GIT 1 Flashcards

Question

Answer 1

Splenic vein thrombosis * CTC p219 * frequently occurs as the result of pancreatitis * diverticulitis * crohn's * can lead to isolated gastric varcies Case contributed by Dr Naim Qaqish◉ Diagnosis certain Presentation Epigastric pain, and tenderness on clinical examination. The splenic vein appears dilated with intraluminal echogenic material and absent signal on colour Doppler consistent with its thrombosis. The thrombosis extends from the splenic hilum till the confluence with the portal vein. Splenic vein diameter is 1.8 cm. The portal vein also appears prominent in size measuring about 15 mm, however, it shows normal hepato-petal blood flow. Normal blood flow in the superior mesenteric artery (SMA). Hepatic veins, IVC and Aorta are patent on colour doppler examination. (Pictures not included).

Answer 2

Splenic infarction * CTC p219 * Can occur from a number of conditions * on a multiple choice test the answer is SICKLE CELL * classically a wedge shaped peripheral low attenuation defect. Dr Mohamed Saber and Dr Yuranga Weerakkody◉ et al. Splenic infarction is a result of ischaemia to the spleen, and in many cases requires no treatment. However, identification of the cause of infarction is essential. Epidemiology Splenic infarcts can occur due to a number of processes, involving either arterial supply, the spleen itself or the venous drainage. As such there is no one affected demographic; rather the demographics will vary with the underlying cause. Clinical presentation Patients with a splenic infarction may present with left upper quadrant pain. Some may have constitutional symptoms such as fevers and chills while others may even have diffuse abdominal pain 5,9. Due to the location of the spleen, tucked under the left hemidiaphragm, referred pain to the left shoulder is also a feature 9. It should be noted that ~40% (range 30-50%) of patients with splenic infarction are asymptomatic 9. Pathology Aetiology The majority of patients with splenic infarcts have one of the following two aetiologies: haematologic disorders more common in younger patients e.g. sickle cell disease hypercoagulable states factor V leiden 15 embolic events more common in older patients e.g. infective endocarditis 11, marantic endocarditis Other aetiological factors include 1,2: splenic vascular disease granulomatosis with polyangiitis 14 splenic arterial aneurysms 7 variant anatomy, e.g. wandering spleen, which may undergo splenic torsion collagen vascular disease pancreatitis 8 non-haematologic malignancies blunt trauma: a segmental splenic infarct can occur as a rare complication 4 splenic artery compression, e.g. by pancreatic tumour splenic embolisation leukaemia (CML most common) 16 Radiographic features The appearance of splenic infarction depends on the timing of imaging and the size of the infarct. Although once the infarct has become established, both ultrasound and CT are sensitive to the diagnosis, in the hyperacute setting CT with contrast is the modality of choice if the diagnosis is suspected 9. Morphologically the typical infarct is of a pyramidal wedge of affected splenic tissue with the apex pointing towards the hilum, and the base on the splenic capsule. As the infarct matures, the wedge of infarcted tissue can undergo one of three processes which will dictate imaging features: resolution: no imaging findings contraction/scarring liquefaction Ultrasound Typically infarcts are hypoechoic compared to the rest of the spleen, although acutely they can be isoechoic and hard to identify. Sonographic features of acute splenic infarcts regarding shape can vary and include 5,9: wedge-shaped (classic) round irregularly smooth (uncommon) During contrast-enhanced ultrasound, the infarcted area remains hypointense throughout all phases of the study 10. As the infarct matures, if it undergoes contraction and scarring it will appear as a hyperechoic region with retraction of the capsule 9. If liquefaction occurs, the area may be rounded and anechoic (splenic pseudocyst). CT CT is often considered the imaging investigation of choice, ideally performed during the portal venous phase, to avoid confusing heterogeneous enhancement normally seen during arterial phase 2,7,9. Imaging features may vary with the stage of the infarct. In the hyperacute phase, CT may show areas of mottled increased attenuation, representing areas of a haemorrhagic infarction. There are various classical and non-classical patterns of established splenic infarcts on CT, which include 3,9: peripheral, wedge-shaped hypoenhancing region: typical multiple infarcts appear as hypodense non-enhancing lesions, with normal intervening enhancing splenic tissue. global splenic infarction, entire spleen is hypoenhancing, e.g. in splenic torsion infarction of a splenunculus 9 In the chronic phase, infarcts may disappear completely, but more commonly, they may reveal progressive volume loss caused by fibrotic contraction of the infarct, with hypertrophy of the surrounding normal spleen 7,9. Alternatively, if the infarct liquefies, a cystic lesion may be left with fluid density centrally 9. Treatment and prognosis Initial management usually consists of hydration, analgesics, and frequent monitoring, with the resolution of symptoms in 7-14 days. Splenectomy was performed for persistent symptoms or complications. Complications Some complications are encountered, more frequently in patients with an embolic aetiology. These include: formation of a splenic pseudocyst(s) infected splenic infarction leading to the formation of a splenic abscess splenic haemorrhage splenic rupture Differential diagnosis Often, when imaging appearances are typical, there is little differential diagnosis. When less typical, or when imaging is suboptimal, alternative diagnoses should be entertained, including 9: normal inhomogeneous splenic enhancement (zebra or psychedelic spleen): seen during arterial phase CT lymphoma usually rounded rather than wedge-shaped usually associated with splenomegaly and lymph node enlargement lymphoma may cause secondary splenic infarction potentially muddying the waters splenic abscess either primary or superimposed infection on a liquefied infarct splenic laceration history of trauma surrounding haematoma note: splenic rupture can complicate infarction

