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WWWTP #24 Answer…

July 1, 2015


Trauma patient came in to the ED:


What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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Anxiety Attack…

May 26, 2015


This patient presented with the chief complaint of an “anxiety attack.”  They felt short of breath, onset after arguing with another person, and they had a history of panic attacks in the past.  Here’s what we found…

Saddle Embolus 1 Saddle embolus 2 Saddle embolus 3

This is a scary pathology that is on the differential of panic attack:  saddle pulmonary embolus.

“Saddle” refers to a main pulmonary artery involvement.  In the images above you can see a filling defect just as the main pulmonary artery branches off to the right and left sides (see red arrow below).

saddle-embolus-3 (edit)

Large main pulmonary emboli are life threatening diagnoses that can easily progress to sudden death.

History of present illness in this patient screamed panic disorder.  However, we had some clinical clues that altered the direction of the case:  hypoxia to the high 80s, tachycardia, and an EKG with a right axis.  On review of systems the patient said she had had vague calf pain over the last week.  Thus we ended up pursuing CT imaging as opposed to treating her “panic attack” with benzodiazepines…good call!

Author:  Russell Jones, MD

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Student Corner: CT Evaluation of Appendicitis

April 9, 2015


Appendicitis is commonly encountered in the ER and is the leading cause of surgical emergency in the abdomen. The initial evaluation for a presentation that is concerning for appendicitis often includes history taking and exam, supplemented by labs. The Alvarado Score is a 10 point rating scale that is widely used as a tool to help decide whether or not a patient presenting with abdominal pain requires CT imaging (although it’s overall clinical usefulness is controversial). It is outlined here by MDCalc. According to the rule, a score of greater than 4 warrants CT evaluation and greater than 7 requires immediate surgical consult.  CT scan is a highly sensitive and specific tool in diagnosing appendicitis, however it comes with radiation, cost, and sometimes IV contrast risks.  In the pediatric patient population radiation from CT scans are not as desirable as the long-term consequences have theoretical potential to be deleterious (long discussion…for another post maybe!).

The purpose of this article is to go over characteristics of appendicitis that can be seen on a CT scan. The use of contrast is a long debated point of contention amongst the emergency medicine community and the usual practice varies between institutions. Medscape has a great rundown of the issue here, which notes that the use of contrast may be more beneficial in circumstances where appendicitis is a relatively less likely diagnosis because the contrast better helps characterize other possibilities.  Contrast studies are also more helpful in the patient not expected to have a large amount of intraperitoneal fat.

As usual, it is important to understand the local anatomy when analyzing radiological images of the abdomen. The image below is an example of an axial cut, non-contrast abdominal CT of a patient who came in with abdominal pain concerning for appendicitis. Try to identify the following structures: vertebrae, psoas major, IVC, iliac arteries, small bowel, colon and appendix.


And below is a labeled version of the same image:

Appendicitis labeled

Key: Blue arrow = bowel gas, ascending colon; Green arrows = small bowel; Purple arrows = L and R Iliac arteries; Yellow arrow = IVC; Red arrow = inflamed appendix

This image contains several signs that indicate that the appendix is inflamed. They include:

  • Diameter greater than 6mm–this usually implies the the appendix has either been twisted or blocked off from the cecum by an appendicolith, which causes inflammation
  • Periappendiceal fat stranding–seen as distinct lines that radiate out from the appendix in the image above, it is caused by inflammation of the appendix causes fluid accumulation around the wall of the appendix which turns the normally hypodense surrounding fat into a hyperdense area; note that the visceral fat around the appendix on the L side of the image looks much different than the visceral fat on the other side of the image
  • Appendiceal wall thickening–normally the wall of the appendix is thin and barely noticeable, but this image shows that the wall is generally thickened and may even be slightly more hyperdense than expected (more below)

Other signs that aid in the diagnosis of appendicitis include:

  • Appendiceal wall enhancement–the wall of the appendix becomes slightly more hyperdense when you compare it to the wall of any other loop of bowel, which is again a product of inflammation; note that this finding is usually more evident on contrast-enhanced CT
  • Abscess–the colon has a large reservoir of commensal bacteria, which can grow and wall off into an abscess if they are trapped in the appendix
  • Appendicolith–a calcified mass that is hyperdense on CT which can be an obstruction between the cecum and the appendix

Overall, CT has a high degree of sensitivity and specificity when used to evaluate the possibility of appendicitis. The clues outlined above, especially when seen together and as a part of a larger clinical picture that fits with appendicitis, are instrumental in confirming the diagnosis.


Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review.BMC Med. 2011 Dec 28;9:139. doi: 10.1186/1741-7015-9-139. Review. PubMed PMID: 22204638; PubMed Central PMCID: PMC3299622.

Reich B, Zalut T, Weiner SG. An international evaluation of ultrasound vs. computed tomography in the diagnosis of appendicitis.Int J Emerg Med. 2011 Oct 29;4:68. doi: 10.1186/1865-1380-4-68. PubMed PMID: 22035447; PubMed Central PMCID: PMC3215954.

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WWWTP #23 (What’s Wrong With This Picture?) Answer

March 12, 2015


Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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Flank Pain…

February 10, 2015


Flank pain for several days, history of nephrolithiasis:

Flank Pain 1 Flank Pain 2 Flank Pain 3 Flank Pain 4

This patient has marked right hydronephrosis with significant right renal perinephric inflammatory cystic changes extending into the contiguous right psoas musculature and right retroperitoneum. There is perinephric stranding and edema.

The differential in this case includes renal abscess (most likely) with extension into the right psoas and retroperitoneum.  Additional considerations are atypical infection such as tuberculosis, and urothelial malignancy.

The patient ended up having Xanthogranulomatous pyelonephritis.  This is a subacute/chronic pyelonephritis usually incited by a staghorn calculus.  For more information on this entity please see

Author:  Russell Jones, MD


1.  Knipe H, Gaillard F et al.  Xanthogranulomatous Pyelonephritis.  Accessed 1/2015.

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Rice bodies…

January 15, 2015


Elderly gentleman came to the ED because he was wandering around the neighborhood.  A bystandard called 911.  He was pleasantly confused, had a mental status consistent with dementia.  The only other pertinent physical exam finding was some erythema, cellulitic appearance to his ankle.  We obtained a tibia and fibula xray looking for gas in the setting of cellulitis and this is what we found:

Rice bodies 2Rice bodies 1


The densities in the soft tissue of his legs are “Rice bodies.”  They are sometimes seen in systemic cysticercosis.  These bodies are calcified dead cysts from the organism Taenia Solium.  Typically this tapeworm is found in pork.  Taenia Solium is rare in the U.S., it is more prevalent in underdeveloped countries especially with a diet that has potential to include raw or undercooked pork.  This should also be on your differential with new onset seizures (1).


Multiple calcifications 1


He also had rice bodies on head CT.  Possibly the cause of his dementia?

Author:  Russell Jones, MD


(1) Parasites – Taeniasis.  Accessed 1/2015.

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Student Corner: A Cavitary Lesion

January 6, 2015


Cavitary lesions in the lungs are gas or fluid filled compartments in an area of pathology, such as a consolidation or a mass. Interestingly, a specific set of pathologies are known to cause this specific finding. Cavitary lesions can be detected on a chest x-ray, as is shown below.

cavitary-mass with IDCavitary masscavitary mass lateral with IDCavitary mass 2

Legend: Red Ellipse–cavity (with margins), Blue Ellipse–air-fluid level

The lesion practically jumps out of the picture on the AP view, but the colored circles are there just to point out the entire area of pathology (blue) and the cavity within (red). The pathology is a bit harder to see on lateral view, but the cavity has an air-fluid level that is easily identified as a vertical line separating a lighter fluid filled portion from an air filled portion. This air-fluid interface is often called a meniscus. You might remember being in chemistry class and measuring water out of tall beakers where the water stuck to the sides of the glass creating a concave meniscus. The surface tension of water allows it to stick to both itself and surrounding surfaces. If you look close enough, you’ll notice that the air-fluid level in the image above, best visualized in the AP view, has a slightly concave shape because the liquid at the bottom is sticking to the solid sides of the cavity.

