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Objective: The purpose of this study was to categorize patients into different grades of nonalcoholic fatty liver disease (NAFLD) by ultrasonography and to compare the findings with their serum lipid profile. Materials and Methods: Descriptive, cross-sectional study design was used. One hundred and nine patients without a history of alcohol consumption of age more than 16 years attending general health checkup were selected at Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, as per the exclusion and inclusion criteria. Ultrasound scanning of the patients was done and their liver size, as well as grading of fatty liver, was done. Data were collected in predesigned pro forma and were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0, IBM (SPSS Inc., Chicago, IL). Results: In this study, the mean age of fatty liver in males was found to be 44.3 years and in females was found to be 51.9 years. 22.9% of patients with NAFLD had increased liver size. Significant association with increasing grades of fatty liver was found with increasing levels of cholesterol (P = 0.028), low-density lipoprotein (LDL) (P = 0.017), liver size (P = 0.001), and body mass index (BMI) (P = 0.045) in patients diagnosed with NAFLD. No significant association with increasing grades of fatty liver was found with increasing levels of triglyceride (P = 0.32) and high-density lipoprotein (P = 0.25). Conclusion: Ultrasound is a safe and first-line modality for the evaluation of fatty liver and its grading. Increasing grades of fatty liver had significant association with increasing levels of cholesterol LDL, increasing liver size, and BMI of patients.

In summary, this study showed that fatty liver was more prevalent in male sex and age group of 40–50 years. Almost three quarters of fatty liver patients had normal liver size while one quarter had increased size of the liver. Almost half of the patients with fatty liver had increased BMI. Increasing grades
of fatty liver had significant association with increasing LDL, cholesterol, BMI, and liver size. No significant association of increasing grades of NAFLD was noted with increasing levels of serum TGL s or decreasing levels of HDL. Ultrasound is an important imaging tool for the diagnosis and grading of fatty liver. It is the first-line investigation modality for diagnosis of fatty liver. It is cheap, easy to use, and handle. However, it has some limitations like observer dependency. Next limitation of ultrasound in the cases of fatty liver is its inability to quantify the fat in the liver. Quantification of fat using CT scan or MRI may be more reliable for estimation and quantification of fat deposition in the liver. This can further be correlated with lipid profile in patients. Studies using CT and MRI for the quantification of fat and correlation with lipid profile can be done in the future. Findings in our study can be used for further management of patients with fatty liver. From the study, it was shown that increasing grades of fatty liver had significant association with deranged lipid profile. Deranged lipid profile is associated with cardiovascular problems. Hence, increasing grades of fatty liver has indirect relationship with cardiovascular problems.

It is clinically important to assess the degree of hepatic injury in addition to the clinical diagnosis of underlying liver diseases. Fibrotic deposits represent the response of liver tissue to damage, and the degree of hepatic fibrosis is an important prognostic indicator and therapeutic target in liver diseases. Invasive liver biopsy has been the golden standard for the assessment of the degree of hepatic fibrosis with hazard. Non-invasive assessments have been widely used to assess the degree of hepatic fibrosis instead of liver biopsy. Ultrasound elastography has been the recent interest for the clinical assessment of hepatic fibrosis. Ultrasound elastography technology involves the use of machinery to generate shear waves in the vicinity of hepatic tissue and then the monitoring the propagation of the shear waves. A mild external force can also be applied to the liver tissue for the monitoring of degree of strain. Then ultrasound devices can calculate the speed of the shear waves and the degree of strain, and convert these data into ultrasound images to determine the elasticity of the liver tissue. Current elastography determining shear wave speed include Transient Elastography (TE), Acoustic Radiation Force Imaging (ARFI), Point Shearwave Elastography (SWE), and Two-dimensional SWE. Various researches have shown a good correlation between the hepatic elasticity and the degree of hepatic fibrosis; therefore, elastography is widely used in the clinical assessment of hepatic fibrosis. Recent reports indicate that ultrasound elastography is helpful in the diagnose cirrhosis and severe hepatic fibrosis with a high level of accuracy. However, ultrasound elastography is only moderately accurate in the assessment of mild-to-moderate hepatic fibrosis. In our studies, the accuracy of TE was as high as 90% and 93% in the diagnosis of cirrhosis in patients having chronic hepatitis B and C. The studies from the China Medical University, Taiwan, showed that the accuracy of ARFI was 83% in the diagnose
cirrhosis in patients having chronic hepatitis C. All current international guidelines recommend the use of ultrasound elastography to assess the degree of hepatic fibrosis. Apart from chronic hepatitis B and C, ultrasound elastography has also been used to assess the degree of hepatic fibrosis in other chronic liver diseases such as alcoholic liver disease, nonalcoholic fatty liver, primary cholestatic liver disease, and primary sclerosing cholangitis. However, it is necessary to adjust the values of elasticity with factors including food intake, hepatic inflammation, bile duct blockage, heart failure, and other relevant factors during the interpretation of degree of hepatic fibrosis. The screening of gastric and esophageal varices is clinically important for the prevention of high-risk hemorrhage. However, the gastroscopic examination is invasive and is poorly tolerated by patients. Therefore, it is reasonable to use some non-invasive screening methods instead. The earlier researches proved a positive correlation between hepatic elasticity and portal hypertension, and portal hypertension was correlated with the occurrence of gastric and esophageal varices in cirrhotic patients. Our data show that a cut-off value of 21 kPa can effectively eliminate the need for gastroscopic examination in cirrhotic patients. Whereas recent international guidelines recommended a TE elasticity of 20 kPa and platelet count of 150,000 as threshold values. Patients having less hepatic elasticity and higher indicates platelet count than the recommended values are not required to take an invasive gastroscopic examination.

