A Global TextBook of Radiology II
A Global TextBook of Radiology II
A Global TextBook of Radiology II
B ook 1995
A Global
TextBook of
Radiology
The NICER C e n te n n ia l
B ook 1995
A Global
TextBook of
Radiology
Edited b y
Holger Pettersson, MD
Professor o f R adiology
U niversity H ospital
Lund, Sw eden
Educational and Scientific D irector
The N IC ER Institute
II
Chest
Abdomen
Urogenital system
Tropical disease
S e r i e s on D i a g n o s t i c I m a g i n g
From
The NICER Institute
The NICER program and the NICER books
The NICER program is a activities to all former course participants and
Yv
S
unique approach to continu all other subscribers to the Bulletin.
ing education in diagnostic The NICER Books embrace a wide spec
imaging, and consists of a trum of radiological knowledge ranging from
global program provided by the basic to state-of-the-art. The first book se
NICER some o f the world’s leading
authorities. Its goal is the
ries, published in 1991- 1992 comprised five
volumes, of 300 - 600 pages per volume. Each
provision of high-quality education, dissoci multi-author volume covered one or two organ
ated from any commercial interests or influ areas, different aspects o f the subject matter
ences, to radiologists throughout the world. being written by leading radiologists and
The teaching program is run by: edited by world authorities.
the NICER Institute Since 1994 NICER publishes a new series
which is an educational foundation based on a on diagnostic imaging called The NICER
collaboration between Yearbook Series. Each year we will publish
the Department of Radiology, University of one volume devoted to a particular radiologi
Lund, Sweden cal topic, but presented in a manner that will
and be informative and interesting to both the gen
the Nycomed Imaging A/S, Oslo, Norway eral radiologist and the specialist.
Till now (1995) more than 5000 course par
The NICER program consists of three parts:
ticipants have attended the courses around the
The NICER Courses
world, and more than 50 000 NICER books
The NICER Case Bulletin
have been distributed.
The NICER Book Series
To celebrate the first century o f diagnostic
The NICER Courses comprise a series of 2-4 imaging, the NICER Yearbook 1995 is called
courses, given in different regions of the world, “centenniar.lt embraces radiology as a whole,
each series running over a period of 2 —4 years. and will be published in English, with transla
The courses in a complete series cover the tions to Chinese, Russian and Spanish: A
whole field of diagnostic imaging, each course Global Textbook of Radiology.
dealing with one or two organ systems. The NICER Institute welcomes you, the
The NICER Case Bulletin is published readers. We hope you will enjoy the reading
twice a year, presenting one or two interesting and we look forward to see you at future
cases and providing information about NICER courses.
^ University of Lund
Sweden N NYCOMED
IMAGING
Published by: The NICER Institute, Oslo • Graphic design: Mons R0nning
Printed by: Casper Evensens Trykkeri A/S, Norway
VOLUME I
VII
Chapter 10 The head and neck....................................................... 229
Sven-Goran Larsson, Saudi Arabia
Anthony Mancuso, USA
Chapter 11 Dental radiology.......................................................... 263
Lars Hollender, USA
Karl-Ake Omnell, USA
VOLUME II
VIII
Chapter 20 The peripheral vessels............................................... 809
Christoph Zollikofer, Switzerland
Frode Laerum, Norway
Chapter 21 The lymphatic system............................................... 871
Elias Zerhouni, USA
Chapter 22 The gastrointestinal tract.......................................... 891
Richard M. Mendelson, Australia
Chapter 23 The liver, biliary tract, pancreas and spleen........... 1027
David J. Allison, United Kingdom
Carl-Gustaf Standertskjold-Nordenstam, Finland
Chapter 24 The acute abdomen................................................... 1079
David J. Allison, United Kingdom
Olle Ekberg, Sweden
Frans-Thomas Fork, Sweden
Chapter 25 The genitourinary system......................................... 1111
Henrik Thomsen, Denmark
Howard Pollack, USA
Chapter 26 Obstetric imaging..................................................... 1217
Con Metreweli, Hong Kong
Chapter 27 Tropical diseases...................................................... 1237
Philip E.S. Palmer, USA
Stanley P. Bohrer, USA
Carlos Bruguera, Argentina
Xing-Rong Chen, China
Mahmoud R. Elmeligi, Egypt
HassenA. Gharbi, Tunisia
S.B. Lagundoye, Nigeria
M. W. Wachira, Kenya
Chapter 28 Radiology in AIDS.................................................... 1309
Marie-France Beilin, France
Philippe Grenier, France
Nadine Martin-Duverneuil, France
Index ..................................................................................... XV
IX
List of Authors
X
Niels Egund, MD Gerald Hanson, PhD.
Department of Radiology Radiation Medicine
Odense University Hospital, World Health Organization,
Odense, Denmark Geneva, Switzerland
XI
Donald R. Kirks, MD Sven Laurin, MD
Department of Radiology Department of Radiology
Children’s Hospital, University Hospital,
Harvard Medical School, Lund, Sweden
Boston, MA, USA
Anthony Mancuso, MD
Aaro Kiuru, PhD Department of Radiology
Department o f Oncology and University of Florida,
Radiotherapy College of Medicine,
Turku University, Gainesville, FL, USA
Central Hospital,
Turku, Finland Nadine Martin-Duverneuil, MD
Department of Radiology
Alf Kolbenstvedt, MD Groups Hospitalier,
Department o f Radiology Pitie-Salpetriere, Paris, France
Rikshospitalet,
University of Oslo, Norway Richard Mendelson, MB, ChB,
MRCP, FRCA, FRACA
Tatsuo Kumazaki, MD Department of Diagnostic
Department of Radiology Radiology
Nippon Medical School, Royal Perth Hospital,
Tokyo, Japan Perth, Australia
XII
Peter Peters, MD Donald Resnick, MD
Department of Radiology Department of Radiology
Westfalische Wilhelms- Veterans Administration
Universitat, Medical Center,
Munster, Germany San Diego, CA, USA
XIII
Axel Stabler, MD Elias A. Zerhouni, MD
Department of Radiology Department of Radiology
Klinikum Grosshadem, The Johns Hopkins Hospital,
University of Munich, Baltimore, MD, USA
Munich, Germany
Christoph Zollikofer, MD
Henrik Thomsen, MD Department of Radiology
Department o f Radiology Kantonspital Winterthur,
Herlev Hospital, Winterthur, Switzerland
University of Copenhagen,
Copenhagen, Denmark
M.W. Wachira, MD
Department of Radiology
Kenyatta National Hospital,
Nairobi, Kenya
XIV
Chapter 18
MODALITIES
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r — -------- Figure 1.
Normal chest x-ray
a) PA view
b) Lateral view
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view is taken with foil inspiration and posteroanterior (PA) beam di
rection. The heart thus comes closest to the film, and magnification of
the cardiac shadow caused by ray divergence is minimized. In order to
further reduce the effect of ray divergence, the distance from the tube is
at least 1.5 metres. When bedridden patients are examined using a mo
bile apparatus, the film must be placed behind the back of the patient,
and the distance from the tube must be shorter. The relative magnifica
tion of the cardiac shadow in this circumstance must be considered when
comparing standard (posteroanterior) and portable (anteroposterior) ra
diographs.
The most important examinations that can be obtained to supplement
the frontal and lateral radiographs are oblique views, lateral decubitus
views, expiratory frontal views, overpenetrated films, lordotic views, flu
oroscopy, and tomography.
Oblique views with the left and right sides, respectively, turned for
wards towards the film, can provide valuable additional information on
pleural thickening and are also useful when poorly defined opacities are
seen in the frontal view, but not in the lateral view. These may be caused
by summation phenomena, which can be confused with opacities. The
oblique views may clarify the diagnosis.
Lateral decubitus views are usually taken with a horizontal direction
of the x-ray beam, i.e. a frontal view of a patient lying on his side. The
objective is to identify small amounts of pleural fluid which collect and
become visible at the most dependent region of the pleural space.
Expiratory views are used to identify a small pneumothorax. By re
ducing the volume of the pleural space during expiration, a small amount
of "trapped" air in the pleural cavity will be forced to increase in breadth
so that the surface of the lung is pushed further away from the chest wall,
thus becoming visible.
For overpenetrated films, higher energy rays are used. These can pro
vide additional information about conditions in the mediastinum behind
the heart shadow and about the soft tissues along the vertebral column.
Lordotic views can help to clarify uncertain findings in the apex o f the
lungs that are hidden behind the clavicle and first rib in the standard
frontal view. The patient stands with his back to the film cassette and
bends backwards to that his back is in lordosis. The clavicles are pro
jected above the apex of the lung, and in some cases opacities may be
come more visible and possible to localize (Fig. 2 a, b).
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Figure 2.
Advantages o f a "lordotic view"
a) PA view o f chest shows an
opacity projected over first
right rib (arrow)
b) Lordotic view shows that the
opacity is completely
extrathoracic, and caused by
an osteochondroma arising
from the transverse process
o f the 7th cervical vertebra.
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Figure 3.
Bronchography
a) PA view, bronchial tree on right side
1. Main bronchus
2. Upper lobe bronchus
3. Stem bronchus
4. Middle lobe bronchus
5. Lower lobe bronchus
b) Lateral view, bronchial tree on right
side
6. Bronchus to superior (apical) segment
o f lower lobe
c) PA view, bronchial tree on left side
1. Main bronchus
2. Upper lobe bronchus
3. Lingula bronchus
4. Lower lobe bronchus
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Bronchography
For this procedure, local anaesthesia is given by inhalator, after which a
soft catheter is passed into the main bronchus on the side to be exam
ined. Fluoroscopy is used for guidance, both at the level of the larynx
and at the level of the carina. The bronchial tree is made visible by ad
ministering an iodized contrast medium in aqueous suspension, which
lines the walls of the bronchial branches (Fig. 3 a-c).
The main indications are the demonstration of bronchiectasis,
bronchial anomalies, and occasionally a fistula communicating with the
pleural cavity.
Because of the use of bronchoscopy and/or high resolution CT, the use
of bronchography has greatly diminished.
Angiography
Pulmonary angiography is used to demonstrate the pulmonary arteries
and veins (Fig. 4). Using fluoroscopic guidance, ECG and pressure mon
itoring, a catheter is passed into the pulmonary artery. After injection of
contrast medium, a series of film sequences are acquired to follow the
passage of the contrast bolus through the pulmonary circulation. The
main indications are suspected pulmonary embolism, vascular anom
alies, or malformations.
The trachea and bronchi receive their nourishment via the bronchial
arteries which originate from the upper part of the descending aorta. In
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Figure 4.
Pulmonary angiography.
Normal finding. Subtraction
film.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 5.
Bronchial carcinoma right up
per lobe.
a) Chest x-ray shows a large,
well-defined expansive
process in right apex.
b) T1-weighted MR image
(coronal section) shows
growth into the chest wall
between the ribs, and into the
mediastinum where air chan
nels and vascular structures
appear as signal-free struc
tures.
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Figure 6.
a) ECG gated spin echo
MR image in the
transcaial plane demon
strates an aneurysm o f
the sinuses o f Valsalva
in a patient with
Marfan's syndrome.
b) ECG gated spin echo
MR image in the coro
nal plane demonstrates
an aneurysm o f the as
cending aorta in a pa
tient with Marfan's syn
drome.
MRI has now been available for more than ten years, but its clinical
role in the thorax is still evolving. Moreover, the indication for prefer
ential use of MRI rather than CT remains controversial. MRI can be con
sidered comparable or preferable to CT for the following indications:
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Figure 10.
ECG gated spin echo image in
the coronal plane demonstrates
inoperability o f lung cancer
due to encasement and inva
sion o f the posterior portion o f
the aortic arch.
Figure 11.
a/ ECG gated spin echo image
in the transaxial plane
shows a paracardiac mass
(lymphoma). The mass is
separated from the cardiac
structures by the low
intensity pericardial line,
b/ ECG gated spin echo image
in the transaxial plane
shows a paracardiac mass
invading the right and left
atrial walls.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Ultrasound (ultrasonography)
Since ultrasound waves do not penetrate through aerated alveoli, the use
of ultrasound in the diagnosis of disease o f the chest is confined mostly
to assessment of the heart by echocardiography (which is usually per
formed in the cardiology department), pleural effusion and specific parts
of the mediastinum.
Pleural fluid can become loculated. This makes the drainage of fluid
difficult. Demonstration of the loculation(s) using ultrasound facilitates
drainage with a minimum of punctures. Samples of tissue may also be
collected through ultrasonographically guided needle punctures.
Isotope scanning
Radioactive isotope scanning is frequently used for the evaluation of sus
pected pulmonary embolism.
An intravenous injection of radioactive particles is administered for
perfusion scintigraphy. The size of these particles is such that they are
’’trapped" by the pulmonary capillaries. A scan is acquired of the iso
tope-containing lungs using a gamma camera. The areas of perfused
lungs emit radiation. Areas that emit relatively less or no radiation are
considered to be underperfused or nonperfused.
Reduced radioactivity may be due to pulmonary embolism, but also
to other conditions, such as interlobar pleural fluid, emphysematous bul-
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Chest wall
The chest wall is made up of the thoracic skeleton and the surrounding
soft tissues. The shape of the thorax varies considerably, from the very
tall, thin individuals, on whom a superficial glance at the frontal view
may lead one to suspect hyperinflation, to short individuals with a large
anteroposterior diameter and an almost barrel-shaped chest in the lateral
view. The clavicles appear symmetrically on either side of the mid-line.
This is an important observation, as asymmetry indicates inadvertent
oblique positioning. In such slightly oblique films, the ascending aorta
and the manubrium stemi may emerge from the medastinal shadow and
give rise to misinterpretations. The medial epiphysis of the clavicle does
not ossify before adulthood, and the epiphysis should not be confused
with a lung opacity. There is a hollow (rhomboid fossa) on the lower side
of the medial end of the clavicle. This can sometimes be so deep and ob
vious that it is confused with a pathological erosion.
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Figure 13.
Bilateral cervical ribs
(arrows).
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The nipple of the breast may be confused with a round basal shadow
in the lung. This is generally no problem as both nipples are seen sym
metrically on either side of the midline in the frontal view, while no
shadow at the corresponding level is seen in the lateral view. The lateral
border of the shadow of the nipples is often more distinct than the me
dial border. Other soft tissue structures that can be identified in frontal
views are the lower part of the sternocleidomastoid and pectoral mus
cles. Misinterpretations may occur when the pectoral muscles have been
removed operatively or are atrophic (for example after poliomyelitis),
and the underlying lung may be regarded as emphysematous, or it is
thought that the contralateral lung has increased opacity.
Pleura
The parietal pleura lines the inner side of the thoracic cavity and the lat
eral side of the mediastinum without passing into the normal lung fis
sures (Fig. 14). Around the structures in the hilar region, it crosses to
cover the medial surface of the lung and continues as visceral pleura on
the surface of the lobes o f the lung. The pleural cavity is located between
the two layers of the pleura, and normally surrounds the whole lung ex
pect the hilar region. In some cases, a fold of the pleura extends from the
hilar region to the diaphragm, forming a ligament that obstructs direct
continuity medially between the front and back of the pleural space. This
ligament, the pulmonary ligament, may form a small tent-shaped trian
gular opacity extending from the hilum toward the dome of the di
aphragm, which may be confused radiologically with adhesion between
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 15.
The rounded, smooth bor
dered prominence in the
right tracheobronchial an
gle (v.a) is caused by a di
lated azygos vein. The p a
tient had occlusion o f the
inferior vena cava and col
lateral circulation to the
azygos vein.
the two layers of pleura. Unlike the parietal pleura, the visceral pleura
follows the surface of the lobes of the lungs into the fissures.
The fissure between the upper and lower lobe (major interlobar fis
sure) is found bilaterally. On the right side, an additional fissure, the mi
nor interlobar fissure, between the middle and upper lobes is also pre
sent. This is the only fissure visible in the frontal plane, while the fis
sures between the upper and lower lobes are projected over each other
in lateral views. The CT scan shows the major interlobar fissure on both
sides.
The fissures may be incomplete, and accessory lobes and fissures may
occur. A fissure consists of two layers of pleura with a potential cleft be
tween them.
A special anomaly found in almost 1% of the population is the azy
gos lobe (Figs. 12, 14). This is due to an abnormal course of the azygos
vein. Normally, this vein runs up along the vertebral column and turns
forwards in the mediastinum to open into the anteriorly situated superior
vena cava at the level of the tracheo-bronchial angle (Fig. 15). When the
anomaly is present, the veins run more laterally and curves forwards. It
makes a deep groove in the right apex. On the medial side of the groove,
one gets the impression of an extra lobe of the lung, and its fissure is es
pecially prominent because it consists of four layers of pleura, since the
vein lies outside the pleura throughout its whole course (Fig. 14). At the
transition between the diaphragm and the chest wall, the layers of the
pleura form a very acute angle, the costophrenic angle. Posteriorly, it ex
tends in a caudal direction; this anatomic feature may explain that a metal
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Lungs
The lungs are divided into lobes, the lobes into segments, which in turn
consist of still smaller units, the so-called secondary lobules. The right
lung has three, and the left two lobes (Fig. 16). The right lower lobe has
five segments, the superior (apical) and four basal (anterior, posterior, me
dial, and lateral) segments. The left lower lobe lacks the medial segment.
Both upper lobes have three segments. The right has posterior, apical,
and anterior segments, while the left has apico-posterior, anterior, and lin
gular segments. The latter extends caudally and anteriorly, corresponding
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 17.
Visible lines between secondary
lobules in a patient with intersti
tial edema (Kerley's В lines).
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Mediastinum
The mediastinum is the area lying between the medial parts of the right
and left pleura. The mediastinum is mobile from side to side, and ob
servation of mediastinal displacement and movement provides impor
tant diagnostic information about the nature of the disease process.
Normally, the lower part of the right mediastinal outline is made by the
right atrium. When this is not the case, but rather this outline is made by
the vertebral column, it is a sign of displacement of the heart and lower
part of the mediastinum to the left.
Above the hilar region, the right mediastinal outline is made by the su
perior vena cava and the brachiocephalic vessels (Fig. 18). Above the
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
left hilum, the upper mediastinal ouline is made by the arch of the aorta
and subclavian vessels. A right-sided aortic arch forms a prominence of
the upper right mediastinal outline. This may be misinterpreted as an ex
pansive process unless the absence of a normal aortic arch is recognized.
In patients whose thorax is very deep (and those with emphysema), the
anterior, upper mediastinum consists o f a tissue lamella so narrow that
the lungs almost meet in the mid-line. When this lamella is oriented sag-
itally (parallel to the x-ray beam) it forms a linear opacity in the mid-line
(anterior junction line) on the frontal film. Further posteriorly, the me
diastinum has narrow areas, for example under the arch of the azygos
vein, where the pleural cavity approximates the oesophaus (the azygo-
oesohpageal recess).
In the tracheo-bronchial angle on the right side, a circular shadow rep
resents the arch o f the azygos vein, lying parallel to the x-ray beam (in
the same way as the aortic arch on the left side). In the presence of ve
nous obstruction and collateral circulation through the azygos system,
the diameter of the azygos vein may increase. Close to the azygos arch,
there is an important lymph node, the azygos node. Like the other lymph
nodes in the mediastinum and hilum, this is only visible in standard ra
diographs when it is enlarged. The azygos node is the primary lymph
node in the spread o f lung cancer from the right lung and from the left
lower lobe. The corresponding node for spread from the left upper lobe
lies to the left in the mediastinum, under the arch of the aorta, with the
left pulmonary artery below it. The node lies close to the obliterated duc
tus arteriosus, and is therefore called the ’’ductus node". The area in which
it lies is called the "aortopulmonary window". In this area, relatively large
expansive processes may escape attention in standard chest radiographs,
while they are easily discovered by CT scan. CT scans disclose normal
mediastinal lymph nodes when there is sufficient mediastinal fat so that
the organs do not all coalesce. The mediastinal lymph nodes are divided
into the anterior, middle, and posterior nodes, with a series of subgroups.
If lymph node enlargement is suspected, one should systematically in
spect the fat spaces in front of and lateral to the trachea, in front of the
carina, below the carina (in the angle between the left and right main
bronchi), and in the aortopulmonary window. The normal size of the me
diastinal lymph nodes varies from one region to another, and there is no
set limit where all larger lymph nodes are pathological and all smaller
ones are normal.
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Figure 21.
Significance o f good inspiration
when taking chest x-rays
a) Firstfilm. Large heart and basal
opacities?
b) New film after instruction on
inspiration. Normal findings.
Diaphragm a
The diaphragm originates from
the lumbar vertebrae posteri
orly with its two crurae (Fig.
20), from a ligament (arcus
tendinosus) between the verte
bral column and the lowest ribs,
from the ribs at the back and lat
erally, and from the sternum in
front. The fibers course upward
in an even curve towards the
central tendinous part, which
has openings for the esopha
gus, vena cava and aorta.
The level of the right dome of the diaphragm is usually somewhat
higher than the left, while the left has greatest mobility, about five to six
cm. On full inspiration, the upper part of the right dome of the diaphragm
is near the tip of the sixth rib at the front, and between the 10th and 11th
rib at the back.
It is important that the patients understand that they must breathe in
and hold their breath. What appear to be basal opacifites in the lung can
vanish on a repeat film obtained with full inspiration, shown by the po
sition of the domes of the diaphragm (Fig. 21a, b). The outline of the
lower side of the diaphragm is only shown when there is free intraperi-
toneal air providing contrast. The complete outline of the upper side of
the diaphragm is seen against the aerated lung tissue, except in the area
where the heart shadow lies in direct contact.
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Figure 22.
Normal retrocrural space (R). The
space consists o f the posterior, infe
rior part o f the mediastinum and
contains fat, vessels, nerves, and
lymph nodes. Aorta (A). Diaphragm
(arrows).
The posterior parts of the domes of the diaphragm are only seen in a
lateral view. In lateral films of normal individuals, the outline o f the right
dome of the diaphragm can be followed forward to the chest wall, while
the left is obliterated in front because of contact with the heart shadow
(Fig. 18). The gastric air bubble may also help to identify the left from
the right diaphragmatic dome in the lateral view. A staircase-shaped di
aphragm in the lateral projection may be a normal variant. In such cases
the frontal view may show two outlines at different levels.
The crurae originate from the anterior part of the lumbar column as far
down as L3 on the right side and L2 on the left. In a CT section of the
abdomen, the crurae may be seen as oval prevertebral structures, which
can be confused with enlarged lymph nodes. In a CT section further cra-
nially, the upper parts of the crurae form a bowed structure over the aorta
at the thoracolumbar transition. In such sections, the other abdominal or
gans are seen in front of the diaphragm, and the retrocrural space, which
is the very lowest part of the chest cavity, is seen behind it (Fig. 22). This
space may contain pathologically enlarged lymph nodes that can only be
demonstrated by CT scan (or MRI).
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Figure 23.
Bulging o f the right mediastinal
outline caused by kyphoscolio
sis. Note the short distance
between the ribs on the left,
large distance on the right side.
PATHOLOGY
Chest wall
Most of the pathological conditions here are due to diseases of the tho
racic cage. With deformities of the thorax such as kyphoscoliosis, the
scoliotic spine may give the impression of a large mediastinal mass (Fig.
23), until a penetrated flm shows the striped translucencies that repre
sent the intervertebral discs. At the same time, the intercostal spaces are
narrowed and ribs vertically oriented on the concave side, with widen
ing intercostal space and diverging ribs on the convex side. Similar
changes can be seen in healed pulmonary tuberculosis with massive
shrinking and volume reduction of the hemithorax on the affected side
with growth retardation. Thoracoplasty performed to eradicate tubercu
lous cavities in the apex of the lung may produce thoracic deformity due
to resection of four to six upper ribs.
A funnel-shaped sternum may be projected deep into the thorax in the
lateral view (Fig. 24), and the heart may be displaced to the left. A bowed,
forward bulging sternum may be seen with congenital heart diseases and
pulmonary emphysema. Aneurysms in the ascending aorta may cause
notching of the sternum.
Fractures are the most common cause of changes in the ribs. A very
recent fracture is often difficult to recognize unless the fragments are dis
located. It is usually unnecessary to verify clinically suspected fracture
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Figure 24.
Lateral view o f patient with funnel
chest (pectus excavatum). The
sternum is projected over the heart
shadow.
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THE LUNGS AND MEDIASTINUM
Diaphragm
The position of the diaphragm varies considerably with the phase of res
piration, and also from one individual to the next. In children and pa
tients who have a deep thorax, or are overweight, the level of the di
aphragm is higher than in tall thin individuals. The diaphragm is also
higher on films taken with the patient supine or in lateral decubitus.
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Figure 25.
Kyphoscoliosis and hiatus hernia.
a) Wide lower mediastinal shadow
because o f scoliosis. Fluid level
projected over the heart
shadow.
b) Lateral view with contrast in
the esophagus and cardiac part
o f the stomach. The flu id level is
behind the heart, and is caused
by herniation o f the body o f the
stomach (paraoesophageal
hernia).
The diaphragm has several weak points that may give rise to hernias.
The most frequent is hiatal hernia through the oesophageal hiatus (Fig.
25 a, b). Parts of the stomach herniate up into the chest cavity. This con
dition is suspected when a frontal view shows a horizontal line (fluid
level) projected over the cardiac shadow. The diagnosis is confirmed by
finding an air-filled cavity behind the cardiac shadow on the lateral film.
For further confirmation, a barium swallow can be done.
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Figure 26.
Rounded opacity in the right
cardiodiaphragmatic angle. Air-
filled haustra (arrows) in the
opacity. Morgagni hernia
containing omentum and a loop
o f the colon.
Hernia can also arise between the diaphragmatic fibers that originate
from the sternum and those originating from the ribs. These may contain
omentum, and give rise to a well-defined, upwards convex opacity be
side the heart. The differential diagnosis is between a cardiophrenic fat
pad, which is a normal variant of no pathological significance, and a peri
cardial cyst. An air-bubble indicates herniated intestine in addition to
omentum, and this can be verified by barium enema, or possibly a bar
ium swallow. Anterior hernias of this type are called Morgagni hernias
(Fig. 26).
Posterior hernias (Bochdalek hernias) are seen as a localized, upward
convex, rounded swelling of the diaphragm, paravertebrally. The open
ing is situated between the fibres of the diaphragm that originate from
the tendinous arch over the psoas and quadratus lumborum muscles, and
the fibres originating from the ribs posteriorly. This type of hernia usu
ally contains retroperitoneal fat, but the upper pole of the kidney, the
adrenal gland, and parts of the liver can also herniate. Sometimes it may
be difficult to decide whether there is in fact a hernia, or whether there
is only a localized relaxation of the diaphragm, an eventration. This is a
congenital condition where parts or most of the diaphragm lack muscu
lature and only consist of a thin membranous sheet.
With rupture of the diaphragm, which most often involves the left
dome, the contents of the abdomen, often the stomach, herniate up into
the chest cavity. When the body and antrum of the stomach herniate, the
greater curvature will lie with its convexity upwards, and obstruction
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
with distention may occur, so that the herniated greater curvature is con
fused with the dome of the diaphragm, and the rupture may be over
looked. A barium swallow can confirm the diagnosis because the cardiac
part of the stomach does not usually herniate, and the outline o f the edge
of the hernia can be seen against the stomach. A CT scan may also con
tribute to a correct diagnosis.
Pleural lesions
The pleural membranes produce pleural fluid, which is resorbed through
lymph channels in both layers. Increased production or diminished re
sorption leads to pathological accumulation of fluid in the pleural cavity.
The pleural fluid may consist of clear transudate, serofibrinous exudate,
blood or haemorrhagic effusion, or chylous exudate. With plain chest ra
diographs it is not possible to differentiate between the different types of
pleural fluid. Pleurocentesis can be performed under guidance of imag
ing techniques. Pleural transudate is clear, yellow, and usually bilateral.
The commonest cause of transudate is cardiac failure. Other causes may
be chronic renal failure, hypoproteinaemia, or over-transfusion.
Exudates may be yellow-brown or purulent, and are caused by tuber
culosis or other pulmonary or pleural infections, or by a subphrenic ab
scess. Other causes are lung cancer and systemic connective tissue dis
eases such as lupus erythematosus or rheumatoid arthritis. Blood in the
pleural cavity can be caused by open or closed thoracic trauma, or haem
orrhagic diseases with prolonged bleeding time. Blood-coloured pleural
fluid may be found with pulmonary embolism and lung cancer.
Chylothorax may be seen after thoracic trauma, or with obstruction of
the thoracic duct or the bronchomediastinal lymph trunks because of ma
lignant disease of infective conditions (filariasis).
In the upright position, small amounts of fluid will accumulate in the
costophrenic angle, first posteriorly, then also laterally. The acute angle
between the diaphragm and the chest wall is filled by an opacity, which,
as the volume of fluid increases, gradually stretches up along the inside
of the chest wall like a cloak (Fig. 27).
If one is uncertain whether there is fluid or only the remains of previ
ous pleural pathology with pleural thickening, the diagnosis can be ver
ified by taking a supplementary film. This is acquired with the patient in
lateral decubitus position with the affected side down, and a horizontal
x-ray beam (Fig. 28). Even small amounts of fluid drain by gravity along
698
THE LUNGS AND MEDIASTINUM
the dependent chest wall and collect as a narrow band between the lat
eral chest wall and the lung. The breadth of the band of fluid increases
when the film is exposed with the diaphragm elevated, i.e. on expiration.
Pleural thickening may also give a band-shaped opacity in a lateral de
cubitus film, but the breadth of this opacity will be the same whether the
patient is upright or lying down.
Large volumes of fluid may give massive opacities over the entire
hemithorax, but usually some aerated lung tissue is visible at the apex.
When this condition is unilateral, the mediastinum will be displaced to
wards the normal side, a sign that is useful in differentiating this opac
ity from that seen in total collapse of the lung (atelectasis) (Fig. 29 a, b).
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
A) Greater than normal proportion o f the heart shadow is located to the right o f the
vertebral column. Slight rightward displacement o f the trachea. These findings indi
cate a left-sided expansion, as caused by a large left pleural effusion.
B) The vertebral column is seen more clearly than normal along the right border o f the
mediastinum. The trachea is shifted to the left. This indicates left-sided reduction o f
volume, caused by atelectasis.
With total collapse, the mediastinum will be pulled towards the involved
side. In the presence o f bronchial cancer and simultaneous total collapse
of the lung and large amounts of pleural fluid, the mediastinum may re
main in the midline.
Sometimes pleural fluid may have a subpulmonary localization on up
right films. On the left side this condition is readily recognized because
of the increased distance between air in the stomach and the base of the
lung. On the right side, the condition can be confused with an elevated
diaphragm, as the upper surface of the accumulated fluid is misinter
preted as the diaphragm. Usually, the costophrenic angle will be rather
round laterally and posteriorly and a lateral decubitus film may disclose
large volumes of fluid.
The pleural fluid may also be loculated in closed pockets (loculi),
which are formed by adhesions between the visceral and parietal pleura.
Encapsulated fluid of this kind will not float freely on lateral decubitus
films; consequently the diagnosis of fluid must be verified by CT scan
or ultrasound. Thoracocentesis of loculated fluid can be guided by ul
trasonography. Free pleural fluid flows into the fissures (Fig. 27) as a
wedge-shaped opacity with the pointed end towards the hilum and the
base peripherally. Encapsulated interlobar fluid also occurs. It usually
assumes a biconvex lens shape using a tangential x-ray beam, but it may
also be globular and be confused with a tumor. As the fluid is gradually
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THE LUNGS AND MEDIASTINUM
Figure 30.
Empyema
a) The right sinus is filled by an
opacity that extends upward along
the chest wall, and has an upward
convex border.
b) CT section at the thoracoabdomi
nal transition showing right-sided
empyema with gas bubbles.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
pleural cavity, giving fluid levels in upright films, and the air is not re
sorbed but increases with time. When the empyema and fistula heal, a
thickened pleura remains with adhesions, which may cause traction upon
the heart and mediastinum. The diaphragm may be tethered upward and
attached to the chest wall, with loss of diaphragmatic motion. Pleural
thickening is often caused by infections and is an accompanying phe
nomenon in pulmonary tuberculosis. The thickening is often seen at the
base, combined with adhesions in the costophrenic angle, which becomes
shallow and right-angled (Fig. 31). The thickening can also be observed
at the inferior extent of the fissures, where it produces linear thickening
of the interlobar fissure. Tent-shaped basal opacities may represent
pleural adhesions after earlier pleurisy. Above the apex of the lung, lo
calized pleural thickening may occur, producing a downwardly concave
half-moon-shaped opacity.
After tuberculous pleurisy, and after bleeding in the chest cavity, large
calcified pleural plaques may be formed. In pneumoconioses such as as-
bestosis, pleural thickening is also a common phenomenon, and thin,
well-defined stripes of calcium in the basal part of the chest wall along
the dome of the diaphragm may also be found. Calcification and pleural
thickening of this kind are best seen in the tangential projection, and ra
diographs of the lung may be supplemented by oblique films with this
type of problem. The optimal method for displaying pleural plaques and
calcification is by CT.
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THE LUNGS AND MEDIASTINUM
Figure 32.
Pneumothorax. A 2-3 cm broad air
cap has developed after fine needle
puncture o f tumor (T). The arrows
show the surface o f the lung.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 33.
Stripe along the lateral chest
wall (arrows) resembles pneu
mothorax, but some scanty vas
cular markings are seen periph
eral to the stripe. Repeat x-ray
after change in position showed
normalfindings. The stripe had
been caused by a skin fold.
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THE LUNGS AND MEDIASTINUM
Figure 34.
Horizontal fluid level in the
right thoracic cavity (open
arrow) shows that both pleural
fluid and pneumothorax
(hydropneumothorax) must be
present. The mediastinum is
pulled to the right because o f
atelectasis o f the lower lobe.
Pericardial calcification
(closed arrow) after
pericarditis.
Figure 35.
A mass anteriorly and cranially in the
mediastinum caused by calcified ret
rosternal goiter (s).
Mediastinal lesions
A lateral view can be used to localize to the anterior, superior or middle
mediastinum a mass observed on the frontal view. The anterior medi
astinum consists of the retrosternal space and the heart, the middle con
sists of the structures along the trachea, esophagus, and between the hi
lar shadows, while the posterior includes the areas on both sides of the
thoracic column.
Anterior mediastinal masses may be caused by retrosternal goitre (Fig.
35), tumor/cyst in the thymus (Fig. 36 a - c), dermoid cyst, and other
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 36.
Thymoma (T) in the anterior mediastinum.
a) PA view
b) Lateral view
c) The CT section shows the thymoma with
peripheral calcification. It is close to
the ascending aorta (A). Pulmonary
artery (P). Vertebral column (C).
Figure 37.
Malignant thyroid tumor with pulmonary
metastases. Compression o f the trachea
from the left (arrows). Bilateral pulmonary
metastases.
THE LUNGS AND MEDIASTINUM
Figure 38.
Mass (T) in the middle, lower part o f the
mediastinum, behind the heart shadow.
Picture after oral contrast medium
showed oesohageal cancer.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 39.
Pneumomediastinum. Stripes o f
air (arrows) along the outlines o f
the heart and mediastinum and
up on the right side o f the neck.
Tracheal tube and feeding tube.
Thorax drain on right side.
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THE LUNGS AND MEDIASTINUM
Figure 40.
Linear border o f the right medi
astinal outline and fan-shaped
opacity in the right apex caused
by radiation fibrosis after radio
therapy fo r breast cancer.
Hilar enlargement
The hilar shadows are made up of the pulmonary vessels. When these
are enlarged, it is necessary to decide whether the enlargement is due to
dilated vessels, or enlarged lymph nodes or other masses. Bilateral en
larged hilar shadows, which seem to ramify, suggest dilated pulmonary
vessels. Conditions that give rise to this include pulmonary hyperten
sion, chronic embolism, excessive pulmonary blood flow such as with
left-to-right shunts, anemia, and pregnancy, or post-stenotic dilatation
associated with pulmonary arterial stenosis.
Enlargement of the hilar shadows without branching suggests a non-
vascular nature. A polycyclic border (Fig. 41 a, b) is characteristic of en
larged hilar lymph nodes. With bilateral enlargement of hilar nodes, the
most important differential diagnoses are sarcoidosis and lymphoma.
With unilateral enlargement, the most important differential diagnoses
are metastases from lung cancer, malignant lymphoma, and infections
such as tuberculosis or histoplasmosis. The radiological finding in lung
carcinoma may be the same as that in unilateral hilar expansion.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 41.
Hilar gland enlargement in sar
coidosis.
a) PA view. Lobulated border o f
left-sided hilar enlargement (ar
rows).
b) Lateral view shows the changes
more clearly (arrows)
Asthma
In bronchial asthma, radiographs of the lungs are often completely nor
mal. There are no specific radiological findings, and the object of radi
ography is partly to exclude other causes of breathing difficulties such
as pulmonary edema or tracheal obstruction, and partly to detect com
plications such as pneumothorax or atelectasis caused by mucus plugs.
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THE LUNGS AND MEDIASTINUM
Chronic bronchitis
Like asthma, chronic bronchitis is defined on the basis of the clinical pic
ture. Half the patients with chronic bronchitis have a normal radiograph,
and the changes that occur are caused by secondary conditions such as
pneumonia or emphysema. Striped or mottled opacities may be due to
scars after previous infections, possibly combined with fluid-filled
bronchiectatic cavities. Bronchography shows irregularities in the walls
and dilated openings from the mucous glands, and the bronchial tree has
fewer and coarser branches than normal.
Emphysema
Unlike asthma and chronic bronchitis, emphysema is defined in strict
morphological terms as a condition of the lung characterized by abnor
mal permanent enlargement of air spaces distal to bronchioles, accom
panied by destruction of their walls without obvious fibrosis. The defin
ition does not include any functional impairment or airway obstruction.
Thus, abnormal function tests or airway obstruction are not invariably
present in emphysema. Emphysema is a general pathological mechanism
with a multitude of causes and appearances. Imaging features correlate
well with microscopy using serial sections, less well with various func
tional parameters.
Classification
Emphysema may be pan-acinar with involvement of the whole acinus,
or it may be localized only in the central or only in the peripheral parts
of the acini (centrilobular and paraseptal emphysema).
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 42.
Emphysema
a) PA view
b) Lateral view
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Figure 43.
Child, suspected o f having aspirated
a foreign body. A foreign body
occludes the middle lobe bronchus,
causing atelectasis o f the middle
lobe. In addition there is a valvular
mechanism in the main bronchus
with hyperinflation o f the right lower
and upper lobes.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 44.
CT picture ofpatient with emphy
sema. Large, air-filled bullae. Note
that only the narrow "anterior
junction line" separates the two
lungs at the front.
Bronchiectasis
In healthy individuals, the bronchial tree has smooth walls and the cali
bre of the branches gradually decreases towards the periphery. In
bronchiectasis, an irreversible dilatation o f the bronchial branches oc
curs. This may be due to congenital or acquired weakness of the wall due
to infection with shrinking and pulling on the wall, or to chronic ob-
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THE LUNGS AND MEDIASTINUM
Figure 45.
Different types o f bronchiectasis.
1. normal bronchial tree;
2. cystic bronchiectasis
3. cylindrical bronchiectasis;
4. multiple successive dilatations
("varicose" bronchiectasis)
Figure 46.
Annular opacities at the base o f the
upper and lower lobes due to
bronchiectasis.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 47.
CT section o f patient with p ro
nounced bilateral bronchiectasis.
Atelectasis
This is a term that is used to describe volume-reduced, collapsed non
aerated lung tissue. Atelectasis is a condition that can be congenital or
acquired, and the atelectatic areas may be limited to small parts o f a seg
ment, or there may be collapse of a whole lobe or lung.
Atelectasis may be caused by obstruction of a bronchus, or external
compression of the lung tissue.
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THE LUNGS AND MEDIASTINUM
Figure 48. Drawing o f changes due to atelectasis o f upper and lower lobes.
When there is collapse of the upper lobes, the lateral films will show the
posterior limit of the collapsed lobe distinctly. In the frontal picture, the
superior mediastinal outline will be obliterated (Fig. 48). On the left side,
parts of the cardiac margin will also be obliterated because the lingular
lobe is part of the left upper lobe. The lateral outline of the collapsed right
upper lobe is normally distinct, because the x-ray beam is tangential to
the superiorly displaced border to the middle lobe. The lateral border of
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 49.
Atelectasis o f the right lower lobe in
patient with metastases from rectal
carcinoma.
a) The PA view shows atelectasis o f
the lower lobe (A), as a sharply
defined triangular opacity. A large
metastasis is seen below the right
hilum, and several small meta
stases (arrows).
b) Lateral view. No sharply defined
opacity, but increased density over
basal parts o f the thoracic column,
which normally becomes darker
caudally. Obliterated posterior
part o f the left dome o f the
diaphragm (arrows).
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THE LUNGS AND MEDIASTINUM
Figure 50.
Atelectasis o f the lower lobe.
a) PA view. Indistinct opacity be
hind the heart shadow (arrows),
with obliteration o f medial part o f
left diaphragmatic outline.
Clearly visible thoracic column
because the heart and medi
astinum are pulled across to the
left.
b) Lateral view. No sharply defined
opacity, but gradually increasing
opacity caudally down the verte
bral column, and obliteration o f
the left diaphragmatic outline.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
folded behind the lung. Adhesion may occur between the folded up part
and the posterior surface of the lung. When the fluid is resorbed, the
folded part may not re-expand because o f the adhesions. It then lies as a
round opacity towards the posterior pleura, while the other parts of the
lower lobe expand into the costophrenic angle. This type o f opacity has
a characteristic appearance and is called round atelectasis.
Neoplasms
Lung cancer is one of the commonest types of cancer in men. Smoking
and air pollution are important causes. The most common histological
types are:
- squamous cell carcinoma
- adenocarcinoma (including alveolar cell tumors)
- small cell carcinoma
- large cell carcinoma
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THE LUNGS AND MEDIASTINUM
Figure 51.
CT section o f the thorax in a
patient with small cell pulmonary
carcinoma. Spreading to the medi
astinum at the time o f diagnosis.
Descending aorta (A), pulmonary
artery (P), tumor (T). Small right
sided pleural effusion.
lead to bronchoscopy.
It is important to obtain tissue for biopsy, and this is done either using
bronchoscopy or by needle puncture through the chest wall under the
guidance of fluoroscopy. When the diagnosis of cancer is established, an
attempt is made to classify the tumor by assessing the size and possible
growth into the adjacent organs. A search for lymph node metastases,
and distant metastases is also performed.
On the chest radiograph, the presence of the following should be as
sessed systematically:
- Central or peripheral tumor
- Invasion of the hilum or mediastinum
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
upper ribs and involvement of the brachial plexus. These patients may
have shoulder pain as the first symptom and be referred for radio
therapy of the shoulder. The extent o f these tumors is now optimally
evaluated by MRI using sagittal and/or coronal planes to determine
penetration of tumor through the apical fat pad with possible in
volvement of the brachial plexus, chest wall, or neck (Figs. 8, 9).
- Elevated diaphragm
Metastases
Pulmonary metastases may be solitary or multiple (Figs. 37, 49). They
are often globular with a smooth surface. When multiple, the sizes dif
fer from one lesion to another. Most metastases are near the surface of
the individual lobe of the lung (including those that lie close to the in
terlobar fissure). Preoperative CT scan is necessary in patients with pre
sumably solitary metastases. It will then be possible to detect additional
metastases located near the mediastinum or in the sinus posteriorly.
Lymphangitic carcinoma
When cancer cells spread to the mediastinal lymph nodes, obstruction to
the flow of lymph from the lung towards the hilum may occur, and can
cer cells may grow along the lymph vessels peripherally. On thoracic ra
diographs, this phenomenom will appear as radiating strands from the
hilar region, and the strands will be accompanied by thickening of the
peripheral interstitial septa. This condition often develops gradually, un
like interstitial edema caused by heart failure where the symptoms often
develop more rapidly.
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THE LUNGS AND MEDIASTINUM
Lung infections
Lung infection (pneumonia) may be bacterial, viral or fungal. Various
kinds of protozoa can also cause lung infection. In pneumonia, opacities
develop in the affected segments of the lung. The opacities may vary
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
ties.
b) Lobar pneumonia, right upper lobe (lateral projection) - uni-focal opacity, distinct
borders. Basally, the opacity is close to the interlobar pleura on the right lower
lobe, but does not affect the lower lobe.
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THE LUNGS AND MEDIASTINUM
whether only single segments, or whole lobes of the lung are affected.
The opacities in pneumonia are often bilateral and are often accompa
nied by collections of fluid in the pleural cavity.
Earlier, it was common to differentiate between the terms lobar pneu
monia (Fig. 53 a, b) and bronchopneumonia (Fig. 54). Lobar pneumo
nia is usually unifocal and concentrated to a single lobe where the opac
ity will be homogenous with sharp outlines which follow the borders of
the affected lobe. The volume of the affected area is not reduced, the
bronchial branches may be aerated, and a so-called air bronchogram -
visible bronchial branches in an opacity - is common. In bronchopneu
monia, the opacities are more scattered and are often seen in several lobes
at the same time. Atelectasis (volume reduction) is common. The opac
ities in bronchopneumonia are thus much less homogenous than in lobar
pneumonia, and seem less consolidated. The air bronchogram is not nor
mally seen.
It is no longer usual to maintain the differentiation between lobar pneu
monia and bronchopneumonia as the radiological picture may vary con
siderably.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 55.
Pneumococcal pneumonia
- massive opacity left lung
with air bronchogram.
Bacterial infections
Bacterial pneumonia may occur in normal ’’healthy" individuals, but in
today’s modem society, bacterial pneumonia often occurs in patients with
reduced resistance to infection. Special risk groups will be patients with
advanced cancer, nutritional disturbances, or immunodeficiency caused
either by immunological disease or various drugs.
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THE LUNGS AND MEDIASTINUM
Figure 56.
a) Staphylococcal pneumonia
with mottled multifocal bilat
eral pulmonary opacities.
b) Staphylococcal pneumonia -
late stage. The opacities coa
lesce and become homoge
nous in character.
c) Staphylococcal pneumonia -
late stage with consolidated
pulmonary opacities. Bilateral
pneumothorax has developed.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 57.
Staphylococcal pneumonia, right up
p er lobe. Volume reduction o f the
upper lobe is seen as the horizontal
fissure has been pulled cranially.
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THE LUNGS AND MEDIASTINUM
Figure 58.
Homogenous consolidated in
filtrate right lower lobe.
Klebsiella pneumonia.
Figure 59.
a) Gram negative pneumonia
with abscess formation.
Considerable volume
reduction o f the affected
lobe. Compensatory
emphysema left lung.
b) CT thorax. Gram negative
pneumonia. Opacity with
abscess formation in right
lower lobe. Pleural fluid
right side.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Anaerobic infections
The most common anaerobic infection, tuberculosis, is caused by my
cobacterium tuberculosis. Tuberculosis is most often seen as limited epi
demics in densely populated areas. The primary infection is almost al
ways due to inhalation of mycobacterium tubeculosis, usually to the mid
dle or basal segments of the lung. After this, spread of bacteria occurs
internally in the lung, possibly also via lymph channels, to lymph nodes
in the mediastinum. The immunity reaction tends to encapsulate the ac
tual tubercle bacillus, which then enters an inactive "dormant” stage. The
tubercle bacilli are most often implanted in areas of the lung with a high
oxygen tension, usually in the apical segments (Fig. 60). At this stage,
the tuberculous opacity looks like a segmental or lobar opacity with con-
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THE LUNGS AND MEDIASTINUM
Figure 61.
Reactivated old tuberculosis with
cavitation andfluid levels in the left
upper lobe.
Figure 62.
Reactivated old tuberculosis with f i
brous, striped opacities and less ex
tensive infiltrates in right upper
lobe.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
apical and posterior segments of the upper lobes and to the superior seg
ments of the lower lobes. It is seen as a mottled, poorly defined alveolar
infiltrate, often with the formation of cavities. In most cases, only one
lung is involved, but bilateral changes are seen in the more advanced cases.
At this stage, the lung changes are very variable with cavities, single or
multiple nodular opacities, pleural fluid, large consolidating infiltrates
(both lobar an diffusely scattered), or pneumothorax (Fig. 62). The great
variability in the radiological picture at this stage makes it difficult to
make a diagnosis on the basis of the radiological picture alone. Infectious
diseases and lung cancer may be relevant differential diagnoses.
Tuberculosis occurs infrequently outside the lungs. Tuberculous lym-
phadenopathy is common, as is involvement of the visceral and parietal
pleura, the pericardium, and the peritoneum. The tuberculous infection
may be disseminated and involve both lungs (miliary tuberculosis). In
these cases characteristic changes are seen with small miliary opacities
diffusely scattered over both lungs.
Tuberculomas in the lungs are seen both in the primary and the later
phases of the disease. A tuberculoma represents a limited, localized con
dition of the parenchyma which heals and later shrinks. Finally, a sharply
limited node-like opacity, usually 1-5 cm in diameter, is seen. This is
usually localized in the upper segment o f the lung. Tuberculomas are
usually solitary, but may be multiple and often calcify. Formation of cav
ities is rare. The differential diagnosis between tuberculoma and a pri
mary lung tumor, or possibly a metastasis may be difficult.
The lung changes in tuberculosis will improve after adequate treat
ment, but often leave considerable changes with fibrosis, infiltrates,
calcification, shrinking, and pleural thickening and pleural adhesions
(Fig. 63). Response to treatment is indicated by shrinking of infiltrates,
reduced wall thickness of the cavities, and fibrosis.
However, any residual tuberculous process may become reactivated
at any time in the later stages of the disease. Reactivation often occurs
many years after the initial primary tuberculous infection.
Before chemotherapy of tuberculosis became usual, pulmonary
tuberculosis was often treated surgically. One of the most common types
of operation was thoracoplasty, where the upper ribs were removed in
order to collapse the upper segments of the lung, where the disease was
most frequently located (Fig 64). Other forms of treatment not
infrequently used were induction of pneumothorax and injection of
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THE LUNGS AND MEDIASTINUM
Figure 63.
Old tuberculosis, predominantly
right-sided, with fibrous infiltrates,
calcification, pleural thickening
with adhesions, and shrinking.
Figure 64.
Left-sided thoracoplasty with resec
tion o f cranial ribs.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 65.
Varicella pneumonia; alveolar
opacities symmetrical distrib
uted in both lungs.
Influenza virus
There are a series of different viruses of this type (influenza A, B, and
C), with several variants within each group- The antingen component
may thus vary considerably, and immunological resistance to the influ
enza virus is therefore infrequent. In uncomplicated influenza, the chest
radiograph is normal. In complicated lung infections caused by the in
fluenza virus, signs of bilateral pneumonia with pronounced consolida
tion of the lung parenchyma are usually seen. Bacterial pneumonia is
often seen in connection with influenza. Radiologically, it is not possi
ble to differentiate between pneumonia caused by the influenza virus
and bacterial pneumonia.
In rare cases, a number of other types of virus such as parainfluenza,
respiratory syncytial-, adeno-, rhino-, and herpes viruses may cause
pneumonia. None of these types have special radiological characteris
tics, and it is not possible to differentiate these infections from bacterial
pneumonia.
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THE LUNGS AND MEDIASTINUM
Figure 66.
Mycoplasma pneumonia -
pneumonic opacities in
both lower lobes, most
pronounced on the right
side.
meter, and normally disappear within a week. In a few patients, the opac
ities may persist for several months. In about 2 % of the patients, the opac
ities may resemble small nodules which calcify causing permanent
changes.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 67.
Actinomycosis - pneumonic
opacity, right upper lobe, with
volume reduction o f the upper
lobe.
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THE LUNGS AND MEDIASTINUM
Figure 68 a + b.
PA and lateral views - echinococcal
cyst right lower lobe. Sharply defined
homogenous opacity. Minimal
amounts ofpleural fluid.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
ities. Nodular opacities are seen when more node-like lesions arise in the
interstitium. These opacities are homogenous, well-defined, and many
vary considerably in size.
Reticulonodular opacities may be seen when several nodular opacities
coalesce forming network-like opacities. Linear, striped opacities may
represent thickening of interalveolar clefts or interlobular septa (Kerley's
A and В lines). In interstitial opacities, a combination of these four main
types is often seen.
738
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Cardiogenic congestion/edema
The first radiological sign of interstitial edema is blurred outlines o f the
pulmonary arteries. The blurring is observed first and most readily in the
hilar regions. In addition, the basal segments of the lung often seem rather
blurred. At the same time, a redistribution o f flow occurs with equiva
lent or larger diameter of the arteries of the upper lobe compared to lower
lobe vessels (antler sign). When fluid collects in the interlobular and in
teralveolar septa, the so called A and В lines (Kerley A/Kerley B) are
formed. When the congestive changes progress, alveolar edema with
fluid in the alveoli develops. This produces diffuse lung opacities with
out air bronchogram. The edema fluid usually develops symmetrically
and collects mainly in the lowest parts of the lungs (Fig. 69). However,
asymmetrical distribution of edema is not unusual, and is most often re
lated to the patient’s position in bed (lying on right or left side). The fact
that the opacities in edema tend to be most pronounced in the lowest lung
739
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 69.
Enlarged heart with congestive
changes in both lungs. Bilateral
pleural fluid.
Figure 70.
Pulmonary congestion/edema
with congestive changes chiefly
in the hilar regions. Relatively
sharply defined opacities (Bat-
wing).
740
THE LUNGS AND MEDIASTINUM
Figure 71.
Heart failure with consider
ably enlarged heart (cor bov-
inum) with congestive changes
in both lungs.
Figure 72.
Near drowning-pronounced
pulmonary congestion (edema
with extensive alveolar
opacities caused by large
collections o f fluid in the
alveoli).
Non-cardiogenic congestion/edema
Drowning
Congestion/edema changes are seen in patients who have almost
drowned (Fig. 72). Diffuse alveolar opacities caused by edema fluid can
be seen on the chest radiograph, tn addition, there is usually aspiration
of water and stomach contents. Increased capillary permeability also
leads to interalveolar collection of edema fluid that is rich in protein,
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Figure 73.
Pulmonary congestion in a p a
tient with reticular opacities in
both lungs.
Inhalation o f gases
The most common gases are nitrogen, phosporus, sulphur dioxide, am
monia, chlorine, and ordinary smoke (in connection with fires).
Congestion/edema usually occurs as a result of a direct effect of the gases
on the endothelial cells in the alveoli. The accompanying edema is usu
ally fairly pronounced with diffuse blurring of the affected lung segment.
The size of the heart is always normal.
R enal failure
Pulmonary congestion/edema is frequently seen in patients with both
acute and chronic renal failure, and is a common cause of death in pa
tients with acute nephritis (Fig. 73). However, the most frequent cause
of the development of pulmonary congestion/edema in these patients is
failure of the left side o f the heart.
Sepsis
Pulmonary congestion/edema is frequently seen in patients with sepsis.
The primary cause is probably the release of vasoactive substances that
affect the permeability of the capillaries/alveoli. It is not possible to make
a radiological differentiation between this type of pulmonary congestion
and that seen in heart failure. However, the size of the heart will be nor
mal unless there is a simultaneous involvement of the heart.
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Fibrosing alveolitis
This is a group of diseases characterized by an inflammatory reaction in
the endothelial cells in the alveoli with an alveolar exudate. As the dis
ease progresses, there is destruction of the alveolar architecture. The dis
ease is also called Hamman-Rich disease. Fibrosing alveolitis may be
seen at the same time in systemic diseases such as rheumatoid arthritis,
disseminated lupus erythematosus, ulcerous colitis, and chronic hepati
tis. The disease is characterized by rapid progression, with only mild
non-specific blurring of the affected lung segment in the early stages,
followed by an increasingly diffuse outline of the pulmonary arteries,
and gradual development of fine reticulonodular opacities in the basal
lung segments (Fig. 74). Gradually, as the fibrosis develops rapidly, there
is reduced volume of the affected lung segment. The reticular opacities
become steadily coarser and gradually appear as annular shadows with
diameters from 5 to 10 mm. The annular shadows represent cystic cavities
in the lungs, giving these a typical honeycomb appearance. This is best
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Figure 74.
Fibrosing alveolitis with retic
ular opacities in both lungs.
seen in lateral views of the lungs, most often basally and posteriorly.
Pneumoconioses
The common characteristic of this group o f diseases - of which asbestosis
and silicosis are the most important - is that they are caused by organic
dust particles that are small enough to reach the alveoli where a type III
Arthus tissue reaction takes place. Four to six hours after exposure, hy
persensitivity pneumonia develops. Initially, the chest radiograph is nor
mal. Later, diffuse blurring of the basal lung segments develop. The in
volved parts of the lungs have reduced circulation because of oblitera
tion of small pulmonary vessels. After temporary exposure to dust
particles, the condition returns to normal, both clinically and radiologi-
cally. However, residual changes may be seen as reticulonodular opac
ities 1-3 mm in diameter.
With continuing exposure to dust, pulmonary fibrosis gradually
develops, characterized by coarse linear striped opacities, specially in
the middle and upper part of the lungs. Considerable volume loss is seen
at a late stage in the development of fibrosis. In pulmonary fibrosis caused
by pneumoconiosis, small round shadows, 5-8 mm in diameter with a
central translucency are seen, giving a honeycomb appearance. This
special fibrosis is most typically seen in the upper lobes, unlike fibrosing
alveolitis where the fibrosis is most pronounced in the basal lung
segments.
Asbestosis
The first visible radiological changes in asbestosis are small irregular
opacities, mainly in the basal parts of the lungs. The middle and upper
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THE LUNGS AND MEDIASTINUM
Figure 75.
Asbestosis - irregular striped
opacities, most pronounced in
the basal lung segments.
parts are involved at a later stage. In the earliest stages, the opacities are
thread-like and are often confused with vascular shadows that branch
into fine thread-like structures (Fig. 75). As the disease progresses, the
linear opacities become coarser and broader, and may obscure the pul
monary arteries that branch out to the involved area. In severe cases,
there are diffuse coarse reticulonodular opacities, which gradually be
come honeycomb-like. These opacities may be so large that they com
pletely obscure the outline of arteries in the area, and also obliterate the
outline of adjacent parts of the diaphragm and heart.
Typical changes in asbestosis are pleural involvement as plateau-
chaped pleural thickening. This is typically seen in the parietal pleura,
while the visceral pleura is not involved. Pleural changes are seldom ob
served unless the disease has lasted for at least ten years. In the frontal
view, the pleural thickening is observed where the pleura is in contact
with the ribs, most often in the middle third of the chest wall. The typi
cal disk-shaped thickening of the pleura is usually called a pleural plaque.
The upper and basal parts of the pleura are not affected until the more
advanced stages of the disease. A pleural plaque is best shown on chest
films taken tangentially.
The standard examination when asbestosis is suspected includes
oblique views of the lungs with the patient rotated 45 degrees (Fig. 76).
In the late stages of the disease (usually after more than twenty years),
there is fairly extensive calcification in the pleural plaques. The disease
is gradually dominated by extensive fibrosis with marked shrinking and
considerable pleural thickening containing calcification. Calcification is
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 77.
Asbestosis - linear opacities in
the basal lung segments, which
obliterate the outline o f the p u l
monary arteries peripherally.
most often observed in the parietal pleural on the domes of the diaphragm
(Fig. 77).
Pleural fluid is unusual in asbestosis. If pleural fluid is seen, it is a
strong indication of the development of malignant mesothelioma. In such
cases, the pleural fluid contains blood. A chest radiograph is usually not
sufficient to clarify the degree of spread of the malignant mesothelioma.
This evaluation is best done by CT scan, which shows the extent of the
pleural changes. By examining in the supine and prone positions, possi
bly also in lateral decubitus, it is easy to differentiate between pleural
746
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Figure 78.
Acute silicosis, alveolar infil
trate right upper lobe with air
bronchogram.
fluid and pleural thickening. Invasion into and destruction of ribs is com
mon with advanced mesothelioma, as are metastases to the lungs and
mediastinum. Distant metastases are also frequently seen.
A needle biopsy of the pleural thickening or tumor mass, under guid
ance of CT, gives the diagnosis, as does cytological examination o f the
hemorrhagic pleural fluid. In addition to the risk of developing malig
nant mesothelioma, patients with asbestosis also show a higher incidence
of lung cancer.
Silicosis
Silicosis was previously a common disease in miners, and is due to in
halation of silicate crystals (silicon dioxide) into the alveoli. Inhaled sil
icate crystals develop small nodes of collagenous hyaline material. These
nodes are visible on the frontal film. The lymph nodes in the hilum o f
the lung are usually enlarged. Eggshell-like calcification in the periph
ery of these lymph nodes is typical of silicosis. Although corresponding
calcification may be seen in sarcoidosis, histoplasmosis, scleroderma and
amyloidosis, it is rarer than in silicosis.
Infiltration of plasma cells and lymphocytes is seen in the alveolar
walls. The typical picture in acute silicosis is thus dominated by an alve
olar infiltrate with air bronchogram (Fig. 78). The alveolar infiltrate may
appear as small nodules. If chronic changes develop, these typical nod
ules disappear and the involved areas appear more like consolidated in
filtrates with fibrosis (Fig. 79).
Patients with silicosis have an increased incidence of pulmonary tu
berculosis.
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Figure 79.
Silicosis, consolidated infil
trates with development o f fi
brosis in both lungs, most p ro
nounced in right upper lobe.
Sarcoidosis
Sarcoidosis is a disease of unknown etiology, characterized by diffuse,
non-caseating granulomas. Granulomas are typical of sarcoidosis, but
may also be seen in other diseases such as tuberculosis, diverse fungal
infections, and in patients with carcinoma and lymphoma. The develop
ment of sarcoidosis is probably determined immunologically by an in
teraction between an unidentified antigen and the organism. Sarcoidosis
is sometimes associated with erythema nodosum. Although sarcoidosis
is most frequent in the lung and mediastinum, the disease is also en
countered in other organs such as skin, peripheral lymph nodes, spleen
and the central nervous system. The diagnosis is usually made defini
tively by a lymph node biopsy.
748
THE LUNGS AND MEDIASTINUM
Figure 80.
Sarcoidosis
a) Frontal view shows enlarged lymph
nodes in both hilar regions
b) Lateral view shows enlarged lymph
nodes in hilar regions.
Figure 81.
Sarcoidosis - mediastinal tumor and
bilateral hilar gland enlargement.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 82.
Sarcoidosis - small nodular
opacities in both lungs.
Bilateral hilar lymphadenopa-
thy.
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Figure 83.
Collagenous vascular disesae
- non-specific changes with
diffuse interstitial fibrosis,
mainly on right side.
Consolidated infiltrate cra-
nially, lateral to right hilum.
Figure 84.
Wegener's granulomatosis - necro
tizing granuloma with flu id level
(arrow) in right upper lobe.
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Figure 85.
Pneumocystis carinii pneumo
nia in HIV/AIDS patient.
a) Indistinctly marginated infil
trate o f mixed alveolar/in
terstitial type, chiefly in left
lower lobe
b) Bilateral infiltrates, most
pronounced on right side.
The infiltrate has indistinct
borders. An obvious air
bronchogram is seen in the
infiltrate on the right side.
c) Lateral view o f b) above.
Middle lobe is also seen to
be involved.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Pulmonary con
gestion/edema Fibrosis Alveolar opacities Hilar lymphadenopathy
Salicylates Furadantin Salicylates Methotrexate
Phenylbutazone Oxygen Anticoagulants Antiepileptics
Heroin Bleom ycin Bleomycin
Methadone Methotrexate
Trauma
Thorax injuries vary considerably from simple, uncomplicated rib frac
tures to large complicated injuries effecting the chest, combined with in
juries in the head, abdomen and extremities. The cause of injury is most
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THE LUNGS AND MEDIASTINUM
often a deceleration trauma, with blunt violence to the chest. In such cases,
there is often a combination of injuries to the chest wall, pleura, lungs,
and mediastinum.
