RADIOLOGY-ALL

case 7 Toddler With Fever and Abdominal Tenderness

2007-05-31T18:13:00.001-07:00

Toddler With Fever and Abdominal Tenderness

[]
BACKGROUND
A 14-month-old boy is brought to the emergency
department by his parents for an evaluation of
persistent fever, vomiting, and diarrhea that has
lasted for 3 days. The mother states that her
son's pediatrician examined him 2 days ago for a
"viral illness." However, the child has appeared
increasingly ill since then. He has become
irritable, and he has been minimally active and
feeding poorly. He has had normal stool output
and appearance and his normal number of wet
diapers. The parents deny observing a runny nose,
cough, and wheezing or stridor. The child lives
at home with his parents, he is not in day care,
and he has had no contacts with people who are sick.

On physical examination, the boy is crying,
fussy, and poorly consoled. His vital signs
include a rectal temperature of 101°F, a
respiratory rate of 32 breaths per minute, a
blood pressure of 98/56 mm Hg, and a heart rate
of 168 beats per minute. His oxygen saturation is
100% while he is breathing room air. The
patient's weight is 10 kg. Palpation reveals
diffuse abdominal tenderness without rigidity or
guarding. The patient has diffusely hypoactive
bowel sounds. His stool is negative for occult
blood. The rest of the physical findings are otherwise unremarkable.

Abdominal conventional radiography and CT are
performed (see Images). Laboratory investigation
reveals the following results: WBC count 19.4 X
109/L with a predominance of neutrophils,
hemoglobin 8.4 g/dL, hematocrit 26.6%, platelets
310 X 109/L, Na 136 mmol/L, K 3.8 mmol/L, Cl 105
mmol/L, CO2 20 mmol/L, BUN 6 mmol/L, creatinine
17.7 µmol/L (0.2 mg/dL), and glucose 4.1 mmol/L
(73 mg/dL). Urinalysis shows trace ketones, but
the results are otherwise normal.

What is the diagnosis?
Hint
The patient's symptoms developed approximately 2
days after the mother dropped a box of pins on the carpet at home.
Author: Anusuya Mokashi, Medical Student, New York Medical College, Valhalla

Justin Weir, Medical Student, New York Medical College, Valhalla

Margaret D. Smith, MD, Program Director,
Department of Medicine, St. Vincent Catholic
Medical Centers (SVCMC) St. Vincent's Hospital
Manhattan, Senior Associate Dean and Associate
Professor of Clinical Medicine, New York Medical
College, St. Vincent's Hospital Manhattan
eMedicine Editor: Erik Schraga, MD, UCLA - Olive
View Medical Center Residency, Department of
Emergency Medicine, Olive View - UCLA Medical Center

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case 7 answer Toddler With Fever and Abdominal Tenderness

2007-05-31T18:13:00.000-07:00

Toddler With Fever and Abdominal Tenderness

[]

Answer
Appendiceal perforation by a foreign body (a
pin): A foreign body was easily apparent on
conventional abdominal radiographs in the right
lower quadrant. CT scanning of the abdomen and
pelvis revealed a radiopaque pin and a
multiloculated fluid collection at the L5 level.
The prominent bowel loops superior to the pin likely represent focal ileus.

On laparotomy, drainage and excision of an
intra-abdominal abscess, as well as appendectomy
and removal of the foreign body, were performed.
The appendix was 4.3 cm, and a metallic pin was
found piercing the bowel wall (see Image 4).
Histology revealed acute serositis with
fibrinopurulent exudates in the lumen and on the
serosal surface of the appendix.

Ingestion of foreign bodies is relatively common
among pediatric patients, who account for
approximately 80% of ingestions. Most objects
pass spontaneously, and only 1% of all
foreign-body ingestions require surgical
intervention. Among adults, foreign-body
ingestions most frequently occur in those with
psychiatric disease or with potential secondary gain.

Management depends on the type of object
ingested. The objects most commonly ingested are
coins, buttons, parts of small toys, pins and
thumbtacks, and disk-shaped batteries. For known
ingestion of nontoxic, smooth, or small objects,
management is conservative, as approximately
80-90% of these foreign bodies spontaneously pass
though the GI tract without harm.

Initial radiographic localization and serial
abdominal radiography should be performed every
24-48 hours to monitor progression of the object
until it is passed in stool. Foreign bodies may
lodge at any site in the GI tract but most often
lodge at anatomic sphincters or areas of
narrowing, acute angulation, or previous surgery,
where they tend to cause obstruction or
perforation. The esophagus has several sites of
potential obstruction, and perforation at these
sites is a particular concern because rates of
related morbidity and mortality are high.
Complications include mediastinitis, lung
abscess, pneumothorax, and pericarditis.
Approximately 90% of foreign bodies that reach
the stomach pass through the remaining GI tract.
Most smooth objects pass with normal bowel transit time.

