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Emergency Imaging: Atraumatic Leg Pain
Case
A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.
On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.
Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture. 
What is the diagnosis?
Answer
Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c). 
Iliopsoas Musculotendinous Unit
The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.2
Signs and Symptoms
In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.1
Imaging Studies
Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.5
Treatment
Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.3
The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.
1. Bergman G. MRI Web clinic – October 2015: Iliopsoas tendinopathy. Radsource. http://radsource.us/iliopsoas-tendinopathy/. Accessed November 22, 2017.
2. Van Dyke JA, Holley HC, Anderson SD. Review of iliopsoas anatomy and pathology. Radiographics. 1987;7(1):53-84. doi:10.1148/radiographics.7.1.3448631.
3. Lecouvet FE, Demondion X, Leemrijse T, Vande Berg BC, Devogelaer JP, Malghem J. Spontaneous rupture of the distal iliopsoas tendon: clinical and imaging findings, with anatomic correlations. Eur Radiol. 2005;15(11):2341-2346. doi:10.1007/s00330-005-2811-0.
4. Bui KL, Ilaslan H, Recht M, Sundaram M. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol. 2008;37(3):245-249. doi:10.1007/s00256-007-0414-3.
5. James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512-514.
Case
A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.
On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.
Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture.
What is the diagnosis?
Answer
Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c).
Iliopsoas Musculotendinous Unit
The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.2
Signs and Symptoms
In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.1
Imaging Studies
Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.5
Treatment
Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.3
The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.
Case
A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.
On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.
Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture.
What is the diagnosis?
Answer
Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c).
Iliopsoas Musculotendinous Unit
The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.2
Signs and Symptoms
In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.1
Imaging Studies
Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.5
Treatment
Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.3
The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.
1. Bergman G. MRI Web clinic – October 2015: Iliopsoas tendinopathy. Radsource. http://radsource.us/iliopsoas-tendinopathy/. Accessed November 22, 2017.
2. Van Dyke JA, Holley HC, Anderson SD. Review of iliopsoas anatomy and pathology. Radiographics. 1987;7(1):53-84. doi:10.1148/radiographics.7.1.3448631.
3. Lecouvet FE, Demondion X, Leemrijse T, Vande Berg BC, Devogelaer JP, Malghem J. Spontaneous rupture of the distal iliopsoas tendon: clinical and imaging findings, with anatomic correlations. Eur Radiol. 2005;15(11):2341-2346. doi:10.1007/s00330-005-2811-0.
4. Bui KL, Ilaslan H, Recht M, Sundaram M. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol. 2008;37(3):245-249. doi:10.1007/s00256-007-0414-3.
5. James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512-514.
1. Bergman G. MRI Web clinic – October 2015: Iliopsoas tendinopathy. Radsource. http://radsource.us/iliopsoas-tendinopathy/. Accessed November 22, 2017.
2. Van Dyke JA, Holley HC, Anderson SD. Review of iliopsoas anatomy and pathology. Radiographics. 1987;7(1):53-84. doi:10.1148/radiographics.7.1.3448631.
3. Lecouvet FE, Demondion X, Leemrijse T, Vande Berg BC, Devogelaer JP, Malghem J. Spontaneous rupture of the distal iliopsoas tendon: clinical and imaging findings, with anatomic correlations. Eur Radiol. 2005;15(11):2341-2346. doi:10.1007/s00330-005-2811-0.
4. Bui KL, Ilaslan H, Recht M, Sundaram M. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol. 2008;37(3):245-249. doi:10.1007/s00256-007-0414-3.
5. James SL, Davies AM. Atraumatic avulsion of the lesser trochanter as an indicator of tumour infiltration. Eur Radiol. 2006;16(2):512-514.
Emergency Imaging: Severe Left Testicular Swelling
A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.
Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).
What is the diagnosis?
The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.
Answer
Testicular Torsion
Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.
“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.1 Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.2
Clinical Presentation
Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.3 The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.4
Doppler Ultrasound
Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.
It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.7
With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.
Treatment
Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.8 When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.3 The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.
1. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. 1994;44 (1):114-116.
2. Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171. doi:10.1001/archpedi.159.12.1167.
3. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
4. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28:80Y86. doi:10.1097/PEC.0b013e31823f5ed9.
5. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-607.
6. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990;175(3):815-821. doi:10.1148/radiology.175.3.2188301.
7. Aso C, Enríquez G, Fité M, et al. Gray-scale and color doppler sonography of scrotal disorders in children: an update. Radiographics. 2005;25(5):1197-1214. doi:10.1148/rg.255045109.
