FAR EASTERN UNIVERSITY – NICANOR REYES MEDICAL FOUNDATION

INSTITUTE OF MEDICINE – BATCH 2020

CLINICAL DIAGNOSIS B: RADIOLOGY

ABDOMEN / GIT
JAN. 11, 2017

DEFINITION OF TERMS  Solid organs – liver, kidneys, spleen

 Density – any area of whiteness on an image  Bones – spine, ribs, pelvis
 Lucency – any area of blackness on an image  Metal/Contrast – barium
 Shadow – anything visible on an image; hence any specific
density or lucency on the other
 Line – a thin density with lucency on both sides or a thin
lucency with density on both sides
 Stripe – any edge or line
 Silhouette – synonym for edge; the loss of an edge
constitutes the “silhouette sign”

RULES OF VISIBILITY
 The edge of any structure is only visible if it is bordered by
a structure of different fundamental density.
 Fundamental densities are air, soft tissues (including fat
and blood), calcium & metal
 Not altered by patient position, direction of x-ray beam
or technique. SOLID ORGANS
 The lightness and darkness of any part of the image is the
result of all structures through which the x-ray beam has
passed.
 Lightness and darkness are easily changed by
technique, but the whole film will be similarly affected

BASIC RADIODENSITIES
 Gas – seen in stomach, large bowel
 Fat lines – psoas, peri-renal, extraperitoneal, perivesical
BONES

GAS BUBBLE FAT LINES

CONTRAST
Fat lines
1- Peri-renal fat (retroperitoneal)
2 – Peritoneal fat (next to the liver)
3 – Abdominal wall fat (separates
muscles of the abdominal wall)

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DIFFERENT ABDOMINAL VIEWS  Consists of a single film with the patient on supine and/ or
 AP Supine upright position
 Film cassette is placed under the patients back and x-
ray tube is positioned anteriorly PLAIN FILM OF THE ABDOMEN
 AP Upright
 Things to look for:
 An essential component of the abdominal examination
 Gas pattern
by confirming the presence of intraperitoneal air
 Extraluminal air
 Horizontal central beam at diaphragm level
 Soft tissue masses
 Lateral decubitus
 Calcifications
 Obtained after the patient has remained in this position
for 10 minutes
NORMAL GAS PATTERN (ABDOMEN)
 Stomach
 Always
 Small Bowel
 Two or three loops of non-distended bowel
 Normal diameter = 2.5 – 3.0 cm
 Large Bowel
 In rectum or sigmoid – almost always

AP SUPINE AP UPRIGHT

 Swallowed air
 Primary source of gas normally seen in the stomach
LATERAL DECUBITUS  Common to see gas in limited quantities in non-
distended small bowel loops
 Colon normally contains gas and feces
INDICATIONS FOR EXAMINATION
 Abnormal accumulation of gas within the intestinal tract –
most common
 Calculi or other abnormal intraabdominal calcifications
 Size, shape and position of the liver, spleen and kidneys
 Abnormal intraabdominal masses
 Free gas within the peritoneal cavity (pneumoperitoneum)
 Ascites
 Radiopaque foreign bodies in the GI tract
 In infants:
 Intraabdominal abscesses
 Intestinal gas pattern differs from that of adults in that
SCOUT FILM gas normally present throughout the small bowel
 Also called a “plain film”  Within few hours after birth, gas can be seen
 Film made without any artificially produced contrast throughout the intestinal tract
substance
 As a preliminary step in the examination of the GI tract, GB
or urinary tract

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NORMAL ABDOMINAL ORGANS

 Liver
 Forms a homogeneous shadow in the right upper
quadrant
 upper border is limited by the right leaf of the
diaphragm
 Right-lateral margin of the liver is usually separated
from the density of the abdominal wall by a thin layer of
“fat”
 Spleen
 Entire organ of part of it can usually be seen in the left
upper abdomen
 Normal size is about 10 to 14 cm long
 Rare instances, spleen is unusually mobile and may be
found medial to the splenic flexure of the colon
FAT LINES
 Psoas
 Outer margins form stripe-like shadows on either side
of the spine from L1 down to the pelvis
 Becomes indistinct as the muscle passes over the mid-
portion of the ileum
 Peri-renal
 Encapsulates both kidneys
 “Fat” is an important substance in rendering the margins
distinct because of its relative radiolucency as compared
to the density of the parenchymatous viscera

