A patient with
education |•| picture quiz
previously fit and well 36 year old woman
presented at the emergency department with a
three week history of sudden onset severe
abdominal pain abdominal pain and vomiting. The pain settled
and she was discharged with proton pump
inhibitors. However, a week later she continued to feel
unwell and was seen by her on-call general practitioner.
She complained of a continuing feeling of left hypochron-
drial abdominal pain that did not radiate and generally
feeling unwell. She had no associated symptoms of nausea or
vomiting, weight loss or anorexia. The pain was not relieved
on rest and there was no relation to food. She did not smoke
and drank on average 4-5 units of alcohol a month. There
were no other aggravating or relieving factors. She was not
taking any drugs and had no noteworthy previous medical
or family history. For contraception, she had had a depot
injection two months before.
Before seeing her general practitioner she had been to the
local emergency department, where, after clinical examina-
tion, she was discharged given proton pump inhibitors with
a suspected diagnosis of acid peptic disease. Although the
initial pain settled she continued to have a dull abdominal
ache and this was the reason for seeing the on-call general
practitioner. She had had a pregnancy test three weeks
before, which was negative. Apart from tenderness found at
the left hypochondrium, clinical examination was unremark-
Fig 1 Ultrasound image able, with no distension or organomegaly. Bowel sounds
through the pancreatic were present. Cardiovascular examination was also
head unremarkable with no peripheral oedema.
(1) What is your differential diagnosis at this stage?
(2) What investigations should be done?
(3) From the ultrasound (figs 1 and 2) and computed
tomography (fig 3) scans, can you locate the abnormality
found in the radiographs?
(1) The differential diagnosis at this stage could be acute
cholecystitis, biliary colic, peptic ulcer disease, acute gastritis,
acute pancreatitis, gastro-oesophageal reflux, renal colic,
intestinal obstruction, and intestinal ischaemia. Acute
appendicitis could be the cause if the appendix is subhepatic
in location. Referred pain in this area can be caused by
myocardial infarction, acute lower lobe pneumonia, or
pulmonary embolus. Occasionally perihepatitis in associa-
tion with chlamydia (Fitz-Hugh-Curtis syndrome) can cause
abdominal pain, but usually there is a history of vaginal
Fig 2 Longitudinal ultrasound image discharge.
through superior mesenteric vein (2) Full blood count with erythrocyte sedimentation rate,
platelet count, bleeding and clotting times, blood film, urinal-
ysis, serum amylase, electrocardiogram, and liver function
tests. These investigations can be followed by an abdominal
ultrasound scan and computed tomography scan.
(3) The white arrows in figs 1, 2, and 3 point to a
thrombus in the superior mesenteric vein.
A diagnosis of superior mesenteric venous thrombosis and
iliac venous thrombosis was made. The computed
tomography also showed a thrombus in the right iliac vein,
despite there being no demonstrable leg oedema and the
patient not complaining of any pain or discomfort in her
Mesenteric venous thrombosis was first documented by
Elliot in 1985 and then further established by Warren and
Eberhard in 1935 as a cause of ischaemic bowel.1 It is an
uncommon but important cause of mesenteric ischaemia. It
accounts for up to 15% of small bowel ischaemia and tends
to affect men and women equally.2
Diagnosis can be difficult to make, and it is often not
Fig 3 Contrast enhanced transverse section achieved at the initial presentation. This is because of the
through the region of the pancreatic head non-specific nature and location of the pain caused by
mesenteric ischaemia and can be associated with gastroin-
education |•| picture quiz testinal symptoms of nausea, vomiting, diarrhoea, and consti- permanent colostomy and the complications of the
pation as well as a general feeling of malaise. procedure—infection, scar tissue formation, and bleeding.
