Embed Size (px)
Citation preview
ER potpourri-Film reading panel
Anjali Agrawal, MDConsultant,Teleradiology Solutions
SER 2016, Bangalore
Panelists Dr Raju Sharma Dr Shanmuganathan Dr Dinesh Varma Dr Rathachai Kaewlai Dr Adnan Sheikh
MBBS: Maulana Azad Medical College, New DelhiMD: AIIMS, New DelhiFellowship in GI Radiology: Massachusetts General Hospital, BostonJoined as Assistant Professor, AIIMS in 1993Professor in Dept of Radiology AIIMS, New Delhi since 2008Area of Interest: Abdominal Imaging
RAJU SHARMA, MD, MAMS
Case 1: 64F, abdominal distention, pain, h/o SBO
Axial CT images
Coronal images
15 days ago
15d agoThis lesion is larger compared to the CT 15 days agoDifferential Diagnosis?
7months ago
10 months ago
Case 1: 64F, abdominal distention, pain, h/o SBO
• Multilobulated thick-walled cystic lesion in the lesser sac and extending along the adjacent peritoneal spaces and gastrohepatic ligament. Cystic lesion in the left hemipelvis
• Minimal ascites, omental and mesenteric thickening
Present exam 15 days ago
Increased size
15 days ago Present exam
Case 1 Diagnosis: Recurrent metastatic disease with mucinous ovarian tumor
Clinical clues are useful
Case 2: 45 M with abdominal pain
Courtesy: Francesco Danza, Roman Catholic University
6 months ago
Diagnosis?
Peritoneal carcinomatosis
Thick enhancing membrane around a conglomerate of small bowel loops in the center “cocoon”
Dilated proximal colon
Diagnosed with adenocarcinoma lung 6 months ago
Case 2 Diagnosis: “Cocoon peritonitis”
•AKA sclerosing encapsulating peritonitis•Rare cause of bowel obstruction due to fibrotic encapsulation of the bowel forming a sac or cocoon•May be idiopathic or secondary to chronic peritoneal dialysis, TB, sarcoidosis, GI malignancy, fibrogenic foreign material •Treatment –Surgical removal of the covering membrane
Hong Kong Med J 2012
29M,with abdominal pain, bilious vomiting and constipation x 3d
Courtesy: Subodh Gupta, MS
Histopathology
The cocoon membrane showed proliferation of fibroconnective tissue with granulomas
RATHACHAI KAEWLAI, MD
Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok,Thailand
Subspecialties: Emergency radiology and body imaging
Training: MD – Siriraj Hospital, BKK Residency – Ramathibodi, BKK American Board (Diagnostic Radiology) –
MGH, Boston, USA Clinical Fellowships – MGH (Boston) and
NEOUCOM (Ohio)
Case 1: 38 M with acute onset severe abdominal pain
Cecum in the lesser sac
Diagnosis?
Cecum in the lesser sac
Cecum mildly dilatedCecum in the lesser sac between the liver hilum and IVC
No twist to indicate cecal volvulus
Lesser Sac
Memorangapp.com
Case 1 Diagnosis: Lesser sac hernia with cecal incarceration
Cecum large and distended within the lesser sac
Cecum and bowel viable Cecum and ascending colon
extremely mobile with no lateral attachments
Right colectomy done to prevent recurrence
Surgery:
Lesser sac hernia via the foramen of Winslow
Review of Internal Hernias: Radiographic and Clinical Findings. LC Martin et al. AJR March 2006
Lesser sac hernias comprise 8% of all internal hernias which have a less than 1% overall incidence.
Circumscribed loop posterior and medial to the stomach
Case 2: 12 F with abdominal pain
Follow-up US
Diagnosis?
Case 2: 12 year old female with abdominal pain
Dilated fallopian tube with thickened and enhancing tubal wall
Right ovary Complex
tubular mass
Follow-up US
Normal left ovaryNormal left ovary flow
Diagnosis: Torsion of the left Fallopian tube
Dilated tube with thickened, echogenic walls and absence of vascular flow in the tube
Isolated torsion of the fallopian tube
Rare cause of lower quadrant pain primarily affecting adolescents and ovulating women. Risk factors:PID, tubal ligation, neoplasm, adhesions, gravid uterus and trauma.
