PGCases 81-120

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Case #120

PG Case 120
A 78 year old lady presented to the surgical service with a lesion on her cheek. What is the most likely diagnosis ?

This lesion has typical appearance of a basal cell carcinoma. BCC occurs most commonly on the face, neck, and hands. Morphological characteristics of BCCs include pearly appearance with central erosion, bleeding on minor trauma, crusts in the centre of large lesions, rolled edges and sometimes telangiectases are visible over the surface. The lesion was excised completely. Because of the large size a skin graft was required to close the defect.

Case #119

PG Case 119
27 yr female attended ED with complaint of right iliac fossa pain for 2 days. Laparoscopy was done for her. Can you identify the cause of her symptoms?

The pictures show a gangrenous appendix with pus in the pelvis.
On examination the patient was tender in her lower abdomen, with maximum tenderness at the Mcburney’s point. She had involuntary guarding in the same area. Cough sign, pointing sign, rovsing sign were all positive and she had rebound tenderness as well. Since the patient demonstrated classical signs of acute appendicitis no radiological investigation was performed for her. The diagnosis was made on clinical grounds and laparoscopy done to confirm the above findings.

Case #118

PG Case 118
A 22 year old man presented to the ED with complaint of swelling and pain at the upper end of his natal cleft for the past 5 days that was getting worse despite taking antibiotics prescribed by his GP. What is the spot diagnosis here?

The picture shows a pilonidal abscess. On examination the swelling was warm to touch, tender and fluctuant, confirming the presence of pus in it.The location is typical for a pilonidal abscess. It usually arises in a pre-existing pilonidal sinus that forms due to hair tracking into the subcutaneous tissue.
The treatment of pilonidal abscess involves incision and drainage in the acute setting. The patients may require a formal excision of the pilonidal sinus at a later stage.

Case #117

PG Case 117
A 70 year old lady was referred by her GP with complaints of projectile vomiting for the past three weeks. The vomitus contained mostly undigested food contents. The patient also reported generalized weakness and significant weight loss. An urgent OGD was done. Can you identify the findings?

The picture taken at OGD shows a pin hole pylorus that could not be entered. On the retroflexed picture you can see lot of gastric contents despite the fact that the patient had been fasting for 12 hours. She had gastric outlet obstruction. Multiple biopsies were taken from the pyloric area to look for evidence of gastric malignancy.

Case #116

46 years old lady presented to ED with upper abdominal pain and vomiting. She had a recent history of travailing to a tropical country. This worm was seen in the vomiting. What is your diagnosis?

PG Case 116
This is Ascaris lumbricoides round worm. The infection is very common in tropical countries when fertilised eggs are ingested. Patients are usually symptomatic but can present with cough, fever, abdominal pain, intestinal ulcer and passing worms. The treatment of choice is mebendazole.

Case #115

PG Case 115
A 70 year old lady was referred by her GP with complaints of projectile vomiting for the past three weeks. The vomitus contained mostly undigested food contents. The patient also reported generalized weakness and significant weight loss. The patient had a CT abdomen done. What is the obvious finding?

The CT image shows a very dilated, fluid filled stomach; whereas the rest of the bowel is of normal caliber. This is consistent with gastric outlet obstruction. Also seen on the CT image is a mass in the pelvis which was arising from the ovaries and was thought to represent Krukenberg tumor i.e. ovarian metastasis of gastric malignancy.
A gastrojejunostomy was performed for the patient to bypass the unresectable mass at the pylorus causing the gastric outlet obstruction.

Case #114

PG Case 114
Can you identify the cause of pneumobilia in this patient?

The CT images show a metallic stent in the common bile duct. It maintains a patent communication between the bowel and the biliary system and hence causes pneumobilia. The stent was placed as the patient had a benign distal CBD stricture and was unfit to undergo a definitive surgical procedure. The large cystic mass seen on the right side is a benign renal cyst.

Case #113

PG Case 113
86 year old female presented to the ED with complaint of severe upper abdominal pain for 4 days accompanied by chills, rigors and fever. CT abdomen was done. What is the obvious cause of the symptoms seen on CT?

The CT shows thick walled gall bladder with calcified gallstones within it. There are pericholecystic inflammatory changes and a small gall bladder perforation can be seen resulting in a localized pericholecystic abscess. There is pneumobilia and air can be seen with the collection as well.
The patient was treated with IV antibiotics and an ultrasound guided percutaneous cholecystostomy was performed.
Can you recall the causes of pneumobilia from one of the previous cases?? Follow us to see what the cause of pneumobilia in this patient was.