PSOAS PERI-RENAL

FLANK STRIPES

 Pancreas
 Cannot be seen on plain films
 Ultrasound and computed tomography
 Urinary bladder
 Usually visible if it contains urine and surrounded by fat

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PRINCIPLES OF EXAMINATION BY CONTRAST  Barium Enema

 Evaluation of gut caliber  Allows visualization of the large intestine
 Narrowing: usually implies inflammation or neoplasm
 Widening: reflects either obstruction or muscle
weakness
 Detection of outpouching
 May either be diverticula or mucosal ulceration
 Local protrusion into the lumen
 Usually neoplastic
 May either arise from the mucosa or wall
 Displacement of Gut
 Most of the gut is not fixed in position
 Extrinsic disease – whether inflammatory or neoplasm –
 Endoscopic Retrograde Cholangiography
will move the gut away from its normal position
 Allows direct injection of the common bile duct and
 Miscellaneous
gallbladder
 Intussusception, volvulus, hernia and sphincters

ABDOMINAL ULTRASOUND
 Ultrasound (US) is firmly established as a primary imaging
modality for comprehensive evaluation of the abdomen,
including the abdominal organs, the peritoneal cavity, and
the retroperitoneum.
 Its role includes:
CONTRAST STUDIES  Screening for disease
 Upper Gastrointestinal Series  Evaluation and follow-up of known abnormalities
 Allows visualization of the esophagus, stomach and  Guidance of biopsy, aspiration, and catheter drainage
small intestines procedures.
 Comprehensive examination commonly includes the use of
Doppler and color flow imaging, as well as specialized
techniques of transvaginal or transrectal US to demonstrate
pelvic extension of disease.

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ABDOMINAL CT SCAN ZENKER DIVERTICULUM

 CT uses a computer to reconstruct mathematically a cross-
sectional image of the body from measurements of x-ray
transmission through thin slices of patient tissue.
 Arises in the hypopharynx just proximal to the upper
esophageal sphincter (UES).
 It is located in the posterior midline at the cleavage plane
(known as Killian dehiscence) between the circular and
oblique fibers of the cricopharyngeus muscle.
 The diverticulum has a small neck that is higher than the sac,
resulting in the trapping of food and liquid within the sac.
 The distended sac may compress the cervical esophagus.
 Symptoms:
 Dysphagia
 Halitosis
 Regurgitation of food

(a to c: axial view, d: coronal view, e: sagittal view)

THE GASTROINTESTINAL TRACT

ESOPHAGUS
 Extends from the cricopharyngeus muscle at the level of C5-
C6 to the gastroesophageal junction (GEJ).
 Muscular tube formed by an outer longitudinal muscle layer
and an inner circular muscle layer lined by stratified
squamous epithelium.
 Normal extrinsic impressions on the esophagus are made by:
 The aortic arch ESOPHAGEAL ACHALASIA
 The left mainstem bronchus, and  A disease of unknown etiology characterized by:
 The LA  Absence of peristalsis in the body of the esophagus
 Marked increase in resting pressure of the LES
 Failure of the LES to relax with swallowing
 Signs/Symptoms:
 Dysphagia
 Regurgitation
 Foul breath
 Aspiration
 Radiographic signs:
 Uniform dilatation of the esophagus, usually with an air
fluid level present
 Absence of peristalsis, with tertiary waves common in
the early stages of the disease
ESOPHAGEAL DISEASES:  Tapered beak deformity at the LES (lower esophageal
GASTROESOPHAGEAL REFLUX DISEASE (GERD) sphincter) because of failure of relaxation
 Occurs as a result of incompetence of the lower esophageal  Increased incidence of epiphrenic diverticula and
sphincter (LES) esophageal carcinoma
 Symptoms :
 Substernal burning pain (heartburn)
 Postural regurgitation (in the supine position)
 Reflux esophagitis
 Dysphagia
 Odynophagia

