Unusual CT Manifestations of Common
Abdominal Diseases
Rosa Bouzas-Sierra, MD--- Rosa.bouzas.sierra@sergas.es
Milagros Ote...
NO DISCLOSURES
Rectosigmoidoscopy:
Solitary linear ulcer in Sigma
CASE 1 : 55 y-old male with rectal bleeding
Solitary rectal ulcer Syndrome:
• occurring mainly in young patients who experience rectal
bleeding
Giant ulcers in ileum ...
CTC
A- GIST
B- Colon Cancer
C- Submucosal Lipoma
D- Intramural Hematoma
Bowel laceration?
* Pickhardt PJ. RadioGraphics 2007
 Woman 45 y, IUD
 Acute pelvic pain, fever
 Bimanual uterine and adnexal tenderness
 WCC: 15,000/μL [reference value, ...
A- Pelvic Inflammatory disease (TOA)
B- Ovarian torsion
C- Hemorrhagic ovarian cyst
D- Ovarian mass
At surgery and pathologic analysis, the ovary was hemorrhagic and necrotic
- Ovarian torsion is the twisting of an ovary on its ligamentous supports
- Concomitant ovarian and tubal torsion (adnexal...
Ovarian torsion Imaging findings
US
Color Doppler
- Complex adnexal mass
- Unilateral enlarged ovary (>4 cm)
- String of p...
Ovarian torsion Imaging findings
CT
- Adnexal mass in the midline, rotated towards the contralateral side of the pelvis
- ...
T2 FSTIRT2
Ovarian torsion Imaging findings
MR - Pregnant women, young girl
- MR imaging is recommended to help detect the...
Take home message: Ovarian torsion in
a “women in their reproductive years”,
without an underlying mass
 49 y-old woman, breast cancer
 Liver and bone metastasis (IV)
 CHT induction and consolidation
No hepatic masses
Chemo...
A- Carcinomatosis
B- Hepatic failure
C-Fluid retention
D- Peritoneal tuberculosis
radiology.rsna.org n Radiology: Volume258:Number1—January2011
normally instruct the cell to grow and
divide. Hence, it act...
Peripheral edema
Weight increase
Pleural and Pericardial
effusions
Ascites
Capillary protein leak syndrome
Ascites alone, ...
 Peritoneal carcinomatosis from ovarian tumor
 Failed available standard CHT
 “Double blind” Trial : Placebo / Antiangi...
 A- Intestinal obstruction and perforation
 B- Partial response with gastric metastases
 C-Partial response with perito...
 Oral contrast media extravasation
GI perforation secondary to
the Antiangiogenic agent
160 patients
The pathogenesis of bowel perforation is unknown, but
suggested mechanisms include ischemia with
thrombosis o...
 Acute B-L Leukemia
 CHT: Since day +35 coincident with medullary recovery:
Fever and facial rash and oedema . Cultures:...
• Pneumatosis Coli
• Pneumoperitoneum
Rutinary follow-up
• Minimal abdominal pain and
distension
• No peritoneal signs, fe...
A- Linear Pneumatosis Coli
B- Subclinical bowel perforation
C- Typhlitis
D- Cystic Pneumatosis Coli ( NSP)
“ Pneumoperitoneum usually
denotes a perforation of an
intra-abdominal viscus, but in
about 10% of patients, a
nonsurgical...
• Mularski RA. et al. Crit Care Med 2000
• Mularski RA. et al. West JMed 1999
• Heng Y et al. Am J Gastro 1995
• Liu DM. Can J Emerg Med 2003
Pneumatosis
Type
Characterization Asociation Surgical
trea...
20 days without steroids
• Take home message
• To be aware of possible
CHT toxicity manifestations
We should look for, not only
on images but in th...
A- Well-differenciated liposarcoma
B- Exophytic renal angiomyolipoma
C- Lipoma
D- Myelolipoma
E- N-differenciated liposarc...
Benign Malignant
Angiomyolipoma
Lipoma
Hibernoma
Myelolipoma
Liposarcoma: 35% of all malignant
retroperitoneal soft-tissue...
