PGCases41-80

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Case #080

PG Case 80

Two surgeons are working to remove the cause of a small bowel obstruction in this patient. What is the diagnosis?

Gallstone ileus. The stone is removed by making a transverse enterotomy in the small bowel. An important point is to make sure a second stone is not missed, therefore the small bowel is carefully palpated and examined prior to making the enterotomy. Such a gallstone is hypothesized to enter the gut lumen via cholecysto-enteric fistula. The name “gallstone ileus” is a misnomer because an ileus is, by definition, a non-mechanical small bowel motility failure. Diagnosis of gallstone ileus requires radiographic studies. Classic findings of pneumobilia, small bowel obstruction, and radiolucent gallstone on abdominal plain films is known as Rigler’s Triad.

Case #079

79
A 70 year old priest recently returned from Brazil, was admitted through ED with massive abdominal distension and pain. He has long history of constipation. See the intra-operative image and give the diagnosis

Megacolon secondary to Chagas disease. Sigmoid volvulus should be in your differential diagnosis. Although rare in Europe, Chagas disease is the most common cause of magacolon in central and south America caused by a Protozoan Trypanosoma cruzi. The megacolon is caused by destruction of the Auerbach’s plexus in the walls of the intestinal tracts of Chagas patients disrupting peristalsis. When megacolon worsens and the conservative measures fail to restore transit, surgery may be necessary such as subtotal colectomy with ileorectal anastomosis or a total proctocolectomy (removal of colon, sigmoid and rectum) followed by ileostomy or followed by ileoanal anastomosis.

Case #078

PG Case 78

Patient was seen in vascular OPD on a routine follow up visit. Had background history of long standing, poorly controlled diabetes. Describe your findings on inspection?

There has been amputation of the big toe. Ulcers can be seen on the dorsal aspect of the second, third and fourth toes. The ulcers show no evidence of superimposed infection. In diabetic patients foot complications result from a combination of vascular insufficiency, peripheral neuropathy, bone deformity (charcot joints, hammer toes) and susceptibility to infections. These ulcers were painless because of the peripheral neuropathy and most likely had resulted from the repeated trauma of somewhat deformed toes against ill-fitting shoes. Previous amputation points towards peripheral vascular disease so healing is compromised as well. The patient was advised to improve glycemic control and other risk factors for vascular disease like smoking, hypertension and high cholesterol. He was also advised dressings for the ulcers, regular visits to podiatrist, good foot hygiene, well-fitting shoes and avoidance of any minor trauma.

Case #077

PG Case 77

The patient underwent a colonic resection. Looking at the fresh gross specimen, what do you think the extent of resection was and where do you see the pathology?

The patient had a subtotal colectomy for a tumour at the splenic flexure. In the specimen we can see few centimetres of the terminal ileum; caecum, ascending colon, transverse colon, and descending colon have been resected. The distal part of the specimen was opened to show the tumour at the splenic flexure. A primary anastomosis was done between the ileum and the sigmoid colon. Since the patient has lost a large part of his colon, he initially experienced diarrhoea that gradually settled within a few weeks as the remaining bowel adapted.

Case #076

PG Case 76

75 year old lady presented to the ED with complaint of upper abdominal pain. On examination she was very tender in the upper abdomen with signs of peritoneal irritation so a CT abdomen was arranged to find the cause. Of note she had background history of gallstones. What can you appreciate on the CT image?

The axial CT image shows a slice through the liver. We can see air within the biliary channels in the liver. This is called pnuemobilia. It needs to be differentiated from protal venous gas which is more omnious. Pnuemobilia occurs due to a connection between the bowel and the biliary tree. Etiology could be a spontaneous biliary enteric fistula due to recurrent attacks of acute cholecystitis or peptic ulcer disease. It could be iatrogenic resulting from biliary enteric anastomosis, biliary sphicterotomy, biliary stenting, ERCP or upper GI endoscopy. Other causes include incompetent sphicter of oddi, emphysematous gall bladder and trauma.

Case #075

PG Case 75

25 year old male sustained a fracture deformity of the right forearm in RTA. What is the most likely diagnosis?

Colle’s fracture. The classical dinner fork deformity of the wrist is evident from the image. Colle’s fracture is a fracture of the distal radius often with dorsal angulation of the fracture fragments with or without fracture of the ulnar bone. The fracture is managed by cast alone to closed reduction or ORIF depending on the severity. It is named after Abraham Colles (1773–1843), an Irish surgeon, from Kilkenny who first described it in 1814.

Case #074

PG Case 74
30 year old man presented with 2 days history of colicky abdominal pain, distention and vomiting. He had history of previous abdominal surgery. CT scan was done. What does it show?

We can appreciate dilated loops of small bowel with air fluid levels on the coronal and axial CT images. This is consistent with the clinical diagnosis of small bowel obstruction. CT is often sought in cases of bowel obstruction to look for the cause. The radiologists are often very helpful in describing a transition point, where the source of obstruction is, proximal to which bowel is dilated and distally bowel is collapsed. Adhesions secondary to previous abdominal surgery are one of the most common causes of small bowel obstruction. Fortunately many of these resolve with conservative management, “drip and suck”. However if there is no clinical improvement they require surgery to relieve the obstruction.

Case #073

PG Case 73
52 year old man presented with four day history of progressively worsening redness and pain in his right external ear. What is your spot diagnosis on inspection of the ear?

This gentleman had cellulitis of the pinna extending onto the face. The patient required ENT consultation. However, the ear canal and ear drum were normal on examination and he was managed with IV antibiotics for the cellulitis.

