PG Cases 121-160

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Case #160

PGCase160
This is a midline laparatomy wound that healed poorly. Can you describe the healing process and the factors that could have contributed towards it?

This is recent laparotomy wound that has healed by secondary intention. The image showed healthy clean granulation tissue adjacent to the umbilicus.
Post-surgery wound infection had caused the laparatomy wound to dehisced. The wound was allowed to granulate and regularly packed and dressed.
Risk factors can include tension on the wound, location, obesity, smoking, previous scarring, surgical error, cancer, chronic use of corticosteroids and increased abdominal pressure.

Case #159

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Right Hemi specimen has been opened. Can you appreciate the pathology?

The first picture on the left is a zoomed in view of the opened caecum, which shows a tiny tumour (marked by the arrow). It is even hard to appreciate the tumour in the second picture which is the zoomed out view of the entire caecal mucosa. The tiny tumour was picked up on colonoscopy, carried out for non specific abdominal symptoms. Biopsy had shown invasive adenocarcinoma. Hence right hemicolectomy was performed. This demonstrates the importance of careful examination of the caecum as well as the entire colonic and rectal folds when performing colonoscopy and any suspicious areas should be biopsied.

Case #158

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80 year old nursing home resident presented to the ED with complaints of abdominal distension and absolute constipation for 3 days. A plain film abdomen was done. What is the most likely cause of his symptoms?

The PFA shows distended large bowel loop coming out of the pelvis and extending toward the right upper quadrant. No air is seen in the rectum. This appearance is consistent with a sigmoid volvulous. Chronic constipation can pre dispose to sigmoid volvulous. Chaga’s disease is another cause.

Case #157

pg case 157-09.07.15
65 year old man presented to the ED with complaint of severe epigastric pain and generalized abdominal tenderness. He had background history of smoking 20-30/day. A CT abdomen was done for him. What is the most obvious finding on the picture shown.

The picture shows a CT image in the axial plane through the upper abdomen. Lung window has been selected on the radiology system to look for air. The image shows free air above the liver. Considering the history, duodenal ulcer perforation was considered as the most likely diagnosis. The patient was resuscitated and had an emergency surgery through an upper midline incision. A Graham patch repair of the duodenal perforation was carried out.

Case #156

pg case 156-08.07.15
An 82 year old patient presented to the surgical services with history of weight loss and persistent non bilious vomiting. A CT abdomen was done. What is the obvious finding on the CT image shown?

The CT image showed a massively dilated stomach, filled with fluid. This finding was consistent with gastric outlet obstruction. Other images of the CT scan showed a large tumour of the pancreatic body invading into the duodenum causing the obstruction. The biliary tree was normal. The pancreatic tumour was deemed to be unresectable and it was not possible to overcome the malignant gastric outlet obstruction with a stent so the patient was planned for a palliative gastrojejunostomy.

Case #155

pg case 155-07.07.15
A young patient presented to the ED with epigastric pain and a chest X ray was carried out as part of routine work up. It picked up an unrelated finding, can you pick it up?

The chest X ray shows abnormal adenopathy on the right side of the mediastinum with patchy consolidation in the right upper lobe. The differential diagnosis for mediastinal adenoapthy could be lymphoma, sarcoidosis, tuberculosis etc. The patient was planned for a CT thorax initially followed by a EBUS guided biopsy.

Case #154

pg case #154-06.07.2015
Elective appendectomy specimen shown. Can you appreciate the gross pathology?

The specimen is of an appendiceal mucocele. The patient had this picked up as an incidental finding on an ultrasound performed for other reasons. The patient did not complain of any particular symptoms with it. An elective appendectomy was performed keeping in mind the neoplastic potential of apeendiceal mucoceles. Histologically they can be simple or retention cysts, can occur due to mucosal hyperplasia, mucinous cystadenoma (low grade appendiceal mucinous neoplasm) or mucinous cystadenocarcinoma.

Case #153

PG Case 153
The patient from a previous case presented 5 years later to the ED with signs and symptoms of small bowel obstruction. She underwent a CT abdomen. What is the diagnosis for her?

This CT slice is taken through the pelvis. It shows a laminated rounded structure in the distal ileum causing obstruction, evident by the dilated fluid filled small bowel loops proximal to it and collapsed bowel distally. The rounded body is the gallstone that was seen in the gallbladder in the previous CT 5 years ago (image shown in the previous case). The diagnosis is gall stone ileus, one of the less common causes of small bowel obstruction. The patient required a laparotomy and enterotomy to extract the gallstone from the ileum and relieve the obstruction.

