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(Crohn’s dse,
• Plain films allow one to view the entire volvulus, appendiceal abscess, and
abdomen before proceeding to a more gallstone ileus)
specific investigation.
Indications: Radiographic findings:
• Abdominal distention
• Abdominal pain • w/in 3-5 hrs after the onset of
• Vomiting obstruction, gas and fluid accumulate
• Diarrhea proximally.
• Abdominal trauma • In upright film, distended bowel loops
*The presence of a palpable abdominal mass w/ air-fluid levels are present (non-
warrants imaging by CT Scan or Ultrasound. specific).
• Degree of small bowel dilatation is
*The plain film is most efficacious when greater in pxs w/ true mechanical
obtained for patients who have significant obstruction than w/ adynamic ileus.
abdominal tenderness or who are strongly • As the loops fill w/ air, they may
suspected of having bowel obstruction, or assume a “STEPLADDER”
perforation, urinary calculi or ischemia. configuration.
• Air may be resorbed through the
*The plain film examination is least effective as intestinal wall as fluid accumulates in
screening study in patients with mild or the bowel lumen – “GASLESS”
nonspecific symptoms. abdomen.
• “STRING OF PEARLS” sign – small
*The major value of NORMAL findings from a amounts of air trapped bet the plicae
plain film exam is that they exclude bowel circulares (upright position).
obstruction or large perforation.
Mechanical colon obstruction
***Films of the abdomen in erect and supine • Usually caused by cancer or
positions are obtained to complete the diverticulitis.
“perforation series.” • Other causes: volvulus, hernia,
fecal impaction.
NORMAL BOWEL GAS PATTERN • Obstruction usu occurs in the sigmoid
• Intestinal tract of adults - <200ml of gas colon (narrower caliber and stool is
• 3 sources of intestinal gas: more solid).
a. swallowed air • Carcinomas of the cecum & ascending
b. bacterial production colon are less likely to cause
c. diffusion from the blood obstruction bec of wider caliber and
• Gas rises and accumulates in the more liquid content of the stool.
anteriorly placed segments of intestine,
including the body of the stomach, Plain film findings:
transverse colon, and sigmoid colon. • Dilated, gas-filled loops of colon
• Gas tends to accumulate in the stomach proximal to the site of obstruction and a
and colon bec of the slower exit of fluid paucity or absence of gas in the distal
and gas from these structures. colon and rectum.
The gas-filled small intestine tends to occupy the • Competent ileocecal valve – the cecum
central portion of the abdomen and has a smaller may become markedly dilated and little
caliber than the colon. if any gas may be seen in the small
bowel (risk of perforation).
*Recognition of mucosal features:
- Haustra of the colon = 2-3cm wide, CLOSED LOOP OBSTRUCTION
occur at intervals of 1 cm.-Plicae • Incompetent ileocecal valve – allows
circulares of small bowel = 1-2mm gas to reflux proximally into the small
wide, occur at intervals of 1mm. bowel, producing plain film findings
that can mimic small bowel obstruction.
*however, the differentiation of colon from small Close search for colonic gas is required.
bowel is difficult without a positive contrast • Sigmoid Volvulus – two parallel gas-
study.*Intestinal gas should be considered a distended colonic loops rising out of the
natural contrast agent in the interpretation of pelvis (dilated loop of sigmoid colon
abdominal plain films. that has an inverted U configuration and
absent haustra).
ABNORMAL BOWEL GAS PATTERNS • Cecal Volvulus – dilated, air-filled
• Mechanical Small Intestine Obstruction cecum in an ectopic location, usu w/ the
• Mechanical Colon Obstruction cecal apex in the left upper quadrant.
• Paralytic (Adynamic) Ileus
• Gastric Outlet Obstruction ***When plain films suggest colonic
obstruction, it should be confirmed by
Mechanical Small intestinal obstruction endoscopy or barium enema.
• Abdominal pain, distention, vomiting.
• hx of previous abdl surgery. PARALYTIC (ADYNAMIC) ILEUS
• Common Causes in Adults: adhesions, • Causes: laparotomy and other types of
hernia, malignancy, inflammatory trauma, sepsis.
• Other causes: hypothyroidism, drugs Conditions that may mimic pneumoperitoneum
that inhibit intestinal motility, • Chilaiditi syndrome – bowel, usu the
hypokalemia. colon becomes interposed bet liver &
• Plain films usually show a diaphragm; common in elderly & pxs
PROPORTIONATE DISTENTION of w/ obstructive airway disease.
small and large bowel • Subdiaphragmatic fat – fatty (linear)
• Colonic ileus may also result in cecal lucency lies lateral to the apex of the
perforation, so, cecal diameters in the hemidiaphragm; occasionally seen in
range of 12 cm are reason for concern. obese pxs.
• Extraperitoneal gas
GASTRIC OUTLET OBSTRUCTION • Subphrenic abscess
• Antrum or pyloric region is the usual • Atelectasis of the lower lobes
site of GOO • Pneumatosis coli – intramural gas
• Most common causes: edema and
spasm resulting from an acute pyloric PNEUMOBILIA
channel ulcer and antral scarring caused • Gas in the bile ducts
by previous ulcers. • Characterized radiographically by thin,
• Other causes: scirrhous gastric CA and branched, tubular areas of lucency in
scarring from previous ingestion of a the central portion of the liver.
caustic substance. • Results from some type of
communication between the bile duct
Plain film: GOO and the intestine.
-dilated air-filled or fluid-filled stomach in the • Common causes: surgical creation of a
left upper quadrant with displacement of the biliary-enteric fistula such as a
transverse colon inferiorly.-can mimic ascites or choledochoduodenostomy,
hepatomegaly (but a small amount of air is choledochojejunostomy, or
almost always present w/in the stomach).- cholecystoenterostomy.
contrast studies are often performed to confirm • Other causes: (non-surgical)
the presence of GOO. choledochoduodenal fistula sec to
penetrating duodenal ulcer,
PNEUMOPERITONEUM cholecystoduodenal fistula sec to a
• A natural consequence of surgical gallstone that erodes into the
exploration of the abdomen. duodenum.
• Usually indicates bowel perforation.
• Upright plain films or cross-table Rigler’s Triad:
decubitus films can detect small *Air in the biliary tree, small bowel obstruction,
quantities of peritoneal gas. ectopic gallstone (diagnostic of GALLSTONE
ILEUS).
Radiographic signs:
• Serosal or Rigler’s sign – gas outlining
both sides of the bowel wall; the bowel Intramural gas or intestinal wall gas
wall appears as thin white stripe (pneumatosis)
(supine). • Collection of gas in the bowel wall.
• Increased lucency in the right upper • Radiographic patterns: bubbly
quadrant – air accumulating superiorly appearance
in the free space between the anterior thin, linear streaks
aspect of the liver and the abdominal • Can be seen in adult patients w/ bowel
wall. infarction.
• Visualization of the undersurface of the
diaphragm. ABDOMINAL CALCIFICATIONS
• Air in the lesser sac of the peritoneal • Extraluminal soft tissue mass – found in
cavity – ill-defined lucency above the up to 1/3 of pxs w/ perforation; may be
lesser curvature of the stomach. caused by a combination of edema,
fluid, and fluid-filled loops of small splenic flexure usually lies anterior to
bowel in the RLQ the spleen.
• Marked splenomegaly may also
• Gas in the appendix – has been displace the stomach medially.
described as acute AP but an air-filled • Elevation of the left hemidiaphragm
appendix may be a normal finding and
simply reflects the position of the RENAL ENLARGEMENT (PLAIN FILM)
appendix in relation to the cecum • Bec of surrounding fat, the renal
outlines are visible on the majority of
• Free peritoneal air – may be seen in abdominal films taken in supine
ruptured appendix position.
• Obliteration of normal fat planes – • An enlarged kidney does not displace
inflammation and edema may alter the intra-abdominal organs bec of its
water content of surrounding fat and retroperitoneal location, except in
obscure normal fat planes of psoas extreme cases.
muscle or flank stripes
ASCITES
• Scoliosis of the lumbar spine – as a • Obliteration of the inferior edge of the
result of splinting (non-specific and can liver
be related to positioning) • Widening of the distance between the
flank stripe and the ascending colon –
ORGANOMEGALY IN PLAIN FILM this distance is normally 2-3mm, but it
• Hepatomegaly may increase as fluid fills the paracolic
• Splenomegaly gutter.
