Category: Medical Images

Clinical Images, Images of clinical medicine

FAQ – Necrotizing Enterocolitis

What is this?
Necrotizing Enterocolitis (NEC) is a syndrome wich consists in intestinal infarction.

What part of the intestine is affected?
Terminal ileum and colon, although the entire GI tract is affected in severe cases.

Why is NEC important?
Because NEC is the most common gastrointestinal emergency in the newborn infant and NEC accounts for substantial long-term morbidity in survivors of neonatal intensive care unit.

What are the risk factors of NEC?
Prematurity, milk feeding, circulatory instability, infection, and impaired mucosal defense. NEC incidence is greatest in newborn infants with birth weight less than 1.5 Kg, so prematurity is the most important risk factor.

How can be prevented?
It is well know that avoidance of hypertonic formulas, medications or contrast agents, prompt treatment of polycythemia, and placement of umbilical artery catheters with the tip below the level of the inferior mesenteric artery, prevent this condition.

What are the manifestations of NEC?
There are systemic and abdominal manifestations.

  • Systemic signs are nonspecific and include apnea, respiratory failure, lethargy, poor feeding, temperature instability, or hypotension (in severe cases).
  • Abdominal signs include distention, gastric retention (residual milk in the stomach before a feeding), tenderness, vomiting, diarrhea, and hematochezia (passage of bloody stools through the rectum).

How NEC is diagnosed?
The presence of abdominal distention, hematochezia, and pneumatosis intestinalis confirm the diagnosis of NEC.
We have to perform several studies, including blood analysis, stool analysis, sepsis evaluation, and radiographic studies.
The results of these studies often are nonspecific, although the radiograph may be diagnostic.

What are the findings at the radiograph?
Marked abdominal distention, dilated loops, pneumatosis intestinalis (bubbles of gas in bowel’s wall) and/or free intraabdominal air.

Could you show me a radiograph with this findings?
Yes, here you can see marked abdominal distention, dilated loops, pneumatosis intestinalis (bubbles of gas in bowel’s wall)
NEC

What is the treatment of this condition?
It depends on the stage of the disease. Medical managemente is appropiate in most cases, but in those patients with advanced NEC and bowel perforation we have to perform surgical intervention.

What are the complications?
The acute complications are infectious and hematologic. The late complications are intestinal narrowing or stricture formation and short bowel syndrome.

What is the prognosis?
Due to advances in neonatal intensive care, agressive treatment, potent antibiotics and earlier diagnosis, approximately 70% to 80% of infants who have NEC survive, and approximately 50% of these are normal. The mortality rate is higher in infants who require surgery for NEC.

Dr. Jon Mikel Iñarritu

Active Variceal Hemorrhage

Active bleeding of esophageal varices can be difficult to treat, it really represents a life-threatening condition when not treated, because just 50% of patients with acute variceal hemorrhage stop bleeding spontaneously.

Endoscopic therapy is currently the definitive treatment of choice for active variceal hemorrhage and it can be performed at the same time as diagnostic endoscopy at the bedside by virtually all trained endoscopists.

Band ligation is effective for achieving hemostasis and for prevention of early rebleeding.

The following images correspond to a case of active variceal bleeding wich was treated with endoscopic ligation:

active bleeding ligation ligation 2
Courtesy of Dr. Mariana Herrera Guerrero

Gallstone Ileus

Gallstone Ileus is an infrequent cause of mechanical bowel obstruction. It is caused by an impaction of a gallstone in the terminal ileum by passing through a billiary-enteric fistula (often from duodenum). It occurs more frequently in women with average age of 70 years.

Clinical picture: Episodic subacute obstruction in an elderly female. Abdominal pain and vomiting which subside as the gallstone becomes disimpacted, and only recurs again as the progressively larger stone lodges in the more distal bowel lumen. Intermittent symptoms may be present for some days prior to evaluation. Hematemesis could occur as an occasional complication that is due to hemorrhage at the site of the biliary enteric fistula.

Physical examination: The patient may be febrile and often appears dehydrated. Common abdominal signs include distension and increased bowel sounds. Jaundice is uncommon, occurring in less than 15% of cases. Many affected patients have serious concomitant medical illnesses, including coronary disease, diabetes mellitus or pulmonary disease.

