PG Cases 241-280

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PG_Case_280

What does this image show?

This image shows CT guided drainage of a diverticular abscess in the left iliac fossa. A needle can be seen puncturing the collection in the LIF. A catheter was then placed which allowed drainage of the collection.

PG_Case_279

68 year old lady presented with acute severe lower abdominal pain, vomiting and diarrhoea. CT abdomen pelvis shows what abnormality?

This CT shows faecal peritonitis with free gas and free fluid seen in the peritoneal cavity, secondary to large bowel perforation. This patient underwent an emergency Hartmann’s procedure

PG_Case_278

89 year old patient with known bladder cancer. What else can you deduce from his history from this imaging?

There are multiple densities noted within the pelvis adjacent to the prostate, these are likely brachytherapy beads.
For men with localized prostate cancer, RT is a reasonable alternative to radical prostatectomy. RT can be delivered as external beam RT or brachytherapy.

PG_Case_277

89 year old male with painless frank haematuria. What do see on his imaging? What would you do next?

CT findings:
Urinary catheter in situ. There is a diffuse bladder tumour which is predominantly involving the dome extending down into the lateral walls of the bladder. This is likely full-thickness. There is extensive peri-vesical inflammatory stranding.

PG_Case_276

Describe the abnormality.

There is a tubular cystic structure anterior to the bladder measuring 2 cm in maximum diameter. There is also some thickening of the bladder wall.

The patient also underwent CT imaging where it was noted that there was a fluid component and calcification within the lesion, so the possibility of an early mucinous adenocarcinoma would have to be considered and excision recommended. It may however be a complication of a urachal remnant.

PG_Case_275

What do you see on this imaging? What may the patient have?

There is ongoing extensive mucosal thickening and oedema of the colon present throughout the colon consistent with pancolititis. The transverse colon measures 6.3cm in diameter.

The patient may have toxic megacolon the hallmarks of which are non-obstructive colonic dilatation larger than 6cm and signs of systemic toxicity.

PG_Case_274

A 63 year old lady with a history of recurrent UTI and left flank pain. Diagnosis and cause?

There is a large staghorn calculus occupying the mid and lower pole extending into the renal pelvis.

Upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces are classified as staghorn calculi. Although all types of urinary stones can potentially form staghorn calculi, approximately 75% are composed of a struvite-carbonate-apatite matrix.

Struvite stones are invariably associated with urinary tract infections. Specifically, the presence of urease-producing bacteria, most commonly Proteus.

PG_Case_273

An 86 year old lady presented with generalised abdominal pain and vomiting. What do you see? What are the most common causes?

Plain film abdomen:
• Dilated loops of small bowel which are predominantly central.
valvulae conniventes are visible.

These findings are suggestive of small bowel obstruction.
The most common cause of small-bowel obstruction is postsurgical adhesions.
Another commonly identified cause is an incarcerated groin hernia.

PG_Case_272

What do you see? Management plan?

This patient has a mild aneurysmal dilation of the abdominal aorta, maximum diameter 4.2 cm. This is infrarenal and ends at the bifurcations.

The Society for Vascular Surgery recommend observation for asymptomatic AAA <5.5 cm in diameter. As such, management consists of ongoing clinical evaluation and AAA surveillance, and risk modification.

PG_Case_271

55 year old lady presented with ongoing headache and had an elevated ESR on testing. Diagnosis?

Temporal arteritis/ Giant cell arteritis. Temporal arteritis is a systemic inflammatory vasculitis of unknown etiology, which typically affects the superficial temporal arteries.
The above image shows histological specimen from a temporal artery biopsy (TAB). A positive temporal artery biopsy has 100% specificity for diagnosis of temporal arteritis. TAB should be performed as soon as possible if temporal arteritis is suspected.
Treatment is with high dose corticosteroids, failure to treat increases the risk of ischemic ocular and cerebral complications and can result in irreversible visual loss.

PG_Case_270

What do you see on the imaging? What would you do about it?

A large 14 x 7 x 11 centimetre fluid and debris filled collection is present within the central lower abdomen. There are smaller interloop collections present.
(There is a reactive intestinal oedema.)
This would be amenable to ultrasound guided drainage.

PG_Case_269

57 year old lady admitted for treatment of acute diverticulitis. CT abdomen pelvis shows what abnormal incidental finding?

Two discrete spleens are seen in the left upper quadrant. They are joined at their inferior poles and have separate splenic hila and splenic arteries.

PG_Case_268

What abnormality is present on this XRAY?

This 5 year old child has a fishing hook embedded in the soft tissue of the submental triangle. As it is superficial it can be managed by removal with adequate analgesia, tetanus vaccination and prophylactic antibiotics.

