Archive | February, 2013

Left Lower Lobe Pneumonia…

February 27, 2013


Just a quick image of left lower lobe pneumonia today:

LLL pneumonia

In this image the left heart border is obscured and there is an infiltrate taking up airspace in the left lower lung.  That’s it, nothin’ fancy about it.

The symptoms of pneumonia described by Hippocrates (c. 460 BC – 370 BC) (1):

Peripneumonia, and pleuritic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common… When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand.

Begs the question:  what does “purged” mean?

Author:  Russell Jones, MD


1.  Pneumonia History.

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Interesting ultrasound of the RUQ…

February 24, 2013


This is a right upper quadrant (RUQ) ultrasound in a middle-aged female presenting with upper abdominal pain:

West Sign GB

What the heck is going on here?

In this image there is an example of a “Wes” sign.  Wes sign is when you see two echogenic lines separated by a hypoechoic space at the expected wall of the gallbladder (1).  This sign is often found with a large calculi occupying the entire lumen of the gallbladder (or when the gallbladder is contracted around a large calculi).  This case, however, is somewhat interesting in that there isn’t an acoustic shadow beyond the majority of the hyperechoic mass inside the gallbladder.  You can the typical expected acoustic shadow near the neck of the gallbladder in this image.  Our thoughts as well as radiology’s thoughts were that this image represents a large calculus at the neck with dense sludge or a bunch of very small calculi filling the rest of the gallbladder (thus allowing sound waves to penetrate beyond).  Fortunately for the patient her pain got much better, she was discharged and is expected to get an elective cholecystectomy in the near future.  Here is a link to an article discussing the “Wes” sign from the Radiology Society of North America:

Wes Sign

Author:  Russell Jones, MD


1.  Rybicki F.  The Wes Sign.  Radiology 2000; 214: 881-882.

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WWWTP #5 Answer

February 21, 2013


This is a 47-year-old gentleman with right lower quadrant abdominal pain:

Omental infarct 1 edited

The arrow points to a well-circumscribed area of fat stranding and inflammation in the right lower quadrant.  This is highly suspect of an omental infarct.

I must confess, in my short tenure as an ED physician I had never come across this diagnosis.  I had to look it up.  Here’s a link to case report which discusses omental infarction from the International Journal of Surgery Case Reports:

Omental Infarction

Quick summary (1):  As it turns out this is somewhat rare but can present much like appendicitis.  It is estimated to occur 4 times per 1000 cases of appendicitis.  Omental infarction is most common in the right lower quadrant and can be associated with various medical disorders such as vasculitis, hypercoagulability, polycythemia, pancreatitis, omental cysts, tumors, and adhesions.  However, most of the time it is idiopathic and seems to have an association with obesity.  The theory is that fatty accumulation in the omentum impedes the distal right epiploic artery or causes a torsion of the omentum.  CT is the diagnostic imaging of choice but this is sometimes caught with laparoscopic exploration for presumed appendicitis.  CT signs include the well-circumscribed fatty inflammation, fat stranding, and a “whirl sign.”

Another free article from the Journal of Surgery Education with a great CT image of the “whirl” sign:

Whirl Sign

The treatment of omental infarction used to be surgical exploration (2).  General consensus currently suggests a course of conservative, non-surgical management with supportive care (however there is no authoritative therapeutic strategy).  From reading both of these case reports it seems to reason that a trial of inpatient supportive care with laparoscopic exploration and omental resection if the patient clinically doesn’t respond.   As an ED physician, I would suggest getting surgery involved and deferring to their surgical expertise with the knowledge that there is no clear answer between supportive care and immediate surgical intervention.

Author:  Russell Jones, MD


1.  Kushal PB, Benjamin CK.  Diagnosis and management of idiopathic omental infarction:  A case report.  Int J Surg Case Rep.  2011; 2(6): 138-140.

2.  Itenberg E, Mariadason J, Khersonsky J, Wallack M.  Modern Management of Omental Torsion and Omental Infarction:  A Surgeon’s Perspective.  J of Surg Ed.  2010; 67(1): 44-47.

