Gastric outlet obstruction in uncomplicated mesentero-axial gastric volvulus associated to hiatal hernia

Gastric volvulus is a rare condition determined by the rotation of one part of stomach around another. Stomach can rotate around its longitudinal or short axis or both. The presentation can be acute, subacute and chronic due to twisting and untwisting andimaging should be performed in the acute phase. MDCT shows high accuracy in thediagnosis and definition of gastric volvulus being the preferred diagnostic test in emergency settings. Gastric volvulus may be associated or determined by pre-existing hiatal hernia and accurate analysis of CT signs may be evaluated on order to differentiate between a stomach in an abnormal position and a volvulus.At CT, a displaced antrum at the same level or cranial to the fundus and a transition point at the pylorus is diagnostic for mesenteroaxial volvulus. We present a case of a 70 years old woman with mesenteroaxial volvulus in hiatal hernia.

Morphometric study applied to testicular and epididymis hydatids torsion

Twisted testicular appendages had difficult differential diagnosis with testicular torsion. The objective of this paper is to evaluate the number, shape, size and determine the laterality pattern of the testicular and epididymal hydatids and evaluate the correlations between the length and width of the testicular and epididymal hydatids with testicular measurements. We analyzed 60 fixed cadavers and 16 patients with prostate cancer without previous hormonal treatment undergoing bilateral orchiectomy, totalizing 76 units and 152 testicles. In relation to the testicular appendices, we analyzed the following situations: absence of testicular and epididymis appendages, presence of a testicular appendix, presence of epididymis appendix, and presence of testicular and epididymis appendix. We measured the length, width and thickness of the testis and classified the appendages as sessile or pedicled. Chi-square test was used to verify associations between categorical variables. McNemar Test was used to verify differences between the percentages of right and left appendages. Correlations between quantitative measures were evaluated using the Pearson Correlation Coefficient (p < 0.05). In 50 cases (65.78%) we observed the presence of some type of appendices, in 34 cases (44.72%) we observed the presence of testicular appendices and in 19 cases (25%) the presence of epididymal appendices. We observed the presence of pedicled appendices in 39 cases (51.32%), with 25 of the cases (32.89%) of pedicled testicular appendices and 14 of the cases (18.42%) of pedicled epididymal appendages, with a significant association between the occurrence of appendices on the right and left sides (p < 0.001). Testicular hydatids were present in around two thirds of our sample being pedunculated in almost half of the cases with bilateral similarity. There is a significant chance in cases of twisted appendices that the same anatomical characteristics are present on the opposite side, which is a factor that tends to indicate the need for contralateral surgical exploration in cases of torsion, however studies with larger samples are needed to confirm these findings.

Pancreatic Torsion Resulting in Acute Pancreatic Necrosis in a Young Dog

We report a case of 7 mo old French bulldog who was referred to North Carolina State University Small Animal Emergency and Triage Services because of acute abdomen, regurgitation, lethargy, and fever. The patient had a history of pulmonic stenosis, which was corrected by balloon valvuloplasty 3 wk before presenting for the current complaint. The patient had nonspecific changes noted on blood work at his referring veterinarian. An abdominal ultrasound examination showed pathological changes that were supportive of a left-limb pancreatic torsion that was confirmed postmortem.

Differentiating Imaging Features of Post-lobectomy Right Middle Lobe Torsion

PURPOSE

The purpose of this study was to identify differences in imaging features between patients with confirmed right middle lobe (RML) torsion compared to those suspected yet without torsion.

MATERIALS AND METHODS

This retrospective study entailing a search of radiology reports from April 1, 2014, to April 15, 2021, resulted in 52 patients with suspected yet without lobar torsion and 4 with confirmed torsion, supplemented by 2 additional cases before the search period for a total of 6 confirmed cases. Four thoracic radiologists (1 an adjudicator) evaluated chest radiographs and computed tomography (CT) examinations, and Fisher exact and Mann-Whitney tests were used to identify any significant differences in imaging features (P<0.05).

RESULTS

A reversed halo sign was more frequent for all readers (P=0.001) in confirmed RML torsion than patients without torsion (83.3% vs. 0% for 3 readers, one the adjudicator). The CT coronal bronchial angle between RML bronchus and bronchus intermedius was larger (P=0.035) in torsion (121.28 degrees) than nontorsion cases (98.26 degrees). Patients with torsion had a higher percentage of ground-glass opacity in the affected lobe (P=0.031). A convex fissure towards the adjacent lobe on CT (P=0.009) and increased lobe volume on CT (P=0.001) occurred more often in confirmed torsion.

CONCLUSION

A reversed halo sign, larger CT coronal bronchial angle, greater proportion of ground-glass opacity, fissural convexity, and larger lobe volume on CT may aid in early recognition of the rare yet highly significant diagnosis of lobar torsion.

Extrapleural fat: description, incidence, and relation with body mass index

BACKGROUND AND AIMS

Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients.

