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297 Cards in this Set

  • Front
  • Back
renal mass lesions
tumor
solid
cyst

infection
lobar nephronia
abscess
xgp

congenital
duplicated collecting system
pseudotumors
fetal lobulation
dromedary hump
column of bertin
suprahilar bump
lobar dysmorphism

Traum
hematoma
solid renal neoplasm
rcc
wilms
oncocytoma
adenoma
angiomyolipoma
transitional cell carcinoma of the renal pelvis or calyces
mets, lung colon melanoma rcc
lymphoma
cystic renal masses
tumors
cystic/necrotic rcc
multilocular rcc
cystic wilm's tumor

true cysts
cortical cysts
medullary cystic disease
adult polycystic kidney disease
cysts in systemic disease-vhl, ts
endstage renal failure
infectious cysts

other
hydronephrosis/duplicated
renal artery aneurysm
abscess
hyperechoic renal mass
angiomyolipoma
rcc
milk of calcium cyst
nephritis
xgp
emphysematous pyelonephritis
focal nephritis
candidiasis

hematoma
infarction
lesions that mimic
renal sinus fat
duplicated collecting system
renal sinus mass
tumors
tcc
rcc
lymphoma
bellini duct carcinoma

other
renal artery aneurysm
renal sinus hemorrhage
complicated parapelvic cyst
wedge shaped renal lesion
renal mets
infarction
lobar nephritis
diffusely hyperechoic kidneys
inflammation
glomerulonephritis
glomerulosclerosis-htn, dm
aids related nephropathy
interstitial nephritis: SLE, vasculitis

ATN
HUS
multipl myeloma
endstage renal disease
medullary or cortical nephrocalcinosis
infantile polycystic kidney disease
renal calcifications
tumors
cysts
rcc

infection
tb

metastatic calcification
medullary nephrocalcinosis
cortical nephrocalcinosis

collecting system
calculi
fat in kidney
angiomyolipoma
lipoma
replacement lipomatosis
hypoechoic perirenal fat
normal variant
perirenal hemorrhage (trauma, anticoagulants, adrenal hemorrhage)
cyst rupture
sle
polyarteritis nodosa
filling defect in colecting system
tumor
tcc
papilloma
leukoplakia, malakoplakia

mobile filling defect
blood clot
sloughed papilla
calculus
fungus ball

other
vascular impression, collateral vessels
artificial overlying bowel gas
papillary necrosis

POSTCARD
pyelonephritis
obstruction (chronic)
sickle cell disease
TB
cirrhosis, ethanol
analgesic, phenacetin
renal vein thrombosis
diabetes
delayed (persistent ) neprhogram (same ddx as renal failure))
prerenal (15%)
RAS
hypotension

renal (70%)
acute glomerulonephritis
ATN-radiodine, ab, anesthesia, ischemia, transplants
acute cortical necrosis-pregnancy related, sepsis, dehydration
tubular precipitation-uric acid, hemolysis, myeloma
acute interstitial nephritis-antibiotics
papillary necrosis-analgesic, sickle cell, DM
renal vein thrombosis

postrenal
obstruction-stone, stricture
extracalyceal contrast agent
striations
medullary sponge kidney
early papillary necrosis
pyelosinus or pyelovenous backflow in obstruction\
interstitial edema

focal collections
late papillary necrosis
calyceal diverticulum
cavity from cyst rupture
abcess
dilated calyces/collecting system
obstruction (calculi, tumor, acute, chronic)
papillary necrosis
congenital megacalyces
calyceal diverticulum
reflux
bilaterally enlarged kidneys
tumor
cystic diseaes (APCKD)
malignancy
leukemia
lymphoma
multiple myeloma

inflammation (acute)
glomerulonephritis
interstitial nephritis
collagen vascular disease
ATN

Metabolic
amyloid
DM
storage disease, acromegaly

Vasular
bilateral renal vein thrombosis
bilaterally small kidneys
chronic inflammation-pyelonephritis, glomerulonephritis, interstitial nephritis

bilateral RAS

reflux (chronic infection)
hypercalcemia

PAM SCHMIDT
parathyroid adenoma, hyperplasia

addison disease

milk alkali

sarcoid

carcinomatosis

hyperparathyroidism, secondary

myeloma

immobilization

D vitamin

thiazides
renal vein thrombosis
tumor
rcc
other-lymphoma, tcc, wilms
adrenal tumors
gonadal tumors
pancreatic carcinoma
extraluminal compression or renal vein by retroperitoneal tumors

renal disease (often with nephrotic syndrome)
membranous glomerulonephritis
SLE
amyloidosis

other
hypercoagulable states
extension of ovarian vein, IVC thrombosis
trauma, surgery
transplant rejection
dilated ureter due to obstruction
functional-primary megaureter

mechanical stensosis
ureteral stricture
bladder outlet obstruction
urethral stricture
dilated ureter secondary to reflux
other
diuresis
ureteral stricture

TIC MTV
tumor
tcc
mets
lymphadenopathy

inflammatory
tb-corkscrew appearance
schistosomiasis-compl. is scc
pelvic disease-chrohns, pid

congenital
ectopic ureterocele
primary megaureter
congenital stenosis

metabolic, drugs
morphine
methysergie, retroperitoneal fibrosis

trauma
iatrogenic
radiation

vascualr
aortic, iliac artery aneurysm
ovarian vein syndrome
lymphocele

other
endometriosis-smooth, extrinsic
stone
multiple ureteral filling defects
wall
ureteritis cystica
allergic mucosal bullae
pseudodiverticulosis
vascular impression
multiple papillomas
melanoma mets
subureotheliala hemorrhage

lulminal
calculi (lucent, opaque)
blood clot
sloughed papillae
fungus ball
air bubbles
ureteral diverticula
congenital
ureteritis cystica
tb
deviated ureters
lateral deviation
bulky retroperitoneal adenopathy
primary retroperitoneal tumors
aortic aneurysm
retroperitoneal fluid collection
malrotated kidney
ovarian/urterine masses

medial deviation
posterior bladder diverticulum
uterine fibroids
retroperitoneal fibrosis associated with aortic aneursym, methysergide, idiopathic, malignancy-related
postoperative (node dissxn)
enlarged prostate (j-shaped ureter)
retrocaval ureter (only on right)
bladder wall thickening
tumor
tcc
lymphoma

inflammation
radiation cystitis
infectious cystitis
inflammatory bowel disease, appendicitis, focal diverticulitis

outlet obstruction
benign prostatic hyperplasia
urethral stricture

neurogenic
bladder filling defect
tumor
primary-tcc, scc
mets
endometriosis
polyps

infection
pid
parasite infection-schistosomiasis
related to infection- leukoplakia, malakoplakia, cystitis cystica, cystitis glandularis

luminal
calculi
blood clot
foreign bodies
bph
bladder neoplasm
primary
tcc
scc
adenocarcinoma
pheochromocytoma from bladder wall
rare-rhabdomyosarcoma, leiyomyosarcoma, primary lymphoma

secondary
mets
hematogenous-melanoma>stomach>breast
direct ext-prostate>uterus>colon
lymphoma
bladder calculi
chronic bacterial infection
chronic bladder catheterization
bladder outlet obstructin
schistosomiasis
renal calculi
bladder wall calcification

SCRITT
schistosomiasis
cytoxan
radiation
interstitial cystitis
tb
tcc
air in bladder
instrumentation, catheter
bladder fistula-diverticulitis, crohn's, colon carcinoma
emphysematous cystitis
teardrop bladder
physiological
normal variant
iliopsoas hypertrophy
fluid
hematoma (usually pelvic fracture)
abcess
masses
pelvic lymphoma
pelvic lipomatosis
retroperitoneal fibrosis
the femal prostate
urethral diverticulum
urethral tumor
periurethritis
pubic bone lesion
adrenal masses
tumor
adenoma 50%
mets 30%
pheochromocytoma 10%
lymphoma
neuroblastom <2yo
fatty lesions
myelolipoma
lipoma
cystic tumors
simple cyst
pseudocyst after previous hemorrhage

other lesions
hemorrhage
tb
wolman's disease

bilateral masses
mets
lymphoma
bilateral pheochromocytoma in men 2, vhl, and neurofibromatosis
granulomatous masses-tb, histo
adrenal calcifications
tumor-neuroblastoma, pheochromocytoma
infection-tb, histo, waterhouse-friederichson syndrome
trauma-hemorrhage
congenital-wolamn's disease
adrenal pseudotumors

