Diseases of the Abdomen and Pelvis 2023-2026: Diagnostic Imaging

286 Pages·2023·26.165 MB·English

by  Juerg Hodler, Rahel A. Kubik-Huch, Justus E. Roos, Gustav K. von Schulthess

IDKD Springer Series
Series Editors: Juerg Hodler · Rahel A. Kubik-Huch · Gustav K. von Schulthess
Juerg Hodler
Rahel A. Kubik-Huch
Justus E. Roos
Gustav K. von Schulthess Editors
Diseases of the
Abdomen and Pelvis
2023–2026
Diagnostic Imaging
IDKD Springer Series
Series Editors
Juerg Hodler
Prof. Emeritus of Radiology
University of Zürich
Zurich, Switzerland
Rahel A. Kubik-Huch
Department of Radiology
Kantonsspital Baden
Baden, Switzerland
Gustav K. von Schulthess
Prof. and Dir. Emeritus Nuclear Medicine
University Hospital
Zurich, Switzerland
The world-renowned International Diagnostic Course in Davos (IDKD) represents a unique
learning experience for imaging specialists in training as well as for experienced radiologists
and clinicians. IDKD reinforces his role of educator offering to the scientific community tools
of both basic knowledge and clinical practice. Aim of this Series, based on the faculty of the
Davos Course and now launched as open access publication, is to provide a periodically
renewed update on the current state of the art and the latest developments in the field of organ-
based imaging (chest, neuro, MSK, and abdominal).
Juerg Hodler • Rahel A. Kubik-Huch
Justus E. Roos • Gustav K. von Schulthess
Editors
Diseases of the Abdomen
and Pelvis 2023-2026
Diagnostic Imaging
Editors
Juerg Hodler Rahel A. Kubik-Huch
Prof. Emeritus of Radiology Department of Radiology
University of Zürich Kantonsspital Baden
Zurich, Switzerland Baden, Aargau, Switzerland
Justus E. Roos Gustav K. von Schulthess
Department of Radiology Prof. and Dir. Emeritus Nuclear Medicine
Luzerner Kantonsspital University Hospital of Zurich
Lucerne, Switzerland Zurich, Switzerland
Foundation for the Advancement of Education in Medical Radiology
ISSN 2523-7829 ISSN 2523-7837 (electronic)
IDKD Springer Series
ISBN 978-3-031-27354-4 ISBN 978-3-031-27355-1 (eBook)
https://doi.org/10.1007/978-3-031-27355-1
© The Editor(s) (if applicable) and The Author(s) 2023. This book is an open access publication.
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Contents
1 Emergency Radiology of the Abdomen and Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . 1
Vincent M. Mellnick and Pierre-Alexandre Poletti
2 Imaging Infectious Disease of the Abdomen (Including COVID-19) . . . . . . . . . . . 15
Rubal Rai, Ramandeep Singh, Peter F. Hahn, Avinash Kambadakone,
and Richard M. Gore
3 Advances in Molecular Imaging and Therapy and Its Impact
in Oncologic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Irene A. Burger and Thomas A. Hope
4 Benign and Malignant Diseases of the Colon and Rectum . . . . . . . . . . . . . . . . . . . 47
Ulrike Attenberger and Inês Santiago
5 Indeterminate Retroperitoneal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Christina Messiou and Wolfgang G. Kunz
6 Diffuse Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
David Bowden and Cäcilia S. Reiner
7 Focal Liver Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Wolfgang Schima and Dow-Mu Koh
8 Diseases of the Gallbladder and the Biliary Tree . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Richard K. Do and Daniel T. Boll
9 Diseases of the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
Thomas K. Helmberger and Riccardo Manfredi
10 Adrenal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Isaac R. Francis and William W. Mayo-Smith
11 Benign and Malignant Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153
Lejla Aganovic and Dominik Nörenberg
12 Imaging Features of Immunotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
Atul B. Shinagare and Ghaneh Fananapazir
13 Benign Disease of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
Helen Addley and Fiona Fennessy
14 Malignant Diseases of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
Yulia Lakhman and Evis Sala
15 Adnexal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199
Sarah Swift and Sungmin Woo
16 Magnetic Resonance Imaging of the Prostate in the PI-RADS Era . . . . . . . . . . . .211
Alberto Vargas, Patrick Asbach, and Bernd Hamm
v
vi Contents
17 Pathways for the Spread of Disease in the Abdomen and Pelvis . . . . . . . . . . . . . .229
James A. Brink and Brent J. Wagner
18 Small Bowel: The Last Stronghold of Gastrointestinal Radiology . . . . . . . . . . . . .241
Moriyah Naama and Pablo R. Ros
19 Small Bowel Disease: An Approach to Optimise Imaging Technique
and Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253
Damian J. M. Tolan
20 Congenital and Acquired Pathologies of the Pediatric Gastrointestinal Tract . . .267
Laura S. Kox, Anne M. J. B. Smets, and Thierry A. G. M. Huisman
21 Congenital and Acquired Pathologies of the Pediatric Urogenital Tract . . . . . . . .277