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STOMACH
 The stomach is a wide muscular bag and represents the
widest part of the gut.
THE TERMS USED TO DESCRIBE THE ANATOMIC DIVISIONS
OF THE STOMACH
 Cardia: refers to the region of the gastroesophageal junction
(GEJ).
 Fundus: is that portion of the stomach above the level of the
GEJ
 Body of the stomach: is the central two thirds, from the
cardia to the incisura angularis.
 Incisura angularis: is an acute angle formed on the lesser
curvature that marks the boundary between the body and
the antrum.
 Parietal cells - hydrochloric acid
 Chief cells - pepsin precursors
 Antrum: is the distal third of the stomach and contains
gastrin-producing cells but no acid-secreting cells.
 Pylorus: is the junction of the stomach with the duodenum,
and the pyloric canal is the channel through the pylorus.
ANATOMIC DIVISIONS OF THE STOMACH
STOMACH DISEASES
GASTRIC ULCERS
 Signs of an ulcer as demonstrated by double-contrast UGI
series include:
 A barium-filled crater on the dependent wall
 A ring shadow caused by barium coating the edge of
the crater on the nondependent wall
 A double ring shadow if the base of the ulcer is broader
than the neck
 A crescentic or semilunar line when the ulcer is seen on
tangent oblique view.
 Some ulcers may be linear or rod-shaped.
 Ulcers are multiple in about 20% of patients.
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GASTRIC CARCINOMA  CBD and pancreatic duct pierce the medial aspect of the
 Is the third most common GI malignancy descending duodenum at the Ampulla of Vater.
 Adenocarcinomas (95%)
 Diffuse anaplastic (signet-ring) carcinoma
 Squamous cell carcinoma
 Rare cell types
 Predisposing factors:
 Smoking
 Pernicious anemia
**mali daw label, yung pataas yung 4th part**
 Atrophic gastritis
 Gastrojejunostomy.
DUODENAL DISEASES
 H. pylori infection increases the risk of gastric carcinoma
DUODENAL ULCERS
sixfold and is the cause of approximately half of gastric
 Causes:
adenocarcinoma cases.
 H. pylori infection in 95% of cases
 Peak age is from 50 to 70 years, with men predominating
 Anti-inflammatory medications
(2:1)
 Crohn disease
 Zollinger-Ellison syndrome
 Viral infection
 Penetrating pancreatic cancer.
 Associated with acid hypersecretion
 Duodenal bulb (95% of the case)
 Radiographic diagnosis:
 Duodenal ulcer depends upon demonstration of the
ulcer crater or niche

DUODENUM
 Roughly C-shaped tube, which runs from the pyloric canal to
the jejunum
 Divided into four parts:
 First part (2 cm)
 Duodenal cap or bulb
 Pyramidal portion, covered by visceral peritoneum
 Second part (descending portion)
 Lateral to the head of the pancreas MESENTERIC SMALL INTESTINE: JEJUNUM AND ILEUM
 8 cm of the duodenum has an opening halfway
 Approximately 7 meters long
down on its posteromedial aspect for the
 Jejunum - proximal two fifths
pancreatic and common bile ducts
 Ileum - distal three fifths
 Third part (horizontal portion)
 The mucosal folds (valvulae conniventes) are more
 8 cm curves anteriorly around L3 vertebra and the
prominent in the jejunum becoming less visible or even
IVC and aorta.
absent towards the distal ileum.
 Fourth part (Ascending portion)
 4 cm
 Passes upwards and to the left on the left side of
the aorta (level of L2), on the left psoas muscle and
posterior to the stomach.

