Lecture 4 (x-ray-abdominal) -Exam 2 Flashcards
1
Q
What are the different contrast agents for ab?
* When do you use them?
A
- Barium sulfate (not water soluble) – if no chance of bowel perforation
- Gastrografin, Isovue, Omnipaque (water soluble) – if any
chance patient has perforated bowel
2
Q
Contrast studies of the GI Tract:
* _ swallow
* Upper GI can be what?
* Barium enema can be what?
* Observations of filling defects must be seenon what?
A
- Barium swallow
- Upper GI (single or double contrast)
- Barium Enema (BE), (single or doublecontrast)
- Observations of filling defects must be seenon several different views if they are to bebelieved
3
Q
What are these?
A
Right: double (barium+air)
Left: single (barium)
4
Q
What are the contraindications of barium studies?
A
- Patients with a large bowel obstructionshould not be given barium by mouth-> VOMITING
- Electrolyte imbalance
- Perforated bowel (from mouth to anus)
5
Q
Upper GI Concepts
- Barium is usually used as what? Air is used as what?
- What is GI constract for?
- Barium is contraindicated when?
- Single contrast UGI=
- Double contrast UGI=
A
- Barium usually used as a positive contrast agent; air used as a negative contrast agent
- For the evaluation of mucosal lining and to search for filling defects
- Barium is contraindicated if a perforated bowel is suspected; patient is given Gastrografin
- Single contrast UGI=barium only
- Double contrast UGI=barium+air
6
Q
Fill in
A
7
Q
Pharynx/Esophageal Imaging:
* What is a modified barium swallow?
* How is it performed as?
* What does the picture show?
A
- The oropharyngeal and pharyngeal swallowing assessment, often known as a “modified barium swallow”
- Performed as videofluoroscopy
- Note the lateral view showing aspiration to larynx and trachea
8
Q
Barium Swallow:
* If clinical suspicion of an esophageal foreign body is high, and no radiopaque foreign body is identified on plain films, what can they do?
* What else can provide good images?
A
- If clinical suspicion of an esophageal foreign body is high, and no radiopaque foreign body is identified on plain films, a barium swallow can exclude the presence of a nonradiopaque foreign body
- CT Neck without contrast or CT esophagus could provide good images as well
9
Q
- What is the gold standard for evaluating dysphagia?
- Why it is performed?
A
- Barium swallow if gold standard at evaluating dysphagia
- Performed to exclude strictures, evaluate motility, look for FB
10
Q
What is this? fill in
A
This oblique view of a normal barium swallow shows the normal impressions made by the (A) aortic arch, (B) left mainstem bronchus, and (LA) left atrium on the esophagus.
11
Q
What is this?
A
Schatzki Ring
* Esophageal ring stenosis typically causing dysphagia
* Very capable at blocking solid food that is poorly chewed, such a meat creating a food bolus
12
Q
What is this? What does it stem from?
A
Esophageal stricture
* Stem fromrepeated bouts of esophagitis with ulceration and then subsequent fibrosis
13
Q
What are these?
A
- Z=Zencker’s diverticulum
- Right side is varices
14
Q
What is boerhaave’s syndrome?
A
See following ETOH binges and frequent vomiting (cannabinoid hyperemesis syndrome)
common in those smoking marijuna
15
Q
What is this?
A
Esophageal Perforation-Boerhaave’s syndrome
16
Q
What is achalasia?
A
LES dysfunction and aperistalsis
– Note Bird’s Beak appearance
17
Q
What is this?
A
Achalasia
18
Q
What is this?
What disease process?
A
Scleroderma:
Collagen-vascular disease characterized by diffuse fibrosis
* Esophageal involvement occurs in 75 to 87% of patients
* Difference from achalasia – no Birds beak LES constriction, just widely patent dysfunctional LES
19
Q
What is the differnce between scleroderma esophageal involvement and achalasia?
A
Difference from achalasia–no Birds beak LES constriction, just widely patent dysfunctional LES
20
Q
What is this?
* What will patients present with?
A
Esophageal Spasms
* See substernal pain unrelated to swallowing due to spntaneous contractions of esophageal muscles (CP with food)
21
Q
What are the different types of esophageal neoplasms? (5)
A
22
Q
Why order an abdominal xray?