Answer 3

* Splenic infections * CTC p220 * most common * histoplasmosis (multiple round calcs) * TB can have a similar appearance (but much less common in the US. (CASE IN PICTURE) * Another possible cause of calcifed granuloma in the spleen * BRUCELLOSIS (CASE 2) * usually solitary and 2cm or larger. * may have a low density center. * encircled by calc * giving a bulls eye appearance * Picture in case two: * An 86-year-old man in Minnesota presented with fever, dyspnea, and new-onset confusion. His history was notable for a febrile illness with night sweats and a weight loss of 23 kg (50 lb) that had occurred while he was in his late 20s, working in an abattoir slaughtering pigs. * IMMUNOCOMPETENT patient * slenic abscess is usually due to an aerobic organism * SALMONELLA is classic * develops in the setting of underlying splenic damage (trauma or sickle cell) * IMMUNOCOMPRIMISED * fungi - occasionally may have bulls eye appearance * TB * MAI * PCP * appear as multiple micro abscesses. Splenic calcification Dr Ammar Haouimi◉ and Dr Yuranga Weerakkody◉ et al. Splenic calcifications can occur is various shapes and forms and can occur from a myriad of aetiological factors. The usual calcification observed in radiographs are the multiple, miliary form presenting numerous small rounded densities averaging from three to five millimetres in diameter where are thought to be often caused by phleboliths. Other associations include: diffuse calcifications systemic lupus erythematosus: rare 1 splenic granulomatous disease 6 splenic tuberculosis splenic histoplasmosis splenic brucellosis splenic amyloidosis 4,5 splenic candidiasis 7 splenic non-tuberculous mycobacterial infection 9 infection with Pneumocystic jiroveci 7 related to sickle cell disease 7 following treatment of lymphoma: Hodgkin disease 3 cat scratch disease: rare 8 hepatosplenic anthrasilicosis: rare 2 calcified splenic lesions splenic haemangioma splenic lymphangioma calcified splenic arterial aneurysm splenic hydatid cyst calcified post-traumatic splenic cyst 10 epidermoid cyst (wall calcification) 11 dermoid cyst 12 splenic infarct 11 congenital cyst 10 References

Answer 4

* CTC p221 * Post traumatic cysts/psuedocysts are the most common cystic lesion in the spleen * They can occur secondary to infarction * infection * hemorrhage * or extension from a pancreatic pseudocyst. * as a point of trivia they are pseudo cysts ebcaue they have no epithelial liniging * they may have athick wall or prominent calcs peripherally. Splenic pseudocyst Dr Ammar Haouimi◉ and Dr Marcin Czarniecki et al. Splenic pseudocysts, also referred as secondary splenic cysts, are acquired cystic lesions not delineated by a true epithelial wall. They represent the majority of the splenic cystic lesions, corresponding to approximately 80% of them (c.f. splenic epithelial cysts). The main causes are: splenic trauma splenic infarction locoregional inflammation: e.g. intrasplenic pancreatic pseudocyst Epidemiology They are thought to account for 80% of benign non-parasitic cysts of the spleen 2. Clinical presentation Splenic pseudocysts, similarly to the splenic epithelial cysts, are mostly asymptomatic, with symptoms presenting only when they are big enough to cause some significant local mass effect 2. Pathology They are acquired lesions and, regardless if due to trauma or infarction, represent the end stage of splenic injury resultant liquefactive necrosis and cystic changes. Microscopically, there is no lining epithelium 1,2. Radiographic features Ultrasound Usually present as well defined cystic lesions with heterogeneous content due to the presence of echoes (e.g. haematic debris). CT Typically shows a hypoattenuating (water-attenuated) relatively well-defined intrasplenic lesion. The margins are thin and have a sharp demarcation to the splenic parenchyma. Calcification may be present in the fibrous wall. There is no rim or internal enhancement. MRI Well-defined cystic lesions with an internal fluid signal intensity that may vary from completely homogeneous to heterogeneous, depending on the presence of haemorrhagic or proteinaceous content: T1: variable T2: very high signal intensity Treatment and prognosis Small and asymptomatic cysts do not require treatment or followup. Symptomatic cysts may be managed surgically or percutaneously drained 2. Complications Complications are rare and include haemorrhage, rupture and infection 2. Differential diagnosis A number of splenic lesions may appear cystic, depending on the modality: primary splenic cysts (~20% of all splenic cysts) infection splenic hydatid cyst splenic bacterial abscess other congenital cystic lesions (tend to be unilocular in a majority of cases) splenic lymphangioma splenic haemangioma cystic splenic metastases

Answer 5

* Splenic Epidermoid Cysts * CTC p221 * second most common cystic lesion in the spleen * Congenitial in origin * As a point of absolutely worthless trivia - they are true cysts and have an epithelial lining * They typically grow slowing and are usually around 10cm at the time of discuovery * They can cause symptoms if they are large enough * They are solitary 80% of the time and have peripheral calcs 25% Multiple hypodense splenic lesions: 19 mm lesion in the inferior anterior spleen corresponding to simple cyst demonstrated on ultrasound. 49 mm lesion in the mid spleen (HU 26), as demonstrated on ultrasound 12 mm lesion in the anterior superior spleen (HU 45) 34 mm lesion in the subcapsular superior spleen (HU 23) 16 mm lesion in the posterior superior spleen (HU 33) The liver, adrenal glands, kidneys, pancreas and bowel including appendix are unremarkable. No free intra abdominal fluid or air identified. Minor dependant lung changes in image bases. The appendix is normal in appearance. Prominent right hilar fossa and para-aortic lymph nodes measuring at the upper limits normal. Conclusion Multiple hypodense splenic lesions are non-specific in appearance on CT criteria. Their density is not of simple cysts however there is no rim enhancement to suggest an abscess. Review of the recent US suggests these lesions likely to reflect epidermoid cysts. Retrospective correlation with an external CT from a year ago shows these lesions to be unchanged, confirming the diagnosis of epidermoid cysts. Case Discussion Epidermoid cysts are a relatively common cause of benign non-infective cystic lesions of the spleen. They are congenital, rarely become symptomatic or complicated and usually present incidentally. In this case, the presentation of fever and recent overseas travel made splenic abscess more concerning but correlation with previous imaging (before the travel) showed the lesions were unchanged. Splenic cyst Dr Ammar Haouimi◉ and Assoc Prof Frank Gaillard◉◈ et al. Splenic epithelial cysts, also referred as splenic epidermoid cysts or primary splenic cysts, are unilocular fluid lesions with thin and smooth walls and no enhancement. They represent ~20% of cysts found in the spleen, and are usually an innocuous incidental imaging finding. Note that most (~80%) simple-appearing cystic splenic lesions represent secondary cysts or pseudocysts (see Differential diagnosis section below). Terminology In practice, both primary and secondary cysts are often described simply as "splenic cyst" for the sake of simplicity, as often the specific aetiology is not evident. Epidemiology They are thought to account for 20% of benign non-parasitic cysts of the spleen 5,8. There may be an increased female predilection. Clinical presentation The clinical presentation can vary ranging from being incidentally discovered on routine imaging to having nausea, vomiting, vague abdominal pain or rarely painful splenomegaly, particularly when the cysts are large. Pathology They are congenital in origin. As “true” cysts, they have an epithelial lining formed secondary to the unfolding of peritoneal mesothelium or collections of peritoneal mesothelial cells trapped within the splenic sulci. A genetic defect of mesothelial migration is considered the cause. While most are sporadic, rarely there is a familial occurrence. They typically grow slowly and are usually large (around 10 cm) at the time of discovery. They are solitary in 80%. Peripheral calcifications are uncommon (10-15%). Radiographic features Ultrasound Usually shows an anechoic to hypoechoic well defined intrasplenic lesion. Internal echoes may be present due to debris. Their margin may be echogenic with distal shadowing due to calcifications 8. CT Typically shows a hypoattenuating relatively well-defined intrasplenic lesion. The wall is thin and has a sharp demarcation to the splenic parenchyma. There is no rim or internal enhancement. Wall calcification may be present. MRI Well-defined cystic lesions with internal homogeneous fluid signal intensity: T1: low signal intensity T2: very high signal intensity Treatment and prognosis Small and asymptomatic cysts do not require treatment or followup. Symptomatic cysts are managed surgically. Complications Complications are rare and include haemorrhage, rupture and infection 6,7. Differential diagnosis A number of splenic lesions may appear cystic, depending on the modality: secondary cysts (~80% of all splenic cysts)splenic pseudocysts post-traumatic pseudocyst: the end-stage of splenic haematoma with resultant liquefactive necrosis and cystic changes post-infarction pseudocyst: also resultant from liquefactive necrosis intrasplenic pancreatic pseudocyst infection splenic hydatid cyst other congenital cystic lesions (tend to be unilocular in a majority of cases) splenic lymphangioma splenic haemangioma splenic bacterial abscess cystic splenic metastases splenic lymphoma: although may appear nearly anechoic, hypoechoic lymphoma tends to have less distinct margins than a cyst 10 splenic peliosis 11,12

