 Here we go. Okay, so Unfortunately, I can't call on you which is good for some of you. You know I'll be called on but I'm gonna show a case with a few slides and Then I'll just ask you for the answer. So I don't know how you want to do it You want people to type? Yeah, so we will ask people to type in the chat box and usually the fastest finger wins the fastest finger first something like that I'll let you run the chat box. Okay. All right. These are routine cases Lynn that I see every day. Okay Patient presents 50-ish year old male presents with F. U. Oh I'll show you a couple images. I think one of the things and I'll just speak over it is look at the spleen What's going on that? There was no calcifications in the spleen on the non-contrast scan There's the spine Here's some of the 3d showing you the spleen the extensive asides and here's the venous phase Right, I think that's very good if you go back first of all, you see the sclerotic bone lesions Then you have this vascular lesion in the spleen you can get hemangiomas can be vascular But this is diffusely vascular you have asides and you have widespread ballistic bone lesions and as you somebody suggested that was an angiosarcoma very good Believe it or not We've had three cases of angiosarcoma in the last four or five months So, you know, we hardly see them but we have been seeing them lately. They're exceedingly rare Okay, they can cause splenic rupture But it's rare. You can see this one article here with 12 cases in radiology. So a pretty uncommon The lesions may exhibit substantial enhancement and again, you can think about hemangioma But just the pattern does not really look like a man. Geoma. I'm angiomas are better defined. Okay, very good Okay, in this case patient presents 50th year old Acute abdomen ER rule out the section. That's why we did the study get impressive spleen okay and You see that high density zone big spleen We got answers from raguram saying splenic rupture than the splenic hematoma and AML rupture Right. So so I guess it's good to say the splenic rupture but Patient was not a trauma patient. Why I guess that's part the second answer would be why the patient has acute bleeding and splenic rupture I mean, obviously trauma is the most common reason for splenic rupture and splenic bleed, but there was no trauma so The spleen looks enlarged some of that as the blood It's sort of a modeled enhancement pattern as well Looks like something's infiltrating perhaps Here it is on the cinematic with this infiltration of the splenic tissue blood the act of bleeding and diagnosis cll Presenting with acute bleed So kind of a great case. Okay Okay, another patient Left up a quadrant pain This is something you may see more frequently than we do, but maybe not So nicely and look at the bone is a good hint and I'm going to keep going down There's in the pelvis You see the big spleen What's happening in the pre-sacral space as well So if you have answers coming through She can fast actually so picture frame vertebra sickle cell Lino, Megali, Hepatospina, Thalassemia Lymphoma These are the answers before So someone got it right. I mean sort of the thing over here the stuff in the pre Spinal region. What is that so? And big spleen sclerotic bone lesions almost like a bone and bone But the soft tissue density is really the critical question. What is this? You could say wainby is adenopathy But that's a classic appearance for extra medullary hematopoiesis And this was a classic case of thalassemia with extra medullary hematopoiesis. Very good Okay another patient Looks similar, but not the same back pain Back pain in a 60 year old Right a very classic location for cordoma Infiltrating I showed this compared to the last case which was extra medullary hematopoiesis Here it's a much more aggressive soft tissue mass and a much different appearance to the bone Here it is nicely on cinematic as well You can see that infiltration of the bone really nicely shown And this was a cordoma. Okay, very good. And again cordoma, you know, uh, the lowest cervical spine But the pre-sacral region is really where we typically like to see it. Okay So a very very nice nice appearance there and again, um Uh, not an uncommon diagnosis, but uh, so something good to be able to recognize Okay, what about this case? This is a 30th year old female with abdominal pain Again more than 95 percent. There's more to one says endometriosis Damn, you guys are good. You must have been watching my uh, you know, there's masses in the rectus muscle enhancing masses down here All right, you follow it down abdominal pain with multiple masses that are enhancing, you know Masses in the abdominal wall. I like to think about desmoid tumors or possibility You think about sarcomas But endometriosis is one of the things that gives you enhancing lesions Typically, it's patients who've had prior c-sections or prior surgeries There's a wide differential for abdominal wall masses But one of them is endometriosis very good So I won't go through those slides and in order to save some time very good and it's just a differential diagnosis, but It's good to think about endometriosis because you can make a it's a great diagnosis. Okay, good Patient with weight loss the next few are going to be bowel and I'm going to give you I'm going to give you this duana lipooma Okay weight loss and GI bleeding So I guess you see a nice measurement there Here it is cinematic. So what are we thinking