Diagnosis: The most important diagnostic test is abdominal plain film. The diagnosis of gallstone ileus is made preoperatively in about one-half of cases. The radiographig findings of gallstone ileus, are:

  • Signs of partial or complete intestinal obstruction
  • Air in the biliary tree (pneumobilia)
  • Direct visualization of the stone
  • Change in position of a previously located stone
  • Two adjacent small bowel air-fluid levels in the right upper quadrant

Treatment: First of all, as any kind of bowel obstruction, the objective is to relief intestinal obstruction after adequate fluid repletion. The options are enterolithotomy, cholecystectomy, and fistula division, with or without common bile duct exploration (one-stage procedure), with definitive repair performed at a second operation (two-stage procedure).
The treatment of choice is the enterolithotomy wich consits in localize and extract the gallstone. Often the cholecystectomy is contraindicated by comorbidities and the general state of the patient.

Case presentation: A 72 year old woman with heart faliure, hypertension and diabetes came to the office with a chief complaint of chills, abdominal pain, nausea and vomiting followed by inability to pass flatus 8 hours prior to consult.

On physical examination the patient was febrile and appeared dehydrated. Abdominal exam: distension and increased bowel sounds. No jaundice.

Labs: Hyperglicemia, mild renal failure, hypernatremia and leukocytosis.

Radiographic tests: Abdominal plain film with signs of bowel obstruction and with not apparent cause, negative US. CT scan just with signs of intestinal obstruction, not pneumobilia, not obstructing gallstones.

The patient bacame hemodinamically unstable while performing the US and we decided to open her. On the OR we found the level of obstruction at terminal ileum and we felt a solid mass. We performed an enterolithotomy and the result was this:

Gallstone Ileus

Regards,

Dr. Jon Mikel Iñarritu

Splenic Injury and Hemoperitoneum in Blunt Trauma

The following pictures are from different clinical cases.

In Blunt Trauma the spleen and the liver are injuried in 40 and 20 percent, respectively.

In the ER, you have three four options in the Work-Up of a patient with blunt abdominal trauma

  • Peritoneal Lavage: Now just performed if you haven’t access to ultrasound (lack of money or lack of trained personnel). It’s indicated in specific cases, as in patients with cranial trauma, spinal trauma, for example.

Positive Peritoneal Lavage - 1 Positive Peritoneal Lavage - 2

Look the blood in the syringe and the tube. This is a positive peritoneal lavage due to blunt trauma.
  • Ultrasound (a.k.a. FAST or Focused Abdominal Ultrasound for Trauma): This is one of the most used techniques, and should be performed for those patients hemodynamically unstables who can’t go to the coputed tomography room.

Positive FAST
Look the irregular border. This is a positive FAST for hemoperitoneum due to blunt trauma.
  • Computed Tomography: This technique has a magnific resolution for spleen, liver and vessels. Excellent evaluation for retroperitoneum. It has one inconvenience, hemodinamically unstable patients are not candidates for this analysis.

Spleen Injury and Hemoperitoneum
Black arrow = Hemoperitoneum.
White arrow = Injuried spleen
  • Diagnostic Laparoscopy: Almost never recquired.

Positive Diagnostic Laparoscopy
Look the blood in the abdominal cavity, this is a positive Laparoscopy for hemoperitoneum due to blunt trauma.

The controversy is when the hospital is not capable of performing the standarized protocol in blunt abdominal trauma (economic reasons), we doctors have to adequate to the circumstances and do our best effort.

For example, the first two photographs (peritoneal lavage) were taken at the Mexican Red Cross where money is the big problem. The rest, were taken at the ABC Medical Center, a nice private hospital. This are the contrasts of healthcare system and medicine practice in developing countries.

Regards,

Dr. Jon Mikel Iñarritu

Worst case of hemorrhoidal prolapse ever & PPH

BEWARE! Gory image

A 45 year old male with history of chronic reducible hemorrhoidal disease came to the emergency department with excruciating pain, rectal bleeding and an anal non-redicible mass after a bowel movement.

On examination, we found this:
hemorrhoidal prolapse

In this case, the only way to reduce the prolapse is a procedure for prolapsing hemorrhoids (PPH) which is an innovative approach to the management of enlarged, prolapsing hemorrhoids. Rather than rely on excision of the complexes, the primary goal is to reduce the hemorrhoidal tissue and anoderm to the correct anatomical location within the anal canal. It is important to keep this goal in mind, because the misinterpretation of anodermal migration externally as external hemorrhoids leads to unnecessary excision of sensate skin during PPH. In fact, with a correctly performed procedure, the relocated anoderm will shrink over time.

For this, we need an hemorroidal circular stapler kit which includes: clear plastic anoscope, half-slit anoscope, suture threader, and the 33 mm stapler.

Here is an animation video of how the procedure works, and how does the anal canal looks like before and after the procedure.

Regards,

Jon Mikel Iñarritu, M.D.