Case #152

PG Case 152
Groin exploration was done for a suspected irreducible inguinal hernia. Can you identify the structure that was encountered during dissection?

The pictures show an encysted hydrocele of the cord. An encysted hydrocele of the cord results from aberrant closure of the processus vaginalis causing a loculated collection of fluid within the spermatic cord. It can sometimes lead to confusion between an inguinal hernia, undescended testes, inguinal lymph node etc. Ultrasonography can be helpful in pre-operative diagnosis.

Case #151

PG Case 151
Patient with unilateral non pitting edema of the lower limb. What is the clinical diagnosis?

The patient has lymphedema of the right lower limb. Lymphedema is caused due to obstruction of the lymphatic channels resulting in accumulation of lymph in the extra vascular space. This in turn stimulates fibroblasts and eventually non pitting edema develops due to organization of the fluid. Lymphedema could be primary or secondary. Primary lymphedema is due to developmental abnormality whereas secondary lymphedema is caused by acquired disruption to the lymphatic system due to infections, malignancy, obesity, surgery, radiotherapy, trauma etc.

Case #150

PG Case 150
A 55 year old man underwent a CT abdomen to look for the cause of lower abdominal discomfort. Can you appreciate the findings?

The sagital CT image shows a huge pelvic mass (marked by a star), compressing the urinary bladder (marked by an arrow) anteriorly and the rectum posteriorly. The patient had surgical resection and per operatively the tumor was adherent to the lower part of the sigmoid colon. En bloc resection was done along with the sigmoid colon, resulting in a Hartmann’s procedure. The histology showed it to be a high grade sarcoma, most likely a leiomyosarcoma.

Case #149

PG Case 149
A 70 year old female presented to the ED with severe upper abdominal pain. On examination she was markedly tender in the upper abdomen. Amylase and CXR were normal, so she underwent a CT abdomen to rule out a possible duodenal perforation. Can you appreciate the cause of her symptoms from the CT image shown?

The CT shows a distended gall bladder with a big laminated stone within it. The gall bladder wall looks thickened as well. Other slices showed some pericholecystic fluid and inflammatory stranding around the gall bladder. There was no pneumoperitoneum. This was consistent with acute cholecystitis and the patient was treated conservatively with antibiotics.

Case #148

PG Case 148
This is a check chest x-ray after a procedure. What procedure was done?

  • This pt had a chest tube placed to the left thoracic cavity.
  • You can see the radio-opaque chest tube outline in the left chest.
  • This pt had a tension pneumothorax requiring emergency chest tube.
  • The bigger the number on the tube (eg 36Fr, 40Fr) means the bigger the tube
  • The French system used to size chest tubes is the diameter of the tube in millimetres times three. So a 40Fr chest tube has a diameter of 13.3mm.

Case #147

PG Case 147
What could be the cause of swelling at the back of the knee of the patient shown in previous case?

A patient of Neurofibromatosis type 1 was shown in the previous case. This picture shows the back of his knee. The swelling is due to a large plexiform neurofibroma. Plexiform neurofibromas are more diffuse growths that can be locally invasive and quite deep; they may be associated with bony erosion and pain.

Case #146

NF
What genetic disorder is the patient suffering from?

The patient had Neurofibromatosis type 1. NF 1 is a multisystem genetic disorder characterized by cutaneous findings including café-au-lait spots, axillary freckling, subcutaneous and cutaneous neurofibromas, skeletal dysplasia, benign and malignant nervous system tumors. Other manifestations may include, high blood pressure, bone abnormalities, optic nerve tumors, Lisch nodules, learning disabilities, attention deficit hyperactivity disorder, autism spectrum disorder, larger than average head size and short stature.
The role of surgical care is to remove tumors that cause pain or a loss of function. Neurofibromas that cause compression on vital structures, obstruct vision, or grow rapidly deserve immediate attention. Orthopedic intervention may be required for rapidly progressive scoliosis and for some severe bony defects.
Source and further reading: “Medscape: Neurofibromatosis Type 1,
Author: David T Hsieh, MD” (http://emedicine.medscape.com/article/1177266-overview)

Case #145

PG Case 145
This is a scar in left antecubital fossa of the left arm. Can you name the procedure?