Complications include fallopian tube necrosis, an increased risk for superinfection and peritonitis. Local necrosis can also result in irreversible damage to the ipsilateral ovary.
Treatment options include surgical detorsion, salpingotomy, and salpingectomy depending on the stage of intervention and presence of complications.
Companion Case : 32 F with pelvic pain and fever
Left ovaryLeft adnexa
Right ovary Right adnexa Bilateral adnexa
Dx: Bilateral pyosalpinges
Increased flow in the thickened and dilated fallopian tubes unlike torsion
Acting Director Radiology; Head of Emergency/Trauma RadiologyThe Alfred Hospital, Melbourne, AustraliaAreas of Interest:Emergency / Trauma RadiologyPast President RANZCRChairman :ANZERGPresident Elect: AOSR
DINESH VARMA, MBBS, FRANZCR
Case 1:17M, Status post cardiac arrest
July 16
Acute neurologic decline, 6 days later
July 22
Diagnosis?
Case 1:17M, Status post cardiac arrest:
July 22
July 16
Bilateral parietal white matter diffusion restriction and ADC hypointensity
Case 1 Diagnosis: Postanoxic leukoencephalopathy
•Uncommon syndrome (2-3%)of delayed white matter injury after a hypoxic-ischemic injury, most commonly due to carbon monoxide intoxication
•Period of relative clinical stability or improvement, then acute neurologic decline, typically 2-3 weeks after the initial insult
•DWI and conventional MRI immediately following the insult may be normal, but reveal confluent areas of restricted diffusion in the cerebral white matter later
•Imaging helps in diagnosis and case management in the acute setting and provides information about long term prognosis
RadioGraphics 2008. Hypoxic-ischemic brain injury:Imaging findings from birth to adulthood
June 2014
Case 2: 41M, AMS, s/p seizure
Courtesy: Matt Fox, MD
Feb 2014June 2014
DWI FLAIR
T2 T1
DWI FLAIR
T2 ADC
DWI Flair
ADC
DWI Flair
ADC
DWIPatchy restriction of diffusion in a cortical distribution (but not in all areas of edema)
Case 2 Diagnosis: MELAS
MELAS (mitochondrial encephalopathy with lactic acidosis and stroke-like episodes
Characterized by 'stroke-like' episodes, typically in childhood or early adulthood (90% present before 40 years of age)
Encephalopathy, seizures, dementia, lactic acidosis , muscle weakness
CT: Atrophy, multiple infarcts involving multiple vascular territories. Parieto-occipital and parieto-temporal involvement is most common, basal ganglial calcification
• MRI: Swollen gyri with increased T2 signal, increased signal on DWI (T2 shine through) with no change on ADC indicating vasogenic edema
• MR spectroscopy: Elevated lactate
K. Shanmuganathan
1979-MD University of Sri LankaRadiology-St, Bartholomew’s Hospital, London1991-Present, University of Maryland School of Medicine, BaltimoreProfessor Diagnostic Radiology, Shock Trauma Center, University of Maryland School of Medicine120 publications, textbooks and chapters, 200 invited lectures
Case 1: 24 F with left sided pleuritic chest pain
CT 5 years ago
Diagnosis?
