Thoracoabdominal Computed Tomography Scan Research Articles

Unusual site of echinococcosis: axillary hydatid cyst—a case report

BackgroundEchinococcosis is a multisystem disease that might affect all organs, especially the liver and the lungs among adults. Axillary hydatid cyst, an extremely uncommon disease, was rarely reported in the literature. We report herein a case of axillary hydatid cyst which revealed a disseminated hydatid disease among a previously healthy woman.Case presentationA previously healthy woman, aged 53 years old, presented with a painful mass in her right axillary region. Physical examination revealed a painful semi-mobile right axillary mass, of 12 cm in size. Thoracoabdominal computed tomography scan revealed numerous cystic lesions: right axillary, pulmonary, hepatic, pancreatic, splenic and intraperitoneal lesions. The diagnosis of disseminated hydatid disease was suspected in front of the cystic lesions and the positive serology result for hydatid disease. An excisional biopsy of the axillary mass lesion was performed, confirming the diagnosis of a hydatid cyst. The patient received albendazole after hospital discharge.ConclusionsAlthough axillary hydatid cyst is an extremely uncommon disease, the diagnosis should be rule out in front of the presence of a mass in the axillary region. Imaging results associated with serological tests might suspect the diagnosis, which can only be confirmed with parasitological or/and histopathological examination. Its management include surgical and medical therapy.

Anatomical Bases for Aesthetic Costal Surgery: Assessing the Thoracoabdominal Limits.

Knowing the anatomy of the ribs is crucial for understanding various rib procedures. The present study is aimed at describing radiological measurements and ratios of 83 Latin American patients undergoing thoracoabdominal computed tomography (CT). A total of 83 thoracoabdominal computed tomography scans of women aged 18-35 conducted at a medical center in Lima, Peru, were reviewed from January 2022 to January 2023. The resulting measurements and ratios were used to calculate frequency distributions. All data were stored in a Microsoft Excel database and analyzed using statistical analysis software SPSS version 28. Ratios and measures of the tenth, eleventh, and twelfth ribs are shown in the different tables, and costal characteristics with an adequate statistical significance are defined. Using radiological measurements and rib ratios, we were able to find key anatomical relationships with an adequate level of significance, which could help establish objective results in rib procedures.

Influence of tube and patient positioning in thoracoabdominal CT examinations on radiation exposure–towards a better patient positioning

Although iso-centric patient positioning is enormously important in computed tomography (CT), it is complicated in thoracoabdominal imaging by the varying dimensions of the body. Patient positioning can affect the appearance of the patient on the localiser. Positioned too close to the x-ray tube, a patient appears considerably more voluminous. The goal of this study is to assess the difference in radiation exposure of combined chest and abdomen CT scans between scans with prior 0°- and 180°-localisers in conjunction with patient positioning. In this IRB-approved retrospective study, patients who had two routine thoracoabdominal CT scans on the same CT scanner, one with a prior 0°- and one with a prior 180°-localiser, were included. To evaluate the radiation exposure of the thoracoabdominal CT examination regarding the tube position during the localiser, volumetric computed tomography dose index (CTDIvol), size-specific dose estimate (SSDE), patient diameter and positioning within the iso-centre for three positions (heart, abdomen, femur level) were compared with regard to the tube position during the prior localiser. CT examinations of 114 patients were included. Despite similar patient weight and diameter between the two examinations, SSDE and CTDIvol was significantly larger (up to 73%) with 180°-localisers. Patient offset from the iso-centre ranged between −9 mm at the centre slice (abdomen level) to −43 mm at the most caudal slice at the pelvis (femur level), causing a significant magnification (p < 0.001) on 180°-localisers with a subsequent increase of the apparent attenuation. The results of this study emphasise the use of 0°-localisers in thoracoabdominal CTs, since 180°-localisers caused patient magnification with subsequent increase in radiation exposure. The advantage of 180°-localisers, namely reducing the dose in thyroid and breast, is eliminated if the dose of the CT scan increases significantly in the abdomen and pelvis.

