A quality improvement project: Reducing the number of unnecessary plain abdominal radiographs performed in the emergency department of a London district general hospital.

Background: Inappropriate completion of abdominal radiographs results in unnecessary exposure to ionizing radiation. This quality improvement project aimed to reduce the number of inappropriate abdominal radiographs performed in the emergency department. Materials and methods: Abdominal radiograph request forms were analyzed with reference to the Royal College of Radiologists (RCR) iRefer guidance. A teaching session was then delivered to ED clinicians and posters were disseminated within the department. Post-intervention data collection followed. Results: Following the intervention, there was an increase in the proportion of abdominal radiographs meeting iRefer guidance, which was accompanied by an increased diagnostic yield of these investigations. There was a reduction in the number of requests post-intervention. Conclusions: Our interventions helped increase awareness of both the guidelines and radiation dose associated with each study. Routine education of the iRefer guidelines will help reduce inappropriate requests. This in turn will reduce unnecessary radiation exposure, whilst also reducing the financial burden.

Asymptomatic peritoneal tuberculosis in a patient with a non-remitting fever and isolated pulmonary symptoms: a case report and literature review.

Tuberculosis (TB) remains one of the leading causes of death globally. Although abdominal or peritoneal TB is a recognised site for extrapulmonary TB to manifest, the diagnosis is often delayed due to the non-specific nature of the presenting clinical features. We present the diagnostically challenging case of a 32-year-old patient with recurrent episodes of fever and a non-productive cough that was initially treated as community-acquired pneumonia with oral antibiotics. A computed tomography scan of the thorax was unrevealing, aside from a large volume of ascites within the partially imaged upper abdomen. The patient did not report any abdominal symptoms and the abdominal examination was unremarkable. Subsequently, a transvaginal ultrasound, a contrast-enhanced computed tomography scan of the abdomen and pelvis, and magnetic resonance imaging of the abdomen and pelvis confirmed a large volume of ascites in the absence of any definite aetiology. A peritoneal biopsy was required before the diagnosis of peritoneal TB was eventually confirmed. This case highlights the importance of considering peritoneal TB in patients presenting with treatment-resistant chest symptoms and persistent pyrexia of undetermined aetiology, even in the absence of abdominal signs and symptoms.

Bilateral sternocleidomastoid pseudotumors-a case report and literature review.

Sternocleidomastoid (SCM) pseudotumors, also known as fibromatosis colli or congenital torticollis, are painless benign neck lumps found in newborns. Whilst unilateral cases are relatively common, bilateral SCM pseudotumors are a rare phenomenon with only a handful of cases reported internationally. We present the case of a 5-week-old infant who was brought to the emergency department with painless, bilateral, palpable anterior neck masses following a slightly traumatic but otherwise uncomplicated spontaneous delivery. An ultrasound scan of his neck revealed well-defined soft tissue lesions within both of the SCM muscles. He was subsequently diagnosed with bilateral SCM pseudotumors. This case emphasizes the importance of considering this entity as a differential diagnosis in infants presenting with bilateral palpable neck masses.

Gallbladder carcinosarcoma masquerading as a hepatic abscess.

Carcinosarcomas of the gallbladder are extremely rare tumors and infrequently reported in the literature. We demonstrate a case of a 64-year-old female who presented with a 2-month history of a right upper quadrant mass, intermittent fevers, and abdominal distension following recent travel to Ghana. A computed tomography (CT) scan of the abdomen and pelvis demonstrated a large hepatic lesion with co-existing gallbladder distension, suggestive of a hepatic abscess. The patient was initially managed with intravenous antibiotics but failed to respond to treatment. A subsequent magnetic resonance imaging (MRI) scan of the liver showed a locally invasive lobulated soft tissue lesion arising from the gallbladder fundus and extending into the liver parenchyma. The lesion was surgically excised with a central hepatectomy. Histopathologic analysis showed a carcinosarcoma of the gallbladder.

Multifocal pancreatobiliary malignancies: A diagnostic and therapeutic challenge.

The synchronous presentation of multifocal pancreatobiliary tumors is a rare occurrence and can prove to be a significant diagnostic and therapeutic challenge. We describe the case of a 70-year-old female who presented with a 2-week history of jaundice, reduced appetite, and mild epigastric discomfort of insidious onset. Radiological evaluation with computed tomography and magnetic resonance imaging demonstrated features consistent with a hilar cholangiocarcinoma , also known as a Klatskin tumor, involving both the cystic duct and gallbladder neck. In addition to this, a pancreatic neoplasm with associated splenic vein occlusion and metastatic deposits in the liver and lung were identified. The patient was managed with percutaneous transhepatic external biliary drainage and stenting by interventional radiology. Cytology results from the brushings obtained from the aforementioned procedure were nondiagnostic. Core biopsies were performed of the pancreatic lesion; the histopathological results of which were in keeping with pancreatic ductal adenocarcinoma . The patient was scheduled for chemotherapy however unfortunately deteriorated clinically prior to commencement. This case highlights the diagnostic and management challenges of synchronous pancreatobiliary malignancies.

Rare case of symptomatic empty sella syndrome in a patient treated with intrathecal chemotherapy for acute myeloid leukemia.

The sella turcica is the normal neuroanatomical location of the pituitary gland. Empty sella syndrome (ESS) is a rare condition in which the sella turcica is partially or completely filled with cerebrospinal fluid. It is a radiological diagnosis that is often made incidentally following imaging for another reason (eg, to exclude intracranial hemorrhage following head injury) or as part of the work-up when investigating a patient's neurological symptoms. ESS can be classified as primary or secondary, depending on the identification of underlying etiologies. We report the highly unusual case of a 74-year-old patient who presented with progressive neurological disturbance many years after receiving intrathecal chemotherapy. Clinical assessment (including cross-sectional imaging) led to a diagnosis of secondary ESS.