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

Emergency #12 – Flashcard

31-year-old male:
* With flank pain
* Increased inflammatory parameters
* Decreased kidney function

Why is the right kidney less dense than the left?

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Obstructive kidney stone in the right proximal ureter (arrow) with secondary hydronephrosis

The increased pressure in the collecting system slows the ultrafiltration of urine and causes a slower enhancement of the right kidney in comparison with the left kidney, reflecting the impaired kidney function

Emergency #11 – Long case

23-year-old male:
* HET
* Macroscopic hematuria and blood at urine meatus

What is the most likely diagnosis? What should we do next?

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 X-ray: Bilateral pelvis fractures discontinuity iliopectineal line most clearly left-sided

CT: Bilateral ramus superior/anterior iliac bone and ramus inferior pubic bone
Avulsion fracture symphysis pubis
Fracture sacrum on the right

Look also in soft-tissue setting!

Large hematoma posterior of symphysis pubis around urethra and perineum, lateral around the pelvic floor obturator internus muscles and cranially in the retroperitoneal Retzius space anterior of the bladder

Do a RUG: Retrograde Urethrogram. If intact, followed by CT Cystography

RUG shows contrast extravasation and complete rupture of anterior bulbous part of urethra, grade V isolated anterior injury. However, the rupture might be at the anatomic weak point, the bulbomembranous junction, meaning avulsion of the puboprostatic ligament and stretching of the membranous urethra. There is no contrast above the urogenital diaphragm (level of symphysis pubis). Contrast in the bladder is a residue from the IV contrast given for earlier total body CT.

Goldman classification urethral injury

Anterior urethra = Penile and bulbous part
Posterior urethra = Membranous and prostatic part

  • Type I: stretching the posterior urethra due to disruption of puboprostatic ligaments and hematoma, but urethra is intact
  • Type II: posterior urethral injury above urogenital diaphragm (between ischiopubic rami)
  • Type III: injury to membranous urethra, extending into the proximal bulbous urethra (i.e. with laceration of the urogenital diaphragm), thus contrast extravasation below diaphragm
  • Type IV: bladder base injury involving bladder neck and proximal urethrainternal sphincter is injured, hence the potential for incontinence
  • Type IVa: bladder base injury, not involving bladder neck (cannot be differentiated from type IV radiologically)
  • Type V: anterior urethral injury (isolated)

* In this case, no CT cystography was performed
* Patient was treated conservatively

Emergency #10 – Long case

23-year-old male:
* Blunt force trauma of the abdomen
* Patient is hemodynamically stable

What do you see?

Arterial phase

Venous phase

Arterial phase

Venous phase

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Findings:

* Linear zone of hypodensity through the pancreatic body on both phases
* Surrounding fluid with relatively high-density retroperitoneal AND intraperitoneal

Note that the pancreas may appear normal in 20%-40% of patients when CT is performed within 12 h after trauma
MRCP may be useful to evaluate the integrity of the pancreatic duct

Pancreatic fracture:

* Complete laceration of the pancreatic body: AAST Grade III
* Require surgery within 24h
* Possible complications: fistula, pseudocyst, pancreatitis, abscesses, hemorrhage, pseudo-aneurysm
* Usually, injuries of other organs as well

Treatment in this case: distal pancreatectomy and closing of main pancreatic duct transsection, discharge to hospital in home country after 2 weeks

Emergency #9 – Long case

60-year-old female:
* Known with hypertension
* Acute pain on the chest
* X-ray
* Abnormal?
* Differential Diagnosis: No.

What should we think of and do next?

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Clinically suspect for aortic dissection

What protocol?
Non-enhanced chest CT, followed by CT angiography chest-abdomen

No NECT was made:

Imaging findings and key messages

* Soft tissue surrounding ascending aorta from the root, continuing around the aortic arch and descending aorta
* Between the soft-tissue band and the intraluminal contrast, we see intimal calcifications, these are NOT displaced outwards
* At some spots, there is contrast extravasation in the soft tissue
* No intimal tear or dissection flap is seen
* Slight pericardial effusion

What is the diagnosis?

Click here to see the diagnosis

Aortic intramural hematoma.

Treatment is like an aortic dissection with anti-hypertensive medication. In this case, it is a type A since the mural hematoma is seen proximal to the left subclavian artery, involving the ascending aorta.

Differential Diagnosis

* Thrombosed false lumen in classic aortic dissection: Typically spirals longitudinally around the aorta, whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall

* Aortitis: Typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration

Treatment/Prognosis

* If an intramural haematoma involves the ascending aorta (Stanford A), treatment is surgical to prevent rupture and progression to a classic aortic dissection

* Conservative management is indicated for an intramural haematoma of the descending aorta (Stanford B)
* 77% of intramural haematomas regress at 3 years
* Survival of >90% at 5 years

* Untreated, an intramural haematoma can be life-threatening as it can lead to: aortic rupture, aortic dissection, aortic aneurysm.

Emergency #8 – Long case

83-year-old man with:
* Painful swelling in the right groin
* No fever
* Nausea but no vomiting, difficulty passing stools
* Swelling not reducible

What do you see? Is it an incarcerated inguinal hernia?

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Click here to see the answer

Imaging findings

* Right-sided inguinal hernia with intestines inside
* Mechanical small bowel obstruction proximal of hernia
* Normal enhancement of the bowel wall

No signs of ischemia.

Differential diagnosis

Mechanical small bowel obstruction: Adhesions/bands–volvulus–internal hernia–obstructing tumour/tumoural implants–other hernia’s–congenital or acquired stenosis

Groin swelling: Adenopathy–femoral hernia–psoas abscess–retracted testicle

Management

If no signs of ischemia are present:
* Careful manual reduction attempt
* If not successful: emergency surgery (risk of strangulation)

If signs of ischemia are present:
* Emergency surgery

Key points

Incarceration only means the hernia is not reducible and does not say anything about the content. An incarcerated inguinal hernia can also contain abdominal fat without bowel loops

Incarcerated hernia can turn into strangulated hernia and lead to small bowel obstruction

Carefully inspect the enhancement of the implicated loop of small bowel

Lack of enhancement is an early sign of ischemia (strangulation) and an indication for urgent surgery