Hepatic and Lung Histiocytosis

A 52-year-old male was admitted for abdominal pain. He had a personal history of tobacco. The physical examination and laboratory tests were normal. A thoraco-abdominal computed tomography scan (CT) reveals a combination of a thin walled pulmonary cystic lesion, and an hepatic hypodense subcapsular lesion (Figure 1). No other abnormalities were showed. The liver magnetic resonance imaging (MRI) showed a normal sized liver with regular contours and multiple nodular lesions (Figure 2). We completed by liver biopsy, that shows infiltration of large cells with irregular nuclei that positively stained to CD1a and S100 (Figure 3).

A case of gastrointestinal stromal tumor metastasized to the left ventricular myocardium

BackgroundGastrointestinal stromal tumors (GISTs), which are the most common soft tissue tumors of the gastrointestinal tract, originate from Cajal interneurons. The main metastatic sites of GISTs are the liver and intra-abdominal cavity, and metastasis to the heart is rare.Case presentationThe patient was a 78-year-old man who was diagnosed with a rectal GIST 20 years previously. Since then, he had undergone repeated operations for metastasis. A follow-up thoracoabdominal computed tomography scan 4 months prior to the operation revealed GIST metastasis to the left ventricular myocardium. The patient wanted the tumor removed and consequently underwent an operation. The surgical findings showed a 3-cm × 3-cm mass in the lateral wall of the left ventricle. The mass was resected from the left ventricular wall in the shape of a tear drop. The left ventricular cavity was closed with a 4–0 polypropylene mattress suture and continuous suture. Postoperative histopathological findings showed nodular tumor growth consisting of bundles of spindle-shaped cells in the myocardium. The margins were negative. Immunostaining showed c-KIT (CD17) positivity and CD34 positivity, consistent with GIST metastasis.ConclusionsThis case involved GIST metastasis to the heart muscle, which has rarely been reported worldwide.

Late metachronous cerebral metastasis of pancreatic adenocarcinoma of the tail of the pancreas: a case\xa0report

BackgroundPancreatic cancer is one of the leading causes of cancer mortality and one of the most lethal malignant neoplasms worldwide. It is known for its local tumor extension to the liver; other common sites include the lung, distant lymph nodes, and bone. Brain metastases are extremely rare and represent less than 0.6% of all brain metastases.Case reportWe report the case of a 66-year-old Caucasian female known to have adenocarcinoma of the tail of the pancreas treated with chemotherapy. During follow-up, thoracoabdominal computed tomography scans did not reveal any residual tumor or any metastasis. Moreover, tumor markers were within normal limits. She presented to the emergency department of our institution following an episode of a generalized tonic–clonic seizure 5 years following the initial diagnosis. Brain magnetic resonance imaging revealed an expansive left frontal intraaxial lesion compatible with high-grade glioma. The patient underwent surgical treatment. Histological examination revealed pancreatic metastasis.ConclusionsThought to be rare, metachronous cerebral pancreatic metastasis should be kept in mind in patients with pancreatic cancer. Early diagnosis and complete surgical resection play a key role in the survival of these patients.

Effective examination methods for identifying the primary origins of metastatic bone tumors of unknown primary origin during the initial visit: A retrospective chart review study