soft tissue density in location of adrenal glands on plain films
gastric fundus
accessory spleen
retroperitoneal varices
other lesions
liver mass
gallbladder mass
renal mass
by CT
gastric fundus or fundal diverticulum
varices
tortuous splenic artery
pancreatic tail
medial splenic lobulation
solid testicular masses
tumor
primary-germinal 95%, nongerminal 5%
mets-prostate, kidney, leukemia, lymphoma

infection
orchitis, abcess, granuloma

trauma-fracture, rupture, hemorrhage, torsion

other-atrophy, dilated rete testes
extratesticular abnormalities
epididymitis-diffuse or focal
spermatocele, epididymal cyst
hydrocele, hematocele, varicocele
tunical or mesothelial cyst
paratesticular hemorrhage, abcess
hernia
neoplasm (primary or mets)
benign-adenomatoid tumor, fibroma, leiomyoma
malignant-mesothelioma, sarcoma
prostate
cystic lesions
utricle cyst
cowper's duct cyst
ejaculatory duct cyst
prostatic retention cyst
seminal vesicle cyst
vas deferens cyst
mullerian duct cyst
hypoechoic structures in hyperechoic endometrium
premenopausal
molar pregnancy
retain placenta, abortus
degenerated placenta
degenerated fibroid

postmenopausal
cystic glandular hyperplasia
endometrial polyps
endometrail carcinoma
fluid in uterine cavity
acquired (cervical stenosis)
tumors-cervical cancer, endometrial cancer
inflammatory-endometritis, pid, radiation

pregnancy related
early iup
pseudogestational sac
blighted ovum

congenital
imperforate hymen
vaginal septum
vaginal atresia
rudimentary uterine horn
uterine enlargement or distortion
fibroids
adenomyosis
less common
congenital uterine anomalies
inflammation-pid, surgery
endometriosis
malignant tumors
uterine bleeding
endometrial hyperplasia or polyp
cancer
estrogen withdrawal
adenomyosis
submucosal fibroid
cervical cancer
small uterus
hypoplasia
nulliparity
synechiae
des exposure
large uterus
multiparity
pregnancy
molar pregnancy
neoplasm
uterine and vaginal cystic masses
nabothian cyst
gartners duct cyst (vaginal wall)
bartholin cyst-perineal cyst
hydrometrocolpos
shadowing structures in endometrial cavity
iud
calcifications from fibroids, tb
pyometra (gas)
ovarian cystic masses
normal cysts (physiological)
follicle, follicular cyst
corpus luteum cyst
too many follicles
polycystic ovary, hyperstimulation syndrome
theca lutein cyst (with high levels of bhcg)
cystic adnexal masses
hemorrhagic cyst
endometrioma
ectopic pregnancy
cystadenocarcinoma
toa
tube cyst
hydrosalpinx
other cysts
paraovarian cyst
fluid in cul-de-sac
pelvic varices
lymphocele
bowel
pelvic abcess
complex ovarian, paraovarian mass
ectopic pregnancy
toa
endometrioma, hemorrhagic cyst
ovarian torsion
tumor
benign-dermoid
malignant-adenocarcinoma
complex tubal mass
pyosalpinx
complex uterine mass
pedunculated fibroid
extruded IUD
endometrial, cervical carcinoma
other complex masses
pelvic abcess
appendicitis
diverticulitis
hematoma
pelvic kidneys
iliac aneurysm
masses with homogenous low-level echoes
TOA
endometrioma
hemorrhagic cyst
solid ovarian mass lesions
benign tumor-fibroma, thecoma, endometrioma, germ cell tumor

malignant ovarian tumors

mets

masses simulation ovarian tumor
pedunculated fibroid
lymphadenopathy
dilated tubes (hydrosalpinx, pyosalpinx, hematosalpinx)
infection
tumor-endometrial or tubal carcinoma
endometriosis
iatrogenic ligation
tubal filling defects (hsg)
polyp
neoplasm
silicone implant
tubal pregnancy
air bubble from injection
tubal irregularity
SIN
tubal diverticula
endometriosis
postoperative changes
TB
pseudokidney sign on US
inflammatory bowel disease
crohn's disease
infectious collitis
tumor
intussusception
always exclude pelvic kidney
luminal narrowing
webs
idiopathic
plummer vinson syndrome
rings
congenital-vascular, muscular rings
schatzki's ring
strictures
skin lesions (epidermolysis, pemphigoid), proximal 1/3 of esophagus
tumor
esophagitis (lye, barret's, infection)
achalasia, scleroderma, chagas

extrinsic compression
vascular aortic arch, arch anomalies, aneurysm, left atrium
left bronchus
mediastinal tumors
megaesophagus
achalasia
scleroderma
dilatation secondary to distal narrowing
tumor, stricture
chagas
diabetic or alcoholic neuropathy
bulbar palsy
esophageal tears (contrast extravavasation, fistula)
esophagitis
tumor
vomiting
mallory-weiss
boerhaaves
tracheoesophageal fistula
bronchopulmonary forgut malformation with communication to esophagus
bronchogenic cysts
extralobar sequestration
solitary filling defect
neoplasm
benign
leiomyoma 50%
pedunculated fibrovascular polyp
cysts, papilloma, fibroma, hemangioma

malignant
squamous cell carcinoma 95%
adenocarcinoma
carcinosarcoma
lymphoma
mets

foreign bodies
varices
uphill varices (phtn), predominantly inferior location
downhill varices (SVC obstruction), predominantly superior location

extrinsic lesions (lymph nodes, engorged vessels, aneurysms, cysts)
thickened folds
early forms of esophagitis
neoplasm
lymphoma
varicoid carcinoma
varices
air-fluid level
hiatal hernia
esophageal diverticulum
any esophageal lesion caused by a motility disorder or a stricture
cancer
achalasia
scleroderma
gastritis
erosive (corrosives, alcohol, stress, drugs)

granulomatous (crohns, sarcoid, syphillis, tb, histo)

eosinophilic (peripheral eosinophilia 60%, hypoalbuminemia, hypogammaglobulinemia, hyperplastic polyps)
hypertrophic gastritis
menetriers disease
ZE syndrome
idiopathic
recurrent gastric ulcer
ze syndrome
peptic ulcer disease
retained gastric antrum
drugs
miscellaneous
radiation (>4000 rad, 6 months to 2 years after)
ulcer
corrosives
rare
pseudolymphoma
suture line ulceration
intraarterial chemo
target lesions of stomach
gastritis (aphthoid type, tiny ulcer)
erosive-nsaid, alcohol
granulomatous-crohns
infections-candidiasis, herpes, syphillis, cmv

submucosal mets (lareg ulcer)
melanoma, kaposi's>>all others ie breast lung pancreas
lymphoma

solitary, giant bull's eye (very large ulcer)
leiomyoma
sarcoma
filling defect of stomach
neoplasm
adenocarcinoma
lymphoma
leiomyosarcoma
mets
kaposi's

others
endometriosis
carcinoid
benign tumors: leiomyoma>lipoma, fibroma, schwannoma
polyps
varices
extramedullary hematopoiesis
ectopic pancreas

extrinsic compression
spleen
pancreas
liver
giant rugal folds
tumor
lymphoma
inflammation
menetrier's disease
ze syndrome
gastritis associated with pancreatitis
bile reflux gastritis
eosinophilic gastroenteritis
linitis plastica
tumor
scirrhous cancer
lymphoma
mets (breast most common)
pancreatic carcinoma

inflammation
erosive gastritis
radiotherapy

infiltrative disease
sarcoid
amyloid (rare)
intramural gastric hematoma

infection
tb, syphillis
antral lesions
tumor
adenocarcinoma
lymphoma
mets

inflammatory
crohns
peptic ulcer disease
tb
sarcoid

other (less extensive)
hypertrophic pyloric stenosis
pylorospasm
antral web
free intraperitoneal air
surgery and laparoscopy and other radiologic interventions
perforated gastric or duodenal air
cecal perforation from colonic obstruction
pneumotosis coli
air through genital tract in females
perforated distal bowel (ie ibd, diverticulitis tumor)
duodenal filling defects
benign neoplasm
adenoma (<1cm)
leiomyoma
carcinoid
villous adenoma-near papilla, high malignant potential

malignant
adenocarcinoma at or distal to papilla
mets (direct invasion from stomach, pancreas, colon, kidney, etc. or hematgenous such as melanoma)

other

bulb
ectopic gastric mucosa
prolapsed antral mucosa
brunner gland hyperplasia
varices

distal
benign lymphoid hyperplasia
ectopic pancreas
annular pancreas
papilla of vater
tumor
edema with impacted or passed gallstone
choledochocele

malignancy of duodenal lesions based on location
-bulb 90% benign
-2nd and 3rd portion 50% malignant
-4th 90% malignant
luminal outpouchings
ulcer
ulcer with contained perf
malignant ulcer
diverticulum
pseudodiverticulum-ulcer scarring
choledochoduodenal or cholecystoduodenal fistula
true diverticulum medial, 2nd part of duodenum
postbulbar narrowing
neoplastic
adenocarcinoma
lymphoma
mets (direct invasion from colon, kidney, pancreas, gb)

inflammatory
intrinsic
posbulbar ulcer
duodenitis
crohns disease
extrinsic
pancreatitis

other
annular pancreas
intramural diverticulum
duodenal duplication cyst
duodenal hematoma
aortic aneurysm (3rd portion)
SMA syndrome
papillary enlargement
normal variant
choledochocele
papillary edema
pancreatitis
acute duodenal ulcer
impacted stone
ampullary cancer
adenomatous polyp
CA
paralytic ileus
postoperative (most common)

vascular
IBD
inflammatory (often localized)
pancreatitis
appendicitis
cholecystitis
diverticulitis
peritonitis

metabolic
hypokalemia
hypocalcemia
hypomagnesemia

medication
morphine, diphenoxylate
mechanical SBO
adhesions
hernias
tumors
gallstones
inflammation with strictures
predominantly thick, irregular small bowel folds

