REFERAT

*Kepaniteraan Klinik Senior/ G1A219040/ 31 Agustus 2019

** Pembimbing/ dr. M. Rizal Syafiie,Sp.B KBD

Tractus Gastrointestinal, Peritoneal Cavity, and Retroperitoneum

Ulfadiya putri, S.Ked*

dr. M. Rizal Syafiie,Sp.B KBD**

KEPANITERAAN KLINIK SENIOR

BAGIAN ILMU BEDAH
RSUD RADEN MATTAHER PROVINSI JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2019

i
 REFRAT
“Tractus Gastrointestinal, Peritoneal Cavity, and

Retroperitoneum”

Oleh :
Ulfadiya putri
G1A219040

KEPANITERAAN KLINIK SENIOR

BAGIAN ILMU BEDAH
RSUD RADEN MATTAHER PROVINSI JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS JAMBI
2019

Jambi, 31 Agustus 2019

DOSEN PEMBIMBING

dr. M. Rizal Syafiie,Sp.B KBD

ii
 KATA PENGANTAR

Segala puji dan syukur penulis panjatkan kehadirat Allah SWT yang telah
melimpahkan rahmat dan hidayah-Nya sehingga penulis dapat menyelesaikan
referat yang berjudul “CT-SCAN ABDOMEN Tractus Gastrointestinal,
Peritoneal Cavity, and Retroperitoneum” sebagai kelengkapan persyaratan
dalam mengikuti Kepaniteraan Klinik Senior Bagian Bedah Rumah Sakit Raden
Mattaher Provinsi Jambi.
Penulis mengucapkan terima kasih kepada dr. M. Rizal Syafiie,Sp.B KBD
yang telah bersedia meluangkan waktu dan pikirannya untuk membimbing penulis
selama menjalani Kepaniteraan Klinik Senior Bagian Bedah Rumah Sakit Raden
Mattaher Provinsi Jambi.
Penulis menyadari bahwa referat ini masih jauh dari sempurna. Oleh karena
itu kritik dan saran yang membangun dari berbagai pihak sangat diharapkan guna
kesempurnaan referat ini, sehingga dapat bermanfaat bagi penulis dan para
pembaca.

Jambi, 31 Agustus
2019

Penulis

iii
 DAFTAR ISI

Halaman Judul ...................................................................................................... i

Halaman Pengesahan ............................................................................................ ii
Kata Pengantar ...................................................................................................... iii
Daftar Isi .............................................................................................................. iv

BAB I Pendahuluan ............................................................................................. 1

1.1 Latar Belakang 1

BAB II Tinjauan Pustaka ..................................................................................... 2

2.1 CT- SCAN .................................................................................................. 3
2.2 Contoh Kasus CT-SCAN ABDOMEN ..................................................... 8

BAB III Kesimpulan ............................................................................................

3.1 Kesimpulan .................................................................................................

Daftar Pustaka .......................................................................................................

iv
 BAB I
PENDAHULUAN

CT Scan (computed tomography scan) adalah proses penggunaan komputer untuk

memperoleh gambaran tiga-dimensional dari ribuan gambar x-ray dua-dimensional. CT

Scan dapat menghasilkan gambar-gambar yang sangat akurat dari objek-objek di dalam

tubuh seperti tulang, organ, dan pembuluh darah. Gambar-gambar ini sangat berguna

dalam mendiagnosa berbagai penyakit, seperti kanker, penyakit jantung, stroke, kelainan

organ reproduktif, dan kelainan gastrointestinal.

Mesin CT Scan berbentuk pipa dengan tempat pasien berbaring di

tengahnya. Pemroses citra (scanner) sendiri terdapat dalam frame pipa tersebut.

Saat mesin bekerja, pipa pemroses citra itu berputar sambil menembakkan sinar

rontgen ke arah pasien dari berbagai sudut. Untuk setiap putaran, sekitar 1.000

gambar bagian dalam pasien diambil. Gambar-gambar ini kemudian di-compile

oleh komputer sehingga menghasilkan gambar cross-sectional bagian dalam

tubuh pasien yang dapat digunakan dalam menganalisa dan mendiagnosa pasien.