Objective:To provide appropriate treatment for patients, early diagnosis of the primary origin of skeletal metastases of unknown primary origin is important. This study aimed to assess the examination strategy effective for identifying the primary origin of skeletal metastases of unknown primary origin.Methods:Sixty-one patients with skeletal metastases of unknown primary origin were reviewed. The primary origin was examined via physical examination, blood test including tumor markers, chest radiography, thoracoabdominal computed tomography scan, positron emission tomography–computed tomography scan, metastatic lesion biopsy, and other assessments. Examination methods considered effective for the diagnosis of the primary origin in a specific type of cancer were investigated.Results:The lung was the most common primary origin site, followed by the lymph nodes, prostate, and breast. Meanwhile, biopsy was the most effective examination, followed by positron emission tomography–computed tomography scan and thoracoabdominal computed tomography scan. Blood tests are useful for detecting hematological malignancies and prostate cancer. Computed tomography scans can be used to identify cancers in the lung, breast, and kidney, which are the common primary origins. Forty-one (67.2%) of the 61 patients with skeletal metastases of unknown primary origin were diagnosed via the first four steps, that is, physical examination, blood test, chest radiography, and thoracoabdominal computed tomography scan. Finally, two patients were diagnosed with skeletal metastases of unknown primary origin.Conclusion:The examination steps used in this study, including physical examination, blood test including tumor markers, chest radiography, thoracoabdominal computed tomography scan, positron emission tomography–computed tomography scan, biopsy, and other assessments were effective in determining the primary origin of skeletal metastases of unknown primary origin during the initial visit.

Incidence rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries: a retrospective cohort study

BackgroundThe aim of this study was to determine the rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries (PRI).MethodsThis retrospective cohort study was conducted in a level I trauma center serving 500,000 inhabitants. A total of 127 consecutive patients with high-energy blunt PRI were included between January 1st, 2014 and December 31st, 2017. Every patient had a total body or thoraco-abdominal computed tomography scan including contrast enhanced arterial sequences. A board-certified radiologist reviewed all the vascular images and precisely described every intra-pelvic arterial lesion in terms of localization. Complete pelvic series (standard radiographs and fine cut computed tomography images) were reviewed by three board-certified orthopedic surgeons experienced in PRI management, and Young and Burgess and AO/OTA classifications were determined. Demographic, clinical, therapeutic and outcome data were extracted from the institutional severely injured patients’ registry.ResultsPatients’ mean age was 45.3 years and 58.3% were males. Fifteen (11.8%) had a total of 21 intra-pelvic arterial lesions: seven lesions of the obturator artery, four of the superior gluteal artery, three of the inferior gluteal artery, two of the vesical artery, and one of each of the following arteries: internal iliac, internal pudendal, fifth lumbar, lateral sacral, ilio-lumbar. These lesions occurred in 8.6% of lateral compression injuries, 33.3% of anteroposterior compression injuries and 23.5% of vertical shear and combined mechanism injuries (Young and Burgess classification, p = 0.003); and in 0% of type A injuries, 9.9% of type B injuries and 35% of type C injuries (AO/OTA classification, p = 0.001). Patients with an intra-pelvic arterial lesion were more likely to present with pre-hospital hemodynamic instability (p = 0.046) and to need packed red blood cells transfusion within the first 24 h (p = 0.023; they needed a mean of 7.53 units vs. 1.88, p = 0.0016); however, they did not have a worst outcome in terms of complications or mortality.ConclusionsThis systematic study found an 11.8% rate of intra-pelvic arterial lesion related to high-energy blunt PRI. The obturator, superior gluteal and inferior gluteal arteries were most often injured. These findings are important for the aggressive management of high-energy blunt PRI.

Posttraumatic bronchobiliary fistulae due to foreign body remnants after \xa0a\xa0road traffic injury: a case report

