HJK Posted December 20, 2015 Share Posted December 20, 2015 Had 50s female with over a year of abdominal pain. New onset n/v for a few weeks Intermittent fever And chills. Was at another ed 3 days ago, CT and pelvic Us done. Fibroids and hemorrhagic cysts. Given vicodin and GYN follow up. Here for better pain med. Reviewed the labs and US but unable to find CT. Noted enlarged liver board and ttp on exams. LFT elevated 3 folds but still in 300s with bili 0.9. Decided to pursue further. CT with contrast and US ruq. Ct negative expect 10mm common duck dilatation, no obstruction. Same radiologist read US a half hour later, obstructing pancreatic mass. Per patient CT 3 days ago was benign. Hmmm.. Thought CT would be more specific than US on those findings. Just puzzled with the finding. Link to comment Share on other sites More sharing options...
HJK Posted December 20, 2015 Author Share Posted December 20, 2015 By the was, patinet was triaged for med refill. Another patinet signed in for left knee pain for 5 days. 83 yo had a mechanical fall 2 weeks ago, didn't see pcp until 5 days ago, diagnosed with right sided rib fracture. Anyways, seems classic sprain. While talking he mentioned, about 5 hours ago, had one episode of nausea with dry heaving without cp or sob. H/o sick sinus synd and afib. EKG unremarkable for him. Hmmm.. should I invest further as well.. Later trop 0.051 than 0.055. Man.. Triage shift can be really nerve racking sometimes.. Back to the CT.. do you guys review CTs always or rely on radiology reads? Fractures and head I usually do but abdomens. Well... Link to comment Share on other sites More sharing options...
Guest JMPA Posted December 21, 2015 Share Posted December 21, 2015 clinically correlate Link to comment Share on other sites More sharing options...
winterallsummer Posted December 28, 2015 Share Posted December 28, 2015 CT much better study than U/S. Call CT radiology and review with the radiologist ask him to take a second look. Needs specific CT pancreas protocol ideally which includes with and without contrast. Clinical correlation as mentioned. To be safe I'd refer to GI for consideration of scope or MRI (eg MRCP or less likely ERCP), or they can repeat CT depending on size of pancreatic mass. Let them decide. Sounds like it could be artifact on the U/S with a negative CT, but stakes are high. With obstructing mass would expect higher Tbili. Any other explanation for the LFTs in 300s? That will need to be rechecked anyway by GI or PCP. But don't see any reason to have admitted them. Link to comment Share on other sites More sharing options...
delco714 Posted December 30, 2015 Share Posted December 30, 2015 Ct should always catch this over sono. I always look at the film. Mistakes happen, misses happen, etc. Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 2, 2016 Share Posted January 2, 2016 radiologists cover themselves by stating "clinically correlate", it is the duty of the diagnosticion to decide if the test is relevant/useful/wrong/needs to be repeated/ bad radiology read. I personally would take any pancreatic mass very seriously Link to comment Share on other sites More sharing options...
NeoTrion Posted January 2, 2016 Share Posted January 2, 2016 To be honest US is not the study of choice for anything deep abdomen. The pancreas is often obscured by bowel gas and of course the head is tucked around the duodenum (hence the romance of the abdomen). I know in radiology we would recommend a CT with contrast if we saw anything with the pancreas. You were right on for that one. I would give this rad a call. Puzzled by this call on US but not CT. Perhaps pancreas protocol giving thinner slices. US is great for a lot of things just not anything you have to go through air to look at or we could use US to do lung biopsies. It will give you better information about bile ducts though. Often we in radiology take for granted that people know what to order and for what. Often correlate clinically means choose a better test to evaluate this condition because this could or could not be several things. Although I have used this when doing liver biopsies and found an incidental finding such as gall stones. Then in my mind you would do an US and turn the patient to test mobility of the stones or do a HIDA scan. We don't say that in reports anymore because it was painting clinicians into a corner on what to do next if we said "recommend CT abdomen to evaluate further." To go against a specialists recommendations is hard to justify in some cases and easy to second guess if something becomes litigious. But I do agree with JMPA that sometimes radiology does "hedge" when we have very little history to go on. I can't tell you how many times I have read a scan or done a procedure because it says "Per Clinician Orders." Help us help you in giving us an idea what your looking for, but that obviously wasn't the case here. I know were I work this got so bad in pathology they required all samples come with an H and P so they could work the differential in their mind and dictate as a possibility. As of the first of this year we are going to require something more substantial in the diagnosis in order to scan anyone. We already require this with any intervention case. All I can say is if you have a question most Rads or PA's in radiology will have no problem helping you out. Sometimes the rad will say "Well I saw that and thought it looked odd, but didn't call it (fill in the blank) because I wasn't convinced." Either way she is headed towards a biopsy (pancreas and probably liver due to high LFTs) and it will more than like be done under CT for both. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.