WAG CLEM
whipple's
amyloid
giardiasis (largerly jejunum, graft vs host, gammaglobulinopathy
cryptosporidiosis (jejunum)
lymphoma, lymphangiectasia, lactase deficiency
eosinophilic gastroenteritis
mycobacterium avium complex
predominantly dilated loops, normal folds

SOSO
sprue
obstruction or ileus
scleroderma
other
medication
morphine
lomotil
atropine
pro-banthine
vagotomy
thick folds without malabsorption (edema, tumor, hemorrhage)
diffuse uniformly thickened folds

focal: nodular thickening, analogous to thumbprinting
thick folds without malabsorption (edema, tumor, hemorrhage)
submucosal edema
ischemia
enteritis
infectious
radiation
hypoproteinemia
GVH reaction

submucosal tumor
lymphoma, leukemia
infiltrating carcinoid causing venous stasis

submucosal hemorrhage
henoch-schonlein disease
hemolytic uremic syndrome
coagulopathies (ie hemophilia, vitamin k, anticoagulants)
thrombocytopenia, DIC
mucosal nodules
mastocytosis
lymphoid hyperplasia
lymphoma
metastases
polyps
crohns disease
benign small bowel tumors
adenoma (most common)
leiyomyoma (second most common)
lipoma
hemangioma
neurogenic tumors (usually in neurofibromatosis)
other
brunner gland hyperplasia
heterotopic pancreatic tissue
malignant small bowel tumors
metastases
melanoma
kidney
breast
kaposi
lymphoma
carcinoid (most common primary, 50% malignant and have mets at dx)
sarcoma(sarcomatous degen of benign tumors such as leiomyosarcoma, lymphosarcoma) usually large ulcerating tumors
adenocarcinoma
mesenteric bowel ischemia
occlusive disease
emboli (afib, ventricular aneurysm)
arterial thrombosis (atherosclerosis)
venous thrombosis (portal hypertension, pancreatitis, tumor)

nonocclusive disease (low flow)
hypotension
hypovolemia
shortened bowel transit time
anxiety
hyperthyroidism
medication
metoclopramide
neostigmine
quinidine
metacholine
partial SBO
colonic mass lesions
nonneoplastic polypoid abnormalities of the colon
normal lymphofollicular pattern
pneumatosis coli
colitis cystica profunda
amyloidosis
endometriosis
ischemic colitis
polyps
polyposis syndromes
benign neoplasm
lipoma (common)
leiomyoma (rare)
malignant neoplasm
adenocarcinoma
mets
lymphoma
polyps
hyperplastic polyps (90%)
not true tumors
no malignant potential
adenomatous polyps (2nd most common)
true tumors
malignant transformation
types
tubular
viloous
tubulovillous
hamartomatous polyps (rare; peutz-jeghers syndrome)
colonic ulcers
aphthoid ulcers (superficial)
crohns disaese (50%)
amebiasis
behcet's syndrome
cmv
herpes

deep ulcers
inflammatory colitis
UC
crohns
behcets
infectious
amebiasis
tb
salmonella
shigella
histoplasmosis
AIDS, candida, herpes, cmv

ischemic colitis
radiation colitis
colonic bowel wall thickening (thumbprinting)

due to edema, tumor, or hemorrhage, luminal indentations size of thumb
edema
infectious colitis
pseudomembranous colitis
cmv colitis
ecoli, shigella, salmonella, amebiasis
neutropenic colitis (typhlitis)
ibd

tumor
lymphoma, leukemia

hemorrhage
ischemia
henoch-schonlein disease, thrombocytopenia, dic
coagulopathies (ie hemophilia, vitamin k, anticoagulants)
tumorlike colonic deformity
tumor
adenocarcinoma
saddle shapped if asym
apple core if circum
mets (common serosal implants-gastric, ovarian)

inflammation
diverticulitis
focal inflammation
ibd
infectious: ameboma, tb

other
endometriosis
pelvic abscess
epiploic appendagitis
long (>10cm) colonic narrowing
scirrhous adenocarcinoma
lymphoma
UC w or w/o ca
crohns
ischemic stricture
radiation
ahaustral colon
cathartic abuse (often right)
uc, crohns
amebiasis
aging (usually left)
colonic obstruction
carcinoma 65%
diverticulitis 20%
volvulus 5%
other
impaction
hernia
megacolon

abnormally distended transverse colon (>6cm); most commonly used with toxic megacolon
toxic megacolon (haustral deformity, pseudopolyps, risk of perf, systemic signs)
uc, crohns
infectious-amebiasis, shigellosis, clostridium difficile

acute colonic distention
obstructive cancer
paralytic ileus
volvulus

chronic megacolon (no or small risk of perf)
cathartic
colonic pseudoobstruction (ogilvie's syndrome, colonic ileus)
psychogenic
congenital (hirschsprungs)
chagas
neuromuscular disorders
parksonism
diabetes
scleroderma
amyloid
metabolic, drugs
hypothyroidism
electrolyte imbalances
adult intussusception
ileoileal (40%)>ileocolic (15%)>others

idiopathic 20%
tumors 35%
polyps, lipoma 25%
malignant tumors (mets, lymphoma, carcinoid), 10%

other
meckel's diverticulum
adhesions
aberrant pancreas
pneumatosis coli
pneumatosis cystoides
copd
patients on vent
mucosal injury (rectal tube, colonoscopy, surgery)
scleroderma
steroids
chemotherapy

pneumatosis intestinalis
infarcted bowel
necrotizing enterocolitis
toxic megacolon
typhilitis
chrohns disease
apthous ulcers->linear fissures->nodules->cobblestone->strictures->spasm (string sign), fistula
ulcerative colitis
valve wide open, labia atrophied, terminal ileum dilated
amebiasis
predominantly affects cecum, not terminal ileum
TB
narrow cecum (fleischner sign), narrow crohns may produce same appearance, terminal ileum (stierlins sign)
typhlitis
inflammatory changes of cecum and/or ascending colon in neutropenic patients; caused by infection, bleeding, ischemia
ileocecal deformities due to tumor
lymphoma
adenocarcinoma
carcinoid of ileum (desmoplastic response) or appendix
intussusception
proctitis
condylomata acuminata
lymphogranuloma venereum
gonococcal proctitis
uc, crohns
liver masses
solid masses
neoplasm
benign: hemangioma
malignant: primary, secondary
focal fatty liver (pseudotumor)
regenerating nodules in cirrhosis

cystic masss
infectious
echinococcus
amebiasis
other abscesses
benign masses
simple liver cysts
polycystic disease of liver
biliary cystadenoma
ostructed intrahepatic GB
malignant masses
cystadenocarcinoma
cystic metastases ovarian tumors
necrotic tumors
cholangiocarcinoma
increased liver density
hemachromatosis
glycogen storage disease
wilson's disease
drugs-amiodarone, cisplatin
apparent increased density of liver parenchyma in patients with anemia
decreased liver density
fatty liver (comon)
obesity, nutritional
alcohol
diabetes
steroids
chemotherapy
hypervascular liver lesions
hemangioma
hemangioendothelioma, hemangiopericytoma, angiosarcoma (all rare), intarhepatic cholangiocarcinoma
metastases
islet cell
melanoma
carcinoid
renal cell cancer
thyroid
breast
sarcoma
hyperechoic liver lesions
round livers
hemangioma
hyperechoic liver mets
hypervascular mets, sarcoma
calcified mets
primary liver tumors (contain fat)
hcc
fibrolamellar hcc
focal fat, lipoma, aml in ts
gaucher's disease

