[Acute thoracoabdominal aortic dissection]. / Acute dissectie van de thoraco-abdominale aorta.

BACKGROUND: A thoracic aortic dissection is a rare condition (2.5-3.5 per 100,000 person years) and patients can present with atypical symptoms. However, a missed diagnosis is often fatal. CASE DESCRIPTION: A 66-years-old male presents himself at the GP's office with sharp pain and loss of strength and sensation in the right arm. Pulse and blood pressure are undetectable on the right arm. An immediate thoracoabdominal CT-angiography is ordered in the nearest hospital. It reveals an aortic dissection (Stanford type A) and the patient is swiftly transferred to a tertiary referral hospital. Upon emergency surgery, the aortic valve, -root and ascending aorta are replaced. The patient is discharged home after one month. CONCLUSION: Swift recognition and referral are paramount to survival in aortic dissection. Patients with a low suspicion can be referred to the closed hospital for immediate imaging. When suspicion is high, direct transfer to a thoracic surgery hospital is warranted.

Comparison of Imaging Strategies with Conditional versus Immediate Contrast-Enhanced Computed Tomography in Patients with Clinical Suspicion of Acute Appendicitis.

OBJECTIVES: To compare the diagnostic accuracy of conditional computed tomography (CT), i.e. CT when initial ultrasound findings are negative or inconclusive, and immediate CT for patients with suspected appendicitis. METHODS: Data were collected within a prospective diagnostic accuracy study on imaging in adults with acute abdominal pain. All patients underwent ultrasound and CT, read by different observers who were blinded from the other modality. Only patients with clinical suspicion of appendicitis were included. An expert panel assigned a final diagnosis to each patient after 6 months of follow-up (clinical reference standard). RESULTS: A total of 422 patients were included with final diagnosis appendicitis in 251 (60 %). For 199 patients (47 %), ultrasound findings were inconclusive or negative. Conditional CT imaging correctly identified 241 of 251 (96 %) appendicitis cases (95 %CI, 92 % to 98 %), versus 238 (95 %) with immediate CT (95 %CI, 91 % to 97 %). The specificity of conditional CT imaging was lower: 77 % (95 %CI, 70 % to 83 %) versus 87 % for immediate CT (95 %CI, 81 % to 91 %). CONCLUSION: A conditional CT strategy correctly identifies as many patients with appendicitis as an immediate CT strategy, and can halve the number of CTs needed. However, conditional CT imaging results in more false positives. KEY POINTS: • Conditional CT (CT after negative/inconclusive ultrasound findings) can be used for suspected appendicitis. • Half the number of CT examinations is needed with a conditional strategy. • Conditional CT correctly identifies as many patients with appendicitis as immediate CT. • Conditional imaging results in more false positive appendicitis cases.

Profiles of US and CT imaging features with a high probability of appendicitis.

OBJECTIVES: To identify and evaluate profiles of US and CT features associated with acute appendicitis. METHODS: Consecutive patients presenting with acute abdominal pain at the emergency department were invited to participate in this study. All patients underwent US and CT. Imaging features known to be associated with appendicitis, and an imaging diagnosis were prospectively recorded by two independent radiologists. A final diagnosis was assigned after 6 months. Associations between appendiceal imaging features and a final diagnosis of appendicitis were evaluated with logistic regression analysis. RESULTS: Appendicitis was assigned to 284 of 942 evaluated patients (30%). All evaluated features were associated with appendicitis. Imaging profiles were created after multivariable logistic regression analysis. Of 147 patients with a thickened appendix, local transducer tenderness and peri-appendiceal fat infiltration on US, 139 (95%) had appendicitis. On CT, 119 patients in whom the appendix was completely visualised, thickened, with peri-appendiceal fat infiltration and appendiceal enhancement, 114 had a final diagnosis of appendicitis (96%). When at least two of these essential features were present on US or CT, sensitivity was 92% (95% CI 89-96%) and 96% (95% CI 93-98%), respectively. CONCLUSION: Most patients with appendicitis can be categorised within a few imaging profiles on US and CT. When two of the essential features are present the diagnosis of appendicitis can be made accurately.

The linea arcuata hernia: a report of two cases.

Two male patients presented to the surgical outpatient clinic with a paramedian abdominal bulge. In the first patient, the hardly known diagnosis linea arcuata hernia (LAH) had been missed at a previous exploration 8 years ago. In the second patient, pre-operative imaging showed an abdominal wall hernia. Diagnostic laparoscopy revealed an LAH. In both cases, the hernia was repaired with a mesh graft.

[Cystic abnormalities of the pancreas: inflammatory pseudocyst or neoplasm]. / Cysteuze afwijkingen van het pancreas: inflammatoire pseudocyste of neoplasma.

A 79-year-old woman presented with complaints of upper abdominal pain, nausea and vomiting since a few days. Laboratory tests showed no abnormalities except for some indications of an inflammation. Based on the medical history, physical examination and findings from radiological examination, initially the diagnosis was 'chronic pancreatitis with formation ofa pseudocyst caused by alcohol abuse'. After one week the patient developed cholestatic liver function disorders with elevated serum pancreatic enzymes. A CT scan of the abdomen showed a dilated gallbladder and progression of the cystic lesion in the pancreatic head with compression of the distal common bile duct. An endoscopic retrograde cholangiopancreatography was performed and the findings fitted a diagnosis of an intraductal papillary mucinous neoplasm. Differentiation between an inflammatory or neoplastic origin of cystic lesions in the pancreas can be difficult. There is a risk ofmisdiagnosing a cystic neoplasm for a pseudocyst. This may lead to delays in making the correct diagnosis.

Pericardial cyst located in the anterior mediastinum mimicking a thymoma. A presentation of two cases.

Pericardial cysts are rare but well recognized tumors of the mediastinum. Most pericardial cysts are located in the right or left cardiophrenic angle. At other locations these cysts may pose a diagnostic problem. We present two cases of an atypically located pericardial cyst and a short review of the literature.

Rupture of true aneurysms of the pancreaticoduodenal arcade: treatment with transcatheter arterial embolization.

We present 2 cases of ruptured true aneurysms of the pancreaticoduodenal arcade, underscoring the role of transcatheter arterial embolization (TAE) as the initial treatment of choice in pancreaticoduodenal arcade aneurysm. Ruptured true aneurysms of the pancreaticoduodenal artery (PDA) are uncommon and few cases have been reported, whereas false aneurysms are seen more often. The first patient we describe is a 63-year-old woman with an aneurysm of the PDA initially treated by TAE. The second case is a 67-year-old woman with an aneurysm of the inferior PDA post-operatively treated by TAE. In both patients TAE via a combined superior mesenteric artery and celiac axis approach was successful. Follow-up contrast-enhanced computed tomography showed prolonged occlusion of both aneurysms. A review of the literature concerning TAE supports our experience that TAE of ruptured aneurysms of the pancreaticoduodenal arcade, when feasible, is at least as effective as conventional surgery, but with lower morbidity and mortality. Therefore, TAE should be the initial treatment of choice in this group of patients.

Further delineation of the acro-renal-ocular syndrome.

A triad of acral, renal, and ocular abnormalities was reported previously in four families. We report on a fifth family, in which a mother, one of her four sons and one of her two daughters are affected. Major findings in the acro-renal-ocular syndrome are upper limb abnormalities, mainly thumb hypoplasia, eye abnormalities such as coloboma and Duane anomaly and renal migration defects. A close embryological-temporal relationship between the traits of this entity suggest a common monogenic cause. The pattern of inheritance is probably autosomal dominant. Because of a wide variability of clinical manifestations, recognition of the syndrome in individual cases may be difficult.