Category: Abdominal cases

Abdominal #2 – Long case

~ EDiR Holders - Dr. Czarniecki; Dr. Ghoneim; Dr. Gümeler; Dr. van Hoyweghen; Dr. Pons; Dr. Tolman ~ Leave a comment

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?

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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?

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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)

Abdominal #1 – Long case

~ EDiR Holders - Dr. Czarniecki; Dr. Ghoneim; Dr. Gümeler; Dr. van Hoyweghen; Dr. Pons; Dr. Tolman ~ 3 Comments

A 47-year-old female presented to the Emergency Room with bilateral upper extremity paresthesia, redness and edema. Her symptoms were not position-dependent. The patient was otherwise healthy, and did not take any medication. There is no pertinent surgical history.

An MR angiogram was ordered. The following images were obtained during bolus tracking:

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Coronal MRV

MRA

T1-weighted images with fat saturation, following contrast administration


Click here to see the diagnosis

Diagnosis:

Superior vena cava (SVC) syndrome from right apical lung mass

Discussion:

In this patient with bilateral neurological deficits and edema, the suspicion of SVC syndrome must be addressed. This can be done using either an MRI or a CT protocol. In this case, the MRI scout bolus images (Image 1 & 2) revealed a pathognomonic sign for SVC occlusion:

Please note the marked collateral circulation following contrast administration to the right upper extremity with dilation of multiple intercostal and lateral thoracic veins. These collateral vessels then pool into the liver’s quadrate (segment 4 of the liver), giving the characteristic “hot spot sign”. This name originates from terminology in nuclear medicine, where it was occasionally seen in the case of SVC syndrome. Nowadays, it is more likely to be noticed on a CT or MR. This image also reveals the complete occlusion of the SVC.

Following fat-saturated T1-weighted axial image acquisition with contrast, the cause of the obstruction is evident. There is an infiltrative right apical mass which obstructs the SVC, as well as bilateral pleural effusions. Additionally, there is tumor thrombus noted in the left innominate vein, likely secondary to stasis.

Please review the following video and identify all these pertinent findings: