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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3679_Библиотеки_им_академика_М_И_Перельмана
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280
The Relevant Diagnosis(es)
• Chest
– Breasts: ■ soft-tissue attenuation artifact
– Lungs: ■ emphysema
– Right atrium and right ventricle: ■ right auricular appendage and pulmonary
hypertension
– Diaphragm: ■ fl attening
• Abdomen
– Spleen: ■ splenectomy
– Stomach: ■ fl uid fi lled after ingestion of fl uids
Discussion
Chest
There is superimposed “cold” breast tissue (a, b) which creates slight breast attenuation artifact in the anterior wall of the left ventricle (c). There are hyperexpanded
“cold” lungs, especially involving the lower lobes, with fl attened diaphragms (a, b);
radiography is confi rmatory (d).
The right ventricle is enlarged with prominent right ventricular myocardial
uptake (a, b, e), consistent with pulmonary hypertension in the setting of advanced
obstructive pulmonary disease; there is a normal right auricular appendage (a, b, e).
There is a large reversible perfusion defect in the inferior wall consistent with right
coronary artery ischemia (c).
Abdomen
The biliary system appears normal; a gallbladder is present but is not included in the
fi eld-of-view. The spleen is surgically absent, and the left kidney and small intestine
occupy the left upper quadrant adjacent to the stomach (a, b). The stomach appears
both “hot” and “cold,” likely refl ecting gastric wall uptake, plus a mixture of duodenogastric refl ux and fl uid ingestion (a, b, f). Given the history of diabetes mellitus,
prolonged gastric distension can suggest gastroparesis.
Relevant Chapter(s)
6, 10, 13, 16, 21, and 22
28 Self-Assessment Cases: Intermediate
https://t.me/med1917
281
28.5 Case Challenge #17
28.5.1 Problem
Clinical Highlights
A 33-year-old male undergoes preoperative planning. He complains of dyspnea.
The regadenoson stress test is normal. Recent echocardiogram showed LVEF of
67 %. Calcifi ed gallstones are noted on ultrasonography.
Images for Review
Fig. 28.5
ab
c
See Video 28.5a See Video 28.5b
28.5 Case Challenge #17
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282
( a ) Rest raw projection images (Video 28.5a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 28.5b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)
( d ) Stress and rest gated SPECT images (Video 28.5c, frame 1) (SA, VLA, HLA)
Characterize the Pertinent Finding(s)
• Chest
– Breasts: □ hot □ cold
– Chest wall:
□ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Lymphatic system: □ hot □ cold
– Diaphragm: □ hot □ cold
d
See Video 28.5c
Fig. 28.5 (continued)
28 Self-Assessment Cases: Intermediate
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• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Breasts: □ normal □ carcinoma
– Chest wall: □ normal □ implanted defi brillator device
– Pleura: □ normal □ effusion
– Lungs: □ normal □ active granulomatous disease
– Mediastinum: □ normal □ paravertebral mass (extramedullary hematopoiesis)
– Right atrium and right ventricle: □ normal □ enlarged atrium
– Vascular system: □ normal □ retention in central veins
– Lymphatic system: □ normal □ metastatic breast carcinoma
– Diaphragm: □ normal □ herniated small intestine
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ cirrhosis
– Biliary system and gallbladder: □ normal □ pathologic variability, gallbladder
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy
– Small intestine and large intestine: □ normal □ ileus
– Kidneys and female reproductive system: □ normal □ atrophy
28.5 Case Challenge #17
https://t.me/med1917
284
28.5.2 Solution
Additional Annotated Images
( e ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC),
splenic activity ( yellow boxes ) on selected non-AC and AC SA and HLA images
The Pertinent Findings
• Chest
– Not applicable
• Abdomen
– Peritoneum: □ hot ■ cold
– Liver: □ hot ■ cold
– Biliary system and gallbladder: ■ hot ■ cold
– Spleen: ■ hot □ cold
– Stomach: ■ hot □ cold
e
28 Self-Assessment Cases: Intermediate
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285
The Relevant Diagnosis(es)
• Chest
– Not applicable
• Abdomen
– Peritoneum: ■ ascites
– Liver: ■ cirrhosis
– Biliary system and gallbladder: ■ pathologic variability, gallbladder
– Spleen: ■ splenomegaly
– Stomach: ■ gastropathy
Discussion
Chest
On rest raw images (a) performed fi rst, the gallbladder appears small and contracted;
the patient was fasting. On later same-day stress raw images (b), the gallbladder
appears more distended with radioactive bile. Differential distension of the gallbladder signals chronic gallbladder disease. The patency of the cystic duct excludes
acute cholecystitis. [Two months later, the patient developed acute cholecystitis
requiring cholecystostomy tube placement.]
