GIT 4 Flashcards
What are the Peritoneal spaces
- Subphrenic space
- divided by the falciform ligament into
- right subphrenic space between diaphragm nd liver
- left subphrenic space between diaphragm and spleen
- divided by the falciform ligament into
- Morison’s pouch
- right subhepatic recess
- hepatorenal recess
- most dependent portion of the abdominal cavity and collects fluid
- morisons pouch communicates with the
- lesser sac via the epiploic foramen
- subphrenic space
- right paracolic gutter
- Lesser Sac
- AKA Omental bursa
- posterior to the stomach and anterior to the pancreas
- medial superior extent between lesser curvature and left hepatic lobe, roofed by the gastrohepatic ligament
- access via the epiploic foramen/winslow
- Paracolic gutters
- pelvic
WHAT IS THIS?
histopathology
- Oesophagus is abnormally lined with columnar, metaplastic acid-secreting gastric mucosa.
- It is usually due to chronic reflux oesophagitis.
- Because there is an increased risk of oesophageal cancer, close follow-up and repeated biopsies are recommended
- IMAGING FEATURES
- A reticular mucosal pattern which may be discontinuous in the distal oesophagus (short segment) is the most sensitive finding.
- Suspect diagnosis if there is
- upper or midoesophageal stricture accompanied by reticular mucosal pattern below transition or ulcer
- Low strictures:
- the majority cannot be differentiated from simple reflux oesophagitis strictures and biopsies are required.
https://radiopaedia.org/cases/barrett-oesophagus?lang=gb
Zoomed-in images of the fine reticular pattern superimposed on oesophagitis (fine granular pattern) found in Barrett oesophagus. The area of fine reticulation is either circled in red or pointed to with red arrows.
Thanks to Steve Rubesin MD for this case.
Case Discussion
Biopsy proven Barrett oesophagus (no histologic dysplasia). This is more than an incidental finding on an oesophagram – this is a critical finding. By the time you find a lobulated oesophageal carcinoma it’s too late; the patient needs to be treated and followed at the first signs of metaplasia in the normal oesophageal stratified squamous epithelium.
It is important to get enough air/gas in the oesophagus in order to optimise one’s double contrast technique and pick up subtle findings like this. In addition to effervescent granules, it is often helpful to tell the patient to swallow as much air as possible while drinking the barium.
In this example, the Barrett oesophagus is at the gastro-oesophageal junction, but it can occur in patches anywhere from the mid-oesophagus down to the gastro-oesophageal junction.
DDx of calcified splenic foci on CT
8
- Healed granulomatous disease
- Sarcoid
- TB
- MAI
- Histoplasmosis
- PCP
- Candida
- Treated lymphoma
- Treated Mets
what is this?
who does it tend to occur in?
where does it tend to occur?
DDx?
Desmoplastic small round cell tumor
- aggressive malignancy usually occurring in adolescents and young adults
- CT shows multiple peritoneal-based soft tissue masses with necrosis and hemorrhage.
- Hematogenous or serosal liver mets can be present without a detectable primary tumor
- Desmoplastic small round cell tumours of the peritoneum are a rare and highly aggressive primary peritoneal malignancy.
- Epidemiology
- Desmoplastic small round cell tumour is usually seen in young adolescents and have a male predominance with a mean survival of 2-3 years.
- Clinical presentation
- A desmoplastic small round cell tumour usually presents with a palpable abdominal mass and abdominal distension with discomfort.
- It is most commonly seen to arise from the pelvic peritoneal cavity, the retrovesical or rectouterine space being the most frequent locations. The tunica vaginalis of the testis is the next most common location.
- Solitary or multiple soft tissue masses are seen with no definite organ of origin, usually in the retrovesical or rectouterine space, which enhance heterogeneously on contrast studies. Necrosis, haemorrhage and fibrous components are common.
- Peritoneal seeding, lymph nodal involvement, liver and bone metastases are common modes of spread.
Differential diagnosis
- peritoneal carcinomatosis
- non-Hodgkin lymphoma
- malignant peritoneal mesothelioma
- rhabdomyosarcoma
- See also
- small round blue cell tumours
https://epos.myesr.org/posterimage/esr/ecr2018/143415/mediagallery/753353
What is the Menetrier Disease Triad?
- Large gastric rugal folds (Hypertrophic gastritis), with protein-losing enteropathy.
- Clincial triad of
- Achlorhydria
- hypoproteinemia
- edema
- Typically occurs in middle aged men
- Complications
- gastric carcinoma 10%
- IMAGING FEATURES
- Giant gastric regal folds, usually the proximal half of the stomach
- Hypersecretion
- poor coating
- dilution of barium
- gastric wall thickening
- Small intestinal fold thickening bc of hypoproteinemia
- Peptic ulcers are common
- Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 83761
Gastric Polyps
- Incidence
- Types
- Incidence
- GPs are far less common than colonic polyps
- 2% of all patients with polyps
- Types
-
Hyperplastic Polyps
- 80% of all gastric polyps
- <1cm
- Sessile
- Not premalignant
- A/w
- chronic atrophic gastritis
- Familial adenomatous polyposis (hyperplastic polyps in the stomach, adenomatous polyps in the colon
- typically similar size, multiple, and clustered in the fundus and body.
- Synchronous gastric carcinoma in 5-25% of patients.
- Adenomatous Polyps
- Infrequent
- malignant degeneration 50%
- solitary
- Villous polyps
- uncommon
- cauliflower like
- sessile
- Stong malignant potential
- hamartomatous polyps
- peutz-jeghers
- cronkhite-canada suyndrome
- juvenile polyposis
-
Hyperplastic Polyps
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992058/
What is this?
Caecal bascule
Dr Matt A. Morgan◉ and Assoc Prof Frank Gaillard◉◈ et al.
