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: Gallbladder 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 abdominal pain- Closed loop bowel obstruction
Two points of obstruction at same location
Findings of ischemia- bowel wall thickening, mesenteric edema, ascites, can enhance however it wants
Causes- Adhesion, Volvulus, Internal Hernia
Treatment- Surgery
63 y/o female with vomiting- mesenteroaxial gastric volvulus
Mesenteroaxial- esophagus below pylorus- can lead to ischemia since twisted around mesentery; associated with wandering spleen; plain film shows intrathoracic stomach 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= duodenum
81 y/o male with abdominal pain- ischemic colitis
Splenic flexure- watershed area; supplied by marginal artery of Drummond Rectosigmoid- Sudeck’s point
Should not involve rectum- 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- duodenitis, 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 peritonitis, 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- Ulcerative Colitis CT- thickening, no skip, pseudopolyps, backwash ileitis, 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- adenomyomatosis
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 diverticulum
Meckel’s can lead to- hemorrhage, SBO, diverticulitis, 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 pancreatitis
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 cirrhosis- 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