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PURPOSE: To evaluate and compare the efficacy of intermittent needle aspiration and continuous catheter drainage in ultrasound-guided management of liver abscesses. METHODS: This was a prospective, randomised study conducted on 100 patients (88 males and 12 females; age range 22–74 years) with liver abscess(es) and having abscess size more than 5 cm, divided into two groups: Percutaneous needle aspiration (PNA) (n = 50) and percutaneous catheter drainage (PCD) (n = 50). Criteria of exclusion were: rupture of abscess before intervention; prior intervention; uncorrectable coagulopathy; concomitant biliary tract malignancy. In the PNA group, pus was aspirated by an 18-gauge needle using freehand technique and the number of aspirations was limited to two. Failure of abscess size to decline below 50% of the original diameter or of clinical improvement after second aspiration was considered as failure of aspiration. In the PCD group, drainage was done by 12-French catheters using Seldinger technique. Drainage was considered as failure if abscess cavity did not resolve and laparotomy was needed to evacuate the pus cavity. RESULT: The success rate in the PNA group was 88% and 92% in the PCD group; however, this difference was statistically not significant, suggesting that both are equally efficacious. The total duration of hospital stay (mean 6.8 days [PNA] vs 10.5 days [PCD]; p value: 0.011) and the average duration between intervention and discharge (5.9 days [PNA] vs 10.2 days [PCD]; p value:0.026) were significantly less in the PNA group. One major complication was seen in our study: peritonitis due to peri-catheter leak in PCD group. CONCLUSION: Both procedures are equally efficacious in the management of liver abscesses; however in view of less duration of hospital stay, patient safety and comfort, procedure simplicity, and the reduced cost, needle aspiration should be used as the first-line procedure in the treatment of liver abscess (even in abscesses more than 5 cm). Catheter drainage should be reserved for cases that do not respond to a second attempt of aspiration. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40477-020-00440-3) contains supplementary material, which is available to authorized users.

L-2 Hydroxyglutaric aciduria is a rare metabolic disorder which is autosomal recessive in inheritance. It is characterised by the increased urinary excretion of L-2 hydroxyglutaric acid and the diagnosis is based on the increased levels of the L-2 hydroxy glutaric acid in the urine, serum & CSF. This is a neurometabolic disorder which is associated with slowly progressive psychomotor delay since childhood. We report a case of an 18 –year old female who presented at the emergency department with seizures, fever and on imaging show classic features.

Aims: The aim of this study is to compare postcontrast three-dimensional (3D) T1-Sampling perfection with application-optimized contrasts by using different flip angle evolutions, 3D fluid-attenuated inversion recovery (FLAIR), and 3D T1-magnetization prepared rapid gradient echo (MPRAGE) sequences in patients of meningitis. Settings and Design: A hospital-based cross-sectional study done in the Department of Radiodiagnosis, IGMC Shimla for a period of 1 year from June 1, 2016, to May 30, 2017. Subjects and Methods: A total of 30 patients suspected of meningitis underwent magnetic resonance imaging evaluation with postcontrast 3D T1-MPRAGE, 3D T1-SPACE, and 3D FLAIR sequences. The abnormal leptomeningeal enhancement was noted by two radiologists together on these sequences and scores were given to the abnormal leptomeningeal enhancement. Statistical Analysis Used: The sensitivity of 3D T1-SPACE, 3D T1-MPRAGE, and 3D FLAIR was calculated and compared. The level of agreement between these sequences was assessed by kappa coefficient. P < 0.05 was taken as statistically significant. Results: 3D T1-SPACE shows superiority in meningeal enhancement along basal cisterns, Sylvian fissure and along cerebral convexities. It is also found to be better in delineating parenchymal lesions. 3D FLAIR failed to demonstrate enhancement along cerebral convexities however found to be better than 3D T1-MPRAGE in delineating enhancement along basal cisterns and Sylvian fissures. 3D T1-MPRAGE has shown subtle enhancement in basal cisterns, Sylvian fissure and along cerebral convexities. 3D T1-SPACE, 3D FLAIR, and 3D T1-MPRAGE has sensitivity of 91.67%, 66.67%, and 54.17%, respectively. Conclusion: Postcontrast 3D T1-SPACE sequence is an excellent tool than postcontrast 3D T1-MPRAGE and 3D FLAIR sequences in the evaluation of meningeal enhancement and depiction of additional lesions in brain parenchyma.

