Portal and Splenic Vein Thrombosis Caused by Acute Pancreatitis

A 30-year-old Hispanic gentleman with past medical history of hypertension and dyslipidemia, presented to the emergency department with complaints of a blunt, constant, epigastric pain radiating to his back for 24 hours. Physical examination revealed a man in severe distress, tachypneic and tachycardic. Laboratory data, as well as the physical exam, were consistent with acute severe pancreatitis. The patient was admitted to the intensive care unit (ICU) and a computed tomography (CT) of his abdomen was obtained revealing a large thrombus in the portal vein (Figure 1).
The patient’s condition deteriorated requiring assisted ventilation and vasopressor support. Two weeks following his admission to the ICU, a repeat CT of the abdomen revealed persistence of the portal vein thrombus and a new splenic vein thrombosis (Figure 2). The patient was managed conservatively with anticoagulation and eventually weaned off assisted ventilation. The patient was discharged home several weeks after his initial admission.


Giant Right Atrium Secondary to Mitral Stenosis

A 59-year-old Hispanic lady with history of rheumatic fever and chronic atrial fi brillation presented to the emergency department with severe dyspnea. Seventeen years prior to this presentation, she had undergone re-do mitral valve replacement, and tricuspid annuloplasty. The patient’s chest radiograph revealed massively dilated right chambers of the heart (Figure 1). An electrocardiogram showed right axis deviation, atrial fi brillation with a controlled heart rate of 70 beats per minute. A chest computed tomography (CT) scan revealed a gigantic right atrium measuring approximately 12 cm in its largest diameter (Figure 2).
These images are relevant because this reveals one of the few cases of massively dilated right atrium, despite previous mitral valve replacement and tricuspid annuloplasty. Other etiologies of a dilated right atrium in patient with dyspnea in the ED and intensive care unit (ICU) include: chronic obstructive pulmonary disease, tricuspid valvular stenosis, severe mitral valvular pathology with pulmonary hypertension, chronic pulmonary emboli, and untreated congenital heart disease.


Respiratory Distress in an Elderly - Delayed Presentation of an Odontoid Fracture

An 85-year-old man with history of severe dementia lay down for a nap and was witnessed by his family to immediately lose consciousness, with agonal breathing. He was ventilated by facemask by the paramedics when they attended. His vital signs were stable. On admission to hospital he grimaced to painful stimulus only (Glasgow Coma Score=6/15). His arterial blood gas revealed - pH 7.21, pCO2 70 mmHg and bicarbonate 27 mmol/L. He was intubated.
The patient had a fall 1 week before. He had complained of intermittent headache and neck pain since then. He also developed new symptoms of breathlessness upon lying fl at. Computed tomography (CT) of cranium and neck was done. Figure 1 and 2 showed a fracture through the base of the odontoid (type II). Figure 3 showed prevertebral soft tissue swelling associated with the fracture. After discussion with the family, he was treated conservatively with a cervical collar in view of his advanced age and dementia.