A 71 year old lady presented to the accident and emergency department with a two-day history of severe abdominal pain. She had not opened her bowel for 24 hours which was unusual for her. She had past medical history of nissen's fundoplication for hiatus hernia and gastro oesophageal reflux disease. Unfortunately, she was sent home with diagnosis of constipation. She returned ten hours later with worsening of abdominal pain. On examination, she was drowsy, pyrexial and tachycardic. Abdomen was distended, tender on palpation with severe guarding and rigidity.

Abdominal X-ray was performed after initial resuscitation.
What is the most likely diagnosis?

A 47-year- old male patient was admitted to  hospital reporting acute onset of severe left iliac fossa pain. Past medical history was unremarkable. Physical examination revealed abdominal tenderness and a slight elevation of body temperature. An abdominal ultrasound was requested.Sonographic examination of left iliac fossa demonstrated hypoechoic wall thickening of a colonic segment surrounded by ill defined hyperechoic pericolic fat changes and thickened gut wall with a target pattern.


Further evaluation of the findings was decided and a CT was performed.
What is the most likely diagnosis?

ANSWER

Most likely diagnosis is Sigmoid diverticulitis

CT findings are Sigmoid wall thickening, presence of a diverticulum and fluid collection in left paracolic sulci.

Diverticula are sac-like protrusions of mucosa through the colonic wall, along the natural openings created by intramural nutrient vessels. Due to higher intraluminal pressure, they are more frequently observed at the level of sigmoid colon.

CT with oral and intravenous contrast is considered the imaging modality of choice for assessing the disease and may reveal segmental thickening of the bowel, enhancement of the colonic wall, pericolic fat stranding, extravasation of air and fluid into the pelvis and peritoneal cavity, abscesses and signs associated to fistula formation.

42-years-old female patient underwent gastric banding 3 years before, had the gastric band extracted 1 year before because of complete intragastric migration.Now she complains of dyspepsia, weight loss, halitosis, gastroesophageal reflux and frequent diarrhoea.Physical examination revealed no significant alterations. 
The oesophago-gastro-duodenal barium study was performed and the image was given below.

Oesophago-gastro-duodenal barium study

What is the diagnosis?

A 27-month-old girl was referred to our hospital because of growth retardation. She was small for her age. Her weight and height were under 3rd percentile. She was vocalising well and her motor development was normal. She had strabismus and there was no other focal neurological signs. She was born through normal vaginal delivery at 28th gestational week and weighed 900 grams. Pregnancy and neonatal period were normal. There was no family history of congenital central nervous system (CNS) disorders. There were no neuroradiological findings of inborn errors of metabolism, leukodystrophy, exposure to hypoxia or inflammatory CNS disease.
Magnetic resonance imaging (MRI) were given here.

Identify the lesion?

52 years old female patient presented with acute onset of severe right-sided abdominal pain associated with nausea, vomiting and one episode of diarrhoea. This was preceded by similar episodes of pain over a 3-week period. On examination the patient had a palpable right iliac fossa mass. Plain film of the abdomen showed a paucity of bowel gas in the right side of the abdomen with an impression of a soft tissue mass in this area.
Abdominal USS and Contrast enhanced CT scan of the abdomen were performed.


What is the most likely diagnosis?

A 38 year old female presented with a sudden onset, severe occipital headache with vomiting, dizziness and blurred vision. The patient had just finished steroid treatment for a chest infection and was on the combined oral contraceptive pill. The patient demonstrated no focal neurology with normal visual acuity/fundoscopy.An un-enhanced CT, performed 10 hours after the initial symptoms and a CT venogram was subsequently performed.These images are gven below.



What is the most likely diagnosis?


ANSWER

Deep venous sinus thrombosis

The un-enhanced CT(upper image) demonstrates increased attenuation within the straight sinus, vein of Galen.
Lower Image demonstrates the filling defects within the vein of Galen,straight sinus and superior sagittal sinus on a CT venogram sagittal reconstruction.

This patient was female, had just finished steroid treatment after a chest infection and was on the combined oral contraceptive pill, all risk factors for venous sinus thrombosis.
The appearance of venous sinus thrombosis on un-enhanced CT is high attenuation secondary to thrombus formation, with corresponding filling defects on CT venogram as demonstrated in this case.

A differential for hyper-attenuation of the un-enhanced venous sinuses is elevated levels of haematocrit (Eg:secondary to polycythaemia ). Children also have higher haematocrit levels and a lower brain density often causing a hyper-dense appearance of the sinuses.Another differential is partial volume effects due to the proximity of the cerebral venous sinuses to bony structures. For both of these differentials, there should not be a corresponding filling defect on a CT venogram.

The venous sinuses can be separated into the deep cerebral veins comprising the straight sinus, internal cerebral veins and the vein of Galen, and the cerebral venous sinuses comprising the sigmoid, transverse and superior sagittal sinuses. High attenuation in the deep cerebral veins on un-enhanced CT has been shown to be 100% sensitive and 99.4% specific for deep venous sinus thrombosis. 

73-year-old diabetic male patient who was admitted to our hospital with severe left flank pain and high fever. Physical examination revealed a left flank palpable mass.

Contrast-enhanced CT

What is the diagnosis?

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