FRCR 2B VIVA SESSION 13

Hinzugefügt: 2026-05-23

[00:00:10]45-year-old patient and suspected acute abdomen.

[00:00:14]So, this is a 45-year-old patient with a acute abdominal pain and this is CT axial I said acute abdomen, not abdominal pain. I said suspected acute abdomen, okay? Okay. Okay, suspected acute abdomen and this is CT axial abdomen and pelvis with contrast.

[00:00:32]I will scroll through the images from top to bottom then I will give my comment. This is an arterial phase. I will check through the images.

[00:00:46]Okay.

[00:00:49]As I'm scrolling, I can see that the bowel loops appear dilated and there is a free fluid seen within the pelvis.

[00:00:58]And I will go back to the abnormality.

[00:01:05]Here the bowel loops here are seen dilated. This is small bowel loops and surrounding with a free fluid.

[00:01:15]I will try to go with the bowel to see where is the transition zone.

[00:01:24]Okay, and the stomach as well is seen distended so I Okay. go down.

[00:01:29]Okay, so dilated bowel loops. You are seeing dilated bowel loops.

[00:01:33]Yes, so um I will try to just find where is the transition zone.

[00:01:40]Why you want to see the transition zone?

[00:01:43]To see what is the if there is any obstructing any obstructing mass any obstructing lesion Anything anything else serious than obstruction?

[00:01:52]Okay, the bowel loops are prominent.

[00:01:54]Okay, okay. Yes, I would like also as the patient come with acute abdomen. I would like also to check the right iliac fossa to make sure that there is no appendicitis and this is not uh What What about the walls of the bowel loops? The wall is thickened and edematous, but I can't see enhancement.

[00:02:13]This is an arterial phase.

[00:02:15]So, I would like also to check the vascular the vessels. Okay.

[00:02:21]>> I can see here's the celiac axis.

[00:02:25]Superior mesenteric is well seen.

[00:02:29]And Okay.

[00:02:37]I think here this is the uh >> [gasps and sighs] >> This is the vessels of the inferior mesenteric. I can't see it well enhanced. [clears throat] >> supplies to which part of the gut?

[00:02:50]Uh the the distal the distal colon the colon. Okay. So, and is the distal colon that you are pointing on?

[00:03:00]This is not distal colon, okay? Inferior mesenteric artery is usually very thin artery and it is fine in this case. So, how will you proceed now? So, for this patient, I would like also to check the other phase the portal venous phase if available. Okay.

[00:03:15]This is portal venous phase.

[00:03:17]Okay.

[00:03:21]So, I will go up in the portal venous phase to check also the veins, check the portal portal vein and Okay.

[00:03:30]I I can see also that there is heterogeneous heterogeneous hepatogram.

[00:03:35]There is area of ill-defined hypodensity seen within the liver as well. Okay.

[00:03:42]>> and I can't appreciate the portal vein.

[00:03:45]Uh I think the portal vein is not Here's a portal vein, but the right portal vein is not visualized.

[00:03:54]Uh It's thrombosed and I >> So, just summarize the case for me and what next?

[00:04:00]Okay, so this is a case of portal vein and superior mesenteric vein thrombosis with mesenteric mesenteric uh >> [snorts] >> uh ischemia affecting the bowel as a small bowel loops uh with bowel bowel dilatation. So, >> what will you advise the patient? What will you >> This is an emergency. This is an emergency. I will call the referring clinician and the patient need to be seen by the A&E team and to start also uh anticoagulant treatment for this ischemic um incident.

[00:04:34]>> okay, you will refer to ER. Any any other referral you want to make?

[00:04:39]Um and also for the surgical for surgical team uh but the patient I think will go back to the A&E and will receive the anticoagulant treatment. And they may seen also by the medical by the medicine team medical team. Okay, and you will not advise a surgical consult.

[00:04:56]Um Um I don't I don't think surgery surgery will be here because they will treat this the um Sorry, the Sorry, the the enhancement is affected. So, they might if it not respond to treatment >> to be very very careful with your wording. Yes.

[00:05:15]>> Okay.

