The document discusses various liver lesions that can be difficult to diagnose. It begins by listing common and rare liver masses and discusses which ones typically require treatment. It then presents several case studies of patients with liver lesions found on imaging. This includes a case of hepatocholangiocarcinoma mimicking HCC and a case of peripheral cholangiocarcinoma in a cirrhotic patient. Other cases discuss rare neuroendocrine tumors and angiosarcoma of the liver. Throughout, the document emphasizes adapting diagnoses based on imaging characteristics, patient history, and recognizing atypical presentations of common lesions.
Imaging assessment of malignant focal and diffuse liver lesions from Ultrasound to Mri with overview of interventional modalities and diagnostic snippets,
Liver Tumors and Hepatocellular carcinoma supported by Hepatoblastoma. Most of the text are from Robbins Pathological basis of disease 9E, Goljan Review of pathology.
Imaging assessment of malignant focal and diffuse liver lesions from Ultrasound to Mri with overview of interventional modalities and diagnostic snippets,
Liver Tumors and Hepatocellular carcinoma supported by Hepatoblastoma. Most of the text are from Robbins Pathological basis of disease 9E, Goljan Review of pathology.
Model relacional i comprovació de la 1era , 2ona, 3era forma normal i la fòrmula normal Boyce-Codd. Transformació del model entitat relació al model relacional.
Il colangiocarcinoma: Presentazione Clinica, Diagnosi e Trattamento - Gastrol...Gastrolearning
Gastrolearning II modulo/8a lezione
Il colangiocarcinoma: Presentazione Clinica, Diagnosi e Trattamento
Prof. D. Alvaro - Università di Roma La Sapienza
Il trattamento chirurgico del colangiocarcinoma - Gastrolearning®Gastrolearning
Gastrolearning II modulo/8a lezione
Il trattamento chirurgico del colangiocarcinoma
Prof. Gian Luca Grazi - Hepato-Biliary-Pancreatic Surgery National Cancer Institute Regina Elena, Roma
What is MIS?
A minimally invasive medical procedure is defined as one that is carried out by entering the body through the skin or through a body cavity or anatomical opening, but with the smallest damage possible to these struct uresIncludes laparoscopic, endoscopic, and other approaches.
Why MIS?
Decreased patient pain
Decreased patient recovery period
Possible decrease in inflammatory response in the patient which may prove to have a better outcome in oncologic operations.
Distant future
In the distant future, there will be a para- digm shift with the development of non-inva- sive surgical techniques in combination with nanotechnologies and a new era in the devel- opment of surgery, and subsequently in surgi- cal techniques, will be opened.
Nanotechnology is an umbrella term for materials and devices that operate at the nanoskill (1 billionth of a meter). In terms of scale, a nanometer is approximately one 1/8000 of a human hair or 10 times the diam- eter of a hydrogen atom. The size of the device can vary but starts from a ten thou- sand-logic element system that will occupy a cube of no more than one hundred nanome- ters. This is a volume slightly larger than 0.001 cubic microns. This would be sufficient to hold a small computer. For example, if red blood cells are approximately eight microns in diameter, the 100 nanomicroprocessor will be 80 times smaller than a red blood cell. Devices this size could easily fit into the circulatory system and could even conceivably enter indi- vidual cells.
CARCINOMA ESOPHAGUS - DR ZAHID IQBAL MIR
Dr. Zahid Iqbal Mir, MBBS MS (General Surgery), DNB (General Surgery) has done his MBBS and masters in General Surgery from the prestigious Govt Medical College Jammu and DNB in General Surgery from NBEMS New Delhi. He is a passionate surgeon, earlier practising at Government Medical College, Jammu as Registrar in Department of General Surgery. Nowadays working as Senior Resident in Department of General Surgery, Government Medical College & Hospital, Sector 32, Chandigarh and a rising name in field of surgery.
He is an enthusiastic, enigmatic and dedicated teacher as well. He is not just a resolute learner, but also an awe inspiring guiding light for his juniors, which makes him the most loveable and respected senior.
Currently he is running “LOVE FOR SCALPEL” for PGMEE aspirants on most of the social platforms, which is gaining immense popularity among residents, medical graduates and undergraduates.
