1. Unusual CT Manifestations of Common
Abdominal Diseases
Rosa Bouzas-Sierra, MD--- Rosa.bouzas.sierra@sergas.es
Milagros Otero-Garcia, MD----- Milagros.otero.garcia@sergas.es
Spain

2. NO DISCLOSURES

3. Rectosigmoidoscopy:
Solitary linear ulcer in Sigma
CASE 1 : 55 y-old male with rectal bleeding

4. Solitary rectal ulcer Syndrome:
• occurring mainly in young patients who experience rectal
bleeding
Giant ulcers in ileum and colon by citomegalovirus :
• in AIDS patients
• Feczko PJ et al. AJR 1980
• Balthazar EJ. AJR 1996
- Carcinoma

5. CTC

7. A- GIST
B- Colon Cancer
C- Submucosal Lipoma
D- Intramural Hematoma

8. Bowel laceration?
* Pickhardt PJ. RadioGraphics 2007

9.  Woman 45 y, IUD
 Acute pelvic pain, fever
 Bimanual uterine and adnexal tenderness
 WCC: 15,000/μL [reference value, <10,000/μL]
 US: No possible (very painful)---- CT

10. A- Pelvic Inflammatory disease (TOA)
B- Ovarian torsion
C- Hemorrhagic ovarian cyst
D- Ovarian mass

11. At surgery and pathologic analysis, the ovary was hemorrhagic and necrotic

12. - Ovarian torsion is the twisting of an ovary on its ligamentous supports
- Concomitant ovarian and tubal torsion (adnexal torsion) occur in up to 67% of
cases
- It is generally considered an acute condition (subacute…)
- All ages
- Reproductive years (pregnancy: 5-fold – first trim.)- highest prevalence
Predisposing Conditions
- Large (>5 cm) cysts and cystic neoplasms (benign mature cystic teratomas….)
- Ovarian hyper- stimulation syndrome
- Normal ovaries (usually right ovary) in adolescent or teenagers
- Non-specific symptoms and laboratory tests. DD: PID, appendicitis…..
- Imaging plays a central diagnostic role (ovary-sparing)
Ovarian torsion
. Chang HC et al. RadioGraphics 2008
. Appelbaum HL et al. AJR 2007
. Rha SE et al. RadioGraphics 2002

13. Ovarian torsion Imaging findings
US
Color Doppler
- Complex adnexal mass
- Unilateral enlarged ovary (>4 cm)
- String of pearls sign: Multiple peripheral cysts
- Free pelvic fluid (8%)
- Decrease or absence of venous flow (93%)
- Absence of arterial flow (60-73%)
- Ovaries without flow in the vascular pedicle
- Twisted vascular pedicle: (circular vessels: “whirlpool sign“)

14. Ovarian torsion Imaging findings
CT
- Adnexal mass in the midline, rotated towards the contralateral side of the pelvis
- Deviation of the uterus to the side of the affected ovary
- Free fluid
- Necrosis seems to be the cause of a cystic appearance on CT

15. T2 FSTIRT2
Ovarian torsion Imaging findings
MR - Pregnant women, young girl
- MR imaging is recommended to help detect the twisted vascular pedicle
(“whirlpool sign“) or in patients with a suspected ovarian mass.

16. Take home message: Ovarian torsion in
a “women in their reproductive years”,
without an underlying mass

17.  49 y-old woman, breast cancer
 Liver and bone metastasis (IV)
 CHT induction and consolidation
No hepatic masses
Chemotherapy-induced pseudocirrhosis
Control: 20 weeks later

