PG Cases 281-320

banner-drogheda

PG_Case_320

Why do you think this image was taken?

This image shows satisfactory nasojejunal intubation in the fluoroscopy suite. The patient then went on to have a CT enteroclysis. (Clips are noted in the RUQ as the patient is post cholecystectomy)
Computed tomographic (CT) enteroclysis refers to a hybrid technique that combines the methods of fluoroscopic intubation-infusion small bowel examinations with that of abdominal CT.
CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.

PG_Case_319

What condition does this patient have?

This patient has Polycystic Kidney Disease
The diagnosis of autosomal dominant polycystic kidney disease (ADPKD) relies principally upon imaging of the kidney. Typical findings include large kidneys and extensive cysts scattered throughout both kidneys. PKD cysts can greatly enlarge the kidneys while replacing much of their normal structure, resulting in chronic kidney disease (CKD).

PG_Case_318

Patient presented with 3/12 worsening SOB, Describe these X-rays?

PA and lateral views have been obtained. The heart size and pulmonary vascularity are normal. There is marked elevation of the left hemidiaphragm. This may be long-standing, but given the presentation, CT should be considered. No other pulmonary pathology is identified. Vertebral body height and alignment are maintained.

PG_Case_317

Patient presented with x2/7 RIF pain, nausea and anorexia. What can you see on these images?

There are a number of an appendicoliths in the appendix. The appendix is thickened measuring 1.5 cm in maximum transverse dimension. There is inflammatory change in the adjacent mesenteric fat. Findings compatible with acute appendicitis. The patient requires an appendicectomy

PG_Case_316

Why do you think this image was taken?

This image shows satisfactory nasojejunal intubation in the fluoroscopy suite. The patient then went on to have a CT enteroclysis. (Clips are noted in the RUQ as the patient is post cholecystectomy)
Computed tomographic (CT) enteroclysis refers to a hybrid technique that combines the methods of fluoroscopic intubation-infusion small bowel examinations with that of abdominal CT.
CT enteroclysis is complementary to capsule endoscopy in the elective investigation of small-bowel disease, with a specific role in the investigation of Crohn disease, small-bowel obstruction, and unexplained gastrointestinal bleeding.

PG_Case_315

What do you see on this x ray abdomen?

Moderate faecal loading in the right hemi colon
Multiple phleboliths in the pelvis.

Phleboliths are literally “vein stones”, and represent calcification within venous structures. They are particularly common in the pelvis where they may mimic ureteric calculi, and are also encountered frequently in venous malformations. There is an association with Maffucci syndrome. Two signs are helpful in distinguishing a ureteric calculus from a phlebolith: Comet tail sign: favours a phlebolith Soft-tissue rim sign: favours a ureteric calculus

PG_Case_314

Describe the X-ray

There is dislocation of the C7 with fracture of the vertebral body and displaced fragment anteriorly. The patient also has earrings in, clearly visible on X-ray

PG_Case_313

Describe your findings

Multiple loculated collections within the pelvis, the largest measuring 12.7 x 5.5 cm and obstructing the distal right ureter resulting in moderate right hydronephrosis and hydroureter. Calcific densities consistent with appendicoliths. Appearance is in keeping with a ruptured acute appendicitis.
The patient underwent a laparotomy, wash-out and appendicectomy. This should also resolve the right sided hydronephrosis

PG_Case_312

Describe these images.

The patient has a basicervical fracture of the neck of the right femur and requires a DHS –dynamic hip screw.

PG_Case_311

What can you see here?

Within the liver there are multiple low-density lesions consistent with cysts. In segment 7 there is a 4.2 cm well defined lesion of higher density likely representing haemangioma.

Indications for Surgery (benign liver tumours)

Bleeding Tumours: This clinical feature consists of an acute onset of abdominal pain related to a subcapsular giant hematoma and/or hemoperitoneum with hemorrhagic shock, generally caused by spontaneous rupture of an adenoma, or in exceptional cases, a hemangioma.
Solitary Symptomatic Tumours: The symptomatic tumours are usually large lesions. The indications for surgery, which include complete removal of the solid lesion, should be discussed based on the severity of symptoms and the risks of surgery.
Solitary Asymptomatic Tumour: Hemangioma, FNH, and cysts, if diagnosed with certainty by imaging, must be managed conservatively regardless of their size. No follow-up is recommended because even if the tumour size increases, surgery will not be indicated if the patient remains asymptomatic.
Multiple Lesions: Management of the multiple forms of benign tumours is difficult because surgical clearance is often impossible and because no clear recommendations are available.

