Diagnostic Utility of Ultrasound-Guided Fine-Needle Aspiration Cytology in Gall Bladder Lesions: An Experience from a Tertiary Care Cancer Center in Eastern India

Introduction

Gallbladder cancer (GBC) is the most common malignancy, representing 80-95% of biliary tract cancers. Although ultrasonography-guided fine-needle aspiration cytology (USG-FNAC) has emerged as an effective diagnostic the tool for the precise diagnosis of gallbladder lesions, data on its diagnostic utility and cytomorphological categorization of gallbladder lesions are lacking.

Aims

To study the diagnostic utility of USG-FNAC in gallbladder lesions.

Materials and Methods

This study was the conducted prospectively on patients who came with clinical and radiological evidence of gallbladder space-occupying lesion and then advised to USG-FNAC over 2 years and 6 months from January 2018 to June 2020.

Results

A total of 314 cases were included. The mean age was 56 years, with a range of 17-88 years. Women predominated over men (Male:Female = 1:2.3). Primary adenocarcinoma of the gallbladder was most common. On cyto-histological correlation, the sensitivity, specificity, and diagnostic accuracy of USG-FNAC of gallbladder lesions were found to be 98.82, 87.23, and 96.3%, respectively.

Conclusion

The USG-FNAC of gallbladder lesion was found to be an easy, quick, cost-effective, and presumptive diagnostic procedure. It should be opted as an initial preoperative diagnostic modality in high incidence areas to avoid inappropriate management with unnecessary morbidity and cost. Moreover, a close cytological examination of the architectural pattern and the cytomorphological features would help in the sub-typing and prognosticating the tumor.

Simple Anthropometric Indices are Useful for Predicting Non-alcoholic Fatty Liver Disease [NAFLD] in Asian Indians

BACKGROUND AND AIMS

With the rising prevalence of obesity and metabolic syndrome, nonalcoholic fatty liver disease (NAFLD) has become the most common liver disorder in both developed and developing nations. Several studies on NAFLD have described waist circumference, a surrogate marker of visceral fat accumulation and waist height ratio as a better screening tool for NAFLD and metabolic syndrome than body mass index (BMI). We conducted this study to assess simple abdominal obesity indices as a predictor of NAFLD and determine the appropriate cut-off levels with reference to NAFLD.

METHODS

1000 subjects with NAFLD detected ultrasonographically and 360 controls attending a Gastroenterology Clinic at Cuttack, Odisha were included in the study and subjected to detailed anthropometric measurements. The abdominal anthropometric cut offs were determined using ROC analysis. Statistical analysis was performed by using SPSS software version 16.

RESULTS

All receiver operating curve (ROC) curves of waist circumference, waist-height ratio and BMI were significantly above the diagonal line. There were no significant differences in the area under the curve values among these abdominal obesity indices in each gender. The appropriate cut-off point of waist circumference in screening for NAFLD was 89 cm for men and 84 cm for women and the optimal cut-off point of waist-height ratio was 0.53 for men and 0.57 for women and the cut-off point of waist to hip ratio was 0.94 for men and 0.87 for women with very good sensitivity and specificity.

CONCLUSIONS

The simple anthropometric parameters, such as BMI, waist circumference, waist-hip ratio and waist-height ratio are useful for predicting NAFLD in Indian adults. The anthropometry cut offs would be very useful in setting target points of life style modification and weight reduction. Besides, our study also clearly demonstrated that a simple assessment of BMI is as efficacious as other anthropometry parameters in predicting NAFLD.

Histological Evaluation of Non-alcoholic Fatty Liver Disease and Its Correlation with Different Noninvasive Scoring Systems with Special Reference to Fibrosis: A Single Center Experience

BACKGROUND

Although liver biopsy remains the gold standard for the diagnosis of non-alcoholic fatty liver disease [NAFLD], many non-invasive markers of liver fibrosis have recently been proposed and assessed as surrogates of liver biopsy.

AIMS AND OBJECTIVE

To evaluate the degree of liver fibrosis by different non-invasive fibrosis scoring systems and to compare each non-invasive fibrosis scoring system with histological fibrosis stage.

