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Perforated Ulcers Shaleen Sathe, MS4 Christina Lebedis, MD CASE HISTORY
Perforated Ulcers Shaleen Sathe, MS4 Christina LeBedis, MD CASE HISTORY 54-year-old male with known history of hypertension presents with 2 days of acute onset abdominal pain, nausea, vomiting, and diarrhea, with periumbilical tenderness and abdominal distention on exam, without guarding or rebound tenderness. Labs, including CBC, CMP, and lipase, were unremarkable in the emergency department. Radiograph Perforated Duodenal Ulcer Radiograph of the chest in the AP projection shows large amount of free air under diaphragm (blue arrows), suggestive of intraperitoneal hollow viscus perforation. CT Perforated Duodenal Ulcer CT of the abdomen in the axial projection (I+, O-), at the level of the inferior liver edge, shows large amount of intraperitoneal free air (blue arrows) in lung window (b), and submucosal edema in the gastric antrum and duodenal bulb (red arrows), suggestive of a diagnosis of perforated bowel, most likely in the region of the duodenum. US Perforated Gastric Ulcer US of the abdomen shows perihepatic fluid (blue arrow) and free fluid in the right paracolic gutter (not shown), concerning for intraperitoneal pathology. Radiograph Perforated Gastric Ulcer Supine radiograph of the abdomen shows multiple air- filled dilated loops of large bowel, with air lucencies on both sides of the sigmoid colon wall (green arrows), consistent with Rigler sign and perforation. CT Perforated Gastric Ulcer CT of the abdomen in the axial (a) and sagittal (b) projections (I+, O-) shows diffuse wall thickening of the gastric body and antrum (green arrows) with an ulcerating lesion along the posterior wall of the stomach (red arrows), and free air tracking adjacent to the stomach (blue arrow), concerning for gastric ulcer perforation. -
Chest and Abdominal Radiograph 101
Chest and Abdominal Radiograph 101 Ketsia Pierre MD, MSCI July 16, 2010 Objectives • Chest radiograph – Approach to interpreting chest films – Lines/tubes – Pneumothorax/pneumomediastinum/pneumopericar dium – Pleural effusion – Pulmonary edema • Abdominal radiograph – Tubes – Bowel gas pattern • Ileus • Bowel obstruction – Pneumoperitoneum First things first • Turn off stray lights, optimize room lighting • Patient Data – Correct patient – Patient history – Look at old films • Routine Technique: AP/PA, exposure, rotation, supine or erect Approach to Reading a Chest Film • Identify tubes and lines • Airway: trachea midline or deviated, caliber change, bronchial cut off • Cardiac silhouette: Normal/enlarged • Mediastinum • Lungs: volumes, abnormal opacity or lucency • Pulmonary vessels • Hila: masses, lymphadenopathy • Pleura: effusion, thickening, calcification • Bones/soft tissues (four corners) Anatomy of a PA Chest Film TUBES Endotracheal Tubes Ideal location for ETT Is 5 +/‐ 2 cm from carina ‐Normal ETT excursion with flexion and extension of neck 2 cm. ETT at carina Right mainstem Intubation ‐Right mainstem intubation with left basilar atelectasis. ETT too high Other tubes to consider DHT down right mainstem DHT down left mainstem NGT with tip at GE junction CENTRAL LINES Central Venous Line Ideal location for tip of central venous line is within superior vena cava. ‐ Risk of thrombosis decreased in central veins. ‐ Catheter position within atrium increases risk of perforation Acceptable central line positions • Zone A –distal SVC/superior atriocaval junction. • Zone B – proximal SVC • Zone C –left brachiocephalic vein. Right subclavian central venous catheter directed cephalad into IJ Where is this tip? Hemiazygous Or this one? Right vertebral artery Pulmonary Arterial Catheter Ideal location for tip of PA catheter within mediastinal shadow. -
Cardiothoracic Fellowship Program