Hepatic cysts are abnormal fluid-filled spaces in the hepatic parenchyma and biliary tree
They are categorized into 3 main types:
fibrocystic diseases of the liver
cystadenomas and cystadenocarcinomas
and hydatid cysts
Similar to Y menu difficult tumours of the liver jfim hanoi 2015 (20)
Common: 200 000 TC/an, 12 000 death
Neuroimaging plays a critical role in the evaluation of patients with traumatic brain injury
CT: first-line of imaging
MR imaging being recommended in specific settings
MR imaging DTI, blood oxygen level–dependent fMRI, MR spectroscopy, perfusion imaging are of particular interest in identifying further injury CT and MRI are normal, as well as for prognostication in patients with persistent symptoms
However, it is an invasive procedure that is not straightforward to perform so is often reserved as a problem-solving tool when both the aortic root and valve are the prime source of interest.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- Prix Galien International Awards Ceremony
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
10. The clue is elsewhere
The Mixed Grill
The Alien
How to be brilliant
Be patient
How to look stupid
Your best friend is…
11. The Mixed-Grill
§ A 68 yo man, with metabolic chronic liver disease (NASH), A
focal liver lesion is found at US.
§ CT is performed, with arterial and portal phase.
53. What is the reason for asymetry of
liver enhancement at the arterial
phase ?
1. Tumour angiogenesis increases regional perfusion («liver
mismatch »)
2. Hypoenhancement of the left lobe
3. Portal flow problem
4. Hepatic vein problem
5. Arterialization of the right liver lobe, related to chronic liver
disease
105. According to mRECIST, in case of HCC, coeliac or
mesenteric lymph node is a measurable target if its
small axis is
1. ≥ 10 mm
2. ≥ 15 mm
3. ≥ 20 mm
4. ≥ 25 mm
106. According to mRECIST, in case of HCC, porta
hepatis lymph node is a measurable target if its
small axis is
1. ≥ 10 mm
2. ≥ 15 mm
3. ≥ 20 mm
4. ≥ 25 mm
107. Finally…
§ Ill-defined mass, with necrosis, portal vein
invasion, satellite nodules and loco regional
Lymph Nodes
§ In a patient with chronic liver disease
108. Which is the tumour that never invades the portal
vein?
1. HCC
2. Cholangiocarcinoma
3. Liver Mets
4. Neuroendocrine tumour
5. Hepatocholangiocarcinoma
109. Which is the tumour that never invades the portal
vein?
1. HCC
2. Cholangiocarcinoma
3. Liver Mets
4. Neuroendocrine tumour
5. Hepatocholangiocarcinoma
110. The most likely diagnosis is HCC,
however:
§ Total absence of hypervascularization
§ TIP : although 20% of HCC are hypovascular, they are
usually not necrotic also
§ AFP basse
Hypovascular + Necrosis + Cirrhosis = Weird !
111. Strategy
§ Most likely diagnosis?
§ HCC on cirrhosis
§ Which is the best treatment?
§ Surgery
§ Is it possible?
< Good status, no Portal Hypertension, left liver normal, no distant
lesion
= Infiltrating tumour, portal envasion, lymph nodes
§ Decision
§ Right hepatectomy
J30
112. Hepato-Cholangiocarcinoma
§ Not so rare : 1-5 % of liver primary malignancies
§ H>F, chronic liver disease
§ Poor prognosis: 5-y survival 18-24%, including resected
cases
§ Diagnosis mainly rely on histology and immunohistology
§ Mucus +
§ DesmoplasticStroma
§ Fibrosis + nécrosis + haemorrhage
§ CK7/CK19 +
§ The biopsy may miss the Cholangiocellular compartment
114. Usual appearance of a rare tumour
§ In a patient with chronic liver disease, absence of
hypervascularization associated to extensive necrosis would
be unusual for HCC
§ Consider Heaptocholangiocarcinoma. Biopsy will not help
115. The Alien..
§ A 64 yo man, with end-stage HBV cirrhosis. During the pre
transplantation staging, US finds a 30 mm hypoechoic mass
§ MRI is performed in order to characterize and stage
119. What is the most likely diagnosis?
A. Low grade Dysplastic Nodule
B. High grade Dysplastic Nodule
C. Regeneration Macronodule
D. HCC
120. Dysplastic Nodules (DN)
§ Easy to recognize features
§ Hyper T1
§ No fat
§ Iso or Hypo T2
§ No arterial enhancement
§ Precursor of HCC (high grade)
§ However
§ Only the minority of DN’s are typical à iceberg syndrome
§ HCC will come, but you don’t know where…
§ The Nodule-in-the-Nodule
§ Famous and pathognomonic, but rare
132. Cytokeratin (CK)
CK7 - CK7 +
CK20 - HCC Cholangiocarcinoma
CK20 + Colorectal Ca Pancreatic Ca
In this patient: CK7+/CK20-
133. Peripheral Cholangiocarcinoma (1
answer is correct):
A. Is more common on a cirrhotic liver
B. Usually comes with dilatation of bile ducts
C. Due to fibrous stroma (unlike HCC), capsular
retraction and delayed enhancement are
pathognomonic features.