linear lesions
air in biliary tree
air in portal vein
biliary ascariasis
multiple hypoechoic liver lesions
tumor
mets
lymphoma
multifocal hcc

infection
multiple pyogenic abscesses
amebic abscesses
echinococcus
candidiasis
schistosomiasis
other
regenerating nodules, cirrhosis
sarcoid
extramedullary hematopoiesis
hematomas
hemangioma
gas in liver
biliary gas (ercp, surgery, central)
portal venous gas (bowel necrosis, diverticulitis, peripheral)
emphysematous cholecystitis
extrahepatic biliary dilatation
intrapancreatic obstruction (most common)
pancreatic cancer
calculus
chronic pancreatitis
suprapancreatic
primary biliary ductal carcinoma
metastatic lymph node
portal
invasive GB carcinoma
surgical strictures
hepatoma
cholangiocarcinoma
types of biliary obstruction
tumor
abrupt termination of duct
mass adjacent to duct
pancreatitis
smooth, long tapering
lithiasis related disease
calculus visible
meniscus sign and intrahepatic dilatating
cholangitis
sclerosing cholangitis (50% have us)
aids cholangitis
intrahepatic biliary calculi (oriental cholangiohepatitis)
caroli's disease
intrahepatic biliary neoplasm (rare)
cystadenoma
cystadenocarcinoma
ultrasound signs of intrahepatic biliary dilatation
collor dopple flow absent in dilated ducts
acoustic enhancement behind dilated ducts; blood, in contrast attenuates acoustic beam
double duct sign-dilated biliary vessel accopanies portal veins
caliber irregularity and tortuosity of dilated ducts; veins are always smooth and taper gradually
spoke-wheel appearance at points of conversion of ducts
diffuse (concentric) gb wall thickening in order of decreaseing frequency
nonfasting gb
acute cholecystitis (50-75% have thickening)
chronic cholecystitis (<25% have thickening)
portal hypertension
hypoalbuminemia (<2.5 g/dl)
hepatitis
AIDS (cryptosporidiosis, cmv, mai)
ascites
benign ascites-gb wall thickening
malignant ascites-no gb wall thickening
focal (eccentric) gb wall thickening
gb carcinoma (40% present with focal thickening)
mets (melanoma >> gastric, pancreas)
benign tumors
polyps (cholesterol, adenomatous)
adenomyomatosis
tumefactive sludge adherent to wall
AIDS
hyperechoic foci in gb wall
calculus
polyp
cholesterol
emphysematous cholecystitis
porcelain gb
dense gb on ct
hepatobiliary (vicarious excretion of contrast material)
calculi
milk of calcium bile
reflux of oral contrast agent after surgery
oral cholecystogram
hemorrhage (hematocrit effect)
focal pancreatic signal abnormality
focal hypoechoic or hypodense pancreatic lesion
tumor
focal pancreatitis
adenopathy
cystic pancreatic lesions
neoplasm
benign
microcystic adenoma aka serous cystadenoma
(pre) malignant
mucinous cystadenoma
mucinous cystadenocarcinoma
ductic ectatic mucinous cystadenocarcinoma iPMT
epithelial

cyst
simple cyst
pseudo cyst
VHL
duct ectasia
hyperechoic pancreas
cystic fibrosis
pancreatic lipomatosis
focal splenic lesions
tumor
mets-lymphoma, melanoma, ovary
hemangioma
lymphangioma
hamartoma
rare lesions-myxoma, chondroma, osteoma, hemangiosarcoma, fibrosarcoma

infection (often ca++)
abcess
candidiasis (common in aids)
tb, mai
schistosomiasis
pneumocystitis carinii

other
infarcts
hematoma (trauma)
cysts-simple, hyatid
fatty nodules in gauchers disease
splenomegaly
tumor
leukemia
lymphoma
infection
infectious mononucleosis
histoplasmosis
metabolic disorders
gauchers
amyloid
hemochromatosis
trauma
vascular
portal hypertension
hematological disorders (anemias, sickle cell, thalassemia, myelofibrosis, myelosclerosis)
peritoneal fluid collections
water density
ascites
urinoma
biloma
seroma
lymphocele
pancreatic pseudocyst
csf from vp shunt
complex
abcess
hematoma
pseudomyxoma peritonei
pancreatic necrosis
intraperitoneal calcifications
arterial calcification
appendicolith
mesenteric node
cholelithiasis
pancreatic calcification
porcelain gb
renal/ureteral calculi
old hematoma, abscess
uterine leiomyoma
fetal skeletal part
pelvic phlebolith
teratoma
liver-echinococcal cyst
common gastrointestinal manifestations caused by AIDS
infection
cmv
candida
herpes
cryptococcus
MAI
tumor
kaposi
lymphoma
common gi manifestations of AIDS by organ system
esophagus
ulcers-candida, cmv, herpes
sinus tracts-tb, actinomycosis
proximal small bowel
ulcers-cryptococcosis
nodules-kaposis sarcoma, mai
distal small bowel
enteritis-tb, mai, cmv
colon
colitis-cmv, pseudomembranous colitis
typhilitis
biliary
strictures-cmv, cryptococcosis
abdominal trauma
injuries in decreasing order of frequency
liver laceration
splenic laceration
renal trauma
bowel hematoma
pancreatic fracture
rare-gb injury, adrenal hemorrhage
abdominal calcifications after cardiac surgery

0.2-2%, complications related to ischemia (ie intraoperative hypotension, hemorrhage, vasculopathy, emboli, clotting abnormalities)
gi hemorrhage 50%
cholecystitis (emphysematous, acalculous, or calculous) 20%
pancreatitis 10%
perforated peptic ulcer 10%
mesenteric ischemia 5%
perforated diveritcular disease 5%
feline esophagus
horizontal corrugations on upper GI

reflux
scleroderma
esophageal stricture
common causes

esophageal cancer
peptic stricture
corrosive ingestion
esophageal diveritculum
zenkers-cervical esophagus in killians triangle

epiphrenic-most are pulsion, treated with resection and myotomy
achalasia
distal spastic narrowing, esophageal dilatation, long air filled esophagus on cxr, +/- absent gastric air bubble

bird's beak, disordered motility on barium

ddx-colonic interposition
scleroderma
dilated patulous esophagus

patulous ge junction

free reflux

adynamic
esophagitis
common causes
reflux
corrive ingestion
candida and herpes in immunocompromised

barium swallow-ragged mucosa, +/- discrete ulcers
food bolus impactin
acute dysphagia with obstructing filling defect

effervescent agents and/or muscle relaxants may help
diffuse esophageal spasm
motility disorder-spastic contractions

test with manometry, medical treatment

corkscrew/nutcracker appearance on barium
linitis plastica
diffuse narrowing and loss of pliability of stomach

leather bottle stomach

causes
infiltrative gastric cancer
metstatic breast cancer
corrosive ingestion
lymphoma
sarcoidosis
thickened gastric folds (>1cm)
common causes
inflammation
infiltration, including tumor
menetriers disease
varices (fundus)

menetriers disease
hypoproteinemic (edema), self limiting in childhood, progressive in adults
gastric filling defects
metastases (lung, breast, melanoma, renal cell)

polyps (syndromes)

gastroesophageal varices

pancreatic rest (single, umbilicated, inferior antrum)
duodenal ulcer, barium findings
round pools, rarely linear
edematous ring
radiating folds
scarred/spastic duodenum
crohns disease
transmural inflammation
chronic recurrent
aphthous ulcers->cobblestoning

sbft-ulcers/cobblestoning, string sign of kantor, long tight stricture of TI, fistulae
small bowel diverticulosis
clinical
diveriticulitis
hemorrhage
obstruction
perforation
bacterial overgrowth

sbft-multiple outpouching on mesenteric border
scleroderma of smantiall bowel
esophagus 75-90%
anorectum 50-70%
SB 40%
colon 10-50%

sbft
dilated atonic bowel, antimesenteric "sacculations", broad based peudodiverticula
nodular lymphoid hyperplasia
idiopathic
hypogammaglobulinemia
lymphoma
giardiasis

sbft-submucosal nodules, any part of GI tct, commonly sb
small bowel filling defects
inflammation
nodular lymphoid hyperplasia
crohns disease

infiltration
whipples diseaes
mastocytosis
waldenstroms

neoplasia
lymphoma
polyposis syndrome
small bowel wall thickening
"saw-tooth" or stack of coins appearance

causes
edema
hematoma
crohns disease
radiation
graft versus host disease of small bowel
after allogenic BMT
GI tract major target

sbft-thickened small bowel, featureless, ribbon like bowel
celiac disease
aka nontropical sprue
gluten intolerant
antigliadin ab
biopsy dx

sbft-small bowel dilatation, coarse or obliterated folds, ileojejunal reversal
sigmoid volvulus treatment
nonstrangulated-tube deflation + elective resection

