* Since 1 day periumbilical pain radiating to RLQ.
* CRP 75, leucocytes 18.000.
What do you see? Appendicitis? Diverticulitis?
* With flank pain
* Increased inflammatory parameters
* Decreased kidney function
Why is the right kidney less dense than the left?
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
* Macroscopic hematuria and blood at urine meatus
What is the most likely diagnosis? What should we do next?
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
* In this case, no CT cystography was performed
* Patient was treated conservatively
* Blunt force trauma of the abdomen
* Patient is hemodynamically stable
What do you see?
* 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
* 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
* Known with hypertension
* Acute pain on the chest
* Differential Diagnosis: No.
What should we think of and do next?
Clinically suspect for aortic dissection
Non-enhanced chest CT, followed by CT angiography chest-abdomen
* 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?
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.
* 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
* 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.
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?
* Right-sided inguinal hernia with intestines inside
* Mechanical small bowel obstruction proximal of hernia
* Normal enhancement of the bowel wall
No signs of ischemia.
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
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
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
* High-energy trauma (HET)
* Car vs. car
What do you see?
* Complex transverse and longitudinal type petrous temporal bone fracture.
* Involvement of inner ear (cochlea, posterior semicircular canal) round window and facial canal.
* Fracture through middle ear ossicular chain (malleolus and incus).
* Soft tissue in middle ear and filled mastoid air cells.
* Some free air bubbles intracranial (pneumocephalus).
* Fracture continuation (not shown here) in temporal, occipital and parietal bone, occipital condyles.
* Sensory and conductive hearing loss
* Facial nerve involvement
Teaching point: Beware of fracture through carotid canal (not shown here), indication to perform additional CTA to look for carotid dissection
Teaching point: Beware of rupture of tegmen tympani, for late complication CSF leakage otorrhoea, with probable CSF hypotension.
A 42-year-old woman, out of hospital cardiac arrest.
What do you see?
54-year-old male. Worsening pain and trouble with swallowing since day 1. High inflammatory parameters. Foreign body?
* Known with uterus myomatosus
* Pregnant 8 weeks
Presents in the ER with vaginal blood loss. Sky high beta-HCG. The gynaecologist could not find a pregnancy with abdominal or endo-vaginal ultrasound.
Is it an ectopic pregnancy?