Summary : This flowchart provides a comprehensive decision-making algorithm for the evaluation and management of solid focal liver lesions detected on ultrasound or non-diagnostic imaging, including initial workup, imaging choices, diagnosis, and subsequent management pathways for various lesion types and patient scenarios. flowchart: # Nodes : • Start (rectangle): "Focal Solid Liver Lesion on Ultrasound or Nondiagnostic Imaging" • Decision (parallelogram): "Evaluate history, physical, laboratory workup" • Decision (diamond): "If cirrhosis present, refer to AASLD guidance on hepatocellular carcinoma" • Branch 1 (rectangle): "Patient <40 years of age with unremarkable PMH, exam, labs" • Branch 2 (rectangle): "All other patients" • Branch 3 (rectangle): "History of malignancy" • Imaging (rectangle): "MRI with hepatobiliary imaging" • Imaging (rectangle): "Triple phase contrast enhanced CT OR Dynamic MRI with hepatobiliary contrast OR Dynamic MRI with extracellular contrast" • Guidance (rectangle): "See appropriate guidance for follow-up based on known type of prior malignancy or multidisciplinary discussion for further management recommendations" • Diagnosis (rectangle): "Diagnosis made" • No Diagnosis (rectangle): "Diagnosis not made" • Multidisciplinary (rectangle): "Multidisciplinary discussion" • Surveillance (rectangle, yellow): "Surveillance imaging, usually 3-6 months" • Lesion types (rectangles): "Adenoma*", "Focal Nodular Hyperplasia", "Hemangioma", "Hepatic hemangioendothelioma", "Fibrolamellar Hepatocellular Carcinoma", "Angiosarcoma" • Management (rectangles): "Stop OCPs or hormone impregnated IUDs, weight loss if appropriate", "No follow up needed", "Consider resection. If unresectable, transarterial embolization", "Asymptomatic", "Symptomatic (i.e. pain)", "Resect or alternative therapy (RF/AMWA/EBRT/TAE)", "Resect or transplant, even if extrahepatic disease is present. Alternative: ablation, SBRT", "Resect or transplant. Alternative: radiotherapy, chemotherapy, immunotherapy", "Resect; consider adjuvant chemo/XRT" • Evaluation (rectangle): "Evaluate MRI features to determine subtype & consider biopsy if concern for beta catenin mutation" • Gender branches (rectangles): "Men", "Women" • Biopsy/Resection (rectangles): "NO biopsy needed. Resect regardless of size OR treat definitively with alternative method of treatment if not resectable", "Greater than 5 cm", "Stop hormonal therapy", "Observe 6–12 mos for regression", "Remains >5 cm", "Resect", "Shrink to <5 cm", "Monitor with contrast enhanced MRI every 6 mos", "Less than 5 cm", "If concern for beta catenin", "Biopsy", "If positive resect", "If negative", "Surveillance imaging every 6 mos, for 2 yrs, then annual", "If growth >20% resect", "Multiple adenomas", "Unilobar", "Resect", "Multilobar", "Focus on treatment of dominant lesion", "In pregnancy", "Ultrasound q 6-12 weeks", "No growth <6.5 cm, US, continue US follow-up", "If growth >6.5 cm or exophytic", "Resect if early in pregnancy OR Embolize if >26 weeks OR Consider resection if third trimester" • Footnotes (rectangles): "*See text for special circumstances, e.g. adenomas, rupture, malignant transformation", "*Note that most FNH lesions are incidental & asymptomatic; see text for further discussion" # Connectors : • Arrows connect nodes in a top-down, left-to-right branching structure. • Initial decision splits into three branches: age <40, all other patients, history of malignancy. • Each branch leads to specific imaging recommendations. • Imaging leads to diagnosis or no diagnosis; if no diagnosis, multidisciplinary discussion and surveillance imaging. • Diagnosis leads to lesion-specific management pathways (adenoma, FNH, hemangioma, etc.). • Adenoma management splits by gender, lesion size, and pregnancy status, with further branches for biopsy, resection, observation, and surveillance. • FNH and hemangioma management split by symptoms (asymptomatic/symptomatic). • Malignant lesions (hemangioendothelioma, fibrolamellar HCC, angiosarcoma) direct to resection, transplant, or adjuvant therapies. # Layout : • Flowchart is organized in a vertical, hierarchical structure with three main branches at the top. • Each branch subdivides into further diagnostic and management pathways. • Color coding: blue for standard nodes, yellow for surveillance imaging. • Decision diamonds and rectangles are used for choices and actions. • Footnotes and special circumstances are indicated with asterisks and referenced to the text. # Analysis : • The flowchart provides a systematic approach for evaluating solid focal liver lesions, integrating patient age, history, and risk factors to guide imaging and management. • It distinguishes between benign and malignant lesions, with tailored recommendations for each, including observation, resection, and advanced therapies. • Surveillance intervals and criteria for intervention are clearly defined, especially for adenomas and lesions in pregnancy. • The algorithm emphasizes multidisciplinary discussion for indeterminate cases and incorporates gender-specific management for adenomas. • Overall, the flowchart enables clinicians to follow a stepwise, evidence-based pathway for liver lesion evaluation and treatment.

