This chest radiograph is from a lady who has become progressively breathless. What can you see?
A 54yr old alcoholic presents with history of increasingly erratic behaviour. Subsequently, he could not be woken this morning. Describe his CT.
What elective procedure is being performed here?
What is wrong with this plain film of the abdomen (PFA)?
This is a photograph of a chronic skin lesion in a retired hairdresser with leg swelling. What is the cause?
A puzzle – This 57 year old man has a history of hypertension. What was the cause?
What has caused this bowel to be grossly distended with thin almost transparent walls?
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.
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.
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.
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.
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.
75 year old presently on warfarin and has a valve replacement. He has an ankle injury. Diagnosis?
This is an ankle injury with proximal fibular fracture.
It is treated with an operation “Tight rope”.
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).
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
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
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
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.
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.
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?
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.
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
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
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
Blunt trauma from a football injury. What is the finding on the CT?
CT image on front seat passenger in a road traffic accident. The Patient was hypotensive on arrival. What can you see?
50 year old lady complaining of abdominal pain, vomiting, constipation and distension. This is the coronal view of her CT. Are you concerned?
CT abdomen was performed on the same lady with abnormal position of IUCD. What is the next appropriate step in management?
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?
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?
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.
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?
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.