CASE 299: PORTAL VEIN FOREIGN BODY, Dr PHAN THANH HẢI, MEDIC, MEDICAL CENTER, HCMC, VIETNAM

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Woman 65 yo, epigatric pain for one week, cannot eat  and  no fever.

Ultrasound of abdomen  in decubitus position  detected  vena porta thrombosis and some  white lines intra portal vein which  came from the wall of gastric  antrum (see 4  ultrasound  pictures  in ventral view).

For clear viewing of  portal  vein  we  scanned  the liver  by sitting position and dorsal view.

Portal vein  was in distension, no flow  due to  thrombosis, and  in crossed section of portal vein we detected a white foreign body.( 2  pictures  with  sitting position scan ).

MSCT with CE  for  evaluation portal vein found out  the  foreign body which  length of 5 cm  intra left  branch of portal vein and one another end was intra gastric antrum wall.

The foreign body was  covered by thrombosis intra  left branch of portal vein (see 3 CT  images).

Blood tests  confirmed  infection  with  rising WBC and high CRP, no  abnormal coagulation test.

With  the  past history of ultrasound  scanning in ventral and dorsal views, MSCT and blood tests, the first choice  of diagnosis was intraportal vein foreign body, which was liked toothpick in penetration the gastric wall and  entering  liver  to left branch of portal vein, that caused  portal vein thrombosis.

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Operation this case  by  open laparotomy detected   one  bonefish with length of 5 cm which penetrated the duodenum  to left lobe of liver and entering the  vena porta  left branche.

Removing bonefish and sutured  duodenum.

CASE 298: Carcinomatosis Ascites, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM.

Woman  64 yo, abdomen distension slowly for 3 months (photo).

Ultrasound  first  found out ascites  with slouge fluid  and  scattered fragments, normal liver, omentum thickening  like cake with  many hypoechoic nodules  and  no tumor in pelvis.

Chest X-Rays  was  normal.

MSCT of abdomen reported  a large amount of  ascites and  great omentum  thickening  with  many  nodules,  enhanced with  CE  and no  ovary  tumor.

Punction of  yellowish  ascites  that cytology was  negative and  ADA negative. Blood test  was  very high CA 125.

Laparoendoscopy cannot detect  primary tumor, but many white  nodules  covered  the  great omentum  but not in parietal peritoneum.

Biopsy the great omentum nodule. Microscopic report  was  undiffentiated adenocarcinoma, suspected  come from GI TRACT or  OVARIAN CARCINOMA.

Discussion

Acites with  large volume is easy  diagnosed  by clinical and ultrasound.

Ascites  fluid analysis rules out  some common diseases.

In this case, CA 125 was very  high in the blood test,  but  CT scanning  cannot detect ovarian tumor.

Laparoscopy for  diagnosis and  biopsy made sure  the case being  carcinomatosis.

This case  also had  gastro-colonoscopic result  and CEA negative.

The  most  suggestion  of diagnosis for  this case is  PPSC  ( PRIMARY PERITONEAL SEROUS CARCINOMA) .

Wait for  histo immunostaining  report.

REF  CASE of  PPSC.

CASE 297: CHRONIC BOWEL OCCLUSION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 47yo,   history of  3 months  with  peristaltism crisii and severe pain at  RLAQ more and more.

Ultrasound  first showed that  small bowel  dilating in  hypermotion and ascites.

MSCT  detected  enterolysis, stenosis at ilium  pre-cecum and suspected tuberculosis. 

Medical  antituberculosis treatment was in setting up, but  onset  total  occlusion was  acute  in emergency.

Operation in emergency detected  one portion of  ilium in hard stenosis. 

Resection that portion and  microscopic result  is adenocarcinoma infiltrating the bowel.

CASE 296: TUMOR of TESTES, Dr PHAN THANH HẢI-Dr NGUYỄN MINH THIỀN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Man 55 yo  pain at left  scrotum some  months ago and himself  detected  one mass in  left scrotum.

One  urologist  in palpation  it  suggested 2 testes in left  scrotum.

Ultrasound  scanning of  left  scrotum  showed that a small amount fluid   hydrocele vaginalis  and  one mass  rounded- border  in  adherence to  left testis with  size of 4 cm, This mass   was  hypovascular  and  soft upon  ultrasound elastoscan (see  3 ultrasound pictures of  this mass).

MRI  with gado of the mass presented it from epididymis that was enhanced with  contrast  gado and suggesting an ADENOMATOID  TUMOR of epididymis.

It is a benign tumor, biopsy was done  and macroscopic report was in correlation to imaging diagnosis.

Operation for removing the mass and microscopic confirmed the imaging diagnosis again.  

REFERENCE:

CASE 295: SPLEEN TUMOR, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman  63 yo, pain at  left subcostal  for one  month without  fever.

Abdomen ultrasound detected  the  spleen changing its surface, irregular lobular border with  many hypoechoic  structures  intraspleen  from hilus and free fluid  around the spleen ( see us 1, us 2).

MSCT with CE found out   inhomogeneous structure of spleen, with  many  hypodense zones, non enhancement  with contrast  from  hilus of  spleen  radiated toward peripheric zones of  spleen,  and  tail of  pancreas was adherent to spleen hilus.

Radiologist  suggested tumor  of  the tail  of pancreas invasive to hilus of spleen ( see  ct 1, 2, 3).

Blood tests were normal all cancer markers, and blood amylase highly elevated.

Preoperative  diagnosis  the case  was  vascular thrombosis of  spleen due to  inflammation of the pancreatic tail.

Operation  for  splenectomy, and  removing the hilus mass of spleen ( see macro).

Microscopic report  was chronic necrosis due to inflammation.

Discussion: Clinical  with pain for more one month  at left upper adominal  area which was  KEHR' s sign.

Ultrasound detected  many avascular zones  in spleen.

MSCT with CE  find out  wedge – shape.

Blood test : high  amylase, looked like  PANCREATITIS  at the tail  complicated to hilus  of SPLEEN  INFARCTION.

REF  case report  from  JOP.

CASE 294: SIGMOID COLON VOLVULUS, Dr PHAN THANH HẢI- Dr LÊ THỐNG NHẤT, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Male patient 56 yo,  in emergency  going to MEDIC  by  acute  abdominal pain  and  distension. Clinical examination   this  patient cannot lay down ( see foto)

Ultrasound scanning of abdomen  first  detected  colon distension with air  and  hyperperistaltism (see 2 US images).

  

Next step,  a standing X-rays of abdomen was done  with  the  sign of C-loop, typical of  sigma colon  torsion (see   X-rays plain film).

MSCT of abdomen without CE presented  dilated colon  with air   (CT 1 double  black  ring  of  colon sigma distention,   CT 2: image  section of sigma colon  asymmetric,  CT 3:   image of coffee  bean, CT 4 : frontal section  with  mesocolon in torsion).

Radiologist  reported   volvulus of  colon sigma for the case.

Emergency  surgery detected  one part of  sigma colon  ischemic, resection  and colostomy with double canon technique.

Conclusion:  Emergency case  with ultrasound first choice for diagnosis, conventional x-rays  also can help patient  but  CT is the  best  information for this case.