Caecal bascule is an uncommon type of caecal volvulus in which the caecum folds up over itself in an anteromedial orientation. In contrast to the more common forms of volvulus, there is no axial “twisting” component 4. A caecal bascule may occur in the setting of a large and mobile caecum and can result in closed obstruction involving the caecal pole and appendix.
Clinical presentation and treatment are not significantly different from the more common axial caecal volvulus.
Radiographic features
Plain radiograph
An abdominal radiograph of a patient with a caecal bascule will demonstrate a distended air-filled caecum located centrally within the abdomen. Occasionally the appendix is distended and air-filled, improving one’s confidence that the caecum is obstructed more distally.
Importantly, as the terminal ileum is usually not involved in the volvulus, the small bowel is not obstructed.
Cause of PUD?
- H pylori
- gram negative plays a major role in the development of a peptic ulcer
- Not all people with HP with develop ulcers
- Prevalence of HP: 10% <30yo, 60% of pop >60yo
- Prevalence of HP in DU and GU: 80-90%.
- Risk factor for adenocarcinoma and lymphoma.
- Approach
- precaution against infection should be taken by all GI personnel
- HP serology may become useful from the diagnosis of PUD.
- PUD heal faster with ABx and antacides then with antacids alone.
imaging features of SMA distribution ischaemic bowel disease
sick patients, hypotension, acidosis, high mortality
requeirses surgery, resection
Xray is similarly to SBO, may see pink-prints in SB wall
submucosal edema > pneumatosis > portal vein gas 5%
Symptoms of This?
Signs
Rx.
- Inflammatory eosinophilic esophagitis
- Dysphagia may be chronic, history of allergies, eosinophilia
- Segmental proximal or mid esophageal mild narrowing
- May involve the entire esophagus
- increased risk of iatrogenic tear
- Responds to steroids
What are the most common Peritoneal Metastases?
- Ovarian cancer
- GIT cancer
- Imaging features
- Greater omentum overlying SB “Omental Cake”
- masses on peritoneal surfaces
- Superior surface of sigmoid colon
- POD
- terminal ileum
- morison pouch
- Gastrocolic ligament
- malignant ascities
- May enhance with Gad as a result of increased permeability of peritoneum
Imaging features of Gastritis
- Multiple tiny, apthoid like erosions throught the antrum and boy of the stomach
- Occurs on rugal folds
- Prominent area gastricae
what is the difference between an incarcerated and strangulated hernia?
- Incarceration
- a hernia that cannot be manually reduced
- strangulation
- occlusion of blood supply to the herniated bowel, leading to infarction
- Findings include bowel wall thickening, hemorrhage and pneumatosis as well as venous engorgement and mesenteric edema
Mesenteric panniculitis
- Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 10092
- A rare disorder characterized by chronic nonspecific inflammation involving the adipose tissue of the SB mesentery.
- When the predominant component is inflammatory or fatty, the disease is called mesenteric panniculitis.
- When fibrosis is the dominant component, the disease is called retractile mesenteritis.
- The latter is considered the final, more invasive stage of mesenteric panniculitis.
- The cause of this condition is unclear.
- Imaging features
- well-circumscribed, inhomogeneous fatty SB mesentery, displaying higher attenuation than normal retroperitoneal fat.
- The mass is usually directed toward the left abdomen where it extends from the mesenteric root to the jejunum.
- Spiculated soft tissue mass, a carcinoid mesenteric mass look-a-like.
What are 2 mimics of an ulcer
- ectopic pancreatic rests may contain a central umbilication that represents a rudimentary duct not ulcer. Commonly located in the antrum.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298353/
- Gastric diverticulum
- commonly in posterior fundus
- contains mucosal folds, neck
- changes shape during fluoroscopy.
What is this?
What is a complication?
Epiphrenic diverticulum
- May occasionally be recognised on chest radiographs by presence of soft tissue mass.
- Often with an air-fluid level, that mimics a hiatal hernia
- Large diverticulum can compress the true oesophageal lumen, causing dysphagia.
Gastric carcinoma
- Fourth most common GI malignancy
- colon
- pancreas
- liver/bilary
- Stomach
- Risk factors
- pernicious anemia
- adenomatous polyps
- chronic atrophic gastritis
- Billroth II > Billroth I
- Location
- fundus/cardia 40%
- Antrum 30%
- Body 30%
- Staging
- T1:
- limited to mucosa, submucosa
- 5YS 50%
- T2
- Muscle, serosa involved
- 5YS 50%
- T3
- penetration through serosa
- T4
- Adjacent organs involved.
- T1:
- Imaging features
- Features of early gastric cancers
- Polypoid lesions Type 1
- > 0.5cm
- normal peristalsis does not pass through lesions
- difficult to detect radiographically
- Superficial Lesions, Type 2
- 2A <0.5CM
- 2B most difficult to diagnose (mucosal irregularity only).
- 2C 75% of all gastric ca.
- Folds tend to stop abruptly at lesion
- Excavated lesion, Type 3
- malignant ulcer.
- Polypoid lesions Type 1
- Features of early gastric cancers
causes?
Anatomy of this condition
- Causes
- anticoagulant tx
- femoral catheterisation
- trauma
- Appearance
- high-attenuation fluid collection
- first several days +/- fluid level (hc level)
- if there is no further bleeding the high-density RBCs decompose to reduced density fluid
- fluid-fluid level
- Anatomy
- usually confined to the rectus muscle
- About 2cm below the umbilicus (arcuate line), the posterior posterior portion of the rectus sheath disappears and fibers of all three lateral muscle groups (External oblique, internal oblique, and transversus abdominis) passes anterior to the rectus muscle.
