lecture 19 part 1

Peace, mercy, and blessings of God be upon you. How are you, guys? I hope you're doing well. This is the last lecture of the Applied course, which is lecture number 19. Actually, I didn't expect that we would take this many cases in this course. But at the end of this course, I say thank God, finally, I mean, now I can be reassured when I say that if someone wants to start writing reports and doesn't need or doesn't want to go to centers, I expect that this course, with the How to Report course, will be very, very enough to get a radiologist, I mean, enough and very suitable to write correct reports and write reports in a standardized way. And, I mean, the things that bothered me when I saw one of the radiologists writing bad reports or that he was writing bad reports and one of the clinicians started to criticize him and so on. So, this was something that bothered me. So, I expect that these two courses, I expect that I would have done in terms of not being something like this or that I didn't hear something like this. Because, in fact, the two courses have a very large number of different cases that cover a very, very large percentage of the clinical practice. And even, I mean, if there is something, of course, these things don't end. Even if there are strange cases, strange cases, you already know how you can write reports in an organized way, in a very good way, and to the point, I mean, and it is clear that it is a respectable report, thank God. So, thank God, first and foremost, God willing, I will collect for you all the reports that we took during the two courses, the How to Report and the Apply. For people, of course, who attended the two courses, they will be in one folder that people can use in their practical life, I mean. For those who attended the emergency with me, I will also collect the emergency cases from the applied course in one folder, and I will send them, God willing, the emergency reports alone after the course is over, God willing. Okay, let's start, in the name of God, the Merciful, the Compassionate. Today's cases are honestly some of the most enjoyable cases, and I left it on the basis that, thank God, we finish the course with it, I mean. So, the first case we have is the case of Fishbone. Actually, this is one of the very funny cases, and it is, the problem is, of course, there is a detection, I mean, of the lesion. The patient was coming complaining of abdominal pain, and it was, as you will see, and as most of the people who sent me, I mean, the examination was almost normal, there was no problem for us in the examination. Most of the people did not see the abnormality, but when you look at the area of the abdomen, or in the area of the omentum, I mean, the area behind the anterior abdominal wall directly, you will feel that this area has some smudging of the fat blades. This area has some smudging of the fat blades. And when it goes down a little, you will notice this structure. Do you see this linear structure? This linear, hyperdense structure, which is transecting the bowel wall, extending from the omen to the outside. This is abnormal. Of course, if one does not focus on it a little, and does not take care of it, he can pass it completely, and the examination was abnormal. To make sure that this is not an enhancing thing, and that it is really hyperdense, look at it in the abdomen. You will notice that, if we look at the abdomen, you will notice that this structure is still there and hyperdense before the anterior abdominal wall. This means that this is a hyperdense in non-contrast. What is the thing that can be like this? Of course, we have to think about a foreign body. And we ask the patient very well about the things that he may have eaten in the past period. Unfortunately, most people do not keep in mind the action that happened. Because, as it happened in this case, the history may be from three or four days. This patient did not have a history that he ate fish and then he had a pain in the abdomen. No, it does not come like this and does not link the subject together. This is what makes the subject Of course, the patient's question after seeing this abdomen, is very strange. What do you see? I do not know what I ate or what I did not eat. In the end, it turned out that this patient had eaten fish and had a fishbone. As you can see, this fishbone is the transecting of the bowel and the abdominal vein as you can see. In the delayed images, you will notice that there is some sort of air flow in the peritoneum. If we look here, you will notice that there is a minute tiny air flow in the area where the smudging is. Of course, this bowel is not stable so it moves. You will notice that the fishbone is a little further from the area where the smudging is, but as you can see, the bowel moves. This minute air flow is abnormal. It is probably the source of the bowel due to the transection of the fishbone of this bowel. If we also notice, we went out a little proximal, you will notice that there is another similar structure in the proximal bowel. This is another fishbone, but this is an intraluminal. Another fishbone in the proximal bowel. It is a very simple description, but of course, it makes a lot of difference to pick up abnormalities. It is very easy to miss. Especially, there is no clear history of the fishbone. Pay attention to the foreign body. These linear things, I show you this view so that people may not be aware of the foreign body and do not know how it looks and how it can be seen in things. A linear hyperdense structure is seen transecting the wall of the distal jejunal loops at the region of the suprapubic region. at the region of the suprapubic region. We determine as much as we can the bowel loops as much as we can. Now we see this structure. What does it do exactly? It is associated with smudging the fat planes around it and tiny extraluminal air foci. There is a similar intraluminal structure. There is another structure that has intraluminal and gastric lumen. It was in the first physics. It was in the gastric lumen and with time, in the proximal jejunal loop it moved from its place and went to the jejunal loop. The study has no problem at all. We say that this is a linear hyperdense structure. We describe this as a structure. This is what we use. Translecting the wall of the distal jejunal loops sorry associated with fat stranding and tiny extraluminal air foci. Then we put the diagnosis as a possibility of foreign body with wall porphyration is to be considered for clinical correlation. and there are other similar structures as you can see the similar structure which is the one you can see now that's it the option is to open operative or to open laparoscope and this is the view of the fishbone which you can see I don't know if you