What is your diagnosis and what patient information will lead you to the correct pathogenesis?
Subphrenic abscess with focal calcification, history of prior appendectomy
Explanation:
Lost appendicoliths (as well as gall stones) can cause delayed abscesses years after the surgical procedure. Due to a tilted position of the patient during surgery, the lost stones may “travel” towards the upper abdomen and can cause abscesses in the Morison pouch.
Therapy consists of surgical or interventional removal of the stone and drainage of the abscess.
References:
– Singh AK, Hahn PF, Gervais D, Vijayraghavan G, Mueller PR. Dropped appendicolith: CT findings and implications for management. AJR Am J Roentgenol. 2008 Mar;190(3):707-11. doi: 10.2214/AJR.07.2917. PMID: 18287442.
laboratory tests revealed elevated levels of serum alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), total bilirubin, and direct bilirubin
What do you see?
A lobulated mass within the bile ducts (shown in red areas)
Dilatation of intrahepatic bile ducts
A 3.5-cm-lobulated mass within the bile ducts (red arrows) with
upstream and downstream dilatation of bile ducts
What is your diagnosis?
Intraductal papillary neoplasm of the bile duct (IPNB) with invasive carcinoma
In our case, the patient underwent surgery and the diagnosis was histopathologically confirmed
Teaching points
IPNBs are premalignant biliary epithelial tumors.
IPNBs originate from and communicate with the biliary tree and can occur anywhere along the biliary tree.
30-40% of IPNBs exhibit mucin hypersecretion.
When symptomatic, patients present with recurrent abdominal pain, cholangitis, and jaundice.
Risk factors for IPNBs include hepatolithiasis, clonorchiasis, primary sclerosing cholangitis, biliary tree malformations, choledochal cysts, and familial adenomatous polyposis.
IPNB is analogous to the intraductal papillary mucinous neoplasm of the pancreas (IPMN).
Imaging findings of IPNB include:
Intraductal mass with upstream and downstream dilatation
Complex cystic mass with biliary ductal dilatation
Ductal dilatation without a mass, with associated parenchymal atrophy
Thread sign at MRCP (linear and curved filling defects due to mucin)
IPNBs may be associated with invasive carcinoma (27-94%)
Imaging findings that suggest invasive carcinoma at MRI include
A visible intraductal mass
Tumor size greater than 2.5 cm
Tumor multiplicity
Ductal wall thickening
Adjacent hepatic invasion
Early surgical intervention is the key management for IPNB.
All patients with IPNB should be considered for treatment, given the high potential for malignancy and for recurrent cholangitis and obstructive jaundice in nonmalignant cases
Mesenteric mass with calcifications surrounded by tethered small bowel loops
Retroperitoneal lymphadenopathy
Hypodense hepatic lesion, most likely metastasis
What is the most likely diagnosis?
Mesenteric, retroperitoneal lymph node and hepatic metastasis of small bowel neuroendocrine tumor (NET)
Most commonly, this tumor originates in the terminal ileum, but in many cases, the submucosal primary lesion can’t be identified on CT
The mesenteric mass shows both calcifications and tethering of the surrounding bowels due to the characteristic desmoplastic reaction of the mesentery
For further work-up, the radiotracer Ga-68 DOTATATE is shown to be the most accurate at identifying NET
Previously had multiple surgeries in the abdomen (cholecystectomy, splenectomy after trauma, aorto-femoral bypass because of left AIC stent occlusion)
The emergency team did not have the impression that the cause might be bowel obstruction
Abdominal X-ray at that time was reported as normal
An ultrasound of the abdomen was requested
Abdominal ultrasound showed multiple distended and fluid-filled small bowel loops with To-and-Fro peristalsis, colon was not distended – indicating small bowel obstruction
One of the most distended bowel loops had slower peristalsis. The lumen was also filled with more particulate matter, demonstrating the ultrasound analog of the small bowel feces sign. The sign is more commonly seen on CT scans
The small bowel feces sign is helpful in finding the point of obstruction. An abrupt change in caliber was noted in the vicinity, in the left lower quadrant
The diagnosis of small bowel obstruction (presumably because of post-operative adhesions) with at least one point of obstruction in the left lower quadrant was made
A CT scan was arranged for better anatomical delineation and to assess for complications
The CT scan confirmed the small bowel obstruction. Small bowel feces sign is demonstrated in the left lower quadrant
The CT confirmed the point of obstruction, seen on ultrasound. However, another part of the small bowel in the vicinity was also slightly narrowed
The mesenterium of the loop of bowel between these two points was edematous
What is the final diagnosis?