1
 BAB II
TINJAUAN PUSTAKA

2.1 CT- SCAN

CT Scan (computed tomography scan) adalah proses penggunaan

komputer untuk memperoleh gambaran tiga-dimensional dari ribuan gambar x-ray
dua-dimensional. CT Scan dapat menghasilkan gambar-gambar yang sangat
akurat dari objek-objek di dalam tubuh seperti tulang, organ, dan pembuluh darah.
Gambar-gambar ini sangat berguna dalam mendiagnosa berbagai penyakit, seperti
kanker, penyakit jantung, stroke, kelainan organ reproduktif, dan kelainan
gastrointestinal. Citra yang dihasilkan CT Scan jauh lebih detail dibanding citra
yang diperoleh x-ray biasa.1,2,3,4

Gambar 1. Mesin CT scan

Mesin CT Scan berbentuk pipa dengan tempat pasien berbaring di

tengahnya. Pemroses citra (scanner) sendiri terdapat dalam frame pipa tersebut.
Saat mesin bekerja, pipa pemroses citra itu berputar sambil menembakkan sinar

2
rontgen ke arah pasien dari berbagai sudut. Untuk setiap putaran, sekitar 1.000
gambar bagian dalam pasien diambil. Gambar-gambar ini kemudian di-compile
oleh komputer sehingga menghasilkan gambar cross-sectional bagian dalam
tubuh pasien yang dapat digunakan dalam menganalisa dan mendiagnosa pasien.
Prinsip dasar CT scan mirip dengan perangkat radiografi yang sudah lebih
umum dikenal. Kedua perangkat ini sama-sama memanfaatkan intensitas radiasi
terusan setelah melewati suatu obyek untuk membentuk citra/gambar. Perbedaan
antara keduanya adalah pada teknik yang digunakan untuk memperoleh citra dan
pada citra yang dihasilkan. Tidak seperti citra yang dihasilkan dari teknik
radiografi, informasi citra yang ditampilkan oleh CT scan tidak overlap (tumpang
tindih) sehingga dapat memperoleh citra yang dapat diamati tidak hanya pada
bidang tegak lurus berkas sinar (seperti pada foto rontgen), citra CT scan dapat
menampilkan informasi tampang lintang obyek yang diinspeksi. Oleh karena itu,
citra ini dapat memberikan sebaran kerapatan struktur internal obyek sehingga
citra yang dihasilkan oleh CT scan lebih mudah dianalisis daripada citra yang
dihasilkan oleh teknik radiografi konvensional.
CT Scanner menggunakan penyinaran khusus yang dihubungkan dengan
komputer berdaya tinggi yang berfungsi memproses hasil scan untuk memperoleh
gambaran panampang-lintang dari badan. Pasien dibaringkan diatas suatu meja
khusus yang secara perlahan – lahan dipindahkan ke dalam cincin CT Scan.
Scanner berputar mengelilingi pasien pada saat pengambilan sinar rontgen. Waktu
yang digunakan sampai seluruh proses scanning ini selesai berkisar dari 45 menit
sampai 1 jam, tergantung pada jenis CT scan yang digunakan( waktu ini termasuk
waktu check-in nya).
Proses scanning ini tidak menimbulkan rasa sakit . Sebelum dilakukan
scanning pada pasien, pasien disarankan tidak makan atau meminum cairan
tertentu selama 4 jam sebelum proses scanning. Bagaimanapun, tergantung pada
jenis prosedur, adapula prosedur scanning yang mengharuskan pasien untuk
meminum suatu material cairan kontras yang mana digunakan untuk melakukan
proses scanning khususnya untuk daerah perut.

3
 CT Scan memiliki beberapa kelebihan dibanding x-ray biasa: citra yang
diperoleh CT Scan beresolusi lebih tinggi, sinar rontgen dalam CT Scan dapat
difokuskan pada satu organ atau objek saja, dan citra perolehan CT Scan
menunjukkan posisi suatu objek relatif terhadap objek-objek di sekitarnya
sehingga dokter dapat mengetahui posisi objek itu secara tepat dan akurat.
Kelebihan-kelebihan tersebut telah membuat CT Scan menjadi proses radiografis
medis yang paling sering direkomendasikan oleh dokter dan, dalam banyak kasus,
telah menggantikan proses x-ray biasa secara total.