• Renal enlargement • Medial displacement of the lateral edge
of the liver (Hellmer’s sign) – more
HEPATOMEGALY (PLAIN FILM) common w/ malignant ascites than w/
• Generalized hepatic enlargement tends cirrhosis
to displace the hepatic flexure and • Fluid accumulation in the pelvis
transverse colon inferiorly and the • Separation of bowel loops
stomach to the left • •Centrally located bowel loops with
• Other signs: bulging flanks – w/ large amounts of
a. displacement of inferior edge of liver beyond ascites, the bowel loops may float to the
the right margin of the psoas muscle highest central portion of the
b. displacement of the duodenal bulb below the abdomen.Ground-glass appearance – in
L2 vertebral body or to the left of the midline large amounts of ascites.
c. inferior displacement of the right kidney
d. enlargement or marked rounding of the
hepatic angle
e. elevation of the right hemidiaphragm with
with decreased motion on normal
respiration
f. inferior displacement of the gastric fundus
away from the diaphragm w/ left lobe
enlargement
g. anterior displacement of the duodenal bulb
on lateral films with caudate lobe
enlargement
Reidel’s lobe
• downward extension or elongation of
the right lobe of the liver in the absence
of hepatic disease.
• normal variant found in about 4-14% of
population, more common in females
• this lobe may extend caudally below the
iliac crest and does not indicate
hepatomegaly.
• downward extension or elongation of
the right lobe of the liver in the absence
of hepatic disease.
• normal variant found in about 4-14% of
population, more common in females
• this lobe may extend caudally below the
iliac crest and does not indicate
hepatomegaly.
SPLENOMEGALY(PLAIN FILM)
• Tip of the spleen extends inferiorly
below the 12th rib.
• Displacement of the splenic flexure of
the colon – uncommon finding bec the
GASTROINTESTINAL
SYSTEM CONGENITAL
ANOMALIES
• Defec<ve
dev’t
of
hepa<c
lobe/segment
• Typically
affect
an
en<re
lobe,
rarely
Liver,
Biliary
Tract,
Pancreas
segmental
o Absence
(agenesis)
To
review
the
gross
anatomy
of
the
liver
o Small
size
with
NORMAL
structure
To
know
the
segmental
anatomy
of
the
liver
(hypoplasia)
A
basic
imaging
correla<on
of
the
segmental
o Small
size
with
ABNORMAL
anatomy
of
the
liver
structure
(aplasia)
• Must
be
dis<nguished
from
lobar
atrophy
Surface
anatomy
• Shaped
like
a
wedge secondary
to
vascular/biliary
disease
• Base
against
the
R
abd.
wall
and
<p
poin<ng
LIVER
to
the
spleen • dual
blood
supply
• Extends
from
the
5th
ICS
in
the
MCL
to
the
R
o portal
venous
system
-‐
75%
costal
margin o hepa<c
artery
-‐
25%
• 12
to
15
cm
coronally
• hepa<c
vein
’
inferior
vena
cava
• 15
to
20
cm
transversely
DIFFUSE
HEPATIC
DISEASE
• cirrhosis
• covered
by
a
fibrous
capsule
(of
Glisson)
• hepa<<s
• capsular
peritoneum
reflects
at
the
• faby
infiltra<on
diaphragm
–
con<nues
as
parietal • Budd-‐Chiari
Syndrome
• reflec<ons
forms
–
coronary,
R
&
L
• iron
deposi<on
triangular
ligaments,
and
falciform
ligament
FOCAL
LIVER
LESIONS
• round
lig.
–
free
edge
of
falc.
l.
–
obliterated
• hemangioma
umbilical
vein
• hepa<c
cyst
• pyogenic
abscess
• amebic
abscess
Anatomic
variants • echinococcal
disease
• Important
to
recognize
variants
to
avoid
• fungal
abscess
labeling
them
as
pathologies • hepa<c
adenoma
• incomplete
accessory
fissures • focal
nodular
hyperplasia
o invagina<on
of
the
diaphragm • focal
fat
infiltra<on
or
sparing
o one
or
more • hepatocellular
carcinoma
• metasta<c
disease
o common
variant
o commonly
seen
at
the
R
lobe
superiorly HEMANGIOMA
• LeS
lateral
segment • cavernous
hemangioma
-‐
most
common
o leSward
extension
of
and
projects
benign
hepa<c
lesion
posteriorly
to
wrap
around
the
• single
or
mul<ple
(10%)
• 4%
to
20%
of
the
popula<on
spleen
• women
>
men
o may
be
mistaken
for
pathology
of
• asymptoma<c;
discovered
incidentally
the
stomach/spleen • most
common
in
the
posterior
segment,
right
lobe
CONGENITAL
ANOMALIES • oSen
subcapsular
or
peripheral
• true
hepa<c
congenital
defects
are
rare • ultrasound
(US)
-‐
well-‐defined,
round,
• either
defec<ve
or
excessive
development homogeneous
hyperechoic
lesion
• large
lesions
-‐
may
be
heterogeneous
with
• Riedel’s
lobe
areas
of
degenera<on
o most
common
anomaly/
more
• on
noncontrast-‐enhanced
CT
(NECT)
-‐
well-‐
common
in
women circumscribed
and
of
low
density
o due
excessive
dev’t
• on
contrast-‐enhanced
CT
(CECT)
-‐
ini<al
o Sessile
accessory
lobe
extending
peripheral
nodular
enhancement
with
near-‐
caudally
from
the
inferior
aspect
of
complete
filling-‐in
on
delayed
images
the
R
lobe
• retain
contrast
for
20
to
30
minutes
• nuclear
single
photon
emission
computed
oSen
with
bulbous
configura<on
tomography
(SPECT)
-‐
with
techne<um
1
labelled
RBC
-‐
decreased
ac<vity
in
early
● liver
is
accessed
by
Entamoeba
histoly/ca
images
and
increased
ac<vity
on
delayed
via
the
portal
vein
• magne<c
resonance
imaging
(MRI)
-‐
useful
● symptoms
similar
to
pyogenic
abscess
for
lesions
<
2
cm.;
well-‐defined,
● US
and
CT
appearance
similar
to
pyogenic
homogeneous
and
markedly
hyperintense
abscess
on
T2-‐weighted
images;
peripheral
to
● oSen
located
peripherally
central
enhancement
on
gadolinium-‐ ● on
aspira<on,
fluid
classically
“anchovy
contrast paste”
● treatment
-‐
metronidazole
HEPATIC
CYST ● may
take
months
to
resolve
Ø second
most
common
benign
lesion
Ø single
or
mul<ple ECHINOCOCCAL
DISEASE
Ø 2.5%
to
10%
of
the
popula<on § caused
by
Echinococcus
granulosis
Ø women
>
men § symptoms
similar
to
pyogenic
abscess
Ø usually
asymptoma<c § common
in
the
right
lobe,
may
be
mul<ple,
Ø seen
in
40%
of
pa<ents
with
polycys<c
and
may
involve
the
chest
kidney
disease;
60%
of
pa<ents
with
§ grow
slowly
and
cyst-‐like
in
appearance
mul<ple
hepa<c
cystc
have
polycys<c
§ US
and
CT
kidneys o double
line
sign,
water
lily
sign,
Ø US
-‐
anechoic
(no
internal
echoes),
sharp
racemose
cyst
wall
margins,
impercep<ble
wall,
increased
o double-‐layer
cyst
wall
with
inner
through
transmission;
US
has
95%
to
99%
germinal
layer
which
gives
rise
to
accuracy “daughter
cysts”
Ø CT
-‐
sharply-‐defined,
water
density
with
no
o daughter
cysts
are
visualized
percep<ble
wall
and
no
contrast
within
the
parent
cyst
in
70%
of
enhancement cases
Ø CT
-‐
delayed
images
show
no
contrast
o 50%
have
shell-‐like
calcifica<ons
enhancement
Ø MRI
-‐
homogeneous
low-‐signal
intensity
on
FUNGAL
ABSCESS
T1-‐weighted
images
and
high
-‐signal
1. immunocompromised
pa<ents
intensity
on
T2-‐weighted
images 2. usually
Candida
3. with
other
organisms
like
Pneumocys/s
PYOGENIC
ABSCESS carinii,
cytomegalovirus,
mycobacteria
● may
be
bacterial,
parasi<c,
fungal 4. have
concomitant
hepa<c
involvement
with
● 85%
to
90%
are
bacterial
or
pyogenic Kaposi’s
sarcoma,
lymphoma
● bacteria
access
the
liver
via
the
biliary
tree
or
portal
vein HEPATIC
ADENOMA
● associated
with
biliary
obstruc<on,
ü seen
exclusively
in
women
of
childbearing
diver<culi<s,
trauma,
inflammatory
bowel
age
(in
98%)
disease,
iatrogenic ü linked
to
oral
contracep<ves,
anabolic
● pain,
fever,
diarrhea,
leukocytosis,
steroids,
glycogen
storage
disease
abnormal
liver
func<on
tests ü composed
of
atypical
hepatocytes
and
● most
commonly
in
the
right
lobe increased
fat
and
glycogen
● US
:
heterogeneous,
round,
hypoechoic
ü usually
asymptoma<c;
pain
if
with
collec<on
with
irregular
thick
walls hemorrhage
:
internal
echoes,
fluid-‐fluid
levels,
ü slight
malignant
transforma<on
poten<al
internal
debris ü US
-‐
well
defined
with
variable
echogenicity;
:
acous<c
shadowing
indicate
gas
indis<nguishable
from
focal
nodular
within
the
abscess hyperplasia
● CT
:
heterogeneous
lesion
with
irregular
ü CT:
discrete,
low-‐density
lesion,
mean
size
margins of
10
cm.
