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Hi Dr Chail, Can You Please Measure For SMA On

Posted on Thu, 2 Apr 2020

Question: Hi Dr Chail, can you please measure for SMA on secretin scan.I found an article that shows secretin mrcp is good for diagnosing sma syndrome.It was a study on use of secretin mrcp for sma.I am emailing the scan and information on how they measure for sma on secretin mrcp incase you are not familiar with because it is rare though, you probably already know the information.They are doing another upper gi next week but thought perhaps you could help by givng me the measurements as well as sending images from the secretin scan.Thank You Very Much for all of your careful attention Dr Chail.

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail, can you please measure for SMA on secretin scan.I found an article that shows secretin mrcp is good for diagnosing sma syndrome.It was a study on use of secretin mrcp for sma.I am emailing the scan and information on how they measure for sma on secretin mrcp incase you are not familiar with because it is rare though, you probably already know the information.They are doing another upper gi next week but thought perhaps you could help by givng me the measurements as well as sending images from the secretin scan.Thank You Very Much for all of your careful attention Dr Chail.

Answered by Dr. Vivek Chail (22 hours later)

Brief Answer:
The aortic mesentric distance is suspicious for SMA syndrome

Detailed Answer:
Hi,
Thanks for writing in to us.

I did as mentioned in the article sent.

The aortic mesentric distance measured is 9.3 mm and is in the grey area between 8 for SMA syndrome and 10 for normal.

There is narrowing of the third part of the duodenum.

Please find images in the below links
https://ibb.co/X70NGQZ
https://ibb.co/VCGRRcM

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (5 hours later)

Hi Dr Chail, I am emailing 3 pictures and we are wondering if the thing we circled that looks like something flattened is the duodenum.Thank you for the last measurements; you have been very helpful.

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail, I am emailing 3 pictures and we are wondering if the thing we circled that looks like something flattened is the duodenum.Thank you for the last measurements; you have been very helpful.

Follow up: Dr. Vivek Chail (2 minutes later)

Hi Dr Chail, we were wondering what that is that looks like a flying saucer sort of.Is that the duodenum flattened? The other 2 pictures are before and after the image.
Just looks like something is flattened in that image.Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (19 hours later)

Brief Answer:
I have viewed the email images.

Detailed Answer:
Hi,
Thanks for your valuable acknowledgements.

I viewed the email images. The small pocket of gas collected adjacent to the cholecystectomy clip is likely air in the pylorus antrum of the stomach. I have checked the area on the 2019 images.

The duodenum is not completely flattened and there is partial luminal distension.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (46 hours later)

Hi Dr Chail

I wanted to know if you see also, nutcracker syndrome.It looks as if the renal vein is compressed also and it stays enlarged as if swollen in all sigital images.He has a varicolocele and studies show, 50-100% of people with varicolocle have nutcracker syndrome.
He had both sides of lymph nodes swell and cause pain in his groin at one time.

I am emailing 3 images to you.One image I believe shows the third duodenum distended, another image from secretin scan shows a high signal area to the right of the left kidney; nutcracker maybe?
The last image shows something that looks odd to me and would like to know what part of intestines it is and if you think it is a problem.Please; what is it?All images are from secretin mrcp.

I am not trying to bother you with so many questions but am afraid they will try to say nothing is wrong with him again.
He has had no appetite,early satiety and constipation all of his life with intermittent vomiting and large tears in his intestines from constipation more so the past 4 years or so.Anyway, his symptoms have worsened and has resulted in several trips to the hospital.Also, the passing out during large blood draws ( small ones do not seem to affect him; is new the past 4 years.
When he vomits its bad and he almost passes out with very rapid pulse and reports that he sort of blacks out during episodes.

I think we found a good surgeon here but if they do not help him here soon, we are taking him out of the country and wondered if you could recommend a surgeon in XXXXXXX ( your in XXXXXXX ,correct?

Thank you again sir.
XXXXXXX Massingill, Logans Mom

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (21 hours later)

Brief Answer:
There are no significant features of nutcracker syndrome

Detailed Answer:
Hi,
Thanks for writing in to us.

In nutcracker syndrome the diameter of the left renal vein is greatly decreased. In XXXXXXX the left renal vein diameter is measuring 4.5 mm and is in the acceptable normal range. Nutcracker syndrome is ruled out.

The areas in green circles are in images 2 and 3 are areas of mucosal fold.

In reply to a good facility in XXXXXXX we have Asian Institute of Gastroenterology in XXXXXXX a city in South XXXXXXX The website is https://aigindia.net/ and you can contact them for more details.

