Transient portal venous gas in upper gastrointestinal bleeding: A case report

Portal venous gas (PVG) or hepatic portal venous gas (HPVG) is the accumulation of gas in the portal vein and its branches. HPVG may be considered as a nonspecific sign of a significant abdominal disease, ranging from potentially lethal diseases to benign conditions. Computed tomography (CT) can detect both the presence of gas and the underlying pathology. I report a 60-year-old male who presented to the emergency department with upper gastrointestinal bleeding and a high lactate level in the blood test. Because of the unknown etiology for the elevated lactate, a CT scan of the abdomen was taken, which showed that he developed intra-and extra-hepatic portal venous gas as well as in the portomesentric-portosystemic collaterals without any signs of mesenteric ischemia. The patient was treated conservatively and the HPVG completely resolved after a few days. Overall, physicians must be aware that prognosis is related to the pathology itself and is not influenced by the presence of PVG. HPVG can be caused by several benign conditions that do not necessarily require urgent exploratory laparotomy.     

Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain

Background

Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain.

Methods

This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient.

Results

From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p?<?0.001).

Conclusion

Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.

     

Letale Magenruptur eines 5-jährigen Mädchens mit Rett-Syndrom

The Rett syndrome is associated with gastrointestinal disorders in motility and the swallowing of air, resulting in gastric distension or even rarely in gastric rupture. A 5-year-old girl with Rett syndrome and acute bronchopneumonia died suddenly and unexpectedly. A forensic autopsy revealed a lethal gastric rupture with 650 ml fluid and gas in the abdominal cavity without signs of peritonitis. The cause of death was neurogenic shock due to the gastric rupture caused by local necrosis of the gastric wall. Diagnosing an acute life-threatening emergency in mentally retarded patients can be very difficult.     

A practical approach to high-resolution CT of diffuse lung disease

Diffuse lung disease presents a variety of high-resolution CT findings reflecting its complex pathology, and provides diagnostic challenge to radiologists. Frequent modification of detailed pathological classification makes it difficult to keep up with the latest understanding. In this review, we describe a practical approach to high-resolution CT diagnosis of diffuse lung disease, emphasizing (1) analysis of “distribution” of the abnormalities, (2) interpretation of “pattern” in relation to distribution, (3) utilization of associated imaging findings and clinical information, and (4) chronicity of the findings. This practical approach will help radiologists establish a way to interpret high-resolution CT, leading to pin-point diagnosis or narrower differential diagnoses of diffuse lung diseases.     

筛窦畸胎癌肉瘤1例报道并文献复习

目的提高对鼻腔鼻窦畸胎癌肉瘤(SNTCS)的影像学认识。方法报道1例经病理证实的筛窦畸胎癌肉瘤,复习相关文献并探讨其临床特征、影像学表现及鉴别诊断。结果肿瘤CT平扫表现为软组织密度肿块,有小囊变,无明显钙化,侵犯鼻咽及前颅底;MRI表现为T1WI不均匀等、稍低信号,T2WI不均匀等、稍高信号,增强扫描肿块明显不均匀持续强化,小囊变区未见强化。结论鼻腔鼻窦畸胎癌肉瘤非常罕见,肿瘤具有一定的影像学特征,确诊需依赖病理学诊断。     

Mustererkennung im hochauflösenden Computertomogramm (HRCT) der Lunge

The pulmonary interstitium is divided into different compartments, with the secondary pulmonary lobule representing the smallest subunit surrounded by connective tissue. Identification of the lobular architecture is a prerequisite for categorizing the broad spectrum of pulmonary interstitial diseases into distinct patterns. High-resolution computed tomography (HRCT) patterns comprise reticular and nodular opacities, ground-glass opacities, and consolidation. Air trapping and emphysema are associated with decreased pulmonary attenuation. The features of these patterns are derived from the anatomic basis and are linked with typical differential diagnoses, although the nonspecificity of the different patterns should be kept in mind. A main objective is to focus on mixed patterns.     

CT heads diagnosing chest pathology? Whatever next?

This case report presents two cases where subcutaneous emphysema visualised on computerised tomography examinations of the head subsequently led to the diagnoses of pathology within the thorax. The pathophysiology of traumatic subcutaneous emphysema within the head and neck is briefly discussed, along with examples of other causes of this condition within this anatomical region. The primary aim of this report is to draw attention to the necessity for a thorough review of any CT head examination, including both intra- and extra-cranial structures, undertaken at a variety of window settings.     