[00:05:15]>> Okay, so now I'll I'll now start it because we have taken too much time for this case. I'll start um giving you the feedback. So, again, see these are gangrenous bowel loops. These are dead bowel loops. There is no point of giving anticoagulation. You just need urgent surgical consult and these loops have to be taken out. Okay, you can't leave them here and wait for the anticoagulant to work.

[00:05:38]Because I think doctor, the enhancement is is not going to >> Yes, that the See the See this is the normal enhancement and see this is this enhancement. These are uh I mean there's no point of, you know, giving anticoagulation and wait. So, this is a very, you know, one of the very commonly asked uh the mesenteric ischemia is one of the very important exam case. I deliberately started with the arterial phase, okay? So, initially you were saying that, you know, the loops are dilated. Yes, the loops are prominent, but you know, there is this diameter criteria. So, what's the normal diameter for a small bowel?

[00:06:14]Uh 3 cm More than 3 cm. It's it's it is around 3 cm, but see, look at the thickness. Look at Look at the wall. Look at the edema.

[00:06:23]So, you you you initially you were making it a small bowel obstruction.

[00:06:27]Yes, there is an element of obstruction because of the sluggish peristalsis.

[00:06:31]But see, the Look at the pattern of enhancement. And then you have to say the the for the portal venous phase and then there is a thrombosis, mesenteric ischemia. So, this is basically venous mesenteric ischemia, which is resulting in bowel infarction. And the patient has urgently referred to be referred to the uh surgical team for further management. Okay? Yeah.

[00:06:51]Yeah, okay. Thank you, doctor. Thank you.

[00:06:53]>> Thank you. So, this is uh uh 32-year-old patient and presented with chest pain.

[00:07:02]Okay, so this is the frontal chest radiograph of a 32-year-old patient who has presented with chest pain.

[00:07:09]Um the lung fields of uh this patient appear to be uh normal. I do not see any soft tissue opacification or nodules.

[00:07:21]Mhm.

[00:07:22]The cardiomediastinal contour is also normal. I do not see any uh retrocardiac Although I would like to window it, but um I do not see the retrocardiac opacity as well.

[00:07:35]Um uh there's no pleural effusion.

[00:07:39]Um I do notice that the um humeral heads bilaterally appear sclerotic. And they also show uh some uh some degree of flattening as well.

[00:07:53]Um in a young patient who's presented with acute chest pain, you said, right?

[00:07:57]Yes, chest pain.

[00:07:58]And these findings in the uh humerus, um I would be suspecting an acute chest syndrome because of sickle cell disease.

[00:08:06]Uh I would like to window to check the vertebral bodies for any central and peripheral depression.

[00:08:11]And I would like to correlate with the history of any um sickle cell >> I I sorry, I can't I can't window this, but in the exam you can window. You can definitely window, but I'm sorry right now we cannot window, but try to look at these vertebral bodies, okay? Very more closely.

[00:08:25]Um Okay. Um I am not able to They don't look um um to be that they seem to be normal from what I can see. Okay. Just move Just move further away from the screen, and then you will be able to see them more closely, okay?

[00:08:44]Okay, sir.

[00:08:46]Um So um my most uh likely diagnosis for this case is an acute chest syndrome um because of uh sickle cell disease, which is an acute medical emergency. And I would immediately um inform the referring clinician, and um this patient would need urgent supportive uh care.

[00:09:05]Okay. Okay.

[00:09:07]Okay, and after that?

[00:09:09]And after that uh he should be um worked up for sickle cell disease or something.

[00:09:16]>> already. Uh yeah, and Yeah, in hematology you'll be basically >> Referral to the hematology MDT.

[00:09:22]Okay, so very good. So okay, this is also very one of very important exam case, and it can come in the short case and in the viva case as well. A single x-ray can come in the viva case as well, okay? So you started off well with the lung fields. There is subtle increase in bone density, but we cannot appreciate it on this. And obviously in exam, you can window these window the screen as well. So, you rightly mentioned these humeral heads that there is sclerosis, there is deformity of their shape. And then if you look very closely, it's very difficult. I know it's difficult, but see this.

[00:09:57]This.

[00:09:59]Okay. So, in in the exam, they will show you a very clear picture. And for additional points, like you could have said that there is not So, you see the bowel loops are there is no stomach shadow. So, there is basically changes of water spleenectomy as well.

