Body

Question 1

54F with abdominal pain, n/v

Answer 1

Closed loop obstruction

There is a cluster of fluid-distended loops of small bowel in the pelvis that are notable for relative absence of intraluminal gas, minimal enhancement of their mucosa, infiltrated mesentery, engorged mesenteric vessels and interloop ascites. The distal small bowel is of normal caliber.

—> findings suggestive of ischemia/closed loop include minimal enhancement of the mucosa and engorged mesenteric fat/vessels, and focal ascites.

—> in pt w/appropriate hx could also be a post-op intramesenteric hernia

Question 2

54m w/cirrhosis 2/2 alcohol

Answer 2

Arterial phase CECT w/multiple hyperdense/hypervascular foci c/w tumor (these wash out on PV phase where the tumor thrombus is also more apparent) we also see cirrhosis w/small nodular border

Criteria to distinguish portal vein tumor thrombus (vs. bland thrombus) are contiguity with parenchymal tumor, expansion of the lumen of the vein, and enhancing thrombus.

Question 3

Incidentally seen liver lesion.

Isodense to liver on other phases

Answer 3

FNH

homogeneously hypervascular on arterial phase imaging and nearly isodense to liver on other phases; the additional presence of a central scar is essentially pathognomonic.

—> in a younger woman w/o hx of cancer, can be dx from the CT appearance

—>hemangioma would be hypervascular but isodense to vessels, not liver.

Question 4

Middle aged man c/o intermittent crampy abdominal pain and constipation

Answer 4

Diverticulosis w/concentric/circular muscular hypertrophy

—Also known as myochosis

get ‘cogwheel’ narrowing of the colonic lumen

Question 5

RUQ pain, n/v

Answer 5

Gallstone eroded into duodenum, w/pneuobilia

”Bouveret syndrome”

—> gallstone iléus is by same mechanism but have SBO

—> mirizzi’s is where a stone intermittently compresses the CBD

Question 6

64M w/hx of cirrhosis. P/w acute RUQ pain and this lesion had a pseudoaneurysm

Answer 6

HCC
Hypervascular liver mass in pt w/cirrhosis that spontaneously bleeds is essentially diagnostic of HCC

—> mets dont usually go to cirrhotic livers

—>

Question 7

24 year old female with pelvic pain

Answer 7

Turbo-ovarian abscess

complex fluid next to the ovary w/appropriate history

Question 8

IgG4 disease manifestations

Answer 8

MC is autoimmune pancreatitis

Can also get hepatobiliary involvement

in the chest, can see soft tissue infiltration/abnormal nodes and aortitis

—> can sometimes have normal IgG4 levels

Question 9

Grandmother tumor

Answer 9

Serous Cystadenoma

many small cysts (>6 cysts
that are <2 cm) that may have a solid
appearance on CT due to apposition of
many cyst walls. MRI is useful to show
the cystic nature of the lesion.

hypervascular(unlike other cystic pancratic neoplasms), doesn’t cause ductal dilatation or tail atrophy (unlike adeno)

Central stellate calcs are classic

Question 10

Mother Tumor

Answer 10

Mucinous Cystic Neoplasm

Middle aged women

benign but has malignant potential

consists of a single or a few
large cysts (<6 cysts that are >2 cm)
and typically occurs in the pancreatic
body and tail.

has a capsule (only other is SPEN)

can have peripheral calcs

Question 11

Daughter Tumor

Answer 11

Solid and Papillary Epithelial Neoplasm (SPEN)

Young women and children, low malignant potential, typically resected.

large mass with heterogeneous solid and cystic areas.Hemorrhage is typical. Has a capsule, as does mucinous cystic neoplasm.

Question 12

Answer 12

Crossing duct sign in Pancreas Divisum

failure of ventral and dorsal ducts to fuse

(duct of santorini is superior and drains to small (minor) papilla) while CBD always drains to major papilla

–> in divisum, main pancreatic duct drains into santorini and minor papilla, while wirsung only drains a small amount of pancreas and drains w CBD into major papilla

Question 13

Pancreatic manifestations of VHL

Answer 13

inherited multisystemic disease w/increased risk of multiple malignancies and cysts in many organs

–>serous cystadenoma (grandma tumor) and neuroendocrine tumors

Question 14

pancreatic manifestations of CF

Answer 14

either fatty atrophy of the pancreas

or replacement with innumerable cysts

Question 15

fatty replacement of the pancreas –> exocrine insufficiency, neutropenia and bone dysplasias

Answer 15

Schwachman-Diamond Syndrome

2nd MCC pancreatic atrophy in childhood(first CF)

Question 16

Answer 16

Corpus luteal cyst—>

unilocular cyst with thick, crenulated walls that enhance on CT (from peripheral vessels, correlates with ring of fire on US)

Type of functional ovarian cyst that forms when corpus luteum fails to involute after ovum is released

remnants of the follicle after ovulation; ranges from 2-5 cm in diameter but involutes as it matures. The corpus luteum produces estrogen and progesterone, maintaining optimum conditions for implantation if the ovum is fertilised:

fertilised: the corpus luteum continues to produce these hormones and maximizes the chance of implantation into the endometrium; it reaches a maximum size at ~10 weeks and finally resolves at around 16-20 weeks

not fertilised: the corpus luteum involutes and turns into a corpus albicans by around 2 weeks

In some instances (like twin pregnancies), may be more than one corpus luteum - (e.g. two corpora lutea)

Question 17

what grade ?

Answer 17

Grade 1:

subcapsular hematoma or contusion, without laceration

Question 18

what grade?