- This arrangement has imaging significance in that rectus sheath hematomas above the line are confined within the rectus sheath
- Inferior to the arcuate line, they are directly opposed to the transversal fascia and can dissect across the midline or laterally into the flank (as seen in pic 2)
- Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 9427
USS features of appendicitis
>6mm
noncompressible
>3mm wall thickness
shadowing appendicolith
echogenic periappendiceal fat
Oesophageal Lymphoma
- The oesophagus and stomach do not normally have lymphocytes, primary lymphoma is rare unless present from inflammation’
- secondary metastatic lymphoma is more common.
- Secondary oesophageal lymphoma accounts for <2% of all GIT lymphomas (Stomach > SB)
- Four radiographic presentations are:
- infiltrative
- ulcerating
- polypoid
- endoexophytic
What are the normal oesophageal contour deformities?
- Cricopharyngeus
- Postcricoid impressions (mucosal fold over vein)
- aortic impression
- LMB
- Left atrium
- Diaphragym
- Peristaltic waves
- Mucosa: thin transient transverse folds. Feline Oesophagus. Vs. Thick folds in chronic reflux oesophagitis. Tiny nodules in older adults: glycogenic acanthosis.
What are the two techniques used to percutaneous treat abdominal/pelvic collections
- Trocar technique
- commonly performed for large abscessers or collections with easy access.
- localise abscess by CT or US
- Anesthetize skin
- make skin nick and perforate subcut tissues
- place 8-16Fr abscess drainage catheter in tandem. Remove stylet
- Aspirate all fluid
- send for culture
- wash cavity with saline
- commonly performed for large abscessers or collections with easy access.
- Seldinger technique
- this is commonly performed for abscesses with difficult access or for necrotic tumours with hard rims
- localize abscess
- anesthetize skin
- localize abscess with 4, 6, or 8 inch seldinger or chiba needle (18gauge or 19gauge thin wall) under imaging guidance
- remove needle, leave outer sheath
- pass guide wire through sheath into abscess cavity
- dilate tract (8, 10, 12 Fn) over stiff guide wire
- Remove stiffener and guide wire.
- aspirate abscess
- this is commonly performed for abscesses with difficult access or for necrotic tumours with hard rims
What is this?
traction diverticula: are (true diverticula) which occur secondary to scarring, fibrosis and inflammatory processes (tuberculous adenitis) in the mediastinum pulling on the oesophageal wall
Complications of Gastric ulcers
- Obstruction
- posterior penetration of ulcer into pancreas
- perforation
- bleeding
- filling defect in the ulcer crater may present blood clots
- Gastroduodenal fistula
- double channel pylorus
What is this?
2 types
imaging features
- Diffuse Dysmotility
- Characterised by intermittent chest pain, dysphagia and forceful contractions.
- Diagnosis is diffuse oesohpageal spasm with manometry
- TYPES
- Primary neurogenic abnormality (vagus)
- Secondary reflux oesophagitis
- IMAGING FEATURES
- Nutcracker corkscrew esophagus
- non-specific oesophageal dysmotility disorders
What are the main types of Oesophagitis?
- Esophagitis may present with erosiions, ulcersr and strictures and rarely with perforations and fistulas.
- TYPES
- infectious
- chemical
- Iatrogenic
- Other
- Types in more detail:
- Infectious
- Herpes
- Candidiasis
- CMV
- Chemical
- Reflux oesophagitis
- corrosive (lye)
- Iatrogenic
- radiotherapy
- extended use of NG tubes
- Drugs
- Tetracycline
- NSAIDS
- Potassium
- Iron
- Other
- HIVE
- Scleroderma
- Crohn’s Disease
- Dermatological manifestations
- pemphigoid
- dermatomyositis bullosa
- Infectious
- IMAGING FEATURES
- Thickening and nodularity of oesophageal folds
- Irregularity of mucosa, granularity, ulcerations
- Retraction, smooth tapered luminal narrowing stricture just above the GOJ
HIV Esophagitis. Large ulcers (red, black and white arrows) are seen in these two views of the distal esophagus from an esophagram in a patient with odynophagia and a CD4 count of 30. Biopsies of the ulcers were negative for CMV.
For more information, click on the link if you see this icon
Ddx for appearance of peritoneal metastases
- peritoneal mesothelioma is very similar to peritoneal carcinomatosis, but usually no primary neoplasm is known
-
peritoneal sarcomatosis: if the primary tumour is of mesenchymal origin (i.e. sarcoma)
- most commonly metastases from a gastrointestinal sarcoma 1
-
peritoneal lymphomatosis
- most commonly metastases from a primary (e.g. non-Hodgkin lymphoma) elsewhere 1
-
peritonitis/sepsis
- smooth thickening and enhancement of the peritoneum, with stranding of the omentum and mesentery may be seen in intra-abdominal sepsis
- benign calcifications tend to be sheetlike, and nodal calcifications in these patients less common 2
- a history of peritoneal dialysis or recent abdominal sepsis is usually easily obtained
- peritoneal tuberculosis (image)
How quickly do benign ulcers respond to Rx?
- Benign ulcers decrease 50%in size within 3 weeks and show complete healing withing 6 weeks with successful medical treatment.
- Benign ulcers may heal with local scarring.
AKA
Associations (3)
- Mesenteric Fibromatosis AKA Desmoid Tumour
- Uncommon benign tumour that is locally aggressive, infiltrates adjacent bowel wall and recurs following resection.
- associations
- FAP
- adenomatous polyposis coli (APC) germline mutation.
- asbestosis
- Imaging
- low attenuation on CT
- High sig on T2 MRI
- Case 1 courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 14806
- Large left-sided abdominal mass with soft-tissue attenuation.
