Imaging of Abdominal Pathology

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Imaging of Abdominal Pathology

• J.J. Jimenez M.D.
• Carle Clinic Department of Radiology

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Methods of Abdominal Imaging

• Plain Film
• Fluoroscopy
• Ultrasound
• CT
• MR
• Nuclear Medicine
• Angiography

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Plain Film

• Limited Usefulness
• Free Air
• Obstruction
• Stones
• Tube Placement

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Approach to Plain Abdominal Films

• Stones
• Bones
• Mass
• Gas
• Look at the corners to cover your

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Fluoroscopy

• Largely replaced by endoscopy
• Still useful for small bowel
• Viable alternative for colon cancer screening
• Dynamic study ie. Swallowing, esophageal motility

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Upper GI and Small Bowel
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Ultrasound

• More widely available
• Excellent anatomic detail in the right hands
• Superior for Gallbladder disease
• Vascular Structures ie. Liver Transplant
• Aneurysm Screening
• Female Pelvis
• Bad for Pancreas---So-So for kidneys

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Computed Tomography

• Workhorse of abdominal imaging
• Great anatomic detail esp. with multislice
• Numerous protocols tailored to clinical problem
• Relatively easy to obtain
• Contrast ?????
• Renal stones no all else YES!!!

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Contrast vs Non Contrast
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Magnetic Resonance Imaging

• Good anatomic detail
• Susceptible to respiratory motion artifacts
• Good for problem solving or when contrast allergy
• Liver masses, adrenal masses, renal masses
• MRCP???
• MR angio??? CT superior

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Nuclear Medicine

• Limited usefulness
• Gallbladder
• Gastric emptying
• Meckels
• GI bleeding
• Oncologic imaging octreotide, PET, CEA,
  Prostascint

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Angiography

• Not used much for diagnostic purposes
• Can be used in GI bleeding and tumors when
  intervention is planned

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Normal CT Anatomy
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Normal CT Anatomy
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Normal CT Anatomy
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Normal CT Anatomy
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Normal CT Anatomy
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Normal CT Anatomy
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MRI Anatomy
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MRI Anatomy
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Coronal Recon at 1.25mm
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Coronal Recon at 1.25mm
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Sagittal Recon at 1.25mm
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Coronal Recon at 1.25mm
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Coronal Recon at 0.625mm
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Sagittal Recon at 0.625mm
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3-D Reformat
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3-D Reformat
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3-D Reformat
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3-D Reformat
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Normal Sonographic Anatomy
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Evaluating For Pathology

• Inflammation
• Mass
• Congential/Structural
• Vascular

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IN ORDER TO RECOGNIZE PATHOLOGY

• YOU MUST RECOGNIZE WHAT IS NORMAL

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Inflammation/Infection

• Fat stranding
• Thickening of structures-edema
• Fluid
• Abnormal Enhancement

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Mass

• Displacement of Normal Anatomical Structures
• Abnormal Enhancement
• Use HU measurements to help determine tissue of
  origin
• Enlargement of Normal Structures

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Evaluating for Pathology

• There will be overlap of findings among different
  disease categories
• THIS IS WHY WE HAVE DIFFERENTIAL DIAGNOSES
• THIS IS WHY CLINICAL HISTORY IS IMPORTANT

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40 YO Female RLQ Pain
Fat stranding
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40 YO Female RLQ Pain
More fat stranding
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40 YO Female RLQ Pain
Calcified appendicolith
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Differential Diagnosis

• Appendicitis
• Inflammatory bowel disease
• Infectious Colitis
• Diverticulitis

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Appendicitis

• Appendix gt 6mm
• Fat Stranding
• Fluid

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54 YO Male w/Abd Pain
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54 YO Male w/Abd Pain
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Differential Diagnosis

• Gastric Adenocarcinoma
• Lymphoma
• GIST Leiomyoma, leiomyosarcoma
• Lipoma
• Vascular Malformation/Varices

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28 YO Female with RUQ Abdominal Pain
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28 YO Female with RUQ Abdominal Pain
Area of hypodensity in medial spleen
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Differential Diagnosis

• Gastric Adenocarcinoma
• Lymphoma
• GIST Leiomyoma, leiomyosarcoma
• Lipoma
• Vascular Malformation/Varices
• Actual diagnosis benign Nissen Fundoplication
  defect with splenic infarct

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74 YO Female With Gastric Lymphoma
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PET- CT of Same Patient
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35 YO Male With Left Flank Pain
Fat stranding
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35 YO Male With Left Flank Pain
Dilated ureter
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35 YO Male With Left Flank Pain
Calcification at ureter and bladder junction
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Differential Diagnosis

• NONE

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69 YO Male With Flank Pain
Perinephric fat stranding and fluid collection
and escaping contrast
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Obstructive Uropathy

• Helical CT 3.75mm cuts with recons at 3mm
• NO CONTRAST
• Prone positioning
• Imaging Clues
• Stone in ureter
• Perinephric stranding
• Hydronephrosis or hydroureter

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57 YO Male with Pancreatitis
Dilated stomach
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57 YO Male with Pancreatitis
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Duodenal Mass

• Tumors
• Adenocarcinoma
• Lymphoma
• Leiomyoma/Sarcoma/GIST
• Inflammatory
• Infection
• Crohns
• Lymphoid Hyperplasia

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53 YO Female w/Abd Pain
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53 YO Female w/Abd Pain
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53 YO Female w/Abd Pain
Dilated right ureter
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Ureteral Mass

• Stone
• Infectious Debris
• Inflammatory
• Blood
• Tumor TCC, SCC

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73 YO Male s/p Colectomy with Abdominal
Distention and Pain
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73 YO Male s/p Colectomy with Abdominal
Distention and Pain
Parastomal hernia
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Small Bowel Obstruction

• Adhesions
• Hernia
• Tumor
• Gallstone ileus

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65 YO Male S/P Right Nephrectomy
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65 YO Male S/P Right Nephrectomy
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Intraabdominal Hemorrhage

• Intra v. extraperitoneal
• Fluid (may be hyperdense)
• Stranding
• Hematocrit effect

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65 YO Female with Abdominal Pain
Thickened sigmoid colon with fat stranding
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65 YO Female with Abdominal Pain
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Differential Diagnosis

• Infectious Colitis
• Diverticulitis
• Inflammatory Bowel Disease
• Neoplasm

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69 YO Male With Abdominal Pain
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Differential Diagnosis

• Carcinoid
• Lymphoma
• Adenocarcinoma
• Inflammation
• Mesenteric lypodystrophy

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19 YO Female With Upper Abdominal Pain
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19 YO Female With Upper Abdominal Pain
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Differential Diagnosis

• Appendicitis w/abscess
• Inflammatory bowel disease
• Infectious Colitis

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26 YO Female With Sudden Onset RLQ Pain
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26 YO Female With Sudden Onset RLQ Pain
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26 YO Female With Sudden Onset RLQ Pain
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Differential Diagnosis

• Trauma
• Ectopic Pregnancy
• Ovarian cyst

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73 YO Female With Lymphoma and Fever
Hypodensities within spleen
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73 YO Female With Lymphoma and Fever
Hypodensity in liver
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Differential Diagnosis

• Lymphomatous involvement
• Opportunistic infection fungal

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43 YO Female With Abdominal Pain and Distention
Fluid
Hypodensity in right lobe of liver
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43 YO Female With Abdominal Pain and Distention
Ascites
Soft tissue density
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43 YO Female With Abdominal Pain and Distention
Enhancing fluid posterior to uterus
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Differential Diagnosis

• Portal Hypertension/liver disease
• Omental Carcinomatosis ovary, pancreas, stomach

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51 yo Male with RUQ pain
Distended gallbladder
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51 yo Male with RUQ pain
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51 yo Male with RUQ pain
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51 yo Male with RUQ pain
Emphysematous Cholecystitis
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54 YO Female With RLQ Pain
Intussusception
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54 YO Female With RLQ Pain
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74 YO Male With RUQ Pain and Rectal Cancer
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74 YO Male With RUQ Pain and Rectal Cancer
Enhancing vessel (superior mesenteric vein) with
hypodense thrombus
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74 YO Male With RUQ Pain and Rectal Cancer
Hypodensity in branch of portal veinportal
venous thrombosis
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80 YO Male W/ Abd Pain
Air in distended bowel wallpneumotosis colitis
Apple core lesion in cecum
Colon carcinoma
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61 YO Male With Abd Pain
Ascites
Varicesenhancing vessels in esophageal wall.
Severe portal hypertension.
Small nodular liver and large spleen, bowel wall
thickening
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61 YO Male With Abd Pain
Bowel wall thickeningportal hypertension
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42 YO Male With Dysphagia
Thickening of esophageal wall
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78 YO Male With RUQ Pain
Distended gallbladder with pericholecystic fat
stranding
Acute cholecystitis
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19 YO With Abd Pain
Fat stranding and rim-enhancing fluid
Periappendiceal abscess (ruptured appendix)
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68 YO Male With Abn Urine Cytology
Papillary areas of thickening at base of bladder
with wall thickening
Transitional cell carcinoma
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62 YO Male With Abd Pain
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64 YO Male With Abd Mass on U/S
Ectopic atrophic kidney
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73 Female With Ovarian Ca
Loculated fluid collection with calcifications
Omental carcinomatosis secondary to ovarian cancer
Hypodensity in spleen
Ascites, nodular appearing liver
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12 YO Sledding Accident
3 weeks later showing healing
Low density fluid collection--splenic
laceration, acute
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24 YO Male With Mono and Abdominal Pain
Fluid behind bladderspontaneous splenic
hemorrhage
Enlarged spleen with surrounding fluid
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33 YO Gravid Female With RLQ Pain
Large mass with complex cystsovarian cancer
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54 YO Male With Abd Pain
Enlarged aorta with concentric thrombus--AAA
Small mass in adrenal gland
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54 YO Male With Adrenal Mass
Good washoutlikely benign adenoma
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42 yo Female with Mass
Defect in abdominal wallspigelian hernia
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52 YO F With Abnl Colonoscopy
DD appendicitis, mucocele, or peritoneal
inclusion cyst
Fluid filled structuremucocele of the appendix
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20 YO Male In Head-On MVA
Hyperdense fluid around liver and spleentrauma
pt. with ruptured spleen
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20 YO In Head-On MVA
Loops of small bowel with shock bowel enhancing
pattern
Small aorta and inferior vena cava
Hypovolemic shock due to splenic rupture
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73 YO F With Epigastric Pain
Mass in head of pancreas
DD Pancreatic neoplasm vs. pseudocyst
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82 YO Male With Abd Pain
Apple core lesioncolon cancer
Dilated thick-walled bowel loop
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76 YO F With Breast Cancer
Multiple hepatic metastatic lesions
T1
T2
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76 YO F With Breast Cancer
T1 LAVA sequence with gadoliniumdiffuse
metastatic disease
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65 YO Male With Prostate Ca
T1
Abnormal base of bladder
T2
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4 week old with vomiting
Pyloric muscle5 mm in thickness
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Ruling out pyloric stenosis

• Pyloric muscle should be less than 3.5 mm
  thickness
• Should be less than 17 mm in length

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82 YO RUQ Pain and Fever
Distended gallbaldder with enhancing wall and air
in gallbladder, small stonescholecystitis with
probable secondary liver involvement
Gallbladder with echogenic material and edema