40-90% recurrence with tube deflation alone

strangulated-emergency resection 50% mortality
cystic pneumatosis coli
asx or nonspecific GI dx, unknown etiology

associations
copd
peptic ulceration
pyloric stenosis
intestinal bypass surgery
transplant surgery

BE:
small intramural gas filled cysts
grape like clusts on xr
multiple polyp like defects on BE
ischemic pneumatosis
disproportionate pain
lactic acidosis

XR:
pneumtaosis (linear not cystic)
portal venous gas
ulcerative colitis
granular mucosa
undermined mucosa
pseudopolyps-filiform
thumbprinting
toxic megacolon
cancer
T2 hyperintense liver lesions
cysts

cystic metastases
cystic primary
may not enhance
progress

metastatic neuroendocrine tumor

hemangioma

biliary cystadenoma or cystadenocarcinoma (large/septae), single large cyst, thik these deiagnoses
liver hemangiomas
7-20%

f>m

right lobe>left

slow flow

attenuation and enhancement follows blood pool

low T1, very high T2, maintains high SI with heavey T2 weighting

interrupted peripheral nodular enhancement-sensitivity 88%, specificity 84-100%

homogenous enhancement by 10-20 min (range = immediate to 60 minutes

sharply lobulated
can have central scar
ddx
hypervascular tumors
cystic mets

atypical features
incomplete filling due to fibrosis and thrombosis

<1 cm, homogenous flash hyperenhancement arterial which will persist on delayed images
peripheral nodular interrupted enhancing liver lesions
hemangioma

treated metastases, rare

hemangioendothelioma-pediatric, multiple confluent lesions that coalesce in the periphery with capsular retraction

angiosarcoma
rare, lung, spleen mets
multifocal small nodules/large dominant mass
radium, inorganic arsenic, vinyl chloride, thorotrast, hemochromatosis
focal fat infiltration in liver
falciform ligament, gb foss, periportal

geographic low density on venous phase

geographic increased enhancement

low signal on out of phase T1 GRE fat-suppressed

no mass effect/non-displaced vessels run through it
nodular focal fatty infiltration
usuall geographic and periportal

can mimic mets

opposed GRE diagnostic

central high density reported on CECT
nodular focal fatty sparing
dark on T2
drops out on fat-sat
bright on out-of phase (rest of liver fatty and dark)
FNH
3%-incidental

30-40 years

80-95% young women

80% solitary

well, defined lobular

subcapsular

MRI
iso to slightly low T1
iso to slightly high T2

50-75% central scar containing vascular channels, bile ductules-low T1/high T2

hypervascular, homogenous arterial enhancement, variable washout (also on CT)

central scar-low SI precontrast and arterial phase with delayed enhancement
differentiating troublesome FNH
ddx
adenoma-can bleed
large hemangioma-40-50 yo
fibrolamellar HCC-younger

55% sulfur colloid scan positive because of Kupffer cells

if scan negative-biopsy
adenoma
similar epidemiology, young women

ocp, steroids

heterogenous T1/T2: hemorrhage, fat (SI on out of phase)

heterogenous, hyperenhancing or homogenous enhancing.
FNH vs HCC
can have similar characteristics, so if underlying cirrhosis, still raise possibility of hcc
liver metastases
hypovascular-colon, pancreas, lung; breast

hypervascular (with washout)-neuroendocrine tumors ie islet cell, carcinoid, pheo; thyroid ca; sarcoma;rcc; breast

high T2, low T1

melanin, blood-high T1 (paramagnetic effects

atypical features
cystic-necrosis, rapid growth, hypervascular
cystic primaries
mucinous adenocarcinoma
colorectal
ovarian

calcifcation (CT>MR)
serous ovarian ca
mucin producing colorectal
hcc
in setting of cirrhosis, or without cirrhosis in chronic HBV infection

hypervascular lesion in high risk patient particularly >2cm (<2cm 50% diagnostic accuracy)

if hypervascular, <2 cm, not bright on T2 ddx, hepatoma, dysplastic nodule, and shunt-->f/u in 3 months (3cm cut off)

washout on venous phase more specific then arterial hyperenhancement

atypical HCC-multifocal, or infiltrating, not T2 right

90% high T2 (50% mosaic)

30% high T1 due to copper, hemorrhage, fat, glycogen

variable T1 and T2 due to fat, hemorrhage, necrosis

5-10% calcifcy, central fibrous scar/septae

venous invasion-
tumor invasion enlarges vein and enhances, can't rely on T1 and T2 signal
hypervascular focal liver mass
ddx

benign
hemangioma
fnh
adenoma
hyperplastic, regenerative nodules in budd chiari

malignant
hcc
hypervascular mets
MRCTN
melanoma
RCC
choriocarcinoma
thyroid
neuroendocrine
cholangiocarcinoma
second most common liver primary

desmoplastic (causes scarring)- biliary epithelial cells

etiologies
psc
carolis
choledochal cyst
thorotrach
clonorchis sinensis

delayed enhancement (10 min) due to scarring, capsular retraction

bile duct dilatation

tumor fingers in bile ducts

types

intrahepatic 20-30%
mass forming
periductal infiltrating
intraductal

peripheral: beyond secondary ducts

hilar: large duct cancer

MRI

infiltrating mass

irregular margins

peripheral bile duct dilatation (high T2)

low T1/high T2

delayed enhancement
cirrhosis-general
etoh/viral hepatitis
biliary obstruction/congestion
drugs
autoimmune disease
hematochromatosis
wilsons

advanced cirrhosis
atrophy
right lobe, medial segment left lobe, expanded gb fossa

hypertrophy
caudate
lateral segment left lobe
cirrhosis-dysplastic nodules
MRI
similar features to RN but may be high T1
typically low T2
4-12% hypervascular
cirrhosis-regenerating nodules
regenerating nodules
low T1/T2, enhance like liver
may have excess iron (siderotic nodules, dark) or copper (bright)

siderotic nodules (MRI>CT)
cirrhosis-fibrosis
diffuse or focal
high T2
low T1
slight enhancement

diffuse
illdefined/patchy
thin/thick bands
perivacular cuffin (PBC)

focal confluent
anterior segment right lobe
medial segment left lobe
wedge-shaped
capsular retraction
may involve entire segment
ddx: HCC
diffuse fatty liver disease
obesity
tpn
alcohol
pregnancy
steroids
chemotherapy
malnutrition
primary hemochromatosis
AR
abnormal iron gi absorpt
RES unable to store RE

Fe deposition in hepatocytes, pancreas, myocardium, joints, endocrine glands, skin

hyperdense CT (70-130 HU)

T2 and T1 GRE, T2* GRE dark compared to paraspinal muscle
hyperdense liver on CT
hemochromatosis
amiodaron
type IV glycogen storage dz
wilsons dz
thorotrast
hemosiderosis
dyserythropoeisis
excessive transfusion
excessive iron accumulation in RES
liver
spleen
bone marrow
reduced signal on T2, T1 GRE, and T2*GRE
budd chiari syndrome
pain, tender hepatomegaly, acute ascites, jaundice

causes
idiopathic
ivc webs/membranes
tumors (hcc,rcc,adrenocoritlcal ca)
pregnancy
hypercoaguable state (PCV, OCP)
budd chiari types
type 1-IVC +/- secondary HV occlusion

type 2-HV +/- secondary IVC

type III-veno-occlusive disease (centrilobular veins)

severe centrilobular congestion leads to delayed or reversed portal venous flow

low density/hight T2 (congested)

ascites

large liver

patchy central enhancement

peripheral hypoperfusion

reversed on delays

small HV/IVC

intravascular thrombi

hepatic infarcts

portal vein thrombosis 20%

chronic-atrophied liver, large caudate
portal vein thrombosis
causes
pancreatitis
ascending cholangitis
post-splenectomy
stasis (cirrhosis)
tumor (hcc, pancreatic, gastric, cholangiocarcinoma)
myeloproliferative or connective tissue disease
trauma/sepsis
portal vein thrombosis imaging
lack of central pv enhancement

peripheral enhancement of vaso vasorum

chronic-cavernous transformation, atrophy

flow sensitive GRE seq/Gd

wedge shaped low T1/high T2

THAD:
decreased local PV perfusion
triangular increased hepatic arterial perfusion
transient increased segmental/lobar late arterial/early pv attenuation
can be idiopathic or due to tumor?
nutmeg liver
Passive hepatic congestion usually secondary to
congestive heart failure
constrictive pericarditis
tricuspid insufficiency
right heart failure

