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(BQ) Part 1 book “Computed body tomography with MRI correlation” has contents: Magnetic resonance imaging principles and applications, interventional computed tomography, interventional computed tomography; heart and pericardium,… and other contents.
5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page i 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page i Computed Body Tomography with MRI Correlation FOURTH EDITION 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page ii 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page iii Computed Body Tomography with MRI Correlation FOURTH EDITION EDITORS JOSEPH K T LEE, MD E H Wood Distinguished Professor and Chair Department of Radiology University of North Carolina School of Medicine Chapel Hill, North Carolina STUART S SAGEL, MD Professor of Radiology Director, Chest Radiology Section Mallinckrodt Institute of Radiology Washington University School of Medicine St Louis, Missouri ROBERT J STANLEY, MD, MSHA Editor-in-Chief American Journal of Roentgenology Professor and Chair Emeritus, Department of Radiology University of Alabama at Birmingham Birmingham, Alabama JAY P HEIKEN, MD Professor of Radiology Director, Abdominal Imaging Section Mallinckrodt Institute of Radiology Washington University School of Medicine St Louis, Missouri 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page iv Acquisitions Editor: Lisa McAllister Managing Editor: Kerry Barrett Project Manager: Fran Gunning Manufacturing Manager: Ben Rivera Marketing Manager: Angela Panetta Design Coordinator: Teresa Mallon Production Services: Nesbitt Graphics, Inc Printer: Maple Press © 2006 by LIPPINCOTT WILLIAMS & WILKINS 530 Walnut Street Philadelphia, PA 19106 USA LWW.com All rights reserved This book is protected by copyright No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in the USA Library of Congress Cataloging-in-Publication Data Computed body tomography with MRI correlation / editors, Joseph K.T Lee, Stuart S Sagel.— 4th ed p ; cm Includes bibliographical references and index ISBN 0-7817-4526-8 Tomography Magnetic resonance imaging I Lee, Joseph K T II Sagel, Stuart S., 1940- III Title [DNLM: Tomography, X-Ray Computed Magnetic Resonance Imaging WN 206 C7378 2005] RC78.7.T6C6416 2005 616.07’57—dc22 2005029421 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of this information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page v To our wives, Christina, Beverlee, Sally, and Fran To our children, Alexander, Betsy, and Catherine; Scott, Darryl, and Brett; Ann, Robert, Catherine, and Sara; and Lauren And to our grandchildren 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page vi 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page vii Contents Contributing Authors ix Preface xi Acknowledgments xiii BASIC PRINCIPLES OF COMPUTED TOMOGRAPHY PHYSICS AND TECHNICAL CONSIDERATIONS Kyongtae T Bae and Bruce R Whiting MAGNETIC RESONANCE IMAGING PRINCIPLES AND APPLICATIONS 29 Mark A Brown and Richard C Semelka INTERVENTIONAL COMPUTED TOMOGRAPHY 95 Charles T Burke, Matthew A Mauro, and Paul L Molina NECK 145 Franz J Wippold II THORAX: TECHNIQUES AND NORMAL ANATOMY 225 Fernando R Gutierrez, Santiago Rossi, and Sanjeev Bhalla 12 LIVER 829 Jay P Heiken, Christine O Menias, and Khaled Elsayes 13 THE BILIARY TRACT 931 Franklin N Tessler and Mark E Lockhart 14 SPLEEN 973 David M Warshauer 15 THE PANCREAS 1007 Desiree E Morgan and Robert J Stanley 16 ABDOMINAL WALL AND PERITONEAL CAVITY 1101 Jay P Heiken, Christine O Menias, and Khaled Elsayes 17 RETROPERITONEUM 1155 David M Warshauer, Joseph K T Lee, and Harish Patel 18 THE KIDNEY AND URETER 1233 Mark E Lockhart, J Kevin Smith, and Philip J Kenney 19 THE ADRENAL GLANDS 1311 Suzan M Goldman and Philip J Kenney MEDIASTINUM 311 Alvaro Huete-Garin and Stuart S Sagel 20 PELVIS 1375 Julia R Fielding LUNG 421 Stuart S Sagel 21 COMPUTED TOMOGRAPHY OF THORACOABDOMINAL TRAUMA 1417 Paul L Molina, Michele T Quinn, Edward W Bouchard, and Joseph K T Lee PLEURA, CHEST WALL, AND DIAPHRAGM 569 David S Gierada and Richard M Slone HEART AND PERICARDIUM 667 Pamela K Woodard, Sanjeev Bhalla, Cylen Javidan-Nejad, and Paul D Stein 10 NORMAL ABDOMINAL AND PELVIC ANATOMY 707 Dennis M Balfe, Brett