CT 5 years ago
Current CT
Case 1 Diagnosis: Infarcted splenule
Infarcted splenule Accessory spleen (splenule ) : failure of fusion of the splenic
anlage, seen in up to 30% of autopsies Occur on vascular pedicles and thus at risk for torsion Differentiate from polysplenia and splenosis. Identify an intact
spleen, no other splenic foci and normal situs Recognize this entity as a cause of abdominal pain that can be
managed non-surgically
Emerg Radiol (2007) 14:123-125
Case 2: 69 F, Unresponsive
Bilateral paramedian thalamic, midbrain and pontine hypodensities
DDx for bilateral thalamic lesions: •Metabolic and toxic disorders (Wernicke’s encephalopathy, Osmotic myelinolysis)•Viral encephalitis•Vascular occlusion-Top of the basilar syndrome, Artery of Percheron infarcts, Deep venous thrombosis •Cerebral hypotension, PRES
Acute infarcts in the pons, midbrain and bilateral thalami
“V sign”
Lazzaro N et al. AJNR Am J Neuroradiol 2010;31:1283-1289
Lazzaro N et al. AJNR Am J Neuroradiol 2010;31:1283-1289
•An uncommon anatomic variant: a single dominant thalamoperforating artery supplies bilateral paramedian thalami and the rostral midbrain•Clinical diagnosis difficult
Case 2 Dx: Artery of Percheron Infarct
Most common etiology is cardioembolic
Additional small infarcts in the right MCA distribution
ADNAN SHEIKH, MD
MD – JJMMC, Davangere, IndiaMusculoskeletal fellowship – Vancouver General HospitalEmergency trauma fellowship – Vancouver General HospitalHead, ER /Trauma radiology, The Ottawa Hospital.Fellowship director, ER/ Trauma radiology, The Ottawa Hospital.Medical Director , 3D printing lab , The Ottawa Hospital
Case 1: A“healthy” 50 year old Fell off a 3 ft high parapetc/o pain, inability to bear weight on the right foot
Initial radiographs
6 weeks later the cast was taken off, unable to bear weight
Diagnosis?
Lisfranc fracture- dislocation
Bony or ligamentous injury involving the tarsometatarsal joint complex
Case 2:32 M,h/o pain and swelling right hip and thigh
Drug overdose, found unconscious and trapped between the toilet seat and wall
Differential Diagnosis?
Case 2:32 M, h/o pain and swelling right hip and thigh
Muscle edema of the right gluteal and upper thigh muscles(R>L)
Case 2 Diagnosis: Rhabdomyolysis
Nonspecific clinical and laboratory syndromeSevere muscle injury due to trauma, severe exercise, extrinsic pressure, ischemia, burns, toxins, autoimmune inflammationEdema may progress to myonecrosis, hematoma and infection or compartment syndrome.Elevated creatine kinase, pigments in urine and hematuria
Fasciotomy and on aggressive IV fluids for rhabdomyolysis
Drug overdose, found unconscious and trapped between the toilet seat and wall
RadioGraphics July 2004
64F, abdominal distention, pain, h/o SBO
64F, abdominal distention, pain, h/o SBO
• Multilobulated cystic lesion in the lesser sac and extending along the adjacent peritoneal spaces and ligaments
• Cystic lesion in the left hemipelvis
• Minimal ascites, omental and mesenteric thickening
15 days ago
15 days ago
7months ago
10 months ago
Diagnosis: Recurrent metastatic disease with mucinous tumor
Case 13: 45 M with abdominal pain
Case courtesy: Francesco Danza, MD
Peritoneal carcinomatosis Thick enhancing membrane around a conglomerate of small bowel loops in the center “cocoon”
Diagnosed with adenocarcinoma lung 6 months ago
Case 13 Diagnosis:Cocoon peritonitis
•AKA sclerosing encapsulating peritonitis•Rare cause of bowel obstruction due to fibrotic encapsulation of the bowel forming a sac or cocoon•May be idiopathic or secondary to chronic peritoneal dialysis, TB, sarcoidosis, GI malignancy, fibrogenic foreign material •Treatment –Surgical removal of the covering membrane
Hong Kong Med J 2012
29M,h/o pain, bilious vomiting and constipation x 3d
Courtesy: Subodh Gupta, MS
Histopathology The cocoon membrane showed
proliferation of fibroconnective tissue
No evidence of TB
Case 14: 24 F with left sided pleuritic chest pain
CT 5 years ago
CT 5 years ago
Current CT
Case 14 Diagnosis: Infarcted splenule
Infarcted splenule Accessory spleen (splenule ) : failure of fusion of the splenic
anlage, seen in up to 30% of autopsies Occur on vascular pedicles and thus at risk for torsion Differentiate from polysplenia and splenosis. Identify an intact
spleen, no other splenic foci and normal situs Recognize this entity as a cause of abdominal pain that can be
managed non-surgically
Emerg Radiol (2007) 14:123-125
8 M with ankle and hip pain for a few weeks and fatigue
Follow-up radiographs 3 weeks later
CBC, DLC, ESR, CRP-NormalIncreased IgA levelDDx: Rheumatic condition, infection, neoplasm
Uptake in the left ankle, greater trochanter apophysis
Uptake in a right rib
Biopsy: Osteomyelitis Organism:Propionibacterium acnesTreated with Clindamycin and steroids
Diagnosis: CRMO
SAPHO
