Interesting Cases

1. Interesting Cases Dr. WALEED AL HAJJI

2. History • Thirty years old male patient who is experiencing left extensive femoro-popliteal DVT. • Hospitalized • One day later he developed chest pain and shortness of breath • Chest X-ray was obtained

4. CT angiography of the pulmonary arteries was done

6. Case was diagnosed as pulmonary embolism; IVC filter was inserted to guard against further PE

7. The patient survived that attack of PE, with follow up CT angiography of the pulmonary artery revealing complete resolution of the embolization of the right pulmonary artery. • Two days later, the patient experienced similar attack of chest pain, that found to be due to another attack of PE. • That was inspite of the IVC filter inserted in place!!!

8. CT of the chest and abdomen was performed

10. A B

11. Diagnosis Double IVC

12. Duplication of the IVC results from persistence of both supracardinalveins. The prevalence is 0.2%–3%

14. A double IVC can be associated with other conditions, such as a horseshoe kidney, a circumaortic renal vein, a retroaortic left renal vein, and a retroaortic right renal vein with hemiazygos continuation of the IVC

16. Case 2

18. Diagnosis • Fenestration of the septum pellucidum. • This is one of the findings in chronic obstructive hydrocephalus. • Also known as non-communicating hydrocephalus is simply hydrocephalus due to obstruction of CSF flow out of the ventricles. • Frequent causes of obstructive hydrocephalus include: • -aqueduct stenosis • -meningitis

19. Features of long standing obstructive hydrocephalus are: • -Marked dilatation of the lateral and third ventricles. • -Thinned and elevated corpus callosum. • -Depression of the fornices. • -Rounding of the infundibular, optic and pineal recesses. • -Ballooning of the suprapineal recess. • -Fenestration of the septum pellucidum.

20. Case 3 This is an incidental finding during an angiography procedure

23. Case 4 History:  Upper chest discomfort.

30. Diagnosis: •  Carcinoma of the gastric fundus (pseudoachalasia • presentation) with direct invasion of the GEJ.

31. Differential Diagnosis for Pseudoachalasia: • Carcinoma of the gastric cardia or fundus with direct invasion of the GEJ or distal esophagus. • Hematogenous metastases from breast, lung, or • pancreatic cancer. • Lymphoma. • Chagas.

32. Malignancy-induced secondary achalasia is an uncommon condition, accounting for only 2 to 4% of patient with findings of achalasia at manometry.  • Most patients with primary achalasia are between 20 and 50 years of age and have symptoms of dysphagia for an average of 4 to 6 years. Whereas, most patients with secondary achalasia are older than 50 years and have symptoms, on average, less than 6 months.

34. Case 5

35. 28 years old male patient • Admitted to the casualty with a stab injury to the left popliteal fossa • No much bleeding was noted on admission!!

37. Traumatic (stab) pseudoaneurysm Pop. A

39. Case 6

40. A 76-year-old woman presented with: • Vague abdominal pain (persistent for over two years) • Recent (over the previous three months), unwanted 8 kg weight loss

43. Differential Diagnosis • Gallbladder carcinoma • Adenomyomatosis • Chronic inflammation • Metastastic disease (metastatic melanoma) • And less likely, multiple polyps

44. Diagnosis Adenocarcinoma of the gallbladder

45. Discussion

46. Pathology Discussion • Cholecystectomy • Diffuse thickening of the wall but no obvious focal lesion.

47. Diffuse papillary projections of epithelium • Diffuse, adenomatous epithelial change • In some areas, dysplastic changes consistent with adenocarcinoma in situ • The tumor focally invades into muscularis propria only superficially

48. Radiology Discussion: • GB carcinoma, a highly lethal condition • Sixth most common gastrointestinal malignancy (after colon, pancreas, stomach, liver, and esophagus) • Because symptoms are often vague, this carcinoma is frequently detected late; in fact, detection is typically related to invasion of adjacent organs

49. Risk factors

50. Post-menopausal status • Cigarette smoking • Gallstones (seen in 85% of cases of gallbladder carcinoma)