Transcript X-ray Conference

X-ray Conference
Presented by F1 潘恆之 Commented by Dr.王俐人
2011/08/10
CASE 1: 8800649
CASE 2: 889344
CASE 1: 8800649
General Data
Age: 88-year-old
 Gender: Male
 Ethnic: Taiwanese
 Marital status: Married
 Occupation: Farmer
 Admission date: 2011/06/30

Chief Complaint

Progressive consciousness disturbance for
2 weeks.
Present Illness

This 88-year-old male has history of hypertension
for years and cerebrovascular accident in 2007
under aspirin for prophylactic use.

This time, he suffered from progressive drowsy
consciousness since 2 weeks before this admission.

There was no fever, chills, productive cough,
dyspnea, chest pain, headache, myalgia, muscle
weakness, drooling, tarry stool, bloody stool,
alcohol consumption nor trauma history.

Tracing back the history, he had suffered from
intermittent hematuria, urinary frequency,
urgency, nocturia, body weight loss, poor
appetite and general malaise since 2011/03.

He had been diagnosed as a victim of benign
prostate hyperplasia and received regular follow
up at our urologic OPD since 2011/05.
Becauses of hematuria, aspirin was hold since
2011/06.

However, the frequency of hematuria
increased and the urine output decreased
gradually. The patient had experienced acute
urinary retention and visited our ER for help
3 days before this admission. Foley catheter
was inserted and then he was discharged on
the same day.

However, oliguria and consciousness
disturbance progressed, so he was sent to
our ER for help again on 2011/07/15.
Past History

Lumbar spine fracture in 2004
Personal History
No known allergy to food or drugs
 Denies smoking, excess alcohol drinking
or betel nuts chewing.

Medication history


Neurologic OPD：
- Aspirin (100mg)
1#
- Zolpidem (10mg) ½#
- Quetiapine (25mg) 2#
- Clonazepam (0.5mg) 1#
qd
prn
hs
hs
Urologic OPD：
- Dutasteride (0.5mg) 1# qd
- Terazocin(2mg)
1# hs
Admission history

1999/04 – urinary tract infection and
pneumonia
Physical Examination
T:36.6/℃ P:118/min R:24/min BP:164/78/mmHg
 GENERAL APPEARANCE: acute-ill looking
 Consciousness: E3V3M5
 HEENT: pink conjunctiva, anicteric sclera
 Chest: smooth respiration, bilateral clear
breathing sounds.
 Heart: regular heart beats, no murmurs.
 Abdomen: soft and flat, normoactive bowel
sounds
 Back: No knocking pain over both CV angle
 Extremity: freely movable, no pitting edema.

Laboratory Findings
Hemogram
unit
7/15
ABG
7/15
WBC
/uL
16100
PH
7.536
RBC
million/uL
2.40
PaCO2
23.5
Hemoglobin
g/dL
5.1
PaO2
179.9
Hematocrit
%
15.8
HCO3
19.5
MCV
fL
65.8
TCO2
20.2
MCH
pg/cell
21.3
SBE
-3.1
MCHC
g/dL
32.3
ABE
-1.1
RDW
%
20.9
Sa%
99.4
Platelets
/uL
193k
Segment
%
91.1
Lymphocyte
%
5.9
Monocyte
%
2.7
Eosinophil
%
0.1
Basophil
%
0.2
Laboratory Findings
Biochemistry Unit
6/13
7/15
7/16
BUN
mg/dL
22.7
76.2
60.4
Cr
mg/dL
1.45
10.58
8.52
Na
Meq/L
123
127
K
Meq/L
6.4
4.8
Ca
Meq/L
7.5
7.8
P
Meq/L
5.5
3.9
Osmolality
mosm/KgH2
O
283
AST
U/L
55
ALT
U/L
ALK-P
U/L
78
Bil(T)
mg/dL
0.9
CRP
mg/L
73.57
Albumin
g/dL
2.64
37
30
Lab
Urinalysis
2011/7/12
2011/07/16
Color
Red
Red
Turbidity
Turbid
Cloudy
Sp. Gravity
1.005
1.020
pH
5.0
8.0
Leukocyte
Trace
+
Nitrite
+
+
Protein
2+
3+
Glucose
Negative
Negative
Ketone
Negative
Trace
Urobilinogen
1.0
1.0
Bilirubin
Negative
Negative
Bacteria
+
+
Blood
3+
3+
RBC
>500
>500
WBC
20
350
Epi.
0
0
7/15
CXR
7/15
Left
decubitus
view
7/15 Brain CT
Recent
r’t precentral
gyral infarct
2011/07/16 Kidney Echo
Left Kidney
Length: 10.2 cm
Right Kidney
Length: 9.8 cm
2011/7/16 Non-contrast CT
2011/7/16 Abdominal CT
Findings：
Bilateral hydronephrosis with
mural thickening and intraluminal
hematomas in the urinary bladder
Impression：r/o urinary bladder
tumors with obstructive uropathy
and hemorrhagic cystitis
2011/07/17 CXR
2011/07/25 Contrast CT
Findings：
1.A bulky heterogeneous mass in the urinary
bladder and prostate gland.
2.Enlarged pelvic LAPs suggest LN metastases.
3.Diffuse lung nodules in bilateral lungs
4.Osteolytic and sclerotic lesions in the spine,
DDx: osteoporosis change, bone metastases.
Impression：
R/O tumor as described. DDx: urinary
bladder cancer, prostate cancer, both urinary
bladder and prostate cancer.
Urine cytology
7/16 – Negative for malignancy
 7/25 – Negative for malignancy

