ABDO/IR Flashcards
Achalasia is
failure of organised oesophageal peristalsis causing impaired relaxation of the lower sphincter resulting in stasis and dilatation
due to loss/destruction of neurones in the auerbach/myenteric plexus
Achalasia imaging
short segment 3ish cm
xr
convex opacity overlapping mediastinum
air fludi level
small absent gastric bubble
displaced trachea on lateral
FLUORO
bird beak/rat tail
dilatation
tram track
incomplete relaxation
pooling/stasis
tertiary contractions
failure of clearance
Achalasia ddx
central/peripheral neuropathy
scleroderma
malignancy
stricture
chagas disease
non spec dysmotility
diffuse spasm
presbyoesophagus
Chagas disease is, and manifestations
tropical parasite infection (trypanosomiasis)
Cardiac
- myocarditis
- dilated cardiomyopathy
GI
- dysmotility and megaoesophagus
- megaduodenum and small bowel
- megacolon
GU
- megaureter
CNS
- meningoencephalitis
- chagoma
Presbyoesophagus is
manigestations of degenerating motor function in the aging oesophagus
Diffuse oesophageal spasm is
a motility disorder of the opesopahgus. may appear as a corkscrew esophagus
nutcracker oesopahgus is
a motility disorder, uisually normal swallow study
Schatzki ring is
a symptomatic narrow b ring occuring in the distal oesophagus and usually assoc with a hiatus hernia
Oesophageal web is
a constriction caused by a thin membrane projecting into the oesophagus, typically cervical
Oesophageal stricture aetiology
Upper and middle
- Barrett
- radiation
- caustic ingestion
- congenital
- intramural pseudodiverticulosis
- skin diseases, eg pemphigoid
Distal
- usually in the setting of GORD or
- scleroderma
- post NGT
- zollinger ellison
- post gastrectomy
Barrets oesophagus is and imaging
metaplasia of the oesophagus, a precursor for adenocarcinoma
imaging
- signs of reflux oesophagitis
- reflux
- long stricture
- large deep ulcer
- reticular mucosal pattern
- thickened folds
Oesophagitis causes
Infective
- HIV
- CMV
- Herpes
- Candida
Non infective
- drugs
- reflux
- corrosive
- idiopathic eosinophilic
- radiation
Oesophagitis imaging
mucosal irreg
erosions and ulcers
abnormal motility
thickened folds
limited distensibility
strictures
pseudodiverticulosis
small ulcers
- reflux
- herpes
- radiation
- drug induced
large ulcers
- cmv
- hiv
- carcinoma
Corrosive oesophagitis imaging
acute
- oedema
- ulceration
- sloughing
- dilatation
- atony
chronic
- single long or multiple stricutres
Idiopathic oesinophilic oesophagitis is
an inflammatory disease characterised by eosiniophilia of the oesophagfus layers
imaaing
- ringed oesophagus
- may coexist with longer stricutres
feline oesophagus is
transient transverse bands seen in the mid and lower oesophagus - almost always associated with reflux
Oesophageal carcinoma subtypes
Squamous (80%)
Adeno (20ish)
- mostly related to barretts, lower GOJ
Other
- mucoepidermoid
- adenoid cystic
- spindle cell
- leiomyosarcoma
- rhabdomyosarcoma
- fibrosarcoma
- lymphoma
Macroscopic
- polypoid
- ulcerating
- infiltrating
- superficial spreading
Oesophageal carcinoma imaging
XR
- wide azygooesophageal recess
- thick posterior stripe/right paratracheal striple
- tracheal deviation
- retrocardiac/posterior mediastinal mass
- air fludi level
- mass in gastric bubble (Kirklin)
Fluoro
- irregular stricture
- dilatation and hold up
- shouldering
CT
- eccentric wall thickneing >5mm
- perioesohpageal stransing/soft tissue
- dilated
- tracheobronchial invasion
- aortic invasion
Oesophageal leiomyoma is
a benign smooth muscle neoplasm of the oesophagus
imaging
- discrete ovoid mass, well outlined
- obtuse angles
- intramural, smooth
- calcifications are pathognomonic
- moderate enhancement
- no invasion
Oesophageal fibrovascular polyps are
benign intraluminal submucosal pedunculated tumours, usually occuring in the upper third of the oesophagus at the level of the upper sphincter
Peptic ulcer disease imaging
pocket of barium filling crater
- post bulbar; zollinger ellison
oedematous collar of swollen mucosa
radiating folds of mucosa away from ulcer
Acute gastritis causes and imaging
aetiology
- infection; hpylori
- systemic illness
- nsaids
- autoimmune
- caustic
- immunosuppression
- eosinophilic
imaging
- gastric wall oedema
- halo sign; enhancing mucosa
Atrophic gastritis imaging
decreased/absent fundal folds
narrow tubular stomach
small absent areae gastricae
linitis plastica - usually nodular
GISTs are
the most common mesenchymal tumours of the GI tract
c KIT histopath
assoc
- carney triad
- NF1
- carney striakis
GIST imaging
Location
- stoamch
- SI
- anorectum
- colon
- oesophagus (uncommon)
- extra GI - mesentery, omentu, retroperitoneum (uncom)
CT
- soft tissue, central necrosis
- often exophytic
- screscent ulceration with air fluid level (torricelli bernoulli sign)
- peripheral enhancment
- calcs uncommon
MR
variable due to necrosis, haemorrhage, cystic change
Concerning; exogastric growth, >5cm, central necrosis and extension to other organs
Gastric adenocarcinoma imaging
Fluoro
Early
- elevated, superficial or shallow lesions
Advanced
- polypoid
- ulcerating
CT
- polypoid +/- ulceration
- focal wall thickening
- ulceration
- infiltrating
Menetrier disease is
a rare idiopathic hypertrophic gastropathy
present with acholhydria, hypoproteinaemia and oedema. typically fundal region.
fluoro
- enlarged and tortuous folds in the fundus and body, sparing the antrum
- diluted barium due to mucus hypersecretion
CT
- thickened rugae, resembling convolutions of brain
- wall thickness normal between folds
Zollinger ellison syndrome is
a clinical syndrome secondary to a gastrinoma
secrete gastrin, hypersecretion of gastric acid
leads to diarrhea, gastritis, GORD and PUD
assoc with MEN 1
Zollinger ellison syndorme imaging
Fluoro
- thickened rugael folds
- multinodular gastric contour
- erosions and ulcers
CT
- thickened rugal folds
- multiple gastric nodules
ddx
- other gastritises
- gastric lymphoma
- menetrier
- outlet obstruction
Inguinal hernia types
Indirect
- lateral to inferior epigastric vessels
- deep inguinal ring
- anterior to spermatic cord in males
- follows round lig in females
Direct
- medial to inferior epigastric vessels
- through a defect in hesselbachs triangle
- weakness in the fascial floor of the inguinal canal
- inguinal canal is usually compressed/displaced (lateral crescent sign)
Meckels diverticulum is
a congenital intestinal diverticulum due to fibrous degeneration of the umbilical end of the vitelline duct that occurs around the dital ileum
Meckels rule of 2
2% population
2 inches
2 feet from IC valve
2/3 ectopic mucosa
2 types of ectopic tissue
2% symptomatic
Meckels presentation
Haemorrhage
Obstruction
- adhesion
- luminal
- intussception
- Littres hernia
Inflammation
Perforation
Neoplasm
Meckels imaging
CT
- blind ending small bowel pouch
- antimesenteric side of the distal ileum
- can invert and cause an internal polypoid lesion
NM
- pertechnetate
- only if gastric mucosa present, mucin secreting cells-
Duodenal diverticulum types and complications
Can be primary (mucosa) or secondary (entire wall)
Can be periampullary
Can be intraluminal (duodenal web)
Complications
- diverticulitis
- haemorrhage
- perforation
- biliary obstruction (Lemmel symdrome)
Duodenal diverticulum ddx
Periduodenal abscess
Duodenal ulcer
Duodenitis
Head of pancreas cystic lesion
Pseudocyst
Duodenal web is
obstruction at the duodenum due to a membranous web or intraluminal diverticulum. small central aperture, different to atresia
ddx
- duodenal stenosis
- duodenal atresia
Duodenal atresia is and assoc
a congenital malformation fo the duodenum with complete obstruction of the lumen
assoc
- downs
- vacterl
- annular pancreas
- other atresias
Duodenal atresia imaging and ddx
XR
double bubble
- if distal gas, stenosis
US
double bubble
- ?connection, might be a foregut duplication
DDX
- stenosis or web
- malrotation and volvulus
- choledochal cyst
- omental cyst
- duplication cyst
Gastroschisis is
extraabdominal herniation of fetal/neonatal bowel loops into the amniotic cavity through a paraumbilical defect. no surrounding membrane. no strong associations
Gastroschisis imaging
herniated content to right side of cord
small AC
ddx
- omphalocoele
- physiological herniation (before 11 weeks)
Omphalocoele is
congenital midline abdominal wall defect at the base of the umbilical cord insertion
Omphalocoele assocaitions
Chromosomal
Other syndromes
- BW
- pent cantrell
- OEIS
- lethel omph cleft palate
Other anomalies
- CNS, cardiac, GU, skeletal
Omphalocoele imaging
mulitple bowel loops in membrane covered defet
direct cord insertion
small AC
polyhydram
allantoic cyst often present
can rupture
ddx
- pseudoomph
- gastroschisis
- physiological herniation
- limb body wall complex
- umbilical hernia
Polyposis syndromes
Hereditary
- Hereditary nonpolyposis colorectal cancer HNPCC
- Familial adenomatous polyposis syndromes FAPS ( incl, classic,. Gardner, Turcot)
- Bannayan riley ruvalcaba
- Cowden
- Peutz jeghers
- TS
- Juvenile polyposis syndromes
Non hereditary
- Serrated polyposis syndrome
- Cronkite Canada syndrome
- Juvenile polyposis syndrome
Can also be adenomatous or hamartomatous
Adenomatous
- FAPS
- Gardner
- (HNPCC - cancers come from adenomatous polyps)
Hamartomatous
- JPS
- BRR
- Cowden
- Peutz Jegher
- Cronkhite Canada
HNPCC/Lynch syndrome is
an AD condition which predisposes to malignancies, including colorectal. Due to mutations in DNA mistamtch repair (MMR) geners
Cancers
- CRC
- GU (endometrial, ovarian, prostate, urothelial)
- SB
- Gastric
- hepatobiliary
- CNS
Diffuse polyposis is characteristically absent
FAPS is
characterised by presnece of hundreds of adenomatous polyps in the colon, mutation of the tumour suppressor APC gene, though can be MUTYH.
<5mm. rectum typically spared. can have extracolonic (duodenal, gastric) polyps
associations
- CRC
- hepatoblastoma
- extracolonic polyps (stomach, duodenum)
- desmoid tumours
- osteomas
- dental anomalies
- papillary thyroid ca
Variants
- gardners
- attenuated FAP
- familial polyposis colli
Gardner syndrome is
FAP
Multiple osteomas
Epidermal cysts
Fibromatoses
Desmoid tumours
Supernumery deeth, odontomas, dentigerous cysts
Ampullary carcionoma
Papillary thyroid ca
Turcot syndrome is
characterised by multiple colonic polyps and increased risk of colonic and primary brain tumours; commonly medulloblastomas or GBM
APC gene
- CRC by 40
- medulloblastomas
HNPCC gene
- not as much CRC
- GBM
Bannayan Riley Ruvalcaba syndrome is
AD disorder caused by mutation of the PTEN gene
Features
- hamartomatous intestinal polyps, typically terminal ileum and large bowel
- macrocephaly
- lipomatosis
- dermal and deep visceral lipomas
- angiolipomas
- haemangiomata
- speckled penis
- hypotonia
- scoliosis
- pectus
- woman:::: breast ca, MR screening
Cowden syndrome is
caused by mutation of the PTEN gene and characterised by hamartomas throughout the body and increased risk of ca
Features
- mucocutaneous lesions, including trichilemmomas
- GI polyps, large and small bowel
- glyucogenic acnathosis
- thyroid goitres
- fibrocystic breast disease
- testicular lipomatosis
Cancers
- breast
- thyroid
- dysplastic cerebellar gangliocytoma, in assoc with Lhermitte duclos disease
Peutz Jeghers syndrome is
AD polyposis syndrome characterised by
- multiple hamartomatous polyps (SB/jejenum), also colon, stomach
- mucocutaneous melanin pigmentation mouth/fingers/toes
Proliferation of all three layers of the mucosa
Cancers
- CRC, stomach, small intestine
- adenoma malignum
- breast
- pancreas
- ovary sec cord
- uterus
- cervix
- testis (sertolis)
- lung
Serrated polyposis syndrome is
characterised by presence of multiple serrated polyps. heterogenous genetic with BRAF and KRAS most common. CRC in 50%.
Juvenile polyposis sydrome is
hundreds of hamartomatous polyps containing fluid or mucus. SMAD4 and BMPR1A implicated. end up with CRC
Assoc
- malrotation
- meckels
- hydrocephalus
- congenital heart
- mesenteric lymphangioma
- pulm AVM
Cronkhite canada syndrome is
a non neoplastic non hereditary hamartomatous polyposis syndrome characterised by rash, alopecia and watery diarrhea
predominantly stomach, large intestine and small bowel. not assoc with malig.
