Abdominal #10

82-yearold patient:
– Presenting with hematuria

What is the most likely diagnosis?

Enhancing mass in the left renal pelvis, most likely TCC

What is the treatment?

Left total nephroureterectomy and bladder cuff excision

Microscopy result: Transitional Cell Carcinoma of 2,5 cm in the renal pelvis, low grade.
TNM classification Pyelum-Ureter (8th edition UICC): pTa.

Teaching Points

Teaching points

– The vast majority of renal pelvis and ureter tumours are transitional cell carcinoma (> 90%), the remainder of tumours are squamous cell carcinoma (< 10%) and adenocarcinoma (< 1%) Transitional cell carcinoma much more commonly occurs in the bladder than in the renal pelvis or ureter - Synchronous and metachronous tumours are frequent because TCC is caused by toxic exposure through for example cigarette smoking - TCC of the renal pelvis can spread to the kidney and intraluminal seeding to more caudal parts of the ureter and to the bladder is common => always look for other space occupying lesions

– For these reasons, an excretory phase is always useful when a kidney mass is suspected, as TCC’s represent 10 to 15% of renal tumours

– CT scan protocol: non enhanced CT, enhanced CT (70-90 sec), delayed phase (10-15 mins)

Abdominal #9 – Flashcard

31-year-old male with:

* Right upper quadrant & epigastric pain
* History of gastric bypass surgery

What aquatic sign is used for the finding in the red circle?

Whirlpool sign

What is shown at the blue arrow?

The transition point from dilated small bowel (with the “small bowel feces sign”) to non-dilated small bowel at the site of internal herniation through a mesenteric defect.

Abdominal #8 – Long case

76-year-old male.
* Presents with acute abdominal pain, enlarged abdomen and no defaecation since a few days.

What do you see?

Abdominal CT scan shows dilated colon loops with a calibre change in the sigmoid. Whirl of mesenterial vessels.

Differential diagnosis is Sigmoid volvulus. This was confirmed on OR.

Sigmoid volvulus is differentiated from a cecal volvulus by its ahaustral wall and the lower end pointing to the pelvis.

Abdominal radiographs will show a large, dilated loop of the colon, often with a few gas-fluid levels. Specific signs include coffee bean sign and absent rectal gas.

CT scan will show large gas-filled loop lacking haustra, forming a closed-loop obstruction. Specific signs include:
– whirl sign: twisting of the mesentery and mesenteric vessels
– bird’s beak sign: if rectal contrast has been administered
– X-marks-the-spot sign: crossing loops of bowel at the site of the transition
– split wall sign: mesenteric fat seen indenting or invaginating the wall of the bowel

Rectal tube insertion for treatment is successful in treating 90% of cases. Occasionally patients suffer from recurrent sigmoid volvulus, for which a surgeon may consider sigmoid colopexy (surgical fixation of the sigmoid colon), or in the surgically unfit, a percutaneous endoscopic colostomy (PEC) might be performed. The mortality rate of sigmoid volvulus is 20-25%. The most serious complication is bowel ischemia, not blow-out perforation as you might expect.

Abdominal #7 – Long case

70-year-old female:

* Presents with acute abdominal pain
* Previous history adnex extirpation and appendectomy
* No raised inflammatory parameters
* No peristalsis
* CT abdomen with IV contrast

What do you see?

Click here to see the answer:

Dilated small bowel loops, radiating distribution (“Bunch of grapes”) with impressive mesenterial venous engorgement and edema in the centre. Ascites perihepatic and in Douglas. Loss of bowel enhancement.

What is the most likely diagnosis?

Closed loop obstruction with bowel ischemia.

Teaching point

Seek for 2 (!) calibre changes next to each other to confirm SBO on basis of Closed loop obstruction.

Peroperative 1 meter of necrotic small bowel was resected.

Abdominal #6 – Long case

56-year-old male:

* Presents with diffuse chronic pain in the abdomen
* Decreased kidney function

A CT is performed:

CT abdomen with IV contrast

What do you see?

Diffuse hypodense solid tissue around the pancreas, compression splenic vein with inhomogeneous attenuation of the splenic parenchyma. Soft tissue manchet around the infrarenal abdominal aorta, compressing the aorta to the spine and continuing around the iliac vessels. No separate lymph nodes can be seen. Right hydronephrosis and hydro-ureter, right kidney shows edematous swelling . Both kidneys show heterogeneous cortical enhancement.