Case #072

PG Case 72

A 75 year old man presented to the ED with complaint of abdominal pain. He gives history of having some procedure done with the vascular surgeons but is unsure of what exactly he had done. A PFA was requested by ED during the work up. Can you tell what vascular procedure he has had?

The plain film abdomen shows an EVAR endograft, which is extending from the abdominal aorta to the common iliacs. The patient had an abdominal aortic aneurysm which was repaired using minimally invasive technique called EVAR. EVAR stands for endovascular aneurysm repair. It involves accessing the abdominal aorta through the femoral artery and placing the graft within it.

Case #071

PG Case 71

What do you see on abdominal inspection? What is this incision called? What surgery, do you think, this man had recently?

This man had an open cholecystectomy. The procedure was started laparoscopically, but there were extensive fibrotic adhesions in and around the calot’s triangle because of his history of repeated attacks of cholecystitis in the past. The surgeon had to convert to open as it was difficult to perform a safe dissection laparoscopically to display the anatomy before ligating the cystic duct and artery. This incision is called Kocher’s subcostal incision and is made about two 2cm below the costal margin on the right side.

Case #070

PG Case 70

A 21 year old boy presented to the ED with 4 days history of lower abdominal pain that had progressively worsened and was associated with anorexia, nausea and vomiting. On examination he was peritonitic in the lower abdomen with maximal tenderness at the McBurney’s point. What do you see at laparoscopy?

The pictures show a gangrenous appendix that had perforated and the omentum and small bowel trying to localize the inflammatory process. The second picture shows pus in the abdomen. The procedure proved to be challenging one but was completed laparoscopically. All the pus in the abdomen and pelvis was sucked out. The patient was kept on intravenous antibiotics post operatively. He had a smooth course to complete recovery. Such patients, however, can develop pelvic collection post operatively.

Case #069

PG Case 69
30 year old female was admitted through emergency department with history of diarrhoea mixed with mucous and fresh red blood. Colonoscopic pictures are shown. Can you pick up the findings and suggest the most likely diagnosis?

The colonoscopy picture shows loss of normal vascular pattern of the colonic mucosa. The mucosa is oedematous, erythematous and friable. There is extensive ulceration associated with psuedopolyp formation. The findings extended from the rectum up to the sigmoid colon. The examination was terminated at that point since there are greater chances of perforation in acute colitis. These appearances are consistent with a diagnosis of ulcerative colitis. Biopsies were taken for confirmation.

Case #068

PG Case 68

An 80 year old gentleman presented to the E D with complaint of abdominal pain. On examination he had a midline pulsatile mass. A CT angio was done for him. What do you see on the CT images?

The axial and sagital CT angio images shown here demonstrate an abdominal aortic aneurysm. Viewing all the CT slices had revealed an infra renal AAA measuring about 8 cm in its greatest dimension. However no leak or rupture was seen on CT. The patient was referred on to the vascular surgery team and had an endovascular repair done.

Case #067

PG Case 67

A 45 year old male patient presented to the surgical clinic with complaint of right sided groin swelling that he noticed about 4 months ago. He feels it is gradually increasing in size and causes him a dragging discomfort. It becomes more pronounced when he coughs or strains. What is likely diagnosis on inspection?

On inspection we can see an oblong inguinal swelling. It does not seem to extend completely down to the scrotum. The overlying skin looks normal. There are no previous scar marks, visible veins, pulsations or peristalsis. Given his history it is most likely to be an Inguinal hernia. The other differential diagnosis could be inguinal lymph nodes, lipoma of the cord, encysted hydrocele of the cord, ectopic/undescended/retractile testes, iliopsoas abscess, saphena varix, femoral hernia, femoral pseudoaneurysm.
The patient had a visible and a palpable cough impulse. The swelling was reducible on lying down. The swelling did not re appear on coughing when pressure was applied at the deep ring. Gurgling was felt on palpation of the swelling. So the clinical diagnosis was an indirect, incomplete, right sided inguinal hernia containing bowel. The patient was scheduled for elective surgery. A mesh repair for inguinal hernias can be performed via an open or laparoscopic approach.

Case #066

PG Case 66

Rapidly growing lesion on the foot with inguinal lymphadenopathy. What do you suspect?

The lesion was strongly suspicious of malignancy and a biopsy revealed it to be a malignant melanoma. It is sometimes difficult to recognize melanoma on the foot and can be misdiagnosed as a foot ulcer, wart/verrucae, tinea pedis/onchomycosis, bruising, foreign body etc. Melanoma occurring in the nail bed can sometimes be confused with ingrowing toe nail, sub-ungal hematoma or pyogenic granuloma. Melanoma on the foot therefore has a poor prognosis than elsewhere due to delayed presentation and misdiagnosis.
The use of the simple acronym ABCDE can help in remembering the main clinical signs of a potential melanoma. However this is not very helpful in recognizing melanoma on the foot. The ABCDE acronym
• A: asymmetry, one half is not identical to the other half
• B: border, irregular or ragged borders
• C: color, irregular discoloration, more than one color present in the lesion
• D: diameter, diameter greater than 6mm
• E: evolution, change in size, shape or color of the lesion

Case #065

PG Case 65

Patient presented to the surgical service with 6 months history of a progressively enlarging lesion on the scalp. What do you suspect and how can it be confirmed?

The large fungating lesion on the scalp looks like an advanced squamous cell carcinoma. A biopsy is needed to confirm the diagnosis. Next, we need to stage the tumor and find out the local spread and distant metastasis. Excision of such a large lesion could pose a challenge for reconstruction.