[00:10:13]Okay. This was a patient of acute chest and room with sickle cell disease. And then you correctly mentioned the management as well. Just one thing to add was that a hematological referral for this patient as well. Okay. Very good. Okay. I'm provided with uh CT scan brain of a 22-year-old patient presented with uh a sudden headache.

[00:10:40]I will scroll from bottom from top to bottom and then I'm coming.

[00:10:45]As I was scrolled through whole stack of images, I was able to appreciate that there is a large hyperdense area seen in the region of left basal ganglia, which is dissecting through the lateral ventricles by lateral lateral and fourth ventricle and third ventricle causing asymmetric dilatation of the ventricles. And it is also causing the midline shift. Singular There is subfalcine herniation also noted on the contralateral side. I'm trying to look out for any uh trans tentorial herniation. There is crowding of structures also noted along the basilar cistern. So, it is representing some trans tentorial herniation as well. Coronal images would be more helpful to comment upon that.

[00:11:27]I'm as I was scrolling from the top, I was also able to appreciate some subtle hyperdensity here along the right high priority regions which represents ongoing component of subarachnoid hemorrhage.

[00:11:41]So, overall the findings are keeping with a large intraparenchymal hemorrhage which has caused dissected into the lateral ventricles with subcomponent of the subarachnoid hemorrhage along the right lateral aspect. In a young patient, I'm more the the differential possibilities would include of as it is in involving the basal ganglia in a young patient, I will inquire about first the history of any hypertension. Is there any history of hypertension?

[00:12:08]If patient does not have any history of the hypertension, the other concern would be of any vasculitis condition in a young patient. So, this patient further requires >> Okay. Okay. Okay. I I I get it. So, what will be your immediate step after this?

[00:12:21]>> Yeah, CT angiogram CT angiography or MR angiography depending upon >> angiogram?

[00:12:27]Um before CT angiogram, MRI brain would be helpful.

[00:12:35]Urgent neurosurgical consult is first thing.

[00:12:38]>> Okay. Yeah, I I >> You see the amount of hydrocephalus. See the the pressure symptoms. Just save the patient first for the angiogram. Okay.

[00:12:45]Yeah. He might die in the angiogram.

[00:12:47]Okay. Yeah. Okay. Okay. Done. Okay. Oh, can I say that if the patient is within the department, I will >> Okay.

[00:12:54]Yes, but you know, neurosurgical consult and angiogram you can say. But okay. So, this is the angiogram. Okay, you can scroll now.

[00:13:02]Okay. Yeah. I'm provided with a CT angiogram where the first finding which I can appreciate is the presence of a VP shunt as the patient was Yeah, managed immediately and there's a decompression of the bilateral lateral ventricles. And there are multiple collaterals seen around the basal cisterns and in the circle of the Willis where I can appreciate attenuated caliber of the bilateral MCA and the ACA and looking for the carotid.

[00:13:30]There's also appear and the bilateral PCA also appears to be severely attenuated throughout the their extent. So given these imaging findings, these are likely keeping with the moyamoya disease with some complicated hemorrhage. This patient now require urgent now further require IR referral.

[00:13:50]Yeah.

[00:13:51]Okay. Okay, good. Very good. So very good. Very well done. And this was your first CT that I showed you almost explain all the findings the pressure symptoms. But again, only one you know, a critical mistake that you made.

[00:14:05]Neurosurgical [clears throat] first.

[00:14:07]Yes, angiogram we will do the angiogram that we will say all the see that if the patient is in the department. But then you have to save the patient. If there is hydrocephalus, if there is hydronephrosis in the kidney, first step should be PCNL. In this case, first step should be and you should you have to your body language. So this there is where where the communication parts comes.

[00:14:26]So how much you can are concerned for the patient? How much you you know you are you know raising the the possibility of urgency. They will mark you on the communication via this.

[00:14:37]Okay.

[00:14:37]>> Okay.

[00:14:38]You again this was the angiogram and then you you explain all the findings very well. You you you know, straight away picked up these collaterals. There is collateral and then again there is attenuation of the supraclinoid portion of the internal carotid arteries. And then this was also the the the 3D map imaging which again shows the attenuation and along with the supraclinoid and this is what the moyamoya syndrome and then again refer the patient again.

