Rita Joarder - Case Studies in Abdominal and Pelvic Imaging

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Springer-Verlag London Limited 2011

Rita Joarder , Neil Crundwell and Matthew Gibson Case Studies in Abdominal and Pelvic Imaging 10.1007/978-0-85729-366-4_1

1. Case 1

Rita Joarder 1, Neil Crundwell 1 and Matthew Gibson 2

(1)

Conquest Hospital, St. Leonards-on-Sea, East Sussex, UK

(2)

Royal Berkshire Hospital, Reading, UK

A 78-year-old male with no prior abdominal surgery presented with acute central abdominal pain and vomiting. On examination the abdomen was distended and tympanic with hyperactive bowel sounds. No hernias were palpable. Abdominal x-ray showed dilated small bowel consistent with a distal small bowel obstruction, but cause was not demonstrated.

An MDCT of the abdomen and pelvis was performed (Image 1: Axial of upper abdomen, Image 2: Axial of upper abdomen just inferior to Image 1 and Image 3: Axial of lower abdomen).

Image 1

Image 2

Image 3

Questions

What is arrowed on Image 1? What is this sign called?

What are the two organs arrowed on Image 2?

What is arrowed on Image 3? Comment on the small bowel in Image 3.

What is the diagnosis?

Answers

Air in the intrahepatic bile ducts ( arrow Image 4) Aerobilia.

The gallbladder ( short arrow Image 5) and duodenum ( long arrow Image 3) lying closely adjacent with a bubble air ( long arrowhead Image 5) between them.

A gallstone in the ileum ( long arrow Image 6) it has a high density rim with low density material and air within centre of the gallstone. The small bowel proximal to the gallstone is dilated ( medium arrow ) and distal to it is collapsed ( short arrow ), i.e. the gallstone is at the point of transition and the cause of the small bowel obstruction.

Gallstone ileus.

Image 4

Image 5

Image 6

Gallstone ileus is a rare complication of gallstone disease, accounting for 14% of all bowel obstructions.

Erosion of a gallstone from the gallbladder to the duodenum causes a biliaryenteric fistula. Cholecystoenteric fistulae occur in less than 1% of patients with gallstones. The gallstone passes through the small bowel and may become impacted causing small bowel obstruction. It is most commonly impacted in the distal ileum but can occur anywhere. An exploratory laparotomy with enterolithotomy is indicated. Enterolithotomy is the most commonly used surgical technique with enterolithotomy combined with cholecystectomy and fistulectomy reserved for selected cases. The clinical presentation depends on impaction site and generally includes abdominal pain, nausea and vomiting. Abdominal x-rays may show the aerobilia, dilated small bowel and sometimes the gallstone; however MDCT is more sensitive and thus the imaging of choice.

Key Points

• Gallstone ileus is an uncommon cause of small bowel obstruction.
• Whilst abdominal x-ray may give the diagnosis CT is usually diagnostic.

Further Reading

Ayantunde AA, Agrawal A. (2007) Gallstone ileus: diagnosis and management. World J Surg 31:1292-7 PubMed

Muthukumarasamy G, Venkata SP, Shaikh IA, et al. (2008) Gallstone ileus: surgical strategies and clinical outcome. J Dig Dis 9:156-61 PubMed CrossRef

Springer-Verlag London Limited 2011

Rita Joarder , Neil Crundwell and Matthew Gibson Case Studies in Abdominal and Pelvic Imaging 10.1007/978-0-85729-366-4_2

2. Case 2

Rita Joarder 1, Neil Crundwell 1 and Matthew Gibson 2

(1)

Conquest Hospital, St. Leonards-on-Sea, East Sussex, UK

(2)

Royal Berkshire Hospital, Reading, UK

A 70 year-old-female with a false eye complained of right upper quadrant pain. She underwent an US of her upper abdomen (Image 1). An MDCT was then performed (Image 2); this was followed by an MRI of which the axial T1 fat sat and T1 sequences are shown (Images 3a and b).

Image 1

Image 2

Image 3

Questions

What are the findings on US?

What does the MDCT show?

What do the unenhanced T1 fat sat and T1 MR sequences show, and what is their significance?

What is the likely diagnosis?

What further sequences would you perform to clarify appearances?

Answers

The US shows a solitary 5.8 cm solid soft tissue mass within the right lobe of the liver highly suspicious for a metastasis or primary hepatoma (Image 4).

The CT confirms a subtle mass within the right lobe of the liver causing distortion of the adjacent vessels (Image 5).

MRI (often more sensitive than USS) confirms a 6.8 cm mass that is mixed but predominantly high signal on T1 fat sat imaging (Image 6a) and again mixed signal on T1 with focal areas of high signal within it (Image 6b). The areas of high signal on unenhanced T1 fat sat and T1 imaging indicate either haemorrhage or melanin.

The patient had a false eye which would fit with a history of choroidal melanoma, and this is therefore most likely to represent a solitary melanoma metastasis.

Dynamic post-gadolinium fat sat T1 scans.

Image 4

Image 5

Image 6

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