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Small bowel enema/enteroclysis

ACUTE ABDOMEN
LARGE INTESTINES
 “Acute abdomen series”
 Large bowel connects the terminal ileum to the anal canal.  Routine assessment of acute abdomen
 Cecum  Chest PA view
 In the right iliac fossa  For optimal detection of pneumoperitoneum and
 Is portion of the right side of the colon inferior to the intrathoracic disease that may present with abdominal
ileocecal valve where the terminal ileum enters the large complaints.
bowel  Abdomen supine view
 It is a blind-ended sac, which is the widest part of the  Most commonly requested
large bowel and into it enters the vermiform appendix.  Abdomen upright or decubitus view (other name cross
 Ascending colon table lateral)
 Extends superiorly to the hepatic flexure.  For definitive diagnosis ultrasound and/or CT scan are
 It is retroperitoneal, the peritoneal reflection on its routinely obtained
lateral side is a formina which has shallow potential
channel called the right paracolic gutter COMMON CAUSES OF ACUTE ABDOMEN:
 Transverse colon  Appendicitis
 Extending from the hepatic flexure on the right to the  Peritonitis
splenic flexure in the left upper quadrant.  Acute cholecystitis
 Descending colon  Intraperitoneal abscess
 From the left upper quadrant, the passes inferiorly to  Acute pancreatitis
the Sigmoid colon  Retroperitoneal abscess
 Rectum  Acute diverticulitis
 Anal canal
 Bowel obstruction
 Acute ulcerative colitis
 Urinary tract infection
 Pseudomembranous colitis
 Urinary tract obstruction
 Amebiasis
 Pelvic inflammatory diseases
 Acute intestinal ischemia

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REMEMBERING NORMAL BOWEL GAS PATTERN Normal lumen Less than 3cm Less than 6 cm except
 Supine radiograph shows the normal distribution of gas in the diameter for cecum that can
stomach (large arrow) and duodenum (small arrow). extend to 9 cm and
 The normal mottled pattern of stool is seen in the distribution maximum of 12 cm
of the right colon (arrowhead).
 A few gas collections within the small bowel (curved arrow) are ADYNAMIC ILEUS
seen in the pelvis.  Other names: Paralytic ileus and non-obstructive ileus.
 Ileus means stasis.
 Does not differentiate mechanical obstruction from non
-mechanical stasis.
 Stasis of bowel contents because of absent or decreased
peristalsis.
 Typically demonstrates diffuse symmetric predominantly
gaseous, distention of bowel.
 Stomach, small bowel and colon are proportionally dilated
without an abrupt termination
 Occasionally, adynamic ileus may result in a gasless
PLAIN ABDOMINAL RADIOGRAPH INTERPRETATION abdomen with dilated loops of bowel that are filled only with
 Assessment of: gas, fluid, soft tissue, fat, calcium densities fluids.
 Normal gas in the abdomen is predominantly swallowed air
 Air fluid levels are seen in normal patients, commonly in
stomach, often in small bowel, but never in the colon distal to
the hepatic flexure.
 Normal air fluid levels in the small bowel should not exceed 2.5
cm in length.
 A normal intestinal gas pattern varies from no intestinal gas to
gas within three to four variably shaped intestinal loops
measuring less than 2.5-3.0 cm diameter.
 The normal colon contains some gas and fecal materials and
varies in diameter from 3 to 8 cm with the cecum having the
largest diameter.

