PGCases161-200

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Case #200

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This chest radiograph is from a lady who has become progressively breathless. What can you see?

There are two primary things to recognise: –
1. A right-sided pleural effusion causing her breathlessness.
2. A portacath.


Case #199

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A 54yr old alcoholic presents with history of increasingly erratic behaviour. Subsequently, he could not be woken this morning. Describe his CT.

• Left subdural haematoma
• Contusion left temporal lobe
• Midline shift
• Compression of lateral ventricles


Case #198

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What elective procedure is being performed here?

The surgeon is injecting saline into a ’tissue expander’ placed under the subcutaneous tissue’ following mastectomy.
This is a method of breast reconstruction performed prior to implant insertion.


Case #197

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What is wrong with this plain film of the abdomen (PFA)?

• There is gross dilatation of the small bowel.
• It can be identified as small bowel by the plicae circulares seen transversing the circumference of the bowel loop.
• Furthermore, there is no gas in the rectum.
• This picture is consistent with small bowel obstruction.


Case #196

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This is a photograph of a chronic skin lesion in a retired hairdresser with leg swelling. What is the cause?

The photograph shows a typical venous ulcer on the lower limb of this patient, classically located superior & posterior to the medial malleolus in the ‘gaiter’ region.
This is in comparison with arterial ulcers which are classically located over the lateral malleolus.


Case #195

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A puzzle – This 57 year old man has a history of hypertension. What was the cause?

Answer: Renal artery stenosis.
You can visualise a stent in the left renal artery.
You can see quite marked calcification of this man’s external iliac arteries.
With this degree of calcification of his large arteries, he certainly has stenosis of his smaller vessels putting him at further risk of hypertension.


Case #194

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What has caused this bowel to be grossly distended with thin almost transparent walls?

A Sigmoid Volvulus.
A redundant sigmoid on a long mesentery may result from years of chronic constipation and laxative use. It is particularly found in long-stay chronic patients and those on psychotropic or sedative agents.
If the patient is stable with no signs of sepsis, the first line treatment is an attempted colonic decompression using a colonoscope. When decompressed the bowel often recovers its anatomical position.



Case #193


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What does this cholangiogram demonstrate?

• Contrast is seen flowing from the catheter tip into the cystic duct into the common bile duct (CBD) and then into the duodenum.
• An opacity can be seen at the distal end of the CBD.
• A stent can be seen skirting the opacity and curling into the duodenum.


Case #192


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What can you see?

• This barium enema shows a distinct ‘apple-core’ lesion.
• This can be seen in the bottom left hand corner of the film and is level to that of the sigmoid colon.
• One can imagine that the circumferential growth which resulted in this ‘apple-core’ effect is progressively narrowing the lumen of this man’s colon. It will be a only a matter of time before it completely obstructs the lumen.


Case #191


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What is wrong with this chest x-ray?

• A chest drain is located in the completely wrong position on the right side.
• The drain has been placed dangerously low between the 8th and 9th rib.
• This risks serious damage to the liver. However in this case, the drain introduced with a pointed introducer has penetrated the base of the lung, skirted the diaphragm, and its tip lies in the para vertebral space between the Aorta and the Inferior Vena Cava.


Case #190


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What has happened this patient? Diagnosis?

Diagnosis: Subungual haematoma.
Differential diagnosis: If it is not a trauma injury ensure it is not a melanoma.

Treatment: Decompression with a needle.

What you need to exclude: An underlying fracture.
What you should organise: An x-ray.


Case #189


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This x-ray was taken from a 42 year old man who just had just arrived on an international flight. What do you see?

• There are regularly shaped radiopacities within the gastrointestinal tract.
• The represent 34 drugs packages swallowed by the patient in order to smuggle drugs.

They have two important complications
1. Rupture: These packages are well wrapped and classified as “type IV” – Dense cocaine paste is placed into a device, condensed and hardened. This is then packaged in tough tubular latex and is then covered with coloured paraffin or fibreglass. There is no official antidote to cocaine, mortality can be 60%.
2. Small bowel obstruction: As you can see the packages are sizable and can cause small bowel obstruction, particularly at the terminal ileum.


Case #188


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75 year old presently on warfarin and has a valve replacement. He has an ankle injury. Diagnosis?

Maissoneuve fracture.
This is an ankle injury with proximal fibular fracture.
It is treated with an operation “Tight rope”.


Case #187


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This man complains of tender swelling in the right groin? Should you be concerned?

• You may need to be concerned regarding a strangulated hernia. Particularly, if the patient presents with vomiting &/or obstruction.
• This is compounded by the fact he has a scar over the right groin which suggests a previous operation (incisional).