Gratz, and Christine Peterson 11 GASTROINTESTINAL TRACT 771 Cheri L Canon 22 MUSCULOSKELETAL SYSTEM 1481 Robert Lopez-Ben, Daniel S Moore, and D Dean Thornton 23 THE SPINE 1661 Zoran Rumboldt, Mauricio Castillo, and J Keith Smith 24 PEDIATRIC APPLICATIONS 1727 Marilyn J Siegel Index 1793 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page viii 5063_Lee_FMppi-xiv 10/20/05 12:44 PM Page ix Contributing Authors Associate Professor of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Julia R Fielding, MD Professor of Radiology, Department of Diagnostic Radiology, Washington University School of Medicine, St Louis, Missouri David S Gierada, MD Assistant Professor of Radiology, Co-Chief, CT and Emergency Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Suzan Menasce Goldman, MD, PhD Kyongtae T Bae, MD, PhD Dennis M Balfe, MD Sanjeev Bhalla, MD Radiology Resident, University of North Carolina School of Medicine, Chapel Hill, North Carolina Edward W Bouchard, MD Senior Technical Instructor, Siemens Training and Development Center, Cary, North Carolina Mark A Brown, PhD Associate Professor and Director of Abdominal Imaging, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina Associate Professor of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Affiliated Professor, Imaging Diagnosis Department, UNIFESP/EPM, São Paulo, Brazil Instructor in Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Brett Gratz, MD Professor of Radiology, Cardiothoracic Imaging Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Fernando R Gutierrez, MD Assistant Professor of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina Jay P Heiken, MD Associate Professor, Vice Chair for Education, Department of Radiology, University of Alabama at Birmingham; Chief, Gastrointestinal Radiology, Department of Radiology, UAB Health System, Birmingham, Alabama Alvaro L Huete-Garin, MD Charles T Burke, MD Cheri L Canon, MD Professor and Director of Neuroradiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina Mauricio Castillo, MD Khaled M Elsayes, MD Institute, Giza, Egypt Staff Radiologist, Theodore Bilhars Professor of Radiology, Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Assistant Professor of Radiology, Catholic University, Santiago, Chile Assistant Professor of Cardiothoracic Imaging, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri Cylen Javidan-Nejad, MD Director of Outpatient Radiology and Chief, GU Section, Professor, Abdominal Imaging Section, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama Philip J Kenney, MD 5063_Lee_Ch11pp0771-0828 10/13/05 2:59 PM Page 814 814 Chapter 11 M B A Figure 11-67 Metastatic squamous cell carcinoma with carcinomatosis 59-year-old man with base of tongue squamous cell carcinoma Patient had extensive metastatic disease involving the brain, neck, skin, abdomen, and pelvis A: CT through the upper abdomen reveals multiple large liver metastases and retrocrural adenopathy (arrow) B: Innumerable metastatic nodules are present in the omentum and mesentery Large mesenteric mass (M) has invaded the adjacent transverse colon, resulting in an annular stricture Squamous cell carcinoma can occur in the anal canal It does not have any discriminating features from adenocarcinoma Carcinoid can occur anywhere in the colon, but it is more common in the rectum These tumors have a similar appearance as carcinoid tumors in the small bowel, and they most commonly present with a metastatic mesenteric mass Carcinoids arising in the colon, rectum, and appendix have a better prognosis than those arising in the stomach, duodenum, and small bowel (248,252) Metastatic disease involving the colon can occur hematogenously (Fig 11-67), as in lung and breast cancer, but it occurs secondary to peritoneal seeding more commonly This is most frequently due to ovarian carcinoma Outside of retention and neoplastic mucoceles, tumors of the appendix are rare The most common appendiceal tumor is carcinoid It usually appears as a focal mass in the distal appendix, and it seldom metastasizes Non-Hodgkin lymphoma can also rarely involve the appendix Most patients with lymphoma of the appendix present with acute symptoms of appendicitis On CT, lymphomatous involvement appears as a diffusely enlarged appendix, typically larger than