The above information is given as requested by you and I am not associated with Asian Institute of Gastroenterology through any kind of partnership but they do have the best facility in the country.
Regards,

Above answer was peer-reviewed by : Dr. Yogesh D

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Vivek Chail (7 hours later)

Thank you for the information Dr Chail, Very Much Appreciated

Follow up: Dr. Vivek Chail (0 minute later)

Thank you for the information Dr Chail, Very Much Appreciated

Answered by Dr. Vivek Chail (9 hours later)

Brief Answer:
Thanks

Detailed Answer:
Thanks for sending your query.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Brief Answer:
Thanks

Detailed Answer:
Thanks for sending your query.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (11 hours later)

Hi Dr Chail, the images in folder are from secretin scan also attached.

We want to know why there is a big ball (signal void) in the first part of Logans duodenum.

It looks like veins crossing his common bile duct are restricting it.In one image at the top of the duct you see the hepatic artery crossing and there is a small black signal void just under it; is an area you mentioned before.

If you look in 3 d ,it looks as if the duct that is wrapping around d2 junction, is it restricting his duodenum some and we wonder if it is why it is distended some.

We also wonder why the third of the duodenum is filled while there is still part of d2 not filled.

There is an area towards bottom of duct above ampulla of vater that has something beside it ( have been told it is scar tissue) and it seems as if it is wrapped around it.

Is there a diverticula at D2 ,where it is protruding out some?

In the duct that is wrapping around it looks like there are a few small signal voids, could that be tiny stones?

In some images it looks as if the third of duodenum is distended like a balloon, is that the sma showing?

Lastly, it looks as if the left intrahepatic duct holds secretin after it has drained every where else and 3 radiologist say there is a signal void in intrahepatic duct.

I know this is a lot of questions and we will pay extra if needed but, it is necessary for us that we understand some of the odd things we are seeing.

It looks like his IVC, or portal vein is really distended and it looks like there is something( black circle) at his ampulla.

Please answer what you can for first query and( 2 follow up questions) included and we will pay again when you think we have exceeded the appropriate amount of time spent.In other words; this counts for all 3 queries and we will pay more.

The surgeon ordered another upper gi and I wonder if you think it is necessary to prove sma as we ourselves can see what you are speaking of.

How certain are your suspicions of sma?
secretin1.zip
XXXXXXX has recently been reporting that his head is getting really hot at times and that his thinking is impaired.Also reports that his stomach feels weird when it is hurting but says he does not know how to explain it.

Please continue with your great descriptions on things, we truly appreciate you Dr Chail.

Sincerely

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (21 hours later)

Brief Answer:
There is air in the duodenum causing signal void

Detailed Answer:
Hi,
Thanks for writing in to us.

There is air in the duodenum and is causing signal void. I have compared the MRCP and CT scan images and there are transient areas of luminal constriction but do not look like any significant area of stricture like any vascular loop in the area.

There are no stones int he biliary tree. The common bile duct is prominent due to post surgery effects.

It is agreed that the IVC is prominent but there is no specific cause that can be identified in the given images.

There is a small constriction in the proximal common hepatic duct as visualised is the secretin images but there is no dilatation of the biliary tree. Therefore the signal void is not looking like a calculus and might be artefactual or a small area of luminal constriction.

Payment is not an issue. You can ask as many questions using each follow up.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (34 hours later)

Hi Dr Chail
Please tell me how sure you are that XXXXXXX has SMA as a cause of his problems.

Are you referring to the bowels or blood vessels when you refer to vascular loops?

Your saying the big black ball to the right of the duodenum is air?
Is that normal?

If his duct is around duodenum, isn't that extramural annular pancreas?
I've read that when the duct is identified to the right of duodenum, extramural annular pancreas is diagnosed & that it is not necessary to see tissue.
I've also read that it is more pathologies between the duct going around the duodenum than the size of the circumference of tissue ( says food can usually pass through.
I've also read that anyone with that configuration should have it corrected.

I've read about friction lesions being caused by the pull on the duct & also think if that is big ball of air distending the duodenum then the duct is causing it possibly.
I read an article where it is just what caused problems with a lady ( the duct going around the duodenum.

Do you think Ercp with spincterectomy would keep the bile from refluxing into his stomach?

The doctor who did EGD says Logan's stomach is huge and was full of bile.

I know annular pancreas is rare & not that much is known about it.

Another radiologists says, " anyone with that configuration of duct can have annular pancreas.
I read about 1 lady diagnosed & they didn't even see pancreas tissue at surgery but it was lead point of problem just the same.