Exophytic angiomyolipoma
WD liposarcoma
Myxoid liposarcoma
CT characteristics Exophytic renal
angiomyolipoma
Well-differentiated liposarcoma
Defect in the Renal Parenchyma + -
Vesse...
• Careful evaluation enables accurate
differentiation of large exophytic
angiomyolipomas and well-differentiated
retroperi...
 Arthrosis for several years treated with NSIDs
 Neutropenia. Medulary biopsy: normal
 Hepatomegaly, abnormal liver fun...
 A- HCC
 B- Hipervascular Metastasis
 C- Vasculitis
 D- A-V shunt
We recomended a hepatic biopsy and antibodies determ...
Cronic hepatitis with severe
inflammatory activity
Necrotic Arteritis in medium
size hepatic artery
Autoimmune Hepatitis, ...
—58-year-old man with polyarteritis nodosa.
Tarhan N C et al. AJR 2003;180:1617-1619
HEPATIC
INVOLVEMENT
- Hepatomegaly is seen in 39% to 40%
- Steatosis due to glucocorticoid therapy or to SLE itself
- Arte...
INTESTINAL VASCULITIS
GASTRIC INVOLVEMENT
COLON AND SMALL BOWEL
INVOLVEMENT
INTESTINAL
PSEUDOOBSTRUCTION
PANCREATIC AND
GA...
‘‘Hepatic disease may be more common in SLE than is usually thought
and we should be aware of it ”
* Abraham S. Ann Rheum ...
CASE 8: 65 year-old woman
 Left lumbar pain, fever, leukocyturia and WCC rise, … suggesting acute Pyelonephritis
 Fecalu...
CT 6 months before, Post-surgery, RT and CHT April-2007
First CT. Post-surgery Dec- 2006
A- Bladder tumor and ureteral infiltration
B- Colon cancer
C- Ovarian cancer
D- Ureteral tumor and colonic invasion
The pa...
Nov- 2006
Nov- 2006
Ovarian cancer (Transitional Type. GIII, PT1c. FIGO I)
----------- Partial response
Colonic-ureteral fistulae
Fistulas in Malignant Gynecologic Disease
- As a result of a primary or recurrent tumor
- As a consequence of:
Surgery (pa...
Cervical cancer. Radiotherapy
Nephrectomy. Entero-cutaneous fistulae
- Ureterocolic fistulas are most common and can be caused by urinary
calculi, iatrogenic trauma, diverticulitis, radiation ...
- Right ureter: terminal ileum, cecum, appendix,
and ascending colon and their mesenteries
- Left ureter: descending colon...
CASE 9 : 24 year-old man. Down Syndrome
 No abdominal complaints
 Abdominal mass (at manual exploration)
 Right mass ef...
A- Teratoma
B- Sarcoma
C- Germ cell neoplasm
D- Leukemia
Blood test: normal
AFT: 0.9 (0.0-12)
Beta HCG: 440.9 (0.0-6.0)
T1 T2
FS T2
DWI, b:600
CE Cor LAVA
Pathology: Classical seminoma TIIIB (T1N3MOS2)
Metastatic disease from a testicular germ cell neoplasm
Down Syndrome Cancer Incidence in DS
Leukemia
Testicular cancer
Other cancers
- Acute lymphocytic
- Acute non-lymphocytic
...
• Because of improvement in medical care, a higher proportion of children
with DS are now surviving beyond adolescence
• T...
Happy Spring
Everybody !!!!!