Answer 6

Hydatid/echinococcal cysts * CTC p221 * third most common cystic lesion in the spleen. * Caused by echinococcus granulosus * Hydatid cysts consist of a spherical mother cyst that usually contains smaller daughter cysts. * Internal septations and debris are often referred to as 'hydatid sand' * water lily sign is seen when there is detachment of the endocyst membrane, resulting in floating membranes within the pericysts * this was classically described on CXR in pulmonary echinococcal disease

Answer 7

Splenic Haemangioma * CTC p221 * The most common benign neoplasm in the spleen * this dude is usually smooth and well marginated demonstrating contrast uptake and delayed washout. * The classic peripheral nodular discontinuous enhancement seen in hepatic lesions may not occur. especially if the tumour is smaller than 2 cm. CT scan of the abdomen at the arterial phase reveals peripheral enhancement of the splenic lesion with subsequent fill-in in the delayed phases. Splenic haemangioma Dr Mohammad Taghi Niknejad and Dr Yuranga Weerakkody◉ et al. Splenic haemangiomas, also known as splenic venous malformations, splenic cavernous malformations, or splenic slow flow venous malformations, while being rare lesions, are considered the second commonest focal lesion involving the spleen after simple splenic cysts 5,12 and the most common primary benign neoplasm of the spleen 6. They are usually found incidentally and have imaging appearances similar to hepatic haemangiomas. Please refer to the main article for a general discussion on cavernous venous malformation. Terminology It is important to note that according to newer nomenclature (ISSVA classification of vascular anomalies) these lesions are merely known as slow flow venous malformations. Having said that it is probably helpful in reports to include the word 'haemangioma' as this term is ubiquitous in the literature and most familiar to many clinicians. The remainder of this article uses the term 'splenic haemangioma' for consistency with the majority of the existing literature. Epidemiology Their autopsy prevalence rate is thought to range around 0.1-14% 7,8,13. Most haemangiomas tend to be discovered in adults from the mid-30s to the mid-50s years of age 8. Clinical presentation The vast majority are asymptomatic and are incidentally discovered. Occasionally they may be associated with splenomegaly, abdominal pain, dyspnoea, diarrhoea, or constipation [ref needed]. Pathology Splenic haemangiomas are comprised of non-encapsulated non-neoplastic vascular channels of varying sizes ranging from capillary to cavernous, containing slow flowing blood. These vessels are lined with a single layer endothelium 2,8. Associations splenic haemangiomatosis: the presence of multiple splenic haemangiomas splenic manifestations of a systemic angiomatosis syndrome such as Klippel-Trénaunay-Weber syndrome Beckwith-Wiedemann syndrome Radiographic features Most lesions tend to be small in size (\< 2 cm 12). Calcification if present, either central punctate or peripheral curvilinear, can be detected on radiographs or CT scans. Ultrasound Haemangiomas can have a variety of sonographic appearances depending on their exact histological composition (i.e. hypo, iso or hyperechoic). The dominant pattern, however, is considered to be a homogeneous echotexture that is predominantly hyperechoic 11. usually does not demonstrate any intrinsic colour flow (~80% of cases) 11,13 contrast-enhanced ultrasound: isoechogenicity to splenic parenchyma in all phases is the most frequent typical enhancement pattern of splenic haemangiomas observed on contrast-enhanced sonography 11 CT Unenhanced CT scans can show a low-attenuation mass; following IV contrast, the vascular channels show centripetal fill (from the periphery inward). Larger lesions can fill more slowly and may do so incompletely and inhomogeneously 2. MRI Reported signal characteristics of most haemangiomas are similar to hepatic haemangiomas and are 6,10: T1: iso to hypo-intense to normal splenic parenchyma T2: hyperintense to splenic parenchyma T1 C+(Gd) most demonstrate early nodular centripetal enhancement and uniform enhancement at delayed imaging smaller lesions may, however, show homogeneous enhancement on immediate post-contrast acquisitions remaining enhanced on delayed images 12 Nuclear medicine Nuclear imaging with 99mTc labelled red cells shows slow accumulation of activity in the lesion followed by slow washout. Nuclear scans with 99mTc labelled sulfur colloid usually show a photopenic defect due to the radionuclide accumulation being restricted to functional splenic tissue. Treatment and prognosis They are benign lesions and carry no malignant potential. Their natural course is very slow growth over time 8. Haemangiomas are generally not treated unless they are symptomatic or very large, with an increased risk of haemorrhage; treatment then is usually a splenectomy. Complications hypersplenism 13 spontaneous rupture with haemorrhage is a risk with larger lesions in some patients, they may cause the Kasabach-Merritt syndrome 8 malignant degeneration (rare) 13

Answer 8

Splenic lymphangioma * rare entities in the spleen but can occur. * usually in childhood * may be solitary or multiple * usually in a subcapsular location * diffuse lymphangiomas may occur. Dr Mostafa El-Feky◉ and Dr Carolina Kachramanoglou et al. Splenic lymphangiomas are relatively rare benign tumours that correspond to abnormal dilatation of lymphatic channels that can be either congenital or acquired. On imaging, they usually present as lobulated and multiloculated cystic lesions without solid component or significant enhancement. For a general discussion on this topic, please refer to the parental article on lymphangioma. Epidemiology Most occur in children, were rarely reported in adults 2. Clinical presentation Presentation ranges from asymptomatic incidental finding to a large multicentric, symptomatic mass requiring surgical intervention. May occur alone on spleen or as part of a systemic lymphangiomatosis 2. Pathology The cysts are thought to be formed by abnormal dilatation of lymphatic channels; this can be congenital or acquired. Cysts tend to be subcapsular and multilocular but can be unilocular. The cyst wall and septa are composed of thin bands of fibrous tissue lined by bland endothelium, the nature of which can be confirmed on immunohistochemistry using endothelial markers (CD31, podoplanin); this may be necessary to rule out a cystic epithelial lesion. The fibrous cyst walls/septa can show focal calcification. Radiographic features Ultrasound Appear as well defined round hypoechoic lesions and may show occasional internal septation and intralocular echogenic debris 3. Tiny echogenic calcifications may be present. CT They appear as single or multiple thin-walled low attenuation masses with sharp margins that are typical subcapsular in location. They are hypodense with no enhancement. The presence of curvilinear peripheral mural calcifications suggests the diagnosis of cystic lymphangioma1,2. MRI T1: hypointense relative to the surrounding viscera. High T1 signal intensity may occur with internal bleeding or large amounts of intracystic proteinaceous content T2: multiloculated hyperintense areas that correspond to the dilated lymphatic spaces. The intervening septa appear as hypointense bands, corresponding to the presence of fibrous tissue T1 C+ (Gd): no significant enhancement See also splenic lesions and anomalies lymphangioma References

Answer 9

Splenic lymphangioma Dr Mostafa El-Feky◉ and Dr Carolina Kachramanoglou et al. Splenic lymphangiomas are relatively rare benign tumours that correspond to abnormal dilatation of lymphatic channels that can be either congenital or acquired. On imaging, they usually present as lobulated and multiloculated cystic lesions without solid component or significant enhancement. For a general discussion on this topic, please refer to the parental article on lymphangioma. Epidemiology Most occur in children, were rarely reported in adults 2. Clinical presentation Presentation ranges from asymptomatic incidental finding to a large multicentric, symptomatic mass requiring surgical intervention. May occur alone on spleen or as part of a systemic lymphangiomatosis 2. Pathology The cysts are thought to be formed by abnormal dilatation of lymphatic channels; this can be congenital or acquired. Cysts tend to be subcapsular and multilocular but can be unilocular. The cyst wall and septa are composed of thin bands of fibrous tissue lined by bland endothelium, the nature of which can be confirmed on immunohistochemistry using endothelial markers (CD31, podoplanin); this may be necessary to rule out a cystic epithelial lesion. The fibrous cyst walls/septa can show focal calcification. Radiographic features Ultrasound Appear as well defined round hypoechoic lesions and may show occasional internal septation and intralocular echogenic debris 3. Tiny echogenic calcifications may be present. CT They appear as single or multiple thin-walled low attenuation masses with sharp margins that are typical subcapsular in location. They are hypodense with no enhancement. The presence of curvilinear peripheral mural calcifications suggests the diagnosis of cystic lymphangioma1,2. MRI T1: hypointense relative to the surrounding viscera. High T1 signal intensity may occur with internal bleeding or large amounts of intracystic proteinaceous content T2: multiloculated hyperintense areas that correspond to the dilated lymphatic spaces. The intervening septa appear as hypointense bands, corresponding to the presence of fibrous tissue T1 C+ (Gd): no significant enhancement

Answer 10

Splenic hamartoma Splenic hamartomas are very rare lesions commonly found incidentally on imaging. They are most often solitary but may be present as multiple nodules in patients with **tuberous sclerosis or Wiskott-Aldrich syndrome.** Terminology The recently-described sclerosing angiomatoid nodular transformation (SANT) of the spleen, a non-neoplastic vascular entity named in 2004 5 may be a fibrosing variant of splenic hamartoma 6. Epidemiology Splenic hamartomas are very rare, with only 3 described in a series of 200,000 splenectomies. Clinical presentation Hamartomas are normally an incidental finding at imaging, surgery or autopsy. They can occur in any age group. Symptoms occur from mass effect if they grow large. Pathology Hamartomas are solitary or multiple, round, well-circumscribed, unencapsulated bulging nodules compressing the adjacent normal splenic parenchyma and compounded by a mixture of normal splenic structures such as white and red pulp. Focal fibrosis and cystic areas can be seen. The pathological differential diagnosis includes haemangioma, Littoral cell angioma, lymphangioma, haemangioendothelioma, sclerosing angiomatoid nodular transformation (see terminology), angiosarcoma. A definite diagnosis can be difficult due to the overlap of features, however, positivity for CD8 is a key feature that differentiates hamartoma from other vascular lesions of the spleen. Radiographic features As hamartomas represent a focal disorganised overgrowth of splenic parenchyma, they tend to have similar echogenicity, attenuation, and signal intensity to the background normal parenchyma 7. Ultrasound Most splenic hamartomas are hypoechoic solid masses but can be heterogeneous due to haemorrhage or cystic changes 7. They are hypervascular on colour Doppler ultrasound and post-contrast administration. CT On computed tomography, hamartomas appear as isodense or hypodense solid masses and demonstrate heterogeneous contrast enhancement relative to the adjacent normal parenchyma. MRI MRI is the preferred imaging technique for the differentiation of hamartomas from haemangiomas, showing: T1: most lesions are isointense T2: most lesions are heterogeneously hyperintense T1 C+ (Gd): it is typical to show vivid enhancement on immediate post-contrast images (key features in the differentiation between hamartomas and haemangiomas) on delayed postcontrast images, hamartoma enhances in a relatively uniform and intense fashion +/- with central hypovascular areas Differential diagnosis Possible differential considerations include splenic haemangioma splenic lymphangioma lobulated multiseptated cystic mass without solid enhancing components may have walls, septa, linear calcifications inflammatory myofibroblastic tumour 8 References