19. A- Carcinomatosis
B- Hepatic failure
C-Fluid retention
D- Peritoneal tuberculosis

20. radiology.rsna.org n Radiology: Volume258:Number1—January2011
normally instruct the cell to grow and
divide. Hence, it acts as a tyrosine kinase
inhibitor. Important to notice is a recent
discovery that cetuximab is active only
in tumors that are wild type for KRAS
(3). The exact mechanism of action is
unclear, as cetuximab recently demon-
strated antitumor activity in patients
with colorectal cancer whose disease
g. Peripheral nerves
, cisplatin, taxanes),
n and gemcitabine),
n), heart (eg, anthra-
tral nervous system
hotrexate, 5-FU) are
s (Table 3).
apies have developed
proved knowledge of
ey target cell surface
case of monoclonal
ous signaling mole-
of kinase inhibitors).
ents affect multiple
ore, have the poten-
cules that are critical
hways, causing toxic-
n previously observed
the toxicities of the
molecularly targeted
here is concern that
Publishedonline
10.1148/radiol.10092129 Content Code:
Radiology2011; 258:41–56
Abbreviations:
EGFR= epidermal growthfactor receptor
5-FU= fluorouracil
TKI= tyrosinekinaseinhibitor
VEGF= vascular endothelial growthfactor
L.H.S. hasdisclosedfinancial relationshipswith
AstraZenecaandNovartis.

21. Peripheral edema
Weight increase
Pleural and Pericardial
effusions
Ascites
Capillary protein leak syndrome
Ascites alone, should not be mistaken for disease progression

22.  Peritoneal carcinomatosis from ovarian tumor
 Failed available standard CHT
 “Double blind” Trial : Placebo / Antiangiogenic
CT, basal CT, 9 weeks

24.  A- Intestinal obstruction and perforation
 B- Partial response with gastric metastases
 C-Partial response with peritoneal carcinomatosis
 D- Partial response and GI perforation

25.  Oral contrast media extravasation
GI perforation secondary to
the Antiangiogenic agent

26. 160 patients
The pathogenesis of bowel perforation is unknown, but
suggested mechanisms include ischemia with
thrombosis of intestinal mesenteric vessels

27.  Acute B-L Leukemia
 CHT: Since day +35 coincident with medullary recovery:
Fever and facial rash and oedema . Cultures: (-)
 Fever and facial rash and oedema disappeared with
high doses of steroids

28. • Pneumatosis Coli
• Pneumoperitoneum
Rutinary follow-up
• Minimal abdominal pain and
distension
• No peritoneal signs, fever, or
leukocytosis

29. A- Linear Pneumatosis Coli
B- Subclinical bowel perforation
C- Typhlitis
D- Cystic Pneumatosis Coli ( NSP)

30. “ Pneumoperitoneum usually
denotes a perforation of an
intra-abdominal viscus, but in
about 10% of patients, a
nonsurgical source is responsible
for free air in the peritoneum”.

31. • Mularski RA. et al. Crit Care Med 2000
• Mularski RA. et al. West JMed 1999

32. • Heng Y et al. Am J Gastro 1995
• Liu DM. Can J Emerg Med 2003
Pneumatosis
Type
Characterization Asociation Surgical
treatment
Microvesicular
pneumatosis
Small collections of air within
the lamina propria
Associated with invasive
procedures
-
Cystic
Pneumatosis
Macroscopic submucosal
cysts
(mm-cm)
- Pneumoperitoneum
. 10% of patients with small
bowel pneumatosis
. 2% of those with large
bowel pneumatosis
• COPD
• Immunosupression
therapy (haematologic)
• Bevacizumab
• Immunocompromise
• Steroid usage
• Inflammatory bowel
disease
• Post bone marrow
transplantation
-
Linear
Pneumatosis
Represent the tracking of gas
through compromised
submucosa
. Bowel ischemia or infarction +

33. 20 days without steroids

34. • Take home message
• To be aware of possible
CHT toxicity manifestations
We should look for, not only
on images but in the clinical
history to help distinguish
new-onset toxicity from
disease progression.
• Reporting CHT toxicity
findings to the oncologist is
important, in order to choose
to discontinue therapy

36. A- Well-differenciated liposarcoma
B- Exophytic renal angiomyolipoma
C- Lipoma
D- Myelolipoma
E- N-differenciated liposarcoma

37. Benign Malignant
Angiomyolipoma
Lipoma
Hibernoma
Myelolipoma
Liposarcoma: 35% of all malignant
retroperitoneal soft-tissue tumors
(a) well-differentiated (most common)
(b) myxoid and round cell
(c) pleomorphic
Retroperitoneal fatty masses in adult
• CraigWC. et al RadioGraphics 2009