When a patient with multiple injuries is examined, a lateral view of
the cervical column, a frontal chest radiograph, and a frontal view o f the
pelvis is usually obtained. The frontal radiograph of the lungs must be
obtained sitting if the patient’s condition permits, otherwise lying. At this
stage the primary concern is to detect life-threatening conditions such as
tension pneumothorax, haemothorax, mediastinal bleeding, and rupture
of the diaphragm. In recent years, it has become increasingly frequent to
use CT scans early in the examintaion of severely multitraumatized pa
tients. Thus, one and the same examination provides more complete de
tails of injuries in different organs, together with the possibility of mak
ing a more precise diagnosis of the extent o f the chest injury. For exam
ple, a small anterior pneumothorax is far easier to diagnose by CT scan
than by a frontal view of the lungs. This also applies to bleeding in the
lung and pleural cavity, and, above all, to mediastinal injuries, the most
important of which is aortic rupture.
Figure 86.
Fracture o f sternum through the upper part o f
the body o f the sternum with forward and cra
nial dislocation o f the distal fragment
(arrows).
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Figure 87.
Fracture o f sternum with large
retrosternal haematoma.
Considerable widening o f the
mediastinum in PA chest x-ray.
Figure 88.
Fracture o f sternum with large
retrosternal haematoma —CT
scan.
ture of vessels and the trachea. Fractures o f the lowest ribs are often ac
companied by simultaneous injuries of the liver and spleen (rupture).
Fractured ribs may be seen together with pneumothorax, indicating a
penetrating pleural injury. Multiple fractured ribs may cause pulmonary
collapse involving larger or smaller parts o f a lung, and accompanied by
unstable respiration (flail chest).
Fracture of the sternum is frequently seen with severe injuries to the
thorax (Fig. 86), usually with dislocation of the different fragments in
relation to each other. A retrosternal hematoma of varying size often de
velops. This will be visible as a widening of the mediastinum (Fig. 87).
A CT scan is necessary (Fig. 88) in order to assess the extent of the
hematoma and to verify the diagnosis, making certain that it is not caused
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THE LUNGS AND MEDIASTINUM
Figure 89.
Traffic injury with penetrating
left-sided thorax trauma.
Pneumo-thorax with total col
lapse o f the left lung (arrows).
Pleural injuries
Pleural injuries are due to complications arising from rib fractures and
other penetrating injuries. The most common complications are pneu
mothorax (Fig. 89), and hemothorax. A chest radiograph aimed at diag
nosing pneumothorax should be taken in the expiratory phase.
Tension pneumothorax may arise after penetrating injuries. Positive
pressure arises in the punctured pleural cavity, with displacement of the
heart and mediastinal structures over towards the contralateral side. This
may compromise venous return to the heart and reduce filling pressure
in the right ventricle. This is a life-threatening condition needing imme
diate relief, e.g. drainage of the affected pleural cavity.
Bleeding into the pleural cavity is usually caused by severance of veins,
and is most often seen at the same time as pneumothorax (hemopneu-
mothorax). If fat is present in the pleural fluid, it is a sign of chylotho-
rax and is due to rupture of lymph vessels. Rupture of the thoracic duct
may occur with blunt trauma.
Lung injuries
Lung injuries, usually contusion of lung tissue, may be accompanied by
injuries of the ribs and pleura (Fig. 90), but are seen just as often with
out simultaneous rib fractures (Fig. 91). With a compression injury of
the lungs, extravasation of blood into the alveoli occurs followed by de-
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Figure 90.
Traffic injury with fracture o f
the 2nd, 3rd, 4th, 5th and 6th
right ribs. Contusion o f lung
tissue in both upper lobes. No
pneumothorax.
Figure 91.
Extensive contusion changes in
both lungs. Thoracic drainage
tubes inserted bilaterally, to
gether with endotracheal tube.
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THE LUNGS AND MEDIASTINUM
Figure 92.
a) PA chest x-ray immediately
after admission to the ward
after head-on collision in a
car. Opacities in left upper
lobe. Large left-sided ex-
trathoracic hematoma.
b) After 2 hours, considerable
widening o f the mediastinum
has occurred as a sign o f
rupture o f the aorta.
Mediastinal injuries
The most frequent injuries
of the mediastinum are
a
aortic rupture, esophageal
rupture, tracheal/bronchial
rupture, pneumomediast
inum, pneumopericardium,
and diffuse mediastinal
bleeding.
Aortic rupture is one of
the most important causes
of death after traffic acci
dents with thorax injuries.
b
The sites of predilection in
the aorta are the ascending aorta immediately before the origin of the in
nominate artery, and the descending thoracic aorta immediately after the
origin of the left subclavian artery (70%). If the rupture is situated in the
ascending part of the aorta, it is frequently accompanied by cardiac tam
ponade. Most of these patients die before hospitalization. Of the patients
who survive the initial injury, 30% die in the course of the first four hours.
Chest radiography sitting in bed is an important examination in pa
tients with thorax injuries. If the width of the mediastinum is increased
in a sitting chest radiograph, or increase in width occurs during the course
of the first hours after admission to hospital, aortic rupture is strongly in
dicated, and angiography should be done emergently (Fig. 92 a, b). A
collection of blood over the apex of the left lung (pleural cap) also points
strongly towards aortic rupture. It is extremely important to rapidly es-
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Figure 93.
a) Aortography, right posterior
oblique (left side elevated) - aortic
rupture (arrow)
b) Aortography, lateral - aortic rup
ture
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THE LUNGS AND MEDIASTINUM
Figure 94.
Rupture o f the esophagus - PA
chest x-ray. A collection o f air
is seen in the mediastinum
with stripes o f air round the
arch o f the aorta and
bronchial tree (black arrows).
Diaphragm injuries
Rupture of the diaphragm is encountered usually as a complication of
blunt trauma to the thorax. The left diaphragm ruptures more often than
the right (Fig. 95). The injury to the diaphragm will often be obscured
by the accompanying chest injuries, and not infrequently remains undi
agnosed in the period immediately after the injury. If it continues to be
undiagnosed and untreated, hernias develop through which parts of the
abdominal organs enter the thoracic cavity. If intestine herniates into the
chest cavity, strangulation may occur. As injuries to the diaphragm are
often accompanied by an elevated diaphragm, rupture of the diaphragm
may be difficult to detect, especially in the initial phase when the pa
tient's condition makes it difficult to obtain a frontal film in the standing
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Figure 95.
PA chest x-ray - left-sided rup
ture o f diaphragm with exten
sive changes in the basal 2/5 o f
the left lung. Two thoracic
drainage tubes have been in
serted into the pleural cavity
on the left side.
Figure 96.
Rupture o f left dome o f di
aphragm with herniation o f the
fundus o f the stomach (v) up
into the thoracic cavity. The
fundus o f the stomach is filled
with contrast. Atelectatic lung
tissue is seen lateral and poste
rior to the fundus.
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Figure 97.
Right-sided pneumonectomy -
empty right hemithorax. Drain
inserted into chest cavity.
Thoracic surgery
Pneumonectomy
Immediately after removal of a lung, the chest radiograph shows an
empty hemithorax (Fig. 97). A thoracic drain connected to suction lies
in the empty chest cavity in order to create negative pressure so that the
mediastinum remains in the mid-line, and the opposite lung remains ex
panded. The mediastinum and trachea will remain in the mid-line with
uncomplicated postoperative progress.
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Figure 98.
a) Chest x-ray 3 weeks after
right-sided pneumonectomy.
Most o f the thoracic cavity
is filled with flu id (PA view)
b) Chest x-ray 3 weeks after
right-sided pneumonectomy
- most o f the thoracic cavity
is filled with flu id (lateral
view).
Lobectomy
After removal of a lobe of the lung, the remaining lobes on the operated
side will increase in volume. Since the amount of tissue in these is con
stant, the remaining lobes, which are to fill the chest cavity, become hy
perinflated and seem to be emphysematous (compensatory emphysema).
If these lobes do not succeed in filling the chest cavity completely, the
remaining space will be filled with fluid or air. Small collections of fluid
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Figure 99.
Postoperative total atelecta
sis o f the right upper lobe.
The upper lobe is seen as a
widening o f the mediastinum
cranially on the right side.
may remain in the chest cavity for several weeks, but are gradually ab
sorbed. The patient is treated in the postoperative phase with a thoracic
drain to maintain negative presssure in the pleural cavity and thus ex
pand the remaining lobes of the lung. Complications such as bron
chopleural cysts and empyema may be seen in this phase. Protracted col
lections of air in the chest cavity postoperatively should raise concern
for the development of a bronchopleural fistula. In such cases, bron
chography will be able to demonstrate the site of leakage.
Heart surgery
Heart surgery is usually performed through a median sternotomy.
Insertion of an aortocoronary by-pass is the most common type o f oper
ation.
In the early postoperative phase, knowledge of the exact position of
the inserted catheters/tubes is important (see separate section). On chest
radiographs, which will nearly always be frontal views, it is important
to assess the aeration of the lungs, and to ascertain whether there is post
operative atelectasis (Fig. 99), collection of fluid in the pleural cavity
(Fig. 100), pulmonary congestion indicating either heart failure, over
hydration, or widened mediastinum. A widened mediastinum may indi
cate postoperative bleeding. If the heart shadow increases in size, this
may be a sign of bleeding into the pericardial cavity, which may induce
cardiac tamponade.
Most patients operated by insertion of an aortocoronary by-pass have
atelectatic changes in the left lower lobe during the first postoperative
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Figure 100.
Large amounts o f right-sided
pleural fluid with basal right
sided opacity. Complete
obliteration o f outline o f
right dome o f the diaphragm.
Figure 101.
Postoperative atelectatic
changes in the left lower lobe
with opacities in the lower
lobe and drawing up o f the
left dome o f the diaphragm.
Considerably dilated gastric
fundus - the fluid level in the
fundus is seen below the
dome o f the diaphragm.
Postoperative monitoring
Central venous catheters are inserted after all types of lung and heart
surgery, partly to monitor the central venous pressure, and partly for par
enteral nourishment. Access is usually obtained by percutaneous punc
ture of the subclavian vein. Chest radiography after insertion of the cen-
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Figure 102.
Frontal film shows proper in
sertion o f left-sided thoracic
drainage tube, tip o f the tube is
located apically and posteri
orly (same patient as in Fig.
101).
Figure 103.
Swan-Ganz catheter inserted
via the right jugular vein and
superior caval vein (black ar
row) through the right atrium
and right ventricle to a lower
lobe artery on the right side
(white arrow). Aortic balloon
pump (open arrow) in the
proximal descending aorta. It
is located near but below the
origin o f the left subclavian
artery.
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Atelectasis
Atelectasis is frequently seen in the postoperative phase, and may be
caused either by hypoventilation, retained secretion in the bronchial tree,
or aspiration. In a frontal chest radiograph it is important to identify the
horizontal fissure on the right side in order to assess possible loss o f vol
ume of the different lobes of the lungs. Volume-reduced lung segments
or lung lobes usually appear as homogenous opacities. Rapid changes,
both progression and regression, are typical features of postoperative at
electasis.
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Pulmonary congestion/edem a
Postoperative pulmonary congestion/edema is due either to heart failure
or overhydration, possibly to fluid retention. Sepsis and conditions of
shock may also cause pulmonary edema as a consequence of increased
capillary permeability. The radiological changes in the postoperative pa
tient may be more difficult to assess than in other groups of patients, as
other lung changes such as atelectasis and aspiration may be seen at the
same time. The lungs are usually also considerably less aerated than nor
mal. The radiological picture is otherwise similar to congestive condi
tions with other etiologies.
Pulmonary em bolism
Pulmonary embolism is frequently seen in the postoperative patient. A
prolonged confinement to bed with development of peripheral thrombi
may also increase the frequency of emboli to the pulmonary arteries.
The radiological picture is non-specific and may include atelectasis,
irregularly defined opacities, and pleural fluid. Perfusion scintigraphy is
usually of limited value, as many other postoperative conditions can also
give areas of the lung with reduced perfusion. A combination of perfu
sion and ventilation scintigraphy improves the likelihood of diagnosing
pulmonary embolism, but pulmonary angiography is often necessary.
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Figure 104.
ARDS - bilateral interstitial
edema - early stage.
Pneumonia
Pneumonia is often seen as a postoperative complication. Pneumonia is
seen particularly often during the development of aspiration or atelecta
sis. The radiological picture may be typical with opacities in ordinary
pneumonia, but the picture is often complicated by the simultaneous pres
ence of other pathological conditions.
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Figure 105.
ARDS - massive bilateral pul
monary opacities.
Figure 106.
Lateral decubitus view with hor
izontal beam. The patient is ly
ing on the right side.
Considerable amounts o f right
sided pleural fluid is demon
strated.
Pleural flu id
Pleural fluid is frequently seen after chest surgery, and, in sitting or semi
supine picture taken in bed, it will appear as diffuse blurring of the basal
lung segments, which obliterates the outline of the costophrenic angle
and diaphragm. A radiograph with the patient in lateral decubitus view
with a horizontal beam usually confirms the diagnosis (Fig. 106). In sit
ting or lying pictures, even considerable amounts of fluid may remain
undetected. Ultrasound in sitting patients easily discloses collections of
fluid in the posterior costophrenic angle.
INTERVENTIONAL PROCEDURES
The most common procedure is needle biopsy of pulmonary or medias-
tial nodules or masses. Under the guidance of fluoroscopy, the tip of a
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772
Chapter 19
The heart
MODALITIES
Conventional radiology
The cardiac radiographic study consists of one frontal and one lateral
film (Fig. 1 a, b). In addition, two oblique projections are taken in spe
cial cases, but these usually give little additional information beyond that
obtained from frontal and lateral views.
The frontal film is exposed in full inspiration. The distance between
the film and the x-ray tube should be standardized in order to permit mea
surement of cardiac dimensions. The normal focal-film distance is 1.80
metres. In the frontal view, the heart appears as a white shadow, where
it is only possible to assess changes in shape and size.
The lateral view is often taken with contrast medium in the esophagus
to facilitate assessment of the position of the posterior outline (left
atrium). It is not possible on the lateral view to evaluate internal struc-
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Figure 1.
a) PA view o f heart o f normal size. The
right atrium makes the right, and the
left ventricle makes the left outline.
Cranially, the superior vena cava is
seen on the right and the arch o f the
aorta on the left side.
b) Lateral view o f a heart o f normal size
with contrast in the esophagus. In
front, the right ventricle is next to the
sternum, and the left atrium form s the
upper part o f the posterior heart out
line and is next to the esophagus. The
posterior border o f the left ventricle
makes the lower part o f the heart's
posterior outline.
tures of the heart but rather the heart size and contour are evaluated.
However, intracardiac and pericardial calcification can be readily as
sessed in a lateral view.
Fluoroscopy is used to localize intracardiac calcifications. This
modality permits evaluation of motion of the calcification during the car
diac cycle. Fluoroscopy may also be useful to identify paradoxical move
ment of the left ventricle (with aneurysms of the left ventricle), and to
examine the relationship between the heart and mediastinal structures.
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Figure 2.
a) Computed tomography; section
through the heart at the level o f
the ventricles. The picture shows
the right and left ventricle and
the course o f the ventricular
septum.
b) Cross section through the upper
part o f the heart; intravenous
contrast medium. The left atrium
is seen at the back, and the right
atrium to the right as a tapering
cleft-like space. The outlets o f the
right and left ventricles, respec
tively, are seen in the middle
anteriorly.
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Figure 3.
Transverse section through the
heart (MRI). Large dilated left ven
tricle in a child. A small triangular
right ventricle is seen at the fro n t
with the right atrium behind it. The
left atrium is seen in fro n t o f the
vertebral column, with the opening
o f one o f the pulmonary veins on the
left.
Figure 4.
ECG gated spin echo (a) and cine
MR (b) in the transaxial plane
display a dissection o f the descend
ing aorta. The intimalflap (arrow)
separates the true (T) and false (F)
channels. On the spin echo image,
the signal in the false channel is
caused by slow velocity o f blood
flow.
a
cine MRI was introduced,
which provides images corre
sponding to multiple phases of
the cardiac cycle. This en
abled evaluation of cardiac
contraction and valvular mo
tion. It is now possible to ob
tain a cine MRI acquisition
b during a breath hold period of
14 to 16 seconds. MR images
can also be obtained at a rate of one per second or slightly longer in or
der to monitor contrast media distribution in the cardiac chambers and
myocardium. Monitoring of the first pass dynamics of MR contrast me
dia constitutes a new method for evaluating mycardial perfusion. Finally,
nearly real time MR imaging of the heart is possible with echoplanar MRI.
The role of MRI of the heart is still evolving and consensus is not es
tablished regarding all the proposed uses of it for cardiovascular diag
nosis. MRI can be considered for the evaluation of the following clini
cal situations:
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Figure 5.
ECG gated spin echo images in the
transaxial (a) and coronal (b) planes
in two patients with constrictive
pericarditis. The thick pericardium
is demonstrated in both patients.
Figure 6.
ECG gated spin echo image in the
transaxial plane demonstrates
hemorrhagic (H) and nonhemor-
rhagic (E) pericardial collections.
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Figure 7.
ECG gated spin echo images in
the transaxial (a) and coronal (b)
planes demonstrate a large left
atrial myxoma (M) nearly filling
the left atrium. E = pericardial ef
fusion;
P = pulmonary arteries; T = tra
chea; arrow = left upper pul
monary vein.
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Figure 9.
ECG gated spin echo image shows a
large tumor (T) o f the lung invading
the left atrium (LA).
RA = right atrium; arrow = peri
cardial effusion
Figure 10.
ECG gated spin echo image in the
coronal plane demonstrates an
aneurysm (arrow) o f the diaphrag
matic segment o f the left ventricle
(LV) after prior myocardial infarc
tion.
A = aortic sinus; P = pulmonary
artery; RA = right atrium
The cine MRI technique can be used to evaluate dimensions and func
tion of both ventricles. Cine MRI is also used to identify pathological
(high velocity turbulent) flow caused by valvular regurgitation and steno
sis (Fig. 12,13). The velocity encoded cine MRI technique provides mea
surement of blood flow and velocity in the heart and great vessels. It has
been used for quantifying the volume of valvular regurgitation and the
gradient across valvular stenosis. It can also be used to measure the vol
ume of left to right shunts and differential flow in the right and left pul
monary arteries.
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Figure 11. ECG gated spin echo images in the transaxial (a) and sagittal (b) planes in
a patient with a severe juxtaductal coarctation (arrow) o f the aorta. Large paraverte
bral collateral arteries are demonstrated (arrows).
Figure 12.
Coronal cine MR images in a patient
with aortic regurgitation. Images in the
upper panels are during systole and
those in lower panels are in diastole.
The signal void emanating from the aor
tic valve in diastole represents the je t o f
aortic regurgitation.
Figure 13.
Cine MR image in a patient with aortic
stenosis. Systolic phase. The signal void
emanating from the aortic valve into the
ascending aorta is caused by aortic
stenosis.
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THE HEART
Angiocardiography/coronary angiography
Angiography (Fig. 14 a-d) is used to examine the heart chambers and the
coronary arteries. Under the guidance of fluoroscopy, a catheter is in
serted, usually via the femoral artery, to the left ventricle, where contrast
is injected. This permits measurement of the volume of the left ventricle
and parameters o f left ventricular function. The movement and compe
tency of the cardiac valves can also be evaluated. The catheter is then
routinely withdrawn to immediately above the aortic valves so that this
portion of the ascending aorta and the aortic valves can be examined. In
addition, selective catheterization of the left and right coronary arteries
is carried out, and films are acquired in several projections to assess
pathological changes such as stenosis or occlusion.
When the right side of the heart is examined (cardiac catheterization),
the catheter is inserted from either the femoral vein, or an antecubital
vein, to selected sites in the right half of the heart or superior vena cava,
depending on the problem under investigation. At the same time, pres
sure is registered, and the oxygen content of the blood is measured. Since
injection of contrast agents into the heart itself necessitates large vol
umes injected very rapidly (45 ml injection volume, 15 to 25 ml per sec
ond with injection into the left ventricle), an automatic high pressure sy
ringe is needed for these injections. Injection into the coronary arteries
is usually carried out by manual injection of from 5 to 8 ml of contrast
medium per injection.
The films in angiocardiography and coronary angiography are usually
recorded on cine film (35 mm film). In order to obtain continuous, sharply
defined images of the movements of the heart, a minimum of 24 frames
per second is often used during these examinations, which can also be
carried out using digital format instead of ordinary cine film.
Echocardiography
Ultrasound scanning of the heart can either be performed as M-mode or
two-dimensional (2-D) echocardiography (Fig. 15 a, b).
M-mode echocardiography gives a one-dimensional image of the struc
tures of the heart. Since the different parts of the heart move synchronously
in relation to each other during the cardiac cycle, the echo from these struc
tures will move coordinate with each other in relation to the ultrasonic
transducer on the chest wall. These echoes are recorded on an oscillograph
or on videotape as a continuous one-dimensional representation.
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Figure 14.
a) Angiocardiography - catheter from the fem oral artery down into the left ventricle.
b) Thoracic aortography with injection o f contrast medium into the thoracic ascending
aorta immediately above the aortic orifice. Normal right and left coronary arteries
are visible.
c) Selective injection o f contrast medium into the left coronary artery with normal ar
teries to the anterior and posterior walls o f the heart.
d) Selective injection o f contrast medium into a normal right coronary artery.
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Figure 15.
a) Echocardiography (two-dimensional) showing the 4 chambers o f the heart, and the
ventricular septum (many echoes) between the right (RV) and left (LV) ventricles.
b) Two-dimensional echocardiography at the level o f the atria, showing the right and
left atria and an atrial septum defect (ASD).
Figure 16.
a) Cardiac scintigraphy showing both ventricles and the ventricular septum (arrows).
Left ventricle in systole.
b) As 16 a - left ventricle in maximal systole. The ventricular septum is shown by a
black arrow.
is very well suited for detecting pathological changes in the flow of blood,
which may occur with atrial septal defect, ventricular septal defect, and
pathological changes in the heart waves (pulmonary, mitral and aortic
orifices).
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Isotope scanning
Isotope scanning of the heart (Fig. 16 a, b) is a noninvasive examination
which provides not only pure pictorial information, but also details of-
physiological conditions. This examination can provide information on
function of the left ventricle; myocardial perfusion; presence of my
ocardial infarcts; and presence and volume of intracardiac shunts.
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NORMAL ANATOMY
In a frontal view of the heart and lungs, the right atrium constitutes the
outline of the heart on the right side. Cranially, the right atrium contin
ues into the superior vena cava. The opening of the superior vena cava
into the right atrium is situated in the posterior part of the atrium. The
atrial septum forms the posterior medial wall of the right atrium. In front
of the atrial septum, the right atrium is situated next to the root of the
aorta. The right ventricle, which is the most anterior part of the heart, is
situated adjacent to the sternum. Anterior and to the left of the root of
the aorta are situated the pulmonary valves and the right ventricular out
let region. The ventricular septum separates the right ventricle from the
left ventricle. The cranial part of the posterior outline of the heart is oc
cupied by the left atrium. The pulmonary veins from the right and left
lungs connect to the posterior portion of the left atrium. The left ventri
cle lies anterior and slightly to the left of the atrium. In a frontal view
most of the left border of the heart consists of the left ventricle (Fig. 17
a-d). A series of transaxial MR images (Fig. 18) displays the morphol
ogy and position of the cardiac chambers. Examination of these imag
ing facilitates understanding of the anatomy of the cardiac contours as
depicted on plain radiographs.
Right atrium
The right atrium is best visualized by angiocardiography with injection
of contrast medium either into the right atrium, superior vena cava, or
inferior vena cava. The right atrium is almost globular in shape with an
appendage (auricle), projecting anteriorly, cranially and leftward from
the body of this chamber. The superior vena cava and inferior vena cava
open into the right atrium at the upper and lower edge of the posterior
wall. The tricuspid valve lies at the front and to the left of the center of
the right atrium. The coronary sinus opens into the posterior wall of the
right atrium between the tricuspid orifice and the inferior vena cava.
Opacification of the right atrium with contrast medium demonstrates the
thickness of the lateral wall against the air-filled right lung. The combined
thickness of the right atrial wall and adjacent pericardium is less than 4 mm.
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Figure 18. Series o f ECG gated spin echo images extending from the base to the mid
portion o f the heart displays the cardiac chambers and great vessels.
A = aorta; I = inferior vena cava; LA = left atrium; L V = left ventricle; RA = right
atrium; RO = right ventricular outflow tract; R V = body o f right ventricle.
Arrows = pericardium; curved arrow = atrial septum; arrowhead = coronary sinus
Right ventricle
The internal anatomy of the right ventricle is demonstrated by angiog
raphy after injection of contrast medium into the right side of the heart
or into the superior vena cava or inferior vena cava. In frontal views the
right ventricle is triangular, with the apex pointing downwards to the left.
The pulmonary orifice is seen cranially. Prominent trabeculations are
characteristic for the right ventricle. The tricuspid and pulmonic valves
are separated by a tunnel of muscle (crista supraventricularis or in-
fundibulum). The right ventricle is not usually border-forming on a
frontal view of the chest. In a lateral view, the anterior border of the right
ventricle forms the anterior outline of the heart.
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Left atrium
The left atrium is not globular like the right atrium, but more flattened
anteroposteriorly. Four pulmonary veins empty in to the posterior aspect,
two on each side. The mitral orifice lies in the caudal, anterior part of the
left atrium, slightly to the left. Like the right atrium, the left atrium has
an appendage (auricle), which, in a frontal view, constitutes the border
of the left side o f the heart between the left ventricle and the pulmonary
artery.
In a lateral view, the posterior outline of the left atrium is clearly seen
where it lies adjacent to the anterior wall of the contrast-filled esopha
gus. The left main bronchus usually runs along the upper posterior part
of the left atrium.
Left ventricle
The left ventricle (Fig. 14) has an elliptical shape with the apex anteri
orly, inferiorly and to the left. The aortic and mitral orifices lie near the
base of this chamber. The mitral valve is bicuspid, the aortic valves, tri
cuspid. The ventricular septum runs obliquely from right posterior to left
anterior, and constists of a muscular and a membranous part.
The internal anatomy of the left ventricle is demonstrated by angiog
raphy. Injection o f contrast medium into the left ventricle is an impor
tant part of coronary angiography. The mitral valves are assessed by left
ventricular angiography, which permits observation of the flow of un
opacified blood from the left atrium into the left ventricle in order to eval
uate the size of the mitral orifice.
Coronary arteries
The right and left coronary arteries (Fig. 14 c, d) arise from the aorta.
The left coronary artery arises from the aortic bulb to the left, posteri
orly. The right coronary artery arises from the right part of the aortic bulb
with its opening in the front, and slightly to the right.
From its aortic origin, the left coronary artery courses to the left. The
main trunk bifurcates into the left anterior descending artery (LAD), and
the circumflex artery (CX).
The LAD proceeds along the front of the heart, where it provides a
number of parallel branches to the interventricular septum (septal
branches) and large branches coursing over the anterior surface of the
left ventricle (diagonal branches) and supply the anterior and lateral walls
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Pericardium
The pericardium is a two-layered sac that surrounds the heart. The two
layers of the pericardium are covered by a serous membrane. In the min
imal space between the two membranes, there is normally about 20 ml
clear fluid.
The pericardium completely surrounds the heart, and extends along
the pulmonary veins, azygos vein, superior vena cava, and inferior vena
cava. The pericardium also covers the pulmonary trunk up to the bifur
cation into the right and left pulmonary arteries, and the caudal 2 cm of
the ascending aorta.
The pericardium is not visible as a separate structure on the chest ra
diograph, but represents the true border of the heart shadow, together
with epicardial fat, against the air in the lungs. The normal pericardium
is easily identified on computed tomography and MRI. Pericardial fat
pads are frequently seen, most commonly at the base of the heart.
788
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PATHOLOGY
The diagnosis o f congenital heart disease is usually established during
infancy or early childhood. The congenital heart diseases are therefore
described in the chapter on Pediatric Radiology.
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790
THE HEART
Figure 21.
Slight to moderate left ventricular
enlargement with rounded and low-
lying heart apex.
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Figure 22.
a) Generally enlarged heart with
large left atrium. The left atrium
is projected over the right
atrium and makes the outline
(black arrow).
b) Lateral view - generally en
larged heart with large left
atrium, which bulges backwards
considerably (black arrow).
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Figure 23.
a) Mitral insufficiency - enlargement o f the left atrium with backwards dislocation o f
the contrast-filled esophagus.
b) Mitral defect with enlargement o f the left atrium (oblique view). The enlarged left
atrium dislocates the contrast-filled esophagus backwards.
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THE HEART
Figure 24.
Considerably enlarged heart with
"mitral configuration ". All parts of
the heart are enlarged. Special ac
centuation o f upper left heart out
line, considerably dilated vascular
structures in the right hilar region.
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there is restriction of the wave front o f unopaficied blood flow into the
left ventricle. In mitral insufficiency, there is regurgitation o f contrast
medium from the left ventricle to the left atrium during systole.
Echocardiography is ideal for evaluation of the mitral valve morphol
ogy and motion. M-mode echocardiography allows the study of reduc
tion in DCR (diastolic closure rate), and also permits demonstration of
thickening of both the anterior and posterior cusps of the mitral valve.
Echocardiography also provides a visual demonstration of the left atrium,
making it possible to calculate its volume. The existence of thrombi in
the left atrium can also be visualized by the same technique.
Echocardiography is the most important modality in the diagnosis of mi
tral defects of non-rheumatic etiology.
Aortic stenosis
Aortic stenosis can occur either on a rheumatic basis or as a result of cal
cification in adult life of congenitally abnormal valves, usually bicuspid
valves. Aortic stenosis on a rheumatic basis is frequently accompanied
by aortic insufficiency. In rheumatic aortic valvular disease, however,
concomitant abnormalities of the mitral valves are always present and
frequently dominate the clinical features and the radiographic findings.
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Figure 25.
Lateral view o f the heart with
calcification o f the aortic valve
cusps (black arrows).
The aortic valves are frequently calcified (Fig. 25). During the com
pensated phase, there is hypertrophy of the left ventricle but usually ra
diographic signs of enlargement of the left ventricle. In the decompen
sated phase, moderate enlargement of the heart may be present, but the
left ventricle size may be increased considerably in the presence of si
multaneous aortic insufficiency. In aortic stenosis, the ascending aorta
is dilated (post-stenotic dilatation). Echocardiography provides a good
view of the aortic valves, and the degree of restriction of motion can be
assessed. The pressure gradient between the valves can be estimated by
mesuring the peak velocity of blood flow using Doppler echocardiogra
phy. Echocardiography has reduced the necessity of catheterization of
the left ventricle, which is beneficial, as this may be difficult to perform
through a stenotic aortic orifice.
Aortic insufficiency
The radiographic features are different for acute and chronic aortic in
sufficiency. Acute aortic insufficiency is usually caused by bacterial en
docarditis, and produces a rapid incrase in the left ventricle end-diastolic
pressure, with development of pulmonary edema. In the acute phase, the
size of the heart will be normal in most patients, but if heart failure de
velops there will be pulmonary edema and redistribution of flow to the
pulmonary vessels in the upper part of the lungs. Acute aortic insuffi-
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Figure 26.
Aortic insufficiency —injection o f
contrast medium into the ascend
ing aorta immediately above the
aortic valve with regurgitation o f
contrast into the whole left
ventricle (black arrows). Aortic
insufficiency grade III.
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Angina pectoris
Angina pectoris is a clinical syndrome, characterized by retrosternal
chest pain with typical radiation to the left arm. When surgery is con
sidered in these patients, coronary angiography is carried out in order to
identify the sites and severities of stenoses in the coronary arteries. In
the presence o f severe stenosis (> 85% reduction in luminal diameter)
or occlusion, collateral vessels are frequently present originating from
the ipsilateral or contralateral coronary artery.
Evaluation o f regional and global function of the left ventricle is an
integral part of angiography in the assessment of a patient with angina
pectoris. The global function of the left ventricle is provided by mea
surements of the ejection fraction and the end-diastolic pressure and re
gional function defined by wall motion. Assessment of left ventricular
function can also be made by echocardiography. Ventricular function
can also be studied using scintigraphy techniques and/or isotope ven
triculography (Fig. 16 a, b). At present, neither echocardiography nor
scintigraphy can provide the necessary morphological information on
the condition of the coronary arteries.
Infarct
Myocardial infarction is ischemic necrosis of the heart muscle leaving
fibrotic scar tissue. Currently, many infarcts are treated with throm
bolytic therapy, which may attenuate the severity and extent of the in
farction.
Uncomplicated infarction causes no changes in the chest radiograph.
If an earlier infarct has led to the development of an aneurysm, this may
appear as a bulging of the outline of the heart (Fig. 27). Calcification
rarely marks the site of prior infarctions or aneurysms. In some cases
acute infarction causes pulmonary venous hypertension or edema, usu
ally with a normal heart size.
In left ventricular angiography, the infarcted region usually shows no
wall motion (akinesis), paradoxical motion (dyskinesis) or severe re
duction in wall motion (hypokinesis). Multiple or large infarcts reduce
the ejection fraction of the left ventricle and increase end-diastolic pres
sure. Dilatation of the ventricle may develop, producing the features of
ischemic cardiomyopathy. Coronary angiography usually demonstrates
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Figure 27.
PA view o f the heart with large left
ventricular aneurysm with massive
bulging o f the left outline o f the
heart.
Complications o f infarction
A number of complications may occur secondary to myocardial infarc
tion, including cardiac rupture. This leads to cardiac tamponade, and
these patients die so quickly that angiography and echocardiography are
seldom carried out.
Aneurysms of the left ventricle may develop after large transmural in
farcts. The diagnosis can be evident on the radiograph, where there is a
focal bulging (evagination) of the normal contour of the heart, most fre
quently in the apical region (Fig. 27). During fluoroscopy, reduced, pos
sibly paradoxical, movement of the aneurysmal area is seen. The diag
nosis is otherwise made by left ventricular angiography, 2D echocar
diography, or MRI (Fig. 10).
Large infarctions that include the ventricular septum may lead to rup
ture of the ventricular septum. This is a complication with high mortal
ity if the rupture occurs in the lower posterior part, but a slightly better
prognosis if the rupture occurs in the anterior part of the ventricular sep
tum. The chest radiographs show an enlarged heart with pulmonary
edema. Right-sided cardiac catheterization demonstrates signs of left-to-
right shunt with highly oxygenated blood in the right half of the heart.
The diagnosis is easily made by left ventricular angiography, where a
leak of contrast from the left to the right ventricle is seen, and by echocar
diography.
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Thrombi in the left ventricle, usually at the apex, are also seen as a
complication o f infarction. This diagnosis can be made by left ventricu
lar angiography, 2D echocardiography and MRI.
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Pericardial diseases
Pericardial cysts
Pericardial cysts are congenital and filled by clear serous fluid. They may
communicate with the pericardial space. About 2/3 of all pericardial cysts
are found caudally and anteriorly on the right side. On the chest radi
ograph, it is impossible to differentiate between cysts and pericardial fat
pads, but the differential diagnosis is readily established by 2D echocar
diography, computed tomography, or MRI. Pericardial diverticula are
less common than pericardial cysts. These are true diverticula, contain
ing all the layers of the pericardium.
Pericardial tumors
Pericardial tumors are very unusual. Mesothelioma is the most frequently
seen malignant tumor. Dermoid is a benign tumor of the pericardium.
Metastases are seen more often. In most respects, the clinical and radi
ological picture resembles that seen with an ordinary pericardial effu
sion. A pericardial tumor is suggested by a hemorrhagic pericardial ef
fusion. The hemorhagic effusion can be defined as such by MRI, when
it causes bright signal on T1-weighted spin echo images. Pericardial tu
mors are best demonstrated by MRI.
Pericardial fluid
Pericardial effusion may be caused by a number of conditions, the most
common being cardiovascular, infectious, malignant, metabolic, or ia
trogenic in origin. Common causes are congestive heart failure, uremia,
acute viral pericarditis, and myocardial infarction. When investigating a
patient suspected o f having a dissecting aneurysm in the ascending aorta,
echocardiography can be used to define a pericardial effusion, which in
dicates leakage into the pericardium and the danger of development of
cardiac tamponade.
In ordinary chest radiographs, pericardial fluid is diagnosed on the ba
sis of a generally enlarged heart without any special part of the heart pre
dominating (Fig. 28). A heart surrounded by considerable amounts of
pericardial fluid can be compared visually to a suspended water bag. The
diagnosis is otherwise difficult to make with certainty on the chest radi
ograph, but easy to make using echocardiography, computed tomogra
phy (Fig. 29) and MRI (Fig. 6). Rapid production of pericardial fluid may
802
THE HEART
Figure 28.
Pericardialfluid with general,
considerable enlargement o f the
heart. No part o f the heart is par
ticularly enlarged.
Figure 29.
a) Pericardial fluid shown by ultrasound. The pericardial fluid is seen between the
markers. The fluid belt is wider posteriorly (+), less marked anteriorly (x).
b) Computed tomography-pericardial fluid. The chambers o f the heart are filled with
contrast medium while the pericardial fluid is seen as a low-attenuated belt around
the whole heart.
lead to cardiac tamponade. In the presence of clinical symptoms of peri
cardial tamponade, drainage may be done using percutaneous catheter
placement (see chapter on Interventional Radiology).
Pericarditis
Previously, tuberculosis was a frequent cause of pericarditis, but this is
rare today. Frequent types are purulent and uremic pericarditis. A not un
usual type of non-purulent pericarditis is seen after heart surgery (post
pericardiotomy syndrome), which is stated to occur in about 10% of all
patients who have undergone heart surgery. In most cases, however, there
are only small amounts of fluid, which it is not necessary to remove from
the pericardial space. Reactive changes after radiotherapy may also re
sult in collections of fluid in the pericardium.
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INTERVENTIONAL PROCEDURES
804
THE HEART
Figure 30.
a) Selective arteriography left coronary
artery. Subtotal stenosis (arrow) o f the
artery supplying the anterior wall o f
the heart (LAD).
b) Balloon catheter inserted into the left
coronary artery to dilate the subtotal
stenosis. Outline o f balloon marked by
arrows.
c) Angiography to check result o f dilata
tion - the calibre o f the artery has re
turned to normal.
sis occurs in about 30 to 50% of the cases, but if this occurs, repeat di
latation of the same vessel can be carried out. Acute complications of the
procedure, such as occlusion and development of infarcts, may take
place. Sudden death has also occurred, but is today rare.
In the USA as well as in Europe, it is now as common to employ coro
nary angioplasty as it is to perform an aortocoronary bypass.
Fibrinolysis
Acute infarction may be caused by thrombi in the coronary arteries. When
acute occlusion caused by thrombi occurs, treatment with fibrinolytic
agents to dissolve the thrombus, thus re-establishing circulation in the
coronary artery, may be indicated. Both systemic and local intraarterial
treatment have been used. Systemically, heparin and large doses of strep
tokinase and tissue plasminogen activator (TPA) have been given intra
venously to induce lysis of the thrombus. Local intra-arterial use of strep
tokinase (or urokinase) is a possible treatment, especially when the con-
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diton has lasted for less than four hours. Local intra-arterial infusion with
fibrinolytic agents often lasts for several hours. Angiography is carried
out during this period to follow the effect on the thrombus and possible
retraction or dissolution of the thrombus. As complications such as bleed
ing are not unusual with this type of treatment, these patients must be
carefully monitored.
Valvuloplasty
It has now become possible to dilate stenotic cardiac valves using large-
diameter balloon catheters. This was performed initially in pediatric car-
dioradiology, where much experience has been accumulated with di
latation of pulmonary stenosis. For mitral valvuloplasty, the balloon
catheter is introduced percutaneously via the femoral vein up to the right
atrium. With the aid of a long, curved needle, the atrial septum is punc
tured and the balloon catheter is passed into the left atrium, and advanced
caudally towards the left ventricle, so that the balloon is positioned in
the mitral orifice. When the balloon is inflated, any adhesions between
the cusps will be broken, and the excursion of the leaflets improved. This
is a safe type of treatment with a relatively low incidence o f complica
tions.
An attempt has also been made to use a method employing a similar
balloon catheter in aortic stenosis. The catheter is introduced retrogradely
from the femoral artery to the aortic orifice, which is dilated. Aortic valve
dilatation is now almost abandoned because of a very high recurrency
rate.
Pericardial drainage
When large amounts of fluid collect in the pericardium, especially when
the amount of fluid is so great that there is danger of cardiac tamponade,
drainage is indicated. It is easiest to carry out pericardial drainage under
the guidance of ultrasound, employing a puncture below the ensiform
process. It is usually preferable to puncture the fluid-filled pericardial
space in the area near the right atrium. In experienced hands, this is a
safe method of treatment without appreciable complicatons. As the fluid
usually sinks down so that the belt of fluid is widest posteriorly, it is best
to use a relatively long catheter, which can be positioned with the tip at
the back of the pericardial space. When the fluid is hemorrhagic, and
large in volume, there may be doubt whether one of the chambers or ap-
806
THE HEART
Figure 31.
After drainage o f pericardial exudate
under the guidance o f ultrasound.
Some air has entered the pericardial
space, which is seen as a double out
line on the left side (black arrows).
pendages of the heart has been punctured instead of the pericardial space.
In these cases, the hemoglobin content o f the fluid will, however, rapidly
differentiate between pericardial fluid and venous blood. If the my
ocardium should be punctured accidentally, so that the tip of the catheter
enters the right atrium, complications such as bleeding into the pericar
dial space usually do not occur because the pressure in the right atrium
is low. In some cases, where pericardial fluid is formed rapidly, perma
nent drainage may be indicated and the catheter can be left in the peri
cardial space. However, it is usually preferable to remove the catheter
once drainage is completed (Fig. 31).
807
Chapter 20
VASCULAR IMAGING
Arterial system
The classic approach for imaging of the aorta and peripheral arterial sys
tem has been angiography performed by means of injection of contrast ma
terial through a direct needle puncture or an intraarterial catheter. However,
non-invasive means of investigation of the peripheral arteries are being in
creasingly used before the more invasive angiographic procedures.
Clinical examination and non-invasive angiologic techniques such as
oscillometry and Doppler pressure measurements are the first steps in
the evaluation of the most common pathology of the vascular system: ar
terial occlusive disease.
For vascular imaging the new non-invasive modalities like ultrasound,
computed tomography (CT) and magnetic resonance imaging (MRI)
have partly replaced angiography for diagnostic purposes.
As a screening tool ultrasound has gained an important role in the
workup of aneurysmal disease including dissections of the aorta, pelvic
and peripheral vessels. The patent lumen, mural thrombus and dissec
tion flap are well demonstrated (Fig. 1). The relatively new techniques
of colour doppler and duplex scanning furthermore allow flow mea
surements and are used to assess stenosis and occlusions of peripheral
arteries and for follow-up studies after bypass procedures. Colour
doppler is the non-invasive method of choice for evaluation of athero
sclerotic disease of the neck vessels and for peripheral AV-malforma-
tions and AV-fistulas. Duplex and colour doppler scanning is also used
in diagnosing venous pathology such as deep vein thrombosis and ve
nous valve incompetence.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 2. CT o f atherosclerotic aneurysm are well seen (A = aorta, LRA = left renal
artery, RRA = right renal artery, LRV = left renal vein, VC = vena cava, U = Ureter
810
THE PERIPHERAL VESSELS
Techniques fo r arteriography
Percutaneous puncture and catherization of the arterial system
(Seldinger technique; Fig. 3): The approach to the arterial system is se
lected according to the clinical signs and location of the target organ re
spectively. Because of its superficial anatomic location the common
femoral artery is the usual site for arterial puncture. Following local anes
thesia and a small skin incision, the artery is punctured using a thin-
walled needle with a 1 - 1.2 mm outer diameter and a central mandril
(Fig. 3). Some needles are additionally covered with a Tefion-sheath ac
cepting a .038 guidewire. The needle is advanced into the artery at an
angle of approximately 45 degrees. After removing the mandril the nee
dle is pulled back till a pulsating backflow is seen. Then a guidewire with
a flexible tip (usually a J-guidewire) is advanced into the vessel. Under
manual compression the needle is withdrawn and an angiographic
catheter is advanced over the guidewire into the artery and positioned at
the desired location. The guidewire is then pulled back and the catheter
is checked for backflow and carefully rinsed with saline. The position of
the catheter is once more controlled under fluoroscopy using manual in-
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812
THE PERIPHERAL VESSELS
Complications
Complications can be caused by a) the puncture (bleeding, hematoma,
pseudoaneurysms, AV-fistula, spasm, thrombus formation and periph
eral embolisation), b) guidewire and catheter manipulation (perforation,
dissection of the intima, spasm, embolization of plaque or air embolism)
and c) contrast material: allergic or toxic systemic (cardiac, renal toxic
ity). With an adequate puncture and catheter manipulation technique and
the use of non ionic or low osmolarity contrast materials, complication
rates in angiography using a femoral approach are less than 1.8%.
Venous system
813
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 4.
A - E ) Normal phlebography o f the lower extremity.
The examination is done in ordinary fluoroscopy rooms by manual ex
posures of films at various levels and in different projections during hand
injection of 5 0 -1 0 0 cc of a contrast medium via a cannula inserted into
a dorsal foot vein. The medial vein of the big toe is usually preferred,
since this is most often the easiest vein to puncture. More lateral dorsal
foot veins may also be chosen where a retrograde insertion may then se
cure a better filling of the deep calf veins. The application o f a hot, wet
towel can help to locate the vein by inducing venodilatation. Tilting the
x-ray table also increases the prominence o f veins by raising hydrosta
tic pressure. In edematous feet, prolonged firm compression o f the ap
propriate area of the dorsum of the foot is necessary. Nitroglycerine paste
is employed by some to obtain local distension of subcutaneous foot veins
for easier puncture. A rubber tourniquet is used at supramalleolar level
to force the contrast medium into the deep veins. This may sometimes
obstruct the filling of the anterior tibial vein. Tourniquets may also be
employed at higher levels. The examination is done with the fluoroscopy
table at 45°-60° in a semierect position, until the contrast column reaches
the pelvis. The table is then lowered, and the extremity passively raised
while the patient does a Valsalva manoeuvre to maximize contrast fill
ing during radiography of the pelvic and lower caval veins. It is impor
tant to carry out the examination on a non-weight bearing, relaxed ex
tremity, since the deep veins will otherwise be compressed by limb mus
814
THE PERIPHERAL VESSELS
cles. The calf veins should be imaged in three projections, lateral oblique,
anteroposterior and medial oblique, the veins above the knee require one
or at most two projections.
Only water-soluble radiographic contrast media can be used for phle
bography. Complications are rare, and are mostly related to the contrast
media employed. One should be prepared for the immediate manage
ment of possible anaphylactoid reactions. Nausea, vasovagal reactions
and injection pain may be encountered.
To avoid post-phlebographic thrombosis the contrast medium em
ployed should be of low osmolality, preferably non-ionic. Ionic contrast
media of higher osmalality are associated with an incidence contrast-in
duced thrombosis of 10-60%. To lessen this risk, hyperosmolar contrast
media should be diluted to a concentration of 200 mgl/ml, or alterna
tively heparin prophylaxis should be administered.
Extravasation of contrast medium at the puncture site may occur by
displacement of the cannula or failed venous puncture. This is usually
no problem if a low-osmolar contrast medium is employed. With high
osmolarity, pain and even skin necrosis may occur.
While ascending phlebography of the lower limb is still the most im
portant diagnostic test for deep venous thrombosis, it has a limited role
in the diagnosis of primary venous insufficiency. Secondary venous in
sufficiency caused by post-thrombotic obstruction of inflow to the large
veins in the pelvis, or venous anomalies like hypoplasia, valvular dys-
or aplasia or Klippel-Trenaunay syndrome may require phlebography to
demonstrate venous morphology.
Retrograde phlebography
This technique is employed to demonstrate valvular incompetence at the
upper femoral level. The common femoral vein is antegradely punctured
with a plastic cannula and contrast medium injected during a Valsalva
manoeuvre of the semi-erect patient. The degree of contrast back-flow
down through incompetent valves into the veins of the thigh may then
be visualized (Fig. 5).
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 5.
Retrograde phlebography showing incompetent
valves at the upper femoral level. Grade I incom
petence is present if the contrast column passes
retrograde and ju st below the inguinal ligament,
grade II i f to the midline, grade III i f to a level at
the knee, and grade IV to a level below the knee.
Isometric phlebography
Visualization of the long saphenous vein for evaluation o f its suitability
as a graft in arterial reconstruction surgery, is achieved by contrast
medium injection into a foot vein in the supine patient during isometric
tension of the limb muscles. This is achieved by pulling on a band pass
ing beneath the soles of the feet.
Videophlebography
This is used for functional studies of venous flow patterns.
Intraosseus phlebography
With this technique a cannula is directly inserted into the medullary space
of the greater femoral trochanter or lateral malleolus, in order to visual
ize the pelvic veins or lower limb veins. The procedure requires general
anaesthesia, and is rarely used.
816
THE PERIPHERAL VESSELS
Cavography
The Seldinger technique is usually used during angiography o f the infe
rior vena cava. The common femoral vein is punctured at the groin, and
a Pigtail catheter is inserted with its tip placed at the bifurcation. Serial
exposures during injection of 40-80 ml of contrast medium at a flow-
rate of 15-20 ml are employed. The patient should perform a Valsalva
manoeuvre, by forced expiration against a closed glottis. Using digital
subtraction angiography (DSA), the concentration of the contrast
medium, as opposed to the volume, can be substantially lowered.
Combined pelvic and caval vein angiography may be performed by con
comitant injection of contrast medium through plastic cannulae inserted
into both common femoral veins at the groin.
Ultrasound
Ultrasound imaging may be used for the non-invasive examination of veins
and their surrounding tissues, either by grey-scale real-time imaging of the
morphology, or by combining the image with pulsed Doppler determina
tion of vascular flow. In this so-called duplex scanning, the two-dimen
sional grey-scale image is combined with the flow velocity signal depicted
as superimposed color information, as a spectral curve, or as sound.
Ultrasound is operator-dependent, however in skilled hands it is very
useful for venous examinations. In some centres it is the most frequently
used diagnostic tool for the depiction of deep venous thrombosis. There
is a wide range of indications for ultrasound mapping of peripheral as
well as central veins.
Low frequency transducers (2.3 MHz) are used to examine the iliac
veins and inferior vena cava and high-frequency transducers (7.5-10
MHz) are used for superficial veins. Other veins are interrogated by mid
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818
THE PERIPHERAL VESSELS
Figure 6.
1 Aorta ascendens
Schematic drawing o f 2 A. coronaria dxt.
normal anatomy o f the 3 A. coronaria sin.
aorta and peripheral ar 4 Truncus brachiocephalicus
5 A. carotis communis dxt.
teries. 6 A. subclavia dxt.
7 A. vertebralis dxt.
8 A. carotis interna dxt.
9 A. carotis externa dxt
10 A. carotis communis sin.
11 A. subclavia sin.
12 A. vertebralis sin.
13 A. axillaris
14 A. brachialis
15 A. radialis
16 A. interossea
17 A. ulnaris
18 Aorta descendens
19 Aorta abdominalis
20 Truncus coeliacus
21 A. hepatica communis
22 A. lienalis
23 A. mesenterica superior
24 A. mesenterica inferior
25 A. renalis dxt.
26 A. renalis sin.
27 A. iliaca communis
28 A. iliaca externa
29 A. iliaca interna
30 A. femoralis communis
31 A. profunda femoris
32 A. femoralis superficialis
33 A. poplitea
34 A. tibialis posterior
35 A. fibularis
36 A. tibialis anterior
netic contrast media. This technology is likely to develop further and be
come considerably more important and useful than today.
NORMAL ANATOMY
819
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
artery), left common carotid artery and left subclavian artery. The aorta
has three main points of fixation: At the level of the aortic valve, the bra
chiocephalic vessels and ligamentum arteriosum and at the diaphrag
matic hiatus. The descending aorta is the direct continuation of the aor
tic arch distally beyond the origin of the left subclavian artery and gives
off the intercostal arteries in pairs before penetrating the diaphragm
through the hiatus to become the abdominal aorta.
The first anterior branch of the abdominal aorta is at the level of about
T12 to LI. This is the celiac trunk which divides into the left gastric, the
splenic and common hepatic artery. About one centimeter lower than the
celiac trunk is the origin of the superior mesenteric artery and the right
and left renal arteries arise, another one to two centimeters caudally. At
the level of L3 to L4 the inferior mesenteric artery originates anterolat-
erally to the left. Other important branches are the paired lumbar arter
ies. The aorta then bifurcates at L4 to L5 into the right and left common
iliac arteries which divide into the internal and external iliac arteries. The
internal iliac artery commonly divides into an anterior division (giving
off the inferior gluteal and obturator artery and the internal pudendal and
visceral artery to the urogenital organs) and the posterior division (ili
olumbar and superior gluteal arteries). At the level of the inguinal liga
ment the external iliac artery becomes the common femoral artery which
bifurcates into the superficial and deep femoral artery.
The superficial femoral artery after passing through the adductor hia
tus becomes the popliteal artery which trifurcates below the knee into
the anterior tibial artery and the tibioperoneal trunk which divides into
the peroneal and posterior tibial arteries. The anterior tibial artery which
runs in the anterior muscular compartment through the interosseous
membrane ends distally in the dorsalis pedis artery. The posterior tibial
artery supplies the plantar aspect of the foot.
In the upper extremities the blood supply originates in the right and
left subclavian artery which give origin to the vertebral arteries on each
side. Other branches of the subclavian artery are the thyreocervical trunk,
the internal mammary artery and the costocervical trunk. At the lateral
end of the first rib the subclavian artery becomes the axillary artery which
becomes the brachial artery laterally to the teres major muscle. The
brachial artery gives off the profunda brachii artery and bifurcates in the
region of the elbow into the radial and ulnar arteries. The latter also gives
origin to the interosseous artery. In the hand the radial artery forms the
820
THE PERIPHERAL VESSELS
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Figure 7.
Vena cava inferior
Schematic drawing o f the left pelvic and
i. ■Common iliac v.
■Internal iliac v.
lower extremity veins. The deep leg veins
from the level o f the popliteal vein are
- External iliac v. paired (not shown). The gastrocnemius
- Common femoral v. veins are paired and duplicated; there are
- Great saphenous v. several soleal veins.
- Deep femoral v.
- Superficial femoral v.
The deep veins (Fig. 7)
Two posterior tibial, two peroneal
- Popliteal v. and two thin anterior tibial veins
■Gastrocnemic v. possess many valves. They run
■Anterior tibial v. along the corresponding arteries as
-Soleus v. venae comitantes in the muscular
- Peroneal v.
compartments of the leg. They join
■Posterior tibial v.
the popliteal vein at the lower
popliteal fossa. From the soleus
muscles, short veins, sinusoids with
rather narrow outlets and mostly no
valves, join the deep calf veins. Two
paired, gastrocnemius veins come
from the corresponding muscle bodies to join with the popliteal vein.
They are usually smaller than the sinusoids and contain valves. The
popliteal vein is usually single and lies under the nerve but superficial to
the artery in the popliteal fossa. It continues medially upwards through
the adductor hiatus and becomes the superficial femoral vein in the ad
ductor canal. In the femoral canal, the superficial femoral vein contains
1-3 valves and receives the deep femoral vein to form the common
femoral vein. Usually there is a valve at the origin of both of these veins
before they merge. The common femoral vein passes medial to the artery
and nerve under the inguinal ligament and becomes the external iliac
vein. In two thirds of cases, a valve is seen in the common femoral vein.
It receives the great saphenous vein medially.
Communicating veins
More than a hundred communicating veins, often called perforators, tra
verse the deep fascia of the leg, linking the axial veins of the deep and
superficial systems to one another. These veins are of functional impor-
822
THE PERIPHERAL VESSELS
Figure 8.
Some perforating vein groups
important fo r surgical treatment o f
venous insufficiency, seen from
behind. (Dodd's group are venae
comm.fem. med. intermedia, Boyd’s
are the w . comm, cruris intermed.,
and Cockett's group empty into a vein
o f the vv. tib. post.). The levels o f two
dorsal perforators are also indicated,
the upper communicating with a
gastrocnemius vein.
Pelvic veins
(Dorsal view)
The valveless external iliac
veins join the internal iliac
veins to form the common iliac vein. In thrombotic occlusion o f the ex
ternal iliac vein, collateral vessels may arise from the the internal pu
dendal vein and rectal vein plexus into the internal iliac. In mesenteric
vein hypertension collateral flow may occur in the opposite direction.
Collaterals may also form via epigastric veins to the internal mammary
vein, or par-umbilical veins in the abdominal wall.
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824
THE PERIPHERAL VESSELS
825
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 9.
Angiograms o f acute ar
terial occlusion.
A) Acute embolic occlu
sion at the typical lo
cation o f the trifurca
tion ju st below the
knee joint. There is a
typical cut-off o f the
contrast column and
only a fe w collaterals
are seen.
B) Acute thrombotic oc
clusion o f the superfi
cial fem oral artery
secondary to athero
sclerotic stenosis. Note
contrast around fresh
thrombus (arrows) and
tortuous collaterals as
seen in pre-existing
stenosis.
826
THE PERIPHERAL VESSELS
Figure 10.
Thoracic aortic
aneurysm
A) Chest X-ray
showing aortic
aneurysm with
somewhat lobu-
lated margins in
the arch and the
proximal de
scending aorta.
B,
C) CT at the level o f
the arch and
aortopulmonary
window showing
true size o f the
aneurysm and
marginal throm
bus formation.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 12.
Translumbar aortography in acute
occlusion o f the infrarenal aorta.
The intercostal arteries (arrows)
serve as major collaterals.
828
THE PERIPHERAL VESSELS
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 14.
Angiography o f pelvic and peripheral
arteries.
A) Oblique view shows severe stenoses
especially in the right external iliac
artery.
B) There is diffuse bilateral disease
with occlusion o f the left superfreial
femoral artery.
C) Diffuse bilateral disease o f the
popliteal arteries and occlusion o f
the posterior tibial arteries. There
is slower flow on the right than on
the left probably secondary to the
more severe iliac disease.
a translumbar or a transaxillary
approach may be needed. It is
important that the angiogram
demonstrates the location and the
length of the stenoses and occlu
sions for optimal planning o f the
therapeutic procedure. Apart
from the narrowing itself, the
significance of stenosis may be
better appreciated by the pres
ence of collaterals, poststenotic
dilatation or differences in con
trast flow. The length of an oc
clusion may be angiographically
overrated in the early phase be
cause of the stasis proximal to the
occlusion and flow through col
laterals distal to the occlusion.
Typically a thrombotic occlusion
develops by begining proximal
to a stenosis and propagating re-
grogradely until it reaches the
closest large collateral (Figs. 13,
14).
830
THE PERIPHERAL VESSELS
Retrograde aortography ofpelvic (A) and fem oral arteries (B) in patient with dilative
atherosclerosis. There is incomplete filling distally due to extremely slow and turbulent
flow.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 16.
Arteriography o f the
femoro-popliteal arteries
in Buerger's disease.
There is a chronic
occlusion o f the right
popliteal artery with nu
merous corkscrew collat
erals (A). Note the
"string o f pearls"
changes in the small
muscular branches on
the left (B) with absence
o f atherosclerotic
changes in the popliteal
artery.
832
Figure 17.
Abdominal aortography
showing bilateralfibro-
muscular dysplasia with
typical "string o f
pearls”- like changes o f
the renal arteries.
Fibromuscular dysplasia
This disease is seen mainly in younger women between 20 and 40 years
of age. Fibromuscular dysplasia involves mainly medium sized arteries
such as the renal and internal carotid artery and there is an increased in
cidence of cerebral aneurysms. Rarely the vertebral artery, the iliac and
subclavian arteries or visceral arteries are involved. According to
histopathologic and angiographic findings various types are differenti
ated. The most frequent form is the medial fibromuscular dysplasia which
exhibits the "string of pearls" arteriographic sign (Fig. 17). Short focal
lesions are seen in medial hyperplasia or intimal fibroplasia.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 18.
Digital subtraction angiogra
phy o f left arm in thoracic
outlet syndrome.
A) Normal subclavian arterio
gram.
B) Severe stenoses o f the
sublcavian artery at the
level o f the clavicle (c)
crossing the first rib (r)
with elevation o f the arm.
C)Note thromboembolic
changes in the arm with oc
clusion o f the radial artery
(arrows).
834
THE PERIPHERAL VESSELS
Figure 20.
Secondary Raynaud's syndrome in 36-year old
smoker with Buerger's disease. Arteriogram o f
lower arm and hand shows diffuse distal disease
with occlusion o f both palmar arches, multiple
digital arteries and distal occlusion o f the ulnar
artery.
Raynaud's syndrome
The primary Raynaud syndrome or Raynaud’s disease due to central dis
turbance of peripheral vasomotor regulation causing vasospasm has to
be differentiated from the secondary Raynaud phenomenon caused by
various underlying vaso-occlusive diseases.
The primary vasospastic Raynaud's disease occurs mainly in young
patients who frequently suffer from migraine and who may have a pos
itive family history. There is typically a generalized symmetric hypocir-
culation which may be triggered by coldness or agitation. The progno
sis is usually relatively good.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Aneurysms
Classification
Aneurysms may be divided into 3 different types true, false and dissect
ing aneurysms.
a) True aneurysms are localised outpouchings, saccular or spindle shaped
which involve all three layers of the arterial wall. The pathogenesis is
mainly a degeneration of the media and in 70% to 80% the etiology
is atherosclerosis. Other causes are congenital weakness of connec
tive tissue (Marfan-, Ehler-Danlos-syndrome); cystic medial necrosis
or post-stenotic. Rarely it may be due to an infection such as lues.
b) False aneurysms represent aneurysms caused by an interruption of
the intima and media leading to a localised and usually asymmetric
outpouching in the arterial lumen which is bounded only by adven
titia or surrounding connective tissue. The etiology is usually trauma,
iatrogenic or infectious and is rarely atherosclerotic.
c) Dissecting aneurysms are caused by a dissection of the arterial wall,
usually the intima and/or media, with formation of a false lumen be
tween the arterial wall layers. This false lumen may thrombose or
836
THE PERIPHERAL VESSELS
Aortic aneurysms
The majority of thoracic aortic aneurysms are due to atherosclerosis and
trauma. The atherosclerotic aneurysm usually involves the descending
aorta frequently extending into the abdominal aorta. Often parts of the
aneurysms contain thrombus. Diameters above 5 - 6 cm have a high in
cidence of rupture and are an indication for operation. Traumatic
aneurysms are typically located in the region of the ligamentum arterio-
sum (above 80%) (Fig. 21). Only about 7 to 10% survive the first 24 hours
if not treated. In less than 20% the rupture is immediately above the aor
tic valve which leads to pericardial tamponade from which patients rarely
recover. Rupture in the area of the descending aorta at the diaphragmatic
hiatus is extremely rare (1%). Chronic traumatic aneurysms in the region
of the isthmus show a typical ring or crescent like calcification.
Figure 21. \H U K ltn
Acute traumatic rupture o f the aorta. ь 25-SEP
Thoracic aortography shows false
aneurysm (arrows) in typical location
o f the arch in the region o f the ductus
ligament.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 22.
Schematic drawing o f
dissecting aneurysms.
A) Type A with dissec
tion beginning ju st
cranial to the right
coronary artery
and re-entry in the
descending aorta.
B) Type В dissection
originating distally
to left subclavian
artery.
C) Type A dissection
with thoracoab
dominal extension
to the aortic bifur
cation.
838
THE PERIPHERAL VESSELS
screening aneurysms in the region of the sinus of valsalva and the as
cending aorta or for aortic dissection. In acute situations angiography is
still the method of choice for evaluation of traumatic aneurysms and type
A dissecting aneurysms, or in type В if possible involvement of visceral
arteries is not exclued by CT. Aortography usually shows aortic insuff-
icency and the involvement of brachiocephalic or coronary vessels in a
better degree in type A dissection. Also in an acute traumatic aneurysm
the lesion may be better shown on angiography than CT especially if
there is only a localised intimal tear. This situation may change with the
use of rapid spiral CT scanning, however.