Point-of-care ultrasound has become firmly established in acute and critical care settings, and is now increasingly being used as an important tool in the assessment of the lungs. In this article, we briefly describe the technique of lung ultrasound and the various lines and signs commonly encountered during sonography of the lung, namely the normally visualised A- and T-lines and the bat sign, sliding sign (power slide sign on colour Doppler), sea-shore sign, curtain sign, and the lung pulse. We have also described signs seen in various pathological conditions like B-lines seen in cases of increased lung density; the quad sign, sinusoid sign, thoracic spine sign, plankton sign and the jelly fish sign seen in pleural effusion; the stratosphere sign and the lung point sign seen in pneumothorax; the shred/fractal sign and tissue-like sign in consolidation, and the double lung point sign seen in transient tachypnoea of the newborn. With adequate and appropriate training, lung ultrasound can be effectively utilised as a pointof-care investigation.

Vaginal foreign body insertion is not an uncommon clinical entity; however, long-standing neglected vaginal foreign body causing vaginolith, vesicovaginal fistula and vesical calculus formation is unusual. We present a case of a neglected vaginal foreign body (plastic cap of a nail colour) leading to vesicovaginal fistula, vaginolith and vesical calculus formation in a 12-year-old female child presenting with continuous dribbling of urine per vagina. Diagnosis was confirmed on ultrasonography, non-contrast CT scan and MRI of the pelvis. The MRI demonstrated the exact size and site of the urinary bladder wall defect, besides the foreign body and the vesical calculus. The foreign body along with vaginolith and the vesical calculus were removed via suprapubic approach under general anaesthesia; the fistula was repaired by suturing the urinary bladder and vagina wall defect.

Summary Background Though cholelithiasis and cholecystitis are common clinical problems, spontaneous cholecysto-cutaneous fistula is a rare complication of cholelithiasis in present-day practice. Very few cases have been reported in literature after 1950s. Case Report A 60-year-old male presented with pain and discharging sinus in the upper abdomen. Ultrasonography and computed tomography confirmed the presence of perforation of the gall bladder and cholecysto-cutaneous fistula. External opening of the fistula was overlying an old surgical scar. Less than five cases of spontaneous cholecysto-cutaneous fistula draining through an old surgical scar have been reported in literature. Initially, the patient was managed conservatively, followed by elective open cholecystectomy and excision of the fistula tract. Conclusions Though very rare in the present era of advanced medical care, cholecysto-cutaneous fistula as a potential diagnosis should be kept in mind in patients presenting with acute upper abdomen pain and discharging sinus. High degree of suspicion is required for early diagnosis and treatment of this condition.

Summary Background We present unique case of a giant extracranial atretic occipital lipoencephalocele in an adult patient with new bone formation within it which was not associated with any developmental malformation of brain. Resection of the lipoencephalocele was performed for esthetic reasons. Case Report 18 year old female patient presented to the surgery OPD with complains of a large mass in the occipital region present since birth. It was of size of a betel nut at the time of birth and gradually increased in size over a long period of time. It was painless and not associated with any other constitutional symptoms. On examination the rounded fluctuant mass was present in the midline in occipital region covered with alopecic skin with dimpling in the overlying skin. On MRI there was mass showing both T1 and T2 hyperintense signal area suggestive of fat component. Herniation of meninges and atretic brain parenchyma was also seen through a defect in the occipital bone in the midline. There was a Y shaped bony outgrowth seen arising from occipital bone into the mass which was quite unusual in association with an atretic lipoencephalocele. Conclusions A large lipoencephalocele with bony outgrowth in an adult patient is a rare presentation of atreic occipital encephalocele.

Is Transvaginal Sonography Better than Transabdominal Sonography in Estimating the Thickness of Lower Uterine Segment? A Prospective Observational Study To compare the trans-abdominal ultrasonography (TAS) with trans-vaginal sonography (TVS) for assessing the thickness of lower uterine segment (LUS) and myometrium (MYO) in pregnant women. Design: A prospective observational study

Empty sella is a radiological-anatomical entity characterised by a sella turcica filled partially or completely with cerebrospinal fluid, leading to varying degrees of pituitary flattening. Literature reports a 5% - 20% incidence of empty sella in unselected autopsies leading many to argue that its an extreme normal variant. Endocrine dysfunction varies from 8% - 25% with primary empty sella with growth hormone deficiency being most common. However isolated gonadotropin deficiency with normal sized primary empty sella are rare if any. We are reporting a case of isolated gonadotropin deficiency with primary empty sella unable to confirm or refute the association as causal or casual.

