Abdominal radiology for radiology residents

1. JAYANTH KESHAVAVMURTHY M.D.
Abdomen Radiology
Case conference
November 1, 2017.

5.  Slipped Lap band
 “O”sign

8.  C diff colitis with thumb printing on X ray

10. FINDING
ERECT SUPINE

13. LEVAMISOLE INDUCED VASCULITIS
 Levamisole is used with cocaine and can
cause pseudo aneurysms and it ruptured
showing the psoas sign.

16. OTHER CAUSES OF LOSS OF HAUSTRATION
 Crohn's colitis
 Cathartic colon
 Diversion colitis
 Dysenteries
 Tuberculous strictures
 Progressive systemic sclerosis
 Amyloid infiltration

17. Inflammatory bowel disease
Crohn's disease Ulcerative colitis
Site of origin Terminal ileum Rectum
Pattern of progression and
endoscopic findings
Skip lesions, cobblestoning mucosa and
aphthous or deep linear ulcers anywhere
along the GI tract (usually rectal sparing)
Proximally contiguous involvement of
exclusively the colon, pseudopolyps
Symptoms Crampy abdominal pain Bloody diarrhoea (haematochezia)
Thickness of inflammation Transmural Mucosa and submucosa3
Radiographic findings String sign on barium X-ray Lead pipe colon on X-ray
Complications Fistulas, abscesses, obstruction Haemorrhage, toxic megacolon
Surgery Used for complications (eg, strictures) Curative
Risk of colon cancer Slightly increased risk Markedly increased risk
Pathology
Crypt abscesses (uncommon), granulomas,
submucosal fibrosis and fissures
Crypt abscesses (common)
Serology Frequently ASCA+ Frequently p-ANCA+
Table 1
Comparison of key findings in Inflammatory Bowel Disease

18.  Images in medicine
 Lead pipe sign in mixed inflammatory bowel
disease
 Obioma J Ekeledo, Chris Scelsi, Jayanth H
Keshavamurthy
 Author affiliations
 http://dx.doi.org/10.1136/postgradmedj-2016-
134596

21. RAY TECH GAUZE

23. KUB
ERECT SUPINE

24. CT

25. FREE AIR AND FLUID ON CT

27. " DISTENDED ABD, N/V EVAL FOR ILEUS, ABD
ETIOLOGY"

28. CT

29. BARDET-BIEDL SYNDROME
 PV gas and ileus.
 Bardet–Biedl syndrome (BBS) is
a ciliopathic human genetic disorder that
produces many effects and affects many
body systems. It is characterized principally
by obesity, retinitis
pigmentosa, polydactyly, hypogonadism,
and renal failure in some cases
 Hyperphagia

31. ACIDOSIS AND ACUTE RENAL FAILURE.

32.  IMPRESSION:
1. OG tube in position.
2. Findings concerning for pneumatosis
intestinalis in the right lower
quadrant. CT scan of the abdomen and pelvis
will be performed without
intravenous contrast due to renal failure.
3. There are loops of bowel dilated in the
midline and are
featureless. There is air up to the left colon.

33. CT

34.  Pneumatosis intestinalis and Mesenteric vein
gas

35. CLINICAL STATEMENT: "INTUBATED, EVAL FOR
CHANGE"

36.  AP supine portable chest redemonstrates satisfactory positioning
of
the endotracheal tube at level of the mid aortic arch, placement of
a
right subclavian central line with tip at the cavoatrial junction and
the lateral septal discs. Bibasilar infiltrates. Continuous
diaphragmatic sign with free intra-abdominal air? PEG, left upper
quadrant and IVC filter.
IMPRESSION:
Severe COPD with bullous emphysema, basilar infiltrates,
satisfactory
tube and line positions. Leaking PEG with free intra-abdominal
air?
Left lateral decubitus abdominal images are recommended.

38. CT

39.  the percutaneous gastrostomy tube
terminates within the anterior peritoneum of
the upper abdomen external to the gastric
lumen.

41. INDICATION: 37 YEARS OLD FEMALE "UPRIGHT, ASSESS FOR
FREE AIR, TOTAL LAP HYSTERECTOMY 9D AGO, SUDDEN ONSET
LOWER ABDOMINAL PAIN, CHEST PAIN"

42. CT

43.  Free air and need surgical consult

46. CT

47.  Right inguinal hernia causing the bowel
obstruction.
 Proven post operatively.

49. 54 YO AML S/P 7+3, NOW WITH DIARRHEA, PT
DECOMPENSATED NOW REQUIRING ICU LEVEL
CARE

50. CT

51.  Typhilitis

55.  Large left bowel containing inguinal hernia
without evidence for strangulation or
obstruction.

57. WITHOUT HISTORY

58. MVC

61.  One day after gel foam embolisation.
 Hemoperitoneum as a cause of ascites

64. CT

65. IMPRESSION:

1. Near-total colectomy with ileocolic
anastomosis
2. Recurrent High-grade small bowel
obstruction secondary to volvulus
at the ileocolic anastomosis.
3. No evidence for bowel perforation or
pneumatosis.