Diagnosis






A bulky heterogeneous mass in the urinary
bladder and prostate with diffuse lung nodules
and osteolytic lesions in the spine, favor bladder
cancer with lung and bone metastases
Hematuria, favor bladder tumor related
Acute renal failure due to obstructive uropathy,
complicated with hyperkalemia and metabolic
acidosis
Normocystic anemia, favor maligancy related,
rule out renal failure related
Recent right precentral gyral infarct
Bilateral aspiration pneumonia
Discussion
Bladder cancer v.s Prostate cancer
Bladder cancer v.s Prostate cancer
Bladder cancer
Incidence 386000 cases/yr
Mean age 65 y/o
Risk factor aging, high fat diet,
family history, race
(blacks)
Prostate cancer
900000 cases/yr
70 y/o
smoking, pollution or
chemical exposures, race
(whites), aging, radiation
therapy, chronic bladder
inflammation, family history
Clinical
presentation
Most common
Bladder cancer
Common
Irritative voiding symptoms
back or hip dull pain
Less common
Obstructive voiding
symptoms
Hematuria (microscopic)
hamatospermia
sexual dysfunction , bone
pain,
Fatigue, weight loss,
anorexia, failure to thrive
Hematuria(initial sign in 80- Obstructive voiding
90%), flank pain, suprapubic symptoms
pain, perineal pain,
abdominal pain.
Advanced cancer
Poor prognosis
factors
Prostate cancer
Fatigue, weight loss,
anorexia, failure to thrive
* Obstructive voiding symptoms：urinary straining, intermittent stream
* Irritative voiding symptoms：daytime and/or nocturnal frequency, urgency,
dysuria, or urge incontinence
Bladder cancer
Distant
Lung, bone, liver
metastasis
Diagnostic Urinary cytology、
instrument ultrasonography、IVP、
cystoscopy、CT、MRI、
bone scan、PET
Treatment a. Surperficial (75%) –
Endoscopic resection
b. Local invasive (20%) –
Surgery, CCRT
c. Metastastic (5%)—C/T
Prognosis 5-year survival rate：
a.Surperficical –85%
b.Local invasive—60~75%
c.Metastastic –14~22%
Prostate cancer
bone
DRE、PSA、TRUS guided
biopsy、bone scan、bone
MRI、PET、circulating
prostate cancer cell
a. Localized –Surgery,
R/T, H/T
b. Advanced – Androgen
deprivation(surgical or
medical)、H/T、C/T
5-year survival rate：
a.Localized – 100%
b.Advanced – 31%
CASE 2: 889344
General Data
Age: 27-year-old
 Gender: male
 Ethnic: Taiwanese
 Marital status: Single
 Occupation: Student

Chief Complaint

Intermittent fever for 3 days
Present Illness

This 27-year-old male patient has history of
frequent hemoperitoneum since 4 years ago
and end stage renal disease under
continuous ambulatory peritoneal dialysis
for 19 years.

He was admitted to this hospital because of
intermittent fever up to 39 degree for 3 days.

He denied chills, productive cough, dyspnea,
chest pain, urinary frequency, micturation
burning sensation, arthralgia or insect bite
history.

According to the statement of the patient's
mother, he had experienced intermittent
nausea, vomiting with dark-green vomitus and
watery diarrhea since 2 years ago.

The frequency of nausea and vomiting
increased since 2 weeks before this admission.
Fever and epigastralgia developed since
2011/06/06. So, the patient was sent to 署立新
竹 hospital initially where tachycardia and
cloudy dialysate were also noted.

