Manfred Spanger

Implementation of a clinical prediction tool for pulmonary embolism diagnosis in a tertiary teaching hospital reduces the number of computed tomography pulmonary angiograms performed.

To evaluate the effect of implementing the Wells score clinical prediction tool (CPT) on rationalising the use of computed tomography pulmonary angiography (CTPA) for diagnosing pulmonary embolism (PE).

Gastrointestinal: Pulmonary embolism of cyanoacrylate glue following endoscopic injection of gastric varices

A 44-year-old female presented with hematemesis on a background of Child-Pugh C cirrhosis secondary to alcoholic liver disease. She had a past history of esophageal variceal hemorrhage 8 years previously and continued to drink alcohol up until this latest presentation. On admission, she was hemodynamically stable with mild ascites. Gastroscopy showed barely visible lower esophageal varices and large fundal gastric varices (GVs). These were treated with 2 injections (2 ml each) of cyanoacrylate glue and Lipiodol injection. One day following endoscopy, the patient became febrile, hypoxic, tachypnoeic, hypotensive and anaemic. Computerized tomography pulmonary angiogram revealed bilateral pulmonary glue emboli and a left basal pulmonary infarct (Figures 1 & 2). There was hematological evidence of disseminated intravascular coagulation secondary to glue emboli with resultant coagulopathy and a left abdominal wall haematoma with generalized bruising in the upper limbs. The patient was resuscitated with large volumes of blood products to correct coagulopathy. She made a gradual improvement following medical management and was discharged to a rehabilitation unit 18 days later. The patient was reviewed in outpatient clinic 6 weeks later and was constitutionally well, with no evidence of hypoxia and has remained well since. Cyanoacrylate injection is widely used for treatment of gastric variceal bleeding since its first introduction in 1987. Complications of Cyanoacrylate injection include sepsis, embolisation, esophageal perforation, and splenic infarction with case reports of coronary emboli, cerebral stroke, and portal vein embolization. Both fatal and nonfatal pulmonary embolism (PE) from glue injection has been reported. Studies investigating risk factor for embolisation from glue injection are lacking. Retrospective and prospective studies indicate that greater volumes of injection predict risk of embolisation. Six out of 140 patients (4.3%) who developed PE were given a mean volume of > 4.2 ml compared to 1.8 ml for those without PE. Alexandar et al. reported volume and speed of injection and the size of gastric varices as risk factors for embolisation. Patients with isolated gastric varices may have spontaneous gastrorenal shunts that predispose them to PE and so may not be good candidates for glue injection. A retrospective study analyzing complications arising in 51 of 753 patients treated with cyanoacrylate injection showed favorable outcomes when using less volume of lipiodol, however, mortality was not reported following embolism. Seewald et al. also supported evidence for a safe injection technique with volume of injected glue mixture limited to 1 ml for each session to prevent embolic complication.

Large vessel calcification in Takayasu arteritis

We report the novel case of a young woman with Takayasu arteritis, with extensive large vessel disease. The case demonstrates that while mechanisms of vascular calcification are poorly understood, inflammation per se might be sufficient to mediate increased mineral stress leading to vessel calcification, even in the absence of renal impairment.

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah’s Witness undergoing left hepatectomy

Highlights • Liver resection in a Jehovah’s Witness patient requires multimodal blood minimization strategies to improve patient centred outcomes.• Combination portal vein embolization and hepatic lobe revascularization for total vascular inflow occlusion can allow a bloodless resection.• Preoperative angio-embolization should be researched in a larger patient cohort to reduce blood loss and blood transfusion

Postoperative wristwatch-induced compressive neuropathy of the hand: a case report

