Abdominal #11

Clinical Information

– 53-year-old male
– Left adrenal nodule was incidentally found on a CT scan
– MRI was performed for better characterization

What are the Imaging Findings

– Left adrenal nodule with loss of signal intensity on out-of-phase image

What is the most likely diagnosis?

Adrenal adenoma:
– The most important characteristic feature is the presence of intracellular lipid.
– Chemical shift imaging is the most reliable technique for diagnosing adrenal adenoma: most of them demonstrate a loss of signal intensity on out-of-phase MR images.

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.