Infective enteritis overview
Proximal: giarida, stronglyloides
Distal: salmonella, shigella, yersinia
Distal ileum/caecum: TB, typhlitis, amebiasis
Ileocaecal TB imaging
most common GI TB, third most common extrapulmon TB
Barium
- flieschner (narrowing of the ileum, thickening of the valve)
- thickening and hypermotility of the caercum
- stierlin sign (empty caecum)
- chronic; fixed rigid valve, conical caecum, pulled caecum from fiorbosis)
CT
ileocaecal thickening
asymmetric valve thickening
mesenteric adenoaptyh with central low attenuation
ddx
- crohns (more ileal, less ascites, more vascularity)
- caecal carcinoma (eccentric, mets)
- small bowel lymphoma (thick, no stricture, lymphadenopathy/hepatosplenomegaly)
- amoebic colitis
Typhlitis is and imaging
necrotising inflammatory conditions originating in the caecum and extending out in immunocompromised
bowel wall thiickening
hypoechoic wall, echoic thick mucosa
fat stranding, pneumatosis
small bowel obstruction
Terminal ileitis ddx
IBD
Infectious
- cdiff
- salmonella
- yersinia
- tb
- typhlitis
Spondyloarthopathies
Ischaemia
Radiation
Vasculitidies
- SLE/PAN/HSP/Behcet and others
Neoplasic
- adenocarc, lymphoma, carcinoid
Drug related
Infiltrative
- EG
- sarcoid
- amyloid
- mastocytosis
Endometriosis
Coeliac disease is
a t cell mediated autoimmune gluten intolerance characterised by loss of villi in the proximal small bowel and malabsorption
Coeliac associations
Pulmonary haemosiderosis (Lane Hamilton)
IgA def
Cavitating mesenteric lymph node syndrome
Small bowel lymphoma
Down syndrome
CEC/Gobbi syndrome
IBD
Coeliac disease imaging
Fluoro
- Small bowel dilatation
- dilution of contrast
- multiple non obstructing intussusceptions (coiled spring)
- jejunoileal fold pattern reversal
- moulage sign
- mosaic pattern
- flocculation
- segmentation
CT
- jejunoileal fold pattern reversal
- small bowel dilatation/thickening
- stranding
- intussusceptions
- strictures
- vascular engorgement
- prominent nodes
- submucosal fat
- hyposplenism
Gallstone ileus is
an uncommon cause of mechanical bowel obstruction, occuring as a complication of chronic cholecystitis. stone fistula to small bowel and impaction at ileocaecal valve
Bouveret syndrome is
Gallstone ileus but causing gastric outlet obstruction
Gallstone ileus imaging
XR
- Rigler triad: obstruction, gas in biliary tree, gallstone
CT
- riglers again
- fistula site
- complications
Aortoenteric fistula is
pathologic communication between the aorta and GIT.
Can be primary (assoc with a complicated aneurysm) or secondary (assoc with graft repair)
Aortoenteric fistula imaging and ddx
Primary
Direct signs:
- ectopic gas in aorta
- presence of vascular contrast in GIT
Indirect signs:
- bowel thickening over aneurysm
- disruption of periarotic fat
- bowel/periaortic haematoma
Secondary
- increased perigraft soft tissue
- pseudoaneurysm formation
- disruption of aneurysmal wrap
- increased soft tissue between the graft and the wrap
ddx
- perigraft infection
- retroperitoneal fibrosis
- infected mycotic aortic aneurysm
- infectious aortitis
Duodenal adenocarcinoma is, risk factors and ddx
most common primary malignancy of the duodenum
risk factors;
- polyposis syndromes
- inflammatory disorders ie crohns, coeliac
- non hered polyps
ddx
- lymphoma
- NET
- pancreatic tumours
- periampullary tumours
- lower cbd tumours
- leiomyosarcoma
- benign polyp/adenoma/leimyoma/lipoma
Periampullary tumours are
those which arise within 2cm of the ampulla of vater
four main types
- pancreatic head/uncinate tumours
- lower common bile duct tumours
- ampullary tumours
- periampullary duodenal adenocarcinoma
Bulging duodenal papilla dddx
normal variant
patulous ampulla of vater
tumours
- IPMN
- ampullary
- periampullary
- cholang
- pancreatic
papillitis
autoimmune panc
choledochocele
impacted stone
GI neuroendocrine tumours classification
functional or non functional
TYPES
Insulinoma
- 50% of nets
- usually <2cm
- mostly pancreas
- 15% malig
Gastrinoma
- pancreas, LN, duodenum
- 20-30%
- variable size
- 75% malig
Non functioning
- pancrease
- 15%
- usually large and malignant
VIPoma
- pancreas, adrenal
- 3%
- 50% malignant
Glucagonomas and somatostatinomas
- rare
- pancreas
- malginant
Insulinomas are
most common pancreatic net, develop from ductal pluripotent cells into unregulated insulin secreting cells. equally distributed in pancreas
whipples triad
- hypoglycaemia
- sx of hypo
- immediate relief with glucagon
Assoc with MEN1
Insulinoma imaging
small
hypervascular
can have calcs
equal pancreas distribution
Gastrinomas are
second most common pancreatic endocrine tumour
associated with MEN1, and the most common type associated with it
associated with PUD - zollinger ellison syndrome
often malignant, extrapancreatic (duodenal)
occur in gastrinoma triangle
Gastrinoma/Passaro triangle boundaries
Confluence of cystic and common bile ducts
Junction of D2/D3
Junction of pancreatic head/neck
VIPoma is
a very rare pancreatic endocrine tumour that secrete vasoactive intestinal peptide.
WDHA syndrome; watery diarrhea, hypokalemia, achorhydria
location
- intrapancreatic, commonly tail
- extrapancreatic neurogenic; symp chain
- extrapancreatic non neurogenic; oesophagus, bowel, liver, kidney
Glucagonoma is
a pancreatic endocrine tumour that secretes glucagon. commonly malignant.
4d syndrome
- dermatitis
- diabetes
- DVT
- depression
typically large and metastatic at time of diagnosis. hypervascular.
Somatostatinomas are
a rare NET.
assoc;
- MEN1
- VHL
- NF1
Inhibitory syndrome
- DM
- cholelithiasis
- diarrhea
typically in the pancreas, but can also be duodenum/ampulla or vater
Whipples disease is
a rare infectious multisystem disorder caused by actinobacteria tropheryma whipplei
presents with migratory arthritis, weight loss, diarrhea, abdominal pain. can have hepatosplenomegaly and lymphadenopathy
Whipples disease features (by system)
GI
- jejunal micronodules
- thickened mucosal folds
- low density mesenteric nodes
CNS
- cortical or subcortical atrophgy
- hydrocephalus
- lesions; t2 hyper and mildly enhancing, no restriction
- midbrain, mesial temporal, hypothalamus and corticospinal tracts\
thoracic
- diffuse/focal infiltrates
- basal opacities
- nodules
- adhesions
- effusion
- nodes
Brunner gland hyperplasia is
disproportionate overgrowth of Brunner Glands in the duodenum from yperacidity. Multiple nodular filling defects, cobblestoning. ddx duodenitis.
Scleroderma GI manifestations
Oesophagus
- Dilated distally
- dysmotility
- reflux
Small bowel
- luminal dilatation
- reduced peristalsis
- hidebound bowel (crowding of valv c)
- accordion sign (evenly spaced mucosal folds)
- sacculation
Large bowel
- psedosacculation
- loss of haustra
- dilatation
- reduced transit
Intestinal angioedema imaging
Long segment concentric thickening
Mural stratification
Mild mesenteric oedema
Ascites
No nodes
Pancreatic trauma AAST grading
Proximal - right of SMV
Distal - left of SMV
Deep - to level of duct
Superficial - before duct
1: haematoma with minor contusion or superficial lac
2: major contusion or lac without ductal injury
3: distal transection or deep injury with duct injury
4: proximal transection or deep injury involving the ampulla or cbd
5: shattered head
Acute pancreatitis complications
Absent necrosis
- Acute peripancreatic fludi collection <4w
- Pseudocyst (encapsulated) >4 weeks
Necrosis
- acute necrotic collection <4w
- Walled off necrosis (encapsulated) >4w
Necrotic pancreatitis
- can lead to emphysematous pancreatitis
Vascular
- haemorrhage
- pseudoaneurysm
- splenic/portal vein thrombosis
Fistula into peritoneal cavity
Abdominal compartment syndrome
CTSI pancreatitis
Balthazar score A-E
A normal 0
B enlargement 1
C inflammatory 2
D single collection 3
E two or more collections 4
Necrosis
none 0
<30% 2
30-50% 4
>50% 6
Score /10
Sentinel loop is
a short segment of adynamic ileus close to an inflammatory process on xr. upper abdomen - pancreatitis. right lower quadrant - appendicitis.
Colon cut off sign is
distension proximal colon, abrupt termination at splenic flexure, decompression distally
LUQ pathologies;
- pancreatitis (phrenicocolic lig via tv mesocolon)
- carcinoma
- IBD
- mesenteric ischaemia
- abdominal aortic aneurysm rupture
- stomach tumorus
Autoimmune pancreatitis associations
Igg4 sclerosing disease
RA
Sjogrens
IBD
Autoimmune pancreatitis imaging
Sausage shape
Minimal stranding, confined to peripancreatic
Peripancreatic low rim/halo
MR
T1 low
T2 minimally incre
C+ delayed
DWI restricts
MRCP ?strictures
Other sites
- nodes
- renal inflamm pseudotumours
- retroperitoneal fibrosis
- pleural effusions
- CBD strictures
-mediastinal nodes
Autoimmune pancreatitis ddx
Diffuse
- lymphoma
- plasmacytoma
- mets
- infiltrative ductal adeno
Focal
- ductal adenocarcinoma
Tropical pancreatitis
SPINK1 mutation
Tropical countries
Younger
Large ductal calculi
Emphysematous pancreatitis is
complications of acute caused by secondary necrotising infection. gas forming bacteria.
Hirschsprung imaging
XR
Bowel obstruction. Affected bowel is smaller in calibre
Fluoro
Affected segment small calibre with proximal dilatation
Saw tooth irregularity of the segment
Reversed rectosigmoid ratio
Meconium plug syndrome is
functional colonic obstruction in a newborn due to an obstructing meconium plug. Usually tyransient and affects the left colon (small left colon syndrome)
Meconium plug syndrome imaging
XR
multiple dilated loops
Fluoro
small calibre left colon with filling defects due to retained meconium
rectum is normal in size
Necrotising enterocolitis imaging
XR
dilated bowel loops
loss of the normal gas shapes
thumbprinting
pneumatosis
portal venous gas
pneumoperitoneum
Ogilvie syndrome is
colonic pseudo obstruction. acute distension without an underlying mechanical obstruction
Ulcerative colitis associations
PSC
Moya moya
Ank spon
CRC
Coeliacs
Lung disease
Uveitis and iritis
Erytheme nodosum and pyoderma gangrenosum
Thrombotic comps
fatty liver
Seronegative spondyloarthropathies
Chronic hepatitis
Ulcerative colitis imaging
XR
Thumbprinting
toxic megacolon
Fluoro
Granular mucosa
Lead piping
CRC
CT
Lead piping
Wall thickening
Mural stratification
Submucosal fat deposition
Thickening perirectal fat
CRC
Pneumatosis
MR
Wall thickening
Diffusion restriction
Enhancement of the mucosa
Loss of haustra
Toxic megacolon is and causes
Acute complication in IBD. Fulminant colitis cuases neurogenic loss tone of the colon leading to severe dilation and perforation
Causes
UC
Crohn
Infectious, particularly cdiff
Neutropaenic colitis
Ischamia
Radiation
Lymphoma
GVHD
Hypothyroidism
Hrischsprungs
Infectious colitis imaging
Wall thickening with homogenous enhancement
Ascites
Stranding
Right colon; yersinia, salmonella
Diffuse; CMV, e coli
Left; shigella, schistosomiasis
Rectosigmoid; gonorrhea, herpes, trchomatis
CRC staging
T0 no evidence
Tis in situ
T1 into submucosa
T2 into muscularis
T3 into subserosa or into non peritonealised tissues
T4a visceral peritoneal layer
T4b adjacent organs
N0 none
N1a 1 regional
N1b 2-3 regional
N1c serosa/non peritoneal tissue without regional
N2a 4-6
N2b >7
M0 no
M1a one organ without peritoneal
M1b multiple organs no peritoneal
M1c peritoneum with or without others
Mucinous neoplasms of the appendix include
Premalignant
- adenoma
- serrated polyp
Uncertain
- low grade appendiceal mucinouss neoplasm
- high grade appendiceal mucinous neoplasm
Malignant
- appendiceal mucinous adenocarcinoma
- poorly diff mucinous with signet ring cells
- mucinous signet ring cell carcinoma
Pseudomyxoma peritonei is
a syndrome of progressive accumulation of mucinous ascites related to a mucin producing neoplasm, usually appendix.
Pseudomyxoma peritonei imaging
Loculated collections of fluid accumulating along the peritoneal surfaces rsulting in scalloped appearance of teh coated organs and omental caking
Omental caking ddx
TB
Lymphoma
Malignant peritoneal mesothelioma
usually from ovaries, gastric or colon
Appendiceal mucocoele is and causes
abnormal accumulation of mucin causing distention of the vermiform appendix
Causes
- mucus retention cyst
- mucosal hyperplasia
- mucinous cystadenoma of the appendix
- mucinous adenocarcinoma of the appendix
Appendiceal mucocoele imaging
XR
peripheral calcs
US
onion sign (layering)
can have some shadowing
CT
low attenuation
at caecum
mural calcs
nodular - cancer
gas - infection
MR
T1 variable
T2 yperintense
Low grade appendiceal mucinous neoplasms (prev cystadenomas) are
rare mucinous tumours of the appendix showing low cytoligc atypia. Distinguished from HAMN on histo grounds.
Suspcious features of HAMN
- soft tissue thickening
- wall irregularity
- PMP
Perianal fistula classification
Intersphinteric - does not cross external
Transpincteric - from intersphincteric space through external into ischiorectal fossa
Suprasphincteric - superiorly into intersphincteric space, over puborectalis and through iliococcygeus into ischiorectal fossa
Extrasphincteric - perineal skin through ischiorectal fossa and levator ani muscle complex into rectum
Splenic haemangiomas are
second most common splenic lesion after cyst. slow flow venous malformation. similar imaging to hepatic haemangioma.
Splenic lymphangioma is and imaging
rare benign tumours corresponding to abnormal dilation of lymphatic channels. can be congenital or acquired. present as lobulated or multiloculated cystic lesions. can have curvilinear mural calcifications
Splenic hamartoma imagig
variable US
CT
heterogenous enhancemnt
iso or hypodense
MR
T1 iso
T2 heterogenously hjyper
C+ vivid immediately post con (unlike haemangioma), delayed uniform with central hypovascular
SANT imaging
US
hypoechoic
CT
homgenous, hypodense or isodense
enhancing rim and radiating enhancing tissue (spoke wheel)
MR
T1 heterogenous low to intermediate
T2 low
C+ peripheral and septal enhancement spoke wheel. non enhancing stellate scar.