DILATED BOWELS

COMMON CAUSES OF ADYNAMIC ILEUS:

 Drugs: e.g., atropine, glucagon, morphine, barbiturates,
phenothiazines
 Inflammation: intestinal (Gastroenteritis) and extraintestinal
(peritonitis, pancreatitis, appendicitis, cholecystitis, abscess)
Small Bowels Large bowels  Metabolic: e.g., diabetes mellitus, hypothyroidism,
Location Central Peripheral hypokalemia, hypercalcemia
 Post- operative: resolved in 4-7 days usually
Characteristics Valvulae conniventes: Haustral markings:
are finer and closer extends only part across  Post traumatic
together (extend wall the lumen (don’t extend  Post spinal injury
to wall) from wall to wall)

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SENTINEL LOOP  Goal of Imaging:

 Refers to a segment of intestine that becomes paralyzed and  Confirm presence of obstruction
dilated as it next to an inflamed intraabdominal organ.  Identify its level
 "Short segment” of adynamic ileus that appears as an  Demonstrate its cause
isolated loop of distended intestine that remains in the same  Radiograph can confirm the presence of bowel obstruction
position on serial film 6 to 12 hours before the diagnosis can usually made
clinically.

RIGHT UPPER LEFT UPPER LOWER

QUADRANT QUADRANT QUADRANT
SENTINEL LOOP SENTINEL LOOP SENTINEL LOOP
-Acute cholecystitis - Pancreatitis - Diverticulitis
- Hepatitis - Pyelonephritis - Appendicitis TERMS:
- Pyelonephritis - Splenic injury - Salpingitis  Complete obstruction - means the lumen is totally
- Cystitis
occluded.
- Crohn disease
LOCALIZED ILEUS PITFALLS  Partial obstruction - "some bowel contents pass through"
 May resemble early mechanical SBO  Simple obstruction - refers to blockage of the luminal
 Clinical course contents without interference blood supply.
 Get follow-up  Strangulation obstruction - means that the blood supply
to the bowel wall is impaired.
Prone
 "Closed loop obstruction" - the bowel loop is blocked at
both segment, seen in incarcerated hernia and volvulus.

SMALL BOWEL OBSTRUCTION

 20% of surgical admission for acute abdominal pain.
 80% of all intestinal tract obstruction.
 The level of obstruction is determined by dilated loops
above the obstruction and normal or empty loops
below the obstruction.
 Stepladder or hairpin loops of small bowel are most
MECHANICAL BOWEL OBSTRUCTION
characteristics.
 Refers to stasis of bowel contents above a focal lesion  S/Sx:
 Obstruction causes:  Crampy abdominal pain
 Obturation (occlusion by a mass in the lumen)  Abdominal distention
 Stenosis owing to intrinsic bowel disease  Vomiting
 Compression of the lumen by extrinsic disease.

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 Radiological plain films:

 Diagnostic only in 50 to 60 % of cases.
 Findings:
 Dilated loops of small bowel (>3cm)
disproportionate to more distal small bowel or
colon
 Small bowel air fluid level that exceeds 2.5 cm in
length.
 Air fluid levels at differing heights within the same
loop (strong evidence of obstruction)
 Small bubbles of gas trapped between folds in
dilated fluid filled loops producing "string of pearl
sign".
 "String of pearl sign" - is a row of small bubbles
of gas oriented horizontally or obliquely across
the abdomen.
 Abdominal CT Scan
 Imaging method of choice when the diagnosis is ACUTE APPENDICITIS
equivocal.  Most common cause of acute abdomen.
 Results from the obstruction of the appendiceal lumen
 14 of the cases are demonstratedin plain film.
 Demonstrate appendiceal caculus (Appendicolith or
Fecalith)
 Localized ileus may be evident in the right lower quadrant
 Ultrasound:
 Noncompressible appendix larger than 6mm in
diameter.
 Visualization of shadowing appendicolith.
 In Perforation
 Loculated pericecal fluid collection.
 Discontinous wall of appendix
 Prominent pericecal fat.

