臺大醫院急診影像學討論會

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1 1 急診影像學案例討論會 2017/04/05 急診醫學部 : 翁梓華醫師 / 林芷君醫師 / 陳世英醫師影像醫學部 : 張晉誠醫師

2 PATIENT year-old man Left Abdominal pain since this morning

3 CLINICAL PRESENTATION [C. C.] Left Abdominal pain since this morning [P. H.] Gastritis, Anemia, Multiple Myeloma, HTN, CVA [P. I.] 1/26 night: Left abd pain Visited 西園 Hospital ER then discharged Abd pain persisted, then visited our ER Vomiting (+), stool passage (+), no fever. [Vitals] BP: 167/93mmHg, T/P/R: 37/105/18 [P. E.] Consciousness: Clear, E4M6V5, Abdomen: Soft, Tenderness over Left Middle Quadrum Bowel sound: Normal active 3

4 LABORATORY STUDIES (1) 4

5 KEY IMAGE Air fluid level (ileus) Mottled Gas Pattern 5

6 IMAGE DIAGNOSIS Suspected right complex renal cysts Suspected bezoar ileus 6

7 張晉城醫師現場指導 KUB 有發現 air fluid level, 加上沒有看到 colon air, 此時即可懷疑有 obstruction/ileus 的情形所有的病人有 obstruction 時都必須仔細看是否有 colon cancer, 因為是造成腸阻塞最常見的原因, 特別在老年病人在電腦斷層閱片時, 可以用 lung window 看腹腔內的 free air 會比較清楚同時也要仔細檢查有無 SMA thrombosis/dissection 及 SMV thrombosis 的情形 7

8 SUBSEQUENT CLINICAL COURSE CT revealed bezoar ileus Vomit with bile-> NPO, IVF, NG decompression, consult GS Few watery stool passage after Primperan+ Dulcolax+ Coca-cola? 1/30: Hypaque: partial ileus-> admission for possible surgery 1/31: bloody, coffee ground substance from NG-> PPI, Sucrafate, PRBC transfusion(hb: 9.7 mg/dl) 2/2: NG remove for improved intake Discharged after being stable 8

9 SUPPLEMENTARY MATERIAL: BEZOAR ILEUS Bezoar: 腸胃道中不可消化的物質 Trichobezoar: hair Phytobezoar: indigestible food (e.g. cellulose) Pharmacobezoar: undigested medication Lactobezoar: undigested milk curds Bezoar Ileus Typical finding: well-defined intraluminal mass with mottled gas pattern in CT scan Treatment: Surgery including manual fragmentation of bezoar and pushing it toward cecum, enterotomy or segmental bowel resection 9

10 GASTRIC TRICHOBEZOAR 10

11 TRICHOBEZOAR 11

12 MOTTLED GAS PATTERN 12

13 MOTTLED GAS PATTERN 13

14 MOTTLED GAS PATTERN 14

15 PATIENT year-old female Chest tightness and epigastralgia for 3-4 days

16 CLINICAL PRESENTATION [C. C.] Chest tightness and epigastralgia for 3-4 days [P. H.] DM, HTN [P. I.] Chest tightness, hoarness for days without radiation pain, Vomiting several times with bile -> LMD, suspected PUD, s/p medication Still frequently vomiting, then visited our ER Denied bloody or tarry stool (-), Stool passage (+, reduced amount), fever (-), URI (-), neurological sign (-), GI bleeding (-) [Vitals] BP: 166/74mmHg, T/P/R: 37.1/80/20, SPO2:95% [P. E.] Consciousness: Clear, E4M6V5, Abdomen: Soft, Tenderness over epigastric area. Bowel sound: Normal 16

17 LABORATORY STUDIES (1) 17

18 KEY IMAGE Leading point: polypoid lesion 18

19 Leading point: polypoid lesion Mesentery vessel 19

20 IMAGE DIAGNOSIS Chest CT: Multiple left pleural nodular lesions. D.D. may inculde metastases, mesothelioma, etc. Multiple tiny nodules at RUL and RML. 3. Mediastinal lymphadenopathy. Abdominal CT: A polypoid tumor in the proximal jejunum, causing intussuception and proximal dilatation Gallstone Hepatic hemangioma. 20

21 張晉誠醫師現場指導 CXR 看到 multiple lung nodule 懷疑 cancer CT 可以看到 mesentery vessel 被帶入 jejunum 中, 在 lesion 最前端可以看到 polypoid lesion, 因此這是很典型 intussusception 的案例 21

