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Gallbladder carcinoma Brief review of gallbladder carcinoma Most common biliary cancer Associated with: 1 Gallstones in 64 - 98% Gallbladder carcinoma occurs in only 1% of all patients w

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Brief review of Epiploic Appendagitis Rare inflammatory and ischemic condition Results from torsion or spontaneous venous thrombosis of one of the appendices epiploicae → ischemia or infarction of the appendix epiploica & localized inflammation Sudden, severe, focal abdominal pain, mimic other conditions such as appendicitis

Can be managed conservatively CT: 1- 4-cm, oval, fatty

pericolic lesion with surrounding mesenteric inflammation

Adjacent cecal wall thickening and compression Rarely, a

central high-attenuation "dot" within the inflamed appendage; corresponds to the thrombosed vein (17)

especially from colon, ovary (most frequent neoplasm of mesentery)

2 Lymphoma 3

Leiomyosarcoma (more frequent than leiomyoma) 4 Neural tumor (neurofibroma, ganglioneuroma)

5 Lipoma (uncommon), lipomatosis, liposarcoma 6

Fibrous histiocytoma 7

Hemangioma 8 Desmoid tumor (most common primary)

Gallbladder carcinoma

Brief review of gallbladder carcinoma Most common biliary

cancer Associated with: (1) Gallstones in 64 - 98%

Gallbladder carcinoma occurs in only 1% of all patients with gallstones! (2) Porcelain gallbladder (in 4 - 60%) (3)

Inflammatory bowel disease (predominantly ulcerative colitis) (4) Familial polyposis coli (5) Chronic cholecystitis Growth types: replacement of gallbladder by mass (37 - 70%)

focal / diffuse asymmetric irregular thickening of GB wall (15 - 47%) polypoid / fungating intraluminal mass with wide base (14 - 25%) Differential diagnosis see note below

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Chief complaint: general weakness

Figure(s)

Addison disease caused by adrenal tuberculosis

Brief review of addison disease

= Primary adrenal insufficiency 90% of adrenal cortex must be destroyed! Cause:

1 Idiopathic adrenal atrophy (60 - 70%): likely autoimmune disorder

2 Granulomatous disease: tuberculosis, sarcoidosis

3 Fungal infection: histoplasmosis, blastomycosis, coccidioidomycosis 4 Adrenal hemorrhage: anticoagulation therapy, bleeding, coagulation

disorders, sepsis, shock

5 Bilateral metastatic disease (rare) Diminutive glands (in idiopathic

atrophy + chronic inflammation) Enlarged glands (acute inflammation,

acute hemorrhage, metastasis

diagnoses?

AnswerMyxoid liposarcoma

Brief review of myxoid liposarcoma most common type

of liposarcoma varying degrees of mucinous

+ fibrous tissue

+ relatively little lipid intermediate differentiation CT solid pattern: inhomogeneous poorly marginated

infiltrating mass mixed pattern: focal fatty areas

+ areas of higher density pseudocystic pattern: density mass calcifications in up to 12% DDx: malignant

water-14

chief complaint: jaundice

PTC

Percutaneous transhepatic cholangiography shows multiple ovoid filling defects in dilated intrahepatic bile ducts Focal stricture is noted in right main

IHD What are the differential diagnoses?

Clonorchiasis of the liver

Brief review of clonorchiasis of the liver Endemic Country: Japan, Korea, China, Taiwan, Indochina Organism: Chinese liver fluke =

Clonorchis sinensis Pathology (a) desquamation of epithelial bile

duct lining with adenomatous proliferation of ducts + thickening of duct walls (inflammation, necrosis, fibrosis) (b) bacterial

superinfection with formation of liver abscess Remittent incomplete obstruction + bacterial superinfection Multiple crescent- / stiletto-shaped filling defects within bile ducts Complication (1) Bile duct obstruction (conglomerate of worms / adenomatous proliferation (2) Calculus formation (stasis / dead worms / epithelial debris) (3)

Jaundice in 8% (stone / stricture / tumor) (4) Generalized dilatation

of bile ducts (2%)

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M/49 Chief complaint: fever,chill

Explanation for figure(s)

Air in anterior pararenal space

Infiltrations adjacent to the duodenum and thickened renal fasciae & septi

Pneumoperitoneum due to perforated duodenal ulcer Radiologic findings of pneumoperitoneum air lesser peritoneal sac gas in scrotum (through open

processus vaginalis) Large collection of gas: abdominal distension, no gastric air-fluid level "wall sign" = "Rigler sign" = "bas-relief sign" =air on both sides of

bowel as intraluminal gas + free air outside (usually requires >1,000 mL of gas) "football sign" = large pneumoperitoneum outlining entire abdominal cavity

outline of falciform ligament (medial RUQ); most common structure outlined

"telltale triangle sign" = triangular air pocket between 3 loops of bowel

"inverted V sign" = outline of both lateral umbilical ligaments "urachus sign" = outline of middle umbilical ligament

