Image of the Day 34: Leaking Thoracic Aneurysm Stanford B/ De Bakey III

This Chest X ray image of a 50 Year old gentleman presented with one week history of left sided chest pain that is tearing in nature and radiating to the back. Pain score is 4-5/10 persisting more than 10 minutes, on and off and no known precipitating or relieving factor. He also develop hoarseness of voice. Vitals signs are as follow; BP 140/100, PR 60 b.p.m, RR 18/min, SPO2 100%, general examination reveal a healthy 50 years old gentleman. What would be your differential diagnosis and how would you proceed in confirming the diagnosis.

The Chest X ray image shows widening of mediastinum arising from the central of the mediastinum with well defined border. The homogenous mass seems to be in continuation fashioned, descending behind the heart border. No effusion noted and no significant perihilar lymphadenopathy.

Based on history and chest x ray image, a diagnosis of Dissecting Aortic Aneurysm was made and he was proceed for CT Thorax with contrast.

CT Thorax report shows fusiform dilatation of the aortic arch and descending thoracic aorta with features of leak of arch and thoracic aortic aneurysm..

A Diagnosis of Leaking Thoracic Aneurysm Stanford B/ De Bakey III with Recurrent Laryngeal Nerve Palsy was made.

Image of the Day 1: Wide Mediastinum 1  [link]

Image of the Day 2: Wide Mediastinum 2  [Link]

Adhesion Colic: Don’t Forget the Erect CXR

This patient is a 45 years old lady with history of hysterectomy five years ago due to uterine fibroid and two history of admission due to sub acute IO secondary to adhesion colic which relief by conservative treatment. She presented to health care provider for three times within 24 hours due to severe abdominal pain.

The pain being described as colicky, starting at the upper abdomen and radiate to the whole abdomen, initially relieve temporarily with IV analgesia given by the healthcare provider. The pain score is 7-8/10, and associated with nausea and vomiting, anorexia and feeling un well.

The abdominal radiograph shows dilated small bowel and the CXR erect shows air under the right diaphragm.

Discussion

Two modalities of radiological investigation in emergency department for evaluating acute abdomen are plain radiograph and CT scan.

Selection of modality depends on your working diagnosis. The current practice to use plain radiograph as screening modality should be discouraged except under certain circumstances.

Abdominal and CXR Erect is particularly helpful in evaluating acute abdomen due to free air secondary to small bowel obstruction, perforated peptic ulcer disease and foreign body. In my practice, I still prefer to take AXR as an evidence of diagnosing constipation.

Meanwhile, CT abdomen has higher sensitivity for bowel obstruction, urolithiasis, appendicitis, pancreatitis, pyelonephritis and diverticulitis (James H Street & Xzabia Caliste)

Adhesion colic can present with varying degree of severity. Most often, it is the movement of bowel together with the joined bowel by adhesion that causing pain. However, the presence of vomiting, constipation warrants and AXR to look for mechanical bowel obstruction. If Patient presented with a very tender abdomen and patient look un well, you should take the erect CXR as well since minority of them may actually develop perforated viscous or leakage of air.