Case #112

PG Case 112
Can you identify the structure seen during laparoscopic cholecystectomy?

The picture is taken during a laparoscopic cholecystectomy and shows the cystic duct that has been cleared and is ready to be clipped. Clear identification of the cystic duct is essential during laparoscopic cholecystectomy. It forms one boundary of the calot’s triangle along with the common hepatic duct and the edge of the liver. The cystic artery runs in the calot’s triangle.

Case #111

PG Case 111
A 72 year old man had colonoscopy for anemia. The lesion shown in the picture was encountered in the caecum. How will you work up and what definite treatment does he need?

The lesion grossly looks like a malignant tumor. Multiple biopsies were taken during the colonoscopy which showed it to be an invasive adenocarcinoma. A staging CT thorax abdomen pelvis was done which showed no distant metastasis. The patient went on to have a right hemicolectomy. The final histology revealed it to be pT4 tumor as it was invading the peritoneum. This would merit the patient to get adjuvant chemotherapy.

Case #110

PG-case-110.pgn
A patient had a laparotomy performed for small bowel obstruction. The picture shows small bowel that was entrapped in an internal hernia. Does the bowel look viable or needs resection?

The patient presented to the hospital late after the onset of symptoms. At the operation, the part of the bowel shown was entrapped in a mesenteric defect resulting from a previous surgery. The bowel looks dark and dusky. This bowel was not viable and had to be resected. Rest of the bowel was healthy so a primary anastomosis was performed and the mesenteric defect was closed.

Case #109

pg-case-109
A 24 year old male presented to the ED with complaint of right iliac fossa pain for the past 8 days that was accompanied by nausea, vomiting and anorexia. On examination he was tachycardiac and had a temperature of 38.4C. Abdomen was tender with guarding in the right iliac fossa. He underwent a CT abdomen. Can you identify the pathology, how will you manage this patient?

The approach towards this patient should be to resuscitate him and at the same time try to find out the source of sepsis so that it can be controlled. The patient had 2 IV lines put in. Routine bloods and blood cultures were taken. He was given analgesia and started on IV fluids and IV antibiotics. Urine output was monitored. His bloods showed a CRP of 294 and WCC of 18. As his history was of 8 days, it was suspected that he might have developed a complication of acute appendicitis at this stage. To confirm the clinical suspicion he underwent a CT abdomen.
An axial section of the CT is shown in the picture. It demonstrated a large abscess with a calcified fecolith adjacent to the caecum. This would be in keeping with an appendicular abscess. In most instances such abscesses can now be drained radiologically, saving the patient an emergency laparotomy along with its associated morbidity and mortality.

Case #108

pg-case-108
Name the procedure performed on the bilateral ingrown toenail.

Wedge resection of ingrown toenail.
A common minor ops procedure, the ingrown part of the nail was excised and the nail bed curetted to prevent recurrence. Usually done under local anaesthetic (ring block) using plain lignocaine, as adrenaline is contraindicated in digits. (adrenaline mixed with lignaocaine usually used in lesions on scalps etc. to reduce bleeding)
Notice the turniquet applied at the base of the big toe also to aid homeostasis.

Case #107

pg-case-107.pgn
A patient swallowed her denture that broke while she was having dinner. How can it be retrieved?

An OGD was done to retrieve the broken denture from the oesophagus. An x-ray performed prior to the procedure showed that it was lodged in middle part of the oesophagus. The first picture shows the denture in the oesophagus covered with some food debris. The foreign body was carefully retrieved with the help of a tripod grasper that is more commonly used to retrieve resected polyps during endoscopy. Great caution has to be taken, not to perforate the oesophagus or produce a tear in the mucous membrane that could bleed, while pulling it up. Great care is also taken while passing through the pharynx lest it falls back into the airway. No complications were encountered during the procedure for this patient. In the second picture you can see the retrieved broken part of the denture.

Case #106

pg-case-106.pgn
A patient admitted on the medical floor broke her denture while eating dinner and swallowed it. She complained of feeling something stuck in her chest afterwards and was able to swallow liquids but not solids. Can you spot it in the x-rays?