A
23
Q
SBO may be missed in 30-70% of all radiographs, What is preferred?
A
CT is preferred if available
24
Q
Why should you decide which quadrant is most painful?
A
- Localize the pain
- Consider all appropriate differentials based on age, HPI and gender
- Create a pattern for looking at ABD series
- Don’t stop looking if you find one thing.
25
point out all the organs you can see
26
What is shown here?
Small Bowel Follow Through study reveals normal anatomy of small bowel
* NORMAL
27
When reading an abdominal x-ray what do you need to look for?
28
Abdominal Series – Plain Films:
How do you evaluate systematically?
* Spine, ribs, pelvis
* Upper quadrants, flanks, and abdominal organs for masses or calcifications
* Flanks of the lower abdomen, Flank stripe (properitoneal fat line)
* Evaluate bowel gas pattern
29
What are ALL the abdominal series?
* Upright PA abdomen (pt must be upright for at least 5 min.). This film is necessary when evaluating the abdomen for free air or bowel obstruction.
* Flat abdomen/KUB (aka supine abdomen)
* PA CXR completes the series – more sensitive for pneumoperitoneum than upright ABD
* AP Supine, left lateral decubitus and AP chest (to be done if patient is unable to stand for upright abdomen or chest)
30
What is an acute abdominal series? What are the usual projections for this series?
* Acute abdominal series is a set of abdominal radiographs obtained to evaluate bowel gas.
* The usual projections for this series are AP supine view (to estimate the amount of bowel gas or possible distension), PA erect view (to assess air-fluid levels), and PA erect chest radiograph (to rule out free air) .
31
Free Peritoneal Air – aka Pneumoperitoneum:
* What is it? where will the more be and where will it less likely be?
* For pts that cannout stand, what image can be used?
* What is the most common cause of free air?
* Free intraperitoneal air will accumulate under the right hemidiaphragm on an upright film. Free air under the left hemidiaphragm is less common because of the phrenicolic ligament
* For the patient who cannot stand, a left lateral decubitus will demonstrate air above the liver
* A perforated viscus (intestinal perforation) is probably the most common cause of free air
32
What is this?
Free Peritoneal Air – aka Pneumoperitoneum
* Looking for crescent shaped radiolucency under the diaphragm.
33
Pneumoperitoneum
* What are the DDX?
Post-op retained air can be seen for up to a month following surgical procedures.
34
What is this?
Pneumoperitoneum
35
What is this?
Pneumoperitoenum
36
Pneumoperitoenum:
* What imaging position is better?
* On supine, you can see what?
* usually seen with how much air?
37
What is this?
Pneumoperitoneum
38
KUB (aka Flat/Supine Abdomen):
* What is it?
* Order this when?
* What is still the most sensitive?
* Kidneys, ureters, bladder
* Order this exam when you need a flat film of the abdomen only (e.g. large kidney stones, constipation, FBs)
* CT scan remains most sensitive
39
What do you need to evaluate for?
Evaluate for foreign bodies
40
What combination of studies complete the abdominal series in a patient that cannot stand?
AP chest and abdomen, LLDP
41
Bowel Gas Patterns:
* What is valvulae conniventes
* What are haustral lines?
* Where is the large bowel?
* Where is air fluid level normally seen?
* Valvulae conniventes (small bowel; parallel lines that extend across the bowel diameter)
* Haustral lines (large bowel, lines do not extend across the diameter of the bowl)
* Large bowel is located more peripherally
* Air fluid level is normally seen in the stomach in the upright abdomen
42
Large or small intestine?
large
43
large or small intestine?
Small
44
What is this?
NORMAL
45
which one is single and double constract
Right: double
Left: single
| Single and double contrast barium enema – ends at cecum
46
What do you need to evaluate the bowel wall for?
* Tumor
* Edema
* Post inflammatory changes
47
What is this? What is it a sign of?
Note an apple-core lesion, which is generally a sign of malignancy
48
What is this?
Abnormal Barium Enema
49
What is this?
WORMS -ew
50
* What is the preferred modality of bowel abnormalities?
* What is the primary plane of this imaging?
