Nam 28 tuổi với đau HC(P)
Viêm ruột thừa lạc chổ. Brief review of Epiploic Appendagitis Rare inflammatory and ischemic condition Results from torsion or spontaneous venous thrombosis of one of the appendices epiploicae ischemia or infarction of the appendix epiploica & localized inflammation Sudden, severe, focal abdominal pain, mimic other conditions such as appendicitis. Can be managed conservatively CT: 1- 4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation Adjacent cecal wall thickening and compression Rarely, a central high-attenuation "dot" within the inflamed appendage; corresponds to the thrombosed vein (17).
Diffuse largeB-cell lymphoma Brief review of round solid mesenteric masses Malignant solid tumors have a tendency to be located near root of mesentery benign solid tumors in periphery near bowel! 1. Metastases especially from colon, ovary (most frequent neoplasm of mesentery) 2. Lymphoma 3. Leiomyosarcoma (more frequent than leiomyoma) 4. Neural tumor (neurofibroma, ganglioneuroma) 5. Lipoma (uncommon), lipomatosis, liposarcoma 6. Fibrous histiocytoma 7. Hemangioma 8. Desmoid tumor (most common primary)
60/M Chief complaint: jaundice, fever and chill *not hach *day thanh
Gallbladder carcinoma Brief review of gallbladder carcinoma Most common biliary cancer Associated with: (1) Gallstones in 64 - 98% Gallbladder carcinoma occurs in only 1% of all patients with gallstones! (2) Porcelain gallbladder (in 4 - 60%) (3) Inflammatory bowel disease (predominantly ulcerative colitis) (4) Familial polyposis coli (5) Chronic cholecystitis Growth types: replacement of gallbladder by mass (37 - 70%) focal / diffuse asymmetric irregular thickening of GB wall (15 - 47%) polypoid / fungating intraluminal mass with wide base (14 - 25%) Differential diagnosis see note below
45/M Chief complaint: general weakness
Addison disease caused by adrenal tuberculosis Brief review of addison disease = Primary adrenal insufficiency 90% of adrenal cortex must be destroyed! Cause: 1. Idiopathic adrenal atrophy (60 - 70%): likely autoimmune disorder 2. Granulomatous disease: tuberculosis, sarcoidosis 3. Fungal infection: histoplasmosis, blastomycosis, coccidioidomycosis 4. Adrenal hemorrhage: anticoagulation therapy, bleeding, coagulation disorders, sepsis, shock 5. Bilateral metastatic disease (rare) Diminutive glands (in idiopathic atrophy + chronic inflammation) Enlarged glands (acute inflammation, acute hemorrhage, metastasis
These are images from contrast-enhanced abdomen CT. There is a large, round mass between the right hepatic lobe and the duodenum. The mass is well encapsulated. Majority of the mass shows fat attenuation and geographic or tread-like areas with soft tissue attenuation are scattered between them. The duodenum and the pancreas are displaced by the mass but look clearly separated from the mass. What are the differential diagnoses?
AnswerMyxoid liposarcoma Brief review of myxoid liposarcoma most common type of liposarcoma varying degrees of mucinous + fibrous tissue + relatively little lipid intermediate differentiation CT solid pattern: inhomogeneous poorly marginated infiltrating mass mixed pattern: focal fatty areas + areas of higher density pseudocystic pattern: water-density mass calcifications in up to 12% DDx: malignant fibrous histiocytoma, leiomyosarcoma, desmoid tumor
M/40 chief complaint: jaundice PTC
Percutaneous transhepatic cholangiography shows multiple ovoid filling defects in dilated intrahepatic bile ducts. Focal stricture is noted in right main IHD. What are the differential diagnoses?
