CASE 197: MIDGUT VOLVULUS, Dr LÊ THANH LIÊM, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 23 yo male patient came to Binh An hospital in Kien giang province with severe pain at his bossom  for  2 days, no diarrhea nor fever.  In last year he suffered some abdominal pain crisis in some times and the pain went away soon with or without medicine drugs.

In present time he cannot lie down and has to be in sitting position to reduce his pain and the pain getting prolonged.

Contrast-enhanced CT showing wrapping of the superior mesenteric vein around the SMA. 

Ultrasound detected edema of mesentery, no thickening of bowel wall and no free fluid. But the superior mesenteric artery SMA twisted itseft at  lower portion and having still flow. CT showed a case of midgut volvulus with contrast-enhanced CT showing wrapping of the superior mesenteric vein around the SMA, but with unclear cause. Plain film X-Ray revealed an intestinal obstruction. 

Surgery was done for removing twisted bowel due to an adhesive band without history of abdominal operation before. After removing the adhesive band and the twisted bowel, entire small bowel turned back in normal color.

Post-Op Diagnosis: Midgut Volvulus by adhesive band.

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CASE 196:PSEUDOMYXOMA PERITONEI due to Appendiceal Mucinous Adenocarcinoma, Dr. Phan Thanh Hai, Dr. Le Tu Phuc, Dr. Le Thong Nhat, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 75 year-old man, without history of interested diseases or surgery, came to Medic Diagnosis Center because of progressive abdominal distention for years.

Abdominal ultrasound detected an amount of large volume, echogenic ascites looked like jelly in peritoneal space. But there were some differences in morphology of ascites between right and left side of abdomen. 

In the right lower quadrant, there were two rim-calcified cysts which were adjacent to cecum. One cyst was ruptured and from this ruptured hole, many echogenic bands radiated to jelly ascites like "sunrise" in appearance. The ascites was immobile.

                      
                     

While in the left abdomen, the fluid was mobile with many floating echogenic nodules. Ultrasound was also detected a membrane covering small bowel loops in the left side.

                      

MDCT showed massive ascites into peritoneum of  fat density. The ascites compressed the visceral liver surface, and the small bowel loop was pushed into the center of fluid cavity. There were two rim calcified cysts in the right lower quadrant, and one cyst had discontinuous wall. 

          

Blood test raised up of Beta 2 Microglobuline of 2,238 ( < 2000 Micro g/L ) and CEA of 7.83 (<5 ng/ml )

An open abdominal surgery was done at Binh Dan Hospital, removed about 5 liters of jelly-like substance. The surgeon detected a tumor of appendix adjacent to the cecum. He also reported about the membrane cover the bowel loops.
   
            

PATHOLOGY: Appendiceal Mucinous Adenocarcinoma

QUESTION: 
Why was the fluid in left abdominal side mobile but in the right one immobile?
How do we explain the membrane covering the small bower loops in the left abdominal side?

CASE 195: ULCERATIVE COLITIS MIMICKING COLON TUMOR, Dr PHẠM THỊ THANH XUÂN-Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 26 yo suffered from colicky pain at RUQ for 2 years,  and  had a feeling of a moving mass but with only loose stool. His status is getting down.

Ultrasound detected thickening of right colon of 8 mm, and intussusception of right colon at some times. There was a walled off at right flank, so cannot ruling out a infected tuberculosis.

Colonoscopy was done but two times met intussusception, and another time in thought to be of ulcerative colitis.

Blood tests were in normal values, no clue of tuberculosis.

But MDCT detected a colon tumor with colon thickening wall of 20mm, caught CE more and loss of fatty tissue surrounding

Hemicolectomy was done by endoscopic colonoscopy, and final diagnosis is ulcerative colitis which induced intussusception of right colon.

CASE 194: ASCARIS in CBD and ULTRASOUND and ERCP, Dr LÊ THỐNG NHẤT, Dr TRẦN NGÂN CHÂU, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER. HCMC, VIETNAM

A 33 yo  female patient from Phu quoc province came to Medic Center for  painful cramp episodes 2 days before as failed in treatment of gastritis.
Ultrasound at Medic revealed an ascaris that was moving inside  common bile duct while unfortunatly CT cannot see it.