[00:15:07]Okay, so this is 8 month old child and his ultrasound abdomen is being provided. Okay.

[00:15:16]This is a static image ultrasound of her baby. Sorry, how many months are you?

[00:15:22]>> 8 months. 8 months >> 8 months baby.

[00:15:24]And >> 8 months baby for both uh, kidneys.

[00:15:28]Uh, in the left kidney I will start with it. I can appreciate that there is evidence of multiple cystic uh, lesions or multiple cystic dilatations noted within the left kidney. It appear to be not connected with the renal pelvis as I couldn't really appreciate hydroureter or hydronephrosis and this is static. In the right kidney also I can appreciate that there is no this cystic appearance does not appear in the right kidney. I can appreciate corticomedullary junction differentiation.

[00:16:00]Uh, no evidence of hydronephrosis or hydroureter.

[00:16:03]Um, uh, okay. So, I really couldn't appreciate um, So, in that in that in this age, if you see this appearance, so >> Uh, I'm suspecting of multicystic dysplastic kidney for this baby.

[00:16:21]And because of this we should go for nuclear study.

[00:16:25]Uh, functional MAG3 to look for the function of the >> which functional study?

[00:16:33]Sorry? Which functional study?

[00:16:36]Uh, dynamic MAG3.

[00:16:39]Okay.

[00:16:43]Okay, this is static image also for the nuclear study dynamic MAG3 for the kidney.

[00:16:50]Uh, I can appreciate that there is evidence of no uptake of the right one.

[00:16:53]However, the left one does not show any uptake. So, it's not functioning and the confirming the diagnosis of multicystic dysplastic kidney. Okay. And what are the associations of multicystic dysplastic kidney?

[00:17:06]Uh, >> [sighs] >> I am I I couldn't remember specifically the association.

[00:17:13]>> contralateral kidney, if the one kidney is multicystic dysplastic, what should we look for the other in the other kidney?

[00:17:19]Uh I'm not sure. I couldn't remember really. Okay. Uh I think it's uh Shah, please correct me. I think it's a vesicoureteric junction obstruction and pelviureteric junction obstruction.

[00:17:30]Yeah, exactly.

[00:17:31]Okay. So, we have to rule it out in the other kidney as well, okay?

[00:17:34]>> Okay. Okay. Okay. So, very good. This was also again very well done. You correctly described all the findings of the ultrasound that these are the dilated cysts not communicating. You cannot see the your description in ultrasound was very good. Very good.

[00:17:47]Excellent description, okay? And then again you move uh the functional study you we have to look for the uh status of function of the kidneys and for this the the scan was done and then we can see the uptake in the right kidney but not in the other kidney, okay?

[00:18:04]Okay. CT abdomen um with IV contrast arterial phase.

[00:18:31]Here there is a large avidly enhancing lesion seen within the um dome of the liver with um central um necrotic area.

[00:18:45]There are actually multiple um avidly enhancing lesions seen within the liver.

[00:18:59]Uh I think it's um it stopped scrolling.

[00:19:03]Yeah, please click on it once and scroll again.

[00:19:08]Okay.

[00:19:09]Yeah.

[00:19:14]Okay.

[00:19:16]Okay, there are multiple enhancing lesions with central core of of non-enhancing area.

[00:19:22]The background of the liver itself um looks uh um normal and not cirrhotic.

[00:19:32]Uh There is another avidly enhancing lesion seen within the uh I would I would say within the pancreas.

[00:19:54]Yeah.

[00:19:56]I think within pancreatic neck.

[00:20:05]Um left kidney is not seen.

[00:20:11]Okay.

[00:20:18]Okay.

[00:20:25]The rest of the bowel looks looks unremarkable. This is the portal venous phase.

[00:20:35]Okay. Um The previously seen lesions is still um seems to be enhancing uh but to a lesser extent, but still it is um of the same enhancement as the liver.

[00:20:52]And um there is I wouldn't say that there is a washout.

[00:20:58]And the the lesion within the um pancreas, I would say um shows the same characteristic. Still it's holding the contrast.

[00:21:10]And the bowels um seems I I've I've seen it before that it was unremarkable.

