Describe Ptosis of the liver
- Liver extends downward without being pathological
- It droops/sags but doesn't cross the psoas mc. or displace bowel gas
Define Hepatomegly and describe its appearance
- rounded inferior angle
- liver extends over psoas muscle/spine
absence of bowel gas in right abdomen (gas dislpaced to lower abdomen)
Define Splenomegaly and describe its appearance
Enlarged spleen extends below 12th rib, gastric air bubble displaced anteromedially
Can displace stomach centrally
List some possible causes of Organomegaly
- hematologic disorders
-ABNORMAL AIR PATTERNS-
In the bowel lumen:
What is normal/abnormal and what are some possible causes?
Normal: air in the large bowel and stomach
- > a few cms of small bowel gas
- 2-3 air-fluid levels
- small bowel > 3cm in diameter
- large bowel >8cm in diameter
Causes: Functional and mechanical causes of obstruction
-ABNORMAL AIR PATTERNS-
In the bowel lumen:
What is abnormal and what are some possible symptoms?
- (part) GI tract in wrong location
- Commonly seen with hiatal hernias
Chilaiditis’s sign / syndrome:
- Large bowel located between the liver and diaphragm.
- Usually asymptomatic
- Can be associated with abdominal pain, constipation, vomiting, respiratory distress
-ABNORMAL AIR PATTERNS-
Outside the bowel lumen:
What is abnormal, where can the air localise, and what does it indicate?
Abnormal: air in the abdominal cavity outside of the GI tract
Air can localize:
- in the wall of the bowel (pneumotosis intestinalis)
- In the peritoneal cavity (pneumoperitoneum)
- In the abdominal vasculature (hepatic, portal)
Indicates: serious bowel disease (ask if surgery)
What are the 4 catagories of Calcifications?
concretion = within a lumen (well marginated, laminated, faceted, solid, moveable)
conduit wall = within the wall of a tube (linear, parallel lines, may be continuous or discontinuous)
cyst wall = within the wall of a cyst or cyst-like structure (oval to round, thin walled calcification)
solid = within the substance of a mass (irregular, fragmented, solid, lobulated [mulberry, popcorn])
What do Gallstones contain?
varying combinations of:
- bile pigments
- and/or calcium carbonate
What % of Gallstone cases will calcify and what does this mean for imaging diagnosis?
- most require contrast study (cholycystography) or ultrasound
What % of Renal Stones will calcify and what symptoms present?
Asymptomatic uless migrated to ureter = very painful
What do you call stone filling a calyx and/or pelvis of kidney?
What is an Aortic Aneurysm?
Weakness in the vessel wall allowing for dilatation
What is an Aortic Aneurysm associated with, and what % will calcify?
Associated with: hypertensive disease
- Approx. 50% (pattern = conduit/cystic)
What shape/size can you expect to see in an Aortic Aneurysm?
- Diameter >3cm = aneurysm
- >5cm = surgical consult
What does a Vas Dereren's Calcification look like and what is it highly associated with?
Appearance: “V” shaped opacity in the pelvis
What are Fibroids, where are they commonly located, describe the size/shape and what can it affect?
Define: Solid calcification of a benign smooth muscle tumor - leiomyoma
Size/shape: single or multiple, small or large, central or at the periphery of the pelvic inlet
What is Achalasia and what are some secondary clinical manifestations?
Failure of relaxation of the gastrooesophageal sphincter due to a decrease or absence of the myenteric plexus = dilation of esophagus
- vomiting of undigested food
- malnutrition issues
What age do you expect Achalasia to present?
If you did a barium swallow on a patient with Achalasia what would you see?
dilated esophagus (varied size-duration)
- contrast may appear irregular (undigested food in the distal esophagus)
- distal esophagus is narrowed/tapered
What is a Sliding Hiatal Hernia and what are some clinical features?
- laxity of the phreno-esophageal membrane allows the cardia of the stomach to pass above the diaphragm
- esophagus should still above herniated portion of the stomach.
Clinically: most cases asymptomatic but can see signs of GERD due to sphincter disfunction,
What is a Paraesophageal Hiatal Hernia and what are some clinical features?
- cardia of the stomach stays below the diaphragm and a portion of the body or fundus passes through a defect in the phreno-esophageal membrane.
esophagus extends below the herniated portion of the stomach.
Clinically: potential for volvulus (surgery)
Define: tear in the mucosal layer greater than 3mm in diameter.
Types: Gastric (1/3rd) and Duodenal (2/3rd) ulcers.
Clinical features: epigastric pain within 2 hours of eating.
- Gastric = >40yrs
- duodenal = adults of any age.
