58.

Small bowel lymphoma

• Primary lymphoma of GIT

- Stomach (51%)

- Small intestine (33%)

- Colon (16%)

- Esophagus (<1%)
• Small bowel lymphoma
– Rare (<1~4% of malignancy of GIT, 20%-
40% of all malignancy of small bowel)
– Terminal ileum (Peyer’s patch)
– Mostly, B-cell origin NHL
– T-cell lymphoma: associated with celiac
disease, Crohn’s disease
 Imaging Findings
• Variable imaging findings
 Infiltrating type (m/c)

 Cavitary type (2nd m/c)

 Multiple nodular type

 Polypoid mass

 Mesenteric nodal lymphoma with secondary

involvement of small bowel
 Infiltrating (circumferential) type

• Involvement of variable
length
• Aneurysmal dilatation of
lumen (antimesenteric side)
due to replacement of
muscularis propria and
destruction of automonic
nerve plexus
• Obstruction – uncommon
• Poor enhancement
• May ulcerate and perforate
Cavitary type Polypoid mass

•Intestinal obstruction by
intussusception
Multiple nodular type Mesenteric nodal lymphoma
invading small bowel
60. Mucinous Adenocarcinoma
• Gastric cancer의 조직학적 종류
– Papillary
– Tubular
– Mucinous: 세포외에 점액이 축적, Ca동반
– Signet-ring cell: Schirrhous carcinoma
 63. Peritoneal cavity
• 교과서 473-476
• 소낭과 대낭을 연결하는 통로: foramen of
Winslow
• 좌측, 우측 횡격막하 공간: falciform lig에 의
해 분리
• 좌측 paracolic gutter와 좌측 횡격막하 공간:
phrenicocolic lig에 의해 분리
• Greater omentum:
– Gastrocolic ligament의 연장
– 4겹
Drawing of the anatomy of the greater
and lesser omentum (a) and axial (b),
coronal (c), and sagittal (d) diagrams of
the upper abdomen. The greater
omentum (GO) is composed of a
double layer of peritoneum that
extends from the greater curvature of
the stomach (S) inferiorly. Its
descending and ascending portions
usually fuse to form a fourlayer
vascular fatty apron; the resulting space
is contiguous with the lesser sac (LS).
The lesser omentum (LO) connects the
lesser curvature of the stomach and
proximal duodenum with the liver (L)
and contains blood vessels, nerves, and
lymph nodes. The lesser sac is empty
and collapsed so that only parts of its
boundaries, such as the posterior
gastric wall and pancreatic body, are
observed on axial CT scans. Ao aorta,
C colon, K kidney, P pancreas, Sp
spleen, 1 falciform ligament, 2
gastrohepatic ligament, 3 gastrosplenic
ligament.
Anterior right subhepatic space. CT scan shows ascites in the
anterior right subhepatic space (R) and lesser sac (L), allowing
visualization of the hepatoduodenal ligament (arrowhead). The
epiploic foramen (foramen of Winslow) is located in the
portacaval space (*).
 Lesser omentum
• Lesser sac 의 앞쪽 경계 (stomach, GHL, and gastrocolic
ligament)를 구성  forms barrier btw the left
peritoneal space anteriorly and the lesser sac
posteriorly
• stretches btw the lesser curvature of the stomach and
the hepatic fissure for the ligamentum venosum
• Content : left gastric artery and vein, the left gastric
lymph nodes
• Hepatoduodenal ligament: caudal continuation of the
lesser omentum
– Contains : portal vein, hepatic artery, common hepatic and
common bile ducts, hepatic nodal group of the celiac LN
chain
• Cross-sectional imaging
– A triangular fat containing area btw the stomach and the liver
at the level of the fissure for the ligamentum venosum
– Normal LN 8mm in diameter occasionally seen
– Pathology : pathologic LNs in esophageal, gastric ca. and
lymphoma, varices in portal hypertension
– Normal structure simulating ds. : bowel, pancreas body,