[00:21:18]Um So, uh what what do you think? You you talked about multiple lesions in the liver and pancreas.

[00:21:28]And you did see the arterial phase, and then now you've seen the portal venous phase. So, what do you think is going on?

[00:21:37]Um The the I'm thinking about the hepatic lesions. Um It could be a multiple um could be adenomas or a um um focal um uh focal I would say um nodular hyperplasia. I'm thinking of a benign lesion within the >> All right. And what about the lesion in the pancreas?

[00:22:08]Um The lesion of the pancreas um It has a similar pattern uh Yes. Yes. Yeah, of enhancement. So, um >> pattern of enhancement as those of the liver lesions, right?

[00:22:27]Yes, it is.

[00:22:30]Um Pancreatic duct is dilated.

[00:22:35]Um yeah, the pancreatic duct I'll just I'll show you how how to quickly look at it.

[00:22:43]It is dilated, yeah.

[00:22:46]Proximal to the lesion, it is dilated, right?

[00:22:50]At the at the distal part, within the tail.

[00:22:52]>> Yeah. Yeah. Yeah. Because the lesion is in the body.

[00:22:56]Yeah.

[00:22:57]So, it's causing um um obstruction within the pancreatic duct. So, do you still think these are these are all benign lesions?

[00:23:07]No.

[00:23:08]No. And what do you think these are?

[00:23:09][clears throat] I'm thinking that the the pancreatic lesion is a malignant one since it's causing obstruction and these metastasis from the same lesion. What what malignant pancreatic lesion enhances in the arterial phase?

[00:23:27]The neuroendocrine lesion.

[00:23:31]Enhances avidly within the arterial phase.

[00:23:35]Okay. And within with so putting it all together with the absent left kidney, I'm thinking this could be a case of the left kidney. I would review the previous history but I would think it was resected for a renal cell carcinoma.

[00:23:53]Mhm. Along with the neuroendocrine tumor in the pancreas and with hepatic metastasis, this could be all together a case of a von Hippel-Lindau.

[00:24:01]I would review the previous images of the patient. And Why can't it Why can't it be all RCC metastasis?

[00:24:12]It could be, yeah.

[00:24:15]It It could be cuz also the RCC shows a um I showed you the arterial phase of multiple artery arterial arterialized lesions in the liver and the pancreas with absent kidney.

[00:24:30]>> Yes.

[00:24:30]What do you think the whole process is?

[00:24:34]A metastasis.

[00:24:36]All of it is metastasis from the kidney.

[00:24:39]It could be another option cuz the RCC is also Yeah, so hypervascular mets, right?

[00:24:44]>> Yes. Yeah. Which Which tumors can throw hypervascular mets?

[00:24:50]Choriocarcinoma um Top of the list is RCC.

[00:24:55]RCC, yeah. Thyroid.

[00:24:57]Melanoma.

[00:24:58]Yeah, the breast and lung, yeah, and all of this. This was an 80-year-old patient. He did have a history of RCC, for which a left nephrectomy was done, and you can see the surgical staples in in the left renal fossa. The left kidney is absent, and then there are multiple arterially enhancing lesions in the liver, and then pancreas. The most common tumor to throw mets to pancreas is RCC. Remember that.

[00:25:26]Just remember that. It's It's a textbook thing. So, this was all a case of metastatic renal cell carcinoma. What are you going to do next in this case?

[00:25:35]I would review the bone scan first of the patient, and then I would urgently refer the patient for the hepatobiliary oncology MDT, or RCC renal um Yeah, yeah, multidisciplinary Yeah, yeah, MDT oncology oncology multidisciplinary consultation, yeah? Thank you very much.

[00:26:03]>> Yes.

[00:26:04]Thank you.

[00:26:06]Yeah, um immediately I can see that um um there is intra-conal region lesions bilaterally seen within uh both orbit. Mhm. Yeah.

[00:26:21]Yeah, um these lesions and try to see the extent I don't know why it scroll very I try to scroll from the Just scroll slowly. You There There There will be a lag of probably a microsecond or so. Yeah. So, just you know, as soon as you scroll, the image is going to move probably 1 microsecond afterwards, yeah? So, just scroll slowly, yeah.

