Artificial Intelligence for Quantifying Cumulative Small Bowel Disease Severity on CT-Enterography in Crohn's Disease

OBJECTIVE

Assessing the cumulative degree of bowel injury in ileal Crohn's disease (CD) is difficult. We aimed to develop machine learning (ML) methodologies for automated estimation of cumulative ileal injury on CT-enterography (CTE) to help predict future bowel surgery.

METHODS

Adults with ileal CD using biologic therapy at a tertiary care center underwent ML analysis of CTE scans. Two fellowship trained radiologists graded bowel injury severity at granular spatial increments along the ileum (1cm), called mini-segments. ML segmentation methods were trained on radiologist grading with predicted severity then spatially mapped to the ileum. Cumulative injury was calculated as the sum (S-CIDSS) and mean of severity grades along the ileum. Multivariate models of future small bowel resection were compared cumulative ileum injury metrics and traditional bowel measures, adjusting for laboratory values, medications, and prior surgery at the time of CTE.

RESULTS

In 229 CTEs, 8424 mini-segments underwent analysis. Agreement between ML and radiologists injury grading was strong (κ=0.80, 95%CI 0.79-0.81) and similar to inter-radiologist agreement (κ=0.87, 95%CI 0.85-0.88). S-CIDSS (46.6 vs. 30.4, P=0.0007) and mean cumulative injury grade scores (1.80 vs. 1.42, P<0.0001) were greater in CD biologic users that went to future surgery. Models using cumulative spatial metrics (AUC=0.76) outperformed models using conventional bowel measures, laboratory values, and medical history (AUC=0.62) for predicting future surgery in biologic users.

CONCLUSION

Automated cumulative ileal injury scores show promise for improving prediction of outcomes in small bowel CD. Beyond replicating expert judgement, spatial enterography analysis can augment the personalization of bowel assessment in CD.

Pancreatic Adenocarcinoma, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Pancreatic cancer is the fourth leading cause of cancer-related death among men and women in the United States. A major challenge in treatment remains patients' advanced disease at diagnosis. The NCCN Guidelines for Pancreatic Adenocarcinoma provides recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pancreatic cancer. Although survival rates remain relatively unchanged, newer modalities of treatment, including targeted therapies, provide hope for improving patient outcomes. Sections of the manuscript have been updated to be concordant with the most recent update to the guidelines. This manuscript focuses on the available systemic therapy approaches, specifically the treatment options for locally advanced and metastatic disease.

Clinical impact of routine esophagram after peroral endoscopic myotomy

BACKGROUND AND AIMS

It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM.

METHODS

Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak.

RESULTS

One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy.

CONCLUSIONS

Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.

Pancreatic Adenocarcinoma, Version 1.2019

The NCCN Guidelines for Pancreatic Adenocarcinoma discuss the diagnosis and management of adenocarcinomas of the exocrine pancreas and are intended to assist with clinical decision-making. These NCCN Guidelines Insights discuss important updates to the 2019 version of the guidelines, focusing on postoperative adjuvant treatment of patients with pancreatic cancers.

Assessing Small Bowel Stricturing and Morphology in Crohn's Disease Using Semi-automated Image Analysis

BACKGROUND

Evaluating structural damage using imaging is essential for the evaluation of small intestinal Crohn's disease (CD), but it is limited by potential interobserver variation. We compared the agreement of enterography-based bowel damage measurements collected by experienced radiologists and a semi-automated image analysis system.

METHODS

Patients with small bowel CD undergoing a CT-enterography (CTE) between 2011 and 2017 in a tertiary care setting were retrospectively reviewed. CT-enterography studies were reviewed by 2 experienced radiologists and separately underwent automated computer image analysis using bowel measurement software. Measurements included maximum bowel wall thickness (BWT-max), maximum bowel dilation (DIL-max), minimum lumen diameter (LUM-min), and the presence of a stricture. Measurement correlation coefficients and paired t tests were used to compare individual operator measurements. Multivariate regression was used to model identification of strictures using semi-automated measures.