51
fill in
Viewed from below as looking towards head
52
Fill in spaces
* IV or oral constract used?
* Look at the patient from what side?
Sag plane
53
How does a frontal or coronal plane CT look like
looking at the pateint form the front
54
CT windows:
* Important to distinguish evaluation of specific tissue by adjusting density, how do we do this? (4)
* Increasing the window level decreases the brightness
* Decreasing the window level will INCREASE the brightness of the image
* Increasing the window width will decrease contrast image
* Decreasing the window width will INCREASE the contrast of the image
55
What windows are these films?
* Left upper – Bone window
* Left lower – Soft Tissue window
* Right upper – Lung window
* Right lower – CTA window
56
What are the different intraabdominal calcifications?
57
35yo female presents with RUQ abdominal pain
* What is the cause?
Gall stone
58
What are these images?
59
What are these?
* Left – phleboliths
* Right - urolithiasis
60
What is going on with the patient
61
Appendicitis:
* Most patients will have what?
* Occasionally what might be present on films
* What is another radiographic sign?
* Do not use what to diagnose appendicitis?
* Most patients with acute appendicitis have normal abdominal plain films
* Occasionally, a calcified appendicolith can be identified in the right lower quadrant
* A localized ileus in the right lower quadrant (dilation of ileus) or obliteration of the right flank stripe are other radiographic signs
* Do NOT use XRay to diagnose appendicitis
62
What do these images show?
Appendicitis
63
What are the advantages of CT?
In certain population like children and preg ppl what do we use for appendicitis?
* Advantages of CT include superior sensitivity and accuracy and ability to demonstrate alternative diagnoses. Several studies demonstrate reduced negative laporotomy rates when CT is used. Disadvantages include use of IV contrast, exposure to ionizing radiation, GI discomfort (oral contrast) and delay waiting for results.
* In certain population, children and in young or pregnant females, ultrasound is preferred over CT due to low cost, quick availability and lack of exposure to ionizing radiation and IV contrast. If ultrasound is negative or equivocal, proceed to CT. Most would recommend going to CT directly for all other patients.
64
Appendicitis in pediatric population
* What is first line?
* What is next step?
* What is used if high suspicion but severe contrast allergy or pregnancy?
In an adult, What is indicated?
* When do you need to consider altenative studies?
In a pediatric population
* RLQ Ultrasound is first-line
* CT with oral and IV contrast is the next step
* MRI (with gabolium) if high suspicion but severe contrast allergy or pregnancy
In an adult, CT with at least IV contrast is indicated
* Consider alternative studies if suspect other pathology or have low BMI
* Normal appendix is rarely visualized on an ultrasound
65
* Where should a flank stripe appear?
* What may onliterate the flank stripe?
* Should appear as a longitudinal fat lucency located along the lateral aspects of the abdominal wall
* Intra-abdominal fluid (ex acites) may obliterate the flank stripe
66
Abdominal/Pelvic Abscess:
* What might be obliterated?
* What is the best imaging choice?
* May see obliteration of the flank stripe
* CT is the imaging method of choice
67
You are seeing a 13yo female with complaints of abdominal pain and vomiting at a large academic pediatric hospital. Patient denies diarrhea or UTI symptoms. She denies vaginal bleeding. Abdomen is soft, patient has mild positive McBurney's and negative Rovsing signs. What imaging choice would be best to screen patient for suspected diagnosis?
* Xray
* CT without contrast
* RLQ Ultrasound with Duplex
* MRI with contrast
* RLQ Ultrasound with Duplex
68
Bowel Obstruction, Free Fluid and Free Air:
* What can occur anywhere in small bowel?
* What is considered abnormal?
* Small bowel obstructions present with what?
* Partial or complete, can occur anywhere in the small bowel
* Small bowel diameter greater than 3cm or large bowel diameter greater than 6cm is considered abnormal
* Small bowel obstructions present with air-fluid levels on upright or decubitus films seen in association with dilated small bowel loops
69
What are the differential dx in adults and kids for bowel obstruction?
Differential diagnosis in adults
* Adhesions
* Hernias
* Neoplasms
Differential diagnosis in pediatrics
* Intussusception
* Hernia
* Appendicitis
70
* Where should small and large bowel obstructions be?