Thank you very much for your attention
Abdominal radiology congress... scottsdale 2012
Abdominal radiology congress... scottsdale 2012
Abdominal radiology congress... scottsdale 2012
Abdominal radiology congress... scottsdale 2012
Abdominal radiology congress... scottsdale 2012
Abdominal radiology congress... scottsdale 2012
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Abdominal radiology congress... scottsdale 2012

  1. 1. Unusual CT Manifestations of Common Abdominal Diseases Rosa Bouzas-Sierra, MD--- Rosa.bouzas.sierra@sergas.es Milagros Otero-Garcia, MD----- Milagros.otero.garcia@sergas.es Spain
  2. 2. NO DISCLOSURES
  3. 3. Rectosigmoidoscopy: Solitary linear ulcer in Sigma CASE 1 : 55 y-old male with rectal bleeding
  4. 4. Solitary rectal ulcer Syndrome: • occurring mainly in young patients who experience rectal bleeding Giant ulcers in ileum and colon by citomegalovirus : • in AIDS patients • Feczko PJ et al. AJR 1980 • Balthazar EJ. AJR 1996 - Carcinoma
  5. 5. CTC
  6. 6. A- GIST B- Colon Cancer C- Submucosal Lipoma D- Intramural Hematoma
  7. 7. Bowel laceration? * Pickhardt PJ. RadioGraphics 2007
  8. 8.  Woman 45 y, IUD  Acute pelvic pain, fever  Bimanual uterine and adnexal tenderness  WCC: 15,000/μL [reference value, <10,000/μL]  US: No possible (very painful)---- CT
  9. 9. A- Pelvic Inflammatory disease (TOA) B- Ovarian torsion C- Hemorrhagic ovarian cyst D- Ovarian mass
  10. 10. At surgery and pathologic analysis, the ovary was hemorrhagic and necrotic
  11. 11. - Ovarian torsion is the twisting of an ovary on its ligamentous supports - Concomitant ovarian and tubal torsion (adnexal torsion) occur in up to 67% of cases - It is generally considered an acute condition (subacute…) - All ages - Reproductive years (pregnancy: 5-fold – first trim.)- highest prevalence Predisposing Conditions - Large (>5 cm) cysts and cystic neoplasms (benign mature cystic teratomas….) - Ovarian hyper- stimulation syndrome - Normal ovaries (usually right ovary) in adolescent or teenagers - Non-specific symptoms and laboratory tests. DD: PID, appendicitis….. - Imaging plays a central diagnostic role (ovary-sparing) Ovarian torsion . Chang HC et al. RadioGraphics 2008 . Appelbaum HL et al. AJR 2007 . Rha SE et al. RadioGraphics 2002
  12. 12. Ovarian torsion Imaging findings US Color Doppler - Complex adnexal mass - Unilateral enlarged ovary (>4 cm) - String of pearls sign: Multiple peripheral cysts - Free pelvic fluid (8%) - Decrease or absence of venous flow (93%) - Absence of arterial flow (60-73%) - Ovaries without flow in the vascular pedicle - Twisted vascular pedicle: (circular vessels: “whirlpool sign“)
  13. 13. Ovarian torsion Imaging findings CT - Adnexal mass in the midline, rotated towards the contralateral side of the pelvis - Deviation of the uterus to the side of the affected ovary - Free fluid - Necrosis seems to be the cause of a cystic appearance on CT
  14. 14. T2 FSTIRT2 Ovarian torsion Imaging findings MR - Pregnant women, young girl - MR imaging is recommended to help detect the twisted vascular pedicle (“whirlpool sign“) or in patients with a suspected ovarian mass.
  15. 15. Take home message: Ovarian torsion in a “women in their reproductive years”, without an underlying mass
  16. 16.  49 y-old woman, breast cancer  Liver and bone metastasis (IV)  CHT induction and consolidation No hepatic masses Chemotherapy-induced pseudocirrhosis Control: 20 weeks later
  17. 17. A- Carcinomatosis B- Hepatic failure C-Fluid retention D- Peritoneal tuberculosis
  18. 18. radiology.rsna.org n Radiology: Volume258:Number1—January2011 normally instruct the cell to grow and divide. Hence, it acts as a tyrosine kinase inhibitor. Important to notice is a recent discovery that cetuximab is active only in tumors that are wild type for KRAS (3). The exact mechanism of action is unclear, as cetuximab recently demon- strated antitumor activity in patients with colorectal cancer whose disease g. Peripheral nerves , cisplatin, taxanes), n and gemcitabine), n), heart (eg, anthra- tral nervous system hotrexate, 5-FU) are s (Table 3). apies have developed proved knowledge of ey target cell surface case of monoclonal ous signaling mole- of kinase inhibitors). ents affect multiple ore, have the poten- cules that are critical hways, causing toxic- n previously observed the toxicities of the molecularly targeted here is concern that Publishedonline 10.1148/radiol.10092129 Content Code: Radiology2011; 258:41–56 Abbreviations: EGFR= epidermal growthfactor receptor 5-FU= fluorouracil TKI= tyrosinekinaseinhibitor VEGF= vascular endothelial growthfactor L.H.S. hasdisclosedfinancial relationshipswith AstraZenecaandNovartis.