- Mesenteric desmoid tumours are bland fibrous tumours that have an association with familial adenomatous polyposis. In this case, there was no such association with confirmation of histology at percutaneous ultrasound-guided biopsy.
- Case 2 courtesy of Dr James Sheldon, Radiopaedia.org, rID: 41007
- Abdominal mass measures 17 x 8 x 16 cm with regions of cystic degeneration/necrosis within the right side of the mass - the largest low density region measures 4.5 x 5.2 cm.
The mass displaces the bowel to the periphery.
Sections show a core paucicellular fibrous tissue composed of bundles of collagen interspersed with bland stellate fibroblasts and a few small vessels. In immunostains, there is strong nuclear staining for beta-catenin.
DIAGNOSIS: Fibrous tissue suggestive of a desmoid tumour.
Ddx of Splenomegally
- Tumour
- infection
- Meatbolic
- Trauma
- Vascular
- Tumour
- leukemia
- lymphoma
- infection
- Infectious mononucleosis
- histoplasmosis
- HIV
- Meatbolic
- Gaucher disease
- Amyloid
- Hemochromatosis
- Trauma
- Vascular
- Portal hypertension
- Hematologic disorders
- anemia
- sickle cell
- thalassemia
- myelofibrosis
- myelosclerosis
Chagas Disease
What is it?
AKA
What causes it
Mortality rate?
- AKA American Typanosomiasis
- Caused by Trypanosoma cruzi which multiply in the reticuloendothelial system (RES), muscle, and glia cells. When these cells rupture and organisms are destroyed a neurotoxin is released that destroys ganglion cells in the myenteric plexus
- Mortality 5% secondary to myocarditis and encephalitis
DDx of Low density LNs
- Inection
- MAI
- Yersinia
- Sprue/cavitary LN sundrome
- Mets
- Necrotizing mesenteritis
- Whipple Disease
What is this?
- Toxic megacolon (TMC)
- Severe dilation of the trasnverse colon
- when inflammation spreased from the mucosa through other layers of the colon
- aperistaltic
- can perfoated
- 30% mortality
- UC is the most common cause
- CD, Peudomembranous colitis, Ischemic colitis, infectious colitis (CMV, Amebiasis)
- Imaging features:
- >6cm
- ahaustral irregular colonic contour
- may show intraluminal soft tissue masses (pseudopolyps)
- BE is contraindicated. proceed to proctoscopy, gravity maneuvers for plain x-ray assessment.
- diameter of transverse colon should reduce as successful treatment proceeds.
- https://radiopaedia.org/cases/toxic-megacolon-3
Detection and imaging features of PUD
- Detection:
- detection rate of ulcers by double contrast barium is 60-80%
- Imaging features:
- ulcer crater seen en face.
- distinct collection of barium that persists on different views.
- The collection is most often round but can be linear
- ulcer crater seen in profile:
- Barium collection extends outside the projected margin of the gastric or duodenal wall.
- Double contrast studies:
- The crater has a white center with a surrounding black ‘collar’
- Great curvature ulcers are commonly because of malignancy or NSAIDS.
- Multiple ulcers are usually due to NSAIDS
- ulcer crater seen en face.
what is the Carman/Meniscus sign?
The Carman meniscus sign describes the lenticular shape of barium in cases of large and flat gastric ulcers, in which the inner margin is convex toward the lumen. It usually indicates a malignant ulcerated neoplasm; in cases of benign gastric ulcers, the inner margin is usually concave toward the lumen 1.
Carman meniscus sign is seen after compression of a gastric tumour that surrounds the lesser curvature thus apposing both surfaces of the surrounding tumour and entrapping contrast between these margins causing a semilunar configuration 2,3.
The following must be present in order to visualise the sign 3:
flat infiltrating ulcerative lesion with heaped-up margins.
saddle region of the stomach i.e. lesser curvature of body or antrum
examination should be single-contrast or biphasic study (sign may be visible in double contrast study but may be not recognised).
compression must be applied to the stomach.
What is eosinophilic gastroenteritis and what are the
clinical findings and
imaging features?
- Inflammatory disease of unknown causes characterised by focal or diffuse eosinophilic infiltration of the GIT
- an allergic or immunologic disorder is suspected because 50% of patients have another allergic disease
- asthma
- allergic rhinitis
- hay fever
- Only 300 cases have been reported to date
- Rx is with Steroids
Clinical Findings
- abdo pain
- diarrhea
- eosinophilia
Imaging features
- stomach
- tapered antral stensosis (common)
- Pyloric stenosis (common)
- Gastric fold thickening
- SB
- fold thickening (Common)
- Dilatation
- Luminal narrowing
Left lumbar hernia, with omental fat protruding as content is noted. Defect measuring 25 mm in diameter.
There is also protrusion of omental fat through a defect in the left posterior rectus sheath, consistent with an incidental hernia here.
A few non-enhancing simple cortical cysts are seen at both kidneys with maximum diameter of 25 mm. Degenerative changes as osteophytosis are seen at the lumbar spine.
Case Discussion
Left lumbar hernia (Petit hernia).
Additional incidental left posterior rectus sheath hernia
Abdominal COmplications after cardiac Surgery
6
- incidence: 0.2%-2%
- most common complications are related to ischemia
- intraoperative hypotension
- hemorrhage
- vasculopathy
- emboli
- clotting abnormalities
- GI Hemorrhage 50%
- cholecystitis 20%
- emphysematous
- acalculous
- calculous
- Pancreatitis 10%
- Perforated peptic ulcer 10%
- Mesenteric ischemia 5%
- Perforated diverticular disease 5%
Gossypiboma
A gossypiboma, also called textiloma or cottonoid, refers to a foreign object, such as a mass of cotton matrix or a sponge, that is left behind in a body cavity during surgery. It is an uncommon surgical complication. The manifestations and complications of gossypibomas are so variable that diagnosis may be difficult and patient morbidity is significant.
