Abdominal #7 – Long case

70-year-old female:

* Presents with acute abdominal pain
* Previous history adnex extirpation and appendectomy
* No raised inflammatory parameters
* No peristalsis
* CT abdomen with IV contrast

What do you see?

Click here to see the answer:

Dilated small bowel loops, radiating distribution (“Bunch of grapes”) with impressive mesenterial venous engorgement and edema in the centre. Ascites perihepatic and in Douglas. Loss of bowel enhancement.

What is the most likely diagnosis?

Closed loop obstruction with bowel ischemia.

Teaching point

Seek for 2 (!) calibre changes next to each other to confirm SBO on basis of Closed loop obstruction.

Peroperative 1 meter of necrotic small bowel was resected.


Dr. Pepe’s Diploma Casebook 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

Dear Friends,

Welcome to the new year and a new webinar. The leading images of the webinar six belong to a 73-year-old woman with dyspnea and chest pain. What do you see?

Diagnosis:

1. Intrathoracic goiter
2. Dilated esophagus
3. Aortic aneurysm
4. Any of the above

If you would like to see the previous webinars, check it here!

Click here to see the answer

You can see the webinar here.

Findings: PA radiograph shows widening of the right superior mediastinum (A, arrow), which in the lateral view is located behind the trachea (B, arrows). The initial impression is of an upper middle mediastinal mass. The first diagnosis that come to mind is a goiter.

However, looking downward in the PA view, bulging of the azygo-esophageal line is evident (A, red arrow). In the lateral view there is opacification of the retrocardiac space (B, red arrow). Therefore, we are dealing with a lesion that extends along the middle mediastinum from top to bottom. The findings point to a dilated esophagus.

Esophagogram was unremarkable. Coronal and sagittal CT shows a cystic tubular mass extending along the posterior wall of the esophagus (C-D, arrows).

Final diagnosis: cystic lymphangioma of mediastinum
 
This is a difficult case and I didn’t expect you to make the diagnosis. But I believe that you should have noticed the bulging of the azygo-esophageal line in the PA view and the occupation of the retrocardiac space in the lateral view, suggesting a dilated esophagus as the most likely diagnosis.
 
Congratulations to MG who was the first to see the findings.
 
Teaching point: Remember that an opacity that goes from top to bottom in the middle mediastinum should suggest a dilated esophagus or an esophagus-related process

Cáceres’ Corner Case 218 – SOLVED

Dear Friends,

an easy case to celebrate the new year. PA radiograph of a 36-year-old woman with chest pain.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows a fracture of the right clavicle (A, arrow). A magnified view of the area raises the possibility of a lytic lesion (B, arrow).

Specific low-Kv images of the clavicle were taken, showing a rounded permeative lesion with a pathological fracture (C, arrow. D, circle). No other lesions were demonstrated in a bone scan. Biopsy followed by surgery came back as chondrosarcoma.

Final diagnosis: chondrosarcoma of clavicle with pathological fracture
 
Congratulations to Archanareddyt, who discovered the pathological fracture
 
Teaching point: when evaluating bone lesions of the chest, take specific views. They allow a better interpretation of the pathologic changes

Musculoskeletal #7 – Long case

10-year-old male:

Axial CT brain bone windows

Non-enhanced axial CT brain soft tissue window

Where is the lesion?

Occipital bone within the medullary cavity

What is it like?

Moth-eaten destructive permeative lytic lesion with wide zone of transition.  There is cortical disruption of both the inner and outer table of the skull and a large soft tissue component.

An MRI is performed.
Axial T1Weighted

Axial T2Weighted
Axial Gadolinium enhanced T1Weighted
What does the MRI show?

Destructive bone lesion with a large soft tissue component which is low signal intensity on T1, heterogenous intermediate signal on T2, and heterogeneous intense enhancement in the post contrast image. It causes mass effect on the adjacent brain parenchyma with no gross invasion.

What is the differential diagnosis?

Given the age of the patient the differential diagnosis includes:

* Osteosarcoma: most common primary bone tumor in young adults. Usually involves the metaphyseal regions of long bones but can occur at other sites. Aggressive lesion with sunburst periosteal reaction and calcified osteoid matrix. 

* Ewing's sarcoma: second most common childhood bone tumor. Typically an aggressive permeative tumor which arises within the medullary cavity of the bone and has a large soft tissue component. 

* Metastasis.

What is the most likely diagnosis?

Ewing’s sarcoma

Cáceres’ Corner Case 217 – SOLVED

Dear Friends,

I am showing today PA chest radiographs in two asymptomatic patients They have subtle findings that can be discovered if you paid attention to the previous webinars.

What do you see?

Prof. Cáceres will take some well-deserved holidays and will come back on January 6th with new cases!

Click here to see the answer

Case 1 findings: PA radiograph shows a well-defined opacity behind the cardiac shadow (A, arrow), better seen in the cone-down view (B, arrow). It has an extrapulmonary appearance and the best option is diaphragmatic hernia.

Coronal and sagittal CT demonstrate herniated abdominal fat through a rent in the posterior diaphragm (C-D, arrows).
 
Final diagnosis:Bochdaleck hernia

Case 1 has been diagnosed by most of you. Congratulations to Archanareddyt,
who was the first. Hope my recommendations in Webinar 4 were helpful!


REMEMBER

In the cardiac area look for:

* Opacities behind the left heart
* Double contour on the right

Case 2 findings: This patient has a faint but visible right infraclavicular nodule (A-B, arrows).

The nodule was overlooked and one year later had grown markedly (D, arrow). At surgery, a melanoma was found.
 
Final diagnosis: melanoma of the lung, missed in the initial examination

Teaching point: This is a difficult case, but easily diagnosed if you remember my oft-repeated mantra: “Search for pulmonary nodules in the pulmonary apices” (Webinar 1). Nobody saw the nodule and I feel useless (sniff).

Emergency #17 – Flashcard

40-year-old male:
* Fell off bike at 40 km/h
* Pain left shoulder

> What views of the shoulder in trauma setting should be done?
> Is this in endo- or exorotation?
> Do you need right shoulder to compare with?

Click here to see the images

Right shoulder for comparison

Additional trauma chest X-ray was done.

Differential diagnosis includes:

* AC-luxation
* CC-luxation
* Left pneumothorax
* No rib #

Dr. Pepe’s Diploma Casebook 151 – All you need to know to interpret a chest radiograph – Fifth Session – SOLVED!

Dear Friends,

Showing today the leading case of the next webinar. PA radiograph belongs to an 86-year-old woman with chest pain.
What do you see?

More images will be shown on Wednesday. You can refresh your memory viewing the older webinars on our youtube channel.

Dear Friends, showing today a lateral film of the case. Hope it helps.

Click here to see the lateral film

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the left mid-lung field (A, arrow), better seen in the cone down view (B, arrow). The opacity is ill-defined, and my first impression would be an intrapulmonary lesion.

The lateral view shows that the opacity is located in the posterior chest wall. It has a typical pregnancy sign (C, arrow), indicating an extrapulmonary origin.
Enhanced axial CT confirms a low-density chest wall mass (D, arrow). Note the anterior displacement of the intercostal vessel (D, red arrow).

Final diagnosis: lymphoma of chest wall
 
Congratulations to all of you who diagnosed a chest wall lesion. Special mention to MK, who was the first to give the answer.
 
Teaching point: This case documents the importance of the lateral chest to clarify indeterminate findings in the PA radiograph.

Check the full webinar here