Saeed Rad, M.D.

Radiographic Sequela On Knee X-Ray

Case: Radiographic sequela seen on this knee x-ray.

Articles

What radiographic sequela do you see on this knee x-ray? 

Image IQ Quiz: Radiographic Sequela On Knee X-Ray

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 On barium swallow with stomach demonstrated inadequate distension of the stomach with increased rigidity associated with a narrow lumen. The normal mucosal gastric fold pattern is no longer seen and in this case, completely absent.

 Linitis plastica is a condition referring to the appearance of the stomach resembling an “old leather bottle.” There is typically diffuse submucosal infiltration by an adenocarcinoma with thickening and loss of distensibility of the stomach. The mucosal gastric fold pattern is can be absent, thickened, or distorted.

Image IQ Quiz: Patient Presents with Inadequate Stomach Distension

Filling defect disrupting the gastric contour and folds with suggestion of outpouching of the ulcer crater with a relatively smooth border consistent with an ulcer. No significant irregularity of the border.

Features that suggest a benign ulcer is an outpouching of the ulcer crater beyond the gastric border, smooth borders, smooth ulcer mound, smooth folds reaching the margin of the ulcer, “Hampton’s line”, and location along the lesser gastric curvature. Features that suggest malignant gastric ulcer includes irregularity of the borders, nodularity of the ulcer mound, and more commonly seen along the greater curvature of the gastric border.

What is the diagnosis in this patient with melena?

Image IQ Quiz: Patient Presents with Melena

 Filling defect diffusely seen broadly within the small bowel consistent with a parasitic infection consistent with ascariasis.

 GI ascariasis appears as potentially single to multiple worms (nematodes) seen as a longitudinal linear filling defect on barium study. Often times, the intestinal tract of the worm itself can be visualized or if its GI tract is empty, a pure filling defect is seen.

What is the diagnosis in this patient with weight loss?


Image IQ Quiz: Patient Presents with Weight Loss

Radiograph demonstrates bowel containing contrast within the chest, within the pleural cavity consistent with a pleuroperitoneal hernia.

Pleuroperitoneal hernias typically occur posteriorly and are a result of a posteriorly located defect when there is a failure in closing the pleuroperitoneal membrane closure while in utero. Bowel, retroperitoneal structures may prolapse through the defect into the pleural space.

Image IQ Quiz: What Do You See on This Bowel X-ray?

Large filling defect with irregular margins seen on this upper GI series on fluoroscopy.

On upper GI series, any filling defects projecting from the wall of the stomach may be seen. Ulceration and cavitation may also be present. Margins of the filling defect may be smooth or irregular.

Patient presents for upper GI series with this finding... What is your diagnosis?


Image IQ Quiz: What's On This Upper GI Series?

 Wall thickening of the ileum is seen on follow-through of GI series on fluoroscopy. Findings are consistent with inflammation of the terminal ileum in Crohn’s disease.

 In the small bowel, in Crohn’s disease, there can be skip lesions and discrete ulcers. The terminal ileum is usually affected first, but remaining segments of the small bowel are also commonly affected. On fluoroscopy, on small bowel follow-through, mucosal ulcers can be seen and widely separated bowel loops of bowel can also be seen due to fatty proliferation (“creeping fat”). There can also be the “string sign” seen, which is narrowing or spasm of small bowel segments. Look for partial bowel obstructions and also pseudodiverticulum formation.

What is causing this appearance on small bowel GI series follow-through?

Image IQ Quiz: What Do You See on This Small Bowel GI Series?

 Bird-beak narrowing as seen on this barium swallow study. The absence of air in the expected location of the gastric bubble on frontal radiograph is also seen here.

 There is often loss of esophageal peristalsis and loss of relaxation of the LES – lower esophageal sphincter. As a result there is an obstructive process resulting in food stasis and marked proximal dilatation of the esophagus. The differential diagnosis is secondary achalasia or pseudochalasia from possible malignancy is also a diagnostic consideration.

What is causing this appearance on this barium study?

Image IQ Quiz: What Do You See on This Barium Study?

This 33-year-old female patient presented to urgent care after reporting an argument and appearing highly anxious. She reported no symptoms, but she revealed to physician that she had ingested something that she should not have in the heat of the moment during the argument she reported. A KUB (kidney, ureters, bladder) X-ray was, then, taken. An electronic cigarette (vaping unit) can be seen, overlying the gastric region on KUB consistent with ingested foreign body.

 Most swallowed foreign bodies usually pass through harmlessly through the small intestine and large intestine. Bowel obstruction and perforation are key complications to monitor with serial KUB imaging. In addition, the foreign body in this case may contain harmful substances, such as nicotine in high amounts. It also contains a battery which may have associated toxicity. Therefore, a foreign body with associated risk should be removed through endoscopy if it remains in esophagus, stomach, or proximal duodenum. In this case, the device was removed by the gastroenterologist.

What foreign body did the patient ingest?

Image IQ Quiz: What Did This Patient Swallow?

Case submitted by Saeed Rad, M.D., radiologist, to

 Patient presents with a history of excessive alcohol (ETOH) intake with increasing difficulty swallowing (dysphagia).

Esophageal varices are seen in over half of patients with portal hypertension, such as in the case of long standing alcohol intake. This is such a case. It is important to note there are other causes of cirrhosis and portal hypertension beyond alcohol intake, including Chid-Pugh C cirrhosis or other causes of liver disease that result in cirrhosis. 

Esophageal varices are dilated submucosal veins of the esophagus and are portosystemic collaterals. Fluoroscopic evaluation with barium demonstrates longitudinal and curvilinear luminal filling defects, representing varices.

What is your diagnosis in this patient with long standing excessive alcohol intake and difficulty swallowing?