What is this?
who does it occur in?
what is the anatomy?
- Indirect inguinal hernia
- defect lateral to the inferior epigastric vessels,
- peritoneal sac protrudes through the internal inguinal ring
- caused by persistence of processes vaginalis
- Indirect inguinal hernias (alternative plural: herniae), a type of groin herniation, are the most common type of abdominal hernia.
- Epidemiology
- 5 times more common than a direct inguinal hernia, and is
- 7 times more frequent in males, due to the persistence of the processus vaginalis during testicular descent.
- In children, the vast majority of inguinal hernias are indirect.
- Pathology
- Indirect inguinal hernias arise lateral and superior to the course of the inferior epigastric vessels, lateral to Hesselbach’s triangle, and then protrude through the deep or internal inguinal ring into the inguinal canal. An indirect hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels. It passes inferomedially to emerge via the superficial ring and, if large enough, extend into the scrotum.
A helpful mnemonic for remembering the features of a Bochdalek hernia is:
5 Bs
Mnemonic
B: Bochdalek
B: big
B: back and lateral, usually on the left side
B: baby
B: bad (associated with pulmonary hypoplasia)
To remember the side in which a Bochdalek hernia more commonly occurs (and to contrast that with Morgagni hernias) Bochdalek has an L for left and Morgagni has an R for right.
In the initial chest radiograph, a radiolucent cystic large lesion is present, which occupies most of the left chest. It has a thin wall and an air-fluid level, it displaces the mediastinum, the trachea and the right lung compensates with overdistention.
Where and what are the different types of diaphragmatic hernias?
which type is imaged and what are the associations with this type of hernia?
- congenital diaphragmatic hernias
- Bockdaleck
- left
- Posterior
- Morgagni
- right 90%
- anterior
- where epigastric artery travels
- rare (2% of CDH)
- Bockdaleck
- traumatic
- left > right
- may be masked by positive pressure ventilation
Morgagni hernias (alternative plural: herniae) are one of the congenital diaphragmatic hernias (CDHs) and are characterised by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias tend to be:
- anterior
- more often right-sided (~90%)
- small
- rare (~2% of CDH)
- at low risk of prolapse
Associations of Morgagni Hernias
- pentalogy of Cantrell
- congenital heart disease
- trisomy 21 (Down syndrome)
- intestinal malrotation 7
What is the difference between oesophageal webs and rings. What are the associations of webs and rings?
- Mucosal structures
- web = asymmmetric
- Ring = symmetric
- may occur anywhere in the oesophagus.
- Associations
- iron-deficiency anaemia (cervical webs)
- Plummer vinson Syndrome (1st picture)
- Hypopharyngeal carcinoma
- iron-deficiency anaemia (cervical webs)
Malignant peritoneal mesothelioma
- Malignancy of mesothelial cells linging the peritoneum.
- Associated with asbestos exposure
- Imaging features
- peritoneal soft tissue nodules, mental and mesenteric masses or nodules
- ascites
- bowel wall thickening
- Fixation of SB
Malignant peritoneal mesothelioma is an uncommon primary tumour of the peritoneal lining. It shares epidemiological and pathological features with - but is less common than - its pleural counterpart, which is described in detail in the general article on mesothelioma. Other abdominal subtypes (also discussed separately) include:
multicystic mesothelioma
tunica vaginalis testis mesothelioma
Epidemiology
Approximately 20-30% of all mesotheliomas arise from the peritoneal serosal lining. As with pleural mesothelioma, there is also a strong association with asbestos exposure (primarily the crocidolite variety), and this occupational hazard probably accounts for disease predominance in middle-aged to older males (most common age group is 50 to 70 years and it may also account for the slightly increased male predilection).
Despite this, ~50% of cases have no history of exposure to asbestos, although prior radiation exposure, exposure to thorium, talc, erionite or mica, as well as in patients affected by familial Mediterranean fever and diffuse lymphocytic lymphoma have also been reported.
The overall incidence is approximately 1-2 cases per million.
Characteristics of Gastroduodenal Crohns Disease
- Aphthous ulcers, usually in antrum and duodenum
- Stricture: Pseudo-Billroth 1 appearance on barium studies.
- Fistulization
Malignant ULCER PUD features
- Mucosal folds
- thick irregular do not extend through collar
- penetration
- ulcers project within ‘projected’ luminal surface
- Carman/meniscus sign
- Location
- eccentrically in tumour mound
- Collar
- thick, nodular, irregular
- Other
- limited peristalsis
- limited distensibility
- Gastrohepatic LNS
- common
what is this?
Ogilvie Syndrome
dilatation of the colon in older adult patients. Often history of laxative abuse, antiparkinson medication or metabolic abnormalities
- dilated ahaustral colon
- often affects just the proximal colon
- no mechanic obstrcution
- water soluble contrast enema is diagnostic study of choice
Colonic dilation with no clear mechanical cause/transition point. A colonic pseudo-obstruction (also known as Ogilvie syndrome) was considered as a possibility due to the post-operative status and associated electrolyte disturbances. Patient improved one day later only with clinical management.
Adynamic ileus, which is usually associated with small bowel dilation, is a differential, although both conditions have a similar clinical management. Toxic megacolon secondary to Clostridioides difficile colitis and ischaemic colitis would present with similar dilation, but associated with bowel wall thickening and associated inflammatory changes such as fat stranding.
Right kidney complex cyst was recommended for ultrasound correlation.
https://radiopaedia.org/cases/ogilvie-syndrome-2
what type of peritonitis can calcify?
what types of this type of peritonitis are there?