气管支气管内膜结核的CT诊断

目的：分析气管支气管内膜结核的CT表现，探讨其影像学特征及其病理基础。方法：收集痰菌、病理及临床证实的气管与支气管结核52例，分析其CT与HRCT表现。结果：CT表现有以下特点：①96．1％CT显示长段不规则气管或支气管壁增厚，其增厚的支气管壁范围较长为特征之一；②25％CT显示远处肺或对侧肺结核支气管播散病灶；③支气管狭窄、阻塞不伴有肺门肿块；④11．5％可见增厚的气管或支气管壁出现钙化。此征象具有特征性；⑤支气管阻塞性肺部病变中，若出现阻塞性肺气肿伴气肿区分支条状或指套样高密度灶、支气管阻塞远端实变、肺内或不张肺内出现大量无壁空洞、“蜂窝样”改变或伴有不规则或“串珠状”支气管扩张表现者也具有一定特征性诊断价值，其中后者考虑为继发于支气管壁破坏或实变与不张肺内病灶纤维化继发的牵拉性支气管扩张所致。结论：气管支气管内膜结核的CT表现，尤其是HRCT表现，有一定特征性，是诊断及鉴别诊断的有效于段。     

Imaging of pediatric neurovascular emergencies

Pediatric strokes are rare but critical diagnoses to make in the emergency setting. They are associated with a set of pathologies that are not frequently encountered in the adult population. Some of these diseases have variable clinical presentations and imaging appearance depending on the age of onset and severity of the underlying pathologies. This article reviews the differential diagnoses and noninvasive imaging evaluation of pediatric cerebral ischemic and hemorrhagic diseases.     

Medical emergencies at a major international airport: in-flight symptoms and ground-based follow-up

BACKGROUND: There is limited recent data about the treatments and outcomes of commercial airline passengers who suffer in-flight medical symptoms resulting in subsequent EMS evaluation. The study objectives are to determine incidence, post-flight treatments, outcomes, morbidity, and mortality of these in-flight medical emergencies (IFMEs). METHODS: A 1-yr retrospective study of emergency medical service (EMS), emergency department (ED), and inpatient hospital records of IFME patients from Chicago O'Hare International Airport was completed. All commercial passengers or crew with in-flight medical symptoms who subsequently activated the EMS system on flight arrival are included in the study. The main outcome measures are: in-flight sudden deaths, post-flight mortality, hospital admission rate, ICU admission rate, ED procedures, inpatient procedures, and discharge diagnoses. RESULTS: There were 744 IFMEs for an incidence of 21.3 per million passengers per year. The hospital admission rate was 24.5%. The ICU admission rate was 5.9%. There were five in-flight sudden deaths and six in-hospital deaths for an overall mortality rate of 0.3 per million passengers per year. Emergency stabilization procedures were required on 4.8% of patients. Cardiac emergencies accounted for 29.1% of inpatient diagnoses and 13.1% of all discharge diagnoses. CONCLUSIONS: The incidence of in-flight medical emergencies is small but these IFMEs are potentially lethal. Although the majority of IFME patients have uneventful outcomes, there is associated morbidity and mortality. These included in-flight deaths, in-hospital deaths, and emergency procedures. Cardiac emergencies were the most common of serious EMS evaluated in-flight medical emergencies.     

Bildgebung des Lungenemphysems

Emphysema is defined as a condition of the lung characterized by abnormal, permanent enlargement of airspaces distal to the terminal bronchiole accompanied by destruction of the alveolar walls and without obvious fibrosis. It is a very common disease with high morbidity and mortality. Histopathologically, there are two types of emphysema: panlobular emphysema, typically occurring in alpha1-antitrypsin deficiency, and centrilobular emphysema, which is strongly associated with cigarette smoking. Computed tomography (CT) allows detection of emphysema with higher sensitivity than conventional chest radiography and pulmonary function tests. CT also allows quantification of emphysema and depicts associated changes and complications. The differential diagnosis of emphysema, which is characterized by the absence of clearly definable walls on CT, includes cystic lung disease, bullae, lung laceration, Langerhans cell histiocytosis, and lymphangioleiomyomatosis -which are all characterized by visible walls on CT.     

Imaging findings of retroperitoneal lymphangiomyomatosis in a patient with lymphoma

A 31-year-old female with lymphoma was incidentally found to have a left retroperitoneal lymphangiomyomatosis (LAM). The tumor was proved by pathology and immunohistochemical study of the tissue specimen obtained by ultrasound-guided core needle biopsy. The characteristic sonographic, computed tomographic, magnetic resonance imaging, and positron emission tomographic (PET) features of this unusual lesion were described. It was managed conservatively and remained stable on 2-year follow-up study. LAM should be considered in the differential diagnoses in cases of a retroperitoneal solid mass with cystic components.     