IntroductionPostoperative peripheral nerve injuries are well-recognised complications of both surgery and anaesthesia and a leading cause of litigation claims. We present a rare cause of compressive sensory and motor neuropraxia of the median, ulnar and radial nerves of the right hand resulting from a wristwatch that was worn on the first postoperative night following minor surgery. Mechanisms of this compressive neuropathy are discussed, with specific recommendations made regarding the wearing of wristwatches, jewellery and constrictive clothing in the immediate postoperative period.Case presentationA 12-year-old white boy presented with a complete glove and stocking sensory and motor neuropathy involving his right hand from a wristwatch that was worn on the first postoperative night following uneventful surgery for a minor procedure. Over the following 12 hours the oedema and erythema resolved with complete return of motor function. After 18 hours, the sensory deficit completely resolved.ConclusionsPostoperative neuropraxia is often preventable. Paediatric patients, especially if thin, may be particularly susceptible to a compression neuropathy from constrictive clothing or jewellery, in particular circumferential varieties such as wristwatches. These items should not be worn in the immediate postoperative period as pressure on peripheral nerves can result in severe and debilitating nerve injury. Education should be given to all medical staff, carers or parents of children undergoing surgery on the avoidance of wearing wristwatches, jewellery or constrictive clothing in the immediate postoperative period. Early medical evaluation of any postoperative nerve injury is of paramount importance.

Hepatobiliary and Pancreatic: Emphysematous gastritis with hepatic portal venous gas

A woman, aged 41 years, was admitted to hospital with acute epigastric pain and abdominal distension. She was known to have ischemic heart disease, hypertension, hyperlipidemia and diabetes and had been previously diagnosed with a sliding hiatus hernia. Her medication at the time of admission included pantoprazole, rosuvastatin, ramipril, metformin and aspirin. On physical examination, there was moderate tenderness on palpation in the epigastrium. Blood tests revealed an elevated white cell count (15.6 ¥ 10/L) with a neutrophilia but other blood tests including an amylase and lipase were within the reference range. A plain abdominal radiograph showed a distended stomach while a computed tomography (CT) scan showed gas within the branches of hepatic portal vein (arrows) and gas in the posterior wall of the stomach (arrows) consistent with emphysematous gastritis (Figure 1). At upper gastrointestinal endoscopy, there was a welldemarcated area of erosive gastritis on the posterior wall of the body of the stomach (Figure 2). She was treated with intravenous fluids and an intravenous proton pump inhibitor and this was followed by a relatively rapid improvement in her symptoms. A repeat CT scan after 1 week showed resolution of hepatic portal venous gas and repeat endoscopy after 3 weeks showed almost complete resolution of gastritis. Emphysematous gastritis is a rare disease characterized by the presence of gas in the wall of the stomach, usually shown on a CT scan. Bacteria associated with emphysematous gastritis have included Clostridium welchii, Streptococcal species, Escherichia coli, Enterobacter species and Staphylococcus aureus. Common predisposing factors include the ingestion of corrosive substances, alcohol abuse, abdominal surgery, diabetes and immunosuppression. Some of these patients have gas in hepatic portal veins. This is usually most prominent near the periphery of the liver in contrast to air in the bile ducts (pneumobilia) that is usually more prominent in and around the hilum of the liver. Because of presumed gastric infection, most patients are treated with broad-spectrum antibiotics. Early complications include gastric perforation and some patients have been treated with gastric surgery. Mortality rates as assessed by case reports appear to be at least 50%. In the above patient, gastritis was restricted to a segment of the stomach and the patient made a spontaneous and apparently complete recovery.

Transjugular biopsy case report of inferior vena cava hepatocellular carcinoma with intracardiac extension

Highlights • Transjugular biopsy of IVC or right sided cardiac masses can be safely performed without sedation or anaesthesia.• Transjugular biopsy of right atrial lesions may serve as a minimally invasive technique for definitive tissue diagnosis.• Multidisciplinary management is paramount for patients with advanced cirrhosis to prevent morbidity and mortality.