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WWWTP? #5 (What’s Wrong With This Picture?)

February 18, 2013


47-year-old male presents with right lower quadrant abdominal pain for 24 hours.  Here is his CT abdomen:

Omental infarct 1Omental infarct 2

What’s wrong with this picture?

Answer to follow.

Author:  Russell Jones, MD

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Good tip for reading CTs…

February 15, 2013


This person came in after a high speed motor vehicle collision.  Their main complaint was neck pain near C-7:

Spine + PTX 1Spine + PTX 3

As you can see under bone windows there is a fracture of C7.  One could stop here and be satisfied that you see the primary pathology in which you were interested.  However, anytime you look at a CT you should pay attention to all parts of the image.  Secondary findings are very common, especially in trauma.  When assessing a CT image, one should change windows on the image to adequately look at all types of tissue that are present.  In a cervical spine CT, the top of the lungs are usually visualized in the catchment area as you get to the upper t-spine.  If you change the window to “lung” windows this is what you’ll see:

Spine + PTX 4

This person also has an anterior, small pneumothorax!  This could have easily been missed if not changing the window to look at the lungs.

One of the basics of CT imaging is to  change windows for all types of tissue.  In the head, your main window change will be from “brain” to “bone” to adequately visualize bony structures of the calavarium.  In the abdomen you should switch to “lungs” to visualize the lungs as well as switch to “bone” to visualize the ribs, pelvis, and spine.  There are many other examples of this principle, but we will leave it at this for now.

Author:  Russell Jones, MD

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Cost Transparency doesn’t reduce testing…

February 11, 2013


Would physicians order less tests if they knew the cost?  Researchers in the Department of Radiology at John’s Hopkins say no.  This month’s issue of the Journal of  American College of Radiology includes a study on the subject:

Durand DJ, Feldman LS, Lewin JS, Brotman DJ.  Provider cost transparency alone has no impact on inpatient imaging utilization.  J Am Coll Rad. 2013 Feb;10(2):108-13 PMID:  23273974

Quick Summary:

The study used retrospective data to identify 10 of the most-utilized radiology tests in their institution.  During a baseline period they measured imaging utilization in a control and an active group.  During the intervention period (which was seasonally matched) they showed the cost of imaging to the active group prior to test utilization.  They measured a mean utilization change between groups and found that there was no statistically significant difference between groups.  They concluded that showing physicians the cost of the test doesn’t dissuade them from utilizing the imaging.

My Thoughts (not to be taken as the expert opinion!):

This is an interesting article that can lead some to believe that physicians don’t care about the cost of imaging.  It strikes a subject that is very “sexy” in the news due to the ever-rising cost of healthcare.  It is no mystery that imaging utilization is increasing on a yearly-basis and at some point the cost to society may outweigh the benefit.  However, in today’s litigious society physicians aren’t willing to risk misses and not utilize imaging capability that is literally in the next room.  I unfortunately don’t have a solution.  However, this article suggests that putting a price tag in front of us is not the answer.

Perhaps the regulatory control agencies can solve the problem (I just chuckled a bit).  In 2012, Centers for Medicare and Medicaid Services (CMS) decided to run a “dry run” measure of ED Head CT usage in non-traumatic headache.  I haven’t heard of the results yet, has anyone else?

Author:  Russell Jones, MD

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Mandible fracture

February 8, 2013

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We’ve all seen it…the dude that had two beers after church and got jumped by a couple guys while he was minding his own business.

Mandible fx 1Mandible fx 2Mandible fx 3Mandible fx 4

This Facial CT demonstrates several comminuted fracture lines through the mandible.  CT imaging is highly sensitive and specific for mandible fractures and is the imaging-of-choice in most emergency departments.  Plain films can also be obtained but subtle fractures can be missed; the extent and characterization of the fractures is much better identified on CT.

Its always difficult in the minor facial trauma to know when to pull the trigger and order a CT of the face…especially in the current environment of questioning CT utilization.  Some clinical exam findings that would increase your suspicion of mandibular fracture include (1):

1.  The patient having subjective feeling that their “teeth don’t fit.”

2.  Malocclusion.

3.  Anesthesia of the upper lip or chin (mental nerve distribution).

4.  Pain or tenderness near the anterior ear, especially with mandibular range-of-motion.  This is concerning for mandibular condyle fracture but also could represent TMJ strain, sprain, or dislocation.