Palmar and plantar pustulosis, costomanubrial junction and vertebral involvement
Case courtesy: Bharti Khurana, MDBWH, Harvard Medical School
Costomanubrial involvement and clavicular osteitis
SAPHO
Case 17:32 M,h/o pain and swelling right hip and thigh
Myositis of the right gluteal and upper thigh muscles(R>L)
Case 17 Diagnosis: Rhabdomyolysis
Severe muscle injury due to trauma, severe exercise,extrinsic pressure, ischemia, burns, toxins, autoimmune inflammationEdema may progress to myonecrosisCan develop compartment syndrome
Fasciotomy and on aggressive IV fluids for rhabdomyolysis
Drug overdose, found unconsciuos and trapped between the toilet seat and wall
Case A 3:73 year old male , R/O mass, heart attack
Dx: Ruptured coronary graft pseudoaneurysm with hemothorax
•Late complication of coronary bypass surgery
•Most aneurysms associated with saphenous vein CABGs occur at the anastomotic sites. Sutural defects, structural weakness of the parent artery, deficiency in the preparation of the saphenous vein and progressive atherosclerosis
•Mediastinal or hilar mass on radiographs, vascular nature of the mass on CECT or MRI, extent and mass effect
•Complications of graft aneurysmal disease are thrombosis, thromboembolism, fistula formation to the right atrium or ventricle, rupture and MI
38-F with shortness of breath
Pericardial Hydatid
Rare -may be mistaken for tubercular pericarditis
Non specific symptoms Imaging CT- cystic nature, daughter cysts & membranes - pericardial effusion +/- MR- highly specific - characteristic T2 hypointense wall of the cyst
Singhal M et al. Isolated pericardial hydatid cyst. Postgraduate Medical Journal 2011; 87: 790.
Case 1: 5 MHad a CT chest for worsening cough. 2.6 x 2.5 cm nodule in the RUL and COPDUnderwent flexible trans-bronchial biopsy using fenestrated forceps. Within a few seconds, developed generalized tonic seizure and left hemiplegia
CT Head: 30 minutes after the seizure episode
24 hrs laterLeft hemiparesis resolved
Partial resolution of air foci and appearance of hemorrhagic infarcts, also had metastases in the brain explaining other hemorrhages
Dx: Cerebral air embolism and small hemorrhagic infarcts Can occur during bronchoscopy when a
patient exhales or coughs against a wedged bronchoscope with local pressure increase and disruption of local capillary network. Treat with hyperbaric oxygen.
Other causes include GI endoscopy, barotrauma, central venous catheters, CV surgery
24 hrs laterLeft hemiparesis resolved
Partial resolution of air foci and appearance of hemorrhagic infarcts, also had metastases in the brain explaining other hemorrhages
Case 5:17M, Status post cardiac arrest:
July 22
July 16
Bilateral parietal white matter diffusion restriction and ADC hypointensity
Case 5 Diagnosis: Postanoxic leukoencephalopathy
•Uncommon syndrome (2-3%)of delayed white matter injury after a hypoxic-ischemic injury, most commonly due to carbon monoxide intoxication
•Period of relative clinical stability or improvement, then acute neurologic decline, typically 2-3 weeks after the initial insult
•DWI and conventional MRI immediately following the insult may be normal, but reveal confluent areas of restricted diffusion in the cerebral white matter later
•Imaging helps in diagnosis and case management in the acute setting and provides information about long term prognosis
RadioGraphics 2008. Hypoxic-ischemic brain injury:Imaging findings from birth to adulthood
Case1:84 M with RLQ pain for 3 days
Linear foreign bodyExtraluminal air
Fat stranding
Dx: Small bowel perforation due to a chicken bone
Take home points-1. Evaluate the perivisceral/mesenteric fat. Dirty fat is an
indicator of acute inflammation2. Play with the window settings on your PACS
Small bowel perforation by a foreign body
Fewer than 1% ingested foreign bodies (usually sharp and elongated) result in intestinal perforation
Small bowel is the most common site, particularly areas of acute angulation
Susceptible population-people wearing dentures, children, alcoholics, psychiatric patients
Signs and symptoms: abdominal pain, nausea, vomiting, fever, peritonitis, abscess, fistula, small bowel obstruction and GI hemorrhage
CT can detect type of foreign bodies-bone, metal and wood; localize the site of FB impaction and detect perforation
Treatment: surgical exploration and repair
Case 2: 56 M with abdominal pain
Disrupted bowel wall and focal thickening
Foreign body
Dx: Impacted tooth with small bowel perforation
Take home points-1. Look for any discrepancy in bowel morphology. 2. Discontinuity in mucosal enhancement may indicate
perforation, in absence of free air.3. Careful review can give an idea of the nature of foreign
body
Case 3: SBO due to an ingested earring
Case 4: 40 F with colicky abdominal pain
High grade small bowel obstruction with small bowel feces sign in the pelvis.
