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Zaheer Raman

FOURTH EDITION

Atif Zaheer, MD

Professor of Radiology and Radiological Science

Program Director, Cross-Sectional Imaging Fellowship

Johns Hopkins University School of Medicine Baltimore, Maryland

Siva P. Raman, MD

Bay Imaging Consultants Walnut Creek, California

ADDITIONAL CONTRIBUTORS

Amir A. Borhani, MD

Michael P. Federle, MD, FACR

Gabriela Gayer, MD

Mitchell Tublin, MD

Elsevier

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

DIAGNOSTIC IMAGING: GASTROINTESTINAL, FOURTH EDITION

Copyright © 2022 by Elsevier. All rights reserved.

ISBN: 978-0-323-82498 -9

Inkling: 978-0-323-82500 -9

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2015.

Library of Congress Control Number: 2021936776

Printed in Canada by Friesens, Altona, Manitoba, Canada

Dedications

To the light of knowledge, Sparked by my grandfather, Protected by my father, Nurtured by my mother, Supported by my wife, Fueled by my teachers and students, Encouraged by my friends, To be conveyed to my sons Asad and Ali, And all doctors, present and future AZ

To my wife, Janani, my son, Jay, and my daughter, Mina, who have supported me in all my endeavors. SPR

Preface

The 4th edition of Diagnostic Imaging: Gastrointestinal continues and expands upon what has made the series so popular among radiologists and learners over the past 20 years. This edition, like previous versions, utilizes the classic style of bulleted text, allowing us to present factual material in a condensed manner with greater clarity and readability compared to traditional prose textbooks. Our chapters present everything you need to know about the multimodality imaging findings for each entity (as described by experts with years of high-level subject matter expertise), in addition to detailed descriptions of the clinical presentation and treatment of each diagnosis. Each chapter also continues to provide lists of the most important differential diagnoses for a given entity, allowing the reader to reference other specific chapters on the most likely candidates and quickly arrive at an accurate and specific diagnosis. In addition to the material provided in the printed textbook, we have also placed a wealth of information (including additional text, images, and references) in Elsevier’s advanced eBook, which accompanies the print version of the book.

All that being said, although this version of the book preserves all that has made the Diagnostic Imaging series of textbooks so beloved by readers over the last 2 decades, this new edition contains a wealth of new material that will appeal to both experienced subspecialty radiologists looking for specific detailed information as well as newcomers seeking to learn the basics of the field. As MRI has taken on a greater role in the world of abdominal and pelvic imaging, we have continued to expand the focus on abdominal and pelvic MRI in this book, including chapters detailing the fundamentals of evaluating perianal fistulas, the staging of rectal cancer utilizing pelvic MRI, and the diagnosis of various liver and pancreatic lesions using abdominal MRI. In addition, we have updated and replaced many of the images from the 3rd edition, maintaining only the very best images from previous versions and incorporating a large number of beautiful new images with a special focus on abdominal and pelvic MRI. All references and text have been updated as well, with all material being current to within a few months of the publication date of this book. Moreover, as the literature and field have evolved, we have included a number of new assessment and management criteria that have become more prevalent and widely used in the field of abdominal imaging since the prior edition, including the LI-RADS criteria for hepatocellular carcinoma; the Fukuoka guidelines for pancreatic intraductal papillary mucinous neoplasms; treatment response assessment; and MRI quantification of iron, fat, and fibrosis, etc.

The rapid preparation of this book was made possible in part by limiting the primary authorship to 2 experienced and highly motivated authors who took responsibility for writing the entirety of the book’s nearly 300 chapters. The book contains not only a summary of the most relevant literature in the field, but also benefits from the authors’ own perspectives and experiences acquired during their clinical careers.

We hope that this new edition of Diagnostic Imaging: Gastrointestinal will be a welcome addition to your library as a quick reference for anything and everything.

