Swiss Journal of Radiology and Nuclear Medicine
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The Unusual Pattern of Violation of Weigert Meyer Rule with Ureterocele in an Adult
Section: Case reports Keywords: CAKUT, Ureterocele, Weigert-Meyer Rule, Stephen's ectopic pathway Background: Duplication of renal system is one of the most common congenital anomalies of the urinary tract. The relationship between the drainage of the two moieties into the urinary bladder is described by the Weigert-Meyer rule which states that the moiety opening into the bladder medially and caudally drains the upper pole while the moiety opening laterally and cranially drains the lower pole of the kidney. Case presentation: We present a case of violation of the Weigert Meyer rule in a 48 year old male who presented primarily in adulthood. On imaging studies, the patient was discovered to have a duplex left renal collecting system with the both moieties draining ectopically into the the bladder and with the lower pole moiety draining caudally and anteriory to the upper pole moiety. We present this case as it describes a rarer variant of a common anomaly as well as for its importance to radiologists and surgeons. Conclusions: Radiologists and urologists should bear in mind the possibility of these violations when dealing with patients with a duplex system. Furthermore, patients with congenital urinary tract anomalies may present primarily in adulthood and have an uneventful childhood. ---------------------------------------------------------------------- Background Congenital abnormalities of the kidney and urinary tract (CAKUT) are the most common anomalies detected in neonates, with an incidence of nearly 3 to 6 per 1000 live births (1). Some of the common anomalies include horseshoe kidneys, duplicated systems, ureteropelvic junction obstruction, etc. The genetic basis for most of these anomalies involves the same molecular pathway which plays a key role in the development of the renal system (2). Duplication of the renal system, albeit a relatively rare occurrence, is one of the most common renal anomalies, seen in about 0.2-2% of the population. It is more common in females, and unilateral involvement is more commonly seen than bilateral involvement (1,3). Duplication may be complete or incomplete. In an incomplete duplex system, the draining systems of both the renal poles drain into the bladder through the same ureteral opening while in complete duplex systems the drainage is via separate ureteral openings (1). In a complete duplex system, the relationship between the drainage of the two moieties into the bladder is described by the Weigert-Meyer rule (4,5). Urinary tract anomalies are commonly diagnosed in children who usually present with obstructive symptoms, reflux, or urinary tract infections associated with complications of these anomalies (4-7). In this article we describe the case of an adult patient with an uneventful childhood who presented with an unusual pattern of deviation from the Weigert Meyer rule. Case presentation A 48 year old male presented in 2023 with episodic lower abdominal and pelvic pain with burning micturition for 1 year. Physical examination was unremarkable. The patient had no significant prior clinical history or family history. Urine microscopy showed microscopic hematuria. Routine investigations including renal function tests were within the normal limit. The patient underwent ultrasonography (Figure 1A-C and Figure 2A-C) which revealed focal ectasia of the calyces of the upper pole of left kidney. The right kidney was normal in morphology. Two echogenic structures showing posterior acoustic shadowing were visualised within the lumen of the urinary bladder on either side, suggestive of calculi. The calculus visualized on the left side was surrounded by a thin rim of echogenic soft tissue and showed no displacement on changing the position of the patient. The calculus on the right side showed displacement to the dependent position on change in patient decubitus. For better assessment and to see the excretory function of the kidneys, further investigation with a CT urography (Figure 3A-F) was performed. The scan and the volume rendered images (Figure 4A-C) derived from it revealed complete duplication of the collecting system of the left kidney with the upper and lower pole moieties showing normal contrast uptake and excretion. The upper pole moiety showed a focal dilation of the intravesical portion, suggestive of ureterocele, with a calculus noted within the same. Few other smaller calculi were also seen in the distal aspect of left upper pole ureter just proximal to the vesicoureteric junction, with resultant upstream hydro-uretero-nephrosis of the entire left upper pole collecting system. The lower pole moiety, which was expected to be orthotopic, drained slightly inferior and anterior to the upper pole moiety, thus deviating from the Weigert-Meyer rule. An intravesical calculus was also visualised. Right kidney was normal in morphology, contrast enhancement and excretion. Limited sections of T2 weighted coronal MRI (Figure 5A-C) was performed for better anatomical delineation, which revealed a duplicated collecting system on the left with a ureterocele of the left upper pole moiety. Few T2W hypointense filling defects were seen within the ureterocele and the distal aspect of left upper pole ureter with resultant upstream hydro-uretero-nephrosis of the upper pole moiety. However, the lower moiety appeared unremarkable. An unusual finding that was observed was the drainage pattern of upper and lower moieties; the ureters draining both the upper pole moiety and the lower pole moiety had an ectopic drainage into the bladder at a location more inferior to the normally expected vesicoureteric junction. Furthermore, the lower pole moiety drained into the bladder slightly caudal and anterior to the upper pole moiety, thereby violating the Weigert Meyer rule. The patient was not in favour of undergoing invasive management and was managed conservatively for pain and infection. Unfortunately the patient was lost to follow up following resolution of the infection. The embryonic development of the urinary tract begins when the nephric duct induces changes in the adjacent mesoderm to sequentially form the pronephros, mesonephros, and ultimately the metanephros. The pronephros is a rudimentary structure and regresses soon after its development. The mesonephros gives rise to the mesonephric duct (Wolffian duct), which forms the bladder and parts of the genital system in males. The metanephros, formed around 5-6 weeks of gestation, is the precursor of renal development. The ureteric bud arises from the mesonephric duct and grows to join with the metanephric mesenchyme. The former gives rise to the collecting system of the kidneys, while the latter forms the renal parenchyma (6). In an incomplete duplex system, the draining systems of both, the upper and lower renal poles drain into the bladder through the same ureteral opening. It occurs when the ureteric bud arising from the mesonephric duct branches prematurely before reaching the metanephric mesenchyme. The point of branching gives rise to a variety of phenotypic appearances of an incompletely duplicated system, which may range from a bifid pelvis to a bifid ureter. In a complete duplication, the two ureteric moieties course separately and drain into the bladder through separate orifices (6). This occurs when two separate ureteric buds arise from the mesonephric duct and join with