Erich Sorantin and Damien Grattan-Smith
Emergency Radiology of the Abdomen 1
and Pelvis
Vincent M. Mellnick and Pierre-Alexandre Poletti
1.1 Trauma Part 1.1.1 R ole of Imaging to Assess Blunt
Abdominal Polytrauma (BAT) Patients
Pierre-Alexandre Poletti
1.1.1.1 P rimary Survey
In a patient admitted with a potential abdominal trauma, a
Learning Objectives normal clinical examination has been shown insufficient per
• To review the role and limitations of the various se to rule out a major intra-abdominal injury [1]. An imaging
imaging modalities in the management of blunt method should therefore be systematically obtained. Based
abdominal trauma patients. on the ATLS recommendations [2], a FAST (focused assess-
• To review the imaging findings associated with ment with sonography for trauma) is immediately performed,
blunt abdominal trauma. in addition to pelvic X-Ray, for the initial triage of trauma
• To discuss the role of imaging in the grading sys- patients. Six regions are classically examined at FAST: right
tems used for the management of blunt abdominal upper quadrant, hepatorenal fossa (Morison’s pouch), left
trauma patients. upper quadrant (subphrenic space), splenorenal recess, pel-
vis (Douglas recess), and pericardium.
Depiction of a large amount of free intraperitoneal fluid
in a hemodynamically unstable patient will mandate imme-
Key Points diate laparotomy, or CT examination in a stable patient. In a
• Absence of free intraperitoneal fluid at FAST exam- hemodynamically stable patient, a normal FAST examina-
ination does not rule out a major traumatic visceral tion along with a normal clinical examination are not suf-
injury. ficient to rule out a significant intra-abdominal injury [3].
• Abdominal CT protocols must include both arterial Indeed, in addition to the well-known limitation of the clini-
and porto-venous phases; they should be completed cal abdominal examination up to 34% of abdominal injury
by delayed series if vascular or urinary tract injuries could be present without associated free fluid, 17% of them
are seen on initial series. would eventually require surgery or angiography embo-
• Splenic post-traumatic pseudoaneurysms mandate lization [4]. Furthermore, FAST examination can miss a
angiographic embolization; they may develop major retroperitoneal bleeding. In isolated minor abdomi-
24–72 h after trauma. nal trauma, there is no unanimously accepted criteria for
systematically performing or not CT in the absence of free
intraperitoneal fluid at FAST. It has been suggested that the
addition of normal bedside imaging (chest and pelvis X-ray,
FAST) normal blood tests and a normal clinical examination
V. M. Mellnick (*) could be sufficient to safely discharge an alert patient with-
Mallinckrodt Institute of Radiology, Washington University School
out further observation or investigation [3]. However, only a
of Medicine, Saint Louis, MO, USA
e-mail: [email protected] minority of patients (<20%) with suspicion of blunt abdomi-
nal trauma fulfill these criteria. All other should undergo fur-
P.-A. Poletti
Service of Radiology, University Hospital Geneva, ther investigations.
Geneva, Switzerland
e-mail: [email protected]
© The Author(s) 2023 1
J. Hodler et al. (eds.), Diseases of the Abdomen and Pelvis 2023-2026, IDKD Springer Series,
https://doi.org/10.1007/978-3-031-27355-1_1
2 V. M. Mellnick and P.-A. Poletti
1.1.1.2 Secondary Survey only based on morphological criteria, was completed by a
Abdominal CT imaging in a hemodynamically stable patient CT-based classification initially proposed by Stuart Mirvis
is usually obtained in the frame of a total body CT protocol [11] and slightly reshuffled in 2018 [12]. This classifica-
(secondary survey). In spite of the fact that there is no con- tion takes into account vascular lesions (pseudoaneurysms,
sensus regarding an optimal CT protocol for polytrauma arteriovenous fistula or active bleedings) confined within
patients, most authors agree that unenhanced abdominal CT the spleen (Fig. 1.1) and those extending beyond the spleen
images are not recommended, and that arterial and portal (active bleeding). Vascular splenic lesions appear at CT as
venous phase should be systematically obtained for a better focal blush of contrast with an attenuation close to arteries
depiction of vascular lesions, using either two acquisitions and greater than that of the spleen parenchyma. Delayed CT
[5] or one single acquisition with a split contrast bolus. images must be systematically obtained in the presence of a
Delayed series should systematically be obtained in case of vascular lesion to differentiate those that vanishes (pseudoa-
suspicion of active bleeding on the initial series. neurysms and arteriovenous fistula) from those which stay
and expand (active bleeding).