PG_Case_267

56 year old male with tender, hot, swollen, weeping right leg .Diagnosis & Risk Factors

Diagnosis – cellulitis of right leg on background of chronic venous insufficiency
Risk factors of cellulitis:
• Injury. Any cut, fracture, burn or scrape gives bacteria an entry point.
• Weakened immune system. — Such as diabetes, HIV…. Certain medications, such as corticosteroids…
• Skin conditions. Skin disorders — such as eczema, tinea pedis, chickenpox and shingles — can cause breaks in the skin and give bacteria an entry point.
• Lymphedema. Swollen tissue may crack, leaving skin vulnerable to bacterial infection.
• History of cellulitis.
• Intravenous drug use.
• Obesity.

PG_Case_266

75 year old lady presented to ED after falling on her right arm. She experienced pins and needles in her first 3 fingers and half her palm . The x-ray image above shows what type of fracture? Which affected nerve is causing her paraesthesia?

Supracondylar Y fracture. This type of fracture occurs from fall with elbow flexed as it hits the ground. Median nerve

PG_Case_265

What is this scar and what is it used for?

A laparotomy is performed when access to the abdomen is required. There is a multitude of reasons for this, as it allows for access to the intra-abdominal organs.

PG_Case_264

40 year old post fall from height. Tender over left chest wall. Diagnosis and management?

As always your priority is to stabilise the patient according to ATLS guidelines. Airway, Breathing Circulation…. From his chest XRAY he has a pneumomediastinum. CT confirmed superior pneumomediastinum and small bilateral pneumothoraces. Pneumomediastinum is the presence of extraluminal gas within the mediastinum. Gas may originate from the lungs, trachea, central bronchi, oesophagus, and track from the mediastinum to the neck or abdomen. In this case the patient was discussed with cardiothoracics and underwent conservative management.

PG_Case_263

62 year old male brought in by ambulance post fall. C2H5OH abuse. Complaining of left chest wall tenderness, and tender LUQ. Urine dipstick: 1+ blood. Diagnosis and management of CT findings?

This patient has a 2 cm exophytic enhancing lesion involving the posteromedial aspect of the right kidney with CT appearances of an incidental renal cell carcinoma. The patient does not have a left kidney. The patient requires a CT renal triphasic, urology referral and MDT discussion.

PG_Case_262

7 year old boy presented to ED with 2 day history of severe RIF pain, nausea, vomiting and anorexia. Clinical features were suggestive of acute appendicitis and urgent laparoscopic appendicectomy was performed. On removal of the appendix what abnormal feature can be seen here?

A parasitic worm can be seen in lumen of the dissected appendix. This could be an incidental finding or the aetiology of this patient’s appendicitis.
The patient and his family will need to be treated with Mebendazole an anthelmintic.

PG_Case_261

What does this photo show?

Dry gangrene of the forefoot.

PG_Case_260

This is a gentlemans right groin. What procedure did he have done?

This man has had a coronary angiogram. The bruising surrounds a small pin-point wound which marks the entry point of the needle before entering the common femoral artery. Other procedures he could have had include: Angiography of lower limb, Angioplasty of coronary or lower limb vessels or Central line in femoral vein

PG_Case_259

What does this photo show?

The photo demonstrates a patient with a prolapsed stoma

PG_Case_258

What causes this abnormality?

There is loss of the angle of the nailbeds with resulting ‘clubbing’ of the nails. The causes of clubbing are multiple, some of the most common are:
1. Bronchiectasis
2. Bronchitis
3. Heart Failure
4. Interstitial fibrosis
5. Lung abscess
6. Lung or pleural cancer
7. Inflammatory bowel disease
8. Endocarditis

PG_Case_257

Spot Diagnosis: This is what you see on entering the patient’s room

The patient is hanging his leg over the side of the bed.
Obviously this patient has significant peripheral artery disease. Gravity helps blood flow get to the extremities. This is in effect the opposite to Buerger’s Test.

PG_Case_256

What is this device and why is it indicated?

This is an Inferior Vena Cava (IVC) Filter placed prophylactically to prevent venous thromboembolism. It may be placed in high risk individuals such as following polytrauma or patients whom anticoagulation may be contraindicated/unsuccessful.

PG_Case_255

What type of tube is seen in this photo?

You can see the tube originating from the right upper quadrant
Note also the dark fluid contained within, which is the bile, characteristically resembling coke. A tube placed in the Common Bile Duct (CBD) with an ascending & descending limb that forms a ” T ” It drains percutaneously and is usually placed after CBD exploration.

Calots Triangle: Cystic Duct Inferiorlateraly, Common hepatic duct medially and inferior border of liver superiorly.

PG_Case_254

What common operation is this likely to be? Can you name the triangle?

This patient is undergoing an elective laparoscopic cholecystectomy. It shows the image as seen through a laparoscopic camera. The operator has the gallbladder between laparoscopic forceps at its tip.
The operator is holding the gallbladder taut up & against the liver to enable proper visualisation of the biliary structures & allow safe dissection of Calots triangle.

Calots Triangle: Cystic Duct Inferiorlateraly, Common hepatic duct medially and inferior border of liver superiorly.

PG_Case_253

Is there anything unusual about this patients PFA post anterior resection?