Clonorchiasis of the liver Brief review of clonorchiasis of the liver Endemic Country: Japan, Korea, China, Taiwan, Indochina Organism: Chinese liver fluke = Clonorchis sinensis Pathology (a) desquamation of epithelial bile duct lining with adenomatous proliferation of ducts + thickening of duct walls (inflammation, necrosis, fibrosis) (b) bacterial superinfection with formation of liver abscess Remittent incomplete obstruction + bacterial superinfection Multiple crescent- / stiletto-shaped filling defects within bile ducts Complication (1) Bile duct obstruction (conglomerate of worms / adenomatous proliferation (2) Calculus formation (stasis / dead worms / epithelial debris) (3) Jaundice in 8% (stone / stricture / tumor) (4) Generalized dilatation of bile ducts (2%)
M/49 Chief complaint: fever,chill
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Pneumoperitoneum due to perforated duodenal ulcer Radiologic findings of pneumoperitoneum air lesser peritoneal sac gas in scrotum (through open processus vaginalis) Large collection of gas: abdominal distension, no gastric air-fluid level "wall sign" = "Rigler sign" = "bas-relief sign" =air on both sides of bowel as intraluminal gas + free air outside (usually requires >1,000 mL of gas) "football sign" = large pneumoperitoneum outlining entire abdominal cavity outline of falciform ligament (medial RUQ); most common structure outlined "telltale triangle sign" = triangular air pocket between 3 loops of bowel "inverted V sign" = outline of both lateral umbilical ligaments "urachus sign" = outline of middle umbilical ligament
M/57 Chief complaint: fever and chill Past medical history: went through whipple’s operation due to pancreatic cancer
Afferent loop syndrome caused by recurred pancreatic cancer Brief review of afferent loop syndrome Complication of subtotal gastrectomy with Billoth II gastrojejunostomy Cause internal hernia, kinking of anastomosis, adhesive band, stomal stenosis, neoplasm, inflammation Abdominal radiographs often normal because the afferent loop is fluid filled as a result of distal obstruction Barium study non-filling of the afferent loop or preferential filling of dilated proximal loop with stasis CT , US two or more thinly marginated, round, cystic structures adjacent to pancreas anterior displacement of the superior mesenteric artery
F/59 Chief complaint: went through extended left hepatic lobectomy and radiation therapy for klatskin tumor
Radiation-induced liver disease Brief review of radiation-induced liver disease US hypoechoic - localized hepatic congestion or edema CTSharply defined band of low attenuation corresponding to treatment port - edema or fatty infiltration Region of increased attenuation in fatty liver - loss of fat in irradiated hepatocytes or regional edema eventually irradiated area become atrophic MR low signal intensity on T1WI, high on T2WI
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Pheochromocytoma Brief review of pheochromocytom Location: anywhere in sympathetic nervous system from neck to sacrum subdiaphragmatic in 98% (a) adrenal medulla (85 - 90%) (b) extraadrenal (10 - 15% in adults, 31% in children): para-aortic sympathetic chain (8%), organ of Zuckerkandl at origin of inferior mesenteric artery (2 - 5%), gonads, urinary bladder (1%) CT: discrete round / oval mass with a mean size of 5 cm (range 3 - 12 cm) solid / cystic / complex mass with low-density areas secondary to hemorrhage / necrosis calcifications may be present DDx: nonfunctioning adrenal adenoma, adrenocortical carcinoma, adrenal cyst
54 /M Chief complaint: abdominal pain
Secondary hepatic lymphoma in non-Hodgkin’s lymphoma Brief review of hepatic lymphoma most lymphoma of the liver are secondary More than 50% of patients with Hodgkin’s or non-Hodgkin’s lymphoma Pathology nodular and diffuse form Hodgkin’s disease: more often miliary lesion, almost splenic lesion CT multiple, well-defined, large, homogeneous low-density Hepatomegaly Additional areas of involvement spleen, para-aortic, celiac, periportal lymph node, kidney
48/M Chief complaint: swallowing difficulty
Esophageal leiomyoma Brief review of esophageal leiomyoma Most common benign tumor of esophagus; 50% of all esophageal benign tumors Age: young adults, 3% in children (associated with Alport syndrome in 22%); M > F Site: frequently lower + mid 1/3 of esophagus 2 - 15 cm large smooth well-defined intramural mass causing eccentric thickening of wall + deformity of lumen may have coarse calcifications Leiomyoma is the only calcifying esophageal tumor!ulceration uncommon diffuse leiomyomatosis / multiple leiomyomas in children
These are images from contrast-enhanced CT scan. There are multiple masses and infiltrations in the omentum. The masses have ill-defined margin. There was an poorly enhanced mass in the pancreas. What are the differential diagnoses?