those affected by appendicitis, generally with a diameter of cm or greater (219) This is similar to the aneurysmal dilatation seen in small bowel lymphoma Inflammation and tumor extension can appear as soft-tissue strands extending into the periappendiceal fat, so this finding cannot be used as a discriminator from appendicitis Lymphadenopathy may or may not be present Malignant dilatation of the appendix can also occur in the setting of cecal colon cancer obstructing the appendiceal orifice (Fig 11-68) Paraganglioma, ganglioneuroma, and other mesenchymal tumors of the appendix are rare C * Figure 11-68 Adenocarcinoma of cecum (C) with obstructed appendix (asterisk) There is marked, asymmetric thickening of the wall in this patient with a cecal adenocarcinoma The mass has obstructed the appendix, resulting in marked dilatation of its lumen (asterisk) 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 815 Gastrointestinal Tract 815 A A B Figure 11-69 Sigmoid diverticulitis with abscess A: There is eccentric thickening of the sigmoid colon, greater along the medial wall (arrow) B: Superiorly, there is abscess (A) containing gas and fluid Note the inflammatory wall thickening of the adjacent loop of ileum (arrow) that is displaced by the intimately contiguous abscess Inflammation Diverticulitis is due to obstruction of a diverticulum with resultant inflammation, and it is most commonly seen in the sigmoid colon CT is the imaging method of choice for patients presenting with the constellation of lowerabdominal pain, fever, and leukocytosis Uncomplicated diverticulitis produces circumferential wall thickening with inflammatory changes extending into the pericolic fat (Fig 11-69) In many cases, the obstructed diverticulum and its fecalith are identifiable Contained colonic perforation is a relatively common complication, and CT can help to assess its extent, as many patients can be treated without surgical management Findings include a focal collection of extraluminal fluid and/or gas In the setting of diverticulitis, gas within the bladder is strongly suggestive of a colovesical fistula This must be interpreted with caution in patients who have been recently catheterized Other findings such as bladder wall thickening should be present Free perforation with pneumoperitoneum is uncommon It is more common in individuals on chronic steroid therapy, presumably because of the inability of their immune systems to mount a response and wall off the perforation Right-sided diverticulitis is not as common, but it has similar imaging findings (Fig 11-70) (115,117) It is more common in Asians and has a more benign course It is important to identify the appendix so as to exclude appendicitis; thin-section CT has markedly improved our ability to this CT imaging findings of uncomplicated appendicitis include dilatation of the appendix (total transverse diameter greater than mm), wall thickening with enhancement, and peri-appendiceal inflammatory changes (Fig 11-71) Multiple other secondary findings include cecal tip thickening, adenopathy, appendicolith, and phlegmon (228) Occasionally, a normal appendix may have a caliber greater than mm (16), so additional findings of periappendiceal inflammation and a thickened enhancing wall must be sought to support the diagnosis of appendicitis Specific protocols for evaluating appendicitis are variable Most agree that thin-section (4 to mm) CT imaging is needed (274), but the administration of oral, intravenous, and rectal contrast material is a topic of debate The performance of CT in the diagnosis of appendicitis is excellent (149,150,224,227,228,241,279), regardless of technique Therefore, some have suggested that no contrast of any kind is needed (16, 59,149,150) Most normal appendices are identifiable, even on unenhanced studies (16,113,226,227,241) However, it has also been shown that intravenous administration of contrast significantly improves accuracy in detection of appendicitis (113) Patients are being imaged earlier in the course of their disease, and early or mild appendicitis may not have periappendiceal inflammatory changes (230) Enhancement of the thickened wall may be the only finding (113) Also, contrast administration improves the likelihood of providing an alternative diagnosis (149,150,226,227) Appendicoliths are more readily identified when bone window settings are routinely reviewed (4) The presence of gas in the appendix is another source of controversy It has been proposed that gas is indicative of a patent, noninflamed appendix, 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 816 816 Chapter 11 A B Figure 11-70 Ascending colonic diverticulitis A: There is mural thickening of the proximal ascending colon with pericolonic inflammation B: The epicenter of the inflammation is a diverticulum (arrow) and not the appendix, seen on slightly more inferior images and it has also been suggested that gas occurs in acute appendicitis In one large study, intraluminal gas was present in both normal and inflamed appendices, so this cannot be used as a discriminator (225) On the other hand, peri-appendiceal or intramural gas is seen only in the setting of appendicitis (225) CT is very accurate in diagnosing complicated appendicitis, including perforation, as well as peri-appendiceal abscess and small bowel obstruction There are five imaging findings that suggest perforation: abscess (Fig 11-72), phlegmon, extraluminal air, extraluminal appendicolith, and focal defect in an enhancing appendiceal wall (99) A * Figure 11-71 Uncomplicated appendicitis The appendix is dilated, measuring 1.6 cm, and has a thickened wall (arrow) An appendicolith (curved arrow) is present Minimal peri-appendiceal inflammatory changes are present Note reactive ascites in right hemipelvis (asterisk) Figure 11-72 Perforated appendicitis Image through the superior pelvis reveals an abscess at the cecal tip (A) Note ileocecal valve (arrow) No appendix was identifiable, but diagnosis was presumed perforated appendicitis, which was surgically confirmed 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 817 Gastrointestinal Tract Independently, these findings are not very sensitive, 21% to 64%, although they are specific, 95% to 100% The defect in the appendiceal wall is the single most sensitive sign, 64% When all findings are present, the sensitivity increases dramatically to 95%, with a specificity of 95% (99) Several chronic inflammatory processes can affect the appendix and mimic acute appendicitis These include granulomatous appendicitis, lymphoid hyperplasia, fibrosis, and nonspecific chronic inflammation (36) The appearance on CT cannot be used to differentiate these processes from acute appendicitis (36) Regardless, appendectomy will often be symptomatically curative As described above, primary appendiceal or cecal tu- * 817 mors can present with signs, symptoms, and imaging findings mimicking appendicitis It is important to suggest tumor on the preoperative CT, as it dictates surgical planning A luminal diameter greater than 15 mm is more indicative of tumor (220) Idiopathic inflammatory bowel disease (IBD) includes Crohn colitis (granulomatous colitis) and UC Crohn colitis most commonly involves the right colon and rectum Similar findings as seen in the small bowel are seen in the colon There is mural thickening with surrounding inflammation and fibrofatty proliferation (Fig 11-73) There may be skip lesions and involvement throughout the reminder of the GI tract UC begins at the anus and extends more * * B A Figure 11-73 Multisegmental Crohn colitis A: There is symmetric mural thickening at the hepatic flexure (asterisks) and pericolonic inflammation B: Similar findings are identified in the sigmoid colon with a small amount of ascites (asterisk) and reactive lymph node (arrow) Note the irregular appearance of the serosa, a finding not typically seen in UC C: The vessels in the sigmoid mesocolon are dilated with multiple small nodes (arrow) Patient was having profuse diarrhea and abdominal pain at the time of the examination C 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 818 818 Chapter 11 Figure 11-74 Ulcerative colitis involving the rectum and sigmoid colon There is sigmoid (large arrow) and rectal (small arrow) thickening Perirectal fatty proliferation is also present proximally without skip lesions Cross-sectional imaging reveals mural thickening (Fig 11-74) The following generalities can help differentiate between Crohn colitis and UC (80) The wall thickening in Crohn disease is more pronounced and typically