You can see some staples at the pelvic region but more importantly you can see thumb-tacks. Thumb-tacks are used as a last ditch effort to stem bleeding from vessels at the back of the sacrum. These vessels emerge flush from the bone, thus making them impossible to suture or tie.

PG_Case_252

This 42 year old old man is about to undergo an elective cholecystectomy. Is this of concern?

This man has an obvious Pectus Excavatum. He may be completely asymptomatic but as he is about to undergo a general anaesthetic this may be a concern to the anaesthethist as it can interfere with pulmonary function & can cause pulmonary hypertension. You would also be expected to look for other skeletal abnormalities along with any of the sequelae of Marfan’s syndrome

PG_Case_251

The photo below demonstrates a swollen left leg which has a blue tinge This is typical of phlegmasia ceru’lea do’lens

The patient has a cool foot and you have difficulty feeling pulses. You apply a doppler probe and hear a strong signal. The swelling however may cause some arterial constriction & so should be monitored carefully. One must forever watch for signs of compartment syndrome in patients with similar presentations. Doppler ultrasound is beneficial in diagnosing venous pathology and may give a reasonable reflection of arterial flow.

PG_Case_250

72 year old gentleman, 8/52 of weight loss with 24hour hx of vomiting & no bowel motion today.Diagnosis?

The history, clinical picture and imaging suggest that this patient is obstructed. It is important to Make the patient comfortable:
1.Get IV access
2.Relieve vomiting with an anti-emetic
3.Give analgesia if in pain
4.Place on intravenous fluids
5.Pass an nasogastric tube and aspirate.
A CT scan to determine the level and cause of obstruction is usually indicated and clinical picture/ failure with conservative management would then warrant laparoscopy/laparotomy.

PG_Case_249

67 year old psychiatric patient bg: rheumatoid arthritis, presents with 8hr hx of vomitus & then collapse. Differential Diagnosis?

This patient likely has an upper GI Bleed. Haematemesis can be either bright red blood or ‘coffee-ground’ vomitus.
In this case it is of the ‘coffee-ground’ variety. Differential includes:
1.Gastritis
2.Ulcer (Peptic/Duodenal)
3.Varices
4.Arteriovenous malformation
5.Mallory-Weiss tear
6. Malignancy

PG_Case_248

64 year old bg of smoking & hypertension presents to ED following sudden onset weakness of his right arm and leg.Aetiology?

The angiography demonstrates stenosis of the left internal carotid
The images from angiography can provide useful anatomical images for planning any potential operative procedures. He makes a good recovery.
Following discussion at a neurovascular MDT this patient was advised for a Carotid End Arterectomy (CEA)

PG_Case_247

62 year old lady presents severe acute epigastric pain. Background: Rheumatoid, cardiac disease, polypharmacy? Diagnosis and management?

As always your priority is to stabilise the patient according to ABCD
Airway
Breathing
Circulation…
From her AP erect xray she has pneumoperitoneum- signifying perforation of a hollow viscus. Depending on her stability she requires an urgent CT scan and laparoscopy/otomy.

PG_Case_246

46 year old lady on dual antiplatelets presents with collapse & acute epigastric pain. Differential Diagnosis?

The arterial phase CT demonstrates a blush at the liver. This is seen as a small white speck and it represents active bleeding. Of note you can also see contrast (white) in the aorta.
You can also see a mass in the liver surrounded by blood.
This lady requires urgent surgical or interventional radiology to control her bleeding. Once stabilised she requires transfer to a Liver Surgery unit for assessment/ resection of the mass.

PG_Case_245

A 42 year old assault victim attended ED 12 hours after been repeatedly beaten. What is your concern?

This man has a large amount of bruising around his left flank reflective retroperitoneal bleeding. Given the position you should be concerned about damage to the spleen. In the absence of trauma this is called Grey-turners sign and may reflect haemorrhagic pancreatitis.

PG_Case_244

38 year old male presents with acute epigastric pain radiating into back + assoc vomiting for 18hrs. Diagnosis?

The patient is quite obviously jaundiced. He has also had a thoracotomy for some reason in the past. He also has a considerable left sided effusion. He has a history of cholelithiasis and no background of C2H5OH use. His presentation would be most in keeping with acute pancreatitis secondary to cholelithiasis. An ultrasound, CT scan, blood profile +/- MRCP may aid in diagnosis.

PG_Case_243

A 23 yr old IDDM, hx of kidney transplant, 10 days post appendectomy presenting with tender, red wound. Diagnosis & Risk factors?

A post operative wound infection- Major risk factors would include the patient’s diabetes and immunosuppression therapy.

PG_Case_242

This 82 year old lady fell whilst getting up from bed to go to the bathroom. What is the likely diagnosis?

The left leg is shortened and externally rotated, consistent with a displaced hip fracture

PG_Case_241

40 year old attends A&E following a twisting injury to ankle. What is the diagnosis? How will you treat?

Displaced medial malleolus fracture. Needs open reduction and internal fixation with screw.