Due to above, the patient was transffered to
our ER for further management on 2011/06/08.
Past History
Gastroesophageal reflux disease has been
diagnosed in 2009
 Liver tumors has been found at age of 18
 Secondary hyperparathyroidism, status
post total parathyroidectomy on
2010/10/19

Personal History

Allergy: unknown inhalation medication
and contrast medium for CT

Alcohol (Denied)

Smoking (Denied)

Betelnut (Denied)
Medication history

Nephrologic OPD
- Calcium carbonate(500mg) 2# TID
- Esomeprazole (40mg)
1# QD
- Ferrous gluconate B (300mg) + Vit B1
(10mg) + Vit C (30mg)
1# BID
- Folic acid (5mg)
1# QW
- MPEG-Epoetin beta
1 amp QM
(100mg/0.3ml)
- Vitamin B complex
1# QD
- Calcitrol (0.25mcg)
2# QD
Admission history (I)

2001/03 – Acute tonsilitis

2005/04 – Acute gastroenteritis
2006/07 – Poor function of CAPD
catheter
 2006/10 – Acute gastroenteritis


2007/09 – Bloody dialysate, favor liver
adnemoa bleeding
Admission history (II)

2008/01 – Bloody dialysate, favor liver
adnemoa bleeding

2009/07 – Bloody dialysate, favor liver
adnemoa bleeding

2010/06 – Ileus, suspect post-operation
adhesion related

2010/10 – Hyperparathyroidism
Surgical history


CAPD catheter implantation in 1993
Inguinal hernia status post heniorrhaphy on
2004/07/06

Hickman insertion via right jugular vein on
2006/07/01

CAPD catheter outflow obstruction status
post exploratory laparotomy with clean the
pertoneal calcifications on 2006/07/10

Secondary hyperparathyroidism status post
total parathyroidectomy on 2010/10/19
Physical Examination

Vital signs：
BT 37.3℃ PR: 148/min, RR: 18/min,
BP: 105/85 mmHg
BH:151cm BW:38kg

General appearance: acute-ill looking

Consciousness: E4V5M6

HEENT: pale conjunctiva, anicteric sclera

dry oral mucosa

Chest: bilateral clear breathing sounds.

Heart: Regular heart beat, no audible murmur
Physical Examination

Abdomen: soft and flat. No rebounding pain
**Bowel sound: hyperactive
**Tenderness over epigastric area
**Tympanic percussion over whole abdomen

BACK: No knocking pain over bilateral CV angle

EXTREMITIES: Freely movable No pitting edema

SKIN: No petechiae nor ecchymosis
No skin rash
**decreased skin turgor
Laboratory Findings
Hemogram
unit
6/8
WBC
/uL
13500
RBC
million/uL
2.40
Hemoglobin
g/dL
8.7
Hematocrit
%
15.8
MCV
fL
75.1
MCH
pg/cell
24.9
MCHC
g/dL
32.3
RDW
%
20.9
Platelets
/uL
174k
Segment
%
64
Band
%
18
Lymphocyte
%
7
Monocyte
%
11
Eosinophil
%
0.1
Basophil
%
0.2
Laboratory Findings
Biochemistry
Unit
6/8
ABG
6/8
BUN
mg/dL
53.5
PH
7.434
Cr
mg/dL
13.80
PaCO2
36.9
Na
Meq/L
130
PaO2
42.2
K
Meq/L
2.7
HCO3
24.1
Cl
Meq/L
92
Sa%
79.7
Ca
Meq/L
8.1
P
Meq/L
4.3
ALT
U/L
5
Bil(T)
0.7
CRP
106.87
Albumin
2.49
Alk-P
78
Lipase
U/L
18
Laboratory Findings
Ascites
2011/6/08
2011/06/13 2011/07/21
Color
Cloudy
Cloudy
Turbid
Turbidity
Yellow
Colorless
Yellow
Sp. Gravity
1.008
1.010
1.001
Protein
Positive
Negative
Positive
WBC
6095
4125
17875
RBC
1275
5
875
100
98
92
Lymphocyte
0
2
8
Macrophage
Few
Few
Few
GNB
2+
-
Neutrophil
Kleb.
Pneumoniae
06/08 CXR
06/08 KUB
06/13 Abdominal echo
-Normal liver size
-Heterogeneous
parenchyma, even
liver surface and
obscure vasculature
Two hyperechoic liver tumors 2.72 & 2.5 cm
at S4
 Parenchymal liver disease, score 6
 Bil. pleural effusion and ascites