RESULTS

In 138 studies, the correlation between radiologists and semi-automated measures were similar for BWT-max (r = 0.724, 0.702), DIL-max (r = 0.812, 0.748), and LUM-min (r = 0.428, 0.381), respectively. Mean absolute measurement difference between semi-automated and radiologist measures were no different from the mean difference between paired radiologists for BWT-max (1.26 mm vs 1.12 mm, P = 0.857), DIL-max (2.78 mm vs 2.67 mm, P = 0.557), and LUM-min (0.54 mm vs 0.41 mm, P = 0.596). Finally, models of radiologist-defined intestinal strictures using automatically acquired measurements had an accuracy of 87.6%.

CONCLUSION

Structural bowel damage measurements collected by semi-automated approaches are comparable to those of experienced radiologists. Radiomic measures of CD will become an important new data source powering clinical decision-making, patient-phenotyping, and assisting radiologists in reporting objective measures of disease status.

Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Ductal adenocarcinoma and its variants account for most pancreatic malignancies. High-quality multiphase imaging can help to preoperatively distinguish between patients eligible for resection with curative intent and those with unresectable disease. Systemic therapy is used in the neoadjuvant or adjuvant pancreatic cancer setting, as well as in the management of locally advanced unresectable and metastatic disease. Clinical trials are critical for making progress in treatment of pancreatic cancer. The NCCN Guidelines for Pancreatic Adenocarcinoma focus on diagnosis and treatment with systemic therapy, radiation therapy, and surgical resection.

Phase I study of definitive chemoradiation with gemcitabine and the WEE1 inhibitor AZD1775 in unresectable pancreatic cancer

TPS512

Background: Targeting cell cycle checkpoints has the potential to enhance the efficacy of chemoradiation therapy. Tumor cells commonly have an abnormal G1 checkpoint due to mutations in the p53 pathway making them reliant on the G2 checkpoint to repair DNA damage. In our preclinical studies, WEE1 inhibition with AZD1775 abrogates the G2 checkpoint and sensitizes pancreatic cancer cell lines and xenografts to chemoradiation. Additionally, AZD1775 attenuates homologous recombination repair and promotes replication stress in cancer cells. Given our preclinical findings, we designed a phase I dose escalation study of the WEE1 inhibitor AZD1775 with gemcitabine and radiation in patients with unresectable pancreatic cancer (NCT02037230). Methods: The primary objective of our phase I study is to determine the MTD (maximum tolerated dose) of AZD1775 when combined with gemcitabine and radiation in patients with locally advanced pancreatic cancer. Our secondary objectives are to estimate the efficacy of this regimen at the target dose and to determine if WEE1 is inhibited by AZD1775 at or below its target dose in surrogate tissues (hair follicles). Patients with unresectable, non-metastatic pancreatic cancer are eligible for the study. Protocol therapy consists of the administration of AZD1775 and gemcitabine at the assigned dose levels in accordance with a Time-to-Event Continual Reassessment Method. All patients on the study are treated with four cycles of therapy consisting of AZD1775 given orally on days 1, 2 and 8, 9 of a 21 day cycle with gemcitabine given intravenously over 30 minutes on day 1 and day 8. Cycles 2 and 3 are administered with concurrent radiation therapy, 52.5 Gy in 25 fractions to the primary pancreatic tumor. The MTD will be determined by the development of dose limiting toxicities (DLT) within the first 4 cycles of therapy with a target DLT rate of 25%. Blood samples obtained at baseline and after cycles 1, 2, and 4 will be used for correlative studies on circulating tumor cells and tumor derived exosomes. Our estimated accrual is 36 patients. To date we have enrolled 21 patients. Supported by P50 CA130810, R01 CA163895, Cancer Center Core grant P30 CA46592, and the Taubman Institute. Clinical trial information: NCT02037230.

