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Cases in Radiology: Episode 2 (abdomen, CT)

Cases in Radiology: Episode 2 (abdomen, CT)


hello again and welcome to another
episode of cases in radiology. i’m Frank Gaillard the editor of Radiopaedia.org
and today we’re going to be looking at at a CT of the abdomen in a
seventy-year-old female who presented with epigastric pain. Her only relevant medical history was that of a
past cholecystectomy. as always now is a perfect time to pause
this video and take a minute or two to have a look at the case at your own pace. just follow the link which is either
visible on your screen or included in the video description. so here we have coronal and axial stacks through the abdomen. two main findings should have been evident. The first is
that there is a small bowel obstruction as envisaged by these enlarged loops of dilated bowel. these can be traced down into the lower
abdomen to this point where there is an abrupt
transition from the distended proximal lumen to the collapsed more distal lumen which has intussuscepted into the distal loop of bowel. this is also seen on axial imaging at this point where there is almost the
characteristic donut appearance with mesenteric fat having been pulled into the lumen of the bowel. going back to the coronal imaging there is the impression off a lead point
mass. the other notable findings are bilateral
very large renal masses, larger on the right. these appear centrally necrotic or cystic. there are numerous lymph nodes scattered
throughout the mesentery which appear enlarged. but no other solid masses are identified. incidental findings include a large
simple renal cyst on the right. the first question you should ask yourself is whether or not the bilateral
adrenal masses and the small bowel intussusception are related. let’s first talk about intussusception.
intussusception is when one part of the bowel gets sucked into the more distal bowel and is further advanced by the action of peristalsis. in children this is most often
idiopathic without an underlying cause identified, or certainly not an
underlying pathological cause; its most often attributed to prominent lymphoid tissue in the submucosa. in adults however a lead point is
usually identified and in most instances it is that of a malignancy. in the large bowel it is that of a colorectal carcinoma which is
by far the most common, however small bowel lymphoma and metastases to both large or small bowel particularly from malignant melanoma,
breast cancer or lung cancer are identified. a number of benign neoplasms are also
encountered. as are some congenital abnormalities although these would be
unlikely to first present in a seventy-year-old. inflammatory and trauma has also
been reported but is unlikely. let’s turn our attention to the adrenal
glands. by far the most common cause of
bilateral adrenal masses is that of metastases; and the primary tumors to consider
are those of lung cancer, breast cancer renal cancer which is not evident in
this case, gastrointestinal malignancies, malignant melanoma and lymphoma. it is also worth considering primary tumours although most often these are unilateral. Pheochromocytomas for example are
encountered bilaterally in up to ten percent of
patients – whether this represents metastatic disease to the contralateral
adrenal gland or synchronous tumours is debatable. going back to this case we are left with
four options. the first is that the small bowel mass and the bilateral adrenal masses are unrelated and that the adrenal masses were merely
incidentally found due to the presentation of a small bowel obstruction. the second is that they are related and that both represent metastatic disease. as we saw the primary lesions to be
considered are breast cancer, lung cancer, and melanoma. the third and fourth possibilities are that one of these lesions represent the primary and that the other
represent metastase. For example, the small bowel mass may be a primary adenocarcinoma or carcinoid of the small bowel with adrenal metastases. Or potentially that we have bilateral
adrenal malignancies with metastases to the small bowel. Review of a chest
x-ray and inspection of the breasts remonstrated no obvious lung mass or breast mass. Further questioning of the patient did
however reveal that seven years ago she had had a malignant melanoma excised from her
back. The patient went on to have a laparotomy and had the small bowel
intussusception resected and the adrenal glands biopsied. malignant melanoma was the diagnosis in
both instances. so this case is a good example of how systematically working through the
differential diagnosis for separate lesions enables the
underlying cause to be narrowed down. malignant melanoma is particularly common
in australia because all a population of
immigrants who have fair skin from northern european countries now exposed to the harsh sun and the depleted
ozone layer. it is a sinister tumour insofar that a
lesion thought to completely have been excised many many years ago can present with metastatic disease and often can
do so in unusual ways. it is one of the classic tumours to metastasise to small bowel and should be thought of high on the
list when such presentations are encountered. hope to see you again next time. Take care.

22 comments on “Cases in Radiology: Episode 2 (abdomen, CT)

  1. Great & splendid work Dr Frank … Hopefully you will find the time to do more … What about android apps like your already done ios apps … as you know, android fans nowadays are more than ios

  2. Thanks again everyone. @Abdalla – currently the Android App is on hold. We are focusing on some major new (and needless-to-say) AWESOME features for the live site and will soon also be focusing our attention on improving the mobile experience on the whole site. Sit tight… good mobile times ahead.

  3. @Almas Yes I suppose both LiF and XP are possible, although in Australia melanoma is common and in the vast majority of cases due to sun exposure. Also the patient is 70, and in genetic cases one would expect an earlier presentation.

  4. I immediately jumped on the 'primary adenoCA with mets to adrenals' train with that old feeing in my stomach that something is not right (cause the intestinal mass did nor seem like an adenoCa) … would definitely have a House M.D. moment if i faced such a case and ask the clinician if the patient does have a history of melanoma.. Thanx for the case..

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