Hepatic/splenic TB imaging
hepatosplenomebgaly
US
miliary nodules or larger masses
CT
miltple low attenuaiting
eventually calcify
can have large lesion with target sign
DDX
Micronodular
- lymphoma
- fungal
- mets
- sarcoid
Macro
- abscess
- mets
- primary
Splenic siderosis is and imaging
gamna gandy bodies
microhaemorrhage with haemosidering dep
usually seen in PH but also haematolgoical conditions
US
multiple echoic with shadowing
CT
look like granuloms
MR
siderotic foci punctate througout
Wandering spleen is
migration of the spleen
abnormality of its suspendosry ligaments
can infarct
aetiology
- sickle cell
- heterotaxy
- trauma
- mono
Pancreatic ductal adenocarcinoma risk factors
Cigs
Chronic pancr
Diet
Obesity/DM
Family hx
Hereditary syndromes
- BRCA2
- HNPCC
- FAMMM
- peutz jehger
Pancreatic ductal adenocarcinoma imaging
Fluoro
- inverted three sign
- wide sweep
US
- double duct
- mass
CT
- poorly defined
- surrounding desmo reaction
- enhance poorly
- double duct
MR
T1 hypo
T1FS hypo
C+ delayed
T2 variable
MRCP DD
Pancreatic ductal adenocarcinoma staging
T1 <2cm
T2 2-4cm
T3 >4cm
T4 encasing SMA/Coeliac aa
N0 none
N1 1-3 regional
N2 4 or more regional
M0
M1
Serous cystadenoma of the pancreas pathology
polycystic
honeycomb
macrocystic (<10%)
Associated with VHL
Serous cystadenoma of the pancreas imaging
Location
- distributed throughout
CT
multicystic
lobulated
bunch of grapes
>6 cysts
<2cm in size
enhancing central scar
stellate central calcification
MR
T1 low
T2 low fibrous scar, high signal cysts
C+ fibrous septa enhance
No communication with duct
Serous cystadenoma of the pancreas ddx
IPMN - communicates
Pseudocyst
Mucinous - peripheral calcs, bigger cysts, usually unilocular
SPPN
Mucinous cystadenoma of the pancreas imaging
Mostly body/tail, can be head
CT
- rounded contour
- peripheral calcs
- heterogenous attenuation
- internal septa
- can be uni or multilocular
Mucinous cystadenocarcinoma of the pancreas imaging
Numerous large cysts
Smooth contour
Thicker walls
Amorphous calcs, septations, solid excrescences can be seen
No central scar
MR
Mucin high T1
Cysts high T2
Calcs low
Pancreatic duct conventional arrangement
Main duct
- Dorsal duct proximal to dorsal ventral fusion
- drains at the ampulla of vater
- connects with the accessory pancreatic duct
Duct of Wirsung
- distal main duct
- segment of ventral duct between fusion and major papilla
- continuous with the main duct proximally
Accessory duct of Santorini
- Portion of dorsal duct distal to dorsal ventral fusion
- Drains anterior superior head
- Can drain to minor papilla
- Can persist as a branch of the main duct
Pancreas divisum is
Failure of dorsal/ventral fusion
Dorsal duct drains most of pancreas via the minor papilla
Can result in a santorinicoele
Types
- Classic; no connection
- Absent; no Wirsung, major papilla only drains CBD
- Functional; filamentous connection
Meandering main pancreatic duct is
Main pancreatic duct that drains into major papilla after performing a reverse Z type or Loop turn in the pancreatic head
Ansa pancreatica is
Communication between the duct of wirsung and duct of santorini
Arises as a brnach duct from the main, descends down, loops upward and terminates at the minor papilla
Anomalous pancreaticobiliary junction is
abnormal junction of the pancreatic duct and CBD outside the duodenum to form a long common channel >15mm
Can have associated biliary dilatation, or
- choledochal cyst
- stricture
- pancreatic anomalies
- synchronous biliary cancer
Annular pancreas is
a morphological anomaly that results in pancreatic tissue completely or incompletely encircling the duodenum. can cause duodenal obstruction.
develops due to failure of the ventral bud to rotate with the duodenum causing encasement
Non neoplastic pancreatic cysts:
Unilocular
- pseudocyst
- simple cyst
Diffuse
- VHL
- CF
- ADPKD
Macro multi
- hydatid
Cystic/solid
- WON
IPMNs are
epithelial pancreatic cystic tumours of mucin producing cells that arise from pancreatic ducts
IPMN types
Main
- segemental or diffuse
- higher malig potential
- look like chronic pancr
Branch
- head and uncinate
- localised and mass like
- can be multifocal
- macro or microcystic
- typically indolent
Mixed
IPMN imaging
Communicate with a duct
CT
single or multiple cystic lesions
dilatation of the main duct
do not calcify
MR
Main
- Main duct >5mm
- segment or diffuse dilation
- mucin signal
- thin parenchyma
- solid mural nodules concerning
- mucin dependantly in the duct
Branch
- single or multiple side branches with dilation
- cystic mass like appearance
- bunch of grapes
IPMN worrisome features
Main
- duct 5-9mm worrisome
- >10mm high risk
- enhancing components
Branch
- main duct >5mm
- cyst >3cm
- >5mm enhancing nodule
- solid mass
- thickened/enhancing cyst wall
- growth rate >5mm/year
Nodes
Abrupt change in calibre with distal atrophy
Elevated CA19 9
Solid pseudopapillary tumour of the pancreas is
a rare and usually benign pancreatic cystic neoplasm most commonly seen in young females
Solid pseudopapillary tumour of the pancreas imaging
Pancreatic tail
CT
encapsulated lesion
solid/cystic
cystic usually more central
Calcifications and enhancing solid components
MR
T1 low
T2 heterogeneous to high
C_ heterogenous and slowly progressive
Acinar cell carcinoma of the pancreas imaging
CT
enhancing oval solid
often NO biliary duct dilatation
can have calcifications
can invade adjacent organs
Pancreatoblastomas are
rare paediatric tumours of the pancreas. around 4yo. assoc with beckwith wiedemann syndrome
Pancreatoblastoma imaging
CT
well defined
heterogenous
solid/multilocular cystic components
enhancing septa
fine calcifications
MR
T1 low
T2 hetero high
Anal cancer imaging and staging
MR
T1 low to muscle
T2 high to muscle
T1 <2cm
T2 2-5cm
T3 >5cm
T4 invasion of adjacent organ
N1a inguina, mesorectal, internal iliac
N1b external iliac
N1c N1a + N1b
M0 M1
Hepatitis imaging
US
hepatosplenomegaly
starry sky
GB thickening
periportal oedema
decreased echotexture
CT
hepatomegaly
periportal oedema
decreased attenuation on NC
lymphadenopathy
MR
T1 periportal oedema
C+ delayed periportal enhancement
IP/OP steatosis
Mirizzi syndrome is
extrinsic compression of the extrahepatic biliary duct from calculi in the cystic duct or gallbladder. may have an associated cholecystodochal or cholecystoenteric fistula
Acute calculous cholecystitis complications
gangrenous
perforation
emphysematous
abscess
fistula
vascular
Acalculous cholecystitis is
cholecystitis without stones or where stones arent contributory. typically critically unwell patients or injured patients.
Chronic cholecystitis imaging
NM/HIDA
delayed visualisation bw 1-4 hours
?EF after cholecystokinin
Emphysematous cholecystitis is
a rare form of cholecystis with wall necrosis causing gas formation in the lumen/wall. surgical emergency. usually older and diabetic patients
Emphysematous cholecystitis imaging
US
Ring down
Champagne sign
CT
Gas
Xanthogranulomatous cholecystitis is
an uncommon inflammatory cause, characterised by multiple intramural nodules. rupture of rokitansky aschoff sunses
Xanthogranulomatous cholecystitis imaging
US
thickening
intramural hypoechoic nodules or bands
stones
infiltration of liver
CT
small intramural hypoattenuating nodules
poor enhancement
local infiltration
Primary sclerosing cholangitis is
an uncommon inflammatory condition affecting the biliary tree resulting in multiple strictures and cirrhosis
unlike PBC, ab titers are low
PSC associations
IBD, especially UC
Autoimmune hepatitis
Sjogrens
Retroperitoneal fibrosis
Mediastinal fibrosis
Riedels thyroiditis
Orbital pseudotumour
PSC imaging
General:
multiple strictures entire tree
cirrhosis, with left lobe atrophy
caudate hypertrophy
US
cirrhosis
irregular ducts
bright portal triads
?GB ca
CT
atrophy involving left
caudate hypertrophy
bile duct dilatations/strictures
MRCP/ERCP
multiple short segment structures
beading intervening
biliary diverticula
mural irregs
PSC complications
hepatic osteodystrophy
cholangiocarcinoma
CRC
HCC
GB ca
PSC ddx
Cirrhosis
- left lobe usually hypertrophied
- caudate not as large
IgG4 related SC
- older
- more systems
- elevated igg4
Secondary sclerosing
- aids
- other strictures
Cholangiocarcinoma
PBC
- younger women
- high ab titres
Alagille syndrome
Hepatic sarcoid
Secondary sclerosing cholangitis causes
Chronic obstruction/recurrent cholangitis
Ischaemic cholangiopathy
Infectious, especially aids
Acute ascending cholangitis causes and imaging
E coli
typically obstructive
- choledocholithiasis
- malig
- sclerosing cholangitis
- biliary procedures
Imaging
- duct dilation
- bile duct wall thickenning
- stones
Recurrent pyogenic/oriental cholangiohepatitis is
commonly found in SE asia patients characterised by bile duct strictures and dilatation with intraductal pigmented stone formation
Recurrent pyogenic/oriental cholangiohepatitis imaging
dilatation and multilevel strictures
intraductal pigmented calculi
regions of segmental atrophy
CT
hyperdense stones
focal fibrosis, heterogenous enhancement and focal steatosis
MR
reduced arborisation of peripheral ducts (arrowhead)
multiple strictures
IgG4 related sclerosing cholangitis is
also known as autoimmune and is part of the igG4 spectrum. can also occur in isolation
Cirrhosis is and aetiology
common endpoint of chronic liver diseases which cause hepatocellular necrosis
Causes:
- alcohol
- viral
- NASH
- biliary disease (PBC, PSC)
- metabolic (haemochromatosis, wilsons, alpha 1)
- autoimmune
- vascular (congenstive, budd chiari)
- CF
Cirrhosis imaging
General
- caudate/left lobe hypertrophy
US
- surface nodules
- coarse/heterogenous
- segmental hypertrophy/atrophy
- enlarged PV
- slow/reversed PV flow
- cavernous malformation
- recanalisation
- collaterals
- portal hepatic vein waveform
- splenomegaly
- ascites
- fatty change
CT
- surface and parenchymal nodularity
- fatty change
- parecnhymal heterogeneity
- PV supply to dysplastic nodules
- lobar hypertrophy/atrophy
- signs of portal hypertension
MR
Regen nodules
- T1 iso or hyper
- T2 iso
- no early enhancement/washout
Siderotic
- T2 hypo
Dysplastic
- can look like regen of hcc
HCC
- arterial enhancement and washout
- late enhancing capsule
- T2 hyper
Cirrhosis ddx
Pseudocirrhosis
Miliary liver mets
Budd chiari
Hepatic failure
Sarcoid
PBC
Chronic portal vein thrombosis
Nodular regnerative hyperplasia
Cirrhosis CNS manifestations
hepatic encephalopathy
alcohol
- osmotic demyelination
- wernickes
- marchaifava bignami
Wilsons (siderosis)
Haemochromatosis (hypopituitarism and parkinsons)
Cirrhosis MSK manifestations
varices
haematomas
infective complications
osteodystrophy
avn
sarcopenia
Cirrhosis pulmonary manifestations
Hepatopulm syndrome
- dilation of pulm vasculature
Portopulmonary hypertension (PAH)
hepatic hydrothorax
ARDS
Primary biliary cholangitis is
chronic progressive cholestatic liver disease. destruction of small intrahepatic bile ducts, portal inflammation and progressive scarring. AMA high. causes cirrhosis
PBC associations
cholelithisis
autoimmune diseases
interstitial lung disease
pulmonary hypertension
hcc
PBC imaging
MR
T2
- parenchymal lace like fibrosis and periportal halo sign
periportal halo sign; low signal intensity around portal venous branches
Other
- periportal hyperintensity
- segmental hypertrophy of the caudate
- hepatic surface irregularity
Portal vein thrombosis causes
Reduced flow
- cirrhosis
- malignancy
Hypercoagulability
- inherited conditions
- malignancy
- myeloproliferative disorders
- IBD
- dehydration
- OCP
- pregnancy
- trauma
Endothelial disturbance
- local inflammation
Portal vein thrombosis imaging
US
- filling defect
- internal flow in tumour thrombus
CT
- dilling defect
- enhancement of the wall (dilated vasa vasorum)
- THAD
- enhancement; tumour
- cavernous transformation in chronic
- bowel ischaemia acute
- portal hypertension
MR
T1
- acute high signal
T2
- acute high signal
- chronic low signal
C+
- may enhance post con in tumour
- THID
Cavernous transformation of the portal vein is
sequla of portal vein thrombus. replcement of PV with numerous tortuous venous channels
Cavernous transformation of the portal vein imaging
General
- dilated vessels
- left atrophy
- hypertrophy segment 4 and caudate
US
- numerous vessels occupying the portal vein bed
CT
- numerous vascular structures
- calcs in the thrombus
AAST liver injury scale
Grade 1
- subcap haematoma <10%
- laceration <1cm
Grade 2
- subcap haematoma 10-50%
- intra haematoma <10cm
- laceration 1-3cm
Grade 3
- subcap haematoma >50%
- intra haematoma >10cm
- laceration >3cm
- vascular injury contained to parenchyma
Grade 4
- laceration 25-75% lobe or 1-3 segments
- vascular injury into peritoneum
Grade 5
- laceration >75%
- vascular; juxtahepatic venous injurie
Multiple hepatic cysts associations
VHL
ADPCKD
Hepatic cyst ddx
hydatid
abscess
biloma
biliary cystadenoma
choledochal cyst
mets
biliary hamartoma
Peribiliary cysts are
seen in chronic liver disease. cystic formation around the biliary ducts, typically hilar. dont communicate with the biliary tree.
Hepatic haemangiomas are
benign vascular liver lesions. congenital, non neoplastic and typically cavernous subtype.