The underlying pathophysiology is an interesting concept to understand when discussing cavitary lesions. A cavity can form in lung tissue for various reasons, but infection is the major underlying cause. Abscesses are localized collections of pathogens, fluid and immune system components that are walled off from the surrounding tissue, therefore creating a fluid-filled cavity. Tuberculosis is a disease process that involves caseous necrosis, which results in coagulation of cell proteins and liquefaction of cellular components. Eventually, the liquid portion drains out through the lymph system or through the bronchi, leaving air pockets behind. Necrotizing pneumonia and non-infectious processes such as ischemia and neoplasm can also cause a similar picture. Rheumatologic diseases such as granulomatosis with polyangitis and sarcoidosis also cause cavitary lesions by causing localized inflammation, which in turn leads to an area of increased mass, which then in turn can cavitate once the inflammatory reaction recruits fluid to the area. In other words, most of these processes, even if they aren’t inherently related to one another, all converge on the same mechanism of causing a localized area of inflammation.

With such a wide array of categories to choose from, it is perhaps more important than usual to contextualize the radiographic image with information about the patient.

This particular patient is a 30 year old male who presents with a cough.  He has been traveling around the world to multiple continents including Sub-Saharan Africa.  The extensive travel history, including to continents with rare infectious diseases leaves infection at the top of the differential. Things like Staphylococcal pneumonia, fungal infections and even amebiasis are possible because of the patient’s travel history. For a complete list of the infectious causes of a cavitary lesion, check the first two references at the bottom of the page.


Gadkowski LB, Stout JE. Cavitary Pulmonary Disease. Clinical Microbiology Reviews 2008;21(2):305-333. doi:10.1128/CMR.00060-07. (LINK)

Ryu, Jay H. et al. Cystic and Cavitary Lung Diseases: Focal and Diffuse. Mayo Clinic Proceedings , Volume 78 , Issue 6 , 744 – 752. (LINK)

Good pathologic image of caseous necrosis with resulting cavitation

Image Contributor:  James Luz, MD

Author:  Jaymin Patel

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What valve has been replaced?

December 16, 2014


Here is a patient with a cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat helps with this dilemma:

If we apply the rules from to our patient, it appears he has an aortic valve:

Valve Lat EditedValve Lat

Valve AP editValve AP

AV = Aortic Valve*

TV = Tricuspid Valve*

MV = Mitral Valve*

PV = Pulmonic Valve*

*These are anticipated locations.  The locations could be altered if the patient has anatomic variations such as chamber enlargement, cardiac rotation, etc.

RadDaily also has additional information using flow directional clues from the shape of the valves.  Check it out!

Author:  Russell Jones, MD

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What valve has been replaced?

December 10, 2014


Here is a patient with a prosthetic cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

Answer to follow.

Author:  Russell Jones, MD

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Massive splenomegaly…Answer

November 17, 2014


Last week I showed you this CT showing massive splenomegaly:

Splenomegally + Masses


The abdominal CT above shows massive splenomegaly with various areas of hypo attenuation throughout the spleen.  Massive splenomegaly is a term used when the volume of the spleen is expected or calculated to be >1000 grams or clinically extends well into the left lower quadrant or past midline.

A short differential diagnosis for massive splenomegaly includes (1):

  • Malaria
  • Myelofibrosis
  • Leukemia (especially CML)
  • Polycythemia Vera
  • Lymphoma (several types)
  • Lieshmaniasis
  • Thalessemia

The ill-defined hypo attenuated lesions in this spleen raise a high concern for lymphoma.

Author:  Russell Jones, MD


1.  Luo EJ, Levitt L.  Massive Splenomegaly.  Hospital Physician, 5/2008.  Accessed 11/2014 at:

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