Lateral x-ray of neck and a chest x-ray were requested to determine where the broken denture was lodged; if it had passed down to the stomach or was still impacted in the oesophagus. The x-rays reveal a metallic object lodged in the midline at the level of the aortic arch, in keeping with the swallowed denture. This could potentially cause oesophageal perforation as the broken denture had sharp edges. The patient however had no symptoms indicating towards that and the x-rays showed no pneumomediastinum or pneumoperitoneum.

Case #105

PG Case 105
A 75 year old man was referred by the GP for colonoscopy due to fresh bleeding PR every time he goes to the toilet. Of note the patient had history of prostate cancer for which he received radiotherapy. Can you appreciate the cause of his symptoms on this colonoscopic picture of the distal rectum?

The picture shows radiation proctitis. The bowel mucosa is inflamed only in the distal part of the rectum and was normal above that. Radiotherapy is commonly used in the treatment of urological, gynaecological and GI malignancies. One of the major side effects of radiotherapy is radiation induced enteritis and proctitis. The rectum commonly gets injured because of its fixed position in the pelvis. Radiation induced enteritis or proctitis can have early and late manifestations. Acute injury occurs due to the direct effects of the radiation on the bowel mucosa and is very common. The patients experience symptoms of cramps, bleeding, diarrhea, tenesmus etc. It is treated symptomatically and usually resolves within weeks of cessation of radiation therapy. Patients with chronic radiation enteritis or proctitis can present with symptoms months or even decades after their treatment. It is an indolent but progressive disease and is hard to treat. Initial treatment involves diet modification, nutritional support, and control of symptoms with medications but surgical intervention may be required for complications like perforation, or fistulation.

Case #104

PG Case 104
An 80 year old lady presented to the surgical service with a lump in the groin on the right side. She had no complaint of pain and was otherwise well. O/E the lump had a positive cough impulse but did not reduce completely. A CT abdomen was done to confirm clinical findings. What is your diagnosis?

The CT pictures shown in coronal and sagital views reveal a right sided femoral hernia containing small bowel. There is no proximal bowel dilatation and the contrast passed freely to the colon so the hernia was not causing any bowel obstruction.
Femoral hernias occur more commonly in women. Femoral hernia presents as a swelling below and lateral to the pubic tubercle. It passes through the femoral canal which lies medial to the femoral vein in the femoral sheath. The neck of femoral canal is narrow so for this reason irreducibility and strangulation are very common in this type of hernia. All femoral hernias are repaired by excision of the sac and closure of the femoral canal.

Case #103

PG Case 103
The picture shows an appendiceal polyp, protruding from the lumen of the appendix, as was shown in one of the previous cases. A specific endoscopic imaging technique is being used here. Do you know what it is?

The polyp is being observed here under narrow band imaging during the colonoscopy. Narrow band imaging is an endoscopy technique where light of certain wavelength is used to enhance certain features of the mucosa. This allows differentiating normal from abnormal mucosa. Narrow band imaging has found application in identification of Barrett’s Oesophagus and colorectal polyps and tumors. It is also sometimes used in cystoscopy to differentiate between benign and malignant cells.

Case #102

PG Case 102
A 55 year old patient had a colonoscopy done for investigation of iron deficiency anemia. The finding shown in the picture was encountered in the caecum. Can you guess what it is?

The picture shows a polyp protruding out from the appendiceal lumen. It was not possible to resect this polyp endoscopically as the base is not visualized. Multiple biopsies were taken that revealed it to be a tubulovillous adenoma with low grade dysplasia. The case was discussed in the multidisciplinary meeting and it was decided that the patient needs a laparoscopic appendectomy or even a partial caecectomy to ensure that the resection margins are clear of the adenomatous mucosa. Appendiceal polyps are rare but associated with similar risk of progression to malignancy as colonic polyps so excision is recommended.

Case #101

PG Case 101
This patient presented to ED with LIF pain, vomitting and reduced stoma output. What operation did he have previously?

