You have air in WHAT?

Any condition preceded by the term "emphysematous" is generally a bad thing to have. Whilst considered relatively rare, these are important conditions to diagnose and can be detected very well with conventional imaging techniques. They classically all occur more commonly in diabetic patients and are more typically related to infection than ischaemia.

Here is a collection of cases where air in the wall of an organ is evident on imaging.

Emphysematous Cholecystitis

This 52yo diabetic woman presented with non-specific abdominal pain. No previous relevant surgical history or old imaging was available. Following cholecystectomy she had multiple episodes of cholangitis following this acute presentation.

There is a rim of gas outlining the gallbladder in the right upper quadrant; this was effectively an abscess completely filling the gallbladder, with gas penetrating into the necrotic gallbladder wall

Emphysematous Cystitis

This 39yo female patient presented with right-sided abdominal pain, guarding and generalised sepsis. She subsequently went into renal failure and required cystectomy and ileal conduit formation.

The structure in the anterior pelvis containing gas in the wall and a large gas-fluid level is the bladder


Emphysematous Gastritis

This 91yo male patient presented with AF, melaena and haemodynamic instability. Things went downhill quite quickly from here.

3 arrows on this coronal CT highlight gas within the wall of the stomach, small veins leading away from the stomach, and intrahepatic portal veins

Emphysematous Pyelonephritis

This 48yo diabetic patient presented with hyperglycaemia and abdominal pain. She eventually recovered without surgery but with significant scarring to the left kidney.

2 arrows on this coronal CT demonstrate the location of gas within the renal capsule superiorly and in the proximal ureter

Its SAD what you know.. or you thought you knew

Abstract

Background The SADPERSONS Scale is commonly used as a screening tool for suicide risk in those who have self-harmed. It is also used to determine psychiatric treatment needs in those presenting to emergency departments. To date, there have been relatively few studies exploring the utility of SADPERSONS in this context.
Objectives To determine whether the SADPERSONS Scale accurately predicts psychiatric hospital admission, psychiatric aftercare and repetition of self-harm at presentation to the emergency department following self-harm.
Methods SADPERSONS scores were recorded for 126 consecutive admissions to a general hospital emergency department. Clinical management outcomes following assessment were recorded, including psychiatric hospital admission, community psychiatric aftercare and repetition of self-harm in the following 6 months.
Results Psychiatric hospital admission was required in five cases (4.0%) and community psychiatric aftercare in 70 (55.5%). 31 patients (24.6%) repeated self-harm. While the specificity of the SADPERSONS scores was greater than 90% for all outcomes, sensitivity for admission was only 2.0%, for community aftercare was 5.8% and for repetition of self-harm in the following 6 months was just 6.6%.
Conclusions For the purposes of suicide prevention, a low false negative rate is essential. SADPERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm. The scale should not be used to screen self-harm patients presenting to general hospitals. Greater emphasis should be placed on clinical assessment which takes account of the individual and dynamic nature of risk assessment.
Direct link is here.


Just goes to show that what is comon practice in one time, could be meaningless in another time. Whats surprising is the time it took to traverse those 2 extremes! Just like THIS article states!

Webucation 13/8/13


Web musings come from abundant surgical sources this time. Enjoy the readings and always support the original content providers.

What we do in our practice is that we look into all the factors (some latent) when deciding who needs a scan with contrast:
  1. Age
  2. GFR - more so than creatinine
  3. Pathology in question - can it be observed rather than immediate diagnosis now?
  4. Renal disease?
  5. Non contrast scan - you will be surprised at its utility
Feel free to comment or ask your friendly radiologists to if they have an opinion.

A pair of paedias

Many of you may already know of this site, but just in case you haven't seen it yet, check out Radiopaedia, a collaborative free radiology educational archive:

http://radiopaedia.org/

They have also recently updated to include:


And while we're at it, there is another lesser known "paedia" dedicated to ultrasound imaging, with instructional pictures and videos as well as examples of anatomy and pathology:


Unfortunately some of this website requires payment but there is still a lot of free information available.

VBG vs ABG slideshow

Anne-Maree Kelly is well published in the area of many things but she has contributed much to the debate about whether ABGs are really necessary as an ED investigation in a lot of contexts.

Here is a great slide show (its self explanatory & you don't need sound amazingly) to illustrate her research and points.

ABG and VBG interchangeable?

My personal view is that of many echoed around the world. Arterial samples in ED are only really needed when you want to know what the lung is doing. If you want to know what the body is doing, then VBGs are good enough (or close enough).

For years now in my daily practice, I can only recall doing an arterial stab on patients on mechanical ventilation (invasive and non).