Gallbladder perforation following transarterial chemoembolisation; a rare but serious complication

Transarterial chemoembolisation (TACE) is the mainstay of treatment for large or multifocal hepatocellular carcinoma (HCC). However, this procedure is not without potential complications. We report the case of a 72-year-old man with cirrhosis with HCC treated by TACE using drug-eluting beads. He developed persistent fever and severe right upper quadrant pain post-procedure. CT abdomen revealed a large fluid collection closely abutting the gallbladder and tracking inferiorly along the right flank. This fluid collection originated from the gallbladder and contained locules of gas with a contrast-enhancing wall, consistent with an infected biloma. These imaging findings confirmed gallbladder perforation complicating TACE. The development of gallbladder perforation post-TACE from acute ischaemic cholecystitis producing gallbladder wall necrosis is exceedingly rare. The presence of gallbladder perforation must be recognised in patients with persisting symptoms and imaging evidence of a perihepatic fluid collection because specific treatment with intravenous antibiotics and percutaneous drainage of the biloma is necessary.

Education and imaging. Hepatobiliary and pancreatic: Emphysematous gastritis with hepatic portal venous gas.

A woman, aged 41 years, was admitted to hospital with acute epigastric pain and abdominal distension. She was known to have ischemic heart disease, hypertension, hyperlipidemia and diabetes and had been previously diagnosed with a sliding hiatus hernia. Her medication at the time of admission included pantoprazole, rosuvastatin, ramipril, metformin and aspirin. On physical examination, there was moderate tenderness on palpation in the epigastrium. Blood tests revealed an elevated white cell count (15.6 ¥ 10/L) with a neutrophilia but other blood tests including an amylase and lipase were within the reference range. A plain abdominal radiograph showed a distended stomach while a computed tomography (CT) scan showed gas within the branches of hepatic portal vein (arrows) and gas in the posterior wall of the stomach (arrows) consistent with emphysematous gastritis (Figure 1). At upper gastrointestinal endoscopy, there was a welldemarcated area of erosive gastritis on the posterior wall of the body of the stomach (Figure 2). She was treated with intravenous fluids and an intravenous proton pump inhibitor and this was followed by a relatively rapid improvement in her symptoms. A repeat CT scan after 1 week showed resolution of hepatic portal venous gas and repeat endoscopy after 3 weeks showed almost complete resolution of gastritis. Emphysematous gastritis is a rare disease characterized by the presence of gas in the wall of the stomach, usually shown on a CT scan. Bacteria associated with emphysematous gastritis have included Clostridium welchii, Streptococcal species, Escherichia coli, Enterobacter species and Staphylococcus aureus. Common predisposing factors include the ingestion of corrosive substances, alcohol abuse, abdominal surgery, diabetes and immunosuppression. Some of these patients have gas in hepatic portal veins. This is usually most prominent near the periphery of the liver in contrast to air in the bile ducts (pneumobilia) that is usually more prominent in and around the hilum of the liver. Because of presumed gastric infection, most patients are treated with broad-spectrum antibiotics. Early complications include gastric perforation and some patients have been treated with gastric surgery. Mortality rates as assessed by case reports appear to be at least 50%. In the above patient, gastritis was restricted to a segment of the stomach and the patient made a spontaneous and apparently complete recovery.

Low accuracy and confidence in chest radiograph interpretation amongst junior doctors and medical students: Brief Communications

Accurate chest X‐ray (CXR) interpretation is an essential skill in clinical practice. Previous studies have shown poor accuracy and confidence rates (CR) of CXR interpretation by junior doctors and medical students. We presented 10 chest radiographs via an online questionnaire to Australian medical students and junior doctors, who were asked to identify the radiographic abnormality from a list of 15 options and to rate their confidence for each answer. Of 67 complete responses, junior doctors achieved a mean score of 57.6% and medical students 56.1%, with CR of 67 versus 58% respectively. There was a significant positive relationship between accuracy and CR among junior doctors (Pearsons coefficient + 0.798, P = 0.006) and students (Pearsons coefficient + 0.716, P = 0.020). This study identified similarities in strength and weakness in CXR interpretation between medical students and junior doctors. There was a positive association between test scores and self‐rated confidence scores.