Case 77

Radiologic fendings

Barium esophagram shows a smooth, linear indentation with regular margins over the
posterio wall of the middle third of the esophagus with mid proximal dilatation of the cervical
esophagus (fig. 77.1) magnetic resonance angiography (MRA) images (figs.772, 77.3) show
an aberrant right subclavian artery (ARSA) arising from the left aortic arch. Causing an
impression in the posterior wall of the esophagus.

Diagnosis

Aberrant right subclavian artery

Differential diagnosis

- Double aortic arch

- Esophageal spasm
- Extrinstic compression of the esophagus from nonesophageal tumors (retrosternal
extension of the thyroid) or lymphadenopathy

Discussion

Background

The origin of the subclavian artery from the proximal descending aorta is referred to as an
aberrant subclavian artery. A left aortic arch with an arsa is the most common congenital
anomaly of the aortic arch; the second most common variant is a right-sided aortic arch with
an aberrant left subclavian artery (ALSA). The left ligamentum arteriosum can form a
vascular ring. Causing tracheal ccompression, and is associated more commonly with ALSA
and right aortic arch.

Kommerell diverticulum is a bulbous dilatation at the origin of the subclavian artery

measuring more than double the diameter of the distal part of the artery. It is more commonly
associated with a right aortic arch and an ALSA. A midline descending aorta is in an
abnormal location anterior to the vertebral bodies and is associated with a right aortic arch
with ALSA.

Both ARSA and ALSA run posterior to the esophagus. Levels of tracheal compression
are different for both varians.

Clinical findings

ARSA presents in adults with dysphagia more commonly thair airway symptoms. ALSA
presnts with
Breathing difficulties due to the airway compression and dysphagia in children. Older
patients can present with shoulder pain, neck pain, or thromboembolic disease of the
extremities.
Complications

Complications include esophageal obstruction, tracheal compression,thromboembolic

disease, and, rarely, arteriesophageal fistula.

Etiology
Embryologically the subclavius artery is derived from the seventh intersegmental artery; a
developmental anomaly leads to aberrant subclavian arteries.

Imaging findings
- Barium esophagram shows smooth indentation over the posterior wall of the middle
third of the esophagus.
- Angiography, computed tomography scan, and MRA can all be used to show the
subclavian artery crossing posterior to the esophagus. Additional information about
the presence, size and complications of kommerell diverticulum can be obtained on
cross-sectional studies.
- Esophagoscopy shows a pulsatile extrinsic compression of the esophagus.

Treatment
- Surgical intervention is considered in symtomatic patiens and patiens complicated
disease. Surgical resection and reanastomosis with revascularization of the vertebral
and subclavian arteries are available

Prognosis
- The prognosis depends on the presentation of disease. Generally, the prognosis is
good in uncomplicated patients without debility in whom surgical treatment is
successful without life-threatening complications. Subclavian steal syndrome can be a
possible complication in surgically treated patients.

PEARL
- Aberrant subclavian arteries should be considered in the presence of a smooth, linear
identation over the posterior wall of the esophagus.

PITFALL
- Posterior indentation over the esophageal wall is also caused by double aortic arch,
benign or malignant tumors of the esophagus, nonersophageal tumors such as thyroid
neoplasms with retrosternal extension, and vertebral spurs.

CASE 78

Clinical Presentation
A 63-year-old man complains of epigastrlc pin chronic fatigue, and weight loss.

Fig. 78.1 (A.B) Contrast - enhanced CT inages demonstrate circumferential thickening of the
gastric antrum with associaled gastne e distention and lymphadenopathy.

Radiologic findings
Contrast - enhanced computed tomography (CT) images (Fig. 78.1) demonstrate
circumferential thicken ing of the gastric antrum with associated gastric distention and
lymphadenopathy.

Diagnosis
Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

Differential Diagnosis
- Gastritis/gastric ulcer .
- Gastric metastases
- Gastric carcinoma

Discussion
Background
The stomach represents the most common primary site of extranodal lymphomas in the
gastrointesti- nal (GI) tract (65-75%), although these tumors account for only 2 to 5% of
gastric primary malignan- cies. However, the relative frequency of gastric lymphoma, unlike
that of carcinoma, has increased as a result of the acquired immunodeficiency syndrome
(ADS epidemic Lymphomas typically occur in patients ages 50 to 60 years and show no
evidencee of sex predilection Chronc sastritis caused by Helicobacter pylori plays a major ole
in the development of lynphoid tissue (MALT which is thought to be the precursor of gastric
MALT Iymphomas. At histology MALT lymphomas can be clas sified into two types:
lowgrade (50-72 of cases) and high grade, which probably results from the transformation of
low-grade lymphomas.

