Morgagni Hernia Causing Incarcerated Bowel and Contributing to Cardiac Arrest.

A Morgagni hernia is a congenital diaphragmatic hernia (CDH)-incomplete formation of the diaphragm. Though congenital diaphragmatic hernias (CDHs) are a common class of birth defect, the majority are diagnosed either prenatally or shortly after birth since these patients can present with cardiopulmonary failure due to pulmonary hypoplasia or pulmonary hypertension.1 However, the Morgagni type of CDH predisposes it to go undetected well into adulthood. We describe the case of a 63-year-old male who presented to the emergency room with epigastric pain and emesis. He was found to have incarcerated bowel in his pericardial sac on computed tomography imaging after being resuscitated from cardiac arrest. He then underwent surgical repair of the defect. This case is unique in its presentation with small bowel inside the pericardium, contributing to cardiac tamponade and subsequent cardiac arrest.

Traumatic Injury to the Portal Vein With Shock Bowel.

A portal vein aneurysm is the dilatation of the portal vein due to a defect in the vein wall. This rare disease manifestation is difficult to predict and has the potential for severe complications. We describe the case of a 68-year-old man involved in a motor vehicle collision who presented with abdominal hemorrhage found on ultrasound, hypotension, and vague abdominal pain. The patient underwent an exploratory laparotomy to control bleeding. Surgery and a subsequent abdominal computed tomography revealed the presence of a portal vein pseudoaneurysm and shock bowel. This case highlights the importance of radiologists to consider the prospect of portal vein aneurysm in the differential diagnosis of hypotension following abdominal trauma.

Diffuse peritoneal leiomyomatosis status post laparoscopic hysterectomy with power morcellation: A case report with review of literature.

•Leiomyomatosis following laparoscopic hysterectomy with morcellation is reported.•Parasitic myomas grow in a benign fashion but may be fatal depending on location.•Fibroids are a contraindication for laparoscopic hysterectomy with morcellation.•Containment bags may address intraperitoneal spillage of malignant tissue.

PET-CT Post-Hepatic Radiation Changes in Gastroesophageal Adenocarcinoma.

Gastroesophageal junction adenocarcinoma on esophagogastroduodenoscopy biopsy. Initial PET-CT showed no definite evidence of distant metastatic disease. One month after radiation treatment, repeat PET-CT showed interval decrease in size of gastroesophageal mass but new multifocal FDG avidity in the caudate and left hepatic lobes. Correlation with contrast-enhanced CT and US images was negative, making metastasis less likely. Ultrasound-guided biopsy confirmed radiation-induced hepatitis, which caused false positively increased FDG uptake from inflammatory changes.

Subclinical dysphagia in persons with Prader-Willi syndrome.

Prader-Willi Syndrome (PWS) is caused by a genetic imprinting abnormality resulting from the lack of expression of the paternal genes at 15q11-q13. Intellectual disability, low muscle tone, and life-threatening hyperphagia are hallmarks of the phenotype. The need for the Heimlich maneuver, death from choking, and pulmonary infection occur in a disproportionally high number of persons with PWS. The widely held belief is that eating behaviors are responsible for choking and aspiration; yet, no investigation had sought to determine if swallowing impairments were present in persons with PWS. To address this research and clinical gap, simultaneous videofluoroscopy and nasal respiratory signals were used to record swallowing function and breathing/swallowing coordination in 30 participants with PWS. Subjects consumed thin liquid and barium cookies under two randomized conditions as follows: (i) controlled (cues to swallow and standardized bolus sizes); (ii) spontaneous (no cues or bolus size control). Under videofluoroscopy, the cohort showed disordered pharyngeal and esophageal swallowing in both conditions with disturbances in timing, clearance, and coordination of swallowing with the respiratory cycle. No participant showed a sensory response such as attempting to clear residue or coughing; thereby supporting the lack of overt symptoms. We conclude that the high death rate from choking and pulmonary infection in children and adults with PWS may be related, in part, to underlying, asymptomatic dysphagia. The combination of rapid eating and dysphagia would increase the risk of aspiration-related morbidity and mortality. © 2016 Wiley Periodicals, Inc.

POEM Procedure: What the Radiologist Needs to Know for This New Surgical Intervention for Achalasia.

Achalasia is a debilitating condition resulting from the failure of appropriate lower esophageal sphincter relaxation. Traditionally, the treatment of choice for achalasia has been a Heller myotomy, performed either via laparotomy or laparoscopically. The latter method has gained wide popularity in its documented lower postoperative morbidity. Recently, however, a new technique has been developed that can be performed by both thoracic surgeons and endoscopists-Per-Oral Endoscopic Myotomy. This procedure offers an alternative to invasive surgery and provides excellent outcomes with minimal recovery time.1 This article would help familiarize radiologists with this new technique, as well as both normal and abnormal postoperative appearances.

Ultrasound imaging of bowel pathology: technique and keys to diagnosis in the acute abdomen.

OBJECTIVE: This article illustrates the normal and pathologic sonographic appearances of bowel, with an emphasis on diagnostic ultrasound techniques. CONCLUSION: The current role of ultrasound for adult bowel evaluation is limited in the United States, with CT emerging as the primary modality for evaluation of the acute abdomen. However, mounting concerns regarding diagnostic radiation and health care costs may affect practice patterns and shift utilization back toward sonography, which is widely available and relatively inexpensive.

Physician activities during time out of the examination room.

PURPOSE: Comprehensive medical care requires direct physician-patient contact, other office-based medical activities, and medical care outside of the office. This study was a systematic investigation of family physician office-based activities outside of the examination room. METHODS: In the summer of 2000, 6 medical students directly observed and recorded the office-based activities of 27 northeastern Ohio community-based family physicians during 1 practice day. A checklist was used to record physician activity every 20 seconds outside of the examination room. Observation excluded medical care provided at other sites. Physicians were also asked to estimate how they spent their time on average and on the observed day. RESULTS: The average office day was 8 hours 8 minutes. On average, 20.1 patients were seen and physicians spent 17.5 minutes per patient in direct contact time. Office-based time outside of the examination room averaged 3 hours 8 minutes or 39% of the office practice day; 61% of that time was spent in activities related to medical care. Charting (32.9 minutes per day) and dictating (23.4 minutes per day) were the most common medical activities. Physicians overestimated the time they spent in direct patient care and medical activities. None of the participating practices had electronic medical records. CONCLUSIONS: If office-based, medically related activities were averaged over the number of patients seen in the office that day, the average office visit time per patient would increase by 7 minutes (40%). Care delivery extends beyond direct patient contact. Models of health care delivery need to recognize this component of care.