Just trying to understand what I am reading compared to what radiologists are telling me.

Thank you Very Much XXXXXXX

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (28 hours later)

Brief Answer:
You can discuss sphincterotomy with your doctors

Detailed Answer:
Hi,
Thanks for writing in to us,
XXXXXXX might be having symptoms of intermittent SMA syndrome. This is because the distance is not too less to call it a severe SMA syndrome but in some images there is a suspicion of possible intermittent SMA effects.

By vascular loops I intend to refer to vessels.

The air in proximal duodenum is a variable finding and can be normal.

There are many variations of extramural annular pancreas and it is difficult to always visualised one. In case of XXXXXXX there can be a mild form of extra mural annular pancreas but is not well visualised on the images.

Sphincterotomy may help in clearing a downward passage for the bile. It can be tried with a positive outlook if your doctors are agreeing to it.

Annular pancreas, especially incomplete types are known to cause variable symptoms in different patients and intramural pancreas makes it even more difficult to classify it as an annular pancreas. I myself have never come across any intramural pancreas in my patients.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (2 days later)

Brief Answer:
Unable to find ultrasound playboy bunny sign image

Detailed Answer:
Hi,
Thanks for writing to us.

I am unable to find the ultrasound image showing playboy bunny sign.
Request you to confirm after uploading the correct image.

Regards,

Above answer was peer-reviewed by : Dr. Raju A.T

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Vivek Chail (20 minutes later)

Hi Dr Chail

I am sending a picture of ultrasound that I think matches play boy bunny sign. They say can be right sided congestive heart failure.
Please, what is your opinion.

Thank you Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail

I am sending a picture of ultrasound that I think matches play boy bunny sign. They say can be right sided congestive heart failure.
Please, what is your opinion.

Thank you Very Much

Follow up: Dr. Vivek Chail (3 days later)

Hi Dr Chail

I am emailing MRCP fron Envision imaging that a radiologist said had images that look pathalogical.I am attaching a single picture from the scan so, you will know which area I am talking about.

Please check the veins for narrowing.

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (22 hours later)

Brief Answer:
Inferior venacava is mildly prominent

Detailed Answer:
Hi,
Thanks for writing in to us.

I do not find the typical playboy bunny sign in the mailed images. The inferior venacava is mildly prominent but an echocardiography is important if he is showing any signs of chest pain or breathlessness.

The MRCP images are also showing a mildly prominent inferior vena cava.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (1 hour later)

Hi Dr Chail

Thank you for your answers to the other questions.
I am emailing a small bowel follow through and want to know if it shows SMA syndrome or other problems.

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail

Thank you for your answers to the other questions.
I am emailing a small bowel follow through and want to know if it shows SMA syndrome or other problems.

Thank you

Answered by Dr. Vivek Chail (19 hours later)

Brief Answer:
The small bowel series is showing a delayed transit of contrast in duodenum

Detailed Answer:
Hi,
Thanks for writing in to us.

The small bowel series is showing a delayed transit of contrast from the gastric outlet to the duodenum jejunum area and might be an indirect sign of a SMA obstruction.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (12 hours later)

Thank you for the information.
Please let me know about questions about IVC. I attached images for.
Another radiologists says that it looks pathological.

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Thank you for the information.
Please let me know about questions about IVC. I attached images for.
Another radiologists says that it looks pathological.

Thank you

Answered by Dr. Vivek Chail (28 hours later)

Brief Answer:
Can you please send me the DICOM images for better visualisation

Detailed Answer:
Hi,
Thanks for writing in to us.

I am not able to see through the images in jpg format smoothly.
Can you please send me the DICOM images for better visualisation.

Sorry for the inconveniences.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (10 hours later)

Hi Dr Chail

I wanted to know what the bubble looking thing is in axial image.I was told it was the portal vein but do not understand why it looks like a bubble.It looks as if the bottom of his ivc ( left branch) is compressed.You can see the high signal and follow it in all the images.

I added some pictures from eastland ct when we took him due to pain.That was before gallbladder was removed and you see air there that I believe you said was in duodenum or pylorus.

I see it in all of his scans but eastland shows it best.
I wondered if it is caused by diverticula.
There is also a signal void in the liver and I was wondering why.

Thank you Sir

Please comment on compressed veins, sma and anything else you see.

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (14 hours later)

Brief Answer:
Looks like common bile duct

Detailed Answer:
Hi,
I am not able to locate series 403 images few of which you have uploaded in the query above.