Metastasis from melanoma Brief review of metastases from malignant melanoma 1. Lymphadenopathy 2. Bone (11 - 17%) : axial skeleton (80%), ribs (38%) 3. Lung (70% at autopsy) : most common site of relapse 4. Liver (17 - 23%; 58 - 66% at autopsy) 5. Spleen (1 - 5%; 33% at autopsy) 6. GI tract + mesentery (4 - 8%) Location: small intestine (35 - 50%), colon (14 - 20%), stomach (7 - 20%) multiple submucosal nodules, "bull's-eye / target" appearance = central ulceration irregular amorphous cavity (exoenteric growth) intussusception (10 - 20%) 7.Kidney (up to 35% at autopsy) 8. Adrenal (11%, up to 50% at autopsy)
44/F Chief complaint: incidental mass
Tuberculous lymphadenopathy Brief review of regional patterns of lymphadenopathy 1. Gastrohepatic ligament nodes superior portion of lesser omentum suspending stomach from liver Common cause: carcinoma of lesser curvature of stomach, distal esophagus, lymphoma, pancreatic cancer, melanoma, colon + breast cancer DDx: coronary varices 2. Porta hepatis nodes in porta hepatis extending down hepatoduodenal ligament, anterior + posterior to portal vein Common cause: carcinoma of gallbladder + biliary tree, liver, stomach, pancreas, colon, lung, breast Complication: high extrahepatic biliary obstruction 3. Pancreaticoduodenal nodes between duodenal sweep + pancreatic head anterior to IVC Common cause: lymphoma, pancreatic head, colon, stomach, lung, breast cancer
53/M Chief complaint: abdominal pain after getting blunt injury to the abdomen These are images from contrast-enhanced CT scan. There are multiple air collections in the mesentery and retroperitoneum where there must be no air normally. Ascites is noted in subhepatic space and paracolic gutters. On precontrast CT scan (not presented), the attenuation of ascites in subhepatic space is quite higher than simple fluid, e.g. bile within gallbladder. What are the differential diagnoses?
34/M Chief complaint: palpable abdominal mass
Malignant gastrointestinal stromal tumor (GIST) of duodenum Brief review of malignant GIST of small bowel Location: duodenum (26%), jejunum (34%), ileum (40%) usually >6 cm in size nodularmass: intraluminal, intraluminal pedunculated, intramural, chiefly extrinsic mucosa may be stretched + ulcerated may show central ulcer pit / fistula communicating with a large necrotic center intussusception
28/F Chief complaint: jaundice CT ERCP
Polypoid hilar cholangiocarcinoma Brief review of extrahepatic cholangiocarcinoma Location: left / right hepatic duct in 8 - 13% confluence of hepatic ducts (Klatskin tumor) in 10 - 26% common hepatic duct in 14 - 37% proximal CBD in 15 - 30%, distal CBD in 30 - 50%, cystic duct in 6% Growth pattern: (1) Obstructive type (70 - 85%) U- / V-shaped obstruction with nipple, rattail, smooth / irregular termination (2) Stenotic type (10 - 25%) strictured rigid lumen with irregular margins + prestenotic dilatation (3) Polypoid / papillary type (5 - 6%) intraluminal filling defect with irregular margins
30/M Chief complaint: abdominal distension These are images from contrast-enhanced CT. There is a large cystic mass in the abdomen. It has homogeneous water attenuation and well demarcation. The mass push the left kidney and small bowels to right side. Which anatomical space did the mass arise from? What are the differential diagnoses?