22 SUBSEQUENT CLINICAL COURSE Vomiting-> NPO, NG for decompression, Prokinetic agent CT abdomin: Intussuception due to jejunal tumor about 3X3 cm+ proximal dilatation CT lung: Multiple left pleural nodular and mass lesion Largest about 5.7x2.2x5.6cm at left posterior lung Admission-> symptom not relieving-> Segmental resection of small bowel with end-to-end anastomosis on 2016/07/15(Pathology: sarcomatoid carcinoma) Develop dyspnea at 2016/07/16 due to pleural effusion(with malignancy cell)-> Pigtail-> stable-> discharged on 2016/07/27 22

23 SUPPLEMENTARY MATERIAL: INTUSSUSCEPTION Definition One segment of bowel is pulled into itself (or a neighbouring loop of bowel) by peristalsis 95% in children Clinical presentation Intermittent abdominal pain Vomiting Right upper quadrant mass Occult or gross blood on rectal examination Image Doughnut sign Pseudokidney sign 23

24 INTUSSUSCEPTION - DOUGHNUT SIGN 24

25 INTUSSUSCEPTION -PSEUDOKIDNEY SIGN 25

26 INTUSSUSCEPTION 26

27 INTUSSUSCEPTION 27

28 PATIENT year-old male Intermittent epigastric pain for 2 months

29 CLINICAL PRESENTATION (1) [C. C.] Intermittent epigastric pain for 2 months [P. H.] HTN, CKD, PUD GI perforation due to foreign body 10 years ago 2012: ICH s/p clot removal 2014: cholecystitis with PTCD drainage 2015: AAA sized 5cm noted at abdominal CT at 基長 Alcohol(+, quitted), Beatles nuts(-), Cigarettes(+, quitted) [P. I.] Intermittent epigastric pain without radiation pain Constipation (+), urinary frequency (+), fever (-), mild poor appetites (+) Knee chest position will relieve the discomfort Tarry stool (-), nausea/vomiting (-), meal association (-) Visited 基長 H OPD -> intestinal vessel abnormality was told -> getting worse -> visited out ER 29

30 CLINICAL PRESENTATION (2) [Vitals] BP: 152/72mmHg, T/P/R: 37.6/75/18, SPO 2 : 99% [P. E.] Consciousness: Clear, E4M6V5, Abdomen: Soft & Flat, Tenderness over upper abdomen (+). No rebounding tenderness. Bowel sound: Normal, McBurney s point tenderness (-), Rovsing sign (-), Obturator signs (-), Murphy sign (-) 30

31 LABORATORY STUDIES (1) 31

32 Gallstone Arterial wall calcification Aorta 32

33 AN ANEURYSM WITH CONTRAST 33

34 Celiac truck SMA Aneurysm Origin of SMA 34

35 IMAGE DIAGNOSIS Superior mesenteric artery aneurysm Suspected periampullary lesion Gallstones and CBD stones Splenomegaly Postoperative change 35

36 張晉誠醫師現場指導這個病人的腹部電腦斷層可以明顯看到 artery calcification 時就應該要懷疑 aneurysm 進一步當 aneurysm 的 arterial wall 旁邊有比較明顯的 soft tissue opacity 或 fat stranding 時, 比較需要懷疑 mycotic aneurysm, 當然也還要配合病人的臨床症狀及血液檢查來協助判斷 36

37 SUBSEQUENT CLINICAL COURSE Fever up to 38.4 with CT image -> possible cholecystitis with IAI -> Tazosin -> fever improved but abdominal pain persist -> admission 2015/05/11: ERCP hold due to high risk of aneurysm rupture 2015/05/12: SMA stenting 2015/05/14: Epigastralgia -> CT Pseudoaneurysm, s/p stenting with endoleak Gallstone Liver abscess 2015/05/21: Cholecystectomy 2015/06/07: Discharged 37

38 SUPPLEMENTARY MATERIAL: SMA ANEURYSM Cause Majority: mycotic 60% Atherosclerotic Inflammation: pancreatitis Symptom and sign Upper quadrants pain Compressive mass effect Claudication abdominis Pulsating epi-mesogastric abdominal mass Hemorrhagic shock Bowel ischemia (thrombus) Diagnosis CT Plain film: calcified aneurysm Duplex scan 38

39 SMA ANEURYSM 39

40 PATIENT year-old male Acute onset of abdominal pain since this noon

41 CLINICAL PRESENTATION [C. C.] Acute onset of abdominal pain since this noon [P. H.] Migraine [P. I.] 2017/01/09: left lower abdominal pain, sharp, needle-like pain. Fever (-), chillness (-), nausea/vomiting (-) Visited 部立台北醫院, where abdominal CT revealed left side nephritis with hypoenhanced renal cortex Refered to our ER for further management [Vitals] BP: 123/80mmHg, T/P/R: 37/72/18, SPO 2 : 99% [P. E.] Consciousness: Clear, E4M6V5 Abdomen: Soft, Tenderness at left lower quardrum, Bowel sound: normal 41