134. Peripheral Cholangiocarcinoma (1
answer is correct):
A. Is more common on a cirrhotic liver
B. Usually comes with dilatation of bile ducts
C. Due to fibrous stroma (unlike HCC), capsular
retraction and delayed enhancement are
pathognomonic features.
135. Peripheral Cholangiocarcinoma (1
answer is correct):
A. Is more common on a cirrhotic liver
B. Usually comes with dilatation of bile ducts
C. Due to fibrous stroma (unlike HCC), capsular
retraction and delayed enhancement are
pathognomonic features.
136. Cholangiocarcinoma (CC)
§ Second more common liver primary malignancy
§ Relative risk is x2 in cirrhotic patients
§ Usual features are:
§ Lobulated mass
§ Hypodense centre (necrosis ou mucus)
§ Mild arterial enhancement
§ Late enhancement (fibrous compartment), non specific
§ Capsular rretraction (20%, non specific)
§ Bile ducts dilatation (20%)
§ Curative treatment is surgery
§ Standard CT is GEMOX (GEMcitabine + OXaliplatine)
§ Poor prognosis in general, however, the doubling time has to be
evaluated as prolonged survival (> 3 years) is sometimes observed
In a cirrhotic patient, delayed enhancement is strongly in favour of a CCC, as
HCC never presents with such a feature
In a non – cirrhotic patient, be careful, as mets may have the same behaviour
138. Your best friend is…
§ A 62 yo woman, with a previous liver transplantation,
presents with abnormal liver tests.
§ MRI is performed to rule out biliary complication.
§ The radiologist report says that there is a « colon artefact
within the liver »
149. The clue is elsewhere
§ A 44 yo woman with severe bipolar disorder and recently
discovered neurosarcoidosis. She is heavily depressed.
§ She complains of dyspnea and cough. Plain CT of the chest
is performed in order to find pulmonary lesions, which is
present.
§ An abnormality in the liver is found, and contrast enhanced
images are obtained. There are no abdominal symptoms,
liver tests are normal excepting for a mild increase of
transaminases
155. Strategy
§ Rule out sarcoidosis (no spleen lesion, nodular liver lesions)
§ Further step(s) ?
§ Biopsy à Denied by the patient
§ PET-CT à Normal
Something has to be done and it is free…
160. Summary
§ Half of GastroEnteroPancreatic NeuroEndocrine Tumours
(GEP-NET) are fortuitously discovered on imaging
§ Discordance between patient’s good condition and advanced
imaging findings is a target sign
§ Don’t expect to rule out GEP-NET if not hypervascularized
§ FDG PET-CT might be negative in well-differentiated lesions
(50%)
§ Don’t forget to look for « hidden areas »
§ DWI is usually the most powerful sequence for detection
161. How to be brilliant…
§ A 75 YO man, with a cirrhosis on NASH. A nodule is found in
the liver at Ultrasound
162.
163.
164.
165. Angiosarcoma
§ Liver angiosarcoma occurs mainly in the elder
§ Third most common primary liver maligancies
§ The prognosis of liver angiosarcoma is very poor with almost
all patients with this kind of disease die within 2 years after
diagnosis
§ Early metastases to other organs, such as lung, spleen, or bone
§ Severe intra-abdominal hemorrhage due to spontaneous rupture
§ Remember the dotted enhancement, translating “peliosis-
like” blood-filled cavities
166. How to look stupid
§ A 45 yo man with alcohol abuse and abnormal liver tests. US
finds a hypoechic 2 cm mass in the right liver lobe
168. Tumours that are commonly
associated with arterio portal
fistula
§ HCC
§ Any tumour after percutaneous biopsy
§ And the most common is …..
169.
170.
171. Tumours that are commonly
associated with arterio portal
fistula
§ HCC
§ Any tumour after percutaneous biopsy
§ And the most common is ….. ANGIOMA
• Up to 16% present with early
arterial enhancement
• Usually small (less than 20 mm)
• No wash out
• Association with arterio-portal fistulae
• Clue : plain MRI mainly T2 (+ no restriction)