Aneurysms of the abdominal aorta are caused mainly by atheroscle
rosis and may be seen in the plain film in up to 80% because of calcifi
cation of the aortic wall. 95% of the aneurysms are located below the re
nal arteries and in 18 % the bifurcation and iliac arteries are also involved.
The danger of rupture ranges from 10% with a diameter of 5.5 cm up to
40 to 80% with a diameter of 8 cm. Penetrating ulcerated plaques also
increase the rate of rupture.
Atherosclerotic abdominal aneurysms also represent a frequent source
of peripheral macro-emboli (10%) as well as cholesterol showers lead
ing to the blue toe syndrome.
The inflammatory aneurysm is a special form of atherosclerotic
aneurysm possibly caused by an auto-immune process. It typically occurs
in men after the fifth decade and may lead to obstruction of the ureters.
Localised dissecting aneurysms of the aorta are extremly rare in the
abdominal aorta and are usually extensions of a type В dissection.
Mycotic aneurysms have no pathognomonic signs but usually occur
rapidly as a complication of an infection, i.e. spondylodiscitis. They have
a high rate of rupture and no other signs of atherosclerosis are usually
seen if they occur in the younger patients.
For the radiologic work-up in abdominal aortic aneurysms ultrasound
is the prime screening method in the acute as well as chronic stage for
all types of aneurysm. It shows the perfused lumen and its clot content
as well as identifying a dissecting membrane (Fig. 1). CT is used for pre
operative evaluation especially with regard to the dimensions of the
aneurysm, its relationship to visceral arteries and the differentiation of
perfused from thrombosed lumen in atherosclerotic and dissecting
aneurysms (Figs. 2 and 23). It may also demonstrate the signs o f an im
minent rupture or "leaking” external to the calcified media. Angiography
839
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 23.
CT o f dissecting aortic
aneurysm type A.
A) Scan at level o f pulmonary
artery bifurcation shows
dissection in ascending and
descending aorta with
partially thrombosed lumen
in the ascending aorta.
B) Scan at level o f origin o f
superior mesenteric artery
again shows dissection flap
(arrows) and both the true
and false lumen patent.
A B C
Figure 24. 3D-reconstruction o f spiral CT in patient with atherosclerotic abdominal
aneurysm (A) and a patient with common iliac artery aneurysm (В, C).
A) 3D shows the kinked infrarenal neck o f the aneurysm with the aneurysm itself involv
ing mainly the distal aorta and the bifurcation. Arrows mark the renal arteries.
B) 2D-reconstruction shows the perfused lumen o f the aneurysms and the calcifications
in the arterial wall. No major thrombus is seen.
C) 3D-reconstruction shows the relation o f the internal and external iliac arteries to a
better degree and the tortuous external iliac arteries are depicted in their entire
length.
840
THE PERIPHERAL VESSELS
bloodflow, whereas the false lumen (FL) with slow flow shows increased signal inten
sity. Note the narrowed origin o f the SMA which is supplied from the true lumen.
VC = vena cava.
is used mainly to show the origin of the renal arteries and the "neck” of
the aneurysm for possible cross clamping (Fig. 11). In the future the use
of spiral CT with 3D-reconstruction may obviate the need for preopera
tive angiography (Fig. 24). MR may be used to demonstrate differences in
flow between the true and false lumens in dissecting aneurysms (Fig. 25).
In inflammatory aneurysms, CT shows a horse-shoe shaped 2 to 3 cm
thick highly enhancing fibrotic cuff which typically spares the dorsal aor
tic wall (Fig. 26).
841
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 26.
Inflammatory aneurysm
o f abdominal aorta.
A) CT shows typical
densely-enhancing
horseshoe-like cu ff o f
tissue around the aor
tic aneurysm
(arrows).
T = thrombus,
Ao = perfused aortic
lumen.
B) Abdominal aortogram
in same patient shows
aneurysm which
angiographically cannot be distinguished from common atherosclerotic aneurysm.
artery. They may thrombose especially in the popliteal artery and pre
sent with acute or chronic ischemia. They also represent a source of ar-
terio-arterial emboli.
If a palpable pulsating mass is found ultrasound and color-doppler are
the best methods for screening to show the dimensions of the aneurysm
and the extent of thrombosis. Angiography is indicated only in the con
text of pre-therapeutic diagnosis of other aneurysms and demonstration
of the general status of the peripheral vasculature.
Classification
There is no simple classification. Because of the various clinical and an
giographic manifestations a vast number of descriptive terms has been
arbitrarily used. A rational classification of hemangioma and vascular
malformations has been proposed by Mulliken and co-workers based on
endothelial characteristics. Two main groups of vascular anomalies may
be distinguished according to these authors, the pediatric cutaneous vas
cular lesion (hemangioma) and vascular malformations,
a) Pediatric cutaneous vascular lesions or pediatric hemangioma usually
appear within the first months of life. They are not present at birth
and more than 90% of the pediatric hemangiomas regress sponta
neously by the age of 5 to 7 years. The majority should not be treated
to allow for the natural history of involution. Only if they produce
symptoms such as eyelid hemangioma or subglottic hemangioma etc.
842
THE PERIPHERAL VESSELS
843
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 27.
28-year old male with
A VM above the right
knee.
А, В) T1 weighted MR-
image in transverse
(A) and coronal
plane (B) showing
the low-signal vas
cular spaces o f the
A VM (arrows) in
the vastus medialis
muscle.
C, D) Early (C) and late
(D) arterial phase
o f femoral angio
gram showing the
dilated feeding
artery (arrows)
and early filling o f
the accompaning
veins (arrowheads)
joining the super
ficial fem oral vein
(FV).
844
THE PERIPHERAL VESSELS
Figure 28.
Iatrogenic fistula o f the deep femoral
artery after thrombectomy with Fogarty
balloon. Selective DSA o f deep femoral
artery (A) shows arteriovenous fistula
(F) with immediate filling o f the deep
femoral vein (V).
over time and large fistulas may lead to left heart failure.
Angiographically these lesions are best evaluated with digital sub
traction angiography because of the very fast blood flow. The most fre
quent causes are iatrogenic i.e. punctures for biopsy (liver, kidney) and
other frequent causes are trauma or rupture of an aneurysm into a neigh
bouring vein (Fig. 28).
845
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 29.
The occurence o f thrombi in per cent from 338 patients
with D V T (after H.E. Schmitt 1977).
16
33
to protect thrombogenic surfaces from rethrom-
46 bosing. Local fibrinolysis may be combined with
a caval filter or balloon obstruction to prevent
45 pulmonary emboli. Recurrent pulmonary em
boli may require the insertion of a caval filter.
Predisposing conditions for DVT are malig
65
nant disease, surgery or other trauma, immo
bility, age and coagulation disorders. The well
66
known Virchows triad of stasis o f blood, inti-
83
mal injury and hypercoagulability is still valid.
83 C onsequences o f D V T
73 Deep venous thrombosis carries the short term
77
risks of pulmonary embolism, pain and swel
83
ling of the limb, venous gangrene or limb loss,
or proximal extension of the thrombus into the
inferior vena cava. It is considered that 80% of
thrombi will resolve by lysis if left untreated.
About three weeks after an acute episode of
DVT, the amount of remaining thrombus is un-
likely to change much.
The long term risks of DVT are post-thrombotic syndrome with valve
destruction or incompetence, eventually leading to venous obliterations and
collateral vessel formation. The result may be secondary varicosis, cuta
neous ulcerations, and claudication. Rethrombosis with the danger of re
current pulmonary embolism and pulmonary hypertension may also occur.
846
THE PERIPHERAL VESSELS
Figure 30.
Pelvic vein spur (arrow) in a patient
with acute DVT o f the leg veins.
Diagnosis
The diagnosis of DVT is accomplished by ascending phlebography or
ultrasound examination.
Direct phlebographic signs of deep venous thrombosis are accom
plished by visualization of an intraluminal filling defect in two projec
tions of a contrast filled vein. A thin lining of contrast around the fresh
thrombotic mass is called the "railroad track sign" (Fig. 31 A, B). The
protruding top of a thrombus may "float" on the top of an occluded seg
ment, or propagate from a venous lumen into a non-occluded vein. Care
should be taken not to mistake an in-flow phenomenon caused by the jet
from a non-opacified vein, for a thrombus.
847
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 31.
A, B) Direct signs o f a fresh deep venous thrombosis, intraluminal contrast defects, in
the popliteal vein and leg vein (arrows).
C) Indirect sign o f extensive thrombosis o f leg veins; no filling ofposterior tibial or
peroneal veins, massive collateral circulation via superficial veins.
Figure 32.
KNEHASEN MED KOMPR,
Grey-scale ultrasound examination
o f the popliteal fossa with the vein
(V) and artery (A).
Uncompressibility o f the popliteal
vein indicates thrombosis o f the
popliteal vein.
848
THE PERIPHERAL VESSELS
849
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 33.
Incompetent perforating veins on the dorsal/lateral
side o f the leg (arrows).
Venous insufficiency
In western communities, chronic venous
insufficiency affects about 2.5 per cent of
the population, and has significant socioe
conomic consequences. The pathophysiol
ogy o f chronic venous insufficiency in
volves incompetence of valve segments
with associated reflux, obstruction of the
vein lumen, or a combination of these re
sulting in peripheral venous hypertension
(Fig. 33). Ablative surgical management is
effective for disease in the superficial and
communicating systems, while deep ve
nous reconstructive surgery must be con
sidered experimental.
,
Secondary varicose venous disease postthrombotic syndrome
Secondary varicose vein disease may result from valve destruction due
to scarring and organization of thrombus, or obstruction of vein seg
ments. A number o f valveless collateral veins will form after obstruction
has occurred. If they appear as cork-screw bundles in the path of the ob-
850
THE PERIPHERAL VESSELS
Figure 34.
Post-thrombotic occluson o f the left common iliac
vein. Note recanalisation by developed collateral
veins.
Retroperitoneal fibrosis
Retroperitoneal fibrosis is an idiopathic
process which can obstruct the retroperi
toneal urinary tract. It may also cause ob
struction of the inferior vena cava. Ascen
ding lumbar veins will often act as the main
collateral pathways (Fig. 35).
851
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 36.
A) Valve aplasia.
Huge tubular veins
in a young man
with extensive vari
cosities.
В, C) Klippel-Trenaunay
syndrome in the left
lower limb with a
large lateral ve
nous trunk arising
from the level o f
the popliteal vein.
Anomalies
Pelvic vein webs are described above. The popliteal and superficial
femoral veins may often be duplicated. Venous hemangiomas occur, as
described earlier in this chapter.
Venous dysplasia, valvular aplasia, is a rare anomaly consisting of
tubular veins lacking valves and inherited. It presents mainly in young
men as multiple bilateral varicose veins in the lower limbs (Fig. 36 A).
In Klippel-Trenaunay syndrome, flat haemangiomas of the skin are
present together with a very large lateral venous trunk in the thigh
852
THE PERIPHERAL VESSELS
(Fig. 36 В, C). This trunk may empty at different proximal levels. Trophic
alterations of the limb may result.
853
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
854
THE PERIPHERAL VESSELS
Figure 38. Various guidewires (A) (from left to right standard 0.035 J-wire, floppy
Benson cerebral-wire, Terumo-wire and .021 steerable wire with flexible gold tip) and
angiographic catheters (B) (from left to right Cobra, headhunter, sidewinder, Pigtail).
855
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Laser angioplasty
Laser angioplasty uses laser energy to remove atheromatous material
mainly by evaporation secondary to high local temperature. The most
common laser systems are the Argon-Laser, the Neodynium Yag-Laser
and the Xenonchloride-Excimer-Laser. Various systems to deliver the
laser energy to the target site such as bare fibre optics, metal caps (hot
tip), sapphire tips and balloons (hot balloon) have been used. The main
problem with the laser technique lies in the steering of the probes (per
foration), the limited diameter of the recanalised lumen and the high costs
of the laser systems and probes. Since most occlusions can be recanalised
with cheaper systems and longterm results are no better than those of
balloon angioplasty, this technique is of limited value as of yet.
856
THE PERIPHERAL VESSELS
857
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 42.
Patient with acute
embolus in trifur
cation treated with
percutaneous aspi
ration embolec-
tomy.
A) Thin walled 8F
endhole
catheter and
60cc syringe to
supply suction.
В, C) Angiograms be-fore and after removal o f embolic occlusion involving the trifur
cation with three passes o f catheter aspiration.
Fibrinolysis/thrombolysis
Percutaneous intraarterial thrombolysis is used to recanalise thrombotic
occlusions. The lytic drug may by infused over a catheter or a perfusion
wire placed proximal to the occlusion (regional fibrinolysis). Today how
ever, it is often preferred to infuse the fibrinolytic drug directly into the
thrombotic occlusion thereby reducing the amount of fibrinolytics nec
essary for recanalisation because of the prolonged contact o f the acti
vated plasmin with the thrombus (local thrombolysis). The agent most
widely used today is Urokinase. For regional fibrinolysis a typical dose
is 50,000 to 100,000 units of urokinase per hour (Fig. 43). In local fibri-
858
THE PERIPHERAL VESSELS
Figure 43.
Patient with threat
ened limb from
acute occlusion o f
superficialfem oral
artery and poor
distal run-off
nolysis the usual dosages are about 5,000 to 20,000 units per cm o f oc
clusion, depending on the age and degree of organization of the throm
bus. The other (much more expensive) agent currently used is rt-PA,
however, no definite advantages of its use in peripheral occlusive dis
ease have yet been proven. In local fibrinolysis a 5F angiocatheter is usu
ally introduced 3 to 4 cm into the clot and increments of 5,000 to 10,000
units of Urokinase are infused. Under fluoroscopic control the catheter
is slowly advanced distally into the occlusion. The thrombus should not
be traversed before most of the proximal clot has been lysed to prevent
distal embolization. Combining this method with PAT may significantly
speed up the procedure and reduce the dose of Urokinase.
Recently the so-called pulse-spray method has been advocated. This
technique uses a catheter with multiple tiny side-holes to disperse small
volumes of highly concentrated fibrinolytic drug into a 5 to 10 cm long
occluded segment. A further development is the microporous balloon
catheter where the balloon is perforated by numerous holes of micro
scopic size. With a mixture of fibrinolytic drug and saline the balloon is
inflated with a comparatively low pressure of one to two atmospheres
leaking the drug by multiple small jets o f highly concentrated Urokinase
or rt-PA into the clot. The clot is infiltrated and compressed against the
arterial wall at the same time (Fig. 44). In our experience this method
speeds up the lytic process and has been especially useful in older clots
and/or chronic occlusion with soft non-organised thrombus. Again this
method may be sucessfully combined with PAT and conventional PTA.
859
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 44. Patient with subacute ischemia o f left leg due to occlusion o f a superficial
femoral artery.
A) 25 cm occlusion o f SFA from origin to the adductor canal. Distal SFA filled via
collateral (arrow) from deep fem oral artery (DFA).
B) After recanalization with guidewire a microp ore-balloon is progressively ad
vanced distally infusing 5,000 to 10,000 units o f urokinase every 1 to 3 minutes.
The balloon (arrows) is placed ju st above the distal stenosis in the adductor
canal region and partial lysis is noted proximal to the balloon.
C) After infusion o f 300,000 units o f urokinase within 60 minutes the lumen has re
canalised, however, there are still some filling defects.
D, E) After additional PTA with a conventional 6 mm balloon there is a widely patent
femoropopliteal artery with only minimal wall irregularities.
Figure 45. Endo-
vascular stents used in
the arterial system.
A, B) Balloon-expand
able Palmaz and
Strecker stent.
C) Self-expandable
Wallstent.
860
THE PERIPHERAL VESSELS
Intraarterial stents
To overcome the problem of insufficient PTA due to elastic recoil, inti-
mal flaps, persistent flow obstructing plaques and restenosis following
PTA, endovascular stents have been developed. Most widely used in the
arterial system are the two balloon expandable stents designed by Palmaz
and Strecker and the self-expandable Wallstent (Fig. 45). These stents
consist of a fine mesh of metal filaments or of thin-walled stainlesss steel
tubing with staggered rectangular slots in the case of the Palmaz-stent.
Mounted on a balloon catheter or a special introducing instrument, the
stents can be released at the desired site via a percutaneous inguinal ap
proach. The expanded metal stents are strong enough to withstand the
recoiling forces of the arterial wall and to keep the lumen well open. The
results in the iliac arteries have been excellent with patency rates of over
90% after 5 years. The stents are especially valuable in the management
of complex iliac lesions and iliac occlusions (Fig. 46 A, B). In the femoro-
popliteal axis intimal hyperplasia is a yet unsolved problem and leads to
reobstruction in 40 to 60% (Fig. 46 C, D). The more distal the stents are
placed respectively the smaller the vessel diameter, the more likely is the
development of intimal hyperplasia. This process is even more likely if
there is an insufficient distal outflow. Therefore, great care should be
taken when considering patients for femoro-popliteal stenting and other
means such as repeated balloon dilation and percutaneous atherectomy
should be tried first.
Embolization procedures
Embolization procedures are an important alternative to surgical treat
ment for arterial bleeding, aneurysms, arteriovenous fistulas and mal
formations (angiodysplasias), as well as tumors of the peripheral vascu
lature. The main indications are:
- Treatment of iatrogenic and traumatic bleeding including AV-fistu-
las and aneurysms especially in the pelvis and in the extremities.
- Congenital AV-malformations and fistulas,
- to stop bleeding of tumors especially in the urogenital tract and for
chemo-embolisation of bone tumors (Osteosarcoma) and primary
or secondary tumors of the liver
861
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 46.
Stenting fo r iliac and femoral
occlusions.
A, B) Occlusion o f external
iliac artery (A) recanal-
izsed with guidewire and
stented with two over
lapping 7 mm Wallstents
(B).
С , D) Patient two years after
femoropopliteal stenting
showing a second recur
rence o f intimal hyper
plasia within the stented
segment. Patient had
been dilated one year
before. Angiogram
shows marked irregular
ities o f the lumen and
stenosis due to initimal
hyperplasia (C). After
PTA there is a good
result (D).
862
THE PERIPHERAL VESSELS
Figure 47.
Embolization materials.
1) Gianturco coils.
2) Polyvinyl alcohol (Ivalon) -parti
cles o f various sizes.
3) Gelfoam particles.
Figure 48.
Patient with inter
mittent bleeding
causing swelling
o f thigh and drop
o f hemoglobin af
ter total hip-pros-
thesis.
A) Antegrade arte
riogram shows
false aneurysm
fed by a deep
femoral artery
branch.
B) After filling the aneurysm with 7 coils and gelfoam plus blocking the feeding artery
with two additional coils the bleeding has stopped. Note the coils filling the
aneurysm (arrow) and the additional coils (arrowhead) occluding the feeding artery.
863
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 49.
Embolization o f
A VM in the vastus
medialis muscle o f
the right thigh
(same patient as in
fig- 27).
A, +B)
Superselective
catheterisation o f
arterial branch
feeding the A VM
(B)
tent o f the malfor
mation with tortuous arterioles and cirsoid early draining veins to a much better
degree than the nonselective arteriogram (A).
C) Arteriogram after superselective embolisation with Ethibloc shows the A VM and
main filling artery blocked. A small branch barely visible before is now seen to be
feeding a small non-occluded part o f the A VM.
864
THE PERIPHERAL VESSELS
Figure 50.
PTA o f venous outflow
stenosis in hemodialy
sis shunt.
A) Shuntogram with
proximal compres
sion shows widely
patent A V-anasto-
moses but multiple
stenoses o f the ve
nous outflow tract
close to the anasto
mosis.
B) Afterfirst dilation
suboptimal result.
C) Good result after
prolongued dilation with high pressure (12 atmos.) fo r 6 and 10 minutes. Prolonged
balloon dilatation in venous outflow stenoses often improves dilation results.
865
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 51.
Patient eight months after placement o f
a 10 mm Wallstent fo r tight recurrent
stenosis in the basilic vein.
A) Recurrent stenosis from intimal hy
perplasia at the efferent end o f the
stent (arrow) and moderate intimal
thickening within the stent (arrow
heads).
B) A second 10 mm Wallstent has been
placed overlapping the first one via a
femoral approach with good immedi
ate result. Patient died two months
later from underlying disease with
functioning shunt.
866
THE PERIPHERAL VESSELS
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 52.
Patient with severe superior V. cava syndrome from mediastinal metastases secondary
to carcinoma o f the breast
A, +B)
Phlebography o f both arms shows tight stenosis o f right brahiocephalic vein and
occlusion o f the left brachiocephalic vein.
C) After stenting with a 12 mm Wallstent on the right and guidewire recanalization
and stenting with a 10 mm Wallstent on the left there is good drainage. Patient was
free o f symptoms within hours.
868
THE PERIPHERAL VESSELS
Elias Zerhouni
871
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
INFECTIOUS DISEASES
a - Viral infections: infectious hepatitis, infectious mononucleosis,
AIDS, rubella, varicella, herpes
b - Bacterial infections: Streptococci, staphylococci, salmonella, bru
cella, listeria monocytogenes, pasteurella pestis, cat-scratch dis
eases, yersinia
с - Fungal infections: coccidiodomycosis, histoplasmosis
d - Chlamydial infections: lymphogranuloma venereum, trachoma
e - Mycobacterial infections: tuberculosis, leprosy
f - Parasitic infections: trypanosomiasis, microfilarissis, toxoplasmosis
g - Spirochetal infections: syphilis, yaws, leptospirosis
MALIGNANT DISEASES
a - Hematologic: lymphomas, leukemias and malignant histiocytosis
b - Metastatic: (common) melanoma, tumors of lung, breast, prostate,
gastrointestinal tract, kidney and head and neck. Seminona, Kaposi's
sarcoma
872
THE LYMPHATIC SYSTEM
MODALITIES
Conventional radiography
The imaging test most often required in the evaluation of lymphatic sys
tem disease is the chest radiograph. Because the lungs are open to the at
mosphere and frequently subject to infection, thoracic lymph nodes can
be slightly larger than in other organs and are more often calcified. For
interpretation purposes, an upper size limit of 1 cm is generally accept
able. Although the total number of thoracic lymph nodes is about 100,
only a few can be assessed by conventional radiography. Moderately
large (2-3 cm at least), hilar, mediastinal, paracardiac and paraspinal
lymphadenopathy can often be detected by postero-anterior and lateral
projection radiography. A contour abnormality is most often the key find
ing in such cases. The following anatomic regions should be most par
ticularly examined because they almost always contain lymph nodes in
close proximity with pleural/lung reflections that are tangential to the X-
ray beam. These are: the aorto-pulmonary window, the right tracheo
bronchial angle, the upper paratracheal regions bilaterally (Fig. 2 a), the
subcarinal angle, the right cardiophrenic angle, the paraspinal reflection,
the posterior junction line and the azygo-esophageal reflection line. The
right bronchus intermedius, as well as the posterior aspects o f the left
main bronchus and right upper lobe bronchus are best assessed on lat
eral views where they present easily seen interfaces with aerated lung.
In patients with well inflated lungs the retrosternal pre-aortic clear space
helps evaluate the anterior mediastinum for masses or adenopathy. In
other regions of the body, plain radiography is often ineffective in as
sessing lymphatic system disease because of lack of soft tissue contrast.
Nonetheless, plain abdominal radiographs can be helpful in evaluating
the liver and spleen for enlargement. Calcified or previously opacified
lymph nodes can be effectively followed by plain radio-graphy.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Lymphangiography
The technique of lymphangiography, once very popular in the evalua
tion of various lymph node beds such as the lower extremities and ab
domen to the level of the cistema chyli is being abandoned in most cen
ters in favor of computed tomography. At a few oncologic centers, lym
phangiography is still preferred for the management of certain
lymphomas such as Hodgkin's disease because opacified lymph nodes
can be assessed repeatedly by simple radiographs over a period of sev
eral weeks and involvement of normal sized lymph nodes can be specif
ically detected by the pattern of opacification. In addition, unlike non-
Hodgkin's lymphoma where peripheral nodes such as mesenteric and
peripancreatic nodes are more often involved but cannot be visualized
by lymphography, Hodgkin's disease involves axial lymph nodes such
as para-aortic and iliac groups which are opacifiable. Using fine local
dissection of superficial lymphatics after coloration of the interstitial flu
ids by a vital dye, lymphatics can be visualized and cannulated with very
fine needles. Lipid based iodinadated contrast agents or even radioactive
874
THE LYMPHATIC SYSTEM
Figure 2.
Metastatic disease in mediastinal
lymph nodes.
a) Plain film. Note right paratracheal
mass.
b) CT scan. Note ill-defined, matted
group o f precarinal lymph nodes
and
c) right paratracheal adenopathy.
Computed tomography
The advent of computed to
mography (CT) has revolution
ized the imaging assessment of
the lymphatic system. The high
tissue density contrast between
lymph nodes and the fat that of
ten surrounds them is large
enough to identify some of the
normal and most of the enlarged
lymph nodes in all body regions
(Figs. 1,2). The cross-sectional
plane of imaging and the uti
lization of fast dynamic intra
venous contrast-enhanced CT
permits easy differentiation of
blood vessels from lymph nodes in most cases provided sufficient fat
surrounds the lymph node. There are, however, several limitations to CT.
After initial optimism, it has become clear that CT cannot reliably de
tect the presence of small focal or diffuse disease in the liver or spleen
875
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 3.
a) CT with contrast enhancement
shows no obvious lymph node.
b) T2-weighted MR scan shows ob
vious bright lymph node in right
hilum.
876
THE LYMPHATIC SYSTEM
Figure 4.
a) T1-weighted and
b) T2-weighted MR scans show a
large metastatic lymph node in
the right hilum with typical high
signal intensity on T2-weighted
scan. Note also a smaller node in
the precarinal region that re
mains dark on the T2-weighted
scan. This low signal would
suggest that this node is normal
or fibrotic. However, at patho
logic examination, microscopic
disease was found. M RI is not
reliable in excluding the pre
sence o f minimal disease in
metastatic nodes.
Figure 5.
a) CT scan shows two small calcified
lymph nodes.
b) MRI scan suggests that a larger node
with central fa t is present and does
not clearly detect calcification.
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878
THE LYMPHATIC SYSTEM
that cannot be detected with CT. In evaluating liver and spleen, it is felt
that MRI and CT play complimentary roles and are often used jointly in
patients with known malignancies in whom accurate evaluation of the
liver and spleen is necessary. MRI is very effective in the evaluation of
the bone marrow. Fatty marrow is easily differentiated from red marrow
879
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
and the normal conversion patterns of red fatty marrow with aging have
been well described. MRI is considered accurate in evaluating the pres
ence or absence of diffuse or focal bone marrow disease. In many cases,
the MR examination may be positive for metastatic disease to the bone
marrow before radionuclide bone scanning. In primary bone marrow dis
eases such as myeloma, lymphoma and leukemia, MR imaging of the
bone marrow is the most accurate method to stage and follow bone mar
row involvement.
MRI can also be useful in the management of patients with known
lymphoma in whom partial regression of tumor masses is often observed.
These residual masses most often represent the fibrotic residual of a ster
ilized tumor mass. It can, however, also represent residual active disease.
With CT, it is impossible to differentiate fibrosis from residual active
disease. With MRI, significant differences in the signal intensity pattern
of fibrosis and residual tumor have been demonstrated on T2-weighted
series (Figs. 6 and 7). MRI is thus used at several centers as a method of
monitoring the residual masses in patients with known lymphomas. If
the signal intensity of these masses is low on T2-weighted series, they
are presumed to represent residual fibrosis. However, if the signal in
tensity remains high beyond six months following initial therapy they
are considered to represent residual disease and further diagnostic steps
are undertaken. More importantly, reappearance of high signal intensity
foci in a previously fibrotic appearing mass is a reliable sign o f tumor
recurrence.
To enhance the detection and assessment of lymphatic system pathol
ogy, multiple contrast agents are being investigated for use with MRI.
MRI has the distinct advantage of greater sensitivity to smaller amounts
of contrast agent as compared to computed tomography. Because of this
increased sensitivity, efforts have been directed to the development of
superparamagnetic iron oxide particles which are cleared from the blood
stream by the reticulo-endothelial system. The presence of a superpara
magnetic particle reduces signal intensity considerably due to a marked
shortening of the T2 relaxation time. In the liver and spleen, the retic-
ulo-endothelial system effectively clears such agents and leads to a
marked decrease in the signal intensity of normal liver and spleen, thus
enhancing the detection of underlying pathology. In addition, since the
clearance from the blood stream is not immediate, these agents can be
used to measure perfusion in various organs. If made small enough, these
880
THE LYMPHATIC SYSTEM
superparamagnetic iron oxide particles can leave the vascular space be
fore trapping by reticular endothelial cells and can penetrate the inter
stitial extra-cellular space. Since foreign particles in the interstitial space
are primarily cleared through the lymphatics, these particles eventually
accumulate in the lymph nodes. Early clinical trials have shown that nor
mal lymph nodes will readily accumulate these particulate contrast
agents whereas lymph nodes involved by metastastic disease do not. It
is hoped that these newer agents will enable more accurate assessment
of loco-regional lymph nodes, thus facilitating the staging of various
types of cancers.
Radionuclide methods
Because of the superb sensitivity of radionuclide imaging, albeit at lower
spatial resolution, the lymphoreticular system has been extensively im
aged with multiple radioactively labeled agents. Using reticulate agents
such as Technetium 99m sulfur colloid particles, the liver and spleen can
easily be demonstrated. Using smaller particles, bone marrow uptake can
be improved, however, bone marrow imaging with radionuclide tech
niques has not gained wide acceptance because of the inconsistency of
uptake. Over the years, many efforts have been expended in the devel
opment of more specific agents including labeled monoclonal antibod
ies and cells such as leukocytes in the hope of using immunological
mechanisms for agent localization. These efforts have generally failed.
A notable exception is the use of Gallium 67 scanning which appears to
more reliably detect areas of disease activity in both inflammatory and
neoplastic processes. For example, in the management of lymphoma,
Gallium 67 scanning is reliable at assessing the disease after therapy.
Over the past few years, the use of single photon emission computed to
mography (SPECT) has improved the spatial resolution of radionuclide
methods. Progress in radiochemistry and labeling agents may lead to an
increased use of SPECT for assessing diseases of the lymphatic system.
More recently, the development of metabolic agents such as FDG-glu-
cose with positron emission tomography (PET) offer the hope of directly
observing the metabolic activity of diseased tissues. Already, prelimi
nary studies show that positive FDG-glucose imaging in lymph nodes
correlates highly with the presence of metastatic disease. This concept
is being used in lung, colorectal and breast cancer as a new method of
detecting lymph node involvement. Greater experience will be needed
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PATHOLOGY
Malignant lymphomas
Malignant lymphomas represent the most common neoplasm in patients
between the ages of 20 and 40 years. The two major variances of ma
lignant lymphoma are non-Hodgkin's lymphoma and Hodgkin's disease.
Although both of these tumors infiltrate reticular endothelial organs, they
are distinct from the biological and clinical standpoints.
Imaging is primarily required to detect nodal and extra nodal disease
in regions inaccessible to physical examination. In two thirds of patients
the disease is suspected by the presence of asymptomatic peripheral
adenopathy that persists over 4 to 6 weeks. Constitutional symptoms such
as fever and night sweats known as В symptoms occur in 25 to 30% of
patients with Hodgkin’s disease and in a lower percentage of patients
with non-Hodgkin's lymphoma. Once the diagnosis is established by
lymph node biopsy, imaging is required for full evaluation. Treatment
of lymphomas can be highly effective if delivered properly with over 80%
and 50% disease free survival being reported for Hodgkin's and non-
Hodgkin's lymphomas, respectively. It is important to understand that
imaging is primarily needed to determine whether the disease is at a lo
calized stage that could be treated with radiation therapy, a very effec
tive approach. If the disease is at a more advanced stage, it is now es
tablished that radiotherapy is not indicated and chemotherapy alone en
tails a similar or better prognosis than radiotherapy or combination
therapy in most cases. The Ann Arbor staging system is the most com
monly used scheme and can serve as a guide for imaging interpretation
(Table 2).
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Figure 8.
Examples o f lymphadenopathy in
lymphomas.
a) CT scan showing enlarged
right and left anterior parac
ardiac nodes. This localiza
tion is very suggestive o f
Hodgkin's disease.
b) CT scan showing retro-crural
adenopathy (arrows) in non-
Hodgkin's lymphoma. In the
retroperitoneum, nodes larger
than 6 mm are considered
abnormal.
c) CT scan o f retroperitoneum, showing a common pitfall mimicking adneopathy, the
crus o f the right hemidiaphragm (arrow).
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THE LYMPHATIC SYSTEM
ual tumor exhibits high or mixed signal intensity due to its higher water
content and longer T2 relaxation times (Figs. 6 and 7). Thus, MRI can
help monitor response to therapy in such cases and help assess early re
currence in residual masses which are commonly the site of relapsing
lymphoma. Gallium 67 scanning is also used extensively for this pur
pose with fibrotic lesions exhibiting no activity. Both MRI and Gallium
67 scanning suffer from false positive results in the first 6 months fol
lowing initiation of therapy because of necrosis and inflammatory reac
tions. More recently, PET scanning with FDG-glucose as a marker for
assessment of non-aerobic metabolism has been proposed for the eval
uation of the problem of partial regression in lymphoma and is still be
ing investigated.
Hodgkin’s disease involves the thorax in over 60% of cases with the an
terior medastinum, tracheo-bronchial, paratracheal and hilar nodes in
volved in 50%), 45 %, 40% and 25 % of cases, respectively. Non-Hodgkin's
lymphoma involves the same nodal groups in less than 15% of cases.
Paraesophageal, posterior mediastinal and pleural involvement are, how
ever, more common in non-Hodgkin’s than in Hodgkin's lymphoma.
Calcification of lymphomatous masses is distinctly unusual in untreated
lymphoma but can be present in post treatment CT studies most partic
ularly after radiation therapy. Non-Hodgkin's lymphoma are more com
mon in the abdomen and involve intestinal structures and other extra
nodal sites in a higher proportion of cases. It is, however, unusual to de
tect extra nodal masses without some associated lymphadenopathy in
lymphoma, whereas other types of focal masses do not exhibit signifi
cant adenopathy. Thus, when confronted with a mass associated with sig
nificant adenopathy and the possibility o f lymphoma, surgical excisional
biopsy rather than image guided needle biopsy should be undertaken be
cause diagnosis and cell typing of lymphoma usually requires larger tis
sue samples.
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Figure 9.
American Thoracic Society map o f
mediastinal lymph nodes fo r lung
cancer staging and reporting.
L. SUBCLAVIAN
ARTERY
AOR TA
LIGAMENTUM
ARTERIOSUM
L. PULMONARY
ARTERY
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THE LYMPHATIC SYSTEM
Figure 10.
Coronal Tl-weighted M RI showing
extensive metastastic peribronchial
and paratracheal adenopathy in
patient with right upper lobe carci
noma.
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Breast cancer
Despite the critical importance of lymph node dissemination in this dis
ease, no method of imaging has been effective in staging cancerous nodes
in breast cancer. Most surgeons do not feel that axillary lymph node imag
ing is necessary. However, for advanced lesions, CT scanning of the chest
to assess internal mammary lymph nodes has been advocated. More re
cently, research using PET scanning and labeled metabolites such as
FDG-glucose or MRI with lymph node specific contrast agents have been
investigated. In the absence o f a reliable method for detecting micro
scopic disease in lymph nodes, it is doubtful that imaging methods can
obviate the need for surgical nodal sampling.
Colorectal cancer
The presence of more than 4 malignant lymph nodes has a significant detri
mental effect on the prognosis of the patient with colorectal cancer. A re
cently conducted prospective multiinstitutional clinical trial in the United
States comparing CT and MRI in the staging of colorectal cancers showed
that both modalities are not very accurate in staging lymph node extension
with CT showing a slightly better performance albeit not statistically sig
nificant. Normal nodes are smaller in the mesentery and retroperitoneum
than in the mediastinum. Nodes larger than 6 mm should be considered
suspicious especially if clustered and with ill defined margins. Peripan-
creatic and portocaval nodes are commonly involved in more advanced
stages of colonic cancer and should be specifically sought by using thin
ner sections in the pancreatic regions as well as excellent intestinal opaci
fication throughout the bowel. At least 16 ounces of oral contrast should
be administered prior to CT examination. Although, monoclonal antibody
imaging has been experimentally successful in the detection and staging
of colorectal malignancies it has not gained widespread acceptance.
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Prostate cancer
Extension of prostate cancer to the regional nodes most commonly in the
internal iliac chain is an absolute contraindication to prostatectomy for
cancer. Imaging methods, however, have had limited success in reliably
detecting nodal invasion preoperatively except in the most advanced
cases. Imaging may be useful in staging the transcapsular extent of the
prostatic tumor and the possible involvement of the neurovascular bun
dles which, optimally, should be spared at surgery. During such imag
ing evaluation, iliac lymph nodes can be visualized and nodes larger than
1 cm are considered highly suspicious for metastatic disease. Needle
biopsy can then be used to assess these lymph nodes. In practice, how
ever, because o f the high rate of false negative nodal examinations, sur
gical sampling with immediate frozen section diagnosis remains the pre
ferred approach.
CONCLUSIONS
Imaging of the lymphoreticular system remains a real challenge in prac
tice. Detection and assessment of pathologic involvement of lymph
nodes is dependent on the presence of gross enlargement of nodes.
Diffuse infiltration of spleen, liver and bone marrow are frequently un
detected with all techniques. Clearly, further research and development
are needed to enable detection of earlier stages of disease in lymph nodes.
Imaging, despite its low accuracy when compared to histologic exami
nation, remains, however, the best method for the staging and monitor
ing of known neoplasms with CT remaining the most efficacious method
to date. Research in newer and more specifically targeted agents with
both MRI and radionuclide methods may, in the future, enable better
evaluation of this important system. In the meantime, because of the de
velopment of molecular markers which can be detected through DNA
analysis after amplification with the PCR reaction, the presence of dis
ease may reliably be assessed on small samples of tissue.It is therefore
likely that more efficient image-guided needle biopsy methods that can
rapidly acquire samples from multiple locations in the body will be im
plemented in clinical practice to supplement imaging.
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Chapter 22
Richard M. Mendelson
General considerations
Many authorities now advocate flexible oesophago-gastro-duo-
denoscopy (OGD) as the primary imaging modality in patients with up
per gastrointestinal symptoms. In locations where endoscopy is freely
available there has been a decline in the number of contrast studies per
formed. While some radiologists may strive to maintain their erstwhile
role in the luminal GI tract, it is more appropriate to define strategies for
the investigation of upper GI symptoms based on the relative strengths
of radiology and endoscopy in given clinical situations. Moreover, it
must be realised that in many parts of the world - both "developing" and
"developed" - such pragmatic considerations as cost and availability will
be the predominant factors in the choice of primary investigation. The
advent of endoscopy has had the desirable side-effect of encouraging ra
diologists to optimize their own techniques with the development of dou
ble-contrast and then biphasic barium studies. There has also been a shift
among GI radiologists towards functional or dynamic studies (for ex
ample videofluoroscopy of swallowing disorders) and imaging modali
ties such as CT and US that can define extramural disease.
In an attempt to best reflect the relative strengths of OGD and barium
studies in patients presenting with various symptom complexes, Table 1
provides a suggested policy for primary investigation, the reasons for
which are given in the appropriate sections of the following text.
891
Chapter 22
Richard M. Mendelson
General considerations
Many authorities now advocate flexible oesophago-gastro-duo-
denoscopy (OGD) as the primary imaging modality in patients with up
per gastrointestinal symptoms. In locations where endoscopy is freely
available there has been a decline in the number of contrast studies per
formed. While some radiologists may strive to maintain their erstwhile
role in the luminal GI tract, it is more appropriate to define strategies for
the investigation of upper GI symptoms based on the relative strengths
of radiology and endoscopy in given clinical situations. Moreover, it
must be realised that in many parts of the world - both "developing” and
’’developed” - such pragmatic considerations as cost and availability will
be the predominant factors in the choice of primary investigation. The
advent of endoscopy has had the desirable side-effect of encouraging ra
diologists to optimize their own techniques with the development of dou-
ble-contrast and then biphasic barium studies. There has also been a shift
among GI radiologists towards functional or dynamic studies (for ex
ample videofluoroscopy of swallowing disorders) and imaging modali
ties such as CT and US that can define extramural disease.
In an attempt to best reflect the relative strengths of OGD and barium
studies in patients presenting with various symptom complexes, Table 1
provides a suggested policy for primary investigation, the reasons for
which are given in the appropriate sections of the following text.
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DYSPEPSIA *
"Simple" +
"Com plicated"
REFLUX OESOPHAGITIS +
DYSPHAGIA +
HAEMATEMESIS/MELAENA
PREVIOUS GASTRIC SURGERY
- for recurrent disease +
- for anatom y / emptying +
Notes:
BA = barium study; OGD = oesophagogastroduodenoscopy
* Complicated dyspepsia is used here to indicate features which, when one or more are
present, may be expected to be associated with a high prevalence o f gastric pathology
(thus requiring biopsy) and it is therefore rational for OGD to be the primary imaging
modality. These features are:
Investigation of dysphagia
Dysphagia may be due to abnormalities of function (neuromuscular) or
structure. Endoscopy and radiology are complementary investigations
but a contrast swallow is the investigation of first choice since it allows
dynamic study of neuromuscular function, as well as the detection of
structural abnormalities in the pharyngo-oesophageal segment such as
webs, that may be missed endoscopically, and diverticula that may pre
sent a hazard to endoscopy. In addition, mild strictures and Schatzki rings
can be overlooked by modem thin-calibre fibrescopes. Radiology is of-
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Neuromuscular disease
Many patients requiring assessment have been victims of stroke or head
injuries. Bulbar palsy leads to a lower motor neurone lesion resulting in
abnormality o f the pharyngeal phase of swallowing. Pseudobulbar palsy
affects the upper motor neurons and primarily causes problems with oral
initiation of swallowing. Disorders of deglutition affect 20-40% of pa
tients with unilateral stroke.
It is seldom possible to diagnose specific diseases from the radi-
ographically observed dysfunction o f swallowing, but one can often de
termine the pathophysiological mechanisms involved. Some specific
neuromuscular disorders and the observed signs at videofluoroscopy are
shown in Table 2.
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Figure 1.
Cricopharyngeal webs extending from
the anterior wall at level indicated by
large arrow. Note "jet"phenomenon
below the webs and prominent
cricopharyngeus impression posteriorly
(white arrow).
Figure 2.
Cricopharyngeal diverticulum
(arrowed). Note marked associated
prominence o f cricopharyngeus and
luminal narrowing.
Structural abnormalities
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Cricopharyngeal webs
These mucosal folds occur on the anterior wall at the hypopharynx/oe-
sophagus junction. Often they are thin and asymptomatic, but they may
be circumferential and cause luminal narrowing (Figs. 1 and 14). A char
acteristic "jet effect" may be seen on contrast swallow when a large bo
lus passes through a web. Differentiation must be made between webs
and the submucosal venous plexus which is a normal structure on the an
terior wall. The latter causes an impression that is effaced as the bolus
distends the lumen. Large boluses and dynamic imaging, such as video
fluoroscopy, may be required to detect webs since they may appear tran
sient during a contrast swallow. Sometimes webs are associated with
iron-deficiency, glossitis and pharyngeal atrophy (Plummer-Vinson or
Paterson-Kelly syndrome). Web-like stenoses may also be seen in vari
ous bullous skin diseases, such as epidermolysis bullosa.
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Pharyngeal tumours
The large majority are carcinomas. They may be diagnosed endoscopi-
cally, but radiographically they are best seen on double contrast pharyn-
gograms as masses within the lumen and/or deformity. Smaller lesions
may be demonstrated as irregularities of the mucosa. Multiple projec
tions are needed for optimal demonstration, including distended views
as described above. CT is useful for staging.
Contrast studies
The examination is multiphasic - double-contrast erect views to show
mucosal detail; single-contrast distended views to best show strictures,
rings and hiatus hernias; single boluses with the patient recumbent to as
sess motility; occasionally mucosal relief views for varices and oe
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Radionuclide scintigraphy
Radionuclide oesophageal transit studies provide a simple, cheap and
non-invasive method of diagnosing motility disorders as well
as unique quantitative information on oesophageal emptying. Boluses of
99mTc-sulphur colloid are given diluted in water, and time-activity curves
generated over different segments of the oesophagus and the stomach
are obtained. Although good sensitivity and specificity have been re
ported compared with manometry, some authors have questioned the re
liability and reproducibility of the technique.
Oesophageal manometry
This study remains the gold-standard for oesophageal motility disordes,
but is not widely available. Contrast studies, performed as outlined
above, correlate well with manometry and provide a satisfactory screen
ing examination in most situations.
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Figure 3.
Longstanding achalasia with compli
cating squamous oesophageal carci
noma. Note dilated lower oesophagus
with beaking o f gastro-oesophageal
junction and hold-up o f barium above.
There is an extensive irregular neoplas
tic mass in the proxim al oesophagus
causing luminal narrowing and thick
ened folds, and displacing the trachea
anteriorly (arrows).
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Figure 4.
Endoscopic ultrasound images
in patient with pseudo-achala-
sia due to carcinoma at the
GOJ. (a) asymmetrical trans
mural tumour (T). Concentric
rings are artefacts from the
endoluminal probe within the
oesophagus (oe); ao=aorta.
(b) peri-oesophageal nodal
metastases (N). Note circum
ferential oesophageal wall
thickening due to tumour with
loss o f normal ultrasonic
layers (compare with Fig. 8).
severity. A gastric air bubble is often absent. Contrast swallow with the
patient erect demonstrates a variable degree of dilatation of the oesoph
agus above a beak-like narrowing at the lower oesophageal sphincter.
The sphincter opens intermittently under the force of the hydrostatic pres
sure of the barium column above it to allow bolus passage. The distal
two-thirds of the oesophagus, which contains smooth muscle, is aperi-
staltic. The abnormalities of peristalsis and of the sphincter are present
even in the early stages of the disease. A variant known as ’’vigorous
achalasia” is described in which there are repetitive tertiary contractions
which may be associated with chest pain; the degree of dilatation is typ
ically less with this variant. Some authors dispute its existence as a sep
arate entity. There is an increased incidence of squamous carcinoma of
the oesophagus in achalasia (Fig. 3).
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Benign strictures
Commoner causes of oesophageal strictures are listed in Table 3.
Varieties of peptic strictures are dealt wiht under Gastro-
oesophageal Reflux Disease. Radiation, caustic and post-infective stric
tures are described in the relevant sections. Bullous skin diseases, espe
cially epidermolysis bullosa and pemphigoid, are associated with prox
imal oesophageal strictures or web-like narrowing.
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Peptic
reflux oesophagitis distal, near GOJ,
above hernia smooth tapering
Barrett's oesophagus more proximal deep ulcer; reticular mucosa
Nasogastric intubation distal long strictures; history
Schatzki ring GOJ symm etrical 2-4 mm long
Caustic single or m ultiple, long history
Radiation related to portal tapered, history
Skin diseases high strictures or w ebs; bullous
diseases
Drug ingestion above left atrium history, enteric KC1 especially
Post-infective usually mid Candida, ТВ
Benign tu m o u rs variable subm ucosal lesion;
smooth m uscle
tum ours co m m o n e st
Malignant
C arcinom a
Leiom yosarcom a
Extrinsic
Lym phom a
Benign tumours
Benign mucosal tumours do not cause luminal narrowing. The com
monest are squamous papillomas seen as small polypoid lesions on dou
ble contrast radiography. Submucosal benign tumours are much more
common; the vast majority of these are leiomyomas. Unlike their coun
terparts elsewhere in the GI tract, oesophageal smooth muscle tumours
are hardly ever malignant, nor do they ulcerate. They may be an inci
dental finding or cause dysphagia. Being of smooth muscle origin they
occur in the mid or distal oesophagus. In profile they appear radi-
ographically as smooth filling defects with right angle or slightly obtuse
re-entrant angles at their borders. En face, the tumour appears to widen
the lumen. Endoscopic ultrasound is useful in confirming the diagnosis.
Other benign submucosal tumours (fibromas, neural tumours, duplica
tion and retention cysts, lipomas) are rare.
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Figure 6.
Ulcerating and stricturing squamous
carcinoma o f the distal oesophagus.
Note shouldered margins.
Oesophageal carcinoma
Radiology has an important role in diagnosis, staging and post-treatment
follow-up of this common neoplasm.
Diagnosis
Most neoplasms are squamous carcinomas; the minority are adenocar
cinomas arising in Barrett's oesophagus. Most patients present with ad
vanced disease. Tumours are infiltrating (irregular narrowing with nodu
larity +/- ulceration and shouldered margins), polypoid (intraluminal fun-
gating), ulcerative (relatively flat with ulceration), varicoid (resembling
varices, with thickened serpiginous folds due to submucosal spread) or
a mixture of any of these types (Figs. 3 and 6). Satellite lesions may be
seen due to vertical submucosal spread. Occasionally "early" lesions are
seen as small protrusions, plaque-like lesions with or without ulceration,
sessile polyps or focal nodules. A superficial spreading variety is also
seen, comprising coalescent raised lesions and/or shallow ulceration. In
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Staging
While surgery remains the mainstay of treatment in resectable carcinoma
and arguably provides the best palliation for squamous and adenocarci
noma, palliative surgery is associated with significant morbidity and
mortality. Other treatment options are becoming more widely accepted.
These include chemo/radiotherapy (which may be used preoperatively
or palliatively in combination with endoscopic techniques to provide pa
tency); endoscopic laser treatment and endoscopic stenting, including
the use of the new metallic expandable stents. Therefore, the purpose of
staging is to assess local resectability and, in those patients treated by
non-operative means, to direct therapeutic options and provide baseline
information and monitoring. Ideally accurate staging should prevent un
necessary surgery in those patients with unresectable tumours, while not
denying surgery to those with potentially curable lesions. Staging is di
rected to the determination of depth of wall penetration, invasion of ad
jacent structures (tracheobronchial tree, pericardium or aorta), involve
ment of regional nodes and distant metastases.
Computed tomography and endoscopic ultrasound are the most accu
rate methods of staging oesophageal carcicnoma. Occasionally the mul-
tiplanar imaging potential of MR may be advantageous. Although CT is
far more widely available the results for T and N staging have been
largely disappointing. This is particularly true for gastro-oesphageal
junction carcinomas. Estimation o f local spread at CT depends on the
identification of transgression of mediastinal fat planes. Unfortunately,
these planes are often lacking in these frequently wasted patients. Wall
thickening beyond the normal of 3 mm is non-specific, and may repre
sent tumour or benign disease. Demonstration of the depth of wall inva
sion is not possible at CT. In addition, identification of nodal metatasis
is entirely dependent on the visiualisation of enlarged nodes, those with
a short-axis length greater than 10 mm being taken as abnormal. CT can
demonstrate local invasion of the tracheobronchial tree, seen as im
pingement or bulging of the posterior wall of the carina or left main
bronchus; tumour abuttment alone is not a specific sign. Identification of
aortic involvement is more difficult. Picus showed that if there is an arc
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Figure 7.
CT at level o f carina showing
asymmetrical mass (m) o f oe
sophageal wall in contact with
descending aorta over arc o f ap
proximately 90 % (arrows) indi
cating tumour invasion is likely.
of contact of 90° or greater between the tumour and aorta, then invasion
is very likely (Fig. 7). Less than a 45 degree arc means no invasion.
Unfortunately, a large group of tumours are indeterminate. Loss of the
triangular fat space between oesophagus, aorta and spine has been re
ported to be a reasonably accurate predictor of aortic invasion. The CT
protocol should be directed towards local staging and identifying distant
metastases. Distention of the oesophagus with gas is useful as well as,
occasionally, decubitus scans. A dynamic incremental scanning tech
nique with intravenous contrast is used to detect liver metastases. EUS
has been found consistently superior to CT in T and N staging, but is of
limited availability. The accuracy o f EUS in T staging is due to the fine
detail achievable in imaging the 5-layer structure of the wall. This struc
ture is a constant finding in the normal upper GI tract (Fig. 8).
A review of several studies showed EUS to be 85 % and 75 % accurate
and CT to be 60% and 74% accurate in the T andN staging, respectively,
of oesophageal carcinoma (although there is an indication that improved
equipment and techniques may be leading to better CT results). There
are two major drawbacks to EUS staging. Firstly, stenosing lesions can-
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Figure 9.
Relatively mild reflux oesophagitis. Note
"smudged" appearance o f mucosa and thick
ened longitudinal folds. In this patient there is
a small hiatus hernia and mild stricture
(arrowed).
patients with symptomatic reflux have normal LOS pressure but exhibit
diminished clearance. There is controversy as to whether this represents
a primary oesophageal motor disorder (for which there is recent evi
dence) or is secondary to associated oesophagitis. A proportion of symp
tomatic refluxers have reduced gastric emptying. Other oesophageal
motility disorders seen in GOR include an increase in frequency of ter
tiary contractions - usually non-segmenting, but occasionally segment
ing, in which case differentiation from diffuse oesophageal spasm must
be made in older patients - and transient contractions o f the muscularis
mucosae leading to transverse striations, so called oesophageal "shivers"
or "feline" oesophagus.
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Oesophagitis
Endoscopy is superior to radiology in the diagnosis of oesophagitis.
Barium studies are accurate for moderate and severe grades of oe
sophagitis, but are insensitive for mild oesophagitis and also are associ
ated with significant false positives. The technique should be multipha-
sic, including double- and single-contrast examinations. Although dou
ble contrast films best demonstrate ulceration, most false-positives occur
due to over-reading of thickened folds and granular mucosa. The mildest
changes of oesophagitis (Fig. 9) include a loss of smoothness, or "smudg
ing" of the mucosal surface, a finely nodular or granular mucosal pattern
in the distal third of the oesophagus and oedematous longitudinal folds
(exceeding 2 mm in thickness in the distended oesophagus or 3 mm on
mucosal relief films). The granular pattern must be distinguished from
Candida oesophagitis which tends to be better defined, from glycogenic
acanthosis (a normal finding manifest as well-defined, usually small nod
ules, more prominent in the mid-oesophagus) and from undispersed ef
fervescent agent. A characteristic oesophago-gastric fold may be seen,
consisting of a prominent gastric fold continuing proximally to the
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Figure 10.
Reflux oesophagitis showing nodular, mildly
narrowed distal oesophagus with saccula
tion above a hiatus hernia (arrowed).
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Figure 13.
Schatzki ring at the GOJ shown on single
contrast full-column view with patient semi-
prone. The lesion was not visible on a double
contrast erect oesophagogram.
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Oesophageal intramuralpseudodiverticulosis
This is an uncommon condition o f somewhat obscure aetiology which
is probably part of the spectrum o f GOR disease. Multiple tiny flask-like
outpouchings are seen in the wall of the oesophagus which represent di
lated ducts of mucus glands (Fig. 14). They may be diffuse or segmen
tal and may only be seen on single-contrast, only entry of the thinner bar
ium into the invaginations being possible. The great majority of cases
are associated with strictures, often of the proximal oesophagus.
Outpouchings may be localised to the area of the stricture. A case of peri-
oesophageal abscess has been reported in this condition.
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Infectious oesophagitis
Opportunistic infections of the oesophagus usually occur in immuno
compromised individuals. They have been increasingly associated in re
cent years with HIV infection (AIDS). Main causes are Candida, Herpes
simplex and Cytomegalovirus (CMV). Candida oesophagitis is often as
sociated with oral candidiasis. Double contrast oesophagography
demonstrates, with a 90% sensitivity, discrete plaques or small nodules,
usually in the proximal or mid-oesophagus. These are typically separated
by normal mucosa and may be orientated in the long axis of the oe
sophagus (Fig. 15). Severe infection, as sometimes seen in HIV patients,
manifests as a diffuse "shaggy" oesophageal contour due to plaques and
pseudomembranes, especially seen when the lumen is collapsed. Herpex
simplex oesophagitis causes discrete superficial ulcers of various shapes,
often stellate and often surrounded by a halo of oedema in the mid-oe
sophagus on a background of normal mucosa. Clustering may occur. This
entity may occasionally be seen in immunocompetent patients and re
quires differentiation from medication-induced oesophagitis (see be
low). The history will usually help.
CMV oesophagitis is usually associated with AIDS. Although the ra
diological picture may be indistinguishable from herpes oesophagitis,
the appearance in other patients is more typical; flat, large ulcers are seen
with associated oedema. Giant ulcers may be present up to several cen
timetres in size. It is now recognised that the HIV virus itself may cause
discrete oesophageal ulceration relatively early in the course of the dis
ease. Tuberculous oesophagitis is rare and is characterised, usually in
the proximal half of the oesophagus, by ulceration, wall thickening and
sinuses and fistulae to trachea or bronchus. Patients often present with
strictures. Radiological appearances may be indistinguishable from car
cinoma. Oesophageal involvement may also be related to narrowing or
displacement by caseating tuberculous nodes in the mediastinum.
920
THE GASTROINTESTINAL TRACT
Figure 16.
Oesophageal ulceration due to medication
(Doxycycline). Note multiple irregular superficial
ulcers surrounded by haloes o f oedema.
Drug-induced oesophagitis
Oesophagitis related to drug ingestion is
due to a local irritative effect and there
fore usually occurs at the sites of physio
logical hold-up, such as the aortic arch or
the level of crossing of the left main
bronchus or, in patients with heart dis
ease, often above a dilated left atrium. The
commonest causes of medication oe
sophagitis are antibiotics, particularly
tetracycline and doxycycline, frequently
in young patients. The oesophagitis re
sults in odynophagia. Superficial ulcers
are seen in the mid-oesophagus which
may be of various configurations (Fig.
16). The ulcers heal on drug withdrawal.
Those ulcers that result from slow-release
potassium supplements tend to occur in an
older age group, are larger and hence may
heal with scarring and stricture formation.
An apparent stricture may be present in
the acute phase due to spasm and/or
oedema. Various other tablets have been
reported to cause oesophagitis.
Caustic oesophagitis
Lye (alkalis) are the commonest causes of
caustic oesophagitis, usually ingested in the form of drain cleaners, re
sulting in liquefaction necrosis. While acids can produce oesophageal
damage, they tend to predominantly affect the stomach. Chest radi
ographs and supine and erect or decubitus abdominal films should be
performed to detect signs of perforation, such as pneumomediastinum or
921
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Radiation-induced oesophagitis
Radiotherapy to the mediastinum can result in acute and chronic effects
to the oesophagus; these have been reported following doses of 45-60
Gy over 6-8 weeks. A combination of radiotherapy and chemotherapy
is more likely than radiotherapy alone to cause oesophageal injury.
Abnormal motility, which may be segmental and related to the radiation
portal, with or without mucosal oedema, is seen within 4-12 weeks of
radiotherapy. Ulceration, and pseudo-diverticula occur mainly when a
mass has been causing extrinsic compression on the oesophagus. Fistulae
between oesophagus and airway are uncommon. Oesophageal strictures
form some months after completion of radiotherapy and are tapered and
occur within the radiotherapy portal.
Oesophageal diverticula
Most oesophageal diverticula are acquired false diverticula, and so com
prise outpouchings of mucosa with or without submucosa. Although
there is controversy as to whether those around the level of the carina are
due to traction, and thus true diverticula, it is now thought that the ma
jority are of the pulsion variety. Other common sites are at a level be
tween the aortic arch and the left main bronchus and in the distal oe
sophagus (epiphrenic). Pulsion diverticula tend to change shape and size
and move longitudinally with oesphageal peristalsis. Epiphrenic diver
ticula may be multiple, are associated with GOR and hiatus hernias and
are presumed related to dysmotility. Oesophageal diverticula hardly ever
cause symptoms.
922
THE GASTROINTESTINAL TRACT
Figure 17.
Spontaneous oesophageal perforation.
Sudden onset o f pain during a meal, (a)
Water soluble contrast swallow shows
an ovoid filling defect (upper border
shown by large arrow) due to intra
mural haematoma, and linear collec
tion o f submucosal contrast (small ar
row). (b) CT o f same patient shows gas
in mediastinum (arrowed) indicating
that there has been a transmural
perforation.
Oesophageal perfora
tions
Perforations may be trans
mural or intramural. The
great maj ority are caused by
instrumentation or dilata
tion. Non-iatrogenic causes
include vomiting and for
eign body impaction. Truly
spontaneous transmural per
forations (Boerhaave’s syn
drome) and intramural lacerations or haematomas do occur, but often there
is a history of vomiting as a precipitating factor. Intramural haematomas
occur in patients on anticoagulant drugs or with bleeding diatheses.
Occasionally, oesophageal injury is a result of penetrating or blunt com
pression trauma. Most iatrogenic injuries occur at the cricopharynx or
923
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Mallory-Weiss lacerations
These are relatively superficial tears occurring in the distal oesophagus
around the gastro-oesophageal junction, limited to the mucosa, with or
without submucosal involvement, following vomiting and presenting as
acute GI haemorrhage. Barium studies are usually negative but in view
of the presentation, endoscopy is in any case the investigation of first
choice.
924
THE GASTRO-INTESTINAL TRACT
Oesophageal varices
Although an optimal barium swallow technique is probably as accurate
as endoscopy in the diagnosis of varices, if these are suspected clinically
then, even in the patient who is not acutely bleeding, endoscopy is the
preferred examination, since it allows assessment of other mucosal le
sions related to portal hypertension and also offers the option of injection
sclerotherapy. However, if a barium study is used, then a single contrast
technique is performed with the oesophagus collapsed - mucosal relief
views. Hyoscine butylbromide is given to relax the body of the oesoph
agus, the mucosa coated with barium and multiple views taken in various
supine-oblique and prone-oblique projections, with the patient in a
Trendelenburg postion. A Valsalva manoeuvre may be used to distend the
varices. The varices are seen as serpiginous filling defects usually along
the line of the longitudinal folds in the distal oesophagus. Distinction must
be made from the rare varicoid carcinoma; unlike varices the configura
tion of the latter will not change with oesophageal distension.
Imaging techniques
Contrast studies
The routine contrast examination for gastroduodenal disease is the dou-
ble-contrast barium meal (DCBM); this has been found consistently su
perior to single contrast studies. There are many variations in technique
for performance of the DCBM, but a frequently used method is a bipha-
sic one that incorporates elements o f the single contrast examination. The
single contrast barium meal is occasionally justified in very elderly, sick
or immobile patients and can be used to answer specific questions, such
as determining the presence of gastric outlet obstruction. Water-soluble
iodinated contrast media are used where there is suspected perforation
or where a recent anastomosis is being tested. The commonest such con
trast is 76% sodium methylglucamine diatrizoate ("Gastrografin").
However, this is contra-indicated if there is a risk of airway aspiration
or suspicion of an oesophago-tracheal fistula, since its hyperosmolality
can precipitate pulmonary oedema. Non-ionic iodinated contrast media
are then used (or, alternatively, low-density dilute barium, with caution).
925
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 18.
Supine double contrast view
o f gastric body and antrum
showing mosaic-like areae
gastricae.
926
THE GASTROINTESTINAL TRACT
The modem biphasic barium meal should include double and single
contrast oesophagograms, compression views of the gastric antrum and
duodenal cap as well as double contrast images of the stomach and duo
denum, and an assessment of oesophageal motility. As part o f the DCBM
it is important to ensure that the second and third parts of the duodenum
have been outlined. It is possible to obtain good double-contrast dis
tended views of the descending duodenum. It is rarely necessary nowa
days to perform a hypotonic duodenogram using a tube method.
If the examination is being performed for suspected gastroduodenal
perforation, a water-soluble contrast is used. Profile views of the filled
stomach are obtained. The patient is then turned onto the right side to
allow duodenal filling and turned through 360°. If no obvious ex
travasation o f contrast is seen, the patient should remain on the right side
for ten minutes or so and then re-fiuoroscoped. If no perforation is seen
but is still strongly suspected clinically, delayed films may show con
trast excreted through the urinary tract, since Gastrografin is absorbed
from the peritoneal cavity. However, this sign is not specific for per
foration since inflamed or ischaemic mucosa can allow absorption and
thus renal excretion.