This patient had large midline laparotomy scar that is well healed and a stoma in the left iliac fossa. The stoma lumen was unable to be appreciated through the bag but its content looks like semi-formed stool. Based on this observation, the patient most likely have had Hartmann’s procedure. Given the full midline laparotomy scar it is possible that he had perforated bowel from diverticular disease or that he could have had challenging resection of the left side of his colon due to colorectal ca.
End colostomy formed during hartmann’s procedure can be reversed. The remaining bowel can be anastomosed to the rectal stump. Reversal of a Hartmann’s resection is often challenging and requires planning, and the assessment of the rectal stump is dependent upon the original indication for the nonrestorative procedure. The reported complication rate after Hartmann’s reconstruction is high, with morbidity rates of 30–40 %, anastomotic leakage rates as high as 15 %, and a reported mortality of up to 10 %. Advanced age and multiple comorbid conditions in a large proportion of patients who recover after Hartmann’s procedure further discourages both surgeons and patients from sometimes opting for reconstruction; 40 % of patients undergoing Hartmann’s resection never have stoma reversal.

Case #100

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88 year old man admitted on the medical floor started complaining of lower abdominal pain. The intern on the team examined the patient and felt that the abdomen was distended and markedly tender. A CT abdomen was arranged for the patient. Can you identify the cause of his symptoms?

The CT showed a massively distended urinary bladder extending to above the level of the umbilicus. The patient was in urinary retention causing hydroureter and hydronephrosis. This was caused due to a urinary tract infection on background of prostatic hypertrophy. A urinary catheter was inserted to relieve the gentleman’s symptoms. Rapid bladder decompression can sometimes result in haematuria so it was gradually emptied. This case emphasizes the importance of detailed history taking and careful clinical examination which could have fetched the diagnosis.

Case #099

pg-case-099.pgn
A patient with history of prostate cancer and complaint of back pain underwent an imaging study. Can you identify what investigation is this?

The pictures show anterior and posterior planar views of a whole body bone scan. No focal uptake was demonstrated in the study, indicating no bone metastasis.
Bone scan images the metabolic activity of bone. It can be helpful in determining bone metastasis. It can also be useful in widespread bone pain and differentiating bone from soft tissue pathology as the cause of pain.
Whole body Tc-99m bone scan is most commonly used and involves injecting the radioactive tracer intravenously. The tracer is taken up by the bones in a few hours and the patient is then scanned. Small amount of tracer remains in the patient and continues to emit radiation. The patients are safe to carry out routine activities; however, it is recommended that close contact with children is avoided for one hour after Tc-99m bone scan.

Case #098

pg-case-098.pgn
55 year old man was admitted into hospital with anemia and abdominal pain. He had upper and lower GI endoscopy that was normal. A CT abdomen was done. Can you appreciate the findings?

The axial and coronal view of CT shows small bowel intussusception, not causing any significant bowel obstruction. The patient underwent laparotomy and a segment of ileoileal intussusception was found, with a tumour at the lead point. En bloc resection and primary anastomosis was done.
Intussusception is rare in adults and is usually caused due an organic lesion at the lead point. A great majority of these turn out to be malignant. Ultrasound can be used to diagnose intussusception but CT scan has the highest accuracy for pre-operative diagnosis and can also help in localizing the site of intussusception.

Case #097

PG Case 97
13 year old boy presented to ED at 9am c/o left testicular pain since 2 am. Pain was sudden and woke him from sleep. He was rushed to theater for urgent exploration. What is the finding? What is the next step in the operation?

On exploration of his right testis, there was 180⁰ torsion resulting in ischaemia. Following detorsion/untwisting and warming with hot saline soaked gauze, there was promising signs of reperfusion. The testis was then fixed at 3 points to the dartos muscles in right hemiscrotum (orchidopexy). It is important to note that the contralateral side also needs to be fixed upon the finding of torsion. Orchidopexy was done to the left testis. Testicular torsion is an emergency . USS of the testis can sometimes help to exclude torsion but if any doubt from the clinical picture exploration is a must. This patient actually had an ultrasound that showed some but reduced blood flow to the testis. Some signs of torsion of testis can include transverse /high lie of testis, severe tenderness and swelling (sometimes the pt can’t even walk), marked skin changes/erythema of scrotum and absence of cremasteric reflex. The onset of pain is usually sudden and gets progressively tender very quickly.

Case #096

PG Case 96
This elderly lady hit her leg off the coffee table. She is on warfarin for A.fib. Can you guess when did the trauma happened based on the image below?

