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LONG CASE PACKET 1 MODEL ANSWERS


Case 1

Observation 

AXR: Dilated loops of small bowel. Normal calibre large bowel

CT Abdomen and Pelvis: Dilated proximal loops of small bowel with thickened small bowel in the right side and calibre change at the level of a small bowel mass in the ileum.

Incidental gallstones and diverticula disease.

No free air or free fluid. No soft tissue disease.

No solid organ or bony metastasis.

Interpretation

Appearances likely represent bowel obstruction.

Principle Diagnosis:

Mechanical small bowel obstruction from obstructing tumour

Differential Diagnosis

Mechanical small bowel obstruction from metastasis or lymphoma

Management

Emergency surgical referral

CT chest to complete staging assessment.

 

Case 2

Observation 

CT Head and MRI Head Observation

Downward descent of cerebellar tonsils by approximately 5mm

Crowding of foramen magnum;;

Grey-white matter differentiation preserved

Normal ventricles

Interpretation

Abnormal position of cerebellar tonsils

Principle Diagnosis

Arnold chiari malformation type I

Differential Diagnosis

Incidental tonsillar ectopia

Further Management

Will need a full spine MRI scan to assess for syrinx and other anomalies.

Neurology Consultation

 

Case 3

Observation 

MRCP: Moderately dilated biliary tree with calibre change in the CBD.

Liver solid lesions and retroperitoneal upper abdomen adenopathy.

Incidental findings, gallstones and liver cysts.

Significant negatives no biliary tree stones.

Interpretation

CBD obstruction with liver solid lesions.

Principle Diagnosis

CBD cholangiocarcinoma with retroperitoneal and liver metastases

Differential Diagnosis

Passed stone causing CBD stricture and cholangitis with liver abscess and adenopathy.

Further Management

Upper GI surgery consultation

Staging CT chest, abdomen and pelvis

Blood tests including inflammatory markers.

 

Case 4

Observation 

CT abdomen and pelvis: Dilated small bowel with calibre change in the right side.

Liver metastasis. Pancreatic body mass. Retroperitoneal lymphadenopathy

Incidental left kidney calculus and sigmoid diverticular disease.

Significant negatives

No free air or fluid. Remainder of solid organs normal. No bony metastasis

Interpretation

Bowel obstruction with metastatic disease

Principle Diagnosis

Metastatic pancreatic cancer with serosal disease causing bowel obstruction

Differential Diagnosis

Neuroendocrine tumour with metastasis

Further Management

Referral to surgery for management of obstruction

Staging CT chest

HPB MDT referral

 

Case 5

Observation 

CT Head: Abnormal high attenuation in the right carotid artery

No intracranial abnormality appreciated

MRA Head: Filling defects in the carotid artery

Interpretation 

Narrowing of the right carotid artery

Principle Diagnosis

Dissection of right carotid artery

Differential Diagnosis

None

Further Management

Urgent neurology review for management

Needs MRI Head

 

Case 6

Observation 

AXR: Radio-opaque material in right lower abdomen

CT Abdomen and pelvis: Cystic lesion in the right side of the abdomen measuring 8 x 12cm with wires and calcification inside

Previous liver resection

Negatives: Normal uterus, solid organs. No free air or fluid.

Interpretation

Ovarian lesion or retained material from previous surgery

Principle Diagnosis

Retained material from previous surgery. Development of an ovarian lesion.

Differential Diagnosis

None

Further Management

Tumour marker correlation

Gynaecology consult