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Device for spasticity…

March 11, 2014

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Here is a CT (with scout film) showing a not-to-uncommon device placed in the abdominal wall:

Baclofen 1 Baclofen 2 Baclofen 3

This is an example of an intrathecal pump, commonly used to deliver baclofen.  The first image shows the pump tubing coursing on the abdominal wall, into the thecal space (inserting just lateral to the spinous process of the lumbar vertebrae).  The second image shows a crossection where the pump is located in the abdominal musculature.  The scout film gives you a good idea how big these pumps are.  They have a reservoir port for percutaneous refilling of the baclofen and they can be interrogated for functioning and changing settings. 

Complications of these can include pump failure, baclofen running empty, tubing kink or breakage, and infection/hematoma, and a cerebrospinal fluid leak at the site of insertion.

Author:  Russell Jones, MD

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Interesting finding on “Pan Scan”…

January 24, 2014

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The trauma “Pan Scan” has been a controversial topic for a while now.  “Pan Scan” has multiple meanings but is usually some combination of head, c-spine, chest and abdomen CT imaging to identify serious traumatic related injuries.  Downsides include cost, radiation, and contrast.  Upsides include early identification of serious trauma including solid organ injuries.  Here is an interesting case that presents an original argument for the “Pan Scan:”

Pills in skin folds 2 Pills in skin folds

This person came in with altered mental status and trauma (single car MVC).  CT identified a large number of hidden pills later identified as an opioid pain medication.  They were hidden in an abdominal fold just above the pubis!

(Disclaimer:  Please don’t misinterpret this as an argument to identify pills with a pan scan.  It would have been much more cost effective to find them on physical exam)

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Elderly male with syncope…

December 18, 2013

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One of my colleagues had an interesting case the other day.  An elderly patient came in after a syncopal event.  The only complaint was mild lower back discomfort.  Bedside ultrasound revealed the etiology (later visualized on this CT):
AAA 2

AAA 3

This CT shows a large infrarenal abdominal aortic aneurysm (AAA) that extended down into the iliac arteries bilaterally.   The aneurysm had intraluminal clot and concern for impending complete rupture near the iliac bifurcation.  The patient was expeditiously taken to the OR for operative repair.

This is a good case that demonstrates the utility of bedside ultrasound in the ED.  Syncope is an event that can be caused by a large variety of pathophysiology, AAA being one of the most feared.  It is very important in this situation to have a high index of suspicion and make the diagnosis quickly, accurately, and disposition the patient to the appropriate care.

For a brief tutorial on bedside aortic ultrasonography I refer you to a great blog from Mount Sinai:

Sinai EM Ultrasound

Image Contributor:  Rupi Chima, MD

Author:  Russell Jones, MD

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Heterotopic pregnancy CT….

November 24, 2013

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22-year old female came in with RLQ pain and a reported ultrasound positive intrauterine pregnancy a week ago, a visit two days ago consistent with spontaneous incomplete Ab on ultrasound.  On exam her RLQ was very tender, US showed minimal blood products in uterine cavity no IUP.  Serum beta-Hcg >5000. 

CT abdomen/pelvis:

Ectopic 1 Ectopic 2

CT shows fluid in pelvis with consistent with blood and has a right adenexal hemorrhagic mass consistent with ruptured ectopic pregnancy.

This patient, by history, had a documented intrauterine pregnancy that resulted in a spontaneous abortion.  She had the feared Heterotopic pregnancy.  Heterotopic pregnancy is when a dual gestation occurs, one in the uterus and one in the fallopian tube in an ectopic location.  It is very rare although seen in increasing prevalence with the advent of ovulation induction drugs (she was not taking these drugs!). 

Author:  Russell Jones, MD

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Big stone…

September 14, 2013

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Middle-aged male came in with left flank pain…

Staghorn Calculi 1 Staghorn Calculi 2

This patient has a large staghorn calculi with stranding around the area of the expected renal calyx.  This is highly suspect for a calyceal rupture.

This is an excerpt taken from the American Urological Association’s 2005 guidelines on the management of staghorn calculi:

Staghorn calculi are branched stones that occupy a large portion of the collecting system. Typically, they fill the renal pelvis and branch into several or all of the calices. The term “partial staghorn” calculus designates a branched stone that occupies part but not all of the collecting system while “complete staghorn” calculus refers to a stone that occupies virtually the entire collecting system. Unfortunately, there is no consensus regarding the precise definition of staghorn calculus, such as the number of involved calices required to qualify for a staghorn designation; consequently, the term “staghorn” often is used to refer to any branched stone occupying more than one portion of the collecting system, ie, renal pelvis with one or more caliceal extensions. Furthermore, the designation of “partial” or “complete” staghorn calculus does not imply any specific volume criteria.

The guidelines can be found here:

AUA REPORT ON THE MANAGEMENT OF STAGHORN CALCULI (2005)

Although all types of stones can grow to staghorn calculi, most are composed of struvite and/or calcium carbonate apatite.  These stones have a strong association with urinary tract infection from organisms that produce urease.  These stones are often causative agents in calyceal rupture, as in the patient above.  Management is dependent on the patient’s symptoms, signs of urosepsis, and multiple other cofactors.  Per the report above, percutaneous nephrolithotomy is the first-line procedure of choice for most patients.  Sometimes shock-wave lithotripsy is required as well as percutaneous nephroscopy.  Please refer to the above guidelines for more information if desired.

Author:  Russell Jones, MD

References:

1.  Preminger GM, et al.  AUA Report on the management of staghorn calculi.  2005.  http://www.auanet.org/education/guidelines/staghorn-calculi.cfm.  Accessed 9/2013.