demonstrates homogeneous enhancement and serosal irregularities (see Fig 11-73) The wall thickening in UC is less than that in Crohn disease, has a layered appearance with increased deposition of submucosal fat, and has a smooth serosal surface Increased deposition of fat limited to the perirectal space is more typical of UC, although it does not have extraluminal or mesenteric changes, such as abscess or fibrofatty proliferation UC results in a lead pipe appearance with narrowing and shortening of the colon Crohn disease typically maintains the normal haustral pattern Patients with IBD have an increased risk of colorectal cancer, but the risk is much greater in UC MRI is used in diagnosing and evaluating Crohn disease (173) Disease activity is best correlated with bowel wall enhancement after IV gadolinium administration (222) MR enteroclysis is showing promising results (222) in the evaluation of disease activity and extramucosal extent MRI is well established as the imaging method of choice in the evaluation of perianal disease in Crohn colitis (151,210) It can accurately evaluate the location of fistulous tracts relative to the levator ani muscles, which is important in surgical planning The Parks classification of fistulae is the most widely accepted terminology and helps surgeons plan their approach (215) MRI is able to differentiate between fistula and fibrous scar, unlike CT Scar tissue is hypointense on T1-, T2-, and proton density–weighted sequences Fistulae are hyperintense on T2- and proton density-weighted sequences MRI is useful for evaluating the fistulae relative to the sphincter and levator muscles Contrast is not necessary for discrimination of fistulae MRI is also useful in the assessment of fistula-in-ano and pilonidal sinus disease (87,253,264) Endoluminal coils are limited in the evaluation of perianal disease compared to a stan- dard phased-array body coil because of decreased field-ofview (86) Ischemic colitis is most commonly due to small vessel disease and not occlusion of the superior mesenteric artery or vein The most common locations affected by ischemia include the splenic flexure, which is the watershed region between the superior and inferior mesenteric arteries, and the rectosigmoid colon, the watershed region at the junction of the inferior mesenteric and inferior hypogastric arteries Complications of ischemic colitis include infarction (Fig 11-75), perforation, and stricture (13) On CT, there is segmental wall thickening that may have a heterogeneous or layered appearance Pneumatosis in this setting is an ominous sign of infarction Otherwise, the initial CT findings cannot predict development of complications Pseudomembranous colitis is most commonly caused by Clostridium difficile in the setting of antibiotic therapy CT findings include marked, low-density mural thickening, a nonspecific finding of colitis (119) Pericolonic stranding and ascites can be present A nodular pattern of fold thickening with an accordion appearance of the haustral folds was originally described in pseudomembranous colitis, but it has been seen to occur in any severe colitis (175) The accordion appearance occurs because high-density contrast material insinuates between the severely thickened lowdensity edematous folds (Fig 11-76) However, this finding may not be present (25) Additionally, CT imaging may be normal in patients with pseudomembranous colitis (25) The positive predictive value of CT in the setting of suspected pseudomembranous colitis is high, 88%, and warrants initiation of medical treatment (136) Although rare, CT cannot predict when surgical intervention is needed (120) Neutropenic enterocolitis, referred to as typhlitis when limited to the cecum, occurs in neutropenic patients and has nonspecific imaging features of colitis (Fig 11-77) Its etiology is unclear but is related to a breach in the mucosal layer with subsequent bacterial invasion It has been shown to also involve the small bowel (138), and typically it is associated with pericolonic fluid CT is the study of choice in this setting because of the risk of perforation with endoscopy and barium enema (102) Neutropenic enterocolitis must be differentiated from GVHD, another abnormality that is sometimes present in patients who are immunocompromised