Background: Present study compares basic FESS and septoplasty with FESS alone in DNS with maxillary sinusitis.Methods: Sixty patients of DNS with chronic maxillary sinusitis were divided into two groups alternatively. After pre-operative symptoms score and computerized tomography (CT scan), twenty patients underwent FESS with septoplasty (group A) and other 20 underwent FESS alone (group B) under local anaesthesia and topical 4% lignocaine with 1:1000 adrenaline. At 6 weeks, post-operative symptom score and CT scan findings were documented and compared statistically by using unpaired student t-test.Results: Ninety six percent of patients in group A and 87.6% in group B have shown complete improvement in facial pain/pressure. Ninety three percent of patients in group A and 83.3% in group B have shown complete improvement in headache. Ninety percent patients in group A and 63.3% in group B has shown complete improvement in nasal obstruction. Seventy six percent of patients in group A and 63.3% of patients in group B have shown complete improvement in nasal discharge. Eighty six percent and 63.3% of patients in group A and group B respectively were satisfied from the surgery. Ninety three percent of patients in group A and 70% in group B were found to have normal maxillary sinus mucosa on HRCT nose and PNS after 6 weeks following surgical treatment. Hundred percent patients in group A and 96.7% of patients in group B were found to have normal OMC on HRCT nose and PNS 6 weeks after surgery.Conclusions: It was observed that FESS with septoplasty is effective for the treatment of chronic rhinosinusitis with deviated nasal septum on VAS as well as radiologically (the Lund and Mackay staging system: radiologic staging) than FESS alone.

To estimate the risk of uterine dehiscence/rupture in women with previous cesarean section (CS) by comparing the thickness of lower uterine segment (LUS) and myometrium with trans-abdominal (TAS) and trans-vaginal sonography (TVS).In this case-control study, in 100 pregnant women posted for elective CS (with or without previous CS; group 1 and group 2 respectively), the thickness of LUS and myometrium was measured sonographically (TAS and TVS). Intra-operatively, LUS was graded (grades I-IV), and its thickness was measured with calipers. The primary outcome of the study was correlation between echographic measurements (TAS and TVS) and features of LUS (grades I-IV) at the time of CS. Secondary outcomes were correlation between myometrial thickness, number of previous CS, and inter-delivery interval with LUS (grades I-IV).Sonographic measurements of LUS and myometrium were significantly different between the two groups (both TAS and TVS p value = 0.000 each). However, the number of previous CS (p = 0.440) and inter-delivery interval (p = 0.062) had no statistically significant correlation with thickness of LUS.Sonographic evaluation of LUS scar and myometrial thickness (both with TAS and TVS) is a safe, reliable, and non-invasive method for predicting the risk of scar dehiscence/rupture. Specific guidelines for TOLAC, after sonographic assessment of women with previous CS, are need of the hour.

Background: Failure to detect uterine perforation during surgical abortion may result in adverse patient outcome besides having medicolegal implications. This rare case of uterine perforation was diagnosed seven days after abortion and underscores the importance of remaining vigilant for this complication during and after the procedure. Case: A female underwent surgical abortion at sixteen weeks gestation and was discharged after the procedure, assuming no complication. She presented with abdominal pain seven days after the event. Ultrasound and CT revealed uterine perforation with abdominal expulsion of fetal parts. Conclusion: A patient complaining of abdominal pain following recent abortion related instrumentation should alert the clinician regarding possibility of perforation. Secondary signs on ultrasound may reveal the diagnosis even if rent is not identified. CT is valuable in emergent situations.

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) is an unusual and special type of Müllerian duct anomaly. Patients usually present in adolescence, soon after menarche, with pain and pelvic mass and rarely with infertility in adulthood. Majority of the cases of OHVIRA have been reported in association with uterus didelphys and the presentation of uterus didelphys with OHVIRA is known as Herlyn–Werner–Wunderlich syndrome. A complete septate uterus with OHVIRA is exceedingly unusual. Less than 30 cases of complete septate uterus with OHVIRA have been reported to date, to the best of our knowledge. We present a rare case of incidentally detected complete septate uterus with OHVIRA in a young woman who presented with acute pain in the right iliac fossa owing to acute appendicitis.

Background: A neglected foreign body in a vagina leading to vesico-vaginal fistulae in young girls is a very rare presentation. As such, it poses significant therapeutic challenges in its