The image showed a large haematoma on her right lower limb with extensive ecchymoses. The non-uniform swelling occupies mostly the lateral aspect of the shin and It looks very tense, making it most likely to be a liquefied sub dermal haematoma above the fascial layer and not an intramuscular haematoma.
Examination of the haematoma revealed fluctuancy and distal pulses were present. It is important to rule out Compartment syndrome characterised by a more uniform swelling of the limb, severe and unproportionate pain as well as maybe faint or absent distal pulses. The evolution of haematoma takes approximately 7 days for the initial blood clots the liquefy. The trauma on this elderly lady actually happened 10 days prior to presentation. Depending on the size, they can be reabsorbed and fibosed or becomes infected. Drainage can be done surgically under GA or under radiological guidance again depending on size and clinical factors.

Case #095

PG Case 95
This 83 year old lady presented with vomiting. PFA was noncontributory. Clinical examination revealed painful lump in the right groin below the inguinal ligament. The image shows the finding at laparotomy. Can you give the diagnosis?

• Incarcerated right femoral hernia
• The knuckle of small bowel was reduced from the femoral canal through midline laparotomy access. That segment of small bowel was dusky and did not show any peristalsis after some period of time and was deemed ischaemic and unhealthy. When in doubt, resection of bowel is preferred as any further complication down the line would mean re-laparotomy and the patient status could not permit that. Small bowel resection was performed with side to side anastomosis

Case #094

PG Case 94
A middle age lady presented to the surgical outpatient clinic with a large neck swelling. On examination the swelling moved with swallowing but the lower limit of the swelling could not be appreciated on palpation. Pemberton sign was positive. CT thorax was done to further evaluate. Can you appreciate the findings on the CT slices shown?

CT images are shown in axial, coronal and sagital planes. They confirm the findings of a retrosternal goiter. The left lobe is much more enlarged than the right one and displaces trachea to the right. Further CT slices showed that the right lobe extends down to the level of the aortic arch. This lady had significant symptoms due to pressure effects of the large goiter and requires a thyroidectomy. However, given the extension of the swelling into the anterior mediastinum may require a sternotomy for it.
A positive Pemberton’s sign during physical examination indicates retrosternal extension of the goiter. It is positive if bilateral arm elevation causes facial plethora.

Case #093

PG Case 93.jpg
An X ray chest and thoracic inlet was requested for a middle age lady presenting to the surgical outpatient clinic with a large neck swelling. On examination the swelling moved with swallowing but the lower limit of the swelling could not be appreciated on palpation. What do you see on the chest and thoracic inlet X rays?

The X ray of thoracic inlet shows a soft tissue density in the neck, which would be consistent with clinical findings of a goitre. Trachea is displaced to the right with accompanying extra luminal left-sided pressure effect and narrowing. There is no abnormality of the cervical spine.The chest X Ray shows a right superior mediastinal mass consistent with a retrosternal extension of the goitre palpated clinically. It also demonstrates deviation of the trachea to the right by the larger left lobe of thyroid. No hilar or mediastinal lymphadenopathy is evident from the chest X ray.

Case #092

PG Case 92
A 30 year old man was involved in a road traffic accident. He had a head on collision and was brought in by ambulance. His GCS was 15/15, pulse was 108/min and BP 100/60mmHg at presentation. He complained of abdominal pain and on examination there was bruising on the upper abdomen. He had an urgent CT thorax abdomen pelvis done. Can you identify the major findings on the CT slices shown?

The patient is managed according to ATLS protocols. After initial resuscitation, CT thorax abdomen pelvis was done with IV contrast. The pictures show axial CT slices in the arterial phase. It demonstrates pronounced haemoperitoneum but no pneumoperitoneum. This indicates that solid organ injury like liver and spleen is more likely than bowel perforation as a result of the blunt trauma. There is also an extensive haematoma in lesser omental sac. The left lobe of the liver is not enhancing with the IV contrast which implies contusion and devitalisation and raises possibility of injury to the left hepatic artery. The patient had to be urgently transferred to a tertiary specialist Liver unit.
American Association for the Surgery of Trauma (AAST) classification system is most commonly used for livery injuries. It helps to decide the course of management since low grade injuries can sometimes be treated non operatively. The grades of hepatic injury are as follows:
●Grade I – Hematoma: subcapsular ●Grade II – Hematoma: subcapsular 10 to 50 percent surface area; intraparenchymal 50 percent of surface area or ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding. Laceration >3 cm in depth.
●Grade IV – Laceration: parenchymal disruption involving 25 to 75 percent of a hepatic lobe, or 1 to 3 Couinaud segments.
●Grade V – Laceration: parenchymal disruption of >75 percent of a hepatic lobe, >3 Couinaud segments within a single lobe. Vascular: juxtahepatic venous injuries (retrohepatic vena cava, central major hepatic veins).
●Grade VI – Hepatic avulsion.
(Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207:646).

