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Liver mass…differential diagnosis

July 14, 2014

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This patient presented with right upper quadrant pain.  I asked last week what your differential diagnosis would be:

Liver Mass 1

Liver mass 2

The CT above shows a multiloculated, rim-enhancing mass in the liver parenchyma.  This is consistent with an abscess.  The differential diagnosis starts by breaking down the categories into bacterial, fungal, and amebic causes. 

Bacterial:  Abscesses can form from ascending cholangitis, especially in setting of biliary malignancies.   Klebsiella pneumoniae has been reported to cause hepatic abscesses, especially in E. Asia (1).  Patients with recent instrumentation (hepatocellular carcinoma embolization, etc) are at risk for MRSA, streptococcus species.  Tuberculosis has been known to cause hepatic abscesses as well.

Fungal:  Disseminated candidiasis in the immunocompromised host can lead to liver and splenic abscesses

Amebic:   Liver abscess is the most common manifestation of extraintestinal entamoeba histolytica (2).  In endemic areas or travelers to endemic areas are at risk for this occurrance. 

Author:  Russell Jones, MD

References

1.  Davis J, McDonald M.  Pyogenic Liver Abscesses.  www.uptodate.com

2.  Leder K, Weller P.  Extraintestinal Entamoeba Histolytica Amebiasis.  www.uptodate.com

 

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Liver mass…

July 7, 2014

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This patient presented with right upper quadrant pain…

Liver Mass 1

Liver mass 2

The CT above shows a multiloculated, rim-enhancing mass in the liver parenchyma.  What is your differential diagnosis?

Author:  Russell Jones, MD

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Aortic dissection…

June 16, 2014

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This patient presented with chest pain radiating to the back:

AD CXR 1

 

The patient’s initial chest X-ray shows a widened mediastinum and an indistinct aortopulmonary window.  CT showed:

AD CT 1 AD CT 2 AD CT 3

This patient has an aortic dissection.  There are two different classification systems for aortic dissection:  Stanford and DeBakey (1).

Stanford Criteria:

  • Type A:  The dissection flap involves the ascending aorta
  • Type B:  The dissection commences distal to the left sub-clavian artery

DeBakey Criteria

  • Type I: The dissection flap involves the ascending aorta and descending aorta
  • Type II:  The dissection flap involves the ascending aorta only
  • Type III:  The dissection flap involves the descending aorta only

This is a Stanford Type A and a Debakey Type I because it involves the ascending aortic arch all the way to the iliac bifurcation.

What is important to remember (besides the number for a cardiothoracic surgeon)?  If the flap involves the ascending aorta these are usually managed operatively. Descending dissections are many times managed medically (1).

Besides rupture, the main problem with aortic dissection is perfusion to various organs.  Virtually every solid organ can be affected depending on the spacial characteristics of the dissection flap.  In this case the last image clearly shows that the right kidney is not perfused, indicating that the dissection flap has occluded the right renal artery.  The kidneys and bowel are the most common organs to develop ischemia.

Author:  Russell Jones, MD

Image Contributor:  Jay Williams, MD

References

  1. Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier, 2011.
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More colonic dilitation…

June 9, 2014

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This patient presented with abdominal pain, nausea, vomiting, and distention:

Volvulus 1 Volvulus 2 Cecal Volvulus 2 Cecal Volvulus

These films and CT show colonic dilatation similar to last week (sigmoid volvulus).  However, in contrast to last week, this is a cecal volvulus.  In this CT there is marked dilatation of the cecum with a central location in the abdomen.  Usually a cecal volvulus will have visible haustra as opposed to a sigmoid volvulus in which colonic haustra will not be present.  Sometimes, as in the above images, the haustra are difficult to see.  This also looks like it may be a more rare form of cecal volvulus called a cecal bascule.  For more information I will defer to our radiology colleagues at Radiopaedia:

Caecal Volvulus

For all you radiologists out there, do you think this is consistent with a cecal bascule?

Why note the difference between cecal and sigmoid volvulus?  The treatment can be drastically different.  Sigmoid volvuli are many times amenable to acute management non-operatively (sigmoidoscopy) whereas cecal volvuli usually require open laparotomy and have a higher frequency of partial colectomy.