BackgroundBronchobiliary fistula is an extremely rare disease that involves abnormal communication between a hepatic segment and bronchial tree. It is mostly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma.Case presentationWe experienced an extremely rare case of bronchobiliary fistula after motor vehicle accident. A 15-year-old Persian boy visited our clinic with chief complaints of persistent pleuritic chest pain, productive cough, weight loss, and fever for 2 months. Coronavirus disease 2019 reverse transcription polymerase chain reaction test was negative. Chest X-ray revealed hazy opacification of right lower lobe. Bronchoalveolar lavage for acid-fast bacillus came back negative. Thoracoabdominal computed tomography scan revealed a collection in segment VIII of the liver communicating with another 13 × 5 cm multiloculated collection in the lower lobe of the right lung, with air foci within the collection. Right posterolateral thoracotomy was performed with the impression of bronchobiliary fistula. Drainage of hepatic collection with debridement, diaphragmatic repair, and open decortication of lung followed by resection of the involved segment of the right lung was performed. Histopathologic evaluations revealed abscess formation in pulmonary tissue, and many multinucleated giant cells were seen that appear to be due to foreign body remnants after previous laparotomy surgery. The foreign body seemed to be the remnants of Surgicel absorbable hemostat.ConclusionsHerein, we report an extremely rare case of a posttraumatic bronchobiliary fistula caused by remnants of Surgicel hemostatic agent. Bronchobiliary fistula is mainly caused by untreated hydatid cyst, liver abscess, iatrogenic stenosis, and, rarely, trauma. Migration and erosion of oxidized regenerated cellulose through the diaphragm seems to be the causative factor of bronchobiliary fistula in this patient.

Faecopneumothorax due to missing diaphragmatic hernia: a case report

BackgroundDiaphragmatic hernias may occur as either congenital or acquired. The most important cause of acquired diaphragmatic hernias is trauma, and the trauma can be due to blunt or penetrating injury. Diaphragmatic hernia may rarely be seen after thoracoabdominal trauma.Case presentationA 54-year-old Turkish male patient admitted to the emergency department with abdominal pain and dyspnea ongoing for 2 days. He had general abdominal tenderness in all quadrants. He had a history of a stabbing incident in his left subcostal region 3 months ago without any pathological findings in thoracoabdominal computed tomography scan. New thoracoabdominal computed tomography showed a diaphragmatic hernia and fluid in the hernia sac. Due to respiratory distress and general abdominal tenderness, the decision to perform an emergency laparotomy was made. There was a 6 cm defect in the diaphragm. There were also necrotic fluids and stool in the hernia sac in the thorax colon resection, and an anastomosis was performed. The defect in the diaphragm was sutured. The oral regimen was started, and when it was tolerated, the regimen was gradually increased. The patient was discharged on the postoperative 11th day.ConclusionsAcquired diaphragmatic hernia may be asymptomatic or may present with complications leading to sepsis. In this report, acquired diaphragmatic hernia and associated colonic perforation of a patient with a history of stab wounds was presented.

Gastrointestinal: Franseen-tip transmural fine-needle biopsy for localized gastric linitis plastica.

A 59-year-old male patient presented with refractory nausea and vomiting. Esophagogastroduodenoscopy revealed a concentric, malignant-appearing stricture in the distal antrum (Fig. 1a). Of note, despite the clinical picture of functional outlet obstruction, endoscopic passage into the duodenum was maintained. However, two extensive rounds of conventional mucosal biopsies (each > 12) did not yield a malignant histology. While a thoracoabdominal computed tomography scan excluded distant metastases, endoscopic ultrasound (EUS) revealed marked, diffusely hypoechogenic wall thickening up to 30 mm with irregular margins and fusion of layers, highly suggestive of gastric linitis plastica (GLP) (Fig. 1b, linear probe: Pentax, EG38J10UT). Final locoregional staging was determined uT3N0, and transmural EUS fine-needle biopsy (FNB) using a novel FNB-dedicated 22G Franseen-tip needle was performed (Acquire, Boston Scientific) (Fig. 1c). Relative to more established EUS-FNB needle, such as the Procore needle, the specific design of the needle with its stabilizing three-point tip allows for improved tissue capture and reduced fragmentation. EUS-FNB was performed in the slow pull technique with extensive fanning through the lesion, resulting in a macroscopically excellent yield (Fig. 1d). Pathology assessment indicated atypical epithelial cells with a prominent desmoplastic stroma within the muscularis propria (Fig. 1e, top). There was faint granular positivity in the periodic acid-Schiff staining, albeit a clear-cut signet ring morphology was absent. Ancillary immunohistochemistries were positive for CK-20 (Fig. 1e, lower left), CDX-2 (Fig. 1e, lower right), and (not shown) carcinoembryonic antigen, while p53 remained negative. In conjunction with clinical characteristics, a final diagnosis of poorly differentiated adenocarcinoma underlying linitis plastica was entertained. After an unremarkable ileocolonoscopy, the patient underwent diagnostic laparoscopy, excluding peritoneal carcinomatosis and providing an enteral nutrition access, and perioperative chemotherapy using FLOT4 (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) was recommended prior to surgical gastrectomy. EUS-based tissue acquisition of either the gastric wall and/or suspicious lymph nodes is instrumental in confirming the malignant nature of gastric wall thickening, albeit the distinct benefit of newer FNB-dedicated needles, such as with a Franseen-tip design, considered to translate into improved maintenance of tissue architecture, is yet to be better determined in systematic, GLP-exclusive analyses.