  19. 19. Peripheral edema Weight increase Pleural and Pericardial effusions Ascites Capillary protein leak syndrome Ascites alone, should not be mistaken for disease progression
  20. 20.  Peritoneal carcinomatosis from ovarian tumor  Failed available standard CHT  “Double blind” Trial : Placebo / Antiangiogenic CT, basal CT, 9 weeks
  21. 21.  A- Intestinal obstruction and perforation  B- Partial response with gastric metastases  C-Partial response with peritoneal carcinomatosis  D- Partial response and GI perforation
  22. 22.  Oral contrast media extravasation GI perforation secondary to the Antiangiogenic agent
  23. 23. 160 patients The pathogenesis of bowel perforation is unknown, but suggested mechanisms include ischemia with thrombosis of intestinal mesenteric vessels
  24. 24.  Acute B-L Leukemia  CHT: Since day +35 coincident with medullary recovery: Fever and facial rash and oedema . Cultures: (-)  Fever and facial rash and oedema disappeared with high doses of steroids
  25. 25. • Pneumatosis Coli • Pneumoperitoneum Rutinary follow-up • Minimal abdominal pain and distension • No peritoneal signs, fever, or leukocytosis
  26. 26. A- Linear Pneumatosis Coli B- Subclinical bowel perforation C- Typhlitis D- Cystic Pneumatosis Coli ( NSP)
  27. 27. “ Pneumoperitoneum usually denotes a perforation of an intra-abdominal viscus, but in about 10% of patients, a nonsurgical source is responsible for free air in the peritoneum”.
  28. 28. • Mularski RA. et al. Crit Care Med 2000 • Mularski RA. et al. West JMed 1999
  29. 29. • Heng Y et al. Am J Gastro 1995 • Liu DM. Can J Emerg Med 2003 Pneumatosis Type Characterization Asociation Surgical treatment Microvesicular pneumatosis Small collections of air within the lamina propria Associated with invasive procedures - Cystic Pneumatosis Macroscopic submucosal cysts (mm-cm) - Pneumoperitoneum . 10% of patients with small bowel pneumatosis . 2% of those with large bowel pneumatosis • COPD • Immunosupression therapy (haematologic) • Bevacizumab • Immunocompromise • Steroid usage • Inflammatory bowel disease • Post bone marrow transplantation - Linear Pneumatosis Represent the tracking of gas through compromised submucosa . Bowel ischemia or infarction +
  30. 30. 20 days without steroids
  31. 31. • Take home message • To be aware of possible CHT toxicity manifestations We should look for, not only on images but in the clinical history to help distinguish new-onset toxicity from disease progression. • Reporting CHT toxicity findings to the oncologist is important, in order to choose to discontinue therapy
  32. 32. A- Well-differenciated liposarcoma B- Exophytic renal angiomyolipoma C- Lipoma D- Myelolipoma E- N-differenciated liposarcoma
  33. 33. Benign Malignant Angiomyolipoma Lipoma Hibernoma Myelolipoma Liposarcoma: 35% of all malignant retroperitoneal soft-tissue tumors (a) well-differentiated (most common) (b) myxoid and round cell (c) pleomorphic Retroperitoneal fatty masses in adult • CraigWC. et al RadioGraphics 2009
  34. 34. Exophytic angiomyolipoma WD liposarcoma Myxoid liposarcoma
  35. 35. CT characteristics Exophytic renal angiomyolipoma Well-differentiated liposarcoma Defect in the Renal Parenchyma + - Vessels in the Lesion + (enlarged internal vessels with aneurysm formation) - Additional Angiomyolipomas + +/- Size Usually larger
  36. 36. • Careful evaluation enables accurate differentiation of large exophytic angiomyolipomas and well-differentiated retroperitoneal liposarcomas Take home message:
  37. 37.  Arthrosis for several years treated with NSIDs  Neutropenia. Medulary biopsy: normal  Hepatomegaly, abnormal liver function test and jaundice (total bilirrubin: 14 mg)  GP: requested an abdominal CT
  38. 38.  A- HCC  B- Hipervascular Metastasis  C- Vasculitis  D- A-V shunt We recomended a hepatic biopsy and antibodies determination in order to diagnose any reumatoid disease.