This patient had formation of bracheocephalic AV fistula for dialysis purpose.
Both the artery and the vein dilate and elongate in response to the greater blood flow and shear stress.
When the vein is large enough to allow cannulation, the fistula is defined as “mature.”

Case #144

PG Case 144
This patient had lung biopsy and was in respiratory distress 24 hours later. What is the chest x-ray finding?

Tension pneumothorax
Note the mediastinal shift and collapsed left lung.
TP is a non-radiological diagnosis and needs urgent needle decompression and chest tube.
Clinical examination will reveal hyperresonnance percussion ,unilateral absence of breath sounds, hypotension, distended neck veins and other signs of respiratory distress

Case #143

PG Case 143
Patient with gunshot wound on the left lateral chest. Chest tube was put in for haemopneumothorax. CT TAP done after that. Can you identify any other abnormality on the left side in this CT image shown?

The CT image shows a small diaphragmatic hernia on the left side containing only fat. This was a case of penetrating trauma but diaphragmatic hernias could result from blunt trauma as well and are frequently missed initially. They can get larger and cause symptoms over time. They are more common on the left side after blunt trauma as the right side is cushioned by the liver.

Case #142

PG Case 142
Post laparotomy patient had to have the wound opened to drain a sub cutaneous collection. Can you identify the type of dressing being used here?

This is negative pressure wound therapy, commonly referred to as vacuum assisted closure or vac dressing.
This type of dressing involves a piece of sponge like material introduced in the wound which is covered by an air tight transparent dressing and connected to a vacuum source. Fluid from the wound is collected in a canister which can be measured and disposed of. Negative pressure enhances wound healing by reducing tissue oedema, bacterial load and promoting fibroblast proliferation, neo vascularisation and matrix molecule synthesis.

Case #141

PG Case 141
5 days post laparotomy patient. Ward staff called you to review the wound. What are your findings on inspection and what would be next step in management?

There is erythema and discharge visible from the wound. The skin edges are sloughy in the middle. The wound is infected and there seems to be a sub cutaneous collection. The next most appropriate step would be to open the stitches and drain the collection. Culture sensitivity swab should be taken and directed antibiotics might be necessary. The wound should be dressed regularly and allowed to heal by secondary intention.

Case #140

PG Case 140
Patient was kicked in the right flank while playing rugby. On examination he was tachycardiac and had bruising on the right flank area. CT abdomen was done. Can you identify the injury?

The CT abdomen shows injury to the right kidney with free fluid/blood surrounding it. This was reported by the radiologist to be a Grade IV injury. Renal
injury due to trauma is classified according to the Organ Injury Scaling (OIS) Committee Scale which is as follows:

Minor I Contusion Microscopic or gross haematuria, Urological studies normal
Haematoma Subcapsular, nonexapnding without parenchymal laceration.
II Haematoma Nonexapnding perirenal haematoma confined to renal retroperitoneum.
Laceration <1cm parenchymal depth of renal cortex without urinary extravasation.
Major III Laceration >1cm depth of renal cortex, without collecting system rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through the renal cortex, medulla and collecting system.
Vascular Main renal artery or vein injury with contained haemorrhage.
V Laceration Completely shattered kidney.
Vascular Avulsion of renal hilum which devascularizes kidney.

Case #139

PG Case 139
40 year old patient was brought to ED with history of stabbing in the right side of chest. On examination he was cold and clammy with a thready pulse of 125/min and BP of 90/60mmHg. Breath sounds were absent on the right side. What does the chest X-ray show?

The chest X-ray shows opacity over the entire right side. The right lung seems to be collapsed. Considering the history, this is consistent with a large haemothorax. This was managed by putting in a chest tube which drained about 500mLs of blood initially. If more than 1500mLs of blood comes out initially on putting the drain or continues to bleed at a rate 200mLs/hour for 3 hours, it is an highly likely that the patient might require a thoracotomy to control the bleeding.

Case #138

PG Case 138
This is a CT image of a man in his 40’s presented with left flank pain and microscopic haematuria. Can you spot the diagnosis?

This is a CT KUB (kidney ureter bladder) done for investigation of renal calculus.
CTKUB differ with CT Abdomen by reduced adjusted radiation and its non-contrast.
CT KUB has less radiation and ideal to diagnose ureteric calculus in patients presenting with suspected renal colic.
Also note the presence of phlebolith which may look like stone but is in the wrong place i.e vessels ( not in ureter or bladder)

Case #137

PG Case 137
Can you spot the abnormal chest X-ray finding?

