CASE 267:PELVIC MASS and MELENA, Dr PHAN THANH HẢI, Dr LÊ ĐÌNH TÍN, Dr LÊ ĐÌNH VĨNH PHÚC, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man  37 yo in urgency by melena and  hypotension.

Ultrasound of  abdomen first detected  one 6cm mass  at  the pelvis, well bordered  (US image 1: mass  near  the  urinary  bladder  wall, US 2: very hypoechoic with linear probe 12MHz, US 3 elasto: this mas soft and inhomogeneous, and video hypervascular mass).

MSCT with CE of this mass showed rapid and high CE enhancement (see 3 CT images).

There were no relation between the mass with GI tract lumen.
 Blood test  Hct  20%  post blood transfusion.  And gastroscopy and colonoscopy: NAD (nothing abnormal detected).
Today, laparotomy found out the mass in the small bowel wall, with vascular congestion. And there was one site eroding the mucosa layer of intestine. Maybe bleeding from this site (see operation images).

Discussion:

Ultrasound first  presented best application for this emergency case. First, sonologist detected one cystic mass at the right pelvis, with linear probe 12 MHz;  but in using of curve  probe 3.5MHz showing a solid  mass in appearance and hypervascular mass on Doppler. Elastoscan also said this mass being a  soft mass. MSCT with CE reported this mass in fast and high contrast enhancement. At the mesenteric border no  bleeding site detected at this time, suggesting a GIST tumor in case of GI tract bleeding. Endoscopy of GI tract was complementary tool for negative detection.
Operation was set on time.

Microscopy  report with IHS is small bowel GIST.

CASE 266: COLO-COLIC INTUSSUSCEPTION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 38 yo, epigastric pain crisis on  periodic treatment  like gastritis but not response.

Ultrasound first in emergency  at MEDIC detected one mass  near  gallbladder with  multilayer cover as  OINION SIGN, and a central cyst.

This mass was  in transverse colon.  Sonologist  suggested a colocolic intussusception  (see 04  ultrasound  images and video clip).

Do you have any idea about the cyst in an intussusception mass?.

MSCT   with CE showed this  mass in transverse colon with cystic mass  looked like   appendicular mucocele.

Emergency laparotomy performed right hemicolectomy,   macroscopic specimen was appendicular mucocele [see photo]..

Microscopic report was  mucocele  appendicular  due to  fibrosis of appendix.

REFERENCE:  Case 181 Medic case.

CASE 265: FISH BONE IN GALLBLADDER: Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 49 yo, pain in RUQ one week ago like gastric ulcer.

Ultrasound of  abdomen suggested gastric cancer  invasive to gallbladder and liver.

Gastroscopy and biopsy ruled out gastric cancer.

MSCT with CE detected  abscess due to perforated fundus of gallbladder and one  foreign body like a fish bone, 3cm in length,  intra gallbladder (see 3 CT pictures).

Ultrasound of  abdomen again for verify diagnosis also made same  information which was  abscess due to fish bone penetrating through gallbladder wall to liver border.

(see 2 ultrasound images and video clip).

Blood tests were normal.

Operation laparotomy removed abscess and gallbladder necrosis with fish bone inside abscess (see 3 photo).

REFERENCE: Case Report

CASE 264: ASCITES, Dr PHAN THANH HẢI, Dr LÝ VĂN PHÁI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 31yo  with epigastric pain 3 days ago.

She came to MEDIC  for  gastroscopy and result was  gastritis, but ultrasound of abdomen  detected free  fluid of ascites around border of liver  and  small stone in gallbladder (see  ultrasound  images).

Liver was normal,  and ultrasound  at pelvis detected  one mass  on the left side of uterus, round,  5cm diameter, solid mass  with  small vessel  inside  and  RI low ( see  ultrasound images). Sonologist  susgested  an ovary tumor  in rupture.

MSCT with CE of this mass on  left lateral of uterus...with  CE enhance  like a  nidus of  pregnancy in rupture with  a lot of blood  clots  in abdomen ( see 3 CT pictures).

Blood tests  :  CA-125  rising 125 UI/mL  and  betaHCG  rising 134UI/mL

WBC 15K  with neutro 75%, Hct  29%.

Emergency  operation  in  BINH DAN hospital  detected  hemoperitoneum due to rupture of  tubal pregnancy (photo).

DISCUSSION: 

Epigastric pain is a common indication to gastroscopy that was not available for this case.

ULTRASOUND of  ABDOMEN  MUST BE  FIRST CHOICE for CASE.

BLOOD TEST  CA-125 RISING  NO  MEANING TO  OVARY  CANCER.

Beta HCG was  most  sensitive  for  diagnosis of this case.

CASE 263: BUFFALO'S NECK, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 27 yo, dental  pain  on right mandibular  for one week, he detected  the right side of neck along  SCM muscle getting hot and swelling, pain and fever (see photo).

He was treated  with antibiotics and went to ultrasound scanning. Sonologist detected this neck mass beeing   like abscess by fluid collection on right and left neck (see 3 photo and video).

MSCT found out the right mass along SCM muscle and one other mass on left side nearby thyroid gland.

Puncture this mass  removed the pus but  direct examination  with gram stain no bacteria. 

Operation for drainage. 

DISCUSSION: IT IS  A CYST of  INFECTION at LATERAL SITE  OF THE NECK. THE MOST COMMON IS  BRANCHIAL CYST.

CT  ALSO SUPPORTED THIS  DIAGNOSIS.

REF..ANATOMY OF  BRANCHIAL CYSTS.

CASE 262: BIG ABDOMEN, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

 Man 50 yo, one week ago, onset periumbilical pain and abdominal distension, no defecation nor fever.

Chest Xray, and  abdomen standing  plain film showed  the  water-air level in  intestine, suggesting  bowel obstruction.

Ultrasound  found out colon dilatation, filling water and moving circular around with hyperperistalsis (see video).

MSCT of  abdomen in  emergency detected dilated right colon and  small intestine, retroperitoneum edema  arround the pancreas and radiologist  suggested  that pancreatitis.

Blood test: WBC  rising 12k, amylasemia normal.
Operation  laparotomy detected  all  bowel in dilatation but  no  necrosis, no tumor obstruction. 
Many white spots like candle   intra peritoneum.
Retroperitoneal space edema. Surgeon said chronic pancreatitis.

Discussion of this case:  clinical findings were abdominal pain and distension for one week. XRay  and  ultrasound found out  bowel obstruction and CT  detected  pancreatitis, but  blood test amylasemia was 17 unit.

Surgeon decided operation by bowel obstruction.
Now  report  is  chronic pancreatitis, it is  a rare  case with normal amylasemia in acute  pancreatitis.

REFERENCE:  case report

CASE 261: HARD BREAST TUMOR like AMBARELLA FRUIT, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 47 yo, she herself detected at the right breast one mass, slow growth, painless like one AMBARELLA fruit.

Ultrasound  first detected  this mass in size of 4 cm, at 10 am clock at  the right breast, with  many  white spots  as  calcification. Color Doppler finding also was a hypovascular mass.

Using elastoultrasound, the mass was  very hard,  scale  blue green color on elastogram, no detected  axillary  lymph nodes.

Mammography also detected  mass and microcalcification.

Core biopsy with ultrasound guided reports microscopic  INTRADUCTAL CARCINOMA, STAGING T2N0MX.

SUMMARY: BREAST CANCER IS  EASY DIAGNOSED BY ULTRASOUND   ELASTOGRAPHY of  THIS VERY HARD  TUMOR  LIKE  GREEN AMBARELLA FRUIT.