Abdomen
Note small liver, ascites, splenomegaly, and gastropathy (a, b). Neither the “high”
spleen nor the “hot” stomach creates artifacts on the processed SPECT images (c, e)
nor on the gated images (d).
Relevant Chapter(s)
18, 19, 20, 21, and 22
28.5 Case Challenge #17
https://t.me/med1917
286
28.6 Case Challenge #18
28.6.1 Problem
Clinical Highlights
A 58-year-old male presents with shortness of breath and chest pain.
Images for Review
Fig. 28.6
ab
c
See Video 28.6a See Video 28.6b
28 Self-Assessment Cases: Intermediate
https://t.me/med1917
287
( a ) Rest raw projection images (Video 28.6a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 28.6b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, HLA, VLA)
( d ) Stress gated SPECT images (Video 28.6c, frame 1) (SA, HLA, VLA)
Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Parathyroid glands: □ hot □ cold
– Breasts: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Myocardium and pericardium: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Lymphatic system: □ hot □ cold
d
See Video 28.6c
Fig. 28.6 (continued)
28.6 Case Challenge #18
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288
• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Vascular system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ primary malignancy
– Parathyroid glands: □ normal □ parathyroid adenoma
– Breasts: □ normal □ breast cancer
– Lungs: □ normal □ emphysema
– Mediastinum: □ normal □ dilated esophagus with gastroesophageal refl ux
– Myocardium and pericardium: □ normal □ pericardial mass
– Right atrium and right ventricle: □ normal □ dilatation
– Vascular system: □ normal □ extravasation
– Lymphatic system: □ normal □ venous extravasation resulting in axillary
lymph node visualization
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ rapid excretion
– Biliary system and gallbladder: □ normal □ gallbladder non-visualization
– Spleen: □ normal □ enlargement
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ active peristalsis
– Vascular system: □ normal □ extravasation
28.6.2 Solution
Additional Images
( e ) PA chest radiograph
e
28 Self-Assessment Cases: Intermediate
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The Pertinent Findings
• Chest
– Lungs: □ hot ■ cold
• Abdomen
– Liver: □ hot ■ cold
– Biliary system and gallbladder: □ hot ■ cold
– Stomach: ■ hot □ cold
– Small intestine and large intestine: ■ hot ■ cold
The Relevant Diagnosis(es)
• Chest
– Lungs: ■ emphysema
• Abdomen
– Liver: ■ rapid excretion
– Biliary system and gallbladder: ■ gallbladder non-visualization
– Stomach: ■ duodenogastric refl ux
– Small intestine and large intestine: ■ active peristalsis
Discussion
Chest
The “cold” lungs are due to emphysema (a, b); radiography (e) confi rms hyperinfl ation and fl attened diaphragms.
Abdomen
There is complete hepatic clearance on both image sets (a, b). The “hot” stomach is
present on both sets of raw data (a, b), perhaps more pronounced on rest compared
to stress. The stomach appears distended. On processed images (c), decreased
uptake in the inferolateral-basal myocardial wall appears more pronounced on rest
images compared to stress (a “reverse” fi xed defect) (c); this may be related to the
nearby gastric activity which is just visible at the lower right corner of some of the
SA frames and the more inferior HLA frames. On gated SPECT images, the inferior
wall has normal wall motion and wall thickening (d), favoring artifact rather than
scar.
There is a curious focus of small intestinal activity located deep in the midline on
the rest raw images (a); this focal activity clears by peristalsis on later stress raw
images (a), confi rming physiologic stasis with peristaltic clearance.
Relevant Chapter(s)
10, 19, 22, and 23
28.6 Case Challenge #18
https://t.me/med1917
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