the metanephros (1,4,7). In a complete duplex system, the relationship between the drainage of the two moieties into the bladder is described by the Weigert-Meyer rule, which states, ‘In a complete ureteral duplication, the ureter whose orifice is more medial and caudal reaches the upper moiety and the other ureter whose orifice is more lateral and cephalad reaches the lower renal moiety’. The upper pole moiety which drains into the bladder caudally is said to be ectopic, while the cephalad draining lower pole moiety is considered to be orthotopic (4,5,8). The basis for this lies in the embryologic development of a duplex system. Embryologically, the lower pole moiety is considered to be akin to the normal ureter of a normal single system kidney, and therefore it drains in its usual orthotopic location. However, the upper pole moiety is said to be similar to an accessory ureter, and follows the pathway of the Wolffian duct to drain into any other mesonephric duct derivative, such as the trigone of the bladder, urethra, genital ducts in males and vagina in females (4). The complications associated with a duplicated system can be separately categorised into those involving the upper pole moiety (ectopic drainage) and those involving the lower pole moiety (orthotopic drainage) (4,9). The complications associated with the upper pole moiety are more common, and are majorly due to its ectopic insertion. The common upper pole moiety complications include ureterocele, obstruction, and incontinence, while the lower pole is usually afflicted by reflux and its sequelae (4-7). Duplicated systems, in most cases, show an obstructed upper pole system and a refluxing lower pole collecting system. Furthermore, it presents during the childhood as recurrent urinary tract infections and other related complications while initial presentation in adults is rare (8,11). However, in our case the primary detection of the anomaly occurred in the middle age of the patient. Moreover, although the upper pole moiety did show a ureterocele and an obstructed system, the lower pole moiety did not show any signs of VUR or its sequelae. The patient also did not have any history of recurrent urinary tract infections during childhood. Majority of the duplicated systems obey the above described Weigert-Meyer rule. However, a handful occurrences of violation of the Weigert Meyer rule have been reported in literature, with most of these deviations being reported in children (10-17). The data regarding prevalence of violation of the stated rule is lacking. One of the first violations of the rule was reported by Weigert himself in 1878, in which an upper pole moiety was seen draining into the bladder cranially to the lower pole ureter (12). Stephens in 1958 mentioned 7 cases of violation of the Weigert-Meyer rule wherein the lower pole moiety was seen draining caudally to the upper pole moiety. He also postulated that the ectopic opening were found along a specific pathway and named it the ‘ectopic pathway’ (13). Ahmed in 1981 reported a case of violation of the stated rule in which the lower pole moiety was seen draining caudally and was associated with a ureterocele, while the upper pole moiety appeared to be attached to a non-functioning ectopic kidney (14). Brown et al reported a case in 1988 where the lower pole moiety was seen ectopically draining into the ipsilateral epididymis and presenting as epididymitis on the background of a urinary tract infection (12). Slaughehoupt et al reported a similar case in 1997 wherein the ectopic ureter arose from the lower pole of the kidney and was seen draining into the ipsilateral vas deferens (15). A case of ectopic lower pole ureter with associated cystic dysplasia was reported by Jain et al in 2008 (16). As depicted in the cases reported by Brown et al and Slaughenhoupt et al where the drainage of the ectopic ureter was noted into a Wolfian duct structure, Mishra et al reported another similar case in 2017 wherein an ectopic ureter arising from the lower pole of the left kidney was seen to drain into the scrotum (10). They were the first to depict the violation of Weigert Meyer rule via a CT reconstruction. A case of ectopically draining lower pole ureter with associated megaureter, similar to that of Jain et al, was reported by Darr et al in 2020 (11). Stormont et al reported a peculiar violation of Weigert-Meyer rule in which there was involution of the lower pole moiety (17). Rathbun et al (2020) reported a case of uncrossed ureteral duplication in an infant. with an adynamic obstruction of the lower pole segment, presenting with hydronephrosis in utero (18). Another case of ectopically draining lower pole moiety with stenosis of its vesicular opening and associated megaureter was reported by Kagantsov et al (2022) in a 5 month old infant (19). In our case, there was a clear diversion from the Weigert Meyer rule, with both the moieties draining into the bladder ectopically; inferior and medial to the expected site of opening. Further, the lower pole moiety was seen draining slightly anteroinferiorly and lateral to the upper pole moiety, Although many theories have been postulated explaining the mechanism behind the violation of Weiger-Meyer rule, the embryological and molecular basis of these violations still remains unclear. Conclusion Thus, while most cases of renal duplication follow the Weigert Meyer rule, this rule is not an absolute law and various phenotypic violations and deviations have been documented. Radiologists and treating urologists should bear in mind the possibility of a violation while dealing with cases of duplicated renal collecting systems. Further, it is possible for patients with duplicated systems to present primarily during adulthood while having an uneventful childhood. Department of Radiodiagnosis, Maulana Azad Medical College, Bahadur Shah Zafar Marg, Delhi, India
Copyright (c) 2025 Rohin Sharma, Radhika Batra, Gaurav S. Pradhan, Ebinesh Arulnathan https://creativecommons.org/licenses/by/4.0
From Fibroscan to 2D Shear Wave Elastography
Section: Research Articles Keywords: Liver fibrosis, Fibroscan, Shear wave elastography, CLD Abstract Background: Proper assessment of liver fibrosis is essential for treating chronic liver disease (CLD). While Fibroscan is commonly used, it often fails in patients with obesity or ascites. Two-dimensional shear wave elastography (2D SWE) adds real-time ultrasound imaging, which may improve its success and reliability in these challenging cases. Objective: We aimed to compare how well Fibroscan and 2D SWE detect and stage liver fibrosis in CLD patients, using liver biopsy results as the gold standard. Methods: In this prospective, hospital based study at Government Medical College Srinagar, we enrolled 155 CLD patients undergoing liver biopsies from October 2022 to November 2025. Independent blinded operators performed Fibroscan with M-probe and 2D SWE on each patient. Liver stiffness was measured in kilopascals (kPa) and compared it to METAVIR fibrosis scores . Dignostic accuracy, agreement rates, and technical failure rates were calculated. Results: Out of 155 enrolled patients, 136 patients completed all evaluations (Fibroscan , SWE & Liver biopsy). Fibroscan failed in 18 of 155 patients (11.6%) mainly due to obesity or ascites, while 2D SWE failed in 8 of 155 patients (5.16%). Notably, SWE achieved valid results in 11 out of 18 patients (61%) in whom fibroscan failed. The two methods agreed 86.8% of the time supported by weighted kappa of 0.893(95% CI : 0.82-0.92) indicating