Tuberculous
Pathology
Reactivation of tuberculous collections lying dormant in the peritoneum accounts for the majority of cases. Direct spread may occur from the gastrointestinal tract, and dissemination through lymphatic or haematogenous means have also been described. Direct extension from the female genital tract has been described 11.
Tuberculous peritonitis is commonly classified as follows:
- wet type
- most common (~90%) 1
- dry type
- fibrotic-fixed type
Of note, there is considerable overlap between the three types.
Tuberculosis in different organ systems may mimic alternate pathology so histopathological or laboratory evidence is often required to support suspicions on imaging before commencing treatment.
Zollinger-Ellison Syndrome
- definition
- Clinical findings 3
- Causes 2
- Imaging features 4
- Definition
- syndrome of overproduction of gastrin
- clinical findings
- PUD
- Diarrhoea
- pain
- Causes
- Gastrinoma 90%
- islet cell tumour in pancreas or duodenal wall 90%
- 50% of tumours are malignant
- 10% of tumours are a/w MEN Type 1
- Antral G-Cell hyperplasia 10%
- Gastrinoma 90%
- Imaging features
- ulcers
- duodenal bulb > Stomach > post-bulbar duodenum
- Multiple Ulcers
- Thickened gastric and duodenal folds
- Increased Gastric secreations
- Reflux oesophagitis.
- ulcers
Richter hernias, also known as parietal hernias, (alternative plural: herniae) are an abdominal hernia where only a portion of the bowel wall is herniated and comprise 10% of strangulated hernias. These hernias progress more rapidly to gangrene than other strangulated hernias but obstruction is less frequent.
Pathology
In contrast to most other types of hernia, only the antimesenteric wall of the bowel herniates without compromising the entire lumen. This herniation is usually through a small, firm defect in the abdominal wall. Although any part of the bowel can be affected, the terminal ileum is most frequently involved.
Richter hernias can occur at 2:
femoral ring (36-88%)
inguinal ring (12-36%)
abdominal wall incisional hernia (4-25%)
rare: umbilical, ventral, Spigelian, supravesical, sacral foramen, triangle of Petit, retrosternal, and diaphragmatic hernias
trocar ports for laparoscopic surgery (port site hernia)
- Pseudomyxoma peritonei
- gelatinous substance accumulates in peritoneal cavity because of widespread mucinous cystadenocarcinoma
- appendix
- ovary
- scalloped indentations of liver
- with or without calcificaiton
- thickening of peritoneal surfaces
- septated ‘pseudo’ ascites
- thin walled cystic masses
- gelatinous substance accumulates in peritoneal cavity because of widespread mucinous cystadenocarcinoma
What is this?
who does it occur in?
what is the anatomy?
- Femoral Hernia
- enlargement of the femoral ring
- peritoneal sac protrudes medial to the femoral sheath
- Occurs more frequently in women
What is a Schatzki Ring?
- Thin annular symmetric narrowing at the junction of the oesophagus with the stomach (B ring level).
- Present in 10%.
- Symptomatic in 30%.
- Symptoms of dysphagia and heart burn usually occur if rings cause oesophageal narrowing of < 12mm. Now considered a conserwence of reflux.
What is the GOJ Anatomy?
- Phrenic ampulla:
- normal expansion of the distal oesophagus. Does not contain gastric mucosa
- A-ring
- a for Above. aka Wolf ring
- indentation at upper boundary of the phrenic ampulla
- B-ring
- indentation at lower boundary of the phrenic ampullar
- normally not seen radiologically unless there is a hiatal herna
- Z-line
- zig-zag line: squamocolumnar mucosal junction between oesophagus and stomach. Not visible radiologically.
- C- ring
- Diaphragmatic impression
- the esophagus lacks a serosa.
- Upper 1/3 has striated muscle
- Lower 2/3 has smooth muscle.
Morgagni hernia
Morgagni hernias (alternative plural: herniae) are one of the congenital diaphragmatic hernias (CDHs) and are characterised by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias tend to be:
anterior
more often right-sided (~90%)
small
rare (~2% of CDH)
at low risk of prolapse
Clinical presentation
Only ~30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
Epidemiology
Associations
pentalogy of Cantrell
congenital heart disease
trisomy 21 (Down syndrome)
intestinal malrotation 7
Pathology
Morgagni hernias most often contain omental fat, but transverse colon (60%) or stomach (12%) may be included within the hernia.
Treatment and prognosis
Some sources recommend laparoscopic surgical repair, even in asymptomatic patients, to avoid the risk of strangulation of the hernia contents 6.
History and etymology
Giovanni Battista Morgagni (1682-1771) was an Italian anatomist and pathologist 8.
Differential diagnosis
cardiophrenic angle lesions: the main differential diagnosis for Morgagni hernia is a cardiophrenic fat pad. It appears radiolucent compared with other lesions not containing fat
focal diaphragmatic eventration
diaphragmatic rupture: from trauma, but usually other supportive signs of chest and/or abdominal trauma would be apparent. This is most commonly seen posterior and posterolaterally
Abdominal wall metastases
- Abdominal wall metastases
- Origin
- melanoma
- skin tumours
- neurofibromatosis
- iatorgenic seeding
- lymphoma
- imaging features
- soft tumour mass in subcutaneous fat with or without focal bulging
Cervical Oesophageal Diverticulae Types.
- Lateral Pharyngeal Pouches
- AP oesophagram at level of pharynx demonstrates lateral outpouchings through weakness in thyrohyoid membrane.
- Large in glassblowers and wind instrument players.
- Zenker Diverticulum
- Pulsion diverticulum
- originates in the midline of the posterior wall of the hypopharynx at an anatomic weak point known as killian dehiscence
- above cricopharyngeus at fiber divergence with inferior pharyngeal constrictor.
- During swallowing, increased intraluminal pressure frces mucosa to herniated through the wall.