CT
early retrograde enhancement of dilated IVC and hepatic veins due to contrast reflux from RA to IVC
heterogeneous, mottled, reticulated, mosaic parenchymal pattern
linear and curvilinear areas of poor enhancement due to delayed enhancement of small and medium-sized hepatic veins
peripheral, large, patchy areas of poor or delayed enhancement
periportal low attenuation (perivascular lymphedema)
decreased attenuation around intrahepatic IVC
hepatomegaly and ascites

MR
periportal high T2 (periportal edema)
reticulated mosaic pattern of low signal intensity linear markings
within 1-2 minutes liver becomes more homogeneous
hepatic infarction
uncommon-dual supply

causes
liver transplant, lap choly
hepatic artery occlusion
shock
sepsis
embolism
vasculitis
eclampsia
OCP

peripheral wedge shaped/geographic areas of low attenuation, low T1/high T2

new ascites

change shape/atrophy over time

bile lakes

necrosis (air)
major causes of sbo
adhesions
malignancy
crohns disease
hernias
intussusception
major causes of lbo
colorectal carcinoma
volvulus
intussusception
hernia
diverticular disease
warning signs of strangulation/closed loop/ischemia
excessive free fluid
mesenteric fat stranding/edema
disproportionate dilatation of one loop
mural non-enhancement
+/-bowel wall thickening/pneumatosis
+/-clustering "balloons on a string"
risk of aortic aneurysm rupture within 5 years by aortic aneurysm
3-3.9 cm 2%
4-4.9 cm 3-12%
5-5.9 cm 25%
6-6.9 cm 35%
7+ cm 75%
biliary stone disease
20%

risk factors
female
obesity
estrogen
hypercholesteremia
middle age to elderly

things to look out for

mirrizi's syndrome-causes taper narrowing of the cbd

stones with air crescent density

MRI
cholesterol-T2 dark, T1 dark
pigment-T2 dark, T1 bright
secondary signs of CBD
bile duct dilatation

eccentric filling defect

dependent

crescent sign of air (useful when stone is same density as bile)
acalculous cholecystitis
10-15% of cholecystitis findings
dilated gb
gb wall thickening
areas of nonenhancement, sloughed wall

associations
prolonged fasting
chronic infection
ischemia
obstruction of cystic duct
ICU patient
gallstone ileus
risk factors
female
advanced age, mean 74-80
10-25% mortality

riglers triad
sbo
pneumobilia
ectopic gallstone
small irregular bile ducts
PSC
intrahepatic duct involvement
beaded ducts
strictures
pruning
biliary diverticula

AIDS cholangiopathy
papillary stenosis
otherwise similar to PSC

recurrent pyogenic cholangitis
PSC
progressive inflammation, fibrosis, destruction of bile ducts

70% male
75% have IBD, 4-5% of UC have PSC
40 yo mean age

complications
cirrhosis
recurrent bacterial cholangitis
cholangiocarcinoma
primary biliary cirrhosis
idiopathic, autoimmune

young/middle aged women, pruritis

inflammatory progressive destruction of small bile ducts ->cirrhosis, PHTN

2 years life expectancy
recurrent pyogenic cholangitis (oriental cholangiohepatitis)
>30 yo

recurrent bacterial cholangitis

intrahepatic pigment stones and obstruction

coliform bacterial seeding of biliary tree

parasite infection
ascaris lumbricoides
clonorchis sinensis
opsithorchis vivemini

central, dilated bile ducts with peripheral tapering

bile duct stones

liver abscesses
ascending cholangitis
biliary bacterial infection-gram -'s

risk factors
choledocholithiasis
indwelling stents
tumors
acute pancreatitis

charcot's triad
pain
fever
jaundice
choledochal cyst
ask to look at the pancreatic duct/main duct confluence to look for cholangiocarcinoma

stones
biliary cystadenoma
f:m 4:1, caucasian

ovarian stroma at histology

middle aged >30 yo

multiloculated fluid collection, often big
enhancing mural nodules, septae
may have thin calcifications

ddx
hydatid cyst
hematoma
simple cyst
biliary hamartomas aka von myenberg complexes
CT
diffuse small low attenuation foci <1cm each

MRI
low to slightly high T1
high T2

US
hyperechoic
comet tail artifacts
right posterior biliary duct variants
normal, drains into right main 55%

low insertion of duct onto main 5%

accessory right to GB (common)-predisp to bile leak

right posterior duct to cystic 1%
inadvertant common duct ligation
bismuth classification

1-CBD> 2 cm from confluence
2-<2 cm from confluence
3-entire CHD
4-involves confluence
5-right variant branch

increasing grade, more difficult repair after complicated cholecystectomy
focal gb wall thickening
adenomyomatosis
gb polyps
gallbladder cancer
adenomyomatosis
focal wall thickening due to mucosal herniations

small cystic spaces-dilated rotikansy aschoff spaces (string of pearls)

mostly fundus

usually associated with gallstones
gallbladder polyp
enhancing lesion

surgery
>1.0 cm
age > 50
symptomatic
coexisting gallstones
otherwise US surveillance every 3 to 6 months for 1 year
gallbladder cancer
eldery (70s)

gallstones 60-90%

adenocarcinoma
infiltrative or endoluminal, fundus or neck

mets to local LN, peritoneum, gi tract, lungs

5 year survival 1%
bile duct strictures
malignant
proximal (superior)
abrupt shoulders
associated mass
eccentric
mets

benign
distal (inferior)
gradual tapering
concentric

ERCP dx
cytology/brushings
sensitivity 44-70%
specificity 100%
pain jaundice/biliary stricture
ddx

malignant
cholangiocarcinoma
gallbladder carcinoma
LAD
pancreatic cancer

benign
trauma
gallstone
ischemic
bosniak type 1
simple cyst (benign)
thin wall
no septa
no calcifications
fluid density (-20 to +20 HU)
no enhancement
bosniak type 2
minimally complicated cyst

hariline thin septa +/- minimal perceived enhancement

fine calcifications in walls or septa

short segment of slightly thickened calcification

uniform high attenuation (<3 cm)
boniak 2f
follow-up if needed

increased # of thin septa

minimal smooth thickening of wall or septa

no enhancing solid components

intrarenal high attn cysts>3cm
bosniak 3
complex (indeterminate)

thickened irregular walls or septa

enhancement of wall or septa

chunky ca++
bosniak 4
malignant cystic masses

enhancing soft tissue components adjacent to but independent of wall or septum
staging of RCC
1-confined to capsule

2-extranrenal but confined to gerotas fascia

3a-vascular invasion
3b-local node mets
3c-both

4a-invasion of distant organs
4b-distant mets

distinguish between 3 and 4 because of px
solid renal mass without obvious fat
ddx
rcc
tcc
lymphoma
mets

pyelonephritis
fungus ball
infarct
renal tcc
6th to 7th decades, m/f 3/1

risk-aniline dyes, aromatic amines, xrt, cigarettes, cytotoxan, artificial sweetners

80-90% current or prior bladder ca

imaging features

polypoid filling defect

circumferential wall thickening

infiltrating or discrete mass mimicking RCC

+/- caliceal dilatation
renal lymphoma
ct incidence of 3-8%
autopy 30-60%
primary renal lymphoma rare

multiple small masses
spread from retroperitoneum
diffuse infiltration
perinephric encasement
single homogenous mass
maybe mixed
oncocytoma
rare benign
can be difficult to distinguish from RCC

central stellate scar
spoke wheel pattern of vessels on angio
not specific enough to avoid resection

up to 30% contain focci of rcc
radical or partial nephrectomy
angiomyolipoma
rare, benign hamartomatous

80% sporadic, 20% syndromic

blood vessels, muscle, fat

95% contain demonstratable fat, -20HU

well defined, cortical (+/- exophytic)

usually<5cm

fat-containing RCC has small amount of fat
rcc risk factors
history of rcc
vhl
cystic dz of dialysis

adpckd not an increased risk
adrenal cyst
rare
45% endothelial lined
39% pseudocysts (prior hemorrhage)