Because of the high risk of intestinal
perforation, urgent intervention is indicated for
all patients who have ingested a long, thin,
sharp, or stiff foreign body that fails to
progress through the GI tract regardless of their
clinical signs and symptoms. Localization with
radiography should be followed by an immediate
attempt to remove the object by means of
endoscopy when possible. Emergency laparotomy is
indicated if the patient develops abdominal pain
or tenderness; fever; or other clinical evidence
of perforation, hemorrhage, or obstruction.
Cathartic agents are contraindicated.

Foreign bodies rarely cause complications in the
small bowel and colon because they are surrounded
by stool and directed to the center of the lumen.
In the rare case when the object becomes static
in the right lower quadrant (terminal ileum,
cecum, or appendix), as in this patient, removal
by means of colonoscopy should be considered.
Other options include laparotomy or laparoscopic
removal under fluoroscopic guidance.

Reported complications of foreign bodies in the
distal GI tract include obstruction, abscess
formation, peritonitis, adhesions, fistula
formation, perforation, and appendicitis. Long,
slender, and sharp objects are most likely to
injure the mucosa and cause inflammation and
perforation, whereas smooth objects lodged in the
appendix tend to cause obstruction, leading to
acute appendicitis, rupture, and abscess
formation. Objects heavier than bowel fluid tend
to rest in the cecum and gravitate to its most
dependent portions. The normal appendix can empty
its contents by means of peristalsis; however,
the presence of a foreign body, adhesions, or
inflammatory infiltrate can hinder its emptying.

For more information on foreign body
perforations, see the eMedicine articles
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/emerg/topic379.htm%5Etarget=%5E_blank%5E>Pediatrics,
Foreign Body Ingestion and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/emerg/topic897.htm%5Etarget=%5E_blank%5E>Foreign
Bodies, Gastrointestinal (within the Emergency
Medicine specialty) and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/ped/topic2777.htm%5Etarget=%5E_blank%5E>Gastrointestinal
Foreign Bodies (within the Pediatrics specialty).

References
* Balch CM, Silver D. Foreign bodies in the
appendix. Report of eight cases and review of the
literature. Arch Surg 1971 Jan;102(1):14-20.
* Cheng W, Tam PK. Foreign-body ingestion in
children: experience with 1,265 cases. J Pediatr
Surg 1999 Oct;34(10):1472-6. Collins DC. 71,000
Human appendix specimens. A final report
summarizing forty years' study. Am J Proctol 1963 Dec;14:265-81.
* Klingler PJ, Seelig MH, DeVault KR, et al.
Ingested foreign bodies within the appendix: a
100-year review of the literature. Dig Dis 1998 Sep-Oct;16(5):308-14.
* Klinger PJ, Smith SL, Abendstein BJ, et al.
Management of ingested foreign bodies within the
appendix: a case report with review of the
literature. Am J Gastroenterol 1997 Dec;92(12):2295-8.
* Rajagopal A, Martin J, Matthai J. Ingested
needles in a 3-month-old infant. J Pediatr Surg 2001 Sep;36(9):1450-1.
* Spitz L. Management of ingested foreign
bodies in childhood. Br Med J 1971 Nov 20;4(785):469-72.
BACKGROUND
A 14-month-old boy is brought to the emergency
department by his parents for an evaluation of
persistent fever, vomiting, and diarrhea that has
lasted for 3 days. The mother states that her
son's pediatrician examined him 2 days ago for a
"viral illness." However, the child has appeared
increasingly ill since then. He has become
irritable, and he has been minimally active and
feeding poorly. He has had normal stool output
and appearance and his normal number of wet
diapers. The parents deny observing a runny nose,
cough, and wheezing or stridor. The child lives
at home with his parents, he is not in day care,
and he has had no contacts with people who are sick.

Justin Weir, Medical Student, New York Medical College, Valhalla

case 6 answer Small-Bowel Obstruction While on Cruise

2007-05-30T13:44:00.000-07:00

Small-Bowel Obstruction While on Cruise

[]

Answer
Diffuse, large B-cell lymphoma (DLBCL): Needle
biopsy of the RLQ mass revealed a DLBCL involving
the intestinal wall. Bone marrow aspiration
revealed normocellular marrow negative for
lymphoma. After diagnosis, the patient received a
round of CHOP chemotherapy, which consists of
vincristine, doxorubicin, prednisone, and
cyclophosphamide (nitrogen mustard), along with
dexamethasone (Decadron) and granulocyte colony-stimulating factor (G-CSF).