Case #064


pg-case-064.png

Following a colonic polypectomy using a hot snare, there was bleeding from the polyp base. What technique was used to arrest bleeding in the photo? What other techniques available do you know?

Explanation:

  • The bleeding was arrested using hemoclips. 3 hemoclips were deployed in combination with adrenaline injection 1:10,000 dilution at the base.
  • Other modalities which may be utilized are the heater probe, bipolar probe, lasers, clips, endo-loop, and argon plasma coagulation.
  • Note that diathermy carry risk of heat damage perforation of bowel.
  • Recently new clotting powder was introduced which can be scattered on the bleeding point but more studies are needed to prove the its efficacy and effectiveness.

Case #063


pg-case-063

Can you identify the pathology and the procedure being performed?

  • This is a colonic polypectomy using a hot snare.
  • This involve using electrocautery to prevent bleeding from the base. Hot snaring is used for larger polyp 7mm or more and ideally for polyps which has a stalk (pedunculated).
  • Larger sessile polyps are more suitably remove by Endoscopic mucosal resection (EMR).
  • This involve ‘lifting’ the polyp by injecting saline +/- adrenaline prior to removal.
  • A range of thermal and non-thermal polypectomy techniques is available.
  • The endoscopist should consider the size, morphological characteristics and the position within the colon (right versus left) before choosing the appropriate technique. The right colonic wall is particularly thin and therefore more susceptible to transmural thermal injury.

Case #062


pg-case-062

A 19 year old girl presented to the ED with RIF pain for one day. On examination she was tender in the RIF. Laparoscopy was performed. What do you see on this laparoscopic picture?

The picture shows the right ovary with a cyst. The patient also had some free fluid in the pelvis, possibly resulting from rupture of an ovarian cyst. Ruptured ovarian cysts or follicles can cause peritoneal irritation and clinically mimic acute appendicitis. Ultrasound pelvis can sometimes be helpful in distinguishing ovarian pathology from appendicitis in patients presenting with right iliac fossa pain.

Case #061


pg-case-061

17 year old boy presented with lower abdominal pain for the past 18 hours. On examination he was quite tender with guarding in the right iliac fossa. He was taken to theatre for a laparoscopic procedure. What pathology do you see on this laparoscopic picture?

The picture was taken at laparoscopy and shows a mildly inflamed appendix. Patients with acute appendicitis typically present with lower abdominal pain that starts peri-umbilically and then migrates to the right iliac fossa after a few hours. This is usually accompanied with nausea, vomiting and anorexia. On examination the patients are tender in right iliac fossa, maximally at the McBurney’s point which lies at the junction of medial two thirds and lateral one third of a line joining the umbilicus and the anterior superior iliac spine. High inflammatory markers (WCC and CRP) support the clinical diagnosis.
Appendectomy can be performed open or laparoscopically. Laparoscopic approach allows quicker recovery, shorter hospital stay and early return to activities.

Case #060


pg-case-060-b

pg-case-060-a

35 years old male presented with abdominal pain and raised inflammatory markers. Can you identify this blind end structure rising for small bowel?

This is a Meckel’s diverticulum. Meckel’s diverticulum is the commonest GI malformation. Is situated in the antimesenteric wall of the small bowel and It is well known for its rule of 2s

  • 2% of the population are affected
  • 2 feet from ileocecal valve
  • 2 inches in length
  • 2 ectopic tissues are present (gastric and pancreatic)
  • 2 to 1 is the male to female ratio

The surgical options are resection of the small bowel segment that contains the diverticulum or simple diverticulectomy. This patient had simple resection of the diverticulum.

Case #059

PG Case 59
82 year old lady presented to the ED with complaint of abdominal pain, vomiting and distention. Her stoma had not been working for the past one day. What do you see on inspection of the abdomen?

On inspection the abdomen looks distended with a swelling on the left side. There is a stoma in the right lower quadrant which is covered with a bag. A vague swelling is also evident on the right side around the stoma site. There is an infra umbilical midline laparotomy scar and a small transverse scar in the left lower quadrant.
The patient had a history of hartmann’s procedure for perforated diverticular disease in the past. The scar in the left lower quadrant is likely to be at the site of the previous colostomy. The patient had subsequently undergone a Hartmann’s reversal and a covering loop ileostomy was made in the right lower quadrant to protect the large bowel anastomosis. She had been medically unwell so did not have the ileostomy reversed as yet. The swelling on the left side had a positive cough impulse and was an incisional hernia arising from the previous colostomy site. The swelling on the right side around the stoma also had a positive cough impulse and was a parastomal hernia. At this occasion the patient had presented with symptoms of bowel obstruction due to the obstructed incisional hernia on the left side. The parastomal hernia was non tender and reducible. The patient was managed with initial resuscitation followed by left sided hernia repair to relieve the obstruction.

Case #058

PG Case 58

A 32 year old patient was involved in an RTA and sustained a head injury. He was brought to ED with a GCS of 3/15. Can you appreciate findings on the CT Brain?

The CT brain shows severe cerebral oedema secondary to the head injury. The normal pattern of gyri and sulci in the cerebral hemispheres and the lateral ventricles, which should be visible in CT slices at this level, are not seen because of the cerebral oedema. The CT also shows midline shift and a shallow acute subdural hematoma on the left side. Large bilateral extra cranial hematomas are also seen. The patient had a GCS of 3/15 and fixed dilated pupils. There were other extensive injuries as well. The patient was resuscitated and managed according to the ATLS protocol but did not survive.

Case #057

PG Case 57

72 year old patient underwent colonoscopy for few episodes of bleeding PR. The pathology encountered lead to a sigmoid colectomy being performed. Can you identify the pathology in this formalin fixed specimen?

