Computed tomography colonography: a retrospective analysis of outcomes of 2 years experience in a district general hospital.

BACKGROUND: Colonoscopy is the gold-standard investigation for direct luminal visualization of the large bowel. Studies have shown the efficacy of computed tomography colonography (CTC) is equivalent to colonoscopy in both cancer and polyp detection. METHODS: A retrospective review of patients undergoing CTC from January 2013 to October 2014 was performed. Patient demographics, indication for investigation, computed tomography findings, optical colonoscopy findings and histology results were recorded. RESULTS: Seven hundred and fifty-eight CTC were performed. Three hundred and seventeen patients were male (42%) and 441 (58%) were female. Endoscopy was advised in 209 cases. One hundred and twenty (16%) were deemed suspicious for cancer of whom 96 (80%) had optical colonoscopy. A total of 12 colorectal cancers were detected. Potential polyps were noted in 58 cases (8%). Forty-four patients underwent endoscopy (75%) and 17 polyps confirmed (38%). Two patients had foci of invasive cancer histologically. Significant extracolonic findings were identified in 60%, including five cases of gastric carcinomas. The most common other findings were gallstones and hernias. CONCLUSION: The rate of colorectal cancer detection in this study was 2%. The rate of biopsy proven cancer was 10% following a suspicious colonogram. Endoscopic correlation was not obtained in 20% of cases of radiological suspicion. CTC is as efficacious as optical colonoscopy for colorectal cancer and polyp detection.

Dysgenesis of the inferior vena cava associated with deep venous thrombosis and a partial Protein C deficiency.

Dysgenesis of the inferior vena cava is rare but it is being increasingly diagnosed by cross-sectional imaging techniques. Patients are usually asymptomatic with abnormalities detected incidentally. An 11 year old boy presented with a 10 day history of fever, vomiting and abdominal pain, which progressed to his back and lower limbs. Magnetic resonance imaging, computerised tomography and Doppler ultrasonography showed the absence of a suprarenal inferior vena cava with bilateral superficial femoral vein thrombi extending cranially to the end of the aberrant inferior vena cava. Haematological testing revealed a partial Protein C deficiency. The presenting clinical picture in this case is unique within the English literature and highlights that deep venous thrombosis associated with inferior vena cava dysgenesis may not present with typical symptoms in children. Early use of advanced imaging modalities would expedite diagnosis and subsequent treatment.

Simultaneous xanthogranulomatous cholecystitis and gallbladder cancer in a patient with a large abdominal aortic aneurysm.

There have been reports of the coexistence of abdominal aortic aneurysm (AAA) with intra-abdominal malignancy including gastric, colonic, pancreatic, and renal. We herein report a case of a previously undiagnosed AAA and a presenting complaint consistent with acute cholecystitis. Following cholecystectomy, this was noted to be a rare form of chronic cholecystitis: xanthogranulomatous cholecystitis. There is a known possible association of this uncommon condition with gallbladder cancer. The management of concomitant pathologies can present a real challenge to the multidisciplinary team, especially with large aneurysms.

Traumatic splenectomy in a cirrhotic patient with hepatitis C and alcoholic liver disease.

Non-operative management is the management of choice for haemodynamically stable patients with blunt splenic injury. However, coexistent liver cirrhosis poses significant challenges as it leads to portal hypertension and coagulopathy. A 52-year-old man sustained blunt abdominal trauma causing low-grade splenic injury. However, he was found to have liver cirrhosis causing haemodynamic instability requiring emergency laparotomy. His portal hypertension led to severe bleeding only controlled by aortic pressure and subsequent splenectomy. Mortality from emergency surgery in cirrhotic patients is extremely high. Despite aggressive resuscitation, they may soon become haemodynamically unstable. Therefore, traumatic splenectomy may be inevitable in such patients with portal hypertension and splenomegaly secondary to liver cirrhosis even in low-grade injury.