PG_Case_310

What do you see?

This patient has undergone open reduction internal fixation with TENS nails. (Titanium elastic nails) to fractures of the mid radial and ulnar shafts.
East et al, have shown TENS nailing of paediatric radius and ulna fractures in unstable, irreducible and open fractures to be a good treatment modality with good, early union of fractures and acceptable range of motion. It provides an attractive alternative to plating these fractures.
Reference:
S East, H Colyn, R Goller,Titanium Elastic Nailing (TENS) Of Paediatric Radius and Ulna Fractures – An Outcome Based Study, Bone Joint J Aug 2013, 95-B (SUPP 29) 35

PG_Case_309

What is unusual in this MRCP reconstruction and what problem may it pose?

There is significant variance in anatomy of the biliary duct with low insertion of the right hepatic duct with insertion with the cystic duct leading to a long parallel course of the cystic and right hepatic duct. The cystic duct inserts into the upper third of the common bile duct. This is the commonest cause for bile duct injury at cholecystectomy and this should be highlighted to the surgeon if operative procedure is to be carried out.

PG_Case_308

Describe your findings

Shattered spleen in the upper pole with significant haemo peritoneum due to the splenic injury. Large perisplenic haematoma with active extravasation of the IV contrast.
The trend in management of splenic injury continues to favour non-operative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years.

PG_Case_307

What do you see here?

Soft tissue deficits associated with exposed tendon and absent paratenon pose difficult reconstructive problems due to tendon adhesions, poor range of motion, poor cosmesis, and donor site morbidity.
A wound that has exposed tendon or bone can be successfully covered with a skin graft only if the thin layer of tissue connecting the tendon or bone (paratenon or periosteum, respectively) is intact. These connective tissues contain the vascular structures necessary for skin graft survival. If the paratenon or periosteum is absent, the graft will not survive. Under these circumstances, some type of flap is needed for wound closure.

PG_Case_306

How would you treat the above?

This is a venous ulcer with sloughy tissue. Slough is generally described as yellow or brown tissue in the wound. This ulcer can be treated by surgical or chemical debridement. Surgical debridement involves the removal of dead tissue from the wound bed. It is carried out under surgical conditions and results in a bleeding wound bed as a result of complete removal of necrotic material.
The term chemical debridement involves the application of chemical / enzymatic agents to the wound bed in order to degrade non-viable tissue without causing harm to newly granulating tissue. Common agents which are used are hypochlorite solutions, sodium hypochlorite, sodium hypochlorite combined with boric acid and hydrogen peroxide.

PG_Case_305

Describe this coronal CT Abdomen and Pelvis

The gallbladder is markedly distended with multiple large gallstones present within it, there is a small amount of inflammatory change associated with the inferior portion of the gallbladder and findings are consistent with acute cholecystitis.

PG_Case_304

Describe what you see ?

In segment 5/4 B of the liver in the surgical bed is a subtle loculated air-fluid collection with peripheral enhancement suggestive of abscess formation.
This patient was 2/52 post liver resection and requires IV antibiotics and discussion regarding intervention: placement of drain/surgical wash-out

PG_Case_303

Describe this coronal CT Abdomen and Pelvis

The gallbladder is markedly distended with multiple large gallstones present within it, there is a small amount of inflammatory change associated with the inferior portion of the gallbladder and findings are consistent with acute cholecystitis.

PG_Case_302

What do you see here? What is the pathogenesis?

These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particularly common in patients of Afro-Caribbean origin.

PG_Case_301

What do you see here?

This is an umbilical hernia containing mesenteric fat with mild inflammatory change in the surrounding subcutaneous fat. No bowel within hernia. No obstruction.

PG_Case_300

How would you describe this leg?

Venous Ulcer

This is consistent with a venous ulcer.