- The cause of Zenker diverticulum is not firmly est.
- but premature contraction and/pr motor incoordination of the cricopharyngeus muscle are thought to play a major role.
- COMPLICATIONS
- Aspiration
- ulceration
- Carcinoma
- Killian-Jamieson DIverticulum
- Below criopharungeus
- Off midline. Ie is lateral
- Lateral to the cervical oesophagus.
Benign Ulcer features
Oesophageal Foreign body
- Imaging features
- FB usually lodges in the coronal orientation
- important to exclude an underlying schatzki ring or carcinoma once the FB is removed.
What is going on here?
Peritoneal nodularity in patients with an IUD may be seen with Actinomycosis
Pelvic actinomycosis infection is a rare but serious infection caused by Actinomyces sp., an opportunistic gram-positive bacteria usually introduced by foreign bodies specially IUCDs, surgery, or trauma. It generally falls under the broader spectrum of pelvic inflammatory disease.
Pelvic infection from several Actinomyces sp. can occur, which include:
- Actinomyces israelii: by far the most common causative organism 3
- Actinomyces naeslundii
- Actinomyces viscosus
- Actinomyces eriksonii
The organisms are indigenous in the oral cavity, gastrointestinal tract, and genital tract, with opportunistic infection occurring when the mucosal barrier is broken.
Associations
- placement of intra-uterine contraceptive devices: usually when it has been present for a prolonged period
- ~25% of IUCDs eventually get colonised by Actinomycosis sp.
- 2-4% of IUCDs that are colonised ultimately develop a serious actinomycotic infection
DDx of Splenic Rim Calcified cystic lesions
4
- Echinococcus (ie hydatid - picture)
- traumatic cyst
- Metastases
- Intrasplenic aneurysm
What are the pathology and imaging features of this?
- Collagen vascular disease that involve the smooth muscle of the oesophagus, stomach and small bowel
- Imaging features
- Lack of primary waves in distal 2/3
- GOJ patulous unless stricture supervenes
- Reflux oesophagitis
- Strictures occur late in disease
- Oesophagus dilates most when stricture sypervenes.
What is this?
Who does it occur to?
What is the anatomy?
- direct inguinal hernia
- defect medial to the inferior epigastric vessels
- the peritoneal sac protrudes through floor of the inguinal canal
- caused by weakness in the floor of the inguinal canal
What are the imaging features of Chagas disease?
- Esophagus
- early:
- hypercontractility, distal muscular spasm. Normal caliber
- Late
- Denervation
- megaesophagus
- aperistalsis
- birds beak appearance at GOJ
- mimicks achalasia
- Oesophageal complications
- ulcers/hemorrhage
- perforation into mediastinum
- abscess formation
- carcinoma 7%
- early:
- Colon
- megacolon (anasphinterneuropathy)
- Sigmoid volvulus) 10%
- Heart
- cardiomyopathy (cardiomegaly)
- CNS
- encephalitis
what is this?
What is the Anatomy?
who does it happen to?
Obturator Canal Hernia
- Occurs through the obturator foramen
- between pectineus and obturator externus
- Has the highest mortality rate of all henrias
- older women
- Obturator hernias (alternative plural: herniae) are characterised by bowel herniating between the obturator and the pectineus muscles. They are a rare type of abdominal hernia and can be a challenge to diagnose clinically.
Epidemiology
Typically obturator hernias occur in older women 2,3 or patients with chronically raised intra-abdominal pressure (e.g. ascites, COPD, chronic cough) 3. They can occur in pregnancy, due to relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal 3. It has been suggested that there is a female predominance with this type of hernia, and they occur in less than 0.04% of all hernias 6.
Types/classification of this condition
Rectus sheath haematomas, as the term implies, occur when a haematoma forms in the rectus abdominis muscle/rectus sheath. It is most common in its lower segment and is generally self-limiting.
Epidemiology
Rectus sheath haematomas are more common in women with a 3:1 F:M ratio.
Clinical presentation
Rectus sheath haematomas most often present as acute onset of abdominal pain with a palpable abdominal mass. Additional findings may include fevers, chills, nausea, vomiting, abdominal tenderness, and abdominal guarding. Depending upon the size and location of the haematoma, patients may also present with signs of hypovolaemic shock or even abdominal compartment syndrome 5.
Pathology
Aetiology
The majority of haematomas result from the rupture of epigastric vessels or by tearing of the fibres of the rectus abdominis muscle. This can be due to 1,4:
spontaneously in the context of anticoagulation therapy (most common)
direct or indirect trauma
coagulopathies e.g. cirrhosis
degenerative vascular diseases
iatrogenic, e.g. from high femoral arterial puncture
Radiographic features
Rectus sheath haematomas are classified based upon computed tomography scan findings to guide treatment 6.
Ultrasound
heterogeneity in rectus abdominis muscle
CT
haematoma is confined to the abdominal wall.
high attenuation on unenhanced images
lack of enhancement
resolution on follow-up studies helps confirm the diagnosis
CT classification
type I: small and confined within the rectus muscle; does not cross the midline or dissect fascial planes 6
type II: also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midline 6
type III: large, usually below the arcuate line, and often presents with evidence of haemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space) 6
Left rectus sheath haematoma comprising three loculations with haematocrit effect. There is active extravasation from the left inferior epigastric artery.
Prior sternotomy. Markedly enlarged right atrium.
Mildly dilated intrahepatic bile ducts.
Small right kidney, 7.1 cm in length.
Severe lumbar scoliosis convex to the right.
Internal fixation (DHS) of left femoral neck.
Case Discussion
Example of rectus sheath haematoma with haematocrit effect and active contrast media extravasation (i.e. active bleeding) from the inferior epigastric artery.