Case #091

PG Case 91
A 55 year old man presented with a 2 weeks history of fever, chills and RUQ pain .inflammatory markers were elevated, USS Abdomen was performed and showed Gallbladder perforation. He went on to have a procedure under radiological guidance. Name the device on his abdomen and what did he have done?

This is a cholecystectomy drain, placed under ultrasound guidance into the gallbladder lumen. 25mls of thick purulent abscess were drained in the first instance and another 30mls the next day. Pt reported marked improvement in his overall condition. He was also started on IV tazocin and metronidazole. Cholecystostomy is often used as a temporizing measure in critically ill patients with acute cholecystitis who cannot undergo cholecystectomy. After the symptoms resolve and the patient’s condition is stabilized, definitive treatment is still cholecystectomy. In acalculous cholecystitis, percutaneous drainage may be the only treatment required.

Case #090

PG Case 90.doc
A long term patient with special needs is admitted on the surgical ward and is getting enteral nutrition through a nasogastric feeding tube. He pulled the tube out in the afternoon which was replaced and a chest X ray requested by the team. You get a bleep on call from the ward to review the X ray so that the feed can be re started. An X ray from one week ago is given for comparison. Is it ok to start the enteral feed?

The latest X ray which is shown on the right reveals that the feeding tube is curled in the left upper thorax. Starting the feed in this case will have disastrous effects in causing the patient aspiration pneumonia and its associated complications. The chest X ray from a week ago shows the correct position in which the tube should be before the feeding is recommenced. It is projected below the diaphragm and within the gas in the stomach.

Case #089

PG Case 89
58 year old patient presented with bleeding PR. Pathology was discovered on colonoscopy for which he had to undergo a sigmoid colectomy. Can you appreciate the dual pathology in this specimen?

This is a picture of a fresh specimen of a sigmoid colectomy. It has been opened at one end to show an ulcerated lesion and just besides it is a pedunculated polyp. The biopsy from the ulcerated lesion revealed it to be an invasive adenocarcinoma whereas the polyp was a tubulovillous adenoma with low grade dysplasia. During the colonoscopy the ulcerated lesion was initially missed as the polyp was completely prolapsing over it. It was picked up during the attempt to snare the polyp. As the lesion looked malignant, polypectomy was not done and the patient eventually had a sigmoid colectomy.

Case #088

PG Case 88
64 year old patient presented with complaint of dysphagia to both solids and liquids. One of the radiological investigations carried out during his work up is shown. Can you identify what investigation is this and can you appreciate the findings?

A barium swallow was done for the patient, the pictures of which are shown. It reveals a distal oesophageal stricture and a large rolling hiatus hernia. Barium swallow gives the location, length, diameter of the stricture and can suggest about the surface of the oesophageal mucosa. It will complement the findings on endoscopy.
The etiology of Oesophageal stricture can be broadly grouped into three categories.
1. Intraluminal causes such as inflammation, fibrosis, neoplasia etc.
2. External compression by mediastinal mass or lymph nodes.
3. Dysfunctional lower oesophageal sphincter or dysfunctional oesophageal peristalsis.

Case #087

PG Case 87

A case of pseudoaneurysm of arch of aorta. Pre and post operative imaging is shown.

Figure 1: Preop CT angiogram demonstrating standard aortic arch anatomy and a pseudoaneurysm on the lesser curve.
Figure 2: Axial view showing the pseudoaneurysm
Figure 3: Centreline image (3D reconstruction) of the aortic arch, again showing standard arch anatomy, and the pseudoaneurysm. The break in the calcium likely responsible for the pseudoaneurysm formation is visible. Distances are shown from the Left Subclavian Artery (LSCA) and the Left Common Carotid (LCCA) showing that the endograft needed to cover the origin of the LSCA.
Figure 4: Postop image showing an excluded aneurysm and an occluded LSCA origin.

Case #086

PG Case 86
What is the finding at the OG junction?