There is a cavitated lesion in the left upper lobe of this chest X-ray.
Common differentials include cavitated and centrally necrotic lung tumour, previous TB/fungal infection or cavitated pneumonia.

Case #136

PG Case 136
Looking at this boy’s leg, Can you tell what complication he might have had post IM nailing of tibia?

The picture shows scar marks along both sides of the leg which are consistent with previous fasciotomy incisions. Fasciotomy is the definitive surgical treatment for acute compartment syndrome which is one of the complications associated with internal fixation of long bones like tibia. The purpose of fasciotomy is to open all the fascial compartments to relieve the pressure and prevent ischemic damage to the muscles. The anterior and lateral compartments are opened through the lateral incision and the superficial and deep posterior compartments are decompressed through the medial incision.

Case #135

PG Case 135
Can you identify the scar on the abdomen? What procedures can this incision be used for?

The scar on the abdomen, shown in the picture, is from a Chevron incision. It is sometimes also called roof top incision or a double Kocher’s incision. This incision can provide excellent access to the upper abdominal vicera. It can be used for operations on the pancreas, total gastrectomy, oesophagectomy, operations for renovascular hypertension, bilateral adrenalectomy, extensive hepatic resections and liver transplantation.

Case #134

PG Case 134
Unwell diabetic patient with cellulitis on the right foot. Can you identify the findings on the X ray?

The X ray shows resorption of the head of the fifth metatarsal due to previous osteomyelitis that had been completely resolved. At this occasion the acute finding on the X ray was the appearance of gas in the soft tissues. The patient was systemically toxic, had rapidly spreading cellulitis and palpable crepitus in the soft tissues of the foot. This was consistent with the diagnosis of necrotizing fasciitis. The patient was resuscitated, given broad spectrum antibiotics and taken to theatre urgently for surgical debridement.

Case #133

PG Case 133
65 year old patient presented to the ED after he slipped on the wet floor in the bathroom, complaining of right hip pain and very limited hip movements on that side. He had an X ray, can you identify the cause of his symptoms on the X ray?

The X ray shows that the patient has had bilateral total hip arthroplasty done and he has dislocated the right hip at this instance. Dislocation is one of the complications of total hip replacement surgery. It can occur in about 4% patients after first time surgeries and in about 15% of patients with revision hip replacements. The hip joint becomes less stable after total hip replacement surgery as the natural mechanisms of joint stability are altered. For this reason patients with hip replacement need to take some precautions which include: do not cross legs, do not bend legs up beyond 90 degrees, do not sit on sofas or in low chairs and do not sleep on your side.

Case #132

PG Case 132
This elderly lady presented with vomiting and tender left groin lump present for the last 48 hours. What is the most likely diagnosis?

Incarcerated femoral hernia• Tender irreducible groin lump in elderly female associated with vomitting is almost likely to be an incarcerated femoral hernia.
• It can be difficult to be sure whether the hernia is above or below the inguinal ligament. CT scan is essential to confirm the diagnosis by finding the transition point in the small bowel.
• Femoral hernia is less common than inguinal hernia but its more commonly found in females due to wider pelvis/femoral canal.

Case #131

PG Case 131
OGD done in cirrhotic patient for anemia. What are endoscopic findings shown?

The picture shows portal gastropathy in the stomach. These changes occur in the gastric mucosa due to portal hypertension most commonly caused by liver cirrhosis. The mucosa is friable with presence of ectatic blood vessels on the surface. Cirrhotic patients can have acute or chronic upper GI bleed due to portal gastropathy. These patients can also have other more common sources of upper GI bleed like oesophageal or gastric varices. The treatment of portal hypertensive gastropathy in the first instance is beta blockers to reduce the portal pressures. Octreotide can be used in case active bleeding.

Case #130

PG Case 130
Patient admitted on the medical ward had arterial line removed two days ago. Surgical team was called to review the pulsatile swelling at the site of arterial line removal. What is the likely diagnosis?

The pulsatile swelling at the site of arterial line removal from the radial artery most likely represents an arterial pseudoaneurysm. This was confirmed by a CT angiogram. The patient was referred to the vascular surgery team for further management.
It is important to perform Allen’s test here to ensure adequate perfusion of the hand by ulnar artery, in which case the radial artery can be embolized or tied off surgically.

Case #129

PG Case 129
What is the diagnosis?

