GI Cases 26-50 - Radioloksabha

GI Cases 26-50 - Radioloksabha

GI Cases 26-50 Case directory 26 27 28 29 30 31 32

33 34 35 36 37 38 39 40

41 42 43 44 45 46 47 48

49 50 Case 26 Case directo ry Omental infarction Case findings:

Normal appendix Fatty lesion with hyper-attenuating streaks anterior to the cecum Thickening of the peritoneum Case 27 Axial T1WI Axial T2WI with fat saturation Axial T1 portal venous

enhancement Axial T1 delayed enhancement Retractile mesenteritis CT: Inhomogeneous mass of soft-tissue density interspersed with areas of fat, arising from the small bowel mesentery

Moderate enhancement of the non-fatty aspects of the process Mass surrounds mesenteric vessels and displaces adjacent small bowel loops MR: Mesenteric mass with irregular borders and low T1 SI T2 intermediate signal intensity Ascites in paracolic gutters and between mesenteric folds PV enhancement: mild enhancement with a radiating pattern of strands and enhanced mesenteric vessels penetrating the

lesion Retractile mesenteritis Also called: sclerosing mesenteritis, systemic nodular panniculitis, liposclerotic mesenteritis Represents fibrous evolution of mesenteric panniculitis Associated with:

SLE Lymphoma Gardner's syndrome Thoracic mesothelioma Retroperitoneal fibrosis Retractile mesenteritis MC presents as a single mass

Small bowel series: CT: Separation of loops, with kinking and angulation, suggesting a serosal process Mesenteric mass with a variable amount of fat and soft tissue

with radiating linear strands reflecting the fibrous reaction of the mesentery May see calcifications MR: Low T1, low or intermediate T2 Mild and gradual contrast enhancement suggesting a fibrotic reaction Case directo ry Retractile mesenteritis

DDX: Liposarcoma: invasion of adjacent structures Desmoid tumor: Associated with Gardner's syndrome MC occur in injured or surgically traumatized sites

Lymphoma Carcinomatosis Case 28 Case directo ry Peritoneal tuberculosis Case findings:

Peritoneal infection can appear as: Marked inhomogeneous thickening of the anterior peritoneal wall and SB Marked enhancement Mesenteric lymphadenopathy

Wet type Dry type Fibroadhesive type Combination of above types Wet type (this case): high-density ascitic fluid with exudative content and thickened mesentery Case 29 Case directory Intramural hematoma

Case findings: Thickening of jejunal loops Etiology: anticoagulation MC occurs in duodenum Case 30 Emphysematous cholecystitis

Case findings: Gas in GB wall that forms a low-attenuation ring outlining the gallbladder Gas is also seen in the left intrahepatic and extrahepatic biliary ducts DDX:

Emphysematous cholecystitis Ascending cholangitis Biliary-enteric fistula Paraduodenal abscess Periappendiceal abscess in malpositioned appendix Gallbladder lipomatosis: Plain-film mimmick of GB wall gas Emphysematous cholecystitis

Case directory Acute infection of GB wall caused by gasforming organisms Unlike other biliary tract disorders, MC in men (65-70%) Four proposed pathogenetic factors: Vascular compromise

Gallstones Impaired immune protection Infection with gas-forming organisms Case 31 History of adenomatous polyposis and fundal gastric polyps Gardners syndrome (with desmoid tumors) Case findings:

Multiple mesenteric and omental masses, which are ill-defined causing a tethered appearance to the mesentery Bowel is displaced but not obstructed Large pelvic mass Mass in the soft tissues of the lower abdominal wall Gardners syndrome (with desmoid tumors)

DDX tethered mesenteric folds: Post-operative changes Post-radiation changes Desmoplastic reaction: carcinoid, peritoneal implants, leiomyosarcoma, lymphoma DDX large solid pelvic mass in adult male:

Prostate / bladder / bowel neoplasm Desmoid tumor Malignant fibrous histiocytoma Leiomyosarcoma Neural tumor Gardners syndrome Autosomal dominant Polyposis:

Osteomas: MC mandible, calvarium, maxilla Soft tissue tumors:

MC colon (100%), stomach (5%), SB (<5 Malignant transformation risk is 100% Desmoid tumor Sebaceous cysts Neurofibroma, fibroma Leiomyoma, lipomas Surgical trauma predisposes Gardner patient to desmoid formation Case directory

Polyposis syndromes AD= autosomal dominant, AR= autosomal recessive, NH= nonhereditary Case 32 Cecal and appendiceal adenocarcinoma Case findings:

Asymmetric thickening of cecum and ascending colon Inflammatory changes of posterior perirenal fascia extending into right colic gutter Thickened appendix DDX: Appendicitis with phlegmon

Cecal malignancy with rupture and associated appendicitis Cecal diverticulitis Crohns disease Case directory Appendiceal neoplasm Rare to have appendiceal involvement with adenocarcinoma

Lymphoma and adenocarcinoma of appendix are less common Appendiceal carcinoid: 90% of all appendiceal tumors are carcinoids MC distal tip of the appendix Produces a solid bulbous swelling 2 to 3 cm in diameter Case 33 Malignant fibrous histiocytoma

Case findings: Mass centered in right retroperitoneum that is separate from right kidney and adrenal gland No clear fat plane is identified between the mass and the right psoas muscle Enhances heterogeneously with areas of nonenhancement (necrosis) DDX:

Malignant fibrous histiocytoma Leiomyosarcoma Lymphoma Liposarcoma Malignant fibrous histiocytoma MC sarcoma in adults, 5th 7th decades

Mesenchymal origin, potential to be in all organs: Case directory MC lower extremities (50%) Upper extremities (about 20%) Abdominal cavity, retroperitoneum (20%)

> 5 cm at presentation May erode into adjacent bony structures Metastatic disease and local recurrence are common Case 34 Hepatic angiomyolipoma Case findings:

CT: mass in the posterior segment of the right hepatic lobe composed mostly of fatty tissue MC solitary mass in liver Hemorrhage uncommon complication Case directory DDX fatty liver lesion

Lipoma Hepatic adenoma Focal fatty infiltration Angiomyolipoma Metastasis (malignant teratoma, liposarcoma) HCC with fatty metamorphosis HCC: well differentiated, hypovascular Angiomyolipoma: hypervascular Case 35

Case directory Mesenteric panniculitis Case findings: CT: hazy infiltration of the mesentery

Also called: sclerosing mesenteritis, mesenteric lipodystrophy, and liposclerotic mesenteritis Benign inflammatory condition of the mesentery, which is frequently asymptomatic and selflimiting MC left side of the abdomen along the orientation of the jejunal mesentery Case 36 Pelvic lipomatosis Case findings:

BE: Ascending curvature of the sigmoid colon Elongation and deformity of the rectum by extrinsic compression CT: Deposits of fat in the perivesical and perirectal spaces causing extrinsic compression of the bladder, sigmoid, and rectum Case

directory Pelvic lipomatosis DDX tear-drop bladder:

Pelvic lipomatosis Hypertrophy of the iliopsoas muscles Retroperitoneal fibrosis Large pelvic abscess Large hematoma, usually due to trauma or anticoagulation therapy Collateral venous circulation from IVC obstruction Large iliac artery aneurysms Adenopathy from lymphoma, and prostatic carcinoma Case 37

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