Superior mesenteric artery (SMA) dissection is a rare disease. Most of the cases are diagnosed through contrast-enhanced computed tomography. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. We present two case reports: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through contrast-enhanced computed tomography.

Superior mesenteric artery (SMA) dissection is a rare condition. In an autopsy series, the incidence of spontaneous isolated SMA dissection was 0.06%. SMA dissection was first reported by Bauersfeld in 1947. Some cases of SMA dissection are isolated whereas others are combined with aortic dissection. The causes of SMA dissection are fibromuscular dysplasia, cystic medial necrosis, and other connective tissue diseases; however, no specific underlying cause of SMA dissection has been identified in the majority of reports. Symptoms of aortic dissection are various and include chest, abdomen, or back pain; loss of consciousness; weak pulse in one arm; and lower limb paralysis. Abdominal pain is the main symptom of isolated SMA dissection, and in most cases, pain onset is sudden and located in the epigastric or periumbilical area. Treatment strategies include conservative management with or without antithrombotic therapy, endovascular therapy with SMA stenting, or open surgery. Some authors have suggested conservative management as first-line treatment for symptomatic patients whereas other authors prefer endovascular treatment[3] especially for patients with persistent abdominal pain and favorable anatomy. Most SMA dissection cases are diagnosed through contrast-enhanced
computed tomography (CECT). Aortic dissection can be diagnosed through bedside ultrasound. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. Herein, we present two cases: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through CECT.

A 57-year-old female presented with a swelling in her right groin for the last 2 years. There was gradual increase in size of the swelling over 2 years. Currently, she presented with acute pain. The swelling reduced on lying down and increased on standing. It was an isolated groin swelling without evidence of associated great saphenous vein varicosity. On examination, there was a small, round swelling, 4 cm below and lateral to the right pubic tubercle, measuring around 6 cm × 5 cm, hard, tender, noncompressible, irreducible, and nonfluctuant. Cough impulse was negative. The overlying skin appeared to be normal. No associated signs of venous insufficiency in the form of varicosity, edema, pigmentation, ulcer, etc., were found. Diagnosis was confirmed by Duplex imaging which showed echogenic contents suggesting thrombosis within sacculation of the terminal part of greater saphenous vein [Figures 1-3]. The saphena varix, a dilated saccular varicose swelling,
arises from the proximal end of the long saphenous vein. It presents as a reducible swelling in the groin situated in the femoral canal region. A cough impulse may be elicited and the swelling disappears when the patient lies down. The differential diagnosis for a nontender, fluctuant groin lump with a cough impulse is a hernia or a saphena varix.[1] The position of the swelling inferior and lateral to the pubic tubercle narrows the differential to a femoral hernia or saphena varix.[2] A history of deep vein thrombosis and examination findings of other venous varicosities in the leg adds further support to the diagnosis. Diagnosis can be confusing clinically, particularly if the varix is thrombosed, and presents as an “irreducible femoral hernia.”[3] Femoral hernia by far is the most common differential for saphena varix and is described as herniation of abdominal viscera through the femoral canal. An incarcerated femoral hernia often requires prompt operative management to decrease the risk of bowel strangulation, perforation, and peritonitis. Thrombosed saphena varix has been rarely described in literature. Duplex ultrasound is a front-line imaging modality where clinical examination cannot diagnose a thrombosed saphena varix. The surgical options available are stripping and ligation of the great saphenous vein, varicose vein ligation, phlebectomy, endovenous vein obliteration, and perforator vein surgery. Treatment of the saphena varix is surgical disconnection and ligation of the saphenofemoral junction. Thrombosis of the saphena varix is rare and clinicians must keep the condition in mind when they encounter any puzzling groin swellings.