M/57 Chief complaint: fever and chill

Past medical history: went through whipple’s operation due to

pancreatic cancer

Figure(s): CT

Afferent loop syndrome caused by recurred pancreatic cancer Brief review of

afferent loop syndrome Complication of subtotal gastrectomy with Billoth II

gastrojejunostomy Cause internal hernia, kinking of anastomosis, adhesive band, stomal stenosis, neoplasm, inflammation Abdominal radiographs often normal

because the afferent loop is fluid filled as a result of distal obstruction Barium study non-filling of the afferent loop or preferential filling of dilated proximal loop with

stasis CT , US two or more thinly marginated, round, cystic structures adjacent to pancreas anterior displacement of the superior mesenteric artery

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Chief complaint:

went through extended left hepatic lobectomy and radiation

therapy for klatskin tumor

Figure(s)

Radiation-induced liver disease

Brief review of radiation-induced liver disease US

hypoechoic - localized hepatic congestion or edema

CTSharply defined band of low attenuation

corresponding to treatment port - edema or fatty

infiltration Region of increased attenuation in fatty liver

- loss of fat in irradiated hepatocytes or regional

edema eventually irradiated area become atrophic MR low signal intensity on T1WI, high on T2WI

28Figure(s)

Pheochromocytoma

Brief review of pheochromocytom

Location:

anywhere in sympathetic nervous system from neck to sacrum

subdiaphragmatic in 98% (a) adrenal medulla (85 - 90%) (b) extraadrenal (10 - 15% in adults, 31% in children): para-aortic sympathetic chain

(8%), organ of Zuckerkandl at origin of inferior mesenteric artery (2 - 5%), gonads, urinary bladder (1%)

CT: discrete round / oval mass with a mean size of 5 cm (range 3 - 12 cm) solid / cystic / complex mass with low-density areas secondary to

hemorrhage / necrosis calcifications may be present

DDx: nonfunctioning adrenal adenoma, adrenocortical carcinoma, adrenal

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54 /M

Chief complaint:

abdominal pain

Figure(s)

Secondary hepatic lymphoma in non-Hodgkin’s lymphoma Brief review of hepatic lymphoma most lymphoma of the liver are

secondary More than 50% of patients with Hodgkin’s or

non-Hodgkin’s lymphoma Pathology nodular and diffuse form

Hodgkin’s disease: more often miliary lesion, almost splenic

lesion CT multiple, well-defined, large, homogeneous

low-density Hepatomegaly Additional areas of involvement spleen, para-aortic, celiac, periportal lymph node, kidney

48/M

Chief complaint: swallowing

difficulty

Esophageal leiomyoma Brief review of esophageal

leiomyoma Most common benign tumor of esophagus; 50% of all esophageal benign tumors Age: young

adults, 3% in children (associated with Alport

syndrome in 22%); M > F Site: frequently lower + mid 1/3 of esophagus 2 - 15 cm large smooth well-defined intramural mass causing eccentric thickening of wall + deformity of lumen may have coarse calcifications

Leiomyoma is the only calcifying esophageal tumor!

ulceration uncommon diffuse leiomyomatosis / multiple leiomyomas in children

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These are images from contrast-

enhanced CT scan There are multiple masses and

infiltrations in the omentum The

masses have defined margin

ill-There was an poorly enhanced mass in the

pancreas What

Figure(s): CT

Metastasis from melanoma

Brief review of metastases from malignant melanoma

1 Lymphadenopathy

2 Bone (11 - 17%) : axial skeleton (80%), ribs (38%)

3 Lung (70% at autopsy) : most common site of relapse

4 Liver (17 - 23%; 58 - 66% at autopsy)

5 Spleen (1 - 5%; 33% at autopsy)

6 GI tract + mesentery (4 - 8%) Location: small intestine

(35 - 50%), colon (14 - 20%), stomach (7 - 20%) multiple

submucosal nodules, "bull's-eye / target" appearance = central ulceration irregular amorphous cavity (exoenteric growth) intussusception (10 - 20%)

7.Kidney (up to 35% at autopsy) 8 Adrenal (11%, up to 50%

at autopsy)