927
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Ultrasonography (US)
Conventional US has little place in gastroduodenal disease in adults, al
though wall thickening due to gastric carcinoma and inflammatory dis
ease in the antrum can often be seen. Real-time US can also be used to
study antropyloric emptying and motility non-invasively. Endoscopic ul
trasound (EUS) is accurate in the T and N staging of gastric adenocar-
cioma and the confirmation of linitis plastica. It may also be used to de
tect and stage gastric lymphoma, and image submucosal tumours such
as smooth muscle lesions and distinguish them from extrinsic impres
sions seen at endoscopy or barium studies.
Investigation of dyspepsia
Dyspepsia means different things to different individuals. It has been
carefully defined as intermittent or continuous pain, discomfort or nau
sea that is referable to the upper gastrointestinal tract, which is present
for at least a month, is not precipitated by exertion and is unrelieved
within five minutes by rest. This definition will include patients with or
ganic gastroduodenal disease, GOR disease, various forms of non-ulcer
dyspepsia and biliary tract disease. If one considers patients with gas
troduodenal dyspepsia of age greater than, say, 45 years or with symp
toms that include one or more of constant daily pain, weight loss, vom
iting, a past history of gastric ulcer or gastric surgery, then these patients
928
THE GASTROINTESTINAL TRACT
Pathology
Sliding hernias
The gastro-oesophageal junction is above the diaphragm (Figs. 11, 19).
The size of the herniated proximal stomach is variable. Small sliding hia
tus hernias are a very common finding and are often asymptomatic. The
major association of sliding hiatus hernias is gastro-oesophageal reflux
(see above).
Para-oesophagueal hernias
These are much less common (about 5%). In this case the gastro-oe
sophageal junction lies below the diaphragm but all or part of the gas
tric fundus is above the diaphragm and lies adjacent to the distal oe
sophagus - usually to the left. Most para-oesophageal hiatus hernias are
non-reducible. They may be recognised on a chest radiograph by an air-
fluid level behind the heart, the nature of which may be confirmed by re
peating the radiograph after the patient takes a few mouthfuls of barium.
Most patients with para-oesophageal hernias are asymptomatic, but corn-
929
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 19.
Sliding hiatus hernia. Area o f
narrowing is arrowed at level
o f diaphragmatic hiatus.
There is a benign gastric ul
cer (small arrow) on the
lesser curve, presumed due to
recurrent mechanical trauma
at the hiatus.
Mixed hernias
In this case the oesophagogastric junction is in the thorax but much of
the rest of the stomach also lies in the chest adjacent to the distal oe
sophagus. A variant of this is the intrathoracic stomach. This is associ
ated with partial twisting of the stomach so that the fundus lies behind
the heart, the greater curvature is cranial, and the antrum passes through
the diaphragm (Fig. 20). When the fundus lies at a level inferior to the
body, distension of the former with food may cause obstruction to the
antrum. Similarly obstruction may occur when a herniated fundus re
turns into the abdomen (Fig. 21). Other viscera, particularly the trans
verse colon, may also be herniated. Although the intrathoracic stomach
is prone to volvulus, chronic volvulus usually only causes mild symp
toms. However, acute torsion presents as an emergency.
The stomach can undergo two main types of rotation and these are of
ten associated with herniation of the stomach. Organo-axial rotation is a
930
THE GASTROINTESTINAL TRACT
Figure 20.
Intrathoracic stomach. The GOJ
is in the thorax (curved arrow),
the gastric fundus lies behind the
heart, the greater curve is upper
most, due to organo-axial rota
tion and the antrum passes
through the diaphragm (straight
arrow).
Figure 21.
Intrathoracic stomach with axial
rotation, but fundus has returned
to infradiaphragmatic position
with resulting partial obstruc
tion. The nasogastric tube
demonstrates the position o f the
GOJ (arrowed).
twist along the long organic axis o f the stomach - that is the line drawn
from the fundus to pylorus. The resulting configuration depends on the
original orientation of the stomach. If the stomach was horizontally ori
entated, then the result is a reversal o f the normal lesser and greater curves
(Fig. 20). When the stomach is more vertically orientated the fundus lies
to the right and the antrum points to the left - so called "mirror-image"
stomach. Organo-axial rotation is only rarely associated with severe
symptoms. Mesentero-axial rotation is less common but much more of-
931
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 22.
Varioliform erosive gastritis.
Multiple punctate erosions
are seen in the gastric antrum
and body, each surrounded by
a halo o f oedema.
Gastritis
Radiology is limited in the diagnosis of gastritis and other superficial
mucosal disease, but certain patterns are recognisable based on the pres
ence of erosions, thickening or atrophy of folds, hyper-rugosity and wall
thickening. Disturbance of the areae gastricae pattern is a further indi
cation of mucosal disease.
Erosive gastritis may be acute or chronic and may be asymptomatic
or accompanied by dyspeptic symptoms or bleeding. Causes include al
cohol, aspirin and other non-steroidal anti-inflammatory drugs, but many
are idiopathic. Two patterns of erosive gastritis are seen. The so-called
932
THE GASTROINTESTINAL TRACT
Corrosive gastritis
Corrosive damage to the stomach is usually due to acid ingestion, but
sometimes alkalis can affect the stomach as well as, more typically, the
oesophagus. The radiological findings depend on the stage of damage.
Acutely there is gastric atony, rugal swelling, ulceration, pneumatosis
or perforation. These may be visible on plain radiographs. Gradually
scarring occurs with resultant deformity and contraction of the stomach
(Fig. 23).
Gastric ulceration
On double-contrast barium meal (DCBM), gastric ulcers are seen as
niches or collections of barium. When viewed en face, ulcers on the pos
terior (dependent) wall are apparent as barium collections when full of
contrast, or ring shadows when empty, with or without radiating folds
(Fig. 25 a). On the non-dependent (anterior) surface they are seen en face
933
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 23.
Stomach o f a young man
approximately 3 weeks after
Formalin ingestion. The
stomach is contracted with
sacculation and ulceration
and antral narrowing.
There is also narrowing and
spiculation o f the proximal
duodenum. GOJ and
pylorus are arrowed.
Figure 24.
Benign gastric ulceration.
Two ulcers (arrowed); that
on the lesser curve is empty
o f barium and seen almost
in profile as a curvilinear
outpouching —note that the
edges (and those o f the ul
cer in Fig. 19) do not pro
trude into the lumen - com
pare with Fig. 26. The pos
terior antral ulcer contains
barium.
934
THE GASTROINTESTINAL TRACT
Figure 25.
a) Benign posterior wall
gastric ulcer showing
radiating folds extending to
ulcer crater.
b) Malignant antral ulcer with
thickened margin and folds
amputated short o f the
ulcer crater.
as ring shadows.
Anterior wall lesions
may not be easily seen
without erect and prone
compression views. In
profile ulcers are seen as
barium-filled collections
extending beyond the lu
men or, if empty, curvi
linear lines of barium
(Figs. 19, 24). The ma
jority of benign gastric
ulcers occur on the lesser
curve or in the antrum
(usually posterior wall).
Greater curve ulcers are
more suggestive of ma
lignancy, but even benign ulcers in this site may have a malignant ap
pearance. There appears to be an association between non-steroidal anti
inflammatory drug therapy and benign greater curve ulcers which may
progress to gastrocolic fistulae. Pyloric and prepyloric ulcers are usually
935
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 26.
Gastric diverticulum just dis
tal to the cardia. Note the
gastric folds running into the
lesion aiding the distinction
from gastric ulceration.
small and benign. Size is not a good indicator of benign or malignant na
ture; giant ulcers are often benign. Features on barium meal that help dis
tinguish benign and malignant gastric ulcers are listed in Table 4. As ul
cer healing occurs the crater diminishes in size and the oedematous edges
disappear. The radiating folds become more apparent as scarring pro
gresses. As re-epithelialisation occurs the crater may end up as a small
residual depression (an ulcer scar) or as an area of flat mucosa with ra
diating folds.
Gastric diverticula are not-infrequently misdiagnosed as gastric ulcers.
These true (congenital) lesions occur on the posteromedial wall just dis
tal to the cardia (Fig. 26). The typical site and often the demonstration
of gastric folds running into them will help distinguish these non-con-
sequential lesions from ulcers.
936
THE GASTROINTESTINAL TRACT
Figure 27.
Malignant gastric ulcer.
Although a typical site (lesser
curve, incisural) fo r a benign ul
cer, note the margins protruding
into the lumen, characteristic o f a
malignant lesion (arrowed).
Figure 28.
Malignant gastric ulcer seen en
face. The ulcer crater is empty o f
barium and the raised margins
typical o f malignancy are clearly
shown (arrows).
937
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Gastric carcinoma
Diagnosis
The diagnosis of gastric carcinoma is usually made by endoscopy or bar
ium meal. "Early" gastric cancers (EGC), i.e. those limited to mucosa
+/- submucosa regardless of the presence of lymph node metastases) are
prevalent in some communities, such as Japan, but are relatively un
common in most Western societies. They can appear as Type I (poly
poid), Type II (superficial; Type Ila elevated; Type II b flat; Type II с
depressed), or Type III (excavated). Mixed types occur. The surface of
early polypoid lesions on DCBM is lobular or granular and simulates the
areae gastricae. Differentiation is required from adenomas and hyper
plastic polyps (see below). Type II lesions are seen as flat mucosal ele
vations. Where a central depression is present (i.e. superficial erosion)
this is irregular in outline with an uneven surface. Folds radiating to-
938
THE GASTROINTESTINAL TRACT
Figure 29.
Diffuse infiltrative gastric car
cinoma, causing obstruction
at the antrum.
Staging
The need for staging of gastric carcinoma is less obvious than for oe
sophageal lesions. However, in communities where EGC is prevalent, it
is useful to help determine therapy and prognosis, particularly where
non-surgical endoscopic treatment is contemplated. Where advanced le
sions are more prevalent it could be argued that surgery, whether for at
tempted cure or palliation, is the treatment of choice and that pre-oper
ative staging does not influence management. However, surgeons' prac
tices differ; if staging is required then this is best achieved by CT or EUS
for local staging, and dynamic enhanced or helical CT (or conventional
939
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
US) for distant metastases. EUS has been shown consistently superior
to CT for local staging, but is of limited availability. CT visualises the
thickened gastric wall and its relationship to adjacent structures, but is
unable to determine the depth of wall invasion. CT can detect lymph
node enlargement but is non-specific, unable to distinguish reactive from
malignant nodes. The criterion for enlargement is usually taken as > 10
mm. Since metastases can also be present in non-enlarged nodes, CT is
not very sensitive. When performed optimally CT, using either a dy
namic sequential technique with bolus contrast enhancement or the
newer spiral (helical) techniques, is relatively accurate (probably in the
region of 90%) at showing whether the patient has liver metastases or
nor, but is significantly less sensitive at demonstrating all lesions in an
individual patient. Moss has suggested a CT staging scheme for gastric
carcinoma (Table 5).
Stage 1
Intraluminal m ass without wall thickening (i.e. < 10 mm thick).
No m etastases.
Stage II
Wall thicken in g > 1 0 mm w ithout tu m o u r extension or m etastases.
Stage III
Thickened w all w ith adjacent organ involvem ent but no d istant metastases.
Stage IV
Distant m etastases with thickened wall.
940
THE GASTRO-INTESTINAL TRACT
Figure 30.
Submucosal smooth muscle tumour
o f the gastric body (seen in single
contrast) exhibiting central ulcera
tion (arrowed). Note otherwise
smooth surface and right angled
conjunction with gastric walls.
Submucosal tumours
Although many cell types can give rise to suomucosai tumours in
stomach, the vast majority are smooth muscle lesions - leiomyomas,
leiomyoblastomas and the malignant leiomyosarcomas. Radiology es
sentially cannot distinguish these three lesions. Most smooth muscle tu
mours are fundal, rounded and often exhibit central ulceration (Fig. 30).
The latter accounts for the frequent presentation of bleeding. Size is vari
able. As for all submucosal lesions they appear on DCBM as smooth sur
faced with normal overlying mucosa. In profile the margins are at right
angles or obtuse to the line of the gastric wall. Much of the bulk of the
tumour may be exophytic to the stomach - an "iceberg” phenomenon.
EUS is useful for confirming the origin of the tumour from muscularis
propria and distinguishing between a submucosal and an extrinsic mass
(Fig. 31). For larger lesions where malignancy is suspected, EUS or CT
are helpful in assessing infiltration o f adjacent structures.
Haematogenous metastases from malignant melanoma, breast and
lung carcinoma, phaeochromocytoma and, in recent times, Kaposi sar
coma, may give rise to small submucosal tumours. These are usually
multiple and have a ’’bull’s eye” or target appearance due to central ul
ceration. Breast carcinoma may spread submucosally like scirrhous car
cinoma.
941
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 31.
EUS image o f submucosal
smooth muscle gastric tumour
(leiomyoblastoma), T. Lesion
seen to arise from muscularis
propria layer o f gastric wall (ar
row). W=normal wall (see
Fig. 8); b=water filled balloon
covering transducer.
(Reproduced with permission o f
Australasian Radiology).
M ucosal polyps
These occur in 1-2% of DCBMs. They appear as rounded filling defects
in the barium pool on the dependent wall or a ring-shadow on the non
dependent wall. They may be pedunculated or sessile. The majority are
hyperplastic and possibly result from regeneration following gastritis.
The minority are adenomas and are important because of their malignant
potential. In addition, there is an increased risk of carcinoma in the same
stomach when adenomas are present. Features to help distinguish be
tween hyperplastic and adenomatous gastric polyps are listed in Table
6. However, if there is any doubt, endoscopy and biopsy are recom
mended.
HYPERPLASTIC ADENOMATOUS
Frequency >90% <10%
Size < 1 cm > 1 cm
Number multiple single or few
Site fundus, body antrum
942
THE GASTROINTESTINAL TRACT
Figure 32.
Gastric lymphoma. An infiltrative
polypoid mass involves the cardia
and proximal stomach.
Gastric lymphoma
These constitute 1-3% of all gastric malignancies. Most are o f the non-
Hodgkin’s lymphoma type, and the lesion may be localised to the stom
ach with or without regional nodes, or part of a generalised involvement.
Radiographic appearance on contrast studies is variable. Infiltrative,
nodular, ulcerative, polypoid or mixed forms occur (Fig. 32). Sometimes
the predominant sign is markedly thickened folds. The site within the
stomach is variable. Often it is not possible to distinguish lymphoma
from carcinoma. Further difficulties arise since mucosal biopsies are fre
quently negative, as much of the spread is submucosal. Distinction is im
portant since the prognosis is considerably more favourable for lym
phoma than for carcinoma. Staging of gastric lymphoma is best per
formed by a combination of CT and EUS. CT (or transabdominal US)
will determine whether there is involvement of regional nodes; CT will
define the presence of more generalised disease in other regions and will
help assess gastric transmural infiltration. EUS is accurate at mapping
out the distribution of disease within the stomach and the depth of in-
943
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Duodenal disease
Contrast examination of the duodenum is part of the DCBM. Good dis
tended views are obtainable using hypotonic agents and it is now rarely
necessary to perform hypotonic duodenography using a tube technique.
Other modalities, including US, CT, endoscopy and endoscopic retro
grade cholangiopancreatography have largely surplanted duodenogra
phy in imaging periampullary and pancreatic lesions.
The duodenum, extending from the pylorus to the duodenojejunal flex
ure, is approximately 25-30 cm long and divided into four parts. The first
part (the ’’cap”) is about 5 cm in length and extends posteriorly, superi
orly and to the right from the pylorus and is triangular in shape on bar
ium studies. The proximal 2-3 cm is intraperitoneal; the rest o f the duo
denum is retroperitoneal. The second part extends from the superior duo
denal flexure, at the end of the first part, inferiorly to the inferior flexure.
At the apex of the superior flexure there is often a redundant mucosal
fold which may be mistaken for a lesion on contrast studies. On the pos
teromedial wall of the descending duodenum is the major papilla which
appears on hypotonic duodenography as a rounded or oval filling defect.
The appearance is variable but there are usually mucosal folds which
serve as landmarks, the most constant of which is a vertical fold extending
distally from the papilla and a hooded fold covering the papilla itself
(Fig. 33). The minor papilla is much less frequently seen radiologically.
The third part of the duodenum extends from the inferior flexure almost
944
THE GASTRO-INTESTINAL TRACT
Figure 33.
Normal hypotonic duodenogram
showing area o f major papilla.
Hoodedfo ld (h) covering papilla (p),
oblique folds (f), proximal longi
tudinal fo ld (pi), distal longitudinal
fold (dl) and probable site o f minor
papilla (a). The pattern o f mucosal
folds is quite variable.
horizontally and to the left across the midline. The fourth part begins
where the duodenum becomes more vertical and directed superiorly to
wards the duodenojejunal flexure. The duodenum terminates at the sus
pensory ligament of Treitz. The normal mucosal pattern o f the duodenal
bulb on DCBM is smooth and relatively featureless. A minority of pa
tients exhibit a fine recticular pattern or small punctate collections of bar
ium which are evenly spaced and appear as triangular spiculations in pro
file. The latter must be distinguished from erosions (which are irregu
larly spaced, less numerous and associated with oedema and other signs
of duodenitis) and barium precipitates (which are more dense and wash
off during the procedure).
945
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 34.
Brunner's gland hyper
plasia/nodular erosive
duodenitis. Note multiple
nodules in duodenal cap,
several with central ero
sion. p=pylorus.
946
THE GASTROINTESTINAL TRACT
Figure 35.
Duodenal ulceration. One mod
erate sized ulcer (arrowed) and
other possible small erosions
are seen. There are oedematous
folds with linear collections o f
barium among them, some radi
ating towards a central erosion.
Note the tenting o f the base o f
the duodenal cap due to fibrotic
scairing (open arrow).
Figure 36.
Multiple duodenal erosions with
radiating and oedematous folds
and duodenal cap deformity.
Consistent with duodenal ulcer
ation and duodenitis. Note the
coarse areae gastricae in the
stomach antrum suggesting
gastritis.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Non-specific duodenitis
Although there is controversy regarding the true nature o f non-specific
duodenitis, and the natural history is somewhat different than duodenal
ulceration, it is probably part o f the spectrum of peptic ulcer disease.
Barium studies are not especially accurate, but criteria for diagnosis in
clude nodularity, thickened folds (> 4 mm thick), bulbar deformity and
punctate collections of barium with halos of oedema, representing ero
sions. There is a significant false negative rate and false positive rate for
DCBM. False positives occur particularly when the diagnosis is made
on the presence of only one radiological sign. The pattern o f duodenitis
may sometimes be predominantly nodular (Fig. 34). There is consider
able overlap with Brunner's gland hyperplasia; indeed the two often co
exist and it is not clear whether the nodules of duodenitis represent in
flammatory infiltrate or Brunner's glands.
Duodenal ulceration
Duodenal ulcers are linear, rounded or irregular in shape on barium stud
ies. About 10% are multiple and about half occur on the anterior wall,
and as such are more difficult to diagnose; compression and profile views,
including prone-oblique views are needed. When acute there may be lit
tle or no associated wall deformity. Radiating folds and cap deformity are
more commonly seen when the ulcer is more longstanding (Figs. 35,36).
The healing process causes fibrosis, deformity andpseudodiverticula (Fig.
37). The base of the pseudodiverticulum, when present, points to the ul
cer crater. Deformity of the cap is assumed to be related to a past history
of duodenal ulcer. When distortion is severe it is often difficult to be def
inite as to whether an ulcer is currently present. It is usually satisfactory
in these circumstances, if the patient has appropriate symptoms, to as
sume the presence of an ulcer and treat accordingly. In particular, the pres
ence of a pseudodiverticulum usually means that there is an ulcer.
Approximately 5% of duodenal ulcers occur distal to the cap: most of
these occur on the medial wall proximal to the papilla of Vater. They are
often difficult to demonstrate radiologically due to accompanying spasm
and oedema. In these circumstances healing often leads to stricturing.
Ulcers distal to the papilla should suggest Zollinger-Ellison syndrome.
948
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Figure 37.
Gross deformity o f the
duodenal cap due to
chronic duodenal ulcera
tion. Note pseudodivertic-
ula (arrows). u=ulcer.
C om plications
Acute bleeding presents as haematemesis and/or melaena. Radiology
plays little part in the initial diagnosis; occasionally angiography is re
quired for diagnosis when endoscopy is unsucessful or equivocal, or for
therapeutic intervention when endoscopic treatment fails or surgery is
contraindicated. Labelled red-cell nuclear medicine scanning may also
sometimes be indicated prior to angiography to localise a source of blood
loss. However, its accuracy in the upper GI tract has been questioned.
Ulcer perforation presents as an "acute abdomen"; usually free in-
traperitoneal gas is seen under the diaphragms on plain abdominal radi
ographs. A water-soluble contrast meal may be required for confirma
tion. An ulcer may penetrate into adjacent structures: involvement of the
pancreas may present as an acute pancreatitis; penetration into the bile
duct will also present acutely with gas seen in the biliary system on plain
films. In the chronic stage the healing process may give rise to duodenal
or gastric outlet obstruction, seen on plain films as a distended stomach,
easily confirmed on a contrast study. In some cases obstruction may be
at least in part due to oedema in the acute phase and may resolve with
conservative management.
Zollinger-Ellison syndrome
This syndrome is due to the hypersecretion of gastric acid in response to
a gastrin-secreting tumour. The tumours are usually in the pancreas, but
a significant proportion are extrapancreatic. Occasionally there is diffuse
islet-cell hyperplasia. Between 40 and 70% of tumours are malignant,
but slow growing. Metastases are often evident at the time of diagnosis.
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Coeliac disease
Duodenal abnormaliaties seen on DCBM may be the first clues to the di
agnosis, particularly in those patients presenting atypically. The charac
teristic finding is the so-called "bubbly bulb", due to multiple small de
fects in a mosaic-like pattern. The appearance is similar to heterotopic
gastric mucosa (see above), but is more diffuse. Thickened folds in the
descending and distal duodenum may also be seen.
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THE GASTROINTESTINAL TRACT
a seat belt. Fixation of the second and third parts of the duodenum
retroperitoneally to the posterior abdominal wall leads to a propensity to
shearing injury. In addition, compression of the third part of the duode
num can occur where it overlies the spine. Early diagnosis of duodenal
perforation is essential since delay is associated with increased mortal
ity. CT is the investigation of choice in blunt upper abdominal trauma
when hepatic, splenic, pancreatic, renal, duodenal or mesenteric injury
is suspected and the patient is haemodynamically stable. In patients who
are unstable diagnostic peritoneal lavage (DPL) or urgent surgery is in
dicated. DPL has largely been replaced by CT in stable patients, but in
some centres this is still performed, although the sensitivity is less in
retroperitoneal trauma to the duodenum than in intraperitoneal injury.
When lavage is undertaken this should preferably be after CT to avoid
errors in interpretation of fluid or gas in the peritoneum. CT is performed
using oral contrast (3 % Gastrografin), administered by a nasogastric tube
if necessary which allows aspiration of the stomach at the end of the pro
cedure. Approximately 250 ml are given 30-40 minutes before the scan,
and a further similar volume immediately prior to it. Scans are performed
using an intravenous contrast bolus-enhanced dynamic incremental
technique. Contiguous slices are obtained from the diaphragm to the
pelvis and then at intervals in the pelvis. Images are viewed at appropri
ate soft tissue windows; in addition, lung windows are recorded for the
upper slices to help exclude basal lung pathology, haemothorax or pneu
mothorax. The findings in duodenal trauma include haemoperitoneum
and/or retroperitoneal fluid (both of which are non-specific), extralumi
nal gas (a sign formerly regarded as reasonably specific for hollow vis-
cus perforation but recently there have been doubts raised as to its speci
ficity), extravasation of contrast medium (specific but infrequent), a "sen
tinel clot" (a high-attenuation blood clot seen adjacent to the involved
bowel), thickened bowel wall, or mesenteric infiltration (a non-specific
sign). The reported sensitivity of CT in duodenal injury is variable in dif
ferent series, but it should be noted that the signs may be subtle. In ad
dition, distinction of duodenal from adjacent pancreatic contusion may
be impossible on CT.
Duodenal haematoma
In distinction to duodenal perforation, intramural haematoma may pre
sent late - up to one or two weeks following the injury. Haematoma is
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Duodenal diverticula
These are frequent findings on upper GI barium studies. They are re
garded as acquired pulsion-type diverticula, and may be single or mul
tiple. The commonest site is the medial wall of the descending duode
num. Their nature is usually obvious; differentiation from ulcers is made
by the appearance of mucosal folds extending into the mouth of the le
sion and variability of shape during the examination. Pseudodiverticula
are associated with duodenal ulceration and most commonly occur in the
bulb. Duodenal diverticula are nearly always asymptomatic, but occa
sionally give rise to complications: diverticulitis may occur and duo-
denocolic fistula has been reported to follow this; this may be more com
mon with laterally placed diverticula. Obstruction is rarely seen when
inspissated food impacts inside the lesion. There is evidence that peri
ampullary diverticula are associated with an increase in the incidence
of common duct calculi and a recurrence of calculi following chole
cystectomy.
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Congenital abnormalities
Occasionally congenital abnormalities may present in adulthood.
Annular pancreas causes narrowing of the lumen of the descending duo
denum due to a ring of pancreatic tissue. There is usually a defect on the
lateral wall of the duodenum associated with an ’’hour-glass” type stric
ture. Patients may present with duodenal obstruction, pancreatitis or pep
tic ulceration. An intraluminal diverticulum, due to an incomplete con
genital web, may cause obstruction to the second or third parts of the
duodenum and is seen as a ”wind-sock” filling defect within the lumen.
Duplication cysts manifest as submucosal or extramural masses.
Duodenal neoplasms
Tumour-like filling defects in the duodenum are dealt with above. True
primary neoplasms of the duodenum are rare. Usually endoscopy and
biopsy are necessary for diagnosis. Adenomas tend to occur in the first
or second parts and may be sessile or pedunculated, appearing as filling
defects or ring shadows on barium studies. In polyposis syndromes they
may be multiple. They have significant malignant potential. Similarly
villous adenomas are of high malignant potential and should be removed;
these appear as cauliflower-shaped filling defects, usually near the
papilla. Other benign neoplasms include smooth muscle tumours and
lipomas.
Primary malignant neoplasms are most commonly adenocarcinomas,
but lymphomas, smooth muscle tumours and carcinoids are also seen.
Adenocarcinomas are polypoid, ulcerating or stricturing. There is a
propensity for the peri-ampullary region. Peri-ampullary carcinomas
may arise from duodenal mucosa, the Ampulla of Vater itself, from pan
creatic tissue or from the bile duct. There is an association o f peri-am
pullary duodenal carcinoma with familial polyposis, particularly
Gardner's syndrome. Duodenal lymphomas have similar characteristics
to small bowel lesions (see below). Duodenal carcinoid tumours have
variable malignant potential. Ectopic islet-cell tumours occur in the duo
denal wall and are associated with ulcers. Secondary malignant tumours
affecting the duodenum usually result from direct spread from neigh
bouring organs such as colon, gallbladder, pancreas and right kidney.
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Figure 38.
Normal enteroclysis demonstrat
ing catheter in first jejunal loop
and well distended jejunum and
proximal ileum with normal pat
tern o f valvulae conniventes.
Imaging techniques
In recent years there has been an increasing emphasis on the usefulness
of CT in the diagnosis of small bowel disease and, with regard to con
trast studies, more widespread use of enteroclysis techniques.
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Plain radiographs
These are of limited use in non-acute disease (see chapter on the Acute
Abdomen) but may be of help in patients with abdominal pain when sub
acute or recurrent obstruction is suspected.
Contrast studies
It is no longer appropriate to perform a follow-through examination as
an adjunct to a barium meal, merely obtaining a few delayed spot films
of the small bowel during the transit of barium. This is an inaccurate ex
amination and, when performed after a double contrast barium meal, is
usually technically inadequate as the high density barium does not lend
itself to this application. The choice of barium study is between an en-
teroclysis examination (small bowel enema - SBE -; intubation study)
and a dedicated small bowel series (small bowel meal). There is contro
versy as to which is the superior study for routine use. Some radiologists
perform enteroclysis on all patients; others perform small bowel meals
almost exclusively; still other use enteroclysis selectively. Each type of
examination has its advantages and disadvantages. Although it is diffi
cult to perform prospective comparative trials, there is a widespread con
sensus that enteroclysis is the more accurate examination, particularly
for the depiction of proximal disease, skip lesions, subtle strictures and
mucosal abnormalities. The infusion of contrast at enteroclysis leads to
continuous flow through the small bowel with resultant maximal disten
sion allowing detection of mild narrowing and the examination of indi
vidual loops with compression. However, enteroclysis requires greater
technical skill, more radiologist's and room time, the relative discomfort
of the passage of a nasojejunal tube, and greater radiation exposure. Many
radiologists argue that, when performed with due attention to detail, the
small bowel meal is sufficiently accurate and is arguably less demand
ing on patient and radiologist. Contraindications to both techniques in
clude suspected bowel perforation and large bowel obstruction. In the
latter, antegrade administration o f barium may worsen the problem when
the barium becomes inspissated proximal to an obstructing lesion.
However, small bowel obstruction is not a contraindication since in these
circumstances the contrast remains sufficiently thin in the already fluid
laden small bowel to avoid exacerbation of the obstruction.
The small bowel meal is performed on a fasting patient. Purgatives to
clear the caecum and terminal ileum of faces are desirable, but not uni
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THE GASTRO-INTESTINAL TRACT
Figure 39.
Ultrasound o f thickened bowel.
Relatively hypoechoic thick walls
(arrowed) with echogenic lumen.
Appearances are nonspecific - in
this case, Crohn's disease o f the
ileum.
Ultrasonography
Bowel imaging with ultrasound suffers from limitations by the presence
of bowel gas and faeces. However, abnormal bowel loops can be imaged
when there is thickening of the wall; these have a sonolucent periphery,
due to oedema or infiltration, and echogenic centre (Fig. 39). Extramural
abscesses can be seen as usually relatively sonolucent masses contain
ing internal echoes (Fig. 43). Omental and mesenteric masses may be
identified, as well as enlarged lymph nodes, which are usually sonolu
cent.
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Computed tomography
The ability of CT to demonstrate bowel wall thickening, extramural and
mesenteric disease has seen its increasing use in suspected small bowel
pathology. It is necessary to give adequate oral contrast to provide good
lumenal distension (with the exception of high-grade small bowel ob
struction, where there is often already distension by fluid content). Up
to a litre or more of dilute water-soluble contrast or dilute barium is given
in divided doses, starting about one hour prior to the scan. A hurrying
agent such as sorbitol or metoclopramide may be added to the contrast.
A dynamic bolus contrast-enhanced examination is performed. It may
be necessary to obtain additional cuts through an area of interest, or to
scan with thinner slices to provide greater resolution o f the bowel wall.
New generation scanners have the ability to acquire images o f large vol
umes in a single breath-hold using helical scanning technology, and this
may prove to be the technique o f choice. Inflammatory diseases or is-
chaemia tend to cause symmetrical bowel wall thickening with homo
geneous attenuation or a "double halo" or "target" appearance on en
hanced images, whereas neoplastic lesions are associated with asym
metrical, iregular thickening.
Pathology
Inflammatory diseases
Crohn's disease
Suspected Crohn's disease is one o f the commonest indications for con
trast studies of the small bowel in the developed world. The role of ra
958
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Figure 40.
Aphthoid ulceration o f terminal
ileum (small arrows). Note also
"cobblestoning" (larger ar
rows).
Figure 41.
Typical features o f Crohn's dis
ease o f the distal ileum includ
ing fissure ulcers (small ar
rows), longitudinal ulcers (ar
rowhead), "cobblestoning"
(open arrows), aphthoid ulcers
(curved arrow) and stricturing.
ic=ileocaecal valve.
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THE GASTROINTESTINAL TRACT
Figure 42.
Crohn's disease o f distal ileum
with stricturing and sacculation
on the antimesenteric aspect
(curved arrows), andfisssure
ulcers (small arrows). Open ar
row points to ileo-caecal valve.
Figure 43.
Ultrasound image demonstrates
pelvic abscess and enterocuta-
neous fistula complicating
Crohn’s diease. Abscess (ar
rows) contains internal echoes.
Hyperechoic foci (arrowhead)
represent gas in bladder (b)
wall.
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disease from fibrotic strictures, when other signs of activity, such as ul
ceration, are absent. There are preliminary data that MR may be useful
in this distinction. Extramural complications often require ultrasound
and/or CT for imaging. Sinuses and fistulae are common; fistulae may
communicate with other loops of small bowel, colon, urinary or genital
tract or skin. Enteroclysis will usually demonstrate such complications,
but ultrasound or CT will demonstrate the extent of the disease and as
sociated abscesses (Fig. 43). Sinograms may be helpful when there is cu
taneous communication. Cross-sectional imaging is particularly useful
in the diagnosis and management of abscesses complicating Crohn’s dis
ease. Many o f these patients are young, and it is therefore reasonable to
perform ultrasound initially to try to avoid ionising radiation, although
a negative examination should usually be followed by CT since this is
superior in the detection of abscesses, which may be interloop, intra- or
retroperitoneal in site. CT is also the investigation of choice in suspected
enterovesical fistula (Fig. 44). There is growing evidence of the sensi
tivity of MR in the detection of fistulae and abscesses related to Crohn's
disease. As well as demonstrating these complications, CT in Crohn's
disease will show the thickened bowel wall, mesenteric streaking and,
sometimes, mesenteric nodules due to mildly enlarged lymph nodes.
The differential diagnosis of Crohn's disease on contrast studies is
wide. There is usually no problem in the appropriate clinical setting
where there are typical changes and distribution of disease. Difficulties
occur when there is sparing of the terminal ileum, diffuse disease or there
are atypical signs. Small bowel tuberculosis (ТВ; see below) may be in
distinguishable from Crohn’s disease and must be considered where ТВ
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Figure 45.
"Backwash ileitis" due to ulcera
tive colitis. Note features o f
chronic ulcerative colitis in right
colon, patulous ileocaecal valve,
dilated distal ileum with granular
mucosa.
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Figure 46.
Graft-versus-host dis
ease in a bone marrow
transplant recipient.
There are several loops
o f ileum which demon
strate a featureless ap
pearance - "ribbon
bowel".
964
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Figure 47.
Chronic ileocaecal tuberculosis.
The caecum and ascending colon
are retracted craniad and are fi
brotic, scarred and sacculated
(curved arrows). The terminal
ileum in this patient is relatively
patulous (straight arrows) and
probably nodular. v=ileocaecal
valve.
Infections
Tuberculosis
Tuberculosis, worldwide, is the most common chronic inflammatory dis
ease of the small bowel. In addition, it is now increasingly seen in the
developed world in association with HIV infection in immunocompro
mised hosts. The radiological features may be indistinguishable from
Crohn’s disease. Less than 50% of patients have demonstrable pulmonary
involvement. The ileocaecal region is the commonest site in the bowel.
Ulcerative and hypertrophic forms have been described. Early signs in
clude thickening of the mucosal pattern and nodularity in the terminal
ileum. In the acute phase there is spasm of the caecum with a narrowed
and ulcerated distal ileum. Ulcers are transverse or circumferential in ori
entation. Occasionally large cavitating ulcers are seen which mimic those
seen in lymphoma. Later the caecum becomes contracted and retracted
in a cephalic direction as the hypertrophic granulomas lead to fibrosis
(Fig. 47). The ileocaecal valve may be patulous, but as the disease pro
gresses it may narrow. Strictures of the distal ileum are typical short and
’’hour-glass” in configuration. Complications include fistulas and perfo
rations which are usually localised. CT will demonstrate the thick-walled
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bowel and may show tuberculous ascites and lymph node enlargement,
which is typically greater than that seen in Crohn's disease, or an in
flammatory mass that may surround the ileum. Nodes may be necrotic
(caseating) and/or calcified. Other features that help distinguish Crohn's
disease and tuberculosis are listed under Crohn fs disease.
Other chronic infections such as South American Blastomycosis and
disseminated Histoplasmosis can simulate Tuberculosis and Crohn's dis
ease in the ileocaecal region. Actinomycosis has a particular propensity
to form sinuses and fistulae in the right iliac fossa.
Giardiasis
Giardia lamblia infestation produces non-specific radiological changes.
The proximal small bowel is maximally affected, where there is thick
ening of the valvulae conniventes. Giardiasis is associated with nodular
lymphoid hyperplasia in patients with hypoglobulinaemia.
Strongyloidiasis
This may be asymptomatic when infestation is mild or produce symp
toms related to the upper GI tract, often simulating peptic ulcer. Small
bowel motility disturbances and hypersecretions may occur. On small
bowel follow-through examinations there is a malabsorption pattern.
Severe, even overwhelming, infestation is seen in immunosuppressed
patients. Ulceration occurs in the proximal small bowel leading to stric
tures and loss of normal mucosal fold pattern (Fig. 48).
AIDS-related infections
A variety of opportunistic pathogens may affect the small intestine in
AIDS patients. It may be difficult to separate out the features of indi-
966
THE GASTROINTESTINAL TRACT
Figure 48.
Strongyloidiasis affecting
the distal duodenum and
proximal jejunum. There
are multiple strictures
and loss o f normal folds.
St=stomach.
Figure 49.
Nodular filling defects in
small bowel o f AIDS pa
tient (some o f which are
arrowed) are consistent
with the submucosal de
posits o f Kaposi sar
coma. Disease was pre
sent elsewhere in the
bowel. Although unveri
fied in this patient, the
thickened folds and poor
coating probably repre
sent co-existent oppor
tunistic infection - most
likely Cryptosporidium.
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Malabsorption
In adults the most common causes of malabsorption are coeliac disease
(non-tropical sprue) and tropical sprue but other specific entities leading
to malabsorption include systemic sclerosis (q.v.), jejunal diverticulosis
(q.v.), Whipple's disease (q.v.), small bowel resections and blind-loop
syndromes. In most cases of malabsorption, when the clinical, bio
chemical and histological diagnosis of sprue is straightforward, radiol
ogy plays little part. Indications for imaging in adult patients with sus
pected coeliac disease, to exclude morphological abnormality, include:
atypical presentation or equivocal small bowel histology; unresponsive
ness to a gluten-free diet or recurrence of symptoms after initial response
(to exclude lymphoma or ulcerative jejuno-ileitis - see below); elderly
patients presenting with recent onset of symptoms; patients with other
disease states such as scleroderma, a history of abdominopelvic radio
therapy, etc. Radiological investigations include small bowel contrast
studies and, in selected patients, CT examination. Findings in adult sprue
on barium studies depend on the method used. If a dedicated per-oral
small bowel meal is performed a "sprue or malabsorption pattern" will
be evident, which is non-specific (Fig. 50). This comprises dilatation,
segmentation and flocculation. The jejunum is moderately dilated and
hypomotile with associated slow transit of barium. Excess fluid in the
lumen leads to segmentation of the barium column into separated clumps
(this sign is not prominent with the use of modem barium suspensions)
and flocculation of barium in severe disease. A mold-like configuration
of barium in the lumen is due to fold effacement (the "moulage" sign).
The valvulae conniventes are of normal thickness unless there is hy-
poalbuminaemia. Transient non-obstructive intussusceptions are seen in
20%. Enteroclysis demonstrates diagnostic signs in 75% o f patients with
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Figure 50.
Barium "follow-through "in patient
with gluten-enteropathy. The je
junum is mildy dilated with slightly
thickened fo ld s, segmentation and
flocculation o f barium.
adult coeliac disease. The jejunal folds are fewer than normal, three or
less per inch length being highly suggestive of the diagnosis. There may
be jejunization of the ileum, i.e. a greater number of folds per unit length
than normal. Intussusceptions are not seen on enteroclysis. In approxi
mately 10 % a 1-2 mm polygonal mosaic mucosal pattern is seen. Double
contrast studies of the duodenum may show a "bubbly bulb" appearance
and/or Brunner’s gland hyperplasia.
Complications of coeliac disease include ulcerative jejunoileitis, stric
tures, small bowel neoplasms (lymphoma or, less commonly, adenocarci
noma), cavitating mesenteric lymph node syndrome, splenic atrophy and
oesophageal carcinoma. Ulcerative jejunoileitis is a very severe disease
which may present de novo or in patients with a known history of coeliac
disease. Acute symptoms may be due to haemorrhage, obstruction or per
foration. Barium studies, if performed, will show areas of stricturing and
thickened folds and often deep ulceration. This entity is probably part of
the spectrum of small bowel lymphoma. Short strictures, frequently mul
tiple, are seen in the chronic form of the disease. Lymphoma complicat
ing coeliac disease is usually multifocal or diffuse. Differentiation radio
970
THE GASTRO-INTESTINAL TRACT
Tumours
A variety of benign tumours occur including adenomas, leiomyomas and
vascular tumours. These are most common in the jejunum, whereas ma
lignant lesions, with the exception of adenocarcinoma, are more com
mon in the ileum. Adenomas may be part of polyposis syndromes but
are less frequent than in the duodenum. Pre-operative diagnosis of ma
lignant small bowel tumours used to be achieved only in the minority of
cases. A combination of enteroclysis and CT scanning can now detect
and suggest the diagnosis in the majority of tumours. Lipomas, leiomy
omas, leiomyosarcomas and carcinoid tumours can give a characteristic
pattern on CT. Adenocarcinoma and lymphoma are more difficult to di
agnose specifically.
Carcinoid tumours
The majority of small bowel carcinoids occur in the distal ileum.
Tumours are considered malignant if there is local invasion or distant
metastases, since differentiation on histological criteria may be difficult.
Lesions larger than 2 cm in size are consistently malignant. Up to 70%
of carcinoid tumours are invasive when discovered. Radiological signs
may be due to the primary lesion, seen as a filling defect or annular le
sion on barium examination, or due to the secondary mass in the mesen
tery which typically provokes a dense desmoplastic response with re
sultant stretching, angulation and kinking of bowel with involvement of
more than one loop, fixation and rigidity. Interference with mesenteric
blood supply may lead to thickening of folds due to arterial ischaemia
or venous oedema. CT scanning is useful in demonstrating the secondary
mesenteric effects and often leads to a definitive diagnosis. Small ill-de-
fined masses in the mesentery exhibit a stellate or spoke-like configura-
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Figure 51.
Carcinoid tumour. CT
scan showing mesenteric
mass (arrowed) with
stellate stranding caus
ing retraction o f an adja
cent sm all bowel loop in
the right iliac fossa with
resultant small bowel ob
struction (note dilated
loops).
tion with stranding extending out to involve adjacent bowel loops and
frequently exerting a retractile effect on them (Fig. 51). Mesenteric nodal
enlargement and hepatic metastases may be detected.
972
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Figure 52.
Small bowel non-
Hodgkin’s lymphoma. (a)
Enteroclysis examination
demonstrates a segment
o f ileum in the right iliac
fossa with wall thicken
ing, destruction o f the
normal fo ld pattern and
aneurysmal ulceration
(arrowed) and mass ef
fect; (b) CT demonstrates
marked wall thickening
and aneurysmal luminal
dilatation, containing
contrast.
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Adenocarcinoma
Small bowel adenocarciomas are most common in the jejunum and usu
ally demonstrate a similar pattern on barium studies to colonic carcino
mas (q.v.) - often a short annular constricting lesion with local destruc
tion o f the mucosal pattern and shouldered margins or, more rarely, a
polypoid intraluminal mass. Enteroclysis is 85% sensitive in diagnosis;
sensitivity is less on follow-through type examinations. CT appearance
is of a soft tissue concentric or eccentric mass with or without mesen
teric nodal enlargement, usually less than that seen in lymphoma. There
is an increased incidence in Coeliac disease, Crohn's disease and Peutz-
Jegher syndrome.
Metastatic deposits
Haematogenous
Haematogenous metastases occur to the antimesenteric border of the
bowel. Most commonly the primary tumours are malignant melanoma,
bronchial or breast carcinomas. Melanoma metastases appear on con
trast studies as multiple submucosal polypoid nodules, often with cen
tral umbilication - so called "target lesions". They are more common in
the stomach than the small intestine. Sometimes they may reach a large
size but despite this, obstruction is infrequent. However, lesions may be
come pedunculated and intraluminal with growth and lead to intussus-
974
THE GASTROINTESTINAL TRACT
ception. Ulceration and bleeding are frequent. CT may show the lesions
to be more extensive than is apparent on enteroclysis, although small le
sions will not be seen. A thickened bowel wall may be visualised at CT
which may mimic a primary neoplasm. In addition, a linitis plastica ap
pearance may be evident in the small bowel. Metastases from bronchial
carcinoma may be single or multiple and may exert a desmoplastic ef
fect on the bowel. There is a propensity to localised or (rarely) free per
foration. Breast carcinoma metastases are cellular submucosal masses.
They are relatively rare in the small bowel in comparison to the stomach.
Intraperitoneal seeding
This is more frequent than haematogenous spread. Seeding tends to oc
cur where ascitic fluid accumulates in the peritoneal recesses, such as at
the ileocaecal region, between mesenteric folds and in the pelvis. In con
tradistinction to haematogenous metastases, these lesions are seen on the
mesenteric surface of the bowel. Commoner primary tumours are carci
nomas of the ovary, cervix and colon. As well as seeding, direct spread
of tumour to small bowel can occur from pelvic malignancies. Only those
lesions large enough to cause alteration in the lumen contour and/or
changes in the mucosal pattern can be demonstrated by barium studies.
The mucosal folds are preserved, but there is tethering of the mucosa
which is seen as a "tacked down" appearance in profile, the folds tend
ing to be distorted in a radial pattern extending from a central point out
side the wall formed by the lesion which may be associated with kink
ing, angulation or stricturing of bowel loops. There may be rounded pro
trusions into the lumen. Larger metastases in the peritoneum can involve
several small bowel loops on the mesenteric border. A lateral film with
contrast in pelvic loops is often useful in demonstrating the tethering.
Small peritoneal seedings cannot be seen on contrast study or CT, but
the latter is superior to enteroclysis in showing mesenteric and omental
deposits. Soft tissue masses may be seen separating or displacing loops
and there may be ascites. Pseudomyxoma peritonei from mucin produc
ing ovarian cystadenocarcinomas is recognisable on CT scanning when
there are septations in ascites and cystic masses with solid components,
with or without abdominal lymphadenopathy.
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Figure 53.
Benign lymphoid hyperplasia o f
distal ileum. Ileocaecal valve is
arrowed.
Kaposi sarcoma
The multiple submucosal, often umbilicated, nodules in this HIV-related
condition are more common in the stomach and duodenum than in the
small bowel. The lesions are discrete and there is preservation of mu
cosal folds between nodules (Fig. 49) (c.f. lymphoma).
Peutz-Jegher syndrome
In this hereditary condition hamartomatous polyps occur in the stomach,
small bowel and colon. These are seen as filling defects of variable size
on contrast studies. There is an association with gastrointestinal carci
nomas as well as other malignant tumours, notably o f pancreas, breast
and reproductive organs. Removal o f polyps is advocated.
976
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Figure 54.
Jejunal diverticulosis on
enteroclysis examination.
Multiple moderate-sized
and large diverticula
present.
Jejunal diverticulosis
These are acquired pseudodiverticula and are seen in middle aged and
elderly patients. Although mostly asymptomatic, a variety of complica
tions do occur. The diverticula tend to be larger and more frequent in the
proximal small intestine. Multiple diverticula may be recognisable on
plain radiography as containing short gas/fluid levels. On barium exam
ination they are seen as multiple barium-containing outpouchings on the
mesenteric surface (Fig. 54). They may be missed on a follow-through
type examination; enteroclysis is more sensitive due to the luminal dis
tension achieved and the opportunity for compression. Small bowel di
verticula are seen in about 2% of enteroclysis examinations. Patients may
present with a malabsorption state or vitamin В 12 deficiency due to bac
terial overgrowth in the diverticular lumen. Rarely diverticulitis may oc
cur which results in haemorrhage or perforation. Strictures or adhesions
from diverticulitis may lead to recurrent bowel obstruction. Other asso
ciations include volvulus, pneumoperitoneum without peritonitis, and a
chronic pseudo-obstruction syndrome due to hypomotility.
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Figure 55.
Systemic sclerosis com
plicated by adhesive ob
struction. Grossly dilated
proxim al jejunum ex
hibits crowding o f nor
mal thickness folds and
sacculation. Adhesive ob
struction was also pre
sent in the left iliac fossa
related to previous
surgery.
Systemic sclerosis
Gut involvement is very common. The oesophagus, small bowel and
colon may be abnormal. The small bowel is affected in over 40% of
cases. There is vasculitis associated with atrophy o f mucosal and sub
mucosal layers of the wall and replacement of the smooth muscle with
collagen. There is resultant hypomotility; this and the reduced absorp
tive function of the mucosa may lead to a malabsorption state. Barium
examination demonstrates often marked dilatation o f the lumen which
particularly affects the descending duodenum and proximal jejunum.
There is atony with associated delayed transit. Sacculations occur on the
antimesenteric side of the bowel, although this feature is more commonly
seen in the colon. A characteristic sign is a "hide-bound" appearance of
the valvulae conniventes (Fig. 55); in a dilated segment the folds are
packed close together, there being more per unit length of intestine, but
they are of normal uniform thickness.
Meckel's diverticulum
The "rule of twos" is usually quoted, that is that Meckel's diverticulum
occurs in 2% of the population, 2 feet from the ileocaecal valve and is
978
THE GASTROINTESTINAL TRACT
Figure 56.
Meckel's
diverticulum
(arrowed)
demonstrated
on enteroclysis
in a young
patient with
recurrent
melaena.
usually 2 inches long. In fact, the site and dimensions are somewhat vari
able. O f those individuals with this congenital abnormality approxi
mately 20-40% will develop symptoms, most commonly melaena.
Ectopic gastric mucosa, which is mainly responsible for the propensity
to bleed, occurs in 20% of all diverticula, but in about 70% of those that
bleed in adults and a higher percentage in children. No single imaging
method is entirely reliable at detecting Meckel's diverticula. Nuclear
medicine studies are valuable; technetium pertechnetate is given intra
venously and is taken up by normal and heterotopic gastric mucosa. The
diverticulum is seen as focal uptake, usually in the right lower quadrant
of the abdomen. In patients who have bled the test has an approximate
sensitivity of 85% for detection overall, but only 60-70% in adults. If
there is active bleeding Tc-colloid may detect the region of extravasa
tion. Small bowel barium meal is unreliable in the detection of Meckel's
diverticulum since peristalsis tends to empty the lumen of the lesion
which fills only transiently. Enteroclysis is more sensitive due to the
greater luminal distension achieved and ability for compression under
careful fluoroscopy (Fig. 56). Recognition depends on finding a blind-
ending sac on the anti-mesenteric side of the ileum which occasionally
contains a gastric rugal pattern. A typical triradiate fold pattern is de
scribed at the base of the lesion due to folds occurring at right angles to
those in the ileum. Even if there is no filling of the lumen of the lesion,
a large diverticulum may be recognised by its mass effects on the neigh
bouring loops.
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Figure 57.
Multiple band adhesions o f small
bowel in left iliac fossa causing re
traction, tenting andfixation o f sev
eral adjacent loops.
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Figure 58.
Acute small bowel ischaemia.
Small bowel barium study
shows partial functional
obstruction, proxim al to
diffuse spastic narrowing o f
ileum with thickened folds and
thick walls. There is a "picket
fence”pattern in places
(arrowed). c=colon.
Figure 59.
Small bowel ischaemia. Same
patient as Fig. 58. CT after in
travenous contrast. Note "tar
get”sign in thickened ileal
loops in right iliac fossa (ar
rowed), oedema in adjacent
mesentery and fluid filled ob
structed bowel to left o f mid
line. Bowel had returned to
normal a fe w weeks later on
follow up contrast study (pa
tient then asymptomatic).
Vascular disease
Acute ischaemia
Acute arterial ischaemia of the small intestine is due to relatively large
vessel thrombo-embolic occlusion or (more commonly in most reported
series) is non-occlusive in origin. The latter is related to low-flow states
as in shock, congestive heart failure, etc. In occlusive ischaemia, plain
radiographs are often disappointing: focal dilatation, wall thickening,
"thumbprinting" or a "gasless" abdomen may be evident. In more ad
vanced disease when infarction has taken place, intramural gas and/or
portal vein gas may be seen. There is rarely an indication for barium stud
ies, but these will show local spasm, submucosal haemorrhage or oedema
(manifest as a "picket-fence" pattern of thickened and rigid mucosal
folds) or "thumbprinting" (Fig. 58). In reversible ischaemia improvement
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Chronic ischaemia
Occlusive arterial disease rarely will cause chronic ischaemia of the
bowel with symptoms of diarrhoea, malabsorption or mesenteric
984
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Figure 60.
Venous infarction o f
bowel due to idiopathic
superior mesenteric vein
thrombosis. CT scan (af
ter IV contrast) demon
strates thrombus in su
perior mesenteric vein
(curved arrow) and
thickened loops o f small
intestine ("target sign ",
arrowed) consistent with
but not specific to is
chaemic bowel. Long
segment o f infarcted
ileum resected at la
parotomy.
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locity jet is seen on CDI. Most workers give a standard test meal and re
peat the examination after about 45 minutes, since in some patients fast
ing flow is normal and a provocation test is therefore needed. In the pres
ence o f significant stenosis the normal post-prandial change seen in the
SMA is lacking. The flow characteristics in the CA do not change sig
nificantly even in normal individuals.
LARGE BOWEL
Imaging techniques
Plain radiography is useful mainly in acute disease such as obstruction,
ischaemic colitis or acute inflammatory colitis (see below). In chronic
disease it is of limited use; the extent of faecal residue may be approxi
mately assessed in patients with constipation. The double contrast bar
ium enema (DCBE) is now the contrast examination o f choice in most
patients with suspected large bowel pathology. The single contrast en
ema is undertaken if the DCBE cannot be performed or in an unprepared
colon if there is suspected large bowel obstruction or leak, in which lat
ter case a water-soluble contrast should be used. The DCBE has ben
shown to be superior to the single contrast technique in the detection of
small polyps and subtle mucosal disease. The single contrast barium en
ema may be used in the very old, disabled or ill patient where moblity is
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Figure 61.
Detail o f double
contrast examina
tion o f sigmoid
colon showing typi
cal innominate
groove pattern in
proximal loop (open
arrows) andfine
granularity o f ac
tive ulcerative coli
tis (solid arrows).
988
THE GASTROINTESTINAL TRACT
Pathology
Diverticular disease
Colonic diverticula are of the acquired pulsion type. In Western societies
they are present in 30-50% of the population over the age of 50 years.
Divertiula are seen predominantly in the sigmoid and distal descending
colon and occur laterally between the mesenteric and antimesenteric tae
nia or sometimes in the antimesenteric inter-taenial area, in which posi
tion they are often small or intramural. In 10% they are seen in the right
side of the colon only, and in 17 % they are scattered throughout the colon.
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990
THE GASTROINTESTINAL TRACT
Figure 63.
Double contrast barium enema
showing left sided diverticula,
some appearing as ring shadows,
others as barium filled outpouch
ings. In addition there is a peri
colic inflammatory mass causing
impression on the medial aspect
o f the sigmoid (arrowed).
Diverticulitis
Acute diverticulitis typically presents with left iliac fossa pain, with or
without a palpable mass, fever and leucocytosis. There is an increasing
tendency to investigate these patients radiologically with CT scanning,
though some authors maintain that there is a continued place for water-
soluble contrast enema, particularly if the CT is equivocal. CT has many
advantages: as well as being more comfortable for the patient, it is able
to confirm the presence of diverticula and the site of disease, demonstrate
peri-colic inflammation - assess abscess formation and help plan man
agement, whether it be medical or, in the case of abscess, surgical or per
cutaneous drainage. As well as showing even small paracolic fluid col
lections, other CT signs include wall thickening and peridiverticular in
flammatory infiltrate into the surrounding fat (Fig. 64). If CT is
unavailable, ultrasound is often able to show pericolic abscess, but suf
fers from the usual limitations of US in the presence of bowel gas. If con
servative management is undertaken, it is reasonable to perform a de
layed double-contrast barium enema when the patient has recovered, to
assess the extent of diverticular diseasee and any co-existing pathology,
since the CT appearance of wall thickening is non-specific and CT can-
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 64.
Acute diverticulitis, (a) CT scan showing sigmoid loop with marked mural thickening
and pericolic inflammation. A row o f diverticula are interconnected by linear inflamma
tory stranding (arrowed), (b) Another case. Double contrast enema showing impression
from pericolic abscess (arrowed). Gas is present in the adjacent pericolic gutter
(curved arrow), (c) Same patient as (b). Small pericolic abscess with inflammatory infil
trate into pericolic fa t and thickening o f anterior pararenal and lateroconal fascia.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 65.
View o f sigmoid/descending
colon junction showing con
stricting carcinoma (open ar
row) and "sentinel”polyp in
barium pool (solid arrows).
Note the "Mexican hat" sign
related to the latter.
being seen tangentially. However, if the "hat" always points towards the
centre of the long axis of the bowel the lesion should be intraluminal, i.e.
a polyp. This rule is useful unless the lesion lies in the midline of the
bowel or is parallel to its long axis.
Inflammatory diseases
Of the non-infective causes of inflammatory bowel disease (IBD) to af
fect the large intestine, ulcerative colitis (UC) and Crohn’s disease (CD)
are by far the commonest.In the patient with acute symptoms, the plain
radiograph may be useful. In UC, the extent of disease can sometimes
be ascertained by the distribution of faecal residue; residue is not seen
in that part of the bowel where there is active inflammation. However,
this sign is not helpful if the colon happens to be empty of faeces nor in
CD where there are often "skip" lesions. The extent and severity of the
disease may be apparent from the visualised mucosal fold pattern.
Mucosal pseudopolyposis, submucosal oedema ("thumbprinting") and
wall thickening may be seen where luminal air provides adequate radi
ographic contrast. In severe colitis, actual or impending toxic megacolon
may be evident.
Most patients with IBD can be examined by DCBE, but the bowel
preparation should be modified in patients with acute symptoms or se
994
THE GASTROINTESTINAL TRACT
Ulcerative colitis
This disease is characterised by episodes of exacerbation and remission.
The rectum is virtually always involved, with a variable but contiguous
extent of the colon being affected proximally. The main categories of in
volvement are: proctitis, distal (or left-sided) colitis and so-called ’’ex
tensive” colitis. The latter term is used to denote disease radiographically
extending as far proximally as the hepatic flexure. In practice this almost
always means that the whole colon is involved. The earliest sign of UC
on DCBE is a finely granular mucosal pattern which is uniform and con
fluent. Progression is manifest as superficial erosions which give a stip
pled appearance to the mucosa (Fig. 61). As these heal a coarsely gran-
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Figure 66.
Double contrast enema showing left
sided ulcerative colitis. Deep "collar
stud” ulcers are present on a back
ground o f abnormal mucosa.
996
THE GASTROINTESTINAL TRACT
Figure 67.
Chronic ulcerative colitis. The left
hemicolon is diffusely mildly nar
rowed and has lost haustral mark
ings. The filling defect in the
splenic flexure region was artefac-
tual.
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Figure 68.
Chronic total ulcerative colitis
complicated by carcinoma. There
is an annular carcinoma o f the as
cending colon (open arrow), su
perimposed on changes o f chronic
colitis - shortened, narrowed
colon lacking haustrae. Plaque
like areas o f dysplasia were also
evident (solid arrows in sigmoid
colon; these reproduce poorly in
the illustration).
998
THE GASTRO-INTESTINAL TRACT
Figure 69.
Post inflammatory filiform
polyps in a patient with a his
tory o f previous acute colitis,
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Figure 70.
Crohn's colitis, overview o f
colon. There are discontinuous
changes with severe involve
ment o f transverse colon (cob-
blestoning and ulceration) and
mild sigmoid disease (aphthoid
ulcers on a background o f nor
mal mucosa). Note also the ter
minal ileal stricture.
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THE GASTRO-INTESTINAL TRACT
UC CROHN'S
Infectious diseases
Entamoeba Histolytica
This is dealt with in the chapter on "Tropical disease".
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even more proximally. The sigmoid loop may be elevated by the fibrotic
reaction. Pararectal, paravaginal and paracolic sinuses can be demon
strated often associated with abscesses. Rectal gonorrhoea results in
small rectal ulcers usually without radiolucent halos on a background of
normal mucosa. Rarely strictures and fistulae may occur. Actinomycosis
affects the right side of the colon and distal ileum where it has a propen
sity for causing complex sinuses and fistulae and fibrous masses which
may mimic neoplasms. Mycobacterium tuberculosis infrequently causes
pure colonic disease. Ileocolic involvement has been described in the
small bowel section. Scarring of the ileocaecal region and ascending
colon, annular strictures and/or deformity of the ascending colon occur
and the picture may be indistinguishable from Crohn’s disease or from
neoplasm. Prevalence of the respective diseases in local practice will ob
viously help. Tuberculosis is suggested by circumferential or stellate ul
cers, ’’hourglass" type strictures and a constricted caecum with a patulous
ileocaecal valve. Occasionally, diffuse colonic disease will mimic UC.
Schistosomiasis affecting the bowel is usually due to S. mansoni or S.
japonicum. The appearances are described in the chapter on "Tropical
disease".
AIDS-related colitis may be due to the co-existence o f multiple or
ganisms ("gay-bowel"). CMV infection may be relatively mild, associ
ated with diffuse mucosal granularity and aphthoid ulceration, or fulmi
nant, causing multiple large discrete ulceration, submucosal haemor
rhage, toxic dilatation, pneumatosis and gangrenous necrosis. There is a
predilection for caecal involvement with deep ulcers; this may also be
seen in renal transplant patients. The haemorrhagic colitis and necrotic
features are related to the vasculitis seen in infection with this organism.
Cryposporidium and atypical mycopbacterial organisms do not produce
a specific radiological picture in the large intestine. CT may be useful in
AIDS-related proctocolitis. Inflammatory infiltrate into the perirectal fat
is seen, but in addition, CT may help distinguish neoplastic from in
flammatory disease. Diffuse mural thickening with a "target-sign"
favours inflammatory disease.
Pseudomembranous colitis is due to endotoxin-producing Clostridium
difficile and is most commonly related to the administration of broad-
spectrum antibiotics. Sigmoidoscopy is usually diagnostic, showing the
typical pseudomembranes, together with the isolation of the toxin from
the stools. The clinical course is variable. Fulminant disease may occur
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 71.
Ischaemic colitis involving "water
shed" region around the splenic
flexure. The proximal descending
colon is shown. There are eccentric
changes with mild narrowing, sac
culation andfine nodularity.
1004
THE GASTROINTESTINAL TRACT
Figure 72.
Pneumatosis cystoides coli af
fecting the sigmoid colon.
Note radiolucent gas blebs
which in profile are seen to
parallel the bowel wall. More
proximally the sigmoid is
normal.
Pneumatosis coli
Gas in the bowel wall may occur for reasons other than ischaemic necro
sis. Pneumatosis (cystoides) coli is a benign idiopathic condition asso
ciated with gas collections, usually in blebs or "cysts" within the wall
and paralleling the lumen. It is most frequently distributed in the sigmoid
and descending colon, often with rectal sparing. There is luminal nar
rowing and scalloping of the contour by the submucosal impressions of
the gas cysts but obstruction is not seen (Fig. 72). Patients are either
asymptomatic or present with intermittent abdominal pain and diarrhoea.
Occasionally, a bleb may perforate and cause pneumoperitoneum with
out peritonitis. The small bowel may be involved in addition to the colon.
A secondary form may be seen where there is a cause o f raised intralu
minal pressure in association with mucosal ulceration, such as may be
present proximal to an obstructing stricture of the colon.
Colorectal neoplasms
Detection
Colorectal cancer (CRC) is the commonest internal malignancy in many
Western countries. It occurs at all adult ages, but the incidence rises
sharply after 40 years of age. Although some individuals fall into high
or above-average risk groups (for example, prior history of colorectal
neoplasia, family history of polyposis syndromes, hereditary non-poly-
posis colorectal cancer families, first degree relative(s) with CRC,
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THE GASTROINTESTINAL TRACT
Figure 73.