Author:  Russell Jones, MD

References

1.   Gaillard F et al.  Caecal Volvulus. http://radiopaedia.org/articles/caecal_volvulus

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Colonic dilitation…

June 2, 2014

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This is a 50 year old male who presented with nausea, vomiting, and abdominal distention.  His initial plain film showed:

CV 1

A CT scan was ordered for given suspicion for colonic obstruction:

CV Scout 1 CT Swirl 1

 

The CT scout film clinches the diagnosis with the classic “Coffee Bean” sign consistent with a sigmoid volvulus. The CT scan not only shows the massively dilated colon but demonstrates the associated “swirl” sign of the mesentery (arrow). He underwent a flexible sigmoidoscopy with partial reduction of his volvulus.  He then underwent a colectomy for definitive management of his volvulus.  He had a return of bowel function and discharged a week later.

Author:  John Ray, MD

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Antibiotic beads in a knee…

May 26, 2014

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This patient had a history of osteomyelitis of his distal femur and a septic knee.  This caused significant destruction requiring knee replacement and antibiotic bead placement (the radio opaque spherical objects).  He re-presented several weeks later with fever and knee pain:

Antibiotic beads 1

Antibiotic beads 2

There are multiple issues with these radiographs that are chronic.  It was helpful clinically to have a comparison which showed that the hardware was all intact and unchanged.  The ACUTE finding on this radiograph is radiolucency under the patella (as well as proximal to the patella) concerning for gas.  This patient was taken to the operating room for a septic joint (again).

Author:  Russell Jones, MD

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Multifocal opacities…

May 12, 2014

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A patient presented to the ED with flu-like symptoms in the height of flu season:

multifocal opacities

Chest CT:

Multifocal opacities CT 2 Multifocal opacities CT

The CT demonstrates multifocal opacities with some cavitation on the larger lesions.  There seems to be a peripheral and lower-lobe predominence.  This could represent atypical pneumonia (legionella, mycoplasma, chlamydia), fungal pneumonia (cocciodomycosis, histoplasmosis, aspergillosis), miliary tuberculosis, metastatic lesions or carcinomatosis, septic emboli, or viral pneumonia.

After a significant inpatient workup the final diagnosis was Human Metapneumovirus.  All others were ruled out and viral testing revealed this culprit.

Image contributors:  David Barnes, MD and Julie Phan, MD

Author:  Russell Jones, MD

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Interesting osteomyelitis…

May 6, 2014

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This patient presented with multiple skin lesions with an ulcerative mass to his thumb…

OM hand

This patient had an ulcerative, indurated lesion to the distal thumb which can be seen on the above radiograph.  The radiograph also demonstrates periostitis and osseous erosion of the distal thumb and metacarpal joint of the thumb.  There are subtle periosteal changes to the third phalanx as well.

It turns out this patient has sporothrix schenkii osteomyelitis.

Author:  Russell Jones, MD

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Is the KUB dead?

May 1, 2014

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Before CT abdomen became commonplace in the ED, a plain radiograph of the abdomen (KUB for Kidneys, Ureters, and Bladder) was often a screening for kidney stone.  Currently, ultrasound and CT abdomen are used quite often to diagnose ureterolithiasis as they offer much more information.  Is the KUB dead?

The answer is no.  KUB still has a place particularly in monitoring the progress of known kidney stones.  I personally use them for repeat customers to assess progress (or more often prove to urology that they have not progressed).  Helpful hint:  if a patient is presenting for a second ED visit for kidney stone pain, check their scout film if they had a prior CT.  If you can see the stone on scout film, you can definitely re-image the patient with a KUB to reevaluate the location of the stone.  Here is an image of an 8mm stone in the upper right ureter (lateral to L3)  as seen on KUB:

KUB stone

This patient has an 8mm stone and presented to the ED with failed outpatient management.  The stone hadn’t moved from a prior CT scan after 1 week of symptoms.  Urology elected to take the patient to the OR for operative management. 

Please comment if you have another good use of the KUB in the ED. 

Author:  Russell Jones, MD

 

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Tearing abdominal pain…

April 24, 2014

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This is a 60 year old male who presented with tearing abdominal pain…

SMA dissection 1

This CT angiogram of the abdomen shows a superior mesenteric artery dissection.  The aorta was normal.  On the above CT image you can see a flap dissecting the SMA.

SMA dissection is a rare pathology in the abdomen.  It can lead to localized mesenteric ischemia and presents with severe abdominal pain.  It is treated various ways including medical management and observation, endovascular repair, or surgical revascularization (1).  Many times it is associated with aortic dissection with a dissection flap extending into the SMA.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

References

1.  Gobble RM, Brill ER, Rockman CB et-al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J. Vasc. Surg. 2009;50 (6): 1326-32.

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