Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
November 2016 Imaging Case of the Month
Michael B. Gotway, MD
Department of Radiology
Mayo Clinic Arizona
Scottsdale, Arizona USA
Imaging Case of the Month CME Information
Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.
0.25 AMA PRA Category 1 Credit(s)™
Estimated time to complete this activity: 0.25 hours
Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.
Learning Objectives:
As a result of this activity I will be better able to:
- Correctly interpret and identify clinical practices supported by the highest quality available evidence.
- Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
- Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
- Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.
Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.
CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.
Current Approval Period: January 1, 2015-December 31, 2016
Clinical History: A 38-year-old man presented to his primary care physician with complaints of pruritus, jaundice, and poor appetite. The patient had been diagnosed with hypertension one year earlier and was treated with hydrochlorothiazide and an angiotensin-converting enzyme inhibitor, but evidently did not tolerate the regimen well, and developed “tea-colored” urine following initiation of this therapy. He was also recently diagnosed with diabetes mellitus and also complained of intermittent right upper quadrant pain.
Laboratory data, including white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 99%.
Frontal and lateral chest radiographs (Figure 1) were performed.
Figure 1. Frontal (A) and lateral (B) chest radiography.
Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven pages)
Cite as: Gotway MB. November 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(5):207-15. doi: http://dx.doi.org/10.13175/swjpcc112-16 PDF
Medical Image of the Week: Chilaiditi Syndrome
Figure 1. An X-ray of the chest showing a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (arrow).
Figure 2. CT scan of the chest showing gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (arrow).
X-ray evidence of air under right hemi-diaphragm in proper clinical context is almost a definitive sign of gastrointestinal tract perforation except in an extremely rare clinical entity called "Chilaiditi Syndrome". We present this unique image and clinical scenario to expand on physician`s knowledge to identify this rare clinical syndrome and to help distinguish it from a dreaded condition like gastrointestinal perforation.
An 81-year-old man with multiple co-morbidities was admitted to the intensive care unit with a diagnosis of acute hypoxic respiratory failure. An X-ray of the chest showed a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (Figure 1). Due to radiological concern of gastrointestinal perforation, an emergent CT scan was performed to rule out perforation. CT scan revealed gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (Figure 2). The patient had no gastro-intestinal tract symptoms and no pathological signs were specifically identified on clinical examination; a diagnosis of the Chilaiditi Syndrome was made. Chilaiditi Syndrome occurs due to interposition of a loop of large intestine in between the liver and the diaphragm. The incidence of Chilaiditi Syndrome is 0.025 to 0.28% and occurs because of congenital anatomical variations of falciform ligament (1). It can also be due to functional abnormalities such as constipation, aerophagia, cirrhosis, paralysis of the diaphragm, chronic lung disease which can cause enlargement of the lower thoracic cavity, obesity, and processes which increase intra-abdominal pressure (1,2). Initial management includes conservative therapy - Bed rest, intravenous fluid hydration, and bowel decompression. Surgical options can be considered (3).
Priyanka Makkar, M.D.1, Rishabh Mishra, M.D.1, and Shivanck Upadhyay, M.D.2
1Internal Medicine department, St. Barnabas Hospital, Bronx, New York
2Department of Pulmonary Critical Care Medicine, St. Barnabas Hospital, Bronx, New York
References
- Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg. 2008 Jan;143(1):93-4. [CrossRef] [PubMed]
- Fisher AA, Davis MW. An elderly man with chest pain, shortness of breath, and constipation. Postgrad Med J. 2003 Mar;79(929):180, 183-4. [CrossRef] [PubMed]
- Blevins WA, Cafasso DE, Fernandez M, Edwards MJ.Minimally invasive colopexy for pediatric Chilaiditi syndrome. J Pediatr Surg. 2011 Mar;46(3):e33-5. [CrossRef] [PubMed]
Cite as: Makkar P, Mishra R, Upadhyay S. Medical image of the week: Chilaiditi syndrome. Southwest J Pulm Crit Care. 2016;13(4):179-80. doi: http://dx.doi.org/10.13175/swjpcc077-16 PDF