Barrett’s oesophagus approx 6 cm in length (vertically ) from top of segment to the OG-junction.
There is an island of regeneration of squamous cell tissue, sometimes seen when pts are on PPI.
Microscopic intestinal metaplasia could still be detected under these islands of SCC regenration tissues.
The presence of squamous islands should not be equated with regression of Barrett’s oesophagus or with decreased cancer risk.

Case #085

PG Case 85
Case of a Crawford type II Thoraco-Abdominal Aneurysm. Treated with a thoracic tube graft (TEVAR) and debranching of the visceral vessels from the left common iliac (Hybrid procedure). The patient presented 4 years post op with back pain and a collapse.

Figure 1 shows a CT angiogram (Maximum Intensity Projection) view of the graft, the endoleak is visible alongside and the cause is also apparent (minimal overlap between adjacent stents leading to a type III endoleak)
Figure 2 shows a 3D view
Figure 3 shows an axial view with a narrow bridge from the intraluminal contrast to the endoleak.Treatment was a thoracic stent to overlap the stent separation

Case #084

PG Case 84
52 year old patient complained of chest pain, heart burn, acid brash and cough at night especially after he had a large meal before going to bed. He had a chest X ray done. Can you spot the findings?

The PA and lateral views of the chest X ray are shown. They demonstrate a hiatus hernia with part of the stomach in the chest and an air fluid level within the stomach.
A hiatus hernia occurs when part of the stomach prolapses through the oesophageal opening in the diaphragm into the chest. They are usually asymptomatic and discovered incidentally. However they can predispose to gastro-oesophageal reflux. Clinical examination is usually not helpful. Obesity, pregnancy, abdominal ascities etc can predispose to development of a hiatus hernia.
The patient was treated with advice on life style modification including taking small multiple meals rather one large meal, eating last meal 4-6 hours before going to bed and keeping the head end of the bed slightly elevated. He was also advised to take regular PPI to reduce the amount of acid refluxing back into the oesophagus.

Case #083

PG Case 83
A 37 year old man presented to the ED with complaint of severe epigastric pain for 3 days. The pain was brought about after excessive drinking at his friend’s bachelor party. The pain was not relieved despite taking PPIs twice daily prescribed by his GP. It was associated with vomiting and nausea as well. At presentation he was tachycardiac and inflammatory markers were high. Serum amylase was 498. A CT abdomen was done.

The axial and coronal views of the CT show an inflamed pancreas with surrounding fat stranding . The pancreas is not enhancing normally with the contrast. These findings are consistent with a diagnosis of acute pancreatitis.
The diagnosis of acute pancreatitis is based on a raised serum amylase and CT is not always necessary to confirm it on the first day of admission. CT is however considered if the clinical diagnosis is in doubt, like in this gentleman where a perforated duodenal ulcer was also a likely possibility consistent with his history and examination. CT scan is usually considered to look for localized complications of pancreatitis that can arise 3-5 days after the attack. Patients with acute pancreatitis who develop tenderness, abdominal distention, fever and leukocytosis should have a CT abdomen. Those who do not improve with conservative management and manifest acute clinical change should also be imaged since this could herald the development of a complication. Balthazar et al have developed a grading system indicating the severity of pancreatitis on CT. They further developed a CT severity index (CTSI) for acute pancreatitis that combines the grade of pancreatitis with the extent of pancreatic necrosis.

Case #082

PG Case 82
What radiological investigation is shown in the picture. Can you appreciate the findings?

This image is of a PET CT. It shows a hot spot or area of increased FDG uptake in the left lung. An area of increased FDG uptake indicates enhanced metabolism which in turn could be due to inflammation, infection or malignancy. This patient had history of colonic cancer and had a lung nodule on one of his follow up surveillance CTs. Whole body PET CT was done to rule out any other possible metastatic deposits.

Case #081

PG Case 81
74 year old man presented to the ED with complaint of severe lower abdominal pain for one day. On examination he was tachycardiac with tenderness and guarding all over the abdomen but most pronounced in the left iliac fossa. CT abdomen was done. Can you appreciate the finding shown?

The axial CT image reveals free air in the abdomen above the liver, marked by the arrow. Free intraperitoneal air can result from bowel perforation. Keeping in mind the gentleman’s history and examination the most likely source suspected was a perforated sigmoid diverticulum. CT confirmed same and also showed free fluid in the abdomen. The patient was resuscitated with IV fluids and broad spectrum antibiotics. He proceeded on to have laparotomy that night. He had purulent peritonitis and Hartmann’s procedure was done.