SURG-34. MULTIDISCIPLINARY MANAGEMENT OF A PATIENT WITH OPTIC PATHWAY-HYPOTHALAMIC LANGERHANS CELL HISTIOCYTOSIS: A CASE REPORT

Abstract Langerhans cell histiocytosis (LCH) of the Central Nervous System (CNS) is rare. Isolated involvement of the hypothalamic region is much more extremely rare with only 0.04 to 0.6% of the cases. We report a case of a 33 year-old female who presented with a one-year history of amenorrhea and a five-month history of intermittent headache, memory lapse, and somnolence. The patient was of normal body mass index with normal visual acuity and intact visual fields. Laboratory examinations revealed panhypopituitarism with central diabetes insipidus. Cranial magnetic resonance imaging showed a large lobulated mass measuring 1.9 x 2.2 x 2 cm in the suprasellar region which extended to the pituitary infundibulum, hypothalamus and retrochiasmatic region, with surrounding edema. The patient underwent right orbitozygomatic craniotomy and subtotal excision of the mass through subfrontal and transsylvian approaches. Histopathological examination of langerhans cells were observed with positive immunohistochemical stain for CD1a and S100 protein antigen markers establishing a diagnosis of CNS LCH. Thoracoabdominal computed tomography scan and bone scan were done postoperatively and showed no evidence of extracranial lesions. The patient had been receiving prednisone and vinblastine based chemotherapy regimen. She remains to be asymptomatic and on close surveillance. To date, there is no standardized treatment strategy for CNS LCH in the adult population. An accurate histopathologic diagnosis and a specialized multidisciplinary team approach especially involving Oncology, Neurosurgery, Ophthalmology and Endocrinology are critical to optimally tailor possible effective treatment options for patients with this similar disease. Long-term follow-up is crucial due to the increased risk of local recurrence and multisystemic involvement.

Aortic volume determines global end-diastolic volume measured by transpulmonary thermodilution

BackgroundGlobal end-diastolic volume (GEDV) measured by transpulmonary thermodilution is regarded as indicator of cardiac preload. A bolus of cold saline injected in a central vein travels through the heart and lung, but also the aorta until detection in a femoral artery. While it is well accepted that injection in the inferior vena cava results in higher values, the impact of the aortic volume on GEDV is unknown. In this study, we hypothesized that a larger aortic volume directly translates to a numerically higher GEDV measurement.MethodsWe retrospectively analyzed data from 88 critically ill patients with thermodilution monitoring and who did require a contrast-enhanced thoraco-abdominal computed tomography scan. Aortic volumes derived from imaging were compared with GEDV measurements in temporal proximity.ResultsMedian aortic volume was 194 ml (interquartile range 147 to 249 ml). Per milliliter increase of the aortic volume, we found a GEDV increase by 3.0 ml (95% CI 2.0 to 4.1 ml, p < 0.001). In case a femoral central venous line was used for saline bolus injection, GEDV raised additionally by 2.1 ml (95% CI 0.5 to 3.7 ml, p = 0.01) per ml volume of the vena cava inferior. Aortic volume explained 59.3% of the variance of thermodilution-derived GEDV. When aortic volume was included in multivariate regression, GEDV variance was unaffected by sex, age, body height, and weight.ConclusionsOur results suggest that the aortic volume is a substantial confounding variable for GEDV measurements performed with transpulmonary thermodilution. As the aorta is anatomically located after the heart, GEDV should not be considered to reflect cardiac preload. Guiding volume management by raw or indexed reference ranges of GEDV may be misleading.