almost perfect agreement as per Landis-Koch criteria : k>0.81 and confirmed by Pearson’s chi-square test ( X2 = 371.22 , p <0.0001). Diagnostic performance metrics revealed high accuracy for both modalities across fibrosis stage F0-F4 with Efficacy exceeding 93% for all stages, though SWE tended to slightly overcall F2–F3 stages yet overall performance was similar. Procedure times were alike (Fibroscan: 5.3 ± 2.2 min; SWE: 5.4 ± 2.5 min). Conclusion: 2D SWE matches Fibroscan’s accuracy but with fewer failures and advantage of real time anatomical guidance, making it a viable alternative especially for obese or ascitic CLD patients. --------------------------------------------- Introduction Chronic liver disease is a substantial worldwide problem. Its major consequence is increasing deposition of fibrous tissue within the liver, leading to the development of cirrhosis with its consequences, portal hypertension, hepatic insufficiency, and hepatocellular carcinoma (HCC). Different histologic stages of progressive liver fibrosis have been described, from no fibrosis (METAVIR stage F0) to the cirrhotic stage (METAVIR stage F4). As fibrosis progresses, there is increasing portal hypertension, loss of liver function, and higher risk of HCC. The stage of liver fibrosis is important to determine prognosis and surveillance and to prioritize for treatment and potential for reversibility. The process of fibrosis is dynamic, and studies have shown that a regression of fibrosis is possible with treatment of the underlying condition (eg, antiviral therapy in viral hepatitis and immunosuppression in autoimmune hepatitis) [1-3]. Liver biopsy remains the gold standard for assessing the degree of hepatic fibrosis. However it is fraught with certain limitations , including its invasive nature , associated procedure-related complications and high cost. [4, 5]. Further, tissue obtained via biopsy represents roughly only 1/50000 of the liver volume, which may result in sampling error [6]. Consequently, there has been a growing interest to develop alternate non-invasive tools that can accurately predict hepatic fibrosis without the need for biopsy. Various non-invasive methods for evaluating liver fibrosis have rapidly improved as alternatives to liver biopsy with fibroscan the commonest non-invasive tool used as an alternative for biopsy. It is a non-invasive, bedside, and rapid test [7]. Fibroscan probe uses a mechanical vibration that creates shear wave within the liver parenchyma and also ready to read the velocity reflected from the liver surface which shows changes according to the degree of liver fibrosis, then giving a measurement reflecting the degree of liver stiffness which is displayed in kilopascal (kPa) [8]. However, technical failure occurs in patients with obesity, ascites, or anatomical obstacles [9]. 2D SWE is relatively recent tool in the era of liver fibrosis grading as a non-invasive tool which uses the usual 2D US probe, yet with production of a focused acoustic beam to generate shear wave within the liver with the degree of liver fibrosis reflected upon the speed of this wave within the liver parenchyma and affects the degree of reflected wave. The same probe can track the reflected wave then calculate the degree of liver fibrosis using the machine software which is presented in kPa after conversion [10, 11]. This study analyses whether 2D SWE represents an evolutionary improvement or a true substitution for Fibroscan in liver stiffness assessment in CLD. Materials and Methods Study Population This prospective study was done in the department of Radiodiagnosis & Imaging in collaboration with department of Gastroenterology and department of Pathology, Government Medical College Srinagar, India over a period of 3 years between October 2022 and November 2025 and included 155 patients with chronic liver disease, scheduled for liver fibrosis staging. Exclusion criteria included heart failure, acute hepatitis, hepatic vascular thrombosis, focal lesions, prior interventions, or incomplete biopsy data. Ethical approval and informed consent were obtained. Elastography Techniques Fibroscan/Transient Elastography using EchosenseFibroscan Expert machine: Examinations were performed with patients in the supine position, right arm maximally abducted. The M or XL probe was selected according to body habitus. Ten valid measurements were obtained through the right midaxillary line, avoiding large vessels. Validity criteria: interquartile range (IQR)/median <30%. Median stiffness values expressed in kilopascals (kPa) were recorded. 2D Shear Wave Elastography Using EsaoteMyLab™ X90 machine: 2D SWE was performed using a convex probe (1–6 MHz) with B-mode ultrasound guidance. Measurements were obtained from the right liver lobe, at least 2 cm below the capsule, avoiding vascular structures. 9–12 valid measurements were recorded, with IQR/median <30% for reliability. Stiffness values were automatically converted to kPa using inbuilt software. Operator blinding: Each elastography method was performed by a separate experienced operator blinded to both the biopsy and the other elastography results. Histological evaluation All liver biopsy specimens were obtained percutaneously from the right lobe of liver using 18-G needles with core length of 2 cms under ultrasound guidance by two radiologists with sufficient knowledge and experience in percutaneous USG guided biopsies. Specimens were fixed, embedded in paraffin, and stained with hematoxylin–eosin, Azan and Gitter stains. Two pathologists with sufficient knowledge and experience in hepatic pathology who were blinded to imaging data evaluated the liver biopsy samples. If there was a discrepancy, they discussed the results and reached a consensus. Fibrosis was staged according to the METAVIR scoring system. F0: No fibrosis. F1: Portal fibrosis without septa. F2: Portal fibrosis with few septa. F3: Numerous septa without cirrhosis. F4: cirrhosis. Statistical Analysis The analysis of data was done using SPSS version 24.0 with results rounded to one decimal. Categorical variables were expressed as frequencies and percentages, and numeric variables as mean ± SD. Inter-method agreement (2D SWE vs Fibroscan) was evaluated via weighted kappa statistic (Table 3). The guidelines of Landis and Koch were followed to interpret k values: 0.00-0.20 indicated slight agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, substantial agreement, 0.81-1.00, almost perfect agreement. Pearson’s chi-square test of independence was used to assess the association between fibroscan SWE fibrosis staging classifications using fibroscan results as reference (Table 3). Statistical significance was defined as p <0.05 , values p < 0.001 were considered highly significant . Sensitivity, specificity, positive, negative predictive values and efficacy of SWE and fibroscan were calculated for each stage of Liver fibrosis in comparison to Liver biopsy (Table 4) Results Out of 155 enrolled patients, 136 completed the study to the analysis level. Fibroscan failed in 18 of 155 patients (11.6%), primarily due to obesity or ascites. Of the Fibroscan failures, 11 patients (61%) were successfully assessed using 2D SWE. 2D SWE failed in 8 of 155 patients (5.16%), mainly from steatosis or motion artefacts. The mean age of the selected patients was 52 ± 7 years SD. Eighty four patients out of 136 were male representing 61.76% of the cases. Fifty two patients out of 136 were female representing 38.24 % of the cases. Fibroscan and 2D SWE both showed very good diagnostic