about? What a mixed bag actually there's uh Lycosacoma Crohn's ulcerative colitis ideal mass Casnoma Crohn's lymphoma Right very good. So yeah, that's a differential. It's focal. This ended up being adenocarcinoma But it could be lymphoma if it was Crohn's I would have worried about Crohn's developing a carcinoma because the wall thickness Okay, good So now I'll show you again following that differential. Here's another patient abdominal pain So similar but different We're getting just and lymphoma is the answer Right, this was B cell lymphoma. It's much bulkier. I think that's one of the helpful Things with lymphoma often you see nodes, but not always, but the bulkiness. Okay small bowel lymphoma very good What about this patient abdominal pain and drop it and a low hematocrit? Okay, so I'm going to look looks like some nodes also So what about this one? What do people think? Yeah, so this angio-dysplasia aml adenociae into sepsion colonic Casnoma Sequel mass was into sepsion. So there's a differential Right, it's good differential. I mean so something's involving the colon and the small bowel whenever I see a colon and small bowel Although we know adenocarcinoma can grow into the cecum and cecum Uh, I don't know of course on the cecum can grow into bowel With those extra nodes present. I always like to think about lymphoma And this was B cell lymphoma of the cecum Okay All right with that. Let me show you another one fever and right lower quadrant pain Answers are coming from appendicular mass gist lymphoma appendicular lymphoma Right bulky tumor. I just I put this one in with the other one nice pet positive This was B cell lymphoma of the cecum kind of interesting the difference between the prior study Which showed a smaller mass and this larger mass present here And then getting away from the cecum patient presents with abdominal pain and weight loss Here's uh, it looks very similar, right? Except, uh, it's not it looks like it's more the stomach, right? and answer So again, we're getting Maybe gist actually and yeah, I think gist is a good thought, you know But then when you realize it's really a big ulceration in the stomach, but gist often ulcerate bulky, this was gastric lymphoma My first thought would have been just to that. It's an ulceration Just commonly ulcerate. They're very large, but Gastric lymphoma can be very bulky and this was a really really nice example of gastric lymphoma Left lower quadrant pain Ansela like carcinoid diverticulitis paniculitis This is coming off Right, this is coming off the small bowel Right, it looks like diverticulitis. And in fact it is but it's not your typical colonic diverticulitis It's small bowel diverticulitis specifically zyginal diverticulitis, which is far less common Often looks like a perforation It's pretty rare Patients are treated typically conservatively. So it's an important diagnosis to make We wrote this article like a lifetime ago, but we see cases every once in a while And what about this case? I think I'm I think I have two cases left This may be the last next last one patient presents with GI bleed. I'm just and then here it is Or it's rule out GI bleed. It's has a history of GI bleeding Okay, and here's the The mip imaging which I really like for looking for sources of bleeding The patient has no positive oral contrast. So I'm so say colon diverticulitis and angiotysplasia sigmoid diverticulitis ulcerative colitis These are the differences And I 100% agree what's interesting here is you have bleeding in multiple sites Now most of the time we do GI bleeding see these 95% accurate But usually it's one side of bleeding and if I only saw this I would say diverticulitis probably is the cause This patient has multiple sites of bleeding It ends up when you get the full history. This patient I think had leukemia and was on checkpoint inhibitors So I show this case to make the point that patients who are on immune therapy Can present with GI bleeding and often it's multiple areas of GI bleeding And that's what happens with immune checkpoint inhibitors We're seeing that used a lot. I'm sure it's being used a lot in india as well for a range of tumors very successfully But there are a lot of complications with checkpoint inhibitors Including a colonic bleeding and multifocal sites of GI bleeding as in this case So it's something good to think about and I won't go through those slides Okay, and then I'm going to end with this case This is suspected GI bleed Inpatient with ALL Okay And I'm showing this case because I made some really good cinematics the other day So pseudo membranous colitis ulcerative colitis thrones disease shock bowels Pan colitis neutropinic state Radiation entritus Neutropinic colitis, these are the answers we're getting those all great thoughts. It's kind of I mean this patient in ALL This patient had a bone marrow transplant previously So right, you know, it has a nice target sign could be ischemia could be inflammatory could be infectious uh, very impressive looking Ilium very impressive vasorecta and in patients with bone marrow transplants graft versus host disease Is one of the things that can occur? Fortunately these days graft versus host is less common Because of different therapies that are given but it can occur and this is a case of graft versus host disease Okay So I'll stop there and I will thank everybody for their attention and I especially would like to thank the organizers for the invite