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Bosniak classification for renal cysts…

June 14, 2013

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Had a gentleman come in for trauma to the abdomen and his incidental finding on CT abdomen was a “Bosniak Type-2 renal cyst”:

Bosniak 2 cyst

On the right kidney you can see a hypoattenuated lesion, less than 3 cm. 

Kidney cysts are one of the most common incidental findings in radiology.  There exhists a Bosniak classification system to help with further workup.  A summary can be found on radiopaedia.org:

Bosniak renal cyst classification

Author:  Russell Jones, MD

References

1.  Weerakkody Y, Gaillard F, et al.  Bosniak renal cyst classification.  www.radiopaedia.org.  Accessed 5/2013.

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Pancreatitis CT…

May 18, 2013

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A colleague pointed out an interesting CT on a patient with epigastric pain…

Pancreatitis CT2Pancreatitis CT1Pancreatitis CT 3

This CT shows stranding around the pancreas with fluid tracking in Gerota’s fascial plane.  What is Gerota’s fascia you say?

Gerota’s fascia (otherwise known as “Renal Fascia”) is the layer of connective tissue surrounding the kidneys and suprarenal glands.  Anterior to this fascial compartment is the prerenal space which contains the pancreas, ascending colon, descending colon, and the second-fourth portions of the duodenum.  Any inflammation with these organs can lead to fluid within Gerota’s fascia.  On the CT above this is demonstrated by the fluid stripe anterior to the left kidney on the middle image (sagittal plane)  and superior to the left kidney on the third image (coronal plane).  For an anatomic picture of Gerota’s fascia see the following Wikipedia reference:

Gerota’s Fascia

Author:  Russell Jones, MD

Image Contributor:  Tag Hopkins, MD

References

1.  Renal Fascia. http://en.wikipedia.org/wiki/Renal_fascia.  Accessed: 5/2013

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Really bad GI bleeder…

May 7, 2013

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We’ve all had them…the really, really bad GI bleeder.  Thus man came in peri-code.  He was resuscitated with massive-transfusion to somewhat clinically stable.  After NG tube initially showed over a liter of blood return it stopped, couldn’t be lavaged or suctioned, and his abdomen started distending over the course of the next 1/2 hour.  We decided to get a CT scan to evaluate the distension and this is what was found: Gastric varices 2CT gastric varicies

The abdominal CT with contrast shows very large varicies extending into the stomach!  His stomach has several fluid densities consistent with hematoma, blood, and an area concerning for active exstravasation.  On the coronal image you can also see some dependent ascites around the liver.  The distal portion of the nasogastric tube is thought to have been obstructed by the large hematoma in his stomach.

The patient ended up improving with octreotide and correcting his INR of 3.5.  He had an esophagogastroduodenoscopy (EGD) which confirmed varicies and several were banded.

WARNING:  CT abdomen is not a usual imaging modality for GI bleeders.  We obtained imaging because the patient had increasing distension and abdominal pain.  We wanted to rule out aortic pathology, mesenteric ischemia, hemorrhagic malignancy, gastric perforation, and other pathology that sometimes can be associated with GI bleeding.  I don’t advocate CT imaging in most GI bleeders.

Author:  Russell Jones, MD

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Free Air…

April 21, 2013

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An elderly patient presented with abdominal pain for a week.  The patient had peritoneal signs on exam and thus xray imaging was pursued (see discussion below):

Free air

Image 1

Free air 2

Image 2

Free Air 1

Image 3

This is an acute abdominal series showing free intraperitoneal air in the right upper quadrant.  Notice that it cannot be determined if the patient has free air on the supine view (Image 1).  This is because the air is layering to the anterior portion of the peritoneal cavity.  In order to reveal air in the peritoneum, one must layer it to one of the sides (Image 2 – patient is laying on their left side and the air flows to the right upper quadrant) or upright (Image 3 – patient is upright and the air layers under the diaphragm, in this case the right side). 

I like the acute abdominal series to look for free air in the setting of a highly concerning exam.  You can also just do an upright chest xray.  They are quick and if free air is found it will likely be a study that will change the patient’s course; surgery will in most cases take the patient to the operating room with just an xray for exploratory laparotomy.  In our case, however, surgery was tied up for a bit and this allowed an extra 1/2 hour ED stay, I pursued non-contrast CT to further identify what was going on:

Free Air CT 1

Image 4

Free Air CT 2

Image 5

This CT shows findings highly concerning for a perforated duodenal ulcer.  In Image 4 you can see the air just above the liver edge anteriorly along with free intraperitoneal fluid layering on the side of the liver and spleen.  She also has an aortic aneurysm.  Image 5 shows an area of free air and stranding near the distal duodenum.  Laparotomy revealed a perforated duodenal ulcer, the aortic aneurysm was incidental. 

Author:  Russell Jones, MD

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Kidney fracture with active extravasation…

March 31, 2013

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This patient came in shortly after a high speed motor-vehicle collision.  Here is the patient’s CT abdomen with IV contrast:

Kidney fx 3Kidney Fx 2Kidney fx 1

This is an interesting CT as it demonstrates “active extravasation” of IV contrast.  The patient has a large left kidney fracture.  You can see a hematoma surrounding the area where you would expect the kidney.  In that hematoma there is a mix of low attenuation material and high attenuation material.  Both of these represent blood; the high attenuation is contrast material that leaking into the hematoma (some of the high attenuation includes perfusing kidney fragments but most of it is extravasating contrast).  The low attenuation is blood that collected before IV contrast administration.

Practically speaking, this means that there is active bleeding into this hematoma.  This is BAD and represents a large amount of bleeding that needs to be stopped.  The patient was actually relatively stable and was taken to interventional radiology where the offending lesion was embolized.

Author:  Russell Jones, MD

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