68.  Abdomen:
Bowel gas pattern is nonobstructive. There is gaseous distention
of
small bowel in the left upper quadrant, mid abdomen and the right
lower quadrant, with several air-fluid levels. No extraluminal gas
is
demonstrated. No soft tissue mass is demonstrated. No
pathologic
calcifications are demonstrated.
Osseous structures and soft tissues are within normal limits.
IMPRESSION:
1. Adynamic ileus is more likely but cannot exclude early small
bowel
obstruction. No evidence of free intraperitoneal air.

69. CT

71. IMPRESSION:

1. Mid sigmoid acute diverticulitis with large
flocculent gas collection and perforation without
organized abscess (small fluid collection within
the left pelvis).

2. Small bowel ileus with 2 areas of distal ileum
bowel wall edema and inflammation secondary
to the associated sigmoid diverticulitis.

72.  status post exploratory laparotomy for colon
resection secondary to ruptured diverticulitis

76. IMPRESSION:

1. Large small bowel containing right inguinal
hernia causing
high-grade obstruction.
2. Volvulus of the distal sigmoid colon
causing proximal high-grade
obstruction

79.  Obstructive bowel gas pattern with multiple
dilated loops of small bowel containing air-
fluid levels.

80. CT

81. IMPRESSION:

1. High-grade partial small bowel obstruction
with focal thickening of a segment of the
ileum. Etiology of the thickened segment is
consistent with an infectious/inflammatory
enteritis. Of note, Crohn's ileitis cannot be
excluded. The terminal ileum is
decompressed on
today's exam.

83. CLINICAL STATEMENT: 25 YEARS" DIFFUSE ABD
PAIN, WORSE WITH LYING SUPINE"

84.  Abdomen:
The bowel gas pattern is nonobstructive with no supine evidence
for
free intraperitoneal air. No abnormal calcifications are seen. The
visualized bones and soft tissues are unremarkable. No focal
consolidation is seen at the lung bases.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Nonobstructive bowel gas pattern.

85.  Addendum: There is paucity of bowel gas in the colon. Erect
abdomen
radiographs showing multiple air-fluid levels. Small bowel loops
are
dilated up to 4 cm, normal is 3 cm.
There is a prominent appendicolith in the right lower quadrant
measuring 1 cm.
Impression:
Patient most likely has an inflamed appendix from an
appendicolith
causing distal small bowel obstruction with paucity of bowel gas in

87.  IMPRESSION:
Perforated appendicitis with an appendicolith at the appendiceal
base with a 3.8 x 6 x 6.2 cm periappendiceal abscess within the
right
hemipelvis (series 301 image 153). Apppendix is retrocecal in
location.
Several additional pockets of loculated ascites are also visualized
within the pelvis which are concerning for additional developing
abscesses.
Secondary inflammation of the sigmoid colon and distal ileum
without mechanical bowel obstruction.

90.  Case of sigmoid volvulus on surgery

93. IMPRESSION:

1. Mild cardiomegaly.
2. Multiple gas distended loops of large
bowel, may represent an ileus
versus obstruction. If clinical concern for
obstruction, CT of the
abdomen and pelvis may be of benefit for
further evaluation.

95. IMPRESSION:

1. Findings consistent with acute sigmoid
volvulus. No CT evidence for bowel
perforation. No pneumatosis coli, portal
venous gas, or
mesenteric venous gas.
2. Emergent surgical consultation is
recommended.

96.  Radiographic features
 Sigmoid volvulus is differentiated from a caecal
volvulus by its ahaustral wall and the lower end pointing
to the pelvis.
 Abdominal radiograph
 Abdominal radiographs will show a large, dilated loop of
the colon, often with a few air-fluid levels. Specific signs
include:
 coffee bean sign
 Frimann Dahl's sign - three dense lines converge towards
site of obstruction
 absent rectal gas

98. CLINICAL STATEMENT: 68 YEARS ABDOMINAL DISTENSION
PT RECEIVES WEEKLY CHEMOTHERAPY OF CY BORK D CYCLOPHOSPHAMIDE
(IV) /VELCADE / DECADRON,

99. IMPRESSION:

Given patient's immunocompromised state,
chemotherapy and steroids for multiple
myeloma, these findings could be suggestive
of toxic megacolon. Differential diagnosis
includes paralytic ileus.

101.  Amyloidosis of bowel