Sistem CT Scan1,2,3,4
Peralatan sistem CT Scan terdiri atas tiga bagian, yaitu:
1. Sistem Pemroses Citra
2. Sistem Komputer dan Kendali
3. Stasiun Operasi dan Stasiun Pengamat

Gambar 2. Blok Diagram Sistem CT Scan

Sistem Pemroses Citra (Scanner)

Sistem pemroses citra terdapat dalam frame pipa dari mesin dan
merupakan bagian sistem yang langsung berhadapan dengan objek/pasien.
Scanner terdiri atas sumber sinar-x, collimator, detektor, dan bagian akuisisi data.
Diagram blok dari scanner mesin CT Scan dapat dilihat pada Gambar 2.

4
 Gambar 3. Diagram Blok scanner (pemroses citra) CT Scan

Sumber sinar-x (x-ray tube dalam gambar di atas) menembakkan sinar-x

ke arah pasien. Collimator adalah penghalang sinar radiasi dan berfungsi
memfokuskan sinar-x yang ditembakkan oleh x-ray tube pada satu slice
(potongan) saja. Detektor radiasi biasanya berupa detektor ionisasi gas. Jika
tabung pada detektor ditembus oleh radiasa maka akan terjadi ionisasi gas-gas di
dalamnya. Ionisasi tersebut menimbulkan arus listrik pada keluaran detektor yang
sebanding dengan intensitas sinar radiasi yang mengenai receiver detektor.
Keluaran detektor kemudian dikirim ke bagian akuisisi data yang berfungsi
mengubah besaran-besaran listrik dari detektor menjadi sinyal analog yang
kemudian akan melalui konversi Analog-to-Digital. Hasil pengkonversian A/D itu
dikirim ke bagian komputer dan kendali untuk di-compile oleh komputer.

Sistem Komputer dan Kendali1,2,3,4

Bagian komputer bertanggung jawab atas rekonstruksi gambar dan sistem
kendali seluruh sistem CT Scan. Sistem Komputer dan Kendali ini terdiri atas
prosesor, sistem I/O, dan hard disk.
Processor atau CPU (unit pemroses pusat) mempunyai fungsi untuk
membaca dan menginterprestasikan instruksi, melakukan penghitungan, dan
menyimpan hasil-hasil dalam memory. CPU yang digunakan mempunyai bus data
16,32 atau 64 bit. Tipe komputer yang digunakan bisa mikro komputer dan bisa

5
mini komputer, namun harus memenuhi unjuk kerja dan kebutuhan sistem CT
Scanner. Harddisk mempunyai fungsi untuk menyimpan data dan software.

Stasiun Operator dan Stasiun Pengamat

CT Scanner pada umumnya dilengkapi dengan dua buah monitor dan
keyboard. Masing-masing sebagai operator station dan viewer station dan
keduanya mempunyai tugas yang berbeda. Operation Station mempunyai fungsi
sebagai operator kontrol untuk mengontrol beberapa parameter scan seperti
tegangan anoda, waktu scan dan besarnya arus filamen. Sedangkan viewer station
mempunyai fungsi untuk memanipulasi sistem pemroses citra. Bagian ini
mempunyai sistem kontrol yang dihubungkan dengan sistem keluaran seperti hard
copy film, magnetic tape, dan paper print out. Dari bagian ini dapat dilakukan
pekerjaan untuk menganalisa hasil scanning.
Contoh Citra yang Diperoleh CT Scanner