Atif Zaheer, MD

Professor of Radiology and Radiological Science

Program Director, Cross-Sectional Imaging Fellowship

Johns Hopkins University School of Medicine

Baltimore, Maryland

Siva P. Raman, MD

Bay Imaging Consultants

Walnut Creek, California

Acknowledgments

LEAD EDITOR

Nina Themann, BA

LEAD ILLUSTRATOR

Richard Coombs, MS

TEXT EDITORS

Arthur G. Gelsinger, MA

Rebecca L. Bluth, BA

Terry W. Ferrell, MS

Megg Morin, BA

Kathryn Watkins, BA

IMAGE EDITORS

Jeffrey J. Marmorstone, BS

Lisa A. M. Steadman, BS

ILLUSTRATIONS

Lane R. Bennion, MS

Laura C. Wissler, MA

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS

Emily C. Fassett, BA

John Pecorelli, BS

Sections

SECTION 1:

Abdominal Manifestations of Systemic Conditions

SECTION 2:

Peritoneum, Mesentery, and Abdominal Wall

SECTION 3: Esophagus

SECTION 4: Stomach

SECTION 5: Duodenum

SECTION 6: Small Intestine

SECTION 7: Colon

SECTION 8: Spleen

SECTION 9: Liver

SECTION 10: Biliary System

SECTION 11: Pancreas

TABLEOFCONTENTS

SECTION1:ABDOMINAL MANIFESTATIONSOFSYSTEMIC CONDITIONS

INTRODUCTIONANDOVERVIEW

4ImagingApproachtoAbdominalManifestationsof SystemicConditions

AtifZaheer,MDandMichaelP.Federle,MD,FACR INFECTION

8HIV/AIDS

SivaP.Raman,MD

12Tuberculosis

SivaP.Raman,MD

16Mononucleosis

SivaP.Raman,MD

METABOLICORINHERITED

18CysticFibrosis

SivaP.Raman,MD

22SickleCellAnemia

SivaP.Raman,MD

26Amyloidosis

SivaP.Raman,MD

28Sarcoidosis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

VASCULARDISORDERS

34SystemicHypotension

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

36SuperiorVenaCavaObstruction

SivaP.Raman,MD

38Vasculitis

SivaP.Raman,MD TRAUMA

42ForeignBodies

SivaP.Raman,MD

48Barotrauma

SivaP.Raman,MDandAmirA.Borhani,MD

TRANSPLANTATION

50PosttransplantLymphoproliferativeDisorder

SivaP.Raman,MD

MALIGNANTNEOPLASMS

54LeukemiaandLymphoma

SivaP.Raman,MD

60MetastaticMelanoma

SivaP.Raman,MD

64KaposiSarcoma

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

66TreatmentResponseAssessment

AtifZaheer,MD

SECTION2:PERITONEUM,MESENTERY, ANDABDOMINALWALL

INTRODUCTIONANDOVERVIEW

72ImagingApproachtoPeritoneum,Mesentery,and AbdominalWall

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFECTION

76AbdominalAbscess

SivaP.Raman,MD

INFLAMMATION

80Peritonitis

SivaP.Raman,MD

84SclerosingMesenteritis

SivaP.Raman,MD

DEGENERATIVE

88Ascites

SivaP.Raman,MD

92OmentalInfarct

SivaP.Raman,MD

EXTERNALHERNIAS

96InguinalHernia

SivaP.Raman,MD

100FemoralHernia

SivaP.Raman,MD

102ObturatorHernia

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

104VentralHernia

SivaP.Raman,MD

105SpigelianHernia

SivaP.Raman,MD

106LumbarHernia

SivaP.Raman,MDandAmirA.Borhani,MD

107UmbilicalHernia

SivaP.Raman,MDandAmirA.Borhani,MD

INTERNALHERNIAS

108ParaduodenalHernia

SivaP.Raman,MD

TABLEOFCONTENTS

112TransmesentericPostoperativeHernia

SivaP.Raman,MD

116BochdalekHernia

SivaP.Raman,MD

117MorgagniHernia

SivaP.Raman,MD

VASCULARDISORDERS

118PortalHypertensionandVarices

SivaP.Raman,MD

122VisceralAneurysmsandPseudoaneurysms

AtifZaheer,MD

TRAUMA

126TraumaticAbdominalWallHernia

SivaP.Raman,MD

128TraumaticDiaphragmaticRupture

SivaP.Raman,MD

TREATMENTRELATED

132PostoperativeState,Abdomen

SivaP.Raman,MD

134AbdominalIncisionandInjectionSites

SivaP.Raman,MD

138PeritonealInclusionCyst

SivaP.Raman,MD

BENIGNNEOPLASMS

140Lymphangioma(MesentericCyst)