Abstract CT035: A dose escalation trial of the WEE1 inhibitor AZD1775, gemcitabine, and concurrent radiation in locally advanced pancreatic cancer

Background: Gemcitabine based chemoradiation for locally advanced pancreatic cancer (LAPC) is safe and effective, although most patients remain unresectable and freedom from local progression is not ensured. Targeting cell cycle checkpoints may enhance the efficacy of chemoradiation. Tumor cells commonly have an abnormal G1 checkpoint due to mutations in p53 or its pathway making them reliant on the G2 checkpoint to arrest and repair DNA damage after radiation. In our preclinical studies, WEE1 inhibition with AZD1775 abrogates the G2 checkpoint and sensitizes pancreatic cancer cell lines and xenografts to gemcitabine and radiation. Additionally, AZD1775 attenuates homologous recombination and promotes replication stress in cancer cells. Given these preclinical findings, we designed a phase I dose escalation study of the WEE1 inhibitor AZD1775 in combination with gemcitabine and radiation in patients with LAPC (NCT02037230).

Methods: The primary objective of this phase I study is to determine the maximum tolerated dose (MTD) of AZD1775 combined with gemcitabine and radiation in patients with LAPC. Secondary objectives include estimation of the efficacy of this regimen at the target dose and to determine if WEE1 is inhibited by AZD1775 at or below its target dose in surrogate tissues. Protocol therapy consists of the administration of AZD1775 and gemcitabine at an assigned dose level in accordance with a Time-to-Event Continual Reassessment Method (TITE-CRM). Study treatment consists of four 21 day cycles. Gemcitabine is given on day 1 and day 8, and AZD1775 on days 1, 2 and 8, 9 of each cycle. Cycles 2 and 3 are administered with concurrent radiation, 52.5 Gy in 25 daily fractions to gross disease using volumetric modulated arc therapy to spare normal tissues. Following cycle 3, subjects have a 3 week break prior to cycle 4. The MTD will be determined by the development of dose limiting toxicities within the first 105 days of therapy with a target dose limiting toxicity rate of 25%. Tumor assessment using CT or MRI is performed at baseline, 1 month after radiation, and approximately every 3 months afterwards, with response characterized per RECIST. Blood samples obtained at baseline and after cycles 1, 2, and 4 will be used for correlative studies on circulating tumor cells and tumor derived exosomes. Target accrual is 36 patients; to date, 16 patients have been enrolled. Dose Escalation SchemaRadiation (Gy)Gemcitabine(mg/m⁁2)AZD1775 (mg)Level -252.5800100Level -152.51000100Level 052.51000125Level 152.51000150Level 252.51000175

Citation Format: Kyle C. Cuneo, Meredith Morgan, Matthew J. Schipper, Jonathan Maybaum, Mary U. Feng, Mahmoud Al-Hawary, Diane M. Simeone, Leah D. Olson, Vaibhav Sahai, Mark Zalupski, Theodore S. Lawrence. A dose escalation trial of the WEE1 inhibitor AZD1775, gemcitabine, and concurrent radiation in locally advanced pancreatic cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT035.

Role of Imaging in Diagnosing and Staging Pancreatic Cancer

Imaging is a key component of diagnosis and staging of pancreatic cancer. CT, MRI, and endoscopic ultrasound are the most used and approved imaging modalities. The updated NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma feature a recently published Pancreatic Ductal Adenocarcinoma Radiology Reporting Template endorsed by the Society of Abdominal Radiology and the American Pancreatic Association. The goal of the template is to standardize the reporting of the imaging findings and to improve communication among the various team members treating patients with pancreatic cancer, to ensure appropriate patient management.

MR enterography-histology comparison in resected pediatric small bowel Crohn disease strictures: can imaging predict fibrosis?

BACKGROUND

Crohn disease is a chronic inflammatory condition that can lead to intestinal strictures. The presence of fibrosis within strictures alters optimal management but is not reliably detected by current imaging methods.

OBJECTIVE

To correlate the MRI features of surgically resected small-bowel strictures in pediatric Crohn disease with histological inflammation and fibrosis scoring.