What is the most likely diagnosis?

Right hydronephrosis and hydro-urter, pancreatitis and nephritis.

Differential diagnosis includes:
Retroperitoneal fibrosis (Ormond disease) or auto-immune mediated IgG-4 disease

CT-guided retroperitoneal biopsy was performed.

Pathology report: Fibrous tissue with chronic inflammation. Not enough signs of IgG-4 mediated disease.

Abdominal #5 – Long case

88-years-old female:
* Presents with acute abdominal pain and pain the right groin
* On clinical examination mass in the right groin
* Slightly elevated inflammatory parameters. Continue on next slide for coronal views.

What do you see?

Right-sided obstructed inguinal herniation with small bowel trapped. Mechanic small bowel ileus. As a coincidence Meckel’s diverticulum (not herniated). Engorgement mesentery but still normal enhancing bowel walls, no direct signs of bowel ischemia yet.

Abdominal #4 – Long case

27-year-old female:
* No previous history
* Presents with acute kidney insufficiency
* DD glomerulonephritis
* Nephrotic syndrome
* US to exclide post-renal obstruction

US: Bilateral hydronephrosis and hydro-ureter. No obstructing mass or stone visible. Bilateral loss of parenchyma, indicating chronic problem.Mobile bladder stone.

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Patient receives bilateral nephrostomy. On antegrade pyelography no calibre changes or strictures, not proximal or distal. No cause for hydrnephrosis and hydro-ureter bilateral.

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Non-enhanced abdominal CT to evaluate nephrolithiasis. Traction on sigmoid, coecum and small bowel, andalso traction on bladder roof. Consider endometriosis in the differential diagnosis and perform MRI pelvis.

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MRI pelvis. Medialised adnexes. T2 hypo-intense fibrotic plaque centered on uterus very suggestive for deep invasive endometriosis (DIE). Fibrotic changes between uterus and rectum, uterus and bladder and uterus and bowels. No endometrioma cysts. Central in fibrotic area small aircollection with fistula towards anterior fornix (not completely shown here), with small abscess on major labia.

What is the most likely diagnosis?

Diagnosis: Endometriosis

Abdominal #3 – Long case

A 70-year-old male presents to the Emergency Room with abdominal pain and distention. The patient has a history stage IV non-small cell lung cancer, chronic obstructive pulmonary disease, hypertension, severe dementia and recent deep venous thrombosis. He presents secondary to 2 days of poor appetite, diffuse abdominal pain, abdominal distention, and increasing dyspnea. He reports no bowel movements in last 2 days.

The decision was made to proceed with a CT of the abdomen and pelvis with intravenous and oral contrast. The following study was obtained.

Whats is the most likely diagnosis?

Diagnosis: High-grade small bowel obstruction due to internal hernia with small bowel pneumatosis and small volume pneumoperitoneum.

In cases with bowel obstruction, the radiologist should aim to identify the cause of the obstruction as early surgical reversal may be curative for the patient. One of the uncommon causes of small bowel obstruction includes internal hernias. This is a difficult diagnosis to make, and a few signs are may be useful to help identify it. Firstly, it is important to look at the overall distribution of the bowel loops. In this case, the distended bowel loops are abnormal in position, as they are within the pelvis as well as positioned anterior to the large bowel.

In this case, the duodenojejunal junction and ligament of Treitz are seen to the right of midline and are positioned inferiorly and posteriorly deep pelvis along the peritoneal reflection. In this case, the low position of the bowel loops may be due to a defect in the sigmoid mesocolon which would make the rare diagnosis of a sigmoid mesocolon hernia.

Most importantly are the ancillary features which make this case a surgical emergency. Firstly, pneumatosis intestinalis is seen within the small bowel wall:

Using the lung window, we are also able to notice subtle pneumoperitoneum:

In cases with suspected bowel ischemia, it is important to additionally look for gas within the portal venous system, which in this case was not present.

Due to multiple comorbidities, and upon further consultation with family and the patient, the decision was made not to operate and undergo conservative management.

Abdominal #2 – Long case

We present the case of a 31-year-old woman with:
* Nausea and vomiting since three days
* Unable to eat or drink without vomiting
* Epigastric pain after eating
* Feels weak

* No prior trauma or illness
* No fever, no diarreha, no hematemesis or bloody stools
* No other family members ill

See below the laboratory findings:

What do you think?

Click here to see the answer

Signs of dehydration with secondary acute renal impairment and electrolyte disorders

Abdominals X-Ray were performed:

What do you see on the X-Rays?

