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CT Abdomen: A Pattern Approach
D Karthikeyan, Deepa Chegu
CHAPTER 1:
Axial Anatomy
NORMAL AXIAL CT ANATOMY
Liver Segments
SURFACE REFORMATION
Uterus and Ovaries
Muscles and Pelvic Structures
Individual Bowel Patterns
CT Peritoneogram—Showing Peritoneal Spaces
Peritoneal Spaces
The Supramesocolic Compartment
Right Supramesocolic Space
Left Supramesocolic Space
The Inframesocolic Compartment
The Right Inframesocolic Space
The Left Inframesocolic Space
The Paracolic Gutters
The Pelvic Peritoneal Spaces
Omentum
Peritoneal Ligaments
The Peritoneal Folds
Peritoneal Pouches
RETROPERITONEUM
ANTERIOR PARARENAL COMPARTMENT
Perinephric Compartment
Posterior Pararenal Compartment
CHAPTER 2:
Liver
INTRODUCTION
TECHNICAL PRINCIPLES OF CONTRAST ENHANCED CT
NONENHANCED CT
Hepatic Arterial Phase [HAP]
Portal Venous Phase (PVP)
CT ARTERIAL PORTOGRAPHY
CT Arteriography
CT Protocols
HEPATIC INFECTIONS
Pyogenic Hepatic Abscess
Amebic Abscess
Hydatid Disease
Hepatic Granuloma
Tuberculosis
Fungal Abscess
Candidiasis (see Fig. 4.14)
Mucormycosis
Diffuse Inflammation
Peliosis Hepatis
Benign Liver Tumors
Hemangioma (see Figs 2.37 to 2.39)
Pathology
Incidence
Diagnostic Triad of Hemangioma: Peripheral Filling, Delayed Filling, and Persistence of Enhancement
Complications of Hemangioma
Focal Nodular Hyperplasia FNH (Figs 2.40A and B)
Pathology
Complications
Nodular Regenerative Hyperplasia
Hepatic Cysts
Incidence
Complication
MALIGNANT HEPATIC TUMORS
Classification of Malignant Tumors
Hepatocellular Carcinoma
Risk Factors for Hepatoma
Vascular Effects of HCC
CT Pitfalls in the Diagnosis of HCC
Cholangiocarcinoma (see also page 83)
Angiosarcoma (see Figs 2.35A and B)
Epithelioid Hemangioendothelioma
Hepatic Lymphoma (see Figs 2.36A and B)
Biliary Cystadenocarcinoma
PEDIATRIC LIVER MASSES
Classification
APPROACH TO LIVER MASSES
PEDIATRIC LIVER TUMOR
Hepatoblastoma
Patterns of Hepatocellular Carcinoma
Angiosarcoma
Non-Hodgkin's Lymphoma
Hemangioma
Atypical Delayed Filling is seen in Hemangioma
Focal Nodular Hyperplasia
Simple Cysts
Pseudo Mass
Blood Supply
Detection By Imaging
Imaging Appearances
Images
Diffuse Liver Disease
Pattern of Involvement
DIFFUSE LIVER DISEASE: CT TECHNIQUE
DIFFUSE CHANGES
Low Attenuation
High Attenuation
Infiltrative Process
Cirrhosis
Primary Sclerosing Cholangitis
Primary Biliary Cirrhosis
Cirrhosis in Metabolic Disorders
Hemochromatosis
Wilson's Disease
Post Sinusoidal Hepatic Disease
Budd-Chiari Syndrome
Cardiac Cirrhosis
Geographic Changes
Focal Fatty Metamorphosis
Hepatic Infarction
Metastatic Disease and Pseudo-cirrhosis
Lymphoma
Discussion on Specific Pathological Processes
Hepatic Cirrhosis
Classification
Etiology
CT Findings
Stages of Cirrhosis
Micronodular Cirrhosis
Redistributed Lobar Volumes
Lobar Hypertrophy
Macronodular Cirrhosis
Expanded GB Fossae