Polypoid carcinoma o f the
caecum (large arrows) with
synchronous sessile (small
arrow) and pedunculated
(arrowheads) sigmoid
polyps.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Polyposis syndromes
Familial adenomatous polyposis and Gardner's syndrome are associated
with multiple, usually innumerable, colonic adenomas. Carcinoma is in
evitable without colectomy. Polyps may be seen throughout the bowel
and have been desribed elsewhere in this text. In Gardner’s syndrome,
soft tissue desmoid tumours and osteomas are also seen. There is a ten
dency to develop peri-ampullary duodenal malignant neoplasms.
Juvenile polyps are a form of hyperplastic benign lesion, usually solitary
and pedunculated in the rectosigmoid area; they have a propensity for
autoamputation. Peutz-Jegher's syndrome is associated with hamar
tomas in the bowel, bur rarely malignant degeneration can occur.
Colorectal carcinoma
Diagnosis
The rectum and sigmoid regions are the commonest sites for carcinoma,
but there has been a relative shift o f distribution to the right side of the
colon in recent years. Multiple cancers are seen in about 5 % or there are
benign polyps present within the same colon, frequently so-called ’’sen
tinel” polyps that occur near the malignant tumour. The double contrast
barium enema, in the best hands, detects approximately 90-95% of
colonic cancers. Most missed tumours are in the sigmoid, often when
there is co-existing diverticular disease, and in the caecum. Plaque-like
lesions are more likely to be be overlooked than polypoid or annular ones.
The vast majority of tumours are adenocarcinomas. The radiographic ap
pearances on barium studies are:
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THE GASTROINTESTINAL TRACT
Staging
The most frequent surgical/pathological method of staging colorectal
carcinoma is by the modified Dukes classification. In recent years the
TNM method has gained increasing acceptance. A single modality that
allows accurate pre-operative staging is not available. Such staging
would facilitate appropriate therapy to be planned and monitored.
Accurate staging demands the determination of local tumour spread,
lymph node metastasis and distant (liver) metatasis. Liver imaging is
dealt with elsewhere in this publication. CT staging of the primary tu
mour (Fig. 74) and lymph node metastasis in colorectal carcinoma, while
initially encouraging, has been shown to be only 48-74% accurate. This
is due to the inability of CT to detect minor degrees of perirectal or peri-
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Figure 74.
CT showing rectal car
cinoma (T) infiltrating
perirectal fa t laterally
and posteriorly (ar
rows) and seminal vesi
cles anteriorly.
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THE GASTROINTESTINAL TRACT
ray coils may lead to further improvements. Early results have been re
ported using Indium-labelled monoclonal antibodies for radionuclide
imaging of colorectal cancers. There appears to be high sensitivity in the
detection o f tumour sites in the abdomen, but there is a significant false-
positive rate.
Recurrent tumours
Investigations have shown both CT and MR scanning to be able to de
tect asymptomatic tumour recurrence when the carcinoembryonic anti
gen levels are normal. Tumour recurrence after surgery for rectal carci
noma occurs in about one third o f patients within the first two years and
is most frequent in the area contiguous with the surgery. Sixty percent
of these patients will have only local recurrence. It has been shown that
resection of recurrent tumour increases survival time. It has therefore
been suggested that a baseline CT (or MR) be performed 2-3 months af
ter initial surgery, followed by imaging every 6-9 months for 2-3 years.
The protocol for imaging should be directed to the detection of both lo
cal recurrence and hepatic metastasis, since there is evidence that resec
tion of the latter, where possible, may also increase survival time. CT ac
curacy for local tumour recurrence suffers from the same limitations as
in staging the primary lesion, that is the inability to detect microscopic
invasion of perirectal or pericolonic fat and to assess metastatic deposits
in nodes of normal size. A further problem occurs after abdominoper
ineal resection for rectal cancer since there is frequently a soft tissue pre-
sacral mass due to oedema, haemorrhage, granulation tissue or fibrosis,
for many months after surgery. This is particularly so if radiotherapy has
been performed. Hence, the rationale for undertaking a post-operative
baseline study at 2-3 months. Any enlargement of the mass should be
cause for concern and lead to percutaneous biopsy. MR scanning is re
ported to help distinguish recurrent rectal tumour from scar tissue, re
current tumour having a high signal intensity on T2-weighted images.
Position emission tomography with fluorine-labelled D-glucose has re
cently been shown to be useful in this function.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
tend to change shape during the barium examination with posture and
compression. CT scanning is definitive in demonstrating the fatty atten
uation of the lesion. Large bowel carcinoids mostly occur in the rectum
and comprise 1-2% of polyps less than 5 mm in size. They are sessile
polyps and should be considered potentially malignant. Nearly all lesions
greater than 2 cm in diameter are malignant. Endometriosis occurs at the
rectosigmoid junction in 85% of cases, due to deposits o f endometrial
tissue in the pouch of Douglas. On barium enemas they are seen as
smooth, often scalloped, submucosal impressions on the bowel lumen
on the anterior wall of the rectum causing mild narrowing. Symptoms
are related to menstrual periods.
Prominent colonic lymphoidfollicles may be seen as a normal variant
on DCBE in young patients. Follicles less than 3 mm in diameter may
be seen in 50% of patients less than 30 years of age. However, when fol
licles of 4 mm or more are seen, usually in the rectosigmoid area, there
is an increased incidence o f inflammatory bowel disease or lymphoma.
Some authors have found a 70% incidence of colorectal neoplasia in pa
tients over 40 years of age with prominent follicles 1-3 mm in diameter,
especially when diffuse or left-sided. This finding should precipitate a
very careful search for neoplasia.
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Figure 75.
Serosal metastases (squamous
carcinoma, primary unknown)
involving proximal descending
colon. Note narrowing, fixa
tion, tethering and spiculation.
Figure 76.
Transperitoneal spread to
pouch o f Douglas from carci
noma o f caecum. There is nar
rowing o f the rectosigmoid re
gion with anterior spiculation.
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Figure 77.
MR images, T2 weighted -
(a) axial and (b) coronal -
showingfistula-in-ano track
(arrowed) running from left
to right posterior to ano-
rectum (r) but inferior to le
vator muscles (Im).
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THE GASTROINTESTINAL TRACT
Figure 78.
Evacuation proc
togram showing no
significant abnor
mality. (a) at rest
(b) during
"squeeze” or lift
(c) during straining
(d) during evacua
tion. See text fo r il
lustrated features.
Solid line depicts
level o f ischial
tuberosities.
V=vaginal contrast;
dotted line=anorec-
tal angle.
Evacuation proctography
Barium paste, the approximate consistency of soft stool is introduced
into the rectum. A vaginal marker is inserted and some workers opacify
the pelvic small bowel with oral barium. The patient is then seated lat
erally on a special radiolucent commode in front of the screening unit.
Hard copy images are obtained with a 100 mm camera, and videofluo-
roscopic recording is made at rest, during "squeezing”, during straining
without evacuation, and then during attempted evacuation (Fig. 78). The
investigation gives morphological and functional information.
Parameters that are measured include the anorectal angle, the level of the
anorectal junction relative to a bony landmark (such as the ischial
tuberosities) and the anal canal width. Changes in these parameters in
the various phases of the examination are more important than the ab
solute values. Features that are observed with each manoeuvre include
the state of opening of the anal canal, the configuration and position of
the anorectal junction, the degree of rectal mucosal prolapse and any rec-
tocele or enterocele formation. A subjective assessment is made of the
efficiency and degree of rectal evacuation.
Normally, at rest the anal canal is closed, the anorectal angle is about
90° and there is a well formed posterior impression at the anorectal junc
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1016
THE GASTROINTESTINAL TRACT
Constipation
Debilitating, chronic constipation in adults may be due to a number of
systemic disorders (e.g. hypothyroidism). Idiopathic constipation may
be related to slow bowel transit, anorectal outlet obstruction or a com
bination of these. Imaging investigations after exclusion of systemic con
ditions will therefore include barium enema (for stenosing lesions and
megacolon), transit studies and evacuation proctography. Transit stud
ies may be performed by the use of radio-opaque ingested markers - se
rial radiographs are taken to assess the number of markers remaining in
the bowel - or by a nuclear medicine method. In the latter study,
11indium-labelled resin microspheres or other material are given by
mouth and images acquired serially. The radiograhic method has the
virtue of cheapness and simplicity and is a reasonable screening test. The
scintigraphic technique is more specific and allows measurement of seg
mental transit which may be important in management. The features seen
on evacuation proctography have been discussed. A subjective assess
ment of rate and efficiency of evacuation may be made as well as the
demonstration of puborectalis dysfunction and morphological abnor-
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
malitis such as rectocele, prolapse and enterocele which may give rise
to a sensation of incomplete emptying. Recently, radio-isotope proctog
raphy has been used to permit a quantitative measure o f evacuation ef
ficiency; this also provides some morphological information.
Incontinence
Incontinence may be associated with other evacuation disorders, such as
the descending perineum syndrome or prolapse, and is accompanied by
a history o f multiparity and/or chronic straining leading to pudendal neu
ropathy and loss of anorectal sensation and deficient sphinters. Obstetric
injury or anorectal surgery may result in sphincter defects. While evac
uation proctography may help characterise some of the associated fea
tures of incontinence, the role of this examination is less clear cut than
in constipation. Endo-anal sonography has become the most useful
method of imaging the internal and external anal sphincters. Detailed im
ages may be obtained which can localise focal defects and influence man
agement (Fig. 79). Endosonography may replace needle electromyo
graphic mapping of the external sphincter. It is also useful in imaging
anorectal fistulae and abscesses, in local staging of ano-rectal carcinoma
and in imaging local recurrence after rectal surgery for neoplasms.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
time o f areas of abnormal uptake, and strict criteria for the localisation
of a source of bleeding seen on delayed images only. This latter prob
lems arises from the rapid antegrade or retrograde movement of ex-
travasated red cells within the bowel leading to false localisation. In ad
dition, pooling can occur in the large bowel from a source more proxi
mally. Figures for correct localisation vary in the literature from 40 to
90%.
It is convenient to discuss upper and lower gastrointestinal haemor
rhage separately. It is usually possible to distinguish these on clincial
grounds and by the passage o f a nasogastric tube. Selective angiography
is performed, the choice of vessel first selected being determined by the
suspected site of bleeding. Although digital subtraction radiography
(DSA) is convenient, many radiologists prefer cut films citing the pit
falls of DSA such as artefacts due to bowel movement, lesser field of
view and decreased spatial resolution. It is estimated that conventional
angiography can detect blood loss of approxinmately 0.5 ml per minute;
DSA can probably detect 1—1.5 ml per minute. Extravasation is seen as
puddling of contrast in the early to mid-arterial phase which changes size
and shape as the series progresses. Venous bleeding is hardly ever
demonstrated.
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THE GASTROINTESTINAL TRACT
1021
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 80.
Superior mesenteric artery
angiogram demonstrating ex
travasation into a bleeding
right-sided colonic diverticu
lum (arrowed).
1022
THE GASTRO-INTESTINAL TRACT
all of these will require urgent resection; some are relatively minor and
will lead to no sequelae or to later colonic strictures. There is no con
sensus as to whether vasopressin or embolotherapy is the initial preferred
method in colonic bleeding. Both techniques have their advocates. There
is some evidence that vasopressin is best in diverticular bleeding and em-
bolisation in others.
Angiographic interventions
These interventions include:
i) Therapy to arrest bleeding - previously discussed
ii) Thrombolytic therapy to dissolve thrombo-emboli to the major
mesenteric vessels.
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1024
THE GASTROINTESTINAL TRACT
Percutaneous gastrostomy
For long term feeding, percutaneous gastrostomy may be performed
safely and relatively simply by radiological or endoscopic methods. The
catheter can be advanced into the jejunum if required.
1025
Chapter 23
The liver
MODALITIES
With the introduction of cross-sectional imaging methods such as US,
CT, and MRI, direct imaging of the liver parenchyma became possible
where previously only angiography and radionuclide imaging had been
available.
Ultrasonography
Because of the location, size and structure of the liver, US is very well
suited for imaging its parenchyma and is therefore usually the first
method employed. It is widely available, easily performed and has no
contraindications. An excessive amount of bowel gas may degrade the
study.
Ultrasound gives information on the size and structure o f the liver and
demonstrates both localized lesions (e.g. hepatic tumours, cysts and ab
scesses) and diffuse disease. Intrahepatic structures, such as portal ves
sels and biliary ducts can be identified. The vascular systems in the liver
may be studied with Doppler US, which can give important differential
diagnostic information especially when a colour-system is used (Fig. 1).
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Figure 1.
US o f the liver. The normal echo
pattern o f the liver is demonstrated.
The echo-free, tubular structures
within the liver are hepatic veins
(arrows).
Computed tomography
A CT study of the liver entails imaging of the entire organ from its su
perior border at the dome o f the diaphragm to its caudal tip. Contiguous
10 mm thick slices are obtained, usually before and after the intravenous
injection of contrast medium (Fig. 2). Because of its iron content, the
density of the liver is slightly higher than that of other intra-abdominal
organs, usually of the order of 65 ± 5 HU. Most pathological lesions have
a density less than that of normal parenchyma. This difference is accen
tuated following a contrast medium injection, but because of pharmaco
dynamic considerations care has to be taken to perform the enhanced
study during a narrow time window of 30-60 seconds following the bo
lus injection of contrast medium. Because of the size of the liver, the con
trast injection may have to be repeated in order to study the entire organ
but this requirement has diminished considerably since the advent of fast
CT scanning and spiral CT. Sequential scans at a single, predetermined
level after a bolus of contrast medium are useful for determining con
trast enhancement dynamics, which are of decisive importance in the di
agnosis of, for example, a haemangioma.
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THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 2.
CT o f the liver, (a) Without
i.v. contrast enhancement
the texture o f the liver is
even. The blood vessels are
seen faintly as low-attenu
ating structures against the
liver parenchyma. The at
tenuation o f the liver (I) is
equal to that o f the spleen
(s). (b) After i.v. contrast
enhancement the attenua
tion o f the liver increases,
as does that o f the spleen.
The hepatic veins are now
clearly visible as highly-
attenuating (white)
structures and are well
discerned against the liver
parenchyma. On this scan
contrast medium is also
seen in the aorta (a).
The size of the liver and information on both focal and diffuse
parenchymal disease are all clearly evaluated by CT. Newer CT tech
nology has also made it possible to visualize blood vessels (CT-angio-
graphy, CT-portography) and to perform 3-dimensional reconstructions
which are important in studying anatomically complex areas, such as the
liver hilum.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 3.
M RI o f the liver. In
these T1-weighted
images the
anatomy o f the
liver is well dis
played in the
transverse, sagittal
and coronal pro
jections. The por
tal and hepatic
veins are seen as
HVKS 2|
•tt©.E7C<4 VISION dark tubular
structures.
Angiography
Arteriography used to be the most precise method for evaluating liver
disease, but its diagnostic use is now limited to the investigation of cer
tain special problems such as the pre-operative mapping of liver vessels
or the detailed evaluation of certain liver tumours.
Therapeutic angiography is particularly important in the liver as the
organ has a dual blood supply (making embolization a relatively safe
procedure) and interventional procedures are associated with a far lower
morbidity than surgery in a variety of circumstances such as acute arte-
1030
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Radionuclide imaging
Radionuclide imaging used to be an important method for studying the
liver, particularly focal lesions in the organ, but it has diminished in im
portance mainly because of its poor spatial resolution and non-specificity
in comparison with other methods. Nevertheless, several specialised
agents may be useful for imaging specific pathology, such as radiolabelled
leucocytes for intrahepatic abscess, In-III octreotide for GFP tumours
metastasing to the liver, and 1-123 SAP (serum amyloid P component) for
hepatic amyloidosis. Hepatic haemangioma is a lesion which is charac
teristically associated with low blood flow but high blood volume and
may be diagnosed by dynamic Tc-99m labelled red cell imaging.
Biliary imaging
Proper evaluation of the liver frequently requires imaging of the biliary
tract. This is considered separately in the succeeding section.
NORMAL ANATOMY
The liver is the largest of the parenchymal organs, and weighs apporox-
imately 1500 grams. It is situated in the upper right hypochondrium and
extends from the right flank across the midline. It may reach as far left
as the spleen. Superiorly the liver abuts the diaphragm and in the sagit
tal direction it extends from the ventral to the dorsal abdominal wall. The
liver is divided into a right and left lobe, and for surgical purposes the
border between these, which is not seen on the anatomical liver surface,
extends obliquely from the gallbladder fossa to the vena cava in the plane
of the middle hepatic vein. The caudate lobe is usually considered as a
separate entity and is situated between the inferior vena cava and the por
tal vein at the liver hilum.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 4.
US o f the liver. There is a subcap-
sular lesion 2 cm in diameter
within the liver parenchyma (be
tween arrows). This lesion is well
demarcated from the parenchyma.
The echogenicity o f this entity, a
rounded tumour, is clearly higher
than that o f the surrounding liver
parenchyma. This finding is consis
tent with the diagnosis ofhaeman-
gioma o f the liver.
PATHOLOGICAL CONDITIONS
Benign tumours
The three most important benign tumours of the liver are cavernous hae-
mangioma, adenoma, and focal nodular hyperplasia. Cysts are frequently
seen in the liver.
Haemangioma is the most frequently occurring liver tumour, both in
adults and children, and is an important lesion to consider in the differ
ential diagnosis of malignant tumours. On US a haemangioma is often
seen as a hyper-echogenic localized lesion (Fig. 4). On unenhanced CT
it is seen as a low-attenuation lesion but with intravenous contrast medium
it exhibits a characteristic enhancement from periphery to centre within
a few minutes (Fig. 5), a phenomenon that is particularly evident in large
tumours. On MRI a haemangioma shows a high signal intensity on T2-
weighted images with similar contrast dynamics to those seen on CT.
Fine-needle biopsy of a haemangioma may yield only blood and this find
ing is not specific. The diagnosis is usually made on a combination of at
least two imaging methods but angiography is rarely necessary.
Liver adenomas and focal hyperplasia (Fig. 6) (both of which are re
ported as being more frequent in females), may be isodense or hypodense
on non-enhanced CT, but may show some transient enhancement with
contrast medium.
1032
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 5.
Contrast-enhanced CT o f the
liver. An initially low-density
tumour is seen centrally in
the liver (*) (upper left im
age). After contrast injection
sequential scanning over
three minutes shows contrast
medium slowly filling in the
tumour from the periphery to
the centre. This finding is
typical o f a haemangioma.
Figure 6.
MRI o f the liver. A high-sig
nal lesion with a dark centre
is seen anteriorly in the liver
(arrows) on this sagittal, Tl-
weighted image. The finding
is consistent with the diagno
sis o f nodular hyperplasia.
The kidney is seen to the
right, posteriorly.
Cysts of varying sizes are frequently seen in the liver and may be soli
tary or multiple. Multiple cysts in the liver, pancreas and kidneys are a
feature of some specific disorders (e.g. autosomal dominant polycystic
disease, von Hippel-Lindau disease). On US a cyst has characteristic fea
tures, with well-defined sharp borders, echo-free contents and peripheral
echo enhancement. On CT the lesions are well defined, with contents ap
proximating to the density of water and exhibiting no contrast enhance
ment o f either their contents or walls (Fig. 7). Cyst walls may rarely be
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Figure 7.
CT o f the liver. A rounded struc
ture is seen which has well de
marcated walls and whose con
tents are o f water density (*). No
contrast enhancement is noted.
These features are typical o f a
liver cyst.
calcified. Hydatid cysts of the liver are common in endemic areas; they
may show a characteristic apearance, especially on CT, with septa and
walls that are frequently calcified (see Chapter 27).
Malignant tumours
Hepatomas or hepatocellular carcinomas are the commonest primary tu
mours of the liver. They occur with varying frequency in different parts
of the world and are commoner in males than females. Cirrhosis and he
patitis В are predisposing factors. They are usually well shown on US,
with both hypo- and hyper-echogenic areas (Fig. 8). On non-enhanced
CT the tumour may be isodense and identified solely by the fact that it
is a space-occuping lesion, but on contrast-enhanced CT the tumour is
characterized by an uneven pattern of contrast enhancement, usually with
areas of diminished density in the (necrotic) centre. There is often evi
dence of portal or hepatic venous invasion. It is important for surgical
planning to delineate the tumour borders and localize the lesion with re
spect to the surgical lobar liver anatomy. This also applies to grading of
the tumour with reference to any extrahepatic spread. In this respect, MRI
may offer some advantage over CT, because of its multiplanar features
(Fig. 9). The tumour may require differentiation from a cholangiocarci-
noma(Fig. 10).
1034
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 8.
US o f the liver. Subdiaphragmatically
there is a large 6 cm tumour (between
arrows) which is o f slightly higher
echogenicity than the surrounding
liver parenchyma, and which is well
demarcated from it. These features
are consistent with the diagnosis o f a
hepatoma.
Figure 9.
MRI o f the liver (fat suppression STIR
sequence). Posteriorly, a lobulated tu
mour o f high signal intensity is seen,
with several smaller satellite tumours.
These features are conistent with the
diagnosis o f hepatoma.
Figure 10.
Contrast-enhanced CT o f the liver.
Centrally in the liver there is a large
tumour (arrows) with dark areas o f
central necrosis and mixed attenua
tion in its periphery. In the ventral
part o f the liver a separate small le
sion is seen (arrowhead), suggestive
o f a metastasis. This tumour, how
ever, proved to be a cholangiocarci-
noma.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 11.
US o f the liver. A large tumour o f mixed
echogenicity (between arrows) is seen
which is well demarcated from the liver
parenchyma (L). The tumour proved to be
a metastasis from a breast carcinoma.
Figure 12. CT o f liver metastases. (a) Two large, expanding lesions (arrows) are seen
within the liver. They show mixed attenuation and enhancement, with dark areas o f
necrosis. In addition, two smaller lesions are seen in the lateral segment o f the left
lobe (arrow-heads). These tumours were metastatic deposits from an angioneurosar-
coma. (b) A 2 cm metastasis (arrows) is demonstrated as a lesion with decreased con
trast enhancement in comparison with the surounding liver parenchyma. In this case
the contrast medium was injected directly in the superior mesenteric artery, which is
said to be the most efficient way to demonstrate small foci in the liver on CT. Note that
no contrast medium is seen in the aorta.
1036
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 13.
MRI o f liver metastases. On
this Tl-weighted image two
metastatic lesions (arrows)
are seen, showing varying
signal intensities.
The most frequent malignant tumours in the liver are metastases from
other primary carcinomas. On US metastatic deposits may be seen as
lesions which may be hypo- or hyper-echogenic in comparison to the
surrounding parenchyma, or may show mixed echogenicity (Fig. 11).
Metastatic lesions are usually multiple. On CT metastases are often seen
as hypodense lesions that remain as such after the injection of contrast
medium (Fig. 12). Certain metastases (e.g. hypernephroma) are hyper-
vascular and therefore show increased contrast enhancement. MRI
seems to be the most sensitive method for detecting liver metastases and
the accuracy of the method may be enhanced by the use of magnetic
contrast agents (Fig. 13). CT-portography may also help in the diagno
sis of metastases.
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Figure 14.
CT o f the liver. Two typical abscesses
are demonstrated, one showing a thick
abscess wall (large arrow), the other
showing a well demarcated smooth wall
(small arrow).
Figure 15.
M RI o f the liver. On this T2-
weighted fa t suppression STIR-
sequence image multiple foci o f
increased density are seen, the
cause being fungal abscesses o f
the liver. Only the largest foci
were seen on ultrasound or CT,
and this study shows the sensi
tivity o f M RI in detecting small
focal hepatic lesions.
Figure 16.
CT o f liver trauma. Contrast
enhancement brings out the he
patic veins, and CT demon
strates decreased perfusion o f
the right lobe o f the liver, de
marcated by the middle hepatic
vein (arrow). This finding indi
cates that the artery o f the right
hepatic lobe is severed. A trau
matic rift is also seen in the left
lobe in the region o f the falci
form ligament.
1038
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 17.
US o f fatty liver. The echogenicity
o f the liver is coarse and clearly
increased in comparison with nor
mal liver (the so-called "bright-
liver”-pattern).
L = liver; К = kidney.
cases the other parenchymal organs have to be studied for traumatic le
sions as well, On US a rupture of haematoma is seen as a hypo-echoic
area. The imaging method of choice in traumatic cases is contrast-en
hanced CT (Fig. 16), which makes it possible to differentiate between
haematoma, other fluid collections (bile) and normal parenchyma. On
MRI a haematoma is seen usually as a lesion with increased signal.
Since many focal liver lesions, with the exception o f cysts, do not show
diagnostically characteristic features on any imaging method, fine-nee-
dle biopsy verification is usually essential to establish the diagnosis. For
some liver disorders a cutting-needle biopsy may be preferable and this
can be obtained with embolization of the track, particularly if there is a
likelihood of haemorrhage (see below).
Parenchymal disease
Fatty degeneration of the liver is fairly common, especially with certain
diseases such as alcoholism, diabetes or chronic infections. On ultra
sound this condition may give increased echogenicity of the liver
parenchyma ("bright liver") (Fig. 17). CT allows direct density mea
surements of the liver, and since fat shows low attenuation this permits
quantitative evaluation of the disease (Fig. 18). The degree of fatty in-
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
filtration may change rather rapidly, according to the stage of the un
derlying disease. An attenuation of less than 30 HU is a clear indication
of fatty infiltration. The changes may only be segmental or focal. Other
focal lesions such as tumours or metastases, are well seen in a fatty liver,
since they have normal density. A fatty liver is usually larger than a nor
mal liver.
Liver cirrhosis may vary in appearance and depending on its aetiol
ogy the liver may be either smaller or larger than normal. Dynamic CT
may show pathological patterns of perfusion of the liver and spleen,
which may also be seen on colour Doppler US.
Clinical information is also important in the evaluation of parenchy
mal liver disease.
INTERVENTIONAL PROCEDURES
One of the commonest and important interventional techniques is guided
fine-needle biopsy which is most easily performed under US-control (Fig.
19). Needle biopsies are important, since neither focal nor diffuse liver
disease necessarily exhibit diagnostic features on imaging. In some dis
orders a cutting needle biopsy is required and in patients with abnormal
coagulation parameters this is most safely obtained using either the trans
jugular approach or a percutaneous technique with embolization of the
biopsy track after obtaining the specimen.
The drainage of liver abscesses ox: sub-phrenic abscesses is another
important interventional technique that has greatly reduced the need for
1040
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 19.
US guidance o f fine needle biopsy. A
percutaneous fine needle biopsy o f a
liver tumour is demonstrated, show
ing the echo from the needle (curved
arrows) within the tumour (between
straight arrows). Normal liver
parenchyma (L) is seen to the left.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
MODALITIES
Ultrasonograhy
The gallbladder is studied by US with a 3.5-5 mHz transducer. The or
gan is studied in both its longitudinal (Fig. 20) and transverse axes, with
the patient lying supine. Views are also obtained with the patient turned
to the left and upright views are sometimes required. Positional changes
help in the diagnosis of gallstones that move with gravity. The extra-
hepatic biliary ducts are well seen by US, but the intrahepatic ducts are
more difficult to image unless they are dilated. The most distal part of
the common bile duct is not usually seen, because of interference with
the image by gas in the duodenum. The overall diagnostic accuracy of
US of the gallbladder is 90-95% .
Peroral cholecystography
Peroral cholecystography was the primary method for imaging the gall
bladder for over 50 years (since its introduction in 1925), until ultra
sonography largely replaced it in the early 1980's. In some departments,
however, oral cholecystography is still employed (Fig. 21).
In peroral cholecystography the contrast medium is administered by
mouth as tablets, absorbed through the intestinal mucosa, bound to al
bumin in the blood and transported to the liver. From the liver the medium
is excreted into the biliary ducts and concentrated in the gallbladder.
Sodium ipodate and calcium ipodate, however, are concentrated by the
liver and are thus not dependent on the gallbladder's concentrating ca-
1042
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 20.
US o f the gallbladder. The
normal gallbladder (gb) is
seen as a cystic structure with
echo-free contents. The walls
o f the gallbladder are smooth.
Normal liver parenchyma (L)
is seen to the left o f the gall
bladder.
Figure 21.
A normal cholecystogram.
(a) In the initial phase the
contrast medium is seen
evenly filling the gallbladder,
the walls o f which are
smooth, (b) After a fatty
meal, the gallbladder has
contracted. Now both the
fundus and the neck o f the
gallbladder, as well as the
cystic duct are filled with
contrast medium and the
common bile duct is demon
strated (arrows).
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
pacity. When its iodine content exceeds 0.5% the gallbladder is visible
on fluoroscopy and conventional radiographs. The concentration of con
trast medium reaches its maximum 10-15 hours after ingestion and imag
ing usually takes place on the day following ingestion. Some centres ad
vocate a scheme whereby a double dose of contrast medium is ingested
on two consecutive days before the study.
Non-opacification of the gallbladder may indicate gallbladder disease,
such as obstruction of the cystic duct. It may, however, also result from
liver disease or disorders resulting in disturbances in the absorption of
contrast medium from the gut, e.g. diarrhoea. Sometimes the patient may
not even have taken the contrast medium or there may have been a pre
vious cholecystectomy. Gallstones are seen as filling defects in the opaci
fied gallbladder. Most gallstones contain some calcium, and in 15-20%
of cases this is enough for the stones to be seen on a plain radiograph.
The gallbladder is radiographed in multiple projections including some
using external compression. The study is often completed by exposing
a so-called contraction film of the gallbladder 1/2-1 hour after the in
gestion of a fatty meal. This may show the changes of adenomyomato-
sis or cholesterolosis.
The diagnostic accuracy o f cholecystography in diagnosing gall-stones
is 85-90% , i.e. slightly less than that of US though the methods are to
some extent complementary. The use of peroral cholecystography has
undergone a modest revival with the increasing popularity of non-oper
ative methods of treating gallstones.
Cholangiography, biligraphy
Visualization of the extrahepatic biliary ducts may require the intra
venous administration of contrast medium. On intravenous cholangiog
raphy the contrast medium is given intravenously as a slow infusion for
approximately 1/2 hour. The contrast medium is bound to the albumin
in the blood and excreted by the liver into the bile. The concentration of
contrast medium in the biliary tree is usually so low that the ducts can
only be demonstrated by tomography. Some contrast material is also seen
in the gallblader, but since it is immiscible with bile and forms a sepa
rate layer in the organ, the method is unsuitable for the diagnosis of gall
bladder disease or stones. Allergic reactions may still occur on intra
venous cholangiography, and the mortality is not insignificant. The di
agnostic accuracy of the method is only 50-60 % and it should be
1044
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
employed only when good indications exist and in those cases where
other available methods (US, ERC, PTC, CT) are unhelpful. There has
been some renewed interest in this technique in patients prior to laparo
scopic cholecystectomy.
Peroperative cholangiography
Peroperative cholangiography is performed in the operating theatre dur
ing operative procedures involving the biliary ducts, and entails the in
jection of contrast medium directly into the exposed biliary ducts through
a needle or cannula. Several injections may be necessary during the study
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Postoperative cholangiography
Postoperative cholangiography entails the injection of contrast medium
through the T-tube used to decompress the biliary tree following opera
tive procedures. The procedure is usually performed 7-10 days after
cholecystectomy to check for any residual biliary concretions. The con
trast medium should be diluted so that small stones are not obscured. The
procedure is performed under fluoroscopic control and films are exposed
in various projections. Care should be taken to avoid the introduction of
air into the biliary tract, since this may simulate stones (see section on
ERC).
Radionuclide imaging
Radionuclide imaging or gammascintigraphy is performed to evalutae
biliary dynamics. The most commonly used agent is 99m Tc-HIDA
which is injected intravenously, where it is bound to albumin and then
excreted through the liver into the bile. The activity over the liver, bil
iary ducts and small intestine is sequentially recorded using a gamma
camera. The study gives information on hepatic function and biliary flow.
It may show reduced flow in, for example, strictures of the biliary tree
or calculus obstruction, non-filling of the gallbladder in obstruction of
the cystic duct, or leakage o f bile from the biliary tree. In normal sub
jects the study takes approximately one hour, but it may take up to 24
hours if the flow of bile is retarded. Radionuclide imaging of the biliary
tree has lost much of its importance with the introduction of other imag
ing methods, such as US, CT and MRI, but may still be useful in special
cases where information on biliary dynamics is important, where direct
visualization of the biliary tree with injected contrast medium is unsuc
cessful, or if the patient is strongly allergic to contrast medium.
1046
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
NORMAL ANATOMY
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
tissue, before it joins the pancreatic duct from the right to run into the
duodenum in the major papilla o f Vater.
The gallbladder
The gallbladder lies on the inferior surface of the liver, and its own in
ferior surface is covered by peritoneum. The organ is 7-10 cm long and
3 cm in diameter with a volume of 30-50 ml. The thickness of its wall
is 2-3 mm. The fundus of the gallbladder points ventrally and the neck
runs dorsally into the cystic duct.
Gallbladder anomalies occur, the commonest being a septum, usually
situated in the fundus which partially divides the organ (the "Phrygian
cap"). Very infrequently agenesis occurs resulting in absence of the gall
bladder. Duplication or even triplication of the gallbladder may occur
but these anomalies are very rare.
PATHOLOGICAL CONDITIONS
Gallbladder
Gallstone disease
Stones or concretions frequently occur in the gallbladder. Clinically the
stones do not occur in isolation, but form part of an entity, gallstone dis
ease. Stones occur about twice as frequently in women as in men. The
majority of stones are cholesterol stones and less than 10% are pigment
stones. Approximately 15-20% of calculi contain calcium and can be
seen on a plain radiograph (Fig. 22). US is the primary method for iden
tifying gallstones. A stone is seen as a rounded, echodense structure, with
a typical acoustic shadow behind it (Fig. 23). Sometimes, especially if
the gallblader is small and deformed, only the acoustic shadow is seen,
the stone itself being difficult to visualize. There are a multitude of US
features associated with the presence of gallbladder stones and the accu
racy of detection of stones on US is very high, approximately 95-98%.
In contrast, stones in the extrahepatic bile ducts may be difficult to vi
sualize on US, bowel gas often interfering with interpretation. Oral chole
cystography has traditionally been regarded as one of the most accurate
radiological methods so far as the diagnosis of gallstones is concerned
but its accuracy is only 85-90%. Gallstones are seen in the contrast-filled
gallbladder as dark filling defects (Fig. 24). The drawback with chole-
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THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 22.
Gallstones containing calcium may be
seen on a plain film, without contrast
medium. Here several gallstones are
seen as a row o f white circles on an
abdominal overview roentgenogram.
Figure 23.
US o f a gallstone. The gallbladder
(gb) is seen as a dark, echo-free cystic
structure. It contains a stone (arrow)
giving distal acoustic shadowing (ar
rowheads).
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Figure 24.
Cholecystogram showing multiple
gallstones, which are seen as filling
defects in the contrast-filled gall
bladder.
Figure 25.
Floating gallstones, seen as a layer
o f filling defects in the contrast-
filled gallbladder with the patient
erect.
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Figure 26.
US o f acute cholecystitis. The gall
bladder (arrows) is filled with
echogenic biliary sludge, and there is
a stone (arrowhead) giving an
acoustic shadow.
and may thus be "floating" on oral cholecystography; they may also form
a layer in the contrast-filled gallbladder, which is seen when a film is ex
posed with the patient in the upright position (Fig. 25). In cholesterol
stones gas-filled fissures may be seen as dark linear strucures - the so-
called Mercedes-Benz sign.
Cholecystitis
Cholecystitis may be acute or chronic. Acute cholecystitis used to be a
diagnosis in which imaging was unhelpful. Peroral cholecystography
could only show that the gallbladder was "non-functioning" as the in
flamed organ does not concentrate oral contrast medium. Fortunately,
the situation is now very different.
Ultrasound has become the primary method for imaging acute chole
cystitis, because the technique demonstrates not only the gallbladder wall
and its contents, but also the adjacent tissues (Fig. 26). On US an in
flamed gallbladder wall appears thicker than normal (over 3 mm) and
with good technique even the various layers of the wall may be identi
fied. Other diseases such as pancreatitis and liver disease, however, may
also cause thickening of the bladder wall. Changes in the surrounding
tissues may include oedema or fluid collections. On US the organ can be
palpated under visual control, and may be tender, the so-called "ultra
sound Murphy's sign". The gallbladder often contains gallstones (pre
sent in 90-95% of cases) or sedimentation of its contents ("sludge"), but
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Figure 27.
Porcelain gallbladder. The walls o f the
gallbladder are calcified, and visible on
the plain film without contrast medium;
this phenomenon may be seen as a
sequela to chronic cholecystitis.
Figure 28.
Limey-bile. As a sequel o f chronic chole
cystitis, the gallbladder may contain cal
cified biliary "sludge", which is here visi
ble on a plain film, without the patient
having taken contrast medium.
these are non-specific findings which may occur in the absence of chole
cystitis. Conversely, in so-called acalculous cholecystitis, stones are not
present although the other signs of acute cholecystitis described above
are often present. CT may show the same findings as US and though the
information given by CT is often not as detailed and precise as that given
by ultrasound, any changes present in the surrounding tissues may be
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Figure 29.
US o f the gallbladder. The gallbladder
wall is thicker than normal and slightly
uneven. There are several rounded poly
poid structures (arrows) arising from
the bladder wall and protruding into the
bladder lumen. These structures do not
show any acoustic echo. The findings
are compatible with hyperplastic chole-
cystosis.
Hyperplastic cholecystoses
Cholesterolosis and adenomyomatosis belong to a group of disorders
termed the hyperplastic cholecystoses, which share the feature of poly
poid lesions of the gallbladder wall. The term cholesterolosis implies the
presence of polypoid deposits of cholesterol in the bladder mucosa
(’’strawberry gallbladder”). In adenomyomatosis there are epithelial mu
cosal sinuses ("Rokitansky-Aschoff sinuses”) extending between poly
poid formations of localized muscular hypertrophy; these sinuses may
vary greatly in size from the minute to the very large. If the polyps are
bigger than 1 mm, they will show on both ultrasound and peroral chole
cystography as typical lesions protruding from the surface of the wall
into the bladder lumen (Fig. 29). Larger polyps may be difficult to dis
tinguish from stones, but stones usually move with changes in posture
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Figure 30.
Gallbladder carcinoma, (a) US o f
the gallbladder. There is an
exophytic growth o f a lobulated tu
mour (*) into the gallbladder (gb),
with infiltration o f the tumour
beyond the gallbladder wall. This
tumour did not move with changes in
posture. These features are sugges
tive o f gallbladder carcinoma, (b)
CT o f the same patient shows the
tumour (arrow) extending into the
gallbladder. Possible tumour infil
tration into the surounding liver
cannot be visualized even on this
contrast-enhanced CT scan.
Gallbladder carcinoma
Gallbladder carcinoma is relatively rare, seen in approximately 0.1 % o f
patients with gallstones. On US a carcinoma may be seen as a space-oc-
cupying lesion in the gallbladder area, as a hypo-echoic mass within the
gallbladder, or as a generalised thickening of the bladder wall (Fig. 30).
It is important to note any extension of the tumour into the surrounding
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Figure 31.
Intravenous cholangiography (tomogra
phy) shows dilated extrahepatic biliary
ducts. Distally in the choledochal duct
an obstructing concretion is seen as a
filling defect (arrows).
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Figure 32.
(a) Per operative needle cholangiography reveals multiple stones in the extrahepatic
biliary ducts, seen as roundedfilling defects. The needle is marked by arrows.
(b) Postoperative T-tube cholangiography reveals several residual stones in the intra-
and extrahepatic biliary ducts (arrows). The T-tube is marked by arrowheads.
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Figure 33.
Endoscopic retrograde cholangiogra
phy. Contrast medium has been intro
duced in a retrograde fashion through
cannulation o f the papilla o f Vater. The
endoscope is seen in the picture. There is
a post-operative stricture in the hepatic
duct (arrow) and a stone (arrowheads) is
seen as a filling defect in the dilated bil
iary ducts above the stricture.
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Figure 35. Percutaneous transhepatic Figure 36. ERCP. There are several ar
cholangiography shows narrowing (be eas o f narrowing o f both the intra- and
tween broad arrows) o f the biliary ducts in extrahepatic ducts (arrows), compatible
the area o f the liver hilum and the proximal with sclerosing cholangitis. The patient
hepatic duct The biliary ducts in both the had had ulcerative colitis fo r several
right and the left liver lobes are dilated years.
above the central narrowing (fine arrows).
Note absence offilling o f the gallbladder.
The patient presented with jaundice,
colourless stools and epigastric pain.
Cholangiocarcinoma.
Figure 37.
Peroperative cholangiography. A cystic
dilatation (arrows) o f the most distal seg
ment o f the common bile duct is demon
strated on this left oblique image. The
finding is compatible with a choledocho-
cele or choledochal cyst.
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Figure 38. Stenting o f biliary ducts, (a) A short stricture is seen in the liver hilum (ar
row) on an ERCP o f a patient with Klatzkin-tumour. Dilatation o f the proximal intra-
hepatic bile ducts is noted, (b) A stent (arrows) has been introduced via the endoscope
into the biliary duct and through the stricture, the proximal end o f the stent lodging in
the confluence o f the intrahepatic bile ducts above the stricture and its distal end in the
duodenum.
INTERVENTIONAL PROCEDURES
The biliary ducts may be approached in a number of ways; retrogradely
through the papilla of Vater, antegradely by means of percutaneous trans-
hepatic puncture or through the gallbladder.
A sphincterotomy or papillotomy may be performed through an en
doscope, and this facilitates the passage of gallstones from the extra
hepatic ducts into the duodenum; the technique can be used in poor-risk
patients.
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Figure 39.
Cholecystostomy. A drainage tube
has been introducedpercutaneously
into the gallbladder. The draining
catheter has slipped out o f the gall
bladder and its tip now lodges in a
fistula from the gallbladder to the
skin.
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The pancreas
MODALITIES
Duodenography
Enlargement of the head of the pancreas, e.g. from a pancreatic cancer
or cyst, may distort or distend the duodenal loop (Frostberg’s sign, or the
’’inverted 3" sign). This may be seen on a single or double-contrast bar
ium study. The sign is indirect and only seen with marked expansion of
the pancreatic head. Barium duodenography has decreased in importance
with the greater use of cross-sectional imaging techniques such as ultra
sound and CT.
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Figure 40.
Calcification o f
the pancreatic
parenchyma
(arrows) seen in
a case o f hered
itary pancreati
tis. The calcifi
cation is visible
on the plain film
and is so exten
sive it defines
the shape o f the
organ.
Ultrasonography
The primary method for studying pancreatic disease is ultrasonography
(US). The pancreas may be visualized by ultrasonography in approxi
mately 85 % of subjects, but in the remainder the organ is partly or wholly
obscured by bowel gas or other bowel contents; this problem is particu
larly evident in acute disease associated with secondary dilatation of gas-
containing bowel loops. The echogenicity of the pancreas is normally
somewhat greater than that of the liver. In most individuals, using good
equipment, the normal pancreatic duct is seen as a narrow streak in the
pancreatic parenchyma and the caudal portion of the common bile duct
is also seen as it enters the head of the pancreas. Important landmarks in
the vicinity of the pancreas include the inferior vena cava, the superior
mesenteric artery and vein, the splenic artery and vein, the hepatic artery
and the portal vein (Fig. 41). It is important to assess the calibre of the
pancreatic and choledochal ducts which are normally 1-3 mm and ap
proximately 5 mm, respectively. Dilated pancreatic ducts indicate either
obstruction or duct ectasia in chronic pancreatitis. Pancreatic tumours
are generally solid lesions and are usually of lower echogenicity than the
surrounding parenchyma. The smallest tumours that can be detected by
US are approximately 1 cm in diameter. Cysts are echofree and show
distal acoustic enhancement. Doppler-US (particularly colour Doppler-
US) is useful to assess the peripancreatic blood vessels which may be in
volved in acute and chronic pancreatitis or by pancreatic neoplasms.
Intra-pancreatic vessels may also be visualized and changes in normal
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Figure 41.
Normal pancreas, (a) The pancreas is
seen on ultrasound as a structure o f
moderate echogenicity (arrows); a =
aorta; с = vena cava; * = venous con
fluence. (b-d) CT o f the pancreas
shows the retroperitoneal organ, de
marcated by fat, and extending from
the duodenum (d) on the patient's right
to the spleen (s) on the left. The
amount o f pancreatic parenchyma and
demarcating fa t planes varies with
age, b is a normal adult, с a child, and
d an old person, (e) On MRI (Turbo
Flash) the pancreas is also well
demonstrated.
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Computed tomography
The importance of US in the diagnosis of pancreatic disorders has al
ready been emphasized but CT provides important information that can
not be obtained by US alone and, together, the two techniques are the
most important imaging methods for the organ. The retro-peritoneal fat
that surrounds the pancreas in many patients affords good delineation of
the organ on CT (Fig. 41), even in the presence o f dilated bowel loops
and oedema, circumstances which considerably diminish the diagnostic
efficiency of ultrasound. Image quality may, however, be adversely af
fected by patient movement, e.g. in a restless subject with abdominal
pain. Both cysts and areas o f calcification are imaged with great clarity
and the use of intravenous contrast medium enhances the detection of
pathological changes in many situations. Tumours, for instance, show
slower contrast enhancement than normal pancreatic parenchyma, but
the CT-study has to be performed when the contrast difference between
the tumour and parenchyma is maximal, i.e. within two minutes of a bo
lus injection of contrast medium. Cysts do not enhance with contrast
medium. In addition to the pancreas itself, neighbouring organs are bet
ter seen on CT than US, e.g. the biliary ducts, kidneys, spleen, bowel and
mesentery, and this allows for the precise grading of pancreatic disease
by CT. Opacification of the bowel with oral contrast medium is impor
tant, in order to differentiate between bowel loops and some type of pan
creatic pathology such as tumours or cysts (though not acute pancreati
tis). Fast CT-scanners will further improve the diagnostic capabilities of
computed tomography in the pancreas.
ERCP
At endoscopic retrograde cholangiopancreatography (ERCP) the papilla
of Vater is cannulated under direct visual control through an endoscope
which has been introduced via the oesophagus and stomach into the duo
denum, and water soluble contrast medium is injected into the pancre
atic duct (Fig. 42). The study provides information about the ductal sys
tem, but not about the pancreatic parenchyma. Pancreatitis is a recog
nized complication of the technique which can result from either the
manipulation required for duct catheterization or the action of the con-
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THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
trast medium on the pancreas. Care has to be taken, therefore, not to over
fill the ductal system and dilute, non-ionic, contrast medium should be
used. Images of the ductal system are taken in various projections under
fluoroscopic control.
ERCP shows changes such as distortion or obstruction of the main
ducts or their branches as may occur in cancer, or may reveal commu
nications between the ducts and pancreatic cysts. The main value of
ERCP is in the mapping and grading of changes in chronic pancreatitis
and in fully delineating the pancreatic duct before pancreatic resection.
In the evaluation of changes in the head of the pancreas it is also impor
tant to visualize the common bile duct, the distal portion of which tra
verses this region.
Angiography
Angiography used to be the definitive method for the diagnosis of pan
creatic tumours. Since the introduction of US, CT, MRI and ERCP as di
rect imaging methods, however, the role of angiography has been reduced
to the diagnosis and preoperative localization of endocrine tumours and,
occasionally, the provision of further information on the potential oper
ability of a pancreatic cancer in particular cases. Pancreatic angiography
is performed by studies of the coeliac and superior mesenteric arteries,
from which multiple smaller arterial branches supply the pancreas.
Superselective studies of the pancreatic vessels are frequently necessary,
particularly in the search for endocrine tumours and during embolization
procedures (see below under Interventional procedures).
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Radionuclide imaging
Radionuclide white cells, though they do not localise in uncomplicated
pancreatitis, may be useful for diagnosing a pancreatic abscess or an in
fected pseudocyst. Insulinomas expressing somato-static receptors
(about 50%) may be localised with the somatostatic receptor analogue,
In-III pentetreotide (octreotide).
NORMAL ANATOMY
The pancreas is 12-15 cm long, 3-6 cm wide and 2-4 cm thick, weighs
65-70 g and is situated transversely in the upper part of the retroperi-
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THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
PATHOLOGICAL CONDITIONS
Acute pancreatitis
The term acute pancreatitis implies primarily inflammation of the organ
itself, but there are often associated secondary inflammatory changes in
the surrounding tissues and organs. The complications of acute pancre
atitis include necrosis of the pancreatic parenchyma, so-called necrotic
or haemorrhagic pancreatitis, and cyst and abscess formation.
Computed tomography, particularly contrast-enhanced CT, has proved
to be o f decisive importance in both the diagnosis of disease and the grad
ing of its severity. The method is valuable for determining the correct
course of management in the individual patient, and is therefore per
formed at an early stage. Other diagnostic methods do not have this de
cisive importance. Since patients with acute pancreatitis are often dehy
drated, proper hydration is essential and intravenous fluids may be nec
essary to avoid contrast-induced renal damage.
The CT examination starts with an un-enhanced study of the upper ab
domen in which the entire area from the dome of the diaphragm to the
pelvic rim is sequentially examined by means of contiguous 5-10 mm
slices. The configuration of the pancreas is noted and an evaluation made
of the organ and its surrounding tissues (e.g. the mesentery), which in
cludes observations concerning the presence of oedema, abscesses, cysts,
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Figure 43.
Contrast-enhanced CT o f
acute pancreatitis, (a) The
pancreatic parenchyma (ar
rows) enhances with contrast
material; the pancreas itself is
slightly oedematous and it is
also surrounded by oedema
(e). In the body o f the pancreas
there is a low-density area o f
fo ca l necrosis (*). These fe a
tures are consistent with acute
oedematous non-haemorrhagic
pancreatitis, with preserved
perfusion o f the pancreatic
parenchyma. Note also the low
attenuation o f the liver, indi
cating fa tty degeneration, (b)
M inimal contrast enhancement
in the body o f the pancreas (p),
but no enhancement in the tail.
The pancreas is swollen and
surrounded by oedematous tis
sue (e). This finding is consis
tent with haemorrhagic-
necrotic pancreatitis.
etc. This preliminary study is used to determine the axial section which
demonstrates the pancreas to best advantage and at this level a dynamic
contrast study is performed. This involves the exposure of that slice every
15th second during two minutes after injection of a contrast medium bo
lus. This gives an idea o f the pattern of perfusion of the pancreatic
parenchyma, and allows the distinction to be made between haemor-
rhagic-necrotic pancreatitis, in which contrast-enhancement of part or
all of the pancreatic parenchyma does not occur, and oedematous pan
creatitis in which contrast-enhancement is preserved (Fig. 43). The
severity of pancreatitis can in this way be estimated and graded, and sec
ondary changes and complications evaluated. Oral contrast medium is
not used in CT studies of acute panceatitis so as not to interfere with den
sity measurements of the organ.
Follow-up studies are performed at regular intervals depending upon
the patient's progress.
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Figure 44.
US o f acute pancreatitis. The
pancreas (arrows) is swollen
and has a lower echogenicity
than usual (compare with Fig.
41). Ventrally an echo-free
pseudocyst (*), 5 cm in diame
ter, is seen.
Chronic pancreatitis
Chronic pancreatitis is assessed by means of US, CT and ERCP.
Ultrasound provides information concerning the size and parenchymal
volume of the pancreas, the calibre of the pancreatic duct and the pres
ence of cysts or other abnormal features (Fig. 44). On CT the parenchyma
is displayed with great precision, the pancreatic duct is sometimes seen
and any areas of calcification that may be present are better demonstrated
than on either US or the plain film. Contrast enhancement often improves
the quality of the imaging and allows more accurate distinction between
various entities such as cysts, abscesses, oedema, fluid collections and
adjacent bowel loops (Fig. 45). Knowledge concerning the anatomy of
the ductal system is of importance in grading the changes of chronic pan
creatitis and therefore influences clinical management decisions such as
the choice of therapy and the nature of any operation that may be nec
essary. The ductal anatomy is best seen on ERCP, which is important in
these selected cases. In chronic pancreatitis ductal changes such as di
latation, ectasia, local narrowing and possible communications with
cysts are seen on ERCP (Fig.46), as well as any concretions that may be
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Figure 45.
CT o f chronic pancreatitis.
Extensive calcification is seen
in the body and the tail o f the
pancreas (arrows). In the liver
parenchyma and hilum, dilated
bile ducts are seen, caused by
obstructive changes in the
pancreatic head.
Figure 46.
ERCP in a case o f chronic
pancreatitis, showing a dilated
pancreatic duct o f varying cal
ibre, and a local stricture (ar
row). A pseudocyst is seen in
the head o f the pancreas (*).
The distal part o f the common
bile duct (dc) is narrowed and
the proximal duct dilated.
Pancreatic tumours
When a pancreatic tumour is suspected, the first imaging studies are un
dertaken with ultrasound. A tumour is seen as an area of abnormal
echogenicity which is usually hypoechoic in relation to the surrounding
parenchyma. A careful assessment is made o f the tumour's location, its
possible effect on the pancreatic and/or common bile ducts, its relation
ship to vascular structures and the extent to which it may be invading
neighbouring organs (Fig. 47). Fine-needle biopsy of the tumour can also
be performed under US-guidance. Computed tomography is often per
formed in addition to ultrasound because of the superior anatomical de
tail it affords; the same features are looked for on CT as are described
above for US. Any extension into the surrounding areas is better shown
on CT than US, as are metastatic deposits in, for instance, the regional
lymph nodes (Fig. 48). The CT study should include iv-enhanced se
quences, in order better to delineate the tumour; malignant tumours en-
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Figure 47.
US o f the pancreas. A tumour (arrows) is seen on the transverse scans as a region with
lower echogenicity than the surrounding parenchyma, (a) Small intrapancreatic tu
mour, diameter 2 cm. (b) Large tumour, obstructing the pancreatic duct (*). These fe a
tures are consistent with the diagnosis o f carcinoma o f the pancreas.
Figure 48.
Contrast-enhanced CT o f a pancre
atic carcinoma, (a) A low density,
expanding lesion (arrow) is seen in
the head o f the pancreas. The tu
mour displaces the superior mesen
teric vein (small arrow) anteriorly,
while the superior mesenteric
artery is intact, (b) The importance
o f a proper early timing o f the CT
study in relation to the contrast
medium injection is demonstrated.
A non-distorting tumour o f less
than 2 cm (arrow) is demonstrated,
the only criterion for its detection
being its decreased contrast en
hancement in comparison with the
surrounding pancreatic
parenchyma.
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Figure 49.
An ERCP in a patient with
carcinoma o f the head o f the
pancreas shows total ob
struction o f the common bile
duct (large arrowhead) and
narrowing o f the pancreatic
duct (small arrowheads),
this is the so-called double
duct sign. The proximal pan
creatic duct is dilated be
cause o f the obstruction.
hance more slowly than normal parenchyma, but this feature is mostly
seen only during the first two minutes after contrast medium injection
(see description of CT technique above). Studies other than US and CT
are usually unnecessary. The smallest tumour that can be detected with
these methods is approximately 1-2 cm in diameter. In doubtful cases
ERCP is performed, where the typical findings o f ductal involvement are
stricture or obstruction with dilatation proximal to the lesion (Fig. 49).
Endocrine tumours have been briefly considered above in the section
on angiography.
Non-neoplastic lesions
Pseudocysts are not infrequently seen, occurring mostly as a complica
tion of pancreatitis. They may or may not have a connection with the
pancreatic duct; in the latter circumstance they may well be infected.
Cysts are well shown on US, CT and MRI and appear as thin-walled,
fluid-filled lesions. Abscesses also frequently arise as a complication of
pancreatitis; they commonly have thick, uneven walls that exhibit con
trast enhancement on CT while the centre has fluid characteristics across
a wide range of viscosity.
Trauma
In abdominal trauma the bowel loops are often distended and computed
tomography (particularly contrast-enhanced CT) is therefore the method
of choice when evaluating traumatic lesions. A disruption of the pan
creas is then seen as a discontinuity in the pancreatic parenchyma.
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INTERVENTIONAL PROCEDURES
Interventional techniques in the pancreas consist mainly of biopsy,
drainage and embolization procedures. Fine-needle aspiration biopsy
(FNAB) may be performed under US, CT or ERCP guidance. Guided
fine-needle biopsy has considerably improved the accuracy of diagnosis
with respect to localized abnormalities, so that a specific diagnosis of a
demonstrable lesion can be obtained in most cases. Aspiration of a cyst
allows analysis of its contents, and permits the identification of, for in
stance, complicating infection. Abscesses and cysts may be drained
through a percutaneous catheter or drain. Internal drainage of a pancre
atic pseudocyst into the stomach or bowel is now feasible and may avoid
the need for surgery. This is advantageous to any patient but is particu
larly useful in individuals in whom surgery or general anaesthesia car
ries an increased risk of complications.
Arterial embolization is extremely useful in the management of pan
creatic aneurysms and may be life-saving in cases of acute bleeding.
Aneurysms usually result from chronic pancretitis but may also occur as
a result of iatrogenic vascular drainage during biopsy or surgery.
Haemobilia is usually an indication for arteriography, and when it occurs
in a patient with an appropriate history the presence of a pancreatic
aneurysm should be strongly suspected. If the necessary expertise is avail
able therapeutic embolization is almost always preferable to surgery in the
management of pancreatic lesions that are bleeding or liable to bleed.
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The spleen
MODALITIES
Plain radiography
The size o f the spleen may be roughly estimated on the plain film, espe
cially if the organ is enlarged. Calcified lesions such as granulomas or
cyst walls, are well seen.
Ultrasonography
US gives good information on the shape and size of the spleen and on
any pathological changes that may be present. Splenomegaly can be iden
tified and measured. Cysts are seen as well-demarcated echo-free struc
tures. Tumours and metastases have an echogenicity differing from that
of normal splenic parenchyma, being either hypo- or hyper-echogenic.
Lesions as small as 1 cm may be identified, with the exception of diffuse
infiltrates such as lymphoma, which may be difficult to discern on US.
Traumatic changes, such as rupture of the spleen and haemorrhage, are
clearly seen on US, as are infarctions and abscesses.
Computed tomography
The best images of the spleen are obtained by CT, which also gives in
formation on any calcification present, e.g. in granulomas or cyst walls
and allows precise measurement of splenic size. Pathological changes
are seen, as on US, but often with greater clarity, especially after iv. con
trast infusion.
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Radionuclide imaging
Localized changes, such as cysts, metastatic deposits, tumours and in
farcts can be shown by radionuclide imaging, though the specificity and
spatial resolution of the technique are inferior to US and CT. Intrasplenic
abscess is difficult to image with radiolabelled leucocytes because the
spleen is a normal site of granulocyte pooling and is therefore very promi
nent in a white cell scan. An abscess may be identified by sequential
imaging, during which an abscess is seen to increase in activity in com
parison with normal splenic tissue which shows a slight fall, or by sub
traction imaging using Tc-99m labelled sulphur colloid.
Images of splenic function may be obtained with autologous radiola
belled blood cells, including heat denatured erythrocytes, platelets, and
leucocytes. Such imaging may be useful for the localization of func
tioning splenunculi and the assessment of the role of the spleen in throm
bocytopenia, particularly ITP.
Angiography
Angiography is not often used for diagnostic purposes (except in acute
bleeding) but may be used as a step in embolizing the spleen or splenic
artery in the treatment of hypersplenism, trauma or aneurysm. Direct
splenoportography, i.e. direct puncture of the spleen and the injection of
contrast medium into the splenic parenchyma through a plastic cannula,
may be performed to map the venous drainage of the spleen in portal hy
pertension. With modem digital subtraction equipment, however, the
requisite information can now almost always be obtained by indirect
splenoportography using the venous phase of a splenic arteriogram and
the direct method is virtually obsolete in advanced centres.
NORMAL ANATOMY
The spleen is located posterolaterally in the left hypochondrium, is 10-12
cm in length and 6-8 cm in width, and weighs 150-200 g. The most com
mon anatomical variant to be seen is an accessory spleen, i.e. one or more
splenunculi that usually lie in the vicinity of the splenic hilum. The size
of the spleen, especially its length, may be estimated on plain radiogra
phy but is best evaluated by US, CT or MRI.
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Figure 50.
Splenic infiltrates. (a) On US
several fo c i o f low echogenic
ity (arrows) are seen within
the spleen; these proved to be
infiltrates, (b) Diffuse infil
trates are seen in an enlarged
spleen on this contrast-en-
hancement CT; these were due
to sarcoidosis o f the spleen.
PATHOLOGICAL CONDITIONS
Splenomegaly
US is usually the first imaging modality to be employed in the investi
gation of splenomegaly as the organ size and the structure of the splenic
parenchyma can be assessed. CT or MRI may be useful in certain indi
viduals to characterize the cause of the splenic enlargement.
Infiltrates
Ultrasound and contrast enhanced CT and MRI are all used for the di
agnosis of neoplastic lesions such as lymphoma, metastatic deposits, or,
rarely, primary tumours (Fig. 50). Splenic infarction is seen as a typical,
often wedge-shaped, peripheral lesion (Fig. 51). The different imaging
modalities are complementary to one another, but US is usually the
method of first choice.
1076
THE LIVER, BILIARY TRACT, PANCREAS AND SPLEEN
Figure 51.
CT o f the spleen, with contrast en
hancement. Dorsally a peripheral
area o f decreased enhancement
(arrows) is seen, representing an
area o f splenic infarction.
Figure 52.
Splenic abscess, (a) On CT an irregular area o f low attenuation is seen (arrows), (b)
An abscess in the spleen has been drained. On this US the draining catheter (curved
arrow) is seen within the abscess (large arrows).
Abscess, infection
With US and contrast-enhanced CT, abscesses are typically seen as lo
calized lesions with thick and contrast-enhancing walls (Fig. 52). Foci
of infection may sometimes be identified by sequential radionuclide
imaging.
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Trauma
Splenic rupture is not uncommon in abdominal injury, and is diagnosed
by US and/or contrast-enhanced CT. Parenchymal lesions and intracap-
sular bleeding are seen with equal clarity using either method, but any
changes in the surrounding region, such as may occur with rupture of the
splenic capsule, are better shown on CT. Angiography can be performed
in order to map the vascular anatomy in detail or to embolize if this seems
feasible and appropriate but a decision whether or not to operate can usu
ally be made solely on the basis of US and/or CT. It must be said, how
ever, that most clinicians would base their decision on clinical findings
rather than on CT and US.
Vascular anatomy
The arterial anatomy of the spleen is evaluated by splenic arteriography,
e.g. prior to an embolization. The venous drainage may be demonstra-
teed in certain problem cases, mainly those involving portal thrombosis
and oesophageal varices, by an arterial contrast medium (indirect spleno
portography, best performed using DSA), or by a direct injection into the
splenic parenchyma through a percutaneously-introduced cannula, di
rect splenoportography.
INTERVENTIONAL PROCEDURES
The most important interventional procedures are guided fine-needle
biopsy, the percutaneous drainage of splenic abscesses and embolization
of the splenic artery in bleeding or splenomegaly. Embolization for the
latter indication carries a considerable risk of infection.
1078
Chapter 24
IMAGING STUDIES
Indication
Patients with severe abdominal symptoms including pain, acute onset of
nausea, vomiting and obstruction, should undergo radiological studies
to try and determine the underlying cause (Fig. 1 a). When bowel wall
lesions or obstruction are suspected plain films are often followed by bar
ium studies in order to check bowel patency and transit time (Fig. 1 b).
In cases where the abdominal cavity is involved abdominal CT (Fig. 1 c)
and ultrasound (Fig. 1 d) will follow. CT and transabdominal ultrasound
are usually chosen for the examination of palpable masses, parenchyma
tous organs, retroperitoneal structures, the abdominal walls and the in
guinal regions. Chest studies are often included in patients with upper ab
dominal symptoms and angiography and/or interventional techniques
may be required in patients presenting with gastrointestinal bleeding.