Clinical Findings
Clinical presentation is usually nonspecitic. Patients may experience symtoms mimicking
gastritis or peptic ulcer disease, such as epigastric pain and dyspepsia. Other symtoms, such
as low-grade fever, chronic fatigue. weight loss and anema. Have been reported

Complications
Patients may experiance GI bleeding due to tumor ulceration or obstruction. Rarely,
perforation may occur.

Etiology
The etiology is still controversial. Several studies have demonstrated the high frequency of H.
pylori infection in patients affected by gastric lymphoma; furthermore, some of these
neoplasms may regress after the eradication of H. pylori. Several cytogenetic abnormalities
have been demonstrated the most common being trisomy 3 and 11:18 transiocation

Imaging Findings
- Double-contrast upper GI examination demonstrates a wide spectrum of radiologic
findings, especially in cases of low-grade lymphomas: multiple erosions and ulcers
either shallow or deep associated with converging thickened gastric folds represent
the most common finding in both Gastric lymphonmas, particularly high-grade
lymphomas, may appear as large masses with or without ulcers. Other fluorascopic
imaging findings include round or oval mucosal nodules of variable size and
prominent areae gastricae. However, differentiation of MALT lymphomas from
gastritis or gastric adenocarcinoma is extremely challenging by imaging despite the
presence of these typical findings

- Multidetector CT has been increasingly performed for the detection of primary gastric
malignancies because of its multiplanar capabilities: appropriate distention of the
gastric lumen (oral administration of water prior to scanning) is recommended to
improve the assesment of the gastric mucosa. The typical ct patterns of gastric
lymphomas include diffuse thickening of The wall (> 50% involved), segmented
thickening, and a localized polypoid mass

- These tumors commonly extend throught the pyloric region into the duodenum,
whereas gastric carcinoma tends to spread to the gastroesophageal junction. Patients
with gastric lymphomas, unlike those with carcinomas, often present with multiple,
bulky lymph nodes usuallly extending below the renal hilum. Another major key point
in the differential diagnosis is the degree of the wall thickening, which is more
prominent in lymphomas (average value 5 cm). The enhancement pattern of
lymphomas is usually variable and therefore nonspecific for the diagnosis of these
tumors

Treadment
- Eradication of H. pylori represents the first line of therapy according to the central
role played by this bacterium in the pathogenesis of lymphomas. Eitther
chemotherapy or monoclonal antibody therapy (rituxinab: anti-C20 monoclonal
antibody) is used in case of failure of antibiotic treatment or in those neoplasms not
associated with H. pylori infection.
- Surgery has a limited role due to the efficacy of medical treatment

Prognosis
The prognoSis depends on the histologic grade: low - grade lymphomas have a favorable
prognosis as they may even regress after antibiotic therapy

Pearl
 Marked gastric wall thickening, especially when associated with bulky
lymphadenopathy, should place lymphoma high in the differential diagnosis

PITFALL
Gastric lymphomas may present overlapping radiologic findings with chronic gastritis
(ulcers, erosions, and fold thickening) and gastric adenocarcinoma(bulky intraluminal
masses) Underdistention of the stomach at CT may simulate thickening.

CASE 79

Clinical Presentation
A 28 year-old man complaits of epigastric pain, anoresia. and weight loss.

Fig.79.1 (A.B) Axial contrast-enhanced CT images of the abdomen show mild enhanicement
and diffuse increased thid neis of the gastsic walls; these findings are suspicious for gastric
neoplasm, although an inflammatory process cannot be excluded. Multiple hypodense cystic
lesions are seen in the liver and both kidneys.

Radiologic Findings

Axial contrast-enhanced computed tomography (CT) images of the abdomen (Fig. 79.1)
demonstrate mild and diffuse thickening of the gastric walls. The images from the upper
gastrointestinal (GI) series (Fig. 79.2) demonstrate abnormal and persistent narrowing of the
distal stomach.