The first picture shows the specimen of a sigmoid colectomy which has been opened to demonstrate a small sigmoid tumour. The second picture is a cross section through the tumour and shows the tattoo that was done by the endoscopist during colonoscopy. Tattooing colonic lesions is important for their accurate localization during surgery or repeat endoscopy. Colorectal lesions, especially those that are small, can be difficult to locate precisely during surgery as they may not be palpable. Precise location of the lesion can be even tougher to determine during laparoscopic colonic resections, if they have not been tattooed. The tattoo provides a visual aid to the site of the lesion, thus helping the surgeon resect the correct part of the bowel. Previously india ink was used for tattooing but now a sterilized solution of carbon particles called “SPOT” is available and is routinely used.

Case #056

PG Case56
This patient had Hartmann’s procedure for perforated sigmoid colon secondary to obstructing rectal cancer. The tumour was excised (T4N2M0). He completed adjuvant chemo and radio therapy. 18 months later he needed a second operation. Look at the RUQ scar. Can you explain what procedure did he have done?

There is a recent L shaped scar in the right upper quadrant. Compare this to the old lower midline scar that have healed over the last 18 months.
This patient underwent partial liver resection for a solitary metastatic lesion. The lesion was picked up on surveillance CT TAP that he had every year. He was referred to the National Hepatobiliary unit in St Vincents.
Currently he is awaiting follow up with the oncology service. Given that he recovered well post operatively, he will most likely given another course of chemotherapy.

Case #055

PG Case 55

42 year old presented to ED with severe colicky right flank pain. No abdominal signs were found on examination. Urine dipstick revealed microscopic hematuria. CT scan was done. Can you identify the cause of his pain on the CT images?

The CT images in coronal and axial sections show an opacity in the path of the right ureter, consistent with a ureteric stone. CT KUB is the investigation of choice if there is clinical suspicion of renal or ureteric colic. CT KUB is a low dose non contrast abdominal CT to identify urinary tract calculi. It will also give information about the size and location of the stone; whether the stone is causing obstruction and proximal hydroureter and hydronephrosis; and will reveal fat stranding in case of infection secondary to the obstruction. Generally stones less than 5mm tend to pass spontaneously. However those larger than 5mm may require urological intervention.

Case #054

PG Case 54
78 year old patient presented with colicky abdominal pain and weight loss. Abdominal CT showed pathology in the caecum near the ileocaecal valve and dilatation of the small bowel proximal to it. A right hemicolectomy was performed. Can you identify the pathology in the specimen?

The picture shows formalin fixed specimen of a right hemicolectomy that has been opened to demonstrate a caecal tumour. The tumour was obstructing the ileocaecal valve and causing obstruction. A right hemicolectomy for a caecal tumour involves resecting few inches of the terminal ileum, right side of the colon and the draining lymph nodes along the ileocolic vessels. The continuity of the GI tract is restored by performing a primary ileocolic anastomosis. A right hemicolectomy can be performed open or laparoscopically,depending upon the expertise of the surgeon as well as considering patient factors.

Case #053

PG Case 53
67 Year old man with hb of 5.9g/L was in ED and was arranged to have emergency OGD in Theater. He was having malena for 3 days. The image is taken from duodenum at OGD. What can you see?

There is multiple ulceration at D1. prior to distention with gas, the ulcers were almost stuck together sometimes called ‘kissing ulcers’. No clots or active bleeding is seen. The patient will require empirical treatment with triple therapy and repeat OGD in few weeks to see if the ulcers have healed.

Case #052

PG Case 52
Describe the stoma in the picture, what kind of stoma is it?

This is a freshly made defunctioning colostomy with a bridge (white plastic tube) in the LIF . There should be two lumens in the colostomy, proximal and distal loop. The bowel was opened transverely halfway across the bowel and the bridge was lodged behind it to keep it in place while the stitches matures and fixed it into the position. The defunctioning stoma is used to divert flow of the bowel in order to protect a distal anastomosis. In this case this is a loop sigmoid colostomy made to protect an iatrogenic rectal injury and repair. Notice also there only 2 small stab incision (one covered and another visible in midline) instead of a laparatomy scar, therefore this is done with laparoscopic assisted vs a laparatomy approach.

Case #051

PG Case 51

21 year old man caught his hand in garage door roller and his arm was pulled upwards. Xray of the right shoulder was done. What injury can you see?

Anterior dislocation in the right shoulder joint. Avulsion fracture in the head of the right humerus. Anterior dislocations (in which the humeral head is displaced anteriorly in relation to the glenoid), account for as many as 95-98% of shoulder dislocations. The reason is that the muscular and ligamentous support anterior to the humeral head is much less robust than the substantial muscular and bony support afforded posteriorly by the rotator cuff and scapula. Techniques commonly used to reduce anterior shoulder dislocations include the following: Stimson maneuver; Scapular manipulation; External rotation; Milch technique; Traction-countertraction. Signs of a successful reduction include the following: Palpable or audible clunk; return of rounded shoulder contour; relief of pain; increase in range of motion (eg, the patient can touch the opposite shoulder with the palm of the affected arm).

Case #050

PG Case 50

You are called to review an 83 year old lady four days post-op for small bowel resection secondary to incarcerated incisional hernia. She has a central line and TPN was started 2days ago. O/e: She is tachypnaoeic and her sats were 85% on 4L of Oxygen. oxygen was increased to 100% and her sats only reach 93%. Bibasal crepitus were heard and abdomen was soft and nontender. ABG showed respiratory acidosis. She had a portable chest x-ray as she was too sick to go down to the department. What are the findings?