Answer 18

Grade II Renal trauma

superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation)

perirenal hematoma confined within the perirenal fascia

Question 19

Answer 19

Grade III Renal Trauma

laceration >1 cm not involving the collecting system (no evidence of urine extravasation)

vascular injury or active bleeding confined within the perirenal fascia

Question 20

What grade?

Answer 20

Grade IV renal trauma

laceration involving the collecting system with urinary extravasation

laceration of the renal pelvis and/or complete ureteropelvic disruption

vascular injury to segmental renal artery or vein

segmental infarctions without associated active bleeding (i.e. due to vessel thrombosis)

active bleeding extending beyond the perirenal fascia (i.e. into the retroperitoneum or peritoneum)

Question 21

what grade?

Answer 21

Grade V

shattered kidney

avulsion of renal hilum or laceration of the main renal artery or vein: devascularisation of a kidney due to hilar injury

devascularised kidney with active bleeding

Question 22

+ calcs/staghorn calculus

Answer 22

xanthogranulomatous pyelonephritis

Question 23

what criteria are used to diffx benign from malignant ovarian lesions?

Answer 23

–> large solid components

–> wall thickness >3mm

–> septal thickness >3mm and/or nodularity

–>necrosis

Question 24

layering calcified stones w/in the renal parenchyma

Answer 24

renal diverticulum.

will see it fill on CT also

Question 25

hematocrit sign in hemorrhage

Answer 25

specific for coagulopathic hemorrhage --\> e.g. over anticoagulation w/warfarin

Question 26

Answer 26

Schistosomiasis ## Footnote (calcs in the bladder wall) Other forms include hepatosplenic (fibrosis and portal HTN, splenomegaly) pulmonary (

Question 27

Answer 27

RCC OR Multilocular cystic nephroma \*can’t be distinguished just on imaging appearance both can enhance and calcify.

Question 28

Answer 28

Ovarian Cystadenoma (serous) usually unilocular cystic mass with thin walls Mucinous is multilocular with thin walls also

Question 29

Ovarian mass, multiloculated with soft tissue and thick septae

Answer 29

mucinous cystadenocarcinoma Serous is unilocular, also thick walled / solid components

Question 30

Answer 30

—\> hepatic adénome seen in young women on OCPs, usu heterogeneously hypervascular w/foci of fat, necrosis, and hemorrhage

Question 31

what are possible patterns of enhancement for this lesion

Answer 31

hepatic cavernous hemangioma --cyst with enhancing mural nodule --peripheral, nodular enhancement, isodense to vessels on all series

Question 32

\>1 year post transplant

Answer 32

PTLD retroperitoneal adenopathy. Can involve adrenals, kidney, GI, other organs etc. Here—indistinguishable from NHL in immunocompetent patient

Question 33

seen in what syndrome

Answer 33

Gardner syndrome ## Footnote familial adenopolyposis multiple osteomas: especially of the mandible, skull, and long bones epidermal cysts fibromatoses desmoid tumors of mesentery and anterior abdominal wall Other abnormalities include: supernumerary teeth/duodenal tumors/papillary thyroid carcinoma

Question 34

Multiple of these:

Answer 34

Odontogenic keratocyst ## Footnote Seen in Gorlin Syndrome/basal cell nevus syndrome phakomatosis—\> Craniofacial anomalies, multiple BCCs, shortened 4th metacarpals

Question 35

Answer 35

—\> hepatic adénoma young women on OCPs, usu heterogeneously hypervascular w/foci of fat, necrosis, and hemorrhage

Question 36

Answer 36

Horseshoe kidney

Question 37

middle aged woman with fatigue and pruritis

Answer 37

PBC (primary biliary cholangitis) ## Footnote lace-like fibrosis and periportal halo sign (hypodensity around portal veins thought 2/2 portal edema) can see periportal hyperintensity (cuffing) on MR segmental hypertrophy, splenic hypertrophy

Question 38

Answer 38

recurrent pyogenic cholangitis ## Footnote present w/recurrent RUQ, fever, and jaundice diagnostic clues: intra- and extrahepatic biliary dilatation and multilevel strictures with intraductal pigmented calculi(T1 bright), usually in the absence of gallbladder calculi a/w clonorchis or ascariasis (liver fluke) infection (serves as a nidus for pigmented gs formation) --reduced arborization of peripheral ducts on MR--'arrowhead sign', multiple strictures

Question 39

Answer 39

hepatolithiasis causes include recurrent pyogenic cholangitis, ductal stasis, caroli disease common in asia and the pacific (rare in america)

Question 40

What is the entity? Why is this not Ogilvie/colonic ileus?

Answer 40

Toxic megacolon ## Footnote with ahaustral appearance of the transverse colon. Get sloughing of normal mucosa, and patient is very sick Ogilvie syndrome/colonic ileus characterized by disproportionate dilation of cecum and ascending colon without obstruction. Will have normal appearing haustra/transverse folds and mucosa, patient not as sick

Question 41

Pt with brief syncopal episode after HD

Answer 41

Amyloid Spondyloarthropathy ## Footnote associated with chronic renal disease/hemodialysis advanced disc space loss with endplate erosion/destruction and malalignment, (findings that closely parallel infectious discitis)

Question 42

Answer 42

Epiphrenic diverticulum ## Footnote Pulsion diverticulum Notice that there aren't any RUGAE in the thing that looks like it could be intrathoracic stomach Happens in old people with dysmotility

Question 43

Manifestations of VHL

Answer 43

H--hemangioblastomas I-- Increased risk of RCC (clear cell, multiples) P-- pancreatic cysts, serous cystadenoma, cystadenocarcinoma, neuroendocrine tumors P--Pheochromocytoma, papillary cystadenomas (epididymal and broad ligament) E-- eye probs (retinal hemangioblastoma)//endolymphatic sac tumors L-- liver, renal, pancreatic cysts L