Diagnosis

Gastric adenocarcinoma

Differential Diagnosis

- Gastric metastases
- Gastritis
- Gastric mucosa-associated lymphoid tissue lymphoma
- Gastric Crohn disease
- Caustic ingestion
- Gastric tuberculosis

Discussion

Background

Gastric carcinoma is a deadly disease, with decreasing incidence in the past 50 years in North
America and Western Europe owing to the earlier identification at imaging and endoscopy.
Currently, the incidence of gastric carcinoma is extremely variable worldwide, with the
highest number of cases in Japan, China, Rusia and Eastern Europe (>30 cases per 100.000);
men are usually 2 times more commonly affected than women, with a peak incidence in those
ages of 50 to 70 years.

differend histologic types have been described: adenocarcinomas (intestinal and

diffuse types) account for almost 95% of case, and lymphomas, leiomyosarcomas,
carcinoids, and sarcomas for the remaining 5%. Adenocarcinomas have been classified into
four different subtypes ; papillary, tubular mucinous and signet ring. Almost 30% of gastric
malignancies arise from the antrum, 30% from the body, and 40% from the fundus and
cardia region

Clinical Findings
Chinical presentation mostly depends on the disease stage: patients may be asymptumatic
(early stage) or may present with bleeding epigastric, pain, anorexia, weight loss, nausea,
vomiting, and upper GI (hematemesis melena, occult blood in stools)

Complications
In advanced stages, liver metastases may cause hepatomegaly and jaundice; less common
sites for metastases include the lung, adrenal glands, and kidneys (Krukenberg tumors)

Etiology
Several dietary and environmental factors have been identified: dietary nitrates, certain
ffoods (salted fish and meat, smoked foods), hypochlorhydria resulting from drugs or
previous surgery, cigarette smooking, and Helicabacter pylori infection. In particular, patients
with H. pylori gastritis are 3 to 6 , times more likely to develop gastric cancer. Other
precancerous conditions include Ménétrier disease, adenomatous gastric polyps, partial
gastrectomy, and pernicious anemia

imaging findings
- Endoscopy is currently considered the diagnostic procedure of first choice in patients
with suspected gastric malignancies.
- Barium studies, either with single or double contrast. have been performed
extensively for the detection of gastric tumors, although their overall sensitivity is
somewhat lower than endoscopy.
- High spatial resolution magnetic resonance imaging, used in in vitro experimental
studies, is a promising imaging modality for the assessment of the depth of gastric
tumor invasion because of its accuracy in depicting the Distant layers of the gastric
wall.

Treatment

- Complete resection of the tumor and adjacent lymph nodes is considered the only
curative treatment, although a surgical procedure may be associated with several late
complications, including dumping syndrome, vitamin B12 deficiency, and reflux
 esophagitis; some selected neoplasms may benefit from endoscopic mucosal
resection.
- Chemotherapy is administered in patients with systemic metastatic disease

Prognosis

Gastric cancer presents a dismal prognosis, with overall 5-year survival rates < 20%;
however, early gastric cancers are potentially curable, with a mean 5-year survival rate of
almost 90% . Hence prompt diagnosis of these tumors is mandatory

Pearl

Distention of the gastric lumen with a negative contrast medium (water, air) may improve
the detection of small superficial gastrice lesions.

CASE 80

Clinical Presentation

A 77 year old man presents with abuluminal pain

Fig. (80.1) Contrast-enhanced CT scan show a lobulated, heterogeneously enhancing mass

arising from the proximal stomach (arrow).

Radiologic Findings

An abdominal computed tomography (CT) scan (Fig. 80.1) shows a large, lobulated,
heterogeneously enhancing mass arising from the proximal stomach.

Diagnosis

Gastrointestinal stromal tumor (GIST)

Differential Diagnosis

- Gastric adenocarcinoma
- Leiomyoma/leiomyosarcoma
- Schwannoma/neurofibroma
- Metastasis

Discussion

Background

GISTS are the most common mesenchymal tumags arising from the gastrointestinal (GI) tract
wall. Nevertheless, they are uncommon, accounting far only 1 to 3% of all GI neoplasms, and
usually patients >50 years of age without any gender predilection. These tumors are also
reported to occur in 10 to 25% of patients affected by neurofibromatosis 1. Previously
mistake for smooth and neural tumors, GISTS show distinctive genetic and histologic
features. They can occur anywhere from the rectum to the esophagus, the stomach being the
most common located site of origin: they can also be located in the mesentery omentum, and
retroperitoneum.

Clinical Findings

The clinical presentation relies on the location, size, and pattern of growth of the tumor and is
mainly characterized by abdominal pain or distention, anemia or melena, or bowel
obstruction.

Complications

Malignant GIST can be aggressive and spread to the liver, retroperitoneum. and mesentery,
and less frequently to the bones, lungs, and lymph nodes. Intraluminal GISTs can cause
bowel obstruction.

Etiology

GISTs have distinctive immunohistochemical properties, the most important being the
expression of KIT (CD1I7), a tyrosine kinase growth factor receptor, which promotes the
growth of mesenchymal neoplastic cells.