This patient has a whiteout of her right lungs i.e massive pleural effusion post op. Causes are many from LRTI/ ARDS to fluid overload and CCF In this case, the pt had to be transferred to the HDU for Bilevel positive airway pressure (BiPAP) or intubation and ventilation if progressively worsen. She will also need drainage of the fluid by pleural tapping or chest drain placement.

Case #049

PG Case 49a
PG Case 49b

This 43 years old lady was complaining of dyspeptic symptoms and epigastric discomfort. What can you see in the OGD?

The first image shows gastric mucosa bulging to oesophagus. In retro flexion of the gastro scope we can notice that the gastro oesophageal junction is widely open. These images are typical for hiatus hernia. The patient was managed with PPI ‘s.

Case #048

PG Case 48

This 65 years old lady was complaining of severe abdominal pain post colonoscopy. What are the radiological findings in this erect chest x ray?

The x ray shows fee air under the diaphragm. This is noticed in both right and left diaphragmatic domes. In a closer look you can see some free air below the heart as well. This lady was under investigation for history of recto-vaginal fistula. The free air was secondary to air leak through the fistula instead of visceral perforation. She was managed conservatively.

Case #047


PG Case 47

An 83 year old man found on the floor had CT Brain which showed parieto-occipital shallow subdural haematoma (previous case 46). He was admitted for neuro-observation as he complained of severe headache. His headache got worse and he was sent for another CT. What type of CT is this and what were they trying to rule out?

This is CT angiogram intracranial to rule out the possibility of cerebral aneurysm particularly Berry aneursym at the level of circle of willis.(see image). Fortunately the CT detected no abnormality. Intracranial aneurysms occur more in women, by a ratio of 3 to 2. Intracranial aneurysms may result from diseases acquired during life, or from genetic conditions. Lifestyle diseases including hypertension, smoking, excess alcohol consumption, and obesity are associated with the development of aneurysms. Cocaine use has also been associated with the development of intracranial aneurysms. Other acquired associations with intracranial aneurysms include head trauma and infections.

Case #046


PG Case 46

83 year old male on warfarin for a.fib was found on the floor by his son. He was amnesic of event and c/o severe headache. CT Brain was done. Can you pick out the finding?

There is a shallow right posterior parieto-occipital acute subdural haematoma. It measures 5.5 mm in maximum depth.
Following discussion with neuro surgery, the patient was admitted for neuro-observation as he was still complaining of severe headache. His warfarin was stopped.

Case #045


PG Case 45

You were alerted by the nurse that a patient in the ward has abnormal LFT’s. On reviewing the patient you noticed that he is connected to this bag via an IV. What is the diagnosis?

This patient developed abnormal LFT’s secondary to total parenteral nutrition (TPN). Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients.Other complications include:
– Abnormalities of serum electrolytes and minerals ,Volume overload, Metabolic bone disease, Adverse reactions to lipid emulsion and developing gall bladder stones and sludge

Case #044


PG Case 44

A 73 year old lady presented to surgical outpatients with complaint of pruritis ani, mucus discharge and faecal staining. Abdominal examination was unremarkable. Picture of PR examination is shown. What is your diagnosis?

The picture shows partial rectal prolapse. Rectal prolapse may be partial thickness (involving just the mucosa) or full thickness involving all layers of the rectal wall. It is caused by weakness of pelvic floor and sphincter complex. Risk factors include post menopausal status, multiple vaginal deliveries and chronic straining due to constipation. Patients may present with mass protruding from the anus, mucous discharge, pruritis ani or fresh rectal bleeding.
Treatment includes avoidance of straining and laxatives (bulk forming and stool softners). For Mucosal prolapse, surgical options include recurrent banding or injections, mucosectomy and stapled anopexy. Transabdominal rectopexy or Delorme’s perineal rectoprexy are the commonly carried out operations for full thickness rectal prolapse.

Case #043


PG Case 43

This device was used during trauma case during resuscitation recently. what is it and where is the preferred site of insertion? And what could be the indication of using such device?

This is the intraosseous catheter, Its preferred site of insertion is the proximal humerus. Proximal tibia, distal tibia and distal femur (pediatrics only)
are alternate insertion sites.

Indications:
The patient needed vascular access

The patient had limited or no venous access

Due to limited time and resources

To prevent multiple IV cannulas and minimize patient pain/anxiety

To minimize vascular access-related complications and facilitate vein preservation

Case #042


PG Case 42

68 year old man c/o of severe tearing like chest pain radiating to his back for the last 2 days. He is a heavy smoker and hypertensive. Troponin was negative and ECG was unremarkable. CXR suggestive of widened mediastinum. What type of CT scan did he have next ? And can you give the diagnosis?

CT Angiogram of the AortaThis showed a leaking pseudoaneurysm aneurysm of the aortic arch measuring 3x2cm the pt was transferred to vascular unit and received Endovascular repair of thoracic aneurysm TEVAR. Pseudo-aneurysm, also known as a false aneurysm, is a hematoma that forms as the result of a leaking hole in an artery. This must be distinguished from a true aneurysm which is a localised dilatation of an artery including all the layers of the wall.

Case #041


PG Case 41

78 year old lady presented to the ED with non specific abdominal discomfort and feeling generally unwell for the past 2 months. She also had a few episodes of vomiting before coming to the ED so PFA was done to rule out bowel obstruction. Can you identify the finding on the plain film abdomen?