More information of hemorrhoidal disease in this site is here:
Thrombosed Hemorrhoid

Intussusception

Intussusception is the invagination of a part of the intestine into itself, in other words is the prolapse of one part of the intestine into the lumen of an immediately adjoining part. It is the most common abdominal emergency in early childhood.

Epidemiology: Most episodes of intussusception occur in otherwise healthy and well-nourished children. Approximately 60% of children are younger than one year old, and 80 percent are younger than two. Is the most common cause of intestinal obstruction in children between 3 months and 6 years old. It appears to have a slight male predominance with a male:female ratio of approximately 3:2.

Etiology: The vast majority of cases is unknow. Another causes are Meckel’s diverticulum, polips, intestinal tumors, Henoch-Schönlein purpura, strange bodies, etc.
The most common form of this disease is the ileo-colic and ileo-ileo-colic invaginations. It could be associated with the rotavirus vaccine.

Clinical picture: Acute onset of intermittent, severe, crampy, progressive abdominal pain, accompanied by inconsolable crying and drawing up of the legs toward the abdomen. This painfull episodes occurs at 15 – 20 minute intervals and then become more frequent and severe. Vomiting may follow episodes of abdominal pain.

This episodes can be followed by vomiting and the passage of “currant jelly” stool (a mixture of blood and mucous). A sausage-shaped abdominal mass may be felt in the right side of abdomen. The prevalence of blood in the stool is as high as 70% if occult blood is included.

Diagnosis: It is based on index of suspicion, frequently the diagnosis is stablished with contrast studies (wich could be also therapeutic).

The abdominal plain film (see below) may be helpful because they may show frank intestinal obstruction or massively distended loops of bowel with absence of colonic gas.

Intussusception. Plain film and barium enema

The ultrasound can be useful also, with a sensitivity and specificity approach 100%. The classic finding is a “bull’s eye” or “coiled spring” lesion (see below) representing layers of the intestine within the intestine.

Intussusception. Ultrasound

Treatment: Nonoperative reduction using barium or air contrast techniques is successful in approximately in 75 – 90% (in the first 24 hours) of patients with ileo-colic intussusception.
Surgery is indicated when nonoperative reduction is incomplete or when a persistent filling defect, indicating a mass lesion is noted. Broad-spectrum intravenous antibiotics should be given before surgery. Manual reduction at operation is attempted in most cases, but resection with primary anastomosis needs to be performed if manual reduction is not possible or if a lead point is seen.

Regards,
Jon Mikel Iñarritu, M.D.

Cascade Stomach: An unsusual cause of abdominal pain

A woman came to the office because of sharp epigastric pain. On physical examination nothing was wrong except of epigastric pain. An endoscopy was performed and reported as normal. An Upper Gastrointestinal Tract Barium Examination was ordered and we found a cascade stomach, which is a rare finding. We exlude other causes of abdominal pain in the first place.

Here are the images.

Cascade Stomach 1

Cascade stomach 2

Cascade stomach 3

As you can see in this series, the fundus, still lies in its usual position relative to the structures of the left upper quadrant but the proximal portion of the body of the stomach is in an abnormally anterior and superior position. When this type of stomach is filled with barium (erect position), static roentgenograms may demonstrate a separate fluid level confined to the fundus. At fluonoscopy, barium first fills the dependent, posterior fundus to the highest level of the “ridge” and then spills or “cascades” into the body and antrum.

On the next day we have performed an esophageal manometry and the patients had lower esophageal incompetence, so we performed a laparoscopic Nissen fundoplication with gastropexia.

Now the patient is painless and in excellent condition.

Regards,

Jon Mikel Iñarritu, M.D.

Purpura fulminans as severe complication of meningococcal infection

Purpura fulminans

It is a severe condition due to meningococcal sepsis, it occurs in 15 to 25% of those patients with meningococcemia.

The clinical picture is as follows: acute onset of cutaneous hemorrhage and necrosis secondary to vascular thrombosis and disseminated intravascular coagulation. Often there is pain followed by petechiae. Ecchymoses develop and evolve into painful indurated, well-demarcated purple papules with erythematous borders (as you can see in the image this lesions are coalescent). Then this lesions progress to necrosis with formation of bullae and vesicles. Gangrenous necrosis can follow with extension into the subcutaneous tissue and occasionally involves muscle and bone.

purpura fulminans

To prevent this complication of meningococcemia you have to be prompt and agressive with IV antibiotics and support of vascular perfusion. The use of Xigris (drotrecogin alfa activated) have shown promising results once the process has instaled. Often this patients require surgical debridement, skin grafting or limb amputation.

Regards,

Jon Mikel Iñarritu, M.D.