0:00

So I'm gonna show you another CT scan

0:03

for this case. This patient, I don't recall the age exactly,

0:09

but was definitely an older gentleman, I think

0:14

about 80 years old, who had come into our emergency room with abdominal

0:18

pain and got a CAT scan. And so we got a contrast enhanced study.

0:23

So I'm just gonna scroll through the images like I did for the

0:25

first case. I'll do axials, coronals, and sagittals. And

0:34

then we'll see the question and see if you guys can help me

0:37

with figuring out what this is. All right. So that's my first

0:52

slow ish scroll through the abdomen of the axial images. I'm gonna scroll

0:56

a little bit faster. You may have picked up on where the pathology

0:59

is and now you can scroll through it to focus on it a

1:04

little bit more, and try to come up with

1:11

some potential causes of what you think is going on here.

1:14

Let's go to the coronal images. We'll see the same finding,

1:18

obviously, but in a different plane. Maybe that'll help you.

1:29

And we'll finish off with the sagittal images up here. I'm gonna scroll

1:37

through it one more time. And then just to be consistent with my

1:45

first CT case that I showed you, I'm just gonna show you the

1:47

bones in case that becomes something that is relevant to this case.

1:52

You can see the bones on the sagittal CT images. All right. Those

1:59

are the findings. Let's move on to the multiple choice question and see

2:04

if our audience can help us out and figure out what we think

2:06

is going on here. Again, for this one, I'm gonna ask most likely

2:10

diagnosis. A lot of the questions will be on that, not all of

2:12

them. So Meckel's diverticulitis is the first option.

2:18

Could this be a foreign body perforation? Acute appendicitis? Always a possibility,

2:25

a very common diagnosis we see. And then Crohn's ileitis as well.

2:35

Everything centering around potentially inflammatory process in this patient

2:44

who's coming in with abdominal pain. As I said, a relatively older patient,

2:48

about 80 plus years old, who'd come in with abdominal pain.

2:51

So it was our duty to figure out what's going on and tell

2:58

our emergency room colleagues that this is what we think is happening.

3:01

All right. Meckel's diverticulitis and foreign body perforation. Good. I'm

3:07

happy nobody picked acute appendicitis and Crohn's. I think that would have

3:12

been tough. I'm scrolling through these images. It may be tough to figure

3:16

out where the appendix is, but it looks like you guys have a

3:18

good eye for that. And even the terminal ileum, where we expect to

3:21

see Crohn's. Let's go through this case again.

3:23

This is a case I read a couple of years ago.

3:26

And the history was, I said, it's abdominal pain. This was an older

3:30

gentleman, as I recall. And so I think we all figured out where

3:33

the abnormality is. And it's right over here. And

3:37

you can see that there is a thick walled blind ending structure.

3:40

If you follow this up and down, this end of it doesn't really

3:44

connect to anything. It's just hanging out over there. The other end,

3:49

you do have this bright object within it. And the other end of

3:54

it appears to be at least communicating with a loop of bowel right over

3:58

there. All right. So there's a blind ending, thick walled tubular structure.

4:02

There's lots of inflammatory change. For those who

4:05

may have not have seen the appendix, if you follow this sort of...

4:08

When I point, by the way, it'll be at the top of my

4:10

double arrows. If you point to this object over here, if you follow

4:14

this, you'll see that that's the blind end of the appendix and follow

4:18

it backward. You can see that it's coming nicely from the cecum. So

4:20

that's gonna be the appendix. The terminal ileum is gonna be

4:25

also not really in the vicinity of this process. It's gonna be this

4:30

area here, which looks removed from this process. I love this coronal CT

4:35

image as well, where you can again see the beautiful blind ending appearance

4:39

of this object with lots of inflammatory change.

4:42

And one particular slice, you can actually see the appendix next to it.

4:46

And again, blind ending coming from a loop of bowel. And so

4:50

this turned out to actually be Meckel's diverticulitis. And so this was

4:54

a surprise to me as well. This was an older gentleman.

4:57

I hadn't quite seen it in this patient population. But if you go

5:00

through it and follow some of the description that I've used to describe

5:04

what we're seeing, you can imagine that that would be a good possibility.

5:08

So you're seeing this blind ending tubular structure arising from the bowel.

5:14

This is gonna be the distal bowel, so the ileum. And that represents

5:19

a Meckel's diverticulum. It's the most common congenital structural abnormality

5:23

of the gastrointestinal tract. As you recall, it's due to persistence of

5:27

the omphalomesenteric duct. There's a rule of twos that people talk about

5:32

all the time. I don't know if that's really...

5:35

How relevant it is on a day to day basis when you see...

5:38

If and when you see these cases. But

5:41

if you see a blind ending structure emanating from the bowel that's inflamed,

5:44

you've gotta think of the Meckel's diverticulitis, particularly within the

5:47

distal bowel. This happened to just be the equivalent of an appendicolith,

5:51

I would say, or just an enterolith, I would say, that's just stuck

5:55

over here, that's inciting some of this inflammatory reaction. And so this

5:59

actually needed to be resected and taken out. And so we have path proof

6:03

that this is a Meckel's diverticulitis. I think Crohn's, we talked about

6:09

the terminal ileum being okay over here, so that's the most common location

6:14

for Crohn's ileitis. The appendix also looked okay. And I think foreign

6:17

bodies are probably the only other thing to think about because certainly

6:20

this could be mistaken for a foreign body.

6:24

But even if it was a foreign body perforation, it would have been

6:26

within a blind ending tubular structure in this location, it would be a

6:30

Meckel's diverticulum. Great. So we're three down, six more to go.

6:37

You guys are doing great. Move on to the next case.