The PFA shows no radiological evidence of bowel obstruction. A large calcified mass can be appreciated in the right upper quadrant. However it is difficult to determine the origin of the calcified mass, whether arising from the liver, adrenal, kidney, colon, pancreas or gall bladder.
A subsequent CT abdomen showed that the calcified mass was arising from the upper pole of the right kidney and was approx 8x9cm in size, with enlarged para aortic lymph nodes, likely to be malignant.

Case #063


pg-case-063

Can you identify the pathology and the procedure being performed?

  • This is a colonic polypectomy using a hot snare.
  • This involve using electrocautery to prevent bleeding from the base. Hot snaring is used for larger polyp 7mm or more and ideally for polyps which has a stalk (pedunculated).
  • Larger sessile polyps are more suitably remove by Endoscopic mucosal resection (EMR).
  • This involve ‘lifting’ the polyp by injecting saline +/- adrenaline prior to removal.
  • A range of thermal and non-thermal polypectomy techniques is available.
  • The endoscopist should consider the size, morphological characteristics and the position within the colon (right versus left) before choosing the appropriate technique. The right colonic wall is particularly thin and therefore more susceptible to transmural thermal injury.

Case #062


pg-case-062

A 19 year old girl presented to the ED with RIF pain for one day. On examination she was tender in the RIF. Laparoscopy was performed. What do you see on this laparoscopic picture?

The picture shows the right ovary with a cyst. The patient also had some free fluid in the pelvis, possibly resulting from rupture of an ovarian cyst. Ruptured ovarian cysts or follicles can cause peritoneal irritation and clinically mimic acute appendicitis. Ultrasound pelvis can sometimes be helpful in distinguishing ovarian pathology from appendicitis in patients presenting with right iliac fossa pain.

Case #061


pg-case-061

17 year old boy presented with lower abdominal pain for the past 18 hours. On examination he was quite tender with guarding in the right iliac fossa. He was taken to theatre for a laparoscopic procedure. What pathology do you see on this laparoscopic picture?

The picture was taken at laparoscopy and shows a mildly inflamed appendix. Patients with acute appendicitis typically present with lower abdominal pain that starts peri-umbilically and then migrates to the right iliac fossa after a few hours. This is usually accompanied with nausea, vomiting and anorexia. On examination the patients are tender in right iliac fossa, maximally at the McBurney’s point which lies at the junction of medial two thirds and lateral one third of a line joining the umbilicus and the anterior superior iliac spine. High inflammatory markers (WCC and CRP) support the clinical diagnosis.
Appendectomy can be performed open or laparoscopically. Laparoscopic approach allows quicker recovery, shorter hospital stay and early return to activities.

Case #060


pg-case-060-b

pg-case-060-a

35 years old male presented with abdominal pain and raised inflammatory markers. Can you identify this blind end structure rising for small bowel?

This is a Meckel’s diverticulum. Meckel’s diverticulum is the commonest GI malformation. Is situated in the antimesenteric wall of the small bowel and It is well known for its rule of 2s

  • 2% of the population are affected
  • 2 feet from ileocecal valve
  • 2 inches in length
  • 2 ectopic tissues are present (gastric and pancreatic)
  • 2 to 1 is the male to female ratio

The surgical options are resection of the small bowel segment that contains the diverticulum or simple diverticulectomy. This patient had simple resection of the diverticulum.

Case #059

PG Case 59
82 year old lady presented to the ED with complaint of abdominal pain, vomiting and distention. Her stoma had not been working for the past one day. What do you see on inspection of the abdomen?

On inspection the abdomen looks distended with a swelling on the left side. There is a stoma in the right lower quadrant which is covered with a bag. A vague swelling is also evident on the right side around the stoma site. There is an infra umbilical midline laparotomy scar and a small transverse scar in the left lower quadrant.
The patient had a history of hartmann’s procedure for perforated diverticular disease in the past. The scar in the left lower quadrant is likely to be at the site of the previous colostomy. The patient had subsequently undergone a Hartmann’s reversal and a covering loop ileostomy was made in the right lower quadrant to protect the large bowel anastomosis. She had been medically unwell so did not have the ileostomy reversed as yet. The swelling on the left side had a positive cough impulse and was an incisional hernia arising from the previous colostomy site. The swelling on the right side around the stoma also had a positive cough impulse and was a parastomal hernia. At this occasion the patient had presented with symptoms of bowel obstruction due to the obstructed incisional hernia on the left side. The parastomal hernia was non tender and reducible. The patient was managed with initial resuscitation followed by left sided hernia repair to relieve the obstruction.

Case #058

PG Case 58

A 32 year old patient was involved in an RTA and sustained a head injury. He was brought to ED with a GCS of 3/15. Can you appreciate findings on the CT Brain?

The CT brain shows severe cerebral oedema secondary to the head injury. The normal pattern of gyri and sulci in the cerebral hemispheres and the lateral ventricles, which should be visible in CT slices at this level, are not seen because of the cerebral oedema. The CT also shows midline shift and a shallow acute subdural hematoma on the left side. Large bilateral extra cranial hematomas are also seen. The patient had a GCS of 3/15 and fixed dilated pupils. There were other extensive injuries as well. The patient was resuscitated and managed according to the ATLS protocol but did not survive.

Case #057

PG Case 57

72 year old patient underwent colonoscopy for few episodes of bleeding PR. The pathology encountered lead to a sigmoid colectomy being performed. Can you identify the pathology in this formalin fixed specimen?

