Abdominal #2 – Long case

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)

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

Neuroradiology #11 – Long case

47-year-old male:
* Presented with epistaxis

Axial & coronal CT+C

Where is the lesion?

The bulk of the tumour is within the ethmoid sinuses extending inferiorly into the nasal cavity and superiorly into the intracranial cavity through the cribriform plates

What is the lesion like?

Enhancing soft-tissue tumor expanding the ethmoid sinuses and nasal cavity

T2, T1 and T1+C

What are the MRI signal characteristics?

Mixed signal intensity on T2, low signal on T1, and intense enhancement on post-contrast images

What is the differential diagnosis of paranasal sinus tumour?

* Olfactory neuroblastoma:  involves the ethmoid sinuses  and extends through the cribriform plate into the anterior cranial fossa. Usually, shows intense enhancement and may show calcifications. They are slow growing with sinus expansion

* Juvenile angiofibroma: benign locally aggressive vascular  tumor that affects adolescents. It is usually lobulated and expands the sphenopalatine foramen. Intense enhancement on post-contrast images

* Sinonasal carcinoma: heterogeneously enhancing mass that erodes the bone and may extend into the orbits or intracranially

* Lymphoma: low T2 signal with intense contrast enhancement and usually expands the bone

Diagnosis:Olfactory neuroblastoma