8. Hadziselimovic F, Geneto R, Emmons LR. Increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility. J Urol. 1998;160(3 Pt 2):1158-1160.
A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.
Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).
What is the diagnosis?
The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.
Answer
Testicular Torsion
Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.
“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.1 Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.2
Clinical Presentation
Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.3 The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.4
Doppler Ultrasound
Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.
It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.7
With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.
Treatment
Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.8 When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.3 The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.
A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.
Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).
What is the diagnosis?
The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.
Answer
Testicular Torsion
Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.
“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.1 Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.2
Clinical Presentation
Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.3 The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.4
Doppler Ultrasound
Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.
It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.7
With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.
Treatment
Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.8 When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.3 The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.
1. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. 1994;44 (1):114-116.
2. Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171. doi:10.1001/archpedi.159.12.1167.
3. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
4. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28:80Y86. doi:10.1097/PEC.0b013e31823f5ed9.
5. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-607.
6. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990;175(3):815-821. doi:10.1148/radiology.175.3.2188301.
7. Aso C, Enríquez G, Fité M, et al. Gray-scale and color doppler sonography of scrotal disorders in children: an update. Radiographics. 2005;25(5):1197-1214. doi:10.1148/rg.255045109.
8. Hadziselimovic F, Geneto R, Emmons LR. Increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility. J Urol. 1998;160(3 Pt 2):1158-1160.
1. Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. 1994;44 (1):114-116.
2. Mansbach JM, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12):1167-1171. doi:10.1001/archpedi.159.12.1167.
3. Sharp VJ, Kieran K, Arlen AM. Testicular torsion: diagnosis, evaluation, and management. Am Fam Physician. 2013;88(12):835-840.
4. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28:80Y86. doi:10.1097/PEC.0b013e31823f5ed9.
5. Baker LA, Sigman D, Mathews RI, Benson J, Docimo SG. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. 2000;105(3 Pt 1):604-607.
6. Burks DD, Markey BJ, Burkhard TK, Balsara ZN, Haluszka MM, Canning DA. Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology. 1990;175(3):815-821. doi:10.1148/radiology.175.3.2188301.
7. Aso C, Enríquez G, Fité M, et al. Gray-scale and color doppler sonography of scrotal disorders in children: an update. Radiographics. 2005;25(5):1197-1214. doi:10.1148/rg.255045109.
8. Hadziselimovic F, Geneto R, Emmons LR. Increased apoptosis in the contralateral testes of patients with testicular torsion as a factor for infertility. J Urol. 1998;160(3 Pt 2):1158-1160.
Emergency Imaging
A 48-year-old man presented to the ED via emergency medical services after experiencing two episodes of syncope following the acute onset of right lower quadrant pain. He was unresponsive at the time of presentation. His vital signs were notable for tachycardia with a heart rate of 130 beats/minute. Although normotensive at initial presentation, the patient’s blood pressure began to fall rapidly. Laboratory values revealed a decreased hemoglobin and hematocrit of 5 g/dL and 18.1%, respectively.
Following his stabilization, a computed tomography (CT) scan of the abdomen and pelvis was performed. Figures 1a and 1b represent selected noncontrast and postcontrast axial images obtained through the lower abdomen/upper pelvis.
What is the diagnosis?
Answer
The precontrast image (Figure 1c) demonstrates a large and irregular high-density collection within the right upper pelvis (white arrows) and high density free fluid along the left lateral abdominal wall (black arrows). The right psoas muscle is obscured (white asterisk, Figure 1c) when compared to the normal psoas muscle on the contralateral side (black asterisk, Figure 1c). The postcontrast image (Figure 1d) shows the same findings and also reveals an enlarged right common iliac artery (red asterisk) and contrast actively extravasating from the artery (red arrow). These findings indicate the presence of a ruptured common iliac artery aneurysm. Both the enlarged common iliac artery aneurysm (red arrow, Figure 1d) and the extravasated contrast (red asterisk, Figure 1d) were confirmed on the three-dimensional reformats of the CT scan (Figure 1e).