:
peripheral
contrast
enhancement ü mul<ple
in
30%
of
pa<ents
:
internal
septa<ons
common ü may
have
dense
enhancement
:
20%
may
contain
air ü 50%
heterogeneous
because
of
hemorrhage
● Differen<al
diagnoses or
necrosis
• cys<c
or
necro<c
metastases MRI
:
inhomogeneous
on
all
pulse
sequences;
• amebic
abscess increased
signal
on
T1-‐weighted
images
• hyda<d,
echinococcal
cysts Nuclear
scan
:
cold
lesion
on
sulfur
colloid
scan
2
Ø nonencapsulated Ø CECT
-‐
enhancement
during
hepa<c
arterial
Ø common
in
women phase
Ø usually
asymptoma<c Ø MRI
Ø composed
of
normal
hepatocytes,
Kupffer
o decreased
signal
intensity
on
T1
cells
and
bile
ducts
in
an
unusual
weighted
images
arrangement o increased
signal
on
T2
weighted
Ø usually
less
than
5
cm
diameter images
Ø rarely
mul<ple Ø nuclear
scan
Ø common
in
the
periphery
of
the
right
lobe o cold
defect
on
sulfur
colloid
scan
Ø classic
appearance
-‐
solitary,
well-‐ o increased
ac<vity
on
gallium
scan
circumscribed
with
central
stellate
scar
of
fibrosis
(central
scar
seen
in
20%) METASTASIS
Ø US
-‐
variable
echogenicity
o the
most
common
malignant
lesion
of
the
Ø CT
-‐
may
be
seen
only
on
the
hepa<c
liver
arterial
phase
of
enhancement o metastasis
is
20%
more
common
than
Ø MRI
-‐
the
central
scar
is
high-‐signal
intensity
primary
HCC
on
T2-‐weighted
(versus
low-‐signal
intensity
o common
primary
source
-‐
colon,
stomach,
in
fibrolamellar
carcinoma) lung,
breast,
pancreas
o abnormal
liver
func<on
test,
hepatomegaly
FOCAL
FAT
INFILTRATION
OR
SPARING o typically
mul<ple,
involve
both
lobes
§ common
in
right
lobe
of
the
liver o solitary
metastasis
in
30%
to
40%
§ associated
with
obesity,
alcohol
abuse,
use
o may
be
calcified
of
steroids,
hyperalimenta<on
o may
be
solid,
necro<c,
cys<c
or
calcified
§ US o can
mimic
any
other
lesion
on
CT
and
MRI
o lobar
or
segmental
distribu<on o should
be
considered
in
pa<ents
>50
years
o margins
are
angulated old
and
in
those
with
known
primary
o no
mass
effect
on
adjacent
vessels
§ CT LIVER TRAUMA
o patchy
or
focal
area
of
decreased
Ø second
most
frequently
injures
intra-‐
abenua<on abdominal
organ
aSer
the
spleen
o typically
adjacent
to
the
falciform
Ø commonly
the
posterior
segment
of
the
ligament
or
gallbladder
fossa
right
lobe
§ sparing
characteris<cally
involve
the
Ø best
evaluated
by
CECT
caudate
lobe,
periportal
region
and
Ø contusions,
lacera<ons,
intrahepa<c
and
adjacent
to
gallbladder
fossa
subcapsular
hematomas
3
o less
sensi<ve
than
US ü increasing
frequency
with
HIV;
cryptosporidia
and
cytomegalovirus
are
the
ACUTE
CHOLECYSTITIS pathogens
v most
commonly
due
to
cys<c
duct
ü thickening
of
the
walls
of
the
bile
ducts
and
obstruc<on
by
cholelithiasis
gallbladder
v 5%
to
10%
are
acalculous
ü intrahepa<c
findings
of
sclerosing
v US
-‐
cholelithiasis,
thickening
of
the
GB
wall,
cholangi<s
Murphy’s
sign ü papillary
stenosis
v cholescin<graphy
-‐
non-‐visualiza<on
of
GB
by
1
hour
(normally
in
30
minutes) RECURRENT
PYOGENIC
CHOLANGITIS
(ORIENTAL
CHOLANGIOHEPATITIS)
CHRONIC
CHOLECYSTITIS v endemic
in
Asia
Ø gallbladder
is
oSen
contracted v acute
abdominal
pain,
recurrent
jaundice,
Ø gallstones,
chronic
inflamma<on,
recurrent
fever,
chills
colic v intra-‐
and
extrahepa<c
bile
ducst
are
Ø cholescin<graphy
-‐
delayed
visualiza<on
in
dilated
and
contain
soS
pigmented
stones
1-‐4
hours and
infec<on
4
o Endoscopic
assessment
of
UGIT
o pancrea<c
pseudocyst
-‐
and
ampulla
encapsulated
collec<on
of
fluid
o Contrast
assessment
of
pancrea<c
and
debris
and
bile
ducts o portal
and
splenic
vein
thrombosis
o Most
effec<ve
method
for
imaging
o pancrea<c
necrosis
pancrea<c
duct
o Therapeu<c
and
diagnos<c
CHRONIC
PANCREATITIS
procedures
may
be
done v repeated
bouts
of
acute
pancrea<<s
§ E.g.