The circled structure looks to me like the distal common bile duct area. It is important to see all the images of the series 403 to confirm my suspicion. Though I am not saying it cant be the left portal vein branch.

Regarding the dilated IVC, there are rare possibilities of isolated dilatation of the IVC
You can read more about it inthe link below

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (34 hours later)

Hi Dr Chail, I do not know which other pictures you are talking about but, will look back and figure out what I sent exactly.

I emailed 6 pictures from Ct Angiography and wanted to know what the area circled is showing.It looks like same signal as stomach but is under the pancreas near the tail 9 if is not the tail.

Please let me know what it is and I will resend other images from previous questions in my next query.

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (13 hours later)

Brief Answer:
There is no adrenal lesion in the images

Detailed Answer:
Hi,
Wishing you XXXXXXX and your family a happy new year.

There is no adrenal lesion in the images. It is from the bowel in the dudenum and Jejunum area near the tail of pancreas.

Regards,

Above answer was peer-reviewed by : Dr. Kampana

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Kampana

Follow up: Dr. Vivek Chail (2 hours later)

Happy New Year to you & your family also Sir.

Is there inflammation in the area or, why else does it look swollen?

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Happy New Year to you & your family also Sir.

Is there inflammation in the area or, why else does it look swollen?

Thank you

Answered by Dr. Vivek Chail (18 hours later)

Brief Answer:
No bowel inflammation

Detailed Answer:
Hi,
Thanks for writing in.

There is no inflammation in the area. It is possible that the bowels were in contraction and causing such an image.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (35 hours later)

Hello Dr Chail
I am sending a few pictures email, from the neck scan that I think show air cyst possibly or ,other problem.Please explain why it looks like there is air cyst if is not that.Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Hello Dr Chail
I am sending a few pictures email, from the neck scan that I think show air cyst possibly or ,other problem.Please explain why it looks like there is air cyst if is not that.Thank you

Answered by Dr. Vivek Chail (13 hours later)

Brief Answer:
Part of the posterior lung in the prevertebral area and is not a cyst.

Detailed Answer:
Hi,
Thanks for writing in.

The area showing cyst like density in the given images is part of the posterior lung in the prevertebral area and is not a cyst.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (9 hours later)

Hi Dr Chail, Thank you for explanation.
XXXXXXX had a EUS a couple of years ago and Dr XXXXXXX said he saw tissue completely surrounding D2 junction of duodenum; said he could see it clearly.
He suspected annular pancreas but, could it have been trapped food he saw?

If not, Please; what else could it have been?

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (2 hours later)

Brief Answer:
contraction of the muscles in the wall of the duodenum causing thenarrowing

Detailed Answer:
Hi,
Thanks for writing in to us.

Chances of trapped food during endoscopy after taking precautions for bowel preparation are less but cannot be ruled out. The likely possibility can be a contraction of the muscles in the wall of the duodenum causing the narrowing of lumen.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (30 hours later)

Hi Dr Chail

The Gastro surgeon ( Dr XXXXXXX Carlton) here wants to know if he can call and talk to you briefly.
I will pay for it.

Please instruct me on how this can be arranged and how I pay you.

He is advising Logan's Gastro to do the ERCP with sphincterotomy as you suggested and will be doing the bypass for Sma syndrome after that.

Thank You Very Much Dr Chail
XXXXXXX Massingill

Follow up: Dr. Vivek Chail (0 minute later)

Follow up: Dr. Vivek Chail (16 hours later)

Hi Dr Chail

I am emailing no contrast ct and a few individual pictures.I am wondering what individual pictures are showing.Please explain and ,Please advise on how our surgeon can speak with you.

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (42 minutes later)

Brief Answer:
Can I request for a written communication to for better understanding

Detailed Answer:
Hi,
Thanks for writing into us.

My regards to Dr XXXXXXX XXXXXXX I guess he is a practicing surgeon in TX and will do the planned procedures ERCP and sphincterotomy and the SMA bypass surgery.

In the present situation, it is difficult to reach out to Dr XXXXXXX due to my scheduled limitations and the fact that there might be a miscommunication in the way I speak English with a different accent.

However, it will be great if I can request Dr XXXXXXX XXXXXXX to send his questions as a list through your moderation and I shall be delighted to reply to all the concerned points in reply.

The image in secretin MRCP is showing a distended duodenum. There is no obstruction.

The CT images are showing a collapsed descending colon.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (1 hour later)

Hi again Dr Chail, I did not send my first question when I paid so, here it is.

