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EXAM US2 2014 1

Pertinent Findings:

  • Hypoechoic rounded mass-like region in the head of the spleen with multifocal hyperechoic “speckled” linear echodensities that cause shadowing and reverberation artifacts consistent with air in the splenic vasculature or parenchyma (or both).  Fairly sharp demarcation between normal and abnormal splenic tissue however blood flow was detected with color flow Doppler in the abnormal region of the spleen.
  • Possible focal splenic vein thrombosis in a splenic vessel at the caudal aspect of the abnormal region of the spleen.
  • Hyperechoic fat and mesentery in particular near the spleen and mid abdomen.
  • Scant free air in the peritoneal space.
  • Mild amount of free fluid in the peritoneal space with hyperechoic particles.
  • Two small hypoechoic nodular structures that may be enlarged regional lymph nodes or enlarged node and a focal hypoechoic region in the left limb or body of the pancreas

Synthesis:

  • Splenic abscess or necrosis and suspected sepsis.  Possible focal infarct although there was blood flow and the area was not completely devoid of flow and not consistent with a complete infarction. A neoplastic process was considered less likely because of the recent exploratory surgery and the assumption that the spleen would have been inspected at that time.
  • Free air most likely secondary to the recent laparoscopy and the amount not considered excessive for this stage postoperatively.  The specific surgery pertaining to the foreign body was not given but it was considered much less likely that the free air was secondary to a dehiscence at the previous surgical site due to the duration of time that had passed since surgery.
  • Free fluid in the peritoneal space with consideration given to suppurative or non-suppurative peritonitis.  Concern was for septic peritonitis.
  • Enlarged nodes with the top differential reactive nodes.  Neoplastic nodes unlikely.
  • Possible pancreatitis.

Appropriate recommendations included: thoracic radiographs to evaluate for aspiration pneumonia (or other pulmonary pathology), fine-needle aspirates of the spleen and a sample of the free fluid including cytological analysis and culture and sensitivity.  Abdominal exploratory surgery and splenectomy was also recommended.

Overall candidates did well on the case and made the appropriate recommendations.  Points were lost if the gas in the spleen was overlooked or misidentified.  Candidates listing a complete splenic torsion as their primary differential also lost points.