Heterotopic ossification at the level of a laparotomy scar

We report the cases of two patients referred to our radiology department for a thoracoabdominal computed tomography (CT) scan as part of their routine postoperative follow-up as both the patients were asymptomatic. The first patient is a 60-year-old female who underwent a laparotomy for gastric gastrointestinal stromal tumor (GIST) 11 months ago, and checked into our radiology department for a thoracoabdominal CT scan as part of her follow-up assessment. The patient had no complaints. The CT scan revealed a 7 cm long vertical linear calcified lesion in the anterior abdominal wall at the anterior aspect of the xiphoid process corresponding to a heterotopic ossification of the laparotomy scar (Figure 1). The second patient is a 33-year-old male who had undergone laparotomy for total gastrectomy one month earlier due to a gastric adenocarcinoma. The patient was received in our department for his first check-up after surgery and concomitant radiochemotherapy. Furthermore, the patient presented no complaints. The thoracoabdominal CT scan performed revealed a vertical calcified lesion at the level of the laparotomy scar extending about 11 cm from the xiphoid region to about 5 cm above the umbilicus, also corresponding to a heterotopic ossification of the laparotomy scar (Figure 2).

Acute and chronic traumatic diaphragmatic hernia: 10 years' experience.

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Retrospective analysis of adult thoracic surface anatomy in Indian population using computed tomography scans

Introduction: Recent studies on human surface anatomy observed inconsistencies in standard surface markings from that given in contemporary anatomy texts, particularly in thoracic surface landmarks. The present study was conducted to reevaluate the thoracic surface anatomy of adults of Indian origin which has not been done so far and compare the observations with the descriptions obtained from other population groups. Material and Methods: The thoracic surface anatomy was analyzed in 100 thoracoabdominal computed tomography scans of the Indian population. Results: It was observed that the positions of the xiphisternal joint, sternal angle, central veins, apex of lungs, cardiac apex, and dome of the diaphragm were within the normal limits with slight deviations from that described in standard anatomy texts. However, certain landmarks showed high degree of difference among the races as well as from the descriptions of the textbooks such aortic arch, bifurcations of the trachea and pulmonary trunk, inferior border of right and left lung adjacent to the vertebral column, and vertebral level of inferior vena cava piercing the diaphragm. Discussion and Conclusion: The surface anatomical landmarks of the thorax are not static, and there is a need to accommodate for a range of values than the constant markings. The relationship of the thoracic structures with the overlying surface landmarks were more variable in relation to vertebral levels than the costal references.

Accuracy of Extended Focused Assessment with Sonography in Trauma (e-FAST) Performed by Emergency Medicine Residents in a Level One Tertiary Center of India.