Did the other individual images I sent show polys or hernia, or, what are the round lesions please.

I can re-email them if you would like.

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (13 hours later)

Brief Answer:
No polyp or hernia in the given images

Detailed Answer:
Hi,
Thanks for writing in to us.

I have received 04 images in mail and there is no image showing any polyp or hernia.

You might like to send any missing images for review.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (7 hours later)

Hello Dr Chail

From the 4 images last sent,can you please tell me what the left sided white circles in the no contrast ct are please.

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Hello Dr Chail

From the 4 images last sent,can you please tell me what the left sided white circles in the no contrast ct are please.

Thank You Very Much

Answered by Dr. Vivek Chail (15 hours later)

Brief Answer:
I am not able to find any images showing white circles in the no contrast

Detailed Answer:
Hi,
Thanks for writing back to us.

I am not able to find any images showing white circles in the no contrast images.
Can you please send them in email.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (4 days later)

Hi Dr Chail

I am emailing a few jpeg images of the area I am wondering about.
Also sending ct angiography.
I wonder about sigmoid or spenic flaxture volvus because area in all scans does not look right.

at the bottom of the pancreas ( body of) in angio axial ct, it looks like there is either part of stomach or bowel in the wrong place or, possibly adrenal gland problem.

There is also signs above the pancreas ( a closed circle and what appears to be diverticula maybe.

There is a vein beside left kidney in all scans that looks prominent as well.
The IVC looks odd as well in both axial and coronal images.

In MRCP (different scan) there is an area near IVC on axial image that another radiologist says looks pathalogical to her.I will attach jpeg of that and will send entire scan on next inquiry.

They say sigmoid knots can be hard to diagnose so, thought perhaps you could look at ct again with the colon given special attention.

He has held feces in his colon in every scan for 4 years now ,even after fasting.He must take laxatives to move his bowels as well.

He has had episodes of blood mucious in stool and has had puking and bowel movement at the same time but only blood and mucious came out.

The severe symptoms are intermittent but bad when it happens.
He has near lost conscious at times and takes a long time for his pulse to slow when it happens.
XXXXXXX ; walked on hands, did cart wheels and flips, very soon after starting to walk and I wonder if something got twisted and is twisting and untwisting periodically.

I also wonder about his spleen as his red blood cells show rare value.

I will email the images and the scan now.

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (22 hours later)

Brief Answer:
Please read the reply to images sent in mail.

Detailed Answer:
Hi,
Thanks for your images.

Please read the reply to images sent in mail.

1. There are no areas of concern for volvulus in the sigmoid colon and splenic flexure area.

2. There is no adrenal gland problem and it might be a partial volume of the area.

3. There is no diverticula in pancreas area.

4. The inferior venacava is mildly prominent but other veins are normal.

5. There are no old rib fractures. It is partial visualisation of the vertebrae and ribs.

Regards,

Above answer was peer-reviewed by : Dr. Prasad

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Vivek Chail (8 hours later)

Ok, Thank you Dr Chail

Follow up: Dr. Vivek Chail (0 minute later)

Ok, Thank you Dr Chail

Answered by Dr. Vivek Chail (28 hours later)

Brief Answer:
Thanks

Detailed Answer:
Thanks for consulting me online

If you are satisfied, kindly close the thread and rate the answer.

Take care

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Brief Answer:
Thanks

Detailed Answer:
Thanks for consulting me online

If you are satisfied, kindly close the thread and rate the answer.

Take care

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (6 days later)

Hi Dr Chail

I just sent you an email.It looks like XXXXXXX has a laryngocele.I have several matching pictures of others diagnosed.Looks like there are other problems also, comparing to others scans who were diagnosed. Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (10 hours later)

Brief Answer:
No laryngocele is visualised in the given images

Detailed Answer:
Hi,
Thanks for writing in to us.

The larynx is mildly prominent but there is no large dilatation of the lateral wall of layngeal airway. The rest of the structures visualised are the epiglottis, valleculae, pyriform sinuses, aryepiglottic folds are normal.

The septation in the right mastoid temporal bone is a normal variation.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (2 days later)

Hi Dr Chail

I sent my last 2 follow up questions to your email.

Thank you

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail

I sent my last 2 follow up questions to your email.

Thank you

Answered by Dr. Vivek Chail (21 hours later)

Brief Answer:
Please see image for SMA aorta distance

Detailed Answer:
Hi,
Thanks for writing in to us.

