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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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28.9.2 Solution
Additional Annotated Images
( e ) Stress raw projection image (Video 28.9e, frame 6) adjusted to view liver and
gallbladder,
99m
Tc sestamibi, gallbladder ( yellow box ), and gallstone ( blue lines )
( f ) CT scan through upper abdomen, gallbladder ( yellow box ), and left renal fossa
( orange box )
The Pertinent Findings
• Chest
– Not applicable
• Abdomen
– Biliary system and gallbladder: □ hot ■ cold
– Small intestine and large intestine: ■ hot □ cold
– Kidneys and female reproductive system: □ hot ■ cold
The Relevant Diagnosis(es)
• Chest
– Not applicable
• Abdomen
– Biliary system and gallbladder: ■ gallstones
– Small intestine and large intestine: ■ malposition
– Kidneys and female reproductive system: ■ nephrectomy
e
f
See Video 28.9e
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Discussion
Chest
There are no abnormalities.
Abdomen
At rest, the gallbladder just begins to fi ll with radioactive bile (a), and at stress (c),
it fi lls completely; there is a striking “cold” “fi lling defect” within its lumen (a, c, e).
Correlative CT image (f) demonstrates large calcifi ed gallstones as the cause.
The left kidney is surgically absent; it is not seen on the raw data (b, d). Note
surgical clips and small bowel positioned in the posterior left upper quadrant (renal
fossa) (f).
Relevant Chapter(s)
20, 23, and 25
28.9 Case Challenge #21
https://t.me/med1917
302
28.10 Case Challenge #22
28.10.1 Problem
Clinical Highlights
A 64-year-old male presents with dyspnea and an abnormal ECG (low voltage).
Images for Review
ab
c
See Video 28.10a See Video 28.10b
Fig. 28.10
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( a ) Rest “white-on-black” raw projection images contrast adjusted for chest
(Video 28.10a, frame 1),
99m
Tc sestamibi
( b ) Stress “white-on-black” raw projection images contrast adjusted for chest
(Video 28.10b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)
Characterize the Pertinent Finding(s)
• Chest
– Breasts: □ hot □ cold
– Chest wall: □ hot □ cold
– Skeleton: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Myocardium and pericardium: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Diaphragm: □ hot □ cold
• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Adrenal glands: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
State Your Relevant The Relevant Diagnosis(es)
• Chest
– Breasts: □ normal □ malignancy
– Chest wall: □ normal □ pacemaker
– Skeleton: □ normal □ anemia
– Pleura: □ normal □ bilateral effusions
– Lungs: □ normal □ asymmetry due to transplant
– Mediastinum: □ normal □ malignancy
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle:
□ normal □ hypertrophy
– Diaphragm: □ normal □ fl attened
• Abdomen
– Abdominal wall: □ normal □ external defi brillator device
– Peritoneum: □ normal □ malignant ascites
– Liver: □ normal □ pericholecystic rim sign of acute cholecystitis
– Biliary system and gallbladder: □ normal □ acute cholecystitis
– Stomach: □ normal □ gastroparesis
– Small intestine and large intestine: □ normal □ primary neoplasm
– Adrenal glands: □ normal □ primary neoplasm
– Kidneys and female reproductive system: □ normal □ primary malignant neo-
plasm (renal cell carcinoma)
28.10 Case Challenge #22
https://t.me/med1917
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28.10.2 Solution
Additional Annotated Images
( d ) Axial CT image of lower chest, pericardial fl uid ( open orange ovals ), and pleu-
ral effusions ( closed yellow ovals )
The Pertinent Findings
• Chest
– Pleura: □ hot ■ cold
– Myocardium and pericardium: □ hot ■ cold
• Abdomen
– Not applicable
The Relevant Diagnosis(es)
• Chest
– Pleura: ■ bilateral effusions
– Myocardium and pericardium: ■ effusion
• Abdomen
– Not applicable
Discussion
Chest
There is a striking large circumferential “cold” region around the heart (a, b). Note
the photopenic (“cold”) lower lungs, left much more apparent than right (a, b). On
the processed non-AC images (c), there is a medium-sized, mildly severe, fi xed
defect involving the inferior lateral wall; this normalizes on the AC images (best
noted on the VLA and HLA orientation) and is likely caused by attenuation artifact
from the large pericardial and/or left pleural effusion. The CT scan (d) confi rms fl uid
around the heart and at the lung bases.