* What are the normal calibers of small bowel, large bowel/transverse colon, and the cecum?
71
What does this show?
Slinky Toy half loop
72
What does this show?
* If cant stand – get LLDP. For abdomen – always get Left LDP. No right.
* String of beads sign – pat has small bowel obstruction.
73
You are seeing a 65yo male wit Hx of multiple abdominal surgeries with 1 day worth of abdominal pain. Abdomen is tight, tympanic. Patient has had vomiting but no BM. KUB notes multiple small bowel dilated loops with air-fluid levels. What is the most likely diagnosis?
* SBO
* Constipation
* Enteritis
* Appendicitis
SBO
74
Ileus Key Concepts:
* An intestinal ileus appears what?
* The stomach, small and large bowel, all do what?
* Differential diagnosis includes:
* A localized ileus or sentinel loop can be seen as what? Seen in patients with what?
* An intestinal ileus appears radiographically as an enlargement of the GI tract
* The stomach, small and large bowel, all dilate. Differential diagnosis includes: trauma, medications, peritonitis, electrolyte disturbances
* A localized ileus or sentinel loop can be seen as a focal dilated loop of small bowel seen adjacent to an area of inflammation. Seen in patients with cholecystitis, pancreatitis, or appendicitis
75
What does this show?
localized loop of bowel (radiolucency)
76
You are seeing a 9yo male with complaints of Abdominal pain. KUB shows distended large bowel at the distal transverse colon. What is upper limit of normal diameter size of colon in this region?
* 3cm
* 6cm
* 9cm
* 12cm
6cm
77
Crohn's Disease:
* What do you see?
* Can involve what?
* As with UC, Crohn's diagnosis can only be made via what?
* See ulcerations, erosions, noncaseating granulomas, and full-thickness bowel wall inflammation
* Can involve entire GI tract
* As with UC, Crohn's diagnosis can only be made via colonoscopy with biopsy.
78
What is this?
Crohn's Disease
79
Ulcerative Colitis:
* What do you see?
* What is shown on imaging?
* Involves what?
* See superficial ulcerations, edema, and hyperemia of the colonic mucosa and submucosa
* Thumbprinting – indentation in contrast bowel lumen caused by submucosal infiltration
* Involves only large intestine, with minimal backwash terminal ileitis.
80
What is this?
Ulcerative Colitis
81
Sigmoid Volvulus:
* What is it?
* Most common where?
* Usually seen in who?
* Diagnosis made by what?
* What is preferred?
* A closed loop obstruction of the bowel - twisting; can lead to ischemia and necrosis
* Most common in the sigmoid colon and cecum
* Usually seen in elderly debilitated patients with chronic obstruction.
* Diagnosis is made by Barium enema or endoscopy
* CT is preferred due to lower invasiveness
82
What is this?
Sigmoid Volvulus
* can be cecal (right iliac fossa) or sigmoid – coffee bean configuration.
83
Sigmoid Volvulus
* What does it show on imaging?
The twisted dilated loop is seen in the abdominal film and forms a central double wall that converges in the lower quadrant – known as the “coffee bean” sign.
84
Cecal Volvulus
* What is it?
* What happens?
* Paucity of gas where?
* Displaced cecum (normal location is within the right iliac fossa)
* Small and large bowel obstruction up to the point of torsion
* Paucity of gas in the distal colon
85
What is this?
Cecal volvulus-more horz
86
Cecal Volvulus:
* What does extend to cecal valve?
* Less common than what?
* Barium enema does not extend to Cecal valve
* Less common than sigmoid volvulus
87
A coffee-bean sign can be observed in which radiologic conditions?
* SBO
* Ulcerative Colitis
* Volvulus
* Intussusception
Volvulus
88
What is intussusception?
89
Intussusception:
* Seen in who?
* usually what? Some studies correlate intussusception with what?
* Seen on what films?
* Diagnosis and treatment of pediatric intussusception is made by what?
* Most patients are children less than 2 years old with a “telescoping” of the bowel
* Usually idiopathic, but can be seen following upper respiratory tract infections
– Some studies correlate rotavirus vaccination with this condition
* Seen on plain film radiographs as a small bowel obstruction
* Diagnosis and treatment of pediatric intussusception is made by single contrast barium enema
90
What is this?