MATERIALS AND METHODS

The study population consists of consecutive patients with biopsy proven NAFLD. Complete medical history was taken and physical examination was done in all patients along with appropriate biochemical evaluations. NAFLD fibrosis score, BARD score, BAAT score and APRI score were calculated and each score was compared with histological fibrosis staging.

RESULTS

The study population consisted of 60 patients having mean age 39.73 years (SD 9.62, range 17-63 years) including 51 (85%) males and 9 (15%) females. On histology fibrosis was present in 68.3% (41/60) patients. Out of 60 patients 41 had fibrosis and among them 17, 22, 2 patients had grade 1, 2, 3 fibrosis respectively and no one had grade 4 fibrosis. 61.67% (37/60) had definite NASH. Comparing the fibrosis of histology with the noninvasive scoring systems, the sensitivity and specificity of NAFLD fibrosis score were 5.56% and 100% respectively. BARD score had 45.83% sensitivity and 80.55% specificity. The sensitivities of BAAT score and APRI score were 0% and 29.16% respectively and the specificities were 100% and 97.22% respectively.

CONCLUSION

The noninvasive scoring systems like NFS, BARD, BAAT, and APRI are not sensitive enough to detect fibrosis but highly specific to include fibrosis if scores are more than cut-off values in our cohort, however they cannot replace liver biopsy. Newer more efficient non-invasive scoring systems have to be devised for the Indian NAFLD population.

Biochemical Profile of Nonalcoholic Fatty Liver Disease Patients in Eastern India with Histopathological Correlation

Aminotransferase assay is often used as a screening test as well as an endpoint for resolution of disease in nonalcoholic fatty liver disease (NAFLD). Aim of the study was to evaluate the relationship of transaminase level with metabolic variables and histology in NAFLD. Single center observational study was conducted in a gastroenterology clinic at Cuttack in coastal Odisha. Subjects were consecutive patients presenting with functional bowel disease and undergoing abdominal sonography. All participants were evaluated for the presence of metabolic syndrome (MS), insulin resistance, liver function test and lipid profile. Various parameters were compared between NAFLD subjects and controls. 53.5 % of NAFLD had normal serum transaminases, whereas 20.8 % of healthy controls had transaminitis. NAFLD patients had significantly higher BMI, fasting plasma glucose, serum transaminases, serum triglycerides, serum insulin and homeostatic model assessment (HOMA) IR than controls. NAFLD patients who had transaminitis had significantly higher incidence of MS and higher mean HOMA IR than those without. There was no significant difference in histopathological features between NAFLD with and without transaminitis. To conclude, over half of NAFLD subjects do not have transaminitis while transaminitis is present in a fifth of healthy people without fatty liver. Hence serum transaminase should not be used as screening test for NAFLD. NAFLD patients with transaminitis had a higher incidence of MS and insulin resistance than those without. However, there was no significant difference in histopathological features between these two groups.

Risk Factors Associated With Non-Alcoholic Fatty Liver Disease in Indians: A Case-Control Study

BACKGROUND/AIMS

NAFLD has today emerged as the leading cause of liver disorder. There is scanty data on risk factors associated with NAFLD emanating from India. The present study was conducted to identify the risk factors associated with NAFLD.

METHODS

464 consecutive NAFLD patients and 181 control patients were subjected to detailed questionnaire regarding their lifestyle and dietary risk factors. Anthropometric measurements were obtained and biochemical assays were done. Comparison of different variables was made between NAFLD patients and controls using principal component analysis (PCA).

RESULTS

NAFLD patients had higher BMI [26.25 ± 3.80 vs 21.46 ± 3.08 kg/m(2), P = 0.000], waist-hip ratio [0.96 ± 0.12 vs 0.90 ± 0.08, P = 0.000] and waist-height ratio [0.57 ± 0.09 vs 0.50 ± 0.06, P = 0.000] compared to controls. Fasting blood sugar [101.88 ± 31.57 vs 90.87 ± 10.74 mg/dl] and triglyceride levels [196.16 ± 102.66 vs 133.20 ± 58.37 mg/dl] were significantly higher in NAFLD group. HOMA-IR was also higher in NAFLD group [2.53 ± 2.57 vs 1.16 ± 0.58, P = 0.000]. Majority (90.2%) of NAFLD patients were sedentary. Family history of metabolic syndrome (MS) was positively correlated with NAFLD. Dietary risk factors associated with NAFLD were non-vegetarian diet [35% vs 23%, P = 0.002], fried food [35% vs 9%, P = 0.000], spicy foods [51% vs 15%, P = 0.001] and tea [55% vs 39%, P = 0.001]. Diabetes, hypertension, snoring and sleep apnoea syndrome were common factors in NAFLD. On multivariate PCA, waist/height ratio and BMI were significantly higher in the NAFLD patients.