[00:26:46]Yeah, so the lesions are um I try to to look for the optic nerve if it's separable from it or not.

[00:26:54]Um To be honest, yeah, I can see the optic nerve. So, this are So, I'm excluding uh optic nerve related diseases.

[00:27:06]Uh Um Apart from these lesions, I'm going to scroll through the images just to see uh Yeah, doing it too. Uh I can see that there is um the I think the left maxillary sinus see seen with thickened wall.

[00:27:32]Um Anything else?

[00:27:35]You have you identified the lesions in the orbit.

[00:27:38]Anything else in the brain parenchyma?

[00:27:46]I can appreciate that there is a cavum septum pellucidum. All right.

[00:27:52]Yeah. Um Yeah, so and there is high signal intensity around the cerebral aqueduct.

[00:28:03]And going down, I want to check for the pituitary area.

[00:28:09]Just Yeah.

[00:28:12]Here's the pituitary area.

[00:28:13]>> Yeah.

[00:28:14]Yeah, looks okay. Okay, fine. Can I check the I I've seen something in the cerebellum. Yeah, there is high signal intensity seen within the cerebellum bilaterally.

[00:28:26]Okay.

[00:28:27]Yeah.

[00:28:30]Anything else?

[00:28:32]Yeah, there is a rounded lesion, I think.

[00:28:37]Yeah.

[00:28:39]Centered on the No, no, go go down down down.

[00:28:45]No, yes.

[00:28:47]Yeah.

[00:28:49]And I'm trying to look the foramen magnum, yeah.

[00:28:53]There is uh I think there is a yes, a lesion in the foramen magnum as well.

[00:28:58]Yeah. High intensity within the um earlier uh So, now I am >> in medulla oblongata, too. Medulla oblongata, yeah. So, um So, I'm thinking of um a lesion which is try to connect a lesion within the orbit and then within the um I think a bilateral temporal as well.

[00:29:27]Um Yeah, and uh the bones looks um as well um enlarged. Yeah.

[00:29:38]So, >> [sighs and gasps] >> I don't know.

[00:29:45]So, >> you have you have identified >> see Can I see Yeah, can I see any other sequences like um You tell me. I'm going to put up that sequence for you.

[00:29:54]Um can I see contrast-enhanced images?

[00:29:58]All right, I'll show you the contrast-enhanced images.

[00:30:01]Yeah.

[00:30:23]I can see that the lesion within the um show enhancement within the orbit.

[00:30:29]Yeah.

[00:30:32]And I think there is some in the suprasellar cistern. I'm not sure. Uh that's normal. Yeah. That's normal, yeah. Yeah. Yeah.

[00:30:45]And And you did talk about some areas here and here and the brain And they they don't they don't they don't show any enhancement. Yeah.

[00:30:55]>> Okay. But the lesions in the orbits and then you see these hyperintense areas along the dentate nuclei in the cerebellum in the brain stem.

[00:31:08]Can you can you figure something out?

[00:31:10]I don't know if it's comes in optic neuritis spectra of syndrome, but I don't know if it's disorders.

[00:31:17]>> Optic neuritis won't show you uh masses in the optic nerve. Yeah, and they will show yeah, this is not masses. Yeah.

[00:31:26]Um The bilateral optic nerve gliomas. Now, can you tell me the diagnosis?

[00:31:35]>> I I thought of optic nerve gliomas, so this is the first thought come to my mind, but I If they're optic nerve gliomas, what what are the lesions in the brain stem in the cerebellum then?

[00:31:46]Yeah, so I look for hemangioblastomas in the brain stems and so this is uh Uh this is NF1. I'm thinking of NF1. Okay, if this is NF1, can you name the lesions that you saw in the brain stem in the cerebellum?

[00:32:06]Uh Uh >> [sighs and gasps] >> I don't know. I forget.

[00:32:12]Have I heard of focal areas of signal intensity foci?

[00:32:15]>> Yeah, foci. Yeah, yeah. Do you know what foci are?

[00:32:20]Yeah, focal focal intensities of high signals seen within the >> Why do they occur? Why do they occur?

[00:32:29]I think it's like a demyelination. Yeah, it's more related to myelin dysfunction.