Intussusception
91
What does this image show?
Distention of stomach from distal intussusception
92
What does this show?
Distended small intestine in 4mo old female from intussusception
93
What is this?
Intussusception
94
Hirschsprung's Disease:
* What is it?
* What do you see?
* Congenital aganglionic megacolon-> usually signmoid colon
* See constipation and obstruction due to lack of nervous supply to perform peristalsis
## Footnote
dx early in babies
95
Meckel Diverticulum:
* What is this due to?
* Clinically see what?
* What is the study of choice? What does it detect?
* Due to incomplete obliteration of omphalomesenteric duct causing fistula between ileum and umbilicus.
* Clinically see painless rectal bleeding "currant jelly stools" in a patient <2yo.
* Tc-99M nuclear scintigraphy is the study of choice
* Detects gastric mucosa within the diverticula
96
Toxic Megacolon:
* What is this?
* What is the most common cause?
* What is usually spared?
* What are contraindicated?
* Extreme dilation of the colon in which the affected area of bowel loses all tone and contractility
* Ulcerative Colitis is the most common cause
* Rectum is usually spared
* Enemas are contraindicated due to high risk of perforation
97
What is this?
Toxic Megacolon
98
Free Peritoneal Fluid:
* Large amounts of free air in the abdomen will appear as what?
* Large amounts of free fluid in the abdomen will appear as what?
* What will be abscence?
* Large amounts of free air in the abdomen will appear more radiolucent (darker) than normal
* Large amounts of free fluid in the abdomen will appear more radiopaque (whiter) than normal
* Note absence of flank stripe
* In some cases flank stripe is still visible, just shifted laterally
99
What does this show?
free peritoneal fluid-Hazy appearancr with abdoiminal contents appearing more central
100
What does this show?
101
What does this show?
Ascites
102
what is this?
Infant Ascites- cannot see organs
103
104
has a bowel obstruction
105
Acites
* Managed by diagnostic or therapeutic paracentesis
* Notice flank stripe is still present but is displaced laterally
106
pregnant
107
CT of the GI tract:
* CT of the GI tract demonstrates conditions that alters what?
* CT can also show what conditions?
* CT of the GI tract demonstrates conditions that alter the thickness of the bowel wall (which plain radiography cannot)
* CT can also show conditions that produce changes adjacent to the bowel wall
108
Contrast Use in Abdominal CT:
* Most abdominal CTs require what? what is the exception?
* What requires oral contrast and IV)
* Any postsurgical evaluation requires what? What does it screen for?
* Rectal contrast can be used in what?
*
109
Which Contrast Given?
* Oral – look at bowel and stomach – stomach is radiopaque but bowel is radiolucent.
* IV contrast – look for BV in liver, kidneys and ureters.
110
Bowel Wall Thickening:
* Diseases that thicken the bowel wall, such as what?
* CT can also show complications of bowel diseases such as what?
* Diseases that thicken the bowel wall, such as Crohn’s disease are seen well on CT
* CT can also show complications of bowel diseases such as bowel perforation, abscess formation, fistula formation, and strictures
111
What does this show?
Bowel Wall Thickening
* Crohn’s disease showing bowel thickening in diseased loops of small bowel (black arrows); compare the normal caliber of the wall of the descending colon (white arrows).
112
Bowel Obstruction CT:
* Where plain films may show only the signs of bowel obstruction (e.g. air fluid levels), CT may demonstrate what?
* Remember the most common cause of SBO is what?
* Where plain films may show only the signs of bowel obstruction (e.g. air fluid levels), CT may demonstrate the cause of the obstruction (e.g. neoplasm, intussusception, adhesions).
* Remember the most common cause of SBO is from adhesions due to prior surgery!
113
Hernia:
* What is the most common? 2nd most common?
* dx?
* What might be needed for small hernias?
* Lower abdominal pain should always receive what?
114
What does this show?
Oral contrasted study showing large pelvic abscess
115
Diverticular Disease:
* What is Diverticulosis?
* What is Diverticulitis?
* Diverticulosis is a common large bowel condition resulting from the herniation of portions of the mucosal and submucosal layers of the colonic wall through the muscular layer
* Diverticulitis occurs when fecal material becomes trapped within a diverticulum, resulting in perforation and abscess formation
116
What is this?
Diverticular Disease
117
What do these show?
* Left: Barium enema with diverticulitis and perforation (curved arrow). Straight arrows indicate asymptomatic diverticuli.
* Right: Sigmoid diverticulitis with a pericolic abscess (A).
118
What is this?
Bladder Fistula
* Bladder fistula (not seen), however, an air-fluid level is seen with stool in the bladder
* Cant see the actual fistula on CT.
119
What does this show
Bowel Perforation
* Sigmoid diverticulitis with free air and pus. Surgical emergency.
120
What do these show?
Colorectal Adenocarcinoma
* Note Applecore Lesions
121
what is this pointing to?
appendix... Scroll to the origin of the ascending colon/cecum and look for the "worm"
122
Appendicitis CT
* What is recommended for all patients?
* Plain films, CT, and ultrasound can what? What is best though?
* CT can determine what?
* What do you need for kids or people with low BMI
* Diagnostic imaging is recommended for all patients suspected of appendicitis
* Plain films, CT, and ultrasound can show pathologic changes in the appendix, but CT shows them best
* CT can determine not only whether appendicitis is present, but also whether perforation or abscess formation have occurred
* Remember need for oral contrast in kids and low BMI adults
123
What does this show?
Appendicitis
* Enlargement of >6mm in diameter indicates inflammation
124
Vascular Imaging of Bowel:
* Bowel ischemia usually presents as what?
* What is the study of choice to look for this issue?
* What is the MCC?
* Bowel ischemia usually presents as pain disproportionate to the exam findings and rectal bleeding (late sign)
* Mesenteric CT Angiogram is the study of choice to look for this issue.
* MCC is NOT occlusion, but hypoperfusion, atherosclerotic plaque development, or surgical damage to IMA
125
What dose this show?
SMA angiography before and after proximal SMA stenting
126
Bowel Ischemia CT
* Interruption of blood flow to the bowel can result in what?
* CT can identify what?
* Interruption of blood flow to the bowel can result in bowel ischemia and necrosis
* CT can identify bowel infarction by showing the presence of gas (pneumobilia/pneumatosis) within the bowel wall, and portal venous system
127
What does this show?
Bowel Ischemia->Mesenterik vein and small bowel wall gas
128
Abdominal Aortic Aneurisms:
* most occur?
Infrarenally
129
Pseudomyxoma Peritonei:
* Known as what?
* what is it?
* What is the m/m of this?
* Known as "Jelly Belly"
* Filling of the peritoneal cavity with mucinous material from metastatic cystadenocarcinoma of the appendix of ovary.
* The morbidity and mortality from this process is very high.
130
What is this?
Pseudomyxoma Peritonei
131
Presence of pneumatosis and pneumobilia on CT in a patient with rectal bleeding and abdominal pain usually represents what condition?
* SBO
* Bowel Ischemia
* Diverticulitis
* Ulcerative Colitis
* Bowel Ischemia
132
Liver Imaging:
* Plain radiographs may show what?
* Nuclear medicine:
* Ultrasound can be useful for what?
* CT with IV contrast is the imaging method of choice for what?
* MRI is valuable in the imaging of what?
* Hepatic angiography is reserved for what?
133
What does this show?
Normal Liver, PO and IV contrast given
134
Where are the hepatic veins adn portal veins?
135
What does this show?
Fatty Liver and metastatic disease
136
Primary Tumors of the Liver:
* Benign tumors such as hepatic adenoma and focal nodular hyperplasia are more common in w ho?
* Hepatocellular carcinoma, or hepatoma is more common in who?
* The most common benign liver tumor is what?
* Benign tumors such as hepatic adenoma and focal nodular hyperplasia are more common in young and middle-aged women who have been taking birth control pills or hormonal replacement therapy
* Hepatocellular carcinoma, or hepatoma is more common in cirrhotic patients
* The most common benign liver tumor is the cavernous hemangioma
137
What does this show?