Krukenberg tumour arising from adenocarcinoma of the gastro-oesophageal junction in a 28-year-old female presenting as lower abdominal swelling mimicking an inguinal hernia.

Krukenberg tumours arising from gastro-oesophageal adenocarcinomas prior to the fourth decade are extremely rare. The authors present the case of a 28-year-old patient who was then 4 years of age, residing close to the Chernobyl nuclear reactor at the time of the nuclear disaster in 1986, and was found to have late-stage Krukenberg tumours from a gastro-oesophageal primary. Her presentation with right groin pain initially raised a suspicion of an occult groin hernia. Clinicians are reminded to delve deeply into the social history in their enquiries with Eastern European patients who present with unusual clinical features and were in utero, young and living in proximity to the nuclear fallout zone at the time of the incident.

Intracranial hypotension secondary to spinal arachnoid cyst rupture presenting with acute severe headache: a case report.

INTRODUCTION: Headache is a common presenting complaint and has a wide differential diagnosis. Clinicians need to be alert to clues that may suggest an underlying secondary aetiology. We describe a novel case of headache secondary to intracranial hypotension which was precipitated by the rupture of a spinal arachnoid cyst. CASE REPORT: A 51-year-old Indian female presented with sudden onset severe headache suggestive of a subarachnoid haemorrage. Investigations including a computed tomography brain scan, cerebrospinal fluid examination and a magnetic resonance angiogram were normal. The headache persisted and magnetic resonance imaging revealed bilateral thin subdural collections, a spinal subarachnoid cyst and a right-sided pleural effusion. This was consistent with a diagnosis of headache secondary to intracranial hypotension resulting from spinal arachnoid cyst rupture. CONCLUSIONS: Spinal arachnoid cyst rupture is a rare cause of spontaneous intracranial hypotension. Spontaneous intracranial hypotension is a common yet under-diagnosed heterogeneous condition. It should feature significantly in the differential diagnosis of patients with new-onset daily persistent headache.

Acute mesenteric ischaemia on unenhanced computer-tomography.

We present a 39-year old man with mesenteric ischaemia. The initial unenhanced images of the, non-oral contrast CT abdomen clearly demonstrated increased density in a significant length of the small bowel and in the veins of the adjacent mesentery. Mesenteric ischaemia is a difficult diagnosis both clinically and radiologically and we demonstrate the potential benefits of an unenhanced abdominal scan (often left out if a contrast enhanced scan is to be performed) and the omission of oral bowel contrast in emergency scans.

A life-threatening complication of Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome predisposes to the development of vascular malformations, which may present as life-threatening haemorrhage. This article presents a patient with Ehlers-Danlos syndrome in whom spontaneous rupture of an unusual arteriovenous fistula occurred. This rare diagnosis can be reached through close attention to the history and examination.

Pseudotumoural gastric lesion caused by fish bone perforation.

We report the case of a 34-year-old previously fit and healthy male who presented to the accident & emergency department with non-specific abdominal pain. The patient proceeded to undergo laparotomy at which a large mass was found adjacent to the stomach. The impression at surgery was of a lymphoma or gastric carcinoma though CT had reported the likelihood of a fish bone or foreign body causing duodenal perforation. Histology later confirmed the presence of a fish bone surrounded by reactive tissue.

Postpartum pneumoperitoneum and peritonitis after water birth.

Pneumoperitoneum (the presence of free gas in the peritoneal cavity) usually indicates gastrointestinal perforation with associated peritoneal contamination. We describe the unusual case of a 28-year-old female, who was 7 days postpartum and presented with features of peritonitis that were initially missed despite supporting radiological evidence. The causes of pneumoperitoneum are discussed. In the postpartum period the female genital tract provides an alternative route by which gas can enter the abdominal cavity and cause pneumoperitoneum. In the postpartum period it is important to remember that the clinical signs of peritonism, guarding and rebound tenderness may be diminished or subtle due to abdominal wall laxity.