Part 1 book “Abdominal imaging” has contents: First principles, understanding normal results, recognising abnormalities, gastrointestinal system, abdominal radiographs, imaging modalities, abdominal ultrasound, obstruction – small bowel,… and other contents.
G R V d e t i n U pocket tutor Abdominal Imaging t i n U d e G R V G R V d e Rakesh Sinha FRCR FICR MD Consultant Radiologist and Assistant Professor Warwick Hospital and Medical School Warwick, UK t i n U pocket tutor Abdominal Imaging © 2011 JP Medical Ltd Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK Tel: +44 (0)20 3170 8910 Fax: +44 (0)20 3008 6180 Email: info@jpmedpub.com Web: www.jpmedpub.com The rights of Rakesh Sinha to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and patents Act 1988 G R V All rights reserved No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission in writing of the publishers Permissions may be sought directly from JP Medical Ltd at the address printed above All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative information about the subject matter in question However readers are advised to check the most current information available on procedures included or from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility of the practitioner to take all appropriate safety precautions Neither the publisher nor the author assume any liability for any injury and/or damage to persons or property arising from or related to use the material in this book d e t i n U This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material If any have been inadvertently overlooked, the Publisher will be pleased to make the necessary arrangements at the first opportunity ISBN: 978-1-907816-04-8 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India (www.jaypeebrothers.com) Richard Furn Publisher: Design: Copy Editor: Development Editor: Paul Mayhew Jane Sugarman Pete Wilder, Designers Collective Ltd Typeset, printed and bound in India Preface With the advent of new imaging modalities the field of abdominal imaging has undergone rapid changes in recent years However, traditional examinations such as abdominal radiography and barium studies are still used for a variety of conditions A good working knowledge of common manifestations of disease in both older and new modalities is therefore vital for students and clinicians This book starts with a concise overview of abdominal anatomy, then provides a step-by-step guide to interpreting normal imaging results before demonstrating the appearance of key abnormalities The book then presents concise, practical information on common abdominal conditions that may be encountered in routine medical or surgical practice, each one illustrated by radiological images of the highest quality Key facts and treatment information are provided for each condition, and a list of key imaging features is included To facilitate visual understanding, these features are labelled on the corresponding images, along with anatomical landmarks and other notable aspects It is hoped that the book will serve as a handy companion for quick reference during teaching and ward rounds, and as a revision tool before examinations Although primarily aimed at medical students and radiology trainees, the book will also be useful to all physicians and surgeons requiring a pocket-sized guide to abdominal imaging G R V t i n U d e Rakesh Sinha v Contents v ix Preface Acknowledgements and Dedication G R V 13 Chapter First principles 1.1 Anatomy 1.2 Imaging modalities Chapter Recognising abnormalities 3.1 Fat-line abnormalities 3.2 Gas shadow abnormalities 3.3 Calcifications 3.4 Abnormalities on barium examinations 3.5 Solid organ abnormalities 49 50 54 57 59 t i n U d e 25 33 38 40 47 Chapter Understanding normal results 2.1 Abdominal radiographs 2.2 Abdominal ultrasound 2.3 Barium studies 2.4 CT and MRI 2.5 CT Angiography vi Chapter Gastrointestinal system 4.1 Achalasia 4.2 Appendicitis 4.3 Coeliac disease 4.4 Colorectal cancer 4.5 Diverticulitis 4.6 Gastric cancer 4.7 Gastro-oesophageal reflux disease 4.8 GI tract haemorrhage 4.9 Ischaemic colitis 4.10 Inflammatory bowel disease – Crohn’s disease 4.11 Inflammatory bowel disease – ulcerative colitis 4.12 Obstruction – small bowel 63 66 68 69 72 75 77 79 82 84 86 88 t i n U d e Chapter Hepatobiliary system 6.1 Cholecystitis 6.2 Cholangiocarcinoma 6.3 Cirrhosis 6.4 Gallbladder cancer 6.5 Haemangiomas 6.6 Hepatitis 6.7 Hepatocellular carcinoma 6.8 Hepatic metastases 6.9 Pancreatic cancer 6.10 Pancreatitis 6.11 Portal hypertension 6.12 Trauma – hepatosplenic injury 90 92 94 96 98 100 104 105 107 109 G R V Chapter Genitourinary system 5.1 Renal artery stenosis 5.2 Renal cell carcinoma 5.3 Renal failure 5.4 Trauma – renal injuries 5.5 Urolithiasis (renal tract stones) 5.6 Testicular cancer 5.7 Testicular hydrocoele 5.8 Testicular torsion 5.9 Testicular varicocoele 5.10 Prostatic cancer 5.11 Benign prostatic hyperplasia Obstruction – large bowel Oesophageal cancer Oesophageal perforation (Boerhaave’s syndrome) Oesophageal varices Peptic ulceration Perforation of the GI tract Pseudomembranous colitis Scleroderma Tuberculosis of the GI tract Volvulus of the colon 