A 60-year-old male who was being treated for acute-on-chronic pancreatitis with a large pancreatic-pseudocyst presented with acute abdomen to the emergency department. On presentation he was hypotensive. Laboratory parameters confirmed low haemoglobin (8.6 gm/dl) and mildly elevated serum amylase levels (180IU). Serum electrolytes revealed a low sodium and pottasium.Contrast CT abdomen was performed and two images were given below.
Axial CECT abdomen

Coronal CECT abdomen
What is the diagnosis? 

ANSWER

Contrast CT abdomen revealed atrophic and papery-thin body-tail of pancreas with relatively spared pancreatic-head. Adjacent peripancreatic fat planes were dirty. No overt fluid collection was seen in its vicinity. Additionally, a giant aneurysmal sac from the right postero-lateral aspect of the abdominal aorta at L1-L2 vertebral level was seen.The sac was seen extending into the right paravertebral gutter with extension also seen into the right psoas sheath.

Giant aortic pseudoaneurysm
Pseudoaneurysm formation is a recognised but relatively uncommon complication associated with pancreatitis. The most common artery affected is the splenic artery, followed by gastroduodenal, pancreaticodudenal, left gastric, hepatic and small intrapancreatic arteries in decreasing order of frequency. The probable aetiopathogenesis suggests that the release of proteolytic pancreatic enzymes (especially trypsin and elastase) into the perivascular space results in enzymatic digestion and weakening of the arterial wall. The damaged vessel wall under the influence of sustained arterial pressure leads to dissection of blood into the perivascular tissues forming a perfused sac that communicates with the arterial lumen.

T1 MRI
T2 MRI




































A 21-year-old man was admitted with bilateral lower extremity weakness and low-back pain.Plain radiograph was performed prior to MRI.
Sagittal T1-weighted and T2- weighted Magnetic resonance imaging (MRI) study was performed after taking plain radiograph.

What are the abnormalities in these images and what is the most likely diagnosis? 

ANSWER

Magnetic resonance imaging (MRI) study showed involvement of the Th 7, 8, 9, 12 and L3 vertebrae. Th7 and Th 8 vertebrae were destructed with collapse of the Th7-8 and Th 8-9 intervertebral disc spaces. Paravertebral and epidural abscesses were also detected at the same level. The spinal cord was compressed to the posterior by expanding epidural abscess. Postgadolinium images showed intense homogenous enhancement at epidural lesions and intense heterogeneous enhancement at paravertebral lesions. Involved vertebrae also enhanced.

Multifocal spinal tuberculosis

80 year old female, with history of cryptogenic cirrhosis, ischaemic heart disease and diabetes mellitus admitted with abdominal pain and bleeding through the colostomy of a Hartmann's procedure for a rectal carcinoma.
This patient presented with a short history of abdominal pain and bleeding from her colostomy. Relevant past medical history includes a palliative Hartmann's procedure for a rectal adenocarcinoma, cryptogenic cirrhosis with portal hypertension , Ischaemic heart disease and Diabetes Mellitus. A CT scan of the abdomen and pelvis showed no evidence of recurrent colonic malignancy or liver metastasis.
Contrast CT just proximal to bifurcation of portal vein is shown here.

















Then  duplex ultrasound scan was performed.
portal vein axial section
portal vein - sagittal section
















Idetify the abnormalities in these images and what is the most likely diagnosis?

A 9-month-old girl was brought by her parents because of swelling of the right leg since birth. On examination there was hemi-hypertrophy, venous varicosities and pinkish discoloration.

Plain radiographs showed marked soft tissue enlargement and mild bone enlargement.



Colour Doppler showed absent deep venous system and few varicose venous channels.















Angiography of right lower extremity showed increased little tortuous arterial branches and absent deep venous system

















What is the most likely diagnosis?


ANSWER

Klippel-Trénaunay Syndrome

Klippel-TrĂ©naunay Syndrome  is a rare congenital malformation characterised by the triad of capillary malformations, atypical varicosities or venous malformations, and bony or soft tissue hypertrophy usually affecting one extremity.The most frequent clinical aspect of Klippel-Trenaunay Syndrome is a dermal capillary stain associated with dilated marginal vein of Servelle often identified in the subcutaneous fat of the lateral calf and thigh. It should be distinguished from Parkes-Weber syndrome by absence of underlying arteriovenous malformation.Prominent superficial varicose veins are present in majority of the patients.Extremity pain, spontaneous haemorrhages, venous insufficiency or thrombophlebitis are commonly encountered. Treatment is usually conservative and includes application of graded compressive stockings or pneumatic compression devices. Percutaneous sclerosis of varicosities and surgical treatment by epiphysiodesis to control leg length discrepancy, excision of hypertrophied soft tissue or less commonly reconstructive surgery of deep venous obstruction has been reported in some patients.

63 year old male patient who underwent a laparoscopic cholecystectomy just one month before this admission. Since then, he experienced pain in the upper abdomen, weight loss of approximately 10 kg, odynophagia and progressive dysphagia which advanced to grade 3.



Two barium swallow images and contrast enhanced CT image are shown here.Comment on the Images.



ANSWER

The barium meal showed a fixed irregular narrowing of the esophageal lumen just proximal to the cardia. Contrast-enhanced CT visualized transmural lesions with irregular outer border, obliteration of the fat plane and invasion of adjacent organs, and a T11 osteoblastic lesion.

Adenocarcinoma of oesophagogastric junction

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