Wk 4, Case 37 - Review

Report
TECHNIQUE:
CT of the abdomen and pelvis with intravenous contrast.
Scans were continued into the pelvis to evaluate the vasculature.

COMPARISON: CT from 2013

FINDINGS:
LOWER THORAX: Pacemaker lead terminates in the right ventricle. There are minimal dependent atelectatic changes bilaterally.

HEPATOBILIARY: There is new pneumobilia. There is an air-fluid level in the gallbladder. A prior 1.6 cm gallstone seen on the prior CT, is no longer present. Instead, there is wall thickening of the segment of duodenum immediately adjacent to the gallbladder. There is intrahepatic, and extrahepatic biliary ductal dilatation, with the lower common bile duct measuring up to 10 mm, increased compared to prior when it measured approximately 6 cm. There are unchanged subcentimeter focal hypoattenuating liver lesions. No new, focal hepatic lesions.

SPLEEN: No splenomegaly.

PANCREAS: There is new main pancreatic ductal dilatation to 5 mm. No focal masses.

ADRENALS: The previously noted right adrenal mass is again seen measuring 3.7 x 3.0 x 3.4 cm in greatest dimension. The mass enhances mildly with the central region enhancing to a lesser degree. Coarse calcifications are again noted. While previously this lesion was called an adenoma, given the mild increase in size, MRI with respect to this lesion may be helpful in further characterization.

KIDNEYS/URETERS: No hydronephrosis, stones, or solid mass lesions.

PELVIC ORGANS/BLADDER: Unremarkable.

PERITONEUM / RETROPERITONEUM: No free air or fluid.

LYMPH NODES: No lymphadenopathy.

VESSELS: Unchanged abdominal aortic aneurysm, measuring 3.8 x 3.8 cm, unchanged since the prior CT. As before, there is trace calcification and nonocclusive thrombus within the proximal SMA.

GI TRACT: There is a focal 10 cm segment of mid small bowel which demonstrates wall edema, and mucosal enhancement. Rounded partially calcified object seen within the distal jejunum/proximal ileum (axial image 50) may represent previously noted gallstone.

BONES AND SOFT TISSUES: Central compression of L5 vertebral body, with mild loss of height, unchanged.


IMPRESSION:
1. Short segment wall thickening with mucosal enhancement of the mid jejunum. Differential possibilities include focal bowel ischemia, infection, or inflammatory response. In regards to ischemia, the appearance and configuration of nonocclusive calcification and thrombus in the proximal SMA is unchanged. In regards to inflammatory change, this may potentially be related to passage of prior gallstone (see below).

2. Unchanged size and configuration of 3.8 cm infrarenal abdominal aortic aneurysm.
3. Interval resolution of the prior 1.6 cm gallstone seen on prior CT, with development of pneumobilia and biliary ductal and pancreatic ductal dilatation, suggestive of chole-duodenal fistula.