SivaP.Raman,MD

144Desmoid

SivaP.Raman,MD

MALIGNANTNEOPLASMS

148AbdominalMesothelioma

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

152PeritonealMetastases

SivaP.Raman,MD

156PseudomyxomaPeritonei

SivaP.Raman,MD

MISCELLANEOUS

160EventrationandParalysisofDiaphragm

SivaP.Raman,MD

161VicariousExcretion

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

SECTION3:ESOPHAGUS

INTRODUCTIONANDOVERVIEW

164ImagingApproachtoEsophagus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFECTION

170 CandidaEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

172ViralEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

173ChagasDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFLAMMATION

174RefluxEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

178BarrettEsophagus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

180CausticEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

182Drug-InducedEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

183RadiationEsophagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

184EosinophilicEsophagitis

AtifZaheer,MD

185EpidermolysisandPemphigoid

AtifZaheer,MDandMichaelP.Federle,MD,FACR

DEGENERATIVE

186EsophagealWebs

AtifZaheer,MDandMichaelP.Federle,MD,FACR

187CricopharyngealAchalasia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

188EsophagealAchalasia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

192EsophagealMotilityDisturbances

AtifZaheer,MDandMichaelP.Federle,MD,FACR

196EsophagealScleroderma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

200SchatzkiRing

AtifZaheer,MDandMichaelP.Federle,MD,FACR

202HiatalHernia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

VASCULARDISORDERS

206EsophagealVarices

AtifZaheer,MDandMichaelP.Federle,MD,FACR

ESOPHAGEALDIVERTICULA

210ZenkerDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

214IntramuralPseudodiverticulosis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

216TractionDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

217PulsionDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TRAUMA

218EsophagealForeignBody

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TABLEOFCONTENTS

220EsophagealPerforation

AtifZaheer,MDandMichaelP.Federle,MD,FACR

224BoerhaaveSyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TREATMENTRELATED

226Esophagectomy:IvorLewisandOtherProcedures

AtifZaheer,MD

BENIGNNEOPLASMS

232IntramuralBenignEsophagealTumors

AtifZaheer,MDandMichaelP.Federle,MD,FACR

234FibrovascularPolyp

AtifZaheer,MD

235EsophagealInflammatoryPolyp

AtifZaheer,MDandMichaelP.Federle,MD,FACR

MALIGNANTNEOPLASMS

236EsophagealCarcinoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

240EsophagealMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION4:STOMACH

INTRODUCTIONANDOVERVIEW

244ImagingApproachtoStomach

AtifZaheer,MDandMichaelP.Federle,MD,FACR

CONGENITAL

250GastricDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFLAMMATION

252Gastritis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

256GastricUlcer

AtifZaheer,MDandMichaelP.Federle,MD,FACR

260Zollinger-EllisonSyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

264MénétrierDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

266CausticGastroduodenalInjury

AtifZaheer,MDandMichaelP.Federle,MD,FACR

DEGENERATIVE

267Gastroparesis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

268GastricBezoar

AtifZaheer,MDandMichaelP.Federle,MD,FACR

270GastricVolvulus

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

TREATMENTRELATED

276IatrogenicInjury:FeedingTubes

AtifZaheer,MDandMichaelP.Federle,MD,FACR

278PartialGastrectomy:BillrothProcedures

AtifZaheer,MDandMichaelP.Federle,MD,FACR

280FundoplicationComplications

AtifZaheer,MDandMichaelP.Federle,MD,FACR

286ImagingofBariatricSurgery

AtifZaheer,MDandMichaelP.Federle,MD,FACR

BENIGNNEOPLASMS

292GastricPolyps

AtifZaheer,MDandMichaelP.Federle,MD,FACR

296IntramuralBenignGastricTumors

AtifZaheer,MD

MALIGNANTNEOPLASMS

300GastrointestinalStromalTumor(GIST)

AtifZaheer,MD

304GastricCarcinoma

AtifZaheer,MD

310GastricMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION5:DUODENUM

INTRODUCTIONANDOVERVIEW

316ImagingApproachtoDuodenum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