Hepatic Adenoma
138
What does this show?
Benign cavernous hemangioma- mroe cystic and uniform
139
Hepatic Cysts and Abscesses
* These are two nonneoplastic liver masses that can be easily diagnosed with what?
* With ultrasound, a hepatic cyst appears as what?
* Diagnosis of a liver abscess is usually confirmed by what?
* These are two nonneoplastic liver masses that can be easily diagnosed with cross-sectional imaging techniques
* With ultrasound, a hepatic cyst appears as a sharply defined round mass with a thin wall that is echolucent
* Diagnosis of a liver abscess is usually confirmed by percutaneous aspiration, performed by a radiologist, using CT or ultrasound guidance
| 1.US 2. CT 3. US guided apiration
140
What are these images
141
What is this? What does it led to?
Polycystic Liver Disease which lead to fibrosis
142
Liver Trauma:
* Blunt trauma caused by what?
* Penetrating trauma - caused by what?
* Liver is most commonly injured by what?
* What is the method of choice for liver trauma?
* Blunt trauma - most commonly caused by MVA’s and falls
* Penetrating trauma - caused by stab wounds, gunshot wounds, and biopsy complications
* Liver is most commonly injured by penetrating trauma
* CT with oral and IV contrast is the imaging method of choice for liver trauma, however, the unstable patient should be imaged at the bedside with portable ultrasound utilizing FAST technique
143
What dose this show?
* Blood filled liver lacerations (black arrows).
* White arrow: normal liver fissure for ligamentum teres.
*
144
Biliary Tree Imaging:
What is the a great starting point for imaging?
What is another noninvasive option?
What is much more invasive?
* Ultrasound is an excellent starting point for biliary tree evaluation
* MRCP is another noninvasive option
* ERCP is much more invasive
145
fill in
146
Obstruction of the Biliary Tree- Imaging Options (6)
147
# Cholelithiasis and Cholecystitis
* What is the imaging method of choice for evaluating gallbladder disease?
* In cholelithiasis, gallstones appear in ultrasound as what?
* Only 10% of gallstones are what? what imaging is needed?
148
Cholelithiasis and Cholecystitis:
* In acute cholecystitis (or acute inflammation of the gallbladder), the condition is caused by what?
* Emphysematous cholecystitis can be seen how?
* Porcelain gallbladder can be seen with what?
* In acute cholecystitis (or acute inflammation of the gallbladder), the condition is caused in 90% of cases by obstruction of the cystic duct by gallstones
* Emphysematous cholecystitis can be seen radiographically with air in the gallbladder wall
* Porcelain gallbladder can be seen with calcification of the gallbladder wall
149
What does this show?
Cholelithiasis
* Gallbladder ultrasound showing echogenic stones with acoustic shadows
150
What does this show?
Emphysematous Gallbladder
* Air withing GB wall.
151
What does this show?
* What will some of these patients develop
Porcelain gallbladder
* Calcified GB wall
* 10 to 20% of all patients with porcelain gallbladder develop gallbladder cancer during their lifetime—prophylactic cholecystectomy is recommended.
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Cholecystitis
* What is it?
* Percutaneous cholecystostomy may be performed for what?
* Gallbladder sludge with thickened GB wall and pericholecystic fluid
* Percutaneous cholecystostomy may be performed for poor surgical candidates and need urgent decompression (thrombocytopenia or elevated INR)
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What does this show?
Cholecystitis
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Cholescintigraphy:
* What is it?
* Also known as what?
* Because the cystic duct is nearly always occluded in acute cholecystitis, there is generally what?
* Nuclear medicine imaging of the liver and gallbladder
* Also known as the HIDA (hepatobiliary iminodiacetic acid) scan
* Because the cystic duct is nearly always occluded in acute cholecystitis, there is generally no visualization of the gallbladder, even on delayed images
## Footnote
Takes about 20-30 minutes from injection to see uptake
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What does this show?
Abnormal Cholescintigraphy
* No uptake after 2 hours of contrast application.
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Percutaneous Transhepatic Cholangiography
* Carried out by what?
* What is seen in great detail?
* Could even see what?