Prophylactic surgery to remove the RLQ mass was
scheduled because of the relatively high risk of
ileocecal bowel perforation during and after
chemotherapy because of the lymphoma's extensive
infiltration of the entire bowel wall, as seen on
CT. The preoperative diagnosis was non-Hodgkin
lymphoma (NHL), ie, DLBCL of the small bowel.
After surgery, lymphoma to the terminal ileum,
right colon, and mesentery of the small bowel
were confirmed. The terminal ileum and proximal
right colon were resected, and an ileocolic anastomosis was made.

Lymphomas are categorized as Hodgkin lymphoma or
NHL. Hodgkin lymphomas are most often localized
to a single axial group of nodes, they spread
contiguously, and they rarely cause extranodal
involvement. In contrast, NHL most frequently
involves several peripheral nodes, they have
noncontiguous or disseminated spread, and they
commonly result in extranodal involvement. NHL
can be further categorized into B-cell and T-cell
lymphomas. DLBCL is a malignancy of mature
B-cells originating from the germinal center or
marginal-zone B cells. It is the most common
histologic subtype of B-cell NHL, accounting for
20% of all NHLs and 60-70% of aggressive lymphoid
neoplasms. On histologic evaluation,
DLBCL-involved lymph nodes show a diffuse pattern
of involvement with loss of normal structures,
such as sinuses and lymphoid follicles.

The median age when DLBCL occurs is in the 60s,
and the patient often presents with a rapidly
enlarging, symptomatic mass, typically in the
neck or abdomen. As many as 40% of patients
present with extranodal involvement. The ileum is
the most common site of extranodal lymphoma,
which accounts for 5% of all lymphomas. As in
this case, mass effect can lead to small SBO.
Depending on the extranodal location of the
lymphoma, other presentations due to mass effect
include superior vena cava (SVC) syndrome,
tracheobronchial compression leading to
respiratory distress, and spinal-cord compression
related to destruction of bone in the vertebral
column. Detection of tumor in the bone marrow is
associated with spread to the CNS in 10-20% of patients.

Constitutional symptoms include fever, weight
loss, and drenching night sweats and occur in 30%
of patients. More than 50% have elevated serum
LDH levels. The International Non-Hodgkin's
Lymphoma Prognostic Factors Project reports a
5-year survival rate of 26-73%; the exact rate
depends on the number of risk factors and the
histologic type. Risk factors for increased
mortality and relapse include age older than 60
years, increased serum LDH level, Ann Arbor stage
III or IV, and more than 1 extranodal disease
site. The mean long-term disease-free survival
rate is about 40%. Relapse is most common in the
first 2-3 years after diagnosis, with relapse
relatively uncommon after 4 years.

For more information on DLBCL, see the eMedicine
articles
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/med/topic1358.htm%5Etarget=%5E_blank%5E>Lymphoma,
B-Cell and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/med/topic1360.htm%5Etarget=%5E_blank%5E>Lymphoma,
Diffuse Large Cell (within the Internal Medicine specialty).

References
* Freeman HJ. Free perforation due to
intestinal lymphoma in biopsy-defined or
suspected celiac disease. J Clin Gastroenterol 2003 Oct;37(4):299-302.
* Gajra A. Lymphoma, B-Cell. eMedicine
Journal [serial online]. November 3, 2005.
Available at:
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/med/topic1358.htm%5Etarget=%5E_blank%5E>http://www.emedicine.com/med/topic1358.htm.