Gambar 4. Gambar axial dan 3D dari tenggorokan manusia

6
Gambar 5. Hasil scan kepala pasien

Gambar 6. Tummor di ginjal pasien

7
2.2 CONTOH KASUS

Case 1
Radiologic fendings
Barium esophagram shows a smooth, linear indentation with regular
margins over the posterio wall of the middle third of the
esophagus with mid proximal dilatation of the cervical
esophagus (fig. 77.1) magnetic resonance angiography
(MRA) images (figs.772, 77.3) show an aberrant right
subclavian artery (ARSA) arising from the left aortic
arch. Causing an impression in the posterior wall of the
esophagus.
Diagnosis
Aberrant right subclavian artery
Differential diagnosis
Double aortic arch
Esophageal spasm
Extrinstic compression of the esophagus from nonesophageal tumors
(retrosternal extension of the thyroid) or
lymphadenopathy
Discussion
Background
The origin of the subclavian artery from the proximal descending
aorta is referred to as an aberrant subclavian artery. A
left aortic arch with an arsa is the most common
congenital anomaly of the aortic arch; the second most
common variant is a right-sided aortic arch with an
aberrant left subclavian artery (ALSA). The left
ligamentum arteriosum can form a vascular ring.

8
 Causing tracheal ccompression, and is associated more
commonly with ALSA and right aortic arch.
Kommerell diverticulum is a bulbous dilatation at the
origin of the subclavian artery measuring more than
double the diameter of the distal part of the artery. It is
more commonly associated with a right aortic arch and
an ALSA. A midline descending aorta is in an abnormal
location anterior to the vertebral bodies and is associated
with a right aortic arch with ALSA.
Both ARSA and ALSA run posterior to the esophagus.
Levels of tracheal compression are different for both
varians.
Clinical findings
ARSA presents in adults with dysphagia more commonly thair airway
symptoms. ALSA presnts with
Breathing difficulties due to the airway compression and dysphagia in
children. Older patients can present with shoulder pain,
neck pain, or thromboembolic disease of the extremities.

Complications

Complications include esophageal obstruction, tracheal

compression,thromboembolic disease, and, rarely,
arteriesophageal fistula.

Etiology
Embryologically the subclavius artery is derived from the seventh
intersegmental artery; a developmental anomaly leads to
aberrant subclavian arteries.

Imaging findings

9
Barium esophagram shows smooth indentation over the posterior wall
of the middle third of the esophagus.
Angiography, computed tomography scan, and MRA can all be used
to show the subclavian artery crossing posterior to the
esophagus. Additional information about the presence,
size and complications of kommerell diverticulum can be
obtained on cross-sectional studies.
Esophagoscopy shows a pulsatile extrinsic compression of the
esophagus.

Treatment
Surgical intervention is considered in symtomatic patiens and patiens
complicated disease. Surgical resection and
reanastomosis with revascularization of the vertebral and
subclavian arteries are available

Prognosis
The prognosis depends on the presentation of disease. Generally, the
prognosis is good in uncomplicated patients without
debility in whom surgical treatment is successful without
life-threatening complications. Subclavian steal
syndrome can be a possible complication in surgically
treated patients.

PEARL
Aberrant subclavian arteries should be considered in the presence of a
smooth, linear identation over the posterior wall of the
esophagus.

PITFALL

10
Posterior indentation over the esophageal wall is also caused by
double aortic arch, benign or malignant tumors of the
esophagus, nonersophageal tumors such as thyroid
neoplasms with retrosternal extension, and vertebral
spurs.

CASE 2

Clinical Presentation

A 63-year-old man complains of epigastrlc pin chronic fatigue, and

weight loss.

Fig. 78.1 (A.B) Contrast - enhanced CT inages demonstrate

circumferential thickening of the gastric antrum with
associaled gastne e distention and lymphadenopathy.

Radiologic findings
Contrast - enhanced computed tomography (CT) images (Fig. 78.1)
demonstrate circumferential thicken ing of the gastric
antrum with associated gastric distention and
lymphadenopathy.

Diagnosis
Gastric mucosa-associated lymphoid tissue (MALT) lymphoma

Differential Diagnosis
Gastritis/gastric ulcer .
Gastric metastases
Gastric carcinoma

11
Discussion
Background
The stomach represents the most common primary site of extranodal
lymphomas in the gastrointesti- nal (GI) tract (65-75%),
although these tumors account for only 2 to 5% of gastric
primary malignan- cies. However, the relative frequency
of gastric lymphoma, unlike that of carcinoma, has
increased as a result of the acquired immunodeficiency
syndrome (ADS epidemic Lymphomas typically occur in
patients ages 50 to 60 years and show no evidencee of
sex predilection Chronc sastritis caused by Helicobacter
pylori plays a major ole in the development of lynphoid
tissue (MALT which is thought to be the precursor of
gastric MALT Iymphomas. At histology MALT
lymphomas can be clas sified into two types: lowgrade
(50-72 of cases) and high grade, which probably results
from the transformation of low-grade lymphomas.