Retained endoscopic capsule at the point of obstruction and underlying bowel stricture due to Crohn’s disease
Active inflammatory bowel disease (Crohn's disease) with multiple long segments of bowel wall thickening, strictures and creeping fat sign.
Endoscopic capsule as a cause of small bowel obstruction in a case of Crohn's disease
Take home points-1. Look for the small bowel feces sign to identify the point of
obstruction2. Careful review can give an idea of the nature of foreign
body3. Look for a possible underlying stricture at the site of foreign
body
Case 5: 64 M with abdominal pain and vomiting
Dx: Cholecystogastric fistula with gastric outlet obstruction
Gastric outlet obstruction caused by a large gallstone passing into the duodenal bulb through a biliogastric or bilioduodenal fistula.
What is it called?
Bouveret's syndrome
Extraluminal fecal matter in the peritoneal cavity and air loculi
Fecaloma at the perforation site
Colon wall thickening due to pressure necrosis
Case 6: 67 F with constipation x 5 d, abdominal pain and distension
Dx: Stercoral perforation
Stercoral colitis
Fecal impaction may rarely lead to perforation, colonic obstruction and fecal peritonitis.
Fecal impaction results in ischemic pressure necrosis of the rectal and sigmoid colonic wall leading to stercoral ulcer formation and subsequently perforation.
Most common locations :anterior rectum, the antimesenteric border of the rectosigmoid junction, and the sigmoid colon.
Mean age 59 yrs. Risk factors : chronic intermittent constipation, use of nonsteroidal anti-inflammatory drugs, antacids, steroids, codeine, and heroin.
Presence of underlying diverticulitis, IBD or obstruction excludes the diagnosis of primary stercoral perforation.
Does it stink in your ER?
Case 7: 38 M with acute onset severe abdominal pain
Cecum in the lesser sac
Cecum mildly dilatedCecum in the lesser sac between the liver hilum and IVC
No twist to indicate cecal volvulus
Case 7: 38 M with acute onset severe abdominal pain
Dx: Lesser sac hernia with cecal incarceration
Take home points-1. Look for abnormal location of a bowel loop indicating an internal
hernia2. Abnormal dilatation of the abnormally located loop may indicate
incarceration3. Absence of beak sign or mesenteric twist can exclude volvulus
Lesser sac hernia via the foramen of Winslow
Review of Internal Hernias: Radiographic and Clinical Findings. LC Martin et al. AJR March 2006
Lesser sac hernias comprise 8% of all internal hernias which have a less than 1% overall incidence.
Circumscribed loop posterior and medial to the stomach
Case 8: 64 F with chest pain, abdominal back pain, evaluate pulmonary embolism or dissection, CT A/P normal. 24 hrs later right flank pain and hypotension , ?aortic dissection
19 HU40 HU
60 HU
Active hemorrhage from a branch of the right gastric artery
Dx:Mesenteric vasculitis with active hemorrhage
Take home points-1. Sentinel clot sign2. Recognize the appearance of
extraluminal contrast indicative of active hemorrhage.