[00:32:34]Yeah. So, what are you going to do next with this patient?

[00:32:38]So, I'll refer the patient to uh pediatric uh neurology MDT meeting and do genetic counseling and genetic testing for the patient. And >> spectrum of neurofibromatosis. You need to know everything about all the neurocutaneous syndromes. They're all very important exams for the lungs also and for the viva too. You need to know everything about every neurocutaneous syndrome, okay? So, there's a long list of so many things happening in a patient with neurofibromatosis one. You read those things up and then you're going to tell accordingly what the patient needs, all right? Okay. Yeah, thank you very much for your time. So, this is a CTA of abdomen and pelvis with IV contrast. I can see that there is extensive peritoneal fat stranding and fluid along with nodularity and thickening of the peritoneum. I can also see perhaps there's some peritoneal soft tissue uh as well.

[00:33:36]Uh I'm scrolling down to the pelvis. I can see there's significant free fluid.

[00:33:42]Now, coming from the blue back up.

[00:33:46]Uh I'm scrolling again.

[00:33:53]So, I can see that there's post-surgical changes along the anterior abdominal wall of the patient. And then there's a large predominantly cystic lesion with surrounding soft tissue component and calcifications along the segment six of the liver with some serosal extension along segment seven as well superiorly.

[00:34:11]Uh I'm looking at this lesion to see if it's intact or if there's any perforation. I cannot see any obvious uh defect of the wall. I can see that there's a localized collection in the right subhepatic region as well extending inferiorly.

[00:34:27]Uh And I'm now looking at the rest of the scan to see for any other uh findings I can see.

[00:34:37]So, there's significant peritoneal thickening as well.

[00:34:42]And there's no enlarged nodes in the para retroperitoneal region.

[00:34:51]The vessels appear patent.

[00:34:53]Uh there's no intrahepatic lesion, although there's significant serosal disease.

[00:34:58]And the cover sections of the lungs on this mediastinal window appears unremarkable. So, in summary that there's a large predominantly cystic lesion uh along segment six of the liver with extensive peritoneal fat stranding and nodularity and enhancement.

[00:35:15]>> You're saying along segment six.

[00:35:19]It's not within segment six.

[00:35:22]Uh it appears like it's involving the serosa rather intrahepatic >> Okay. Okay, I get it.

[00:35:28]Yeah, please continue.

[00:35:30]So, uh there usually with this kind of a mental pattern of fat stranding I would like to see the appendix as well.

[00:35:39]I'm scrolling down to the colon.

[00:35:45]And Here it is.

[00:35:51]Yeah, it's distended and appears to we have low-density in it.

[00:35:59]So, uh taking into account all these findings uh there appears to be extensive mental peritoneal disease with serosal deposits and soft tissue peritoneal deposits as well. I'll be thinking along the lines of an appendiceal mucinous mucinous neoplasm.

[00:36:15]Okay.

[00:36:17]And what is this whole process called?

[00:36:22]peritoneal carcinomatosis peritoneal carcinomatosis Uh how are the margins of the liver?

[00:36:31]I mean, is there anything wrong with the margins of the liver?

[00:36:39]There's scalloping of the margins of the liver.

[00:36:41]>> Yeah. Yes, yeah, there's significant scalloping. Yeah.

[00:36:46]So, this is pseudomyxoma >> refer the peritonei. No, yeah, sorry, pseudomyxoma peritonei. Yes, yes. Yeah.

[00:36:52]But, not quite peritoneal carcinomatosis. I've referred the patient to the oncology MDT. Mhm.

[00:36:59]And I'll see if there's any peritoneal nodule to refer for a biopsy.

[00:37:05]Yeah. So, so there's something and And for the How do these patients do?

[00:37:09]Yeah, what is the prognosis of the disease?

[00:37:12]Uh as far as I remember correctly, it's not very good. It's not very good. They keep recurring.

[00:37:17]>> They come back, yeah. Yeah. So, usually they are usually treated by surgical debulking.

[00:37:22]And yet, they appear again. So, the prognosis not Thank you very much.

[00:37:26]>> Yeah. Yeah, the findings were well explained. You know, just a little bit of uh you know, with the diagnosis, it was not peritoneal carcinomatosis. It was pseudomyxoma peritonei.