PATIENTS AND METHODS

Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI>30) and non-obese (BMI<30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant.

RESULTS

Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured <5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458).

CONCLUSIONS

Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.

Extrapleural fat: description, incidence, and relation with body mass index

BACKGROUND AND AIMS

Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients.

PATIENTS AND METHODS

Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI > 30) and non-obese (BMI < 30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant.

RESULTS

Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured < 5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458).

CONCLUSIONS

Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.

A pictorial review of lung torsion using 3D CT cinematic rendering

Lung torsion is the abnormal rotation of a lobe or lung around its bronchovascular pedicle. It most commonly occurs in the setting of pulmonary resection, though it has also been described after large-volume thoracentesis and video-assisted thoracic surgery, as well as spontaneously. Resulting ischemia can lead to infarction, making this an emergent diagnosis. As findings are often nonspecific, a high index of suspicion is required, especially in the postsurgical setting. 2D CT angiography findings are subtle and include direct signs of pedicle rotation on CT as well as indirect findings including loss of normal parenchymal enhancement, atelectasis of torsed lobe/lung, and abnormal fissure position. These direct and indirect findings are often appreciated on different window presets and upon review of images in multiple planes, with need to collate the information subsequently. 3D cinematic rendering (CR) using multi-planar light sources can readily highlight spatial relationships of vasculature in the chest and may be able to assist in the confident diagnosis of this sometimes subtle but life-threatening pathology. We have provided the first characterization of common lung torsion findings on 3D CR.

Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review

The kidney is the most commonly transplanted solid organ. Advances in surgical techniques, immunosuppression regimens, surveillance imaging, and histopathologic diagnosis of rejection have allowed prolonged graft survival times. However, the demand for kidneys continues to outgrow the available supply, and there are efforts to increase use of donor kidneys with moderate- or high-risk profiles. This highlights the importance of evaluating the renal transplant patient in the context of both donor and recipient risk factors. Radiologists play an integral role within the multidisciplinary team in care of the transplant patient at every stage of the transplant process. In the immediate postoperative period, duplex US is the modality of choice for evaluating the renal allograft. It is useful for establishing a baseline examination for comparison at future surveillance imaging. In the setting of allograft dysfunction, advanced imaging techniques including MRI or contrast-enhanced US may be useful for providing a more specific diagnosis and excluding nonrejection causes of renal dysfunction. When a pathologic diagnosis is deemed necessary to guide therapy, US-guided biopsy is a relatively low-risk, safe procedure. The range of complications of renal transplantation can be organized temporally in relation to the time since surgery and/or according to disease categories, including immunologic (rejection), surgical or iatrogenic, vascular, urinary, infectious, and neoplastic complications. The unique heterotopic location of the renal allograft in the iliac fossa predisposes it to a specific set of complications. As imaging features of infection or malignancy may be nonspecific, awareness of the patient's risk profile and time since transplantation can be used to assign the probability of a certain diagnosis and thus guide more specific diagnostic workup. It is critical to understand variations in vascular anatomy, surgical technique, and independent donor and recipient risk factors to make an accurate diagnosis and initiate appropriate treatment.^©RSNA, 2019.

A Case of Torsion of the Gallbladder Suspected with SPECT-CT: Review and Recommendations

Torsion or volvulus of the gallbladder is a rare situation that rapidly progresses to gangrene and linked with a poor prognosis, even death, if unrecognized and untreated. An interesting and rare case of gallbladder volvulus in which diagnosis was obtained by comparing CT images and HIDA scan with SPECT-CT is presented. Relevant literature is reviewed, and recommendations are outlined.

Fatty masses of the abdomen and pelvis and their complications

There are numerous common and rare macroscopic fat-containing masses found in the abdomen and pelvis. These include benign masses, such as lipoleiomyoma, ovarian teratoma, mesenteric teratoma, and lipoma, as well as malignant masses, including liposarcoma and malignant transformation of benign entities. Any mass may become symptomatic due to the development of a complication which may range from ovarian torsion to intussusception to hemorrhage. Imaging plays a vital role in diagnosis and treatment planning when confronted with a symptomatic fat-containing mass.

Torsion of a Giant Antimesenteric Lipoma of the Ileum: A Rare Cause of Acute Abdominal Pain

Patient: Male, 67

Final Diagnosis: Torsion of a giant antimesenteric lipoma of the ileum

Symptoms: Acute abdomen

Medication: —

Clinical Procedure: En bloc segmental resection with end-to-end anastomosis

Specialty: Surgery

[Gallbladder volvulus: Diagnostic and surgical challenges]

BACKGROUND

The gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is an extremely rare surgical disease and definitive diagnosis is usually made during surgery.

CASE REPORT

A 78 year old woman presented with upper right quadrant abdominal pain, with no comorbidities and no other accompanying symptoms. Analysis revealed haemodynamic instability and leukocytosis. Computed tomography of abdomen showed an acute cholecystitis. During emergency right hypochondrium laparotomy, the gallbladder was found to be twisted counterclockwise with huge gangrenous gallbladder distal. Open cholecystectomy was performed and after the surgery, the patient was discharged in a few days.