Site:

The venous ulcer is most commonly found over the lower third of the medical aspect of the leg, immediately above the medial malleolus (“gaiter area”)

Shape:

The size varies enormously, and they can be extremely large

Edge and base:

The edge is sloping and pale purple/brown in colour

The base is usually covered with pink-coloured granulation tissue but there may also be some white fibrous tissue

They are usually rather shallow and often have seropurulent  discharge

Surrounding Skin

Look for signs of primary varicose veins

The signs of chronic venous disease are usually present: induration, pigmentation, and brown discolouration of lipodermatosclerosis

Oedema, spider veins and telangiectasia may be present

 

PG_Case_299

How would you treat this?

Incision and drainage of the abscess, -in the drainage of an abscess, the incision should be made at the most prominent part. If possible, it should be made in a dependent area. Ideally, the direction of the incision should be in line with the natural skin crease.

PG_Case_298

79 year old nursing home resident presented with abdominal distension and vomiting. PFA shows?

Sigmoid volvulus.
Treatment in this instance involved endoscopic decompression with colonoscopy. If the patient had evidence of peritonitis or ischemic bowel, emergency surgery would be indicated.

PG_Case_297

Describe this rash and what is the likely cause?

Henoch-Schönlein purpura (HSP) is an acute immunoglobulin A (IgA)–mediated disorder characterized by a generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the lungs and the central nervous system (CNS).
Skin findings (usually the first sign of HSP) – Erythematous macular or urticarial lesions, progressing to blanching papules and later to palpable purpura; typically symmetrical and tend distributed in dependent body areas, such as the ankles and lower legs in older children and adults and the back, buttocks, upper extremities, and upper thighs in young children; hives, angioedema, and target lesions can also occur.

PG_Case_296

Can you see any abnormality here?

CT shows small left frontal scalp haematoma. Small high attenuation foci in the subcutaneous soft tissues overlying the left frontal bone which may represent glass foreign bodies.
This patient fell down the stairs and broke a pane of glass. A left sided frontal scalp wound was sutured in ED prior to CT. He required opening of the wound and a washout in theatre under GA.

PG_Case_295

What do you see on this Chest X-Ray?

Elevation of the left hemidiaphragm with interruption of the left hemidiaphragm contour suggestive of diaphragmatic hernia.

PG_Case_294

What do you see on these X-Rays

CT C-Spine confirmed

      1. Comminuted fractures of C1 anterior arch and right C1 lateral mass with malalignment of the lateral masses of C1 and C2.
      2. Fracture of the right lamina of C2.
      3. Fractures of C5 involving the right lamina and extending into the right foramen transversarium. Probable non-displaced fracture of C5 spinous process.
      4. Fracture of the right C6 lamina.
      5. Moderate spondylosis at C5/C6 and C6/C7.

Urgent spinal unit review was sought

PG_Case_293

Describe what you see and what is the most likely diagnosis?

The following mnemonic is useful to remind you what to do with a lump.

Should The Children Ever Find Lumps Readily

S –Size/Site/Shape/Surface/Skin changes/Symmetry/Scars
T –Temperature/Tenderness/Transilluminability
C –Colour/Consistency/Compressibility
E –Edge/Expansility and pulsatility
F -Fluctuation/Fluid thrill/Fixation
L –Lymph nodes/Lumps elsewhere
R –Resonance/Relations to surrounding structure and their state e.g. neurovascular status

This lump was a lipoma. Lipomas can occur anywhere in the body where there are fat cells, although they most commonly occur in the subcutaneous layer of the skin, particularly in the neck and trunk .

PG_Case_292

What is this bandage and what would it be used for?

This is a compression bandage: profore
The multi-layer compression bandage system has been specifically designed for the management of venous leg ulcers and associated conditions.
For patients with venous disease, the application of graduated external compression can help to minimise or reverse the skin and vascular changes, by forcing fluid from the interstitial spaces back into the vascular and lymphatic compartments. As the pressure within the veins of a standing subject is largely hydrostatic, it follows that the level of external pressure which is necessary to counteract this effect will reduce progressively up the leg, as the hydrostatic head is effectively reduced. For this reason it is usual to ensure that external compression is applied in a graduated fashion, with the highest pressure at the ankle.
Do not use on patients with an ankle brachial pressure index (ABPI) of less than 0.8, or on diabetic patients with advanced small vessel disease

PG_Case_291

What does this patient have?