 CT Scan findings:
(1)Erect radiograph of the abdomen reveals dilated air-filled loops of
 An abnormally dilated enhancing appendix (>6 mm).
small bowel containing air fluid levels at different heights within the same
 Enhancing appendix surrounded by inflammatory
loop (arrows). Note the valvulae conniventes (arrowhead) that extend
across the entire diameter of the bowel lumen. The small bowel stranding or abscess.
obstruction was caused by adhesions  Pericecal abscess or inflammatory mass with calcified
(2) CT demonstrates dilated fluid- and air-filled loops of small intestine appendicolith
(wide arrows). A transition to non dilated bowel is evident in the distal
ileum (arrowhead), indicating an obstructing adhesion at that point. The
more distal small bowel (thin arrows) and the descending colon (curved
arrow) are collapsed

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LARGE BOWEL OBSTRUCTION

 Predominantly a condition of the elderly.
 20% of all bowel obstruction. CECAL VOLVULUS
 Cecum dilates to the greatest extent, irrespective of the site
 Medially displaced cecum
of LBO.
 Most colonic obstruction occur in the sigmoid colon.
 Causes of LBO:
 Colon Ca (50-60%)
 Metastatic disease (commonly pelvic in origin)
 Diverticulitis
 Volvulus
 Fecal impaction
 Amebiasis
 Ischemia
 Adhesions
 Radiographic findings in Plain films: (usually diagnostic)
 Demonstrating dilation of the colon from the cecum to
the point of obstruction.
 Colon distal to the obstruction is devoid of gas.
 Air fluid levels distal to the hepatic flexure are strong
evidence of obstruction

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Air in Rectum Air in Small Air in Large  Often anechoic fluid, echogenic mesentery, mesenteric
or sigmoid Bowel Bowel fat and small lymph node can be identified in the center
Localized Yes 2-3 distended Air in rectum of the intussusception.
Ileus loops or sigmoid
 "Donut" configuration of alternating hyperechoic and
Generalized Yes Multiple Yes-
hypoechoic rings representing alternating mucosa,
Ileus distended Distended
loops muscular wall and mesenteric fat tissues

SBO No Multiple No
dilated loops
LBO No None-unless Yes-
ileocecal valve Dilated
incompetent

INTUSSUSCEPTION
 Telescoping of the proximal segment of small bowel
(intussuceptum) into a distal segment (intussuscipiens)  CT Scan:
 Acquired cause of intestinal obstruction after 6 months of  Diagnostic
age.  Demonstrating a characteristic target like intestinal
 Idiopathic: major cause of SBO in children mass
 Types of Intussusception:  "The inner central density is the invaginating loop,
 Enteroenteric surrounded by fat density mesentery that is enveloped
 Ileocolic by receiving loop
 Colocolic
 Abdominal radiograph:
 Non-specific
 Normal or may demonstrate intestinal obstruction.
 May sugest a soft tissue mass with internal fat in the
right upper quadrant
 Barium studies:
 Demonstrate trapped barium between the
intussusception and the receiving bowel forming
COILED spring appearance. HIRSCHPRUNG DISEASE
 Enema reduction is performed using the water soluble  Is the result of absence of ganglion cells in the distal colon
contrast or air under pressure resulting in abnormal peristalsis and inability to effectively
evacuate the colon
 Functional colonic obstruction is caused by congenital
absence of ganglion cells in the distal colon resulting in
abnormal peristalsis.
 Rectum is always involved but the extent of proximal
involvement varies.
 The aganglionic segment is characteristically contracted.
 In order infants a well-defined change in caliber at the zone
of transition is characteristics.
 Ultrasound:  Rectal biopsy is suggested for definitive diagnosis
 Cylindrical mass, consisting of an outer hypoechoic ring
surrounding tissue of variable echogenicity.
 Concentric rings may be seen representing layers of
edematous intestines with alternating with layers of
mesentery.

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SIGMOID VOLVULUS
 Most common in the elderly and in individuals on high
residue diet.
 The sigmoid colon twist around its mesentery resulting in
closed loop obstruction.
 Proximal colon dilates while the rectum empties.
 3 to 8% of large bowel obstruction in adults.
 Plain Radiograph:
 Usually diagnostics.
 The sigmoid colon appears as a large gas filled loop
without haustral markings arising from the pelvis and
extending high into the abdomen and often to the
diaphragm.
 The three white lines formed by the lateral walls of the
loop and the summation of the two opposed medial
walls of the loop converge inferiorly into the illiac fossa.