NORMALVARIANTSANDARTIFACTS

320DuodenalFlexurePseudotumor

AtifZaheer,MDandMichaelP.Federle,MD,FACR

321ProminentDuodenalAmpullaMimickingMass

AtifZaheer,MD

CONGENITAL

322DuodenalDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFLAMMATION

324Duodenitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

326DuodenalUlcer

AtifZaheer,MDandMichaelP.Federle,MD,FACR

330BrunnerGlandHyperplasia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

VASCULARDISORDERS

332SMASyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TRAUMA

334GastroduodenalTrauma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TREATMENTRELATED

336AortoentericFistula

AtifZaheer,MDandMichaelP.Federle,MD,FACR

BENIGNNEOPLASMS

338DuodenalPolyps

TABLEOFCONTENTS

AtifZaheer,MDandMichaelP.Federle,MD,FACR

MALIGNANTNEOPLASMS

342DuodenalCarcinoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

346DuodenalMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION6:SMALLINTESTINE

INTRODUCTIONANDOVERVIEW

350ImagingApproachtoSmallIntestine

AtifZaheer,MDandMichaelP.Federle,MD,FACR

CONGENITAL

356Malrotation

AtifZaheer,MDandMichaelP.Federle,MD,FACR

358DuplicationCyst

AtifZaheer,MDandMichaelP.Federle,MD,FACR

359SmallBowelDiverticula

AtifZaheer,MDandMichaelP.Federle,MD,FACR

360MeckelDiverticulum

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFECTION

364MesentericAdenitisandEnteritis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

366IntestinalParasitesandInfestation

AtifZaheer,MDandMichaelP.Federle,MD,FACR

368OpportunisticIntestinalInfections

AtifZaheer,MD

INFLAMMATION

372Celiac-SprueDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

376WhippleDisease

SivaP.Raman,MD

377Mastocytosis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

378CrohnDisease

AtifZaheer,MD

384IntestinalScleroderma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

388Intestinal(Angioneurotic)Angioedema

AtifZaheer,MDandMichaelP.Federle,MD,FACR

390SmallBowelNSAIDStricture

AtifZaheer,MDandMichaelP.Federle,MD,FACR

METABOLICORINHERITED

392IntestinalLymphangiectasia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

DEGENERATIVE

394Ileus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

396SmallBowelObstruction

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

402PneumatosisofIntestine

AtifZaheer,MDandMichaelP.Federle,MD,FACR

406Intussusception

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

410MalabsorptionConditions

AtifZaheer,MDandMichaelP.Federle,MD,FACR

411GallstoneIleus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

412EntericandPerianalFistulaeandSinusTracts

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

VASCULARDISORDERS

420IschemicEnteritis

AtifZaheer,MD

TRAUMA

424MesentericandSmallBowelTrauma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TREATMENTRELATED

430PostoperativeState,Bowel

AtifZaheer,MDandMichaelP.Federle,MD,FACR

434RadiationEnteritisandColitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TRANSPLANTATION

438SmallIntestineTransplantation

AtifZaheer,MDandMichaelP.Federle,MD,FACR

BENIGNNEOPLASMS

442Intramural(Mesenchymal)IntestinalTumors

AtifZaheer,MDandMichaelP.Federle,MD,FACR

443IleocecalValveLipomaandLipomatousInfiltration

AtifZaheer,MDandMichaelP.Federle,MD,FACR

444HamartomatousPolyposisSyndromes

AtifZaheer,MDandMichaelP.Federle,MD,FACR

MALIGNANTNEOPLASMS

446CarcinoidTumor

AtifZaheer,MD

450SmallBowelCarcinoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

452IntestinalMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

456IntestinalGIST

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION7:COLON

INTRODUCTIONANDOVERVIEW

460ImagingApproachtoColon

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFECTION

466InfectiousColitis

TABLEOFCONTENTS

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

472NeutropenicColitis(Typhlitis)