38. Exophytic angiomyolipoma
WD liposarcoma
Myxoid liposarcoma

39. CT characteristics Exophytic renal
angiomyolipoma
Well-differentiated liposarcoma
Defect in the Renal Parenchyma + -
Vessels in the Lesion +
(enlarged internal vessels with
aneurysm formation)
-
Additional Angiomyolipomas + +/-
Size Usually larger

40. • Careful evaluation enables accurate
differentiation of large exophytic
angiomyolipomas and well-differentiated
retroperitoneal liposarcomas
Take home message:

41.  Arthrosis for several years treated with NSIDs
 Neutropenia. Medulary biopsy: normal
 Hepatomegaly, abnormal liver function test and jaundice
(total bilirrubin: 14 mg)
 GP: requested an abdominal CT

43.  A- HCC
 B- Hipervascular Metastasis
 C- Vasculitis
 D- A-V shunt
We recomended a hepatic biopsy and antibodies determination in
order to diagnose any reumatoid disease.

44. Cronic hepatitis with severe
inflammatory activity
Necrotic Arteritis in medium
size hepatic artery
Autoimmune Hepatitis, Aneurism
Outcome: normalization of all
parameters after appropriate treatment
Liver Aneurysm
ANA(+)/ ENA(+)/ antiSSA(+)
LES

45. —58-year-old man with polyarteritis nodosa.
Tarhan N C et al. AJR 2003;180:1617-1619

46. HEPATIC
INVOLVEMENT
- Hepatomegaly is seen in 39% to 40%
- Steatosis due to glucocorticoid therapy or to SLE itself
- Arteritis (21%) of SLE
- Nodular regenerative hyperplasia of the liver, is a rare but important
complication of SLE associated with noncirrhotic portal
hypertension.
- Autoinmune hepatitis. The most common one, is the classic
“lupoid hepatitis” with chronic active hepatitis
• Up to 4,7% of patients with SLE have chronic active hepatitis
• Up to 10% of patients with Autoinmune hepatitis have SLE

47. INTESTINAL VASCULITIS
GASTRIC INVOLVEMENT
COLON AND SMALL BOWEL
INVOLVEMENT
INTESTINAL
PSEUDOOBSTRUCTION
PANCREATIC AND
GALLBLADDER INVOLVEMENT
PERITONITIS AND ASCITES
MALABSORPTION AND
PROTEIN-LOSING
ENTEROPATHY
- In 53% in those with active SLE and abdominal pain. Involves small arteries
- CT: shows ischemic bowel disease
- Opportunistic infections (eg. Mucormycosis) may mimic GI vasculitis and should
be suspected in these immunocompromised patients with not active LES
- Perforation from peptic ulcer disease ( 6% to 8%)
- Pernicious anemia
- Pneumatosis cystoides intestinalis (benign pneumoperitoneum)
- Necrotizing enterocolitis
- CMV enteritis, prone to salmonella infection
- Intestinal obstruction without a mechanical cause. Initial manifestation of lupus (
41% to 50% .
- Associated urinary tract involvement with ureterohydronephrosis, suggesting a
smooth muscle dysmotilityand secondary vesiculoureteric reflux or to fibrosis of the
ureterovesicular junction. One- third of patients have interstitial cystitis
- Recurrent pancreatitis occurs in 43% of patients. Chronic pancreatitis in 14%
- Primary sclerosing cholangitis and autoimmune cholangiopathy.
- Acute pancreatitis is a rare. Associated with thrombosis and cutaneous vasculitis.
- Ascites from infection, bowel infarction, perforation, pancreatitis, mesenteric
vasculitis, or serositis.
- Chronic ascites lupus can be due to nephrotic syndrome, heart failure, protein-
losing enteropathy, constrictive pericarditis, lupus peritonitis, or indolent infections
such as tuberculosis.