Clinical Findings
Clinical presentation is usually nonspecitic. Patients may experience
symtoms mimicking gastritis or peptic ulcer disease,
such as epigastric pain and dyspepsia. Other symtoms,
such as low-grade fever, chronic fatigue. weight loss and
anema. Have been reported

Complications
Patients may experiance GI bleeding due to tumor ulceration or
obstruction. Rarely, perforation may occur.

Etiology

12
The etiology is still controversial. Several studies have demonstrated
the high frequency of H. pylori infection in patients
affected by gastric lymphoma; furthermore, some of
these neoplasms may regress after the eradication of H.
pylori. Several cytogenetic abnormalities have been
demonstrated the most common being trisomy 3 and
11:18 transiocation

Imaging Findings
Double-contrast upper GI examination demonstrates a wide spectrum
of radiologic findings, especially in cases of low-grade
lymphomas: multiple erosions and ulcers either shallow
or deep associated with converging thickened gastric
folds represent the most common finding in both Gastric
lymphonmas, particularly high-grade lymphomas, may
appear as large masses with or without ulcers. Other
fluorascopic imaging findings include round or oval
mucosal nodules of variable size and prominent areae
gastricae. However, differentiation of MALT lymphomas
from gastritis or gastric adenocarcinoma is extremely
challenging by imaging despite the presence of these
typical findings

Multidetector CT has been increasingly performed for the detection of

primary gastric malignancies because of its multiplanar
capabilities: appropriate distention of the gastric lumen
(oral administration of water prior to scanning) is
recommended to improve the assesment of the gastric
mucosa. The typical ct patterns of gastric lymphomas
include diffuse thickening of The wall (> 50% involved),
segmented thickening, and a localized polypoid mass

13
 These tumors commonly extend throught the pyloric region into the
duodenum, whereas gastric carcinoma tends to spread to
the gastroesophageal junction. Patients with gastric
lymphomas, unlike those with carcinomas, often present
with multiple, bulky lymph nodes usuallly extending
below the renal hilum. Another major key point in the
differential diagnosis is the degree of the wall thickening,
which is more prominent in lymphomas (average value 5
cm). The enhancement pattern of lymphomas is usually
variable and therefore nonspecific for the diagnosis of
these tumors

Treadment
Eradication of H. pylori represents the first line of therapy according
to the central role played by this bacterium in the
pathogenesis of lymphomas. Eitther chemotherapy or
monoclonal antibody therapy (rituxinab: anti-C20
monoclonal antibody) is used in case of failure of
antibiotic treatment or in those neoplasms not associated
with H. pylori infection.
Surgery has a limited role due to the efficacy of medical treatment

Prognosis
The prognoSis depends on the histologic grade: low - grade lymphomas have a
favorable prognosis as they may even regress after antibiotic
therapy

Pearl

14
Marked gastric wall thickening, especially when associated with bulky
lymphadenopathy, should place lymphoma high in the differential
diagnosis

PITFALL
Gastric lymphomas may present overlapping radiologic findings with chronic
gastritis (ulcers, erosions, and fold thickening) and gastric
adenocarcinoma(bulky intraluminal masses) Underdistention of
the stomach at CT may simulate thickening.

