Subclavian steal syndrome is a rare phenomenon occurring from retrograde blood flow in the vertebral artery due to proximal stenosis in the subclavian artery. As a result, the arm gets blood supply from the vertebral artery at the expense of the vertebrobasilar system. The patient remains largely asymptomatic until there is an increase demand for blood supply to the arm, resulting in a constellation of symptoms including dizziness, vertigo, blurred vision, diplopia, headache, syncope, postural hypotension, neurologic deficits, and rarely, memory problems. The management approach depends on the severity of clinical symptoms but includes medical treatment, endovascular therapy and lifestyle modifications.
Non-alcoholic fatty liver disease (NAFLD), is a disease spectrum characterized by fat accumulation in hepatocytes presenting as hepatic steatosis to advance disease with active hepatic inflammation, known as nonalcoholic steatohepatitis. Chronic steatohepatitis will lead to progressive hepatic fibrosis causing cirrhosis and increased risk for developing hepatocellular carcinoma (HCC). Fatty liver disease prevalence has increased at alarming rates alongside obesity, diabetes and metabolic syndrome to become the second most common cause of cirrhosis after alcohol related liver disease worldwide. Given this rise in prevalence, it is becoming increasingly more important to find non-invasive methods to diagnose disease early and stage hepatic fibrosis. Providing clinicians with the tools to diagnose and treat the full spectrum of NAFLD will help prevent known complications such as cirrhosis and HCC and improve quality of life for the patients suffering from this disease. This article discusses the utility of current non-invasive liver function testing in the clinical progression of fatty liver disease along with the imaging modalities that are available. Additionally, we summarize available treatment options including targeted medical therapy through four different pathways, surgical or endoscopic intervention.
Gastric emphysema (GE) or gastric pneumatosis is a rare entity defined as air within the gastric wall. Etiologies include pneumothorax, instrumentation, infection, gastric wall ischemia, and mechanical injury. Several theories exist as to how the air disrupts the integrity of the gastric wall. These include a bacterial infection with Clostridium species and other gas-forming aerobic colonic bacilli, instrumentation with direct submucosal gastric wall injury, mechanical injury following increased intra-abdominal pressure, penetrating air through the mediastinum from increased intrapulmonary pressure or, gastric wall ischemia, which may be secondary to an underlying process. The diagnostic test of choice is CT of the abdomen. A hypodense linear fringe on the gastric wall is seen in GE, associated with gastric distention without thickening. In emphysematous gastritis, there is gastric wall thickening. There are no standardized guidelines for GE, but most cases have a good prognosis with a spontaneous resolution with conservation treatment. However, emphysematous gastritis management requires aggressive treatment due to the mortality rate of emphysematous gastritis approaching 60%. Patients are often considered for surgical intervention with total gastrectomy, given that active infection could delay or prevent healing. It is imperative to differentiate GE and emphysematous gastritis and understand the underlying pathogenesis as clinical outcomes are vastly different.
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