Admission course
06/08~06/08 ER
S/S: Fever, nausea/vomiting, epigastralgia,
cloudy dialysate
=> Vancomycin (IP) + Fortum (IP)  8D (06/08)
06/08~06/14 8D ward
06/13 S/S: Recurrent fever, shock
vomited with massive coffee ground,
dyspnea, cloudy dialysate
Fluid supply, Give PPI, Intubation
Remove CAPD catherter  GS ICU (06/14)
Vancomycin (IV) + Fortum (IV)
Shift CAPD to H/D since 06/15
06/14~06/23 GS ICU
S/S: Fever, productive cough, coffee ground
Keep Vancomycin (IV) + Fortum (IV) for
aspiration pneumonia
06/18 PES：esophageal ulcer and superficial
gastritis
06/21 CT： peritoneal calcifications, ascites,
liver tumor over S4
06/23 Extubation  8D ward (06/23)
06/23~06/24 8D ward
06/24 S/S：Recurrent fever, chills, tachypnea,
tachycardia, chest discomfort, dyspnea
Impending hypoxia respiratory failure
Intubation + Dopamine  GS ICU (06/24)
06/24~07/08 GS ICU
 IV form antibiotics：Fortum + Teicoplanin +
Meropenam + Fluconazole
 06/27 S/S：hematemesis
 PRBC transffusion, PPI, DDAVP
 06/27 Nasophrayngoscope：

No nasal nor oral bleeding
 07/01 Panendoscope：
Esophageal ulcers, gastric polyp
=> 07/05 Extubation  8D ward (07/08)
07/08~ 8D ward
=> S/S：intermittent fever, fair digestion function,
no nausea nor vomiting, cloudy dialysate
IV form antibiotics：Teicoplanin + Meropenam
+ Fluconazole
Diagnosis
Refractory CAPD peritonitis status post PD
tube removal on 6/14 , disease progression
with moderate amount of cloudy ascites
under pigtail tube drainage since 6/21
 End stage renal disease under H/D QW135
via right neck Hickmann
 UGI bleeding, favor esophageal ulcer related
 Right side aspiration penumonia
 Liver nodules, suspect hemangioma
 Diffuse peritoneal calcification, favor CAPD
peritonitis related, rule out prior
hemoperitoneum related

Discussion

What is the etiology of the peritoneal
calcification?
Peritoneal calcification：Causes
and Distinguishing Features on CT
American Journal of Roentgenology:182, Feb 2004
Introduction

The etiology of peritoneal calcification：
1. Peritoneal malignancies
2. Sclerosing peritonitis due to peritoneal
dialysis
3. Peritoneal tuberculosis
4. Prior meconium peritonitis
5. Hyperparathyroidism
6. Pneumocystis carinii infection
7. Postsurgical heterotopic ossification
American Journal of Roentgenology.:182, February 2004
Materials and Methods
Retrospective review of reports from
74765 abdominopelvic CT examinations
perfromied during a 7-year period.
 Examining medical and histopathologic
records
 Calcification morphology was classified as
nodal, nodular or sheetlike on the
consensus interpretation by 2
independent radiologists.
 Chi-square analysis

Result
—84-year-old woman with serous ovarian adenocarcinoma.
Nodular calcification
Agarwal A et al. AJR 2004;182:441-445
©2004 by American Roentgen Ray Society
—84-year-old woman with serous ovarian adenocarcinoma.
Nodal calcification
Agarwal A et al. AJR 2004;182:441-445
©2004 by American Roentgen Ray Society
—30-year-old woman who was undergoing continuous
ambulatory peritoneal dialysis.
Sheetlike calcification
Agarwal A et al. AJR 2004;182:441-445
©2004 by American Roentgen Ray Society
—30-year-old woman who was undergoing continuous
ambulatory peritoneal dialysis.
Sheetlike calcification
Agarwal A et al. AJR 2004;182:441-445
©2004 by American Roentgen Ray Society
—46-year-old woman with ovarian papillary serous
adenocarcinoma.
Nodular calcification
Agarwal A et al. AJR 2004;182:441-445
©2004 by American Roentgen Ray Society
Conclusion

The common causes of peritoneal calcification：
- Benign causes –
1. Peritoneal dialysis related (N=4)
2. Prior peritonitis (N=3)
3. Cryptogenic origin (N=1)
- Malignant cause –
1. Ovarian carcinoma (N=9)

Sheet-like calcification was more common in
benign cause; nodal calcification and calcified
lymph nodes were seen only in malignant cause.
American Journal of Roentgenology.:182, February 2004
THE END