  39. 39. Cronic hepatitis with severe inflammatory activity Necrotic Arteritis in medium size hepatic artery Autoimmune Hepatitis, Aneurism Outcome: normalization of all parameters after appropriate treatment Liver Aneurysm ANA(+)/ ENA(+)/ antiSSA(+) LES
  40. 40. —58-year-old man with polyarteritis nodosa. Tarhan N C et al. AJR 2003;180:1617-1619
  41. 41. HEPATIC INVOLVEMENT - Hepatomegaly is seen in 39% to 40% - Steatosis due to glucocorticoid therapy or to SLE itself - Arteritis (21%) of SLE - Nodular regenerative hyperplasia of the liver, is a rare but important complication of SLE associated with noncirrhotic portal hypertension. - Autoinmune hepatitis. The most common one, is the classic “lupoid hepatitis” with chronic active hepatitis • Up to 4,7% of patients with SLE have chronic active hepatitis • Up to 10% of patients with Autoinmune hepatitis have SLE
  42. 42. INTESTINAL VASCULITIS GASTRIC INVOLVEMENT COLON AND SMALL BOWEL INVOLVEMENT INTESTINAL PSEUDOOBSTRUCTION PANCREATIC AND GALLBLADDER INVOLVEMENT PERITONITIS AND ASCITES MALABSORPTION AND PROTEIN-LOSING ENTEROPATHY - In 53% in those with active SLE and abdominal pain. Involves small arteries - CT: shows ischemic bowel disease - Opportunistic infections (eg. Mucormycosis) may mimic GI vasculitis and should be suspected in these immunocompromised patients with not active LES - Perforation from peptic ulcer disease ( 6% to 8%) - Pernicious anemia - Pneumatosis cystoides intestinalis (benign pneumoperitoneum) - Necrotizing enterocolitis - CMV enteritis, prone to salmonella infection - Intestinal obstruction without a mechanical cause. Initial manifestation of lupus ( 41% to 50% . - Associated urinary tract involvement with ureterohydronephrosis, suggesting a smooth muscle dysmotilityand secondary vesiculoureteric reflux or to fibrosis of the ureterovesicular junction. One- third of patients have interstitial cystitis - Recurrent pancreatitis occurs in 43% of patients. Chronic pancreatitis in 14% - Primary sclerosing cholangitis and autoimmune cholangiopathy. - Acute pancreatitis is a rare. Associated with thrombosis and cutaneous vasculitis. - Ascites from infection, bowel infarction, perforation, pancreatitis, mesenteric vasculitis, or serositis. - Chronic ascites lupus can be due to nephrotic syndrome, heart failure, protein- losing enteropathy, constrictive pericarditis, lupus peritonitis, or indolent infections such as tuberculosis.