Imaging Findings

Although tumor expression of the KIT receptor is needed for a definitive diagnosis of GIST,
imaging, especially CT, has proved to be instrumental. GISTs are usually seen as exophytic,
heterogeneously enhancing, rarely calcified masses arising from the GI tract wall. Most of
them, especially larger ones, show heterogeneous density due to the presence of intratumoral
necrosis (Fig. 80.2), hemorrhagic foci, and cystic degeneration.

Treatment

- Surgical removal is recommended, but despite complete resection, the recurrence rate
is high, especially in the setting of less well differentiated lesions.
- New drugs targeting the growth factor receptor KIT appear promising, but so far they
have been used only for unresectable tumors.

Prognosis
- Recent advancements in therapy have increased the average survival rate, especially in
malignant nonmetastatic GISTs.

Fig. 80.2 Contrast-enhanced CT in a different patient shows a large heterogeneous mass

arising from the stomach. Multiple hepatic cysts are present.

CASE 81

Clinical Presentation
A middle-aged man presents for evaluation of long-standing dysphagia with episodic periods
of more intense discomfort.

Fig. 81.1 (A) Contrast-enhanced axial CT image demonstrates a large hiatal hernia. The distal
esophagus is midline, and the gastroesophageal (GE) junction as well as a portion of the
stomach is located within the intrathoracic hernia. (B) Overhead radiograph and (C) spot
fluoroscopic image from an upper gastrointestinal series show a large hiatal hernia. The
radiograph illustrates that the Uconcave greater curvature of the gastric body is located
cephalad to the “convex” lesser curvature, the GE junction and pylorus. The GE junction and
pylorus maintain their normal relationship.

Radiologic Findings
Contrast-enhanced axial computed tomography (CT) image demonstrates a large hiatal hernia
(Fig.81.1A). The distal esophagus is midline, and the gastroesophageal (GE) junction as well
as a portion of the stomach is located within the intrathoracic hernia. An overhead radiograph
and spot fluoroscopic image (Fig. 81.1B,C) from an upper gastrointestinal (GI) series show a
large hiatal hernia. The radiograph

Diagnosis

- Organoaxial gastric volvulus in a large hiatal hernia

- Differential Diagnosis
- Sliding hiatal hernia
- Paraesophageal hernia
- Large intra-abdominal mass with superior displacement of the stomach

Discussion

Background

Gastric volvulus represents abnormal torsion of the stomnach, usually > 180 degrees. If the
greater curvature rotates superior to the lesser curvature along the long axis of the stomach.
This is termed an organoaxial volvulus and accounts for -60% of gastric volvulus case. If the
antrum and pylorus rotate. Anterosuperior to the fundus and GE junction, this is termed a
mesenteroaxial volvulus, representing -30% of volvulus cases. The volvulus is also classified
with respect to the diaphragm: supradiaphragmatic (two thirds) or subdiaphragmatic /
intraperitoneal (one third)

Clinical Findings

In cases of chronic volvulus, patients typically present with nonspecific abdominal

complaints, including vague abdominal or chest pain early satiety or fullness dysphagia, or
dyspnea. Chronic volvulus may be noted incidentally on chest radiographs or an upper GI
series or esophagram. Acute volvulus demonstrates more dramatic presentations, including
severe pain, an inability to ingest liquids or solids or pass, an enteric tube, gastric outlet
obstruction, and peritonitis when there is gastric ischemia or perforation Purportedly
diagnostic of acute obstructing volvulus, the classic Borchardt triad describes severe constant
chest or epigastric pain, nausea with inability to vomit, and difficulty passing a nasogastric
tube.
Complications

Organoaxial volvulus can be complicated by strangulation in-5 to 20% of cases secondary to

twisting of the left gastric artery and occlusion of venous drainage. Ischemia in
mesenteroaxial volvulus is rare. Any type of gastric volvulus can be associated with gastric
outlet obstruction. Obstruction with strangulation is usually seen only in cases of acute
volvulus. Mortality ranges from < 10% for chronic cases to > 40% for acute volvulus

Etiology

Organoaxial volvulus is usually seen in adults and is associated with a diaphragmatic defect
in 50% of cases, including hiatal hernia, paraesophageal hernia, eventration, and
diaphragmatc rupture. This defect allows for abnormal movement of the gastric body into the
thorax with resultant o this way, the majority of organoaxial volvulus in this way, the majority
of organoaxial volvuls case also represent the supradiaphragmatic variety in comparison,
mesenteroaxial volvuli are over whelmingly subdiaphragmatic and most often seen in
children. Thought to be de to abnormal laxity of the suspensory ligaments of the stomach,
mesenteroaxial volvulus can be also be associated with a “wandering” ectopic spleen

Treatment

- Acute gastric volvulus is initially treated with attemted nasogastric tube

decompression.
- Surgical repair is indicated for all cases of volvulus and involves untwisting of the
volvulus, return of the stomach to a subdiaphragmatic position, gastropexy in an
anatomical position, and repair of any predisposing diaphragmatic defect. Surgical
access may be via thoracotomy, laparatomy, or peritoneal laparscopy.