How would you asses if a patient has a Peptic Ulcer and what would it look Like?
Asses: (best) endoscopy, contrast (less invasive).
- round to oval collection of barium - extends beyond the normal confines of lumen (specifically, into the mucosal wall)
- different appearance possible.
- <5mm easily missed using contrast
What % of Peptic Ulcers are Ulcerating Carcinomas and how can you radiographically determine if an ulcer is benign?
- Lesser curvature location
- Ulcer crater extends beyond edge of lumen
- Crater margins are smooth and well-defined
- Mucosal folds are smooth and extend to edge of ulcer crater
- Ulcer crater located centrally within an edematous mound (an area with reduced contrast collection)
Malignancy = these findings are not present, or opposite
Where is the highest/lowest prevalence of Gastric Carcinoma and what are the survival rates?
- Highest = Japan, China, and Russia
- Lowest = Australia, NZ, US
Survival rates: 5 year
- around 20% - if caught at advanced stage when clinical sighns show
- early detection = 90%.
What are the 3 main types of Gastric Carcinomas seen on contarst studies what are the clinical findings and distribution?
Polypoid (fungating, mass-like) - Large, irregular mass extends into the lumen, may contain ulcerations
Infiltrative (scirrhous, linitus plastica) - narrowing of long segments of the stomach, stiffening of the wall, and shrinking of the stomach
Ulcerating - aggressive ulceration
Clinical: similar to gastric ulcers and gastritis -misleading
Distribution: (carcinomas) evenly throughout the stomach
What is Inflammatory Bowel Disease and what are the 2 main types?
- An idiopathic disease, probably involving an immune reaction of the body to its own intestinal tract
Types: ulcerative colitis and Crohn disease
What is Ulcerative Colitis and what radiographic findings do you see?
- starts rectum and progresses in a retrograde manner towards the ileum.
- limited to the colon
- small, surface ulcers
- continuous, circumferential involvement of the bowel wall
- loss of haustration and shortening of the bowel (lead-pipe or stove pipe colon)
- toxic megacolon - very dilated
- margins hazy fragmented
What part of the GI tracts does Crohn's Disease affect, describe the progression and radiographic findings
Location: any part of the GI tract typically - intestines.
Progression: (colon) start at the ileocecal region and progress to varying amounts towards the rectum- (unusual)
- deep ulcers with or without a “cobblestone” muscosal pattern
- discontinuous, non-circumferential involvement of the intestinal wall (skip lesions)
- fistulas, strictures (deep construction)
What are Polyps/Adenomas, how are they classified by their gross appearance?
- localized proliferations of dysplastic epithelium which are initially flat, but with increased growth project from the mucosa forming polyps.
sessile (flat or broad-based)
pedunculated (having a stalk).
- sessile (flat or broad-based)
- pedunculated (having a stalk).
How are Polyps/Adenomas seen on contrast x-rays, what gives an increased incidence of it becoming carcinogenic and what are the clinical symptoms?
Imaging: focal filling defects (areas of absence of contrast).
- increased dysplasia = higher incidence of carcinoma.
- rare = <1 cm
- approx. 40-50% in villous lesions >4cm.
Clinical: generally asymptomatic.
rarely large enough to cause obstructive signs in the absence of malignant change
What is the sequence of development of Carcinomas, who is most likely to get it and what are the survival rates?
Sequence of development: dysplasia-adenoma-carcinoma
High risk: elderly except for people with hereditary non-polyposis and polyposis syndromes or chronic inflammatory bowel disease
- undetected until late = reduced survival rates.
- General 5-year survival is 60% (varies depending on stage of detection)
What do Carcinomas look like?
- dependent on the stage of the tumor.
- Early invasive carcinoma may look like original adenoma.
- tumor commonly obliterates evidence of the underlying adenoma.
- Over time, lesion spreads circumferentially through circular lymphatics to produce a constricting annular (apple-core) lesion in the mucosa.
- cover large areas as symptomatic only in late stages
What is Diverticulosis and where is it most commonly located?
- Chronic/recurrent increase in intraluminal colonic pressure causes herniation of the mucosa through the colon wall
Location: (Diverticuli) m.c. sigmoid colon, can be anywhere along the colon.
What size are diverticuli and what happens when they become inflamed?
Size: <2mm, studding mucosa
Inflammation= (diverticulitis) abscess formation.
What clinical symptoms can Diverticulitis present and what is the result of recurrent episodes?
- left lower pain,
- palpable mass = abscess formation.
Recurrent episodes: extensive focal scarring and signs of obstruction.
What clinical presentations can you expect with Diverticulosis?