In the recent CT images the SMA aorta distance is measuring 5.5 mm.
Please find the image in the link given below.

https://ibb.co/QvYjpf0

Regarding the IVC diameter, it is mildly dilated but in the absence of other features of cardiac congestion, it might be an isolated finding. There is no significant feature of nut cracker phenomenon on the left renal artery.

The liver parenchyma is not showing any significant abnormalities.

Regards,

Above answer was peer-reviewed by : Dr. Prasad

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. Vivek Chail (5 hours later)

Hi Dr Chail.
Thank you for the measurement on prime ct.Can you Please answer the email sent before that one?

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail.
Thank you for the measurement on prime ct.Can you Please answer the email sent before that one?

Thank You Very Much

Answered by Dr. Vivek Chail (31 hours later)

Brief Answer:
Replies to previous queries

Detailed Answer:
Hi,
Thanks for writing in to us.

Regarding the prominent IVC, it is mildly dilated but in the absence of other features of cardiac congestion, it might be an isolated finding. There is no significant feature of nut cracker phenomenon on the left renal artery.

There is no abnormal area in the throat.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (8 days later)

Hi Dr Chail, I paid again yesterday and sent a query to your email.I just sent a follow up query as well.

Thank You Sir

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail, I paid again yesterday and sent a query to your email.I just sent a follow up query as well.

Thank You Sir

Answered by Dr. Vivek Chail (18 hours later)

Brief Answer:
The area in the stomach is the contrast and air together in the lumen.

Detailed Answer:
Hi,
Thanks for writing in to us.

The area in the stomach is the contrast and air together in the lumen. It is a normal finding.

The area in the middle near the heart is showing normal image artefacts due to different structures in various imaging planes.

The right lower anterior abdominal wall showing mild heterogeneousity due to the fat in the area.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (3 days later)

Hi Dr Chail

Thank you for the previous explanations.I sent you an email and wold like to know if any sort of compression on the aorta is seen and why his esophagus looks that way.

Thank You Very Much
I already paid again

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (5 hours later)

Brief Answer:
There is no aorta compression in the given images

Detailed Answer:
Hi,
Thanks for writing in to us.

The aorta diameter is in normal range. There is no compression of the aorta in the given images.

The esophagus gets distended when food is in the lumen and otherwise shows collapsed walls.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (37 hours later)

Hi Dr Chail

I wanted to ask; how come the only thing that comes up when I research the duct of wirsung going around Logans duodenum is, annular pancreas? Dr XXXXXXX viewed the scan and said it looked like annular pancreas to him as well.Are you saying it is not just because there is no narrowing? Just wondered because I have read a lot of articles on annular pancreas and some say." food can usually pass through but, pathologies in and around the ducts themselves is more the problem.I read one article where a man had a hepatic artery coming from superior mesenteric artery and he had annular pancreas.Logans hepatic artery is narrowed and I wondered if you could tell if it is connected correctly.The main thing I want answered is, why when all articles say ," when duct is identified to the left of duodenum, a diagnosis of annular pancreas is made, no need to identify tissue.Please, why are you saying it is not annular ancreas when the duct is definatley to the left of his duodenum.

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (12 hours later)

Brief Answer:
There is annular pancreas by definition without annulus of pancreas tissue

Detailed Answer:
Hi,
Thanks for writing back to us.

I have reviewed the matter of concern.

Technically pancreatic parenchyma or annular duct is seen to completely surround the 2nd part of duodenum in a case of annular pancreas. So what Dr. XXXXXXX says is correct. However there is no annulus of pancreas tissue surrounding the pancreas.

So we can change to call it annular pancreas with annular duct and non visualisation of complete annulus of pancreas tissue in the area.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (35 hours later)

Hello Dr Chail

I emailed the mesenteric doppler complete.Please give me your opinion on the readings.I am going to pay again as I believe I used all follow up questions.

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Hello Dr Chail

I emailed the mesenteric doppler complete.Please give me your opinion on the readings.I am going to pay again as I believe I used all follow up questions.

Thank You Very Much

Answered by Dr. Vivek Chail (13 hours later)

Brief Answer:
Celiac artery reading is high

Detailed Answer:
Hi,
Thanks for writing in to us.

The SMA and splenic arteries are showing normal range of peak systolic velocity.

I have doubt over the reading of the celiac artery velocity and is high. Doppler readings depend a lot on the machine settings so I would have liked to repeat the celiac artery velocity reading to confirm.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (17 hours later)

Hi Dr Chail

So, you think the reading is incorrect on celiac trunk? If it is correct , is that indicative of Mals?

