Abdominal #9 – Flashcard

31-year-old male with:

* Right upper quadrant & epigastric pain
* History of gastric bypass surgery

What aquatic sign is used for the finding in the red circle?

Whirlpool sign

What is shown at the blue arrow?

The transition point from dilated small bowel (with the “small bowel feces sign”) to non-dilated small bowel at the site of internal herniation through a mesenteric defect.

Abdominal #8 – Long case

76-year-old male.
* Presents with acute abdominal pain, enlarged abdomen and no defaecation since a few days.

What do you see?

Abdominal CT scan shows dilated colon loops with a calibre change in the sigmoid. Whirl of mesenterial vessels.

Differential diagnosis is Sigmoid volvulus. This was confirmed on OR.

Sigmoid volvulus is differentiated from a cecal volvulus by its ahaustral wall and the lower end pointing to the pelvis.

Abdominal radiographs will show a large, dilated loop of the colon, often with a few gas-fluid levels. Specific signs include coffee bean sign and absent rectal gas.

CT scan will show large gas-filled loop lacking haustra, forming a closed-loop obstruction. Specific signs include:
– whirl sign: twisting of the mesentery and mesenteric vessels
– bird’s beak sign: if rectal contrast has been administered
– X-marks-the-spot sign: crossing loops of bowel at the site of the transition
– split wall sign: mesenteric fat seen indenting or invaginating the wall of the bowel

Rectal tube insertion for treatment is successful in treating 90% of cases. Occasionally patients suffer from recurrent sigmoid volvulus, for which a surgeon may consider sigmoid colopexy (surgical fixation of the sigmoid colon), or in the surgically unfit, a percutaneous endoscopic colostomy (PEC) might be performed. The mortality rate of sigmoid volvulus is 20-25%. The most serious complication is bowel ischemia, not blow-out perforation as you might expect.

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.


Abdominal #6 – Long case

56-year-old male:

* Presents with diffuse chronic pain in the abdomen
* Decreased kidney function

A CT is performed:

CT abdomen with IV contrast

What do you see?

Diffuse hypodense solid tissue around the pancreas, compression splenic vein with inhomogeneous attenuation of the splenic parenchyma. Soft tissue manchet around the infrarenal abdominal aorta, compressing the aorta to the spine and continuing around the iliac vessels. No separate lymph nodes can be seen. Right hydronephrosis and hydro-ureter, right kidney shows edematous swelling . Both kidneys show heterogeneous cortical enhancement.

What is the most likely diagnosis?

Right hydronephrosis and hydro-urter, pancreatitis and nephritis.

Differential diagnosis includes:
Retroperitoneal fibrosis (Ormond disease) or auto-immune mediated IgG-4 disease

CT-guided retroperitoneal biopsy was performed.

Pathology report: Fibrous tissue with chronic inflammation. Not enough signs of IgG-4 mediated disease.


Abdominal #5 – Long case

88-years-old female:
* Presents with acute abdominal pain and pain the right groin
* On clinical examination mass in the right groin
* Slightly elevated inflammatory parameters. Continue on next slide for coronal views.

What do you see?

Right-sided obstructed inguinal herniation with small bowel trapped. Mechanic small bowel ileus. As a coincidence Meckel’s diverticulum (not herniated). Engorgement mesentery but still normal enhancing bowel walls, no direct signs of bowel ischemia yet.


Abdominal #4 – Long case

27-year-old female:
* No previous history
* Presents with acute kidney insufficiency
* DD glomerulonephritis
* Nephrotic syndrome
* US to exclide post-renal obstruction

US: Bilateral hydronephrosis and hydro-ureter. No obstructing mass or stone visible. Bilateral loss of parenchyma, indicating chronic problem.Mobile bladder stone.

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Patient receives bilateral nephrostomy. On antegrade pyelography no calibre changes or strictures, not proximal or distal. No cause for hydrnephrosis and hydro-ureter bilateral.

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Non-enhanced abdominal CT to evaluate nephrolithiasis. Traction on sigmoid, coecum and small bowel, andalso traction on bladder roof. Consider endometriosis in the differential diagnosis and perform MRI pelvis.

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MRI pelvis. Medialised adnexes. T2 hypo-intense fibrotic plaque centered on uterus very suggestive for deep invasive endometriosis (DIE). Fibrotic changes between uterus and rectum, uterus and bladder and uterus and bowels. No endometrioma cysts. Central in fibrotic area small aircollection with fistula towards anterior fornix (not completely shown here), with small abscess on major labia.

What is the most likely diagnosis?

Diagnosis: Endometriosis

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