Lymphangioma Brief review of lymphangioma Congenital malformation of lymphatic vessels Pathology usually multiloculated large thin-walled cystic mass with chylous / serous / hemorrhagic fluid contents Location: mesentery, proximal bowel dilatation (in partial bowel obstruction) US: multiseptated cystic mass with lobules fluid anechoic / with internal echoes / sedimentation CT: cystic mass with contents of water- to fat-density MR: serous contents: hypointense on T1WI + hyperintense on T2WI hemorrhage / fat: hyperintense on T1WI + T2WI Treatment: surgery (difficult due to intimate attachment to bowel wall)
42/M Chief complaint: frequency past medical history: total gastrectomy due to stomach cancer 3 years ago
Isolated bladder metastasis from stomach cancer Brief review of Isolated bladder metastases from stomach cancer Extremely rare Focal or diffuse thickening of the bladder wall on CT Differential diagnoses Cystitis Bladder cancer Tuberculosis
F/65 Chief complaint: known systemic lupus erythematosus patient These are images from contrast-enhanced CT. There is an abnormal vessel connecting right hepatic vein to middle hepatic vein. More inferiorly the accessory right inferior hepatic vein which is not seen normally, is seen to be drained into the IVC. What are the possible causes?
Budd-chiari syndrome with veno-veno collateral due to idiopathic occlusion of right hepatic vein Brief review of Budd-chiari syndrome Definition: global / segmental obstruction of hepatic venous outflow Causes: A. idiopathic B. thrombosis: Hypercoagulable state, Injury to vessel wall C. nonthrombotic obstruction: Tumor growth into IVC / hepatic veins, Membranous obstruction of suprahepatic IVC, Right atrial tumor, Constrictive pericarditis, Right heart failure communications between right / middle hepatic vein and inferior right hepatic vein enlarged inferior right hepatic vein hypertrophy of caudate lobe hypodensity in atrophic areas / periphery with inversion of portal blood flow patchy enhancement with normal portal blood flow narrowing / obstruction of intrahepatic IVC
M/33 Chief complaint: received hormonal (steroid) therapy for aplastic anemia
Hepatic adenomas Brief review of hepatic adenoma Radiologic-pathologic correlation Rich in fat Hyperechoic mass: ultrasound Hypodense mass: CT Hyperintense mass: MR No stroma, internal Anechoic, potentially cystic mass: ultrasound hemorrhage Hyperdense area: CT Hyperintense area: T1-weighted image (MR) Peripheral “feeders” Peripheral enhancement: angiography Kupffer cells Sulfur colloid uptake, SPIO uptake Hepatocytes, no ductule IDA uptake, no excretion Associated with: oral contraceptives, steroids, pregnancy, diabetes mellitus, glycogen storage disease
M/82 Chief complaint : frequent watery diarrhea and abdomen distension Past medical history: being under long term antibiotics due to aspiration pneumonia These are images from contrast-enhanced CT scan. Diffuse, circumferential wall thickening of the rectum and the sigmoid colon is demonstrated. Thickened colonic wall looks having three layers on CT and these layers are clearly seen throughout the rectum and sigmoid colon. Mucosal layer which is well enhanced is clearly seen in contrast with edematous submucosal layer having homogeneous low attenuation. There is ascites. What are the possible causes?
Pseudomembranous colitis Brief review of pseudomembranous colitis Cause: overgrowth of Gram-positive Clostridium difficile Predisposed: (a) complication of antibiotic therapy, some chemotherapeutic agents (b) following surgery / renal transplantation / irradiation (c) shock, uremia (d) proximal to large bowel obstruction (d) debilitating diseases: lymphosarcoma, leukemia (e) immunosuppressive therapy with actinomycin D Location: rectum (95%); confined to right + transverse colon (5 - 27%) CT colonic wall thickening of 4 - 22 mm smooth circumferential thickening (44%) accordion pattern nodular thickening homogeneous enhancement due to hyperemia pericolonic stranding ascites
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