Chief complaint:

incidental mass

Figure(s): CT

Tuberculous lymphadenopathy Brief review of regional patterns of lymphadenopathy 1 Gastrohepatic ligament nodes superior portion of lesser omentum suspending stomach from liver Common cause: carcinoma of lesser curvature of stomach, distal esophagus, lymphoma,

pancreatic cancer, melanoma, colon + breast cancer DDx: coronary varices 2 Porta hepatis nodes in porta hepatis extending down hepatoduodenal ligament,

anterior + posterior to portal vein Common cause:

carcinoma of gallbladder + biliary tree, liver, stomach, pancreas, colon, lung, breast Complication: high

extrahepatic biliary obstruction 3 Pancreaticoduodenal nodes between duodenal sweep + pancreatic head

anterior to IVC Common cause: lymphoma, pancreatic head, colon, stomach, lung, breast cancer

53/M

Chief complaint: abdominal pain after getting blunt

injury to the abdomen

These are images from contrast-enhanced CT scan There are multiple air

collections in the mesentery and retroperitoneum where there must be no air

normally Ascites is noted in subhepatic space and

paracolic gutters On precontrast CT scan (not presented), the attenuation

of ascites in subhepatic space is quite higher than simple fluid, e.g bile within gallbladder What are the differential diagnoses?

34/M

Chief complaint:

palpable abdominal mass

Malignant gastrointestinal stromal tumor (GIST) of

duodenum

Brief review of malignant GIST of small bowel

Location:

duodenum (26%), jejunum (34%), ileum (40%)

usually >6 cm in size nodularmass: intraluminal,

intraluminal pedunculated, intramural, chiefly extrinsic mucosa may be stretched + ulcerated may show central ulcer pit / fistula communicating with a large necrotic center intussusception

46

Chief complaint:

jaundiceCT

ERCP

Polypoid hilar cholangiocarcinoma Brief review of

extrahepatic cholangiocarcinoma Location: left / right hepatic duct in 8 - 13% confluence of hepatic ducts

(Klatskin tumor) in 10 - 26% common hepatic duct in 14

- 37% proximal CBD in 15 - 30%, distal CBD in 30 -

50%, cystic duct in 6% Growth pattern: (1) Obstructive type (70 - 85%) U- / V-shaped obstruction with nipple, rattail, smooth / irregular termination (2) Stenotic type (10 - 25%) strictured rigid lumen with irregular margins + prestenotic dilatation (3) Polypoid / papillary type (5 - 6%) intraluminal filling defect with irregular margins

It has homogeneous water attenuation and well demarcation The mass push the left

kidney and small bowels to right side

Which anatomical space did the mass

Figure(s)

obstruction)

US: multiseptated cystic mass with lobules fluid anechoic / with internal echoes / sedimentation

CT: cystic mass with contents of water- to fat-density

MR: serous contents: hypointense on T1WI + hyperintense

on T2WI hemorrhage / fat: hyperintense on T1WI + T2WI

Treatment: surgery (difficult due to intimate attachment to

bowel wall)

Figure(s)

Isolated bladder metastasis from stomach

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Budd-chiari syndrome with veno-veno collateral due to

idiopathic occlusion of right hepatic vein

Brief review of Budd-chiari syndrome Definition: global /

segmental obstruction of hepatic venous outflow

Causes: A idiopathic

B thrombosis: Hypercoagulable state, Injury to vessel wall

C nonthrombotic obstruction: Tumor growth into IVC / hepatic veins, Membranous obstruction of suprahepatic IVC, Right atrial tumor, Constrictive pericarditis, Right heart failure

communications between right / middle hepatic vein and inferior right hepatic vein enlarged inferior right hepatic vein

hypertrophy of caudate lobe hypodensity in atrophic areas /

periphery with inversion of portal blood flow patchy

enhancement with normal portal blood flow narrowing /

obstruction of intrahepatic IVC

M/33

Chief complaint:

received hormonal (steroid) therapy for aplastic anemia

Hepatic adenomas Brief review of hepatic adenoma

Radiologic-pathologic correlation Rich in fat

Hyperechoic mass: ultrasound

Hypodense mass: CT Hyperintense mass: MR No stroma, internal Anechoic, potentially cystic mass: ultrasound hemorrhage Hyperdense area:

CT Hyperintense area: T1-weighted image (MR) Peripheral “feeders” Peripheral enhancement: angiography Kupffer cells Sulfur colloid uptake,

SPIO uptake Hepatocytes, no ductule IDA uptake, no

excretion Associated with: oral contraceptives, steroids,

M/82

Chief complaint : frequent watery diarrhea and abdomen distensionPast medical history: being under long term antibiotics due to

throughout the rectum and sigmoid colon Mucosal layer which is well enhanced is clearly seen in contrast with edematous submucosal layer having homogeneous low

attenuation There is ascites What are the possible causes?

(d) proximal to large bowel obstruction

(d) debilitating diseases: lymphosarcoma, leukemia

(e) immunosuppressive therapy with actinomycin

D Location: rectum (95%); confined to right + transverse colon (5 - 27%)

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