Technique of examination
No special preparation for the study is necessary but the patients will
commonly already have a gastric tube and a urinary catheter in situ. The
survey, preferably using full-size images includes:
A. vertical beam images with the patient in the supine (Fig. 2), left
(Fig. 3) and right lateral oblique (Fig. 4) positions, including the di
aphragmatic and inguinal regions (Fig. 5), and
1079
Figure 1.
a) АР plain film in a patient with
vomiting, showing gas in the
gastric antrum to the left o f the
vertebral column, in the bulb to
the right o f the vertebral col
umn, in distal loops o f the ileum
and in the left colonic flexure.
b) Follow-through study 90 min
с
utes after the ingestion o f 200
ml o f diluted barium suspen
sion. The distended, proximal
duodenal loop and the gastric
retention indicate a mid-duode-
nal obstruction.
c) Abdominal CT o f the same pa
tient verifies a large duodenal
carcinoma which has almost
obliterated the lumen.
d) Abdominal ultrasound o f the
same tumour prior to a fine nee
dle puncture. The carcinoma is
seen as an hypoechoic mass
lesion.
THE ACUTE ABDOMEN
Figure 2.
Frontal, supine, abdominal film
showing a normal distribution o f
gas and normal haustra in the
large bowel. The ilio-psoas mus
cles (I) and the kidneys (2) are
outlined by fa tty tissue.
Figure 3.
Left oblique vertical beam plain
film o f the left hypochondrium in
a patient with numerous areas o f
pancreatic calcification. The left
ilio-psoas muscle and left kidney
are clearly outlined.
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Figure 4.
Right oblique vertical beam plain film o f the
lateral abdominal wall showing fa t between
the abdominal wall muscles (white arrow)
and around the lower border o f the right
lobe o f the liver (arrowheads). Benign rib
calcification is seen underneath the right
breast.
Figure 5.
Frontal pelvic survey in a
patient with a left inguinal
hernia (1) with signs o f
obstruction in a dilated
proximal loop o f ileum with
swollen mucosal folds, often
compared to fingerprints
(2). The urinary bladder
(arrows) is delineated by
fat.
THE ACUTE ABDOMEN
Figure 6. Frontal, horizontal beam plain film in an erect patient with a collection o f
free gas underneath the right hemi-diaphragm. In order to disclose even smaller
amounts o f subphrenic air, a spot film with tight coning should be centred at the di
aphragmatic level
B. horizontal beam images with the patient erect, to demonstrate the sub
phrenic spaces (Fig. 6), or in the right and left decubitus positions, to
demonstrate the paracolic and parahepatic and spaces.
In patients with acute colitis one supine view usually suffices, which can
be enhanced if necessary by minimal air insufflation of the large bowel
(pneumocolon, see below).
Image interpretation
In order to recognize pathology, a knowledge of normal abdominal
anatomy is essential. Areas o f calcification, soft-tissue masses and fluid
collections have to be interpreted with the full knowledge of the patien
t’s history and in close collaboration with the referring clinician.
Fat spaces
As fat is more radiolucent than blood, muscle and solid organs such as
the liver, spleen and kidney, it is depicted as dark grey areas on the ra
diograph. Fat is found along the abdominal wall and ilio-psoas muscles,
in the paracolic spaces (Fig. 4), in the retroperitoneum and in the mesen
tery. It also envelopes the kidneys, urinary blader and rectum, thereby
delineating these structures and the displacement or abolition of these fat
spaces may indicate the presence of pathology.
Gas collections
Gas is seen as dark black areas on the radiograph, and is normally pre
sent in the stomach, large bowel (Fig. 2) and rectum. Gas may also be
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found in small bowel loops if the patient is suffering from pain or is un
der mental stress. Deviations from the normal appearances are seen as
abnormally distributed or abnormally large collections of gas either
within the lumen, indicating obstruction (Fig. 5), or outside the bowel as
a result of perforation (Fig. 6).
Normally, there is some saliva and gastric juice, as well as gas in the
stomach and this results in an air-fluid level which is seen on horizontal
beam films lying just underneath the left hemi-diaphragm close to the
midline. Every other air-fluid level found may signify an abnormality -
see below under "obstruction".
Calcification
The chondromatous part o f the ventral thoracic cage may already con
tain areas of calcification in healthy, young adults (Fig. 4). If there is any
doubt an oblique view will disclose the extra-abdominal location of such
calcification.
Intra-abdominal, well-defined, shell-like, benign areas of calcifica
tion may be found along the midline representing calcified lymph nodes
or, lying centrally in the true pelvis, may be seen in the myomatous
uterus.
Punctate calcification may be found in the prostatic gland in elderly
men, or in phleboliths, often symmetrically distributed in the true pelvis.
The latter may be difficult to differentiate from a stone in the ureter; as
a general rule, however, phleboliths are doughnut-like whereas urinary
tract stones are oval in shape and homogeneous. In the elderly a varying
amount o f calcification may be seen in the aorta and in the iliac and
splenic arteries.
Bowel content
Bowel content is recognized by its rich content o f tiny air bubbles. It is
seen as amorphous masses in the right side of the colon and more formed
collections in the left colon and rectum. It has to be differentiated from
an abscess which may have the same feature of multiple, tiny air bub
bles.
1084
THE ACUTE ABDOMEN
When the small bowel is air filled it is recognized by its 1-2 mm folds
running spirally from one side to the other (Fig. 1 b), while the large
bowel folds are broken, forming the typical haustra (Fig. 2). The outer
contour of the normal gut is convex.
PATHOLOGY
Calcification
Calcified stones are radio-opaque, bright grey (on the radiograph), well-
defined and round. Multiple, facetted and multilayered stones may be
found in the gallbladder and the urinary bladder in patients with long
term catheters. Single or multiple stones may be seen in the renal pelvis
and ureters and occasionally in the biliary tree and pancreatic duct.
Benign lesions such as myomata of the uterus, adenomata of the adren
als, organized haematomas, leiomyomas, renal cyst walls and dermoid
may all calcify.
Malignant calcification is a rare entity, usually located in the periph
ery of a hepatoma or centrally in the necrotic parts of a malignancy.
The areas of calcification associated with inflammatory lesions are usu
ally multiple and small and found in the pancreatic gland as a sign of
chronic pancreatitis (Fig. 3). Shell-like calcification may be seen in pa
tients with echinococcosis of the liver.
Vascular calcification occurs in phleboliths, atherosclerotic plaques
and in aneurysms where it commonly has a shell-like appearance (e.g.
splenic artery aneurysms).
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Figure 7.
a) Large volume o f ascites obliter
ating the fa t planes around the
kidneys and iliopsoas muscles
and pushing air-containing
bowel loops towards the middle
o f the abdomen, allowing only
barium-filled loops to sink lat
erally.
b) Abdominal ultrasound o f the
same patient revealing free
flu id ventral to the liver seen as
a dark, hypoechoic zone be
tween the liver and the ventral
abdominal wall. The white hy-
perechoic curvilinear line in
the lower part o f the image is
the diaphragm.
Ascites
When the fat planes around the urinary bladder and the rectum are oblit
erated this is often due to the presence of an increased amount of fluid
in the abdominal cavity, seen as a crescentic density in the pelvis (Fig. 7).
Larger volumes of ascites separate the bowel loops and obliterate the fat-
lines in the paracolic gutters, and volumes in excess of 1 litre displace
the air-containing bowel loops centrally in the abdomen while obliterat-
1086
THE ACUTE ABDOMEN
Figure 8.
Abdominal CT in a pa
tient with a perforated
peptic ulcer. Free gas is
seen in the midline (1)
close to the contrast-filled
stomach (2). A minimal
amount o f ascites is seen
around the liver and
spleen (4). Fat is shown
as dark grey areas sur
rounding the kidneys,
large abdominal vessels
and the pancreas behind
the stomach. The gall
bladder (3) is also seen.
ing the fat contours of the kidneys and psoas muscles (Fig. 7 a).
Nowadays, ascites is ruled out by abdominal ultrasound (Fig. 7 b) or
CT (Fig. 8) as these modalities can detect very small quantities of free
fluid.
Pneumoperitoneum
Perforation of a bowel loop allows gas to pass into the abdominal cav
ity. It collects in non-dependent sites, and is best detected on a horizon
tal beam film centred at sites such as the subphrenic space in an erect pa
tient or the uppermost part o f the abdominal cavity in a recumbent one.
In order to improve the image quality coned views are recommended
(Fig. 6). If only a tiny volume of gas has leaked through a perforation
this may only be disclosed on CT (Fig. 8).
Large volumes of gas may be found after open abdominal surgery or
following perforation of the large bowel. In these circumstances the free
gas may be demonstrated even on vertical beam images as it delineates
the gallbladder and the outer, serosal border of the bowel wall, which
will be seen as thin, curved lines (Fig. 9). Postoperatively gas disappears
within two weeks if no complication occurs.
Intra-peritoneal gas may also be seen in patients on peritoneal dialy
sis and following hysterosalpingography and percutaneous endoscopic
or interventional procedures.
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Figure 9.
Large amount o f free abdominal
air in a young patient with cae-
cal perforation due to a sigmoid
carcinoma. Widened loops o f
sm all bowel are recognized by
their spiral folds. The bowel
wall is outlined as a white line
by the gas on either side.
1088
Figure 10.
Abscess following a Billroth-1
resection located in the lesser
sac and beneath the diaphragm
(arrows). Secondary pleuritis
with obliteration o f the aorto-
diaphragmatic (1) and lateral
(2) pleural recesses. (When
Gastrografin is given, the anas
tomotic leak is demonstrated.
The air-fluid levels in the ab
scesses are clearly seen.)
Figure 11.
Pneumatosis cystoides coli in
an elderly patient with multiple
air-filled cysts seen as blackfill
ing defects in the barium-filled
lumen.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 12.
Necrotic appendicitis in a
16-year-old boy. A large
soft-tissue mass is seen in the
right lower quadrant repre
senting fluid-containing
bowel loops. The proximal
small bowel is slightly di
lated with short air-fluid lev
els (arrows) and the large
bowel is dilated with long
levels indicating adynamic
(paralytic) ileus.
Figure 13.
Ultrasonography o f the left
lower abdominal quadrant in
a 65-year-old patient with
fever and clinical signs o f
sigmoiditis, disclosing
marked thickening o f the
bowel wall (calipers).
Diverticula can just be dis
cerned to the left o f the im
age.
Inflammatory conditions
Localized inflammation causes limited peritonitis with secondary paraly
sis of neighbouring bowel loops in which fluid and gas collect. Adjacent
fat planes are obliterated owing to oedema. Lateralised peritonitis in young
adults causes sometimes a decompressing contraction of the ipsilateral
psoas muscle and a secondary scoliosis. In patients with localized signs
and symptoms, whether due to possible cholecystitis, pancreatitis, appen
dicitis (Fig. 12), salpingitis or sigmoiditis, CT and ultrasound (Fig. 13)
1090
THE ACUTE ABDOMEN
Figure 14.
Acute cholecystitis with wall
oedema (arrow) and multiple
large stones in the gallblad
der (1) creating a broad
acoustic shadow (2). The
common bile duct is widened
(d) indicating a peripheral
obstruction.
Cholecystitis
Nowadays patients with suspected cholecystitis undergo ultrasonogra
phy of the gallbladder and the bile ducts as the primary imaging inves
tigation. In acute cases the bladder is dilated and globular and a rim of
fluid is occasionally seen (Fig. 14). The gallbladder is usually tender to
pressure of the probe, a modem manifestation of Murphy’s sign. Stones
reflect and absorb all the ultrasound energy so creating an acoustic
shadow beyond the stones. In chronic cases a thick gallbladder wall is
also seen.
Gangrenous cholecystitis is caused by gas-producing bacteria; it is
seen as free gas in the gallbladder or as a rim of emphysema in the wall
(Fig. 15).
Pancreatitis
Pancreatitis causes the gland to become swollen (Fig. 16) and its sur
rounding fat planes are obliterated. In severe cases the oedema will spread
into the transverse mesocolon toward the stomach and left kidney.
Secondary peritonitis paralyses the duodenum and the overlying trans
verse colon. The disease may be complicated by the formation of cysts
and abscesses in the lesser sac and sub-phrenic spaces, left sided pleuri-
tis, lung atelectasis and pneumonia. Although ultrasound may be used,
CT is a better choice of imaging modality as these patients are frequently
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 15.
Abdominal survey reveal
ing gas in the gallbladder
(star) with wall emphy
sema (arrows).
Figure 16.
Acute pancreatitis with a
swollen pancreatic gland
(I) and partially obliter
ated retroperitoneal fa t
planes. The fascia around
the left kidney is markedly
engorged (arrows) and
flu id can be seen in the
lesser sac (2).
1092
THE ACUTE ABDOMEN
Figure 17.
Ultrasound image in a patient
with an inflamed appendix
(arrows) and a small abscess
(a).
Peritonitis
Generalized peritonitis is accompanied by a purulent exudate which
causes the obliteration of fat planes and a secondary ileus with long air-
fluid levels (Fig. 12).
Appendicitis
Ultrasonography is often helpful in confirming the diagnosis of appen
dicitis in patients in whom the history or clinical presentation is atypi
cal. A normal appendix cannot be seen, whereas a swollen organ may be
identified together with its surrounding oedema (Fig. 17).
Enteritis
Patients with gastro-enteritis and sigmoiditis are not usually examined
radiologically. If studies are undertaken in the former condition, how
ever, they reveal a number of small to medium-sized air fluid levels in
both the small and large bowel; patients with sigmoiditis normally un
dergo investigation only if the disease is complicated by perforation or
obstruction.
Colitis
Both pseudo-membranous colitis and toxic ulcerative colitis may cause an
acute abdomen. The former is drug-induced and caused by toxins and
Clostridium difficile; the latter may give rise to peritonitis. The colon in
both entities is paralysed and the wall is thickened by oedema, seen as poly
poid ’’thumbprint" indentations into the air column of the lumen (Fig. 18).
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Figure 18.
Abdominal survey in a patient with
toxic colitis. The transverse colon
(1) is stringlike and "fingerprinted”
with numerous polypoid identa-
tions. Gas is seen in widened ileal
loop (2) and stomach (3).
Ulceration
Ulcers in the stomach, pylorus and duodenal bulb may heal with scar for
mation, secondary stenosis, gastric retention and dilatation. In the erect
view, this is seen as a long air-fluid level in the fundus, close to the left
hemi-diaphragm. An ulcer may also be complicated by perforation into
the abdominal cavity and lesser sac. A perforated ulcer is, in fact, the un
derlying pathology in four out of five patients presenting with free ab
dominal gas. If the perforation is rapidly sealed by omentum, only a small
volume of gas may escape, which is hard to detect radiographically un
less CT is used or the perforation itself is outlined by a suitable water-
soluble contrast material such as Gastrografin (Fig. 19).
A dorsal-wall perforation may fill the lesser sac with gastric contents
and induce secondary pancreatitis with its associated complications; the
condition is usually readily demonstrated on CT. A non-perforated ul
cer is nowadays diagnosed and treated endoscopically.
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THE ACUTE ABDOMEN
Figure 19.
A patient treated with steroids fo r
psoriatic artritis who suddenly de
veloped severe epigastric pain. Plain
abdominal film s were within normal
limits. A lateral film o f the stomach
shows leakage o f GastrografinR (ar
row) through a perforated duodenal
ulcer (1 = gastric body, 2 = gastric
antrum, 3 = duodenal bulb)
General considerations
Bowel obstruction leads to a mechanical or dynamic ileus which may be
intermittent in cases where the obstruction is incomplete. There are a va
riety of causes, including postoperative adhesions and peritoneal bands,
an obstructing bowel tumour, infiltration from a malignancy adjacent to
the bowel, invagination, strangulation, internal or external herniation,
obstruction from ingested material, inflammatory lesions and bleeding
into the bowel wall.
The contents of the bowel distal to the obstructive lesion are usually
evaucated with gas and fluid accumulate proximally. Peristaltic activity
in the proximal bowel is increased in order to overcome the obstruction
and this is manifested on auscultation as a change of pitch in the bowel
sounds. On abdominal survey films the proximal air-filled bowel loops
appear as dark, radiolucent arches. On horizontal-beam films the air-fluid
levels in the respective limbs o f these arches may reach different heights
as a sign of peristaltic activity in the bowel (Fig. 20).
Special considerations
A high mechanical obstruction is a serious condition that can easily be
overlooked. An abdominal survey shows an absence of bowel gas, just
as in the newborn with oesophageal atresia. Vomiting is the dominant
clinical feature.
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Figure 20.
Patient with small bowel ileus. Air-fluid
levels are seen at different levels in the
limbs o f dilated small bowel loops.
Multiple air-fluid levels are seen as a
sign o f low small bowel obstruction.
The colon is collapsed. There is a gall
stone in the gallbladder (arrow). The
examination is performed with the p a
tient erect. There is an air-fluid level in
the stomach (*) which is normal. Note
the spiral arrrangement o f bowel folds.
Figure 21.
a) A patient with severe vomiting who
had recently undergone an axillo-
fem oral bypass. The plain abdominal
film shows a stomach distended with
gas in an otherwise gas void ab
domen (apart from small amounts in
the descending colon).
b) The same patient examined in the
left lateral decubitus position with
an horizontal beam. There are air-
fluid levels seen in the gastric fu n
dus, duodenal bulb, and descending
duodenum (arrow), respectively.
(A barium examination o f the stomach showed jejunal obstruction due to bleeding as
a result o f anticoagulant therapy.)
1096
THE ACUTE ABDOMEN
Figure 22.
CT o f the abdomen in a patient
with carcinoma o f the pancreas
and a Roux-en-Yanastomosis.
There is obstruction o f the Y-
loop which is markedly dis
tended (*). Widened intrahep
atic biliary ducts are demon
strated and the wall o f the
abdominal aorta is calcified.
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Figure 23.
a) Air-fluid levels are shown in
the dilated ascending, trans
verse and descending colon
in a patient with large bowel
obstruction.
b) Barium study showing com
plete obstruction at the tran
sition between the rectum
and sigmoid colon; the prox
imal colon is distended with
gas (arrow).
c) Ultrasound examination
showing a dilated caecum
and the distal ileum dis
tended with fluid.
Intussusception
Ileocaecal invagination in children does not necessarily produce any ra
diological abnormality. Clinical suspicion of this condition, therefore,
should always lead to a large bowel examination, using either barium or
C 0 2 insufflation (i.e. pneumocolon). With either method the invaginated
small bowel will be delineated by the introduced contrast. The condition
1098
THE ACUTE ABDOMEN
Figure 24.
Ultrasound examination o f
an ileo-ileal invagination
(intussusception) in a child
showing the typical appear
ance o f a "bowel (t) within a
bowel (t)".
b
Figure 25.
a) Gas is seen in the extrahepatic bil
iary tree (arrow) and in the gallblad
der (*) in a patient with gallstone ileus. The small bowel loops are wide (arrow
head) and filled with fluid. The intraluminal gas is outlining the mucosal folds.
b) A fistula (1) from the gallbladder to the duodenum was demonstrated during a bar
ium follow-through in a patient with an entrapped gallstone (2) in the mid-small
bowel.
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Figure 26.
Strangulation
ileus. An ultra
sound examination
shows fluid in di
lated small bowel
loops (arrows).
Gallstone ileus
In patients with chronic cholecystitis a gallstone may erode through a
fistula from the gallbladder to the bowel. Depending on the size of the
stone and the level of the fistulous communication (duodenum, ileum or
right colonic flexure) the stone may get stuck at one of a number of dif
ferent levels, e.g. the bulb, the sigmoid colon, or, as is most often the
case, the distal ileum (Fig. 25). Gas passes spontaneously through the
fistula into the gallbladder and biliary tree and this combination of bil
iary gas and mechanical obstruction is pathognomonic for gallstone ileus.
Strangulation
Depletion of the supply of oxygenated blood to the bowel creates alarm
ing clinical symptoms and the affected bowel loop soon fills with haem-
orrhagic fluid (Fig. 26). On abdominal survey films a rounded mass is
seen together with signs o f obstruction but the true cause is seldomly di
agnosed preoperatively.
1100
THE ACUTE ABDOMEN
Figure 27.
Volvulus o f small bowel around
an adhesion. The appearance
looks like a spiral nebula and this
is caused by progressive gaseous
distension o f the small bowel
which forces it to rotate around
its mesenteric root.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 28.
a) Volvulus with marked distension o f
the sigmoid colon up to the right
hemidiaphragm. Moderate dilatation
o f the rest o f the colon.
b) A barium enema shows a twist in the
bowel at the level o f the distal sig
moid.
colon indicating that the torsion is incomplete. All types of colonic volvu
lus are verified by means of a barium enema that reveals a beakshaped
deformity corresponding to the site of torsion (Fig. 29).
Comments
The further evaluation o f a patient with an acute abdomen and abnormal
survey films should always be a matter for consultation between the ra
diologist and the referring clinician. If the patient is to undergo further
1102
THE ACUTE ABDOMEN
Figure 29.
a) There is a long air-fluid level in
the pelvis in a patient with dis
tension o f the caecum (arrows).
b) A barium examination shows a
beak-like deformity o f the proxi
mal ascending colon signifying a
caecal volvulus (arrow).
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 30.
a) Chronic ileus in a woman
with advanced ovarian carci
noma that has developed into
a paralytic ileus with long
air-fluid levels.
b) Postoperative paralytic ileus.
A left decubitus view shows a
long flu id level in the colon.
It is normal practice to verify the level and type o f any obstruction with
either a barium follow-through or enema. If the level o f the obstruction
is unclear, a barium enema should always be performed first.
In order to speed up the diagnosis when a follow-through examination
is being performed, GastrografinR may be added to the bariumsulphate
in the proportion 1:4. The radiographic examination should start 15 min
utes after this is ingested and be repeated at regular intervals. When the
1104
THE ACUTE ABDOMEN
Figure 31.
Pseudo-obstruction in a patient
with Parkinson's disease. There
is dilatation o f both large and
small bowel loops.
contrast medium has reached the obstruction, spot films are taken dur
ing fluoroscopy for detailed assessment of the situation.
Paralytic ileus
Adynamic ileus is often seen after abdominal surgery and as a secondary
complication of peritonitis and circulatory insufficiency, but it can also
occur as a sequel to longstanding dynamic ileus (Fig. 30). Intoxication
or glucose and electrolyte imbalance may also cause adynamic ileus.
The abdominal survey films show slightly gas-distended small bowel
loops with long air-fluid levels, signifying lack of bowel activity, i.e. a
"silent abdomen". If there is peritonitis as well, fluid is present in the
peritoneal cavity. Pseudo-obstruction without any known aetiology can
be seen in the elderly (Fig. 31), a condition that is fatal if the bowel is
not decompressed by surgery or colonoscopy.
Ischaemia
Acute bowel ischaemia may be caused by embolism or thrombosis in the
mesenteric vessels, but is more often caused by a low arterial blood flow
without evidence of obstruction. The circulatory insufficiency causes
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 32.
a) Gas in the portal vein has a tendency to accumulate in the periphery o f the liver
(arrows) while gas in the biliary tree collects in the hilar region.
b) A plain abdominalfilm shows gangrenous bowel with gas in the rectal wall down to
the anus (arrows).
1106
THE ACUTE ABDOMEN
Figure 33.
Rupture o f the left renal artery.
The left kidney (1) is displaced
anteriorly owing to a perirenal
bleed (2). The normal right kid
ney is excreting iodine to the re
nal pelvis.
Abdominal trauma
Blunt abdominal trauma may cause bowel wall bleeding (see above), but
can also cause rupture of solid organs and vessels and patients present
ing with a history of such trauma should be examined with CT.
Abdominal survey films may, however, demonstrate enlargement of or
gans or loss of normal contours owing to the infiltration of surrounding
fat planes by ascites, blood, bile and oedema. The patient may also pre
sent with peritonitis. Rupture of a kidney or the urinary bladder can be
detected during intravenous urography as leakage of opacified urine.
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Gastrointestinal bleeding
Patients who bleed from the gastrointestinal tract often undergo a sub
stantial array of examinations. In a patients with chronic bleeding the
following steps are recommended: fibreoptic-endoscopy of the oesoph
agus stomach and duodenum; colonoscopy, and scintigraphy. If these
studies are negative, barium examinations of the entire gastrointestinal
tract should be performed and angiography may eventually be required.
During ongoing bleeding an emergency angiography should be consid
ered. The examination should be performed with selective catheteriza
tion of the coeliac trunk, superior and inferior mesenteric arteries with
superselective studies as appropriate. The examination is often compli
cated in these severely sick patients. Common bleeding sources in el
derly patients are arteriovenous malformations which are usually seen in
the ileocoecal area. The source of bleeding can be detected either by the
demonstration of leakage of contrast medium into the bowel lumen or
by the identification of a vascular lesion likely to be responsible for it.
Another cause of bleeding is bowel ischaemia, usually seen in the colon.
Bowel ischaemia is frequently caused by a low perfusion pressure that
causes secondary bleeding owing to non-occlusive hypoxia which can
not be detected during angiography. Bleeding from the gastrointestinal
tract is often intermittent and angiography may be required on several
occasions before the correct diagnosis is established. For a more detailed
1108
THE ACUTE ABDOMEN
INTERVENTIONAL PROCEDURES
Ongoing gastrointestinal bleeding may be treated by embolization using
metallic coils, small pieces of spongostan, polyvinyl alcohol and other
agents. Patients may also be treated intravenously by an infusion of va
sopressin.
A patient with an abscess in the peritoneal cavity is often best treated
with a drainage catheter inserted percutaneously under local anaesthesia
using ultrasound or CT guidance.
Ileocolic intussusception and volvulus of the sigmoid colon can also
be resolved using radiological techniques as described earlier.
CONCLUSIONS
The radiological evaluation of an acute abdomen is often difficult and it
is essential for the radiologist to be familiar with the appearances of the
normal abdomen. The assessment of any abnormalities is based on a va
riety of radiological observations including the detection of abnormal
collections of gas or fluid inside or outside the gastrointestinal tract; the
demonstration of calcification, masses, and the enlargement or dis
placement of organs; and the recognitition of any effacement of normal
anatomical structures and contours. Any radiological interpretation
should always be undertaken in the light of a detailed knowledge of the
patient's history and clinical presentation.
1109
Chapter 25
MODALITIES
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Figure 1.
KUB covering the majority o f the ab
domen and the pelvic cavity. This is an
indispensable adjunct to intravenous
urography, and one should not attempt
to interpret a urogram without it. The
most common defiency is failure to
demonstrate the upper and lower
reaches o f the urinary tract.
Figure 2.
Nephrographic phase.
a) Nephrogram taken 30 s
after start an intra
venous bolus injection o f
contrast medium. A t this
time there is an obvious
demarcation between
medulla and cortex in
normal kidneys.
b) Nephrotomogram taken
45 s after administration
o f contrast.
1112
THE GENITOURINARY SYSTEM
Figure 3.
Urogram o f the normal upper
urinary tract taken before (a)
and after (b) application o f
abdominal compression. The
calyces are much better visual
ized after the abdominal com
pression has been applied.
Figure 4.
Coned exposure o f the bladder filled
with contrast medium during intra
venous urography.
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 5.
Multiple calyces/papillae demonstrated at
intravenous urography. An uncommon
normal variant.
1114
THE GENITOURINARY SYSTEM
Direct Pyelography
Direct pyelography means direct injection of contrast medium (75-100
mg I/ml) into the upper urinary tract. It may be performed either through
a catheter placed in the ureter during cystoscopy (retrograde) or through
a needle or a nephrostomy tube (antegrade). A meticulous technique (e.g.
sterile conditions, low injection pressure, diluted contrast medium solu
tion with a low viscosity, fluoroscopic surveillance) should always be
employed (Fig. 6). At this examination the visualization of the calyces,
pelvis and ureter is independent of the kidney function in contrast to in
travenous urography. Backflow (extravasation) into the renal
parenchyma and surroundings (pyelosinous backflow, intrarenal back
flow, pyelovenous backflow and pyelolymphatic backflow) should be
avoided through a low injection pressure since backflow not only may
cause complications (e.g. pain, infection) but also obscure the disease.
The examination is excellent for demonstration of 1) small mucosal
abnormalities, 2) diverticula and cavities, 3) urinary leakage, and 4) ob
structing process in the upper urinary tract, when intravenous urography
has not been conclusive. The indications include: 1) non-visualization of
the upper urinary tract on intravenous urography (unless there is an ob
vious cause such as a large tumor, in which case CT would be preferred),
2) an inconclusive or suspicious-appearing segment of the upper urinary
tract which may be better visualized with direct pyelography, 3) unex
plained hematuria in which intravenous urography did not completely
delineate the entire ureter and/or renal pelvic cavity, 4) to differentiate
intrinsic from extrensic ureteral processes, 5) severe contrast material re
action during intravenous urography (the examination may be performed
with gas), 6) as an aid in the diagnosis of renal failure, e.g. renal papil
lary necrosis and 7) possibility of upper urinary tract obstruction (stric-
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Figure 6.
Normal antegrade pyelogram demonstrating the
pelvis and the upper part o f the ureter. It is o f ut
most importance not to overdistend the pelvis and
to use no greater than a 10-20 % contrast solu
tion in order to avoid obscuring at both retro
grade and antegrade pyelography.
Cystography
Cystography means specific examination
of the bladder with contrast medium. It
can be performed following intravenous
injection of contrast media (in conjunc
tion with intravenous urography) or fol
lowing direct installation of contrast
medium either through a urethral or a
suprapubic catheter. The bladder is exam
ined in several views and exposures are often also taken during voiding
(Fig. 7 a). A post-void film is essential. If vesicoureteric reflux is sus
pected the field of view should include both ureters and kidneys and flu
oroscopic surveillance should be performed both during the filling (low-
pressure) and voiding (high pressure) phase keeping fluoroscopy time to
a minimum. In case of examination for female incontinence the vagina
is marked with barium sulphate, so-called colpocystourethrography.
Cystography is mainly performed for the diagnosis of posttraumatic or
post-operative urinary extravasation, to evaluate certain diverticula and
to look for vesico-ureteral reflux.
Urethrography
Urethrography may be performed antegrade (micturition, voiding) or ret
rograde. Urethrography is an example of an examination which modem
imaging techniques have not yet displaced. In males an obturating can-
ula system or a small balloon catheter is placed with the tip in the fossa
1116
THE GENITOURINARY SYSTEM
Hysterosalpingography
Today hysterosalpingography is primarily used in the work-up of female
infertility; previously it was also used for diagnosis of uterine body and
cervical disease. As with urethrography either a cone-tipped obturator is
placed in the external cervical orifice or a tiny balloon catheter inserted
in the uterine cavity. A water-soluble contrast medium is injected slowly
in order to demonstrate that the salpinges are open and that contrast
spreads freely in the peritoneal space (Fig. 8). Exposures are taken after
the patient has been lying on all sides for a few minutes in order to se-
1117
THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 8.
Normal hysterosalpin-
gogram (HSG). There is
fre e flow through the
salpinges and out into
the peritoneal space.
cure free distribution of the contrast medium in the pelvic cavity of the
peritoneal space.
Angiography
Angiography of the genitourinary system does not differ from the same
examination of other organ systems. A catheter is introduced into the ve
nous or arterial system using Seldinger technique. The tip of the catheter
is placed during fluoroscopic guidance in a vessel leading to or coming
from the region of interest. Injection of vasoconstrictive drugs may be
useful when the veins are examined through retrograde injection but with
the modem digital equipment visualization of the venous tree is often
possible following intraarterial injection of contrast material.
Renal arteriography to diagnose and differentiate renal masses is rarely
performed now due to the advent of ultrasonograhy and especially CT.
Angiography may be performed in the planning of surgery on an anom
aly (e.g. horseshoe kidney) or partial nephrectomy. Other residual indi
cations for renal arteriography includes suspected renal artery stenosis,
vasculitis (e.g. polyarteritis nodosa), aneurysms and arterio-venous fis
tulae. Arteriography is necessary during vascular interventions such as
embolization, stenting and balloon dilatation of the venal vessels.
Ultrasonography
Ultrasonography has gained a central position in genito-urinary imag
ing. It has a diagnostic potential in almost every part of the genito-uri
nary tract and is furthermore easy, cheap and non-invasive. The major
disadvantage is that it is very operator dependent.
1118
THE GENITOURINARY SYSTEM
Figure 9.
Ultrasonography o f a
normal kidney. The nor
mal parenchyma is echo
poor, whereas the renal
sinus is echo rich. The
поп-dilated renal pelvis
is obscured by the sinus
echoes.
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Figure 10.
CT o f normal kidneys
before (a) and after (b)
intravenous administra
tion o f contrast medium.
tire urinary tract may be examined before the excreted contrast material
has reached the renal pelvis (approx. 1 1/2 min. after the contrast medium
has reached the renal artery) (Fig. 10). Therefore the timing of the scans
should be tailored to the specific purpose of the examination. Dynamic
CT with rapid scans through the same slice or spiral CT after bolus con
trast administration is sometimes used to study vascularity more pre
cisely.
CT is excellent in detecting and differentiating renal masses and in
staging renal malignancies. It is very sensitive in identifying calcifica
tions, even non opaque stones. It surpasses the efficiency of ultrasonog
raphy in identifying perinephric, peri-ureteral and pelvic processes sec
ondarily affecting the urinary tract. CT is the method o f choice for eval
uating renal injuries thought to be clinically severe (or if the initial
1120
THE GENITOURINARY SYSTEM
Figure 11.
MRI o f normal kidney.
a) Coronal Tl-weighted image
showing good demarcation be
tween cortex and medulla.
b) Axial Tl-weighted image.
c) Coronal T2-weighted image
showing that the kidney
parenchyma is signal intense.
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Nuclear Medicine
Nuclear medical examinations give functional information about the
genitourinary system, especially about the kidneys and the adrenals (Fig.
12). Their role in imaging of the lower urinary tract and genital organs
is limited. In contrast to conventional X-ray the ionizing radiation is in
ternal and generated by radionuclides, which emit radiation that is de
tected by a gamma camera or Single Photon Emission Computer
Tomography (SPECT). Many radiopharmaceuticals are available for ex
amination of the genitourinary tract. The most frequently used are: 99mTc
MAG3, 99mTc DTPA, 131I-Hippuran, 123I-Hippuran, 99mTc DMSA, 99mTc
Glucoheptonate, 57Cr-EDTA. The latter is used for in-vitro determina
tion of the glomerular filtration rate. The rate at which 99mTc DTPA and
1122
THE GENITOURINARY SYSTEM
Figure 12.
Renography (a: Histogram
b: Scintigram) o f normal
kidneys performed with
99mTc MAG3. Normal his
togram values:
Time to peak <3,5 min.; Split
function within the normal
range 43-57 %; and Residual
activity at 20 min. < 22 %.
m mm
X-ray and MR contrast media are cleared from the plasma, can also be
used. DTP A is nearly exclusively filtered by the glomeruli, whereas hip-
puran and MAG3 are both filtered by the glomeruli and excreted by the
tubular cells. DMSA and glucoheptonate accumulate in the functioning
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 13.
Cortex
Coronal section o f the
kidney showing the re
lationship o f the cor
tex, the medulla, and
Renal pelvis
the renal collecting
system.
Ureter
tubular cells and are excellent for renal scintigraphy. MAG3, DTP A and
hippuran are used for renography and interventional renography. With
all 6 radiopharmaceuticals the function of each individual kidney can be
determined. Nuclear medical imaging is an indispensable complement
to all the more morphologic imaging modalities since it provides infor
mation about renal function/perfusion and particularly about renal out
flow obstruction (diuresis renography), renal artery stenosis (captopril
renography), split functions, scar detection, and renal transplant moni
toring. Scintigraphy is useful for diagnosis o f urinary leakage, and iso
tope cystography is an alternative to conventional cystography for the
diagnosis of vesico-ureteral reflux. Special radiopharmaceuticals are
available for both cortical (131I cholesterol) and medullary (131I or 123I
MIBG) adrenal imaging.
Anatomy
Kidney
The kidneys (Fig. 13) are located in the retroperitoneum and measure ap
proximately 12 cm (height), 6 cm (width) and 4-5 cm (depth). The re
nal surfaces are usually smooth, but fetal lobulation may persist for life.
The kidneys move with respiration; the cranio-caudal excursion may be
as much as 10 cm. The renal pelvis is normally within the confines of
the kidney, but it may also be extrarenal. The size of the pelvis depends
in part on the state of hydration. At ultrasonography the parenchyma is
echopoor whereas the renal pelvis and the surrounding sinus tissue
(mostly fat) is echorich. The arcuate vessels when seen mark the loca
1124
THE GENITOURINARY SYSTEM
Figure 14.
Relations o f a transplant
kidney. The graft artery
may also be anastomosed
end to end to the internal
iliac artery.
Figure 15.
Enhanced CT o f a normal
renal transplant in the
right iliac fossa.
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Ureter
The ureters course along the psoasmuscles from the renal pelvis, pass
over the common iliac vessels, and enter the bladder deep in the bony
pelvis dorsolaterally. Visualization of the normal ureter requires in the
majority of patients intraluminal contrast.
Bladder
The urinary bladder is best examined when it is full, at which time it fills
the anterior part of the pelvis. The top of a filled bladder may extend into
the abdomen. Normally the bladder contains between 200 and 500 ml.
The bladder wall is thicker in men than women and decreases from 2 cm
to 2 mm during filling. In males the bladder is located ventral to the an
terior wall of the rectum with the seminal vesicles posterior. The outlet
o f the bladder (e.g. neck) is separated from the membranous urethra by
the prostate. In females the uterus and vagina are located behind and un
derneath the bladder and the urethra, whereas the salpinges and the
ovaries are located supero-laterally to the empty bladder. The upper one-
third of the bladder is intraperitoneal.
Urethra
The male urethra (Fig. 16) consists of four parts: pars prostatica in which
the ejaculatory ducts empty on either side of the posteriorly located veru-
montanum; pars membranacea, the shortest part, is the part of the ure
thra, which transverses the urogenital diaphragm, and is followed by pars
bulbosa and pars pendula. Taken together the prostatic and membrane
ous parts are defined as the posterior urethra while the bulbous and pen
dular portions are known as the anterior urethra.
The female urethra is 2 to 3 cm in length and is located anterior to the
vagina. It is surrounded by the internal and the external sphincter.
Physiology
The kidney has several functions including excretion o f metabolic prod
ucts and foreign substances ("waste products"), regulation of body fluid
osmolality and volume, regulation of electrolyte balance, regulation o f
1126
THE GENITOURINARY SYSTEM
Figure 16.
Diagram o f the male
urethra and genitals.
Seminal vesicle
Rectum
Figure 17.
DCT
The nephron. The
kidney is divided into
cortex, medulla and Afferent
arteriole
papilla. The blood
enters the glomerulus Efferent
(G) through the arteriole
afferent arteriole and C ortex
leaves fo r the vasa
recta (VR) through
the efferent arteriole.
The filtered compo
nent passes through
PCT (proximal con M edulla
voluted tubule), PST
(proximal straight
tubule), tDL (thin
descending limb o f
the loop o f Henle),
tAL (thin ascending Papilla
limb o f the loop o f
Henle), TAL (thick
ascending limb o f the
loop o f Henle), DCT
(distal convoluted tubule), CCD (cortical collecting duct), MCD (medullary collecting
duct), PCD (papillary collecting duct) and out into the calyx.
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1128
THE GENITOURINARY SYSTEM
Figure 18.
CT o f the bladder demon
strating a je t (arrow) o f con
trast medium entering the
bladder from the ureter (ar
rowhead).
The micturition reflex arc is parasympathetic and derived from the sec
ond through fourth sacral cord segments. The external sphincter has a
somatic innervation. Receptors in the bladder wall initiate the micturi
tion reflex via afferent fibers in the arc in response to bladder distention.
This voiding reflex can then be inhibited or facilitated by activity origi
nating in the cerebral cortex and extending down the spinal cord to the
sacral level. During voiding, the bladder detrusor contracts and actively
funnels the bladder neck; the sphincters surrounding the membranous
urethra then relax, allowing complete expulsion of the bladder content.
Between voiding, the intravesical pressure normally remains at a low
level because of the reflex arc by the inhibitory effect of the central ner
vous system as well as the elastic properties of the bladder smooth mus
cle. Urinary continence is maintained by the internal and intrinsic sphinc
ters combined.
Pathology
Prerenal pathology
The kidneys are commonly affected by disorders of the aorta, renal ar
teries, and renal veins. Hypertension is a frequent concomitant of renal
artery disease - both as a cause and as an effect. Disorders that affect the
renal artery and its major branches include atherosclerosis, fibromuscu-
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 19.
Arteriosclerosis.
Arteriogram demonstrating
arteriosclerosis in the
lower abdominal aorta and
a stenosis (arrow) o f the
left renal artery close to the
aorta.
Figure 20.
Fibromuscular dysplasia.
Arteriogram demonstrating
several narrowings in the
right renal artery o f a
young woman.
1130
THE GENITOURINARY SYSTEM
Hypertension
Hypertension is reported to affect from 7% to 20% of the adult popula
tion. An exact prevalence is, however, unknown, mainly because of dif
ferences in the study populations and the diagnostic criteria. Among the
rare secondary causes of hypertension renovascular disorder is the most
frequent. The prevalence depends not only on the source of the study
population but also on the definition of hypertension in that population
and on its severity. The prevalence of renovascular hypertension in a hy
pertensive population with diastolic pressure between 90 and 104 mmHg
is probably less than 1%, whereas in a population with a diastolic pres
sure above 125 mmHg the prevalence is reported to about 30%. With
such a low prevalence in the largest group of patients, screening of all
hypertensive patients for renovascular hypertension with either scintig
raphy, intravenous urography, or digital angiography is not advisable
owing to the low number o f true positives, the cost and the unacceptably
high false-positive rate. Before the patient is referred for an imaging ex
amination, some selection must take place. Patients with a diastolic pres
sure above 110 mm Hg, young patients, those with a sudden rise in blood
pressure independent of age, and patients with a poor response to ther
apy should be examined further. The captopril-enalpril renogram appears
to be the most cost-effective procedure for screening those patients.
Understanding the effects of angiotensin-converting enzyme inhibition
on the kidney distal to a stenosis and appreciating the potential effect of
sodium balance or antihypertensive medications are crucial in anticipat
ing the putative changes in the radionuclide studies of the renovascular
bed following angiotensin-converting enzyme inhibition (Fig. 21).
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1132
THE GENITOURINARY SYSTEM
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 23.
Wedge-shaped photon defi
cient area in the left kidney
due to an infarct demon
strated during 99mTc
DMSA scintigram.
E m b o li and thrombi
Emboli or in situ thrombosis can result in acute obstruction of the renal
artery or its branches. Failure to restore renal blood flow within a few
hours after renal artery occlusion usually results in infarction and loss o f
function. Intravenous urography and nuclear medicine will show absent
function or delayed function if the obstruction is incomplete (Fig. 23).
A rim-like nephrogram ("cortical rim-sign") may be seen on enhanced
CT or angiography due to collateral circulation. However the cortical
rim sign may also be seen in renal vein obstruction, acute tubular necro
sis (vasomotor nephropathy) and cortical necrosis. Ultrasonography is
often normal in the acute stage; in the ensuing days the size decreases
and the kidney becomes more echogenic. Both Doppler ultrasonography
and angiography (Fig. 24) will show absence o f flow.
1134
THE GENITOURINARY SYSTEM
Figure 24.
Multiple infarcts in a transplanted
kidney shown at arteriography.
Estimated original outline o f the graft
( ------- )■
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Renal pathology
A nom alies
Renal agenesis is often an incidental radiological finding. A major clue
is the characteristic compensatory hypertrophy of the contralateral kid
ney. If this is lacking one should search for an ectopic kidney. A nonvi
sualizing kidney on urography caused by renal agenesis can be confirmed
by ultrasound or CT. Ultrasonography can evaluate the renal fossae, but
CT is more effective in evaluating the lower abdomen for a small ectopic
kidney (Fig. 25). Renal anomalies, especially agenesis, are associated
with a significant incidence of seminal vesicle anomalies, and in the fe
male, with utero-vaginal anomalies. This should be kept in mind during
ultrasonographic examination.
Fusion anomalies of the kidney are often asymptomatic. Intravenous
urography will show the abnormal axis of fusion and delineate the ureters
1136
THE GENITOURINARY SYSTEM
Figure 25.
Normal sized ectopic
kidney above os
sacrum. The kidney is
also rotated.
Figure 26.
Intravenous urography demonstrat
ing crossed renal ectopy. The "left"
kidney is located below the right
kidney.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 27.
A horseshoe kidney is easily
demonstrated at intravenous
urography. The renal axes inter
sect inferiorly.
Figure 28.
A horseshoe kidney is well
outlined at digital subtraction
angiography.
1138
THE GENITOURINARY SYSTEM
Figure 29.
Simple renal cyst.
Ultrasonography reveals an ane-
choic cyst with dense echoes in
the posterior wall. There is
acoustic enhancement deep to the
lesion.
Cysts
Simple cysts are the most common renal mass. They have been detected
more readily since the advent of ultrasound and CT, and may be found
in more than 50% of patients over the age of 50 years. The ultrasound
criteria for a benign cyst include the absence of internal echoes, smooth,
sharply defined walls and acoustic enhancement beyond the posterior
wall proportional to the fluid content (Fig. 29). Refraction lines at the
edges o f the cyst are typical, as is the absence of flow on color Doppler
ultrasonography. The CT criteria for a benign cyst include homogenous
attenuation value near the density of water, imperceptible cyst wall,
smooth interface with renal parenchyma, and lack of enhancement fol
lowing intravenous contrast injection (Fig. 30). When these criteria are
met, the diagnosis of a simple cyst is accurate in 93% - 98% of cases.
In those cases not meeting the strict criteria for ultrasound or CT, nee
dle aspiration or enhanced MRI should be considered to establish the fi
nal diagnosis (Fig. 31). MRI is extremely sensitive to vascularity and has
detected small occult tumors in the wall of renal cysts. Unlike CT, it is
not unusual to visualize cyst walls with MRI. Scintigrams obtained with
a renal parenchymal agent such as 99mTc-glucoheptonate or 99mTc-dirner-
captosuccinic acid demonstrate an area of absent activity that persists
through the dynamic (blood pool) and static (parenchymal) phases.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 30.
Simple renal cyst in a left kid
ney demonstrated at en
hanced CT. Homogenous
low-attenuating process,
which does not enhance after
administration o f intravenous
contrast (apparent unsharp
ness at cyst-kidney interface
is due to volume averaging).
1140
THE GENITOURINARY SYSTEM
Figure 31.
Simple renal cysts demonstrated
at MRI. The patient had one
cyst in each kidney.
a) T1-weighted image.
b) T2-weighted image. MRI
clearly delineates renal cysts.
On TI-weighted images the
content is signal poor often
with a clearly delineated
wall, whereas on T2-
weighted images it is signal
intensive, sometimes with
edge enhancement.
Figure 32.
Adult autosomal dominant polycys
tic kidney disease demonstrated at
intravenous urography. Both kid
neys are enlarged with irregular
contours. The pyelocalyceal sys
tems are splayed and deformed.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 33.
Adult autosomal dominant
polycystic kidney with m ul
tiple parenchymal calcifi
cations on unenhanced
CT. The patient is on re
placement therapy due to
end-stage renal failure.
1142
THE GENITOURINARY SYSTEM
Figure 34 .
Medullary sponge kidney
(tubular ectasia).
a) Nephrogram.
b) Excretory phase.
Intravenous urography
shows multiple distinct col
lections o f contrast material
in dilated papillary collect
ing ducts ("brush effect”)
and punctuate calcifications
in the same locations.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 36.
Renal variants (pseudotumors),
which may simulate a tumor.
lobation hump
Prominent Suprahilar
column of Bertin "bump"
Pseudotum or
One of the most common space-occupying lesions in the kidney is the
hypertrophied column o f Bertin, which is an infolding or double thick
ness of healthy renal cortex, most characteristically separating the supe
rior from middle pole calices. Other so-called pseudotumors include the
prominence of the lateral renal margin secondary to the splenic impres
sion ("dromedary hump”) and the hilar lip, which often occurs superior
to the hilus, secondary to focal hypertrophied parenchyma (Fig. 36).
Focal parenchymal hypertrophy adjacent to an area of scarring from pre
vious inflammation is another cause for a pseudotumor. The diagnosis
1144
THE GENITOURINARY SYSTEM
Figure 37.
Angiomyolipoma. CT without
(upper row) and with (lower
row) intravenous contrast
medium applied and bone set
tings (left column) and soft tis
sue setting (right column) o f
window and level. The an
giomyolipoma (arrows) had
attenuation values similar to
that o f fat. At ultrasonography
it was hyperechoic.
Adenom a
Renal adenomas are slow-growing, solid parenchymal epithelial tumors
that originate in mature tubular cells and are thought to be pre-malig-
nant. Cystic areas and calcifications can occur. Lesions less than 3 cm
are usually benign, but the final classification is based on histology and
clinical behavior rather than on size.
Angiomyolipom a
Angiomyolipomas (hamartomas) contain varying amounts of smooth
muscle, blood vessels and mature fat cells. Demonstration of fat by CT
(Fig. 37) (negative attenuation values [-15 or lower]) or MRI (fat sup
pression sequence) within the tumor is nearly pathognomonic of it an an
giomyolipoma, although there have been a few cases of fat-containing
renal cell carcinoma. On the other hand some angiomyolipomas contain
undetectable amounts of fat or have the fat masked by hemorrhage and
are therefore not diagnosed until after removal. Sonography is non-spe
cific and reveals a hyperechoic mass. Surgery is unneccesary in the vast
majority of the cases.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 38.
Oncocytoma (arrowheads)
in the left kidney at en
hanced CT. Centrally a
scar (arrow) was found.
The findings are only sug
gestive o f oncocytoma.
Oncocytoma
Oncocytomas are epithelial neoplasms believed to originate from the
proximal collecting tubules. These tumors are characteristically benign,
but due to their solid nature can not be definitely categorized as benign
prior to surgery. A central scar demonstrated at ultrasonography, CT (Fig.
38) or MRI is suggestive of, but not pathognomonic. Because a renal cell
carcinoma may mimic an oncocytoma completely, conservative surgery
(i.e. partial nephrectomy) is rarely justified.
R en a l cell carcinoma
Renal cell carcinomas occur most commonly in the sixth decade and are
often detected incidentally. Depending on the initial imaging study further
evaluation by at least one other study is usually required. Symptoms, when
present, are usually non specific; e.g. hematuria, flank pain and a palpable
tumor may occur in adult polycystic kidney disease as well as in renal cell
carcinoma. Intravenous urography typically shows renal enlargement with
a well-circumscribed or occasionally irregular mass. Five% - ten% will
show calcification, which if central or diffuse is extremely suspicious. The
kidney is often rotated on its axis and/or displaced (Fig. 39). Tomograms
obtained during the nephrogram phase show a lucent or inhomogenous
mass whose interface with the adjacent renal parenchyma may be smooth
or irregular. When the mass extends beyond the renal contour a thick or
irregular wall can sometimes be discerned. CT, MRI and ultrasonogra
phy can all be used in establishing the nature of a renal mass more pre
cisely. Demonstration of a solid mass is indicative of a renal cell carci
noma until another diagnosis has been proven. CT is excellent for both
1146
THE GENITOURINARY SYSTEM
Figure 39.
Renal cell carcinoma in the
upper pole o f the right
kidney. The collecting
system is displaced and the
upper pole is occupied by a
mass.
Figure 40.
Renal cell carcinoma.
a) Tumor in the latero-
posterior part o f the left
kidney.
b) Tumor in the anterior
part o f the right kidney
slightly dislocating the
liver. Both the contrast-
enhancing wall and the
inhomogenous enhance
ment o f the lesion exclude
the possibility o f a simple
cyst. a
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 41.
Recurrent renal cell carci
noma. The process (arrows) in
the left renal bed does not en
hance and its appearance is
not reminiscent o f any normal
abdominal structure.
Figure 42.
Renal cell carcinoma. Mixed
hyper- and hypoechoic mass
(arrows) in the upper pole.
diagnosis and staging. The CT criteria for renal malignancy include het
erogeneous tissue with an attenuation value near to that of renal
parenchyma, contrast enhancement, irregular interface with surrounding
parenchyma, and areas of calcification (Fig. 40). Secondary spread to re
gional lymph nodes and extension into the renal vein are clear signs of
a malignant tumor. At most institutions CT is used as the primary modal
ity to stage renal carcinoma prior to treatment because of its diagnostic
accuracy, and its ability to detect local extension, regional lymph node
involvement, and distant metastases as well as to evaluate the contralat
eral kidney. CT is also best for evaluating the renal bed for recurrent tu
mor (Fig. 41). Ultrasonography can also be used for the diagnosis of a
solid mass (i.e. sound absorption) and thereby exclude the presence of a
cyst. Common ultrasonographic patterns are a hyperechoic somewhat at-
1148
THE GENITOURINARY SYSTEM
Figure 43.
Renal cell carcinoma in the
lower pole o f the right kidney
at MRI. Tl-weighted image af
ter application o f intravenous
contrast - gadodiamide
(Omniscan). There is central
necroses.
tenuating mass (Fig. 42) and a complex mass containing echo-poor, rel
atively transsonic areas that represent foci of liquefaction necrosis.
Ultrasonography may also be used for excluding a tumor in the opposite
kidney and extension into the perinephric space. MRI demonstrates an
inhomogenous, enhancing mass. The Tl-weighted and T2-weighted sig
nals vary with the composition of the tumor (Fig. 43). MRI appears to
be the most sensitive and most accurate method of diagnosis in renal cell
carcinoma and detecting venous extension. However, because of its ex
pense, lack of universal availability and because CT and ultrasonogra
phy are also very accurate, it is usually reserved for special situations,
i.e. patients with very complicated lesions, or those who can not receive
iodinated contrast medium. Renal angiography is seldom necessary any
more for diagnosis.
Lym phom a
Imaging techniques demonstrate renal involvement in approximately
one-third of patients with systemic lymphoma. Renal lymphoma can pre
sent as a mass, as multiple, unilateral or bilateral masses, as diffuse in
filtration with renal enlargement or as infiltration into the sinus or the
perinephric space. Retroperitoneal adenopathy is nearly always present.
Leukemic and myelomatous infiltration causes renal enlargement.
M etastases
Metastases to the kidney are usually associated with primary neoplasms
of the lung, breast, stomach, cervix, colon, and pancreas. Differentiation
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Infection
Acute pyelonephritis is usually caused by bacteruria resident in the gas
trointestinal and genital tracts. Underlying systemic diseases and condi
tions of altered host resistance predispose to renal infection. Imaging
studies are unnecessary in most adult patients with typical clinical signs
who respond to medical therapy. If an imaging examination is indicated,
ultrasonography is often preferred at the initial imaging procedure be
cause of its ability to demonstrate calculi, hydronephrosis, intrarenal or
perinephric abscesses. Subtle parenchymal changes associated with in
fection, as well as extrarenal spread, are more consistently demonstrated
by CT than by ultrasonography and include patchy area of underperfu
sion, small, dense nephrographic foci and perinephric edema. 99mTc-glu-
coheptonate or 99mTc dimercaptosuccinic acid scintigraphy is also use
ful, because localized infections appear as focal defects, often before they
can be seen with CT or ultrasonography. Hydronephrosis and ureteral
obstruction is demonstrated on delayed images.
Emphysematous pyelonephritis is a very serious condition which is
due to extensive necrosis and gas formation caused by gram-negative or
ganisms. Gas in the renal parenchyma (and sometimes in the perinephric
space and in the pyelocalyceal system) may be seen on plain film or CT.
Ultrasonography show increased echogenicity with blurred acoustic
shadowing due to reverberations of sound in the gas medium. Intrarenal
gas is readily seen on CT scans.
Severe pyelonephritis, if inadequately treated or unresponsive to an
tibiotics may lead to the formation of a chronic occult infection or a re
nal abscess. Intravenous urographic findings include obliteration of the
ipsilateral psoas stripe, diffuse enlargement or a focal mass, and defor
mity of the pyelocalyceal system. Ultrasonographically, a renal abscess
appears as hypoechoic or anechoic mass with fluid-fluid (or fluid-debris)
level and distal acoustic enhancement. The wall may appear as an
echogenic rim. Unenhanced CT scans show low attenuation within the
abscess cavity. The wall enhances, but the center does not. The findings
at MRI are similar. Pus is signal intensive on T1-weighted and T2-
1150
THE GENITOURINARY SYSTEM
Figure 44.
Bilateral reflux nephropathy. IVU lO m in
Clubbed calyces with overly 77 12 0 8 jj#
T c -9 9 m DMSA R IG H T
Figure 45. Right-sided reflux nephropathy. 99mTc DMSA scintigraphy is more sensi
tive than intravenous urography fo r depicting scars or active parenchymal disease
since it only mirrors active tubular cells. Oblique views are o f great importance fo r the
detection o f small scars.
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1152
THE GENITOURINARY SYSTEM
Figure 46.
Tuberculosis. Retrograde
pyelography was performed
since no contrast medium was
excreted during intravenous
urography. Typical changes
with medullary-papillary
cavitation, moth-eaten
calyces and pipe stem ureter.
P apillary necrosis
Papillary necrosis is believed to be due to localized ischemia. It is espe
cially frequent in diabetes mellitus and analgesic abusers. Less common
associations include hypotension, renal vein thrombosis, obstruction,
sickle cell disease, and sickle cell trait. Intravenous urography remains
the best imaging modality for demonstrating the various stages of pap-
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Figure 47.
Renal papillary necrosis due to
analgesic abuse. Irregular calyces
with central contrast defects
(= necrotic papillae) and backflow
o f contrast into the collecting
tubules (pyelotubular backflow).
A necrotic papilla obstructs outflow
from the renal pelvis.
Figure 48.
Nephrocalcinosis secondary to Alport's disease.
Chronic calcifications outlining the contracted
kidneys.
1154
THE GENITOURINARY SYSTEM
Nephrocalcinosis
Nephrocalcinosis is a form of metastatic or dystrophic calcification in
the renal parenchyma. It can be secondary to hypercalcemic and hyper-
calcuric states, hyperoxaluria, medullary sponge kidney cortical necro
sis, adult polycystic kidney disease chronic nephrosclerosis and chronic
glomerulonephritis (Fig. 48). CT is the best modality to diagnose tiny
calcifications, whereas more gross calcifications may be seen on plain
films. Calcifications within or close to the genito-urinary tract may have
many causes (Fig. 49).
M edical disease
The kidney is involved in numerous pathologic conditions. Some like lu
pus erythromatosus are systemic, while others like glomerulonephritis
are localized to the kidney. The so-called "medical” diseases of the kid
ney involve primarily the renal parenchyma as distinct from the collect
ing system and tend to be bilateral. The kidneys may be enlarged, nor
mal in size, or small. Since many of these diseases resemble each other
radiologically the role of imaging in patients with such renal disease
and/or renal failure is not to make a specific histological diagnosis, but
Costochondral calcification
Adrenal calcification
Splenic granulomata
Renal artery calcification Caliceal stone
Stone in caliceal diverticulum
Staghom calculus
Cortical nephrocalcinosis
Medullary nephrocalcinosis
Calcification in renal tumor Calcification in wall o f renal cyst
Calcified mesenteric nodes Aortic aneurism
Ureteral stone
Diac artery calcification
Appendicolith
Phleboliths
Calcified uterine fibroid
Calcified vasa
Bladder stones
Prostadc calculi
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Figure 50.
End-stage renal failure.
Ultrasonogram demonstrating a
small contracted kidney (ar
rows) with high echogenicity
and loss o f corticomedullary
boundary.
1156
THE GENITOURINARY SYSTEM
Figure 51.
1311 hippuran renography o f
renal transplants. The 5 min.
images as well as the his
togram show good uptake in
and excretion from the graft
in the right side, whereas
there is only a very slow up
take in the left sided graft.
The latter is undergoing
chronic rejection, whereas
the one in the right side has
recently been transplanted.
Transplantation
Renal transplantation has been a routine procedure at many institutions
for three decades. The failing allograft can present a complex and con
fusing diagnostic problem. The clinical presentation of fever and ten
derness of the renal graft is non-specific. Initially one will exclude any
overt mechanical problem such as hydronephrosis, urinoma, lymphocele
etc. that can be remedied by imaging-guided intervention or surgery.
However, these complications cause less that 5% of graft dysfunction.
This is the reason why most attention is directed to the interplay of the
intersti-tial processes causing the decrease in renal function, and why ra
dionuclide studies, which can quantify perfusion and function, have as
sumed an important role in the management of renal transplants (Fig.
51). The most commonly adopted procedures are perfusion studies and
renography. Nuclear medical examinations can with high certainty ex
clude pathology and should be the primary imaging tool for monitoring
post-operative renal transplants. Ultrasonography can yield an anatomic
record of the renal allograft, but except for Doppler imaging, no con
clusions can be drawn about any aspect of renal function. Duplex and
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Traum a
The kidney is the most frequently injured organ in blunt abdominal
trauma. The choice of imaging depends on the patient's clinical condi
tion, the severity of trauma and the possibility of multiple involvement.
In a patient who presents with hematuria following relatively minor flank
trauma it is appropriate to begin with an intravenous urography. In a mod
erately or severely injured patient - whenever possible - contrast-en
hanced CT should be the initial imaging procedure, since it depicts the
extent of renal and perinephric injury and may demonstrate injuries of
other abdominal viscera. Ultrasonography is not helpful in the acute sit
uation and only causes the appropriate examination and treatment of a
traumatized patient to be delayed. The usefulness of ultrasonography is
limited because it is often impossible to perform properly due to the
trauma (pain, ileus, wounds et c.). In the most severe injuries there may
not be time for any pre-operative imaging.
Intravenous urography will demonstrate whether there are one or two
functioning kidneys. A renal contusion or intrarenal hemorrhage appears
as a localized decrease in intensity of the nephrogram or as an intrarenal
mass with splaying of the collecting system. Extravasation of opacified
urine indicates a lacerated collecting system, which is often associated
with a serious parenchymal injury (but does not always mean surgery).
It must be kept in mind that asymmetric opacification can be due to pre
existing disease. If the patients is in shock at time of injection, the kid
neys may not opacify or there may be a persistent nephrogram without
opacification of the collecting system. In a patient who has sustained rel
atively mild trauma and is clinically stable, further imaging is usually
1158
THE GENITOURINARY SYSTEM
Figure 52.
Posttraumatic renal
hematoma involving on the
right kidney (probably sub-
capsular). Upper level: No
contrast has been adminis
tered. Lower level: After intra
venous contrast medium ad
ministration. The attenuation
value o f the hematoma (ar
rows) is higher than o f the re
nal parenchyma before admin
istration o f contrast medium
but lower after contrast was
given.
Postrenal pathology
Duplication of the renal collecting system is the most common urologi
cal anomaly and easily diagnosed on urography when renal function of
both the upper and lower segments is preserved. When complete, reflux
into the lower collecting system commonly occurs, and an ectopic ureter
with or without associated ureterocele often obstructs the upper collect
ing system. Obstructed duplication may be suspected on the urogram
when there is downward displacement of the lower calyces and an in
sufficient number of them, the so-called ’’drooping lily" sign. Ultrasound
is a good method to demonstrate the dilated upper collecting segment,
which is seen as a cystic structure just superomedial to the normal renal
parenchyma, but ultrasound can not determine whether there is obstruc
tion. For this purpose diuresis renography may be used to distinguish be-
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Figure 53.
Ureteroceles. Mild dilatation o f
both distal ureters with bulbous
protrusion into the bladder. The
lucent rim surrounding the
ureteroceles is mucosa elevated
by the intravesical portion o f the
dilated ureters.
U rothelial tumors
Most urothelial neoplasms are malignant. Transitional cell carcinoma,
the most common, occurs most often in older men. Squamous cell car
cinoma and mucinous adenocarcinoma are much less common. The var
ious imaging techniques (intravenous urography, pyelography (Figs.
