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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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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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Classic Xray…

February 3, 2014

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This patient presents with a peritoneal abdomen on exam:

Free air 1 Free air 2 

This is a great abdominal series showing free peritoneal air.  This is a sign of gastric, bowel, or colonic perforation and is a surgical emergency. 

The abdominal series has limited utility in the ED due to poor sensitivity and specificity for most intraabdominal pathology.  However, in a patient with a peritoneal abdomen it is a quick and cost-effective means of screening for free air.  This patient was emergently taken to the operating room for exploratory laparotomy. 

Author:  Russell Jones, MD

Image Contributor:  Ali Naqvi, MD

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ROCKIN!

September 26, 2013

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A patient told me the other day that he swallowed a rock.  He had a psych history and we initially didn’t believe him.  However…

Rockin! 1 Rockin! 2

This acute abdominal series shows a radioopaque object strikingly similar to a rock in the right lower quadrant with obstructive changes (dilitation and air-fluid levels) of the small bowel.  Our fellow surgeon colleagues found a rock at the illeocecal junction when they opened him up!

Author:  Russell Jones, MD

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Interesting Acute Abdominal Series…

May 1, 2013

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This patient presented with nausea, vomiting, diffuse abdominal pain, and no bowel movement for a couple days.

Ogilvie's syndrome

This patient has a history of Ogilvie syndrome and this abdominal xray helps support this diagnosis.  Ogilvie syndrome is an acute pseudo-obstruction of the GI tract without a mechanical obstruction.  Xray will often show massive (>10cm) dilitation of the colon, usually on the cecal side.  This patient’s cecum measures out to be 21 cm!

Brief summary of Ogilvie Syndrome courtesy of Wikipedia:

Ogilvie

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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Nailed!

December 3, 2012

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Here’s a good reason not to put nails in your mouth while doing construction at home:

The patient accidentally swallowed the nails while trying to hammer one in and you can see them on the radiograph above.  The good news is they weren’t in the airway which can cause much more acute life threatening injuries.  Sharp objects such as this in the GI tract usually warrant a GI or surgical consult because of the high risk of perforation.

Author:  Russell Jones, MD

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Pelvic foreign body

November 27, 2012

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A 35 year-old female came into the ED with diarrhea for several weeks.  She had a story highly suspicious of c.diff and we sent her for an acute abdominal series to evaluate for megacolon, other findings.  Here is her supine view:

As far as megacolon this is negative.  However, the foreign body in her left pelvis region was interesting and we initially had no idea what to make of it.  When in doubt, go ask the patient…

She has an Essure® device implanted into her left fallopian tube.  Not only that, she had an ectopic pregnancy in her past on the right side with a right sided salpingectomy (thus no bilateral Essure®). 

An Essure® device is a small, flexible implant non-surgically placed in the fallopian tube in place of a tubal ligation. 

Didn’t explain her diarrhea though.  She had c.diff.

Author:  Russell Jones, MD.

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