SOME INTERESTING CLINICAL FACTS FOR RADIOLOGISTS!

     Interesting clinical pearls ( An ongoing project!)

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1. Pancreatic cysts in VHL almost never become malignant

2. Bladder ca (TCC) is a "field disease". They can reoccur in other normal areas and usually require radical cystectomy; whereas, adenocarcinomas (Urachal ca) do not re-occur in other places. 

3. Portal hypertension appears early in NAFLD

4. NAFLD more often leads to rise in SGOT & SGPT. Whereas, alcohol or medications (like statins) or cholestasis give rise to GGTP. Specifically, it is high in chronic alcoholic cholestatic hepatitis

https://pubmed.ncbi.nlm.nih.gov/37545/#:~:text=The%20GGTP%20is%20an%20enzyme,cholestasis%20and%20in%20the%20alcoholism.

5. Cardiovascular disease is the major cause of death in patients with NAFLD

6. Impacted ureteric calculus - Present at the same site for > 2 months causing moderate to severe hydronephrosis or caused obstructive anuria. On URS in such stones,it is difficult to pass standard guide wire. Such sites are prone to stricture after the URS. Stone burden of > 16 mm was another risk factor for ureteric stricture.

https://journals.lww.com/urol/Fulltext/2019/11030/Ureteral_stricture_after_ureteroscopy_for_stones_.9.aspx

7.  Spontaneous bacterial peritonitis (SBP) is usually seen in cirrhotics and presents with abdominal distension, abdominal pain, diarrhea and sign of sepsis. CT shows hazy mesentery.

https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all

8. GI Bleed, based on the location are divided into: upper GI (upto ampulla of vater), middle GI (ampulla to the cecum) and lower GI (below cecum upto anal canal)

9. The prostate apex is deficient of the capsule and ca in this region may lead to local extension early

10. In proximal ureteric stones measuring < 10 mm, SWL scores over URS for management. In rest of the locations or when the size is > 10 mm URS scores over SWL

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707902/

11. Ileus can be due to low sodium or potassium

12. SGOT (AST) and GGT are  typically raised in Alcoholic hepatitis

- SGOT/SGPT ration of > 2 is suggestive alcoholic hepatitis & cirrhosis. 

- SGOT is elevated due to liver cell injury; however, it is not liver specific and found in other organs also. 

- SGPT (ALT) are more sensitive and specific for acute liver damage

- Elevated GGT indicated continuous heavy drinking

https://pubmed.ncbi.nlm.nih.gov/520102/#:~:text=An%20SGOT%2FSGPT%20ratio%20greater,and%20none%20with%20obstructive%20jaundice.

https://pubs.niaaa.nih.gov/publications/assessingalcohol/biomarkers.htm#:~:text=GGT%20may%20elevate%20because%20of,of%20GGT%20(Gjerde%20et%20al.

13. Absolute Eosinopenia is a marker for Enteric Fever

https://d-nb.info/1264321368/34

14. Omentum is removed during the surgery for ovarian ca. 

15. Pseudo-cushing syndrome is a well described complication of chronic alcoholism and results from transient alteration of ACTH. It is reversible after alcohol abstinence. 

https://www.sciencedirect.com/topics/medicine-and-dentistry/cushingoid-syndrome

16. Anesthesia precipitating small bowel obstruction: While anesthesia doesn't directly cause adhesions, the physiological changes it induces in the postoperative period (reduced bowel motility, immobility) can certainly act as precipitating factors for small bowel obstruction in individuals with pre-existing abdominal adhesions from prior surgery. This understanding is a fundamental aspect of postoperative care and risk management in surgical patients.

17. Low CD4 count in cirrhosis:

A low CD4 count in a cirrhosis patient may not necessarily indicate underlying malignancy, and is often a marker of advanced liver disease itself, potentially due to splenic sequestration. However, certain conditions like hepatocellular carcinoma (HCC), a type of liver cancer, are associated with cirrhosis and can also impact CD4 counts, so a low count alongside other factors should prompt further investigation. 

Low CD4 count and cirrhosis

• Splenic sequestration: 

  In cirrhosis, portal hypertension can lead to the accumulation of CD4 T cells in the spleen, lowering the absolute count in the blood without necessarily indicating a compromised immune system.
• Advanced liver disease: 

  The low CD4 count can be a sign of advanced liver dysfunction, rather than advanced immunodeficiency. 
• Hepatocellular carcinoma (HCC): 

  A persistently low CD4 count is linked to a higher risk of hepatic events, including HCC, in patients with cirrhosis, particularly those coinfected with HIV. 
• When to suspect malignancy

• Low CD4 count in conjunction with other factors: 

  If a low CD4 count is observed alongside other signs of liver issues or a longer duration of high viral load in coinfected individuals, it could signal a higher risk of HCC. 
• Screening: 

  Regular screening with ultrasound and blood tests for alpha-fetoprotein (AFP) is recommended for people with cirrhosis to detect liver cancer in its early stages. 
• 
  
• Key takeaway

While a low CD4 count is a concern, it doesn't automatically point to malignancy in a cirrhotic patient. It's important to consider the broader clinical context and rule out other explanations for the low count, such as splenic sequestration. However, a low CD4 count should also be seen as a risk factor for liver cancer, necessitating careful monitoring and appropriate screening. 

16. Biliary dilation in post-bariatric surgery: a radiologist's essential take

Dilated gallbladder or common bile duct post-bariatric surgery, especially Roux-en-Y gastric bypass, is a recognized finding. While dilation often suggests obstruction, it may also be a functional change following surgery. Radiologists must correlate imaging with clinical symptoms (e.g., pain, jaundice) and consider altered anatomy in their assessment.

Reference

• Common bile duct dilation after bariatric surgery | Surgical Endoscopy SpringerLink

Prepared by: Dr. Sharad Maheshwari

Posted on: 8.7.2022

Updated: 7.11.2023