Prognosis

Following successful repair with gastropexy, the risk of recurent gastric volvulus is low and
is related to failure of gastropexy and adequancy of repair of any known diaphragmatic defect

PEARL

Acute gastric valvulus is a surgical emergency because of the moderate risk of ischemic
strangulation and gastric outlet obstruction and requires diaphragmatic repair of both the
gastric torsion and any defect

PITFALLS

Chronic volvulus can be intermittent, and the upper GI series may only demonstrate hiatal or
araesophageal hernia during an asymptomatic period
CASE 82

Clinical Presentation

A 42-year-old man presents with postprandial epigastric discomfort.

Fig. 82.1 Ultrasound image shows

a well-defined cystic structure with
a gut signature in continuity with
the lateral duodenal wall and the
lumen of the vertical part of the
duodenum. The lumen and the wall
of the lesion are contiguous with the
lateral wall of the second part of the
duodenum.

Radiologic Findings

Upper abdominal ultrasound shows a well-demarcated hypoechoic structure (Fig. 82.1) in

close proximity to the second portion of the duodenum. The structure has a gut signature on
ultrasound with alternating hyper- and hypoechoic layers in the wall.

Diagnosis

Duodenal diverticulum arising from the lateral wall of the duodenum

Differential Diagnosis

- Postbulbar duodenal ulcer

- Pancreatic pseudocyst
- Cystic pancreatic tumor
- Duodenal duplication

Discussion

Background

The duodenum is the second most common site for diverticula formation after the large
bowel. The incidence of duodenal diverticula is 5 to 15g on barium examinations, 20 to 25%
at autopsy. The peak incidence of duodenal diverticula is found in the 5th to 6th decades of
life. They typically arise from the medial wall of the second and third pacts ot the duodenum
within 2 cm of the a Vat Intraluminal dundenal divecticula are sare Deticua a Large in size
and ane Iess cummn iv ula can alo be classified as pimary o secondary (due to postbullar uloy
ampula o tend to be Lateral wall from the medial wall of the second and third parts of the
duodenum within 2 cm of the ampulla of vater. Intraluminal duodenal diverticula are rare.
Diverticula arising from the lateral wall tend to be larger in size and are less common.
Diverticula can also be classified as primary or secondary (due to postbulbar ulcer)
Clinical Findings
- Asympromatic
- Abdominal discomfort
- Pain in the epigastric ar umbilical region
- Central abdominal pain radiating to the back
- Jaundice in the case of compression of the biliary channels
- Pain and fever in cases of diverticulitis

Complications
- Diverticulitis
- perforation
- Pancreatitis secondary to perforation
- Bleeding
- Obstructive jaundice due to compression of the biliary channels
- Cholangitis
- Failure of endoscopic retrograde cholangiopancreatography if the common bile duct
drains into the diverticula
- Increased incidence of cholelithiasis
- Neoplastic change
- Bezoar formation

Etiology
Primary diverticula are thought to arise because of the presence of a weakened wall in the
duodenum at the vessel's entry site. biliary ductal entry sites, muscular weakness in the wall,
or heterotopic pancreatic tissue.

Imaging Findings
. On an upper gastrointestinal series with barium, the diverticula are seen as typical
outpouchings arising drom the duodenum without any distortion of mucosal folds, which
changes their configuration with time (fig82.2). delayed retention of barium in the diverticula
is a diagnostic finding. Intraluminal diverticula appear as intraluminal projections of barium-
filled linear structures with surrounding lucency, giving a “typical wind sock” appearance
Ultrasound demonstrates a clear fluid- or food-containing structure with the presence of gas
in the nondependent portion of the lesian. The wall of the duodenal diverticula typically
shows the multilayered gut signature on ultrasound. Use of real-time ultrasound imaging
helps, and diverticula can be better demonstratted after the ingestion of large quantities of
fluids
- CT shows gas-containing diverticula (Fig. 82.3) In cases where gas s absent,
diverticula can be confused with cystic neoplasms, pseudocysts, or abscess. In such
cases, repest scans may demonstrate the presence of gas within the structure.
Fig. 82.2 Upper gastrointestinal series image in a different patient shows the presence of
diverticula arising from the medial wall of the second and third parts of the duodenum
(arrows).