An isolated aneurysm of the common iliac artery is uncommon, occurring in only 1% to 2% of the population—the same frequency as aortic aneurysm.1 However, the risk of rupture of this type of aneurysm is high.2 Patients with common iliac artery aneurysm are typically asymptomatic prior to rupture. However, some patients have reportedly presented with claudication, tenesmus/constipation, sciatica, and lower extremity paresis due to nerve compression, as well as urinary obstruction caused by ureteral obstruction.1,3 Once the iliac artery aneurysm has ruptured, patients typically present with acute abdominal, groin, and/or thigh pain, although isolated testicular pain has been described in the literature.1,4
Treatment for iliac artery aneurysm includes open and endovascular repair, depending on patient presentation and the adjacent structures involved. While mortality is low for patients with a nonruptured common iliac aneurysm, acute rupture is present in approximately one out of three cases, and the surgical mortality rate is as high as 55%.3
The patient presented in this case was taken to the operating room where an angiogram of the right common iliac artery (red arrow, Figure 1f) revealed continued acute extravasation of contrast (red asterisk, Figure 1f). Surgical repair was attempted but the patient did not survive due to complications of hypotension and cardiac arrest.
2. Reber PU, Brunner K, Hakki H, Stirnemann P, Kniemeyer HW. Incidence, classification and therapy of isolated pelvic artery aneurysm. Chirurg. 2001;72(4):419-424.
3. Bacharach JM, Slovut DP. State of the art: management of iliac artery aneurysmal disease. Catheter Cardiovasc Interv. 2008;71(5):708-714.
4. Dolan RD, Zino S. A ruptured left common iliac aneurysm presenting as testicular pain in a 56-year-old man. BMJ Case Rep. 2014. doi:10.1136/bcr-2012-006568.
A 48-year-old man presented to the ED via emergency medical services after experiencing two episodes of syncope following the acute onset of right lower quadrant pain. He was unresponsive at the time of presentation. His vital signs were notable for tachycardia with a heart rate of 130 beats/minute. Although normotensive at initial presentation, the patient’s blood pressure began to fall rapidly. Laboratory values revealed a decreased hemoglobin and hematocrit of 5 g/dL and 18.1%, respectively.
Following his stabilization, a computed tomography (CT) scan of the abdomen and pelvis was performed. Figures 1a and 1b represent selected noncontrast and postcontrast axial images obtained through the lower abdomen/upper pelvis.
What is the diagnosis?
Answer
The precontrast image (Figure 1c) demonstrates a large and irregular high-density collection within the right upper pelvis (white arrows) and high density free fluid along the left lateral abdominal wall (black arrows). The right psoas muscle is obscured (white asterisk, Figure 1c) when compared to the normal psoas muscle on the contralateral side (black asterisk, Figure 1c). The postcontrast image (Figure 1d) shows the same findings and also reveals an enlarged right common iliac artery (red asterisk) and contrast actively extravasating from the artery (red arrow). These findings indicate the presence of a ruptured common iliac artery aneurysm. Both the enlarged common iliac artery aneurysm (red arrow, Figure 1d) and the extravasated contrast (red asterisk, Figure 1d) were confirmed on the three-dimensional reformats of the CT scan (Figure 1e).
An isolated aneurysm of the common iliac artery is uncommon, occurring in only 1% to 2% of the population—the same frequency as aortic aneurysm.1 However, the risk of rupture of this type of aneurysm is high.2 Patients with common iliac artery aneurysm are typically asymptomatic prior to rupture. However, some patients have reportedly presented with claudication, tenesmus/constipation, sciatica, and lower extremity paresis due to nerve compression, as well as urinary obstruction caused by ureteral obstruction.1,3 Once the iliac artery aneurysm has ruptured, patients typically present with acute abdominal, groin, and/or thigh pain, although isolated testicular pain has been described in the literature.1,4
Treatment for iliac artery aneurysm includes open and endovascular repair, depending on patient presentation and the adjacent structures involved. While mortality is low for patients with a nonruptured common iliac aneurysm, acute rupture is present in approximately one out of three cases, and the surgical mortality rate is as high as 55%.3
The patient presented in this case was taken to the operating room where an angiogram of the right common iliac artery (red arrow, Figure 1f) revealed continued acute extravasation of contrast (red asterisk, Figure 1f). Surgical repair was attempted but the patient did not survive due to complications of hypotension and cardiac arrest.
A 48-year-old man presented to the ED via emergency medical services after experiencing two episodes of syncope following the acute onset of right lower quadrant pain. He was unresponsive at the time of presentation. His vital signs were notable for tachycardia with a heart rate of 130 beats/minute. Although normotensive at initial presentation, the patient’s blood pressure began to fall rapidly. Laboratory values revealed a decreased hemoglobin and hematocrit of 5 g/dL and 18.1%, respectively.
Following his stabilization, a computed tomography (CT) scan of the abdomen and pelvis was performed. Figures 1a and 1b represent selected noncontrast and postcontrast axial images obtained through the lower abdomen/upper pelvis.
What is the diagnosis?