Cardiothoracic Fellowship Program Table of Contents Program Contact ............................................................................................ 3 Other contact numbers .................................................................................. 4 Introduction ........................................................................................................... 5 Goals and Objectives of Fellowship: ..................................................................... 6 Rotation Schedule: ........................................................................................ 7 Core Curriculum .................................................................................................... 8 Fellow’s Responsibilities ..................................................................................... 22 Resources ........................................................................................................... 23 Facilities ....................................................................................................... 23 Educational Program .......................................................................................... 26 Duty Hours .......................................................................................................... 29 Evaluation ........................................................................................................... 30 Table of Appendices .................................................................................... 31 Appendix A -
The Supine Pneumothorax
Annals of the Royal College of Surgeons of England (1987) vol. 69 The supine pneumothorax DAVID A P COOKE FRCS Surgical Registrar, Department ofSurgery, St Thomas' Hospital JULIE C COOKE FRCR* Radiological Senior Registrar, Department ofDiagnostic Radiology, Brompton Hospital, London Key words: PNEUMOTHORAX; COMPUTI ED TOMOGRAPHY; TRAUMA Summary TABLE I Causes of a pneumothorax The consequences of an undiagnosed pneumothorax can be life- threatening, particularly in patients with trauma to the head or Broncho-pulmonay pathology Traumatic injuy and in those mechanical ventilation. Yet multiple requiring Asthma it is these patients, whose films will be assessed initially by the Bronchial adenoma surgeon, who are more likely to have a chest X-ray taken in the Bronchial carcinoma Penetrating trauma supine position. The features of supine pneumothoraces are de- Emphysema Blunt trauma scribed and discussed together with radiological techniques used to Fibrosing alveolitis Inhaled foreign body confirm the diagnosis, including computed tomography (CT) Idiopathic which may be ofparticular importance in patients with associated Marfan's syndrome fatrogenic cranial trauma. Pulmonary abscess Pulmonary dysplasia CVP line insertion Introduction Pulmonary infarct Jet ventilation Pulmonary metastases Liver biopsy In a seriously ill patient or the victim of multiple trauma Pulmonoalveolar proteinosis Lung biopsy the clinical symptoms and signs of a pneumothorax may Radiation pneumonitis Oesophageal instrumentation be overshadowed by other problems. Usually in these Sarcoid PEEP ventilation circumstances a chest X-ray will be taken at the bedside Staphylococcal septicaemia Pleural aspiration with the patient supine and the appearances of a Tuberculosis Pleural biopsy pneumothorax will be different from those seen when the Tuberose sclerosis patient is upright. -
Radiology Fundamentals: Introduction to Imaging & Technology
Radiology Fundamentals Harjit Singh ● Janet A Neutze Editors Jonathan R Enterline ● Joseph S Fotos Associate Editors Jonathan J Douds ● Megan Jenkins Kalambo ● Marsha J Bluto Contributing Editors Radiology Fundamentals Introduction to Imaging & Technology Fourth Edition Editors Harjit Singh, MD, FSIR Janet A Neutze, MD Professor of Radiology, Surgery, Associate Professor of Radiology and Medicine Associate Division Chief, Ultrasound Director of Education, Penn State Heart Co-director, Radiology Medical Student and Vascular Institute Education Program Fellowship Director, Cardiovascular Pennsylvania State College of Medicine and Interventional Radiology Penn State Hershey Medical Center Pennsylvania State College of Medicine Hershey, PA, USA Penn State Hershey Medical Center [email protected] Hershey, PA, USA [email protected] Associate Editors Jonathan R Enterline, MD Joseph S Fotos, MD Resident, Department of Radiology Resident, Department of Radiology Pennsylvania State College of Medicine Pennsylvania State College of Medicine Penn State Hershey Medical Center Penn State Hershey Medical Center Hershey, PA, USA Hershey, PA, USA Contributing Editors Jonathan J Douds, BS Megan Jenkins Kalambo, MD Medical Student Resident, Department of Radiology Pennsylvania State College of Medicine University of Texas Health Science Center Penn State Hershey Medical Center at Houston, Houston, TX, USA Hershey, PA, USA Marsha J Bluto, MD Practicing Physician Physical Medicine and Rehabilitation Mill Valley, CA, USA ISBN 978-1-4614-0943-4 e-ISBN 978-1-4614-0944-1 DOI 10.1007/978-1-4614-0944-1 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011938463 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. -