NECROTIZING ENTEROCOLITIS
 Etiology: hypoperfusion and hypoxia of the gut.
 Radiograph:
 Initially: dilated loops of small bowel or colon.
 Hallmark: Pneumatosis cystoides intestinalis  appears
as linear, curvilinear or bubbly to granular collection of
air.
 Ultrasound:
FECAL IMPACTION
 Echogenic punctate foci in the liver vessels and bowels.
 Most common cause of large bowel obstruction in elderly
 Thickening of the bowel wall and decrease blood flow
and in bedridden patients.
within the bowel wall with Color Doppler imaging  Plain radiography:
suggestive of necrosis  Demonstrate a large mass of stool with a characteristics
mottled appearances in the distal colon

PNEUMOPERITONEUM
 Free air within the peritoneal cavity.
 Sign of bowel perforation.
 Causes:
 Duodenal or gastric ulcer perforation (most common)
 Trauma
 Recent surgery or laparoscopy

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 Infection
 Post-operative pneumoperitoneum usually resolves in 3-4
days.
 Radiography: Plain Film
 Upright chest radiograph
 Most sensitive for free air.
 Small amount of air are clearly demonstrated
beneath the domes of the diaphragm.
 Left lateral decubitus or cross-table lateral view
 Demonstrate air outlining the liver.
 Supine radiograph
 Gas on both sides of the bowel wall (RIGLER SIGN)
 Gas outlining the falciform ligament.
 Gas outlining the peritoneal cavity (FOOTBALL
SIGN)
 Triangular or linear localized extra-luminal gas in
the right upper quadrant

ASCITES
 Serous fluid in the peritoneal cavity.
 Causes:
 Cirrhosis
 Hypoprotenemia
 Congestive heart failure

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FATTY INFILTRATION
 Common and non-specific responses of hepatocytes to
injury and toxins.
 Hepatocytes becomes filled with cholesterol and
triglycerides.
 Causes:
 Alcoholism
 Obesity
 Malnutrition
DIFFUSE LIVER DISEASE
 Hyperalimentation
HEPATOMEGALY
 Steroid therapy
 Rounding of the inferior border of the liver.  Diabetes mellitus
 Extension of the right lobe of the liver inferior to the lower  Pancreatitis
pole of the right kidney.  Glycogen storage disease
 Liver length = >15.5 cm midclavcular line.  Chemotherapy
 Reidel lobe  Ultrasound:
 An elongated inferior tip of the right lobe of the liver  Liver parenchyma is increase in echogenicity in areas of
 Normal variant most often in female. fat infiltration.
 When present, left lobe of liver is smaller in size.  Echogenicity of the fatty liver is significantly greater
than the echogenicity of the normal kidney
parenchyma.
 Flip-flop sign= density difference in FAT Bright on US
and Dark on CT
 CT scan:
 Fat infiltration lowers the attenuation of the hepatic
parenchyma and makes the liver appears dense.
 Fatty infiltrated liver enhances less than normal livers.

 Causes:
 Vascular congestion - Congestive heart failure ; Hepatic
vein thrombosis
 Metabolic/Diffuse infiltration
 fatty infiltration, alcohol, drugs/chemotherapy, hepatic
toxins, Gauchers disease, lipodoses.
 Carbohydrates- Glycogen storage disease and Diabetes
mellitus.
 Iron – hemochromatosis
 Amyloid – amyloidosis
 Tumor/Cellular infiltration
 Diffuse metastases.
 Diffuse hepatocellular CA
 Lymphoma
 Extramedullary hematopoiesis
 Inflammation/infection –
 Hepatitis
 Sarcoidosis
 Tuberculosis
 Cyst - Polycystic disease.