Gastrohepatic ligament)
The left gastric vessels and coronary
varices can be identified within the
GHL(curved arrow), which is the
triangular fat-containing area btw the
stomach and the liver.
Solid arrow : falciform ligament
Open arrow : gastosplenic ligament
Ls : lesser sac
 66. 위장관 투시검사
• 07, 09연수강좌
<Barium>
• coating: size가 크고 밀도가 높을수록 잘됨.
• 위: 고밀도 200 – 240 w/v%
• 식도 (100), 소장 (<30, 40-60), 대장 (70-120): 저밀도
• 09 연수강좌에는 위, 식도는 큰 입자, 고밀도로, 소장,
대장은 작은 입자, 저밀도가 좋다고..
• Barium suspension의 밀도
– w/v (weight-to-volume): 더 널리 쓰임
• 100% w/v: 최종 volume이 100mL인 suspension에 100g의
barium sulfate가 들어있음
– w/w (weight-to-weight)
• 50% w/w: 최종 100g의 barium suspension에 50g의 Ba sulfate
가 함유
최적의 점막코팅: high density, low viscosity
 67. CT colonography
• 최적의 하제: sodium phosphate,
magnesium citrate가 더 선호
• 점막의 세밀한 관찰을 위해 effective mAs
를 10-50mAs로
• 2차원 단면영상 볼 때는 wide window로
• Supine and prone에서 각각 1회 스캔

09 연수강좌
<Laxative>
• PEG: 대장내시경(다량의 수분이 남음)
• Sodium phosphate: 소량의 수분, 그러나 전
해질 장애 유발가능. (심장, 신장, 복수환자 x)
• Magnesium citrate
<Fecal tagging>
• 잔변에 radiopaque 조영제로 표지하는 것
• 시행전날 경구 조영제를 식사와 함께 섭취
<Colonic distension>
• 자동화된 CO2 주입법
<CT scan>
• 앙와위와 복와위 스캔 시행
• Slice collimation: 3mm이하 slice collimation
과 1.5mm 이하의 reconstruction inverval
• 방사선 조사는 진단의 정확도를 떨어뜨리지
않으면서 barium enema의 절반 이하 (as low
as 10mAs)로도 스캔이 가능하다고 보고되었
음. 실제 임상에서 50mAs 스캔시 내장내, 외
평가 가능
• 조영증강 필요시 polyp은 동맥기 (또는
mucosal phase)에 잘보임
<Interpretation>
• Primary 2D interpretation: wide window
(width 1500, level -200)
• 암의 장벽침범 정도와 대장외 소견을 볼때
는 soft tissue window (width 400, level
10)으로
70. Liver MR Contrast Agent

RadioGraphics 2006; 26:1621–1636

Radiology 2001; 218:27–38
• Extracelluar agent
– Composed of gadolinium chelate
– Ionic agents (Gd-DTPA, Gd-DOTA, Gd-
BOPTA), Nonionic agents (Gd-DTPA-BMA,
Gd-HP-DO3A, Gd-DTPA-BMEA, Gd-BT-DO3A)
– Nonspecific contrast agent
– Renal excretion
– Liver 병변 찾을 때 정확한 enhancement
timing이 중요, 매번 optimal arterial and
portal imaging을 얻기 어려움, breath
holding이 잘 안되는 환자에서 정확한
enhancement timing을 찾기 어려움

RadioGraphics 2009; 29:1725–1748

• Hepatobiliary agent
– Taken up by functioning hepatocytes and excreted
in the bile
– Mn-DPDP, Gd-BOPTA, Gd-EOB-DTPA
– In the liver, can be used to improve lesion detection,
to characterize lesions as hepatocellular or
nonhepatocellular, and to specifically characterize
some hepatocellular lesions
– Biliary excretion of these agents can be used to
evaluate the anatomic structure and function of the
biliary tree
– Particularly useful in determining whether a lesion is
of hepatocellular origin (eg, FNH, adenoma) or not
(eg, cyst, hemangioma, metastasis) Meta는 enhance (-)
– Not possible to distinguish benign lesion from well-
differentiated HCC with hepatobiliary-specific
agents