Introduction: It could be claimed that extended focused assessment with sonography for trauma (e-FAST) is the most important use of ultrasound in every emergency department (ED). It is a rapid, repeatable, non-invasive bedside method that was designed to answer one single question, which is, “whether free fluid is present in the peritoneal, pleural and pericardial cavity or not?” This examination may also be used to evaluate the lungs for pneumothorax.Objective: The current comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients.Method:This diagnostic accuracy study was conducted prospectively in patients presenting over a period of 12 months from January 1, 2013, to December 31, 2013 to the ED of Kerala Institute of Medical Sciences (KIMS), Kerala, India. All multiple trauma patients older than 18 years of age presenting within 24 hours of their traumatic event, who underwent both e-FAST and thoracoabdominal computed tomography (CT) scan were included. The e-FAST exams were first performed by the EMRs and then by RCs. The thoracoabdominal CT scan findings were considered as the gold standard. The results were compared between both groups to assess the inter-observer variability. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated both for EMRs and RCs.Results:In the study period, 150 patients with a mean age of 42.06 ± 18.1 years were evaluated (76.7% male). Only 19 cases (12.7%) had a history of fall from a height, and the others were admitted due to RTA. Thirty-four cases (22.7%) did not require surgery; but the others underwent various interventions. Both EMRs and RCs reported positive findings in 20 cases (13.3%) and negative findings in 130 cases (86.7%). The correlation of e-FAST done by EMRs with that by RCs was 100%. E-FAST exam had a sensitivity of 90.4%, specificity 99.2%, PPV 95.0%, NPV 98.4%, and accuracy 98%, both for EMRs and RCs. Conclusion: Based on the findings, the sensitivity, specificity, and accuracy of e-FAST exams performed by EMRs were equal to those performed by RCs. It seems that e-FAST performed by EMRs were almost accurate during the initial trauma resuscitation in the ED of a level one trauma center in India.

Why Would a Patient Complain of Dysphagia and Heartburn After Multiple Bariatric Surgeries?

Question: A 43-year-old woman presented for management of a complication of her bariatric surgery. The history goes back to September 2000 when the patient presented with a body mass index (BMI) of 45 (120 kg to 1.63 m). An adjustable gastric band was placed. One year postoperatively, the band migrated, which resulted in removal of the band. In 2003, the patient regained weight and reached a BMI of 47 kg/m2. She underwent a Roux-en-Y gastric bypass. The Roux-en-Y gastric bypass failed in the long term; the patient regained weight and reached a BMI of 45. A supportive band was also placed on the gastric pouch and failed to result in significant weight loss, which necessitated its removal. Currently, the patient has a BMI of 55 and she complains of heartburn accompanied by intermittent abdominal epigastric pain and dysphagia for solid food for the last few months. A 3-dimensional thoracoabdominal computed tomography (CT) scan was done (Figure A–C). What is the diagnosis and how it should be managed? Look on page 654 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A 3-dimensional thoracoabdominal CT scan was done that showed herniation of the gastric pouch, the gastrojejunal anastomosis, the alimentary limb, and the residual excluded stomach into the thoracic cavity through the hiatal orifice (Figure A–C). The patient underwent laparoscopic reduction of the intrathoracic contents into the abdominal cavity and repair of the hiatal orifice. Mesh repair of the hiatal defect was preferred. The postoperative course was uneventful. She was doing well at follow-up 6 months after surgery. Bariatric surgery is booming in all countries.1Debs T. Petrucciani N. Kassir R. et al.Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005–2014.Surg Obes Relat Dis. 2016; 12: 1602-1609Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar However, hiatal hernia is an uncommon pathology after bariatric surgery. The patient underwent multiple bariatric surgeries, with repeated dissection of the angle of His and the diaphragmatic crura, which might have increased the risk of herniation, owing to enlargement of natural orifices such as the hiatal orifice. The reduced formation of adhesions owing to the laparoscopic approach could also play a role. Morbid obesity itself is an independent risk factor for development of hiatal hernia. The intra-abdominal and visceral fat in obese patient leads to a higher intragastric pressure. In addition, obesity reduces the inferior esophageal sphincter pressure and causes esophageal motility problems. Abnormal changes in the collagen and reduced elastin in the diaphragmatic crura after bariatric surgery predispose these patients to hiatal hernias.2Pandolfino J.E. El-Serag H.B. Zhang Q. et al.Obesity: a challenge to esophagogastric junction integrity.Gastroenterology. 2006; 30: 639-649Abstract Full Text Full Text PDF Scopus (395) Google Scholar, 3Curci J.A. Melman L.M. Thompson R.W. et al.Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia.J Am Coll Surg. 2008; 207: 191-196Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Management of hiatal hernia after bariatric surgery consists of reduction of the contents into the abdominal cavity, closure of the hiatal orifice and mesh repair.