* Law M, Williams S, Wong J. Role of surgery
in the management of primary lymphoma of the
gastrointestinal tract. J Surg Oncol 1996;61:199-204.
* Randall J, Obeid ML, Blackledge GR.
Haemorrhage and perforation of gastrointestinal
neoplasms during chemotherapy. Ann R Coll Surg Engl 1986 Sep;68(5):286-9.
* ReMine SG, Braasch JW. Gastric and small
bowel lymphoma. Surg Clin North Am 1986 Aug;66(4):713-22.
* Sakakura C, Hagiwara A, Nakanishis M, et
al. Bowel perforation during chemotherapy for
non-Hodgkin's lymphoma. Hepatogastroenterology 1999 Nov-Dec;46(30):3175-7.
* Wada M, Onda M, Tokunaga A, et al.
Spontaneous gastrointestinal perforation in
patients with lymphoma receiving chemotherapy and
steroids. J Nippon Med Sch 1999;66(1):37-40.
BACKGROUND
A 57-year-old man presents to a local emergency
department with severe abdominal pain after being
evacuated from a cruise ship. The pain, which is
most severe in the right lower portion of his
abdomen, started soon after he boarded the ship 2
days ago. Since then, the pain has worsened, and
the patient has noticed his abdomen becoming
progressively "bloated." The pain is associated
with nausea and vomiting. He has not been able to
have a bowel movement. On further questioning,
the patient reports having night sweats,
low-grade fevers, intermittent abdominal
discomfort with constipation, and a 30-lb weight
loss over the last 2-3 months. He has no
significant medical history and is not taking any
medications. He does have a significant family
history of colon cancer, soft tissue sarcoma,
pancreatic cancer, chronic myeloid leukemia (CML), and prostate cancer.

On physical examination, the patient is alert and
oriented. His temperature is 98.8°F, his pulse is
65 beats per minute, his respiratory rate is 18
breaths per minute, and his blood pressure is
104/67 mm Hg. Abdominal examination reveals
localized tenderness to palpation in the right
lower quadrant (RLQ), with a palpable mass. He
has generalized abdominal distension but no
guarding, rebound, or percussion tenderness.
Rectal examination reveals guaiac-positive, brown
stool. Findings from the respiratory and
neurologic portions of the physical examination are unremarkable.

Laboratory investigations are ordered and reveal
a hemoglobin value of 9.4 g/dL, with a
corresponding hematocrit of 30.8%. His WBC count
is 6.2 X 109/L, and his lactate dehydrogenase
(LDH) level is elevated at 285 U/L. Results of an
electrolyte panel, liver function tests, and
renal function tests are within normal limits.
Abdominal CT is performed, which demonstrates a
large right lower quadrant mass (see Image). The
mass causes a small-bowel obstruction, and
several enlarged retroperitoneal and mesenteric
nodes are noted (not pictured). What is the
likely etiology of this mass, and what is its treatment?
Hint
Note the patient's strong family history of cancer.
Author: Anusuya Mokashi, Medical Student, New York Medical College, Valhalla

Janis A. Pastena, MD, FACS, FACEP, Associate
Professor of Clinical Surgery, New York Medical College
eMedicine Editor: Eugene Lin, MD, Department of
Radiology, Virginia Mason Medical Center,
Seattle, WA, Assistant Clinical Professor of
Radiology University of Washington Medical Center, Seattle, WA

Rick G. Kulkarni, MD, Assistant Professor, Yale
School of Medicine, Section of Emergency
Medicine, Department of Surgery, Attending
Physician, Medical Director, Department of
Emergency Services, Yale-New Haven Hospital

case 6 Small-Bowel Obstruction While on Cruise

2007-05-30T13:43:00.000-07:00

Small-Bowel Obstruction While on Cruise

[]

BACKGROUND
A 57-year-old man presents to a local emergency
department with severe abdominal pain after being
evacuated from a cruise ship. The pain, which is
most severe in the right lower portion of his
abdomen, started soon after he boarded the ship 2
days ago. Since then, the pain has worsened, and
the patient has noticed his abdomen becoming
progressively "bloated." The pain is associated
with nausea and vomiting. He has not been able to
have a bowel movement. On further questioning,
the patient reports having night sweats,
low-grade fevers, intermittent abdominal
discomfort with constipation, and a 30-lb weight
loss over the last 2-3 months. He has no
significant medical history and is not taking any
medications. He does have a significant family
history of colon cancer, soft tissue sarcoma,
pancreatic cancer, chronic myeloid leukemia (CML), and prostate cancer.

case 5 answer Routine Screening Radiograph in a 60-Year-Old Smoker

2007-05-30T13:42:00.000-07:00

Routine Screening Radiograph in a 60-Year-Old Smoker

[]

Answer
Pulmonary hamartoma: A hamartoma is a benign neoplasm in an organ
composed of tissue elements normally found at that site but that are
growing in a disorganized mass. Pulmonary hamartomas are usually
solitary, though multiple tumors have been reported in the Carney
triad of pulmonary chondromas, gastric epithelioid leiomyoblastoma,
and functioning extra-adrenal paraganglioma.

Found in 0.25% of general population, pulmonary hamartoma is the
third most common cause of solitary pulmonary nodules and the most
common benign tumor of the lung. Pulmonary hamartomas account for
6-8% of all solitary pulmonary lesions and 75% of all benign lung
tumors. The tumors most frequently occur in men and are usually found
in the fifth to sixth decades of life. No racial predilection is
observed. Most individuals with hamartomas are smokers.

Suggested theories for the etiology of these lesions include
congenital malformation of a displaced bronchial anlage, hyperplasia
of normal lung tissues, cartilaginous benign neoplasia, and responses
to inflammation.

About 15% of the pulmonary hamartomas are calcified. Characteristic
punctate, or popcorn, calcifications are found on plain films in
about 10% of cases. This popcorn appearance is almost pathognomonic;
other patterns of calcification include curvilinear and stippled. On
CT, the following findings are considered diagnostic of a hamartoma:
solitary lesion; diameter smaller than 2.5 cm; circumscribed,
lobulated, and smooth wall; and fat content in about 50%,
calcification in about 15%, or both. The detection of fat is aided by
using 2-mm slice thickness CT. During follow-up, most tumors grow
slowly at a mean rate of 3 mm/year.

Malignant transformation of pulmonary hamartomas is probably
nonexistent, but the literature does show a higher-than-expected
incidence of lung cancer in patients with these lesions. Most
patients with hamartomas are usually asymptomatic, especially when
the lesion is peripheral (as in up to 90% of cases). However, central
or endobronchial lesions are frequently associated with symptoms or
signs of obstruction (eg, hemoptysis, coughing, wheezing,
expectoration, leukocytosis). Peripheral lesions have no lobar predilection.

Histologic diagnosis can be obtained by means of fine-needle
aspiration of peripheral lesions. The results are diagnostic if
cartilage or fibromyxoid fragments are recognized. The differential
diagnosis of pulmonary hamartomas includes bronchogenic carcinoma,
solitary pulmonary metastasis, granuloma, carcinoid tumor and rarely
papilloma, lymphoma, and pulmonary leiomyoma, among other conditions.

Treatment of symptomatic or rapidly growing masses or those larger
than 2.5 cm in diameter consists of wedge resection or enucleation of
peripheral tumors and bronchoscopic removal of endobronchial lesions.
Lesions that show minimal growth or that do not produce symptoms can
be followed up conservatively.

For more information on pulmonary hamartoma, see the eMedicine
articles
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/radio/topic316.htm%5Etarget=%5E_blank%5E>Hamartoma,
Lung and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/radio/topic782.htm%5Etarget=%5E_blank%5E>Solitary
Pulmonary Nodule (within the Radiology specialty) and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/med/topic3559.htm%5Etarget=%5E_blank%5E>Solitary
Pulmonary Nodule (within the Internal Medicine specialty).

References
* Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of Diseases
of the Chest. St Louis, Mo: C.V. Mosby; 2000.
* Siegelman SS, Khouri NF, Scott WW Jr, et al. Pulmonary
hamartoma: CT findings. Radiology 1986;160(2):313-7.
BACKGROUND
A 60-year-old man presents to the emergency department after
accidentally falling when he tripped over a sidewalk curb. On the
review of systems, the patient reports occasionally having a dry
cough. He states that he has had the cough "for quite some time" and
attributes it to his 40-pack-year history of smoking cigarettes. On
further questioning, he denies having weight loss, hemoptysis, or
shortness of breath.

On physical examination, the patient is a man of moderate build, in
no apparent distress. His blood pressure, heart rate, and respiratory
rate are within normal limits. He has normal breath sounds and no
respiratory distress. Findings on chest, abdominal, and the rest of
his physical examination are unremarkable. A chest radiograph is
obtained. When the results are reviewed, a CBC and chemistry panel
are ordered and deemed noncontributory. Contrast-enhanced chest CT
scanning is performed.

What is the diagnosis?
Hint
The diagnosis is the most common benign tumor of the lung.
Author: Gautam Dehadrai, MD, Staff Radiologist, Department of
Radiology, Veterans Affairs Medical Center, Albuquerque, NM
eMedicine Editor: Rick G. Kulkarni, MD, Assistant Professor, Yale
School of Medicine, Section of Emergency Medicine, Department of
Surgery, Attending Physician, Medical Director, Department of
Emergency Services, Yale-New Haven Hospital, Conn

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case 5 Routine Screening Radiograph in a 60-Year-Old Smoker

2007-05-30T13:41:00.000-07:00

Routine Screening Radiograph in a 60-Year-Old Smoker
[]
BACKGROUND
A 60-year-old man presents to the emergency department after
accidentally falling when he tripped over a sidewalk curb. On the
review of systems, the patient reports occasionally having a dry
cough. He states that he has had the cough "for quite some time" and
attributes it to his 40-pack-year history of smoking cigarettes. On
further questioning, he denies having weight loss, hemoptysis, or
shortness of breath.

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thus make your contibution to public service : mother theresa
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case 3 answer Abdominal Swelling in a 75-Year-Old Man

2007-05-30T13:38:00.001-07:00

Answer
Pancreatic pseudocyst: These are the most common cystic lesions of the pancreas, accounting for approximately 75% of all pancreatic masses. Pancreatic pseudocysts are defined as localized amylase-rich fluid collections in or adjacent to the pancreas and surrounded by a fibrous wall that does not possess an epithelial lining. Hence, they are pseudocysts as opposed to true cysts. Postinflammatory pseudocysts are the most common cystic masses of the pancreas. They most commonly develop after acute or chronic pancreatitis, but they may also form after surgery and trauma, particularly in children. Pancreatic pseudocysts are typically solitary, but they are multiple in about 15% of patients. Two thirds of these lesions form in the tail of the pancreas. In rare cases, the collections can occur in the pelvis and even in the mediastinum. About 80% of cases are caused by alcohol or gallstone diseaserelated pancreatitis.

In acute pancreatitis, pseudocysts form because of ductal disruption secondary to pancreatic necrosis (postnecrotic pseudocyst) and subsequent ductal leakage that results in the extravasation of enzyme-rich pancreatic secretions and their loculation in potential spaces, including the lesser peritoneal sac and the anterior pararenal space. Most fluid collections associated with acute pancreatitis resolve spontaneously. However, those that persist for >4 weeks become encased in a fibrous capsule. Even cysts that persist >6 weeks may be followed up conservatively as long as they are <6 cm in diameter. A diameter of >6 cm usually indicates a low likelihood of complete spontaneous resolution. These relatively large cysts are associated with substantially increased morbidity rates and should be drained.

In contrast, patients with chronic pancreatitis develop pseudocysts because of elevated pressures in the pancreatic duct resulting from strictures, ductal calculi, or other causes. The elevated pressure in the duct leads to a small ductal disruption that is frequently retained in the parenchyma of the gland (retention cyst). In fact, chronic pancreatitis is the most common cause of pancreatic pseudocysts. Patients with chronic pancreatitis usually present with vague abdominal pain, early satiety, and sometimes nausea and vomiting.

The differential diagnosis of localized peripancreatic fluid collections includes cystic neoplasms (serous or mucinous cystadenomas or cystadenocarcinomas), acute pancreatic fluid collections (within 3-4 wk of acute illness), and organized pancreatic necrosis. (Patients with organized pancreatic necrosis are more ill than others.)

CT scanning is the diagnostic modality of choice and has a sensitivity of >90%. Ultrasonography and MRI are also used. Most pseudocysts resolve with expectant treatment. However, complications can occur and include infection with abscess formation, rupture into the peritoneum producing ascites, bleeding due to erosion of adjacent blood vessels, mass effect on the bile ducts that causes jaundice, and pyloric obstruction.

Drainage of pseudocysts is indicated when complications develop or when the patient becomes symptomatic. Drainage can be performed in 1 of 3 ways: surgically, percutaneously, or endoscopically by means of transmural or transpyloric approach. Surgical internal drainage (cystogastrostomy) is the criterion standard. This patient was referred to a gastroenterologist for possible endoscopic transmural drainage.

For more information about pancreatic pseudocyst, see the eMedicine articles Pseudocyst, Pancreatic (within the Radiology specialty) and Pancreatic Pseudocysts and Pancreatic Necrosis and Pancreatic Abscess (within the Internal Medicine specialty).
BACKGROUND
A 75-year-old man presents to the primary care clinic with a 4-week history of progressive abdominal swelling and early satiety after meals. He also complains of mild persistent nausea. He has no history of fevers, shortness of breath, or leg swelling, though he had a long history of alcohol use until about a year ago, when he had an episode of acute alcoholic pancreatitis. He subsequently stopped drinking alcohol.

Physical examination reveals mild pallor in the patient's general appearance with a blood pressure of 178/94 mm Hg, pulse of 84 beats per minute, respiration of 20 breaths per minute, and a temperature of 96.8°F. No icterus, cyanosis, or clubbing is identified. The patient's abdomen is distended, and he has tenderness to palpation on the left side. Laboratory examination reveals a WBC count of 7.0 X 10⁹/L (7000 cells/µL), a hemoglobin concentration of 11.0 g/dL, hematocrit of 37, and platelet count of 220 X 10⁹/L (220,000/µL). Results of liver function tests, including bilirubin levels, are normal. Serum amylase and lipase values are also in the normal ranges.