The first picture shows the specimen of a sigmoid colectomy which has been opened to demonstrate a small sigmoid tumour. The second picture is a cross section through the tumour and shows the tattoo that was done by the endoscopist during colonoscopy. Tattooing colonic lesions is important for their accurate localization during surgery or repeat endoscopy. Colorectal lesions, especially those that are small, can be difficult to locate precisely during surgery as they may not be palpable. Precise location of the lesion can be even tougher to determine during laparoscopic colonic resections, if they have not been tattooed. The tattoo provides a visual aid to the site of the lesion, thus helping the surgeon resect the correct part of the bowel. Previously india ink was used for tattooing but now a sterilized solution of carbon particles called “SPOT” is available and is routinely used.

Case #056

PG Case56
This patient had Hartmann’s procedure for perforated sigmoid colon secondary to obstructing rectal cancer. The tumour was excised (T4N2M0). He completed adjuvant chemo and radio therapy. 18 months later he needed a second operation. Look at the RUQ scar. Can you explain what procedure did he have done?

There is a recent L shaped scar in the right upper quadrant. Compare this to the old lower midline scar that have healed over the last 18 months.
This patient underwent partial liver resection for a solitary metastatic lesion. The lesion was picked up on surveillance CT TAP that he had every year. He was referred to the National Hepatobiliary unit in St Vincents.
Currently he is awaiting follow up with the oncology service. Given that he recovered well post operatively, he will most likely given another course of chemotherapy.

Case #055

PG Case 55

42 year old presented to ED with severe colicky right flank pain. No abdominal signs were found on examination. Urine dipstick revealed microscopic hematuria. CT scan was done. Can you identify the cause of his pain on the CT images?

The CT images in coronal and axial sections show an opacity in the path of the right ureter, consistent with a ureteric stone. CT KUB is the investigation of choice if there is clinical suspicion of renal or ureteric colic. CT KUB is a low dose non contrast abdominal CT to identify urinary tract calculi. It will also give information about the size and location of the stone; whether the stone is causing obstruction and proximal hydroureter and hydronephrosis; and will reveal fat stranding in case of infection secondary to the obstruction. Generally stones less than 5mm tend to pass spontaneously. However those larger than 5mm may require urological intervention.

Case #054

PG Case 54
78 year old patient presented with colicky abdominal pain and weight loss. Abdominal CT showed pathology in the caecum near the ileocaecal valve and dilatation of the small bowel proximal to it. A right hemicolectomy was performed. Can you identify the pathology in the specimen?

The picture shows formalin fixed specimen of a right hemicolectomy that has been opened to demonstrate a caecal tumour. The tumour was obstructing the ileocaecal valve and causing obstruction. A right hemicolectomy for a caecal tumour involves resecting few inches of the terminal ileum, right side of the colon and the draining lymph nodes along the ileocolic vessels. The continuity of the GI tract is restored by performing a primary ileocolic anastomosis. A right hemicolectomy can be performed open or laparoscopically,depending upon the expertise of the surgeon as well as considering patient factors.

Case #053

PG Case 53
67 Year old man with hb of 5.9g/L was in ED and was arranged to have emergency OGD in Theater. He was having malena for 3 days. The image is taken from duodenum at OGD. What can you see?

There is multiple ulceration at D1. prior to distention with gas, the ulcers were almost stuck together sometimes called ‘kissing ulcers’. No clots or active bleeding is seen. The patient will require empirical treatment with triple therapy and repeat OGD in few weeks to see if the ulcers have healed.

Case #052

PG Case 52
Describe the stoma in the picture, what kind of stoma is it?

This is a freshly made defunctioning colostomy with a bridge (white plastic tube) in the LIF . There should be two lumens in the colostomy, proximal and distal loop. The bowel was opened transverely halfway across the bowel and the bridge was lodged behind it to keep it in place while the stitches matures and fixed it into the position. The defunctioning stoma is used to divert flow of the bowel in order to protect a distal anastomosis. In this case this is a loop sigmoid colostomy made to protect an iatrogenic rectal injury and repair. Notice also there only 2 small stab incision (one covered and another visible in midline) instead of a laparatomy scar, therefore this is done with laparoscopic assisted vs a laparatomy approach.

Case #051

PG Case 51

21 year old man caught his hand in garage door roller and his arm was pulled upwards. Xray of the right shoulder was done. What injury can you see?

Anterior dislocation in the right shoulder joint. Avulsion fracture in the head of the right humerus. Anterior dislocations (in which the humeral head is displaced anteriorly in relation to the glenoid), account for as many as 95-98% of shoulder dislocations. The reason is that the muscular and ligamentous support anterior to the humeral head is much less robust than the substantial muscular and bony support afforded posteriorly by the rotator cuff and scapula. Techniques commonly used to reduce anterior shoulder dislocations include the following: Stimson maneuver; Scapular manipulation; External rotation; Milch technique; Traction-countertraction. Signs of a successful reduction include the following: Palpable or audible clunk; return of rounded shoulder contour; relief of pain; increase in range of motion (eg, the patient can touch the opposite shoulder with the palm of the affected arm).

Case #050

PG Case 50

You are called to review an 83 year old lady four days post-op for small bowel resection secondary to incarcerated incisional hernia. She has a central line and TPN was started 2days ago. O/e: She is tachypnaoeic and her sats were 85% on 4L of Oxygen. oxygen was increased to 100% and her sats only reach 93%. Bibasal crepitus were heard and abdomen was soft and nontender. ABG showed respiratory acidosis. She had a portable chest x-ray as she was too sick to go down to the department. What are the findings?

This patient has a whiteout of her right lungs i.e massive pleural effusion post op. Causes are many from LRTI/ ARDS to fluid overload and CCF In this case, the pt had to be transferred to the HDU for Bilevel positive airway pressure (BiPAP) or intubation and ventilation if progressively worsen. She will also need drainage of the fluid by pleural tapping or chest drain placement.