performance across the METAVIR spectrum, with close concordance to histological staging and to each other. Fibroscan demonstrated exact stage agreement with liver biopsy in 123/136 cases(90.4%) while SWE achieved agreement in 120/136 cases(88.2%) (Table 1&2). Intermethod Concordance between 2D SWE and fibroscan was observed in 118/136 cases (86.8%), supported by weighted kappa of 0.893(95% CI: 0.82-0.92) indicating almost perfect agreement as per Landis-Koch criteria: k>0.81 and confirmed by Pearson’s chi-square test (X2 = 371.22, p <0.0001) (Table 3) Diagnostic performance metrics revealed high accuracy for both modalities across fibrosis stage F0-F4. Efficacy exceeded 93% for all stages (Fibroscan: 94.9-97.8%, SWE: 93.4- 97.1%). SWE showed slightly higher sensitivity in F0 and F4, whereas Fibroscan demonstrated superior sensitivity in F1 and F3. For F2, the sensitivities of both modalities were comparable. Specificity remained consistently high for both tests (>95%) across all stages. PPV varied by stage, with Fibroscan outperforming SWE in most stages except F3, where SWE showed higher PPV. Negative predictive values were uniformly high for both modalities (>95%). Overall accuracy ranged from 93% to 98% for both methods, with no major performance differences observed between Fibroscan and 2D SWE (Table 4). Fibroscan showed minimal understaging and overstaging relative to liver biopsy with most discrepancies limited to one fibrosis grade. Fibroscan understaged fibrosis in 4 patients (2.9% cases) and overstaged fibrosis in in 9 patients (6.6% cases). Fibroscan under-staging occurred mainly in intermediate stages (F2–F3), while over-staging was generally limited to single-stage shifts. 2D SWE showed a comparable pattern of discrepancies, understaging fibrosis in 3 patients (2.2% cases) and overstaging fibrosis in 11 patients (8.0% cases). SWE showed under-staging primarily in early fibrosis (F1–F2) and over-staging mainly around the F2–F3 transition. SWE showed a higher incidence of overstaging and lower incidence of understaging. Exam duration was comparable (Fibroscan: 5.3 ± 2.2 min; SWE: 5.4 ± 2.5min) with no significant difference between the two techniques regarding the duration of the technique. Discussion Chronic Liver disease represents a major global health burden, characterized by progressive fibrous tissue deposition leading to cirrhosis , portal hypertension , hepatic decompensation and hepatocellular carcinoma (HCC). Accurate fibrosis staging is crucial for prognosis, treatment, prioritizing and monitoring reversibility with etiology- specific therapies such as antivirals or immunosuppression. Liver biopsy remains the gold standard for the evaluation of the liver fibrosis, yet its invasive nature, high cost, sampling errors due to limited tissue representations necessitate reliable non-invasive alternatives like fibroscan and 2D SWE. This prospective study at Government Medical College Srinagar compared Fibroscan and 2D SWE in 155 patients with chronic liver disease. Both modalities showed strong concordance with biopsy findings. Fibroscan is considered one of the most used alternatives for biopsy and already put in patient’s management algorithms in most of the European countries. However, some limitation was observed with the use of fibroscan regarding obesity and ascites (8, 12). SWE is a relatively new technique that can be utilised as part of the standard ultrasound examination to assess the presence of liver fibrosis or cirrhosis [13]. The use of the SWE method offers the advantage of being integrated into a conventional ultrasound system. It can be performed during a standard B-mode liver ultrasound, which is commonly used for the follow-ups of patients suffering from a chronic liver disease. In addition, the advantages offered by the SWE include the ability to choose the positioning of the ROI in the liver, thus avoiding interfering structures such as large blood vessels and bile ducts. In addition, the SWE method is not influenced by obesity or ascites. In our study Fibroscan failed in 18 of 155 patients (11.6%) mainly due to obesity or ascites, while 2D SWE failed in 8 of 155 patients (5.16%). SWE achieved valid results in 11 out of 18 patients (61%) in whom fibroscan failed. This is already consistent with similar studies as Osman, Ahmed M et al [14]. who reported a failure rate of fibroscan reaching 14.3% and Castera et al [15] who reported a failure rate of fibroscan reaching 20% with overall 5 years experience with patient’s obesity considered one of the most important causes of technique failure. Osman, Ahmed M et al [14] recorded less failure rate of SWE compared with fibroscan with SWE failure rate 6.7% which is consistent with our results. The lower failure rate of SWE can be explained by the simultaneous B-mode visualization available during the SWE technique which provides the opportunity to select the proper site for reading away from the ascites interface and can avoid areas of obesity which was more common in the axillary region rather than the anterior chest wall in our patients. This is in controversy to the fibroscan which depends on the application of the probe blindly on a specific anatomical level on the patient’s body at the midaxillary level which showed more fat level rather than the anterior chest wall [9, 15, 16]. In our study Fibroscan and SWE both showed very good diagnostic performance across the METAVIR spectrum, with close concordance to histological staging and to each other but SWE showed a tendency to slightly overestimate the fibrosis stage relative to fibroscan (8.0% in SWE Vs 6.6% in fibroscan) with overstaging mainly around the F2-F3 transition, SWE however showed lower incidence of understaging relative to fibroscan. These results are consistent with previous research by Osman, Ahmed M et al[14] ,O’Hara et al [17] , Foucher J et al [18] and Zeng J et al [19] suggesting SWE's sensitivity to focal stiffness heterogeneity. Exam times were similar, suggesting that SWE’s advantages in anatomical guidance do not reduce efficiency. SWE’s integration into routine ultrasound platforms also supports cost-effective, comprehensive evaluation. This study confirms 2D SWE as a viable substitute for Fibroscan in liver fibrosis staging with equivalent diagnostic accuracy and improved technical success, particularly in obese (Fig 2a , 2b & 2c) or ascitic (Fig 3a , 3b & 3c) patients. Guidelines from European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) , World Federation for Ultrasound in Medicine and Biology (WFUMB), and European Association for the Study of the Liver (EASL) support both modalities with choice of modality determined by patient habitus and clinical context [13, 20]. Operator training and device-specific cut-offs remain critical to optimize reliability. Limitations in this study include single-center design, lack of interobserver reproducibility analysis, and minor sample attrition due to technical failure. Nevertheless, the results support the routine use of 2D SWE in most CLD scenarios, particularly where Fibroscan is inappropriate or unsuccessful. Conclusion 2D SWE and Fibroscan provide comparable liver stiffness assessment in patients with chronic liver disease. 2D SWE offers practical edge in patients with obesity/ascites, and facilitates a broader, more anatomically precise assessment. SWE can be considered not merely an evolution, but a viable alternative for Fibroscan as the non-invasive standard for liver fibrosis staging in CLD especially in obese/ascitic patients.