Answer 11

Littoral cell angioma of the spleen Dr Francis Deng◉ and Radswiki◉ et al. Littoral cell angioma of the spleen is a rare, benign primary vascular tumour of the spleen. Epidemiology Littoral cell angiomas may occur at any age and have no gender predilection. Associations Littoral cell angiomas have been diagnosed in association with various malignancies outside the spleen 10,12. The condition has also been linked to Crohn disease 13,14. Clinical presentation The lesion is often detected incidentally in asymptomatic patients. Symptomatic patients may present with abdominal pain, splenomegaly on physical examination, and/or laboratory evidence of hypersplenism including anaemia and thrombocytopenia. Pathology Littoral cell tumours arise from the littoral cells lining the sinusoids of splenic red pulp. Littoral cell angiomas are the benign type, as opposed to the less common, low-grade malignant littoral cell haemangioendothelioma and the rare and aggressive littoral cell angiosarcoma 9. Macroscopic appearance The spleen is enlarged with multiple nodules, the colour of which varies by age of blood products 7. Microscopic appearance Histopathology demonstrates a proliferation of anastomosing vascular channels congested with blood and lined with tall endothelial cells that show hemophagocytosis 7,8. Immunophenotype The tumour cells express both vascular endothelial markers (such as CD31 and factor VIII) and histiocytic markers (such as CD68) 7,8. Radiographic features Imaging usually demonstrates splenomegaly and multiple mass lesions. CT The masses are hypoattenuating compared to normal spleen 2-8. They demonstrate progressive homogeneous contrast enhancement, later than normal splenic parenchyma 2. MRI The masses are often low in T1 and T2 signal intensity due to haemosiderin 7. Treatment and prognosis As many patients are symptomatic and imaging findings are non-specific, splenectomy is usually performed for definitive histological diagnosis and treatment. Littoral cell angiomas are considered benign. Differential diagnosis The imaging differential includes metastases lymphoma sarcoidosis other primary splenic vascular tumours, such as haemangioma, hamartoma, haemangioendothelioma, angiosarcoma

Answer 12

Angiosarcoma of the spleen Dr Ammar Haouimi◉ and Dr Yuranga Weerakkody◉ et al. Angiosarcomas of the spleen are rare malignant splenic neoplasms. The term is usually given to describe a primary angiosarcoma of the spleen although angiosarcoma elsewhere can also rarely metastasise to the spleen. **Despite its absolute rarity, a splenic angiosarcoma is considered the most common primary non-hematolymphoid splenic malignancy 2,17.** Epidemiology The general consensus is that there is no recognised gender predilection (occurs almost equally in females and males) 1,17. Occasional publications, however, suggest a slight male predilection 4. Commonly seen in older patients, with the peak incidence is thought to be around the **6th decade.** Clinical presentation Clinical symptomatology can be highly variable, often posing difficult diagnostic problems. Pathology Macroscopic examination often shows splenomegaly with cut sections revealing discrete lesions in a majority of cases. These can range from well-circumscribed firm nodules to poorly delineated foci of necrosis and haemorrhage associated with cystic spaces. Microscopically, the tumours are often heterogeneous. The lesions typically demonstrate focal vasoformative component lined by atypical endothelial cells. Solid sarcomatous, papillary, and epithelioid growth patterns can be observed. Associations Unlike with primary hepatic angiosarcoma, there is no known association between splenic angiosarcoma and occupational exposure to chemicals, such as vinyl chloride or arsenic, or prior injection with the contrast agent thorium dioxide 4. Radiographic features Ultrasound Reported sonographic features include splenomegaly with largely heterogeneous echotexture, including cystic and solid components 4,17. Increased vascularity on Doppler is commonly present 17. CT CT may show solitary or multiple nodular masses of heterogeneous low attenuation in an enlarged spleen; necrosis and haemorrhagic areas may account for the heterogeneity 17. There is generally irregular and poorly defined contours 16. Occasional large subcapsular intrasplenic or perisplenic extracapsular blood collections (haemoperitoneum) may be present. Some of these masses may show peripheral enhancement with the margins of the lesions often irregular or poorly defined. Less frequently, CT scans may show a moderate splenomegaly with a micronodular involvement of the organ 16. pre-contrast CT: the tumours may appear hyperattenuating due to components of acute haemorrhage dynamic contrast-enhanced CT scans: the lesions may exhibit substantial peripheral contrast enhancement similar to that of hepatic haemangiomas 4 MRI Reported MRI features include: T1 and T2: nodular hypointense (relative to the normal adjacent splenic parenchyma) masses on both T1- and T2-weighted images large masses with increased signal intensity on both T1- and T2-weighted images that are likely related to areas of subacute haemorrhage, as well as tumour necrosis areas of decreased signal intensity within the tumour, owing to chronic haemorrhage with haemosiderin deposition C+ (Gd): usually shows intense and multinodular (heterogenous 15) enhancement with focal areas of non-enhancement, likely representing intratumoural haemorrhage and necrosis Treatment and prognosis It is an extremely aggressive fatal neoplasm at is almost universally fatal (median survival at approximately 24-36 months at the time of initial writing11) despite treatment 3,5. **Distant metastases occur most frequently in the liver (approximately 70% of cases), lung, pleural lymph nodes, bone, and brain. Prompt splenectomy prior to splenic rupture may improve survival 5.** **Complications** **spontaneous splenic rupture 2,4: can occur in up to 30% of cases 4** History and etymology It was first described in 1879 by T Langhans 1. Differential diagnosis General imaging differential considerations include vascular splenic lesions such as: splenic haemangioma Littoral cell angioma of spleen lymphangioma of spleen haemangiopericytoma of spleen See also angiosarcoma - general splenic lesions and anomalies