ERCP was performed to make clear diagnosis of ascaris in CBD and removing ascaris out.

The worm was still alive outside patient body being a male ascaris with hook and genital specula.

In ten years, there were 42 worms of CBD ascaris from 54 cases detected by ultrasound which were removed out by ERCP.

CASE 193: MEDIC RADIOLOGY CASE 07: ACQUIRED TRACHEOBRONCHOMALACIA, Dr LÊ HỮU LINH, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 31 yo female patient came to Medic Center for loss of her voice and dyspnea. For 2 years she had got suddenly deafness after giving birth. During 6 months, she coughs slightly and complaints dyspnea, getting worse when  making every effort.  There are slight whistles of her chest in 2 phases of breathing which are more clear in fast breathing.

Laryngoscopy showed normal appearance and normal motion of vocal cords, but no sound in speaking.

Bronchial endoscopy was done easily, lumen were smooth and soft, no obstacle, but getting stenosis in first part of  trachea and  bronchii which were thought to be a tracheobronchomalacia.

Chest CT confirmed  the result of bronchial endoscopy that an unknown stenosis of  1/3 upper part of trachea, stenosis of right and left main bronchii, and right intermediate bronchiole. And an old scar of right lung apex.

Because of dyspnea getting worse so she underwent a tracheostomy. After tracheostomy, chest CT proved total stenosis of trachea, and stenosis of right and left main bronchii, and  right intermediate bronchiole.

Surgery was performed to repair the trachea. And the final diagnosis is an acquired tracheobronchomalacia which causes stenosis of trachea and main bronchii. For the cause of this case is still unknown and with the deafness we may think about the immunologic reaction of a polychondritis.

CASE 192: AVM IN THE KIDNEY. Dr Nguyen Nghiep Van , Dr Nguyen Hoai Thu, Medic Medical Center, HCMC.

A 51 yo female patient suffered from hematuria for a few weeks. She went to Medic Center for abdominal ultrasound. Color Doppler of the abdomen detected an AVM at the upper pole of the right kidney, d= 4.6cm in diameter, which has aliasing inside and spectral waveform of AVM (see 2 images).

MSCT with CE detected A-V shunt at the upper pole of right kidney (see 3 images).

The patient underwent DSA to make sure AVM diagnosis. The right renal artery divides into 2 branches: the upper branch feeding for lower pole of the kidney, and the lower branch, for  the A-V shunt. This is not detected on the Angio MSCT ( see 3 images ).

Noted the IVC dilated and early filling contrast, therefore we decided not to treat by coiling, because the coil may move to right atrium. And the patient transmitted to Binh Dan hospital for nephrectomy.

CASE 191: MEDIC RADIOLOGY CASE 06:TWO CASES of CERVICAL MYELOPATHY and SPINAL SCHWANNOMA, Dr NGÔ TẤN HÙNG, MEDIC MEDICAL CENTER, HCMC, VIETNAM

                      

CASE 1: 47yo M patient, Vinh long province. 6 months with:  Lower extremities weakness and numbness. Neck pain, muscles atrophy. No disturbance in sphincter tone as it related to his bowel or bladder function.Tender reflex (++), Babinski’s sign (++), Hoffmann’s sign (++).

MRI= Intra-and extradural and paravertebral mass of C3.

Microscopic result: Schwannoma of nerve sheath.

CASE 2 : 53yo F patient, Binh thuan province. 4 months with: Right leg weakness. No neck pain. No disturbance in sphincter tone as it related to his bowel or bladder function. Tender reflex (++), Babinski’ s sign (++), Hoffmann’ s sign (++).

MRI= Intra-and extradural mass of C6-7

Microscopic result: Schwannoma of nerve sheath.

DISCUSSIONS:

LOW EXTREMITIS WEAKNESS :  BE CAREFUL WITH CERVICAL SPINAL CORD LESIONS.

CERVICAL MYELOPATHY: A routine neurological examination is important. Complaints involving gait, equilibrium, and /or paresthesias, extremities weakness or numbness. Cervical spine pain is rarely among these complaints. [Bucy PC, Heimburger RF, Oberhill HR. Compression of the cervical spinal cord by herniated intervertebral discs. J Neurosurg.2009].