Copyright (c) 2025 Dr Akib Arfee, Dr. Omair Ashraf Shah, Dr Asif Iqball , Dr Afshana Bashir, Dr Aaqib Manzoor https://creativecommons.org/licenses/by/4.0
A Comparison of diagnostic performance of CT with rectal contrast vs. CT with rectal and intravenous contrast for the diagnosis of acute appendicitis
Section: Research Articles Keywords: Acute appendicitis, Imaging, Radiation, iodine contrast, diagnostic performance Aim: Computed tomography (CT) is an essential investigation for the evaluation of suspected acute appendicitis (AA) owing to its high accuracy and the ability to provide an alternate diagnosis, however, there is still debate on the optimal CT technique with protocols varying between institutions. The present study aimed to compare the diagnostic accuracy of CT with rectal contrast (CT-RC) with that of CT with both rectal and intravenous contrast (CT-IVRC) in the diagnosis of AA. Material and methods: CTs of 135 patients were analysed by 2 radiologists retrospectively. Clinical outcome was used as the final diagnosis. The diagnostic accuracy of each CT technique was calculated and compared with each other. Results: There was strong agreement inter- and intra-observer agreement for the diagnosis of AA (kappa= 0.76, 0.87, 0.89 and 0.91 for CT-RC and CT-IVRC, respectively). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of CT-RC and CT-IVRC for the diagnosis of AA were not statistically different from each other (p-value>0.05 for all comparisons). The accuracy of two CT protocols in diagnosing AA ranged from 82% to 88%. The area under the curves (AUC) for diagnosing AA on CT-RC and CT-IVRC for two observers were 0.87. 0.9, 0.89 and 0.91 respectively. Conclusions: CT-RC proved to be as accurate as CT-IVRC in the diagnosis of AA. CT with rectal contrast alone could be performed in suspected cases of AA particularly in patients with contraindications to intravenous contrast administration. -------------------------------------------------------------------- Introduction Acute appendicitis (AA) constitutes one of the im-portant causes of abdominal pain and is a frequent reason for emergency department (ED) visits. AA is the most common cause of hospitalization in young patients presenting with acute abdomen (1). AA has an estimated annual occurrence of 5.7–50 per 100,000 population per year with a peak incidence between the age of 10 -30 years (1). The clinical data and laboratory information may not be always sufficient to diagnose or exclude AA or to provide an alternative diagnosis. Although appendectomy has been the standard of care for the management of AA, recently there has been a gradual shift towards conservative management of AA (2-3). However, before a firm management decision is made it is essential to establish a confident diagnosis of AA. Imaging comprising of ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) all can be used to clinch the diagnosis of AA (3). US is the preliminary diagnostic tool (4). However, abdominal CT has superseded US for the evaluation of suspected AA in most centres owing to its high accuracy and the ability to provide an alternate diagnosis in non-appendicitis patients (5). It has been observed that CT decreases the negative appendectomy rates without increasing the rate of AA-related complications like perforation or peritonitis (6). MRI is reserved for specific clinical scenarios where the US may be unable to provide a diagnosis and CT is contraindicated like in pregnancy (7, 8). The debate for the selection of optimal CT technique in the evaluation of suspected AA is still unresolved and different centres opt for different protocols (5). CT with administration of both intravenous (IV) and positive oral contrast has been the traditional technique with arguably the highest diagnostic yield (5, 9). The widespread use of this technique was based on the premise that this is the standard body imaging technique capable of maximising the visualisation of the appendix and allowing for the identification of extra-appendiceal pathologies (5). Despite its remarkably high accuracy for diagnosing AA, this technique is not necessarily the optimal or safest technique. Administration of IV contrast is fraught with many potential risks including the risk of anaphylactic reactions, risk of contrast-induced nephropathy (CIN), potential risk of extravasation and increased cost (10). The use of positive oral contrast is associated with time delays as it requires the passage of contrast to the caecum (11). The alternative protocols used by different centres across the world include IV contrast alone, positive oral contrast alone, rectal contrast alone, both IV and rectal contrast and no use of contrast (12-17). The use of positive oral contrast and rectal contrast can aid in the easy detection of the appendix when the caecum and terminal ileum are opacified with contrast and secondly, filling of the lumen of an appendix with contrast essentially rules out appendicitis (5). Positive oral contrast is associated with a time delay of approximately 1-2 hours which is the usual transit time and secondly, in 18-30% of patients the contrast fails to reach the caecum (5). Additionally, oral contrast will not be tolerated by patients with nausea or vomiting. Rectal contrast is associated with shorter delays of around 20 minutes and acceptable levels of patient discomfort (18). The use of rectal contrast-enhanced CT (CT-RC) has been studied in isolation and has been found useful with a sensitivity of 98% and a diagnostic accuracy of 98% (19). However, a direct comparison between CT-RC and rectal contrast plus IV contrast-enhanced CT (CT-IVRC) is lacking. The purpose of this study was to compare the diagnostic accuracy of CT-RC with that of CT-IVRC in the diagnosis of AA. Methods Study design and patient cohort This was a single-centre retrospective cross-sectional analytical study conducted for a period of one year, between January 2020 to December 2020. The study was approved by the institutional research committee. Due to the retrospective nature of the study, the requirement for patient consent was waived. One hundred thirty-five patients who presented to ED with abdominal pain with a clinical suspicion of AA and underwent abdominal CT with both rectal and IV contrast were retrospectively enrolled in the study. Abdominal CT was performed after administration of rectal contrast followed by a second scan after administration of IV contrast according to the departmental protocol. Patients who had only rectal or IV-enhanced scans were excluded. The final diagnosis of AA was confirmed by surgery/histopathology or conservative management with follow-up for more than 2 months. We searched our electronic database for cases of non-traumatic acute right lower quadrant or lower abdominal pain who reported to ED and underwent abdominal CT with a clinical suspicion of AA in the year 2020. Radiological, clinical, surgical, pathological and follow-up data were collected and analysed retrospectively. Among the entire cohort of 135 patients, 56 pa-tients received a final diagnosis of AA. Taking surgery or conservative management for AA as the reference standard we evaluated the diagnostic accuracy of CT-RC and compared it with that of combined CT-IVRC. Data collection CT acquisition protocol and image interpreta-tion All CT scans were performed on 64-slice Multi-detector CT. All patients underwent a CT-RC first. Rectal contrast was administered in the left lateral position using a rectal tube and 1-1.5 litre of normal saline mixed with 20-30ml of iodinated contrast. From the initial left lateral position patients were rolled into a supine and then right lateral position to allow the passage of contrast into the caecum. After 20 minutes first scan was acquired in a single breath-hold after setting up the patient in a head-first supine position in the CT gantry. The following scanning parameters were used: slice thickness 1-1.5 mm, tube voltage 100-120 kVp, tube current of 90-130mAs and a beam pitch of 1.5. The tube current was regulated by an automatic exposure control sys-tem. Images were