I just emailed the eastland ct back to you because I noticed his right kiney artery looks compressed or, his right one is enlarged.Please give me your opinion.It matches a ct showing spermatic vein compression.He had pain in both sides of his groin in the past.

Thanks Dr Chail

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (4 hours later)

Brief Answer:
The arteries of both the kidneys are normal

Detailed Answer:
Hi,
Thanks for writing in to us.

I would have repeated the Doppler exam of the celiac trunk on a different machine if needed.

The arteries of the kidneys are normal.

The testis veins are very small and compression can cause varicocele. On the left it drains to the left renal vein and on the right to the inferior venacava. The veins do not look compressed but a scrotum scan might be needed to evaluate groin and pain in the testis area.

The bilateral ureters are normal.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (12 hours later)

Hi Dr Chail

Thank you for explaining the last inquery.

I am requesting clarification on what you mean by;"
The right lower anterior abdominal wall showing mild heterogeneousity due to the fat in the area.

Can you Please explain in more detail what the statement above means and send me the image you are referring to?

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (33 hours later)

Brief Answer:
The findings are not significant.

Detailed Answer:
Hi,
Thanks for writing in to us.

Please find the picture in your reply mail.
The findings are not significant.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Brief Answer:
The findings are not significant.

Detailed Answer:
Hi,
Thanks for writing in to us.

Please find the picture in your reply mail.
The findings are not significant.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (38 hours later)

Hi Dr Chail, Thank you for the explanation.I just sent a reply email with a few other pictures.I want to know if you see diviseum ,what lights outside the abdomen on eastland ct are and sent a question about his bowels in eastland scan that look odd to me.

Please explain what pictures show and email back any relevant images.

Thanks agin
XXXXXXX Massingill

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (15 hours later)

Brief Answer:
There is likely pancreas divisum type II

Detailed Answer:
Hi,
Thanks for writing in to us.

1. The image in circle is not showing compression.

2. There is no whole in the area. That is artefactual.

3. That is not the narrowed hepatic artery.

4. It looks like a pancreas divisum type II.

5. There is no significant lesion in the ampulla of Vater area.

6. In a fat suppressed image area surrounding the pancreas will be dark.

7. The area is outside and might be a marker.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (8 hours later)

Hello Dr Chail

Thank you for the previous answers.I just sent a follow up with images and questions.

I was wondering if you could send me images of the narrowed hepatic artery from previous scans ,if it is not too much trouble.

Thank You Very Much

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (20 hours later)

Brief Answer:
There is no narrowing of celiac and common hepatic arteries

Detailed Answer:
Hi,
Thanks for writing in to us.

Celiac and common hepatic artery images sent in mail.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Brief Answer:
There is no narrowing of celiac and common hepatic arteries

Detailed Answer:
Hi,
Thanks for writing in to us.

Celiac and common hepatic artery images sent in mail.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (7 hours later)

Hi Dr Chail

I just emailed you some images of area with fat stranding.I believe XXXXXXX may have a small intercostal hernia there according to matching pictures of cases.It may explain his shortness of breath a lot and sharp pains in his chest at times.

If I need to pay again, Please let me know but a few times I paid before writing in my question so, follow ups were off.
I do not mind paying again though Sir as I really do believe you to be a Invaluable Dr.

Sincerely
Logan's Mom

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (13 hours later)

Brief Answer:
There is no obvious rib problem or intercostal hernia.

Detailed Answer:
Hi,
Thanks for writing in to us.

There is no obvious rib problem or intercostal hernia.
Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Brief Answer:
There is no obvious rib problem or intercostal hernia.

Detailed Answer:
Hi,
Thanks for writing in to us.

There is no obvious rib problem or intercostal hernia.
Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (3 days later)

Hi Dr Chail

I sent my husbands scans via drop box and sent a few images in email.Please Sir, can you see hernias or anything else wrong.He has reflux and has pain and tingling in feet as well as gets dizzy at times and often chokes on food.He is also having trouble urinating.

Thank You Sir

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (5 hours later)

Brief Answer:
I have have been waiting for the Dropbox image files.

Detailed Answer:
Hi,
Thanks for writing in to us.

I have received only a viewer file on Dropbox and have been waiting for the image files.

The images sent in mail do not show a confirmed paraduodenal hernia.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (30 hours later)

Hi Dr Chail

Please look for any hernias on Kevins scan.It looks like hiatal and possible diaphragm hernia.His veins take an odd course as well.Are there any anomalies of his veins?

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail

Please look for any hernias on Kevins scan.It looks like hiatal and possible diaphragm hernia.His veins take an odd course as well.Are there any anomalies of his veins?

