Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Not everything in the gallbladder is gallstones: an unusual case of biliary ascariasis.

A 25-year-old female presented with a sore throat, fever and epigastric pain after coming from India. She had an obstructive pattern of liver function tests and an ultrasound scan abdomen showed features suggestive of acute cholecystitis and pancreatitis, with no obvious gallstones. She made no improvement with intravenous antibiotics. Subsequently, a contrast CT demonstrated a curvilinear structure within a thickened gallbladder and common bile duct. After input from multiple specialities, she had a MR cholangiopancreatography (MRCP) which further confirmed the curvilinear filling defect impacted in the gallbladder neck and proximal common bile duct. Biliary ascariasis with mild pancreatitis was diagnosed and was successfully treated with mebendazole. At one-month outpatient follow-up, her liver function tests and ultrasound scan had returned to normal. This case report discusses the radiological findings seen with biliary ascariasis using a range of imaging modalities. It also highlights the importance of the multidisciplinary team in managing a patient who presents a diagnostic challenge, in order to achieve the best patient outcome.