Summary : This flowchart presents an algorithm for the management of duplex system ureteroceles (DSU) in infants after the first 3–6 months of life, outlining diagnostic and treatment pathways based on symptoms, presence of hydronephrosis/obstruction, vesicoureteric reflux (VUR), and renal function. flowchart: # Nodes : • Start (rectangle): DSU • Decision (rectangle): Asymptomatic, No severe HUN or obstruction • Decision (rectangle): Symptomatic or severe HUN or obstruction • Decision (rectangle): No VUR (from Asymptomatic) • Decision (rectangle): VUR (from Asymptomatic) • Decision (rectangle): VUR (from Symptomatic) • Decision (rectangle): No VUR (from Symptomatic) • Decision (rectangle): Low grade (from VUR, Asymptomatic) • Decision (rectangle): High grade or multiple infections (from VUR, Asymptomatic) • Decision (rectangle): Good function (from No VUR, Symptomatic) • Decision (rectangle): No/poor function (from No VUR, Symptomatic) • Action (rectangle, green): Observation • Action (rectangle, green): Bladder surgery or endoscopic management • Action (rectangle, green): Ectopic: upper to lower tract anastomosis • Action (rectangle, green): Intravesical endoscopic decompression • Action (rectangle, green): Ectopic UPPN # Connectors : • DSU splits into two main branches: Asymptomatic/No severe HUN or obstruction and Symptomatic/severe HUN or obstruction. • Asymptomatic branch splits into No VUR and VUR. • No VUR leads to Observation. • VUR splits into Low grade (leading to Observation) and High grade or multiple infections (leading to Bladder surgery or endoscopic management). • Symptomatic/severe HUN or obstruction splits into VUR and No VUR. • VUR leads to Ectopic: upper to lower tract anastomosis. • No VUR splits into Good function (leading to Intravesical endoscopic decompression) and No/poor function (leading to Ectopic UPPN). # Layout : • The flowchart is organized in a top-down manner, starting with DSU at the top, splitting into two main diagnostic branches, and further subdividing based on clinical findings and test results. • Treatment and follow-up actions are shown at the bottom in green rectangles. • Color coding: Diagnosis (light blue), Treatment (green), Follow-up (dark blue). # Analysis : • The algorithm prioritizes observation for asymptomatic cases without VUR or with low-grade VUR. • Surgical or endoscopic intervention is recommended for high-grade VUR, multiple infections, or symptomatic cases with obstruction. • The presence and grade of VUR, as well as renal function, are key determinants in management decisions. • The flowchart provides a clear, stepwise approach to guide clinicians in selecting appropriate management strategies for infants with DSU.

Summary : This flowchart presents an algorithm for the management of pregnant patients with atrial ectopy, outlining decision pathways based on symptom severity and recommended interventions. flowchart: # Nodes : • "Pregnant patient with atrial ectopy" (rectangle, top node) • "Premature atrial contractions" (rectangle, second row) • "Asymptomatic or tolerable symptoms" (rectangle, third row, left branch) • "Intolerable symptoms" (rectangle, third row, right branch) • "Reassurance with no intervention (COR 1)" (rounded rectangle, green, fourth row, left branch) • "Beta-blocker treatment, preferably metoprolol or propranolol (COR 1)" (rounded rectangle, green, fourth row, right branch) # Connectors : • Downward arrows connect each node to the next step. • After "Premature atrial contractions", the flow splits into two branches: left for "Asymptomatic or tolerable symptoms", right for "Intolerable symptoms". • Each symptom node leads to its respective intervention node. # Layout : • Vertical arrangement with a split into two parallel branches at the symptom assessment stage. • The final row contains two green recommendation nodes side by side. # Analysis : • The algorithm prioritizes symptom assessment in pregnant patients with atrial ectopy. • Asymptomatic or tolerable cases are managed conservatively with reassurance and no intervention. • Intolerable symptoms prompt pharmacological intervention, specifically recommending beta-blockers (metoprolol or propranolol). • Both recommendations are classified as COR 1, indicating strong support for these management strategies. • The flowchart provides a clear, stepwise approach for clinicians, emphasizing minimal intervention unless symptoms are significant.