This patient has a right sided pleural effusion.
Chest radiographs are the most commonly used examination to assess for the presence of a pleural effusion; however, it should be noted that on a routine erect chest x-ray as much as 250-600 ml of fluid is required before it becomes evident.
A lateral decubitus film is most sensitive, able to identify even a small amount of fluid. At the other extreme, supine films can mask large quantities of fluid.

PG_Case_290

How would you describe this leg?

Venous Ulcer:This is consistent with a venous ulcer.
Site:The venous ulcer is most commonly found over the lower third of the medical aspect of the leg, immediately above the medial malleolus (“gaiter area”)
Shape:The size varies enormously, and they can be extremely large
Edge and base:The edge is sloping and pale purple/brown in colour
The base is usually covered with pink-coloured granulation tissue but there may also be some white fibrous tissue
They are usually rather shallow and often have seropurulent discharge
Surrounding Skin:Look for signs of primary varicose veins
The signs of chronic venous disease are usually present: induration, pigmentation, and brown discolouration of lipodermatosclerosis
Oedema, spider veins and telangiectasia may be present

PG_Case_289

Describe this XRAY pelvis

Left hip prosthesis (hemiarthroplasty) in normal position. No fracture seen. Osteopenia. Moderate OA changes in the right hip joint.
A total hip replacement (total hip arthroplasty) consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head.

PG_Case_288

What does this CT-AP show?

Right renal tumour. Partial nephrectomy is contraindicated in this case as the tumour is invading the renal sinus.

PG_Case_287

What abnormality is present on this scan?

There is extensive surgical emphysema and an extensive pneumomediastinum. Extensive free gas is noted within the abdomen and pelvis.
Surgical emphysema occurs where there is a leak of air/gas from internal structures or produced as a result of gas forming infections. The resulting air travels via fascial planes to the subcutaneous tissues.
This can be caused by air/gas arising from internal structures. These causes include pneumothorax, pneumomediastinum, fistula or ruptured oesophagus or trachea. Another cause of surgical emphysema is where air/gas is introduced externally, such as with penetrating trauma, positive pressure ventilation or chest tube insertion. Finally gas produced from necrotising fasciitis can also cause surgical emphysema.

PG_Case_285

90 year old female admitted with LIF pain and vomiting. Diagnosis and Treatment?

There is a markedly distended viscus in the abdomen consistent with a sigmoid volvulus. Gaseous distension of the colon proximal to this is noted. No free gas is evident.
Decompression may be achieved with the introduction of a stiff tube per the rectum, aided by endoscopy or fluoroscopy

PG_Case_285

Describe the abnormality in this pelvic X-Ray

Radiopaque foreign body projected over the sacrum consistent with a rectal marble – the 7 year old patient presented with peri-anal pain and reportedly inserted a marble into his rectum.
Removal of rectal foreign bodies can be challenging depending on the shape, material and orientation within the rectum. If possible they should be removed via the anus, although in some cases a laparotomy may be required. Techniques described include:

  • manual extraction / obstetric forceps / snares etc..
  • abdominal pressure / manipulation may help
  • passing a Foley catheter distal to the object and inflating the balloon

Following successful transanal retrieval colonoscopy/sigmoidoscopy is prudent to exclude colonic injury.
In paediatrics, the appropriate legal authority or child protective services should be notified immediately in the case of suspected or known sexual assault.

PG_Case_284

20 year old male presented to ED after being stabbed. What do you see in this image?

This is a post IV contrast CT scan of the abdomen, showing a shattered spleen in the upper pole with significant haemoperitoneum due to splenic injury and large perisplenic haematoma with active extravasation of the IV contrast.
The American Association for the Surgery of Trauma (AAST) splenic injury scale is the most widely used grading system for splenic trauma.

PG_Case_283

This patient with acute cholecystitis failed to improve on antibiotic therapy. What might you do next?

Using ultrasound guidance and a single pass trocar technique a pigtail catheter can be placed into the gallbladder. Fluid can be aspirated to decompress the gallbladder and sent for microbiological assessment.

PG_Case_282

What do you notice on this image?

A small 1,2 cm umbilical hernia containing fat.

PG_Case_281

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