42 LABORATORY STUDIES (1) 42

43 KEY IMAGE Wedge shape hypodense lesion, suggestive of renal infarction 43

44 KEY IMAGE Suspicious renal artery dissection 44

45 IMAGE DIAGNOSIS A wedge shape low density lesion about 21 mm noted in left kidney 45

infarction 而非 APN 或 renal abscess 46 Nephritis without cortical ring sign Renal

46 張晉誠醫師現場指導電腦斷層可見明顯 wedge shape hypodense lesion, 此時即可懷疑為 renal infarction 如果有注意到 infarction 部位最外層的 cortex 出現薄薄的一層 hyperdense 的變化時 (cortical ring sign) 就更懷疑是 renal infarction 而非 APN 或 renal abscess 46 Nephritis without cortical ring sign Renal infarction with cortical ring sign (From: )

47 SUBSEQUENT CLINICAL COURSE CT revealed renal infarction-> OR for PTA with stenting on 2017/01/13 Discharged after the stenting without complication 47

48 SUPPLEMENTARY MATERIAL: RENAL ARTERY DISSECTION WITH RENAL INFARCTION Cause Aortic dissection extending to involve the renal artery Iatrogenic (e.g. catheterisation) Trauma Atherosclerosis Fibromuscular dysplasia Diagnosis CT Ultrasound Angiography 48

49 PATIENT year-old male Left hip pain for several days

50 CLINICAL PRESENTATION [C. C.] Left hip pain for several days [P. H.] HTN, Gout, BPH, CKD stage /05/19: Gallstone with chronic cholecystitis s/p laparoscopic cholecystectomy 2008/01/14: CAD 2VD s/p POBAS Left knee osteoarthritis s/p total knee arthroplasty 2011/02/19: Persistent hematuria, s/p cystoscopy and urethroscopy [P. I.] Low BP (SBP 70) was noted at triage, baseline SBP [Vitals] BP: 75/55mmHg, T/P/R: 36.5/93/20, SPO 2 : 99% [P. E.] Consciousness: Clear, E4M6V5, Extremities: Left hip pain 50

51 LABORATORY STUDIES (1) 51

52 LABORATORY STUDIES (2) 52

53 KEY IMAGE Aortic wall calcification Aneurysm 53

54 Abdominal aneurysm 54

55 Left gluteal muscle hematoma 55

56 IMAGE DIAGNOSIS Abdominal aortic aneurysm, with suspicious intramural hematoma. Left gluteal muscle hematoma. 56

57 陳世英醫師現場指導有時候 hip pain 要考慮是 abdominal aortic aneurysm 造成的神經壓迫所導致的 referral pain, 雖然這個病人事實上是左臀局部血腫所造成因此這個病人的 AAA 是 incidental finding, 不過大小卻是到需要開刀介入的情形 57

58 SUBSEQUENT CLINICAL COURSE CT: AAA 6.5cm with suspected intramural hematoma-> consult CVS-> transferred to SICU- >PRBC, PLT given-> persist anemia and thrombocytopenia-> consult Hema, suspected DIC or MAHA 2016/08/08: EVAR with Palmaz stent 2016/08/16: Discharged under stable condition 58

59 SUPPLEMENTARY MATERIAL: ABDOMINAL AORTIC ANEURYSM Epidemiology Prevalence of rupture increases with age Males more commonly affected than females Prevalence is almost 10% in people over 65 years old 10th commonest cause of death in Western populations Presentation May be asymptomatic; aneurysms most commonly discovered incidentally at abdominal imaging Pain if there is a rapid change in diameter or impending rupture Pain and shock in rupture 59

60 SUPPLEMENTARY MATERIAL: ABDOMINAL AORTIC ANEURYSM Pathophysiology Atherosclerosis is by far the commonest cause Inflammatory, infective and vasculitic conditions may also be causes Diagnosis US for population screening and monitoring small aneurysms CT is the gold-standard for aneurysm assessment CT is used in the acute setting of potential aneurysm complication 60

61 ABDOMINAL AORTIC ANEURYSM 61

62 ABDOMINAL AORTIC ANEURYSM WITH RUPTURE 62

63 ABDOMINAL AORTIC ANEURYSM- LEAKAGE 63

64 ABDOMINAL AORTIC ANEURYSM- ATHEROSCLEROTIC CHANGE 64

65 KEY WORDS Ileus Bezoar Intussusception Renal artery dissection Gluteal muscle hematoma Abdominal aortic aneurysm Superior mesentery artery aneurysm 65

66 66 THANK YOU FOR YOUR ATTENTION!

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