Hepatic haemangioma associations
extra hepatic haemangiomata
hereditary haemorrhagic telangiectasisa
kasabach merritt syndrome
hepatic arterioportal shunt
Hepatic haemangioma imaging
US
- well defined
- hyperechoic
- peripheral feeders
CT
- discontinous nodular peripheral enhancement
- progressive centripedal fill in
- bright dot sign
MR
T1 hypo
T2 hyper
Gad peripheral nodular discontinuous. retain on delayed
Prim variable on delayed
DWI high, with high or mixed ADC
Giant hepatic haemangioma imaging
CT
heterogenous, central low attenuation
typical enhancement but less consistent
may never totally fill in
MR
T1
- hypo
- clefts of low
T2
- clefts high
C+
- hypo clefts
- otherwise similar
Hyalinised/sclerosing hepatic haemangiomas are
variants of haemangiomas which contain extensive fibrous tissue and thrombosed vascular channels giving an unusual imaging appearance that cant be differentiated from malignancy
Hyalinised/sclerosing hepatic haemangioma imaging
MR
T1
- hypo
T2
- variable, typically lower than a regular
C+
- absent or mild arterial
- slight peripheral late
- usually a thin peripheral rim
Can have some retraction and THID
Flash filling hepatic haemangiomas are
atypical haemangiomas, benign, with imaging features that can be suspcious for malignancy
Flash filling hepatic haemangioma imaging
Small
US
hyper
CT
intense homogenous arterial enhancement
isodense on delayed
can have phleboliths
MR
T1 hypo
T2 hyper
C+ enhancement no washout
ddx
- hcc
- hypervascular met
- fnh
Focal nodular hyperplasia is
a regenerative mass of the liver, second most common benign liver lesion. thought due to hyperplastic growth of normal hepatocytes with malformed biliary drainage
FNH associations
Hepatic haemangioma
HHT
AVM
Hepatic adenoma
PV atresia
Budd chiari
Portal hypertension
FNH types
Typical and atypical
Typical
- poorly encapsulated
- central scar with radiating fibrous septa
- large central artery
- absent portal veins
Atypical
- lacks a central scar and central artery
- pseudocapsule
- lesion heterogeneity
- non enhnacing central scar
- intralesional fat
FNH imaging
US
- variable
CT
- bright homogenous arterial
- non enhancing central scar
- hypo to iso attenuaitng on portal venous
- no fat, calc, haemorrhage
- delayed scar enhancement 80%
MR
T1
- iso to hypo
- hypo scar
T2
- iso to hyper
- hyperintense scar
Gad
- intense arterial enhancement
- iso on portal venous
- central scar enhancement on delayed
Prim
- early arterial enhancement
- enhancement persists on delayed
- fades on delayed
- central scar does not enhance on hepatobiliary
FNH nuclear medicine
Sulfar colloid
- taken up by kuppfer cells of reticuloendothelial system
- photopaenic 30%
HIDA
- should be taken up in about 90%
FNH DDX
Adenoma
- more heterogenous on portal and delayed
- no gad retention on delayed
- assoc wth fat/calc/haemorrhage
- inflammatory type looks similar on Prim
- no scar
HCC
- cirrhosis
- washout
- capsule
Fibrolamellar
- more distinct on T1/T2
- larger
- calcification, necrosis
- mets, local invasion
- decreased activity on HIDA/sulphur
Hypervascular mets
- multiple
- washout on PV/Delayed
- older
Haemangioma
- peripheral discontinuous
- flash filling can look similar
Cholangio
- hypo in art/venous with delayed enhancement
- dominant large central scar
- capsular retraction
Multiple focal nodular hyperplasia syndrome is
two or more FNH’s with
- haemangioma or
- vascular malformation or
- intracranial tumour
Assoc
- meningiomas
- astrocytoms
- liver haemangiomata
- phaes, gist
- klipper trenauanay weber
Hepatic adenomas are
benign hormone induced liver tumours. typically solitary, predilection from haemorrhage
Hepatic adenoma associations
OCP
Anabolic steroids
Glycogen storage disease
Obesity
Metabolic syndrome
Diabetes mellitus
Hepatic adenoma pathology/types
Usually solitary and large
Typically subcapsular and commonly right lobe
Can have dystrophic calcs
Classification
1. inflammatory
- most common
- highest bleed rate
2. HNF1 alpha mutated
- women, OCP
- often multiple
3. Beta catenin mutated
- men on steroids
- glycogen storage diosrders of FAP
4. unclassified
Hepatic adenoma imaging
US
variable echogenicity
hypoechoic halo seen
CT
variable depending on fat and hamorrhage
well marginated
iso to liver
transient relatively homogenous arterial
iso dense on PV and delayed
calcs can be seen from old haemorrhage
MR
T1
- variable
T2
- mildly hyper
IP/OP
- signal drop due to fat
Gad
- early arterial enhancement
- iso on delayed
Prim
- usually hypointense on hepatobiliary phase due to redcued uptake
NM
photopaenic on sulphur colloid 75%
increased on HIDA
cold on gallium
Hepatic adenoma ddx
HCC
- washout
- rim enhancement persists on delayed
FLHCCC
- central scar
- calcs more common
FNH
- t2 bright scar with late enhancement
- retains primovist
Mets
- hypo on T1, moderately hyper t2
- fat and haemorrhage less common
Haemangioma
Hepatic adenomatosis is
loads (>10) of hepatic adenomas.
Inflammatory hepatic adenoma is and imaging
most common
OCP
metabolic syndrome
highest rate of haemorrhage
MR
Prim
- enhancement on hepatobiliary agent, due to OATP receptors
- similar to FNH
IP/OOP
- no signal drop
T2
hyper
atoll sign
HNF1 alpha is and imaging
second most common
only women on OCP
multiple 50%
MR
Gad
- Moderate arterial, less than inflammatory
- less likely to have persistent PV/delayed enhancement
T2
iso to mildly hyper
IP/OP
signal drop
Beta catenin is and imaging
adenoma. men. male hormon. glycogen storage. FAP.
imaging overlaps with the others
HCC risk factors
viral hepatitis
alcohol
biliary cholangitis
congenital biliary atresia
errors of metabolism
- haemochromatosis
- alpha 1 antitrypsin
- type 1 glyco stroage
- wilsons
obesity and DM
HCC types and general imaging
Massive/focal
- large mass
- necrosis, fat, calcs
Nodular
- multifocal
- central necrosis
Infiltrative
- diffuse
- can be hard to distinguish from cirrhosis
supply from hepatic artery - early enhancement and washout
can have a central scar
rim enhancement on delayed post con causing a capsule appearance
propensity to invade vascular structures
HCC CT features
vivid arterial
washous out rapidly
can have assocaited wedge shaped perfusion abnormality due to arterioportal shunts
focal fatty sparing halo
portal vein thrombus
HCC MR features
T1
- variable
- iso to hypo
- hyper from fat or decreased background
T2
- variable
Gad
- arterial enhancement
- washout
- persistent rim enhancement
Prim
- arterial with PV washout
DWI
- high
HCC ddx
hypervascular mets
- less common in cirrhotics
- less vascular invasion
FNH
- no vascular invasion
- non enhnacing halo
- central scar
- prim persists on delayed
- sulphur colloid 80% positive
Cholangio
- peripehral
- bilairy obstruction
- delayed enhancement
THADS
Lymphoma
TB
LIRADS major and ancillary features
Major
- non rim arterial hyperenhancement
- non peripheral washout
- enhancing capsule/pseudocapsule
- threshold growth >50% <6months, >100% >6 months, new >1cm <24months
Ancillary
Favouring malignancy not HCC in particular:
- US visibility
- subthreshold growth
- corona enhancement
- fat sparing in a solid mass
- restriction
- mild to moderate T2 hyper
- iron sparing in a solid mass
- transitional phase hypo
- hepatobilairy phase hypo
Favouring HCC in particular
- non enhancing capsule
- nodule in nodule
- mosaic architecture
- fat in mass
- blood in mass
Favouring benign
- stable size >2years
- size reduction
- marked T2 hyper homogenous
- undistorted vessels
- parallels blood pool
- hepatobiliary isointensity
Fat containing liver lesions
Benign
- focal fat
- adenoma
- fnh (rare)
- angiomyolipoma
- teratoma
- adrenal rest tumour
- glisson capsule pseudolpoma
Malignant
- HCC
- met liposarc
- primary liposarc
- other fat containing liver mets
Fibrolamellar hcc is
a histoligcal variant of HCC with laminated fibrous layers between the tumour cells. typically younger adults, no cirrhosis/hepatitis
Fibrolamellar HCC imaging
US
variable
CT
Single, large
Fibrous central scar
Arterial enhancement
Central scar persistent enhancement
Can have calc
MR
Scar hypo on all sequences
Scar can occassionally be T2 bright
T1 iso to hypo
T2 hypo to hyper
Gad
- arterial heterogenous
- PV/delayed; iso to hypo, delayed scar enhancement
Prim
- uptake not reported
Sulphur colloid
- wont take up tracer
Barcelona clinic liver cancer staging (HCC)
Uses performance status, Child Pugh score and radiologic extent
Stage 0
- PS 0
- CP A
- Solitary <2cm
Stage A
- PS 0-2
- CP A-C
- Solitary >2cm or
- Multiple <3cm
Stage B
- PS 0
- CP A-C
- Multifocal >3 lesions or
- Multifocal with one >3cm
Stage C
- PS 1-2
- CP A-C
- Vascular invasion and/or nodal and/or mets
Stage D
- PS >2
- CP C
- No radiology
Cholangiocarcinoma is
malignant epithelial tumour arising from the biliary tree excluding GB or AoV
Cholangiocarcinoma RF
Carolis
Choledocholithiasis
PSC
Oriental cholangitis
Cirrhosis
Toxins
Hepatitis, HIV
IBD
Fibropolycystic liver disease
Cholangiocarcinoma types
Intrahepatic
Extrahepatic
- perihilar (incl Klatskin)
- distal (to cystic insertion)
Macroscopic appearance
- Mass forming
- Periductal infiltrating
- Intraductal growth
Mass forming
- intrahepatic
- peripheral
- central fibrosis
Periductal infiltrating
- most common at hilum
- combo with mass forming seen
- longitudinal growth along wall
Intraductal
- papilla or tumour thrombus endophytic
- alterations in calibre
- can be mural/polypoid
- mucin prodn
Mass forming cholangiocarcinoma imaging
US
- homogenous
- intermediate echos
- peripheral hypoechoic halo
- capsular retraction
CT
- homogenously low on NC
- heterogenous minor peripheral enhancement
- gradual centripedal fill in
- capsular retraction
- distal duct dilation
- vascular compression wo invasion
MR
Similar to CT
DWI Target sign
Prim
- can reflect differention
- hypo; poor
- rim; intermediate
- diffuse; well diff
Periductal infiltrating cholangiocarcinoma imaging
US
- altered bile ducts without a clear mass
CT
- regions of duct wall thickening or of the periductal parenchyma with altered calibre of the involved duct
- common at the hilum
- longer than benign strictures
- contrast enhancement
- proximal/peripheral dilation
Intraductal cholangiocarcinoma imaging
US
- alterations in calibre
- can have a polypoid intraluminal mass
CT
- alterations in calibre
- enhancing polypoid mass
Cholangiocarcinoma ddx (by type)
Mass forming
- mets
- HCC
- other primary liver tumours
- abscess
Periductal
- benign stricture
Intraductal cholangiocarcinoma
- intraductal HCC invasion
- hepatolithiasis
- biliary cystadenoma or cystadnocarcinoma
- benign stricture
Bismuth Corlette classification is
for perihilar cholangiocarcinomas based on extent of ductal infiltration
type 1
- CHD below confluence
type 2
- involves confluence
type 3a
- 2 with right duct origin involvement
type 3b
- 2 with left duct origin involvement
type 4
- 3a + 3b
type 5
- CBD/cystic junction
Intrahepatic cholangio staging
T1
a; <5cm no vascular
b; >5cm no vascular
T2
- solitary with intrahepatic vascula
- multiple +/- vascular
T3
- visceral peritoneum
T4
- local extrahepatic structure invasion
Perihilar cholangio staging
T1
confined to duct
T2
a; beyond duct into fat
b; beyond duct into liver
T3
branches of portal vein or hepatic artery invovlement
T4
invades PV or bilateral branches or
unilateral second order radicals with contralateral PV/HA invovlement
Distal cholangio staging
T1
wall invasion <5mm
T2
wall invasion 5-12mm
T3
wall invasion >12mm
T4
involves coeliac, SM or CH artery
Fibropolycystic liver disease includes
congenital hepatic fibrosis
ADPCKD
biliary hamartomas
carolis disease
choledochal cysts
Multiple biliary hamartomas are
also known as von meyenberg complexes. multiple benign biliary hamartomas. assocaited with dom/recess polycystic kidney and liver disease.