Fig. 82.3 Axial contrast-enhanced CT image in a 63-year- old man shows the presence of a
gas-filled diverticulum arising from the lateral wall of the third part of the duodenum (arrow).

T2-weighted magnetic resonance images show a hyperintense fluid-containing structure and

hypointense gas within the nondependent portion of the lesion.

Treatment

Conservative treatment is preferred in asymptomatic primary duodenal diverticular disease

without any complications. The patient can be advised to adopt a position that favors
diverticular emptying. Surgical treatment in symptomatic primary diverticular disease is
undertaken only in patients with complications and persistent symptoms despite conservative
management. In patients with secondary disease because of an ulcer, the treatment of the
ulcer by medications and surgery is recommended.

Prognosis

The prognosis for primary duodenal diverticular disease is excellent with lesser incidence of
complications. In patients with secondary diverticula due to a postbulbar ulcer who are
treated, the prognosis is good; however, the rates of complications are higher.

PEARL
The presence of gas and continuity with the duodenum help to differentiate duodenal
diverticula from other pathologies.

PITFALL
Duodenal diverticula filled with fluid can be mistaken for cystic neoplasms from the head of
the pancreas, in which case barium examination should be considered.

CASE 83

Clinical Presentation

A 57-year-old man presents with abdominal pain and discomfort. Physical examination
reveals a palpable mass in the anterior abdominal wall, in the midabdomen.

Fig. 83.1 (A,B) Axial CT image show small bowel loops herniating through the abdominal
wall and surrounded by arim of soft tissue density with stranding, consistent with mild
inflammation. There is mild distention of the small bowelproximally to the herniated loops.

Radiologic Findings

Axial computed tomography (CT) images (Figs. 83.1) show small bowel loops herniating
through the abdominal wall and surrounded by a rim of soft tissue density with stranding,
consistent with mild inflammation. There is mild distention of the small bowel proximally to
the herniated loops.

Diagnosis

Abdominal wall hernia

Differential Diagnosis

- Abdominal wall tumors (desmoid, lymphoma, hemangiomas, lipoma, metastases, etc.)

- Rectus sheath hematomas (posttraumatic, associated with coagulopathy)
- Enlarged lymph nodes (infections, lymphomas, etc.)
- Enlarged, prominent vessels (as seen in cirrhotic patients with portal venous shunts)
- Undescended testis
- Abdominal wall endometriosis

Fig. 83.2 An axial contrast-enhanced CT image through

the pelvis demonstrates a direct left inguinal hernia. Small
bowel loops are present along the left spermatic cord.
Neither inflammatory changes nor signs of strangulation

Fig. 83.3 Axial contrast-enhanced CT image shows a left

ventral hernia containing small bowel loops and mesentery.
are present.

Discussion

Background

A hernia is commonly defined as the protrusion of any viscus from its proper cavity into a
saclike structure formed by the same membrane with which the cavity is usually lined.
Different types of hernias have been described according to their anatomical distribution, the
most frequent in both men and women being inguinal hernias (direct Fig. 83.2 and indirect).
Others include

- Femoral hernia: occurs medial to the femoral vein and posterior to the inguinal
ligament: com monly right-sided
- Ventral hernia:
a. Midline defects: umbilical, paraumbilical, epigastric, and hypogastric hernias.
Umbilical is the most common type, usually occurring in women (risk factors:
obesity, multiple pregnancies, ascites, intra-abdominal masses)
b. Lateral defects—spigelian hernia (Fig. 83.3): occurs along the lateral aspect of the
rectus muscle through the hiatus semilunaris
- Posterior defects—lumbar hernia: occurs either through defects in the superior
(Grynfeltt) (Fig.83.4) or inferior (Petit) lumbar triangle

Fig. 83.4 (A.B) Lumbar hernia of Grynfeilt seen on CT (arrow). Note that this hernia contains
a portion ofGerota fascia. The contents of these hernias can be confused with a lipomatous
tumor.
Fig. 83.5 Axial CT image of the pelvis shows a herni
ated bowel loop in the left obturator fossa (arrow).

- Obturator hernia: occurs through the obturator foramen, usually in elderly multiparous
women (Fig. 83.5)
- lncisional hernia: represents a delayed complication of abdominal surgery

Abdominal wall hernias are very common, with more than 500,000 operations performed in
the United States every year. Unfortunately, surgical repair is associated with a high rate of
complications (up to 20%), such as recurrence, fluid collections, and infection of prosthetic
materials. The clinical diagnosis may be difficult in cases of obesity or abdominal scarring
from a previous surgery: hence imaging plays a central role in recognizing this pathologic
entity and decreasing the morbidity associated with complications.