Thank You

Answered by Dr. Vivek Chail (14 hours later)

Brief Answer:
There are no large diaphragmatic defects or hernias.

Detailed Answer:
Hi,
Thanks for writing in to us.

There are no large diaphragmatic defects or hernias.

The lower end of esophagus is mildly patulous however does not confirm a hiatus hernia. Hiatus hernia is best evaluated using an oral contrast CT or a barium swallow.

The veins need to be visualised on an IV post contrast scan.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (10 hours later)

Thank You Dr Chail,
they told my husband he has a hiatal but I know the scan I sent was no contrast.Thanks for looking at it anyway and givng us your opinion.

I was just wondering about Logans scans
, the largest amount of his scans were with regular contrast and show signs of SMA and though the secretin scan shows it somewhat ,I wonder if it shows it less because the contrast used was water.

Does regular contrast work more like food than water contrast when it passes?

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (14 hours later)

Brief Answer:
Iodine oral contrast (diluted) behaves more like water

Detailed Answer:
Hi,
Thanks for writing in to us.

Barium oral contrast is more like a food and viscosity can be changed with dilution.

Regular oral Iodine (non barium) contrast is between food and water, heavier than water and not as viscous as food. There is dilution of contrast given in the bowel so a higher dilution means less viscous and better flow and usually behaves like water.

Regards,

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Vivek Chail (8 days later)

Hi Dr Chail

I emailed a few images with questions.

Thank You

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail

I emailed a few images with questions.

Thank You

Answered by Dr. Vivek Chail (23 hours later)

Brief Answer:
No ectopic pancreas tissue in the pylorus area

Detailed Answer:
Hi,
Thanks for writing in to us.

There is no ectopic pancreas tissue in the images of the pylorus area shared in the mail.

The stomach is not showing a persisting hiatus hernia. The area circles is a non distended part of the stomach.

There are no varices visualised.

Hope XXXXXXX is doing better.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Vivek Chail (2 days later)

Hi Dr Chail
I sent you a follow up email.

Thank you Sir

Follow up: Dr. Vivek Chail (0 minute later)

Hi Dr Chail
I sent you a follow up email.

Thank you Sir

Follow up: Dr. Vivek Chail (9 hours later)

Hello Dr Chail

I know you have not had time to answer the last follow up yet but wanted to ask you ,if you think XXXXXXX gastric bypass is a good choice for SMA or,is , laparoscopic duodenojejunal anastomosis a better choice.

Thank you very much

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (5 hours later)

Brief Answer:
Differences in magnetic fields and movement can cause artifacts

Detailed Answer:
Hi,
Sorry for the delay in replying.

There can be slight differences in magnetic fields and can cause a perception difference in contrast enhancement.

MRI shows a few artifacts due to movements of the vessels and this can cause shadows. The small structures are ducts and vessels.

There is no umbilical hernia.

Regarding the choice of surgery, I need to study literature and get back to you with outcomes of the surgical procedures as per research articles.

Regards,

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Answered by Dr. Vivek Chail (0 minute later)

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. Vivek Chail (18 hours later)

Hi Dr Chail

I sent you envision mrcp w/ ultra sound as well as mrcp from mid town imaging.Can you please measure and send me the images.We are seeing a new surgeon here on the 30 th because Dr XXXXXXX just dropped us.Took a month of no response from him after multiple calls and emails before receptionist simply said," Dr XXXXXXX decided not to do surgery.I sent several emails and called asking why he would not talk to you or, go over scans that you and other radiologist say are suspicios for sma but, got no answer at all.

This new Dr is supposed to be good at complex cases and I think is an XXXXXXX man so, I am hoping he will respect your opinions more and at least speak with you and the other second opinions from XXXXXXX that also say there is high suspicion for sma syndrome.

I sent the scans via drop box.

If they do not, when we get our tax refund back, we will be coming to XXXXXXX or, going to Mexico.Either way, I will let you know who we are working with.I am going to pay again now and Thank You again for your detailed explanations and patience with me. XXXXXXX Massingill

Follow up: Dr. Vivek Chail (0 minute later)

Answered by Dr. Vivek Chail (16 hours later)

Brief Answer:
I have your old images in my computer.

Detailed Answer:
Hi,
Thanks for writing in to us.

The Dropbox images are not complete.

I have your old images in my computer.

Please allow me some time to see through and sen you the required measurements.

Regards,

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Answered by Dr. Vivek Chail (0 minute later)