Multiple biliary hamartomas imaging
US
variable
echogenic when small
hypoechoic when larger
ct
no enhancement
5-30mm
predilection for subcapsular liver
MR
T1 hypo
T2 hyper
C+ non enhancing
Caroli disease is
a congenital disorder of multifocal cystic dilation of the segmental intrahepatic ducts
also a type 5 todani choledochal cyst
associated with hepatic fibrosis, medullary sponge kidneyy, polycystic kidney disease
Caroli disease imaging
US
may show dilated ducts
intraductal bridging septa
dilated ducts surrounding portal vein branch
calculi
CT
multiple hypodense rounded foci
inseparable from dilated intrahepatic ducts
central enhancing dot represent portal vein radicles
MR
T1 hypo
T2 hyper
C+ central portal radicle enhancment
MRCP continuity with ducts
Todani classification
Type 1
A: entire extrahepatic duct
B: focal extrahepatic duct
C: CBD portion extrahepatic duct
Type 2
True diverticulum
Type 3
Within duodenal wall, choledochocoele
Type 4
A: Intra and extra hepatic ducts
B: Multiple of the extra hepatic ducts
Type 5
Multiple intrahepatic ducts
Type 6
Cystic duct
Choledochal cyst is, associations and complications
Congenital cystic dilatations of the biliary tree
Assoc
- biliary atresia
- hepatic fibrosis (5)
- Anomalous pancreaticobiliary ductal junction
Complications
- Stones
- Cholangiocarcinoma
- Perforation
Hepatic hydatid imaging
XR
curvilinear/ring calc overlying the liver
US
sepated with daugther cysts and echogenic material
souble echogenic shadow
CT
cyst
peripheral calcs
Septa and daughter cysts
watter lilly sign, detached endocyst
variable attenuation
MR
T1 mixed low
T2 mixed high
C+ walls and septa enhance
Double target sign seen in
hepatic abscess
Sinusoidal obstruction syndrome/hepatic veno occlusive disease is
a condition arising from obstruction of heaptic venules
sloughing of endothelial vells empbolise venules cause fibrosis
assoc with BMT, chemo, jamaican bush tea
Sinusoidal obstruction syndrome/hepatic veno occlusive disease imaging
US
hepatomegaly
portal vein dilation/pulsatility
hepatofugal flow
elevated HA RI
GB wall thicekning
ascites
CT
hepatomegaly
nutmeg liver
portal vein dilation
ascites
Budd chiari syndrome is
occurs with partial or complete hepatic vein obstruction
Budd chiari causes
Idiopathic
Congenital
- web
- interrupted diaphragm
Venous thrombosis
Injury/inflammation
- BMT/Chemo
- autoimmune disease
- behcets
- tumour invasion
- IVC leiomyosarcoma
Budd chiari imaging
US
hepatosplenomegaly
heterogenous echotexture
hypertrophy caudate
regen nodules
GB wall thickening
ascites
Dopler
lack of flow
reversed flow
collaterals
thrombus
HP RI increase
CT
early enhancement of the caudate and central liver
delayed peripheral enhancement (flip flop)
nutmeg liver
hepatic vein non idendification
caudate enlargement
Gallbladder adenomyomatosis imaging
focal, segmental or diffuse
US
comet tail
mural thickening
CT
rosary sign
thickening
MR
thickening
pearl necklace sign
Gallbladder polyp types
Benign
- cholesterol
- inflammatory
Neoplastic
- papilary neoplasms
- pyloric gland adenomas
Malignant
- adenocarcinoma ++
- mets, scc, angiosarc
GB polyp malignant features
> 10mm
Sessile morphology
Solitary
Growth
Hyperenhancement
Gallbladder carcinoma is
a type of gb cancer, referring to primary epthelial malignancies. vast majority are adeno, can be squamous.
risk factors
- chronic cholecystitis
- stones
- fap
- IBD
- polyps
- porcelin gb
- PSC
Hepatoblastoma associations
Beckwith wiedemann syndrome
Hemihypertrophy
FAP
FAS
Prematurity
Gardner
Glycogen storage disease
Biliary atresia
Hepatoblastoma imaging
XR
Right upper quadrant mass
calcs
CT
heterogenous
hypoattenuating
necrosis and haemorrhage
chunky dense calcs
MR
T1 hypo
C+ hjetero
T2 heterogenously hyper
Hepatic mesenchymal hamartoma is
an uncommon benign hepatic lesion, children <2
admixture of ductal structures within loose stroma
typically low afp
Hepatic mesenchymal hamartoma imaging
disorganised solid cystic lesion with septations
XR
non calc mass
CT
heterogenous
swiss cheese
solid/septal enhancement
MR
cystic
unifocal
Infantile hepatic haemangiomas are
liver lesiosn with large endothelial lined vascular channels
can present with CCF, hydrops, kasabach merrit
3% have high afp
asspc with other haemangiomas
Infantile hepatic haemangioma imaging
XR
hepatomegaly
15% calcs
US
variable
vascular channels
CT
peripheral enahncement with fill in
mid aortic calibre change
coeliac and hepatic artery large
MR
T1 hypo
T2 hyper
flow voids
similar enhancement to CT
Undifferentiated embryonal sarcoma of the liver is
a rare aggressive malignant liver tumour. paeds 6-10. afp not elevated
Undifferentiated embryonal sarcoma of the liver imaging
right lobe
under 15yo
necrotic/cystic
normal afp
XR
non calc
large
US variable
CT
hypodense
solid elements
multiople hyperdense septa
heterogenous enhancement
rim enhancing pseudocapsule
MR
T1 hypo
T2 hyper
C+ hetero
areas of haemorrhage
pseudocapsule
Post transplant liver evaluation
normal
- perihepatic haematoma
- right sided effusion
- minimal ascites
- periportal oedema
Complications
- rejection
- arterial thrombus
- hepatic abscess
- biliary ischaemia/stricture
- pseudoaneurysm
- venous thrombus
- bile leak/obstruction
- PTLD
- biliary cast syndrome
Milan criteria is
suitability for liver transplant in cirrhosis and HCC
single tumour <5cm or up to 3 tumours <3cm
no extra hepatic
no major vessel involvemnt
TIPS is
a transjugular intrahepatyic portosystemic shunt, a treatement for protal hypertension in which direct communication is formed between a hepatic vein and a branch of the portal vein to allow flow to bypass the liver
AIDS cholangiopathy is
a secondary opportunistic cholangitis that occurs in aids patients from immunosuppression. can look like PSC
Hepatic schistosomiasis is and imaging
chronic result of egg deposition into small portal venules leading to periportal fibrosis and cirrhosis
US
Common
- irregular contour
- mosaic pattern
- septal fibrosis
- spleomegaly/GG bodies
S Japonicum
- septa and capsular calc
S Mansoni
portal vein wall thickening, Bulls eye appearance
CT
common
- irregular contour
- splenomegaly and GG bodies
S Japonicum
- turtle back sign
- capsular calcification
- periportal fat deep into liver
S Mansoni
- low attenuation surrounding portal vein branches assocaited with marked contrast enhancement
Idiopathic noncirrhotic portal hypertension/portosinusoidal vascular disease is
clinical diagnosis of portal hypertension without cirrhosis, vascular obstruction, schisto, metabolic or other chronic liver disease
Nodular regenerative hyperplasia is
a histopath entity chracterised by transformation of normal hepatic parenchyma into small nodules of hyperplastic hepatocytes without intervening fibrosis. falls in the spectrum of porto-sinusoidal vascular disease, one of the morphological lesions seen with idiopathic non cirrhotic portal hypertension
Hepatic peliosis is
a rare benign vascular condition characterised by dilatation of sinusoidal blood filled spaces in the liver. can also happen in spleen and bone marrow.
Appearance is variable, with multiple lesions and variable enhancement pattern.
Can be globular centrifugal, centripedal. usually continuous unlike haemangioma.
HELLP syndrome is
a pregnancy related condition with haemolysis, elevated liver enzymes and low platelets
imaging
- hepatomegaly
- haemorrhage
- hepatic infarct
Wilsons disease hepatobiliary manifestationss
Depends on severity
- fatty change
- hepatitis
- cirrhosis
- hepatic necrosis
CT
- hepatic attenuation can be increased
- cirrhosis with multiple nodular lesions and perihepatic fat layer and normal caudate
MR
- NOT ferromagnetic
- cirrhotic change
Hepatic angiosarcoma is
rare. third most common liver primary. variable appearance on CT and MR. heterogenous with haemorrhage typically.
Hepatic inflammatory pseudotumour is
a rare benign hepatic lesion. associated with oriental cholangitis. Variable and heterogenous on imaging.
Hepatic lipoma is and imaging
an uncommon benign lesion of the liver. Assocaited with renal AML and TS.
well circumscribed, macroscopic fat
US
hyper
“discontinuous diaphragm” from artefact
CT
homogenous fat
MR
T1/2 high with suppression
marginal india ink
Hepatic AML is
an uncommon benign hamartomatous hepatic lesion. bloo, muscle and fat components. associated with TS.
Hepatic AML imaging
fat and prominent vasculairty
CT
heterogenous with macro fat
arterial enhancement
hypo on PV
MR
T1 hyper
T2 hyper
Suppression
in/out of phase for smaller fat
vascular part hyper enhancement
Hepatic epithelioid haemangioendothelioma is and imaging
rare low to intermediate grade neoplasm
multiple solid tumour nodulars, coalesce
CT
multiple nodules with congolmerate confluent perigion
peripheral or subcapsular distribution
halo or target enhancement of larger
can have capsular retraction
vessels terminate at edge “lollipop sign”
MR
T1 hypo
T2 heterogenous increased
C+ peripheral halo or target type enhacnement
Renal agenesis is
congenital absence of one or both kidneys. if bilateral Potter syndrome. failure of meta nephros indevelopment
Renal agenesis associations
trisomies
turners
mullerian anomalies
CHD
skeletal anormalies
potter sequence
vacterl
Renal agenesis imaging
absent kidney and renal artery
contralteral hypertrophy
lying down adrenal
Horseshoe kidney is
the most common renal fusion anomaly. typically between lower poles but can be lower and upper (sigmoid). isthmus gets caught on the IMA
Crossed fused renal ectopia is
where the kidneys are fused and located on the same side
Crossed fused renal ectopia types and imaging
types
- inferior
- sigmois
- lump
- disc
- L shaped
- superior
imaging
- anteiror or posterior notch
PUJ obstruction types
Congenital
- idiopathic
- abnromal muscle arrangement
- collagen collar
- extrinsic compression
- crossing vessel
Adult
- trauma
- calculus
- scarring
- malignancy
- extrsinc compression
PUJ obstruction imaging
US
dilated pelvis with collapsed ureter
CT
same
MAG3
- with diuretic
- high extraction rate
- evaluation between obstructive and non obstructive
- non obstructive; excretion, downsloping
- obstructive; no excretion, no downsloping
DTPA
- predominantly glomerular filtration
PUJO ddx
congenital megacaliectasis
- central renal pelvis relatively collapsed
extrarenal pelvis
- no calyceal distention
parapelvic cyst
MCDK is
a non heritable paediatric cystic renal disease. multiple cysts formed in utero. bilateral is fatal
can be pelvi infundibular (multiple small cysts) or hydroneprhotic obstructive (domiannt cyst in pelvis)
MCDK associations
VUR
PUJO
ureteral ectopia
VUJO
urterocoele
Meckel gruber
Zellweger syndrome
Joubert syndrome related disorders
Meckel gruber
encephalocoele/holoprosencephaly
cystic kdineys
postaxial polydactyl
MCDK imaging
multiple cysts or varying sizes
parenchyma fibrous/echogenic
Acute tubular necrosis is
acute kidney injury with renal tubular damange. deposition of depbris in the tubules results in oliguria.
On imaging, there is perfusion without excretion NM in transplant assessment to differentiate from renal cortical necrosis. can cause persistent or striated neprhogram on CT.
Acute tubular necrosis causes
hypovolaemia/ischaemia
- dehydration
- blood loss
- septic shock
drugs
- amphtericin
- contrast
- cisplatin and other chemo
- immunosuppressants
- antivirals
Persistent nephrogram causes
Hypotension
Bilateral intrarenal obstruction
- ATN
- acute urate uropathy
Vascular
- renal artery stenosis
- renal vein thrombosis
Other
- myeloma kidney
- contrast nephropathy
Striated nephrogram causes
contrast stuck in oedematous or necrosed tubules
Unillateral
- ureteric obstruction
- acute pyelo
- renal vein thrombosis
- renal contusion
- radiation
Bilateral
- ARPCKD
- acute pyelo
- ATN
- hypotension
Spotted nephrogram
segmental or subsegmental corticomedullary hypoattenuation
secondary to multiplem small vessel infracts
vasculitis, embolic disease
Rim nephrogram
enhancing cortex, absent medullary
seen weeks following global infarction, due to collaterals
Reverse rim nephrogram
absent cortical, normal medullary enhancement
indicates acute cortical necrosis
Cortical rim sign
Thin subcapsular cortex enhancement. Differentiates pyelo from renal infarct.
Renal artery/vein thrombosis
ATN
Acute cortical necrosis
Renal cortical necrosis is
a result of severe systemic illness and can cause permanent impairment
severe shock
microangiopathic haemolysis (HUS)
renal transplant
Renal cortical necrosis imaging
CT
non enhancing cortex and enhancing medulla (reverse rim)
may have cortical rim sign
eventually cortical nephrocalcinosis
MR
low T1/T2 affective inner cortex
Low intensity renal parenchyma causes
haemolysis
infection
vascular disease
- vein
- cortical necrosis
- arterial
- rejection of t/p
Renal papillary necrosis is and causes
ischaemic necrosis of the renal papillae and medullary pyramids. sloughing off of papillary tissue.
NSAID
Non steroidals
Sickle cell
Acetaminophen (paracetamol) and phencetin
Infection
Diabetes or dehydration
Renal papillary necrosis imaging
filling defects in the collecting system
- ball on tee
- lobster claw sign
- signet ring
AAST kidney injury scale
Grade 1
- subcap haematoma or contusion
Grade 2
- Superficial laceration <1cm, no collecting
- perirenal haematoma confined to fascia
Grade 3
- lac >1cm, no collecting system
- vascular injury/bleeding, confined to fascia
Grade 4
- lacerating involving collecting system
- lacteration of the renal pelvis
- vascular injury to segmental artery or vein
- segmental infarcts without assoc bleeding
- active bleeding beyond perirenal fascia
Grade 5
- shattered
- avulsion or renal hilum, lac main renal artery or vein
- devascularised with active bleeding
Urolithiasis RFs
dehydration
malformations
UTIs
cystinuria
hypercalcuria
- pth
- sodium
- hyper vit d
- cushing
- sarcoid
- milk alkali
hyperoxaluria
- low absorption/intake calc
hypocitraturia
- rta, diarrhea
hyperuricosuria
- gout
- myeloprolif
- idioapthic
Urolithiasis types
Calcium oxalate
Struvite
Calcium phophate
Uric acid
Cystine
Lithogenic medications
Urolithiasis imaging
Opaque
- calcium
- struvite
- cystine
Lucent
- uric acid
- medication
US
lower sens
echogenic
acoustic shadowing
twinkle artifact
colour comet tail artefact
slower jets
elevated RI
CT
opaque/non opaque. opaque can varyy in density
99% opaque
dual energy to chekc comp
Urolithiasis treatment
Surgical indications
- larger
- long duration sx
- proximal location
- trucks/pilots
- infection
- solitary kidney
Intervention types
- retrograde stent and laser
- PCN with antegrade stent and laser
- ESWL for larger
PCNL for large near junction like staghorn
Calcium
- ESWL
- perc nephrostomy
Struvite
- need to be surgical, residual can harbour infection
Uric acid
- elevation of ph
Cystine
- alkalisation
Medullary nephrocalcinosis causes
HAM HOP
Hyper pth
Acidosis, renal tubular
Medullary sponge
Hypercalcaemia
Oxalosis
Papillary necrosis
Cortical nephrocalcinosis
COAG
Cortical necrosis
Oxalosis
Alport syndrome
Glomerulonephritis
ADPCKD is
a hereditary form of adult polycystic kidney disease. associated with aneurysms, hypertension, biliary hamartomoas, other visceral cysts.
PKD 1 and PKD 2 genes, GANAB gene
ADPCKD DDX
VHL
ARPKD
- enlarged kidneys
- smaller cysts
- present in childhood
- CM diff lost
Acquired cystic kidney disease
- occurs in dialysis
Medullary cystic
- at medulla cortex junction
MCDK
- can be unilateral, younger
ARPCKD is
a paediatric cystic renal disease. liver involvement, proportional to age of onset with hepatic firbosis. associated with carolis and biliary hamartomos.
RCC associations
VHL (bilateral, younger, clear cell)
TS (younger)
Birt Hogg Dube (chromophobe, bilateral)
Paraneoplastic syndromes
- hypercalcaemia
- hypertension
- polycythaemia
- stauffer (LFT)
- limbic encephalitis
RCC types
Clear cell/conventional
- prox convulted tubules
- clear cytoplasm
- vascular
- clear cell multilocular rcc variant
Papillary
- distal convoluted tubules
- can be multifocal and bilateral
- type 1; sporadic, good prog
- type 2; inhertid, bilateral, multifocal
Clear cell papillary
Chromophobe
- intercalated cells of collecting ducts
- similar to oncocytomas
Collecting duct
Renal medullary
- sickle cell
Sarcomatoid
- advanced, can de diff
RCC imaging
CT
- soft tissue
- necrosis/calcs
- enhance, variably
- also hypervascular or canonball mets
MR
T1 heterogenous
T2
- clear; hyper
- papillary; hypo
C+ arterial enhancement
Pseudocapsule
- lower grade, adenomas or oncocytomas
Macroscopic fat in RCC almost always occurs in the presence of ossification/calcification
I/OOP loss suggests microscopic fat, common in clear cell carcinomas
Clear cell RCC imaging
CT
- exophytic
- more enhancing
- more heterogenosu
MR
T1 heterogenous
T2 hyperintense
I/OP; microscopic fat
Multilocular cystic renal neoplasm of low malignant potential is
a low grade adult renal tumour composed entirely of numerous cysts
Papillary RCC imaging
Tend to be smaller
CT
less vascular thna clear cell, hypo compared to normal cortex in CM phase
MR
pseudocapsule
T1 hypo
T2 hypo
C+ less entence
DWI restriction
Chromophobe RCC imaging
associated with BHD
CT
homogenous
can be spoke wheel like oncocytoma
MR
T2 iso to hypo
homogenous enhancement
uncommon to have necrosis
TCC is
the most common primary tumour of the urinary tract and can be found along its entire length.
associated with horseshoe, calculi, pseudodiverticulosis and ureteritis cystica
can be papillary or non papillary.
TCC pelvis imaging
US
hypoechoic
CT
soft tissue
minimally enhancing
can be small filling defects or invasive/obliterating
can be more infiltrative
disotrtion of calyces
can have a dappled/stippled appearance
TCC ureter imaging
can obstruct when small
filling dfect with goblet sign transition
can be circumfrentially invasive
TCC bladder
most common type, can be superfical or invasive
CT
focal thickening or masses protruding inward
can have calcs
Nephroblastomatosis is
diffuse or multifocal invovlement of the kidneys with nephrogenic rests. foci of metanephric blastema that persist beyond 36 weeks gestation.
Nephroblastomosis imaging
US
hypoechoic nodules
reniform enlargement with thick peripheral rind
diffuse decrteased echoes
CT
low attenuation peripheral nodules with poor enhancement
MR
T1 low
T2 low
C+ hypo
Nephrotic syndrome is
loss of plasma proteins in the urine. hypoalbumiaemia, hyperalbuminuria, hyperlipidaemia and oedema. can be congenital or acquired. why am i writing this flashcard fuck everything
Renal AVM AVF
AVM - has a vascular nidus. typical congenital and rare. usually osler weber rendu or somethign
AVF - no nidus, usually acquired/iatrogenic
Renal artery stenosis is and pathology
narrowing of the renal artery , secondary htn
juxtaglomerular apparetus senses low flow as low pressure and secretes renin. vasoconstriction and aldosterone causing retension and htn.
renal artery stenosis causes
atherosclerosis
FMD
vasculitides
NF1
coarctation
dissection
segmental arterial mediolysis
Renal artery stenosis imaging
PSV > 180
increased renal aortic ratio RAR >3
turbulent dlow
pulsus parvus et tardus (slow rising)
decreased RI in severe <0.55
Fibromuscular dysplasia is
a heterogenous group of vascular lesions characterised by idiopathic non inflamm non atherosclerotic angiopathy of small and medium sized arteries
causes small stenoses with intervening areas of dilatation :string of beads”.
most commonly affects the renal arteryes, cervicalencephalic arteries, iliac artereis, coeliac trunk and mesenteric, subclavian and axillary
Renal artery aneurysm causes
FMD
ddegenerative
vasculitidies, incl behcets
TS, NF
intrinsic collagen def, ED, Marfans
trauma
Renal vein thrombosis causes
Children
- dehydration/sepsis
- sickle cell
- polycythemia
- UVC
Adults
- nephrotic syndrome
- SLE
- amyloid
- glomerulonephritis
- collagen vasc disease
- dm
- sepsis
- tumour thrombus
Medullary sponge kidney is
a sporadic condition where the medullary and papillary portions of the collecting ducts are dysplastic and dilated and in most cases develop medullary nephrocalcinosis
assoc with ED, hemihypertrohy and carolis
Medullary sponge kidney imaging
clusters of pyramidal medullary calcification
delayed post con - paintbrush appearance to the renal medullary regions
Medullary sponge kidney ddx
Medullary calcifications
- hyper pth
- RTA type 1
- hypervit D
- milk alkali syndrome
White pyramid sign
Autosomal recessive polycystic kidney disease is, and types
paediatric cystic renal disease
presents with enlarged echogenic kidneys with multiple small cysts. liver involvement with coarse echoes, biliary tract cysts, portal htn and hepatic fibrosis
perinatal type
- minimal fibrosis
- oligohydram and pulm hypoplasia
neonatal
infantile
juvenile
- gross fibrosis
Cystic nephroma imaging
US
multilocular cystic mass from kidney
septal vasc
CT
multilocular cystic mass
variable septal enhancement
no nodular or solid enhancement
can have perinephric stranding
MR
T1 variable
T2 hyper
C+ septal enhancement
DDX
multilocular cystic renal neoplasm of low malignant potential
Cystic nephroma is
a rare benign renal neoplasm occuring in adult femules
distinct from paediatric cystic nephromas which have dicer 1
Cystic nephroma imaging
multilocular cystic encapsulated mass
US
septal vasc
variable echo, usually anechoic
CT
multilocular cystic mass
herniates to pelivs
variable septal enhancement
no nodular or solid enhancement
MR
T1 variable
T2 hyper
Septal enahncemnt
ARPCKD ddx
ADPKD
Beckwith Wiedemann
Laurence Moon Beidl
Meckel gruber
Bosniak classification
Class 1 - being simple
- hairline wall <2mm
- no septa, calc, solid
- water density
- no enhancemnt
Class 2 - minimally complex
- few hairline septa or calcs <1mm
- perceived enhancement
- high attenuation <3cm
- well marginated
Class 2F - Minimally complex
- multiple hairline thin septa or minimall thickened walls
- perceived but no measurable enhancement
- calcs, can be thick and nodular
- high attenuation lesion totrally intraintranl >3cm no enhancement
- follow up in reasonable timeframe
Class 3 - indeterminate
- thickened irregular, or smooth walls, or septa with enhancement
- 55% malignant
Class 4 - clearly malignant
- 3 + enhancing soft tissue components to but independant of wall/septum
Renal AML is
a type of benign renal neoplasm encountered sporadicially as well as TS. PEComa with vascular, muscle and fat elements. Can haemmorhage. Macroscopic fat is cornerstone of imaging but can be fat poor.
Renal AMLs are
benign renal neoplasm. can be sporadic or related to phakomatosis (TS usually, can be in VHL or NF1). considered a perivascular epithelioid cellular differention tumour (PEComa) and are composed of vascular, muscle and fat elements. Can haemorrhage.
Mesoblastic nephroma imaging
US
variable
can have polyhydramnios
CT
solid hypoattenuating with variable enhancement
heterogeneity is uncommon
MR
T1 iso to hypo
T2 variabnle
DWI restricted
Renal transplant complications
Medical
- ATN
- rejection
- infection
- pyelonephritis
Surgical
- renal artery stenosis
- renal vein thrombosis
- AVF
- pseudoaneurysm
- urinary obstruction
- allograft compartment syndrome
- allograft torsion
- fluid collections
Fluid collections
- immediate: haematoma/seroma
- 1-2 weeks urinoma
- 3-4 weeks: abscess
- beyond; lymphocoele
Cystic nephromas are
rare benign renal neoplasms, classicly occuring in women 40-50. distinct from paeditriac cystic nephroma.
Cystic nephroma imaging
US
multilocular cystic mass from kidney
septal vasc
CT
multilocular cystic mass
variable septal enhancement
no nodular or solid enhancement
can have perinephric stranding
MR
T1 variable
T2 hyper
C+ septal enhancement
DDX
multilocular cystic renal neoplasm of low malignant potential
Renal rhabdoid tumiours are
highly aggressive rare malig of earl childhood
similar to ATRT of the brain
<2yo
ARPCKD imaging
US
antenatal - oligo
cysts
- small, rarely >1cm
enlarged kidneys, reniform shape
liver
- coarse
- carolis
- portal hypertension
MR
enlarged kidneys with diffusely increased T2
oligo
Complications
- potter sequence
- systemic hypertension
- portal hypertension
ARPCKD ddx
ADPKD
Beckwith Wiedemann
Laurence Moon Beidl
Meckel gruber
Renal oncocytomas are
benign renal tuimours, difficult to tell from malig preop. usually older men. assoc with BHD and TS.
Renal oncocytoma imaging
difficult to distinguish from rcc
sharp central stellate scar, only 1/3 and can be seen in rcc
IVP
sharply demarcated large exophystic with nephrogenic enhancement
US
well circumscribed mass with echo similar to kidney
may see scar
CT
homgenous
large, heterogenous
calc can be present
enhancement
non enhancing central scar
can have bland renal vein thrombus
segmental enhancement inversion
MR
T1 hypo
T2 hyper, central scar
C+ homo/hetero
DSA
spoke wheel
Thrombotic thrombocytopaenic purpura is
a rare life threatening condition with thrombocytopaenia, microangiopathic haemolytic anaemia and end organ damage. get PRES changes on imaging
Renal AML imaging
US
hyper with shadowing
TS - numerous
CT
macroscpic fat (not pathognmonic)
5% fat poor
- no ossification favours aml
MR
FS
india ink
DSA
hypervascular, sunburst
venous; onion peel
Mesoblastic nephromas are
benign renal tumours typically occuring in utero or infancy. most common neonatal renal tumour. assoc with polyhydram, fetal hypercalc. mesenchymal. can be classic or cellular
Mesoblastic nephroma imaging
XR
soft tissuie mass
rare to have calcs
US
well defined with low level homgenous echoes
concentric echoic and hypoechoic rings
can be more complex
can have vasc
can be cystic
CT
can be solid with variable enhancement or heterogenous
typically no calcs
MR
T1 iso to hyper
T2 variable
DWI retricts in solid
can be more variable
ddx
wilms (older)
rhabdoid
sarcoma
Renal rhabdoid tumiours are
highly aggressive rare malig of earl childhood
similar to ATRT of the brain
Renal replacement lipomatosis imaging
XR
calculi and bowel displacement
CT
atrophy
lipomatosis
renal calculi
perinephric abscess
ddx
lipoma
liposarcoma
aml
xgp
Renal lymphangiomatosis is
rare disorder with dilatation of the perirenal, parapelvic and intrarenal lymphatics
US
perirenal collection
cysts
ascites
poor CM diff
CT
perinephric fluid attenuation 0-10
cystis
can have fluid retroperitoneal
DDX
cystic renal dysplasia
ADPKD
ARPKD
Page kidney si
systmic hypertension secondary to extrinsic compression of the kidney by a subcapsular collection
Haemolytic uraemic syndrome is
a multisystem thrombotic microangiopathic disease
triad of renal failure, haemolytic anemia and thrombocytopaenia
typically follows GI infection with shiga toxin producintg e coli
can also be assoc with collagen vascular diseases, malig and medications
T2/FLAIR in BG (putamen) and centrum semiovale
Thrombotic thrombocytopaenic purpura is
a rare life threatening condition with thrombocytopaenia, microangiopathic haemolytic anaemia and end organ damage. get PRES changes on imaging
Cushing syndrome is
due to excess glucocorticoids which may be exogenous or endogenous. disease - ACH pituitary adenoma. syndrome- all aetiologies
Renal haemosiderosis causes
chronic intravascular haemolytic states
- sickle cell
- thalassemia
Paroxysmal nocturnal haemoglobinuria
Mechanical haemolysis from a cardoac valve
ddx
- cortical nephrocalcinosis
Lithium induced renal disease is and imaging
characterised by progressive decline in function from direct injury to renal tubules
imaging
US
- uniform microcysts
- punctate echogenic foci
CT
- microcalcs within microcysts
MR
- abundance of microcysts in cortex and medulla
Adrenal calc ddx
Haemorrhage
- WFS
- trauma
- neonatal asphyxia
- coagulopathy
Infection
- tb
- histo
tumours
- mets
- neuroblastoma
- adrenal myeloliupoma
- adrenala denoma
- adrenocortical carcinoma
- phae
other
- addison
- wolman disease
Renal replacement lipomatosis imaging
XR
calculi and bowel displacement
CT
atrophy
lipomatosis
renal calculi
perinephric abscess
ddx
lipoma
liposarcoma
aml
xgp
Adrenal trauma path
haemorrhagfe is most common, thought to be direct compression or increased pressure from IVC compression
laceration less common
lots of associated injuries. highly mortality in trauma patients
Adrenal insufficiency is and cuases
refers to inadequate secretion of corticosteroids. partial or complete destruction of the adrenal cortex (primary/addisons). Secondary is from lack of stimulation.
Primary
- autoimmune disorders
- granulomatous disease TB/sarcoid
- neoplastic (mets, lymphoma, leukaemia)
- adrenal haemorrhage
- systemic fungal infection
- adrenoleukodystrophy
- congenital adrenal hyperplasia
- drugs
- bilateral adrenlectomy
Secondary
- suppression of axis from glucocorticoids
- hypothalamic or pit lesiosn
ACTH stimulation
- cortisol doesnt rise; primary
- cortisol rises; secondary
CT hypoperfusion complex imaging
small calibre aorta
collapsed IVC
IVC halo sign
thickened bowel loops
- hyper on non con or submucosal oedema
- usually jejunal
hypoenhancing spleen
chock pancreas
hypoenhancing liver
hyperenhancing adrenals
hyperenhanceing kidneys
ascites
shock thyroid
Adrenal haemorrhage aetiology
TRrauma (usually unilateral)
Sepsis (esp meningococaemia)
- Waterhouse Friderichsen syndrome
DIC
Anti phosopholipid syndrome
Heparin induced thrombocytopaenia
steroids/anticoags
Tumour
neonates
- birth trauma, sepsis, hypoxia, DM
- wolmans
Adrenal vein thrombosis
Adrenal adenoma ddx
Cortical carcinoma
Phae
Adrenal mets
- HCC and RCC can contain fat
Myelolipoma
Cushinds causes
steroids
rest are endogenous:
adrenal adenoma
primary pigmented nodular adrenal dysplasia
acth secreting tumour
- pit adenoma
- small cell lung
- bronchial carcinoid
- small cell thymus
- pancreatic neuroendocrine
- pahaeo
- benign ovarian
adrenocorticotropin independant macronodular-adrenocortical hyperplasia AIMAH
corticotropin releasing hormone secreting trumour
Adrenal calc ddx
Haemorrhage
- WFS
- trauma
- neonatal asphyxia
- coagulopathy
Infection
- tb
- histo
tumours
- mets
- neuroblastoma
- adrenal myeloliupoma
- adrenala denoma
- adrenocortical carcinoma
- phae
other
- addison
- wolman disease
Primary hyperaldosteronism is
excess aldosterone production
occurs secondary to adenomas, hyperplasia or carcinoma
when primary due to adenoma - Conn syndrome
clinical; diastolic hypertension, met alkalosis, hypokalemia. musuclar weakness, paraesthesia, headache, polyuria and polydipsia
primary - low renin
secondary - high renin
Primary hyperaldosteronism imaging
adrenal adeomas unilateral and small
hypodense
minimal enhancement
can do venous sampling
Adrenal myelolipoma is
a rare benign adrenal tumour. fat components. non fx, but assoc with endocrine disorders (cushings, conn, CAH)
can rarely be extra adrenal; retroperitoneum, perirenal space and thorax
Adrenal myelolipoma imaging
CT
fat components
can have calcs
MR
T1 hyper
FS suppression
T2 intermediate to high
C+ vivid
Adrenal adeoma imaging
Typical
- small
- round low density smooth
Atypical
- haemorrhage
- calc
- necrosis
- large
CT
- fat; highly sensitive and specific <0 100sp, <10 98 sp
- lipid poor; assess washout. typically washout rapidly.
- >120HU on PV, washout should be ignored
Washout
- >60% absolute
- >40% relative
MR
- chemical shift drop; >16.5% diagnostic
- 10-30 HU 100 spc and 89% sn
- 10-20 HU CT 100/100
Adrenal adenoma ddx
Cortical carcinoma
Phae
Adrenal mets
- HCC and RCC can contain fat
Myelolipoma
Posterior urethral valves are
most common congenital obstructive lesion of the urethra and common cause of obstructive uropathy in infancy
result from formation of thick valve like membrane of wolffian duct origin that courses obliquely from the verumontanum to the most distal portion of the prostatic urethra
Adrenal cortical carcinoma imaging
CT
large
irregular
heterogenous
calc 30%
venous invasion
mets
MR
high T2
heterogenous
hetergenous enahcnement
Posterior urethral valves imaging
US
bladder distention
hydronephrosis
oligohydramnios and renal dysplasia (severe)
keyhole sign
Postnatal US
keyhole sign
hydronephrosis
mild renal dysplasia
urethral diameter >6mm
VCUG
dilation and elongation of the posterior urethra (keyhole)
linear radiolucent band
VUR 50%
bladder trabeculation
Phaeochromocytoma imaging
tend to be large >3cm
US
variable
CT
large, heterogenous
necrosis and cystic change
enhance avidly
can have calcs
MR
T1 hypo, hetero
T2 markedly hyper
i/oop no loss
C+ heterogenous, prolonged
NM
octreotide
MIBG
Dotate PET and DOPA pet
Adrenal myelolipoma is
a rare benign adrenal tumour. fat components. non fx, but assoc with endocrine disorders (cushings, conn, CAH)
Adrenal myelolipoma imaging
CT
fat components
can have calcs
MR
T1 hyper
FS suppression
T2 intermediate to high
C+ vivid
Adrenal hyperplasia is
non malignant growth of the afrenal glands. rare cause of ACTH independant cushings, and conn syndrome.
can be
congenital or acquired
micronodular or macronodular
congenital
- CAH
- primary pgimented nodular
macronodular
- adrenocorticotropin independant macronodular adrenocortical hyperplasia AAIMAH
Adrenal hyperplasia imaging
Enlarged limbs of one or both adrenals >10mm
Normal morphology
Nodular or uniform
MRI may have drop on on out of phase due to lipid content, like an adenoma
Multiple ureter filling defects ddx
TCC
ureteritis cystica
vascular indentation
multiple stones
blood clots
Stevens johnsons syndrome
Posterior urethral valves imaging
US
bladder distention
hydronephrosis
oligohydramnios and renal dysplasia (severe)
keyhole sign
Postnatal US
keyhole sign
hydronephrosis
mild renal dysplasia
urethral diameter >6mm
VCUG
dilation and elongation of the posterior urethra (keyhole)
linear radiolucent band
VUR 50%
bladder trabeculation
Vesicoureteric reflux is and associations
abnormal flow of urine from bladder to upper tract in young children
primary maturation abnormality of the VUJ reslting in a short submucosal tunnel and loss of the normal pinchcock mechanism during micturition
assoc
- congenital obstructive posterior urthral membrnae
- bulbar urethral obstruction (Cobb collar)
- ureteral partail obsturction
- duplex collecting system
Vesicoureteric reflux imaging
VCUG
- confirm refleuxc and grading
- ?during filing or micturition
- presence or absence of associated abnormalities
- length of ureteric tunnel
- width of lower ureter
NM
mag 3
Urethral stricture causes
Infection
- gonococcal vs non
Inflammatory
Trauma
Iatrogenic
- intraumentation
- turp
Congenital
Urethral diverticulum are
focal outpouchings of the urethra. occur more commonly in women. broad range of LUTS. can develop stones, infection and malignancy
Ureteritis cystica is and imaging
benign condition of hte ureters representing multiple small submucosal cysts
results from chronic irreitation from stones or infection
imaging
- multiple small smooth walled rounded lucent filling defects projecting into lumen
Multiple ureter filling defects ddx
TCC
ureteritis cystica
vascular indentation
multiple stones
blood clots
Stevens johnsons syndrome
Cystitis glandularis is and imaging
proliferative disorder with glandular metaplasia of the transitional cells lining the urinary bladder. seen with chronic outlet, infection, calculi. differentiate to goblet cells
imaging
fluoro
- filling defect
us
- polypoid thickning trigone
ct
- hypervasc polypoid mass
MR
T1 low
T2 low with central branching hyper which enhances
- intact muscle layer
Hutch diverticulum are
congenital diverticula seen at the VUJ in absence of posterior urethral valves or neurogenic bladder. assoc VUR. micky mouse appearance.
Bladder wall calcification causes
CREST
Cystitis
Radiation
Eosiniophilic cystitis
Schistosomiasis
TB
Urethral diverticulum are
focal outpouchings of the urethra. occur more commonly in women. broad range of LUTS. can develop stones, infection and malignancy
Neurogenic bladder is and causes
dysfunctional urinary bladder due to lack of neurologic coordination
Stroke, MS, parkinsons, cauda equina
Lapides classification
- sensory (posterior column or afferent tracts)
- motor (motor neurones)
- unihibited neurogenic bladder (incomplete above S2)
- reflex neurogenic bladder (complete above S2), pine cone/christmas tree
- autonumous neurgenic bladder (conus/cauda lesions)
Neurogenic bladder imaging
markedly contracted or distended bladder
Sensory
- inability to sense fullness, large rounded smooth
- voiding is preserved
Motor
- atonic bladder
Uninhibited
- rounded with trabeculation from detrusor contractions. large interureteric ridge
Reflex
- detrusor hyperreflexia with dyssynergic sphincter. contrast to posterio urethra and elonfated pointed urethra with pseudodiverticula
- pine cone
Autonumous
- intermediatye between contracts and atonic
Bladder diverticula causes
Congenital:
- hutch diverticulum in paraureteral region
Secondary:
Outlet obstruction
- stenosis
- neurogenic
- posterior urethral valve
- prostatic enlargement
- ureterocoele
- urethral stricture
Congenital syndromes
- diamond blackfan
- ehlers danlos
- menkes
- prune belly
- williams
Post op
can be assoc with stones, rupture, malignancy
Hutch diverticulum are
congenital diverticula seen at the VUJ in absence of posterior urethral valves or neurogenic bladder. assoc VUR. micky mouse appearance.
Penile trauma imaging and grading
US
tunica albuginea - hyper, covering corpora cavernosa and spongiosum. hypoechoic breach may be seen in longituindnal axis. haematoma either side
MR
tunica albuginea hypo on all sequences
tear T2 hyperintense
Grading
0 - haematyoma
1 - tunica/cavernosa defect
2 - tunica/cavernosa defect with haematoma
3 - defect in tunica, buck gascia and corpus spongiosum
4 - corpus with urethra and/or vascular injury
Peyronie disease is
common cuase of painful penile induration. plaques form in tunica alburginea causing deformity and shortening and pain.
plantar fibromatosis and dupytrens contracts. assoc with trauma, dm, bb’s, pagets of bone and phenytoin
Types of bladder ca
TCC
Squamous
Adeno
Small cell
Squamous cell bladder ca is
most common non tcc bladder cancer. m
risk factors
- schisto
- chronic irritation
- chronic infection
- intravesical bcg
Adenocarcinoma bladder causes and imaging
Persistent urachal remnant
Cystitis glandularis
Schisto
Exstrophy
Urachal
- midline at dome or along course remannt
- peripheral calcs
- mixed solid cystic
Non urachal
- diffuse thickening
- paravesical fat stranding
Testicular seminoma facts and imaging
normal afp
can have incr bhcg
classic anaplastic or spermatocytic (older)
US
homogenous
flow
larger can be heterogenous
CT
nodes and mets
MR
T2 hypo
C+ heterogenous
DWI restricts
non seminomatous; more heterogenous, with cysts and calcifications
Peyronie disease is
common cuase of painful penile induration. plaques form in tunica alburginea causing deformity and shortening and pain.
plantar fibromatosis and dupytrens contracts. assoc with trauma, dm, bb’s, pagets of bone and phenytoin
Extratesticular cystic lesion ddx
hydrocoele
epididymal cyst
spermatocele
haematocele
hernia
abscess
pyocele
varicocele
Testicular germ cell tumours
Seminoma
Non seminoma
- embyronal
- choriocarcinoma
- yolk sac
- teratoma
- mixed
1st decade; YS and tera
2nd; chorio
3rd; embryonal
4th; seminoma
>7th; lymphoma
Adenomatoid tumours are
benign solid extratesticular lesions of the epidiymis/tunica vaginalis or spermatic cord
Testicular sex cord stromal tumours
Sertoli
Leydig
Granulosa
Fibroma thecoma
Non seminomatous biochemical
AFP - yolk sac
bhcg - chorio
LDH can be up
Extratesticular cystic lesion ddx
hydrocoele
epididymal cyst
spermatocele
haematocele
hernia
abscess
pyocele
varicocele
Tubular ectasia of rete testes is and imaging
repreents dilated testicular mediastinal tubles. often bilateral, older dudes. assoc with spermatocoeles and may occur after a vasectomy. results from obliteration of the efferent ducts.
US
small cystic tubular strctures that replace and enlarge teh testicular mediastinum
lack of vascularity/mass effect
MR
cystic dilation
hyper on T2
no enhancement
ddx
- intratesticular varicocoele
- cystadenoma
Adenomatoid tumours are
benign solid extratesticular lesions of the epidiymis/tunica vaginalis or spermatic cord
Prostatitis imaging
US
focal hypoechoic region
abscess formation
increased flow
CT
best for abscess; peripherally enhancing
MR
Acute
T1 peripheral hypo or transitional hypo
T2 hyper
Diffuse enhancing
abscess should restrict
Prostatic utricle cyst is
an area of focal dilatation that occurs within the prostate utricle/verumontanum. midline cystic masses difficult to distinguish from mullerian duct cysts. assoc with hypospadius, cryptorchidism, unilateral renal agenesis
Sertoli tumours of the tests are
uncommon sex cord stromal tumours. less common than leydigs. have a large calcifying subtype. assoc with PJ and carney complex
BPH imaging
US
volume >30
enlarged central gland of mixed echoes
calc may be seen
pseudocapsule representing compressed peripheral zone
elevated post mic volume
assoc bladder hypertrophy
IVP
fishhook ureter
bladder trabec/diverticula
CT
MR
enlarged transition zone
heterogenous signal with intact low signal pseudocapusle
Prostate cancer imaging
US
TRUS to assess and guide bx
typically hypoechoic lesion, can be hyper/iso
systematic sextant bx
MR
T1; prostate contour, neurovascular bundle encasement, post bx haemorrhage
T2
low signal in high signal peripheral zone
DWI
often shows restriction
DCE
shows enhancement
EPE; look for
- asymmetry NV buncles
- obliteration of the rectoprostatic angle
- involvement of the urethra
- seminal vesicle invasion
Prostatitis imaging
US
focal hypoechoic region
abscess formation
increased flow
CT
best for abscess; peripherally enhancing
MR
Acute
T1 peripheral hypo or transitional hypo
T2 hyper
Diffuse enhancing
abscess should restrict
Prostatic utricle cyst is
an area of focal dilatation that occurs within the prostate utricle/verumontanum. midline cystic masses difficult to distinguish from mullerian duct cysts. assoc with hypospadius, cryptorchidism, unilateral renal agenesis
Pirads DWI score
TZ/PZ
1: normal
2: linear/wedge shaped ADC hypo and/or DWI hyper
3: focal, mild or moderate ADC hypo and/or mild/moderate DWI hyper. Can be marked on either ADC or DWI but not both.
4: focal marked ADC hypo and marked DWI hyper <1.5cm
5: same as 4 but >1.5cm or definite EPE
TZ lesions with a T2 score of 2 or 3, DWI score 2 high (4 or 5) can upgrade PIRADS by 1 point
Pirads DCE
Negative
- no early/contemp enhancement or
- diffuse multifocal enhancing, no corresponding T2/DWI or
- focal enhancement corresponding to a benign prostatic hyperplasia lesion
Positive
- focal and
- earlier or contemp and
- corresponds to sus finding on T2/DWI
for PZ lesions of 3, DCE can upgrade to 4
Prostate cancer imaging
US
TRUS to assess and guide bx
typically hypoechoic lesion, can be hyper/iso
systematic sextant bx
MR
T1; prostate contour, neurovascular bundle encasement, post bx haemorrhage
T2
low signal in high signal peripheral zone
DWI
often shows restriction
DCE
shows enhancement
EPE; look for
- asymmetry NV buncles
- obliteration of the rectoprostatic angle
- involvement of the urethra
- seminal vesicle invasion
PiRADS is
reporting scheme for suspected prostate cancer in treatment naive glands.
each lesion can be scored 1-5 on DWI and T2, as well as presence of absence of DCE.
TZ: primarily determined by T2 score. can be modified by DWI score.
PZ: primarily determined by the DWI score. can be modified by DCE
Peritoneal thickening ddx
Smooth
- peritonitis
- carcinomatosis
- PH
- familial mediterranean fever
- sarcoid
Irregular
- carcinomatosis
- TB (dry)
- encapsulating peritoneal sclerosis
- PMP
- mesothelioma
Nodular
- carcinomatosis
- TB (FF)
- actinomycosis
- primary pertoneal neoplasms
Pirads DWI score
TZ/PZ
1: normal
2: linear/wedge shaped ADC hypo and/or DWI hyper
3: focal, mild or moderate ADC hypo and/or mild/moderate DWI hyper. Can be marked on either ADC or DWI but not both.
Barium peritonitis is
a rare complication of barium studies. GI perf with spillage into peritoneal cavity resulting in peritonitis, granuloma and stone formation.
Acute - chemical perotonitis. acites and shock
Chronic - extensive fibrosis around barium with granuloma formation. adhesions are common
TB peritonitis is
extrapulmonary TB affecting the peritoneum. frequently seen with other GI TB.
Risk factors; HIV, dialysis, cirrhosis
Can be wet, dry or fixed fibrotic. can also be mixed.
TB peritonitis imaging
CT
nodular or symmetrical thickening of the peritoneum and mesentery
abnormal enhancement
ascites
enlarged low attenuation nodes
Wet
- exudative high attenuation ascites
Dry
- caseous nodes and fibrous adhesions. thickened cake like omentum
fibrotic
- omental cake like mass with fixed bowel loops, matted loops and mesentery with loculated ascites
Right paraduodenal hernia
through fossa of Waldeyer, congenital failure of fusion of the ascending colon mesentery to the peritoneum in the right lower quadrant
imaging
- inferior to third part duodenum
- behind SMV, SMA and right colic vein
Lesser sac hernia
protrude through foramen of winslow
Imaging
- posterior to PV, CBD, hepatic artery and anterior to IVC
- gas/fluid/vessels in lessert sac
- can have abnormal position of the caecum
Barium peritonitis is
a rare complication of barium studies. GI perf with spillage into peritoneal cavity resulting in peritonitis, granuloma and stone formation.
Acute - chemical perotonitis. acites and shock
Chronic - extensive fibrosis around barium with granuloma formation. adhesions are common
Sigmoid mesocolon hernia
small bowel loops protrude into a peritoneal pocket formed between two adjacent sigmoid segments and their mesentery
Small bowel mesentery internal hernia
Can be transmesenteric or intramesenteric
Transmesenteric
- through defect in mesentery
- much more common
Intra
- into the mesentery through a mesenteric defect
- predominantly paeds
Imaging
- Trans might not be sac like
- Intra; sac like, with anterior and superior displacement of the SMA
Right paraduodenal hernia
through fossa of Waldeyer, congenital failure of fusion of the ascending colon mesentery to the peritoneum in the right lower quadrant
Lesser sac hernia
protrude through foramen of winslow
Imaging
- posterior to PV, CBD, hepatic artery and anterior to IVC
- gas/fluid/vessels in lessert sac
Internal hernia due to gastric bypass surgery
Roux en Y three potential sites for hernia
- at TV mesocolon defect through which the roux limb passes, if retrocolic
- mesenteric defect at enteroenterostomy
- behind the roux limb mesentery placed in a retrocolic or antecolic position (retro or ante petersen type)
Sigmoid mesocolon hernia
small bowel loops protrude into a peritoneal pocket formed between two adjacent sigmoid segments and their mesentery
Small bowel mesentery internal hernia
Can be transmesenteric or intramesenteric
Transmesenteric
- through defect in mesentery
- much more common
Intra
- into the mesentery through a mesenteric defect
- predominantly paeds
Imaging
- Trans might not be sac like
- Intra; sac like, with anterior and superior displacement of the SMA
Lumbar hernia is
hernias through defects in the lumbar muscles or posterior fascia
can be superior or inferior
superior (grenfeltt lesshaft)
- superior lumbar triangle
inferior (petit)
- inferior lumbar triangle
Broad ligament hernia
small bowel through congenital or acquried defect in the broad ligament
Internal hernia due to gastric bypass surgery
Roux en Y three potential sites for hernia
- at TV mesocolon defect through which the roux limb passes, if retrocolic
- mesenteric defect at enteroenterostomy
- behind the roux limb mesentery placed in a retrocolic or antecolic position (retro or ante petersen type)
Spigelian hernias are
hernias through the spigelian fascia.
between the lateral border of the rectus abdominaus and the semilunar line, through the transversus abdominus aponeurosis, close to the level of the arcuate line
Maydl hernia
rare type where more than one loop enters the hernial sac with an intervening intra abdominal loop
Sclerosing mesenteritis is
an uncommon idiopathic disorder characterised by chronic non spec inflammation invovling the adipose tissue of the bwoel mesentery
Associations:
malignancy
- lymphoma, lung, melanoma, CRC, RCC, myeloma
abdominal surgery
systemic inflamm conditions
- retroperitoneal fibrosis, sclerosing cholangitis, riedel thyroiditis, orbital pseudotumour
Mesenteric cysts aetiology
lymphatic - simple and lymphangioma
mesothelial - simple, benign, malignant
enteric
urogenital
mature cystic teratoma
non pancreatic pseudocysts
Encapsulating peritoneal sclerosis is
a rare benign cause of bowel obstruction characterised by total or partial encasement of the small bowel within a thick fibrocollagenous membrane
can be idiopathic or secondary to
- dialysis
- tb
- shunts
Malignant peritoneal mesothelioma imaging
CT
solid heterogenous mass
calcified pleural plques
nodular, irregular peritoneal and omental thickening, progressing to cake
peritoneal/omental masses
variable ascites
direct invasion of viscera
concurrent pleural involvement
MR
T1 low
T2 high
C+ enhances
Gallium
avid
ddx
carcinomatosis
- dystrophic calc
PMP
Lymphoma
TB
Multicystic peritoneal mesothelioma is and imaging
rare benign subtype of mesothelioma. no assoc with asbestos.
CT
well defined low attenuating cystic pelvic masses
no calcs
MR
T1 low
T2 high
septal enhancement
Sclerosing mesenteritis is
an uncommon idiopathic disorder characterised by chronic non spec inflammation invovling the adipose tissue of the bwoel mesentery
assoc
Sclerosing mesenteritis imaging
US
distortion and thickening of echogenic mesnetery
halo sparing vessels
CT
well or ill defined mesenteric mass with surrounding mist
misty attenuation
fat halo around traversing mesenteric veseels and soft tissue nodules “fat ring sign”
punctate or coarse calcs
hyperattenuating pseudocapsule
small soft tissue nodes
Encapsulating peritoneal sclerosis imaging
XR
bowel obstr
wall may calcify
CT
enhancing peritoneum, thickened
obstruction
dixation of loops
ascites or localised fluid collections
bwoel wall thckenign
peritoneal or mural calc
calcified or reactive adenopathy
Segmental arterial mediolysis is
vascular disease in middle age causing spontaneous intrabdominal haemorrhage. characterised by aneurysms, stenoses, dissections and occlusions within splanchnic arterial branches. not atherosclerotic or inflammatory
Segmental arterial mediolysis imaging
branches of visceral arteries
aneurysms, stenoses, dissections, occlusiosn
Peritoneal cysts are
cyst like structure that appears in relatio to the peritoneal surfaces resulting from a non neoplastic reactive mesothelial proliferation.
usually caused by the accumulation of ovarian fluid that is contained by a peritoneal adhesion.
assoc
- previous trauma
- pid
- endometriosis
- ibd
Peritoneal inclusion cyst imaging
US
- large ovoid irreg anechoic
- invaginates surrounding structures
- lack of a discrete wall
- no nodularity
- minmal debris
- can range from small to v large
Desmoid tumour is
a bening non inflammatory fibroblastic tumour with a tendency to local invade without mets
assoc
- gardner syndrome
- fap
- pregnnacy/oestrogen therapy
b catenin gene ctnnb1 or apc gene
Desmoid tumour imaging
US
hypo
CT
well circumscribed
can be more aggressive
homo or focally hyperattenuating
enahnce
MR
T1/T2 low
C+ variable
Gardner syndrome
FAP
osteomas
Epidermal cysts
fibromatoses
desmoid tumours
supernumery teeth, odontomas, dentigerous cysts
duodenal/ampulla tumours
papillary thyroid ca
Retroperitoneal fibrosis is
part of a spectrum of entities with a common pathogenic process of inflammatory response to atherosclerosis combined with autoimmune factors
Retroperitoneal fibrosis aetiology
Idiopathic (Ormond)
Radiation
Medication
Inflammation
- pancreatitis, pyloe
- igg4
Malignant
Asbestos
Retroperitoneal fibrosis iamging and ddx
fibrosis encasing retro structures causing ureteric and vascular obstruction/displacement
aorta/ivc away from VBs implied malignant, as does local invasion
IVU
- medial deviation (maiden waist sign)
- tapering of the lumen
- uni/bilateral hydro
CT
soft tissue mass around aorta and iliac vessels
encasing without invading
variable enhancement
starts at bifurcation adn extends up
MR
T1/T2 dark, unless active inflammation
DDX
- lymphoma
- erdheim chest
- emh
Idiopathic retroperitoneal fibrosis is and assoc
also known as Ormond syndrome. subtype with no cause found.
assoc; other autoimmune processes
- pbc
- fibrosing mediastinitis
- ra
- ank spond
- PAN
- SLE
- hashimoto
Isolated periaortitis is
a non aneurysmal form of chronic periaortitis. related to atherosclerosis or igg4 related disease.
low densitive soft tissue mantle with or without dilation
may have branch vessel narrowing
Isolated periaortitis is
a non aneurysmal form of chronic periaortitis. related to atherosclerosis or igg4 related disease.
low densitive soft tissue mantle with or without dilation
may have branch vessel narrowing
Inflammatory abdominal aortic aneurysm is
a variant of AAA characterised by inflammatory thickening, perianeurysmal fibrosis an adherence to surrounding structures
Inflammatory abdominal aortic aneurysm imaging
CT
dilation
thickened wall
cuff of perianeurysmal soft tissue and inflammatory changes sparing the posterior wall
enahnces with contrast
entrapement of retroperitoneal structures
ddx
mycotic aneurysm
- usually more saccular with nodulairt, irregular config and may contain air
Primary retroperitoneal neoplasms ddx
Liposarcoma
Undifferentiated pleomorphic sarcoma
Leiomyosarcoma
Rhabdomyosarcoma
Fibrosarcoma
Malignant peripheral nerve sheath tumour
Solitary fibrous tumour
Extragonadal germ cell tumour
primary retroperitoneal adenocarcinoma
Retroperitoneal liposarcoma is and subtypes
malignant tumour of mesenchymal origin that may arise in any fat containing region of the body
well diff
- lipoma like
- inflammatory
- sclerosing
myxoid
pleomorphic
round cell
dedifferentiated
Retroperitoneal liposarcoma ddx
lieomyosarcoma
UPS
fibrosarcoma
lipoma (rare)
exophytic aml
UPS retroperitoneum is
one of the most common types of primary retroperitoneal neoplasms. high grade
can be storiform, pleomorphic, myxoid, giant cell, inflammatory and angiomatoid
25% have dystrophic calc, otherwise non spec imaging features
Retroperitoneal leiomyosarcoma is and imaging
one of the commonest retroperitoneal neoplasms. most common extra uterine site of leiomyosarcomas.
freq involve the IVC. can be intravasc, extra vasc or mixed.
imaging is non spec. tend to develop massive cystic components. no fat no calcs.
IVC leiomyosarcoma ddx
other retroperitoneal tumours should compress ivc at the periphery (negative embedded organ sign)
mesenchymal tumours involving the ivc
- angiosarc
- liposarc
- leiomyomatosis
- ups
tumours extending to ivc
- cardiac angiosarc
- hccc
- acc
- rcc
plummer vinson is
dysphagia, iron def anemia, upper oesophageal webs
