CASE 202: BOWEL OBSTRUCTION, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman  88yo  suddenly got  epigastric pain and  vomitting. Ultrasound abdomen first  nothing abnormal detected. After 10 hours,  ultrasound in second time shows small intestine dilated and hyperperistalsis, colon no dilated (see 2 pictures of small bowel dilated) but cannot  make sure why small bowel in obstruction.

Chest X-ray  revealed air-water level at  right subdiaphagmatic, so suspected  a  subdiapragmatic abcess.

But  MSCT  detected  small intestin moving over the liver and fixed to right diaphragm and in strangulation (see CT pictures).

Summary: Ultrasound, X-ray, CT cannot make sure why small bowel in obstruction, but  surgery in emergency is done.

Emergency operation detected  small bowel fixed onto falciform ligamentum by one orifice of 2 cm diameter. It is an internal hernia due to defected falciform ligamentum. See picture of orifice of falciform ligamentum.

REFERENCE:

CASE 201: ULTRASOUND FIRST of R. HYDRONEPHROSIS, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 37 yo in pregnancy for 7 weeks, onset acute pain at right kidney.
Ultrasound first at  FV hospital revealed  hydronephrosis of  right kidney in first degree, but cannot find out any stone. After 24 hours,  second ultrasound at MEDIC CENTER detected one small stone  intramural urinary bladder at right ureteral orifice (see  picture 1:  hydronephrosis of right kidney , picture 2:  uterus in gestation, picture 3: intramural stone).

Urologist  requests  MRI  for make sure the right ureteral stone (2 MRI pictures).

Cystoendoscopy in emergency for releasing pain by JJ stent in ureter.

Discussion: Ultrasound first or second time are better for patient by safety and cost-benefit.

CASE 200: BREAST FAT NECROSIS MASS, Dr PHAN THANH HẢI- Dr JASMINE THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 59 yo, herself detected a mass at her left breast, no pain, no hot. Ultrasound findings are  a 3 cm mass under skin, no border, hyperechoic with central necrosis, doppler no hypervascular and without axillary nodes.

On mammography, the left breast had a small nodule in hyperdensity withoud calcification and well-bordered.

Sonologist report of this case  suspected fat necrosis or pseudotumor.

RADIOLOGIST CANNOT DIAGNOSE THE LESION ON MAMMOGRAM. HE PREFERED TO DO FNAC.

AFTER ONE DAY, FNAC  REPORT WAS   FAT NECROSIS, NO NEED  OF OPERATION.

REFERENCES: FAT  NECROSIS OF THE BREAST

CASE 199: A PSEUDOANEURYM of STAB WOUND, Dr NGUYỄN NGHIỆP VĂN-Dr NGUYỄN HOÀI THU, MEDIC MEDICAL CENTER, HCMC, VIETNAM

A 20 yo female patient got a stab wound at her left forearm 2 months before. She presented a swelling pulsatile mass at her left forearm. Color Doppler ultrasonography shows  a pseudoaneurysm at the middle part of the left ulnar artery, d =3.2 x 3.7cm in diameter. ( see 3 images)

ANGIO detected pseudoaneurysm at the middle part of left ulnar artery. ( see 3 images)

Left upper extremity angiography : The half-moon images  of contrast material filling showed in the left ulnar artery.

Because the sac had small pedicle (seen on Color Doppler ), we decided to embolization the pseudoaneurysm by histoacryl glue. After embolosclerotherapy, the pseudoaneurysmal sac disappeared.

CASE 198: INTRAGASTRIC POLYPOID TUMOR, Dr PHAN THANH HẢI-Dr PHẠM THỊ THANH XUÂN, MEDIC MEDICAL CENTER, HCMC, VIETNAM

Woman 61 yo with  epigastric distention.
Adominal ultrasound detected one  polypoid  mass being intragastric lumen. The gastric wall is rounding (4 ultrasound pictures= image 1: section of antrum, image 2 : long section over aorta,    image 3 and 4  at gastric fundus).

MSCT with 2 images, that  well show an intragastric big tumor.

Endoscopy confirmed a big polyp from gastric fundus, which has a short but large root, and rough surface, with size of 4x4 cm.

Pedunculus of gastric fundus area. Biopsy report  is adenoma.
Wait for surgery.

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?