Abdomen
There are no abnormalities.
Relevant Chapter(s)
9, and 12
d
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28.11 Case Challenge #23
28.11.1 Problem
Clinical Highlights
A 56-year-old male presents with epigastric pain and suspicion of coronary artery
disease.
Images for Review
( a ) Rest raw projection images contrast adjusted for extracardiac structures
(Video 28.11a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images at usual contrast settings for heart (Video 28.11b,
frame 1),
99m
Tc sestamibi
Characterize the Pertinent Finding(s)
• Chest
– Parathyroid glands: □ hot □ cold
– Chest wall: □ hot □ cold
– Skeleton: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Diaphragm: □ hot □ cold
Fig. 28.11
ab
See Video 28.11a See Video 28.11b
28.11 Case Challenge #23
https://t.me/med1917
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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
– Parathyroid glands: □ normal □ mediastinal adenoma
– Chest wall: □ normal □ external artifact
– Skeleton: □ normal □ metastases
– Pleura: □ normal □ effusion
– Lungs: □ normal □ malignancy
– Mediastinum: □ normal □ esophageal refl ux
– Right atrium and right ventricle: □ normal □ right auricular appendage
– Vascular system: □ normal □ extravasation
– Diaphragm: □ normal □ fl attening
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ postoperative resection
– Biliary system and gallbladder: □ normal □ cholecystectomy
– Spleen: □ normal □ enlargement
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ stasis (slow peristalsis)
– Kidneys and female reproductive system: □ normal □ left nephrectomy
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28.11.2 Solution
Additional Images
d
See Video 28.11c
c
28.11 Case Challenge #23
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( c ) Stress/rest processed SPECT images (SA, VLA, HLA)
( d ) Stress gated SPECT (Video 28.11c, frame 1) (SA, VLA, HLA)
The Pertinent Findings
• Chest
– Chest wall: ■ hot □ cold
• Abdomen
– Biliary system and gallbladder: □ hot ■ cold
– Stomach: ■ hot ■ cold
– Small intestine and large intestine: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Chest wall: ■ external artifact
• Abdomen
– Biliary system and gallbladder: ■ cholecystectomy
– Stomach: ■ duodenogastric refl ux
– Small intestine and large intestine: ■ normal
Discussion
Chest
On close inspection, one can detect the appearance of diffuse activity external to the
patient’s right side on frames 46–47 of the rest raw images (a); the explanation for
this fi nding is that another radioactive patient walked past the gamma camera when
it was positioned at just the right angle to register photons emanating from the
“other human source.”
The MPI is normal. An inferobasal wall fi xed defect is likely diaphragmatic
attenuation artifact in this male (c). Note the hepatic and gastric activity below the
heart on the rest images. LVEF is 65 % and there is normal wall motion and wall
thickening (d). The right ventricle is normal.
Abdomen
Absence of gallbladder on both rest raw (a) and stress raw (b) images is confi rmed
by history of cholecystectomy. Duodenogastric refl ux is identifi ed on raw rest
images (a) and is cleared by water ingestion on stress raw images (b). Note the clue
of a distended, “cold” stomach. The small intestine demonstrates physiologic peristalsis (a, b).
Relevant Chapter(s)
7, 20, 22, and 23
28 Self-Assessment Cases: Intermediate
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28.12 Case Challenge #24
28.12.1 Problem
Clinical Highlights
A 73-year-old man presents with a complicated medical history including dilated
cardiomyopathy, coronary artery disease with right coronary artery stenting, congestive heart failure, hypertension, chronic renal failure, diabetes mellitus, and cirrhosis with elevated bilirubin level (1.3 mg/dL).
Images for Review
Fig. 28.12
ab
c
See Video 28.12a See Video 28.12b
28.12 Case Challenge #24
https://t.me/med1917
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