GVHD produces luminal narrowing and mucosal enhancement but less colonic wall thickening (138) Other infectious colitidies include CMV, Salmonella, Shigella, and E coli The imaging appearance of these infections is nonspecific, but deep ulcerations in the setting of an immune-compromised patient with colitis should raise the suspicion of CMV (203) Bloody diarrhea is commonly seen in CMV colitis, whereas watery diarrhea prevails in pseudomembranous colitis Toxic megacolon is a complication that can be seen with any colitis, but it most commonly occurs in the setting of UC It presents with marked colonic distension and is a risk for 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 819 Gastrointestinal Tract 819 C * B A Figure 11-75 Colonic perforation secondary to necrosis 47-year-old woman with extensive vascular disease and multiple prior vascular bypass grafts presented with abdominal pain and vomiting A: There is a large abscess in the right flank (asterisk) It contains gas and oral contrast material and displaces the hepatic flexure medially (C) There is concentric mural thickening in the descending colon, which is dilated and fluid-filled No pneumatosis is seen B: Slightly more caudal images reveal a perforation in the ascending colon with a stream of oral contrast material (arrow) spilling into the abscess An ileocolectomy was performed for frank necrosis secondary to ischemia perforation Patients with this condition are systemically ill, but the severity of illness can be masked in patients receiving steroids There is an overlap in the imaging findings between toxic megacolon and severe colitis Both have marked wall thickening in a layered pattern, pericolonic inflammation, and ascites However, the possibility of toxic megacolon should be entertained when there is luminal distension, to 10 cm, of the entire colon and distortion of the haustral fold pattern in the setting of systemic sepsis (110) Radiation colitis can occur within a few weeks or many years after the exposure It is most commonly imaged in the chronic stage, where there is luminal narrowing and circumferential wall thickening (Fig 11-78) These findings are most commonly seen in the pelvis after radiation therapy for cervical or prostate cancer The perirectal fat is increased and may contain fibrous strands Primary epiploic appendagitis occurs with infarction of one of the colonic fatty appendages It occurs as a result of thrombosis or torsion, is self-limiting, and does not necessitate surgical intervention On CT, epiploic appendagitis appears as a round or oblong fatty mass, to cm in size, located lateral or anterior to the colon (Fig 11-79) There are variable surrounding mild inflammatory changes There may be a central band or dot This is thought to be a vein or fibrous septum (199,229) Omental fat necrosis has a similar appearance on CT, but the lesion is typically larger, less well defined, and located anterior or medial to the colon (Fig 11-80) Figure 11-76 Pseudomembranous colitis There is severe lowdensity mural thickening of the transverse colon The positive oral contrast material (arrows) is insinuating between grossly edematous colonic folds in an accordion-like fashion 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 820 820 Chapter 11 B A Figure 11-77 Neutropenic colitis of the right colon in a 54-year-old man undergoing chemotherapy for lung cancer A: There is concentric mural thickening in the hepatic flexure The wall thickening is severe (arrows) and low-density Also noted is adjacent fluid B: Image through the cecum demonstrates mural edema and pericolonic inflammation Miscellaneous CT is well suited for the evaluation of colonic obstruction It not only identifies the point of obstruction but can also determine the etiology Primary tumors appear as a mass with concentric annular narrowing Serosal implants or hematogenous metastases are more eccentric in location In cecal volvulus, the cecum is markedly dilated and lies most often in the left-upper quadrant (Fig 11-81) There is small bowel obstruction Sigmoid volvulus has a markedly enlarged sigmoid colon that usually projects in the right-upper quadrant or mid epigastrium, and there is distal colonic obstruction Both may have a whirl appearance of the mesenteric vessels S