CT-fluid density, no enhancement

MR-bright T2, dark T1, no enhancement

maybe hemorrhagic
adrenal myelolipoma
rare, benign
hyperintense T1, fat saturation due to macroscopic fat, no drop out on out of phase
CT criteria for adenoma
hu < 10-18 on noncontrast

rapid contrast washout
>60% decreased between pv and 15 min delayed

<52HU on 10 min delayed
MR criterial for adenoma
>20% signal drop on out of phase
or compared with muscle or spleen

if lipid poor, use washout characteristics

hypointense on T2, variably enhances
adrenal mets
most common malignancy of adrenal gland

often bilateral

do no fat sat

also consider adrenal lymphoma
pheochromocytoma
90% in medulla

>3cm at presentation

10% bilateral

10% malignant

T2 lightbulb bright but not common, no fat sat, late enhancement
adrenal carcinoma
rare aggressive tumor

large (90%>6cm)

heterogenous, necrosis, hemorrhage

can invade IVC
cross fused ectopia
one or both kidneys on wrong side

ureter crosses midline to insert on correct side with normal insertion at bladder trigone

ectopic kidney associated with reflux
horsehoe kidney
lower poles directed toward midline
lp calyces overlap spine
prominent extrarenal pelvis
kidneys joint by parenchyma or fibrous tissue below IMA

predisposed to
trauma
stones
uti

association
upj obstruction
wilms tumor, carcinoid, rcc?
turners
other anomalies such as skeletal, cardiac, and vater

look for mullerian duct anomalies
unilateral renal enlargement
ddx
obstruction
renal vein thrombosis
pyelonephritis
cystic renal disease
developmental
contralateral renal atrophy
klippel trenauny webber
bilateral renal enlargement
edema-ie those things that cause unilateral enlargement

deposition disease ie amyloid

leukemia

SLE

HIV nephropathy

cystic renal disease
adpckd
1/1000
cysts of nephrons and collecting tubules
htn, renal failure 3rd decade
10% die of berry aneurysm
acquired renal cystic disease
20% <40 yo
>33% >60 yo

cysts may enlarge and cause sx's from mass effect
lap decortication
alcohol ablation

increased risk of RCC
simple renal cyst
ddx
calyceal diverticulum-fills on delay, retains stone

focal caliectasis

peripelvic cyst/hydro

upj obstruction

aneurysm/pseudoaneurysm-follows blood pool on ct

AVM/AVF

lymphoma on US
renal ptosis
hypermobile kidney

may cause upj obstruction

normal number of calices

distinguish from "drooping lily" (duplicated ureters with upper pole obstruction)
proximal blind ending ureter
associations
dysplastic kidney
prior nephrectomy
ureteral diverticulum (congenital)
megacalicosis
dilated calices
too many calices
nondilated pelvis
renal enlargement

associations
ureterocele
megaureter
contralateral upj
upj obstruction
primary
congenital narrowing

secondary
crossing vessel (artery or vein)
mass
retroperitoneal fibrosis
circumcaval ureter-hairpin turn in ureter and crosses medial to spinal tv processes
congenital megaureter
looks like hirschsprungs-tight distally, dilated proximally
ureteral filling defect
tcc
clot
sloughed papilla
calculus
fungus
polyp
multiple small mucosal lesions in upper urinary tract
pyelouretritis cystica-related to infection, no premalignant

multifocal tc

malakoplakia-not premalignant

leukoplakia-more common in bladder, premalignant

vascular impressions

edema due to stent
focal pyelonephritis
focal illdefined perfusion anomaly

striated nephrogram

focal contour bulge

urothelium thick or enhancing

perinephric edema (beware obstruction/hydronephrosis)
xanthogranulomatous pyelonephritis
renal enlargement

calyces and papilla replaced by low density masses

cortical atrophy

extension into perirenal space

staghorn calculus

uncommon form of chronic renal parenchymal infection

yellow nodules componsed of foamy lipid macrophages

usually diffuse, maybe focal

extension into the perirenal space (abscess/fistula) is common
prolonged nephrogram
ddx
unilateral
renal vein thrombosis
ureteral obstruction
severe RAS

bilateral
systemic hypotension
ATN (contrast toxicity)
intratubular obstruction ie myeloma, uric acid crystals, tamm-horsefall
striated nephrogram
ddx
multiple infarctions
pyelonephritis
hypotension/ATN
renal vein obstruction
contusion
intratubular obstruction
medullary nephrocalcinoisis
increased medullary Ca++, increased medullary hyperechogenicity with shadowing

ddx
hyperparathyroidism 40%
distal RTA
medullary sponge kidney
papillary necrosis
lasix treatment (#1 in infants and premies)
papillary necrosis

POSTCARD
ivp signs
ball on a t
elongated lobster claw calyces

ddx
pyelonephritis
obstruction
sickle cell
tb
coagulopathies/christmas dz
analgesics (NSAIDS)
renal vein thrombosis
diabetes
cortical nephrocalcinosis
chronic glomerulonephritis
ischemia/cortical necrosis
aids nephropathy

other
oxalosis
alport syndrome
hypercalcemia
acute renal cortical necrosis
peripheral nonenhancing cortex before calcifying
renal tb
putty kidney-shrunken calcified amorphous kidney mimics staghorn calculi, caseous necrosis

75% unilateral

shrunken calcified bladder-"thimble" bladder

IVP
big round distorted cottonball calyces with infindibular narrowing
papillary necrosis

developing countries

usually secondary to another primary infection
acute pancreatitis
etiologies
etoh, cholelithiasis >90%
hyperlipidemia
drugs (steroids, AZT, DDI, diurections, antibiotics)
post ercp or surgery
infectious (measles, mumps, viral)
familial
acute pancreatitis CT grading
grade A-normal pancreas

grade b-enlarged heterogenous gland, no peripancreatic inflammation

grad c-intrinsic pancreatic abnormalities + peripancreatic inflammation

grade d-single fluid collection

grade e->=2 large fluid collections and/or pancreatic or peripancreatic gas

complications
pseudocyst
pseudoaneurysm
splenic or pv thrombosis
abscess-fluid with air
necrosis
hemorrhage
pseudocyst features
>4 weeks to develop

0-30 HU, no enhancing contents or nodules

wall ca++ common

ddx thrombosed pseudoaneurysm

can occur anywhere
chronic pancreatitis
permanent structural and functional damage

75% etoh

other etiologies-hyperlipidemia, hyperPTH, pancreas divisum

2-4% will develop pancreatic CA

imaging findings:
ca++
variable size
dilatation of pancreatic duct and bile ducts (double duct sign)
pseudocysts, pseudoaneurysms
venous thrombosis and collaterals
drainage of noninfected pancreatic pseudocysts indications
>5cm, esp if increasing in size
symptomatic
obstruction of bile duct, stomach, or duodenum

complications 5-10%
infection
bleeding
chronic cutaneous fistula
pancreas divisum
5%

failure of fusion of dorsal and ventral pancreatic buds
head drained by duct of wirsung
body and tail drained by santorini

recurrent pancreatitis

+/-bulky pancreatic head with fat cleft

ERCP dx
pancreas divisum imaging findings
ERCP injection of major papilla demonstrates truncated duct of wirsung with branching in head (as opposed to pancreatic CA which has no branching)
annular pancreas
band of pancreatic tissue encircles the second portion of the duodenum

50% obstruction in neonates (double bubble)

50% periampullary ulcers and pancreatitis in adults

ERCP-main duct of wirsung circles around and then crosses midline

UGI-short segment duodenal narrowing

ddx-pancreatic adenocarcinoma of head
pancreatic carcinoma
5th leading cause of cancer deaths, 28000/year

90% of pancreatic neoplasms

elderly males

70% head, 20% body, 10% tail

5 year survival <5%

90% cases unresectable at time of dx
pancreatic carcinoma imaging features
low density mass, occasionally isodense

hypoechoic mass

dilated PD and/or bile duct distal to mass (double duct sign)

pancretic atrophy

perivascular cuffing-sign of unresectability

teardrop sign-tethering of vessels, sign of unresectability

interrupted duct sign
criteria for unresectability of pancreatic carcinoma
>5cm

adjacent tissue or organ invasion excluding duodenum

arterial stenosis, occlusion, or encasement (celiac + branches, SMA)