sphincterotomy,
v pancrea<c
calcifica<ons;
irregularity
of
the
biopsy,
stone
extrac<on,
ducts
with
beading
and
saccular
dilata<on
balloon
dilata<on,
stent
of
the
branches
inser<on,
cyst
drainage v cause
is
almost
always
alcohol
abuse
or
§ MRI
specifically
MRCP-‐
can
demonstrate
gallstones
common,
cys<c
and
pancrea<c
ducts v calcifica<on
suggest
alcohol
abuse
v Plain
film,
barium
studies,
US,
CT
scan,
ERCP
ACUTE
PANCREATITIS
ü alcohol
abuse,
choledocholithiasis;
trauma,
PANCREATIC
ADENOCARCINOMA
drugs
(steroid,
INH,
sulfonamides),
pep<c
v 95%
of
all
malignant
tumors
of
the
pancreas
ulcer
disease,
viruses
(mumps,
coxsackie,
v poor
prognosis
hepa<<s) v hypoechoic/
low-‐density
mass;
usually
head
ü diagnosis
is
clinical;
imaging
is
used
for
or
uncinate
process
(60%
to
70%)
prognos<ca<on
and
iden<fy
complica<ons v jaundice
ü Chest
film
changes v atrophy
of
the
distal
gland
o LeS
pleural
effusion,
basal
v smooth
dilata<on
of
the
pancrea<c
duct
atelectasis,
elevated
v dilata<on
of
the
main
pancrea<c
duct
and
hemidiaphragm
the
bile
duct
(double-‐duct
sign)
ü Abdominal
film
changes v Barium
studies
o Colon
cut-‐off
sign
–
transverse
o Widened
duodenal
loop
with
colon
is
dilated
but
cuts
off
fixa<on
abruptly
at
the
splenic
flexure o Anterior
displacement,
spicula<on
o Sen<nel
loops
of
medial
mucosal
folds
§ DUODENAL
ILEUS
–
MOST
o Nodular
mucosal
filling
defects
SPECIFIC o Inverted
3
or
Frostberg
sign
o Small
bowel
ileus
v Compression
and
invasion
of
the
second
o Gasless
abdomen
due
to
persistent
por<on
of
the
duodenum
with
ulcera<on
of
vomi<ng the
inner
wall
ü Barium
studies v Reverse
3
sign
of
Frostberg
o Widened
duodenal
loop
or
C-‐loop
v Ultrasound
with
compressed
medial
border o Posi<ve
findings
in
80-‐90%
of
cases
o Ampullary
edema § Early
–
focal
bulge
to
o Thickening
of
gastric
and
duodenal
pancrea<c
outline
folds § Late
–
irregular
lobulated
ü CT
scan mass
of
low
or
mixed
o Best
imaging
technique echogenicity
o pancrea<c
enlargement,
decreased
o Distal
chronic
pancrea<<s
density
due
to
edema,
o Dilated
CBD,
pancrea<c
duct
distal
intrapancrea<c
fluid
collec<on,
to
tumor
blurring
of
the
gland
margins o Signs
of
spread:
liver
metastasis,
o Phlegmon
–
low
density
mass portal
and
peripancrea<c
nodes,
o Hemorrhage
–
high
density
mass invasion
of
retroperioneal
fat,
o Fluid
collec<ons,
pancrea<c
or
venous
occlusion
peripancrea<c
v CT
scan
o Abscess o Superior
to
ultrasound
in
assessing
ü Free
peritonel
fluid tumor
invasion
of
peripancrea<c
ü Complica<ons structures
o phlegmon
-‐
inflammatory
mass o Preferred
technique
for
assessing
o hemorrhage
-‐
from
arterial
injury operability
o abscess
forma<on v CT
findings
indica<ve
of
unresectability
(Whipple’s
procedure)
o liver
metastasis
5
o ascites
o local
extension
(except
the
duodenum)
o arterial
encasement
o venous
occlusion
o lymph
node
enlargement
outside
the
field
6
ESOPHAGUS, STOMACH. Classification of esophageal motility disorders
DUODENUM l PRIMARY
Methods of Examination of the Upper Gastrointestinal – Achalasia
Tract – Diffuse esophageal spasm
1. Plain film – Intestinal pseudoobstruction
2. Upper GI series – Hypertensive peristalsis
1. Examination with an opaque – Presbyesophagus
contrast medium – Congenital tracheoesophageal
1. Barium sulfate – agent of fistula
choice; inert and isotonic – Chalasia
2. Double contrast method – l SECONDARY
examination with an opaque – Connective tissue
contrast medium plus gas – Chemical or physical
producing medications – Infection
– Metabolic
Rules to follow prior to UGIS – Endocrine
• Free passage through colon must be certain – Neurologic
• Barium studies in a patient with suspected – Muscular
perforation must be approached with – Vascular
caution. Water soluble contrast materials – Neoplasm
are useful on some occasions but these – Pharmacologic
agents are hypertonic and should be used ACHALASIA
with caution in the elderly and dehydrated l Failure of normal lower esophageal
patients sphincter opening produces persistent V
configuration of head of the barium column
ESOPHAGUS above the sphincter
l Straight muscular tube l Impairment or absence of Auerbach’s plexus
l 20-24cm long ganglion cells
l Joins the hypopharynx just above the sternal l Pseudoachalasia-a constricting annular CA
notch,at the level of C5 or C6 and GE jxn at extending from the gastric fundus may cause
the level of T11 motor abnormalities in the esophageal body
l Attaches to the gastric cardia behind the
xiphoid process DIFFUSE ESOPHAGEAL SPASM
l Cricopharyngeus muscle- major element of Clinical syndrome characterized by:
UES 1.symptom of intermittent dysphagia and chest
l LES- 2-4cm with minimal muscle thickening pain
l Divided into proximal,middle and distal 2.forceful,simultaneous repetitive contractions on
l Jxn of proximal and middle 3rd is near the manometry
aortic arch level 3.segmental lumen-obliterating contractions on
l Proximal 3-4cm lies in the lower part of the radiograph
neck, the remainder is intrathoracic behind 4.thickening of the esophageal wall
the heart l Peristalsis may occur in the upper
esophagus
Major impressions: l All nonperistaltic movement are observed in
a. Level of aortic arch the smooth muscle part
b. Left mainstem bronchus
c. Left ventricle TRACHEOESOPHAGEAL FISTULA
Type A =esophageal atresia- NO fistula =10%
Types of examination Type B=esophageal atresia-PROX fistula=1%
l Esophagography Type C=esophageal atresia-DIST fistula=80%
l Flouroscopy Type D=esophageal atresia-PROX + DIST=1%
l Endoscopy Type E=H-type fistula-NO atresia=10%
l Esophageal Manometry
PRESBYESOPHAGUS
Esophagogram/Barium swallow l Curling or corkscrew esophagus
l Ingestion of barium sulfate suspension l Helix configuration suggest possible
l Types: shortening of the spiral esophageal muscle
– Double contrast – demonstrate wall
neoplasm and esophagitis ESOPHAGEAL PERFORATION
– Full column l Nearly all perforations are caused by trauma
– Mucosal relief – esophageal varices l Non-traumatic esophageal perforation is
– Fluoroscopic observation and generally caused by caustic ingestion or
motion recording technique – neoplasm
esophageal motility l The most frequent sites are adjacent to the
cricopharyngeus
1
l Abnormal radiographic finding include
pneumomediatinum ,mediastinal widening BARRETT’S ESOPHAGUS
and cervical emphysema l Partial lining of the esophagus by columnar
type epithelium reflects an adaptive
CAUSTIC ESOPHAGITIS alteration caused by chronic reflux
l Alkaline-coagulation necrosis in minutes esophagitis
l Acid-more superficial l Has a predilection to develop
l During the 1st 24 hrs,esophagus often adenocarcinoma
appear normal l Generally older than 40y/o
l Blurred margin,contour irregularity l Punch-out esophageal ulcer that resembles
l Ulceration gastric ulcer morphology or when an
l Thickened folds unexplained stricture of the middle
esophagus is observed
HIATAL HERNIA
l Types: DIVERTICULAR DISEASE
1) Axial I. Pulsion diverticulum – mucosal herniations thru
2) Paraesophageal muscular wall
3) Mixed - Related to esophageal motility disorders
l Relevant landmarks: - Oval or rounded or smooth
1) Diaphragmatic hiatus a. Zenker’s diverticulum – along the posterior
2) Esophagogastric jxn wall of the upper end of esophagus at its
3) LES segment junction with the pharynx
4) Loculus of herniated stomach b. Epinephric – lower third of esophagus just
above the diaphragm
SLIDING HIATAL HERNIA II.Traction – due to extrinsic inflammatory
l part of the stomach moves through the involvement of esophagus; mid-esophageal
diaphragm so that it is positioned outside of III.Intramural pseudodiverticulosis – multiple small
the abdomen and in the chest. outpuchings in the wall
l lower esophageal sphincter (LES) often
moves up above its normal location in the FOREIGN BODY
opening of the diaphragm. l In the esophagus flat objects such as coins
l Most people have no symptoms, and it is are oriented in the coronal plane
often diagnosed when a person is being l In contrast,flat foreign body in the trachea is
evaluated for other health concerns. oriented in the sagittal plane
l If the LES moves above the diaphragm, it
may not close well and stomach acid and ESOPHAGEAL VARICES
juices may go back into the esophagus (acid l Changeable fold thickening or serpigenous
reflux) commonly known as heartburn. and polypoid defects in the lower esophagus
l Best shown by mucosal relief technique
PARAESOPHAGEAL HERNIA
l Stomach bulges up through the opening in ESOPHAGEAL RINGS
the diaphragm (hiatus) alongside the l Schatzki’s ring-asymptomatic, mucosal fold
esophagus (upside-down stomach). at the esophagogastric jxn
l LES remains in its normal location inside the l Exaggeration of the normal transverse
opening of the diaphragm. mucosal fold-thickened to 4-5mm in width
l This type of hernia most commonly occurs causing narrowing of the luminal aperture
when there is a large opening in the l Steak house syndrome
diaphragm next to the esophagus. l Rings<12mm always accompanied by
l The stomach and, rarely, other abdominal dysphagia
organs (such as the intestine, spleen, and l Rings >12-20mm may or may not cause
colon) may also bulge into the chest symptoms
2
- Edges of the lesion are sharply demarcated – Fluid-filled, appears as
producing sharp angle or overhanging edges pseudotumor
Infiltrating – annular constricting filling defect or – Mucosal folds are characteristically
narrowing of the lumen absent or sparse, stomach appears
- Stenotic area is irregular and mucosal folds smooth
are absent l In older children, stomach appears same
l About 90%are squamous cell in origin as in adults.
3
l responsible for almost all ulcers, 60-80% HYPERPLASTIC
(gastric), 95-100%(duodenal) l up to 90% of all gastric polyps
l increased secretion of gastrin with high l elongated, branching, cystically dilated
basal and peak acid outputs glandular structures
l eradication of H. pylori accelerates ulcer l rare malignant potential
healing and decreases recurrence rate l <1cm,sessile
Radiographic findings l often multiple
l Presence of an ulcer crater or niche ADENOMATOUS
l views obtained en face and in profile l less than 20% of all gastric polyps
l En face: presence of dense ovoid collection l dysplastic epithelium
of barium within the crater l malignant transformation in 50%
l In profile: barium filled projection extending l >1cm, sessile, pedunculated, or lobulated
from the lumen l often solitary
l barium coating the rim of the unfilled ulcer
crater produces the “ring sign” LEIOMYOMA
Complications l 40% of all benign gastric tumors
l gastric outlet obstruction(20%) l consist of intersecting bundles of spindle-
l penetration to contiguous organs shaped cells in a characterisitc whorling
l perforation(7%) pattern
l fistula(duodenum,small bowel,colon) l endogastric(80%), exogastric(15%),
l hemorrhage(20%) “dumbbell”-shaped(5%)
l mostly solitary lesions, <3cm
BENIGN VERSUS MALIGNANT l epigastric pain, UGIB, palpable mass
BENIGN Radiographic findings:
l Project beyond the lumen l discrete submucosal masses
l more likely to be deep l tumors larger than 2 cm frequently contain
l surrounding mucosa is smooth areas of ulceration
l Edematous mound is symmetrical and l may contain calcification
smooth Management:
l radiating folds are smooth and distinct from l small, asymptomatic masses ®follow-up
each other l >2cm ®resected
MALIGNANT
l Extends into the lumen LIPOMA
l more likely to be shallow l 2-3% of benign gastric tumors
l surrounding mucosa has a nodular or l mature fat cells surrounded by a fibrous
irregular component capsule
l Infiltrating tumor is usually asymmetrical and l no malignant potential
maybe distinctly masslike l usually asymptomatic, may cause upper GI
l radiating folds may be irregular, nodular, bleeding or gastric outlet obstuction
variable in thickness, and may merge l solitary lesions, frequently in the antrum
Radiographic findings:
BENIGN TUMORS OF THE STOMACH l CT has proved to be a valuable technique
l 85-90% of all neoplasms in the stomach and ®well-circumscribed areas of uniform fatty
duodenum are benign density with an attenuation of -80 to -120
l 50% mucosal Hounsfield units
l 50% submucosal l soft consistency ®change in size and
MUCOSAL LESIONS shape with peristalsis or palpation at
l Polyps fluoroscopy
(hyperplastic,adenomatous)
l Villous tumors POLYPOSIS SYNDROMES
l Polyposis syndromes l Familial adenomatous polyposis
(familial adenomatous polyposis, Peutz- ® detection of adenomatous polyps in
Jeghers, Cronkhite-Canada) stomach or duodenum is important
SUBMUCOSAL LESIONS ®periodic surveillance of the UGI tract
l Leiomyoma l Peutz-Jeghers syndrome
l Lipoma ®hamartomatous polyps
l Neurofibroma
l Cronkhite-Canada syndrome
®gastrointestinal polyposis with nail and hair
POLYPS (HYERPLASTIC/ADENOMATOUS)
l 50% of all benign gastric tumors changes
l mostly asymptomatic, may cause upper GI ®innumerable benign sessile polyps with
bleeding or gastric outlet obstruction distinctive “whiskering” effect
l some adenomatous polyps undergo
malignant degeneration TUMORS
l need for endoscopic biopsy and removal of l Vast majority are malignant epithelial
polyps is related to size and appearance neoplasm
4
l Most are detected by direct visual or
endoscopic technique
l Primary radiologic manifestation are –
inraluminal mass and/or deformity caused by
tumor infiltration with loss of normal
distensibility
DUODENUM
- C-shaped curve extending from the pyloric
canal to the junction of the duodenum and
jejunum at the junction of the ligament of
Treitz
- Four segments:
- Duodenal bulb – usually devoid of
mucosal folds
- Descending limb – contains major
and minor papillae
- Transverse limb – extends across
SMA
- Limb ascending to ligament of
Treitz
5
1
APPENDICITIS
● obstruction at the appendix g
inflammation g perforation g
abscess formation
● rarely requires imaging
● plain film may be normal, partial
or complete obstruction pattern,
RLQ mass, pneumoperitoneum;
calcification/ appendicolith
● ultrasound may demonstrate
thickened appendix wall
DIVERTICULOSIS/DIVERTICULITIS
● due to low residue diet
● incidence of 10-20%
● infection of an obstructed
diverticulum g diverticulitis
● usual site - sigmoid
● ddx- annular carcinoma
POLYPOSIS SYNDROMES
● familial adenomatous polyposis
syndromes (FAPS)
• familial polyposis coli
• Gardner’s syndrome -
epidermoid cysts,
craniofacial osteomas,
neurofibromas, soft tissue
fibromas
• Turcot’s syndrome -
intracerebral gliomas
● polyps may be 5 mm or less
magnetic resonance imaging
Genito-urinary Tract ●
● renal scintigraphy
● retrograde pyelography
KIDNEYS ● renal angiography
Paired, retroperitoneal, bean-shaped organs ● percutaneous antegrade pyelography/
Upper border of T11 & lower border of L3 nephrostomy
R kidney is ~2cm lower than the L ● voiding cystography/ cystourethrography
Normal length: ● cystography
Adult: 11-15cm
3.7+/-0.37x ht of L2 PLAIN FILM X-RAY
Children: length of L1-L4 including the 3 ● kidneys- bean-shaped, T11 to L3 level
intervening disc spaces +1cm ● right kidney lower than the left
● kidneys descends 2-3 cm in the upright
3 ANATOMIC SPACES position
A. Perirenal ● left kidney may have fetal lobulation;
B. Anterior pararenal dromedary hump
C. Posterior pararenal
EXCRETORY UROGRAPHY/INTRAVENOUS
The kidneys are usually visible on a standard PYELOGRAPHY/INTRAVENOUS
anteroposterior radiograph of the abdomen because UROGRAPHY(EXU/IVP/IVU)
the PERIRENAL FAT surrounding the kidneys ● renal pelvis - triangular or conical, variable
produces a transradiant line. ● major and minor calyces
The calyces, pelvis, and ureter can only be ● ureters with three normal narrowings
demonstrated by the use of Radioopaque compounds ● bladder - transversely round or oval above
in IVP or Retrograde pyelography. the symphysis pubis
● rounded dome in male; flat or concave dome
HILUS in females
Medial border ● relatively larger in children
Orifice of renal sinus
Renal Sinus: CONGENITAL ANOMALIES OF THE KIDNEYS
1. Renal pelvis and calyces ANOMALIES IN NUMBER
2. Branches of renal artery and tributeries of renal vein A. Supernumerary Kidneys
3. Lymph vessels and nerves - more than 2 separate kidneys
4. Small amount of fat - extremely seldom/ rare
- Independent kidney with its own vascular supply,
URETER a capsule and its own urinary tract but is usually
5mm in diameter, 25 cm in length hypoplastic and rudimentary
2 portions: Superior abdominal portion ● Cause: very early division of the ureter
Inferior pelvic portion anlage before the invasion into the
metanephric blastema
3 AREAS OF NORMAL NARROWING ● Diagnosis