The topicality and use of the radiological exam in gunshot wounds of the limbs. An assessment of 132 cases

INTRODUCTION: Gunshot wounds of limbs are frequent injuries especially in Western countries. They can be single or associated with other penetrating gunshot wounds, for instance to the chest, abdomen and skull. PURPOSE: We investigated the current role and usefulness of conventional radiography in the assessment of gunshot injuries to limbs because, despite major advances in diagnostic imaging, this method remains the examination of choice in this condition. We stress the valuable contribution of conventional radiography to detection of bone blow-out fractures, multifocal traumatic bone changes, bone and joint injuries, bullet retention, and finally subcutaneous emphysema. MATERIAL AND METHODS: We retrospectively reviewed 132 cases of firearm injuries of limbs submitted to radiography March 1996 to July 1999. All the patients were men ranging in age 17-66 years (mean: 35). Radiography followed a preliminary physical examination, and follow-ups were carried out in the following days after orthopedic reduction of bone fractures or surgery with metal osteosynthesis. Emergency CT was performed first when chest, abdomen, or skull were involved. RESULTS: The lower limbs were involved three times as much as the upper ones; the leg was most frequently involved (61%), followed by thigh (61%), forearm and hands (24%), and feet (15%). The right lower limb was wounded in 65% of cases, especially tibia (55 cases) and femur (46 cases). Spiral injuries to bone diaphysis were the most frequent ones, followed by mixed fractures caused by cortical bone sinking from bullet impact. Bullets were retained in 60% of cases; subcutaneous emphysema was found in 78% of cases and vascular injuries in 25 cases in relation to disarranged fractures. We observed 4 arteriovenous fistulas during 3 years' follow-up. DISCUSSION AND CONCLUSIONS: Gunshot wounds to the limbs need a different clinical, diagnostic and therapeutic approach than thoracoabdominal and skull injuries, which require immediate and quick diagnosis and emergency treatment. The cases with injury to a primary artery from open and splintered fractures require emergency surgical reconstruction with vascular anastomosis and reduction of compound fractures, to prevent necrosis and amputation. Conventional radiography does depict the bullet and its site, subcutaneous emphysema, blow-out fractures, and the location of bone splinters. This permits adequate emergency surgery and an efficacious orthopedic approach, as well as selection of the cases to be submitted to clinical monitoring.     

Perineal hernia

Abdominal wall hernias are a common abdominal pathology with higher prevalence in our population. It is usually asymptomatic but complications such as strangulation, incarceration or bowel obstruction need early detection and emergency surgery. The purpose of this article is to describe the infrequent type of hernia, illustrate the imaging findings and review the differential diagnosis. A 76-year-old woman was admitted in the emergency room with abdominal pain, vomits and diarrhoea. At her admission, a colonoscopy was attempted to perform but it was not possible to go beyond the stenosis. A barium enema and a multi-detector computed tomography (MDCT) were performed revealing a large mass in the left ischiorectal fossa, containing herniated loops of sigmoid colon adjacent to rectum. Abdominal wall hernias occur at areas of congenital or acquired weakness in the abdominal wall and are considered external hernias. MDCT is essential to identify wall hernias, make an accurate diagnosis and help for its clinical assessment. Knowing the radiological features of various types of abdominal hernias on MDCT and barium-enhanced radiographs allows confident diagnosis of these pathologies.     

Characterization of 133Xe gas washout in pulmonary emphysema with dynamic 133Xe SPECT functional images

PURPOSE: To characterize regional ventilation impairment of pulmonary emphysema using dynamic 133Xe single photon emission computed tomography (SPECT) functional images, compared with other forms of chronic obstructive pulmonary disease (COPD). METHODS: Dynamic 133Xe SPECT was performed in 34 patients with emphysema and 15 patients with other forms of COPD. Three-dimensional voxel-based functional images of the half-clearance time (T1/2) mainly reflecting the initial rapid washout of 133Xe gas from the large airways, and of the mean transit time (MTT) reflecting 133Xe gas washout from the entire lungs, including the small airways and alveoli, were created based on an area-over-height method. T1/2 and MTT values were compared with the regional extent of low attenuation areas (%LAA) on density-mask computed tomography images and the diffusing capacity of the lungs for carbon monoxide (DLCO). RESULTS: The MTT/T1/2 ratio in each lung in emphysema was significantly higher than that in other forms of COPD (1.60+/-0.74 vs. 1.21+/-0.26; P<0.01). In the selected unilateral lungs with similar T1/2 values, MTT values were also significantly higher in emphysema. MTT values in each lung showed a significantly closer correlation with the corresponding %LAA values compared with T1/2 values in emphysema (R=0.698, P<0.0001 vs. R=0.338, P<0.01; P<0.05); while only the T1/2 values showed a significant correlation in other forms of COPD (P<0.0001). In correlation with DLCO, MTT values showed a significantly closer correlation compared with T1/2 values in emphysema (R=0.909, P<0.0001 vs. R=0.555, P<0.001; P<0.05); while either value did not show a significant correlation in other forms of COPD. CONCLUSION: MTT values are more critically affected in emphysema compared with other forms of COPD without significant alveolar destruction, and MTT and T1/2 values appear to be differently correlated with the regional extent of LAA between these two disorders. Direct comparison of regional T1/2 and MTT values on functional images may contribute to the demarcation of lung pathology of these two disorders.     

