No abstract

Intussusception of the gastrointestinal viscera is rarely encountered in adult patients and is frequently associated with a polypoidal lead point, which is often malignant. We would like to present the case of a 68-year-old male with a history of decompensated liver disease and multiple medical comorbidities, who was discovered to have an incidental gastrogastric intussusception on CT. No polypoidal lead point was seen and we believe this to be the first case of its kind to be described. We suggest that distortions in the patient’s visceral and vascular anatomy and raised intra-abdominal pressure resulting from concomitant ascites, hiatus hernia, portal hypertension and oesophageal varices have provided an alternative mechanism for a gastrogastric intussusception to develop.

Objectives: Computed tomography scans of the kidney, ureters, and bladder (CT-KUB) are crucial in investigating urinary calculi but impart a substantial radiation doses. Radiation can be limited by minimising the scanning field to the necessary area (i.e. from the kidneys to urethra). Before auditing, the superior limit of CT-KUB scans had not been formally clarified at our trust. Consistently ensuring the upper limit of scans is at or below T10 has been shown to be a viable method of performing CT-KUB scans. This study aimed to assess the overscan length of CT-KUB investigations and modify practice accordingly to minimise it. There were two standards that were set for CT-KUB scanning. First, the mean percentage overscan length (i.e. percentage of the scan above the kidneys) should be <15%. Second, all scans should include the superior borders of both kidneys. Methods: 90 consecutive CT-KUB scans for ureteric calculus were retrospectively investigated using IMPAX software in the first phase of data collection. After these data were analysed, a newly devised protocol using T11 as the superior scan limit was delivered to radiographers in the department. and 105 in the second phase (re-audit). The analysis parameters were: percentage overscan length, distance between diaphragm and upper border of kidneys, vertebral level at which the scan commenced, and whether both kidneys were fully included. Results: In the first phase, overscan of >15% was present in 94.4% of scans. The mean percentage overscan length was 28.2%. The superior vertebral limit of 59% of scans was at T10 or below and a lower superior vertebral limit correlated with decreasing overscan. 99% of scans fully included both kidneys. In the second phase (3 months later), the mean overscan percentage reduced to 10.6% (standard deviation = 4.4%). Excessive overscan affected 35.2% of scans. The superior vertebral limit of 8% of scans was at T10 or below. 100% of scans fully included both kidneys. Conclusion: Excessive overscanning was due to inconsistent technique in capturing CT-KUB scans. Before this audit, the superior limit of CT-KUB scans had not been formally clarified at our trust. By successfully standardising the process with a reproducible method, the overscan target was comfortably met. Therefore, patient dose was minimised without compromising scan quality. Advances in knowledge: This audit has successfully shown a feasible standardised protocol for CT-KUB investigations which can be used to minimise overscanning of patients.

images in clinical medicineT h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 366;1 nejm.org january 5, 2012 74A 40-year-old woman with asthma presented with a 2-day history of pleuritic pain of acute onset in the right side of the chest. She had been coughing markedly for 2 weeks and was treated in the community with antibiotics for a lower respiratory tract infection. There was no history of trauma. Her medical history also included hypertension, depression, and osteoporosis. On presentation, physical examination revealed crepitus along the right midaxillary line. A posteroanterior chest radiograph showed subcutaneous emphysema over the right lateral thoracic wall (Panel A, arrows). Subsequent computed tomographic imaging (Panel B, coronal reformat; Panel C, axial reconstruction) showed subcutaneous emphysema (arrows) and a focal intercostal muscle defect in the ninth intercostal space (asterisks), with lung and pleural herniation. She underwent right posterolateral thoracotomy at the ninth intercostal space for repair of the intercostal hernia and an associated diaphragmatic tear. There was no evidence of recurrent hernia at her 3-month follow-up visit.