Answer 13

Splenic lymphoma Splenic lymphoma, also termed as lymphomatous involvement of the spleen, represents the most common malignancy to involve the spleen. They are commonly secondary, rarely being primary (referred as primary splenic lymphoma). This article focuses on the location-specific primary and secondary lymphomas involving the spleen, for a broader and systemic discussion, please refer to the main article on lymphoma. Epidemiology The spleen is involved in about 30% of all Hodgkin lymphoma and 30-40% of patients with systemic non-Hodgkin lymphoma (NHL) 2,4. The primary splenic lymphoma is rarer, representing about 2% of all lymphomas 2. Clinical presentation Lymphoma can often present with B symptoms (fever, night sweats and weight loss 3), please refer to the main article for further discussion in the systemic presentation. Both primary and secondary splenic lymphoma may cause left upper quadrant pain 3. Pathology Primary splenic lymphomas are in general due to diffuse large B-cell lymphoma (DLBCL) 4. Please refer to the main article on lymphoma for further discussion in the secondary involvement of the spleen. Radiographic features Splenomegaly is perhaps the most common manifestation on imaging, but a normal size spleen does not exclude lymphoma involvement 2,3. The most common criteria to determine splenomegaly on imaging is the measurement of the organ craniocaudal height, which is considered normal when less than 13 cm 4. Associated enlarged splenic hilum lymph nodes may be seen either in the primary or secondary forms. The secondary form will show signs of disease involving other organs and systems, particularly nodal disease. Ultrasound The focal disease may manifest as small circumscribed nodules, sometimes referred as a milliary pattern, or bulky splenic masses 2 and, generally, these are hypoechogenic on ultrasound. A diffuse infiltrative disease is usually only characterised as an enlarged spleen 3. CT post-contrast images: the focal lesions are hypoenhancing compared to the background parenchyma and they are best appreciated in a late venous phase, particularly when the lesions are small 4 calcification of the splenic lesions is uncommon but might be seen after treatment 4 MRI Single or multifocal disease will present as well-defined masses 1-2: T1: low to iso-intensity compared to the background parenchyma T2: low to iso-intensity compared to the background parenchyma T1 C+ (Gd): focal lesions will have a mild or absent enhancement compared to the background parenchyma (hypo enhancing lesions) 2,3 DWI: relatively low ADC values inferring diffusion restriction 3 Nuclear medicine PET-CT (18F-FDG) PET has become the imaging modality of choice to stage and follow-up of Hodgkin and aggressive forms of NHL disease 4. Splenic lymphoma can manifest on PET either as a diffusely FDG-avid spleen, in cases of a diffuse infiltrative disease, or as single or multiple FDG-avid focal splenic lesions 4.

Answer 14

Metastatic disease to the spleen this is rar. when it does occur it occurs via common things breast lung melanoma - the most common primary neoplasm to the spleen.

Answer 15

the pancrease is involved in 85-90% of CF patients/ Inspissated secretions cause proximal duct obstruction leading to the two main changes in CF. 1. fibrosis 2. fatty replacement (more comomn of the two) pts with CF who are diagnosed as adults tend to have more pancreas problems than those dx as children those with redisdual pancreatic exocring function tend to have bouts to recurrent acute pancreatitis as they keep getting clogged up with thick secretions small 1-3mm pancreatic cysts are common complete fatty replacement is the most common finding in adult CG

Answer 16

* Follows blood pool

Answer 17

on USS can be difficult to see. Central stellate spokewheel appearance Legion enhances from the centre out wards.

Answer 18

Actively transported into the hepatocyte.

Answer 19

no think HCC if there is central wash out or liver met.

Answer 20

dark on HBP

Answer 21

cystic met

Answer 22

Intrahepatic CholangioCa.

Answer 23

can be fat rich or fat poor (cf. Renal AMLs)

Answer 24

Fibrolammellar HCC

Answer 25

* GIST is the most common mesenchyma neoplasm of the GIT and is defined by its expression of KIT (CD117). * KIT = Tyrosine kinase inhibitor. Responds to Gleevec (a KIT tyosine kinase inhibitor) * Differentiates it from other types of mesenchymal tumours includeding * leiomyomas * leiomyosarcomas * schwannomas * neurofibromas * Stomach most common site 70%. * Small intestine 20-30% * anorectum 7% * Patients with NF 1 have increased prevalence of GIST - often multiple small ones. * PATHOLOGY: * arises from the interstitial cells of cajal which are pacemaker cells that drive peristalsis. * May be benign or malig. * Increased size = increased chance of malignancy * Increased mitoses = increased chance of malignancy * DDx * submucosal Gastric mass * mesenchymal tumours * GIST * Fibroma * lipoma * Neurofibroma * Carcinoid * ectopic pancreatic rest.

Answer 26

Case Discussion The Torricelli-Bernoulli sign, in this case, denotes an air-fluid level in the ulcer crater due to trapping of air when the patient changes position from upright to supine. Case courtesy of Dr Yair Glick, Radiopaedia.org, rID: 67049

Answer 27

* Liver * Lymphoma: LAD is not common in GIST. if LAD is present consider alternate dx of Lymphoma. * PET is a sensitive modality for follow up of patients on Tx.

Answer 28

* Gastric **Leiomyosarcoma/GIST** * **Extraadrenal paraganglioma** * **Pulmonary chondroma** Carney triad Dr Bahman Rasuli◉ and Assoc Prof Frank Gaillard◉◈ et al. Carney triad is a rare syndrome defined by the coexistence of three tumours: extra-adrenal paraganglioma (e.g. spinal paraganglioma) initially, only functioning extra-adrenal paragangliomas were included, but subsequent work includes non-functioning extra-adrenal paragangliomas 1 gastric gastrointestinal stromal tumours (GIST) pulmonary chondroma CARNEY Triad In most cases, only 2 of the 3 tumours are present at the time of diagnosis. It typically affects young people. Terminology It is not to be confused with the related Carney-Stratakis syndrome, or the unrelated Carney complex History and etymology First described by J Aidan Carney, an American professor of pathology, and colleagues in 1977 5.