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 May reveal parencymal inhomogeneity with patchy

areas of increase and decrease attenuation.
 Fine or coarse nodularity of the liver surface is
characteristics.
 MR:
 T1WI and T2WI - heterogenous parenchymal signals.
 T2WI- high signal fibrosis

CIRRHOSIS
 Characterize pathologically by diffuse parenchymal
destruction fibrosis with alteration of hepatic architecture
and innumerable regenerative nodules that replace normal
liver parenchyma.
 The pathologic changes of cirrhosis are irreversible but
disease progression can be limited or stopped by
eliminating the causative agent.
 Causes:
GALLBLADDER
 Hepatic toxins (alcohol, drugs)
 Blind ended sac is an outpouching from the biliary system.
 Infection (viral hepatitis)
 It lies immediately beneath the inferior surface of the liver
 Biliary obstruction
(segment 4b, quadrate lobe) in which it produce a small
 Hereditary (Wilson Disease)
 Morphologic alterations seen on imaging studies: indentation.
 Hepatomegaly (early)  10 cm long
 Hepatic atrophy (late)  Connected to the common hepatic duct by the cystic duct,
 Coarsening of hepatic parenchymal texture. confluence of these give rise to common bile duct.
 Irregularity (nodularity) of the liver surface.
 Hypertrophy of the caudate lobe with shrinkage of the
right lobe.
 Regenerative nodules
 Extrahepatic signs of cirrhosis include:
 Evidence of portal hypertension
 Splenomegaly
 Ascites
 Transjugular intrahepatic portosystemic shunt (TIPS)
 Treatment portal hypertensions and esophageal GALLSTONE
variceal bleeding.  Incidence: 8% of the general population.
 Ultrasound  15% of the population aged 40 to 60 years old.
 Demonstrates heterogenous parenchyma with  Types:
coarsening of the echotexture and decrease  85% - predominantly cholesterol.
visualization of small portal triad.  15% predominantly bilirubin (pigment stones) - related
 Liver surface reveals fine nodules. to hemolytic anemia.
 CT:  Most common in women (F:M=4:1)
 Early – Normal  15% of gallstone contain sufficient calcium to be identified
on plain film.

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 Milk of calcium bile is a suspension of radioopaque crystals

within the gallbladder bile.
 Plain abdominal film:
 10% of stones are sufficiently radioopaque.
 "Laminated or faceted calcifications"
 Ultrasound:
 95% of all gallstone are detected.
 "Bright or echogenic structures, mobile with posterior
shadowing”
 WES or double arc shadow sign - when the gallbladder  Adenomyomatosis
is completely filled with gallstone.  May be focal and present as a polypoid mass fixed to
 CT scan: the gallbladder wall
 80 - 85% sensitivity in detecting gallstone.
 MRCP
 Gold standard
 T2W1 - demonstrate gallstone as "filling defects",
rounded or faceted dark objects with high density bile.

ACUTE CHOLECYSTITIS
 Acute inflammation of the gallbladder is caused by gallstone
obstructing the cystic duct in 90% of cases.
 Ultrasound findings:
MISCELLANEOUS FINDING IN GALLBLADDER  Gallstone
 Gallbladder Polyps  Thickened gallbladder wall
 Common benign, polypoid masses that result from  Focal gallbladder tenderness elicited by transducer
accumulation of trigycerides and cholesterol pressure directly over the gallbladder
macrophages in the gallbladder wall.  “Positive sonographic Murphy's sign”
 No clinical significance.  Pericholecystic fluid
 US: "echogenic non shadowing nodules that extend to  Dilated gallblader
the gallbladder wall“  Power Doppler evidence of wall hyperemia.
 CT scan findings:
 Gallstone
 Distended gallbladder
 Thickened gallbladder wall
 Subserosal edema
 High density bile
 Intraluminal sloughed membranes
 Inflammatory stranding in perihcholecystic fat
 Pericholecystic fluid
 Blurring of the interface between gallbladder and liver
 Biliary Sludge
 Prominent arterial phase enhancement of liver adjacent
 Results from biliary stasis.
to the gallbladder
 The bile thickens and forms mobile masses that move
with changes in patient position.

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SPLENOMEGALY

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