[00:37:36]>> Yeah. Yeah. Thank you very much.

[00:37:39]So, uh I'm presented by axial CT scan of the chest.

[00:37:45]Uh I think without contrast.

[00:37:49]Uh there is contrast with IV contrast.

[00:37:53]Uh I'm scrolling through the presented images.

[00:37:58]No history for this patient, Dr. Share?

[00:38:01]Uh no history for this patient.

[00:38:04]Okay. So, I'm I think this scan is self-explanatory.

[00:38:09]Yeah.

[00:38:11]I'm scrolling through the presented images of this female patient. As I can see the prominent breast shadows bilaterally.

[00:38:22]Uh I like to scroll through the whole images before uh full commenting.

[00:38:36]Yes, scrolling down through the presented images.

[00:38:47]Yes, so I'm scrolling again again through the images after the first to scroll.

[00:38:53]The first thing I did so in the first around in the scroll through the images that I can see there is diffuse fatty uh diffuse thickening of the uh wall of the chest wall of the patient with uh uh fatty involvement. However, there is a scalloping of the anterior chest wall and also there is a scanty of the thickness of the chest wall muscles.

[00:39:29]Uh I am trying to go through the images also uh till the last image is I can see uh uh Yes, this is this is scalloping and also uh the heart is seen shifted to pectus excavatum.

[00:39:52]Yeah, let's Yes, this is a case of comment on the inter- intra-pulmonary or you know, findings here in this case.

[00:40:01]>> [clears throat] >> Yes.

[00:40:02]Uh so, this is a case of pectus excavatum.

[00:40:06]The left lower zone of the lung uh showing uh uh consolidative area with multiple um hypo- and hyperdense uh contents through this uh uh view. I am trying to assess this if it is uh under the if there's underlying pathology rather than uh pure consolidations like like sequestration or uh Here in the hilum I'm searching for any connection to the aorta from this area to suggest uh this is sequestry uh pulmonary sequestration.

[00:41:05]I can see Yes, there is uh arterial branch seen extending from the aorta uh uh through this area to the left lower uh uh zone abnormality which likely representing uh uh arterial feeding of of this area which is in keeping with pulmonary sequestration. In my routine practice, I'd like to check this patient this exam in the coronal images to confirm the finding and also ask about the clinical history if there is any history of repeated Yeah, this patient is I don't I think he's 16 years old and she did present with repeated Yeah, she did repeat she did present with repeated chest infections. Yes, so this confirms the possibility of intralobar pulmonary sequestrations.

[00:42:02]>> How do you differentiate between the two?

[00:42:05]Uh as the venous drainage of intralobar is through the pulmonary veins. However, this is over.

[00:42:14]I'm trying to trace this.

[00:42:18]No, I am.

[00:42:24]This is arterial supply. I'm trying to trace the venous drainage of this. Uh However, it is better to be assisted in the venous phase of the images.

[00:42:59]Let me see.

[00:43:01]Material here, I couldn't see any uh Yeah. Okay. So, uh this is intralobar sequestration.

[00:43:07]Yes. Here there is venous drainage.

[00:43:10]Through the pulmonary veins. This is over.

[00:43:11]>> What are you What are you going to do next?

[00:43:14]Uh so, this patient needs to be transferred to the pediatric or to the respiratory team for management of any recent infected process first. Uh then after that it will be >> sequestration. You can see air forces, multiple hypoenhancing areas within it.

[00:43:35]So, this is infected sequestration, intralobar sequestration. Here Here Here is venous drainage.

[00:43:42]Yeah. And you correctly identified the arterial supply to this lesion. Here.

[00:43:48]Okay. So, refer first to the respiratory team for treatment of the recent infection. And after that will be referred to the cardiosurgical MDT for discussion of the management, surgical management.

[00:44:01]>> Very nice. Well done.

[00:44:03]Very well done. Yeah. Thank you very much. Yeah, this was it for the day.

[00:44:08]Thank you all. I think uh I've I've completed all the four candidates, yeah.

[00:44:15]This was candidate eight, right?

[00:44:17]Yeah, this is my fourth case.

[00:44:20]Yeah. Yeah, so thank you all. Thank you very much.