RadioGraphics 2009; 29:1725–1748

71. Peliosis Hepatis (간자색반병)
• 교과서 273
• Cystic hepatic sinusoid dilatation과 간 내 다양한 크기의
multiple-blood filled lacunar space의 존재가 특징인 질환
• 간세포나 내피세포로 싸여 있는 혈액이 차 있는 양성 병변
– Phlebectatic type(정맥확장형) : 얇은 콜라겐 조직과 내
피세포가 내층을 이룸
– Parenchymal type(실질형) : 간세포에 의해 둘러싸임
• 원인 : anabolic steroid, corticosteroids, tamoxifen, oral
contraceptive, renal or cardiac transplantation, tbc,
carcinomatosis등의 만성 소모성 질환, DM, necrotizing
vasculitis, Hodgkin’s disease, AIDS, 비소중독과 관련
• US : heterogeneous echogenicity
• CT
– Pre-enhance : multiple low attenuated or cystic masses
– Enhance : 크기, sinusoid와의 연결정도, 혈전이나 출혈등에 따라
다양하게 조영
– Phlebectatic type
• Arterial phase : central nodular enhancement
• Portal and delayed phase : 원심성으로 조영 증강 되어 종괴
를 채움(centrifugal enhancement)
hemangioma(centripetal)와 반대의 enhance pattern
• MR
– T2WI : high SI(혈액이 차 있는 공간)
– T1 & T2WI : variable SI due to hemorrahge( subacute
hemorrhage의 경우 high SI)
– Gd enhancement = CT enhancement
 72. Pancreas Anatomy
• Head가 가장 두터움
• Uncinate process: head로부터 후내측으로 돌출, SMV
의 뒤쪽에 위치
• Neck: splenic vein과 SMV가 만나는 부위 바로 앞
• Pancreas의 대부분은 retroperitoneum에 위치, tail은
splenorenal ligament내에서 intraperitoneal location
• Pancreas의 body앞에 gastric body와 antrum이 위치,
pancreas neck앞에 gastric pylorus가 위치
• Mesenteric root는 pancreas body의 하부에서 발생하
고 transverse mesocolon으로 연결
 Pancreas에서 발생하는 질환은 stomach과
duodenum에 직접 영향, small bowel과 colon에는
mesentery와 transverse mesocolon을 통해 영향을 미
침.
교과서 p410
 74. Chronic Pancreatitis
• 반복되는 급성 췌장염에서 진행되서 발생하
는 것이 아니고 췌장의 비가역적 형태변화,
특징적인 통증 또는 외분비와 내분비 작용이
영구적으로 손상된 독립된 별개의 질환
1. Chronic calcified pancreatitis
2. Chronic obstructive pancreatitis
– Pancreatic duct obstruction으로 발생, Ca은 드
물다
• 췌관확장: chronic pancreatitis의 진단에 특
징적, 염주 모양의 불규칙한 확장
• 췌관내의 calcification: 가장 믿을만한 소견
 77. Solid Pseudopapillary Tumor
pancreas
• 젊은 여성, 평균 25세
• 저등급 악성종양, 완전절제시 예후 좋음
• Tail > head> body
• Capsule에 싸여있음
• 내부에 다양한 정도의 hemorrhage and cystic
change
• 30%에서 Ca++, 주로 periphery에
• Imaging
– Solid mass부터 solid and cystic lesion (m/c), 그리고
complete cystic lesion까지 다양
– Capsule은 enhance (+)
– DDx: cystic neoplasm, nonfunctional endocrine
tumor (주로 old age), calcified and hemorrhagic
pseudocyst
교과서 439
Figures 2.4. (2) Fast spoiled
gradient-echo fat-
saturated T1-weighted
MR image reveals a
round, well-
circumscribed,
low-signal-intensity 1.5-cm
mass in the enlarged
pancreatic head just
anterior to the common
bile duct (arrow).
(3) On a single-shot fast
spin-echo T2-weighted
MR image, the mass is
slightly hyperintense
(arrow). (4a) Initial
contrast-enhanced arterial
phase fast spoiled
gradient-echo fat-
saturated T1-weighted
MR image
demonstrates
the lesion as slightly
hypointense (arrow). (4b)
On a contrast-enhanced
portal phase fast
spoiled gradient-echo
fatsaturated
T1-weighted MR image, the
lesion (arrow) is almost
imperceptible.
78. Recurrent Pyogenic Cholangitis
• 여러 개의 stone이 extra- and intrahepatic duct에
• 간내 및 간외담관 확장
– 중심부가 심하고 주변부가 급격히 좁아져 비례하지 않음
– 간외 담관확장은 stone위치와 상관 x, stone의 proximal
and distal 모두 늘어남
• Lt lateral segment (m/c) & Rt posterior segment
• 담관 협착과 segmental atrophy가 동반
• 75-80%에서 bile duct stone(+), 대부분 pigmented
stone
• Bile duct의 wall thickening
• Complication: bile duct stone, biliary stricture and
dilatation, liver abscess, biloma, cholangiocarcinoma
(2-5%)
• RPC. (a) Coronal T2-weighted MR image shows
segmental biliary dilatation in the left hepatic
• lobe with associated hepatolithiasis (arrows). (b)
Axial delayed gadolinium-enhanced 3D T1-
weighted MR
• image shows segmental biliary dilatation in the left
hepatic lobe with periductal enhancement (arrow).