CONCLUSION

Gallbladder volvulus, or gallbladder torsion, is a rare condition and should be considered when clinical and imaging findings of complicated cholecystitis are present. The performance of urgent laparoscopic surgery would be first option to avoid perforation, peritonitis and haemodynamic instability.

Epipericardial Fat Necrosis: Sonographic Findings and Their Correlation With Computed Tomography

Epipericardial fat necrosis is a rare cause of chest pain. It presents as pleuritic pain in an otherwise healthy patient. Computed tomography has proved to be the most effective diagnostic imaging technique because of its ability to reveal typical alterations in the cardiophrenic space. As far as we know, sonographic findings concerning this entity have not been reported in the literature. We report 4 cases admitted to our institutional emergency department with chest pain. Among other tests, chest wall sonography was requested in these patients and showed special findings that should be evaluated with chest computed tomography.

Hollow organ abdominal ischemia, part II: clinical features, etiology, imaging findings and management

Acute hollow organ ischemia commonly presents with acute pain prompting radiologic evaluation and almost always requires urgent treatment. Despite different risk factors and anatomic differences, ischemia is commonly due to low flow states but can also be due to arterial and venous occlusion. Radiologic diagnosis is critical as many present with nonspecific symptoms. Contrast-enhanced computed tomography (CT) is the modality of choice. Magnetic resonance imaging (MRI) is preferred in suspected appendicitis in pregnant patients and is superior in biliary necrosis. This article provides a pictorial review of the CT/MRI features of hollow abdominal organ ischemia while highlighting key clinical features, pathogenesis, and management.

Imaging findings of splenic emergencies: a pictorial review

Although traumatic injuries are the cause of common splenic emergencies in the emergency room, various nontraumatic conditions may also affect the spleen with possible life-threatening results. In this pictorial review, we present imaging findings of usual and unusual splenic emergencies. It is essential to be familiar with key imaging findings and advantages of different modalities to reach a definitive diagnosis.

TEACHING POINTS

• Delayed splenic rupture is commonly related to subcapsular hematoma. • Subtle haemorrhage is commonly restricted to the site of injury "sentinel clot sign". • The whorled appearance is the key imaging feature of splenic torsion.

Evaluating Patients with Left Upper Quadrant Pain

Imaging plays a major role in the evaluation of patients who present to the emergency department with acute left upper quadrant (LUQ) pain. Multidetector computed tomography is currently the primary modality used for imaging these patients. The peritoneal reflections, subperitoneal compartment, and peritoneal spaces of the LUQ are key anatomic features in understanding the imaging appearance of acute diseases in this area. Diseases of the stomach, spleen, pancreas, and splenic flexure are encountered in patients with acute LUQ pain. Optimization of the imaging protocol is vital for accurate diagnosis and characterization of these diseases in the acute setting.

Omental infarction and its mimics: imaging features of acute abdominal conditions presenting with fat stranding greater than the degree of bowel wall thickening

The segmental omental infarction is a rare self-limited disorder presenting with aspecific clinical symptoms that may mimic several acute abdominal conditions. Therefore, a correct noninvasive diagnosis is important because treatment approaches range from monitoring to surgery. As omental infarction results in an important fat stranding that is much greater than the degree of bowel wall thickening, it suggests a narrower differential diagnosis: appendicitis, diverticulitis, epiploic appendagitis, and mesenteric panniculitis. In this pictorial essay, we point out the importance of imaging in identifying this typical sign allowing alternate diagnoses such as segmental omental infarction that can be conservatively managed.

Imaging of common solid organ and bowel torsion in the emergency department

OBJECTIVE

This article will discuss the most common forms of torsion encountered in the emergency department.

CONCLUSION

Torsion refers to the twisting of an object about its axis and represents the pathophysiologic mechanism underlying an important group of disorders affecting both the bowel and the solid organs of the abdomen and pelvis. Although these disorders typically present with the acute onset of pain, clinical findings are often nonspecific, with imaging playing a key role in diagnosis. Missed or delayed diagnosis may result in complications, such as ischemia; end-organ loss; and, in some cases, death. Therefore, it is critical to have a thorough understanding of the pathophysiology and imaging findings of these entities to avoid the morbidity and mortality associated with a missed or delayed diagnosis.

Omental infarction preceded by anatomically upturned omentum

We report the case of a 49-year-old man who presented with acute abdominal pain. Contrast-enhanced computed tomography of the abdomen revealed spontaneous omental torsion with no other noticeable findings. Notably, a computed tomography exam 6 months prior demonstrated the omentum located within the anterior hepatic space, suggesting that the patient had a hypermobile, upturned omentum. To our knowledge, this is the first case report illustrating an anatomically upturned omentum as precursor to omental infarction.