A 48-year-old Man with Epigastric Pain and Melena

A 48-year-old male patient presented to the emergency department with the complaints of epigastric pain and melena for the past 3 days. The pain was started suddenly and has progressed and after a while, he passed melena stool. He also mentioned some episodes of vomiting that was not bloody. The pain score was about 8/10 (based on verbal quantitative scale) and slightly radiated to back. He loosed his appetite and the pain aggravated by meal. He did not use any drug regularly and had no positive medical history for specific disease or prior hospital admission. The patient was slightly pale and sweaty. His pulse rate was 80/minute and blood pressure was elevated as 180/100 mm Hg. Routine blood tests such as liver enzyme and serum amylase levels were normal. Complete blood cell count showed mild anemia (Haemoglobin =10 g/dl) and leucocytosis (16600/mm3). On physical examination, there were not any positive findings except mild epigastric tenderness without rebound or guarding. Electrocardiography revealed normal sinus rhythm without any pathologic findings. The patient was admitted in surgical ward and plain abdominal computed tomography (CT) scan and abdominal CT angiogram was done. The findings of CT are shown in figures 1A-D

Optic nerve sheath diameter as a non-invasive indicator of intracranial hypertension in traumatic brain injury: correlation with CT head and prognostic implications

Background: Ultrasound guided measurement of optic nerve sheath diameter (ONSD) is an emerging non invasive bedside tool that is being used to detect raised intracranial pressure (ICP) in patients with traumatic brain injury(TBI). Early detection of raised ICP can guide in the timely management of such patients with raised ICP due to TBI. Methods: A prospective, observational, open labelled study planned with a 30 patients of TBI of both genders, aged between 18 to 70 years. ONSD readings were taken 3 times a day for three days from the time of admission with portable SonoSite ultrasound machine. Data was expressed as mean ±standard deviation. Values were compared using T test and P value was calculated. Results: Highest reading recorded in patients with GCS <8 was 6.26±0.73 in comparison to 5.38±0.56 (p=0.001) in patients with GCS >8. Highest reading of ONSD  correlating  with a positive CT finding at admission was 6.22±.81 and was 5.46±.57 (p=0.006)  in patients with negative findings on CT. ROC curve with average cut off of 6 mm  correlated with positive CT findings with sensitivity of 80%, specificity of 70%  and negative predictive value of 87% was found. Conclusions: Ultrasound-guided ONSD monitoring shows promise for diagnosing intracranial hypertension in traumatic brain injury. Correlations with CT, GCS, and outcomes emphasize its clinical relevance, warranting further validatio

Endoscopic Assisted Infracochlear Approach for Excision of a Large Congenital Hypotympanic Cholesteatoma: A Case Report

Congenital cholesteatoma is a rare lesion resulting from failed involution of epidermoid rest cells, which take part in the formation of the mucosa of the middle ear cleft during embryonic development. We report the first case report of a large congenital hypotympanic cholesteatoma with extension to the jugular foramen and carotid canal, in a 13-year-old girl, which was excised successfully by endoscopic-assisted hypotympanotomy infra-cochlear approach

Quantitative assessment of airway and parenchymal components of chronic obstructive pulmonary disease using thin-section helical computed tomography

Purpose: The purpose of this study was to diagnose and characterise chronic obstructive pulmonary disease (COPD) into its forms, patterns, and severity using MDCT. Material and methods: In this prospective study, spirometric and MDCT evaluation was done in 52 consecutive patients diagnosed with COPD. In each patient six segmental bronchi were evaluated for CT morphometric indices of bronchial wall thickness (BWT) and wall area percentage (WAP). Quantitative evaluation of emphysema was done using inbuilt software, and volume of emphysematous lung was determined using percentage low attenuation area (LAA). COPD was categorised into the following: emphysema predominant; airway predominant; or mixed phenotypes, and severity grading was assigned as mild, moderate, or severe. Results: Centrilobular was the predominant emphysema pattern occurring alone (36.5%) or in combination with paraseptal changes (34.6%). Among COPD phenotypes, emphysema predominant was the commonest (44.3%), followed by mixed (30.8%), and bronchitis predominant (25.0%). The mean BWT in the airway-predominant group was significantly higher (1.94 ± 0.28 mm) than in the emphysema-predominant subgroup (1.79 ± 0.23 mm) with a p value of 0.005. Conclusion: MDCT is an indispensable tool in quantitative and qualitative evaluation of COPD patients. Measurement of CT indices like BWT, WAP, and %LAA can reliably categorise COPD into phenoty