Late gastrobronchial fistula postsleeve gastrectomy

A 50-year-old woman presented to the emergency department with a 1-day history of hemoptysis and a deteriorating general condition over the previous month. She took a self-prescribed nonsteroidal anti-inflammatory drug. Her chief surgical history consisted of a sleeve gastrectomy 5 years previously when her body mass index (BMI) was 42 kg/m2 without metabolic co-morbidities, complicated by staple-line gastric leak at the esophagogastric junction, treated successfully by 2 endoscopic stents. A thoraco-abdominal computed tomography scan with oral contrast found a gastrobronchial fistula (Fig. 1). The original fistula had extended across the diaphragm into the left inferior pulmonary lobe. The patient’s BMI was 23 kg/m2. For this rare complication [ 1 Silva L.B. Moon R.C. Teixeira A.F. et al. Gastrobronchial fistula in sleeve gastrectomy and Roux-en-Y gastric bypass--a systematic review. Obes Surg. 2015; 25: 1959-1965 Crossref PubMed Scopus (24) Google Scholar , 2 Sakran N. Assalia A. Keidar A. Goitein D. Gastrobronchial fistula as a complication of bariatric surgery: a series of 6 cases. Obes Facts. 2012; 5: 538-545 Crossref PubMed Scopus (28) Google Scholar ], a surgical solution was chosen after a multidisciplinary discussion. Eight days after medical preparation by parenteral nutrition and noninvasive ventilation, she underwent surgery. The first step was a posterolateral left thoracotomy through the sixth intercostal space for a left inferior lobectomy (Fig. 2A). The second step was a total gastrectomy through a left subcostal incision (Fig. 2B) with a Roux-en-Y limb and a jejunostomy. Her postoperative course was smooth. At 1 month follow-up, she was on a full oral diet with a BMI 23.5 kg/m². Fig. 2(A) Left inferior lobectomy with the fistula. (B) Fistula on the esophagogastric junction after sleeve gastrectomy. View Large Image Figure Viewer Download Hi-res image

Aortic Calcification Progression in Heterozygote Familial Hypercholesterolemia

BackgroundPatients with homozygous and heterozygous familial hypercholesterolemia (HeFH) develop severe aortic calcifications in an age- and gene dosage-dependent manner. The purpose of this study was to determine the rate of progression of aortic calcification in patients with HeFH. MethodsWe performed thoracoabdominal computed tomography scans and quantified aortic calcium (AoCa) score in 16 HeFH patients, all with the null low-density lipoprotein (LDL) receptor DEL15Kb mutation. Patients (12 men, 4 women) were rescanned an average of 8.2 ± 0.8 years after the first scan. ResultsMean LDL cholesterol (LDL-C) during treatment was 2.53 mmol/L; all patients were receiving high-dose statin/ezetimibe; 5 of 16 were receiving evolocumab. Baseline LDL-C was 7.6 ± 1.3 mmol/L. Aortic calcifications increased in all patients in an exponential fashion with respect to age. Age was the strongest correlate of AoCa score. Cholesterol, LDL-C, or age × cholesterol did not correlate with AoCa score or its progression. Control patients (n = 31; 8 male, 23 female; mean age 61 ± 11 years) who underwent virtual colonoscopy were rescanned over the same period and showed an abdominal AoCa score of 1472 ± 2489 compared with 7916 ± 7060 Agatston U (P < 0.001) in patients with HeFH during treatment (mean age, 60 ± 14 years). The rate of progression was 159 vs 312 Agatston U/y in control participants vs those with HeFH. ConclusionsHeFH patients exhibit accelerated aortic calcification that increases exponentially with age. LDL-C at baseline or during treatment seems to have little effect on the rate of progression of AoCa score. Strategies to prevent aortic calcifications with statins have not met with clinical success and novel approaches are required; statins might also contribute to the process of arterial calcification.