54-55), contrast-enhanced CT (Fig. 55), MRI and ultrasonography (Fig.
56)) demonstrate an irregular filling defect in the renal pelvis, often as
sociated with obstructive hydronephrosis or mucosal irregularity. Severe
hydronephrosis or infiltration of the parenchyma by tumor commonly re
sults in nonvisualization on intravenous urography or contrast-enhanced
1160
THE GENITOURINARY SYSTEM
Figure 54.
Small pelvic tumor (arrowheads)
demonstrated during retrograde pyel
ography.
Figure 55.
Large pelvic tumor demonstrated by
retrograde pyelography (a) with the
patient positioned at various angles
and by CT (b).
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Figure 56.
Pelvic tumor (arrows).
Ultrasonography shows an echo-
poor mass within the echo-rich
pelvis.
Figure 57.
Urothelial tumor in the lower ureter at
retrograde pyelography.
Infection
Pyelitis and ureteritis are
chronic inflammations of the
uroepithelium and suburoepithe-
lium, often resulting in cysts.
Intravenous urography shows
multiple round eccentric fillings
defects related to the pyeloca-
1162
THE GENITOURINARY SYSTEM
Figure 58.
Ureteritis cystica. Intravenous
urography reveals multiple
round filling defects in the pelvis
and upper part o f the ureter.
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Figure 59.
Pouch stone (arrow) form ed
around a metal suture. Foreign
bodies (e.g. metal sutures which
are not covered with mucosa)
within the urinary tract may act as
a nidus around which calculi can
be formed.
Figure 60.
Staghorn stone in the left renal col
lecting system (arrows) and in the
lower left ureter (arrowheads) with
hydronephrosis in the right kidney
due to a small stone, which can not
be seen on this urogram. The uro
gram was taken 3 hours after
administration o f the contrast
medium. No excretion o f contrast
medium is seen on the left side.
1164
THE GENITOURINARY SYSTEM
Figure 61.
Nephrotomogram demonstrating a cal
culus (arrows) in the renal pelvis. It was
not seen on the plain film. The kidney
has also a dromedary hump.
Figure 62. Large stone in the left renal pelvis on KUB (a) and after administration o f
intravenous contrast medium (b). The stone does not totally obstruct the outflow from
the renal pelvis. The contrast medium partly obscures the stone.
Calculi
It is estimated that 2-3% of the population develop urinary calculi. Men
are affected twice as often as women. Approximately 10% of stones are
caused by an identifiable metabolic abnormality such as hyperparathy
roidism, but most are idiopathic. Chronic infections and/or foreign bod
ies (Fig. 59) can also cause stones. The incidence of calculi is unusually
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Figure 63.
Renal pelvic calculi (ar
rows).
a: Large staghorn calcu
lus.
b: Small pelvic calculus.
A t ultrasonography cal
culi are highly
echogenic and show
sharp acoustical show
ing.
1166
THE GENITOURINARY SYSTEM
Figure 64.
Stricture in the lower ureter follow
ing ureteroscopy demonstrated at
intravenous urography. Such stric
tures may be found months after a
patient has undergone
ureteroscopy.
Obstruction
Obstruction to antegrade flow of urine may occur at any level from the
renal collecting tubules to the distal urethra (Fig. 64). The urographic
manifestations of acute obstruction are normal or enlarged kidneys, an
obstructive nephrogram (Fig. 65), mild to moderate dilatation of the pye
localyceal system which may be visualized best on delayed films, and
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Figure 65.
Obstructive nephrogram on the left side
due a ureteral calculus. The renal
parenchyma on the left is still opacified
by contrast medium, whereas it has al
ready been excreted on the right side.
1168
THE GENITOURINARY SYSTEM
Figure 66.
Urogram before (a) and after (b)
Anderson Hynes pyeloplasty fo r
uretero-pelvic junction obstruc
tion. After surgery the renal
pelvis is much smaller and the
form o f the calyces has nearly
normalized.
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Figure 67.
Hydronephrosis.
Ultrasonography shows a di
lated, fluid-filled (echo poor)
collecting system.
Figure 68.
Hydronephrosis due to
ureteral calculus. Immediately
after administration o f con
trast medium there is poor
parenchymal opacification
(a - right kidney), whereas 24
hours after the administration
both opacification o f the
parenchyma and the pelvis
(b - right kidney) may be
found. The slight excretion on
the left side 24 hours later is
probably due to reabsorption
o f contrast medium through
pyelosinous reflux on the right.
1170
THE GENITOURINARY SYSTEM
Figure 69.
Hydronephrosis due to cervical
carcinoma. Sagittal Tl-weighted
image after administration o f con
trast shows the ureter (arrows) as
a dilated, elongated, low signal
intensity column.
Figure 70.
Diuresis renogram.
a) Classic diuresis renogram
Furosemide
responses when the
Dilated obstructed
frusemide is injected 20
min. after the radiopharma
ceutical. The response (bot
tom left) is equivocal. In
such cases it may be an ad
vantage to repeat the study
and inject the frusemide 15
min. before the radiophar
maceutical
b) Diagram showing conver
sion o f equivocal (F +20)
washout to obstructive or
non-obstructive patterns on
F - 15 diuresis renograms.
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Figure 71 a, b.
No obstruction at diuresis
1
renoscintigraphy. There is a good
ф 1
1172
THE GENITOURINARY SYSTEM
Figure 72 a, b.
Obstruction at diuresis renoscintig
raphy. There is absence o f response
to Lasix on both sides. Also in this
case Lasix was injected 20 min.
(arrow) after 99mTc MAGy
Retroperitoneal fibrosis
Although the cause of retroperitoneal fibrosis is uncertain, it is a known
complication in patients taking methysergide and has been alleged to be
related to several other drugs (such as 13-blockers). Occasionally a spe
cific cause can be identified e.g. an aortic aneurysm with perianeurysmal
fibrosis or a retroperitoneal tumor with a marked desmoplastic reaction.
Retroperitoneal fibrosis usually occurs between L5 and S2 and generally
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Figure 73.
CT in a patient with retroperi
toneal fibrosis reveals a dense
soft tissue attenuation mass
surrounding the aorta. This
mass extended from L2 to L5.
Traum a
The ureters are well protected in the retroperitoneal paraspinal region
and are seldom traumatized in blunt abdominal trauma. On the other
hand, partial or complete disruption of the ureter can result from pene
trating injuries such as knife or bullet wounds. Iatrogenic injuries can re
sult from instrumentation or surgery. Provided adequate renal function
is preserved, intravenous urography may demonstrate narrowing or dis
ruption of the ureter; if renal function is diminished, direct pyelography
may be needed to evaluate adequately the injured segment. CT, ultra
sonography and MRI give information about the surroundings.
1174
THE GENITOURINARY SYSTEM
Figure 74.
Various causes o f hema
turia. Treatment with anti
coagulants can also cause
hematuria.
Diverticula
Diverticula are acquired (usually) or congenital (rarely) outpoutchings
of the bladder wall. They may range from very small to so large that they
press on other pelvic organs. The wall of a diverticulum is often smooth
in contrast to the irregular trabeculated bladder wall. Approximately one-
fourth of all diverticula contain calculi and in approximately 3 % a ma
lignant tumor may be present. Two important investigations for the di
agnosis of diverticula are ultrasonography which demonstrates an
echopoor out-poutching (Fig. 75), and cystography, which quantifies the
degree of diverticular emptying. As with unenhanced CT and MRI it is
important to demonstrate the neck of the diverticulum in order to avoid
the wrong diagnosis of a perivesical fluid collection. At intravenous urog-
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Figure 75.
Bladder diverticulum. It is o f utmost
importance to demonstrate the neck
o f the diverticulum in order to dis
tinguish it from a fluid collection
with no connection to the bladder.
Figure 76.
Trabeculated bladder with divertic
ula. Due to outflow obstruction
(BPH) a spiral metallic prosthesis
has been inserted in the prostatic
urethra. There are also metal clips
outside the genito-urinary tract
(large bowel anastomosis from pre
vious sigmoid resection).
raphy (Fig. 76), enhanced CT (Fig. 77) and enhanced MRI, contrast
medium is found in the outpouching confirming the presence of a diver
ticulum. Intravenous urography often overlooks non-filling diverticulae
or those located on the anterior bladder wall, but cystography will demon
strate them. Frequently the pelvic ureter will be medially displaced.
Urethral diverticula occur most frequently in females. They may be so
large that they elevate the bladder base, giving the impression of a "fe
male prostate". The primary examination is voiding urethrography, but
sometimes ultrasonography during micturition has been reported to be
successful.
1176
THE GENITOURINARY SYSTEM
Figure 77.
Bladder diverticula filled with
contrast medium. Urothelial
cancer in the upper left part o f
the bladder.
Tear-drop bladder
At intravenous urography a so-called tear-drop or pear-shaped bladder
is sometimes seen. This special configuration o f the bladder is due to
compression from extravesical processes. The possible causes can be re
vealed at ultrasonography, CT and MRI and include hematoma, abscess,
urinoma, hypertrophy of the iliopsoas muscle, lymphoma, tumor, fibro
sis, bilateral iliac aneurysms, occlusion of the vena cava and pelvic lipo
matosis.
Urachus
Urachal remnants can be seen in all degrees ranging from a tiny elonga
tion of the anterior upper contour of the bladder to a fistula extending to
the umbilicus. A tumor may arise in the residual tissue. CT is the best
modality to demonstrate a urachal tumor since it very often contains very
gracile calcifications anterosuperiorly to the bladder.
Infection
In simple cystitis no changes are found with the various imaging modal
ities, but in severe cystitis one can find a slightly diminished bladder ca
pacity with a thick bladder wall and mucosal edema at ultrasonography,
CT and MRI and sometimes on intravenous urography. In chronic cys
titis the bladder shrinks and the wall thickens. Bilharzia causes chronic
cystitis and mucosal edema as well as thickening of the distal ureter in
cluding the vesicoureteral orifices. With time thin linear calcifications
may develop in the bladder ureters and even renal pelves. Calcifications
may also be due to tuberculosis, but most frequently these are found in
the seminal vesicles seminalis, and ampullae of the vasa deferentia.
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THE NICER GLOBAL TEXTBOOK OF RADIOLOGY
Figure 78.
Bladder stone.
Ultrasonography shows an
echorich process in the upper
part o f the bladder with
acoustic shadowing.
C alculi
Bladder calculi are indicative of residual urine since they very rarely de
velop in a bladder which can be completely emptied. Some stones (e.g.
uric acid) do not contain calcium and together with very small calcium
containing stones they may be overlooked at conventional roentgenog
raphy, but they can be seen at ultrasonography (Fig. 78) and CT.
N eurogenic bladder
Residual urine including maximal bladder volume is easily determined
by ultrasonography. Residual urine can also be measured at nuclear med
icine. The main cause o f incomplete bladder emptying is bladder outlet
obstruction, but neurogenic diseases often cause residual urine, which is
also a consequence of vesicoureteral reflux. Urodynamic evaluation and
cystography are complementary examinations in the evaluation of pa
tients with neurogenic diseases and are often performed simultaneously
(video urodynamics). Cystography gives information about the bladder
neck and vesicoureteral reflux.
Trauma
In connection with trauma lesions may involve the bladder and the male
urethra. Rupture of bladder and the urethra in a patient who is not se
verely injured is properly diagnosed by cystography (Fig. 79) and ure
thrography, respectively, showing contrast outside the natural lumen. In
case of a multitraumatized patient CT should be performed as the primary
examination since it gives information about the surroundings (Fig. 80)
and the relations to bones. While intraperitoneal bladder rupture should
be operated promptly, a conservative attitude toward the management of
extraperitoneal bladder rupture is sometimes justified. Disruptions of the
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Figure 79.
Extraperitoneal bladder rupture.
Cystography shows bladder rupture
secondary to a pelvic fracture.
Figure 80.
Extraperitoneal bladder rup
ture. Contrast medium
around the bladder 10 hours
after intravenous urography,
which showed only slight el
evation o f the bladder. A
fracture o f the symphysis
was obvious on one o f the
subsequent sections. It was
impossible to perform ultra
sonography adequately due
to pain.
Bladder hernia
Bladder hernia, which occurs most commonly in the inguino-scrotal area,
is diagnosed equally well by all modalities. Therefore the least expen
sive modality - ultrasonography - should be used as the primary modal
ity. Sometimes it may be necessary to perform cystography to demon
strate the outline of the hernia to the surgeon. In the 1970's colpocys-
tourethrography was frequently performed in females with incontinence
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Figure 81.
Artificial sphincter. A plain film
should be taken both during inflated
and deflated phase. I f the fluid con
tains contrast medium, the integrity
o f system may be studied.
Figure 82.
Urethral stricture verified by ure
thrography.
and/or genital hernia for diagnosis and planning of treatment. Its value
was severely questioned in the 1980's but now the examination is re
served for rare cases of recurrent incontinence.
Artificial sphincters
Plain radiographs are excellent for control of the placement and eval
uation of mechanical malfunctioning artificial sphincters (Fig. 81) and
other prostheses. Urethrography may be necessary if intraurethral erosion
is suspected. Diagnosis of fluid accumulation including infection and ab
scesses around the artificial material requires ultrasonography and/or CT.
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Urethral stricture
Stricture (stenosis) of the urethra, urethral trauma and urethral tumors
are the urethral diseases most frequently investigated radiologically.
Strictures occurs almost exclusively in males, are readily diagnosed by
urethrography demonstrating luminal narrowing (Fig. 82), and in adults,
are nearly always acquired (e.g. infection, post-cystoscopy lesion,
trauma, catheter). Urethrography should be performed in patients in
whom urethral fistulas are suspected. Problems with urethral catheteri
zation (except for BPH) are also an indication for urethrography. Most
urethral neoplasms occur in the anterior urethra of the male and are usu
ally imposed on long standing strictures. Squamous cell carcinoma is by
far the most common type. Urethral tumors are much less common in
women, are not related to a stricture, and can be o f any cell type.
Figure 83.
Bladder tumor.
Ultrasonography may detect
tumors as small as 10 mm (a).
Normally the echogenicity o f
bladder tumors is moderate
(b). On (b) one can also see a
balloon catheter (b) and por
tions o f a hypertrophic
prostate (p).
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Figure 84.
Bladder tumor at vesicoureteral
junction (lower part) causing
hydronephrosis (upper part).
Tum or
Ninety percent of all bladder tumors arise in transitional epithelium.
Cystoscopy with biopsy is the most sensitive method of detecting blad
der tumors, but imaging must be done for staging. Ultrasonography, CT
and MRI each have their advantages. Ultrasonography can also recog
nize some bladder tumors, but it often overlooks low grade papillo
matosis, very small tumors (< 10 mm), and tumors in trabecular blad
ders. At abdominal or transrectal ultrasonography localized thickening
and/or protrusion in the bladder lumen is found (Fig. 83). The echogenic
ity of bladder tumors is moderate. It is very important that before an ul
trasonographic examination the bladder be well filled, because a folding
of the wall should not be interpreted as a tumor. It is often difficult to
differentiate between small to moderate sized bladder tumors and tra-
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Figure 85.
Bladder tumor. There is
a filling defect arising
from the right bladder
wall.
с
Figure 86. Bladder tumor.
a. Sagittal Tl-weighted image demonstrating a tumor in the bladder base.
b. Same as (a) after administration o f gadodiamide. Only slight increase in signal
intensity o f the tumor.
с: T2-weighted image o f a signalpoor tumor at the ureterovesical junction causing di
latation o f the ureter (different patient than a and b).
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Figure 87.
Ileal urinary conduit. Diagram
demonstrating a bladder substi
tute (conduit) made from part o f
ileum and anastomosed to the
ureters (Bricker procedure).
Figure 88.
"Pouchography " ("loopography ")
demonstrating leakage (arrows)
at the anastomoses between the
ileal loop and the urethra.
Enteric neo-bladder
In cases of muscular invasion (but without extravesical spread) or of con
genital or acquired atrophic bladders, total cystectomy is often per
formed. A bladder replacement is made by parts of the bowel. There are
several types of "bowel bladders" each with their advantages and disad
vantages (Fig. 87). The radiologist is involved in postoperative control
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Figure 89.
Renal artery stenoses before (a)
and immediately after (b) percuta
neous transluminal renal angio
plasty.
Intervention
Angiographic interventions
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Figure 90. Stenosis o f arterial anastomosis o f transplant before (a) and months after
(b) percutaneous transluminal angioplasty. The dilatation improved the flow (and
function) considerably.
off the intima of the renal artery. The arterial media is also split and the
adventitia is stretched beyond its elastic recoil. The atheromatous plaque
is forced into the medial portion of the artery. The adventitia remains in
tact, the media heals by fibrosis, and there is reendotheliazation over the
tears in the intima. A similar process of controlled injury also occurs with
nonatherosclerotic stenosis (Fig. 90). The intima is disrupted and the le
sions are split or stretched beyond their point of elastic recoil. The over
all technical success rate for percutaneous transluminal renal angioplasty
is generally reported as 80-90%. Obviously the number, type, location
and experience of the radiologist contribute significantly to the success
or failure of the procedure. Complications of renal artery percutaneous
transluminal angioplasty may be considered as general complications
such as adverse contrast medium reaction or problems at the puncture
site, or specific to percutaneous transluminal renal artery, such as a rup
ture, dissection, embolus, or thrombosis of the renal artery.
Embolization
Percutaneous transcatheter embolization of the renal artery or of the vesi
cal branches of the internal iliac artery is used in a variety of situations.
It may be used in cases where renal ablation without surgery is desired
or where arrest of bleeding from the kidney or the bladder is needed.
Embolization is also effective for treatment of arteriovenous fistulas and
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Figure 91.
Percutaneous stone dislodgement
from the mid ureter to the renal
pelvis with a balloon catheter. In
the pelvis ESWL was applied.
Vein sampling
Selective renal vein sampling provides a method of measuring the renin
level being secreted by each kidney.
Non-angiographic interventions
Nephrostomy
Percutaneous nephrostomy is the single most valuable interventional tech
nique in uroradiology. It relieves obstruction of the urinary tract and provides
access to the collecting system for a variety of diagnostic and therapeutic pro
cedures. The indications include: 1) Reliefof obstruction (preserve renal func
tion, treatment of infection, relieve pain), 2) Urinary diversion (heal leak or
fistula), 3) Diagnostic study (antegrade pyelography, Whitaker test, biopsy
or brushing for biopsy), 4) Removal of solid material (stone (Fig. 91), foreign
body), 5) Access for ureteral intervention (stricture dilation, stenting, ureteral
occlusion), 6) Infusion of chemolytic agents, and 7) Access for nephroscopy.
The procedure may be guided with fluoroscopy, ultrasonography (Fig. 92) or
CT; the combination of ultrasonography (guidance) and fluoroscopy (control
incl. placement) is the best. Either trocar technique or the Seldinger technique
may be used. With some experience and adequate equipment the success
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THE GENITOURINARY SYSTEM
Figure 92.
Percutaneous nephrostomy.
Under continuous real-time
ultrasonographic guidance a
posterior calyx is punctured
using either a trocar or
Seldinger technique. The tip o f
the needle is easily seen (ar
row).
Figure 93. Steps in percutaneous stent placement. After access to the renal collecting
system is gained through a nephrostomy, which has been in place fo r one to two weeks
a straight guide wire is passed through the region o f ureteral obstruction and into the
bladder. After dilatation a double-pigtail catheter is straightened and passed over the
guide wire. The pigtail catheter is advanced by a pusher until one end is in the bladder
and the other in the renal pelvis. When the guide wire is removed from the catheter,
the pigtail catheter acquires its desired shape. A nephrostomy catheter is left in the
pelvic cavity until it has been documented that the stent functions properly.
rate is above 95%. The most common complications are related to bleed
ing, urine extravasation and infection.
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Drainage
Both renal and non-renal retroperitoneal abscesses are particularly well
suited to percutaneous drainage. They can usually be approached poste
riorly during guidance with CT or ultrasonography such that peritoneum,
bowel, and other organs are not transversed. In most patients percuta
neous drainage results in cure and surgery can be avoided. The response
to percutaneous abscess drainage is seen within the first 24 to 48 hours.
The complications of percutaneous abscess drainage include bleeding,
spread of infection into a previously uninfected space, and exacerbating
bacteremia or sepsis during manipulation.
Biopsy
Percutaneous biopsy has become a common radiological procedure.
Using a variety of imaging modalities cutting needles provide tissue for
histological evaluation. Aspiration needles provide material for cy-
topathology and may be used to diagnose the primary tumor, but they
are commonly used to confirm the presence of metastases when the pri
mary tumor has been diagnosed previously. Fine needle histology biop
sies can also be obtained. They are used to diagnose the occurrence of a
primary tumor. Gross needle biopsy (18-20G) is used primarily for re
nal biopsy in patients suspect of having a medical renal disease in order
to obtain enough tissue for immunological diagnosis. The most common
complication of biopsy is bleeding. In about 60% of patients undergo
ing medical renal biopsy perinephric bleeding occurs, but it is rarely nec
essary to treat (transfusion, surgery) it. Arteriovenous fistulas occur in
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many patients but in nearly all patients they close within the next days.
If persistent, they can be embolized. Tumor seeding can not be excluded,
but it occurs rarely.
Ureteral occlusion
In patients with urinary leakage, which does not stop following urinary
diversion, ureteral occlusion can be performed either by inserting a bal
loon in the ureter or injecting embolizing drugs.
Anatomy
The normal prostate is formed like a pyramid with the widest part, the
base, which lies adjacent to the bladder, measuring approximately 4.5
cm in diameter. The apex lies adjacent to the membranous urethra (Fig.
16). The prostate is approximately 3.5 cm in length and weighs approx
imately 20 gram in healthy young men. At both ultrasonography and
MRI one can distinguish between the central gland, which consists of
the histological central and transition zones, and a peripheral zone. This
distinction is of great importance, since hypertrophy mainly originates
in the transition zone, which is the area around urethra above the veru-
montanum, whereas malignant tumors are most frequently found the pe
ripheral zone. Prostatitis can originate in any part of the prostate.
The normal testis measures approximately 4-5 x 3 x 2.5 cm and has
at both ultrasonography and MRI an homogenous structure. An inho-
mogeneous structure indicates occurrence of disease.
The penis consists of three cavernous bodies, a corpus spongiosum
which surrounds the urethra, and paired corpora cavernosa which lie dor
sal to the urethra (Fig. 16). The penis receives its blood supply from the
internal pudendal branch of the internal iliac artery.
Pathology
Diseases in the prostate occur frequently. For the most part, however,
the spectrum of diseases is limited to infection, hyperplasia and cancer.
Today prostate cancer is the most frequent cancer among males in North
America and parts of Europe.
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Figure 94.
Urethral obstruction due to BPH demon
strated at urethrography. Note the nar
rowed elongated prostatic urethra.
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Figure 95.
Prostate cancer.
a: Hypoechoic process on
transrectal ultrasonogra-
phy.
b: Ultrasonography is an ex
cellent method for biospy
guidance.
1 CM/DIV
Prostate cancer
Diagnostic imaging in prostate cancer includes primary diagnosis and
staging, but not screening. For the first purpose transrectal ultrasonog
raphy is suitable as the primary examination, since it may demonstrate
a hypoechoic area in the peripheral zone. However, hypoechoic
processes may also represent benign nodules and invasive rectal cancer.
Therefore, a biopsy must be taken from any suspicious hypoechoic area
(Fig. 95). In case of a normal transrectal ultrasonography prostate can
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Figure 96.
Low-signal prostate cancer
(arrow) in the left side o f the
peripheral zone. T2-weighted
image obtained with whole
body coil.
SE-210MgL^i
:L I h k T & O m ]
Figure 97.
Prostate cancer in the right
side. The cancer breaks
through the fibrous capsule
so it is a stage С cancer (ar
row). T2-weighted image ob
tained with an endorectal
coil.
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Figure 98.
"Super” bone scan demon
strating symmetrical in
creased uptake o f the radio
pharmaceutical with diffusely
metastatic disease due to
prostatic cancer. It is signifi
cant that the kidneys are not
seen due to extensive skeletal
deposition o f the radionu
clide.
Scrotal enlargement
Despite the fact that the scrotal contents including the testes can easily
be examined manually it may be difficult to determine the character and
cause of scrotal enlargement. The most important diagnoses are epi
didymitis, orchitis, abscess, hydrocele, spermatocele, varicocele (Fig.
99), testicular tumor, torsion and testicular rupture. Ultrasonography
with a 7 MHz probe is valuable in most cases, since it can distinguish
between solid and cystic lesions and determine whether the lesion is in-
tra- and extra testicular. In case of epididymitis an enlarged epididymis,
which is more echo rich than the normal epidydimis, containing small
cystic areas is found. In case of orchitis the testis is uniformly enlarged
with either an unchanged or slightly diminished echopattem. The ultra
sonographic signs of a scrotal abscess are similar to those of abscesses
in other organs. Testicular cancer breaks the homogenous echopattem of
the normal testis; more or less well demarcated areas are found in the
diseased testes (Fig. 100). There is no relation between the echopattem
including demarcation and the various cancers, although presence of
amourphous calcification should raise the possibility of teratoma.
Approximately one-half of the testicular cancers are seminomas; the re
maining cancers are embryonal cell carcinoma, teratoma, and teratosar-
coma and choriocarcinoma. In older men lymphoma is the most com
mon tumor. In case of diffuse infiltrating cancer the ultrasonographic
findings are nonspecific, but diffusely enlarged, hypoechoic (and pain-
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Figure 99.
Hydrocele (arrow), spematocele (arrowhead)
and varicocele (open arrows) at scrotal ultra
sonography.
Figure 100.
Testis cancer.
Ultrasonography demonstrat
ing echo poor tumor in the
right testis. Normal left testis.
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Figure 101.
Testis cancer. Signal poor process
in the left testis, whereas the right
testis has a high homogenous signal
on this T2-weighted image.
Testicular trauma
An echopoor area may be found by ultrasonography in a patient having
been subjected to a testicular trauma. This finding may to due testicular
bleeding and a hematoma in the surrounding tissues. MRI may be able
to demonstrate the rupture of the tunica albuginea.
Testicular torsion
Doppler ultrasonography is the most appropriate examination to perform
when testicular torsion is suspected. Demonstration of blood flow in the
mediastinum testis nearly always rules out testicular torsion, since the
torsion most frequently takes place in the spermate cord just proximal to
this level. Alternatively MRI or scintigraphy may be performed; the lat
ter will show a photon deficient area at the site of the torsed testes.
Impotence
In impotence of organic origin Doppler ultrasonography may be useful
for obtaining information about the arterial blood flow to the penis. If an
abnormally low blood flow is found, selective arteriography of the in
ternal pudendal arteries before and after papaverine are indicated to
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Figure 102.
Normal fem ale genitals. Sagittal T2-
weighted image demonstrating a normal
cervix with a central high signal intensive
stripe (the canal) surrounded by low sig
nal intensity due to fibrous tissue. The
uterine body has also a zonal structure
with a high signal centrally (endo
metrium), a thick outer myometrial zone
with an intermediate signal intensity, and
a narrow inner zone with low signal
intensity.
Intervention
Imaging guided intervention is limited to biopsy of the prostate - mainly
guided by ultrasonography (Fig. 95), dilatation/embolization of penile
arteries/veins in patients with impotence or priaprism and embolization
of varicoceles.
Anatomy
The uterine cervix is only partially available for visual inspection.
Transvaginal ultrasonography can show the border between the cervix
and the parametria. On T2-weighted MR images of the cervix two to
three zones are often seen (Fig. 102); it has for the major part a low sig
nal intensity because of its high fibrous structure. The cervical canal con
taining mucus and epithelial glands is seen as a central high signal in
tensive stripe. On Tl-weighted images the structure is homogenous and
it is possible to demarcate it from its surroundings.
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Figure 103.
Ovaries. Abdominal and
transvaginal ultrasonography
o f a normal ovary.
Transvaginal ultrasonogra
phy gives more details.
The size of the uterus depends on the hormonal state of the female. At
ultrasonography its echogenicity is homogenous with an echo rich cen
terline (the endometrium). On T2-weighted images the uterine body has
a typical zonal structure (Fig. 102). The central high signal intensity area
represents the endometrium. The myometrium has two different zones:
a thick outer zone with an intermediate signal intensity and a narrow in
ner zone with a low signal intensity, called a junctional zone. On T l-
weighted images the uterus has a homogenous medium signal intensity
structure and the outer surface is more clearly demarcated from the sur
roundings than on T2-weighted images. The uterus is often located an-
terior-superiorly to the vagina, but it may be even more anteflexed. It
may also be retroflexed or retroverted.
Visualization of normal salpinges requires direct injection of contrast
media. (Fig. 8). Sometimes the isthmic part is seen in the uterine cornua
at ultrasonography and MRI.
The ovaries may be located anywhere in the pelvic part of the abdomen.
Their size depends on the hormonal cycle. Following external hormonal
stimulation they may become very large. At ultrasonography (Fig. 103)
performed late in the menstrual cycle echo poor areas (follicles) are seen
in the ovaries, which already are somewhat hypoechoic. It is often diffi
cult to see normal ovaries at abdominal ultrasonography, whereas at trans
vaginal ultrasonography is often possible to identify one or two non-en-
larged ovaries. MRI is able to demonstrate normal ovaries in most women
of reproductive age. They appear as slightly heterogeneous masses, and
they are well delineated on axial, sagittal and coronal images. On T l-
weighted images they have a low to medium signal intensity difficult to
distinguish from the surrounding bowel loops; on T2-weighted images
they are often indistinguishable from the surrounding fat.
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Figure 104.
Cervical cancer.
a) Transverse T2-weighted image
demonstrating tumor invasion
into the right parametrium (ar
row).
b) T2-weighted image demonstrat
ing that the cervical tumor ex
tends into the uterine body,
where three leiomyomas (arrow
heads) were also present.
Pathology
Transvaginal ultrasonography has become an important supplement to
the traditional gynecological examination of the uterus and its adnexae.
Structures larger than 6 cm may be overlooked at transvaginal ultra
sonography. Therefore both transvaginal and transabdominal ultra
sonography should always be performed.
Cervix
Correct staging of cervical cancer is of utmost importance because it is
decisive for the choice of treatment. A patient with stage lb cancer (con
fined to cervix) can undergo surgery, whereas a patient with stage Ila is
better treated with radiotherapy. Radiotherapy of a recently operated re-
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THE GENITOURINARY SYSTEM
Figure 105.
Multiple cervical ovula nabothi in a
patient with stage I endometrial
cancer o f the uterine body.
Figure 106.
Bicornuate uterus. T2-weighted im
age showing two areas with high
signal intensity.
loil: Sm all_8ody
S 1500/40
Uterus
Uterine anomalies have been reported to be best delineated on MR-im-
ages (Fig. 106). They can best be evaluated with a combination of T2-
weighted axial and sagittal images. The diagnostic capability of MRI
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Figure 108.
Endometrial cancer stage II. Total disappearance o f the zonal structure and occur
rence o f necroses.
a) T2-weighted image.
b) Tl-weighted image after administration o f gadodiam ide.
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Figure 110.
Malignant ovarian tumor. T l-
weighted image after adminis
tration o f gadodiamide. Solid
mass (arrows) whose signal
intensity increased after appli
cation o f contrast medium and
a major cystic part which had
a moderate signal intensity
unchanged after administra
tion o f contrast medium.
higher signal intensity than that of the myometrium and cervix. The over
all accuracy of MRI for stage I and II is higher than that for clinical ex
amination and CT. The use of MR-contrast medium improves the accu
racy of staging (Figs. 105, 108). As regards stage III and IV MRI is not
more accurate than CT. MRI seems also to be useful to control the ef
fect of chemotherapy. With the use of MRI (and CT) intravenous urog
raphy and bowel X-ray for indirect demonstration of invasion are no
longer indicated.
Ovaries
A torsed ovary can be diagnosed with Doppler ultrasonography demon
strating absence of blood flow in the ovary. Ovarian tumors - even the
malignant ones - are often asymptomatic for a long time. Normally it is
possible by ultrasonography to measure the size of the ovaries (the larger,
the higher the risk for malignancy) and determine whether the process
is solid and/or cystic. The flow pattern determined by color Doppler can
give some indications about whether the mass is benign or malignant.
The MRI appearance of ovarian tumors (Figs. 109, 110) can vary con
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Figure 111.
Recurrent ovarian tumor (ar
row) close to the enhancing
uterus.
Figure 112.
Peritoneal carcinomatosis.
Tl-weighted image after ad
ministration o f gadodiamide
demonstrating high signal
intensity tissue around the
bowel (arrow) and ascites
(arrowhead). The bladder is
displaced to the right.
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Figure 113.
Tubo-ovarial abscess.
Ultrasonography shows an
echo poor septated process
close to the uterus (U).
Figure 114.
Endometriosis. T2-weighted
image showing signal intensive
and signal poor cystic
processes.
Adnexa
In the adnexae fluid collections, hematomas, abscesses (Fig. 113) and
endometriosis (Fig. 114) may occur. Transvaginal ultrasonography is ex
cellent for the diagnosis (mainly echopoor areas) and treatment of the
three first diseases. Abscesses from bowel diverticula and inflammatory
bowel diseases may be difficult to differentiate ultrasonographically
from diseases in the adnexae. In case of an uncertain ultrasonography
primarily MRI and secondarily CT should be performed. At MRI in
fected cystic masses have longer Tl and T2 relaxation times than hem
orrhage. On T2-weighted images they have a high signal, but their ap
pearance can vary considerably. Endometriosis presents various types of
lesions. Large endometrial cysts or endometriomas have very variable
features. They undergo cyclic bleeding during the menstrual cycles.
Neither ultrasonography nor MRI can exclude the occurrence of en
dometriosis, but the sensitivity of MRI is higher than that of ultra-
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Figure 115.
Extra pulmonary small cell cancer
occupying the pelvis and displacing
a normal cervix and uterine body
cranial T2-weighted image. The
anatomy is well demonstrated on this
sagittal image.
Figure 116.
Hydrosalpinx.
Hysterosalpingography demonstrat
ing a closed and dilated right am-
pullary end.
sonography.
In rares cases tumors like extrapulmonary small cell cancer and sar
comas may arise from the connecting tissue. MRI is superior compared
to both CT and ultrasonography in the work-up of these rare malignan
cies (Fig. 115).
Infertility
For evaluation of infertility primarily ultrasonography and secondarily
MRI should be performed to exclude anomalies and cystic ovaries. The
next step is hysterosalpingography, which can demonstrate congenital
anomalies, processes in the uterine cavity and postinflammatory changes
of the salpinges and the peritoneal cavity. A typical finding is bilateral
sactosalpinx (hydrosalpinx) (Fig. 116), in which case the ampulary ends
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Figure 117. Anatomic relations o f the adrenal glands and arterial supply.
are closed and dilated; sometimes minor adhesions may be broken dur
ing the examination.
Intervention
Biopsy and diagnostic puncture are performed under imaging guidance.
Included is also oocyte aspiration for in-vitro insemination. It should be
remembered that transvaginal punctures nearly always are very painful.
Selective catheterization of the salpinges can be performed through the
uterine cavity. Thereby, some occlusions of the isthmic part of the salp
inges can be reopened. The technical success rate is between 80 and 90%
and the pregnancy rates are around 30%. Also balloon dilatation of
stenotic portions of the salpinges is possible.
ADRENALS
Anatomy
Along with kidneys, the adrenal glands lie within the perinephric space
(Fig. 117). In most patients, there is sufficient perinephric fat so they are
easily seen on CT. The right adrenal glands lies anteromedial to the up
per pole of right kidney and immediately posterior to the inferior vena
cava. The left gland is anteromedial to the upper pole of the left kidney
and posterior to portions of the splenic vein and artery. The right adrenal
gland consistently extends above the upper pole of the kidney while the
left is more often at the level of the left upper pole and extends to the re
nal hilus. Both adrenal glands have an inverted Y configuration with the
tail of the Y pointing anteromedially. The adrenal glands weigh only
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about 5 g each and vary from 3 to 6 mm in width. The small size makes
it difficult to distinguish between a normal or an atrophic or hypoplastic
configuration.
The best imaging modality for the study of the adrenal glands is in
most instances CT. In medullary disease scintigraphy is very useful es
pecially for localization of aberrant tissue along the sympathetic chain
in the retroperitoneum. It should be remembered that ultrasonography
can not exclude adrenal pathology; it can only confirm its presence. MRI
is also excellent for adrenal imaging and offers unique advantages (see
below).
Pathology
Adrenal diseases are often divided into two major groups: functional (hy
per and hypo) and non-functional diseases. Since adrenal hormones can
be readily measured, there is seldom doubt as to which category a pa
tient belongs.
Cushing's syndrome
Cushing's syndrome is the manifestation o f excess glucocorticoids.
These steroids may come from either exogenous or endogenous sources.
Endogenous Cushing's syndrome is due to overproduction of cortisol by
the adrenal cortex. This can be due to an autonomous adrenal tumor, be
nign or malignant, or due to adrenal hyperplasia from unregulated ACTH
production. The most common etiology of Cushing's syndrome is bilat
eral adrenal hyperplasia, which accounts for approximately 70% of
cases. A few of these patients have macronodules, which can be demon
strated by CT. These macronodules measure less than 3 cm and may be
less than 1 cm in diameter. Macronodular hyperplasia is due to an ACTH-
secreting pituitary microadenoma in the majority of cases. A benign but
autonomous adrenal cortical adenoma is the etiology of 20% of cases of
endogenous Cushing's syndrome, and a primary adrenal cortical carci-
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Figure 118.
Adrenal tumor (aldos-
teronoma). Ultrasonography
demonstrates a small echo
poor tumor cranially to the
right kidney in a patient with
Conn's syndrome.
Conn's syndrome
Conn's syndrome, or primary aldosteronism, is the result of excess al
dosterone produced by the adrenal glands. As with Cushing's syndrome,
it may be caused by either adrenal hyperplasia or a primary adrenal tu
mor. A benign but unregulated aldosterone secreting adenoma is the most
common etiology of primary aldosteronism, being responsible for almost
80% of cases, while hyperplasia is responsible for nearly all of the re
mainder (Fig. 118). Cortical carcinoma accounts for less than 1% of
cases. Aldosteronism also occurs in patients with renovascular hyper
tension. However, this form of secondary aldosteronism is distinguished
from primary aldosteronism by measuring the serum renin which is low
in Conn's syndrome.
Adrenogenital syndromes
Adrenogenital syndromes are the result of an inborn error in the adrenal
enzyme which blocks or impairs the synthesis of cortisol or aldosterone
and are manifest at birth. Androgen-producing (virilizing) tumors are
rare, may be benign or malignant, and occur in either males or females
at any age. Feminizing tumors are even less frequent.
Addison's disease
Adrenal insufficiency may result from inadequate stimulation by ACTH
(secondary) or may be due to tissue destruction of the adrenal glands
(primary). Primary adrenal insufficiency, or Addison's disease, occurs
only after at least 90% of the adrenal cortex has been destroyed.
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Figure 119.
Adrenal metastases from lung
tumor. Large process cranial
to the kidney with mixed
echogenicity. Biopsy showed
metastases from lung tumor.
Figure 120.
Adrenal cortical carcinoma
displacing the right kidney
centrally. Mixed enhance
ment after administration o f
contrast medium indicating
central necrosis.
Idiopathic adrenal atrophy is the most common cause and is most likely
an autoimmune disorder. Destruction can also be due to granulomatous
disease, usually tuberculosis. However, other causes such as infarction,
amyloidosis, hemochromatosis, hemorrhage, or destruction by histo
plasmosis, blastomycosis, disseminated fungal infection, lymphoma,
and metastatic tumor are possibilities. The radiographic manifestations
of adrenal insufficiency depend on the cause of adrenal dysfunction.
Calcifications caused by tuberculosis or histoplasmosis made be seen on
plain abdominal radiographs, but the most useful examination is CT,
since it not only demonstrate calcifications but also the size and shape
of the adrenal glands.
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THE GENITOURINARY SYSTEM
Pheochromocytoma
Pheochromocytomas are tumors comprised o f chromaffin cells and are
usually located in the adrenal medulla. Extraadrenal pheochromo-cy-
toma (paragangliomas) may lie anywhere between the base of the brain
and the epididymis but usually lie along the symphatic chain in the
retroperitoneum. They are rare tumors and account for less than 1% of
patients with systemic hypertension. Classically the hypertension is
paroxysmal, but it may be sustained and of any magnitude.
Approximately 13% of all pheochromoctymas are malignant.
Pheochromocytomas may be associated with other endocrine tumors or
with von Hippel-Lindau syndrome and neurofibromatosis. The multiple
endocrine neoplasia (MEN) syndrome, Type 2 A, includes medullary car
cinoma of the thyroid and parathyroid hyperplasia as well as pheochro
mocytoma. The MEN syndrome, Type 2B, is comprised of pheochro
mocytoma, medullary carcinoma of the thyroid, and the mucocutaneous
manifestations of mucosal neuromas, intestinal ganglioneuromatosis,
and a marfanoid habitus. The majority of patients with MEN 2A or 2B
syndromes have pheochromocytomas that are bilateral and almost al-
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Figure 121.
Malignant phaeochromocytoma.
1231 MIBG scintigraphy.
a) Normal
b) Large process at the site o f
the right adrenal gland.
c) Lung metastases taking up the
radiopharmaceutical.
d) Metastases behind the blad
der.
1212
THE GENITOURINARY SYSTEM
Figure 122.
Incidentaloma. Small low at
tenuating process in the left
adrenal gland found inciden
tally in an asymptomatic p a
tient. This probably represents
an adenoma.
Adenoma
Benign, nonhyperfunctioning adrenal adenomas are commonly encoun
tered on abdominal CT examinations (Fig. 122). Typically it is a well-
defined, rounded, homogenous mass; calcification, central necrosis or
hemorrhage occur rarely. MRI may be used to distinguish the adenomas
from metastases since metastases typically has a higher signal on T2-
weighted images. Most adenomas contain lipid and can be identified my
MRI fat-detection technique. Large adenomas can be detected by ultra
sonography, which then is useful to distinguishing solid tumors from
cysts. Sometimes smaller lesions can be found especially if associated
with endocrinopathy.
Carcinoma
Primary adrenal cortical carcinoma in an uncommon malignancy with a
median age at presentation in the fifth decade. The typical CT-appear-
ance is a large mass with central areas of low attenuation representing
tumor necrosis (Fig. 120). Often calcifications are seen. Evidence o f he
patic or regional lymph node metastases as well as venous extension are
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Figure 123.
Adrenal cortical carcinoma. T l-
weighted image demonstrating a
moderately signal intensive process
cranial to the right kidney.
Myelolipoma
A myelolipoma is a hamartoma comprised of mature adipose cells and
hematopoetic tissue. CT is the most definitive radiographic examination.
A fatty adrenal mass is virtually diagnostic of a myelolipoma. MRI does
not add anything. Ultrasonography will show a highly echogenic mass.
Small islands of calcium or even bone formation are sometimes present.
Hemorrhage
Adrenal hemorrhage may be spontaneous, traumatic, or related to anti
coagulation. Spontaneous hemorrhage often occurs in patients with sep
ticemia, hypertension, renal vein thrombosis, or adrenal pathology such
as a tumor. Again CT is the most reliable method of diagnosis. Initially
the hematoma has a high attenuation. Follow-up studies usually show re
sorption of the hematoma and a gradual decrease in density to near wa
ter. Also MRI appearance will reflect the evolution from acute to chronic
stages with hemoglobin breakdown; initially high signal at both Tl - and
T2-weighted sequences. If detected, the echogenicity at ultrasonography
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THE GENITOURINARY SYSTEM
Cysts
Adrenal cysts are uncommon and their detection does not differ from di
agnosis of cysts in other organs. Some adrenal cysts are probably the
residua of old hemorrhage ("pseudocysts”).
Hemangioma
Adrenal hemangioma is a rare tumor of the adrenal cortex and does not
differ from hemangiomas of other organs. The CT-appearance depends
on tumor morphology. Typically, a large mass with a thick irregular wall
and hypodense center is seen. Ultrasound demonstrates a complex mass
and may reveal cystic areas.
Metastases
The adrenal glands are a common site of metastatic disease. Of patients
with an epithelial malignancy 27% will have adrenal metastases with
time. Figures for patients with breast cancer and lung cancer are 54%
and 36%, respectively. The radiographic appearance of adrenal metas
tases is unspecific. They may be small, unilateral or bilateral. A metas
tases is a solid mass on ultrasound, and when less than 3 cm in diame
ter, is usually homogenous, whereas in larger lesions central necrosis and
hemorrhage may occur. CT features suggesting malignancy includes a
large size (> 3 cm), poorly defined margins, invasion of adjacent struc
tures, inhomogenous attenuation, and a thick irregular enhancing rim.
Evidence of widespread metastatic disease makes the diagnosis easier.
MRI demonstrating a high signal on the T2-weighted images is also help
ful. However, the definitive method is still percutaneous aspiration
biopsy.
Lymphoma
Involvement of the adrenal gland by malignant lymphoma is more com
mon with non-Hodgkin lymphoma than Hodgkin's disease. The adrenal
glands are seldom an isolated site of disease, although other involvement
may be distant. Adrenal lymphoma can be diagnosed by ultrasound, CT
and MRI. On US, lymphoma appears as a well-defined, relatively
echogenic homogeneous tissue mass. However, CT provides the best
morphologic delineation. The adrenal glands are enlarged with either a
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Intervention
The most frequent interventional procedure on the adrenals is percuta-
neoues aspiration biopsy. Cyst aspiration is rarely performed. The most
worrisome complication is precipitation of a hypertensive crises by a
pheochromocytoma.
The arterial supply to the adrenal glands comes from many feeding ar
teries. In contrast each adrenal gland is drained by a single vein. This
fact make the adrenal glands suitable for venous sampling.
1216
Chapter 26
Obstetric imaging
Con Metreweli
There is no doubt that in the last twenty years obstetric diagnosis has
been dominated by ultrasound. It is such an essential tool for the obste
trician that apart from a few centres, obstetric ultrasound is mostly out
of the hands of radiologists. Obstetricians and gynaecologists have been,
and are, leading the way with ultrasound applications and development.
One has only to look at transvaginal US (TVUS), colour flow imaging
(CFI) and pulsed doppler and 3D imaging to realise that in its obstetric
applications US is being pushed to its limits.
There is a danger that obstetricians, having so much satisfaction and
control with US, will miss out on the latest upcoming developments es
pecially as there are few radiologists interested in obstetric imaging. For
this reason, this chapter is biased towards a radiologist's point of view
rather than an obstetrician's in the hope that radiologists currently min
imally involved will rekindle their interest in this field.
MODALITIES
The imaging technologies that may be used in obstetric practice are:
Ultrasound (US)
Transvaginal ultrasound (TVUS)
Colour Flow Imaging (CFI)
Conventional Radiography (X-ray)
Computed Digital Radiography (CDR)
Computed Tomography ICT)
Magnetic Resonance Imaging (MRI)
Ultrasound (US)
Sometimes termed conventional, or transabdominal, ultrasound is the
most widely available and most used imaging technique in obstetrics. It
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1218
OBSTETRIC IMAGING
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APPLICATIONS
Diagnostic imaging in pregnancy fulfills two major requirements. The
first and numerically most frequent is in screening and monitoring the
pregnancy and the second is in assisting in diagnosing the complications
of pregnancy.
1220
OBSTETRIC IMAGING
Fetal abnormality
The demonstration of fetal abnormality involves radiologists, as well as
radiographers and obstetricians. Radiologists should be able to contribute
significantly in this field with their experience in imaging and anatomy
and with MRI looming on the horizon as a powerful supplementary tech
nique for the fetus. However, as diagnosis of fetal abnormality is gener
ally less useful towards the end of pregnancy there has been great pres
sure to make the diagnoses earlier. This is not surprising, as all major
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Fetal well-being
The majority of findings in routine antenatal US tend to show the end re
sult, of what has happened to the fetus in its intrauterine environment up
to that point of time. The aim of fetal well-being studies is more to pre
dict what is likely to happen in the future o f that pregnancy based on
mainly physiological parameters. Such studies of fetal physiology in
volve the considerable use of Doppler wave form studies, and available
time. As radiology is a shortage speciality and this territory appears to
be the prerogative of the obstetrician it will not be mentioned further
here.
Complications of pregnancy
The complications of pregnancy that are most likely to require the ser
vices of the radiologist, and the techniques that may be potentially use
ful, are:
Threatened abortion
The radiologist may be requested to investigate PV bleeding with or with
out pain in early pregnancy. The common causes will be pseudomen
struation with a viable pregnancy, ectopic and molar pregnancy (see be-
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OBSTETRIC IMAGING
Figure 1.
A 3D US o f a living em
bryo within its gestation
sac next to an aborting
twin (asterisk). The umbi-
cal cord (arrowhead),
limb buds (small arrows)
and yolk sac (large ar
rows) o f the living twin
are clearly visible.
low) aborting twin (Fig. 1), missed abortion, and incomplete abortion.
Crucial to the management of such cases is the necessity to demon
strate a living embryo or fetus in a healthy gestation sac. This is achieved
by demonstration of what is usually termed fetal heart motion (strictly
speaking, it should be embroynal heart motion). If this can be demon
strated the chances of a successful ongoing pregnancy will be between
90-97%. It is usually clearly visible and there is no need for M-mode
scan or Doppler other than for documentary proof.
Ectopic pregnancy
The presence of an ectopic pregnancy can now be very confidently es
tablished even without the necessity to measure serum HCG although
this is still a useful adjunct.
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If there is still doubt, measure the serum HCG. If the HCG level exceeds
1,800 MIU per ml there should be an intrauterine sac visible with TVUS.
Go back and recheck. If still negative a follow-up of HCG and TVUS
must be performed. Copious blood in the cul de sac is a late sign! If doubt
still remains, the gynaecologist/obstetrician will get fed up and do a la
paroscopy!
Early diagnosis of ectopic pregnancy allows for non-surgical interven
tional treatment with TVUS guided direct injection of Methotrexate into
the ectopic sac.
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OBSTETRIC IMAGING
mal in 12 weeks or still remains high or begins to rise again, and if there
is a persistent corpus luteum cyst, TVUS and CFI is again essential to
seek the site of remaining trophoblast. A chest x-ray is necessary to ex
clude lung metastases.
The conventional gray scale image may appear to be normal or only
mildly abnormal but CFI invariably reveals a wealth of unsuspected ves
sels indicating the presence and location of persistent trophoblast/chori-
ocarcinoma.
Fetal abnormality
There are now excellent reference texts concerned with fetal abnormal
ity and virtually half of the subject matter in obstetric ultrasound texts is
devoted to this subject. It would be impossible to do justice to the sub
ject in just a few pages, but some general observations and comments
are pertinent.
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Figure 2.
Acrania. Free floating
brain is seen above a mi-
croopthalmia (arrow).
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OBSTETRIC IMAGING
Figure 3.
a) Transverse scan o f a fe
tal abdomen (19 weeks
GA) with a choledochal
cyst (arrow).
b) Longitudinal scan show
ing the sinus venosus an
terior (arrowhead) and
IVC posterior (arrow) to
the choledochal cyst.
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OBSTETRIC IMAGING
Figure 4.
3D US o f a fetal face.
such as echo planar sequences suffer from a relativley limited spatial res
olution and therefore may not be suitable for some organs. Because of
the rapid rise times and high gradients heat deposition will be high but
this can be balanced by the shorter scan time. Transmitted maternal aor
tic pulsation can be minimised by placing the mother in a decubitus po
sition. The fetal brain has a high water content providing some further
constraints to MRI diagnosis, especially as there has been a greater in
terest in the fetal brain than other parts.
The reported experience does appear to be clustered into the last
trimester and is invariably supplementary to an echographically dis
closed abnormality. In some of these cases there were doubts and diffi
culties (consistent with group g) above). There is generally reasonable
agreement between MRI and US but in certain cases MRI does add fur
ther information of clinical value, and is likely to become an important
supplementary technique.
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OBSTETRIC IMAGING
Placenta praevia
Placenta praevia occurs in about 0.5% of all pregnancies. US is already
very accurate in determining placental site and the presence of placenta
praevia and is therefore the technique of first choice.
The conept of placental migration and possible confusion caused by
an overfilled or underfilled bladder are well known but there are about 5%
pregnancies in which it may be difficult to establish placental location
relative to the external os with confidence. These are: the obese mother,
posterior location of placenta and intervening fetal head, vasa praevia,
and the rare but potentially fatal placenta accreta and percreta.
In these situations further investigation prior to delivery are now avail
able. The most easily available would be TVUS.
The probe is introduced gently with on-screen guidance to avoid im
pacting the cervix. The uterus is examined from positions in the vaginal
fomices. With the addition of CFI it is easy to identify placenta cover
ing the internal os, and marginal vessels covering the os. Obliteration of
the placental myometrial line and high flow venous lakes within the pla
centa suggest placenta accreta.
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Figure 5.
Transverse scan o f an
early viable pregnancy
with a large complex
mass with thick septae
behind the uterus.
Claims have also been made for the value of MRI in such situations,
but as yet there has not been any study comparing the value of TVUS
and CFI with MRI.
On cost and availability it would seem that US, TVUS and CFI is suf
ficient.
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OBSTETRIC IMAGING
Eclampsia
MRI has not only provided another non-ionising radiation type of imag
ing diagnosis, but has its own unique information to reveal. In obstetrics
this has been very true in studies of eclampsia and preeclampsia.
Pregnancy induced hypertension can result in headache, confusion,
raised intracranial pressure and coma, visual loss and paralysis from cere
bral hemorrhage with long term morbidity. Early diagnosis and appro
priate treatment is essential in these previously healthy women.
Women with preeclampsia may show hyperintense signals on T2-
weighted images in the deep cerebral white matter. Those with eclamp
sia show increased signal at grey matter junctions, cortical oedema and
haemorrhage especially in the region of the posterior cerebral circula
tion.
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PELVIMETRY
Conventional standing lateral pelvimetry means a very high radiation
dose with increased risk of subsequent malignancy in the fetus. However,
it is still thought to be of value in cases where trial of labour for breech
presentation is being considered or cephalopelvic disproportion is sus
pected.
Pelvimetry can be obtained with digital radiography or CT with a de
sirable dose reduction, or with MRI. With CT, both sagittal and AP views
can be obtained (Fig. 6 a, b). Dose reductions are typically around 10%
of conventional radiography with fast film screen combinations.
However, accuracy can only be achieved with protocols for the most
ideal window and level settings and proper trraining in interpretation.
This should be done by the radiologist. Obstetricians not being used to
CT often misplace the calipers.
Pelvimetry using MRI should observe the heat related hazards men
tioned previously, but when available MRI is now the method of choice.
Fetal movement does not blur the landmarks and therefore there is no
need for fetal sedation (Fig. 7).
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OBSTETRIC IMAGING
Figure 6.
CT pelvimetry
a) Lateral view showing outlet measure
ment
b) AP view fo r maximum transverse diam
eter o f the inlet
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Figure 7.
M RI pelvimetry with ЛР inlet
and outlet measurements.
1236
Chapter 27
Tropical diseases
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live there, or who have never visited that part of the world. When re
viewing the diagnostic images of someone who has visited or lived in
the tropics, it is essential to know not only where they come from, but
also how long they were there. Most o f the tropical diseases are due to
infections or parasites and there is a variable delay before they become
clinically obvious. The pattern also depends on the stage of the disease
and the general health of the patient.
The radiologist should have as much information as possible about the
results of the laboratory tests for the individual patient, particularly in
travellers who have returned home after visiting the tropics. There are
too many specific diagnostic tests for each infection for them all to be
included here, but there is one which is useful for screening when a par
asitic infection is suspected. In the acute stage, the invasion or multipli
cation of so many parasites often causes a marked peripheral
eosinophilia. Any patient with a strange infection or an unusual abnor
mality on a radiograph or ultrasound scan, who has just been to the trop
ics and who has a raised eosinophil count, is not likely to have one of the
more commonM western diseases". Unfortunately, this is not absolute and
the differential cell count may be normal. As is necessary for every di
agnostic interpretation, the whole clinical picture must be taken into ac
count. What also makes it more difficult is that many patients who live
or have lived in the tropics will suffer from multiple diseases. Parasitic
infection may almost be a normal state, and the illness which brings them
to their doctor may be added onto, or be an acute exacerbation superim
posed on several other less obvious infections. And, to complicate the
diagnosis even further, laboratory findings may be misleading, because
normal levels are not the same in every part of the world, while high im
munological titres may indicate a past infection not relevant to the pre
sent illness.
If the patients bring images with them, extract as much information
from them as possible, even if the quality is not ideal. Imaging facilities
vary enormously throughout the world, but there is usually some useful
information even in a poor film or scan. Do not put poor quality images
aside as unhelpful: compare them with the current findings. You and your
patient may need all the help you can get!
In a global textbook such as this, it is not possible to provide a detailed
account of the epidemiology, and life history of the many tropical dis
eases, nor can they all be included. Some have no radiological interest,
1238
TROPICAL DISEASES
AMOEBIASIS
Infection with the pathogenic protozoan, Entamoeba histolytica, occurs
worldwide and at all ages. Once known as amoebic dysentery, almost
any part of the body can be infected, including the skin and the lungs. In
some patients the colon and liver escape or show no clinical evidence of
infection. A normal gastrointestinal tract certainly does not exclude
amoebiasis. There are numerous strains ofE. histolytica, which are non-
pathogenic and others which are found as commensals. Amoebiasis may
be non-invasive. Infection is acquired through contaminated food or
drink, and is particularly prevalent where sanitation is poor. It is proba
ble that flies and other insects also spread the disease.
There is a wide spectrum of clinical presentation. An amoebic infec
tion may cause either severe, acute illness or chronic ill health. Many pa
tients have a history of diarrhoea, but in contrast some patients are con
stipated. Acute amoebic dysentery presents with frequent loose, blood
stained stools, colic, tenesmus and in many cases, severe systemic illness.
Chronic amoebic dysentery may cause ill health, yet the colonic symp
toms may not be striking. Pain is usual in the right lower abdomen, and
the liver may become enlarged and tender. Children may present with
intussusception, adults with intestinal obstruction. Some patients will
complain of cough and have symptoms of pneumonia with a pleural ef
fusion, but no symptoms referable to the bowel.
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a) An amoebic infection distorting the caecum and causing mild ileocecal obstruction.
There is a "skip” area o f colitis at the splenic flexure and probably another in the
descending colon. (Nigeria)
b) Amoebiasis causing constriction in the proximal transverse colon and at the ileo-
coecal junction (Amoeboma). There are areas o f ulcerating colitis just below the
splenic flexure and ju st above the sigmoid colon. (Nigeria)
c) Severe and extensive amoebic colitis, with spasm o f the descending and sigmoid
colon. There is shortening and ulceration o f the caecum and ascending colon: the
terminal ileum is dilated. (Nigeria)
d) Late stage o f amoebic colitis. The colon has become smooth, with decreased haus-
tration, particularly the rectum and sigmoid. (Nigeria)
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TROPICAL DISEASES
and there is usually reflux into the terminal ileum. There may be in
flammatory pseudopolyps (Fig. 1 a). Ultrasound will show the thicken
ing of the wall of the right colon and as the diseases progresses, there
will be a pericaecal mass. It is important to examine carefully the whole
colon, because amoebic bowel infections often occur at several differ
ent sites, with intervening normal areas of bowel (Fig. 1 a). Only in
Crohn's disease, tuberculosis and lymphoma are similar multiple sites
likely. When the infection is acute and severe (fulminating amoebic col
itis), the colon may be very dilated, resembling the toxic megacolon
which is seen in ulcerative colitis: perforation or haemorrhage may oc
cur. Fortunately, ulcerative colitis is rare in many parts of the world,
which helps the differential diagnosis, but careful mucosal biopsy is nec
essary if surgery is considered. In less severe cases, there can be coarse
mucosal thickening throughout the length of the colon, with pericolic ex
tension due to fistulae. Involvement of the small bowel, or extension to
the bladder or skin, can occur but is uncommon. In the later stages the
caecum becomes contracted, often with shortening of the ascending
colon. Fibrosis during healing can result in a smooth, narrow, rigid colon
(Fig. Id).
Amoeboma
Amoebic infection can cause an amoeboma, which is a localised hyper
plastic granulomatous reaction, usually in the colon, but sometimes in
the ileum (Fig. 1 b). This causes a large mass with central stenosis which
closely resembles a carcinoma. Again, geography is important, because
cancer of the colon is rare in many parts of the world and an amoeboma
is often the more common cause of such a tumour. However, amoeboma
are also geographically variable, being common in some regions and rare
in others. Diagnostically, the demonstration of another area of colitis
elsewhere in the bowel makes an amoebic infection more likely than a
tumour. Unfortunately, neither ultrasound nor any other form of imag
ing can reliably distinguish between a carcinoma and an amoeboma; rec
tal biopsy followed by a short period of antiamoebic treatment may pre
vent unnecessary surgery (which can be dangerous with any severe amoe
bic infection).
Infants and children are not spared any of these varieties of amoebia-
sis, and, in addition, intussusception may be caused by the rigidity or
swelling of a segment of amoebic bowel. Reduction by any form of in-
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1242
TROPICAL DISEASES
Figure 2.
Amoebic liver abscess.
a) I f ultrasound or other scanning is not
available, a liver abscess can be
demonstrated by intravenous high
dose contrast infusion, with tomogra
phy. This large amoebic abscess
shows a well marked peripheral, hy-
pervascular inflammatory rim.
(Kenya)
b) A liver abscess shown by ultrasound.
(Kenya)
c) A CT scan o f an amoebic abscess at an early stage, with poor edge definition
(arrowheads). (Pakistan)
d) The abscess becomes more clearly shown (arrows). (Pakistan)
e) Amoebic abscesses in both lobes o f the liver. (Pakistan)
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Figure 3.
Amoebiasis in the chest.
a) An amoebic hepatic abscess causing a raised right diaphragm with pleural effusion
and right lower lobe oedema and infection. (Kenya)
b) An amoebic hepatic abscess causing a subphrenic abscess, elevation o f the right di
aphragm, right pleural effusion and lower lobe oedema. (Egypt)
c) A large right amoebic empyema with raised right diaphragm and right lower lobe
consolidation, all due to an amoebic abscess in the liver. (Nigeria)
fore there will be positive results with ultrasound. After treatment the
abscess may heal completely over a period of months, or may leave a
scar which may calcify eventually. If untreated or unresponsive (or sub
ject to trauma) the abscess may rupture into the biliary tract or peri
toneum, pericardium or chest. It is extremely difficult to distinguish be
tween amoebic and pyogenic abscesses in the liver with any form of
imaging. The early lesions may suggest hepatoma or even hepatitis or
haematoma. Aspiration may be necessary, or the result of specific treat-
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TROPICAL DISEASES
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SCHISTOSOMIASIS (BILHARZIA)
This infection with one or more of four different species of parasitic blood
flukes (trematodes) is one of the most common and widespread diseases
suffered by humanity. The life cycle o f the fluke requires warm water
and a specific snail, so the disease is only acquired in the tropics. If
brought back by travellers into colder climates, further spread of the in
fection is unlikely. Schistosomiasis is endemic in many tropical coun
tries: at least 200 million persons are infected, together with other pri
mates and many mammals. How much cross-infection occurs between
human and other species is debatable.
The life cycle is of clinical significance, and complex. Infection may
occur without the patient being aware that it has happened. It starts with
an infected snail, which, together with the schistosome sporocyst can tol
erate several dry weeks. The snail is normally in water which must never
fall below 15° C, and should be placid, stagnant or slow moving. Any fresh
water in the tropics, natural or artificial, may be part of the life-cycle.