CONCLUSION

The risk factors associated with NAFLD are sedentary lifestyle, obesity family history of MS, consumption of meat/fish, spicy foods, fried foods and tea. Other risk factors associated with NAFLD included snoring and MS.

Nonalcoholic fatty liver disease (NAFLD) without insulin resistance: Is it different?

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of insulin resistance [IR]. However, a significant proportion of NAFLD patients are devoid of IR. Is NAFLD sans IR a different entity? The aim of the study was to compare the anthropometric, metabolic, biochemical, ultrasonography, and histological profile of NAFLD patients with and without IR.

METHODS

Retrospective analyses of 336 NAFLD patients diagnosed during the last two years was done. Patients without IR were compared with those with IR.

RESULTS

Out of 336 patients, 153 [45.53%] were without IR. Although age, gender, BMI and transaminase levels were comparable, significantly higher proportion of patients in non-IR group were non-obese [43.14% vs. 25/14%; P=0.0005], and had mild fatty change on ultrasonography; [78.43% vs. 67.21%; P=0.022]. Higher proportion of them had elevated transaminases; [67.97% vs. 56.83%; P=0.036]. Serum triglyceride [178.52±78.78 vs. 204.86±94.72 mg/dl; P=0.02], FBG [85.39±13.80 vs. 98.93±31.56 mg/dl; P=0.00], PGBG [123.76±36.77 vs. 148.07±64.67m g/dl; P=0.00], and serum insulin [6.33±2.18 vs. 15.39±12.56 μIU/ml; P=0.00] were significantly lower in patients without IR. Although there was no difference in histology, interestingly fibrosis was seen in one third of patients despite absence of IR.

CONCLUSION

Nearly half of our NAFLD population was without IR; one third of them had significant fibrosis. NAFLD is probably a heterogeneous disease and IR is not the sole factor responsible for NAFLD; further studies are needed to find out other possible etiological factors.

Ultrasonographic demonstration of inner tube sign: a tropical dilemma

INTRODUCTION

Ultrasonographic demonstration of intra biliary parallel lines or "inner tube sign" is considered diagnostic for biliary ascariasis in regions where ascariasis is endemic.

PATIENTS & METHODS

148 patients with inner tube sign on ultrasonography were evaluated. In most, diagnosis was confirmed by ultrasonographic demonstration of restitution of normal appearance of bile duct with passage of round worms in vomitus or faeces.

RESULTS

Diagnosis was confirmed in 122 of 148 patients. 26 patients were lost to follow-up. Biliary ascariasis was responsible for the sign "parallel lines" in 113 patients. Of the remaining, intrabiliary stents were responsible for the "inner tube sign" in six whereas in three it was due to hydatid membranes following intrabiliary rupture of hydatid cyst.

CONCLUSION

Biliary ascariasis is the commonest cause of inner tube sign in the tropics. However, this sign can also be produced by biliary stents and hydatid membranes. Awareness of these possibilities is essential for sonologists in the tropics.

Profile of patients with incidentally detected nonalcoholic fatty liver disease (IDNAFLD) in coastal eastern India

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) has emerged as the commonest hepatic problem in both developed and developing countries. This study was conducted to delineate the clinical profile of incidentally detected NAFLD patients.

METHODS

A retrospective analysis of clinical, biochemical and histological parameters was performed for 632 patients in whom fatty liver was diagnosed by ultrasonography during 2006-2010. Every patient's clinical presentation, history, liver function tests, blood sugar, lipid profile, ultrasonogram, histology and other relevant investigations were analyzed. Patients referred for transaminitis or overt chronic liver disease were excluded.