48. ‘‘Hepatic disease may be more common in SLE than is usually thought
and we should be aware of it ”
* Abraham S. Ann Rheum Dis 2004
** Ebert EC. J Clin Gastroenterol 2011
Patients with liver disease should be treated as soon as possible,
especially those patients with jaundice or persistent increase of liver
enzymes values”
Take home message:

49. CASE 8: 65 year-old woman
 Left lumbar pain, fever, leukocyturia and WCC rise, … suggesting acute Pyelonephritis
 Fecaluria and pneumaturia
• History: pelvic surgery, radiotherapy and chemotherapy
Dec-2007

50. CT 6 months before, Post-surgery, RT and CHT April-2007

51. First CT. Post-surgery Dec- 2006

52. A- Bladder tumor and ureteral infiltration
B- Colon cancer
C- Ovarian cancer
D- Ureteral tumor and colonic invasion
The patient has an acute pyelonephritis secundary to an ureteral fistula

53. Nov- 2006

54. Nov- 2006

55. Ovarian cancer (Transitional Type. GIII, PT1c. FIGO I)
----------- Partial response
Colonic-ureteral fistulae

56. Fistulas in Malignant Gynecologic Disease
- As a result of a primary or recurrent tumor
- As a consequence of:
Surgery (particularly if the surgical procedure is radical and complex or
if the surgical field includes previously irradiated tissue)
Radiation therapy (eg, cervical, colorectal, endometrial cancer)
Types:
- Vesicovaginal and enterovaginal fistulas (more frequent)
- Ureterovaginal, enterovesical, enterocutaneous, and uretero-alimentary
tract
. Narayanan P et al. RadioGraphics 2009
. Yu NC et al. RadioGraphics 2004

57. Cervical cancer. Radiotherapy

58. Nephrectomy. Entero-cutaneous fistulae

59. - Ureterocolic fistulas are most common and can be caused by urinary
calculi, iatrogenic trauma, diverticulitis, radiation therapy, transitional cell
carcinoma, and tuberculosis
• Symptoms: flank pain, hematuria, recurrent urinary tract infections,
pneumaturia, fecaluria, and diarrhea
• Diagnosis: Retrograde pyelography, and contrast-enhanced CT: Gas in the
ureter
Barium studies of the intestinal tract often will not reveal the
fistula
Uretero–Alimentary Tract Fistula

60. - Right ureter: terminal ileum, cecum, appendix,
and ascending colon and their mesenteries
- Left ureter: descending colon and sigmoid
colon and their mesenteries
- Either ureter may be injured during surgery, or
radiation performed on these structures, or
engulfed in an adjacent mass
. Avritscher R et al. RadioGraphics 2004
I would add: The ovary
Take home message:

61. CASE 9 : 24 year-old man. Down Syndrome
 No abdominal complaints
 Abdominal mass (at manual exploration)
 Right mass effect that displaces right
abdominal structures

63. A- Teratoma
B- Sarcoma
C- Germ cell neoplasm
D- Leukemia

64. Blood test: normal
AFT: 0.9 (0.0-12)
Beta HCG: 440.9 (0.0-6.0)

65. T1 T2

66. FS T2
DWI, b:600
CE Cor LAVA

67. Pathology: Classical seminoma TIIIB (T1N3MOS2)

68. Metastatic disease from a testicular germ cell neoplasm

69. Down Syndrome Cancer Incidence in DS
Leukemia
Testicular cancer
Other cancers
- Acute lymphocytic
- Acute non-lymphocytic
- 19-fold higher
- Seminomatous (gonadal and extragonadal)
- 50-fold higher (0.5% compared with an expected incidence of 0.087%
in the general population)
- Non-Hodgkin lymphoma, stomach, colon, small intestine, breast,
endometrial, brain, kidney, liver cancers…
* Hill DA et al. Arch Intern Med. 2003 … N: 4872 (DS)
** Goldacre MJ et al. Arch Dis Child 2004 ....N: 1453 (DS)--- 460 000(NDS)
*** Rima d et al. European Journal of Medical Genetics 2006
**** Cools M et al. Human Pathology 2006

70. • Because of improvement in medical care, a higher proportion of children
with DS are now surviving beyond adolescence
• Therefore, more patients reach the predisposition age range when
testicular cancer is most prevalent (35 years)
• Testicular palpation in this population should be considered a
component of routine physical examination
Take home message:

71. Happy Spring
Everybody !!!!!
Thank you very much for your attention