Imaging of Common Abdominal Traumatic Injuries Whether a systematic follow-up imaging patients should
Intraperitoneal Fluid be performed in hemodynamically stable blunt splenic
Hemoperitoneum is the commonest CT sign to suggest an trauma patients remains a yet unsolved question. It has been
intra-abdominal organ injury. Rarely, hemoperitoneum can reported that a majority of traumatic splenic pseudoaneuryms
be associated to retroperitoneal organ traumatic lesions, clas- (38%–74%) would only be detected on control CT performed
sically kidney injuries (or pancreatic tail injuries) by fluid within 24–72 h after admission [13]. For practical reasons,
spreading through the splenorenal ligament. In the absence most of the trauma associations do not recommend a system-
of active bleeding, hemoperitoneum has a density between atic delayed CT in hemodynamically stable splenic trauma
20 and 40 HU. At the direct contact of the lesion, clotted patients. With a reported 75% sensitivity and 100% specificity
blood achieves a higher density (50–70 HU) which is referred for detection of delayed splenic pseudoaneurysms (in skilled
to as the “sentinel clot sign.” This sign if often useful to iden- hands), bedside contrast enhanced sonographic examination
tify the actual site of injury [6]. Free fluid without evident has been advocated as a good option in this setting [14].
organ injury may be present at CT in 1–5% of trauma patients
and does not always herald need for surgery. Liver Injuries
The AAST liver injury classification, as well as its adaptation
Organ Injuries for CT proposed by Stuart Mirvis in 1989, were based on the
In a consecutive series of trauma patients with positive CT anatomic disruption of the liver, including the length and
for at least one intra-abdominal injury [7] the following depth of the lacerations, as well as the size of the subcapsular
organ were involved, by order of frequency: spleen (37%), hematoma.
liver (32%), urinary tract (15%), bowel and mesentery Most of liver injuries, including high AAST grade lesions
(11%), pancreas (3%), diaphragm (<1%). (III–V), can be managed non-operatively in hemodynami-
Spleen Injuries
Spleen is the most frequently encountered organ injury in
blunt abdominal trauma patients. Most splenic injuries can
be treated conservatively, in the absence of absolute clini-
cal indication for surgery at admission. However, delayed
failure of nonsurgical treatment (bleeding) has been for-
merly reported in 10–31% of cases [8] and may occur up to
10 days (or even later) after trauma. A major improvement
in the non-operative management of blunt splenic trauma
patients was achieved when two major observations were
reported in the scientific literature. Firstly, an association
was established between the presence of intrasplenic vascu-
lar injuries at CT and an increased risk of delayed bleeding
[9]. Secondly, the angiographic embolization of these vas-
cular injuries has been associated with a significant drop in
Fig. 1.1 AAST Grade IV splenic injury. A 41-year-old man admitted
the rate of unsuccessful non-operative management (from
after a motor vehicle collision. Axial contrast enhanced CT image, arte-
13% to 6%) [10]. Based on these observations, the classi-
rial phase, shows a blush of contrast media (arrow) within a splenic
cal AAST-1994 surgical splenic injury scale classification, hypodense laceration, consistent with an arterial pseudoaneurysm
1 Emergency Radiology of the Abdomen and Pelvis 3
cally stable patients. In 2018, the AAST-based liver grading bladder rupture. Thus, a CT cystography should complete
system has been updated in a new organ injury scaling (OIS). the initial CT series in the presence of a pelvic rim fracture,
The major change of the 2018 OIS is the inclusion of vascu- ideally by instilling at least 250 mL of diluted contrast media
lar lesions, confined in the liver parenchyma or freely bleed- into the bladder. This technique has been reported 95% sen-
ing into the peritoneum, to define severity. Such lesions are sitive and 99% specific to detect a bladder rupture. It should
seen in about 20% of blunt liver trauma patients. not be performed if the patient requires angiography since the
The most common ominous CT signs to be considered extravasated contrast material can obscure the sites of bleed-
predictive of failure of non-operative management are the ing. Extravasation of vesical contrast material in the extra-
presence of an extracapsular bleeding into the peritoneal peritoneal tissues, including the prevesical space of Retzius,
cavity, the extension of the laceration into the major hepatic is characteristic of extraperitoneal bladder rupture [17]. This
veins or vena cava, and the presence of an important hemo- is the most frequent type (80%) of bladder rupture in adult
peritoneum [15, 16]. Systematic routine follow-up CT is not patients, which can be treated by transurethral or suprapubic
recommended in blunt liver trauma patients; repeated imag- bladder catheterization. Spreading of contrast media into the
ing should only be guided by a patient’s clinical status. Bile peritoneal recesses is the hallmark of intraperitoneal bladder
duct injuries (biloma, biliary fistula, bile leak) have been rupture, which account for about 20% of cases [17]. They
reported as a complication in 2–8% of blunt liver trauma require surgical repair to avoid peritonitis (Fig. 1.3). Rarely,
patients. MRI with biliary specific contrast agent may be both intra- and extraperitoneal bladder ruptures may coexist.
