Category: Abdominal cases

Abdominal #22

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45-year-old female patient:

* Generally unwell with abdominal pain and palpable cervical lymph nodes

Clinical information:

– Newly diagnosed HIV infection with a very low CD4 count of 30 cells/uL
– Generally unwell
– Presents at the emergency department with abdominal pain and palpable cervical lymph nodes

What do you see?

Diagnosis:

Most likely pulmonary and extrapulmonary tuberculosis in an immunocompromised patient with miliary pulmonary lesions, tuberculous colitis and ileitis, and necrotic extrapulmonary adenopathy (cervical and abdominal adenitis)
Microbiological analysis of an excised abdominal node confirmed the presence of Mycobacterium tuberculosis

Treatment:

Ileocaecal resection, tuberculostatic medication, and HAART

Teaching points:

– Be aware of TB in immunocompromised patients
– Cervical nodes are the #1 site of extrapulmonary TB adenopathy and the most common cause of adenopathy worldwide
– Intestinal tuberculosis can mimic inflammatory bowel disease

Abdominal #21

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86-year-old patient:

– With sudden collapse

Clinical information:

– Patient known with infrarenal aortic aneurysm
– Sudden collapse at home
– Transfer to the hospital with ambulance

Axial and coronal slices of an abdominal CT in 2019 show a tortuous abdominal aorta with aneurysmal dilatations and eccentric thrombus. There is a thrombosed saccular component at the level of the aortic bifurcation (arrow)

CT at presentation:

What is the diagnosis?

Diagnosis:

– Ruptured aortic aneurysm
* known infrarenal aortic aneurysm
* massive retroperitoneal hematoma extending into the posterior pararenal and perirenal compartments
* active contrast extravasation
– Point of weakness: saccular aneurysmal component

Teaching points:

– This case did not show a classic sign of pending rupture; however, a clear point of weakness was retrospectively identified (the saccular aneurysmal component at the aortic bifurcation)
– Radiological signs of pending rupture:
* !! High attenuating crescent (= acute haematoma within the mural thrombus or aneurysmal wall)
* Focal discontinuity of intimal calcification and ‘tangential calcium sign’
* ‘Draped aorta sign’, present when
* The posterior aortic wall is unidentifiable as a distinct line
* The posterior aorta follows the contour of the spine on one or both sides
– Reference: CT signs of pending aortic aneurysm rupture, J.P. Heiken, radiologyassistant.nl
https://radiologyassistant.nl/abdomen/aorta/aneurysm-rupture

Abdominal #20

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61-year-old female:
– With elevated ALT, AST, and bilirubin

What do you see?

What do you see?

Wall thickening and enhancement of the gallbladder wall
Mild common bile and intrahepatic duct dilatation
Filling defect within the distal common bile duct

Diagnosis:

Choledocholithiasis

Abdominal #19

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A 79-year-old female patient:
– Presented with abdominal pain, nausea, vomiting
– Previous history of cholecystitis and pancreatitis
– Laboratory findings:
*Elevated C-reactive protein and white blood cell levels

What do you see?

Pneumobilia (arrow)

Cholecystoduodenal fistula (red arrow)
Gastric (blue arrow) and duodenal (green arrow) distension

Gallstone located in the proximal jejunal segment (red arrows)
Gastric distension (blue arrows)

What is your diagnosis?

Gallstone ileus


Abdominal CT images obtained two years earlier show that the gallstone is in the gallbladder (arrows).

Teaching points:

* Gallstone ileus is a cause of mechanical small bowel obstruction that generally affects the elderly and has high mortality. It is a rare complication of chronic cholecystitis. It develops when a gallstone passes through a cholecystoenteric fistula leading to small bowel obstruction.

* Gallstones most commonly become impacted in the distal ileum.

* The classical imaging findings on abdominal radiographs form Rigler triad: pneumobilia, small bowel obstruction, and ectopic radio-opaque gallstone

* CT is the most frequently used imaging modality for the diagnosis as it demonstrates the rim-calcified or total-calcified ectopic gallstone, abnormal gallbladder with air collection, presence of air-fluid level, biliary-enteric fistula, and transition point of small bowel obstruction. However, only a minority of gallstones are calcified. Therefore, they may be overlooked in intestinal lumen, which may result in misdiagnosis. Multiplanar reformatted CT images can be helpful to locate the migration site of the ectopic stones.

* Treatment: Surgery with removal of gallbladder stone is the definitive treatment.

In our case, the patient underwent surgery. Enterotomy with gallstone removal was performed. According to the operation note, the gallstone was located in the jejunum 20 cm distal to the ligament of Treitz.

Abdominal #18

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75-year-old female:
– Day 4 post Whipple procedure
– Ongoing abdominal pain with increased inflammatory markers and slightly increased lactate levels

What do you see?

– Post-operative changes following partial pancreatectomy and duodenojejunostomy (partially shown)
– Prominent mesenteric nodes
– Partially occlusive thrombus of the superior mesenteric vein (best seen on axial slice) extending to a large jejunal branch (seen on coronal slice)

What is the most likely diagnosis?

Partial SMV occlusion as a complication to recent Whipple procedure

Abdominal #17

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Known patient with recently diagnosed poorly differentiated vaginal carcinoma with staging FDG PET/CT study. What is the study showing?

What do you see?

– A hypermetabolic lower vaginal lesion representing the known vaginal neoplasm associated with a larger hypermetabolic uterine body neoplastic lesion suggesting synchronous malignant process
– Multiple hypermetabolic enumerable bilateral lung deposits associated with a single right lower para-tracheal nodal deposit

Abdominal #16

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What do you see on the following images?

Click here to see the answer

TB cervical lymphadenitis

Mild progression in size of multiple necrotic lymph nodes in bilateral supraclavicular, axillary regions, at all anterior and posterior cervical chain (more prominent at right side lower anterior cervical chain)