Chitra Chandrasekhar

US and CT Evaluation of Acute Pelvic Pain of Gynecologic Origin in Nonpregnant Premenopausal Patients

The interpretation of imaging findings in the premenopausal patient with acute pelvic pain is influenced by knowledge of the physiologic changes that occur in the pelvis as well as by the patients clinical history. Although ultrasonography (US) is the modality of choice for initial imaging, gynecologic disease is detected or suspected with increasing frequency at computed tomography (CT) because of the increasing availability and use of this modality. As a result, the recognition of common features of gynecologic entities on both US and CT images is essential for prompt diagnosis and expeditious management. Categorizing lesions according to their anatomic location, physiologic or pathologic origin, and internal characteristics (cystic, solid, or mixed) allows efficient and accurate diagnosis.

Emergent Right Upper Quadrant Sonography

Objective. The purpose of this presentation is to review the sonographic spectrum of disease entities evaluated by right upper quadrant (RUQ) sonography on an emergent basis. Methods. Right upper quadrant sonography was performed on an emergent basis in patients who came to the emergency department with signs and symptoms suspicious for or simulating acute cholecystitis or diseases of the liver and biliary tree. Results. A wide gamut of acute and chronic cholecystitis and diseases of the liver and biliary tree were visualized on RUQ sonography. Several other entities in addition to hepatic and biliary disease were also suspected on sonography and further evaluated by computed tomography. Conclusions. Right upper quadrant sonography is the first line of imaging in patients with signs and symptoms of hepatic, gallbladder, or biliary disease as well as RUQ pain. Patient triage or additional imaging may be obtained on the basis of emergent RUQ sonographic findings.

Ectopic pregnancy: a pictorial review

Ultrasound has remained the primary modality for investigating the pelvis of women in the reproductive age group, especially in an emergency setting. Recognition of different sonographic presentations, including typical and atypical findings of ectopic pregnancy, is important to determine surgical or nonsurgical management. This pictorial review article will exemplify different sonographic presentations of ectopic pregnancy.

Pathology of the Urinary System and the Male Genital Tract

The genitourinary system consists of the two kidneys, two ureters, urinary bladder, and male and female genital organs. This chapter covers the urinary system and the male genital tract.

Referral to physical therapy of a previously undiagnosed ankle metastatic lesion.

A 59-year-old woman was referred to physical therapy with a 5-month history of progressive worsening ankle pain after a twisting injury sustained while walking in her home. The previous diagnostic assessment by her primary care physician and podiatrist included radiographs that were formally reported as showing degenerative changes and evidence of old bimalleolar fractures (Figure 1). The patient was subsequently referred to physical therapy for conservative management. At evaluation, she reported worsening of diffuse ankle pain, redness, and swelling since the initial injury. In addition, she reported a significant history of a prior ankle fracture (23 years earlier) and a 30-pack-year history of smoking. At initial physical therapy evaluation, she presented with a warm, edematous ankle, and decreased global range of motion. The initial treatment included joint mobilizations to decrease pain, a rolling walker to decrease weight bearing, and a compression garment to reduce swelling. A home exercise program that consisted of active range of motion exercises to improve talocrural and subtalar motion was provided. Upon her follow-up physical therapy visit 3 days later, the patient reported 50% reduction in pain and improved ankle mobility. The patient returned to the physical therapy clinic 1 week later with worsening pain with weight bearing, along with increased swelling and redness. Because of this recent increase in symptoms with conservative treatment and continued pain after a seemingly trivial injury, the physical therapist was concerned about the patient’s clinical course and referred the patient back to her physician for further diagnostic imaging. Repeat radiographs performed approximately 7 months after her initial workup revealed progressive destruction of the distal tibia and fibula as well as marked soft tissue swelling (Figure 2). Retrospectively, an independent review of the original radiograph revealed an ill-defined lucency of the distal tibia and fibula (Figure 1). Magnetic resonance imaging revealed a 9-cm enhancing focus that involved the ankle and foot, most concerning for either metastatic deposit or primary bone neoplasm (Figure 3). A needle biopsy of the ankle confirmed the presence of histopathologic changes consistent with an adenosquamous tumor. An additional workup denoted a primary nonesmall-cell lung cancer with metastases to the brain and liver. Multiple treatments, including radiation and chemotherapy, ultimately failed. The patient died 9 months after her initial cancer diagnosis. Nonesmall-cell lung cancer comprises 80%-85% of all lung cancers [1]. Patients with nonesmall-cell lung cancer frequently have osseous metastasis, with the foot (acrometastases) being 1 of the rarest sites (0.03%-2%) [2,3]. The most common osseous sites for metastasis include the vertebrae (76%), pelvis (68%), femur and/or hip (41%), and the base of the skull (46%) [4].

Pathology of the Breast and Female Genital Tract

This chapter presents various diseases of the female sex organs, including the vulva, vagina, uterus and adnexa (ovary and salpinges), placenta, and breast. Discussed are common diseases, including congenital abnormalities, infection and inflammation, diseases related to endocrine disorders and to pregnancy, and both benign and malignant tumors.

Pathology of the Gastrointestinal Tract

This chapter presents representative photographs of common diseases in the esophagus, stomach, small and large intestines, appendix, and rectum. Most of the diseases discussed here are infectious or neoplastic; a few others appear that students should be able to identify. A few microscopic photographs are added to support the understanding of gross lesions.

Pathology of the Liver, Biliary System, and Exocrine Pancreas

The liver is the largest solid visceral organ in the body and the most important “chemical factory,” with functions that cannot be replaced by any artificial means. Functions of the liver can essentially be divided into three major groups: synthetic, metabolic, and exocrine. The liver is the key organ in the metabolism of nutrients (glycogens, proteins, fats) and of exogenous chemical materials (drugs, toxins). It has enormous compensatory capacity and regenerative ability. Damage to the liver may not be detected until the late stage, and it is practically impossible for the anatomic pathologist to state exactly how much of the liver parenchyma must be destroyed before liver failure occurs. Massive destruction of the liver parenchyma or severe disorganization of its normal architecture may ultimately lead to hepatic failure. In fulminant liver failure, liver transplantation is by far the only rescue.