3. Vessel morphology to detect the cause for bleed
Bilateral large adnexal masses with hyperdense components.
Right ovary
Left ovary
Free fluid
Uterine deviation to the right
Case 9: 25 F with RLQ pain
Soft tissue deposit
Dx: Bilateral struma ovarii with torsion of the right ovary and benign strumosis
Take home points-1. Consider the possibility of torsion in presence of a large adnexal
mass and appropriate clinical setting2. Ascites , abnormal location of the ovary, ipsilateral deviation of the
uterus indicate adnexal torsion
Struma ovarii Struma ovarii is composed predominantly of thyroid tissue. It
accounts for approximately 3% of all mature cystic teratomas US and CT demonstrate its complex appearance with
multiple cystic and solid areas. When struma ovarii is not associated with hyperthyroidism, the differential diagnosis should include mature cystic teratoma without fatty tissue, cystadenoma or cystadenocarcinoma, endometriosis, tuboovarian abscess, and metastatic tumor
Malignant transformation of thyroid tissue in struma ovarii and metastasis are extremely uncommon
In rare cases, benign thyroid tissue may spread to the peritoneal cavity. This condition is termed "peritoneal strumosis."
Case 10: 20 F with LLQ pain
Whirl sign: spiral appearance of the vascular pedicle
Periadnexal fat infiltration
Uterus (U)deviated to the left
U
Right ovarian teratoma
Left ovarian teratoma
Dx: Bilateral ovarian dermoid cysts with torsion on the left
Take home point-Look for the whirl sign in adnexal torsion
Case 11: 12 cm cystic tumor of the right ovary. Is there torsion?
No wall thickening, fat infiltration, ascites or ipsilateral uterine deviation
Left ovary
Uterus
Case 12: Right ovarian cyst. Is there torsion?
Smooth adnexal mass abnormally located in the pelvis with ipsilateral deviation of the uterus and tubal thickening
Case 15: 25 year old pregnant female with RLQ pain. Free fluid seen on the sonogram. Fetal cardiac activity absent.
Hemoperitoneum
Fetal parts
Uterus defect
Dx: Ruptured uterine pregnancy Uterine rupture in pregnancy is a rare (0.07%)and
catastrophic complication with high incidence of fetal and maternal morbidity.
Signs and symptoms nonspecific resulting in a delayed diagnosis.
Unlike uterine scar dehiscence, uterine rupture is a full-thickness separation of the uterine wall and overlying serosa. Associated with massive bleeding, fetal distress and expulsion or protrusion of fetus, placenta or both into the abdominal cavity.
Risk factors:Scarred uterus, placenta accreta/percreta, multiple gestation, molar pregnancy, obstructed labor
Case 16: 57 M with a stiff neck and sore throat
CT findings:Elongated irregular calcification anterior to the C1 vertebra extending up to mid C2 level.
Ill-defined fluid in the prevertebral space extending from C1 through C4-5 level without rim enhancement.
No other evidence of inflammatory changes.
Dx: Acute calcific tendinitis of the longus colli
Aka acute prevertebral calcific tendinitis and retropharyngeal calcific tendinitis
Relatively benign and unusual cause of acute neck pain and stiffness. Inflammatory process caused by calcium hydroxyapatite crystal deposition in the superior oblique tendon of the longus colli muscles
Clinically mimics more serious entities such as retropharyngeal abscess, spondylodiscitis or spine trauma
Recognition of calcific tendinitis of the longus colli is important to prevent unnecessary intervention
Case 18: MVA,chest pain
Dx: Buckle fractures of the sternum
Case 21: 23 F with leukocytosis, RLQ pain and tenderness, vaginal discharge, cervical motion tenderness
Arterial phase
nephrourographic phase
Dx: TOA with perihepatitis (Fitz-Hugh Curtis Syndrome)
Characterized by right sided abdominal pain and perihepatitis associated with pelvic inflammatory disease (gonococcal or chlamydial)
Localized RUQ peritonitis (hepatic capsular/pericapsular enhancement on the arterial phase) with PID (mild pelvic edema, thickened fallopian tubes, enlarged ovary, abnormal endometrial enhancement and fluid, frank tuboovarian abscess) suggest the diagnosis
