35 y/o female with RUQ pain- Acute Chole

Primary diagnosis is stones + Murphy

Gallbladder wall thickening and pericholecystic fluid are secondary findings

On CT: wall thickening, distension, parenchymal hyperenhancement, tensile fundus sign, fat stranding

55 y/o male with RUQ pain- Acute Chole

MRI Findings are the same

92 y/o with - Closed loop

Two points of obstruction at same location

Findings of - bowel wall thickening, mesenteric edema, ascites, can enhance however it wants

Causes- , , Internal

Treatment- Surgery

63 y/o female with - mesenteroaxial

Mesenteroaxial- below - can lead to ischemia since twisted around mesentery; associated with wandering spleen; plain film shows intrathoracic with 2 air fluid levels

Organoaxial- twist around esophagus- usually asymptomatic

55 y/o male with abdominal pain- perforated gastric ulcer

Any time free air in non-trauma, non-obstruction, should be first consideration

If intraperitoneal air= stomach; retroperitoneal air=

81 y/o male with abdominal pain- ischemic

Splenic flexure- watershed area; supplied by marginal artery of Drummond Rectosigmoid- Sudeck’s point

Should not involve - too much redundant vasculature

85% of cases are reversible- some with continued colitis, some with stricture

60 y/o male with abdominal pain and weight loss- Celiac Disease

On barium- , dilution, dilation, slow transit, flocculation, moulage, reversal of jejunoileal folds, small bowel in small bowel intussusception

CT- laminar flow, dilated and flaccid small bowel, mesenteric lymph nodes, prominent mesenteric vessels, thickened bowel wall, intramural fat, intussusceptions, dilated colon, fat layering in colon

63 y/o male with diffuse abdominal pain- colon cancer leading to acute appy

0.85% of patients with appy have colon cancer

It is the cause of acute appy in 10-25% of elderly patients

Cecum thickened out of proportion to appendiceal inflammation

67 y/o male with abdominal pain- sigmoid volvulus

Sigmoid volvulus- RUQ, more reliable is amount of colonic distention; 75% of the cases of colonic volvulus; if , goes directly to surgery; no peritonitis- to colonoscopic decompression

Cecal volvulus- LUQ, no other colonic dilation; if debilitated- cecostomy; otherwise- surgery

Usually a venous infarction

71 y/o female with distension- colonic pseudo-obstruction

Dilated colon without transition- gradual transition at splenic flexure is expected

Caecal perforation concern at 9-12 cm cecum

Trauma, burns, DM, surgery, meds, electrolytes, uremia

27 y/o female with abdominal pain- CT- thickening, no skip, pseudopolyps, backwash , fat halo

Associations- PSC, Moya Moya, Ank Spon, colon cancer

Extraintestinal- Uveitis and Iritis, erythema nodosum and pyoderma gangrenosum, Fatty liver, IBD spondylosis

10-15% progress to Crohn’s

21 y/o female with abdominal pain- Crohn’s

15-25 years

Most common site is TI; Tons of other complications including renal stones

CT- fat halo sign, strictures; enhancement patterns in order of severity (homogeneous, mucosal, stratified), fistulae, creeping fat, skip lesions

Acute, Fibrostenosing, Fistulizing

48 y/o male with LLQ abdominal pain- Omental infarct

Fatty mass, sometimes with twisting vessels

50 y/o male with LLQ Pain- Epiploic Appendagitis

Central thrombosed vessel, fatty, has capsule, surrounding fat stranding

75 y/o with abdominal pain-

Rokitansky-Aschoff sinuses; cholesterol precipitates in these sinuses due to static bile

US- wall thickening; can be segmental and sclerosing

CT- abnormal wall thickening and enhancement

MRCP- cysts in wall

27 y/o male- Budd-Chiari CT- early enhancement of caudate lobe (separate drainage to IVC); mottled liver; cannot see hepatic veins (will get collaterals in chronic form)

Angiography- Spider web collaterals

57 y/o with abdominal pain- SVC syndrome

Hot quadrate sign- Tc99m sulfur colloid and CT

Collaterals from SVC and azygous occlusion

50 y/o male- incidental organ of zuckerkandl paraganglioma (this actually turned out to be pseudotumor)

Zuckerkandl= chromaffin cells at takeoff of IMA

42 y/o with fever= Disseminated MAC

Hypodense lymph nodes= Metastatic carcinoma, infections (TB and fungal), Whipple disease (Tropheryma whipplei), celiac sprue

36 y/o male with GI bleed- Meckel’s

Meckel’s can lead to- hemorrhage, SBO, , perf, cancer

Arises from antimesenteric small bowel; 40-100 cm from IC valve; 60% have gastric mucosa;

Free Tc99m- goes to gastric mucosa; therefore, goes to Meckel’s with gastric mucosa

53 y/o with jaundice- Panc cancer

Diff for panc mass with panc duct dilation- neuroendocrine and adenocarcinoma

Unresectable- things you cannot cut out (celiac trunk, common or proper hepatic, SMA), distant mets (retroperitoneal or mesenteric nodes, omental, liver)

Borderline resectable- involvement of PV or SMV

Resectable- abnormal peripancreatic lymph node

68 y/o female- intrapancreatic splenule

CT and MRI- mimics spleen on all phases

Definitive- appropriate location and has red and white pulp pattern of enhancement on arterial phase

Nuc med- Damaged red cell or Sulfur colloid

70 y/o man- panc neuroendocrine tumor

Remember- panc duct dilation can be either neuroendocrine or adenocarcinoma

CT- Usually hypervascular but can look like anything

MRI- usually T2 hyperintense; will also restrict diffusion

52 y/o male with abdominal pain- interstitial edematous

Classification based on Revised Atlanta Classification

No necrosis= IEP

41 y/o male with abdominal pain- Walled off necrosis

Pancreatic fluid collections

Type of Acute >4 weeks Infected Pancreatitis

Interstitial Acute Pseudocyst Air bubbles Edematous Panc peripancreatic fluid collection

Necrotic Panc Acute necrotic Walled off Air bubbles collection necrosis

67 y/o female with liver cysts- Pancreas Divisum Dorsal panc duct directly enters the minor papilla; usually asymptomatic, occasionally causes pancreatitis

Can do secretin study to see if physiologically significant

67 y/o female with abdominal pain- annular pancreas

Children- obstruction

Adults- pancreatitis or incidental

Complete- duct surrounds duodenum

Incomplete

Associations- Downs, pancreatitis, cancer, IPMN

51 y/o male with abdominal pain and hypotension- Segmental Arterial Mediolysis

Cause of spontaneous intra-abdominal hemorrhage in ages 50-80

Fusiform aneurysms, stenosis, dissections, and occlusions of splanchnic branches

Lysis of smooth muscle of outer media

Skip pattern, most commonly of SMA branches

Immune suppression is counterproductive

54 y/o male with rectal cancer- Giant cavernous hemangioma

Hemangiomas> 5cm

Need peripheral nodular, interrupted enhancement; just filling with contrast happens with mets and cholangiocarcinoma

57 y/o female- Focal nodular hyperplasia

Hard to see on T2; central T2 hyperintense scar; scar enhances on delayed; homogeneous arterial enhancement with equilibration on equilibrium phase

OATP1 receptors for hepatobiliary specific agents

56 y/o male with - HCC

2 cm arterial enhance with pseudocapsule

38 y/o female with incidental liver mass- FNH

Same as 57 y/o above- multihance 2 hour delayed

43 y/o male eval for mets- Melanoma lung met

T1 hyperintense lung nodule- melanin, blood, calcium, mucous

55 y/o with elevated bili- biliary cast syndrome

Casts form in bile ducts- possible causes- ischemia, prolonged cold ischemia time, acute rejection, biliary infections, biliary obstruction

55 y/o male for HCC Screening- Thoracic splenosis

Prior trauma with spleen rupture- can do sulfur colloid to confirm