GA.

Indirawati
Jakarta , 13th August 2016
Why CT ??

 Cross sectional imaging

 Global assessment
 Operator independant
 ( almost ) readily available
 Direct visualization
 Periappendiceal & other structures
 Severity & extention
 Sometimes : Non Enhanced CT is OK
• Obstruction of appendiceal lumen

• Distention of appendix
• Superimposed infection

• Ischemia
• Eventually : perforation
Findings

 Non filling appendix

 Enlargement ( > 6 mm / > 7 mm ) in outer
diameter
 Thickened , abnormal wall enhancement
 Periappendiceal fat stranding
 Appendicolith : more on CT than plain photo
 Thickened caecum and terminal ileum wall
 Appendicolith ( 25 – 40 % with CT )
 Right lower quadran lymphadenopathy
With perforation :

 Pericaecal abscess
 Retroperitoneal air
 Fluid collection , in RLQ
 Displacement of bowel loop from RLQ
 Marked ileocaecal thickening
 Peritonitis
 Small bowel obstruction
 Defect of wall enhancement
• Staging

• Assessing recurrent disease

• Detecting distant metastases

• Follow up
 Accuracy 70-80 %
 Able to asses nodes & metastases
 Small masses

 CT Colonography
Findings

 Assymetric wall thickening (+/- iregular

surface)
Wall thickness normal : < 3 mm
3-6 mm indeterminate , > 6 mm abnormal
 Annular : thickening bowel wall & lumen
narrowing
 Focal , intraluminal soft tissue density mass
 Stricture with bowel obstruction
 Length of bowel involvement :
 Enhancement : grey

 Associated feature : invagination ,

obstruction , fistulae ( ? )
Extracolonic extension
o Mass with irregular border
o Pericolonic fat stranding /streaky bands
o Loss of soft tissue plane between colon &
surrounding structures
o Peritoneal metastase / omental cake
o Messenteric LN
STAGING
Stage A : limited to mucosa +/- submucosa
( T1N0M0 )
Stage B : limited to serosa or adjacent tissues
( T2/3N0M0 )
Stage C : LN metastases ( T2/3N1M0 )
Stage D : Distant metastases ( any T / M )
Colon mass
Colon mass
Increased use of CT for evaluating
IBD

Detection & characterization of the

lesion
Findings
 Circumferential diffuse & symmetrical wall
thickening
 Length of bowel involvement : > 10 cm –
entire colon
 Fold enlargement, lack of haustral pattern
 Luminal narrowing , accordion sign
 Pericolonic fat stranding / proliferation
 Widening of presacral space
 Lymphadenopathy
 Ascites
 Toxic megacolon maybe present
 Toxic megacolon :

A syndrome of colonic dilatation,

abdominal
pain , fever & leucocytosis.
Perforation 50 % cases
High mortality rate !!
Spectrum
 Crohn’s disease
 Ulcerative colitis
 Pseudomembranous colitis
 Thyphlitis
 Radiation
etc
 Target signs
1. Enhancing inner ring of bowel wall
( mucosa )
2. Non enhancing middle ring
( submucosa )
3. Enhancing outer ring bowel wall
( muscularis propia )
Findings
 Small outpouchings of colonic wall
 Contains air, contrast or fecal material
Diverticulitis
 Focal bowel wall thickening
 Pericolonic fat stranding
 Possibly gas / fluid collection adjacent to the
wall ( abscess ) , sinus tract , fistulae etc
 Sigmoid ( 65% -70 % ) , descending colon ( 25
% - 30 % )
 Location : antimesenteric side
• Caused by many conditions
• Variable clinical presentation

• CT findings sometime non specific

• Involving small or large bowel

• Best : Clinico - radiological diagnosis

 Causes
Hypovolemic shock
Congestive heart failure
Closed loop obstruction /mechanical
Thrombosis / occlusion of SMA / SMV
Inflammation
Others
Findings

 Segmental symmetric thickening of bowel

wall
 Luminal narrowing or dilatation with air –
fluid levels
 Small bowel feces sign
 Variety of mucosal enhancement
 Loss of haustra
Findings
 Messenteric fat infiltrated by edema
( “ misty messentery “ )
 Intramural gas
 Vascular engorgement
 Free fluid
 Portal venous gas
Inflammation
Inflammation
 Bowel within bowel.
Proximal segment ( intussusceptum ) into
lumen of distal segment ( intussuscipiens )

 Ileo-ileal,ileo-colic, colocolic
 Short segment : non obstructing ,idiopathic
 Long segment : obstructing , mass
 CT Findings
1. Early stage : “ Target Sign “
Outer layer = intussuscipiens
Inner layer = intussusceptum
2. As it progress : “ Sausage – shaped mass “
Layering pattern of low density ( mesenteric
& fat ) and high density ( bowel wall )
3. Reniform / kidney like mass
Due to wall edema / thickening

4. Features / sign of bowel obstruuction

3 . Kidney shaped / reniform
Due to mural thickening

4. Signs of bowel obstruction

Direct CT findings

 Discontinuity of the bowel wall

 Extraluminal air
Indirect CT findings
 Bowel wall thickening
 Abnormal wall enhancement
 Abscess
 Inflammatoy mass adjacent bowel
Stomach duodenum perforation
o Abundant
o Around liver & stomach

Post bulbar duodenum perforation

o Right anterior pararenal space
Small bowel perforation

o Small
o Messenteric fold
o Around liver
Large bowel perforation

o Variable
o Pelvic
o Messenteric fold
o Retrperitoneal space
Appendix perforation
o Around appendix

Use : “ Wide window setting “

Synonyms
Peritoneal carcinomatosis
Peritoneal implant
Omental cake
Findings
 Nodular enhancement of peritoneum
 Hypovascular omental caking
 Ascites

DD : TB peritonitis
1. Diferentiating between extraluminal &
intramural gas
2. Detection of lymphnode
3. Notice omental cake
4. Vascular abnormalities
5. Check adrenal / suprarenal gland