Case #186


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This is the KUB/PFA of a 64 yr old gentleman. It is clearly abnormal.
To begin with, in the past he has been operated on by a general surgeon.
What operation have they performed?
What are the foreign bodies seen?

He has a number of staples in the pelvis. This tells us that he has had surgery at this level. This may have been for malignant or benign (e.g. diverticulitis) disease.
What are the foreign bodies seen?
You can see a stent running from the right renal hilum to the bladder
This was obviously placed to allow free drainage of urine past an obstruction which may have been causing hydronephrosis
However there are two other ‘stents’, both leaving the renal hila but neither going to the bladder


Case #185


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This patient has a painless swelling in midline when he coughs. No previous surgery. Diagnosis?

Divarication of recti.
• Gap between rectus abdominis muscles from stretching of linea alba.
• Must be differentiated from abdominal hernia.
• Commonly occurs in pregnancy, newborn babies and it can also occur in men.
• No treatment is necessary. Abdominoplasty can be performed for cosmetic reasons


Case #184


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This 38 yr old man was refused entry to a nightclub for having too much to drink.
Last night while walking away he fell and passed out for 1-2minutes.
He was found by his wife unconscious on the sofa this morning.
Describe the CT.

Right temporal extradural haematoma
Compression of lateral ventricle
Midline shift


Case #183


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Describe the procedure below and what important steps must be performed before closing.

Laparotomy and small bowel enterotomy for removal of gallstone ileus.

• The small bowel enterotomy will be closed primarily and it’s important to explore the whole of small bowel for additional stones.


Case #182


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80 year old woman presented with bilious vomiting and evidence on PFA of small bowel obstruction. What can you see in her CT abdomen?

A large gallstone in jejunum.

• Another common site of gallstone ileus would be terminal ileum.
• Rigler’s triad.
• Lower abdominal/pelvic calcification.
• Small bowel obstruction/gastric dilatation.
• Pneumobilia.


Case #181


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This patient presents having landed clumsily following a rugby tackle. What is wrong with his finger?

This is a mallet finger. Injury to the extensor tendon of the terminal phalanx from a forcible rupture .The patient is unable to actively straighten at the terminal interphalangeal joint. This means that the affected finger is bent at the TIP joint when all the fingers are extended. The affected joint can be passively straightened.

What is the conservative management?
6 weeks splintage with the proximal interphalangeal joint flexed and the distal joint extended. This allows the tendon to reattach.

What is the operative management?
K-wiring fixation.


Case #180


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This lesion has been present for 18 months
However it has swollen and become painful with a cheesy discharge over the past 3 days.
What is it?

The photo demonstrates an infected sebaceous cyst on this gentleman’s back.
A sebaceous cyst is a benign swelling which lies under the skin and is filled with sebum.

Upon examination the skin is immovable over the cyst and tightly adherent to it. Is this expected?
Yes it is expected as the sebaceous cyst lies within the skin itself.

What causes them?
Sebaceous cysts are caused by blockage of a sweat gland (sebaceous gland).

How are they treated?
They must be resected (if symptomatic) with that part of skin containing the sweat gland. If complicated by infection the patient is also treated with antibiotics.


Case #179


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An 88 year old woman presented with a two day history of coffee ground vomiting, epigastric pain.
Epigastric distension was observed and mild tenderness to palpation was noted in the upper abdomen, but without signs of peritonism.

The classical radiologic diagnosis comprises Rigler’s triad of gastric or small bowel dilatation with pneumobilia and an intra-intestinal gallstone on computed tomography


Case #178


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The photo demonstrates so called ‘trash foot’.
What causes this so-called trash foot?

This condition results from microemboli being liberated and travelling to their most distal point, in this case the digital arteries of the foot.
How does this liberation result?
•Cardiac esp bypasses, catherisation, arrhthymias or valvular disease
•Aneurysms in peripheral vessels
•Aneurysm repair
What is generally the outcome?
Some cases resolve with minimal residual damage however some patients will eventually require amputation of the worst affected areas.
Anticoagulation at the time of insult eg IV heparin can help, however the technique of embolisation is often impossible to use in these cases where the arteries are too small to permit use of a balloon used to remove clot


Case #177


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Blunt trauma from a football injury. What is the finding on the CT?

• Splenic laceration grade 3 with haematoma.


Case #176


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CT image on front seat passenger in a road traffic accident. The Patient was hypotensive on arrival. What can you see?