What is the diagnosis?
Hint
The patient was hospitalized 12 months ago for alcoholic pancreatitis.

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case 3 answer Abdominal Swelling in a 75-Year-Old Man

2007-05-30T13:35:00.000-07:00

case 3 Abdominal Swelling in a 75-Year-Old Man

2007-05-30T13:34:00.000-07:00

Abdominal Swelling in a 75-Year-Old Man
BACKGROUND
A 75-year-old man presents to the primary care clinic with a 4-week history of progressive abdominal swelling and early satiety after meals. He also complains of mild persistent nausea. He has no history of fevers, shortness of breath, or leg swelling, though he had a long history of alcohol use until about a year ago, when he had an episode of acute alcoholic pancreatitis. He subsequently stopped drinking alcohol.

Physical examination reveals mild pallor in the patient's general appearance with a blood pressure of 178/94 mm Hg, pulse of 84 beats per minute, respiration of 20 breaths per minute, and a temperature of 96.8°F. No icterus, cyanosis, or clubbing is identified. The patient's abdomen is distended, and he has tenderness to palpation on the left side. Laboratory examination reveals a WBC count of 7.0 X 10⁹/L (7000 cells/µL), a hemoglobin concentration of 11.0 g/dL, hematocrit of 37, and platelet count of 220 X 10⁹/L (220,000/µL). Results of liver function tests, including bilirubin levels, are normal. Serum amylase and lipase values are also in the normal ranges.

What is the diagnosis?
Hint
The patient was hospitalized 12 months ago for alcoholic pancreatitis.
Author: Gautam Dehadrai, MD, Department of Radiology, Norman Regional Hospital, Norman, Okla
eMedicine Editor: Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, Conn

case 2 answer Woman With an Acute Onset of Nausea and Vomiting

2007-05-30T13:32:00.000-07:00

Woman With an Acute Onset of Nausea and Vomiting

Answer
Cecal volvulus: The initial scout image (see Image 1) demonstrates a markedly dilated segment of bowel with a kidney- or coffee-bean appearance. The vector of the C-loop points toward the right lower quadrant and suggests a cecal volvulus. The axial CT image (see Image 2) demonstrates a colon dilated to 8 cm, with an air-fluid level. The collapsed ascending and transverse colon are adjacent to the dilated bowel (arrow).

The patient underwent exploratory laparotomy for the bowel obstruction and suspected cecal volvulus without a preoperative attempt at reduction. The cecum was edematous, with a dusky appearance (see Image 3). A floppy segment of bowel not adherent to the lateral wall had folded upward into the upper abdomen and twisted around; these observations were consistent with a final diagnosis of cecal volvulus. The volvulus was reduced, and the color of the involved bowel improved ("pinked up") nicely (see Image 4). Right colonic resection was performed (because of risk of recurrence and underlying ischemic damage having already occurred even though flow may be restored) with stapled ileocolostomy without complication. Pathology revealed ischemic changes, with marked dilatation and serosal adhesions; no perforation was observed. The patient recovered uneventfully.

Cecal volvulus is a condition characterized by twisting or folding of the right colon. Volvulus of the large bowel is the cause of approximately 10% of large-bowel obstructions. Cecal volvulus represents approximately 1-2% of intestinal obstructions and about one third of all cases of colonic volvulus. (Most cases are due to sigmoid volvulus.) Cecal volvulus occurs predominantly in patients with poor right colon xation (found in 10-25% of the general population) and is due to excessive cecal mobility.

Patients with cecal volvulus usually present with an acute onset of severe, colicky pain with nausea and vomiting unless partial obstruction is present or unless the volvulus is intermittent; in these cases, the onset may be relatively insidious. Abdominal distention may or may not develop. Sudden distention of the cecum due to trauma, laxative use, constipation, postpartum ligamentous laxity, or distal colonic obstruction are proposed etiologies. Cecal volvulus also occurs in a variety of other clinical situations, such as after colonoscopy or barium enema study and in pregnancy.

An abdominal series alone helps in diagnosing approximately 50% of all cases of cecal volvulus. Radiographs show a single air-fluid level in a dilated air-filled cecum in the mid abdomen or left upper quadrant. The cecal valve may produce a soft-tissue indentation, creating a coffee-bean or kidney-shaped appearance to the air-filled cecum. The small bowel should be dilated or fluid filled unless the process is early in its course and collapsed. If abdominal radiographs are nondiagnostic, CT scanning or contrast enema study helps in further defining the condition. Barium enema study can show beaking at the point of the volvulus in the mid ascending colon. CT scans show the volvulus itself and progressive tapering of the afferent and efferent limbs, which leads to a twist; this is described as the whirl sign.