  43. 43. ‘‘Hepatic disease may be more common in SLE than is usually thought and we should be aware of it ” * Abraham S. Ann Rheum Dis 2004 ** Ebert EC. J Clin Gastroenterol 2011 Patients with liver disease should be treated as soon as possible, especially those patients with jaundice or persistent increase of liver enzymes values” Take home message:
  44. 44. CASE 8: 65 year-old woman  Left lumbar pain, fever, leukocyturia and WCC rise, … suggesting acute Pyelonephritis  Fecaluria and pneumaturia • History: pelvic surgery, radiotherapy and chemotherapy Dec-2007
  45. 45. CT 6 months before, Post-surgery, RT and CHT April-2007
  46. 46. First CT. Post-surgery Dec- 2006
  47. 47. A- Bladder tumor and ureteral infiltration B- Colon cancer C- Ovarian cancer D- Ureteral tumor and colonic invasion The patient has an acute pyelonephritis secundary to an ureteral fistula
  48. 48. Nov- 2006
  49. 49. Nov- 2006
  50. 50. Ovarian cancer (Transitional Type. GIII, PT1c. FIGO I) ----------- Partial response Colonic-ureteral fistulae
  51. 51. Fistulas in Malignant Gynecologic Disease - As a result of a primary or recurrent tumor - As a consequence of: Surgery (particularly if the surgical procedure is radical and complex or if the surgical field includes previously irradiated tissue) Radiation therapy (eg, cervical, colorectal, endometrial cancer) Types: - Vesicovaginal and enterovaginal fistulas (more frequent) - Ureterovaginal, enterovesical, enterocutaneous, and uretero-alimentary tract . Narayanan P et al. RadioGraphics 2009 . Yu NC et al. RadioGraphics 2004
  52. 52. Cervical cancer. Radiotherapy
  53. 53. Nephrectomy. Entero-cutaneous fistulae
  54. 54. - Ureterocolic fistulas are most common and can be caused by urinary calculi, iatrogenic trauma, diverticulitis, radiation therapy, transitional cell carcinoma, and tuberculosis • Symptoms: flank pain, hematuria, recurrent urinary tract infections, pneumaturia, fecaluria, and diarrhea • Diagnosis: Retrograde pyelography, and contrast-enhanced CT: Gas in the ureter Barium studies of the intestinal tract often will not reveal the fistula Uretero–Alimentary Tract Fistula
  55. 55. - Right ureter: terminal ileum, cecum, appendix, and ascending colon and their mesenteries - Left ureter: descending colon and sigmoid colon and their mesenteries - Either ureter may be injured during surgery, or radiation performed on these structures, or engulfed in an adjacent mass . Avritscher R et al. RadioGraphics 2004 I would add: The ovary Take home message:
  56. 56. CASE 9 : 24 year-old man. Down Syndrome  No abdominal complaints  Abdominal mass (at manual exploration)  Right mass effect that displaces right abdominal structures
  57. 57. A- Teratoma B- Sarcoma C- Germ cell neoplasm D- Leukemia
  58. 58. Blood test: normal AFT: 0.9 (0.0-12) Beta HCG: 440.9 (0.0-6.0)
  59. 59. T1 T2
  60. 60. FS T2 DWI, b:600 CE Cor LAVA
  61. 61. Pathology: Classical seminoma TIIIB (T1N3MOS2)
  62. 62. Metastatic disease from a testicular germ cell neoplasm
  63. 63. Down Syndrome Cancer Incidence in DS Leukemia Testicular cancer Other cancers - Acute lymphocytic - Acute non-lymphocytic - 19-fold higher - Seminomatous (gonadal and extragonadal) - 50-fold higher (0.5% compared with an expected incidence of 0.087% in the general population) - Non-Hodgkin lymphoma, stomach, colon, small intestine, breast, endometrial, brain, kidney, liver cancers… * Hill DA et al. Arch Intern Med. 2003 … N: 4872 (DS) ** Goldacre MJ et al. Arch Dis Child 2004 ....N: 1453 (DS)--- 460 000(NDS) *** Rima d et al. European Journal of Medical Genetics 2006 **** Cools M et al. Human Pathology 2006
  64. 64. • Because of improvement in medical care, a higher proportion of children with DS are now surviving beyond adolescence • Therefore, more patients reach the predisposition age range when testicular cancer is most prevalent (35 years) • Testicular palpation in this population should be considered a component of routine physical examination Take home message:
  65. 65. Happy Spring Everybody !!!!! Thank you very much for your attention

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