Final diagnoses
Closed loop small bowel obstruction, presumably because of adhesions after previous surgeries. Mesenteric edema indicates ischemia
No evidence to suggest that the cause of bowel obstruction would be a tumor, hernia or other etiology
SMA patent
No signs of perforation
The role of radiology in small bowel obstruction 1
The radiological diagnosis of small bowel obstruction is most commonly made with abdominal radiography
Occasionally, patients will present to the ultrasound department because of various justified and sometimes less justified reasons
The diagnosis of small bowel obstruction can be readily made on ultrasound, as demonstrated in this case. However, finding the cause and location of the point of obstruction is often difficult. The precise localisation of the point of obstruction, as seen in this case, is infrequently seen in real life practice
The role of radiology in small bowel obstruction 2
The CT scan excels compared to other modalities in finding the point of obstruction, the cause and associated complications in small bowel obstruction
It is almost always the next step in diagnostic management after positive abdominal X-ray or ultrasound findings
The most common complications of small bowel obstruction are bowel ischemia and perforation
The role of radiology in small bowel obstruction 3
A useful mnemonic for the cause of small bowel obstruction is ABC:
Adhesions – think of them after abdominal surgery
Bulge (i.e., hernias) – most commonly external like inguinal, femoral, and umbilical hernias (these are usually apparent clinically/can be seen with ultrasound), less commonly internal
C – Cancer or other tumors, which obstruct the bowel
If the point of obstruction is found, and a tumor is not differentiated and the point is not located in an external hernia, then it is presumed that the causes are adhesions (especially if the history mentions abdominal surgeries in the past)
Closed loop obstruction 1
A special type of bowel obstruction where the bowel is obstructed at two points in the immediate vicinity, thus forming a closed loop
The two points of obstruction compromise more easily; first, the venous and later the arterial blood flow to the closed loop of bowel
Associated with worse prognosis, as it leads more quickly to ischemia
A simple small bowel obstruction due to adhesions may be managed conservatively. A closed loop obstruction, however, is a surgical emergency
Closed loop obstruction 2
The CT signs in small bowel obstruction are:
Finding two points of obstruction in immediate vicinity (the collapsed bowel segments here are often hook-shaped and pointing to each other)
An odd C- or U-shaped configuration of bowel loops
Dilated bowel loops and mesenteric vessels converging to a central point
Mesenterial edema, bowel wall thickening and regional ascites indicate ischemia. A hyperdense bowel wall on non-contrast scan (due to intramural hemorrhage) and air in the bowel wall (pneumatosis intestinalis) are late signs of ischemia
Normal bowel wall enhancement does not rule out ischemia: can be normal, reduced or even increased
For more information on this topic, I recommend the excellent closed loop obstruction articles and videos on radiologyassistant.nl
59-year-old female:
– Presented with weight loss (35 kg weight loss in 1 year)
– Diagnosed with celiac disease 2 years ago
– Laboratory findings: low levels of sodium, potassium, chloride, and calcium in the blood
What do you see?
What so you see?
Multiple mesenteric lymphadenopathies that contain fat-fluid levels (red arrows)
Splenic atrophy (red arrows)
What is the most likely diagnosis?
What is the most likely diagnosis?