Portosystemic Collaterals
Nodular Lesions in Cirrhosis
Portal Hypertension
Collateral Pathways in Portal Hypertension
Portal Venous Occlusion
CT Appearances of Thrombosed Veins
Diseases Causing Segmental Occlusion of the Portal Vein
CT Diagnosis of Malignant Thrombosis of the Portal Vein
Signs of Malignant Thrombi
Malignant Thrombus
Miscellaneous Conditions-Cystic Lesions of Liver
Developmental Lesion
Hepatic (Bile Duct) Cyst
Polycystic Liver Disease
Bile Duct Hamartoma
Caroli Disease
Neoplastic Lesions
Undifferentiated Embryonal Sarcoma
Biliary Cystadenoma and Cystadenocarcinoma
Cystic Subtypes of Primary Liver Neoplasms
Cystic Metastases
Abscess
Intrahepatic Hydatid Cyst
Hepatic Extrapancreatic Pseudocyst
Hematoma
Biloma
Focal Liver Lesions
Female Predominance
Male Predominance
Pathology based on Age
Symptomatic
Incidentaloma
CHAPTER 3:
Gallbladder and Biliary Tract
INTRODUCTION
CT Techniques
Technique
CONGENITAL LESIONS
Gallbladder Number
Gallbladder Position
Gallbladder Shape
GALLSTONES
Milk of Calcium Bile
CHOLECYSTITIS
Acute Cholecystitis
Complications of Acute Cholecystitis
Empyema
Gangrenous Cholecystitis
Emphysematous Cholecystitis
Xanthogranulomatous Cholecystitis
PORCELAIN GALLBLADDER
ADENOMYOMATOSIS
Hemobilia
ACUTE ACALCULOUS CHOLECYSTITIS
CHRONIC CALCULUS CHOLECYSTITIS
GALLBLADDER NEOPLASMS
Carcinoma of the Gallbladder
Clinical Features
Imaging Findings
Carcinoma with Mural Thickening
Carcinoma as a Polypoid Mass
Carcinoma as a Gallbladder Fossa Mass
Vicarious Contrast Excretion
Approach to Thick Walled Gallbladder on CT
BILIARY OBSTRUCTION
Level and Extent of Obstruction
Cause of Obstruction
BILIARY TRACT DISEASES
Choledocholithiasis
CHOLANGIOCARCINOMA (CCA)
Choledochal Cyst
Classification
Pyogenic Cholangitis (Oriental Cholangitis)
Sclerosing Cholangitis
Pneumobilia
Causes
CHAPTER 4:
Spleen
HELICAL CT
WANDERING SPLEEN
NUMBER (POLYSPLENIA, ASPLENIA)
SIZE (SPLENOMEGALY, SPLENIC ATROPHY)
ATROPHY
Autosplenectomy
SOLITARY LESIONS (E.G. CYSTS, LYMPHANGIOMAS, HEMANGIOMAS, HAMARTOMAS)
Cysts
Lymphangiomas
Hemangiomas
Infection and Inflammation
Granulomatous Lesion
Splenic Calcifications
MALIGNANCY
Chronic Myeloid Leukemia
Hodgkin's Lymphoma
NonHodgkin's Lymphoma
Diffuse Disease
Infarction
Splenic Hilar Collateral
Pseudoaneurysm
Discussion
Primary Splenic Artery Aneurysm
DIFFERENTIAL DIAGNOSIS IN SPLENIC PATHOLOGY
Primary Causes of Anomalies of Splenic Size
Splenomegaly
Small Spleen
Patterns of Involvement in Splenic Parenchymal Disease
Solitary Lesions
Multiple Focal Abnormalities
Diffuse Disease Without Focal Lesion
CHAPTER 5:
Pancreas
EXAMINATION TECHNIQUES
Technique for Angiography
ANOMALIES AND ANATOMICAL VARIANTS
Pancreatic Divisum
Annular Pancreas
Ectopic Pancreatic Tissue (see Fig. 8.41 page 255)
INFLAMMATORY CHANGES OF THE PANCREAS
Acute Pancreatitis
TERMINOLOGIES
Pancreatic Necrosis
Acute Fluid Collection
Pseudocyst
