CASE 99

Clinical presentation
Nonspesific abdominal pain

Fig. 99.1 Upper gastrointestinal series shows an outpouching (arrow) arising from the gastric
fundus.

Radiologic Findings
Upper gastrointestinal (GI) series shows an outpouching arising from the gastric fundus (Fig.
99.1).

Diagnosis

Gastric fundal diverticulurn

Differential Diagnosis
Cystic adrenal, renal, or pancreatic lesions
• Necrotic lesions or abscess in cases where air—fluid levels are present
• Duplication cysts

Discussion

Background

Fundal diverticula are the most common gastric diverticula arising from the cardiofundic
region. They are congenital and usually seen on the posterior wall of the stomach. These are
true diverticula and contain all layers of the stomach wall: they are variable in size, ranging
from 1 to 10 cm.

Fig. 99.2 Axial CT image of the upper abdomen shows a

contrast-filled fundal diverticulum (arrow).

Clinical Findings
Patients are often asymptomatic Some patients may present with intermittent pain, worse
when supine.

Complications
Usually these are asymptomatic; however, cases of bleeding and ulcerations exist. Patients
may present with pain and abdominal discomfort If diverticu are large, impaired emptying
may occur. Additionally, the condition may lead to excessive workup due to misinterpretation
of a diverticulum as an adrenal mass.

Imaging Findings

- Lateral view of a barium swallow and upper GI studies may demonstrate an

Outpouching on the posterior aspect of the gastric cardia, with a characteristic finding
of a fundal diverticulum
 - Computed tomography may show a collection of contrast material arising from the
posterior aspect of the gastric fundus. ¡t usually projects in the retroperitoneal cavity.
Occasionally, when poorly opacifje with oral contrast, a fundal diverticujum may
mimic an adrenal mass and is considered in the differential for an adrenal pseudomass
(Fig. 99.2).

Treatment and Prognosis

• Treatment is conservative and expectant.

PEARL

Classic appearance on barium studies

Pitffal
When poirly dioles with oral Congrast pr id collapsed, Hattrick fundal Diverticula mau mimik
adrenal lesions

CASE 103

Clinical Presentation

A 73-year-old woman presents with abdominal discomfort and flank pain.

Fig. 103.1 Coronal reformatted contrast-enhanced CT

image show a heterogeneous, ill-defined mass in the left
perinephric region surrounding the left kidney. The lesion
shows areas of fat density and foci of calcifications adjacent
to the left kidney.

Radiologic Findings

Coronal reformatted, contrast-enhanced computed tomography (CT) image shows a

heterogeneous, ill-defined mass in the left perinephric region surrounding the left kidney. The
lesion shows areas of fat density and foci of calcifications adjacent to the left kidney (Fig.
103.1).

Diagnosis

Dedifferentiated retroperitoneal liposarcoma

Differential Diagnosis

- Malignant fibrous histiocytoma

- Retroperitoneal lymphoma
Metastases
- Retroperitoneal dermoid
- Infection (rare)

Discussion
Background

Liposarcoma is the second most common type of soft tissue sarcoma in adults and is most
commonly seen in the 5th decade of life.

Clinical Findings

- Abdominal fullness
- Flank pain
- Vomiting
- Abnormal renal function tests in patients with renal invasion
- Hematuria

Complications
Invasion of adjacent organs, mainly kidneys
Metastases (very rare)

Etiology
Unknown

Imaging Findings

- On imaging, a retroperitoneal, large, ill-defined, heterogeneous, fat-containing mass

with involvement of adjacent organs and bridging across the fascial planes is seen.
Tumors are almost always large in size at presentation, and patients usually present
with nonspecific symptoms.
- CT may show calcifications that are commonly nodular in configuration.
- Involvement of adjacent organs, mesenteric vessels, and renal vessels is common and
should be carefully assessed at imaging. Contiguity with an adjacent organ remains an
important issue for complete assessment because tumors tend to invade adjacent
organs without any direct evidence of involvement on imaging.
- The presence of fat on CT and magnetic resonance imaging (MRI) helps in
diagnosing the condition; however, macroscopic fat is not always present in
liposarcomas (Fig. 103.2).

Fig. 103.2 Axial contrast-enhanced CT image in a differ

ent patient shows a hypoattenuating lesion with a thick
enhancing capsule. The lesion is posterior to the kidney,
compressing and displacing the kidney anteriorly. Because
no discrete focus of macroscopic fat was seen, it was dii
ficult to diagnose this lesion as liposarcoma; however, the
lesion was found to be dedifferentiated liposarcoma on sur
gical pathology.