• Patient was resuscitated and transferred to the Liver unit. She was treated conservatively and remained stable.
• Nonoperative management of both low and high-grade injuries can be successful in hemodynamically stable patients.
• The main indication of the operative approach to the blunt liver injury is hemodynamic instability, not the grading of the injury.


Case #175


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50 year old lady complaining of abdominal pain, vomiting, constipation and distension. This is the coronal view of her CT. Are you concerned?

• The caecum is almost 12 cm which indicates a high risk for perforation. The distension however goes all the way in the large bowel down to rectum. So this is most likely pseudo-obstruction.


Case #174


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CT abdomen was performed on the same lady with abnormal position of IUCD. What is the next appropriate step in management?

• The CT abdomen showed IUCD has migrated into the intra-abdominal cavity with perforation of uterus.
• Laparoscopic retrieval of the device would be the best option.

Case #173

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30 year old lady presents to her GP with left hip/LIF pain. The GP sent her for some x-rays. Any abnormality?

Abnormal position of IUCD. This was inserted apparently 6 years ago. Possible causes of abnormal position of IUCD would be large fibroids distorting the shape of her uterus or migration of the device.

Case #172

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This is CT abdomen performed on a patient 2 days post RIG insertion. What can you see?

RIG or radiological inserted gastrostomy is a percutaneous tube for feeding (in this case patient is high risk of aspiration).
• In this patient, she was vomiting and complaining of diffuse abdominal pain 2 days post RIG insertion.
• The CT abdomen showed free intraperitoneal air and migration of the catheter into the duodenum caused by the breakdown of the gastropexy suture.
• The patient was treated conservatively and repositioning of the Rig under fluoroscopy guidance.

Case #171

PG Cases 12.01.16
This intubated ICU patient developed hypotension and respiratory failure post central line insertion. What is the diagnosis?

Tension pneumothorax.
• Pneumothorax can be seen following central venous line insertion.
• Other complications include: –
– Air Embolism.
– Central line infection.
– Venous thrombosis/deep vein thrombosis.
– Misplacement (carotid, common femoral artery etc).
– Haemorrhage and formation of a hematoma is slightly (more common in jugular venous lines).

Case #170

PG Cases 08.01.16
Following ERCP one week later, the pancreatitis patient is still complaining of severe abdominal pain and distention, comment on the pancreas image?

• Oedema of the pancreas and peripancreatic fluid and fluid in lesser sac. There was no pancreatic necrosis.
• The patient was treated conservatively with antibiotics (meropenem) and TPN.
• After the ERCP, he was commenced on an oral diet and after consultation with hepatobiliary unit in St Vincent’s. The patient was also booked for a laparoscopic cholecystectomy

Case #169

PG Cases 06.01.2016
This is the same CT abdomen of the of what thought to be alcoholic pancreatitis, There is oedema of the distal CBD in the region of the sphincter of Oddi where a small calculus measuring approximately 3 mm is seen. What is the next step in management?

ERCP.
• Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat biliary obstruction including gallstones.
• After sphincterotomy the stones are removed with balloon trawl.
• Risks include pancreatitis, intestinal perforation, bleeding, ascending infection, allergy to contrast and oversedation.

Case #168

PG Cases 17.12.2015
This CT abdomen was done on a 55yo male who was thought to have alcohol induced pancreatitis. What can you see?

• There are multiple gallstones in a distended gallbladder. Also the CBD was dilated to 2.1cm with an obstructed stone at the distal CBD.
• Therefore his diagnosis was revised to gallstone induced pancreatitis.

Case #167

PG Cases 15.12.2015
89 year old lady c/o shortness of breath and dizziness with systolic BP of 78. Can you spot the finding in her CXR?

A large retrocardiac hiatus hernia.• The HH has escaped into her mediastinum causing external obstruction to her venous return in turn causing her dizziness. It has air fluid level but subsequently she had CT Thorax and Abdomen showing empty stomach indicating no obstruction.
• She has been referred to an upper GI specialist for opinion but managed conservatively at present.

Case #166

New Picture (1)
Maggot therapy result on a large left shin haematoma.

• This large wound from a haematoma on the left shin was managed by a tissue viability team and was deemed suitable for prescribing maggot therapy. However not all wounds are suitable. A moist, exudating wound with sufficient oxygen supply is a prerequisite.
• Maggot therapy works by 4 principles: Debridement, Disinfection of the wound, Stimulation of healing, Biofilm inhibition and eradication.
• The appearance of a wound’s surface is typically increased with the use of maggots due to the undebrided surface not revealing the actual underlying size of the wound. They derive nutrients through a process known as “extracorporeal digestion” by secreting a broad spectrum of proteolytic enzymes that liquefy necrotic tissue, and absorb the semi-liquid result within a few days. In an optimum wound environment maggots molt twice, increasing in length from 1–2 mm to 8–10 mm, and in girth, within a period of 48-72 hours by ingesting necrotic tissue, leaving a clean wound free of necrotic tissue when they are removed.
• In vitro studies have shown that maggots inhibit and destroy a wide range of pathogenic bacteria including methicillin-resistant Staphylococcus aureus (MRSA), group A and B streptococci, and Gram-positive aerobic and anaerobic strains.