Pancreatic Abscess
Hemorrhage and Pseudoaneurysm
CTSI (CT Severity Index)
Groove Pancreatitis
Alcoholic Chronic Pancreatitis
Autoimmune Pancreatitis
Chronic Obstructive Pancreatitis
Spectrum of Cases Depicting Various Stages of Acute Pancreatitis
PATTERN OF INFLAMMATORY CHANGES IN ACUTE PANCREATITIS
Traumatic Pancreatitis
Chronic Pancreatitis
Radiographic Diagnosis
Role of Imaging in Chronic Pancreatitis
Differentiation Inflammatory Mass from Carcinoma
Spectrum of Chronic Pancreatitis
Causes for Pancreatic Calcification
Chronic Pancreatitis
Tumor
Hyperparathyroidism
Cystic Fibrosis
Pancreatic Lipomatosis
Neoplasms of the Pancreas
Types of Pancreatic Neoplasms
Incidence and Prognosis
Clinical Presentation
Rarer Presentations of Pancreatic Carcinoma
CT EVALUATION OF PANCREATIC CANCER
Tumor Detection
Issues in Pancreatic Tumor Imaging
Pancreatic Mass vs Inflammatory Mass
Vascular Encasement
Adenopathy
Metastases
Pancreatic Adenocarcinomas
Microcystic Cystadenoma (Fig. 5.40)
Macrocystic Cystadenoma or Cystadenocarcinoma (Fig. 5.38)
Islet Cell Tumors
Intraductal Papillary Mucinous Tumor
Solid Papillary Epithelial Tumor (Figs 5.52A and B)
CT Morphology
Differential Diagnosis of Cystic Lesions of the Pancreas
SOLID AND PAPILLARY EPITHELIAL NEOPLASM
Pitfalls in Diagnosis of Pancreatic Masses
Stomach, Duodenum, and Proximal Jejunum
Adenopathy
Pancreatic Tuberculosis
Portocaval Nodes
Peripancreatic Nodes
Nodes in the Root of the Mesentery
Adrenal Masses
Renal Masses
Mesenteric Masses
DIFFERENTIAL DIAGNOSIS IN PANCREATIC DISEASE
Pancreatic Calcifications
Inflammatory Causes
Developmental
Neoplasms
Focal Pancreatic Mass
Inflammatory
Neoplastic
Miscellaneous
Pancreatic Duct Dilatation
Pancreatic and Peripancreatic Cystic Lesions
CHAPTER 6:
Genitourinary System
NONCONTRAST CT
Hematuria
Calculi
Renal Masses
Papillary Necrosis
Renal Pelvic and Ureteral Disease
Bladder Abnormalities
CLASSIFICATION OF CONGENITAL RENAL ABNORMALITIES
Renal Agenesis
Solitary Kidney
Bilateral Renal Agenesis
Simple Renal Hypoplasia
Ask Upmark Kidney
Renal Aplasia
Anomalies of Rotation
Renal Ectopia
Crossed Renal Ectopia
Horse-shoe Kidney
Cystic Disease
URINARY INFECTIONS
Etiology and Pathogenesis
Urethritis
Cystitis
Prostatitis
Acute Pyelonephritis
Chronic Pyelonephritis (Chronic Infective Tubulointerstitial Nephritis)
Xanthogranulomatous Pyelonephritis
Emphysematous Pyelonephritis
Renal and Perirenal Gas
Pyonephrosis
Renal and Perirenal Abscesses
Tuberculosis
Tuberculosis
RENAL MASSES
Classification
Non-neoplastic
Neoplastic
Approach to Renal Masses
Pattern of Growth
Renal Cell Carcinoma (also known as adenocarcinoma, Gravitz's tumor, hypernephroma)
Unenhanced CT
Corticomedullary Phase
Advantages
Delayed De-enhancement
CT Findings
Oncocytoma
CT Findings
Pseudotumors
Dromedary Hump
Angiomyolipoma
Lymphoma
PATTERNS OF RENAL CELL CARCINOMA
Renal Pelvic Tumors
