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 .