Findings and interpretation:

• There is a large para-esophageal hiatus hernia which contains a part of the stomach.
• The part of the stomach which is herniated in the chest is the distal body and antrum, with the greater curvature oriented superiorly. This part of the stomach is distended with an air-fluid level within, indicating obstruction.
• There is an antro-pyloric transition point where the stomach is collapsed.

Pertinent negative findings:

• There is no evidence of gastric ischemia.

The findings represent rotation of the stomach on its mesentery (rotation along the long axis), causing mechanical obstruction.

Principal diagnosis:

Organo-axial gastric volvulus.

Differential diagnosis:

• Para-esophageal gastric hernia without volvulus (however, the gastric rotation is clearly demonstrated).

Management:

Urgently contact referring physician and inform of findings; recommend urgent surgical referral. The patient will likely require surgical de-torsion.

Findings and interpretation:

• The liver is enlarged with numerous lesions occupying all segments of the liver.
• Some of the lesions are hyper-attenuating on the non-contrast images, likely indicating prior haemorrhage into the lesions.
• The lesions are avidly and somewhat homogeneously enhancing on the arterial phase; they show iso-enhancement in the portal venous phase.
• Some of the lesions show focal areas of non-enhancement.
• On the delayed phase, the lesions are somewhat hypo-enhancing compared to background liver parenchyma.
• There is a course calcification at the left lateral segments.

Negative findings:

• No primary distant cancer is detected.

The findings reflect multiple tumours in the liver. Findings suggest that these tumours have undergone previous episodes of haemorrhage.

Principal diagnosis:

Hepatic adenomatosis.

Differential diagnosis:

Hypervascular metastases from unknown primary.

Management:

Discuss at hepato-biliary surgery MDT.

Correlate with clinical data: is the patient taking anabolic steroids?

Suggest ultrasound guided core biopsy for histological diagnosis.

The patient may require liver transplantation.   

Findings and interpretation:

• Both ovaries are enlarged with multiple cystic lesions showing thick and uniformly enhancing walls; these lesions show the characteristic features of abscesses.
• There is a similar multi-cystic lesion (abscess) extending through the right inguinal canal to the superficial tissues of the groin; this appears to follow the round ligament into the peritoneal cavity. This most likely represents spread of infection forming abscesses along a canal of Nuck hernia.
• There are innumerable small nodules of similar size randomly distributed throughout the scanned lower lung zones. This suggests haematogenous spread of disease. There is also a left sided mild pleural effusion with related subsegmental atelectasis.

The findings represent multi-system involvement by an infectious disease, with post-primary pulmonary manifestations (miliary tuberculosis) and tubo-ovarian abscesses.

Principal diagnosis:

Multi-system tuberculous infection involving the adnexae and lungs.

Differential diagnosis:

• Haematogeneously spread nodules may represent metastases.
• Tubo-ovarian abscesses may be caused by a plethora of different organisms.

Management:

Alert referring physician of findings.

Correlate with sputum cultures for acid-fast bacilli.

The patient should be isolated and close contacts screened for disease.

Findings and interpretation:

• There is marked, eccentric, irregular mural thickening of the stomach (at the lesser curvature) with widespread punctate foci of calcification.
• There are many surrounding rounded low densities (representing thick, loculated fluid) around the lesser curvature, lesser sac and spleen. These loculated gelatinous densities show scalloping of the surfaces of the spleen which they completely surround, and of the lateral surface of the liver which they are intimately related to.
• There is a large area of ill defined soft tissue infiltration / thickening of the omentum, showing heterogenous soft tissue density and enhancement; these are the features of omental caking.
• There is an umbilical hernia with a large hernial sac containing caked omentum.
• There is a moderate amount of free fluid in the peritoneal cavity.

Incidental findings:

• The pancreas is atrophic.
• There are a few small, simple renal cysts.

The findings represent a mucinous malignancy involving the stomach, with spread of malignancy to the peritoneum and omentum. There are mucinous deposits in the peritoneum and metastatic involvement of the omentum.

Principal diagnosis:

Gastric mucinous adenocarcinoma with pseudomyxoma peritonei.

Differential diagnosis:

• Carcinoma from a different site metastasizing to the stomach and peritoneum.

Management:

Alert the referring physician of the findings.

Recommend ultrasound guided biopsy of the omental deposits for tissue diagnosis.

Findings and interpretation:

MRI brain:

• There are bilateral, well defined, cerebello-pontine angle lesions which extend into and widen the internal acoustic meatus on both sides. These show intermediate T1 and T2 signal intensity. They avidly enhance on the post-contrast images.
• There are bilateral, well defined soft tissue lesions which extend from the pre-pontine cistern into Meckel’s cave, the right sided one being far larger than the left and widening it’s space. They similar signal intensity to the previous lesions, yet the right sided one shows central T2 hyper-intensity. It shows peripheral avid enhancement with a central non-enhancing region (indicating cystic change).
• There are bilateral smaller lesions with similar radiological features in the lateral cerebello-medullary cisterns.

Lumbosacral spine:

• There is an intradural, extramedullary lesion located at the level of L2/L3 and arising from the filum terminale.
• The lesion shows heterogeneous enhancement.

Pertinent negative findings:

• The spinal lesion shows no herniation through the neural foramina.

There are multiple nerve sheath tumours (schwannomas) of the cranial nerves. The spinal lesion represents a low grade spinal tumour.

The synchronous presence of these lesions indicates a congenital disorder.  

Principal diagnosis:

Neurofibromatosis type II with multiple schwannomas and myxopapillary ependymoma.

Differential diagnosis:

The spinal lesion may also be a schwannoma or meningioma.

Management:

Refer for discussion at neurosurgery MDT to discuss operative management of spinal ependymoma.

Recommend genetic testing / screening of relatives for NF2.

Findings and interpretation:

• The ACL (anterior cruciate ligament) fibres show full thickness disruption and high PD signal.
• There is partial disruption of the PCL fibres with focal high PD signal.
• There is disruption of all three layers of the MCL with surrounding amorphous high PD signal representing oedema and blood.
• There is a lateral meniscal tear with displacement of the posterior horn anteriorly and showing a double anterior meniscus sign.
• There is low T1 and high PD signal at the terminal sulcus of the lateral femoral condyle and at the posteromedial tibial plateau, indicating bone contusions.
• There is a large amount of fluid around the knee joint, which has escaped the disrupted joint capsule to surround the vastus medialis and proximal gastrocnemius muscles.

Pertinent negative findings:

• The medial meniscus is intact.

There is complete rupture of the ACL and MCL and tear of the lateral meniscus; disruption of the joint capsule has allowed the haemarthrosis to escape the knee joint.

Principal diagnosis:

Traumatic knee injury

Differential diagnosis:

None

Management:

Alert referring physician and recommend orthopaedic referral; the patient will likely require surgical management.