Answer 29

1. Leiomyoma: most common benign tumor. May ulcerate. 10% malignant. In picture. 2. Lipoma 3. fibroma 4. schwannoma 5. hemangioma 6. Lymphangioma 7. Carcinoid (malignant transformation 20%) Gastric leiomyoma Dr Bruno Di Muzio◉◈ et al. Gastric leiomyomas are rare benign mesenchymal tumours, usually asymptomatic and found incidentally. Clinical presentation Most leiomyomas are found incidentally in asymptomatic patients. Symptoms related to a gastric leiomyoma will depend on the tumour size, location, and presence/absence of ulcerations. Larger tumours are more prone to have associated ulcerations and thus cause bleeding, which can manifest clinically as haematemesis, melaena, and iron-deficiency anaemia. Epigastric discomfort or pain has also been reported in those symptomatic patients 3. Pathology Gastric leiomyomas are tumours of moderate cellularity that originate from the muscular propria or lamina muscularis mucosae of the stomach. They are characterised by bundles of spindle cells with eosinophilic cytoplasm 3,4. Although most tumours have an endoluminal growth, two other patterns have been described: intramural/mixed (dumbbell-shaped) and exophytic 1,3. Immunohistochemistry Gastric leiomyomas are negative for c-kit and CD34, cf. GIST which is positive for both 2. Leiomyomas are positive for desmin and smooth muscle actin 3. Radiographic features CT It usually presents as a well-defined solid mass with smooth contours and showing low homogeneous contrast enhancement 1,2,4. Calcifications, intratumoural haemorrhage, and cystic degeneration are rare 2. Complications Complications are rare and may include 5 haemorrhage (haematemesis, melaena) obstruction fistulisation / perforation malignant degeneration (exceptional) Differential diagnosis Consider: gastrointestinal stromal tumour (GIST) main differential diagnosis to consider on imaging heterogeneous attenuation and enhancement due to central areas of necrosis, haemorrhage, or cystic degeneration gastric schwannoma gastric lipoma Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 59038

Answer 30

* Malignant ulcer: folds short of collar * ulcerated luminal mass * rigidity, diffuse narrowing: Linitis plastica * THickened wall ? 1cm by CT * LAD * gastrohepatic ligament * GaSTREOCOLIC LAIGAMENT * PERIGASTRIC NOES * HEPATIC METS Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 74769 Linitis plastica Dr Mohammad Taghi Niknejad◉ and Assoc Prof Frank Gaillard◉◈ et al. Linitis plastica is a descriptive term usually referring to the appearance of the stomach, although the rectum can also be described this way. The appearance is said to be reminiscent of an old leather water-bottle. Pathology The underlying cause is usually a scirrhous adenocarcinoma with diffuse submucosal infiltration, leading to thickening and rigidity to the stomach wall 2. It is important to realise that as the infiltration is submucosal, gastric biopsies are frequently negative 2. Radiographic features Fluoroscopy During a barium meal, the stomach cannot be adequately distended due to the increased rigidity of the wall with only a narrow lumen identified. The normal mucosal fold pattern is absent, either distorted, thickened, or nodular 2. CT Typically the stomach is diffusely thickened with a small lumen. Evidence of nodal involvement or widespread metastatic disease should also be sought. Differential diagnosis Whether you define linitis plastica as only the appearance of the stomach, irrespective of cause or use it only in the setting of infiltrating adenocarcinoma of the stomach is up to you, but be aware that there does not appear to be general agreement. Thus the cause of linitis plastica are also the differential, and include 4,5: neoplastic gastric adenocarcinoma (scirrhous) metastases breast lung lymphoma: less rigid diffuse gastric diverticula (rare) 6 inflammatory radiotherapy eosinophilic enteritis granulomatous disease Crohn disease tuberculosis sarcoidosis scarring (e.g. ingestion of corrosives) gastric amyloidosis History and etymology Etymology: linitis means inflammatory change, plastica means inelastic, not pliable. The term was coined by William Brinton (1823-1867) in 1854. Hence the disease is also unsurprisingly called Brinton disease.

Answer 31

* 3% of all malignancies * NHL more common than HL * Primary Gastric lymphoma * arises from lymphatic tissue in the laminal propria mucosae. * 10% * Usually originates from muycose associated lymphoid tissue (MALT lymphoma) * Secondary Gastric Lymphoma * Gastric involvement in generalised lymphoma 90%

Answer 32

1. H pylori infection 2. Inflammatory bowel disease 3. celiac disease

Answer 33

* diffuse infiltrating sdisease * the normal gastric wall thickness should be 2-5mm when distended \> 6mm is abnormal * Thickend folds * ulcerating mass * Lymphomas tend to spread across the pylorus into the duodenum more than carcinomas HL of the stomach mimics Scirrhous carcinoma as there is a strong desmoplastic reaction.

Answer 34

* **Organoaxial** * rotation around the long axis of the stomach * stomach rotates 180 degrees so that the greater curvature is cranially located * ie upside-down stomach * seen in adults with large hiatal hernia * complications are rare * **Mesenteroaxial in Picture.** * stomach rotates along its short axis * Funduss is caudal to antrum * more common when large portions of the stomach are above diaphragm ie traumatic diaphragmatic rupture in children. * Obstruction and ischaemia likely.

Answer 35

* dilated peripheral branches of short gastric and left gastric veins. * appear as serpentine, nodular folds in body or fundus or as polyploid filling defects in the fundus. * Gastric varices are commonly a/w esophageal varices, * the combination is often due to portal hypertension * Gastric varices **without** oesphageal varices are often caused by SPLENIC VEIN OBSTRUCTION are are most commonly secondary to **pancreatitis** or **pancreatic Carcinoma.** ## Footnote **Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 83760**

Answer 36

* Trauma from endoscopy * infection * ischemia * increased intraluminal pressure * vomiting * spontaneous or traumatic rupture of a pulmonary bulla into areolar tissue surrounding the esophagus * in the absence of underlying disease.

Answer 37

* Major Papillae * vater papilla * orifice for ducts * appears as a round filling defect located below the promontory * \8-10mm in length * abnormal if \>15mm * Minor papilla * Accessory papilla * 'Santorini papilla' * Located superiorly and ventral to the major papilla * mean distance from major papilla is 20mm * not usually visualized * Promontory * shoulder like luminal projection along medial aspect of the second portion of the duodenum * begins superior to the majorpapilla

Answer 38

* DU's are 2-3 times more common than gastric ulcers. * All bulbar duodenal ulcers are considered benign. * Postbulbar or multiple ulcers raise the suspicion for zollinger ellison syndrome.