Cystic Renal Masses
Bosniack Classification of Renal Cyst
APPROACH TO RENAL CYST EVALUATION
Cystic Renal Disease—Classification
Nongenetic Disease
Acquired
GENETIC
Glossary of Terms in Cystic Kidney
Computed Tomography
Calcification
Benign Calcification
Mitotic Lesion with Calcification
High Attenuation
Septations
Benign Septations
Multiple Locules
Wall Thickening, Nodularity and Enhancement
Hereditary Renal Cancer
Small Renal Mass
PEDIATRIC RENAL TUMOR
Primary Renal Tumors of Infancy
Primary Renal Tumors in Older Children
Nephrogenic Rests — GLOSSARY
Perilobar nephrogenic rests
Intralobar
Nephroblastomatosis
Imaging Findings
CT TECHNIQUE FOR PELVIS AND URINARY BLADDER
Trabeculation
Cystitis
Outpouching from Bladder
Diverticula
Bladder Herniation
Bladder Stones (Fig. 6.85)
Extrinsic Bladder Compression
Pelvic Hematoma or Urinoma
Neoplasms of Bladder
Urachal Disease
PELVICALYCEAL SYSTEM AND URETER
Congenital Anomalies
DEVIATIONS OF URETER
MEDIAL DEVIATION OF THE URETER
Upper Ureter
Lower Ureter
LATERAL DEVIATION OF THE URETER
Upper Ureter
Lower Ureter
Abnormalities of Ureteric Caliber
Dilatation in the Absence of Intrinsic Obstruction
Entire Ureter
Lower Ureter
Upper Ureter
Nonobstructive Ureteral Dilatation
Approach to Suspected Ureteric Obstruction
Secondary Signs of Urinary Tract Obstruction
SPECTRUM OF URETERIC CALCULI
URETERAL NARROWING
Ureteric Tumors
Ureteral Narrowing
Urine Leaks
Causes
Diagnosis and Imaging Features
Ureteral Urine Leaks
Causes
Diagnosis and Imaging Features
Ureteroceles
Primary Mega Ureter
Pelviureteric Junction Obstruction
Neobladder
Noncontinent Urinary Diversion
Continent Urinary Diversion
Etiology
RENAL VASCULAR DISORDERS
Arteriovenous Communications
CT Findings
Aneurysms of the Renal Artery
CT Findings
Vasculitis
Polyarteritis Nodosa
CT Findings
Systemic Lupus Erythematosus
CT Findings
Renal Neoplasms that Cause Renal Hemorrhage
CT Findings
Renal Artery Stenosis
CT Findings
Renal Infarction
Causes of Renal Infarction
Renal Vein Thrombosis
CT Findings
Causes of Renal Vein Thrombosis
Renal Hemorrhage
Causes of Subcapsular Renal or Perinephric Hemorrhage
RENAL TRANSPLANT
Parenchyma
Vasculature
Pyeloureter
Perirenal Hematoma
Perirenal Lymphocele
Perirenal Abscess
Parenchymal Abscess
Renal Artery Stenosis
Renal Artery Thrombosis
Intrarenal Arteriovenous Fistula and Pseudoaneurysm
Renal Graft Torsion
Renal Vein Thrombosis
Urinoma
GRAFT RENAL ARTERY THROMBUS
Post-transplant Lymphocele
Post-transplant Renal Artery Stenosis
CHAPTER 7:
Adrenal Gland
INTRODUCTION
ADRENAL PSEUDOMASSES
Hyperfunctioning Adrenal Medullary Neoplasms
Hyperfunctioning Adrenal Cortical Neoplasms
CT in Differentiating Benign from Malignant Adrenal Masses
METASTASIS
ADRENAL MASS
Myelolipomas
Miscellaneous
Adrenocortical Carcinoma
Pheochromocytoma
NEUROBLASTOMA
ADRENAL HYPERPLASIA
ADRENAL CYST
CONGENITAL ADRENAL CORTICAL HYPERPLASIA