Cavitating mesenteric lymph node syndrome
Teaching points
– Cavitating mesenteric lymph node syndrome is associated with celiac disease
– It is characterized by the triad:
(a) low attenuation lymphadenopathies that may contain fat-fluid levels
(b) splenic atrophy
(c) villous atrophy
– Cavitating mesenteric lymph node syndrome is associated with poor prognosis
– Many patients die of complications of cachexia and intestinal hemorrhage. Patients are prone to sepsis, often due to infections commonly associated with clinical hyposplenism, such as pneumococcal infection
– In our case, US-guided biopsy of one of the mesenteric lymphadenopathies was performed. Histopathologic examination showed acellular, chylous fluid. It was negative for malignancy or mycobacterial infection. The diagnosis of cavitating mesenteric lymph node syndrome was made in the clinical setting of celiac disease
73-year-old female patient:
* Abdominal pain
* Suspicion for ileus
Findings
Small bowel obstruction, with small bowel wall distension and transition point in the pelvis. At the point of transition there is a metal structure visible with the lumen of the bowel
No signs of bowel wall ischemia, no perforation
What is the most likely diagnosis?
What is the most likely diagnosis?
Acute small bowel obstruction due to migrated stomach tube plate
Requires surgery within 24 h Possible complications: Perforation, abscess, ischemic changes Treatment in this case: Laparotomy and surgical removal of the metal plate
2-year-old girl:
– Intermittent abdominal pain during the last 3 days
– Ultrasound exam of the abdomen was performed
Right lower quadrant imagesWhat is the diagnosis?
What is the diagnosis?
Ileocolic intussusception
Intussusception
– Most common in small children (6 months–2 years)
– Proximal bowel (intussusceptum) invaginates into the distal bowel (intussuscipiens), most commonly ileocecal (90%)
– Classic triad of intermittent abdominal pain, vomiting and palpable right upper quadrant mass
– Red-currant jelly stool in late phase (signs of ischemia)
– Ultrasound is the imaging modality of choice
a) axial: alternating hyper- and hypoechoic concentric layers (target sign), sometimes with hyperechoic crescent-like mesentery (crescent in a doughnut sign)
b) longitudinal: pseudokidney sign (hilum = hyperechoic mesentery, cortex = hypoechoic bowel)
-US can identify lead points (e.g. lymph nodes, tumor, Meckel diverticulum), presence of trapped or free fluid
What is the next best step in the management?
What is the next best step in the management?
Imaging-guided reduction
– avoids surgery
– absolute contraindications: perforation, peritonitis, hemodynamic instability
– pneumatic or hydrostatic – increases the intraluminal pressure in the colon
– under fluoroscopic or ultrasound guidance (US better because of the lack of ionizing radiation)
Hydrostatic reduction under ultrasound guidance was performed
Fluid-distended cecum with gaping ileocecal valve and reflux of fluid in the terminal ileum as a marker of successful reduction
Reference
Pušnik L, Slak P, Nikšić S, Winant AJ, Lee EY, Plut D. Ultrasound-guided hydrostatic reduction of intussusception: comparison of success rates between subspecialized pediatric radiologists and non-pediatric radiologists or radiology residents. Eur J Pediatr. 2023 Jul;182(7):3257-3264. doi: 10.1007/s00431-023-04987-1. Epub 2023 May 6. PMID: 37148276; PMCID: PMC10354123.
– Bilateral perirenal soft tissue thickening extending to the renal sinus, encasing the renal arteries and veins (blue arrows) There is mild dilatation of bilateral renal calyces from the retroperitoneal infiltration
– Soft tissue encasement of the descending aorta (red arrows)
– Left renal cyst (green arrow)
What is the most likely diagnosis?
What is the most likely diagnosis?
What is the most likely diagnosis?
Erdheim-Chester disease
Teaching points
– Erdheim-Chester disease (ECD) is a non-Langerhans cell histiocytosis characterized by multiorgan xanthomatous infiltration
– The diagnosis is based on clinical, imaging, and histopathological features
– Patients with ECD may present with bone pain, diabetes insipidus, exophthalmos, constitutional symptoms, interstitial lung disease, ureteral obstruction, renal impairment, cardiac dysfunction and tamponade, cerebellar or pyramidal symptoms, and xanthelasma.