Case #165

PG Cases 03.12.15
Describe the findings of the image below and what would be the primary concern(s) here?

• Severe left shin haematoma.
• This patient was transferred from a nursing home after hitting her left leg at the edge of the bed whilst mobilising in her room. She is on warfarin for atrial fibrillation and her INR was 2.3
• The immediate concern here would be ongoing bleeding into the soft tissue and may cause her to develop compartment syndrome.
• Her distal pulses however was present and she was brought to theatre the following day for evacuation of the haematoma. There was no active bleeding seen.
• She was then put on compression dressing and will be reviewed daily particularly due to the state of her skin and the need for referral to the plastics team.

Case #164

PGCase 02.12.15.png
These are the CT abdomen of two female both in 60’s who are known to have diverticular disease on previous colonoscopies. The duration of the symptoms were similar, both complaining of alternating bowel habit and LIF pain for approx 12-14 days. But the CT abdomen images were completely different, resulting in contrasting way they were managed. Can you explain the images?

• Image A showed florid sigmoid diverticular disease but minimal fat stranding and no evidence of complicated diverticulitis.
• Image B however showed free fluid in the pelvis with stranding of the intra-abdominal fat in the pelvis, diverticulae of the sigmoid with wall thickening of the sigmoid, and surrounding fluid collections with air, compatible with perforation and abscesses formation ( Hinchey 3).
• Whilst patient A only needed antibiotics , pt B will need intervention, with either radiological drainage of the abscess or laparoscopic washout with possibility of Hartman’s procedure.
• Hence CT Abdomen is warranted in suspected diverticulitis to rule out complications ( and to stage complicated diverticular disease) as it will effect the treatment and management.
• The Hinchey staging system for complicated diverticular disease has four stages , Hinchey 1 being the least severe (paracolic abscess) and 4 the most severe with faecal peritonitis from perforated diverticular disease.

Case #163

PGCase 01.12.15
73 YO MALE BG MALIGNANT MELANOMA LEFT CHEEK WITH LOCAL LN METS 2014 – TREATED WITH NECK DISSECTION, RADIOTHERAPHY AND INTERFERON. C/O ABDOMINAL PAIN OVER PAST 6/12 – SIGNIFICANT WEIGHT LOSS, AND INCREASE IN ABDOMINAL GIRTH

• CT Abdomen shows large volume ascites and extensive mesenteric, omental and peritoneal carcinomatosis extending into the lower abdomen. Large ill-defined confluent mesenteric mass measuring 14.7 x 9.2 x 9 centimetres.

• These findings are most likely from metastasis of the known melanoma. The patient had USS guided biopsy of the mass and immunochemistry staining was positive for Melan A, the melanocyte marker and histological features are of metastatic malignant melanoma.

• Malignant melanoma are known to be able to metastasise anywhere but head and neck melanomas have predilections to metastasise to atypical sites such as spleen, GI, pancrease, subcutaneous tissue , non-liver, adrenal, bone, or lymph node.

Case #162

PGCase 07.10.15

This is the PFA of a 61year old lady c/o vomiting, abdominal distention and cramps. She had a small bowel resection 30 years ago from Crohn’s. What is the diagnosis?

Small bowel obstruction. The PFA showed 3 dilated loops of small bowel in the LIF. These typically showed stacked coin appearance and volvular connivantes traversing the diameter of the small bowel. Top differential would be SBO from adhesions but exacerbation of her Crohn’s and incarcerated femoral hernia needs to be ruled out.

Case #161

PG case 05.10.15

This patient has a history of bowel cancer. 5 years later, after a routine follow-up surveillance CT TAP he needed this procedure. Explain?

CT Guided lung biopsy for a suspicious nodule/mets

• This pt was found to have a suspicious nodule for metastasis on surveillance CT.
• Procedure was performed using Chiba/green needle pairing and an FNA was attempted.
• Post procedure CT demonstrated a small pneumothorax and is a normal finding post biopsy.
• CXR was performed 3 hours post biopsy and the pneumothorax did not progress. Cliically he was well and subsequently discharged. The sample was sent to the lab and will be discussed at the oncology MDM.