• Para-umbilical hernia
• This particular hernia is more common in adults versus a true umbilical hernia which commonly happen in children
• Common risk factors include obesity, pregancy, ascites, chronic cough, chronic constipation, and problems urinating because of an oversized prostate gland.
• Repair of this hernia can be done as an elective with or without mesh and usually as daycase

Case #128

PG Case 128
A 60 year old patient with background history of alcoholic cirrhosis presented with abdominal pain and distention after taking NSAIDs. What is the obvious finding on this CT abdomen?

The CT image shows massive amount of free air in the abdomen accompanied with significant amount of ascities around the liver. The site of perforation could not be exactly identified on the CT, however the clinical history and examination pointed towards a perforated duodenal ulcer. The patient had to undergo laparotomy and omental patch repair of the duodenal ulcer. The patient had a long and stormy post-operative course due to the liver cirrhosis.

Case #127

PG Case 127

A 70 year old man had colonoscopy for bleeding PR and anal pain. He had background history of external beam radiotherapy for prostate cancer. Can you appreciate the cause of his symptoms on this endoscopic picture taken in the rectum?

The picture shows a rectal ulcer just at the anorectal junction. This was accompanied by radiation proctitis seen in the middle and lower third of the rectum. Rest of the colonoscopy was normal. Multiple biopsies were taken from the ulcer which showed no malignant features. Biopsies from the rectum confirmed radiation induced damage. The case was discussed in GI MDM and it was concluded that the ulcer was caused by ischemic damage due to radiotherapy. The patient was referred for trial of hyperbaric oxygen therapy as this has shown benefit in such patients in some case series.

Case #126

PG Case 126
Patient had small bowel resection. Can you identify the pathology by looking at the gross specimen?

This is the specimen of resected small bowel which has been opened to show the mucosa. The bowel wall is oedematous and thickened. The lumen is somewhat narrowed due to fibrosis. The mucosa demonstatres ulceration and fissuring with cobblestone appearance. The communicating fissures and crevices in the mucosa separate islands of more intact, erythematous and swollen epithelial lining. These findings are consistent with active crohn’s disease and subsequent microscopy confirmed the diagnosis.

Case #125

PG Case 125
50 yr old man presented with colicky abdominal pain and anemia. After thorough workup he required laparotomy and small bowel resection. The resected specimen is shown. Can you identify what was the reason for the resection?

The specimen shows ileoileal intussusception. Proximal part of the bowel telescopes into the distal part and can potentially cause obstruction and sometimes strangulation and subsequent necrosis. Intussusception is more common in children and usually occurs without a lead point. However in adults it is, in a great number of cases caused by a lead point in the bowel, which could be a lipoma, meckel’s diverticulum, hypertrophied peyer’s patches or a tumor (primary or metastatic to the bowel). In this patient the intussusception was caused by a metastatic tumor deposit in the small bowel which acted as the lead point. En bloc resection is recommended in adults to avoid the potential risk of perforation and tumor dissemination.

Case #124

PG Case 124
Pt fell and injured left elbow. Can you appreciate the injury on X ray?

The X ray shows fracture of the olecranon process. The patient required open reduction internal fixation for this.

Case #123

PG Case 123
36 year old man got into a fight in the pub and injured his right leg. X ray of ankle and lower leg is shown. Can you appreciate the findings?

The X ray shows fracture of the fibula and ankle dislocation. The patient had reduction and back slab application in ED. However, he required open reduction internal fixation for this injury.

Case #122

PG Case 122
A 55 year old woman fell from a small kitchen ladder onto her flexed right hand. Can you identify the type of fracture?

The X ray shows fracture of distal radius with associated palmer displacement and angulation of the distal fracture fragment. This is known as Smith fracture or reverse Colles fracture. The treatment depends upon the patient characteristics and the type of fracture. It can be managed by closed reduction and cast application or by open reduction and internal fixation.
This has been named by Robert William Smith (1807-1873) who was a surgeon at Trinity College Dublin.

Case #121

PG Case 121
Can you identify the anatomical structures displayed during a laparoscopic cholecystectomy?

The picture shows biliary anatomy that should be essentially displayed before clipping and cutting any structure during laparoscopic cholecystectomy. The cystic artery (marked by a star) can be seen running in the calot’s triangle. The Calot’s triangle is formed by the cystic duct, the common hepatic duct and the inferior aspect of the liver.