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 113 115 118 120 123 125 126 128 130 132 134 137 141 143 145 148 150 151 154 156 159 163 165 vii d e Index viii Bibliography t i n U Chapter Miscellaneous disorders 9.1 Abscess (intra-abdominal) 9.2 Abdominal aneurysm 9.3 Ascites 9.4 Abdominal hernias 9.5 Lymphoma 9.6 Penetrating and projectile injuries 9.7 Adrenal tumours – phaeochromocytomas 189 191 193 196 199 201 Chapter Gynaecological disorders 8.1 Ectopic pregnancy 8.2 Endometriosis 8.3 Fibroids 8.4 Ovarian cancer 8.5 Ovarian cysts 8.6 Pelvic inflammatory disease 169 170 172 174 176 179 181 183 185 G R V Chapter Paediatrics 7.1 Cryptorchidism 7.2 Hypertrophic pyloric stenosis 7.3 Intussusception 7.4 Necrotising enterocolitis 7.5 Congenital renal anomalies 7.6 Common paediatric tumours – neuroblastomas 7.7 Common paediatric tumours – Wilms’ tumour 7.8 VACTERAL syndrome 7.9 Vesicoureteric reflux 203 205 207 209 211 213 216 219 221 Acknowledgements I would like to thank my colleagues at the Radiology Department, Warwick Hospital and also colleagues at South Warwickshire Foundation for their encouragement, help and advice I would especially like to thank the editorial team at JP Medical, London for their expertise and help during the production of this book Finally I would like to thank my wife and family for their help and support during the writing and production of this book G R V d e Dedication t i n U This book is dedicated to Dr Jogendra P Sinha, Emeritus Professor of Radiology, a role model for generations of residents over several decades ix chapter First principles 1.1 Anatomy G R V For convenience the abdominal cavity is divided into nine segments (Figure 1.1) These regions can be demarcated on an abdominal radiograph by drawing a horizontal line through the 9th ribs and the pelvic brim, and two vertical lines from the centre of the costal cartilage of the 9th rib to the middle of the inguinal ligament The organs (Figure 1.2) contained in these segments are as follows: • Right hypochondrium: gallbladder, right lobe of liver, duodenum, hepatic flexure of colon, upper pole of right kidney and pancreatic head • Epigastrium: stomach, pancreatic body, left lobe of liver • Left hypochondrium: spleen, splenic flexure of colon, and upper pole of left kidney • Right lumbar region: ascending colon and right kidney Figure 1.1 The nine abdominal segments Note normal calcification of the costal cartilages t i n U d e 98 Gastrointestinal system Key imaging findings A Thickened folds in the oesophagus B Beaded or serpiginous folds C ‘Worm-eaten’ appearance D Enhancing vessels around the oesophagus on CT Clinical insight Varices become more prominent during Valsalva’s manoeuvre and this procedure may be performed during barium examinations to demonstrate varices Treatment Endoscopic banding or sclerot herapy of bleeding varices 4.17 Peptic ulceration Peptic ulcers are one of the most common GI disorders, and it is estimated that 25% of all individuals develop ulcers during their lifetime, although only a small proportion seek medical treatment Presentation may be with abdominal pain, dyspepsia and heartburn Key facts • Ulcers are most common in middle-aged/elderly indivi duals, people with alcohol problems and those who use analgesics • Most ulcers are associated with H pylori and are most common in the distal stomach along the lesser curvature and the first part of the duodenum • Duodenal ulcers are invariably benign whereas gastric ulcers may be benign or malignant (Table 4.2) Benign gastric ulcer Malignant gastric ulcer Barium protrudes beyond the stomach outline Does not protrude No adjacent nodules or masses Sits on a mass Round or oval Irregular contour Table 4.2 Benign versus malignant ulcers Peptic ulceration Radiological findings Barium examination (Figures 4.37 and 4.38) Most are round /elliptical in appearance and are seen as small collections of barium within the ulcer crater (Figure 4.37) Converging folds Figure 4.37 Barium examination showing round, target-shaped ulcers in the stomach (arrows) Figure 4.38 Barium examination showing scarring of the duodenum after an ulcer, creating a trifoliate appearance (arrow) 99 100 Gastrointestinal system may be seen due to collagenous tissue in the base of the ulcer Oedema around the ulcer may create an ulcer mound Duodenal ulcers may cause scarring and deformity of the duodenal cap, which may cause a triangular or trifoliate appearance of the duodenal cap (Figure 4.38) Key imaging findings A Crater containing barium B Round or oval shape C Ulcer mound D Trifoliate appearance of duodenal cap Treatment Treatment is based on relief of symptoms using antacids and eradication of H pylori 4.18 Perforation of the GI tract Free air within the peritoneal cavity (pneumoperitoneum) Key facts • Pneumoperitoneum almost always implies perforation of the GI tract, the most common cause of which is a perforated peptic ulcer • Other aetiological factors include perforation secondary to bowel obstruction and diverticular perforation Radiological findings Chest radiograph The most common finding on erect radiographs is that of free air under the diaphragm (Figure 4.39) Very small amounts of free air (