Case #049

PG Case 49a
PG Case 49b

This 43 years old lady was complaining of dyspeptic symptoms and epigastric discomfort. What can you see in the OGD?

The first image shows gastric mucosa bulging to oesophagus. In retro flexion of the gastro scope we can notice that the gastro oesophageal junction is widely open. These images are typical for hiatus hernia. The patient was managed with PPI ‘s.

Case #048

PG Case 48

This 65 years old lady was complaining of severe abdominal pain post colonoscopy. What are the radiological findings in this erect chest x ray?

The x ray shows fee air under the diaphragm. This is noticed in both right and left diaphragmatic domes. In a closer look you can see some free air below the heart as well. This lady was under investigation for history of recto-vaginal fistula. The free air was secondary to air leak through the fistula instead of visceral perforation. She was managed conservatively.

Case #047


PG Case 47

An 83 year old man found on the floor had CT Brain which showed parieto-occipital shallow subdural haematoma (previous case 46). He was admitted for neuro-observation as he complained of severe headache. His headache got worse and he was sent for another CT. What type of CT is this and what were they trying to rule out?

This is CT angiogram intracranial to rule out the possibility of cerebral aneurysm particularly Berry aneursym at the level of circle of willis.(see image). Fortunately the CT detected no abnormality. Intracranial aneurysms occur more in women, by a ratio of 3 to 2. Intracranial aneurysms may result from diseases acquired during life, or from genetic conditions. Lifestyle diseases including hypertension, smoking, excess alcohol consumption, and obesity are associated with the development of aneurysms. Cocaine use has also been associated with the development of intracranial aneurysms. Other acquired associations with intracranial aneurysms include head trauma and infections.

Case #046


PG Case 46

83 year old male on warfarin for a.fib was found on the floor by his son. He was amnesic of event and c/o severe headache. CT Brain was done. Can you pick out the finding?

There is a shallow right posterior parieto-occipital acute subdural haematoma. It measures 5.5 mm in maximum depth.
Following discussion with neuro surgery, the patient was admitted for neuro-observation as he was still complaining of severe headache. His warfarin was stopped.

Case #045


PG Case 45

You were alerted by the nurse that a patient in the ward has abnormal LFT’s. On reviewing the patient you noticed that he is connected to this bag via an IV. What is the diagnosis?

This patient developed abnormal LFT’s secondary to total parenteral nutrition (TPN). Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in > 90% of patients.Other complications include:
– Abnormalities of serum electrolytes and minerals ,Volume overload, Metabolic bone disease, Adverse reactions to lipid emulsion and developing gall bladder stones and sludge

Case #044


PG Case 44

A 73 year old lady presented to surgical outpatients with complaint of pruritis ani, mucus discharge and faecal staining. Abdominal examination was unremarkable. Picture of PR examination is shown. What is your diagnosis?

The picture shows partial rectal prolapse. Rectal prolapse may be partial thickness (involving just the mucosa) or full thickness involving all layers of the rectal wall. It is caused by weakness of pelvic floor and sphincter complex. Risk factors include post menopausal status, multiple vaginal deliveries and chronic straining due to constipation. Patients may present with mass protruding from the anus, mucous discharge, pruritis ani or fresh rectal bleeding.
Treatment includes avoidance of straining and laxatives (bulk forming and stool softners). For Mucosal prolapse, surgical options include recurrent banding or injections, mucosectomy and stapled anopexy. Transabdominal rectopexy or Delorme’s perineal rectoprexy are the commonly carried out operations for full thickness rectal prolapse.

Case #043


PG Case 43

This device was used during trauma case during resuscitation recently. what is it and where is the preferred site of insertion? And what could be the indication of using such device?

This is the intraosseous catheter, Its preferred site of insertion is the proximal humerus. Proximal tibia, distal tibia and distal femur (pediatrics only)
are alternate insertion sites.

Indications:
The patient needed vascular access

The patient had limited or no venous access

Due to limited time and resources

To prevent multiple IV cannulas and minimize patient pain/anxiety

To minimize vascular access-related complications and facilitate vein preservation

Case #042


PG Case 42

68 year old man c/o of severe tearing like chest pain radiating to his back for the last 2 days. He is a heavy smoker and hypertensive. Troponin was negative and ECG was unremarkable. CXR suggestive of widened mediastinum. What type of CT scan did he have next ? And can you give the diagnosis?

CT Angiogram of the AortaThis showed a leaking pseudoaneurysm aneurysm of the aortic arch measuring 3x2cm the pt was transferred to vascular unit and received Endovascular repair of thoracic aneurysm TEVAR. Pseudo-aneurysm, also known as a false aneurysm, is a hematoma that forms as the result of a leaking hole in an artery. This must be distinguished from a true aneurysm which is a localised dilatation of an artery including all the layers of the wall.

Case #041


PG Case 41

78 year old lady presented to the ED with non specific abdominal discomfort and feeling generally unwell for the past 2 months. She also had a few episodes of vomiting before coming to the ED so PFA was done to rule out bowel obstruction. Can you identify the finding on the plain film abdomen?

The PFA shows no radiological evidence of bowel obstruction. A large calcified mass can be appreciated in the right upper quadrant. However it is difficult to determine the origin of the calcified mass, whether arising from the liver, adrenal, kidney, colon, pancreas or gall bladder.
A subsequent CT abdomen showed that the calcified mass was arising from the upper pole of the right kidney and was approx 8x9cm in size, with enlarged para aortic lymph nodes, likely to be malignant.