– ECD has a wide range of manifestations throughout the body
– Skeletal involvement is the most common. At imaging, there is bilateral patchy or diffuse symmetric osteosclerosis of the lower extremity metaphyses and diaphyses, with relative sparing of the subchondral surfaces. Radiographically, cortical thickening, coarsened trabeculae, medullary sclerosis, and loss of the corticomedullary differentiation may be demonstrated
– Kidneys and retroperitoneum are often involved
– CT and MRI may show ‘hairy kidney sign’ that is demonstrated as irregular symmetric infiltration of the bilateral perirenal and posterior pararenal spaces
– Obstructive uropathy may result from medial displacement of the ureters
– Periaortic soft tissue is often shown, which is known as ‘coated aorta sign’
– Pulmonary involvement has been reported in 15-35% of patients with ECD and includes smooth interlobular septal thickening, micronodules, ground-glass opacities, thickening of interlobar fissures, and parenchymal consolidation
– Chest radiographs will often show interstitial edema pattern with cardiomegaly and pleural effusions that do not respond to diuretics
– Orbital and central nervous system involvement are common findings. Retrobulbar masses that can cause proptosis and optic nerve edema may be present
– The hypothalamic-pituitary axis is the most common site affected within the central nervous system. Absence of the normal T1 hyperintense signal of the neurohypophysis occurs with enhancing nodular soft tissue of the pituitary stalk and posterior pituitary gland that results in central diabetes insipidus. Intra- and extra-axial cerebral and spinal lesions may be observed
– Treatment: Targeted therapy such as BRAF inhibitors, MEK inhibitors, interferon alfa, steroid therapy, radiotherapy, and surgery may be performed. There is no known cure for ECD and historically the prognosis has been poor
– In our case, a biopsy from the perirenal soft tissue was performed. The histopathological findings confirmed the diagnosis of ECD
17-year-old male patient:
* Cholestatic jaundice, otherwise healthy
* Ultrasound showed extensive biliary tree dilatation
What should be done next?
What should be done next?
*MRCP
*Non-contrast MR of the abdomen with MRCP was performed
MRCP ImagesMRCP Image
T2 images, axial and coronalT2 Axial ImageT2 Coronal Image
DWI (left) with ADC map (right)DWI with ADC mapDescribe the findings
Describe the findings
*Marked biliary tree dilatation, common bile duct almost 2 cm wide with abrupt caliber change at the level of the pancreatic head
*No gallstones seen in biliary ducts or the distended gallbladder
*Diffuse pancreatic enlargement with marked restricted diffusion, no peripancreatic fat stranding, free fluid or collections
*Main pancreatic duct narrowing, barely visible
Differential diagnosis includes…
Differential diagnosis includes…
*Pancreatic cancer (especially diffuse infiltrative)
*Pancreatic lymphoma
*Autoimmune pancreatitis
Autoimmune pancreatitis is:
– Rare type of chronic pancreatitis
– Associated with IgG4-related sclerosing disease and autoimmune diseases
– Bulky appearance of the pancreas on imaging (“sausage shaped”), main pancreatic duct narrowing and absence of peripancreatic inflammatory changes seen in the acute pancreatitis
– Stenosis of the common bile duct is typical
What is the best course in treatment?
What is the best course in treatment?
Corticosteroids
Follow-up MRCP three weeks later showed improvement after corticosteroid therapy
Cholecystectomy was also performed
57-year-old patient:
With recently diagnosed poorly differentiated vaginal carcinoma underwent FDG PET CT for staging
What do you see?
What do you see?
FDG PET/CT study showing:
-A hypermetabolic lower vaginal lesion representing the known vaginal neoplasm associated with a larger hypermetabolic uterine body neoplastic lesion suggesting synchronous malignant process
-Multiple hypermetabolic enumerable bilateral lung deposits associated with a single right lower para-tracheal nodal deposit representing metastatic disease
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