Clinical Findings

Clinical presentation depends on the anatomical location and severity of abdominal hernias.
Patient presentation can range from vague abdominal tenderness and discomfort with a
palpable abnormality to a bowel obstruction.

Complications

Major complications include strangulation (Fig. 83.6) and incarceration (Figs. 83.1), both
leading to bowel obstruction or perforation in case of missed or delayed diagnosis.
Incarceration refers to those hernias that cannot be manually reduced because of progressive
narrowing of the neck of the hernia sac. Strangulation refers to ischemia of the protruded
organ due to impaired blood supply. Other, less frequent complications include herniation of
other organs, either solid (liver, kidneys) or nonsolid (stomach, bladder).

Fig. 83.6 Axial contrast-enhanced CT image shows a ventral

hernia in the left lower quadrant, which contains a loop of
descending colon. There is a small amount of fluid in the her
nia sac. The bowel within the colon demonstrates mild wall
thickening. The colon distal to the hernia is underdistended.
These findings are consistent with strangulation.
CASE 90

Clinical Presentation

A 72 year-old woman presents with abdominal distention, fullness, and pain in the right iliac
fossa

Fig. 90.1 (A) Axial contrast-enhanced CT image shows the presence of a cystic lesion with
thick walls in the right illac fossa with surrounding fat stranding and free fluid. (B) Axial
contrast-enhanced CT image of the liver in the same patient thows scalloping of the liver
margins and ascites with peritoneal thickening
Radiologic Findings

Contrast computed tomography (CT) images show the presence of a cystic lesion in the right
lower quadrant with ascites and scalloping of the liver margins (Fig. 90.1)

Diagnosis

Malignant mucocele of the appendix with pseudomyxoma peritonei

Differential Diagnosis

- Abscess

- Normal fluid-filled ileal loop

- Tuberculous ascites

- Peritoneal metastases

- Malignant ascites

- Ovarian cystic lesions

- Bowel perforation

- Peritoneal mesothelioma

- Meckel diverticulitis with perforation

Discussion

Background

Mucocele of the appendix is the accumulation of mucus with luminal distention of the
appendix. The reported incidence is 0.2 to 0.5% of appendectomies, It can be benign or
malignant. The variety results from occlusion of the appendiceal luminal opening into the
cecum from a phlebo-lith or impacted feces. A malignant mucocele results from mucin-
secreting adenocarcinoma of the appendix. Either a benign or a malignant mucocele can
result in the development of pseudomyxoma peritonei on rupture.

Clinical Findings

- Chronic pain in the abdomen

- Abdominal distention

- Mass in the right iliac fossa

- Intermittent colicky pain due to intussusception

- Vomiting
Complications

- Rupture of the mucocele

- Development of pseudomyxoma peritonei

- Intestinal obstruction

- Intussusception

Etiology

Obliteration of appendiceal lumen from any cause

Imaging Findings

- On ultrasound, the mucocele may appear as a thin-walled cystic mass in the right iliac
fossa, attached to the cecum, filled with diffuse internal echoes in the dependent
portion with or with- with out septa and polypoidal luminal projections, and with
posterior acoustic enhancement. The pres- ence of a solid mass within the
nondependent portions of the lesion indicates the possibility of adenocarcinoma.
Similar findings are seen with CT, with the mucocele appearing as a low-attenu- ating
structure in the right lower abdomen.

- Calcifications within an unruptured mucocele can be curvilinear or plaquelike and can

be appreciated on plain radiographs of the (Fig. 90.2) The size of the lesion varies,
with lesions measuring up to 15 cm reported in the literature. A ruptured mucocele
show fluid-density ascites with internal echoes and fixed bowel loops. In patients with
the development of pseudomyxoma peritonei, diffuse coarse internal echoes within
the ascitic fluid can be seen with scattered calcifications and scalloping on the
peritoneal surfaces of the abdominal organs. Multiple solid translucent globules of
uniform size that calcify in the course of time and shift with movement are
pathognomonic of the myxoglobulosis variant of a mucocele.

- The presence of mucinous nodules within the remnant umbilical vein is a feature that
the nondependent portions of the lesion indicates the possibility of with lesions
mucocele shows fluid-density ascites with the development of pseudomyxoma
Multiple solid trans- differentiate pseudomyxoma peritonei from ascites.