RESULTS

Out of 632 consecutive NAFLD patients, 484 (76.6%) were males and 148 (23.4%) were females. Mean age of our patients was 42.44 +/- 10.18 years. Their mean body mass index (BMI) was 26.14 +/- 3.38 kg/m2. Obesity (BMI > 25), diabetes mellitus, hypertension, hyperlipidemia, metabolic syndrome and insulin resistance were present in 61.7%, 15.2%, 19.8%, 62.0%, 40.0%, and 54.4% patients, respectively. SGOT and SGPT were elevated in 38.29% and 55.1% patients, respectively. The common primary diseases for which these patients sought consultation were non-ulcer dyspepsia (NUD) (54.5%) and irritable bowel syndrome (IBS) (29.4%). Of the 64 patients who underwent liver biopsy, one-fourth had definite NASH while one-third patients had fibrosis.

CONCLUSION

In India, incidentally detected NAFLD (IDNAFLD) patients are predominantly middle aged males, most of whom are not lean. Most of these patients seek consultation for functional bowel disease.

Malignant duodeno-colic fistula

Colo-duodenal fistula is a rare complication of gastro-intestinal malignancy and inflammatory bowel disease. The fistula often results in diarrhea and vomiting with dramatic weight loss. Vomiting may be feculent or truly fecal associated with foul smelling eructation. We present an unusual case of colonic carcinoma, where a 61-year-old female patient presented with pain abdomen and vomiting secondary to a malignant colo-duodenal fistula near the hepatic flexure. Ultrasonography showed a mass in the hepatic flexure area, and invasive adenocarcinoma was confirmed on histology from biopsy obtained during colonoscopy. Coloduodenal fistulae from colonic primaries are rare, but early diagnosis may allow curative surgery.

Biliary ascariasis associated with chronic calcific pancreatitis of the tropics

A case of biliary ascariasis associated with Chronic Calcific Pancreatitis of the tropics in a 50-year-old lady is reported. Although acute pancreatitis is a common complication of biliary ascariasis, there are no reports linking ascariasis to chronic pancreatitis. The association of these two entities in the present case is most probably coincidental as both these entities are not very uncommon in coastal Orissa.

Prevalence of nonalcoholic fatty liver disease in coastal eastern India: a preliminary ultrasonographic survey

Non-alcoholic fatty liver disease (NAFLD) is a common clinical condition which is fast assuming importance as a possible precursor of more serious liver disorders, including cirrhosis of the liver and hepatocellular carcinoma. There are no data in the published English literature on the prevalence of NAFLD in India. The present study was performed to assess a prevalence of NAFLD by ultrasonography in a general population in coastal eastern India. Asymptomatic, apparently healthy attendants accompanying the patients attending the Gastroenterology outpatient were subjected to abdominal ultrasonographic examination for the presence of fatty liver; individuals who gave a history of alcohol abuse were excluded from the study. The subjects of the study comprised 159 apparently healthy attendants, who underwent ultrasonography. Fatty liver was diagnosed by ultrasonography in 39 of these 159 persons (24.5%). Fatty liver was seen more commonly in males (26.9%) than in females (13.8%). Persons with ultrasonographic fatty liver had a higher body mass index (BMI) (mean 25.9 +/- 4.17 kg/m2) than persons without fatty liver (mean 22.1 +/- 3.27 kg/m2) (p<0.001). The estimated prevalence of NAFLD in an unselected apparently healthy and asymptomatic population as detected by ultrasonography in our study was found to be 24.5%. This is similar to the prevalence rate published from the west. However, contrary to figures from the west, males appeared to have a greater predilection for fatty liver than females in our study. NAFLD is perhaps as common in developing world as in the developed countries despite a lower prevalence of obesity. Indian males may have a greater genetic predisposition to developing NAFLD.

Sensitive spectrophotometric method for determining pentachlorophenol in various environmental samples

A new, simple, and sensitive spectrophotometric method is described for determination of pentachlorophenol, a widely used insecticide and herbicide, in various environmental samples. The method is based on the reaction of pentachlorophenol with concentrated nitric acid to form chloranil, which liberates iodine from potassium iodide. The liberated iodine then selectively oxidizes leucocrystal violet to form crystal violet, which has an absorption maximum at 592 nm. Beer's law is obeyed over the concentration range of 0.1-1.6 micrograms pentachlorophenol/25 mL (0.004-0.064 ppm). The method was applied satisfactorily to determination of pentachlorophenol in air, water, plant material, textile effluent, and biological samples.