Clinical Acute Abdominal Pain in Children
Clinical Acute Abdominal Pain in Children Urgent message: This article will guide you through the differential diagnosis, management and disposition of pediatric patients present- ing with acute abdominal pain. KAYLEENE E. PAGÁN CORREA, MD, FAAP Introduction y tummy hurts.” That is a simple statement that shows a common complaint from children who seek “M 1 care in an urgent care or emergency department. But the diagnosis in such patients can be challenging for a clinician because of the diverse etiologies. Acute abdominal pain is commonly caused by self-limiting con- ditions but also may herald serious medical or surgical emergencies, such as appendicitis. Making a timely diag- nosis is important to reduce the rate of complications but it can be challenging, particularly in infants and young children. Excellent history-taking skills accompanied by a careful, thorough physical exam are key to making the diagnosis or at least making a reasonable conclusion about a patient’s care.2 This article discusses the differential diagnosis for acute abdominal pain in children and offers guidance for initial evaluation and management of pediatric patients presenting with this complaint. © Getty Images Contrary to visceral pain, somatoparietal pain is well Pathophysiology localized, intense (sharp), and associated with one side Abdominal pain localization is confounded by the or the other because the nerves associated are numerous, nature of the pain receptors involved and may be clas- myelinated and transmit to a specific dorsal root ganglia. sified as visceral, somatoparietal, or referred pain. Vis- Somatoparietal pain receptors are principally located in ceral pain is not well localized because the afferent the parietal peritoneum, muscle and skin and usually nerves have fewer endings in the gut, are not myeli- respond to stretching, tearing or inflammation. -
Complicated Pseudodiverticulosis of Small Intestine: a Rare Case Report
International Surgery Journal Raj MK et al. Int Surg J. 2019 Sep;6(9):3433-3437 http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902 DOI: http://dx.doi.org/10.18203/2349-2902.isj20194096 Case Report Complicated pseudodiverticulosis of small intestine: a rare case report Kamal Raj M., V. Venkatachalam*, Manasa A. Institute of General Surgery, Madras Medical College, Chennai, Tamil Nadu, India Received: 08 July 2019 Revised: 16 August 2019 Accepted: 19 August 2019 *Correspondence: Dr. V. Venkatachalam, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Diverticular disease though being a common entity in large bowel is recently noted to occur more proximally as well. In the jejunum, the mucosal outpouchings, called as pseudo-diverticulae, occurs with an incidence of 0.5-1.5%. Diagnosed incidentally as majority of them remain asymptomatic. When they are symptomatic, dyspepsia and bloating, recurrent abdominal cramping, malabsorption and megaloblastic anemia occurs. On occasions it is not uncommon for patients to present with hemorrhage, infections, obstruction or perforation. Perforation, being a rare presentation occurs in less than 6% of the cases. We present a case of a 70 year old male, who presented as acute abdomen, found to have isolated jejunal diverticular perforation intraoperatively. Keywords: Jejunal diverticula, Perforation, Acute abdomen, Pseudo-diverticulae INTRODUCTION for 2 days. He also gave history of dyspepsia and bloating following food consumption. -
Postpartum Pneumoperitoneum and Peritonitis After Water Birth Brown Et Al