1. Ureteropelvic junction (UPJ)/Superior isthmus - demonstration of presence of separate pelvis,
2. Ureterovesical junction(UVJ)/Intramural constriction ureter, and blood supply is necessary to make the
3. Bifurcation of iliac vessels/Inferior isthmus diagnosis
- anomalous kidney is small and rudimentary and
Renal pelvis – funnel-shaped expanded upper end of other kidney of same side is smaller than normal on
the ureter. opposite side
- lies within the hilus of the kidney and
receives the major calyces B.RENAL AGENESIS
Kidney is either absent or
BLOOD SUPPLY undeveloped including its vessels
Renal Artery – branch of the aorta; divides into 2 main and ureters
branches: POSTERIOR and ANTERIOR branches ● Cause: Failure of the ureteric bud to contact
Interlobar Arteries the metanephric blastema
Arcuate Arteries ● Incidence of 1/1000, often in males
Interlobular Arteries Virtually always unilateral; majority
are on the left side
Renal Vein emerges from the hilus in front of the renal ● often go unnoticed because they are
artery and drains into the IVC compatible with normal life
● compensatory hypertrophy of the normal
kidney (> as 10% of the normal renal volume)
METHODS OF EXAMINATION OF THE GENITO- Radiographic features:
URINARY TRACT ● Absence of renal shadow on one side
● plain film x-ray ● Unusually large kidney on the other side
● excretory urography ● Trigone is usually deformed with ureteral
● ultrasonography
orifice missing on involved side
● computed tomography
● Angiography: absence of renal artery ANOMALIES IN POSITION
Ectopic kidney:
RENAL HYPOPLASIA A. Simple ectopy: the kidney does not ascend
1. reduction in the number of nephrons. properly and is found in the pelvis or over the
2. kidneys are small (< 3 percentile) with a brim.
normal parenchymal structure • Prone to obstruction and infection
3. appear as one small kidney with the other B. Crossed ectopy without fusion: The kidney
one larger than normal. then lies on the opposite side and is not attached
4. Functions normally to the normally placed kidney
5. Small kidneys also have small arteries and • Crossed renal ectopia may be
are associated with hypertension requiring associated with VUR.
nephrectomy.
RENAL ANOMALIES
RENAL DYSPLASIA AND MULTICYSTIC KIDNEY CROSSED ECTOPY- fusion of the kidneys on the
- seen in only one kidney as irregularly lobulated mass same side
of cysts and usually absent or atretic ureter (in • lower one is ectopic; ureter crosses
newborn). the midline to enter the bladder on
- associated with contralateral abnormalities, especially the opposite side
ureteropelvic junction obstruction. • Both kidneys are lower in position
- Dysplasia of the renal parenchyma is seen with • associated with rotation anomalies
urethral obstruction or reflux present early in pregnancy • associated with partial obstruction
or obstructed ureter.
- Cause: atresia of the renal pelvis and ureter during ANOMALIES IN FORM
embryonic development of the kidney. HORSHOE KIDNEY
1. Most common type of renal fusion.
MULTICYSTIC DYSPLASTIC KIDNEY 2. Both lower poles connect across the
1. Disorganized, dysplastic kidney with midline by an isthmus lying next to the
essentially no function. aorta and inferior vena cava.
2. The MCDK is typically unilateral 3. Usually supplied by multiple arteries
(bilateral MCDK would result in stillbirth 4. Hydronephrosis can be associated
or fetal demise). when ureteropelvic junction obstruction
3. Developmental abnormality unrelated to is caused by high ureteral insertion or
polycystic kidney disease and other anomalous vessels.
hereditary forms of cystic renal Radiographic features
dysplasia ● Alteration in the axis of kidneys
● Mass observed connecting lower poles
ANOMALIES IN ROTATION
A. Nonrotation Urography
- renal pelvis anterior to kidney lie 90º from - Malrotation with pelvis anterior or
horizontal (lie ventral) anterolateral in position
- Nephrographic demonstration of
B. Incomplete Rotation parenchymal isthmus connecting lower poles
- pelvis lies between 30º and 90º from horizontal - Varying dilatation of collecting system
(lies ventromedial) - Possible non function of one kidney because
of massive obstructive hydronephrosis
C. Reverse rotation - Upper ureteral displacement
- pelvis lies lateral to kidney; vessels are twisted
around anterior surface of kidney (lies lateral; Abdominal sonography of the abdomen in this patient
vessels run ventral to hilum) revealed: a) kidneys located at a lower level than
normal b) the lower poles of both kidneys pointing
D. Excessive Rotation medially, c) a bridge of renal tissue or isthmus
- renal vessels are twisted around posterior connecting the two kidneys. This isthmus is seen
surface of kidney (renal pelvis lies dorsal to passing anterior to the abdominal aorta. These
lateral, vessels run dorsal from kidneys to hilum ultrasound images are diagnostic of horseshoe kidney.
-‐
2
-‐
• Unilateral atresia is usually hypothesis as to why congenital UPJ
asymptomatic but may cause obstruction occurs
hypertension.
B. Duplex ureter Anteroposterior IVP in the excretory phase. Contrast
a. consequence of the development material fills the dilated calyces and pelvis of the right
of two ureteric buds in the kidney. No contrast enhancement is seen in the right
mesonephric duct. ureter suggesting ureteropelvic junction obstruction.
b. The ureter draining the lower The right kidney demonstrates relatively increased
segment migrate more cephalad renal length in comparison with the left kidney; this is
and lateral than the ureter draining consistent with obstruction
the upper segment. (Weigert Meyer
Rule) Megaureter and vesicoureteral reflux. Postvoid image
c. There is often reflux to the ureter of from a voiding cystourethrogram (VCUG) shows
the lower collecting system. Upper bilateral vesicoureteral reflux and bilateral
pole ureter is prone to ureteral ureterovesical junction obstruction caused by stenosis
ectopia and obstruction. of the distal ureters
d. More common in females and is
often bilateral 21-year-old man with left megaureter. Coronal
e. Often asymptomatic but commonly maximum-intensity-projection excretory MR urogram
presents with persistent or reveals markedly dilated distal ureter, less dilated
recurrent urinary tract infections upper ureter, normal-sized pelvis, and minimally
rounded renal calices.
DOUBLE COLLECTING SYSTEM
● Renal units containing 2 pyelocalyceal Vesico-ureteral Reflux Grading
systems
● Two ureters empty separately into the CONGENITAL ANOMALIES OF THE URINARY
bladder or fuse to form a single ureteral BLADDER
orifice ● Develops from the urogenital sinus and the
Associated with congenital genitourinary tract surrounding splanchnic mesenchyme
abnormalities ● The urogenital sinus is comprised of 3
regions:
COMPLETE DUPLICATION OF URETER a. The cranial or vesical region which will form the
- second ureteral bud bladder and which is attached to the allantois.
arising from b. The middle or pelvic region.
mesonephric duct c. and the caudal or phallic region.
- ureters develop from
separate ureteric buds ANOMALIES IN NUMBER
originating from a single wolffian duct A. Agenesis
- Rare
ANOMALIES IN POSITION AND FORM - No bladder is present
Ureterocele: - Urethra and penis are absent in male
A sacculation of the bladder end of the ureter that can - Generally stillborn but all surviving infants are
occur either in the bladder or ectopically. female
Girls > boys. - Complaint: persistent incontinence
Bilateral in 10%
Asymptomatic or cause obstruction/ incontinence/ Agenesis of the bladder in a 5-day-old girl with wetting.
infection. Image from bilateral ureterography performed with
catheters placed in ectopic ureteral orifices shows
Simple ureterocele. (a) IVU image shows the typical dilated and tortuous ureters (u) with dilatation of the
cobra head appearance at the end of both ureters renal pelves and calices. Intrarenal reflux is also noted.
(arrowheads). ★ = bladder. (b) IVU image shows the IVU showed poorly functioning hydronephrotic kidneys.
contrast material-filled bladder (★) with a negative
B. DUPLICATION
filling defect (arrowheads) that represents a a. Complete Duplication
ureterocele. (c) Transverse US image of the bladder ● Involves 2 completely separate bladder, each
(B) demonstrates a sonolucent cystic structure with an with its own wall of muscle and mucosa
echogenic wall (U) that projects into the bladder, a separated by peritoneal fold
finding that represents a simple ureterocele ● Right and left kidney drain into left and right
bladder via single ureter
URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION ● 2 urethras are present
● Cause: Intrinsic narrowing of the junction of ● Male: 2 penises or one penis with 2 urethras;
the renal pelvis and ureter scrotum is bifid
● Result of a patent but aperistaltic segment at ● Female: 2 urethra, 2 vagina, 2 uterus with
the UPJ one horn and FT
● Abnormal recanalization of the ureter during b. Incomplete Duplication
embryologic development is the favored ● Septum partially divides the bladder
-‐
3
-‐
● Partial horizontal septa à hourglass ● pyelectasis, caliectasis, ureterectasis,
appearance of bladder hydroureter
-‐
4
-‐
● matrix calculi - mucoprotein and ● wall is very thin
mucopolysaccharide; Proteus infection ● mass is quite radiolucent and sharply
● hyperparathyroidism - hypercalcemia demarcated from renal parenchyma
● osteolytic metastasis, leukemia, multiple ● beak-like deformity - “claw sign”
myeloma, sarcoidosis
● gout/ hyperuricemia; hyperoxaluria ACQUIRED RENAL CYSTIC DISEASE
● develops during dialysis treatment
RENAL TUBERCULOSIS ● large number of cysts, less than 3 cm
● Infection is hematogeneous ● cortical and medullary
● Early lesions are multiple involving the renal ● develop renal cell carcinoma in 7%
papillae ● complication: retroperitoneal hemorrhage
● As disease progresses, involvement of the
adjacent infundibula often leads to VON HIPPEL LINDAU DISEASE
obstruction ● autosomal dominant phakomatosis
● May lead to stricture formation if there is ● retinal angiomatosis, CNS
ureteral involvement hemangioblastomas, pheochromocytoma
● If destruction continues, irregular cavities are ● multiple simple renal cysts; one third have
found adjacent to the calyces which leads to renal cell carcinomas
virtual destruction of the entire kidney
● Demonstration of tubercle bacilli in the urine AUTOSOMAL RECESSIVE PKD
● Alteration in kidney size ● grossly elongated, dilated collecting ducts
● Calcification throughout the renal parenchyma
● Multiple ureteral stricture formation ● both kidneys symmetrically and uniformly
enlarged
ULTRASOUND FINDINGS OF ACUTE ● associated hepatic cysts
PYELONEPHRITIS
Normal AUTOSOMAL DOMINANT PKD
Renal enlargement ● spherical fluid-filled cysts, 1-3 cm in size
Compression of the renal throughout
sinus ● may have curvilinear wall or intrarenal
Abnormal echotexture punctate calcifications
Hypoechoic (edema) ● knobby appearance of kidney surface
Hyperechoic (hemorrhage) ● kidneys are greatly enlarged
Loss of corticomedullary ● associated hepatic cysts; also in the
differentiation pancreas, spleen, lungs and ovaries
Poorly marginated mass ● associated with 10% rupture of berry
Gas within the renal parenchyma aneurysm of the arteries at the base of the
Decreased blood flow in power brain
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•Type 3 - with thick septation or ● usually transitional cell; squamous cell and
chunky calcifications, uniform thick adenocarcinoma are rare
wall or non-enhancing nodules ● irregular filling defect, usually at the base,
• Type 4 - thick walls, enhancing resulting in ureteral obstruction
components and solid enhancing ● appearance vary depending on whether
nodules sessile or polypoid
BOSNIAK CLASSIFICATION ● MRI used in staging diagnosed bladder
• Type 1 = no chance of malignancy malignancy
• Type 2 = may have chance of
malignancy POSTERIOR URETHRAL VALVES
• Type 3 = 57% probability of ● causes obstruction leading to infection,
malignancy vesicoureteral reflux, hydronephrosis, and
• Type 4 = 100% malignant eventually renal damage
● almost exclusively in males, often in children
RENAL CELL CARCINOMA ● enuresis; bladder distension, dribbling, poor
● solid, with or without cystic component stream, failure to thrive
● tumor enhancement on contrast infusion ● in newborn - flank mass caused by urinary
● areas of necrosis or hemorrhage do not ascites, respiratory distress
enhance ● voiding cystourethrography
● perihilar lymphadenopathy, direct tumor ● thin membrane arising from the
invasion of adjacent organs veromontanum which partially obstructs the
urethra during voiding
WILM’S TUMOR
● nephroblastoma
● most common abdominal neoplasm in
infancy and childhood
● arise from embryonic renal tissue
● tends to become very large
● x-ray - large intrarenal tumor with distortion of
calyces and pelvis
● impaired renal function
● ultrasound - homogeneous echogenic renal
mass
● CT show no vessel encasement
URINARY BLADDER
● smooth-walled, round or oval
● 5 to 10 mm above the symphysis pubis
● floor parallels the superior aspect of the pubic
rami
● dome is round in males, flat or slightly
concave in females
VESICAL CALCULI
● obstruction & infection are the chief causes
● half are radioopaque, visible in plain x-ray
● common in males
● usually midline, unless within a bladder
diverticulum
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Male and Female Genito-urinary Tract Ø associated with infection of other parts
of the GU tract
Prostate Ø ultrasound - enlarged, heterogeneous
• inner gland (transition zone - appearing epididymis with increased
periurethral) flow by Doppler
• outer gland (central and peripheral Ø orchitis usually present
zone) Testicular Tumor
1. transition zone ● painless scrotal mass - from the testicle
o site of benign prostatic or elsewhere?