can see the image or not but this is the view of the fishbone which is present transecting the bowel ok this is the view of the laparoscope and they removed it the next case is the foreign body we will leave it as it is because these are important things after that I have a very nice case which is the case of the roe-on-wye or the roe-on-wye complication of course I talked more than once about the roe-on-wye complication and people know this story in the how to report lecture I said one of the most important roe-on-wye complication is the internal hernia we talked before about the roe-on-wye and we talked about its component and the elementary limb and the pylobankratic limb and the gastric pouch and we will talk about this story later anyway roe-on-wye is one of the operations that its purpose is specialization and it depends on two things it reduces the size of the stomach so it reduces the capacity of the stomach so the stomach gets full and it depends on there is a large part of the food that bypasses a large part of the bowel so there is no absorption of large amounts of food so it helps specialization roe-on-wye has two purposes its purpose is to reduce the amount of food due to reduction of volume of the stomach and also to reduce the absorption of the food by bypassing what happens and what they do ok this sample was brought from abdominal pain after roe-on-wye and actually when we look at the test we will notice the following we will notice that the mesenteric area and the mesenteric fat planes you feel that it has small jelly fat planes and especially in the distal abdomen or in the pelvic region and the bowel loops in the distal ileal bowel loops their enhancement pattern is a little less than the other bowel loops so this is a little worrying especially after roe-on-wye and you will notice that there are tubular structures within the mesenteric fat planes these tubular structures within the fat planes are continuous if I show you the colonel it will be clearer this is the mesentery it is very smudgy and misty and the attenuation is very high this is not normal and the tubular structures are not enhancement this is superior mesenteric artery next to the superior mesenteric artery you will notice that the superior mesenteric veins these tubular structures are not illuminated there is non-opacification of the structures or vessels or veins of the superior mesenteric vein this is the artery next to the vein the artery is illuminated this is the venous phase when we come to the origin of the superior mesenteric vein when we look inside we will notice that this is the portal and this is the splenic and this is supposed to be the beginning of the superior mesenteric when we look at the superior mesenteric this is the superior mesenteric vein and this is the artery we will notice that the superior mesenteric vein is very narrowing and disappear this is the superior mesenteric vein and after that what we see here is the superior mesenteric artery and the veins after that the venous tributaries are not illuminated there is an occlusion of the superior mesenteric vein and this explains or explains why the bowel which is distally has a pore enhancement and also the mesenteric fat planes the high attenuation is the result of the occlusion of the superior mesenteric vein ok let's come to a reason what makes the superior mesenteric vein occluded in this story when we look at this we will notice that there is some sort of wire ball sign do you see this this is the wire ball sign look at this you will notice that there is a wire ball sign in this area the wire ball sign is the sign of volvulus and the volvulus is very easy to occlude the vein and also occlude the artery and this is very well known when the volvulus occurs the vein and artery are occluded this may be the reason for the occlusion of the vein ok as I said before guys the volvulus in the veins of the superior mesenteric vein is the sign of internal hernia as I said the most important complications after the superior mesenteric vein is the internal hernia and the internal hernia after the superior mesenteric vein has other signs because of the complexity of the process the process of the vein is very complex and its anatomy changes and the instance of the internal hernia is very high so they put more than one sign if you see it to say that there is an internal hernia even if the typical pattern of the internal hernia does not exist the typical pattern of the internal hernia is the dilated bowels the sac configuration the closed loop obstruction that we know you may not see it in the internal hernia the post row on y and they relied on other signs among the other signs I say that this is an internal hernia even if I do not see the typical pattern of the internal hernia is the volvulus so the wire bowl sign is a sign of volvulus but in the post row on y to me this is an indication of internal hernia you will also notice if you look here on the third part of the dedenum you will notice that the third part should go through the midline you will notice here that there is a twist look here on the third part of the dedenum it should go like this no, there is a twist it does not go through the midline and this other bowl loops This is a very famous scene in the science of the lanterns here, they call it a mushroom shape masonry. The masonry acts like a mushroom shape, as if this bowl is the stump of the mushroom, and the rest of the bowl is the head of the mushroom. This is the appearance of the mushroom shape, and the twist is the signs of internal hernia. This is described as internal hernia, and if you saw it in the beginning, you could say it has signs of volvulus. I have two signs of volvulus, which for me are indirect signs of internal hernia. The first is the mushroom shape appearance of the bowl, and the second is the wire ball appearance of the masonry. These two signs explain to me why the masonry is closed, and explain to me why the masonry has congested masonry, and the rest of the distal loops are closed. Some people may doubt this information, I am not sure, especially since the science is very clear here. Some people may say that this is a result of a change of the complexity of the anatomy of the bowl, and the shape of the bowl changes in this way. I have a clear evidence that the masonry is closed, and this is definitely pathological, but it can help me a lot if the masonry has old movies. Before the masonry is closed, I will show you a sample of the same masonry, but before the abdominal vein. This was in 2022, and in 2024 the masonry was closed. When we look at the area of the superior mesenteric vein, we will notice that the location of the superior mesenteric vein is in front of the superior mesenteric artery. Thank you for watching.