used to identify the involvement of a main bile duct which
could mandate surgical management. CT or ultrasound fol- Bowel and Mesenteric Injuries
low- up examination can be recommended in case of clini- CT signs of bowel and mesenteric injuries may be subtle and
cal suspicion of liver abscess that complicate liver trauma in often require a meticulous analysis for not being overlooked.
about 4% of cases. Delay in assessing the diagnosis of these conditions is asso-
ciated with a high morbidity due to peritonitis, sepsis, hem-
Urinary Tract Injuries orrhage, or bowel ischemia. Most traumatic bowel injuries
Urinary tract injuries are usually, but not always, associated involve the small bowel, especially the proximal jejunum
with a gross hematuria. CT examination is the reference and the distal ileum. The transverse colon is the most fre-
standard for the evaluation of the urinary tract. Arterial quent site of large bowel traumatic injuries. Some CT signs
phases are important to demonstrate vascular kidney injuries of bowel injuries are usually very specific but few sensitive
while portal venous phases will better show parenchymal to assess the diagnosis of bowel rupture: discontinuity of the
damage and differentiate an active bleeding from a pseudoa- bowel wall (rare), intra- or retroperitoneal air without other
neurysm. The AAST classification for renal injuries has been reason to explain this air, segmental absence of enhancement
slightly revised in 2018. Grade I to III renal injuries, the vast (devascularization). Some nonspecific signs, such as seg-
majority (75–98%) of renal traumatic lesions, do not involve mental bowel thickening or free intraperitoneal fluid, unex-
the collecting system and are managed non-operatively. Any plained by a solid organ injury, should alert for a potential
vascular injuries, including active bleeding, confined within bowel perforation.
the Gerota fascia are still considered grade III. Grade IV However, an extended diffuse small bowel circumferen-
injuries extend into the collecting system or involve segmen- tial hyper-enhanced wall thickening is more suggestive of a
tal renal vein or artery injuries (active bleeding or thrombo- shock bowel syndrome (hypoperfusion complex), especially
sis) (Fig. 1.2). Grade 5 injuries refer to avulsion of the main in the presence of a flat vena cava, enhanced adrenal grands,
renal artery or vein, a devascularized kidney with active and delayed nephrograms. A diffuse small bowel wall thick-
bleeding or an extended maceration with loss of identifiable ening (without hyperenhancement), along with a dilated
parenchyma. Surgical treatment or angiographic therapeutic vena cava, is classically observed after a vigorous resuscita-
management may be indicated in grade IV and V injuries. tion (volume overload). An update of the AAST-bowel and
Any attempt of reperfusion of a devascularized kidney mesentery classification, including the recent advances in
should be performed within 5 h after trauma to avoid irre- CT imaging has been recently released [18].
versible ischemic damages. If a bowel injury is clinically suspected in the absence of
Ureteral injury is exceedingly rare in blunt trauma and CT clear CT signs of bowel rupture, a follow-up CT can be per-
signs may be very subtle, such as mild periureteral fluid or formed 4–6 h later, after admission of i.v. and oral contrast to
fat stranding. A 3–20 min delayed excretory phase series are look for an extravasation of intra-intestinal contrast material.
required to make the definitive diagnosis of partial or com- CT signs suggestive of mesenteric injuries consist in an
plete ureteral tear. active extravasation of contrast media from mesenteric ves-
Bladder injuries are associated with pelvic fractures in sels (Fig. 1.4), a mesenteric hematoma adjacent to a bowel
90% of cases, while about 2–11% of pelvic fracture have wall thickening (devascularization), an abrupt termination (or