Answer
The precontrast image (Figure 1c) demonstrates a large and irregular high-density collection within the right upper pelvis (white arrows) and high density free fluid along the left lateral abdominal wall (black arrows). The right psoas muscle is obscured (white asterisk, Figure 1c) when compared to the normal psoas muscle on the contralateral side (black asterisk, Figure 1c). The postcontrast image (Figure 1d) shows the same findings and also reveals an enlarged right common iliac artery (red asterisk) and contrast actively extravasating from the artery (red arrow). These findings indicate the presence of a ruptured common iliac artery aneurysm. Both the enlarged common iliac artery aneurysm (red arrow, Figure 1d) and the extravasated contrast (red asterisk, Figure 1d) were confirmed on the three-dimensional reformats of the CT scan (Figure 1e).
An isolated aneurysm of the common iliac artery is uncommon, occurring in only 1% to 2% of the population—the same frequency as aortic aneurysm.1 However, the risk of rupture of this type of aneurysm is high.2 Patients with common iliac artery aneurysm are typically asymptomatic prior to rupture. However, some patients have reportedly presented with claudication, tenesmus/constipation, sciatica, and lower extremity paresis due to nerve compression, as well as urinary obstruction caused by ureteral obstruction.1,3 Once the iliac artery aneurysm has ruptured, patients typically present with acute abdominal, groin, and/or thigh pain, although isolated testicular pain has been described in the literature.1,4
Treatment for iliac artery aneurysm includes open and endovascular repair, depending on patient presentation and the adjacent structures involved. While mortality is low for patients with a nonruptured common iliac aneurysm, acute rupture is present in approximately one out of three cases, and the surgical mortality rate is as high as 55%.3
The patient presented in this case was taken to the operating room where an angiogram of the right common iliac artery (red arrow, Figure 1f) revealed continued acute extravasation of contrast (red asterisk, Figure 1f). Surgical repair was attempted but the patient did not survive due to complications of hypotension and cardiac arrest.
2. Reber PU, Brunner K, Hakki H, Stirnemann P, Kniemeyer HW. Incidence, classification and therapy of isolated pelvic artery aneurysm. Chirurg. 2001;72(4):419-424.
3. Bacharach JM, Slovut DP. State of the art: management of iliac artery aneurysmal disease. Catheter Cardiovasc Interv. 2008;71(5):708-714.
4. Dolan RD, Zino S. A ruptured left common iliac aneurysm presenting as testicular pain in a 56-year-old man. BMJ Case Rep. 2014. doi:10.1136/bcr-2012-006568.
2. Reber PU, Brunner K, Hakki H, Stirnemann P, Kniemeyer HW. Incidence, classification and therapy of isolated pelvic artery aneurysm. Chirurg. 2001;72(4):419-424.
3. Bacharach JM, Slovut DP. State of the art: management of iliac artery aneurysmal disease. Catheter Cardiovasc Interv. 2008;71(5):708-714.
4. Dolan RD, Zino S. A ruptured left common iliac aneurysm presenting as testicular pain in a 56-year-old man. BMJ Case Rep. 2014. doi:10.1136/bcr-2012-006568.
Emergency Imaging
An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.
An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.
|
|
|
What is the diagnosis?
Answer
Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.
Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.1
|
|
|
As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.2 Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.2
After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.
The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.
Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.
- Anderson DJ. Carcinoid tumor in Meckel’s diverticulum: laparoscopic treatment and review of the literature. J Am Osteopath Assoc. 2000;100(7):432-434.
- Malik AA, Shams-ul-Bari, Wani KA, Khaja AR. Meckel’s diverticulum-Revisited. Saudi J Gastroenterol. 2010;16(1):3-7.
- Altinli E, Pekmezci S, Gorgun E, Sirin F. Laparoscopy-assisted resection of complicated Meckel’s diverticulum in adults. Surg Laparosc Endosc Percutan Tech. 2002;12(3):190-194.
- Nath, DS, Morris TA. Small bowel obstruction in an adolescent: a case of Meckel’s diverticulum. Minn Med. 2004;87(11):46-48.
- Cullen, JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994;220(4):564-568; discussion 568,569.
An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.
An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.
|
|
|
What is the diagnosis?
Answer
Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.
Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.1
|
|
|
As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.2 Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.2
After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.
The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.
Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.
An 11-year-old boy is brought to the ED with a 1-week of history of increasing crampy lower-quadrant abdominal pain. His vital signs were only significant for mild tachycardia. On physical examination, the child’s abdomen was tender to palpation in the bilateral lower abdominal quadrants with guarding. Laboratory evaluations were unremarkable.