hyperplasia ● common between 25 to 35 years
o can occlude urethra when ● seminoma, choriocarcinoma, embryonal
severe carcinoma, teratoma/ teratocarcinoma
2. peripheral and central zones ● lymphoma, leukemia, metastasis
a. lie posterior and lateral to the ● varied appearance on ultrasound; does
transition zone not correlate with histology
b. primary tumor site in 70-80% ● must do CT of retroperitoneum for
of cases nodal spread
Modalities: ● ddx: testicular hematoma from trauma
ultrasound and MRI Hydrocele
transrectal ultrasound - introduced in the 70’s by Ø fluid collection between the layers of
Watanabe the tunica vaginalis
Prostatic CA Ø often idiopathic
Ø primarily hypoechoic Ø may be secondary to trauma, infection
Ø most originate in the peripheral zone or tumor
Ø as tumors enlarged, histology become Varicocele
more infiltrative ● abnormal collection of dilated veins in
Ø transrectal ultrasound-guided biopsies the spermatic cord
Ø very high prevalence ● due to abnormal venous valvular
Ø affects up to 30% of patients who died mechanism or obstruction to blood
of other causes return
Ø which of these patients have clinically ● 90% of idiopathic varicocele occur in
significant tumors? the left - due to more obtuse union of
Ø tumor volume predicts tumor behavior left spermatic vein to the left renal vein
Ø tumors 3cc or more - likely to have (right spermatic vein joins the IVC at
extracapsular spread and aggressive acute angle)
histology ● ultrasound evaluation, with valsalva
Ø screening with prostate specific antigen maneuver and upright position
(PSA) & ultrasound ● may cause male infertility because of
increased scrotal temperature
Scrotum ● surgical repair
§ contains the testis, epididymis, Spermatocele
spermatic cord • dilatation of efferent ductules
§ testicle is covered by fibrous sheath - • usually in the head of epididymis
tunica albuginea, and surrounded by • generally symptomatic
tunica vaginalis • must be differentiated from varicocele
§ epididymal head - superior to testis;
epididymal body and tail - posterior and OB-GYNE RADIOLOGY
inferior to testis o anatomy of the gravid and nongravid
§ blood supply to testicle from the female pelvis
spermatic cord which contains the o no ionizing radiation
testicular artery o assess thermal index and mechanical
§ imaging by ultrasound and nuclear index
scintigraphy o magnetic resonance imaging
§ high resolution, linear array ultrasound; First trimester
with Doppler imaging • 0-12th menstrual week
Testicular Torsion • fertilization occurs at day 14 or week 2
ü testicular pain in newborn or adolescent menstrual age
male • gestational age = menstrual age
ü twisting of spermatic cord causing • earliest sonographic finding of an
compromise of venous and arterial flow intrauterine pregnancy = intradecidual
ü diagnosis should be prompt, within 6 sign
hours, to ensure testicular viability • intradecidual sign - echogenic mass in a
ü nuclear scintigraphy, doppler ultrasound subendometrial location; seen at 3.5 to 4
ü Doppler ultrasound weeks
o presence of arterial signal from • gestational sac - can be identified at
the central portion of the 4.5 weeks by endovaginal ultrasound;
testicle excludes torsion well-defined, thick, echogenic rim;
o confirm normal flow in the surrounded by thick echogenic
contralateral testis endometrium
Epididymitis • gestational sac measures approximately
1 cm at 5.5 weeks
• estimate of gestational age using mean Ø thickening in the decidual reaction
sac diameter (MSD) identified by 7 to 8 weeks
• yolk sac - seen at 6 weeks; well-defined Ø placenta clearly defined by end of 1st
echogenic ring trimester
• absence of yolk sac by the time MSD is Ø smoothly marginated structure with
8mm, consider failed pregnancy homogeneous fine echopattern
• embryo - seen at 6.5 weeks ; lies Ø later, the fetal surface develops
adjacent to the yolk sac; fetal cardiac undulations and the internal echopattern
activity visible become heterogeneous
• placenta should be easily visible by 9 Ø calcium deposition in the basal plate,
weeks increasing after 29 weeks
Threatened Abortion Placenta Previa
Ø vaginal bleeding in the first 20 weeks = ● most common cause of vaginal bleeding
threatened abortion in 2nd and 3rd trimester
Ø may be associated with mild cramping ● relationship of placenta to internal
Ø closed cervical os cervical os identified through a
Ø occurs in 25% of clinically apparent distended maternal urinary bladder
pregnancies ● “placental migration” - represents
Ø about 50% subsequently abort differential growth rate of the lower
Blighted Ovum uterine segment
● early pregnancy failure Abruptio placenta
● crown-rump length (CRL) of > 5mm ● painful vaginal bleeding
but with no cardiac activity ● retroplacental lucency representing
● GS > 16mm but with no embryo blood clot between the placenta and
● GS > 8mm but with no yolk saac myometrium
● rescan pregnancy after 1 week
Ectopic pregnancy UTERUS
ü abdominal pain and vaginal bleeding ● elongated, pear-shaped, hollow,
ü endovaginal and transabdominal muscular organ
scanning ● usually midline and anteverted
ü transabdominal scanning - locate large ● myometrium - homogeneous
mass or free fluid echopattern, with a linear central bright
ü pathognomonic finding = identification echo representing the endometrial
of an extrauterine gestational sac that cavity
contains a live embryo (seen in 30% of CERVIX
cases) ● contiguous with the vagina
ü other findings - empty uterus, decidual ● vagina - midline bright linear echo
cyst, adnexal mass, particulate fluid in representing the collapsed vaginal canal
cul de sac, pseudogestational sac in the OVARIES
endometrial cavity ● lateral to the uterus
ü decidual cyst - 2- to 5-mm cyst near ● increasing volume during puberty;
endomyometrial junction decreasing volume after menopause
ü tubal ring = echogenic ring of early ● average volume = 24 cc; longest
gestational sac with positive pregnancy dimension can reach 5 cm
test and empty uterus; seen in 50% of ● small cystic structures represent
ectopic pregnancy developing follicles
ü adnexal mass - complex or echogenic
solid in appearance LEIOMYOMA
ü echogenic fluid in the posterior cul-de- § uterine fibroid
sac § most common benign neoplasm of the
ü quantitative serum ß-hCG determination uterus
- lower than normal pregnancy and § commonly asymptomatic
plateaus rather than rise with time § may be multiple
§ uterine fibroid
Estimating Gestational Age § most common benign neoplasm of the
● gestational sac uterus
● crown rump length § commonly asymptomatic
● biparietal diameter § may be multiple
● head circumference § may contain “popcorn” configuration
● abdominal circumference calcification
● femur length § US = well-defined hypoechoic,
Fetal death isoechoic or hyperechoic mass
● absent fetal cardiac activity § with thin hypoechoic border or
● absent extremity motion pseudocapsule
● fetal stimulation - ballottement of § degree of deformity of uterine contour
anterior abdominal wall depends on location and size
● within days of fetal death, fetal skin § subserosal leiomyomas may be
become edematous and alterations in pedunculated; exophytic
the fetal anatomy § intramural leiomyomas are more
common
PLACENTA § influenced by estrogen; tend to grow
during pregnancy
• increased serum ß-hCG level
ADENOMYOSIS • clinical hallmark = vaginal bleeding in
ü deposits of endometrial glands within 1st trimester or early 2nd trimester
the myometrium • uterus may be appropriate, large or
ü pain, uterine tenderness, menorrhagia, small for dates
metrorrhagia, intermenstrual bleeding • may exhibit symptoms of hyperemesis
ü can be focal or diffuse gravidarum or pre-eclamptic toxemia
ü US - mixed echogenicity with no well- • complete or classic h. mole - no fetal
defined margins tissue or amniotic membranes; 46,XX
ü cysts within the myometrium are almost genotype
exclusively a feature of adenomyosis • partial h. mole - contain fetal tissue or
ü cysts are dilated, fluid-fileld amniotic membranes; polyploidy
endometrial glands that become genotype
noticeable during the secretory phase of • US
the cycle o echogenic solid appearing
mass that completely fills the
ENDOMETRIAL CARCINOMA endometrial cavity
• most common malignant neoplasm of o small vesicles in the 1st
the uterine body trimester, becoming more
• abnormal postmenopausal bleeding complex and may reach 2 cm
• diagnosed by direct examination of o larger hypoechoic areas
endometrial tissue obtained by represent hemorrhage
endometrial biopsy
• US
o enlarged uterus with distorted
endometrial echoes
o inhomogeneous, hypoechoic
myometrium
o hypoechoic ring surrounded by
a widened endometrial cavity
o widened fluid-filled
endometrial cavity due to
hematometra
CERVICAL CARCINOMA
v second most common uterine neoplasm
v diagnosed by direct observation of the
cervix and sampling of the cervical
epithelium
v imaging of the pelvis is helpful in
staging of cervical ca
OVARIAN MASSES
Ø ultrasound as a screening examination
o palpable mass
o unexplained pelvic pain
o endocrine disorders
Ø cystic masses - fluid-filled, no internal
echoes, have smooth walls, with
posterior enhancement
Ø complex masses - exhibit cystic and
solid characteristics
Ø solid masses - varying degrees of
internal echoes in homogeneous or
heterogeneous pattern
Ø cystic masses are generally benign
Ø solid tissue, heterogeneous appearance,
thick irregular septa increases the
probability of malignancy
Ø cysts with papillary projections =
papillary cystadenocarcinoma
Ø ascites - more common in malignant
GESTATIONAL TROPHOBLASTIC
DISEASE
• complete or classic hydatidiform mole
• partial hydatidiform mole
• hydatidiform mole with coexistent live
fetus
• invasive mole
• metastatic gestational trophoblastic
disease (choriocarcinoma)