Torsion of a wandering spleen presenting as acute abdomen

BACKGROUND: Wandering spleen is a rare condition which if uncorrected, can result in torsion and infarction. Clinical presentation of a wandering spleen can vary from asymptomatic abdominal mass to acute abdominal pain. Radiological investigations play a pivotal role in diagnosis as the clinical diagnosis is usually impossible. CASE REPORT: We present a case of wandering spleen with torsion and complete infarction that occurred in a 32-year-old multiparous female. The diagnosis was established preoperatively on colour Doppler and CT of the abdomen with subsequent confirmation on surgery. CONCLUSIONS: Wandering spleen is a rare clinical condition which can present as acute abdomen. An increased awareness of this entity together with the timely use of ultrasound and CT of the abdomen can play an important role in preoperative diagnosis and surgical management

Rapunzel syndrome : rare 'tale' of a broken 'tail'

BACKGROUND: Rapunzel syndrome is a rare and unique form of trichobezoar, in which a cast of hairs is formed in the stomach with its 'tail' extending up to varying lengths into the small bowel. Almost all cases described in literature are of 'classic' and more common form of Rapunzel. Sometimes however, the tail of bezoar is broken into smaller fragments. There is not much literature available on this rarer subset of Rapunzel syndrome. CASE REPORT: In this report we present the ultrasound (USG) and CT findings of a case of Rapunzel syndrome in which the tail had broken into five separate fragments. The patient presented clinically with intestinal obstruction due to the impaction of the distal- most fragment in the ileum. CONCLUSIONS: Our case highlights the fact that although USG features may be suggestive, a careful evaluation of CT images is essential for a confidant preoperative diagnosis of Rapunzel syndrome. In cases of this syndrome with a broken tail, CT is essential for precise count and localization of the separated fragments to ensure their complete removal at the time of surgery. We also propose to name the fragments of the broken tail as 'bezoarlets'. This word aptly describes the tail fragments as it suggests their origin from the larger gastric bezoar and the suffix 'lets' conveys they are smaller in size

Magnetic resonance imaging (MRI) characterization of perianal fistulous disease in a rural based tertiary hospital of North India

BACKGROUND: To diagnose and characterize the perianal fistulous disease using Magnetic resonance imaging (MRI) in a hilly and rural area of North India. MATERIAL AND METHODS: This prospective hospital based study was conducted for a period of one year from April 2014 to April 2015 in the departments of Radiodiagnosis and Surgery of our institute. A total of 50 consecutive patients presenting with perianal fistulous disease fulfilling the inclusion and exclusion criteria were included in the study and taken up for MRI. The perianal fistulae were classified according to St James University hospital classification and tracks were assessed with regard to anatomical plane, length, ramifications, abscess formation, enteric communication, external cutaneous opening, enhancement and suprasphincteric extension. Surgical correlation was done in 31 patients who opted for surgical treatment. Rest of the 19 patients preferred alternative medicine for treatment or chose to postpone their surgery. RESULTS: The disease was much more prevalent in males in comparison to females with male to female ratio of 24:1. Grade 4 was the most common type of fistula (34%) while Grade 5 was the least common type (4%).MRI showed a high sensitivity of 93.7% and positive predictive value (PPV) of 96.7% when correlated with surgical findings. A substantial number of patients (38%) preferred alternative medicine or non surgical form of treatment. CONCLUSIONS: MRI is a very sensitive modality for the evaluation of perianal fistula. In our study group, the disease predominantly affected middle aged men. Ramifications and abscesses were commonly seen, affecting nearly half of the patients and majority of the patients had active fistulous tracks with posteriorly located enteric opening. Overall, transsphincteric fistulae were most common. Significant number of patients avoided surgery or showed preference for non surgical treatment

Unusual case of sciatic nerve and deep pelvic endometriosis with lumbosacral plexus spread presenting with muscular atrophy and foot drop

Endometriosis is an important disorder which affects women in the childbearing age group. In addition to the commonly observed intrapelvic sites, it can very rarely affect extrapelvic location such as the sciatic nerve. We describe an uncommon case of sciatic endometriosis leading to gross muscular atrophy and foot drop. The patient additionally had perineural extension of endometriosis along the ipsilateral lumbosacral trunk and coexisting intrapelvic endometrial implants in retrocervical area, uterosacral ligament, and urinary bladder wall

Pediatric clear cell renal cell carcinoma with pelvicalyceal system invasion and contiguous extension upto bladder : novel and bizarre tumor behaviour

BACKGROUND: Paediatric renal cell carcinoma (RCC) is a rare neoplasm which differs significantly in its clinico-pathological behaviour from the adult variant. The clear cell variant constitutes a relatively small histological subset of this neoplasm. CASE REPORT: We present a very unusual, pathologically proven case of clear cell variety of pediatric RCC which showed invasion into the pelvicalyceal system with contiguous extension up to the urinary bladder. Such a novel manifestation of paediatric RCC has not been described previously in literature. A relevant review of literature is included. CONCLUSIONS: The aggressive biological behaviour of the paediatric RCC in our case and the consequent atypical imaging findings are distinctly unusual. These findings may represent a new aggressive variant of this rare neoplasm. The radiologist and clinician should be aware of these novel manifestations of paediatric clear cell RCC