifemoral bypass followed by explantation of two grafts. He is doing fine at >12 months of follow-up.

Subclavian Artery Pseudoaneurysm Following Lung Abscess in a Child

To the Editor: Subclavian artery aneurysms (SAA) are rare in children. The few cases reported are associated with BlalockTaussig shunt placement, aberrant subclavian artery, thoracic outlet syndrome or trauma [1–3]. We report a child with mycotic (infective) SAA associated with lung abscess. A 7-y-old girl was treated in an outside hospital as a case of right foot abscess and concurrent left lung abscess. The abscess was drained, pus culture was sterile and blood culture grew Escherichia coli. Into four weeks of antibiotic therapy, she developed sudden-onset swelling over left supraclavicular area, with increase in size following fine needle aspiration. Imaging revealed pseudo-aneurysm arising from proximal part of left subclavian artery (SCA), for which she was referred to our hospital. There was no prior central venous catheter (CVC) placement or trauma. At admission, child was noted to have a pulsatile swelling in left supraclavicular region, measuring 3 × 3 cm and she required oxygen support. Examination revealed tachypnea, flattening of left hemithorax and amphoreic breath sounds in left hemithorax. CT angiography revealed aneurysm in proximal 1/3rd of left SCA (Fig. 1). The cause considered was contiguous spread from lung abscess, because of the close proximity. The preferred management for mycotic aneurysms is surgery [4], especially when they are wide necked like in our index child. However, because of financial constraints endovascular embolotherapy with balloon and thrombin injection was done. Post-embolization check run showed complete obliteration of aneurysm, but repeat ultrasonography 12 h later revealed recanalization. So, primary closure of rent using median sternotomy and supra clavicular incisions was done. Post-operatively she received aspirin for 3 mo. At a follow-up of 24 mo, she remains well. This case represents an unusual complication that can arise from apical lung abscess. A pseudo aneurysm occurs due to a breach in tunica media and externa due to iatrogenic trauma from arterial puncture, contiguous infection or penetrating injury [5]. This results in a communicating hematoma, whose wall is formed by extravascular fibrous tissue. The mycotic pseudo-aneurysms have high chance of spontaneous rupture or dissemination of infection. Evidence favours surgery [4], but endovascular embolotherapy [6] is an alternative therapy with fewer complication rates, but higher failure rates.

Endovascular Transjugular Occlusion of Congenital Intrahepatic Portosystemic Venous Shunt Using Simultaneous Fluoroscopy and Transabdominal Ultrasound Guidance: Report of 2 Cases

Congenital intrahepatic portosystemic venous shunts (CIPVS) are rare anomalies that can be detected before birth or in early infancy or later in life. Symptomatic shunts are treated as they carry high risk of complications like hepatic encephalopathy. Various treatment options include surgery, endovascular embolization, and percutaneous closure devices. We treated 2 infants with CIPVS successfully by endovascular embolization of the shunt using vascular plug through transjugular route. Transabdominal ultrasound guidance in addition to fluoroscopy was used at the time of vascular plug placement. We emphasize that the use of transabdominal ultrasound during endovascular occlusion enhances the safety and technical success rate.