Approximately 90% of patients with cecal volvulus have an axial twist of an ascending segment of the colon; this has been called a type 2 volvulus. About 10% have a cephalic fold of the cecum across the ascending colon in the transverse plane, or a type 1 volvulus (also referred to as a cecal bascule). The etiology of type 1 is controversial. Some believe that patients with type 1 volvulus have a focal adynamic ileus of the cecum, whereas some think that the cause is an adhesive band due to previous abdominal surgery.

Treatment usually consists of surgical reduction with or without colonic resection and ileocolostomy. Nonsurgical techniques, such as barium enema and colonoscopy, are less successful for reducing cecal volvulus than for sigmoid volvulus, and the rate of associated perforation is higher with a cecal volvulus than with a sigmoid volvulus. Nonsurgical reduction may be most successful in type 1, or cecal bascule type. Although treatment and management of both types is the same, a type 2 volvulus increases the risk of vascular compromise and perforation. Perforation occurs in 65% of cases involving mechanical distention combined with a vascular compromise. Gangrene is observed in as many as 20% of patients, and the mortality rate is estimated to be as high as 20-40% in the elderly.

For more information on cecal volvulus, see the eMedicine articles Cecal Volvulus (within the Radiology specialty) and Obstruction, Large Bowel (within the Emergency Medicine Specialty).

References

Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.

Ferderle M, Jeffrey RB, Anne VS, Erasco A. Diagnostic Imaging: Abdomen. Amirsys: Salt Lake City, UT; 2004.

Khan AN. Cecal volvulus. eMedicine Journal [serial online]. Available at: http://www.emedicine.com/radio/topic137.htm. June 29, 2005. Accessed July 18, 2006.

Weissleder R, Wittenberg J, Harisinghani MG. Primer of Diagnostic Imaging. St Louis: Mosby; 2003.

BACKGROUND
A 46-year-old woman presents to the emergency department with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and vomited twice the past several hours. She underwent laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or the passage of flatus since the pain began. She denies having fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.

On physical examination, the patient is awake, alert, and oriented. Her vital signs are in the normal range, with a heart rate of 84 beats per minute and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. Cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. Other physical findings are normal.

Laboratory investigation reveals an elevated WBC count of 14.0 X 10⁹/L (14.0 X 10³/µL) with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.

Contrast-enhanced CT of the abdomen and pelvis is ordered. Images 1 and 2 show an anteroposterior (AP) scout image and a selected axial section, respectively.

What is the diagnosis?
Hint
This entity is commonly described as various foods, specifically "beans".
Author: Craig Johnson, DO, Diagnostic Radiology Residency Program, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals

Rathachai Kaewlai, MD, Emergency Radiology Fellow, Massachusetts General Hospital-Harvard Medical School

Kenneth Nazinitsky, MD, Assistant Professor of Radiology, Diagnostic Radiology, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals
eMedicine Editor: Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, Conn

case 2 Woman With an Acute Onset of Nausea and Vomiting

2007-05-30T13:31:00.000-07:00

Woman With an Acute Onset of Nausea and Vomiting

BACKGROUND
A 46-year-old woman presents to the emergency department with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and vomited twice the past several hours. She underwent laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or the passage of flatus since the pain began. She denies having fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.

On physical examination, the patient is awake, alert, and oriented. Her vital signs are in the normal range, with a heart rate of 84 beats per minute and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. Cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. Other physical findings are normal.

Laboratory investigation reveals an elevated WBC count of 14.0 X 10⁹/L (14.0 X 10³/µL) with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.

Contrast-enhanced CT of the abdomen and pelvis is ordered. Images 1 and 2 show an anteroposterior (AP) scout image and a selected axial section, respectively.

What is the diagnosis?
Hint
This entity is commonly described as various foods, specifically "beans".
Author: Craig Johnson, DO, Diagnostic Radiology Residency Program, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals

Rathachai Kaewlai, MD, Emergency Radiology Fellow, Massachusetts General Hospital-Harvard Medical School

Kenneth Nazinitsky, MD, Assistant Professor of Radiology, Diagnostic Radiology, Northeastern Ohio Universities College of Medicine-Canton Affiliated Hospitals
eMedicine Editor: Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, Conn