Dr. Pepe’s Diploma Casebook: Case 10 – SOLVED!

Dear Friends,

This week’s case is an 85-year-old man with weight loss. Would you call this study normal?

Fig. 1: 85-year-old man with weight loss

Click here for the answer

Be Sociable, Share!

    25 Responses to : Dr. Pepe’s Diploma Casebook: Case 10 – SOLVED!

    1. Ricardo Macareno says:

      It identifies a thoracic aortic elongation senile degenerative spine changes with previous marginal osteophytes and vertebral body wedging dorsal anterior low.
      A striking arrangement of abundant bowel below the left diaphragm, that given the patient’s clinical context, it would be advisable to continue the study with abdominal ultrasound.

    2. Kelvin says:

      An abdominal ultrasound is of no use in evaluating bowel.


      1. Gas under the diaphragm, especially on the left and extending medially.
      2. Wedging of T10 – looks like an oldstanding osteoporotic collapse…posterior elements preserved.
      3. A possible (cavitating) lesion in the lower retrosternal space…must measure around 3-4 cm

      Cardiothoracic ratio borderline, thoracic aorta might be at the upper limit of normal…

      The diagnosis we need to exclude here is a gastric/colo-rectal NG … might have perforated (ie T4 by definition) and have spread (? cavitating pulmonary deposit).

      I would recommend CT and gastro-colono-scopy.

    3. Burak says:

      There is a free air in the below of the left diapragm.suggesting that an abdominal perforation.also there Might be a deep sulcus sign. Pneumomediastinum.?

    4. Burak says:

      During oral part of the examination How would we should answer the questions? Say all the findings ?

      • Dr: Pepe says:

        When the examiner presents a case you should describe the findings and make a differential diagnosis. You can suggest any additional examination which will clarify the diagnosis.

    5. Alessandro says:

      Crushing T10

    6. reem says:

      thoracic aortic elongation and widening

    7. Genchi Bari Italia says:

      ” Troppo” bella la silhouette cardiovascolare in LL, perchè delineata da aria “libera” nel mediastino:pneumo-mediastino.A ciò si aggiunge sottile falda di aria libero in addome:pn-peritoneo, con anomala morfologia del contenuto intestinale in sede sottodiaframmatica sx. La “fisiologica” comunicazione tra lo spazio retroperitoneale ed il mediastino, suggerisce che la patologia è a livello colico distale.Un clisma opaco con mdc iodato idrosolubile( Gastrographin diluito) può chiarire la patologia di base.

      • Kelvin says:

        Siccome la TC è un esame diagnostico di natura molto più informativa, perché non fare TC in prima istanza invece della clisma opaca? Entrambi coinvolgono raggi X, ma la TC ci da più informazione, e può servire come esame di stadiazione se la causa del pneumo-peritoneo fossi una K colon perforata.

    8. DrD says:

      1.Emphysema pulmonum.Bronchitis chronica.Cardiomegalia,Fractura Th-9 consolidata.Spondyloarthrosis deformans.Chilaiditi’s syndrom.

    9. Rahul says:

      Mottled and curvilinear lucencies in the region of the splenic flexure are concerning for large bowel pneumatosis. Additionally there appears to be gas under the left hemidiaphragm. Correlation with the patients serum lactate as well as a CT abdomen with a CT angiogram to evaluate the mesenteric vasculature is warranted to exclude ischaemic colitis.

    10. Agata Malkiewicz says:

      I agree with all these chest findings.
      Additionally there are signs of bowel pneumatosis or/and free air below diafragm.

    11. Angelis Barlampas says:

      There are air filled bowel loops under the left hypohondrium.
      It seems that there is free abdominal air under the left hemidiaphragm.
      There is a small cavitating lesion at about the medial segment of medial lobe.
      We can see anterior wedging of a lower thoracic vertebra, with height loss, (there is no clear evidence of bone reaction, it could possibly be an osteoporotic fracture)
      Possible diagnosis: intestinal tumor , with bowel perforation and cavitating pulmonary metastase. Pathologic or osteoporotic vertebral fracture.
      Farther investigation needs to be taken, like bone scintigram, thoracic and abdominal CT, bood tests for cancer markers, etc.

    12. Katerina says:

      1. Free air under the left diaphragm
      2. Distended splenic flexure with pneumatosis
      3. Pneumomediastinum
      4. Air (free?) on the left of the trachea just above the aortic arch

      Possible cause: bowel perforation (probably colon), ischaemic colitis, previous colonoscopy
      Suggested exams: CT

      Other findings:
      5. Pulmonary emphysema
      6. Increased anterior-posterior diameter of the trachea (tracheobronchomegaly?)
      7. Wedging fracture (probably old) of TH10
      8. Increased diameter of thoracic aorta
      9. Cardiomegaly

    13. Sumat says:

      Cystic lesions bilateral hila
      Anterior wedging of one of dorsal vertebra
      Free air abdomen
      In context of history of wt loss possibility of mitotic aetiology cannot be ruled out
      Adv ct thorax and abdomen

    14. Xose says:

      Left colonic pneumatosis, pneumoperitoneum, pneumomediastinum, weight loss, all these suggest a probable obstructing colon carcinoma.
      Beside, I can see some small lung nodules, metastatic ?

    15. Burak says:

      There should be more MSK , head and neck,Cardiovascular imaging Cases.

    16. Manolis says:

      Free subdiafragmatic air, pneymoperitoneo. Body thoracic vertebrae fracture.