Answer 39

* Bulbar 95% * anterior wall: most common site. Perforate. * Posterior wall: penetration into panccrease * Post Bulbar 5%. * Risk factors * COPD * Severe stress * injury * surgery * burn * Steroids *

Answer 40

Imaging features * persistent round or elliptical collection * radiating folds * spasm * linear ulcers 25%. * Kissing ulcers: 2 or more ulcers located opposite each other * Giant ulcers * Crater is \>2cm * Ulcer largely replaces the duodenal bulb * A large ulcer crater may be mistaken for a deformed bulb but does no change shape during fluoroscopy. * DU's often heal with a scar, this can lead to deformity and contraction of the duodenal bulb * Clover leaf deformity * hour glass deformity * Post bulbar ulcers any ulcer distal to the first portion of the duodenum should be considered to have underlying malignancy until proved otherwise * only 5% are benign ulcers, mostly secondary to ZES.

Answer 41

* the duodenum is immobile in the retroperitoneum, most perforations occur there. * mortality of untreated duodenal rupture is 65%.

Answer 42

* perforation * extraluminal retroperitoneal gas * Extravasation of oral contrast material * Perforation or hematoma * thickening of the duodenal wall or high-density mass (clotted blood) can narrow the lumen * Fluid in right anterior pararenal space or in the peritoneum * duodenal diverticula commonly project into the head or uncinate process of pancreas and really present coming from lateral wall. * Figure 39A: Axial noncontrast CT image of the upper abdomen demonstrates a large, heterogeneous intraluminal mass in the second and third portions of the duodenum, compatible with a hematoma (arrow). There are regions of internal hyperdensity, indicating acute hemorrhage.

Answer 43

* More common than malignant tumours 1. lipoma 2. leiomyoma (most common) 3. villous adenoma (cauliflower like) 4. adenomatous polyp 5. lymphoid hyperplasia 6. Heterotopic gastric mucosa * small angular filling defects in the bulb, larger than nodules of lymphoid hyperplasia and smaller than Brunner gland hyperplasia 7. Brunner gland hyperplasia 8. ectopic pancreas

Answer 44

* anatomic variant characterised by movement of gastric mucosa bulging into the base of the duodenal bulb. No pathological significance * lubulated stellating filling dect in the duodenal bulb. * filling defect in contiguity with antral regal folds

Answer 45

* Malignant tumours of the duodenum are infrequent. * the most common locations of malignant tumours are in the periampullary and infraampullary areas * TYPES * adenocarcinoma (most common) * leiomyosarcoma * lymphoma * mets * benign tumours with malignant potential * villous polpys * adenomatous polps * carcinoid.

Answer 46

* Immeadiate complications * anastomotic leak * abscess * gastric outlet obstruction secondary to oedema * bile reflex gastritis * ileus * Late complications * bowel dysmotility * dumping * postvagotomy hypotonia * ulcer * bowel obstruction * outlet obstreuciton * adhesions * stricture * Prolapse, intussusception * Gastric carcinoma * in 5% of patients 15 years after surgery * Bilroth II \> Billroth I * Metabolic effects: malabsorption * Afferent loop syndrome * small ouch syndrome

Answer 47

* Billroth I * Gastrectomy * Gastroduodenostomy * for Gastroduodenal ulcers * Billroth II * Gastrectomy * Gastrojejunostomy * For gastroduodenal ulcers or * Gastric cancer.

Answer 48

* Vagotomy * Types * Total gastrectomy * truncal vaotomy * selective vagotomy * parietal cell vagotomy * drainage procedures * To failitate gastric emptying after vagotomy Multiple surgical clips are seen along the lesser curvature of the stomach. Case Discussion This is the post-procedural appearance of a highly-selective vagotomy performed because of recurrent peptic ulcer disease in the 1980s. https://radiopaedia.org/cases/highly-selective-vagotomy

Answer 49

* pancreaticoduodenectomy * Gastrojejunostomu * cholodochojejunostomy * pancreaticojejunostomy

Answer 50

* Roux-en-Y * a small gastric pouch (\<30ml) and a small gastrojejunostomy (12mm) are constructed. * The remaining stomach is intact but functionally separate from the food pathway. * Complications * narrowing/stenosis * immediate postsurgical narrowing is common and often subsides * stenosis (lumen \<6mm) at \>6weeks after surgery is rare. * weight loss can be dramatic * Anastomotic leak * 1-6%. * core common after laparoscopic than open surgery. * commonly at the gastrojejunal anastomosis or at the enteroenteric anastomosis (both are life threatening) * Contrast material outside the confines of the gastric puch and anastomisis indicates a leak. * immediate surgical exploration is required. * Fistula * during surgery the gastric puch and remnant are separated. * oral contrast should not directly enter the gastric remant. * if there is contrast in the remnant, this indicates a gastric gastic fistula * contrast may been seen on small bowel follow thru in the excluded stomach bc of retrograde filling through the duodenum. * Internal Hernia * The most common herniation is the trasmesentertic (or transmesocolonic type which occurs through the dect in the transverse mesocolon * the herniated bowel is usually the Roux limb itself with a varying amount of additional SB loops. * Weight gain * degradation of pouch restriction: * very rapid passage of contrast through a patulous anastomoisis degrades the restrictive properties of the laparoscopic roux en Y gastric bypass, resulting in weight gain. * Gastrogastric fistula * uncommon * a fistulous tract arising from the ouch may opacify the excluded stomach and is thought to be a result of patient opvereating.

Answer 51

* Band placed too low in stomach * band not place around stomach * band place around esophagus which is undesirable because the sensation of satiety lacking and risk of perforation. * slippage of the band with upward herniation of stomach (late complication)

Answer 52

* The angle of the cuf with the spinal column (phi angle) should be 4-58 degrees on plain radiographs.

Answer 53

* an adjustable band is laparoscopically placed around the proximal stomach, creating a small upper pouch 2cm distal to the GOJ. * The cuff is connected to a reservoir placed in the anterior rectus sheath or subcutaneous tissues. * The reservoir allows adjustment of band diameter percutaneously.

Answer 54

* the left side (the greater curvature and fundus) of the stomach is surgically removed laparoscopically after staples are placed from the angle of His (angle formed as lateral border of oesophagus meets the medial morder of fundus) and the pylorus.

Answer 55

* Occult bleeding * recurrent obstrucitve symptoms * Malabsorption * Extent of Crohn disease.

Answer 56

1. Luminal Diameter * \>3cm abnormal 2. Fold thickness * valvulae conniventes 1-2mm * they are more prominent in the Jejunum than the illeum * \>3mm is abnormal 3. wall thickness * normal is 1-1.5mm 4. secretions * There should normally be no appreciable fluid in the SB * Excess secreations cause dilation of barium column.