Treatment
Surgical resection of the tumor is the treatment of choice in patients without metastases.
Contiguity with the kidneys necessitates nephrectomy in adittion to resection of the primary
neoplasm
Prognosis
The prognosis is worse in patients with renal involvement and vascular encasement of the
aorta and o/r inferior vena cava. However, in patients with surgically resectable
liposarcoma without adjacent organ involvement, the prognosis remains excellent after
treatment, althought long - tern Followup up imaging is important to deret recurrence

Pearl
Large, ill-defined, heterogenous, fat-density retroperitoneal lesion

Pitfall

Lesions that do not demonstratif macroscopic far on MRI and fat density on CT candit be
differentiated drop Outher retroperitoneal Sarcomatous lesions, neccesitating a biopsy

CASE 108

Clinical Presentation

A 60-year-old woman presents with abdominal discomfort.

Fig. 108.1 Axial CT image with oral and intravenous contrast demonstrates a hazy
appearance to the mesentery with small mesenteric lymph nodes.

Radiologic Findings

Axial computed tomography (Ci) image with oral and intravenous contrast (Fig. 108.1)
demonstrates a hazy appearance to the mesentery with small mesenteric lymph nodes.

Diagnosis

Misty mesentery

Differential Diagnosis

- Mesenteric panniculitis

- Malignancy, specifically non-Hodgkin lymphoma

- Inflammation due to processes such as inflammatory bowel disease and pancreatitis

- Infection

- Mesenteric edema/lymphedema

- Trauma and hemorrhage

Discussion

Background

The term misty mesentery refers to increased cr attenuation of the mesenteric fat caused by
infiltration with fluid, inflammatory cells, tumor, or fibrosis.

Clinical FIndings
Clinical FIndings may be nonspecific or secondary to the underlying condition. FIndings may
be incidental in an asymtomatic patients imaged for Outher respons.

Etiologi
The increased CT attenuatiob may be the result of the mesentric fat by a barier of causes.
Depending on the underlying condition. Cause include fluid as mesenteric edema dus to
hypoalbuminemic states, cirhosis, inferior vena cava obstruction, budd-chiari syndrome, or
lymphatic obstruction: hemorrhage; or imflamatory cell as in mesenteric paniculitis, tumor
cell, and fibrosis.

Imaging findings
Minta mesenteric regresi to nonspesific increased CT attenuation of the mesenteric fat.

Treatment
Close followup with CT is recommended to search for occult malignancy. Followup
examinations may demonstratif resolution of the imflamatory condition. In cases of
persistent misty mesentery with unknown Cause, biopsy may be necessary for definitipe
diagnosis.

Prognosis
The prognosis depends on the underlying condition

PEARL
Misty mesentery refers to increased CT attenuation of the mesenteric fat and is a
nonspecific finding that may occur in a variety of Clinical situations

Pitfall
Failure to recognize misty mesentery on CT may luas to a delay in diagnosis and treatment
of infiltrating neoplastic conditions

CASE 110

Clinical Presentation

A 48-year-old man complains of abdominal pain, severe bladder pressure, and pain with
coughing for 2 years.
Fig. 110.1 (A—D) Axial and sagittal images of the abdomen and pelvis show a large, low-
attenuating mass in the right lower quadrant of the abdomen extending into the pelvis with
internal septations.

Radiologic Findings

There is a large, low-attenuating mass in the right lower quadrant of the abdomen extending
into the pelvis with internal septations (Fig. 110.1).

Diagnosis

Multilocular mesothelial (peritoneal) inclusion cyst

Differentiated diagnosis

- lymphangioma

- varian cystadenoma/cystadenocarcinoma

- cystic carcinoma

- mesenteric - mental cyst

- visceral cysts

Discussion

Background

Multiloculated mesonthelial (peritoneal) inclusion cysts, or multicystic Mesothelioma of

the peritoneum, is a nonneoplastic proliferation of mesthelial cell lining the peritoneum,
omentum, and abdominal and pelvic viscera with a predilection for surfaces of the pelvis.
They usually Occur in ujung to middle-aged women.

Clinical findings

Most patients are premenopausal women who present with pelvic or abdominal pain.

Etiology

Multiloculated mesonthelial (peritoneal) inclusion cysts usually Develop in the setting of

fluid secretion from active ovaries. The formation of cysts is facilitated by the presence of
peritoneal adhesions, which accumulate fluid and Cause reactive proliferation of
mesonthelial cells.

Imaging Findings
Crsss-sectional imaging demonstrates Multilocular thin-walled cysts containing watery
secretions. Internal septations may show enhacement on contrast-enhanced computed
tomography or magnetic resonance imaging.

Treatment

- treatment is achieved by total Surgical excision.

- oral contractive treadment may be useful in suppressing fluid secretion from the ovaries.

- Radiation And chemotherapy are not effective.

- in rare cases, laparoscopic or open surgical excision of adhesions may be necessary

Prognosis

With Surgical excision the rare of reccurance is 30 to 50%