Emergency #14 – Flashcard

18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250

What do you see? Perforated appendicitis? What is your diagnosis?

Diagnosis Perforated sigmoid diverticulitis (Hinchey 3 or 4, peritonitis)

> Mesenterial fatty infiltration, free air bubbled outside bowel lumen.
> Also subdiaphragmal free air and free fluid.
> Notice enlarged reactive lymph nodes and peritoneal thickening and enhancement, indicative of peritonitis.
> Patient was operated, free faeces was found in the abdomen.

Hinchey classification of acute diverticulitis:
* Stage 1a: phlegmon
* Stage 1b: diverticulitis with pericolic or mesenteric abscess
* Stage 2: diverticulitis with walled off pelvic abscess
* Stage 3: diverticulitis with generalised purulent peritonitis
* Stage 4: diverticulitis with generalised faecal peritonitis

Abdominal #3 – Long case

A 70-year-old male presents to the Emergency Room with abdominal pain and distention. The patient has a history stage IV non-small cell lung cancer, chronic obstructive pulmonary disease, hypertension, severe dementia and recent deep venous thrombosis. He presents secondary to 2 days of poor appetite, diffuse abdominal pain, abdominal distention, and increasing dyspnea. He reports no bowel movements in last 2 days.

The decision was made to proceed with a CT of the abdomen and pelvis with intravenous and oral contrast. The following study was obtained.

Whats is the most likely diagnosis?

Diagnosis: High-grade small bowel obstruction due to internal hernia with small bowel pneumatosis and small volume pneumoperitoneum.

In cases with bowel obstruction, the radiologist should aim to identify the cause of the obstruction as early surgical reversal may be curative for the patient. One of the uncommon causes of small bowel obstruction includes internal hernias. This is a difficult diagnosis to make, and a few signs are may be useful to help identify it. Firstly, it is important to look at the overall distribution of the bowel loops. In this case, the distended bowel loops are abnormal in position, as they are within the pelvis as well as positioned anterior to the large bowel.

In this case, the duodenojejunal junction and ligament of Treitz are seen to the right of midline and are positioned inferiorly and posteriorly deep pelvis along the peritoneal reflection. In this case, the low position of the bowel loops may be due to a defect in the sigmoid mesocolon which would make the rare diagnosis of a sigmoid mesocolon hernia.

Most importantly are the ancillary features which make this case a surgical emergency. Firstly, pneumatosis intestinalis is seen within the small bowel wall:

Using the lung window, we are also able to notice subtle pneumoperitoneum:

In cases with suspected bowel ischemia, it is important to additionally look for gas within the portal venous system, which in this case was not present.

Due to multiple comorbidities, and upon further consultation with family and the patient, the decision was made not to operate and undergo conservative management.

Musculoskeletal #3 – Long case

Axial CT abdomen bone window

Axial CT abdomen soft tissue window

Where is the lesion?

Left iliac bone

What are the radiological characteristics/findings?

Large lytic lesion with wide zone of transition, cortical destruction, and large soft tissue component.
No specific matrix.

What is the differential diagnosis of an aggressive iliac bone lesion?

* Metastasis
* Plasmacytoma: solitary plasma cell tumor expansile lytic lesion with bone destruction and soft tissue component. Usually shows low signal intensity on T2 with variable post contrast enhancement. 
* Chondrosarcoma: malignant cartilage tumor destructive lytic lesion with intralesional rings and arcs calcification (chondroid matrix). High signal intensity on T2. 

What is the most likely diagnosis?

Plasmacytoma

Abdominal #2 – Long case

We present the case of a 31-year-old woman with:
* Nausea and vomiting since three days
* Unable to eat or drink without vomiting
* Epigastric pain after eating
* Feels weak

* No prior trauma or illness
* No fever, no diarreha, no hematemesis or bloody stools
* No other family members ill

See below the laboratory findings:

What do you think?

Click here to see the answer

Signs of dehydration with secondary acute renal impairment and electrolyte disorders

Abdominals X-Ray were performed:

What do you see on the X-Rays?

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Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border

Air – fluid level at the right upper quadrant: free air?
Absense of gastric air and fluid-air level
Colonic air at the right upper quadrant (Chilaiditi)

Apparent soft tissue mass at the right upper quadrant

Elongated right liver lobe (Riedel lobe)
Instability of the symphysis pubis

Summary

* Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border
* Air – fluid level at the right upper quadrant: free air?
* Colonic air at the right upper quadrant (Chilaiditi)
* Apparent soft tissue mass at the right upper quadrant

* No apparent dilated bowel loops
* Elongated right liver lobe (Riedel lobe)
* Instability of the symphysis pubis

Differential diagnosis of a large amount of air in the RUQ

* Pneumoperitoneum
* Subphrenic abscess
* Hepatic abscess
* Anterior interposition of colon to the liver

* Loculated pneumothorax (mimick)
* Situs inversus – gastric air (mimick)
* Pneumobilia, portal venous gas (smaller amount)

Images from an abdominal CT-scan:

What do you see on the CT images?

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Anterior defect in the right hemidiaphragm

Partial herniation of stomach (blue arrow) and transverse colon (green arrow)

Gastric outlet obstruction due to compression of the pyloric region (red arrow),with secundary dilatation with fluid (blue arrows)

Normal position of the gastro-esophageal junction and hiatus

Collapse of the right middle lobe (green arrow) and partial collapse of the right lower lobe (blue arrow).

Summary

* Anterior defect in the right hemidiaphragm
* Partial herniation of stomach and transverse colon
* Gastric outlet obstruction due to compression of the pyloric region of the stomach, with secundary dilatation with fluid
* Normal position of the gastro-esophageal junction and hiatus
* No signs of ischemia
* Collapse of the right middle lobe and partial collapse of the right lower lobe.

What is the most likely diagnosis?

Click here to see the answer

Morgagni hernia of the diaphragm

Patient had a laparoscopic reduction of the hernia with mesh closure of the defect. No signs of ischemia at surgery.
Uneventful recovery with resolution of pain and normal intake the day after.

Morgagni hernia

* Rare congenital diaphragmatic hernia (<5% of all CDH)
* Anterior (retrosternal)
* Right-sided (90%)
* Usually small
* +/- 30% symptomatic: respiratory distress (newborn), recurrent chest infections, abdominal symptoms
* Contents: omental fat, transverse colon (60%), stomach (12%)

* Treatment: surgical repair
> In symptomatic cases, some say also in asymptomatic cases: prevention of strangulation of hernia contents
*Prognosis: good

* Differential diagnosis:
> Traumatic diaphragmatic rupture
> Diaphragmatic eventration / weakness / paralysis (abnormal contour / position of the dome)
> Cardiophrenic angle lesions ( pericardial fat pad, cyst, lipomatosis, tumor)