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFLAMMATIONANDISCHEMIA

474UlcerativeColitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

478ToxicMegacolon

AtifZaheer,MDandMichaelP.Federle,MD,FACR

482IschemicColitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

486Appendicitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

492MucoceleofAppendix

AtifZaheer,MD

496ColonicDiverticulosis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

500Diverticulitis

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

506EpiploicAppendagitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

DEGENERATIVE

510SigmoidVolvulus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

514CecalVolvulus

AtifZaheer,MDandMichaelP.Federle,MD,FACR

516ColonicIleusandOgilvieSyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

520FecalImpactionandStercoralUlceration

AtifZaheer,MDandMichaelP.Federle,MD,FACR

521RectalProlapseandIntussusception

AtifZaheer,MD

TRAUMA

522ColorectalTrauma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

BENIGNNEOPLASMS

524TailgutCyst

AtifZaheer,MD

526ColonicPolyps

SivaP.Raman,MD

530VillousAdenoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

MALIGNANTNEOPLASMS

534ColonCarcinoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

540RectalCarcinoma

AtifZaheer,MD

546FamilialAdenomatousPolyposis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

552AppendicealTumors

AtifZaheer,MDandMichaelP.Federle,MD,FACR

553ColonicMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION8:SPLEEN

INTRODUCTIONANDOVERVIEW

556ImagingApproachtoSpleen

AtifZaheer,MDandMichaelP.Federle,MD,FACR

NORMALVARIANTSANDARTIFACTS

560AccessorySpleen

SivaP.Raman,MD

CONGENITAL

562AspleniaandPolysplenia

SivaP.Raman,MD

INFECTION

566SplenicInfectionandAbscess

SivaP.Raman,MD

DEGENERATIVE

570SplenomegalyandHypersplenism

SivaP.Raman,MD

VASCULARDISORDERS

574SplenicInfarction

SivaP.Raman,MD

TRAUMA

578SplenicTrauma

SivaP.Raman,MD

582Splenosis

SivaP.Raman,MD

BENIGNNEOPLASMS

584SplenicCyst

SivaP.Raman,MD

586PrimarySplenicTumors

SivaP.Raman,MD

MALIGNANTNEOPLASMS

590SplenicMetastasesandLymphoma

SivaP.Raman,MD

SECTION9:LIVER

INTRODUCTIONANDOVERVIEW

596ImagingApproachtoLiver

AtifZaheer,MDandMichaelP.Federle,MD,FACR

CONGENITAL

602CongenitalHepaticFibrosis

AtifZaheer,MD

TABLEOFCONTENTS

606ADPolycysticLiverDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

610VariantVascularandBiliaryAnatomyofLiver

AtifZaheer,MD

INFECTION

614HepaticPyogenicAbscess

AtifZaheer,MDandMichaelP.Federle,MD,FACR

618HepaticTBandFungalInfections

AtifZaheer,MD

622HepaticAmebicAbscess

AtifZaheer,MDandMichaelP.Federle,MD,FACR

626HepaticHydatidCyst

AtifZaheer,MDandMichaelP.Federle,MD,FACR

630HepaticSchistosomiasis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

634ViralHepatitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

INFLAMMATION

640AlcoholicLiverDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

644AutoimmuneHepatitis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

646SteatosisandSteatohepatitis

AtifZaheer,MD

652HepaticInjuryFromToxins

AtifZaheer,MDandMichaelP.Federle,MD,FACR

656Cirrhosis

AtifZaheer,MD

660PrimaryBiliaryCholangitis

AtifZaheer,MD

666FocalConfluentFibrosis

AtifZaheer,MD

670NodularRegenerativeHyperplasia

AtifZaheer,MDandMichaelP.Federle,MD,FACR

676RegenerativeandDysplasticNodules

AtifZaheer,MDandMichaelP.Federle,MD,FACR

684SolitaryNecroticNodule

AtifZaheer,MDandMichaelP.Federle,MD,FACR

685PeribiliaryCysts

AtifZaheer,MDandMichaelP.Federle,MD,FACR

METABOLICORINHERITED

686GlycogenStorageDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

688Hemochromatosis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

692WilsonDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

DEGENERATIVE

696Hepatomegaly

AtifZaheer,MDandMichaelP.Federle,MD,FACR

VASCULARDISORDERS

698TransientHepaticAttenuationorIntensity

Difference(THADsandTHIDs)