An obvious deformity, laceration of the gingival area (indicating an open fracture), or severe mechanism are high concerns for mandibular fracture and CT imaging should be considered.  The “tongue blade test” (have the patient bite down on a tongue blade with their molars on both sides.  Negative test if the patient is able to break the tongue blade) has a 95% sensitivity in excluding injury in a patient with mild jaw pain and no obvious injury or instability (1).

Author:  Russell Jones, MD


1.  Bailitz J.  Trauma to the Face.  In:  Tintinalli JE, Stapczynski JS, et al.  Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide.  7ed.

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Pneumorrhacis. What?

February 4, 2013


I admire radiologists for their medical vocabulary.  I was sent some images from one of my colleagues the other day demonstrating “pneumorrhacis.”  Being a simple minded ER doc, I had to look it up.


Pneumorrhacis:  air in the intra or extra dural space (1).  For a good, concise summary of this rare phenomena see


This patient was a trauma patient with a pneumothorax as the source of the air.  You can see on the CT there is air everywhere!  Its basically dissecting fasical planes in the neck, chest, and abdominal wall in addition to the extradural space.

Here is a brief review article discussing pneumorrhacis from the European Spine Journal (2).  It is available on PubMed for free download or from this link:

Pneumorrhacis article

Author:  Russell Jones, MD

Image Contributor:  Steve Glocke, MD


1.  Pneumorrhacis.

2.  Oertel MF, Kornith MC, Reinges MH, et al.  Pathogenesis, diagnosis, and management of pneumorrhacis.  Eur Spine J (2006) 15 (Suppl. 5):S636–S643

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February 1, 2013


This image was sent to me by one of my colleagues.  He saw an un-immunized 22-year-old with sore throat and muffled voice:

EMREMS epiglottitis

This CT shows swelling and edema in the epiglottis.  CT imaging of this diagnosis can occur in the STABLE epiglottitis patient.  It will likely be a patient with unclear pathology and identified on CT rather than a easily clinically identified epiglottitis.  Why?  Because clinical epiglottitis that is very clearly identified is an airway emergency and they don’t end up in the CT scanner.  The classic appearance will be a patient in the “tripod” position, drooling, stridor, hoarse voice, and looking ill.  Lateral soft-tissue plain films can also make the diagnosis.  Usual suspects causing epiglottitis include:  H. Influenza, S. Aureus, Streptococcus sp., and Moraxella Catarrhalis (1).

Epiglottitis affects both children and adults and should be on your differential in an adult with these symptoms.  Since childhood vaccinations have become widespread in developed countries the incidence of childhood epiglottitis has decreased.  The incidence has remained stable in adults.  This patient is interesting because of the un-immunized status.

Some thoughts pertaining mainly to children:

CT imaging of the neck in children is a controversial subject.  Remember that the thyroid gland is anatomically present in the radiation area and the future risk of thyroid malignancy isn’t quite known.  You must weight the risk of radiation against the benefit of the imaging test in this situation.  CT is very good at detecting and characterizing childhood illnesses such as peritonsillar abscess, retropharyngeal abscess, and epiglottitis.  If you highly suspect one of these pathologies CT is usually warranted as these diagnoses can cause significant morbidity and will many times need intervention.  Keep in mind, however, that soft tissue neck plain radiographs may give you enough information to direct management and has much less radiation burden.

Some radiology signs are applicable to epiglottitis:

1.  Thumbprint sign:  on lateral CT or Plain film the epiglottitis will resemble a thumb in shape and size rather than the expected thin appearance.  This is present on the CT above.

2.  Halloween sign:  describes the usual appearance of the epiglottis on CT axial cut.  See image on Wikipedia®.  Halloween Sign.

Author:  Russell Jones, MD

Image Contributor:  James Chenoweth, MD


1.  Epiglottitis.

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