reconstructed using a reconstruction increment of 0.7mm into a slice thickness of 1 mm. Using the same position and parameters a second scan was obtained after IV contrast administration in the portal venous phase. To avoid any bias the CT scans were anonymised by a third radiologist (B.A) who was not involved in reading the images and then presented to the interpreting radiologists. Each patient had two sets of images including CT-RC and CT-IVRC. The CT images were analysed independently by two radiologists, one consultant and another resident with 15 and 4 years of experience, respectively, who were blinded to the clinical and outcome data. The CTs were analysed for the following charac-teristics: Visualization or non-visualization of an appendix Fluid-filled or air-filled appendiceal lumen maximum outer diameter of an appendix presence of fecolith in the lumen of appendix presence of peri-appendiceal fat stranding enlarged surrounding nodes presence of peri-appendiceal free fluid or collection presence of extra-luminal air. Appendicitis was defined according to the established criteria of maximal outer diameter >6mm with surrounding inflammation like peri-appendiceal fat stranding or fluid with a non-opacified lumen (20). Statistical analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSSInc. Chicago, IL, version 21.0). Continuous variables were expressed as means and standard deviations. Categorical variables were expressed as counts and percentages. Fisher’s exact test was used to examine the categorical variables. Two sample student t-tests was used for the comparison of continuous variables when the data was normally distributed, while the Mann-Whitney U test was used when the data was not normally distributed. A p-value less than 0.05 was considered statistically significant. Cohen’s kappa was used to determine inter-observer reliability for reading CT images. Results 135 patients were enrolled into the study comprising 69 (51%) male and 66 (49%) female patients. The mean age of the study population was 32.26±11.73 years. Based on surgery/histo-pathology or conservative management 56 (41.5%) patients received a final diagnosis of AA and the remaining 79 (58.5%) were found to have an alternate diagnosis. Among the baseline characteristics only WBC counts and CRP levels were significantly higher in the AA group compared to the non-AA group (Table 1). Computed tomography findings of acute appendicitis Various CT findings were correlated between the AA and non-AA groups. The appendix diameter was significantly higher in AA patients compared to non-AA patients (10 mm vs 5.2 mm) (p-value <0.001). Similarly, wall thickening, peri-appendiceal stranding, peri-appendiceal nodes, peri-appendiceal fluid, presence of appendicolith and wall interruption had a statistically significant association with a diagnosis of AA, whereas the presence of intraluminal contrast or intraluminal air and absence of abnormal wall enhancement were negative predictors of AA on both CT-RC and CT-IVRC (all p-values <0.05) (Table 2 and 3) (Figs. 1-5). Agreement between the two observers for various parameters on CT-RC and CT-IVRC: A consultant and a radiology resident were the interpreters. There was good agreement (k= 0.76) between the two readers in diagnosing AA on CT-RC (Table 2). However, there was almost perfect agreement (k= 0.87) between the two readers in diagnosing AA on CT-IVRC (Table 3). For individual parameters, the level of agreement was moderate (kappa= 0.41 – 0.60) between the two observers in interpreting some parameters like wall thickening, intraluminal contrast, or intraluminal air, peri-appendiceal nodes and peri-appendiceal fluid and good to very good agreement (k > 0.60) in interpreting other parameters (peri-appendiceal stranding and appendicolith) on CT-RC. However, the level of agreement in-creased marginally between the two observers on CT-IVRC for various individual parameters (good agreement (k>0.60) for all the parameters except periappendiceal lymph nodes) (Table 3). Observer 1 was able to provide a diagnosis in all cases on both CT-RC and CT-IVRC, whereas Observer 2 was not able to provide any diagnosis in two cases on both CT-RC and CT-IVRC. Intra-observer agreement for both readers: The intra-observer agreement for various parameters for both observers is given in Table 4. The level of agreement was marginally better for both the observers on CT-IVRC. Comparison of diagnostic performance of two CT protocols in detecting acute appendicitis: The receiver operator characteristic (ROC) curve showed that the area under the curve (AUC) for diagnosing AA on CT-RC for two observers was 0.87 and 0.9, respectively. The AUC for diagnosing AA on CT-IVRC for two observers was 089 and 0.91, respectively (Table 5). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of CT-RC were not significantly different between CT-IVRC and CT-RC for both observers (Table 5). Discussion CT is a sensitive and specific imaging tool for diagnosing AA, with pooled sensitivity and specificity of 96% and 92% (1). The use of CT in this clinical setting has been shown to decrease negative laparotomy rates and improve patient care (6). Despite its widespread use, there is still no firm consensus over the optimal CT technique for the diagnosis of AA. So, different institutions follow different CT protocols. CT with IV, oral contrast, rectal contrast and non-contrast CT are all employed for the diagnosis of AA (10). Non-contrast CT can be performed rapidly without the attendant risks and discomfort of contrast, but it may fail to detect AA in some cases especially when the reader is inexperienced. IV contrast administration entails the risks of allergic reactions and CIN. CT with oral contrast is time-consuming, may lead to diagnostic delay and may not be feasible in patients with nausea and vomiting. CT-RC which can be performed rapidly is free from potential allergic reactions associated with IV contrast administration, and, therefore, may be the preferred initial technique in the diagnostic workup of suspected AA (12). The present study demonstrated that the two CT protocols employing only CT-RC and CT-IVRC had comparable diagnostic accuracy for the diagnosis of AA. The AUC for both protocols was around 0.90 for both observers. The major advantage of the current study was that it provided a direct comparison between CT-RC and CT-IVRC. In contrast to previous studies (15-19), no difference was found in the ability (diagnostic accuracy, sensitivity, specificity, PPV, or NPV) to identify patients with AA. Similarly, they did not differ significantly in their ability to provide an alternative diagnosis in non-appendicitis patients. CT-RC is equally accurate, although less sensitive, compared to combined CT with oral and IV contrast and significantly superior to non-contrast CT for the diagnosis of AA (15). S. Walker et. al in a study using CT-RC obtained a sensitivity of 94%, specificity of 100%, and accuracy of 96%, in diagnosing AA (16). Mittal V.K et.al performed a randomized controlled trial to compare the accuracy of CT-RC alone with a triple contrast CT (oral, rectal, and IV contrast administration) and concluded that CT-RC had a comparable diagnostic performance and was better tolerated by patients, financially cheaper and reduced the time to diagnosis and negative appendectomy rate with no missed diagnosis (20). Our results reiterate that CT-RC has several advantages. It is less time-consuming, tolerated well by patients with no potential hazards of IV or oral contrast and has a comparable diagnostic accuracy. Additionally, the diagnostic accuracy was almost similar for both experienced and relatively inexperienced radiologists. However, retrospective design, single centre and small sample size are some important limitations of the study. Conclusion CT-RC has a comparable diagnostic performance compared to CT-IVRC in the detection of AA. CT-RC could be performed in suspected cases of AA particularly where there is a contraindication to IV contrast administration or if there is a risk of developing a severe adverse reaction.