AtifZaheer,MDandMichaelP.Federle,MD,FACR

704ArterioportalShunt

AtifZaheer,MDandMichaelP.Federle,MD,FACR

708PortalVeinOcclusion

AtifZaheer,MDandMichaelP.Federle,MD,FACR

714PassiveHepaticCongestion

AtifZaheer,MDandMichaelP.Federle,MD,FACR

718Budd-ChiariSyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

724VenoocclusiveDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

726HepaticInfarction

AtifZaheer,MDandMichaelP.Federle,MD,FACR

730PeliosisHepatis

AtifZaheer,MDandMichaelP.Federle,MD,FACR

734HereditaryHemorrhagicTelangiectasia

AtifZaheer,MD

740HELLPSyndrome

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TRAUMA

744HepaticTrauma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TREATMENTRELATED

748Radiation-InducedLiverDisease

AtifZaheer,MDandMichaelP.Federle,MD,FACR

752PostoperativeChanges,Liver

AtifZaheer,MDandMichaelP.Federle,MD,FACR

756TransjugularIntrahepaticPortosystemicShunt(TIPS)

AtifZaheer,MDandMichaelP.Federle,MD,FACR

762HepaticTransplantation

AtifZaheer,MDandMichaelP.Federle,MD,FACR

BENIGNNEOPLASMSANDTUMOR-LIKE CONDITIONS

772HepaticCyst

AtifZaheer,MDandMichaelP.Federle,MD,FACR

780HepaticCavernousHemangioma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

788FocalNodularHyperplasia

AtifZaheer,MD,GabrielaGayer,MD,andMichaelP. Federle,MD,FACR

794HepaticAdenoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

802BiliaryHamartoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

806HepaticAngiomyolipoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

810HepaticInflammatoryPseudotumor

AtifZaheer,MDandMichaelP.Federle,MD,FACR

TABLEOFCONTENTS

MALIGNANTNEOPLASMS

814HepatocellularCarcinoma

AtifZaheer,MD

822FibrolamellarCarcinoma

AtifZaheer,MD

828Peripheral(Intrahepatic)Cholangiocarcinoma

MichaelP.Federle,MD,FACR

834EpithelioidHemangioendothelioma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

840BiliaryCystadenocarcinoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

846HepaticAngiosarcoma

AtifZaheer,MD

850UndifferentiatedSarcoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

852HepaticMetastasesandLymphoma

AtifZaheer,MDandMichaelP.Federle,MD,FACR

SECTION10:BILIARYSYSTEM

INTRODUCTIONANDOVERVIEW

862ImagingApproachtoBiliarySystem

AtifZaheer,MDandMichaelP.Federle,MD,FACR

NORMALVARIANTSANDARTIFACTS

870BiliaryNormalVariantsandArtifacts

SivaP.Raman,MD

CONGENITAL

874CongenitalAbnormalitiesofGallbladder

SivaP.Raman,MD

878CaroliDisease

SivaP.Raman,MD

882CholedochalCyst

SivaP.Raman,MD

INFECTION

888RecurrentPyogenicCholangitis

SivaP.Raman,MD

892AscendingCholangitis

SivaP.Raman,MD

896PancreatobiliaryParasites

SivaP.Raman,MD

900AIDSCholangiopathy

SivaP.Raman,MD

902GallbladderHydropsandEmpyema

SivaP.Raman,MD

INFLAMMATION

906GallstonesandSludge

SivaP.Raman,MD

912AcuteCalculousCholecystitis

SivaP.Raman,MD

916AcalculousCholecystitis

SivaP.Raman,MD

920XanthogranulomatousCholecystitis

SivaP.Raman,MDandMitchellTublin,MD

924EmphysematousCholecystitis

SivaP.Raman,MD

928MirizziSyndrome

SivaP.Raman,MD

932HyperplasticCholecystoses

SivaP.Raman,MD

936PorcelainGallbladder

SivaP.Raman,MD

938MilkofCalciumBile

SivaP.Raman,MDandMitchellTublin,MD

940Autoimmune(IgG4)Cholangitis

SivaP.Raman,MD

944PrimarySclerosingCholangitis

SivaP.Raman,MD

DEGENERATIVE

948Biloma

SivaP.Raman,MD

VASCULARDISORDERS

952IschemicBileDuctInjury

SivaP.Raman,MD

TRAUMA

956BiliaryTrauma

SivaP.Raman,MD

TREATMENTRELATED

960Chemotherapy-InducedCholangitis

SivaP.Raman,MDandMitchellTublin,MD

BENIGNNEOPLASMSANDTUMOR-LIKE CONDITIONS

962GallbladderPolyps

SivaP.Raman,MD

MALIGNANTNEOPLASMS

966GallbladderCarcinoma

SivaP.Raman,MD

970AmpullaryCarcinoma

SivaP.Raman,MD

974BiliaryMetastasesandLymphoma

SivaP.Raman,MD

975BiliaryPapillomatosis

SivaP.Raman,MDandMitchellTublin,MD

976BiliaryIPMN

SivaP.Raman,MD

SECTION11:PANCREAS

INTRODUCTIONANDOVERVIEW

982ImagingApproachtoPancreas

AtifZaheer,MDandMichaelP.Federle,MD,FACR

CONGENITAL

990AgenesisofDorsalPancreas

SivaP.Raman,MD

991AnnularPancreas

SivaP.Raman,MD

992PancreasDivisum

SivaP.Raman,MD

TABLEOFCONTENTS

996AsymmetricFattyLobulationofPancreas

SivaP.Raman,MD

998EctopicPancreaticTissue

SivaP.Raman,MD

INFLAMMATION

1000AcutePancreatitisandComplications

SivaP.Raman,MD

1010ChronicPancreatitis

SivaP.Raman,MD

1016GroovePancreatitis

SivaP.Raman,MD

1020Autoimmune(IgG4)Pancreatitis

SivaP.Raman,MD

DEGENERATIVE

1026PancreaticLipomatousPseudohypertrophy

SivaP.Raman,MDandMichaelP.Federle,MD,FACR

TRAUMA

1028PancreaticTrauma

SivaP.Raman,MD

TREATMENTRELATED

1032PostoperativePancreas

SivaP.Raman,MD

1038PancreaticTransplantation

SivaP.Raman,MD

BENIGNNEOPLASMSANDTUMOR-LIKE CONDITIONS

1042PancreaticSerousCystadenoma

SivaP.Raman,MD

1048NonneoplasticPancreaticCysts

SivaP.Raman,MD

MALIGNANTNEOPLASMS

1052PancreaticDuctalCarcinoma

SivaP.Raman,MD

1060MucinousCysticPancreaticTumor

SivaP.Raman,MD

1066PancreaticIPMN

SivaP.Raman,MD

1072PancreaticNeuroendocrineTumors

SivaP.Raman,MD

1078PancreaticSolidandPseudopapillaryNeoplasm

SivaP.Raman,MD

1082PancreaticMetastasesandLymphoma

SivaP.Raman,MD

1086AtypicalandRarePancreaticTumors

SivaP.Raman,MD

Zaheer Raman

ImagingApproachtoAbdominalManifestationsofSystemicConditions

OrganizationalApproachtoAbdominal Diseases

Mostinformationaboutimagingabdominaldisorders, includingthegastrointestinalandgenitourinarysystems,fits neatlyintoanorgan-by-organframework.However,this approachmakesitdifficulttodiscussdiseasesorconditions withmanifestationsthroughouttheabdomenandbeyond. Forthisreason,someconditionsarebestdiscussedfroma systemicperspective.Doingsoprovidesamoreaccurate portrayaloftheseentitiesandavoidsunwantedredundancy. Becausemanysystemicdisordersaffectlymphnodegroups, neuralstructures,ormajorvesselsthroughouttheabdomen, medicalillustrationsprovideahelpfulreminder ofimportant anatomicalconsiderations.

Systemicinfections(includingAIDS,tuberculosis,and mononucleosis)arediscussed,alongwithimportantcluesto helpidentifytheinfectiousandneoplasticdiseasestheymay causeorsimulate.

Degenerativeconditions,suchassarcoidosisandvascular disorders,arerarelylimitedtoasingleorgan.Theseare presentedinalltheirguises,alongwithtipsastohowto addressdifferentialdiagnoses.

Foreignbodiesmaybeencounteredthroughoutthe gastrointestinalandgenitourinarysystemandarewell-known tobefoundrepeatedlyincertainindividuals.Keysto recognitiononimagingandavoidingcommonpitfallsare coveredhere.

Manymalignantneoplasmsare,bytheirverynature,systemic processes,suchaslymphoma,leukemia,andmalignant melanoma.Therefore,takingasystemicapproachtosuch diagnosesgivesustheopportunitytobringtogethersome generalprinciplesaboutthepresentation,diagnosis,and managementoftheseimportantdiseases.