Click here to see the answer
Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border

Air – fluid level at the right upper quadrant: free air?
Absense of gastric air and fluid-air level
Colonic air at the right upper quadrant (Chilaiditi)

Apparent soft tissue mass at the right upper quadrant

Elongated right liver lobe (Riedel lobe)
Instability of the symphysis pubis


* Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border
* Air – fluid level at the right upper quadrant: free air?
* Colonic air at the right upper quadrant (Chilaiditi)
* Apparent soft tissue mass at the right upper quadrant

* No apparent dilated bowel loops
* Elongated right liver lobe (Riedel lobe)
* Instability of the symphysis pubis

Differential diagnosis of a large amount of air in the RUQ

* Pneumoperitoneum
* Subphrenic abscess
* Hepatic abscess
* Anterior interposition of colon to the liver

* Loculated pneumothorax (mimick)
* Situs inversus – gastric air (mimick)
* Pneumobilia, portal venous gas (smaller amount)

Images from an abdominal CT-scan:

What do you see on the CT images?

Click here to see the answer
Anterior defect in the right hemidiaphragm

Partial herniation of stomach (blue arrow) and transverse colon (green arrow)

Gastric outlet obstruction due to compression of the pyloric region (red arrow),with secundary dilatation with fluid (blue arrows)

Normal position of the gastro-esophageal junction and hiatus

Collapse of the right middle lobe (green arrow) and partial collapse of the right lower lobe (blue arrow).


* Anterior defect in the right hemidiaphragm
* Partial herniation of stomach and transverse colon
* Gastric outlet obstruction due to compression of the pyloric region of the stomach, with secundary dilatation with fluid
* Normal position of the gastro-esophageal junction and hiatus
* No signs of ischemia
* Collapse of the right middle lobe and partial collapse of the right lower lobe.

What is the most likely diagnosis?

Click here to see the answer

Morgagni hernia of the diaphragm

Patient had a laparoscopic reduction of the hernia with mesh closure of the defect. No signs of ischemia at surgery.
Uneventful recovery with resolution of pain and normal intake the day after.

Morgagni hernia

* Rare congenital diaphragmatic hernia (<5% of all CDH)
* Anterior (retrosternal)
* Right-sided (90%)
* Usually small
* +/- 30% symptomatic: respiratory distress (newborn), recurrent chest infections, abdominal symptoms
* Contents: omental fat, transverse colon (60%), stomach (12%)

* Treatment: surgical repair
> In symptomatic cases, some say also in asymptomatic cases: prevention of strangulation of hernia contents
*Prognosis: good

* Differential diagnosis:
> Traumatic diaphragmatic rupture
> Diaphragmatic eventration / weakness / paralysis (abnormal contour / position of the dome)
> Cardiophrenic angle lesions ( pericardial fat pad, cyst, lipomatosis, tumor)

Abdominal #1 – Long case

A 47-year-old female presented to the Emergency Room with bilateral upper extremity paresthesia, redness and edema. Her symptoms were not position-dependent. The patient was otherwise healthy, and did not take any medication. There is no pertinent surgical history.

An MR angiogram was ordered. The following images were obtained during bolus tracking:

Click here to see the images
Coronal MRV


T1-weighted images with fat saturation, following contrast administration

Click here to see the diagnosis


Superior vena cava (SVC) syndrome from right apical lung mass


In this patient with bilateral neurological deficits and edema, the suspicion of SVC syndrome must be addressed. This can be done using either an MRI or a CT protocol. In this case, the MRI scout bolus images (Image 1 & 2) revealed a pathognomonic sign for SVC occlusion:

Please note the marked collateral circulation following contrast administration to the right upper extremity with dilation of multiple intercostal and lateral thoracic veins. These collateral vessels then pool into the liver’s quadrate (segment 4 of the liver), giving the characteristic “hot spot sign”. This name originates from terminology in nuclear medicine, where it was occasionally seen in the case of SVC syndrome. Nowadays, it is more likely to be noticed on a CT or MR. This image also reveals the complete occlusion of the SVC.

Following fat-saturated T1-weighted axial image acquisition with contrast, the cause of the obstruction is evident. There is an infiltrative right apical mass which obstructs the SVC, as well as bilateral pleural effusions. Additionally, there is tumor thrombus noted in the left innominate vein, likely secondary to stasis.

Please review the following video and identify all these pertinent findings: