Giant duodenal diverticulum masquerading as a sealed perforation.

Giant duodenal diverticula are large outpouchings involving all layers of the duodenal wall. Whilst often an incidental finding, giant duodenal diverticula can present with diverticulitis or biliary obstruction. We report a case of a giant duodenal diverticulum that was initially misdiagnosed as a localised duodenal perforation on CT. Additional ultrasound and fluoroscopic imaging demonstrated the final diagnosis of acute cholecystitis. The clinical course of this patient highlights the challenge of recognising a giant duodenal diverticulum and the limitations of solely relying on CT in the context of an acute abdominal presentation.

Proteus Mediastinitis Causing Fatal Pseudoaneurysm following Aortic Valve Replacement.

We report an unusual case of Gram-negative mediastinitis following aortic valve replacement via median sternotomy. The patient presented two months after surgery following a urinary tract infection in septic shock with a discharging sternal wound and blood cultures positive for Proteus mirabilis. Imaging revealed a large anterior mediastinal abscess and aortic pseudoaneurysm which subsequently ruptured resulting in fatality. Gram-negative mediastinitis is a rare complication of cardiac surgery that can present late following initial clinical improvement and should be considered when "remote site" infections are present. Computerised Tomography scanning has a role to play in the identification of this.

Appropriate patient selection in the management of common bile duct stones: when not to do ERCP.

Background. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive and accurate for diagnosing intra common bile duct stones (ICSs). However, given limited access, routine utilisation for investigating all patients with gallstone disease is neither practical nor cost-effective. Conversely, many individuals proceed directly to endoscopic retrograde cholangiopancreatography (ERCP), an invasive test with appreciable complications. Aim. Identify factors associated with ICS in order to improve risk-stratification for MRCP/ERCP. Methods. All patients having undergone cholecystectomy between November 2007 and October 2008 were reviewed. High-risk features for ICS were predefined, and their true presence confirmed by ERCP or intraoperative cholangiogram. Multivariate logistic regression was performed on candidate risk features. Results. Of 231 patients, 10.4% had ICS. Defining a high-risk group with "both" biochemical and ultrasound risk factors predicted ICS with 92% specificity and also bore strong association (OR 8.88). However, isolated hyperbilirubinaemia, ultrasound impression of CBD stones, and clinical risk factors did not (OR 1.10, 0.97, and 1.26). Normal liver biochemistry and normal ultrasound had a NPV of 99.5% for ICS. Conclusions. Ultrasound impression of CBD calculi without ductal dilatation is not predictive of ICS. Patients with normal liver biochemistry and normal CBD diameter on ultrasound are unlikely to have ICS and should not proceed to ERCP.

Fecally loaded inguinoscrotal hernia masquerading as testicular mass.

An 88-year-old man presented with clinical signs suggestive of a testicular mass. The initial ultrasound examination was inconclusive however regional computed tomography eloquently distinguished a large indirect inguinoscrotal hernia with a hernia sac containing a loop of fecally loaded sigmoid colon.

Choledochal-duodenal fistula presenting as an upper GI bleed.

Gallstones are common and largely asymptomatic, but can result in significant morbidity in a small proportion of patients. Choledochal-enteric fistulation is one such complication with an associated mortality of 15-18%. The authors present a case of an 88-year-old man admitted to the general medical ward with an acute upper gastrointestinal bleed. Oesophagogastroduodenoscopy found a large gallstone impacted in the pylorus and CT scan revealed a choledochal-duodenal fistula. At laparotomy it was found that a 6.2 cm gallstone had fistulated into D1 and the pylorus and impacted there, causing outflow obstruction - Bouveret's syndrome. A subtotal cholecystectomy was performed and the stone was removed by a separate gastrostomy. A radiological follow through study on day 14 showed contrast passing freely through the duodenum with no leak and the patient went on to make a slow, but uneventful recovery.

Minimal-preparation CT colon in detection of colonic cancer, the Oxford experience.

BACKGROUND: the main colonic imaging modalities, including barium enema, colonoscopy and computed tomography colonography, require bowel preparation. Performing these imaging procedures in the elderly can difficult due to immobility, incontinence and poor tolerance of bowel cleansing. Minimal preparation CT (MPCT) colon was introduced in the early 1990s in the UK. Much of the published literature on MPCT colon is limited by small patient numbers and short duration of follow-up. OBJECTIVE: the aim of this study is to review our experience with the MPCT technique involving a large consecutive cohort of patients with long follow-up. METHODS: all studies of MPCT performed in a 1-year period between July 2000 and July 2001 at our institution were reviewed retrospectively. MPCT reports were cross-referenced with the cancer registry to allow for an average period of 30 months follow-up. A definite diagnosis of cancer was only given following the appearance on the cancer registry. Those patients who had negative MPCT colon were assumed to be true negatives if no corresponding name was identified on the cancer registry. In the event of data mismatch, patient notes were reviewed to ascertain a diagnosis. RESULTS: 391 MPCT examinations were performed during the period of the study (209 males, median age 82: age range 56-91 years). Thirty-four patients who had MPCT colon during the study period appeared on the cancer registry. A further three patients with disseminated colorectal malignancy identified on MPCT colon died without histological confirmation (tumour prevalence = 9.5%). Thirty-two of the registry confirmed 34 cases were detected on MPCT colon, giving a sensitivity of 0.94 (95% confidence interval 0.86-1.00). Including the three cases without histological confirmation gives a slightly higher sensitivity of 0.95. There were seven patients with definitely abnormal MPCT colons, who did not appear on the registry, resulting in specificity for definite abnormality of 0.98 (confidence interval 0.97-1.0). However, three of these seven are those who died of disseminated colorectal malignancy as above, raising the specificity to 0.99. Fourteen cases (3.5%) of extra-colonic malignancies were observed in this study. CONCLUSION: even with the longer follow-up of this large cohort of patients the sensitivity and specificity in our study for the diagnosis of colorectal cancer with MPCT remains comparable with that of other studies and this technique competes well with other common colonic imaging modalities.