Whilesomeconditions,suchassystemichypotensionor hypervolemia,donotrepresentdiseaseperse,theycanresult inimportantclinicalandimagingabnormalitiesthatmustbe recognizedtoavoidmisguidedpatientmanagement.

Finally,withthecontinuedevolutionofsystemicanticancer therapies,quantificationoftumorburdenusingimaging,such

(Left)CoronalvolumerenderedCTAshowstheentire commonhepaticarteryſt arisingfromthesuperior mesentericartery.Theleft gastricarteryalsohasa separateoriginfromthe aorta,thoughitisdifficultto perceiveonthisimage.The celiactrunkinthispatient consistsonlyofthesplenic artery.Congenitalvariations ofvascularanatomyarevery common.(Right)Obliqueview ofaCTAclearlyshowsthe originoftheaccessoryright hepaticarteryſtfromthe superiormesentericartery.

ascomputedtomography(CT)andmagneticresonance(MR), isincreasinglybeingusedtoassesstheeffectivenessof anticancerdrugs.Thisrequiresunifiedevaluationanddiseasespecifictreatmentresponsecriteriaarediscussedand comparedtoprovideapracticingradiologistanoverviewof themethodology.

ImagingModalities

Plainradiographymaintainsanimportantroleforsurveillance ofsomegeneralizeddiseaseprocesses,suchastheosseous andvisceralmanifestationsofsicklecellanemiaorcystic fibrosis.

Ultrasoundisanimportantimagingtoolfortheevaluationof biliary,vascular,gynecologic,andscrotalpathology,butitlacks bothsensitivityandspecificityinevaluatingotherprocesses, especiallybowelpathology.

CThasbecometheessentialtoolforthecomprehensive evaluationofmosttraumatic,inflammatory,andneoplastic abdominalprocesses.Inpatientswithcancer,forinstance,the abilitytoquicklyandaccuratelyexaminedifferentanatomic areas(thorax,abdomen,andpelvis),organs,andstructuresof differentcomposition(e.g.,lung,liver,andbone)isa tremendousadvantage.Thus,thereiscontinuedgrowthand popularityofCTeveninthiseraofpowerful"competing" modalities,suchaspositronemissiontomography(PET)and MRimaging.PETandMRimagingdoserveanimportantrole asproblem-solvingtoolsforevaluatingabdominalpathology. MR,withitsexcellentsofttissuecharacterization,is particularlyhelpfulinevaluatingmasseswithinsolid abdominalorgans.

Catheterangiographyremainsthemostaccuratemeansof identifyingcertainvasculardisordersandoftenresultsin catheter-basedtherapiesinthesamesetting.Forvasculitides, whichroutinelyaffectvesselsthroughoutthebody, angiographymaintainsanessentialdiagnosticandtherapeutic role.

ImagingApproachtoAbdominalManifestationsofSystemicConditions

Abdominal

Inferiorphrenicveins

Inferiorvenacava

Renalveins

Rightgonadalvein

Ascendinglumbarvein

Middlesacralvein

Adrenalveins

Ascendinglumbarvein

Externaliliacvein

Internaliliac(hypogastric)vein

Thoracicduct

Cisternachyli

Lumbartrunks(ofcisterna chyli)

Rightlumbar(retrocaval)node

Aortocavalnodes

Celiacnodes

Superiormesentericnodes

Intestinaltrunk(ofcisterna chyli)

Lumbar(paraaortic)nodes

Inferiormesentericnodes

Commoniliacnodes

Externaliliacnode

Internaliliac(hypogastric) nodes

(Top)Theinferiorvenacava(IVC)isformedbytheconfluenceofthecommoniliacveins,whichareformedbytheconfluenceofthe internalandexternaliliacveins.Notetheascendinglumbarveins,whichanastomosefreelybetweentheIVCandazygous,hemiazygos, andrenalveins.TheseformapathwayforcollateralflowintheeventofIVCobstructionandplayanimportantroleinthesystemic spreadofpelvictumorsandinfection.(Bottom)Themajorlymphaticsandlymphnodesoftheabdomenarelocatedalong,andshare thesamenameas,themajorbloodvessels.