• • 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

• • Intraductal papillary neoplasm of the bile duct (IPNB) with invasive carcinoma
  • In our case, the patient underwent surgery and the diagnosis was histopathologically confirmed

• • 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

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

What so you see?

Multiple mesenteric lymphadenopathies that contain fat-fluid levels (red arrows)

Splenic atrophy (red arrows)

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

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 so you see?

– Periaortic soft tissue (red arrows)
– Bilateral pleural effusions (green arrows)
– Bilateral perirenal soft tissue thickening (blue arrows)

– 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 should be done next?

*MRCP
*Non-contrast MR of the abdomen with MRCP was performed

MRCP Images

T2 images, axial and coronal

DWI (left) with ADC map (right)

Describe 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

Pancreatic biopsy confirmed 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