MATERIALS AND METHODS

We included children with Crohn disease who had symptomatic small-bowel strictures requiring surgical resection and had preoperative MR enterography (MRE) within 3 months of surgery (n = 20). Two blinded radiologists reviewed MRE examinations to document stricture-related findings. A pediatric pathologist scored stricture histological specimens for fibrosis (0-4) and inflammation (0-4). MRE findings were correlated with histological data using Spearman correlation (ρ) and exact logistic regression analysis.

RESULTS

There was significant positive correlation between histological bowel wall fibrosis and inflammation in resected strictures (ρ = 0.55; P = 0.01). Confluent transmural histological fibrosis was associated with pre-stricture upstream small-bowel dilatation >3 cm at univariate (odds ratio [OR] = 51.7; 95% confidence interval [CI]: 7.6- > 999.9; P = 0.0002) and multivariate (OR = 43.4; 95% CI: 6.1- > 999.9; P = 0.0006, adjusted for age) analysis. The degree of bowel wall T2-weighted signal intensity failed to correlate with histological bowel wall fibrosis or inflammation (P-values >0.05). There were significant negative correlations between histological fibrosis score and patient age at resection (ρ = -0.48, P = 0.03), and time from diagnosis to surgery (ρ = -0.73, P = 0.0002).

CONCLUSION

Histological fibrosis and inflammation co-exist in symptomatic pediatric Crohn disease small-bowel strictures and are positively correlated. Pre-stenotic upstream small-bowel dilatation greater than 3 cm is significantly associated with confluent transmural fibrosis.

A pilot study of diffusion-weighted MRI in patients undergoing neoadjuvant chemoradiation for pancreatic cancer

PURPOSE: In the current study we examined the ability of diffusion MRI (dMRI) to predict pathologic response in pancreatic cancer patients receiving neoadjuvant chemoradiation. METHODS: We performed a prospective pilot study of dMRI in patients with resectable pancreatic cancer. Patients underwent dMRI prior to neoadjuvant chemoradiation. Surgical specimens were graded according to the percent tumor cell destruction. Apparent diffusion coefficient (ADC) maps were used to generate whole-tumor derived ADC histogram distributions and mean ADC values. The primary objective of the study was to correlate ADC parameters with pathologic and CT response. RESULTS: Ten of the 12 patients enrolled on the study completed chemoradiation and had surgery. Three were found to be unresectable at the time of surgery and no specimen was obtained. Out of the 7 patients who underwent pancreaticoduodenectomy, 3 had a grade III histopathologic response (> 90% tumor cell destruction), 2 had a grade IIB response (51% to 90% tumor cell destruction), 1 had a grade IIA response (11% to 50% tumor cell destruction), and 1 had a grade I response (> 90% viable tumor). Median survival for patients with a grade III response, grade I-II response, and unresectable disease were 25.6, 18.7, and 6.1 months, respectively. There was a significant correlation between pre-treatment mean tumor ADC values and the amount of tumor cell destruction after chemoradiation with a Pearson correlation coefficient of 0.94 (P = .001). Mean pre-treatment ADC was 161 × 10^− 5 mm²/s (n = 3) in responding patients (> 90% tumor cell destruction) compared to 125 × 10^− 5 mm²/s (n = 4) in non-responding patients (> 10% viable tumor). CT imaging showed no significant change in tumor size in responders or non-responders. CONCLUSIONS: dMRI may be useful to predict response to chemoradiation in pancreatic cancer. In our study, tumors with a low ADC mean value at baseline responded poorly to standard chemoradiation and would be candidates for intensified therapy.

A randomized phase 2 trial of gemcitabine/cisplatin with or without cetuximab in patients with advanced urothelial carcinoma

BACKGROUND

Epidermal growth factor receptor overexpression is associated with poor outcomes in urothelial carcinoma (UC). Cetuximab (CTX) exhibited an antitumor effect in in vivo UC models. The efficacy of gemcitabine/cisplatin (GC) with or without CTX in patients with advanced UC was evaluated.

METHODS

Patients with advanced UC, measurable disease, and adequate organ function were randomized 1:2 to cisplatin (70 mg/m(2) ) on day 1 plus gemcitabine (1000 mg/m(2) ) on days 1, 8, and 15 (arm A) or GC plus CTX (500 mg/m(2) ) on days 1 and 15 (arm B). The primary endpoint was the overall response rate. The secondary endpoints were the response duration, safety, progression-free survival, overall survival, determination of whether or not CTX sensitized nonresponders to GC, and exploratory biomarker analysis. The accrual targets were 27 and 54 patients for the 2 arms, respectively. The overall response rate was reported by arm with binomial confidence intervals (CIs). Kaplan-Meier methods were used for time-to-event endpoints.

RESULTS

Eighty-eight eligible patients were randomized; 87 were toxicity-evaluable, and 85 were response-evaluable. The overall response rates were 57.1% for arm A (95% CI = 37%-76%) and 61.4% for arm B (95% CI = 48%-74%). The median progression-free survival times were 8.5 months for arm A (95% CI = 5.7-10.4 months) and 7.6 months for arm B (95% CI = 6.1-8.7 months). The median overall survival times were 17.4 months for arm A (95% CI = 12.8 months to unreached) and 14.3 months for arm B (95% CI = 11.6-22.2 months). The most common grade 3/grade 4 adverse events in both arms were myelosuppression and nausea. Thromboembolism, acneiform rash, fatigue, pain, hypersensitivity reactions, elevated transaminases, hyponatremia, and hypomagnesemia were more common in arm B; 3 grade 5 adverse events occurred in arm B. The presence of primary disease significantly correlated with thromboembolism. An increased soluble E-cadherin level after cycle 2 correlated with a higher risk of death.

CONCLUSIONS

GC plus CTX was feasible but was associated with more adverse events and no improvements in outcomes.

Effect of neoadjuvant chemoradiotherapy (nCRT) on survival in patients with borderline resectable (BR) pancreatic adenocarcinoma (PDA) with acceptable peri-operative morbidity

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Background: The impact of nCRT for patients (pts) with BR PDA has been debated, with wide variation in practice. Most studies in pts undergoing nCRT have no or historic controls, rather than a direct comparison of BR pts treated in the same era. We aimed to assess the effect of nCRT on operative, pathologic, and survival endpoints in pts with BR PDA. Methods: 241 pts underwent pancreatectomy (177 without and 64 with nCRT) for PDA (2001-2011). CT scans at dx were re-reviewed by a pancreatic radiologist using a standardized template. Pts were categorized as resectable, BR, or unresectable according to 2012 NCCN criteria. BR pts (n=74) were extracted for analysis. Survival was compared using log-rank tests; pathologic features and peri-op factors were compared using Wilcoxon rank sum tests (continuous variables) or Fisher's exact test (binary variables). Results: Median follow up was 26 ±21 months. nCRT was associated with higher 1 and 3 yr OS, lower margin and node positivity, decreased pre-op CA19-9, and lower post-op pancreatic fistula (POPF), with higher operative time, vascular reconstructions, and transfusion (PRBCs). On univariate analysis, POPF negatively impacted survival (HR 2.34, 1.16-4.75, p=0.02) as did pre-op CA19-9>150 U/mL (HR 2.11, 1.16-3.87, p=0.015). Conclusions: Pts receiving nCRT for BR PDA had higher 1 and 3 yr OS, more negative margins, and fewer positive nodes, with minimal additional peri-op co-morbidity, compared with pts going directly to surgery. These data support consideration of enrolling all pts with BR PDA into a neoadjuvant program prior to resection. [Table: see text]

Anaplastic lymphoma masquerading as sclerosing mesenteritis: a case report

INTRODUCTION

Sclerosing mesenteritis is a rare fibroinflammatory disease of unknown pathogenesis and etiology. Although more commonly benign in its clinical course, sclerosing mesenteritis can mimic certain malignant disorders, such as lymphoma.

CASE REPORT

This report describes the case of a previously healthy young woman who develops an acute illness thought to be related to sclerosing mesenteritis following an extensive diagnostic work-up including biopsy sampling, which was negative for malignancy. However, despite aggressive medical care, the patient passed away. Autopsy revealed extensive inflammation secondary to anaplastic lymphoma.

CONCLUSION

The case very graphically highlights an important clinical observation that lymphoma can masquerade as sclerosing mesenteritis.

Therapeutic high-density barium enema in a case of presumed diverticular hemorrhage

Many patients with lower gastrointestinal bleeding do not have an identifiable source of bleeding at colonoscopy. A significant percentage of these patients will have recurrent bleeding. In many patients, the presence of multiple diverticula leads to a diagnosis of presumed diverticular bleeding. Current treatment options include therapeutic endoscopy, angiography, or surgical resection, all of which depend on the identification of the diverticular source of bleeding. This report describes a case of recurrent bleeding in an elderly patient with diverticula but no identifiable source treated successfully with barium impaction therapy. This therapeutic modality does not depend on the identification of the bleeding diverticular lesion and was well tolerated by our 86-year-old patient.

Maintenance sunitinib postchemotherapy (CT) in patients (pts) with advanced urothelial carcinoma (UC): A randomized placebo controlled phase II trial

5073

Background: Although response to CT is common in pts with advanced UC it is rarely durable. Sunitinib is an oral small molecule inhibitor of receptor tyrosine kinases regulating angiogenesis including VEGFR-1, -2, -3, and PDGFR-α, -β with demonstrated antitumor activity in a variety of solid tumors. Inhibition of angiogenesis following CT may delay disease progression. Therefore, we are evaluating maintenance sunitinib in a phase II study. Methods: Pts with advanced UC, > stable disease (SD) after 4–6 cycles of CT, a performance status (PS) 0–2, adequate organ function and < 42 days from last CT dose were randomized to sunitinib 50 mg or placebo; 4 weeks (wks) on 2 off in 6 wk cycles. Pts were stratified by response to CT. Disease was assessed every 12 wks. Pts were unblinded for progression or unacceptable adverse events (AEs), with placebo pts offered open label sunitinib. The primary end point is 6 month progression rate using a modified version of the randomized selection design (Simon 1985). 42 pts/arm are to be accrued to allow selection of the superior arm with 90% probability. Other endpoints include safety, response rate (RR), time to progression, median survival, RR to open label sunitinib and correlation of changes in serum VEGF and sVEGFR-2 levels with outcome. Results: To date, 28 pts have been registered and 26 have completed > 12 wks of therapy. Median age is 69 years (48–81) and PS is 1 (37% PS 0, 52% PS 1). 12% had a complete response (CR) to prior CT, 46% a partial response (PR) and 42% SD. 14 pts have progressed after a median of 2 cycles (range 1–12). 7 pts received open label sunitinib at progression, 1/7 remains on treatment. Median duration on open label therapy is 2.2 months (11 days-15 months). Best response to open label therapy to date is progressive disease (2 pts), SD (2 pts) for 24 wks, PR in 1 pt through 60 weeks and 2 pts have not reached first assessment. Grade 3 AEs on open label sunitinib included: bladder hemorrhage, increased creatinine, fatigue, thrombocytopenia and hand-and-foot syndrome. No grade 4 or 5 AEs were observed. Conclusions: Preliminary results indicate that maintenance sunitinib post CT is feasible in advanced UC pts and is associated with clinical activity. Supported by Pfizer.

[Table: see text]

Characteristic Locations of Inguinal Region and Anterior Abdominal Wall Hernias: Sonographic Appearances and Identification of Clinical Pitfalls

OBJECTIVE

The purpose of this article is to show the typical locations of anterior abdominal wall and inguinal region hernias and to illustrate their sonographic appearances and describe pitfalls in clinical diagnosis of hernias that may be resolved with sonography.

CONCLUSION

Awareness of the expected locations of anterior abdominal wall hernias and potential clinical pitfalls allows an accurate diagnosis of a hernia and helps in differentiating a hernia from other abnormalities.