Under the stimulus of sunlight, the snails release larval cercaria, which
penetrate the bather’s skin, unrecognized except perhaps for irritation and
erythema which may last for a few days - the "swimmer's itch". Often
this is thought to be "sunburn". Then the larvae take a 10-21 day mi
gration by way of the lymphatics and thoracic duct, the heart and the
lungs until the portal system is reached and maturation starts. Copulation
occurs only in the liver, where a pair of flukes may live 15-20 years or
more. The adults do not multiply in man but do not waste their time: de
pending on the species, one pair may produce from 300 to 3000 eggs per
day. These are swept away to their predestined site, e.g. for S. haemato
bium, the walls of the urinary bladder and ureters. This selective distri
bution explains the clinico-pathological disease patterns for each type of
schistosomiasis.
The flukes are strictly intravenous parasites and cause no clinical dis
eases while alive (if one can ignore all those ova). Dead worms embolize
and cause a granulomatous reaction. No organ escapes. Granulomas are
also caused by the ova. Most ova die and calcify, which is why organs
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Figure 4.
Acute schistosomiasis: the
Katayama stage. There are in
creased interstitial and vascular
markings in both lungs and mild hi
lar lymphadenopathy. (China)
1248
TROPICAL DISEASES
a b
Figure 5. S.haematobium
a) The bladder is full, the ureters show strictures and dilatation.
b) After micturition the bladder is empty but strictures in the lower ureters cause
ureteric dilatation and delayed emptying. (Nigeria)
S. haematobium
Schistosomiasis haematobium mainly involves the urinary tract.
Haematuria may be the first clinical indication, apart from tiredness and
generalized ill health. All the early imaging findings are in the urinary
tract. Plain radiography at this stage is not helpful, and ultrasound is very
dependent on the skill of the observer. A contrast urogram may show
persistent filling of the lower segment of the ureters (Fig. 5). Careful ul
trasound scanning may show thickening and nodularity of the ureteric
walls. Next, the lower ureteric segment becomes dilated, due to con
striction within the bladder wall. These early changes, although mini
mal, are important because they can still be reversed by treatment.
In the next stage the lower ureters are shown by contrast urography or
ultrasound to be nodular, beaded or irregularly dilated. As these changes
progress, the dilatation may affect the whole ureter or be segmental, usu
ally most marked at 2-5 cm above the bladder. Multiple strictures and
dilatations then develop, always bilateral but seldom symmetrical (Fig.
6 a). At this stage, fine ureteric calcification may be seen radiographi-
cally and on ultrasound (Fig. 6 b). Later, these calcified areas coalesce
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Figure 6.
S. haematobium
a) Markedly dilated ureters with lower
third strictures. There is calcification
in the walls o f the bladder. (Nigeria)
b) This heavily calcified bladder has
contracted completely (arrowheads).
There is also calcification in the
ureters (arrows). (No contrast has
been used.) (Nigeria)
and the ureters appear "calcified", even along their full length.
The bladder changes progress in a similar way. First, on contrast cys
tography, there is "haziness" in the bladder outline, due to submucosal
oedema, then multiple small flat papillomas can be seen. Ultrasound will
demonstrate the early thickening of the bladder wall, then the papillomas
and the calcifications. Changes in the upper urinary tract only develop as
the ureteric obstruction increases. If there are renal abnormalities found
during what is thought to be the early stage of schistosomiasis, renal tu
berculosis must be excluded. Tuberculosis seldom causes calcification in
the ureter. After treatment for a tumour there may be a small localized
area of calcification in the bladder, a very different apperance.
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TROPICAL DISEASES
Figure 7. S. haematobium
a) A contrast cystogram showing reflux
up both ureters, which are stenosed d
and dilated irregularly. (Nigeria)
b) A contrast urogram in the late stages o f schistosomiasis. There is bilateral hy
dronephrosis and hydroureter, with irregular strictures in the lower thirds o f the
ureters. (Egypt)
c) A large bladder calculus and a slightly smaller calculus in the lower end o f the left
ureter. There is the same calcification in the bladder wall. (Egypt)
d) A contrast urogram showing a large malignant tumour in the bladder, displacing
the contrast to the left. The bladder walls are calcified, the ureters are dilated and
stenosed, and there is delayed emptying. (Nigeria)
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TROPICAL DISEASES
Figure 8.
S. mansoni
a) Multiple mucosal polyps in the
descending and sigmoid colon
(barium enema). (Egypt)
b) Severe sigmoid polyposis coa
lescing into a mass (barium en
ema) (Egypt)
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S. Mansoni
The earliest findings are in the colon, starting with oedema and mucosal
ulceration, followed by loss of haustration. These changes can be demon
strated with a barium enema or ultrasound, and if untreated will progress
to multiple mucosal polyps, usually in the rectum, sigmoid or descend
ing colon (Fig. 8). The polyps are very fragile, on a short stalk, bleed eas
ily, and may cause intussusception or obstruction. Where there is com
bined infection with S. haematobium and S. mansoni, polyps are even
more common. Severe schistosomiasis can cause extensive colonic ul
ceration leading eventually to pericolic inflammation, with strictures. A
solitary bilharzioma, resembling an amoeboma, may occur in either the
large or small bowel. In teenage patients particularly, there can be se
vere enteritis. S. Mansoni infection does not seem to be associated with
an increased risk of cancer, except perhaps in the rectum. As the infec
tion continues, calcification may be seen, particularly around the rectum,
but often in multiple areas throughout the length of the colon. It is asymp
tomatic and usually of no significance. As occurs in the bladder, the cal
cification is in ova rather than in fibrotic scars. Neither in the bowel or
the bladder does the extent of calcification indicate the severity or ac
tivity of infection. The end-result of the S. mansoni infection can be a
smooth colon, very similar to the end-result of ulcerative colitis and caus
ing similar clinical disabilities.
S. mansoni can occasionally affect the small bowel, and even the blad
der. In the duodenum there can be quite marked oedema, and the symp
toms may resemble peptic ulceration.
S. Japonicum
S. japonicum can be an acute or chronic infection which mainly affects
the small bowel, but also the descending and sigmoid colon, and the rec
tum. These are the parts of the gut with venous drainage into the inferior
mesenteric vein. The ova cause wide-spread submucosal granulomas.
On ultrasound, and particularly contrast radiography, there is oedema of
the bowel with a cobble-stone appearance of the mucosa (Fig. 9).
Eventually, the bowel mucosa will become coarse and irregular, partic
ularly in the upper small bowel. There may be areas of dilatation and de
creased motility with excess mucus. A retroperitoneal inflammatory
granuloma has been reported (and can also occur in S. haematobium). S.
japonicum has also been known to cause intestinal polyps.
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Figure 9.
S. japonicum
a) Oedema o f the duodenal loop
(barium meal) (China)
b) Early colitis, especially in the
descending colon (barium
enema). (China)
a
The lungs in
schistosomiasis
The pulmonary radiographic
findings vary with the type of
schistosome, although in the
stage of acute infection all
can cause the Katayama syn
drome if the patient has never
previously had schistosomia
sis (see above). The end-re-
sult of this first stage is al
ways a normal chest radio
graph.
In 5. haematobium infec-
tion the majority of chest ra
diographs will be normal, in
spite of the fact that histolo
gical sections will show mul
tiple ova in about 50% of all cases. A few elderly patients may develop
generalised, symmetrical interstitial fibrosis, which histologically is due
to numerous peribronchial ova and associated diffuse fibrosis. Emp
hysema and clinical cor pulmonale are uncommon, but may develop later
in a few patients.
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Figure 10.
S. mansoni
Aneurysmal dilatation o f the main
pulmonary arteries and pulmonary
conus: there is decreased peripheral
lung vasculature. (Egypt)
In S. mansoni infection the lung changes are more important. The ova
may embolize and penetrate the pulmonary arterioles, causing a localised
inflammatory reaction. Some cause distinct bilharziomas, but in the ma
jority of patients the arterioles narrow and many are obliterated. This
causes pulmonary artery hypertension. Radiographically the main pul
monary arteries become prominent, but seldom symmetrically. The pe
ripheral vascular markings decrease, particularly at the lung bases.
Because there may be ova damaging the pulmonary artery walls, the main
pulmonary arteries may become aneurysmal, especially the main pul
monary trunk (Fig. 10). Apart from this excessive and asymmetrical di
latation, there is nothing to distinguish the radiographic changes due to
schistosomiasis from other causes of pulmonary fibrosis and hyperten
sion. It is unlikely that the calcified granulomas would be mistaken for
miliary tuberculosis, varicella pneumonia or histoplasmosis.
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Figure 11.
S. mansoni
a) Ultrasound. Typical appearance
o f hepatic periportal fibrosis
(arrowheads). (Nigeria)
b) Atrophy o f the right lobe o f the
liver and periportal fibrosis
(Brazil; Courtesy o f Professor G.
Cerri)
Clinically, the liver and spleen enlarge in the early stages. The portal
pressure rises, but ascites does not immediately develop and hae-
matemesis is unlikely. It is not until later, as the fibrosis increases, that
varices develop: a collateral circulation is opened, and there is ascites
with all the clinical sequelae. (Fig. 13 a)
Schistosomal cirrhosis is readily recognized on ultrasound and CT:
both show the periportal fibrosis. The earliest stages seen on ultrasound
are diffuse, scattered echogenic areas, usually either rounded, in sheets
or in bands (Fig. 11 a). Characteristically, there are faint, central sonolu
cent areas. The portal tract is thickened by fibrosis, and it is common to
find atrophy of the right lobe of the liver, with associated hypertrophy of
the left lobe (Fig. 11 b and Fig. 12 d). There is a standard WHO proto
col to grade the degree of periportal fibrosis, which should be used to as
sess progress and for epidemiological surveys.
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1260
Figure 14.
Ultrasound o f
hydatid cysts.
(Tunisia)
a) Uncomplicated
cyst. Stage I.
(Liver)
b) Uncomplicated
cyst with hydatid
sand. Stage I-U.
(Liver)
c) Multivesicular
cyst in right kid
ney. Stage III.
d) Heterogenous hy
datid cyst, a solid
mass. Stage IV.
(Liver)
e) The pathogno
monic appear
ance o f mem
branes within the
cyst. (Liver)
f) Heavily calcified
old hydatid cyst.
Stage V. (Liver)
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TROPICAL DISEASES
Stage III. The fluid is now divided by septa, which are often quite thick
and result in oval or rounded spaces within the well- defined surround
ing cyst. There will be enhanced back wall echoes, and there may be so
many septa that there is a coarse net appearance. Whenever the cyst mem
branes are detached, the internal spaces are less well rounded.
Stage IV. A well-defined cyst is not seen. Instead, there is a roughly
rounded mass with an irregular outline. There are three different ultra
sound patterns:
(a)Hypoechoic, with some internal irregular echoes. This indicates an
infected, multiseptate cyst.
(b) Hyperechoic. A solid "mass" without back wall shadowing.
(c) An intermediate, mixed pattern, about half hypoechoic but with nodu
lar hyperechoic clusters.
The stage IV patterns are not always easily recognised as being due to
hydatid disease. It is important to search carefully for the linear or band-
pattem of the surrounding membranes, for the hyperechoic contour, per
haps with some acoustic shadowing, and for fluid in intra- or extracys-
tic spaces. Another characteristic appearance is variation of the echoes
in different areas within the mass. But perhaps most helpful in diagno
sis is the finding of another hepatic, or extrahepatic cyst at a different
stage. Hydatid cysts (of E. granulosus) are seldom solitary and all are
not likely to be at the same stage of development.
Stage V. A thick-walled, unusually hyperechoic cyst, causing a well-
defined, cone-shaped acoustic shadow. Cysts vary so much in size that
while small cysts may be imaged completely, very large cysts may only
be seen in part, usually the arching image from the thick front wall. The
full outline must be scanned.
In older, or damaged ( E. granulosus) cysts, hyperechoic calcification
may be seen within the cyst walls. When calcification is heavy, it may
indicate severe damage or even death of the cyst. Separation of the in
ternal germinal layer occurs within 48 hours of the appropriate medical
treatment, but may also be seen as a result of injury, usually from indi
rect trauma to the liver or other organs. With scanning it is possible to
recognize the cysts at an early stage, and show that there are multiple
cysts at different stages of development in most patients. Although the
accurate diagnosis of hydatid disease is easy when there are multiple typ
ical cysts, it is sometimes difficult to differentiate a solitary cyst from a
hepatoma. In some parts of the world hepatomas are common and also
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Figure 17.
a) CT scan o f multiple pulmonary hy
datid cysts. (Tunisia)
b) CT scan o f a partly collapsed me
diastinal hydatid cyst. The folded
membranes are clearly shown.
(Tunisia; courtesy o f Professor M.
Ben Cheikh)
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Figure 18.
a) Posterior mediastinal hydatid cyst, af
fecting the vertebral body and trans
verse process. (Tunisia)
b) Destruction o f the right side o f the
pelvis and the right fem ur by hydatid
disease. (Tunisia)
c) CT scan o f a hydatid cyst in the gluteal
muscles. (Tunisia; courtesy o f
Professor M. Ben Cheikh)
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Figure 19.
Cerebral hydatid cysts. CT scan.
(Tunisia)
(Previous surgery with relapse)
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Figure 20.
Alveolar (E. multilocularis)
hydatid cyst o f the liver, with fine
punctate calcification and
multiple small cysts. (China)
is not available. In some ways the clinical progress may resemble that
caused by E. granulosus, for example, by rupture through the diaphragm
from the liver with resulting pleural and pulmonary disease. But in most
cases the imaging appearances of E. multilocularis infections are differ
ent and the clinical course more persistent, almost malignant in failure
to respond, in recurrrence and in outcome.
Alveolar hydatid disease produces a mass-like infiltrating lesion with
out well-defined borders in almost all organs or tissues, including bone.
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CHAGAS' DISEASE:
AMERICAN TRYPANOSOMIASIS
This infection, due to Trypanosoma cruzi, is confined to the Americas,
from Texas to Argentina, and is particularly common in rural areas of
Brazil, Argentina, Uruguay, Chile and Venezuela. Children and young
adults are most often infected, because the trypanosome is transmitted
by reduviid or triatomine bugs, which bite at night. These bugs com
monly live in the mud or adobe walls of huts or stables, and in homes
which have cracked walls through which they can enter. At least one
hundred and fifty animal species carry the organisms, but particularly
domestic dogs and cats, pigs, monkeys, opossums and armadillos. The
clinical infection can be acute, subacute or chronic. It starts from the orig
inal bite as the trypanosomes spread through the lymphatics to the lymph
nodes (7-14 days) and then into the blood stream 5 days later. T. cruzi
multiplies within the host cell and the disease is extremely difficult to
diagnose and treat: almost any part of the body may be affected, but par
ticularly smooth and striated muscle, glial and nerve cells. The try
panosomes may be found in the blood for the first 6 weeks o f the acute
stage, but not thereafter. The characteristic lesion is a Chagoma, a fi
brotic encapsulated focus which can develop at the site of inoculation or
elsewhere. It is particularly important in the heart and central nervous
system.
Apart from the acute and chronic phases, there is an uncommon sub
acute form affecting the heart, in which there are large numbers of the
parasites in the peripheral blood and in the cardiac tissues. It is likely that
there is also a latent phase, because millions of people in the endemic ar
eas are known to have been infected yet do not show clinical signs of the
disease. Careful electrocardiography and oesophageal motility studies
suggest that although the disease is clinically silent, it is still active and
capable of further progression.
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Figure 21.
Chaga's cardiomyopathy, MRI. The
Tl-weighted, postgadolinium en
hanced image shows patchy areas of
inflammation in the cardiac muscle.
(Brazil)
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a, b
Figure 22.
The changes in the oesophagus in
Chaga 's disease. (Brazil)
a) An erect contrast barium swallow
shows a normal oesophagus with
normal peristalsis.
b) When supine, the same patient has
tertiary oesophageal contractions.
c) In the intermediate stage, the
oesophagus is dilated, the gastro-
oesophageal region is narowed.
This resembles achalasia.
d) In the advanced stage, the
oesophagus is elongated and
grossly dilated, with a flu id level
and retainedfood.
mega-oesophagus. The retained liquid and food may obscure the devel
opment of oesophageal carcinoma (Fig. 24), which may infiltrate the wall
and allows rupture of the contents into the mediastinum, leading to ab
scess formation. Although the abnormalities on chest radiographs or me-
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TROPICAL DISEASES
Figure 23.
Chaga's disease, (barium enema).
Megacolon with dilatation and gross
elongation. The sigmoid colon reaches
into the upper abdomen. Obstruction
due to volvulus is very likely to occur
at this stage.
b
Figure 24. Chaga’s disease
a) An air-contrast examination shows a small tumour
in the mid third o f the oesophagus. It is essential to
empty as much o f the contents o f a mega-oesopha
gus as possible, before doing the contrast examina
tion.
b) The CT scan o f the same patient confirms the thick
ening o f the oesophageal wall and that the tumour
has not spread into the mediastinum.
(Allfigures o f Chaga's disease - courtesy o f Professor
a G. Cerri, Brazil).
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Ascariasis
The Nematode round worm, Ascaris lumbricoides, (alone or occasion
ally together with A. suum) probably infects 25% of the world's popula
tion, but in the tropics the infection rate may be as high as 90% in some
populations. This is not surprising, because during a busy period o f 6-12
months, one (very) fertile female worm can produce up to 200 000 ova
every day! This bounty is acquired by humanity from contaminated food,
water and soil, and re-infection is common. The worm is most frequently
found in patients aged from 1-15 years and no intermediate host is
needed. Clinically there may be no symptoms, or there may be ill health,
vague abdominal pain, colic or acute obstruction. In children, ascaris are
one of the commonest causes of jaundice.
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and asymmetrical densities around the larvae as they pass through the
lungs. Some may progress to bronchopneumonia, and if an adult worm
has been regurgitated and inhaled, there may be atelectasis or lobar pneu
monia.
The worms may be visible on a plain radiograph of the abdomen, seen
as a coiled, hazy indistinct "ball of wool" when the worms are outlined
by bowel gas (Fig. 25 a). But ultrasound is more accurate. The body of
the worm shows as two hyperechoechoic lines on either side of a hy-
perechoechoic space when seen on a longitudinal scan relative to the
worm. If scanned transversally, there will be a round, hyperechoechoic
center (the worm's alimentary canal) surrounded by a hyperechoechoic
ring (the worm's body). This is the characteristic "target sign", and may
also be seen in the biliary tract (Fig. 25 b). Ascaris is the only intestinal
worm which ingests barium and it does this most reliably after the pa
tient (and the worm) has fasted overnight (Fig. 25 c, d). There will be
then be one or more white lines (the worm's alimentary canal) within the
stomach or small bowel, perhaps surrounded by a clear space on either
side (the negative shadow of the worm's body) within the barium col
umn. There may be excess intestinal secretions: worms are irritating.
Most of the Ascaris inhabit the small bowel and their movements can
be monitored by ultrasound or barium studies. A few will be in the stom
ach or duodenum, but the majority will be in the lower ileum, with some
in the caecum and colon (Fig. 26). Ascaris is a common cause of in
testinal obstruction in children in any region where infestation is more
than usually prevalent. The level of the obstruction is usually ileocaecal,
especially if the child has been given an anthelmintic which has caused
a mass of dead worms. Ultrasound is a rapid way to demonstrate the tan
gled, obstructing bodies. In many parts of the world an erect plain radi
ograph of the abdomen of a child which shows multiple small bowel fluid
levels is recognised as yet another complication of ascaris infections.
The worms may have to be removed surgically, which is yet another good
reason to be a radiologist!
Ascaris is the commonest cause of jaundice in children in Africa, Asia
and South America. Ultrasound will demonstrate the worm within the
biliary tract, either as a target sign or a linear shadow. If in the cystic
duct, it will probably cause obstruction. The worm can, of course, also
be seen by CT or intravenous cholangiography. Cholecystitis and hepatic
abscesses can be caused by worms and ascaris have been found in sub-
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Strongyloidiasis
Infection with S. stercoralis is particularly significant in any patient who
is immunosuppressed. In others, the infection is usually asymptomatic
or, at the worst, causes mild peptic ulcer symptoms or occasional colic.
Strongyloides are more common in adults than in children, and infection
occurs through the skin, usually the foot. As with many other worms,
there are early chest symptoms (cough) and a peripheral eosinophilia.
Although imaging is not the way to recognise strongyloidiasis, radiolo
gists should be aware of the parasite’s effects and complications.
In the early stages of S. stercoralis infections, contrast studies of the
alimentary tract, using microfine, non-flocculating barium, will show
mucosal oedema from the pylorus to the upper jejunum, sometimes also
in the stomach. Barium passes rapidly and the bowel is apparently in
flamed and irritable. The appearance may be indistinguishable from
sprue.
In the later stages, the bowel becomes fibrosed and more rigid, peri
stalsis is absent: the mucosa is atrophied: ulceration occurs and the ap-
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Figure 27.
Strongyloidiasis.
Distended, gas-filled loops o f small
bowel due to strongyloides. (Nigeria)
pearence may incorrectly suggest obstruction (Fig. 27). The colon may
be involved and in patients with severe immunosuppression (e.g. as in
AIDS) very severe colitis may occur, leading eventually to sepsis and
death. Barium contrast studies of the large bowel at this stage show se
vere ulcerating colitis with sinus formation.
Giardiasis
This is yet another alimentary parasite which should be known to radi
ologists, although it is not their responsibility to make the diagnosis.
Giardia lamblia are ingested through contaminated food and especially
water, and have been found throughout the world, wherever there are
water reservoirs. Most patients are unaware of their infection, others have
vague abdominal symptoms with intermittent diarrhoea and malabsorp
tion. It must be remembered that having Giardia lamblia in the alimen
tary trace does not mean that this is the cause of the patients symptoms;
other diseases must be excluded.
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TROPICAL DISEASES
Hookworm (ancylostomiasis).
"Hookworm" is an infection with a nematode worm, usually
Ancylostoma duodenale or Necator americanus, or both. (A. ceylanicum
can also be pathogenic for man.) The worms enter the body through the
feet and spread through the lymphatics and blood to the lungs and even
tually down the oesophagus to the jejunum. Although the origin has been
known for nearly a century, millions of people are still infected and it is
a common cause of chronic anaemia in many tropical countries. Some
patients will be symptom-free, others will have severe infections and a
marked peripheral eosinophilia. It is essential to differentiate between
hookworm infection and hookworm disease, between the mild and the
severe. At the onset of infection, and while the worm is migrating and
developing, the clinical complaints are pruritis and erythema: the
"ground itch" of barefoot people. Within 3-14 days there may be a cough
and low fever, but the chest radiograph will be normal. There can then
be a long latent period, particularly if the host is otherwise healthy. But
in the malnourished or otherwise unhealthy, there may be mild gastric
symptoms, and if the parasite load is heavy, anaemia and further mal
nutrition result.
In chronic infection, causing anaemia, a chest radiograph may show
cardiomegaly. A barium contrast study will show a normal gastroin
testinal tract in many patients, but in others there will be a deficiency or
malabsorption pattern. There is a marked geographical variation in the
reported imaging abnormalities, possibly due to association with a vari
ety of other parasites. Hookworms have been known to occur in tissues
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Figure 28.
Helminthoma.
A large mass arising from the medial
wall o f the caecum (barium enema).
(Zimbabwe)
outside the bowel, but for all practical purposes ancylostomiasis is a small
bowel infection.
Helminthoma
Almost any parasite can migrate into the bowel wall, yet this happens
surprisingly seldom. When it does occur, there is an inflammatory, gran
ulomatous reaction forming a tumour, the helminthoma. The intestinal
parasites which most commonly infiltrate are nematodes, and one in par
ticular, oesophagostomum. Ascaris and ancylostoma rarely also cause
the same reaction. There is a different result when a parasite perforates
completely through the bowel wall, causing a localized peritoneal ab
scess, compared with the granulomatous reaction which occurs first
within the wall itself and then subsequently perforates. Clinically, when
this occurs, most patients will be suspected of having appendicitis or per
haps intussusception or perforated diverticulum. The correct diagnosis
of helminthoma is very seldom made before surgery (and not always
even at surgery). With a barium enema or ultrasound scan, a mass can
be demonstrated in the wall of the bowel, often eccentric, and sometimes
leaving the lumen open (Fig. 28). Very seldom is the whole internal di
ameter of the bowel affected, although it may be narrowed due to pres-
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TROPICAL DISEASES
sure. The mucosa appears intact and the mass is often surprisingly well-
defined. Helminthomata occur most commonly in the caecal area, less
often in the sigmoid and only occasionally elsewhere in the bowel.
Clinically or radiologically the mass might appear to be an inflammatory
abscess or a bowel tumour. A radiologist will only make the correct di
agnosis if he or she has a very high index of suspicion and a great deal
of good luck! Usually the diagnosis is made by the histopathologist, who
may be as surprised as everyone else.
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Figure 29.
Clonoarchiasis.
A T-tube retrograde cholangiogram
showing the dilated, saccular biliary
tract, filled with debris. (Korea)
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Figure 30.
AP (a) and lateral (b)
views o f the dense chronic
bone reaction due to
typhoid osteomyelitis.
There is a central
sequestrum. (Pakistan)
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Figure 31.
Lymphogranuloma.
Barium enema. Note the smooth
tapering rectum o f lymphogranuloma
venereum (small arrows). There is a
perirectal abscess (arrowheads).
(China)
Lymphogranuloma venereum
Appropriately, the last gastrointestinal disease to be considered is lym
phogranuloma venereum, affecting the rectum and lower colon. It is
caused by Chlamydia trachomatis and, except in rare cases involves only
the rectosigmoid, the lower colon, the genital tract, the surrounding tis
sues and regional lymph nodes. Clinical proctocolitis and suppurating
lymphadenopathy are common. The infection is acquired by sexual con
tact: transmission by any other route is very uncommon.
Ultrasound will show the thickening of the rectal wall and the sur
rounding oedema and inflammatory reactions. A barium enema will
show spasm, narrowing of the rectum and lower colon, and then loss o f
the normal colonic pattern (Fig. 31). Eventually, there will be loss o f
haustration, multiple fistulae, perirectal abscesses and sinuses. The dis
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ease progresses to fibrosis and stricture formation and may involve the
last 25 cm of the large bowel. In women, rectovaginal fistulae may de
velop. The differential diagnosis will include mycotic infection, amoe
biasis and tuberculosis (because of the fistulae formation), but in prac
tice there is usually little doubt about the correct diagnosis.
Paragonimiasis
This is the result of an infection with one or other lung flukes of the genus
paragonimus, usually P. westermani. (There are 15 other species of
paragonimus, which can infect man.) The infection is found throughout
the tropics but particularly in Asia, and is usually mistaken for tubercu
losis. Paragonimiasis is acquired by eating raw or inadequately cooked
crabs, crayfish, and occasionally from eating animals which also enjoy
fresh water crabs. The life cycle is similar to that of schistosomiasis, and
includes warm water snails, but there is no direct infection of man.
Clinically, the majority of patients, even with heavy infections, are not
ill. The minority will complain about chest pain, chronic cough and
chocolate-coloured sputum, while remaining remarkably well in general
health. At this stage the sputum often contains multiple recognizable eggs
of P. westermani.
Apart from the lungs, cerebral involvement is not uncommon and
causes convulsions, fever, headache or other neurological symptoms.
Some species prefer the central nervous system and the lungs may re
main clear, but this is in less than 20% of the patients.
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Melioidosis
Infection with the gram negative bacillus, Pseudomonas pseudomallei,
is known as melioidosis. While occurring most commonly in South East
Asia, cases have been reported from many other parts of the world, usu
ally in visitors returning from Asia. The exact method of infection is un
known, but may be due to contaminated dust or soil, perhaps from in
sect bites.
Clinically, the disease may be asymptomatic or subclinical. It is eas
ily mistaken for tuberculosis or other fungal infection, both clinically and
radiologically. Those with clinical symptoms may present with an acute
illness with a high temperature. Others, who have a less acute infection,
present with haemoptyses and a low fever or, less commonly, as a chronic
extrapulmonary infection.
The radiological appearance of the chest suggests tuberculosis. In the
acute variety, there will be multiple irregular nodular densities which
may coalesce or cavitate. There may be lobar pneumonia, or both ap
pearances may be seen simultaneously in different parts of the lungs.
When the infection is less acute, there can be lobar consolidation and
cavity formation (Fig. 33). In both forms, acute and subacute, pleural in
volvement and hilar adenopathy are uncommon. In those without clini-
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Figure 33.
Melioidosis.
a) Bilateralfluffy nodules
throughout both lungs.
(Vietnam)
b) Two thin-walled cavities
(tomogram). (Vietnam)
CARDIAC DISEASE
Acquired valvular disease is
still by far the commonest
cause of cardiac pathology in
the tropics and essential hypertension is widespread. However, there are
several cardiac diseases which are specific to the tropical countries: it is
not possible to describe all of them in detail here, but they must be dis
tinguished from many of the common, nontropical cardiac problems.
Cardiomegaly
An enlarged heart in South America may be due to Chaga's disease, but
in Africa cardiomegaly may be due to idiopathic endomyocardial fibro
sis, which can be predominantly right- or leftsided. Alternatively, idio-
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TROPICAL DISEASES
Figure 34.
A large heart with a left ventricu
lar, partially calcified aneurysm.
On contrast angiography the
aneurysm did not fill properly,
probably due to a thrombus.
(Nigeria)
AORTIC DISEASE
Idiopathic arteritis (Takayasu’s disease, or aortic arch arteritis) is un
usually common in the tropics but follows the patterns recognised else
where. It occurs most frequently in young children and young women,
is rare over the age of 30, and may affect any part of the aorta: these fac
tors make a syphilitic aneurysm an unlikely alternative diagnosis. Aortic
arteritis is commonly associated with hypertension and can clinically
present as an unexpected cerebrovascular accident in a young person.
Alternatively, renal failure, obscure abdominal pain or cardiac failure in
a young female are other presentations. The anatomical distribution of
the vascular disease will dictate the clinical symptoms. The arteritis can
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TROPICAL DISEASES
Osteomyelitis
There is a wide variety of osteomyelitis found throughout the tropics and
bone infection is probably more common than in many temperate cli
mates. Osteomyelitis due to typhoid and salmonella should also be con
sidered, especially in patients with sickle cell disease. The use of ultra
sound in the early diagnosis of any acute bone infection is important in
children. Needle aspiration guided by ultrasound will not only decom
press the abscess, but allow identification of the organism and accurate
antibiotic therapy. Healing will be quicker and the skeletal deformity will
be less. Tuberculosis can affect the skeleton in a wide variety of ways,
resembling an acute osteomyelitis, a cyst in a long bone, an acute or
chronic arthritis, a severe periosteal reaction, or a destructive lesion.
Think of tuberculosis in any tropical bone disease, but remember typhoid,
klebsiella and syphilis also: then worry about more common organisms!
Tropical ulcer
A tropical ulcer is an acute specific, localised necrosis of skin and soft
tissues, followed by a chronic ulcer involving the entire skin and subcu
taneous tissues. It usually occurs in the front of the lower leg or on the
foot. The acute organism is Bacillusfusiformis , with secondary infection
inevitably following. Tropical ulcer must not be confused with the sores
due to cutaneous Leishmaniasis. After the acute phase, the surrounding
oedema and granulation tissue persist, and in many patients the ulcer
spreads to involve the deep fascia, the tendons and the underlying bone.
When this occurs there is a characteristic radiological change, almost al
ways first in the tibia but involving the fibula also. A localized periosteal
reaction, usually fusiform and linear but sometimes with spiculation, de
velops under the soft tissue ulcer (Fig. 36). This eventually results in a
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с
Figure 36. Tropical ulcer.
Four different patterns o f bone reaction beneath tropical
ulcers.
a) A laminated periosteal reaction on the tibia. (Nigeria)
b) An “osteoma ” on the anterior edge o f the tibia.
(Nigeria)
c) AP and lateral views o f a large tibial “osteoma ”.
(Nigeria)
d) A very irregular hypertrophic postero-lateral “os
teoma ” on the fibula, with minimal cortical thickening
on the tibia. (Kenya).
All these reactions are smooth and there are no changes
which might suggest malignancy.
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bony destruction which spreads, involves the cortex and the medullary
cavity and may lead to pathological fracture (Fig. 37). Systemic tumour
dissemination and metastatic spread is possible, but is not common. The
whole chronic destructive process can be prevented if the initial skin
wound is thoroughly washed with soap and water and kept clean.
Ainhum
This is an unusual afflication of one or more toes, usually in middle-aged
black men who are otherwise healthy. A constricting, sometimes painful
groove develops around the base of the toe which can lead to autoam
putation. It can occur, but is much less common in the fingers. The aeti
ology is unknown. The fifth toes, often bilaterally, are the most com
monly affected, but other phalanges may be involved. Clinically, the dis
ease is obvious, easy to diagnose, and appears trivial. However, it can
be painful and crippling. The radiological changes are similarly charac
teristic (Fig. 38). The fibrous groove around the toe can be seen in the
soft tissues and there will be underlying localized osteoporosis, usually
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TROPICAL DISEASES
of the proximal phalanx. The cortex becomes absorbed and the affected
phalanx is concentricaly thinned and asymmetrically tapered. If there is
infection, there may be a small cortical reaction. Eventually, there is an
gulation of the digit, a pathological fracture which can be very painful,
and autoamputation. Fortunately, treatment is seldom necessary, but
surgery may be helpful to ease the pain or the lymphoedema which re
sults from the tight constriction.
It is important for the radiologist to distinguish this benign process
from leprosy. It is unusual for leprosy to affect only one bone and very
seldom in leprosy is the only clinical abnormality in one toe, or even one
toe of each foot. Unlike leprosy, there is no sensory loss in ainhum, no
other soft tissue abnormality and very seldom any ulceration or infection.
It is, clinically and radiologically very easy to recognise and there are very
few complications. There is no indication for complex investigations to
exclude some other disease. Ainhum is an entity in its own right.
Leprosy
This bacillary infection has been feared for centuries and there are still
several million lepers in the world, with 650,000 new patients every year.
It is a chronic and destructive infection due to M. leprae with many unan
swered questions. As with many of the other tropical diseases, there can
only be a brief summary here, but if suspected, reference to a more com
prehensive description is strongly recommended.
Many of the clinical results of leprosy are in the soft tissues, and for the
radiologist it is the effects of soft tissue infection, distorsion and dener
vation which are of importance. However, one result is absolutely diag
nostic. Calcification of nerves occurs in leprosy and in no other condi
tion. It may be linear, along the nerve, sometimes in flakes, or oval cal
cification may be the end-result of a perineural abscess. Contrast injection
along the nerve sheeth has been suggested, to localise the calcification,
but a clinical diagnosis of leprosy should be much easier! Except in the
skeleton (particularly the extremities) there are no other significant imag
ing findings. Leprosy granulomas do occur in the liver, spleen and in many
other organs, but are not reliably identifiable by any imaging method.
When primary bone changes in leprosy are recognised, they are
medullary and destructive, with only a little bone response until healing
occurs. The digits are the most frequently affected, showing localised
osteoporosis, honeycombing and concentric bone absorption. There can
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The end-results are major destructive bone loss with disorganised joints,
most obviously in the digits and later in the tarsus, less often in the car
pus (Fig. 39). Similar destructive changes can be seen in the nasal bones
and occasionally elsewhere.
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Figure 39.
Leprosy.
a, b) The destructive
process o f lepro
sy in the foot and
the hands. (India)
Filariasis
Many different filaria infect millions of people around the world.
Amongst them, the most important are Wuchereria bancrofti, Brugia
malayi and B. timori. These filaria cause elephantiasis. Loa loa causes
"calabar swellings" and Onchocerca volvulus causes onchocerciasis or
"river blindness". Each have a distinctive geographical distribution, but
together infect millions of people. All are transmitted by insect bites.
The limbs of patients who have gross clinical elephantiasis do not have
very specific radiological changes. There is loss of the soft tissue fat lines.
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The underlying limb bones may show marked periosteal and cortical
thickening, which results from the soft tissue changes and is not an ef
fect of the filaria on the bones. Contrast urography will show dilated re
nal lymphatics in patients with lymphuria. Lymphangiography is tech
nically very difficult and only useful to exclude congenital lymphoedema
(which is often unilateral).
Not all elephantiasis is due to filariasis. Any lymphatic obstruction,
e.g. due to tuberculosis, Kaposi's sarcoma, or L.G.V., may be responsi
ble. To make the differential diagnosis more difficult, filarial elephanti
asis can be unilateral.
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TROPICAL DISEASES
Figure 41.
Tropical eosinophilia.
Soft bilateral fluffy nodules
throughout the lungs. There
was a 67 % peripheral
eosinophilia, which suggested
the correct diagnosis:
filariasis. (Nigeria)
Porocephalosis
Porocephalosis results from tongue worm infection, usually Armillifer
armillatus or Porocephalus crotali. There are few clinical symptoms.
The A. armillatus are acquired by eating snakes, or drinking water used
by snakes.
Many of these small parasites calcify and may be recognized as fine
strands of calcification in the soft tissue (Fig. 40). They are then dead,
but the filaria cannot be accurately identified. The fine calcified remnants
must be distinguished from cysticercosis (usually oval and more nu
merous) and porocephalosis (multiple, crescentic or horseshoe calcifi
cations in the abdomen or chest, but seldom elsewhere). (See also guinea
worm page 63).
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DIROFILARIASIS
The dog heart worm, D. immitis, can infect man. Pulmonary infarction
may result. The worm usually presents radiologically as a small solitary
dense lesion on a chest radiograph which may eventually cavitate. The
differential diagnosis will include carcinoma, mycotic (fungus) infection
and tuberculosis. Accurate diagnosis from a chest radiograph is not
possible.
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TROPICAL SPLENOMEGALY
Enlargement of the spleens of those who live in the tropics can be due
to many causes, particularly malaria and leishmaniasis. In many patients
the exact cause remains unknown. There are no characteristic imaging
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MALARIA
Malaria is a very significant cause of morbidity and mortality. At least
one million people of all ages die o f malaria every year. For the radiol
ogist, the only significant imaging abnormality in the patient with malaria
(apart from the large spleen) is the fortunately uncommon development
of severe bilateral pulmonary oedema. This has no radiological charac
teristics to differentiate it from pulmonary oedema of any other aetiol
ogy. It is important to be aware that this pulmonary oedema is an intrin
sic complication of severe malaria and does not have to be the result of
fluid overload or any other therapy. It is very difficult to treat and can be
fatal. Generalised oedema may be the result of malarial nephropathy/
glomerulonephritis. There are no distinguishing features on imaging.
In infants, cerebral malaria can cause cerebral oedema and suture di
astasis (separation) might be mistaken for an intracranial tumour, espe
cially when the child lapses into a coma.
The splenomegaly of malaria can be gross, but the ultrasound appear
ance remains homogeneous. Pressure distortion and displacement of the
left kidney can occur.
Taeniasis
Tapeworms occur throughout the world. Human infection results from
eating undercooked, or raw, infected meat. There may be no clinical ill
ness or abdominal discomfort, but loss of weight and diarrhoea may oc
cur. There may be a 10% eosinophilia. Multiple tape worms can cause
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TROPICAL DISEASES
Cysticercosis
As occurs with so many other parasites, cysticercosis results from swal
lowing infected food or water. Occasionally, autoinfection in a patient
who has a resident tape worm may occur. Except in the brain (or the eye)
the cysticercus becomes surrounded by a fibrous capsule, but may re
main alive for some years. When it dies the cellular reaction may even
tually calcify, usually after about 3 years. Living and dead may occur to
gether. In skeletal muscles, the dead cysts cause few symptoms, but heart
block has been recorded in the cardiac conducting tissue. In the central
nervous system the scarring may cause epilepsy, and occasionally severe
encephalitis and death. If the cerebral ventricular system is blocked, there
may be raised intracranial pressure and the clinical symptoms may sug
gest a cerebral tumour.
The first calcified cysts were recognised radiologiccally in the 1890s,
long before the adult worm. Radiographically the calcified cysticercus
is oval or linear and from 4 to 10 mm in length: larger cysts have been
reported. The oval cysts lie with their long axis in the line of the muscle
(Fig. 43 a). They may be very numerous, particularly in the legs and back,
and may be a chance finding seen in the thoracic muscles on a routine
chest radiograph. If cysticercosis is suspected, soft tissue radiographs of
the upper legs should be obtained. The appearance of the cysts is so char
acteristic, and in many patients there are so many cysts that the differ
ential diagnosis is straightforward. No other soft tissue calcification re
sembles this or is present in such large numbers.
In the brain, it is rarely possible to see the calcified cyst on a plain ra
diograph of the skull. In fact, plain skull radiographs are not likely to be
a useful examination in this disease. Soft tissue radiographs of the thighs
will provide more confirmation if cysticercosis is suspected as the cause
of seizures. However, on CT not only the calcified cysticercus but the
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Figure 43.
Cysticercosis.
a) The typical oval calcification o f
cysticercosis lying in the thigh
muscles. (Nigeria)
b,c) CT scans o f calcified cysticerci,
lying periventricularly, but in
this patient not causing any other
lesions (post contrast). (Egypt)
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TROPICAL DISEASES
multiple cerebral cysts can be visualized in the cortex and the walls of
the ventricles (Fig. 43 b). MR will demonstrate the cysts, but not the cal
cification. The cysts are thin-walled and contain clear fluid and free float
ing scolices. Some cysts may be quite large, so that the ventricular sys
tem is blocked with resulting internal hydrocephalus. Complete obliter
ation of the aqueduct can occur, but is uncommon. In some cases there
will be basal arachnoiditis. Very rarely, there is erosion of the skull by
the underlying cyst.
Similarly, spinal cysticercosis can be recognized by CT or MR. The
cysts may be intradural or extramedullary, are of different sizes, but usu
ally spherical. They may fragment or become irregular and there may be
associated arachnoiditis. Complete spinal canal obstruction can occur,
but is uncommon. If CT or MR are not available, myelography will
demonstrate intradural and extramedullary filling defects of different
sizes, or irregularity of the contrast column and in some cases partial or
complete obstruction. Plain radiographs of the spine do not demonstrate
the cysticercus.
(Figures number 28,29, 33 a, b, 39 a, b, come from the "Radiology of
Tropical Diseases" by Palmer, P.E.S. and Reeder M.M., Springer,
Heidelberg, 2nd edition. In press.)
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Chapter 28
Radiology in AIDS
More than 12 years have passed since the initial publications docu
menting the onset of the acquired immunodeficiency syndrome (AIDS)
epidemic, caused by a retrovirus, the human immunodeficiency virus
(HIV). By November 1993, AIDS had been diagnosed in more than
750,000 patients worldwide, with reported mortality of over 50%. It is
estimated that the number of HIV positive people througout the world is
between 5 and 7 million. From the outset, a wide variety of systemic
manifestations, both neoplastic and non-neoplastic, have been noted in
patients with AIDS. The manifestations that have benefitted most from
imaging modalities are those involving the central nervous system, tho
rax and abdomen.
Cerebral pathology
The occurrence of AIDS has made cerebral infection a routine problem.
Diagnostic difficulties are related to the multiplicity of pathology that oc
curs in association with cerebral HIV infection, often treatable oppor
tunistic infections arise as a consequence of the immunodeficiency and
simultaneously, tumours, especially primary CNS lymphomas, develop
with increased frequency. Neuroimaging techniques (CT and/or MR
scans) have a triple role: detection, diagnosis and monitoring under treat
ment. MRI is the most sensitive procedure, providing more precise eval
uation of not only infra- but also supratentorial lesions, detection of the
white matter and meningeal lesions, which are invisible or highly un
derestimated with CT, and better detection of hemorrhagic lesions.
Furthermore, because of the underlying immunodeficiency, with poor
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Figure 1.
Toxoplasmosis.
Post-contrast CT scan. Ring-en
hanced lesions in the right basal
ganglia and the left frontal lobe
with a large mass effect and p e
ripheral oedema.
Figure 2.
Toxoplasmosis.
Post-contrast CT scan. A very
large, single, ring-enhanced
parieto-occipital lesion with a
large mass effect and peripheral
oedema.
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RADIOLOGY IN AIDS
Figure 3.
Toxoplasmosis.
Axial gadolinium-enhanced
Tl MR-image. Punctiform
nodular enhanced lesion is
clearly seen at the left frontal
corticomedullary junction.
Note the ventricular enlarge
ment.
Parenchymatous lesions
These lesions can be subdivided schematically into cerebral masses and
white matter lesions.
Cerebral masses
Cerebral masses, which have as a common denominator contrast en
hancement, are represented predominantly by opportunistic infections
and primary CNS lymphoma. The radiological findings are often quite
suggestive of the diagnosis, but the lesions may resemble one another
quite closely. Therefore, disease monitoring of the lesion during an an
titoxoplasma treatment test may confirm the diagnosis and should be un
dertaken before stereotaxic biopsy is considered.
In France, haematogeneously spread toxoplasmosis is the most com
mon opportunistic infection. Its characteristic appearance (Fig. 1) con
sists of multiple, bilateral, infra- and supratentorial lesions, which are
most frequently found at the corticomedullary junction and in the basal
ganglia. Single lesions (Fig. 2) are less common but can be observed
even with MR. The diagnosis of toxoplasmosis is based on the appear
ance of the lesions, but their site and response to anti-toxoplasma treat
ment is also very important. The lesions may appear as nodular (Fig. 3)
(toxoplasmic granulomas) or ring-like (Figures 1, 2) (toxoplasmic ab
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RADIOLOGY IN AIDS
Figure 4.
Primary lymphoma.
Post-contrast CT scan. Large
homogeneously enhanced
periventricular mass with mild
peripheral oedema and mass
effect.
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Figure 5.
HIV encephalitis.
Plain CT scan. Bilateral and
symmetric diffuse hypodensity
in the periventricular white
matter without any mass effect.
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RADIOLOGY IN AIDS
Vascular lesions
Vascular lesions can be of embolic origin (endocarditis), vasculitis (tu
berculosis, aspergillosis, CMV, candidiasis) can have ischaemic (vas
cular narrowing or occlusion) or hemorrhagic (infectious aneurysms or
haemorrhagic infarcts) presentations.
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Figure 6.
Lymphoma.
Axial Tl MR image at the T4
level. Extensive spinal cord
compression (arrows) with ad
jacent corporeal erosion (ar
rowheads).
Spinal pathology
Neuroimaging (particularly MRI) is essentially devoted to the detection
of extradural compression of the spinal cord or its nerve roots by, for ex
ample, lymphoma (Fig. 6), immunoblastic sarcoma, plasmocytoma,
metastases and more rarely, spondylodiscitis (candidiasis, tuberculosis).
The clinically, frequently observed HIV myelopathy and polyneu
ropathies do not lend themselves to radiological diagnosis (non-specific
hyperintense medullary signal, rarely thickened nerve roots).
THORACIC MANIFESTATIONS
Thoracic manifestations of AIDS can be divided into infectious and non-
infectious entities, the latter including neoplastic and non-neoplastic dis
eases. The type of pulmonary manifestations seen in AIDS has evolved
considerably; this is partly due to improvement in therapy, such as the
widespread use of prophylaxis for Pneumocystis carinii pneumonia
(PCP), while infection due to Mycobacterium tuberculosis has been ris
ing at an epidemic rate, and the number of patients with Kaposi's sar
coma (KS) has been decreasing continuously.
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RADIOLOGY IN AIDS
Figure 7.
Cystic PCP. Radiographic
CT correlation.
a) Posteroanterior chest ra
diograph shows the pres
ence o f diffuse pulmonary
infiltration, predominantly
distributed in upper and
middle lung zones, associ
ated with subtle, bilateral
thin-walled cysts in the up
per lobes.
b) CT scans made through
the carina at the same
time as (a), shows that nu
merous cysts o f various
sizes and wall thickness
are seen bilaterally in the
upper lobes that are infil
trated with nodular and
ground glass opacities.
Subtle bilateral pneumoth
orax is also seen.
Infectious diseases
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Figure 8.
M. Tuberculosis.
Posteroanterior radiograph shows
consolidation in the upper part o f the
left upper lobe containing several
cavities. This pattern is consistent
with mycobacterium or bacterial in
fections.
Mycobacterial infection
Infection with Mycobacterium tuberculosis occurs in about 10% of cases
and its incidence is increasing every year. The radiologic appearance of
tuberculosis reflects the degree of impairment of the immune system.
When the deficiency is subtle, tuberculosis is usually indistinguishable
from that which occurs in non-HIV-infected patients, with upper lobe
cavitary infiltrates (Fig. 8). The more advanced the immunodeficiency
is, the more suggestive of primary disease the radiographic pattern is, in-
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RADIOLOGY IN AIDS
Bacterial infections
The incidence of bacterial infections in AIDS patients has risen sharply.
It is currently estimated that 5-30% of AIDS patients develop bacterial
pneumonia during the course of their disease.
In pyogenic infections, the radiograph typically shows lobar consoli
dation, nodules and focal infiltrates with or without an associated pleural
effusion. However, some cases present with a predominant interstitial
infiltrate which is indistinguishable radiographically from that usually
associated with PCP infection. A prompt diagnosis of bacterial infection
is necessary because most patients respond to routine antibiotic therapy.
In some cases, CT can be of value by revealing foci of cavitation or necro
sis, as well as documenting the presence of unsuspected loculated pleural
effusions or bronchiectatic foci.
Fungal diseases
Fungal infections are uncommon, occurring in less than 5 % of AIDS pa
tients. They include infections with Cryptococcus neoformans,
Histoplasma capsulatum, Coccidioides immitis, Candida albicans and
Aspergillus.
C. neoformans is the most common cause of fungal pulmonary infec
tion in patients with AIDS. Chest radiographs may show a wide range
of abnormalities but, in most patients, films are either normal or show
focal parenchymal disease. In histoplasmosis, the chest radiograph is nor
mal or shows disseminated nodular disease. In patients with coccid
ioidomycosis, films usually reveal a diffuse interstitial infiltrate often as
sociated with thin-walled cavities. Aspergillus is rarely the cause of pri
mary infection, however, secondary aspergillosis of cavities has been
noted in association with PCP.
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Figure 9.
KS.
a) Posteroanterior radiograph
shows bilateral perihilar in
filtrates predominantly dis
tributed in middle and lower
lung zones.
b) CT scan through the lower
lobes shows a typical pattern
o f tumours extending along
perivascular and peri
bronchial pathways from the
hila into the lung associated
with a few, small, poorly de
fined peripheral nodules.
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ABDOMINAL MANIFESTATIONS
Abdominal manifestations of AIDS are numerous and include
parenchymal, lymph node and primary gastrointestinal and urinary tract
disorders. Abdominal symptoms are frequent and affect up to 90% of
patients with AIDS or AIDS-related complex (ARC). Multiple infections
are the rule in AIDS and may be associated with lymphoma and/or
Kaposi's sarcoma (KS). Moreover, AIDS patients can also be affected
by protozoan and bacterial infections, such as tuberculosis, related to
sexual promiscuity and low socioeconomic status. Multiple sites of in
fections are involved in 64% of patients. Clinical symptoms and physi
cal findings alone rarely suggest a specific etiology. The role o f imaging
methods is to identify the target-organ as well as the extent of pathologic
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RADIOLOGY IN AIDS
Malignant lymphomas
An increased incidence of all lymphomas is observed in AIDS patients,
especially non-Hodgkin's lymphoma (NHL) of the small noncleaved cell
type, immunoblastic sarcoma and Hodgkin's disease of the high-grade
mixed-cellularity type. Moreover, the Center for Disease Control rec
ognizes undifferentiated lymphomas as a criterion for AIDS. The ma
jority of AIDS-related lymphomas (ARL) have aggressive histologic
subtypes and are diagnosed at advanced stages, generally stage III or IV.
They carry a poor prognosis, the median survival time for patients on
chemotherapy being 5.5 months. AIDS patients with systemic NHL have
an abnormally large number of Epstein-Barr virus-infected В cells.
Symptoms at the time of presentation are often nonspecific and include
weight loss, fever, night sweats, diffuse abdominal pain and malaise.
Only 4% of patients have demonstrable peripheral adenopathy.
Moreover, 74-95% of AIDS patients have involvement of extranodal
sites and the majority of patients have multiorgan involvement.
Intrahepatic involvement is a stricking feature of ARLs, when com
pared to non-immunocompromised patients. Its incidence is between 9%
and 26%, compared with 4-6% in patients without AIDS. US and CT
are equally valuable in diagnosing multiple small nodular areas of macro
scopic involvement. The typical findings include hypoechoic nodules on
US, and hypodense, homogeneous and well-defined nodules on CT (Fig.
10). However, the nodules can occasionally be hyperechoic with a tar
get appearance on US, and peripheral enhancement on CT. Diffuse in
filtration is less frequent and is associated with homogeneous he-
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Figure 10.
AIDS-related lymphoma.
Abdominal contrast-enhanced
CT scan shows bilateral renal
enlargement with low-density
lymphomatous renal masses
associated with two focal he
patic lesions (arrows).
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Figure 11.
Kaposi's sarcoma o f the
duodenum and proximal
ileum.
Note the presence o f multi
ple, irregular filling defects
associated with wall thick
ening.
patients with AIDS. The sites of involvement include the skin (93%),
lymph nodes (72%), the gastro-intestinal tract (48%) and both the liver
and spleen (34%).
Nodal involvement is characterized by bulky mesenteric and retroperi
toneal adenopathies with nodes more than 1.5 cm in diameter. On CT
scans, they are typically homogeneous with no low-density areas (as in
mycobacterial infection). However, KS cannot be distinguished from
other neoplastic or infectious causes and pathologic confirmation is
mandatory. It can be reliably obtained by fine needle aspiration biopsy.
Involvement of the stomach and small bowel is common, while the colon
is rarely affected. The lesions present as intraluminal filling defects on
barium studies, of variable size and number (Fig. 11). Central umbilica-
tion is characteristic of KS, with a ’’target" appearance on air-contrast
studies. Graded compression can help visualize a lesion hidden between
folds; coalescent lesions may produce thickened folds visible on CT
imges. Focal hepatic lesions of KS are rarely encountered on US or CT;
they include hepatic nodules and periportal infiltration with subsequent
dilatation of the intrahepatic bile ducts. As KS can involve almost any
abdominal organ, it can produce a variety of nonspecific lesions which
can be biopsied under CT guidance.
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Opportunistic infections
Oesophagus
Candida is the most frequent cause of oesophagitis in AIDS and oe
sophageal candidiasis is diagnostic of AIDS in a patient with known HIV
seropositivity. The main symptom is dysphagia. Double-contrast oe-
sophagography has a higher sensitivity (85-90%) in detecting esphageal
candiadiasis than single-contrast studies. Candiadiasis can produce a dif
fusely ulcerated shaggy mucosa or more limited lesions such as focal
plaques, subtle, longitudinally orientated filling defects and cobbleston
ing.
Cytomegalovirus (CMV) oesophagitis typically produces discretely
marginated diamond-shaped ulcers with a peripheral lucency that repre
sents a zone of edema against a background of normal mucosa.
Furthermore, CMV often involves the distal half of the oesophagus with
extension of the process in the stomach. Another unique feature of CMV
is its propensity for causing giant oesophageal ulcers resulting from both
infectious destruction of the mucosa and ischemic necrosis induced by
CMV vasculitis. Herpex simplex virus is the third major aetiology of oe
sophageal infection in AIDS patients. It produces radiographic findings
similar to those observed in CMV oesophagitis at both the early and ad
vanced stages of disease.
Stomach
Most infectious gastric lesions are detected on barium studies, performed
to evaluate the oesophagus or the small bowel in patients with dyspha
gia or diarrhoea. They rarely produce symptoms which suggest a diag
nosis or focus investigations on the stomach. CMV is the main aetio-
logical organism. It typically produces wall thickening of the OG junc
tion and antrum, associated with gastroesophageal ulcerations which can
lead to stricture formation and stenosis. Submucosal involvement can
appear as "thumbprint" lesions, usually more regular and less discrete
than the masses seen in KS. Gastric invasion by Mycobacterium tuber
culosis with lesser omental abscess has also been described.
Small bowel
On upper gastrointestinal barium studies, abnormalities are often multi
focal and affect the duodenum in 82% of the cases, the jejunum in 64%
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RADIOLOGY IN AIDS
and the ileum in 46%. The main clinical manifestations of small bowel
disease is diarrhoea. Mild diarrhoea is a frequent symptom in AIDS pa
tients which can be related to infection, tumours or drug therapy. Some
patients present with severe diarrhoea, accompanied by weight loss, de
hydration, electrolyte imbalance and m a l a b s o r p t i o n . The most common
cause of this serious syndrome is protozoan infection by Cryptosporidia
of Isospora belli. Radiographic findings include thickened folds in the
proximal small bowel, fragmentation, spasm, and mild dilatation. More
severe involvement produces mucosal atrophy with a subsequent "tooth
paste" appearance. Differential diagnoses include giardiasis, strongyloi-
dosis, acquired hypogammaglobulinemia, cystic fibrosis and mycobac
terial infections. Several antimicrobial treatments have been attempted
with limited success. Both Mycobacterium tuberculosis (MT) and
Mycobacterium avium intracellulare (MAI) may be encountered in the
small bowel. On barium studies, MAI infection is characterized by a
pseudo-Whipple appearance and marked hypertrophy of the valvulae
conniventes in the distal ileal loops. Associated mesenteric and retroperi
toneal lymphadenopathy, splenomegaly and ascites are usually shown
by CT.
CMV infection predominantly involves the distal ileum which has a
narrowed appearance with discrete submucosal nodules and thickened
folds. Ulceration, intestinal perforation or fistula are potential compli
cations of the necrotizing vasculitis induced by CMV.
Colon
Colitis may be due to opportunistic infections, as well as to the common
pathogens which are frequently encountered in homosexual men. The
"gay bowel syndrome" includes traumatic and infectious lesions of the
rectum and colon by pathogens such as amoebae, gonococci, salmonel-
lae, shigellae and Campylobacter. In 90% of homosexual men, CT shows
an infiltration of the perirectal fat and thickening of the rectal wall.
Although several colitides are unique to immunocompromised patients,
only CMV colitis produces distinctive radiographic findings. They in
clude diffuse mucosal granularity, aphthous ulcers and caecal spasm with
terminal ileal fold effacement. The presence on CT of a "target sign" due
to submucosal oedema as well as right-sided and ileal involvement, are
suggestive of CMV colitis. In advanced stages, CMV colitis may pre
sent with toxic megacolon, perforation, deep ulceration and submucosal
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Figure 12.
Hepatic abscess.
a) Contrast-enhanced CT
scan shows small hepatic
abscesses (arrows) with a
hypodense and nodular
appearance. Liver biopsy
was positive fo r MAI.
b) In another patient, con-
trast-enhanced CT scan
shows ill-defined area o f
low-density in the right
hepatic lobe (arrow).
Liver biopsy revealed
Candida albicans.
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RADIOLOGY IN AIDS
Figure 13.
Adenopathy from
Mycobacterium tuberculosis
infection.
CT scan demonstrates bulky
retroperitoneal, coeliac and
periportal nodes with central
low density areas.
present with right upper quadrant pain, jaundice, fever or abnormal liver
function tests. US or CT can demonstrate segmental or diffuse dilata
tion, irregularity, and narrowing of the intra- or extra-hepatic bile ducts.
Wall thickening of the bile ducts and gallbladder is frequently associ
ated with enhancement of the wall of the bile ducts on CT. Periportal hy
perechogenicity due to fatty infiltration of the liver has been observed in
addition to cholangitis. Noninvasive imaging with US and CT may sug
gest AIDS-related cholangitis. However, direct cholangiography or
ERCP may be useful to document the presence of subtle cholangitis. The
only effective treatment is endoscopic sphincterotomy which can be per
formed in patients with isolated ampullary stenosis in order to obtain re
lief of the right upper quadrant pain.
Lymph nodes
Abdominal opportunistic infections produce clinical and radiographic
patterns that can be indistinguishable from AIDS-related Kaposi's sar
coma, lymphoma or even lymphadenopathy syndrome. MAI produces a
systemic infection and is more common than MT. Culture is necessary
to differentiate them. They typically involve the mesenteric and retroperi
toneal lymph nodes and produce bulky nodal masses. On CT images, the
presence of focal parenchymal lesions and low-attenuation lymph nodes
suggest MT (Fig. 13), whereas marked hepatic and splenic enlargement,
diffuse jejunal wall thickening and solid lymphadenopathy suggest MAI.
Low-attenuation lymph nodes in MT probably represent areas of necro
sis or caseation. Definitive diagnosis requires culture of the nodal tissue
which can be obtained by percutaneous biopsy.
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Genito-urinary tract
The incidence of urinary tract infection has been reported to be as high
as 50% in AIDS patients. Pyelonephritis is frequently complicated by
intrarenal or perinephric abscesses. CT in these patients shows swollen
kidneys with perirenal fascia thickening and focal areas of low density,
with a peripheral enhancement representing renal abscesses. MT and as-
pergilloma can present as multiple masses, with a hyperechoic appear
ance on ultrasonography. Hydronephrosis can be caused by an obstruc
tion due to fungus balls. Intrarenal areas of increased echogenicity have
been reported in patients with Pneumocystis carinii disease, MAI and
histoplasmosis. These changes can be associated with extrarenal infec
tions and with AIDS-related nephropathy which is characterized by in
creased echogenicity. Multiple pathologic processes have been proposed
to explain this increased echogenicity, including glomerulopathy, acute
tubular necrosis, interstitial nephritis, nephrocalcinosis, tubular dilata
tion and atrophy.
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Index
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XVI
INDEX
XVII
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XVIII
INDEX
XIX
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XX
INDEX
XXI
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XXII
INDEX
XXIII
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XXIV
INDEX
XXV
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XXVI
INDEX
XXVII
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XXVIII
INDEX
XXIX
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XXX
INDEX
XXXI
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XXXII
INDEX
XXXIII
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XXXIV
INDEX
XXXV
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XXXVI
INDEX
XXXVII
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XXXVIII
INDEX
XXXIX
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XL
INDEX
XLI
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XLII
INDEX
XLIII
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XLIV
INDEX
XLV
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XLVI
INDEX
XLVII
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XLVIII
INDEX
vesicoureteral reflux (VUR) 591, 601 wet-lung disease 539, 541, 542
vestibular aqueduct 230 Whipple's disease 968, 969
vestibule 230 WHIS (WHO Imaging System) 14, 96
video urodynamics 1178 WHIS-Manual 98
videophlebography 816 WHIS-RAD 96
vigorous achalasia 902, 904 white matter 170
villous adenoma 1006 WHO "Manual of Radiographic
viral pneumonia 549, 733 Technique" 94
Virchows triad 846 WHO Imaging Systems (WHIS) 14, 96
visceral pleura 684 WHO Basic Radiological System 96
visible light 20 WHO (World Health Organization) 85
visual display 70 WHO-BRS 96
vitamin A poisoning 528 WHO-designed x-ray unit 95
- В 12 deficiency 977 Wilms' tumor 596, 602, 605
- D dependent rickets 526 window width 108
- D hypovitaminosis 831 wolfian duct 598
- D resistant rickets 525 workstations 113
vocal cord 257 World Health Organization (WHO) 85
voiding reflex 1129 worm-shaped polyposis 999
voiding cystourethrograhy (VCUG) 591 wormian bones 503
volume scanning 810 Wuchereria bancrofti 1299
volvulus 573,1101 Wurzburg University 3
vomiting 573 Wtirzburg Physical Medical Society 9
von Hippel-Lindau disease 103 3 X radiation 17
voxel size 58 X-ray guided FNAB 633
voxel 57,81 X-ray examination 17
VSD (ventrcular septal defect) 558, 566 X-ray spectrum 24
VUR (vesicoureteral reflux) 591, 601 X-ray 20
Waldeyer's ring 884 X-ray generator 36
Wallstent 861 X-ray tube 36
wash-in defect 795 xanthogranulomatous pyelonephritis 1152
water solubility 119 xenon-133 681
water siphon test 913 Xenonchloride-excimer-laser 856
Waters view 238 Y cartilage 482
Waters projection 263 Yersinia enterocolitica 959, 966, 1001
watershed infarctions 178 Zellweger syndrome (cerebro-
wavelength 20 hepatorenal syndrome) 498, 1228
wedge fracture 310 Zenker's diverticulum 893, 898
Wegener's granulomatosis 751, 1156 Zollinger-Ellison syndrome933, 948, 949