Fig. 90.2 Asial contrast - enhanced CT image in a different patient reveals a cystic lesion with
thick walls in the right illiac fossa. The lesion shows the presence of calcifications in its wall

Treatment

- Surgical resection of the appendix is the treatment of choice for an unruptured

mucocele of the appendix. In patients with a ruptured mucocele with the development
 of pseudomyxoma perito nei, wide peritoneal stripping is done for cytoreductive
surgery, followed by heated intraoperative intraperitoneal chemotherapy with
mitomycin C, doxorubicin, and fluorouracil (5-FU)

- Systemic chemotherapeutic agents can be used in resistant discase and recurrent

disease.

Prognosis

- Patients with an unruptured mucocele of the appendix have an excellet prognosis.

Patients with pseudomyxoma peritonei and mucinous adenocarcinoma have a
worse prognosis with treatment resistant disease, higher mortality, and
posttreatment complications

PEARLS

- A cystic oblong mass in the right iliac fossa should include mucocele in the
differentia

- Scalloping of the peritoneal l surfaces of abdominal organs represents

pseudomyxoma peritonei

PITFALL

- between benign Imaging cannot always differentiate appendix and

pseudomyxoma peritonei. and malignant causes of mucocele of the

CASE 91

Clinical Presentation

A 74-year-old man presents with lower abdominal pain and discomfort associated with a
recent change in bowel habits.

Fig. 91.1 An axial contrast-enhanced CT image shows dif

fuse diverticulosis, most significant in the sigmoid colon,
with evidence of related mild muscular hypertrophy. No
pericolonic inflammatory changes are noticed.

Radiologic Findings
An axial contrast-enhanced computed tomography (CT) image (Fig. 91.1) shows diffuse
diverticulosis, most significant in the sigmoid colon, with evidence of related mild muscular
hypertrophy. Nopericolonic inflammatory changes are noticed.
Diagnosis

Diverticulosis

Differential Diagnosis

- Inflammatory bowel disease (Crohn disease and ulcerative colitis)

- Colonic carcinoma

- Small bowel diverticulosis

Discussion
Background

Diverticula are outpouchings of the intestinal walls, involving either all the layers (true
diverticula) or just the mucosal and submucosal layers (false diverticula). Diverticular disease
has been described anywhere in the gastrointestinal (GI) tract but is most frequently present
in the sigmoid colon (95—98%) due to the higher segmental intraluminal pressures. These
diverticula usually form through weaker points of the colonic walls, which represent the
natural openings for the vasa recta and other nutrient vessels.

Fig. 91.2 (A.B) Axial contrast-enhanced CT images show diffuse bowel wall thickening of
the sigmoid colon with surrounding inflammatory mesenteric fat stranding. These findings
are consistent with severe diverticulitis.

Clinical Findings

Diverticulosjs is a common, usually asymptomatic condition. Patients with multiple

diverticula may present with different symptoms according to their location; clinical
presentation most frequently includes left lower abdominal pain, nausea, and changes in
bowel habits, including diarrhea, constipation, and tenesmus.

Complications

Major complications include GI bleeding (melena, hematochezia) and diverticulitis due to

occlusion of the neck of a diverticulum by stool, inflammation, or ingested material, causing
subsequent micro perforation of a diverticulum and associated pericolic inflammation (Fig.
91.2). Inflammation may resolve or progress, causing abscess formation, fistulas (to local
structures, e.g., the bladder, uterus, or vagina), abdominal obstruction, or free perforation.

Etiology
Diverticulosis is related to the low-fiber/high-fat diet typical of industrialized countries
leading to abnormal peristalsis, intestinal dyskinesia, and increased intraluminal pressures, Its
incidence increases with age; in fact. colonic diverticular disease is uncommon in people
younger than 40 years. Genetics may play a predisposing role, as left-sided diverticula are
usually described in Caucasian populations, whereas right-sided diverticula are typically seen
in persons of Asian descent.

Imaging Findings

- Water-soluble contrast enemas represent a safe but somewhat outmoded imaging

study for diverticulosis.

On CT, diverticula appear as multiple, air-filled outpouchings of the intestinal walls ranging
in size from 2 to 3 mm to 2 cm (giant diverticula have been reported but are rare) and usually
located in the sigmoid colon: the affected intestinal segment may have thickened walls due to
muscular hypertrophy. CT is also useful to evaluate the complications of diverticular disease,
such as acute diverticulitis (wall thickening and pericolic fat stranding), abscesses (fluid
collections with peripheral enhancing rims), and perforation (extraluminal free air).
Colovesicular fistulas are suggested by the presence of gas in the bladder or focal bladder
wall thickening ¡n close proximity to the affected segment of the bowel with loss of dividing
fat planes.