Copyright (c) 2025 Ahmet Aslan, Arshed Hussain Parry, Muhammed Taher Alali, Banoo Loai Alsaleh, Rami Moraya Sharahili, Abdulaziz Almutawea, Husham Bakry, Isam Mazin Juma https://creativecommons.org/licenses/by/4.0
The Pediatric Ovarian Torsion at Two Years of Age
Section: Case reports Keywords: Ovarian torsion, pediatric, young girl, normal ovary Introduction Pediatric ovarian torsion is a relatively uncommon cause of acute abdominal pain. It carries significant risk of morbidity and possible mortality if not diagnosed and treated immediately. Case presentation In this report, we present a case of pediatric ovarian torsion in a two-year-old girl that was suspected on clinical assessment, diagnosed by ultrasound, and confirmed by exploratory laparoscopy. The right ovary was necrosed and oophorectomy was performed. This case report underlines the importance of a timely diagnosis to salvage the ovary. Conclusion This case report discusses the diagnosis of pediatric ovarian torsion including risk factors, symptoms, imaging modalities, and surgical diagnostics to improve diagnosis and shorten time to treatment. In addition, this case supports the use of laparoscopy for diagnosis of ovarian torsion if indicated by clinical suspicion and supplemental imaging studies. -------------------------------------------------------------------------- Introduction Ovarian torsion (OT) is a surgical emergency that can lead to impaired or lost fertility if the diagnosis and intervention are delayed. Complete or partial ovarian torsion occurs due to the twisting of the vascular pedicle of the ovary. The twisting of vascular pedicle causes obstruction of lymphatic and venous flow followed by obstructed arterial flow which if unrelieved ensues in ovarian infarction (1). Pediatric ovarian torsion is an uncommon cause of acute abdominal pain in children. In adults, a large sized uterus provides support to the ovaries, which generally remain stably tucked, thus, reducing the chances of spontaneous torsion. Therefore, torsion in adults usually occurs when a cyst or mass develops within the ovary. Moreover, it is estimated to account for 3% of all cases of acute abdominal pain in adult women. On the other hand, pediatric OT is an uncommon cause of acute abdominal pain. The small size of uterus provides space for ovaries to move freely at the cost of stability which predisposes ovaries to twist leading to torsion (2,3). It is pivotal to diagnose OT at the earliest, allowing a timely intervention to salvage the ovary as the delay in diagnosis can lead to impaired or lost fertility. Besides a missed or neglected OT can have serious complications such as intra-abdominal sepsis, septicemia, and death (4,5). Case Presentation A-2-year year old girl, presented to emergency department (ED) with right lower abdominal pain that has been persistent for 2 days. The pain was intermittent with no radiation. It was associated with anorexia, non-bilious vomiting, and constipation. No history of fever or diarrhea was forth-coming. There was no relevant past medical or surgical history. On examination, the child was lying comfortably in bed. The abdomen was soft and non-tender to palpation with normal bowel sounds on auscultation. The child was afebrile with temperature of 37.2 °C. A cardiovascular system examination re-vealed sinus tachycardia with a pulse rate of 112 beats/minute, and blood pressure of 100/70 mmHg. Her respiratory rate was 26 breaths/minute, and her oxygen saturation was 100% on room air. Complete blood count revealed normal hemoglobin and platelet count with elevated white blood cell count (13.9 x109/L). C-reactive protein concentration was 9 mg/l. Her urine analysis was normal. Kidney function test, liver function test, serum electrolytes, and other basic biochemical investigation results were within normal limits. The patient was subjected to ultrasound examination of abdomen and pelvis, which showed an enlarged right ovary with multiple follicles and small peri-ovarian free fluid suggesting right ovarian torsion. The bowel loops were normal in caliber. No features of appendicitis or intussusception were seen. Furthermore, evidence from clinical pictures and ultrasound findings lead to the decision to admit the patient and keep her fasting for exploratory laparoscopy and a possible right oophorectomy. The intraoperative laparoscopic findings demonstrated a torsed and completely gangrenous right ovary with no macroscopic viable ovarian tissue seen. The fallopian tube appeared healthy with intact fimbria. Minimal blood was seen in the right para-colic gutter and pelvis. Right oophorectomy was performed leaving behind the fimbria. The specimen was sent for histopathology examination which revealed widespread necrosis of the ovarian medulla and cortex, replaced by a dark brown tissue with hemorrhage and marked acute and chronic inflammation. No evidence of malignancy was seen. Post-operatively, the patient was discharged on pain medication and attached to pediatric surgery for follow-up. Discussion Adult females with OT usually present with typical clinical features which makes the diagnosis relatively easy. In comparison, the younger patients present with vague clinical features and are not able to articulate their symptoms clearly which makes the diagnosis challenging. A thorough clinical examination complimented by imaging in-vestigations is pivotal in clinching the diagnosis at the earliest to avert the deleterious consequences of OT. OT is an important differential diagnosis in a female patient presenting with abdominal pain. The highest prevalence is seen in women of reproductive age group (2-5). It also constitutes as the fifth most common gynecological emergency in the reproductive age group. It has a cumulative prevalence of 2.7% and an incidence of 4.7 per 100,000 patients in women below 20 years of age (6-9). Pediatric and adolescent cases of OT account for about 15% of the total cases. Among the pediatric age group 52% cases of OT are reported between the age of 9 and 14 years. OT is uncommon in infants with only 6% of cases reported in children under 1 year old (10, 11). Right ovarian torsion is more common compared to the left side presumably due to presence of sigmoid colon on left side leaving little space for the ovary to twist (1). In the reproductive age an ovarian lesion (dermoid or functional cyst) predisposes to torsion as it makes the ovary heavier rendering it vulnerable to twist. However, in the pediatric and adolescent females usually no incriminating ovarian lesion is seen. An earnest diagnosis of OT is essential to avoid any potential morbidity or mortality. Diagnosis of OT hinges primarily on clinical history and examination supplemented by imaging. However, confirmation of the diagnosis is usually made at the exploratory surgical procedure. Given the rarity of the condition and the non-specificity of the clinical and laboratory findings