Boerhaave's syndrome

Spontaneous esophageal perforation (Boerhaave syndrome) is a life-threatening emergency. It usually has misleading clinical manifestations and causes severe complications. In the presence of the clinical manifestations: vomiting, pain, emphysema, this diagnosis must be considered and confirmed by radiological evaluation of the chest and the esophagus. We report two cases and we describe the severity of this syndrome, its cause, its pathogenesis, and its characteristic clinical features and radiological signs.     

Trapped on the “whirl”: diagnostic sign on emergency CT

The “whirl sign” is an uncommon finding on emergency CT. However, it is easy to overlook if not kept in mind. Its recognition is of capital importance, being most of its causes potentially lethal. Surgical treatment is also mandatory when signs of complication are found. The whirl sign is usually found associated to midgut, cecal and sigmoid volvulus, small-bowel volvulus and closed-loop obstructions, and post-surgical mesenteric windows (including retroanastomotic hernias). CT is an optimal imaging technique to depict the so-called sign and associated CT features suggesting complication (circumferential wall thickening, pneumatosis intestinalis, pneumoperitoneum, mesenteric fat stranding, free intraperitoneal fluid, mesenteric haziness). Radiologists must be able to recognize the whirl sign and seek associated findings that strongly support the diagnosis of a spectrum of entities, some of them lethal if no treatment is established.     

Posterior reversible encephalopathy syndrome and venous thrombosis

Posterior reversible encephalopathy syndrome (PRES) and venous thrombosis are frequently encountered first in the emergency setting and share some common characteristics. The clinical presentation in both entities is vague, and the brain parenchymal findings of PRES syndrome may resemble those of venous thrombosis in some ways. Both entities often occur in a bilateral posterior distribution and may be associated with reversible parenchymal findings if the inciting factor is treated. These diagnoses should be at the forefront of the differential diagnosis when confronted with otherwise unexplained brain edema, among other findings described in this article.     

Role of emphysema in the etiology of functional impairment in patients with severe chronic obstructive pulmonary disease. Study with high resolution computerized tomography]

PURPOSE: To investigate whether high-resolution CT (HRCT) can detect the subjects with massive emphysematous destruction in a group of patients with severe chronic obstructive pulmonary disease (COPD) and therefore be of help in selecting the candidates to surgical lung volume reduction. MATERIAL AND METHODS: We examined 40 former smokers with severe COPD (FEV1, < or = 40% of the predicted value, with no major improvement after inhalation of bronchodilators). Clinico-functional assessment included: a flow/volume loop (mean FEV1 = 28.6% of predicted), arterial blood gas analysis at rest breathing room air (mean values: PaO2 = 65.2 mmHg, PaCO2 = 47.4 mmHg), hematocrit value (mean: 45.2%) and the body mass index (mean value: 23.8). The patients were divided into two groups, namely bronchitic (21) and dyspneic (19) subjects, according to onset symptoms. All the patients underwent HRCT with evaluation of emphysema presence, type, site and extent: centrilobular emphysema was seen in 11 cases, panlobular emphysema in 3 and mixed emphysema in 26 cases; the site was superior in 75%, inferior in 7.5% and diffuse in 17.5% of cases; the mean visual score was 40.8%. The presence, type, site and severity of airways disease were also studied, as well as the pathologic dilatation of the pulmonary artery. The patients were divided into three groups (mild, moderate, severe) according to emphysema extent and they were considered to have bronchial disease in the presence of at least 2 of the 6 signs of bronchial involvement. RESULTS: The emphysema extent score was significantly correlated with the hematocrit value and Tiffeneau index (p < .2) in all the 40 patients. The severity of bronchial obstruction was the same in bronchitic and dyspneic patients. The subjects with chronic bronchitis had milder emphysema (mean extent 35% versus 47% in the dyspneic subjects) and a higher frequency of bronchial involvement. A decrease in FEV1 was significantly correlated with emphysema extent (p < .1) in dyspneic, but not in bronchitic, patients. Moreover, the former had better arterial blood gas and lower hematocrit values. CONCLUSIONS: HRCT is a useful tool in diagnosing the presence of emphysema in vivo and in assessing its extent in COPD patients because it permits to divide the patients into two groups which roughly correspond to the clinical patterns of types A (dyspneic) and B (bronchitic). Severe emphysema patients are the best candidates to surgical lung volume reduction. Airways involvement might play a major role in causing bronchial obstruction in the subjects with mild emphysema. In our series HRCT did assess the severity of emphysema in COPD subjects, but our lung function screening failed to predict emphysema extent.