Gastrointestinal Radiology: Postpartum pneumoperitoneum and peritonitis after water birth Brown et al. Postpartum pneumoperitoneum and peritonitis after water birth Vanessa Brown 1, Sascha Dua 1*, Anna Athow 1, Rudi Borgstein 1, Oladapo Fafemi 1 1. Department of General Surgery, North Middlesex University Hospital Trust, London, UK * Correspondence: Miss Sascha Dua, 18 Eton Rise, Eton College Road, London, NW3 2DD, UK ( [email protected] ) Radiology Case. 2009 Apr; 3(4): 1-4 :: DOI: 10.3941/jrcr.v3i4.12 ABSTRACT Pneumoperitoneum (the presence of free gas in the peritoneal cavity) usually indicates gastrointestinal perforation with associated peritoneal contamination. We describe the unusual case of a 28-year-old female, who was 7 days postpartum and presented with features of peritonitis that were www.RadiologyCases.com www.RadiologyCases.com initially missed despite supporting radiological evidence. The causes of pneumoperitoneum are discussed. In the postpartum period the female genital tract provides an alternative route by which gas can enter the abdominal cavity and cause pneumoperitoneum. In the postpartum period it is important to remember that the clinical signs of peritonism, guarding and rebound tenderness may be diminished or subtle due to abdominal wall laxity. CASE REPORT Journalof Radiology Case Reports was performed (Fig. 1) and the patient referred to the CASE REPORT gynaecologist who requested an ultrasound of the abdomen A 28-year-old woman presented to the emergency department and pelvis to rule out retained products of conception (Fig. 2). with a two-day history of generalised abdominal pain. She had The ultrasound showed a bulky uterus with a small amount of given birth to her first child three days previously at home. -
CHEST RADIOLOGY: Goals and Objectives
Harlem Hospital Center Department of Radiology Residency Training Program CHEST RADIOLOGY: Goals and Objectives ROTATION 1 (Radiology Years 1): Resident responsibilities: • ED chest CTs • Inpatient and outpatient plain films including the portable intensive care unit radiographs • Consultations with referring clinicians MEDICAL KNOWLEDGE: • Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognitive sciences and the application of this knowledge to patient care. At the end of the rotation, the resident should be able to: • Identify normal radiographic and CT anatomy of the chest • Identify and describe common variants of normal, including aging changes. • Demonstrate a basic knowledge of radiographic interpretation of atelectasis, pulmonary infection, congestive heart failure, pleural effusion and common neoplastic diseases of the chest • Identify the common radiologic manifestation of thoracic trauma, including widened mediastinum, signs of aortic laceration, pulmonary contusion/laceration, esophageal and diaphragmatic rupture. • Know the expected postoperative appearance in patients s/p thoracic surgery and the expected location of the life support and monitoring devices on chest radiographs of critically ill patients (intensive care radiology); be able to recognize malpositioned devices. • Identify cardiac enlargement and know the radiographic appearance of the dilated right vs. left atria and right vs. left ventricles, and pulmonary vascular congestion • Recognize common life-threatening -
Deep Sulcus Sign Developed in Patient with Multiple Fibrous Bands Between the Parietal and Visceral Pleura
eISSN: 2508-8033 Brief Image in Trauma pISSN: 2508-5298 Deep Sulcus Sign Developed in Patient with Multiple Fibrous Bands between the Parietal and Visceral Pleura Chan Yong Park1, Kwang Hee Yeo1, Sung Jin Park1, Ho Hyun Kim1, Chan Kyu Lee1, Seon Hee Kim1, Hyun Min Cho1, Seok Ran Yeom2 1Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea 2Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea A deepening of the costophrenic angle occurs in cases with a deep sulcus sign. We report a case of deep sulcus sign in a 47-year-old man who fell from the fifth floor. Supine chest radiography showed a right-sided pneumothorax with deep sulcus sign. Chest computed tomography (CT) demonstrated a large pneumothorax with multiple fibrous bands between the parietal and visceral pleura of the upper lobe of the right lung. (Trauma Image Proced 2017(1):7-9) Key Words: Pneumothorax; X-Rays; Diagnosis; Tomography, X-Ray computed CASE A 47-year-old man presented to the emergency department after falling from a fifth floor height. His vital signs were systolic blood pressure 60 mmHg, pulse rate 111 beats/min, respiration rate 31 breaths/min, body temperature, 36.4℃, and oxygen saturation 96%. The injury severity score was 29, revised trauma score 5.15, trauma and injury severity score 74.8%. His arterial blood gas analysis was pH 7.35, pCO2 29 mmHg, pO2 75 mmHg, hemoglobin 16.7, SaO2 94%, lactic acid 11.8 mmol/L, and base excess -8.0. Supine chest radiography showed a right-sided pneumothorax with a deep sulcus Fig. -