ADDISON'S DISEASE
INFECTIONS
Differential Diagnosis for Adrenal Lesion
Adrenal Malignancies
Nonmalignant Adrenal Disease
Unilateral Adrenal Lesions
Calcific Adrenal Lesions
CHAPTER 8:
Gastrointestinal System
CT INDICATION FOR EVALUATING THE GUT
Technical Considerations
Points to be Evaluated
Pitfalls
Regimens for Abdominal Survey
Consideration for Specific Areas
Esophagus
Stomach
Duodenum
Small Intestine
Colon
TECHNIQUE FOR GASTRIC CT
Oral Contrast Agent
Inflammatory Conditions
Gastritis
Emphysematous Gastritis
Gastric Neoplasms
Gastric Adenocarcinoma
Gastric Lymphomas
Stromal Tumors
Gastric Carcinoid
Post Gastrojejunostomy CT
Miscellaneous Cause of Gastric Wall Thickening
Gastritis
CT of Malignant Gastric Masses
CT Staging of Gastric Adenocarcinoma
Stromal Cell Lesion
Gastric Volvulus
CT of Duodenum
CT Technique
Duplications and Diverticula
Malrotation
Annular Pancreas
Duodenal Trauma
Inflammatory Process
Infectious Processes
Hematologic Abnormalities
Neoplastic Processes
Diaphragms and Webs
Other Causes of Outlet Obstruction
IMAGING OF SMALL BOWEL
Normal Findings and Interpretation of Small Bowel CT
Small Bowel Malignancies
Predisposing Conditions
Types of Tumors
Adenocarcinomas
Carcinoid Tumors
Primary GI Tract Lymphoma
Sarcomas
Neuroendocrine Tumors
Metastatic Lesions
Benign Lesions
Adenomas
Leiomyomas
Lipomas
Other Benign Lesions
Polyposis Syndromes
Peutz-Jeghers Syndrome
Cronkhite Canada Syndrome
The Solitary Polyp
Multiple Polypoid Lesions
NON-NEOPLASTIC SMALL BOWEL DISEASES
Ischemic Bowel Disorders
Mesenteric Ischemia and Infarction
Causes of Acute Bowel Ischemia and/or Ischemic Colitis
CT Manifestations of Bowel Ischemia
Target Sign
Persistent Arterial Insufficiency without Reperfusion
Transient Arterial Insufficiency with Subsequent Reperfusion
Impaired Venous Drainage
Ischemia due to Closed-loop Small-Bowel Obstruction
Portomesenteric Vein Gas
Mesenteric Vein Gas
GI Vasculitis
Vasculitis
Major Categories of Noninfectious Vasculitis
Systemic Lupus Erythematosus
Specific Disorders
Polyarteritis Nodosa
Churg-Strauss Syndrome
Henoch-Schönlein Purpura
Systemic Lupus Erythematosus
Antiphospholipid Antibody Syndrome
Inflammatory Bowel Disease Associated Vasculitis
Henoch-Schönlein Syndrome
Malabsorption
Adult Intussusception
Small Bowel Obstruction
Classification of Hernias
External Hernias
Internal Hernias
Causes of Small Bowel Obstruction in Adults
Extrinsic Lesions
Intrinsic Lesions
Intussusception
Intraluminal Lesions
Peritoneal Carcinomatosis
Appendicitis and Diverticulitis
Hernia
Extrinsic Causes
Strangulation
Volvulus
Epidemiology
Etiology and Pathogenesis
Primary Small Bowel Volvulus
Secondary Small Bowel Volvulus
Age and Sex Distribution
Clinical Features
Internal Hernias
Paraduodenal Hernia
Transmesenteric Hernias
What is Malrotation?
Why is Malrotation of Concern?
How is Malrotation Diagnosed?
