Case conference March 30, 2017.

Dr.Jayanth H Keshavamurthy. M.D.

Abdomen cases

Case 1

Pre op renal transplant 2 years apart

All findings in 2 nd radiograph

• PD catheter• Calcific densities- Lanthanum• Surgery on right femur to prevent AVN- vascularized

fibular graft.

Lanthanum carbonate (LC) is used as a phosphate binder in dialysed patients. Abdominal pain and constipation are known side effects of its use. Furthermore, in radiological studies, LC tablets are seen as intense radio-opaque deposits within the entire gastrointestinal tract—findingswhich can lead to diagnostic misinterpretations.

Background: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with collapse of the articular surface and subsequent arthrosis. Free vascularized fibular grafting has been reported to be successful for patients with early stages of osteonecrosis, but little is known about its efficacy after the femoral head has collapsed.

Case 2

Scout radiograph what and where is the abnormality?

CT AXIAL

CT CORONAL

CT SAGITTAL

EMPHYSEMATOUS CYSTITIS.

Emphysematous cystitis is a rare infection of the urinary bladder by gas-producing organisms, typically seen in diabetics.

On radiographs, emphysematous cystitis can present as a radiolucent line in the bladder wall and/or gas within the bladder.

On ultrasound, echogenic foci within the bladder wall with dirty shadowing artifact are concerning for emphysematous cystitis.

Treatment of emphysematous cystitis consists of intravenous antibiotics supplemented by control of the patient’s hyperglycemia and adequate urine drainage.

In contrast, emphysematous pyelonephritis, a more life-threatening infection, often necessitates percutaneous catheter drainage or nephrectomy.

Case 3

See the direction of the long rectal tube

Plain abdominal radiographs demonstrate a large, dilated loop of colon with inverted U shape showing the classic "coffee bean appearance“ without haustra. There may be few air-fluid levels.Specific signs include: - Coffee bean sign - Frimann Dahl's sign - three dense lines that converge towards the site of obstruction and absent rectal gas .

• In cecal volvulus, there is only one air-fluid level (two are present in sigmoid volvulus).

• Transverse colon volvulus does not originate in the pelvis.

• A less commonly noted sign is the northern exposure sign where the sigmoid ascends cephalad to the transverse colon, where normally its entirety is confined inferior .

• Javors BR, Baker SR, Miller JA (1999) The Northern Exposure Sign: a Newly Described Finding in Sigmoid Volvulus. AJR Am J Roentgenol 173(3):571-4Slide 20

Bird’s beak sign on fluroscopy

CT findings include a large gas-filled loop without haustral markings, forming a closed-loop obstruction.Specific signs on CT: - Whirl sign - twisting of the mesentery and mesenteric vessels- Beak sign - if rectal contrast has been administered .

Sigmoid volvulus which was reduced by rigid endoscopy and see the sigmoid tube terminating in RUQ. Once stable he will get elective surgical fixation.

Discussion• Among cases of colonic volvulus, sigmoid volvulus is most

common, comprising 60-75% of cases. • By comparison, cecal volvulus accounts for 22-33% of cases.• Other less common segments of colonic volvulus include the

transverse colon (3.6%) and splenic flexure (1%). • While sigmoid volvulus more commonly occurs in the elderly

population, the average age of people with cecal volvulus in Western countries is 53 years old. 

• Predisposing factors for cecal volvulus include congenital improper fixation of the bowel to retroperitoneal structures, prior abdominal surgery with resultant adhesions, ileus, previous colonoscopy, chronic constipation, and high-fiber diets.

• A CT abdomen provides more information regarding level of the obstruction and the torsion of the loop. Torsion of 360° is found in half of patients, 180° in 35% of cases and 540° in 10% of cases .

• The whirl sign described by Shaff et al. is constituted by the afferent and efferent limbs leading into the volvulus with a central portion comprised of tightly twisted mesentery.

• The tightness of the whirl is proportional to the degree of rotation

• A sigmoid volvulus requires prompt intervention as the mortality rate is up to 21%.

• Sigmoidoscopy with endoscopic decompression is successful in 70-90% of cases.

• If a perforation is suspected, immediate surgical exploration is warranted.

• Sigmoid volvulus reoccurs in 40-70% of patients without surgery. • Options to prevent recurrence include endoscopic sigmoidopexy

or sigmoid resection

Operative techniques such as primary sigmoid resection and anastomosis, sigmoidopexy, and percutaneous endoscopic colostomy have been used to manage sigmoid colon volvulus

Case 4

79 ear old with abdominal pain

Findings

• Organizing pancreatic pseudocyst throughout the lesser sac with inflammatory changes but organization of the pseudocyst.

• This large pseudocyst displaces the gastric gas bubble shadow superiorly and was thought as left upper quadrant free air on Abdomen radiographs.

Case 5

21 year old with history of G tube KUB 6 months apart

Emphysematous gastritis

Case 6

https://3s.acr.org/CiP/Pages/CaseView?CaseId=sDKbx1AFOdM%3d&Archive=true

This is a case of Cecal volvulus from Dr. Janet Munroe.

Case 7

• 66 y/o AAF with Node Positive Colon Cancer. Thepatient is status post sigmoidectomy with laparoscopic mobilization of the splenic flexure for colonic adenocarcinoma

Emphysematous gastritis with portal venous gas

Case 8

IMPRESSION:1. There is demonstration of pneumatosis intestinalis involving several mildly dilated loops of ileum within the abdominal right lower quadrant. Additionally, small volume mesenteric venous gas isidentified adjacent to these small bowel loops. Finally, note is made of interloop fluid as well as mild inflammatory stranding within the mesentery.

2. Patient was managed conservatively.

Case 9

52 year old male with cirrhosis and abdominal pain

Findings

• Cirrhosis.• TIPS• Pneumatosis coli---not intestinalis.• Large amount of ascites