Diagnosis of Pneumothorax in Critically Ill Adults Postgrad Med J: First Published As 10.1136/Pmj.76.897.399 on 1 July 2000
Postgrad Med J 2000;76:399–404 399 Diagnosis of pneumothorax in critically ill adults Postgrad Med J: first published as 10.1136/pmj.76.897.399 on 1 July 2000. Downloaded from James J Rankine, Antony N Thomas, Dorothee Fluechter Abstract The diagnosis of pneumothorax is estab- Box 1: Mechanisms of air entry lished from the patients’ history, physical causing pneumothorax examination and, where possible, by ra- x Chest wall damage: diological investigations. Adult respira- Trauma and surgery tory distress syndrome, pneumonia, and trauma are important predictors of pneu- x Lung surface damage: mothorax, as are various practical proce- Trauma—for example, rib fractures dures including mechanical ventilation, Iatrogenic—for example, attempted central line insertion, and surgical proce- central line insertion dures in the thorax, head, and neck and Rupture of lung cysts abdomen. Examination should include an inspection of the ventilator observations x Alveolar air leak: and chest drainage systems as well as the Barotrauma patient’s cardiovascular and respiratory Blast injury systems. x Via diaphragmatic foramina from Radiological diagnosis is normally con- peritoneal and retroperitoneal structures fined to plain frontal radiographs in the critically ill patient, although lateral im- x Via the head and neck ages and computed tomography are also important. Situations are described where an abnormal lucency or an apparent lung will then recoil away from the chest wall and a edge may be confused with a pneumotho- pneumothorax will be produced.1 rax. These may arise from outside the Air can enter the pleural space in a variety of thoracic cavity or from lung abnormali- diVerent ways that are summarised in box 1. -
Evidence-Based Management of Suspected Appendicitis in The
October 2011 Evidence-Based Management Volume 13, Number 10 Of Suspected Appendicitis In Authors Michael Alan Cole, MD Associate Physician, Department of Emergency Medicine, Brigham The Emergency Department and Women’s Hospital; Clinical Instructor, Harvard Medical School, Boston, MA Nicholas Maldonado, MD Abstract Emergency Physician, Brigham and Women’s Hospital/Massachusetts General Hospital, Harvard Affiliated Emergency Medicine Residency, Boston, MA Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in persons under 50 years of age, Peer Reviewers with a peak incidence in the second and third decades. Women John Howell, MD, FACEP, FAAEM Clinical Professor of Emergency Medicine, The George Washington have a greater risk of misdiagnosis and a higher negative appen- University, Washington, DC; Director of Academics and Risk Management, dectomy rate. Atypical presentations of appendicitis are com- Best Practices, Inc., Inova Fairfax Hospital, Falls Church, VA monly misdiagnosed, resulting in increased morbidity, mortality, Christopher Strother, MD Assistant Professor of Emergency Medicine and Pediatrics, Director, and potential litigation. The variability of presentation relates to Emergency and Undergraduate Simulation, Mount Sinai School of the varied anatomical location and the visceral innervation of the Medicine, New York, NY appendix. Patients presenting with possible appendicitis should Robert Vissers, MD, FACEP be risk stratified based on history, physical examination, and Chief, Emergency Medicine, Quality Director, Legacy Emanuel Hospital, Adjunct Associate Professor, Oregon Health & Science University School laboratory data. An elevated white blood cell (WBC) count alone of Medicine, Portland, OR (> 10,000 cells/mm3) offers poor diagnostic utility; however, CME Objectives combining WBC count > 10 and C-reactive protein (CRP) level > Upon completion of this article, you should be able to: 8 achieves notable predictive power in the diagnosis of acute ap- 1.