Approach to the Diseased Small Bowel—Summary
Obstruction
Neoplasms
Cavitary Masses
Annular Lesions
Contour Distortions of Extrinsic Origin
Tethering of Folds
Extrinsic Mass Effect and Tethering
Separation of Bowel Loops without Tethering
Dilated Lumen, Normal Folds
Normal Number of Folds (per inch)
Decreased Number of Folds in Duodenum or Jejunum
Increased Number of Folds per inch Duodenum or Jejunum
Abnormalities in Fold Size
Thick, Smooth, and Straight Folds
Mucosal Nodularity and Irregular Fold Thickening of Ulceration
Tubular Bowel
Sacculations
Gastrointestinal-Stromal Tumors (GISTs)
Introduction
Characteristics on CT Scan
Clinical Manifestations
Diagnosis
CT SCAN FEATURES OF COLONIC DISEASES
Technique
Normal Colon
Pathologic Conditions
Inflammatory Conditions
Ischemic Colitis
CT of Colonic Ischemia
Inflammation of Appendage Epiploicae
Tuberculosis
Pseudomembranous Colitis
Obstruction/Ileus
Specific Causes of Colonic Obstruction
Miscellaneous
Colonic Malignancies
CT Staging of Primary and Recurrent Colonic Tumors
Benign Neoplasms
PATTERNS OF BOWEL MALIGNANCY
CT TECHNIQUE FOR RETROPERITONEUM AND PERITONEUM
Patterns of Fluid Collection in Abdominal Diseases
Right Subhepatic and Subphrenic Fluid Collections
Left Subphrenic fluid
Lesser Sac Fluid
Interloop Fluid
Free vs Loculated Peritoneal Fluid
Peritoneal Fluid Density
Peritoneal Pathology
Inflammatory Process of the Peritoneum
Neoplastic Peritoneal Diseases
Mesenteric Disease
Inflammatory Disease of the Mesentery
Neoplastic Diseases of the Mesentery
Peritoneal Metastases
Spectrum of Peritoneal Carcinomatosis
Sclerosing Peritonitis
Pneumoperitoneum
Background
Pathophysiology
Anatomic Locations of Abdominal Gas Collections
Root of the Small-Bowel Mesentery
Characterization of the Retroperitoneal Space
Identification of the Organ of Origin
Lesions that Extend between Normal Structures
Lesions that extend along Normal Structures
Characteristic Tumor Components
Fat
Myxoid Stroma
Necrosis
Cystic Portion
Small Round Cells
Vascularity
Retroperitoneal Fibrosis
Aortic Aneurysms
Inflammatory Abdominal Aortic Aneurysm
Impending Rupture
Aortic Dissection
Etiology/Pathophysiology
Iliopsoas Hemorrhage
Inflammatory Lesions
AN APPROACH TO ABDOMINAL PAIN
Non-traumatic Abdominal Emergencies
Examination Technique
INTRODUCTION
CT ANGIOGRAM
3D Rendering Techniques
CTA of the Kidney
Renal Transplant Donor Evaluation
CTA of the Pancreas
Pancreatic Tumor Evaluation
CTA of the Mesentery
CTA of the Abdominal Aorta
CTA of the Liver
Oncologic Imaging
CHAPTER 9:
Abdominal Trauma
CT TECHNIQUE FOR BLUNT ABDOMINAL TRAUMA
HEMOPERITONEUM
HEPATIC INJURY
GALLBLADDER INJURY
SPLENIC TRAUMA
RENAL TRAUMA
BLADDER INJURY
Mechanism of Injury
CT Cystographic Technique
CT Cystographic Findings in Bladder Injury
Type 1: Contusion
Type 2: Intraperitoneal Rupture
Type 3: Interstitial Injury
Type 4: Extraperitoneal Rupture
Type 5: Combined Rupture
BOWEL AND MESENTERIC INJURIES
Bowel Discontinuity
Extraluminal Oral Contrast Material
Extraluminal Air
Intramural Air
Bowel-wall Thickening
Bowel-wall Enhancement
Mesenteric Infiltration
Intraperitoneal and Retroperitoneal Fluids
PANCREATIC INJURY
CLASSIFICATION
CT FINDINGS
IVC IN ABDOMINAL TRAUMA
ADRENAL INJURY
DIAPHRAGMATIC INJURY
INDEX
TOC
Index
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