* Carried out by injection of a water-soluble contrast material directly into the liver through the skin
* The biliary tree is seen in great detail, as well as a site of biliary obstruction
* Could even see an intraluminal stone - choledocholithiasis
## Footnote
CBD stone in pic
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PTCA
* What can it show?
Ascending Cholangitis
* Pancreatic carcinoma obstructing common biliary duct and leading to hepatic abscesses, appearing as rounded collections of contrast agent in dome of liver.
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What is the difference of MR vs ER Cholangiopancreatography
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* What is the difference between MRCP and ERCP?
* Which one is depicted on the picture?
* MR is noninvasive
* ERCP
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You are seeing a 35yo female with chronic Hx of obesity for evaluation of RUQ abdominal pain following Church's Chicken meal. She has a positive Murphy sign. What imaging modality would you order?
1. MRCP
2. Ultrasound
3. Cholescintigraphy
4. CT without contrast
Ultrasound
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What does it show?
Normal Pancreas
* Pancreas is a retroperitoneal organ, so is ascending and descending colons with upper 1/3rd of the rectum
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Pancreas:
* The pancreas is not visible on plain films, but pancreatic calcifications may be evident in some patients, and are usually diagnostic of what?
* Ultrasound may show what?
* CT is the imaging method of choice for patients suspected of having what?
* ERCP Pancreatography can lead to what?
* The pancreas is not visible on plain films, but pancreatic calcifications may be evident in some patients, and are usually diagnostic of chronic pancreatitis
* Ultrasound may show pancreatic masses, pseudocysts, and pancreatic duct dilation, but pancreatic anatomy is more clearly delineated by CT with Contrast
* CT is the imaging method of choice for patients suspected of having pancreatic cancer, pancreatitis, pancreatic abscesses, and pancreatic trauma
* ERCP Pancreatography can lead to pancreatitis
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Pancreas ERCP:
* ERCP involves what?
* When ultrasound or angiographic studies of what?
* ERCP involves cannulization, under fluoroscopic control, of the common bile duct and the pancreatic ducts via the ampulla of Vater during upper endoscopy
* When ultrasound or angiographic studies of suspected pancreatic disease is uncertain, ERCP is usually conclusive
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What does it show?
Pancreatitis
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What does this show?
* Who is it usually seen in?
* Pancreatic mass with PO contrast – mass pressing over the bowel.
* Usually see smokers presenting with painless jaundice
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What is Courvoisier's law (Courvoisier's sign)
a statement that the gallbladder is smaller than usual if a gallstone blocks the common bile duct but is dilated, if the common bile duct is blocked by something other than a gallstone, such as pancreatic cancer.
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What does this show?
Courvoisier's law (Courvoisier's sign)
* BIG PAN
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# Cirrhosis, Splenomegaly and Ascites
* Cirrhosis resulting from what?
* CT is the imaging method of choice for what?
* Cirrhosis resulting from chronic alcoholism will alter the size, shape, contours, or density of the liver
* CT is the imaging method of choice for cirrhosis, and may show splenomegaly (from portal hypertension), and ascites
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What are these images?
* Spleen should be close to liver in terms of radiopacity.
* Also see radiopacity around descending aorta – calcification – atherosclerotic plaque.
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What is this?
Liver Mets, Splenomegaly, and Ascites.
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Splenomegaly
* Can be seen with?
Can see with malignancy (lymphoma), hemochromatosis, thallassemia and many other conditions
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Splenic Trauma:
* The spleen is the organ most frequently injured during what?
* What is the imaging method of choice for splenic trauma?
* The spleen is the organ most frequently injured during blunt abdominal trauma
* CT is the imaging method of choice for splenic trauma, however, the unstable patient should be imaged at the bedside with portable ultrasound using FAST technique
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What does this show
Splenic Trauma
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What does this show?
Fractured spleen with blood clots of varying densities
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You are seeing a 55yo male who was involved in a MVC. He has strong odor of ETOH. There is no external trauma besides a few abrasions. Upon arrival his BP is 88/46 and HR is 122. What organ is the most likely injured in this case?
1. Pancreas
2. Liver
3. Spleen
4. SmallBowel
Spleen
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Herina
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Cirr and fibrosis
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What does this show?
Spleen rupture
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