An abdominal radiograph did not reveal any abnormality, and targeted ultrasound did not reveal a dilated appendix. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast were ordered and representative images are provided (Figures 1a and 1b). Note that additional images from the CT demonstrate the abnormality depicted in these figures was not a loop of small bowel (although it appeared to originate from a loop of distal small bowel) and that the appendix was normal.
|
|
|
What is the diagnosis?
Answer
Computed tomography revealed a blind-ending tubular structure (white arrows, Figure 1c) deep to the umbilicus arising inferiorly from a loop of distal ileum with surrounding fat stranding (Figure 1d). The fluid-containing tubular structure demonstrates marked enhancement of the mucosa. These findings are most consistent with Meckel’s diverticulitis.
Meckel’s diverticulum is the most common anomaly of the gastrointestinal (GI) tract and results from incomplete obliteration of the vitelline duct. As per the rule of “twos,” Meckel’s diverticulum usually occurs 2 feet (40-60 cm) proximal to the ileocecal valve; is 2 cm wide (and 3 cm long); is found in 2% of the population; typically presents before age 2 years; is twice as likely to be symptomatic in boys; and contains ectopic gastric mucosa in approximately half of the cases.1
|
|
|
As many patients are asymptomatic, Meckel’s diverticulum is diagnosed as an incidental finding after a barium study or abdominal surgery is performed for other GI conditions. Symptoms occur as a result of ectopic gastric tissue, obstruction, and/or inflammation. Painless lower GI bleeding, the most common presentation, is reported in up to 50% of patients with symptomatic Meckel’s diverticulosis.2 Hemorrhage results from ulceration caused by secreted acid and enzymes from ectopic digestive mucosa. Intestinal obstruction is another common complication usually seen in children, which can be caused by volvulus of the small bowel around a diverticulum, intussusception, incarceration within a hernia, and internal herniation. Inflammation of the Meckel’s diverticulum, or Meckel’s diverticulitis, is more common in older patients and presents similarly to acute appendicitis.2
After removal of a complicated Meckel’s diverticulitis, postoperative morbidity and mortality rates have been reported to be 12% and 2%, respectively. In contrast, postoperative complications after resection of incidental diverticula are fewer, and morbidity and mortality rates are as low as 2% and 1%, respectively.3-5 Meckel’s diverticulitis should be included as a differential diagnosis when appendicitis or medically managed abdominopelvic inflammatory processes are suspected, as delayed diagnosis can lead to perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death.
The patient presented in this case was taken to the operating room, and the Meckel’s diverticula confirmed and removed. He experienced an uneventful postoperative course and was discharged a few days later.
Dr Rotman is a radiology resident at Weill Cornell Medical College in New York City. Dr Belfi is an assistant professor of radiology at Weill Cornell Medical College in New York City and an assistant attending radiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College, New York. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.
- Anderson DJ. Carcinoid tumor in Meckel’s diverticulum: laparoscopic treatment and review of the literature. J Am Osteopath Assoc. 2000;100(7):432-434.
- Malik AA, Shams-ul-Bari, Wani KA, Khaja AR. Meckel’s diverticulum-Revisited. Saudi J Gastroenterol. 2010;16(1):3-7.
- Altinli E, Pekmezci S, Gorgun E, Sirin F. Laparoscopy-assisted resection of complicated Meckel’s diverticulum in adults. Surg Laparosc Endosc Percutan Tech. 2002;12(3):190-194.
- Nath, DS, Morris TA. Small bowel obstruction in an adolescent: a case of Meckel’s diverticulum. Minn Med. 2004;87(11):46-48.
- Cullen, JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994;220(4):564-568; discussion 568,569.
- Anderson DJ. Carcinoid tumor in Meckel’s diverticulum: laparoscopic treatment and review of the literature. J Am Osteopath Assoc. 2000;100(7):432-434.
- Malik AA, Shams-ul-Bari, Wani KA, Khaja AR. Meckel’s diverticulum-Revisited. Saudi J Gastroenterol. 2010;16(1):3-7.
- Altinli E, Pekmezci S, Gorgun E, Sirin F. Laparoscopy-assisted resection of complicated Meckel’s diverticulum in adults. Surg Laparosc Endosc Percutan Tech. 2002;12(3):190-194.
- Nath, DS, Morris TA. Small bowel obstruction in an adolescent: a case of Meckel’s diverticulum. Minn Med. 2004;87(11):46-48.
- Cullen, JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994;220(4):564-568; discussion 568,569.