B A Figure 11-78 Radiation proctitis, colitis, and enteritis 43-year-old woman status post–external beam radiation for cervical cancer A: Multiple small-bowel loops in the central pelvis have mural thickening (arrow) with a layered, hyperenhancing appearance from the submucosal edema The sigmoid (S) is diffusely thickened and low density B: Similar changes are seen in the rectum (arrow) with layered mural edema There is also presacral edema 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 821 Gastrointestinal Tract * 821 B Figure 11-79 Epiploic appendagitis There is an oblong fatdensity mass anterolateral to the ascending colon (arrow) Also present is a thin soft-tissue ring and mild inflammatory change Figure 11-80 Omental fat necrosis A fat-density mass with a Pneumatosis cystoides intestinalis is a benign condition in which multiple cysts containing gas are seen in the wall of the colon and less commonly in the small bowel This condition can be idiopathic and is associated with pulmonary and connective tissue diseases The cysts can rupture, causing a benign pneumoperitoneum CT Colonography peripheral soft-tissue ring lies adjacent to the deformed bladder (B) This is larger than the typical epiploic appendicitis There is a large postsurgical flank hernia from prior renal transplant (asterisk) CT colonography (CTC) is a new addition to the colorectal cancer screening armamentarium and is showing great promise Patients must undergo a routine bowel cleansing Magnesium citrate or phospho-soda is preferred over polyethylene glycol, which results in too much residual C A B Figure 11-81 Cecal volvulus A: The dilated cecum with air-fluid level occupies the left abdomen There is small-bowel obstruction indicated by multiple dilated loops in the right abdomen Mesenteric vessels are congested (arrow), and (B) there is a whirled configuration of the mesenteric root (arrow) 5063_Lee_Ch11pp0771-0828 10/13/05 3:00 PM Page 822 822 Chapter 11 151 findings were considered highly important, e.g., they revealed potential malignancy, aneurysm, and so on (92) They thus generated additional tests for the patients This is not only a morbidity issue for the patient, but there are cost and medical-legal implications Very early studies with MR colonography are under way Both liquid enemas and various gas agents are being evaluated for luminal distension REFERENCES Figure 11-82 15-mm sigmoid polyp (arrow) on supine axial source image from CT colonography examination This polyp was confirmed at endoscopy colonic fluid (177) A fecal tagging agent can be administered for days preceding the study; this has been shown to improve specificity and decrease interpretation time (162) The colon is insufflated with room air or CO2, and thin-section (2- to 3-mm) contiguous slices are performed through the entire colon Both prone and supine positions are used to improve distension and provide comparable views to confirm pathology (38,67,285) Initial studies indicate intravenous glucagon is probably not necessary (200,285) A meta-analysis of the first fourteen published clinical series evaluating CTC performance found a sensitivity on a per-patient basis of 86% for polyps greater than or equal to 10 mm (Fig 11-82) (252) On a per-polyp basis, sensitivity was 80% with a specificity of 81% Because CTC is still in its early stages of development and refinement, a single optimal protocol has yet to be established Techniques used in the initial CTC studies varied, as did their individual results In the largest and most recent trial that included 300 patients, sensitivities on a per-patient and per-polyp basis for polyps greater than or equal to 10 mm were 100% and 90%, respectively (283) CTC is better tolerated by patients than either barium enema or colonoscopy (79,257,265), which will hopefully improve compliance with screening recommendations Computeraided diagnosis (CAD) is currently undergoing evaluation and may have a role in polyp detection (256,287) CAD is able to offer a second opinion or a double reading It is hoped that this will improve sensitivity as well as decrease interpretation time As with all CT screening examinations, CTC commonly identifies extracolonic, incidental abnormalities The majority 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