0:00

This is my PACS and we have a list of cases.

0:06

There's about nine cases over here. This is all de identified.

0:08

These are random medical record numbers, random accession numbers, random

0:13

date of births, all assigned to January 1st. So we don't need to

0:16

worry about any of that stuff. And over the next hour,

0:20

we're just going to go through these nine cases. There'll be a multiple

0:23

choice question or two after each case. The plan is to just scroll

0:27

through them. I'm not going to say much as I scroll through it.

0:31

At least I'm gonna try not to say much, just so you guys

0:34

can go through your own search pattern. We'll ask a question and then

0:37

we'll talk a little bit about the case right after it.

0:39

Most of these, as you can see, are MRI cases. There's a few

0:42

CT cases. The point here is to show you some

0:46

cases which I think are challenging, are kind of fun

0:48

to go through. So let's start with our first case. This is gonna

0:51

be here. It's gonna be a CT case to warm everybody up.

0:55

Now let's do a two by two. Let's take some of the annotations away. I

0:58

should do a one by one here. And I'm just gonna start scrolling

1:01

through it, the axial images. And first time around, maybe just

1:11

have a look, gather some thoughts about some of the findings that you're

1:15

seeing. If I'm scrolling too fast or too slow,

1:20

feel free to chime in in the chat box. So these are the

1:26

axial images. You can see it's a contrast enhanced CT scan.

1:31

A lot of stuff going on as we scroll through these axial images.

1:36

I'm gonna scroll back up one more time so you guys can have

1:40

a look and just see everything now that you've had

1:43

just a few seconds to absorb some of the findings that

1:47

are here. And I'll move on to the coronals as well.

1:54

So you get another chance to look at everything.

1:58

And so you're seeing the same findings in a different plane.

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And clearly, there's sort of a diffuse process going on. It may also

2:11

be important to look at some of the organs just to kind of

2:13

help you figure out what could be causing that diffuse process.

2:20

These are the sagittal images. And I'll just sort of

2:26

put it on bone windows as well. So you get to see the

2:30

bones at least in one of the planes. All right, you just see

2:34

there's something in the chat box over here.

2:40

Everyone's had a chance to look at the cases. If we could have

2:43

the first multiple choice question up for the audience, please.

2:48

So we're gonna ask what the most likely diagnosis here is.

2:50

Or options. TB, Pseudomyxoma, Encapsulating peritoneal sclerosis. It's a

2:58

mouthful there. And Barium peritonitis as well. So clearly, something is

3:05

involving the peritoneum. What is the right answer over here? All right,

3:13

so we are neck and neck with tuberculous peritonitis and encapsulating peritoneal

3:18

sclerosis. So that's great. So let's go through

3:20

some of the answers here. And I think somebody chimed in in the

3:23

chat box and also said encapsulating peritoneal sclerosis. All right, so

3:28

here we have a CT scan. The history is probably abdominal pain.

3:33

I don't want to harp too much on history, unless it's really relevant

3:36

to making the diagnosis. I'm not sure if it is in this instance.

3:39

And as you look at it, it's a contrast enhanced CT scan.

3:42

You're seeing this Hyperattenuating curvilinear content that's sort of lining

3:49

the peritoneum lining. And now I can window it a little bit better.

3:53

Maybe you can see it now. Surrounding the spleen, surrounding the right

3:57

subhepatic space over here in the liver, the left subhepatic space,

4:00

going through all the respective ligaments. As you go down, you can see

4:03

it beautifully sort of outlining some of the paracolic gutters. You can

4:07

see it beautifully outlining multiple loops of small bowel where the mesentery

4:10

is, going all the ways down to the pelvis. And so this is

4:13

really a diffuse process. And so all. This is a diffuse process involved

4:17

in the peritoneum. So how can we sort of narrow it down to

4:21

one of the four options that we've given?

4:23

So I think Pseudomyxoma peritonei was one of the things I think nobody

4:27

answered or maybe very few answered. And I think we can sort of

4:29

exclude that because those are often seen with mucinous appearing, secreting

4:34

neoplasms. You can't get these calcifications, but classically, they'll

4:38

get scalloping on the borders of the liver and spleen. And so,

4:41

yes, there is some free fluid in the cites here. You're not getting

4:45

that scalloping and mass effect upon those organs. And so we can probably

4:48

put that lower on our differential diagnosis. I think TB, you know, I

4:53

put it there because whenever you see calcifications anywhere in the abdomen

4:56

and pelvis, you have to think of TB, particularly when it's diffused like

4:59

this. So, you know, that's one possibility, and certainly tuberculosis can

5:04

affect the peritoneum. But, you know, the best answer in this instance,

5:08

given all the other findings that I'll go through, is probably encapsulating

5:10

peritoneal sclerosis. And so one of the things you have to look at

5:13

is what else is going on in this case? The liver and spleen

5:16

look okay. Look at the kidneys. They're small, right? They're shrunken kidneys

5:21

with numerous cysts. And so when you see that appearance of small kidneys

5:24

with numerous cysts, you gotta think of Acquired Cystic disease of dialysis.

5:29

That's one of the things you have to think about. So when you

5:31

look at that, you say, okay, when I see that appearance on the

5:34

kidneys, it's a good chance the patient's on dialysis or has been on

5:37

dialysis, peritoneal dialysis. And so whenever I think about that, I say,

5:41

okay, well, what are the complications associated with peritoneal dialysis

5:44

that I can see in the abdomen and pelvis? And one of them

5:46

is encapsulating peritoneal sclerosis. It's a relatively uncommon complication,

5:52

but it's really characterized by areas of intraperitoneal inflammation and

5:57

fibrosis. And really when you get to the end stage, you gonna to see

6:00

these very thick and coarse calcifications. At an earlier stage, you'll

6:05

just see thickening of the peritoneum lining without these calcifications

6:08

surrounding the peritoneum. But it can be quite devastating. As you can

6:12

see what it's doing here to a lot of these loops of small

6:14

bowels, it's sort of just not allowing them to breathe, right? These small

6:18

loops of bowel are clustered in one location. It's often called cocooning

6:22

of the small bowel. And oftentimes, you know, the calcifications themselves

6:26

are not going to cause issues, but what they do to the other

6:28

organs, particularly the small bowel, can lead to a high rate of morbidity

6:32

and mortality. And so the other finding that I wanted to show you

6:36

that supports the diagnosis patient is in renal failure, has been a renal

6:41

failure, is this beautiful example of Rugger Jersey spine. I have to say,

6:44

you know, you read about it in the textbooks,

6:46

but this is one example where you really do see it very nicely.

6:49

And so, you know, the combination of the kidney appearance, the Rugger Jersey

6:52

spine tells this patient, you know, has renal failure, has been on dialysis,

6:56

and then you see these findings. I think of the four options,

6:59

encapsulating peritoneal sclerosis is probably the best option over there.

7:05

So that's the first case.