Classification of the causes of mesenteric venous The patient is currently undergoing investigation to exclude
thrombosis is made on a primary, idiopathic, or secondary secondary causes of the mesenteric venous thrombosis,
basis. Primary and idiopathic causes, such as splanchnic although the presumptive cause is the contraceptive depot
venous thrombosis are relatively rare at 15-20% and are not injection.
associated with predisposing conditions.13 Any atypical presentation of abdominal pain should
Secondary causes represent 80% of all cases, the most warrant investigation for mesenteric venous thrombosis,
common of which are pancreatitis, history of deep vein especially when risk factors are present, because it is rare but
thrombosis, inflammation after abdominal surgery, and fatal. It is said that to diagnose mesenteric venous thrombosis
neoplasm.3 The oral contraceptive has been identified as you must be looking for it.
causing 9-18% of cases in young women.1
Diagnosing mesenteric venous thrombosis requires a high Lynda Djabella fourth year medical student, University of Manchester
index of suspicion and the use of investigative imaging. email@example.com
Prognosis depends on early diagnosis and effective treatment
Nanda Kumar consultant radiologist, Blackburn Royal Infirmary
with anticoagulation and surgical resection of necrosed bowel
and the minimisation of recurrence by lifelong management Competing interests: None declared.
if the patient’s medical history carries a high risk of further
thrombosis. 1 Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J
In this case the diagnosis was missed the first time, and this
2 Gastroenterology grand rounds: discussion
is often the case with mesenteric venous thrombosis.
Fortunately, this patient was diagnosed before the ischaemia (accessed 1 April 2006).
led to necrosis of the bowel and to a much worse prognosis. 3 Bradbury MS, Kavanagh PV, Bechtold RE, Chen MY, Ott DJ, Regan JD, et
Patients that need surgical resection of the necrosed bowel al. Mesenteric venous thrombosis: diagnosis and non-invasive imaging.
have more complicated prognoses, with the possibility of Radiographics 2002;22:527-41.
Headache, visual blurring, and
54 year old man presented with a six month
history of severe headaches and visual blurring. (1) What are the radiological findings?
He also noted decreased libido and progressive (2) What are the differential diagnoses?
impotence. And he complained of general fatigue, (3) Why does this patient have bitemporal hemianopia?
intolerance to cold, and decreased appetite.
On physical examination, blood pressure was 105/60 mm
Hg (with postural hypotension) and his pulse rate was 60 Answers
beats/min. In addition there was pallor and bilateral gynaeco- (1) The coronal T1 weighted scan postcontrast shows a space
mastia without Cushingoid or acromegalic features. Visual occupying lesion in the sellar and parasellar regions (right
field testing showed bitemporal hemianopia. greater than left).
Notable laboratory test results were testosterone 180 (2) Non-functioning pituitary tumour, meningioma arising
(normal range 300-1100) ng/dl, T4 4 (4-12) mg/dl, thyroid from the tuberculum sellae, and craniopharyngioma.
stimulating hormone 0.5 (0.5-5.0) mIU/ml, and prolactin 48 (3) Bitemporal hemianopia occur secondary to compression
(<10) ng/ml. An adrenocorticotropic hormone stimulation of the optic nerve fibres from the nasal half of the retina.
test showed a peak cortisol concentration of 10 (>20) mg/dl. This area is responsible for temporal vision, which
In view of the panhypopituitarism and visual field defects decussates at the optic chiasm. It is an indication of
magnetic resonance imaging of the brain was ordered possible sellar or parasellar masses compressing the
(figure). chiasm. Sellar mass of pituitary origin compresses the
chiasm below resulting in an initial superior bitemporal
quadrantonopia. However, some parasellar lesions—for
example, craniopharyngioma—compress the optic chiasm
from above resulting in inferior bitemporal
Pituitary tumours are responsible for between 8-10% of
intracranial tumours.w2 They may present secondary to their
endocrine effects or as a result of compression to the
surrounding structures—for example, optic chiasma or other
Based on size, pituitary tumours can be divided into
macroadenoma (>1 cm diameter) and microadenoma (<1
cm diameter). Currently, pituitary tumours are classified
The magnetic based on the hormone secreted which in some cases can be
resonance multiple (box 1).w2–w4
imaging of the The presentation of pituitary tumours can be divided into
brain two groups—mass effect and endocrine effect. Mass effects
106 STUDENTBMJ | VOLUME 15 | MARCH 2007