Glick, Y. Rectus sheath haematoma with active extravasation. Case study, Radiopaedia.org. (accessed on 29 Sep 2021) https://radiopaedia.org/cases/55889
Name 4 different types of Infectious oesophagitis and their imaging features.
- Herpes simplex
- Candidiasis
- CMV/HIV
- Mycobacterial
- Herpes simplex
- Small ulcers <5mm
- normal mucosa between ulcers
- More diffuse than reflux ulcers
- Candidiasis
- plaque-like, reticular
- Shaggy margins
- Often involve entire oesophagus
- CMV/HIV
- Typically, elliptical large ulcers, but may be tiny ulcers such as herpes
- Etiologic distinction between CMV and HIV ulcers is important because therpies are different
- Behcet disease may have a similar appearance
- Mycobacterial
- ulcers, sinus tracts.
What is this? (arrowed)
hampton line
1-2mm lucent line around the ulcer caused by thin mucosa overhanging the crater mouth seen in tangent. It is a reliable sign of a benign ulcer but present in very few patients.
Sclerosing peritonitis
- uncommon but important complication of chronic ambulatory peritoneal dialysis (CAPD)
- incidence increases with the duration of CAPD.
- The exact cause is not known.
- Clinical onset is heralded by abdominal pain, anorexia, weight loss, and eventually partial or complete SBO.
- Loss of ultrafiltration is common, as is flooding dialysis effluent
- early dx is essential as cessation of CAPD and tx with total parenteral nutrition, hemodialysis, immunosuppression +/- renal transplant may result in recovery
- Imaging features
- x-ray
- are normal in early disease.
- later, curvilinear peritoneal calcification can be seen within the abdomen
- may show centrally located, dilated loops of bowel with wall thickening, edema, and thumb printing
- CT
- peritoneal enhancement
- thickening
- calcification
- loculated intraperitoneal fluid collection
- adherent and dilated loops of bowel
- x-ray
- Case 1 courtesy of Dr Vitalii Rogalskyi, Radiopaedia.org, rID: 66354
-
Case 2 courtesy of Dr Vikas Shah, Radiopaedia.org, rID: 7529
-
Sheet-like calcification across the upper and mid abdomen. Extensive arterial calcification. Multiple surgical clips in left iliac fossa; there was an undisclosed history of a renal transplant. No signs of bowel obstruction.
- Case Discussion
- Encapsulating peritoneal sclerosis may be a complication of peritoneal dialysis. Chronic inflammation leads to thickening and calcification of the peritoneum, forming a calcified cocoon encasing the bowel and leading to subacute bowel obstruction. There are features here that make it a great exam film:
- the cause of renal failure: diabetes leading to extensive arterial calcification
- the previous treatment for the renal failure was peritoneal dialysis, leading to the calcification
- the most recent treatment is a transplant, evidenced by the surgical clips in the left iliac fossa
-
Sheet-like calcification across the upper and mid abdomen. Extensive arterial calcification. Multiple surgical clips in left iliac fossa; there was an undisclosed history of a renal transplant. No signs of bowel obstruction.
- Encapsulating peritoneal sclerosis is a rare benign cause of acute or subacute small bowel obstruction. It is characterised by total or partial encasement of the small bowel within a thick fibrocollagenous membrane.
- AKA
- abdominal cocoon
- sclerosing encapsulating peritonitis,
- sclerosing peritonitis,
- encapsulating peritonitis,
- peritonitis chronica fibrosa incapsulata.
Epidemiology
Encapsulating peritoneal sclerosis can occur at any age, with reports ranging from 2-day neonate to 82 years 5.
Clinical presentation
The presentation is non-specific and patients may present with vomiting, abdominal pain and/or a subacute bowel obstruction 5.
Pathology
It can be idiopathic or secondary due to:
- continuous ambulatory peritoneal dialysis (prevalence ~0.7%)
- tuberculosis
- peritoneovenous or ventriculoperitoneal shunts
- treatment with practolol
- tuberculosis,
- sarcoidosis,
- familial Mediterranean fever,
- gastrointestinal malignancy, ovarian carcinoma 6,
- protein S deficiency,
- liver transplantation,
- fibrogenic foreign material, and
- luteinised ovarian thecomasRadiographic features
DDx
congenital peritoneal encapsulation, which is characterised by a thin accessory peritoneal sac surrounding the small bowel.
What are the three types of internal hernias?
Paraduodenal hernia (L>R)
SB grouped in sac like configuration (1st picture)
Lesser sac hernia (second picture)
What is this??
Pseudodiverticulosis
Neumerous small oesophageal outpouchings reporesetnging dilated glands interior to the muscularis
- Usually occur at >50 years old.
- DYsphagia is the presenting symptom.
- underlying disease include candidiasis, alcoholism and diabetes.
- ASSOCIATED FINDINGS
- oesophageal stricture may occur above and/or below
- Oesophagitis.
- IMAGING FEATURES
- Thin flask shaped structes in longitudinal rows parallel to the long axis of the oesophagus
- diffuse distribution or localised cluters near peptic strictures.
- Much smaller than true diverticulae
- When view en face, they can sometimes be mistaken for ulcers.
- When viewed in profile they often seem to be floating outside the oesophageal wall with barely perceptible channel to the lumen.
- CF: Oesophageal ulcers almost always visibly communicate with the lumen.
What is this?
Findings?
- Spontaneous perforation of the oesophagus secondary to a sudden increase in intraluminal oesophageal pressure. Severe epigastric pain. Rx is with immediate thoractomy.
Mortality 25%. - Imaging features
- pneumomediastinum
- pleural effusion (left > Right)
- Mediastinal hematoma
- Rupture immediate above diaphragm
- usually on the left posterlateral side 90%