+/- venous invasion (PV, SMV)

hepatic mets

distant adenopathy

peritoneal carcinomatosis
pancreatic carcinoma ddx
mets
islet cell tumor
lymphoma
tumor from adjacent organ

focal fat
focal pancreatitis
necrosis
cystic pancreatic tumors
5-10% of pancreatic malignancies

microcystic adenoma (serous)
mucinous cystic neoplasm
solid and papillary epithelial neoplasm
IPMT
anaplastic CA
cystic islet cell tumor
cystic met
lymphoma
microcystic adenoma
benign
f/m 4:1
mean 65 yo
head=body=tail
35% ca++ +central stellate scar
cysts>6, each <2cm
honeycomb appearance
glycogen
vhl
mucinous cystic neoplasms (macrocystic)
frankly or potentially malignant
f/m 9:1
mean age 50 yo
tail>body
15% peripheral ca++
solitary small or large or if multiple cysts <6, >2 cm
mucin
solid and papillary epithelial neoplasm (SAPEN)
rare, low grade malignancy

young women, mean age 24 yo

large, well encapsulated solid and cystic mas, hemorrhage and necrosis, fluid-debris level

pancreatic tail

complete resection curative
intraductal papillary mucinous tumor (IMPN, mucinous ductal ectasia)
epithelial hyperplasia--carinoma

mean age 65yo

main duct-diffuse or segmental dilatation

branch duct-cystic dilatation, multiple cysts

combined types

ERCP-patulous dilated papilla with mucin pouring from it, mural nodules

ipmt branch duct type less likely to have malignancy if <3cm, can follow-up

diffuse duct type-more likely malignant and need resection, suspect if absent findings of chronic pancreatitis

ddx
chronic pancreatitis
cystic tumors
islet cell tumors
85% functional

insulinoma
most common
>90% benign and resectable
small

gastrinoma
2nd most common
60% malignant
small
cause of ZE syndrome

15% nonfunctioning
3rd most common
80-90% malignant
large, mean size >5cm
25% ca++

CECT-immediate intense enhancment, can be more il-defined, less enhancing if not insulinoma?

US-hypoechoic mass

MRI-T1GRE + FS +C shows immediate intense enhancement, can be more il-defined, less enhancing if not insulinoma?
calcified liver mass
mucinous adenoCA
gi tumors (colon)
breast
prostate

ovarian serous adenoCA

mets which engulf granulomas

other
treated lymphoma
osteo/chondrosarcoma
mets tx with lipiodol
foregut duplication cysts
CT
fluid density

MRI
high T2 signal, low to slightly high T1 signal

if see vertebral involvement, suggest neurenteric cyst

surgical management

ddx
pseudocyst
focal solid splenic lesions
ddx
hemangioma #1
melanoma
lymphoma, often infiltrative
sarcoid
phlegmon,abscess
gastric polypoid filling defects
ddx
polyp
fb, clot, bezoar
mets
lymphoma
leiomyoma, lipoma, fibroma
ectopic pancreas
colonic wall thickening
ddx
immunocompetent
pseudomembranous colitis
ischemic
inflammatory
lymphoma (look for LAD)

if immunocompromised
CMV colitis
other
typhillitis
gvhd
gastric fundal lesions
GIST
lymphoma
gastic adenocarcinoma
fatty pancreatic replacement
ddx
cystic fibrosis
obesity/old age (cryptogenic)
diabetes
chronic pancreatitis
TPN
corticosteroids
bladder ca
2% of cancer deaths

risk factors

tcc 90%-smoking, aniline dyes, age

scc 8%-stones, chronic inflammation

acc 2%-congenital defect (urachal defects), chronic inflammation
bladder ca imaging
variable morphology
polypoid papillary mass in low grade tumors
focal wall thickening in high grade tumors

+/- surface ca++ (tcc)

cystoscopy is gold standard for can, moderate imaging detection rate (CT 70% detection rate)

field cancerization-increased risk of tcc in other areas of uroethlium

pelvic sidewall recurrence is typical

tends to seed along needle tracks
bladder masses ddx
hematoma

leiomyoma-smooth, dumbell shaped

schistosomiasis-diffusely calcified bladder wall, may track ca++ up ureter, assoc w scc

pheochromocytoma-smooth very enhancing mass
neurogenic bladder
spastic-small trabeculated, conical, "christmas tree" bladder

atonic or flaccid-large, smooth
prostate cancer
most common noncutaneous man cancer

second most common cause of cancer death in men

low T2 signal in peripheral zone

findings of T3 cancer
focal irregular bulge
NVB invasion
RP angle obliteration
SV invasion
prostate cancer staging and treatment
stage 1/2, organ confined-surgery, radiation, observation

stage 3-radiation therapy only

stage 4-systemic tx
urethral anatomy
anterior part
bulbar segment
penile segment

posterior part
membranous segment
prostatic segment
urethral stricture
post-traumatic, post-inflammatory, idiopathic

length influences tx-measure between shoulders, >1.5 cm precludes primary anastomosis

need RUG and VUG
urethral diverticulum
1-6% adult women

unknown etiology

nonspecific urethral sx

may not be seen on vcug
double ballooon urethrogram
t2 and t1 post gad (enhancing mucosa)
circumcaval ureter
congenital anomaly

ivc derives from subcardinal or postcardinal vein

ureter trapped behind ivc

pain, hematuria, utis, stones

ureter lies medial to lower lumbar pedicle, crosses anterior to right iliac vessels

associations-horsehoe, turners, double vena cavae

ddx
normal oblique impression of crossing iliac vessels at l5 or s1

adenopathy

retroperitoneal fibrosis

pelvic lipomatosis
renal infarcts
wedg shaped peripheral defects

emboli from arrythmias, myxomas, s/p myocardial infarct

emboli bilateral in 50%

after xrt

arteritides-polyarteritis nodosa, methamphetamine

ddx
acute focal bacterial nephritis
infiltrating neoplasm
horshoe kidney
1/400, ima crosses isthmus
multiple arteries, double ureters

complications-injury, upj obstruction, lower pole moiety, stones, wilms tumor

assoc-turners, trisomy 18, fanconis anemia, vater

ddx
cross fused ectopia
disc (cake, lump) kidney-usually lower than horseshoe, often in pelvis, may have single ureter
unopacified kidney
ddx
renal artery embolus-large smooth unopacifiefd kidney, with cortical rim of contrast, shrink after 2-3 weeks

obstruction
renal vein thrombus
absent or ectopic kidney
infection (xgpn)
tumor
mcdk
renal cell ca
m/f 2/1, 50-70, 2% bilateral, 7-9% esrd

familial rcc, mult, bilateral

vhl-38% rcc, multiple 75%

mass, flank pain, hematuria

clear cell 80%-enhances a lot
papillary 15%-not as much enhancement

calcification 8-18%

iuv-bulge, hypervascular mass
us-86% isoechoic, 10% hypo
ct/mr-enhances less than parench
rcc staging
t1 tumor <=7cm, limit to kidney
t1a <=4cm
t1b between 4 and 7cm
t2 tumor >7cm, limited to kidney

*t1 and t2 surgical

t3 tumor into renal vein, ivc, adrenal, but confined to gerotas fascia
t3a adrenal gland/perinephric tissues
t3b renal vein
t3c ivc or its wall above diaphragm
t4 tumor beyond gerotas fascia/distant mets
renal mass
ddx
rcc
oncocytoma
angiomyolipoma
mets
xgpn
acute focal bacterial nephritis
persistent or increased density nephrogram
contrast reaction
acute tubular necrosis 60&
acute tubular blockage ie mm, urate nephropathy, tamm horsfall protein
acute gmn
nephrocalcinosis

STADIM DITCH
sarcoid
tb
a-vitamin
d-vitain
immobilization
milk alkali
medullary sponge
diuretics
lasix
idiopathic
thyrotoxicosis
carcinoma
hyperparathyroidism
upj obstruction
congenital
functional
stenosis
acquired
scarring, reflux
tumor
intraluminal lesion

5% have a contralateral renal agenesis or mcdk

lower segment of duplex kidney has upj more often than upper
urethral diverticulum complications
infection
stones
bladder outlet obstruction
adenocarcinoma

ddx
anterior vaginal mass/cyst
gartner duct cyst
paramesonephric remnant cyst
epithelial inclusion cyst
ectopic ureterocele
endometrioma
urethral tumo-scca
unilateral enlarged kidney
compensatory hypertrophy
obstruction
acute bacterial nephritis
duplex kidney
cross fused ectopia
tumor
mcdk, adpck
traum
renal vein thrombosis
acute arterial infarction
xanthogranulomatous pyelonephritis
focal or diffuse, middle aged females

secondary to chronic uti's

80% have calculi, usually struvite

lipid laden macrophages (xanthoma cells) replace normal parenchyma

hypovascular, may not have renal function

nephrectomy

ddx
abscess
renal cell ca
lymphoma
tcc
duplicated bladder
type 1 involves mucosa and muscle wall; peritoneal fold separates 2 bladders

type 2 internal septum of mucosa or mucosa and muscle divides bladder

type 3 transverse band of muscle; hourglass shape

associated anomalies-duplicaed penis, urethra, vagina, uterus, colon; rectourethral fistula