a timely diagnosis of OT can be challenging. Patients of OT usually present with nonspecific lower abdominal pain. The pain may be continuous or intermittent ranging in intensity from mild to severe. Associated symptoms like nausea and vomiting are commonly seen. A right sided OT can closely mimic appendicitis. Other differential diagnosis includes intussusception, gastroenteritis, and urinary tract infection. The physical examination findings of fever, tachycardia and lower abdominal tenderness are nonspecific. Complete blood count, inflammatory markers and urinary analysis are commonly performed in suspected cases of OT to rule out other common mimics (6, 7). Aseptic pyuria is recognized in some patients (7). Ultrasound is the primary diagnostic tool for establishing the preoperative diagnosis. Ultrasound has a reported sensitivity of 92% and specificity of 96% in detecting OT. The ultrasound features of OT include an enlarged multifollicular ovary with free fluid around the ovary or in peritoneal cavity. Doppler ultrasound is a useful adjunct that increases the specificity. Doppler findings of reduced or absent vascular flow suggests diagnosis of OT. However, the preserved ovarian vascularity does not rule out torsion as ovary has a dual blood supply from ovarian and uterine artery. Additionally, an incomplete torsion may not compromise arterial blood flow to the ovary. Detection of a twisted vascular pedicle on Doppler referred to as whirlpool sign constitutes a highly specific sign of torsion (11). In cases with non-diagnostic ultrasound findings additional studies like magnetic resonance imaging (MRI) and computed tomography (CT) are undertaken which can help in diagnosing as well as excluding the common differentials. However, in cases with ultrasound findings of OT treatment should be undertaken without subjecting the patient to CT or MRI. Surgical exploration is the definitive stan-dard for diagnosis and confirmation of OT via direct visualization. Our patient presented with clinical features suspicious of OT which was further substantiated by ultrasound and finally confirmed by laparoscopy (Fig.2). Our patient recovered with no complications. Histology of the specimen demonstrated widespread necrosis of the ovarian medulla; cortex replaced by a dark brown hemorrhagic change. In a resource-constrained setting, it is a challenging to establish the diagnosis in a very limited time frame. Our patient had to undergo oophorectomy, but she did not have other complications. It is important to exclude OT with certainty in a young girl presenting with significant unexplained abdominal pain. Early diagnosis and treatment can salvage the ovary. Conclusion This case report highlights the importance of earnest timely diagnosis and emergent surgical intervention to salvage ovarian function and to limit any possible morbidity.
Copyright (c) 2025 Mujahed Abdul Sattar Raheem, Arshed Hussain Parry, Hussam Hassan Ismail, Wael Hamed Ibrahim, Martin Corbally https://creativecommons.org/licenses/by/4.0
A Case of Radiation-induced Differentiated Thyroid Cancer
Section: Case reports Keywords: Ionizing radiation, differentiated thyroid cancer, radioiodine therapy The association between differentiated thyroid cancer and exposure to ionizing radiation has been well known since the radioactive fallout of the 20th century. Post-radiotherapy monitoring should focus on three main objectives: assessment of the oncological response, evaluation of acute or late toxicity due to ionizing radiation, and screening for a second cancer. Surveillance is recommended following cervical, upper mediastinal, craniospinal, or total body radiotherapy. The risk of a second cancer is maximal for irradiation received before the age of five and decreases with age. It is no longer significant if irradiation occurs after the age of 15 to 20. A 16-year-old female patient with stunted growth and a history of a posterior fossa medulloblastoma diagnosed and operated on at age 5, received 55.8 Gy irradiation to the brain and posterior fossa over 21 sessions (radiation completed in September ,2013). She was declared cured with annual clinical and radiological follow-up. Eleven years later, she presented with a WHO stage 3 thyroid goiter associated with cervical lymphadenopathy. A total thyroidectomy with lymph node dissection confirmed a differentiated thyroid cancer classified as pT1bN1bM1. The patient received three further therapeutic cycles of radioiodine therapy, which successfully sterilized the multiple secondary pulmonary lesions discovered during the scan after the first course of treatment. She has been declared cured based on satisfactory clinical, biological, and morpho-functional criteria and is currently undergoing lifelong follow-up.
Copyright (c) 2025 Arnauld Muhoza, Esso-Mada Kpekpeou, Maha Chaoui, Aicha El Boukhrissi, Nadia Ismaili Alaoui https://creativecommons.org/licenses/by/4.0
Section: Specials Keywords: New Year’s Greeting 2026 *]:pointer-events-auto [content-visibility:auto] supports-[content-visibility:auto]:[contain-intrinsic-size:auto_100lvh] scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" dir="auto" tabindex="-1" data-turn-id="51fe8d2e-5591-4be2-b831-d0ced9019e17" data-testid="conversation-turn-2" data-scroll-anchor="true" data-turn="assistant"> New Year’s Greeting 2026 (Editor-in-Chief) As we welcome the New Year 2026, I would like to extend my warmest greetings to all our readers, authors, reviewers, and colleagues around the world. Video_Greetings_2026 Over the past year, The Swiss Journal of Radiology and Nuclear Medicine has continued to grow as a platform for thoughtful scientific exchange. The articles published throughout 2025 reflected the impressive breadth and depth of our discipline — from advances in diagnostic imaging and interventional techniques to developments in nuclear medicine and translational research. Each contribution enriched our shared understanding and underscored the value of collaboration across institutions, countries, and subspecialties. We are deeply grateful to everyone who has supported the journal — not only through research and authorship, but also through peer review, editorial work, and dedicated readership. Your engagement makes this journal a living forum for academic curiosity, critical thinking, and clinical progress. A new year always brings with it the hope for renewal. In that spirit, let us continue to foster scientific rigor, open dialogue, and respectful exchange. And beyond our professional world, we join the global community in wishing for peace, understanding, and wellbeing for all people — wherever they may live. On behalf of the editorial team, We wish you a healthy, fulfilling, and inspiring 2026. With warm regards, Gerd Nöldge & Frank Mosler Editors Swiss Journal of Radiology and Nuclear Medicine
Copyright (c) 2025 Frank Mosler, Prof. Dr. Gerd Nöldge https://creativecommons.org/licenses/by/4.0