CASE 3
Clinical Presentation
A 28 year-old man complaits of epigastric pain, anoresia. and weight
loss.
Fig.79.1 (A.B) Axial contrast-enhanced CT images of the abdomen
show mild enhanicement and diffuse increased thid neis
of the gastsic walls; these findings are suspicious for
gastric neoplasm, although an inflammatory process
cannot be excluded. Multiple hypodense cystic lesions
are seen in the liver and both kidneys.
Radiologic Findings
Axial contrast-enhanced computed tomography (CT) images of the
abdomen (Fig. 79.1) demonstrate mild and diffuse
thickening of the gastric walls. The images from the
upper gastrointestinal (GI) series (Fig. 79.2) demonstrate
abnormal and persistent narrowing of the distal stomach.
Diagnosis
Gastric adenocarcinoma
Differential Diagnosis
Gastric metastases

15
Gastritis
Gastric mucosa-associated lymphoid tissue lymphoma
Gastric Crohn disease
Caustic ingestion
Gastric tuberculosis
Discussion
Background
Gastric carcinoma is a deadly disease, with decreasing incidence in
the past 50 years in North America and Western Europe
owing to the earlier identification at imaging and
endoscopy. Currently, the incidence of gastric carcinoma
is extremely variable worldwide, with the highest
number of cases in Japan, China, Rusia and Eastern
Europe (>30 cases per 100.000); men are usually 2 times
more commonly affected than women, with a peak
incidence in those ages of 50 to 70 years.
differend histologic types have been described:
adenocarcinomas (intestinal and diffuse types) account
for almost 95% of case, and lymphomas,
leiomyosarcomas, carcinoids, and sarcomas for the
remaining 5%. Adenocarcinomas have been classified
into four different subtypes ; papillary, tubular mucinous
and signet ring. Almost 30% of gastric malignancies
arise from the antrum, 30% from the body, and 40%
from the fundus and cardia region
Clinical Findings
Chinical presentation mostly depends on the disease stage: patients
may be asymptumatic (early stage) or may present with
bleeding epigastric, pain, anorexia, weight loss, nausea,
vomiting, and upper GI (hematemesis melena, occult
blood in stools)

16
 Complications
In advanced stages, liver metastases may cause hepatomegaly and
jaundice; less common sites for metastases include the
lung, adrenal glands, and kidneys (Krukenberg tumors)
Etiology
Several dietary and environmental factors have been identified:
dietary nitrates, certain ffoods (salted fish and meat,
smoked foods), hypochlorhydria resulting from drugs or
previous surgery, cigarette smooking, and Helicabacter
pylori infection. In particular, patients with H. pylori
gastritis are 3 to 6 , times more likely to develop gastric
cancer. Other precancerous conditions include Ménétrier
disease, adenomatous gastric polyps, partial gastrectomy,
and pernicious anemia
imaging findings
Endoscopy is currently considered the diagnostic procedure of first
choice in patients with suspected gastric malignancies.
Barium studies, either with single or double contrast. have been
performed extensively for the detection of gastric
tumors, although their overall sensitivity is somewhat
lower than endoscopy.
High spatial resolution magnetic resonance imaging, used in in vitro
experimental studies, is a promising imaging modality
for the assessment of the depth of gastric tumor invasion
because of its accuracy in depicting the Distant layers of
the gastric wall.
Treatment
Complete resection of the tumor and adjacent lymph nodes is
considered the only curative treatment, although a
surgical procedure may be associated with several late

17
 complications, including dumping syndrome, vitamin
B12 deficiency, and reflux esophagitis; some selected
neoplasms may benefit from endoscopic mucosal
resection.
Chemotherapy is administered in patients with systemic metastatic
disease
Prognosis
Gastric cancer presents a dismal prognosis, with overall 5-year
survival rates < 20%; however, early gastric cancers are
potentially curable, with a mean 5-year survival rate of almost
90% . Hence prompt diagnosis of these tumors is mandatory
Pearl
Distention of the gastric lumen with a negative contrast medium (water, air)
may improve the detection of small superficial gastrice lesions.

CASE 4
Clinical Presentation
A 77 year old man presents with abuluminal pain
Fig. (80.1) Contrast-enhanced CT scan show a lobulated,
heterogeneously enhancing mass arising from the
proximal stomach (arrow).
Radiologic Findings
An abdominal computed tomography (CT) scan (Fig. 80.1) shows a
large, lobulated, heterogeneously enhancing mass arising
from the proximal stomach.
Diagnosis
Gastrointestinal stromal tumor (GIST)
Differential Diagnosis
Gastric adenocarcinoma
Leiomyoma/leiomyosarcoma
Schwannoma/neurofibroma

18
Metastasis
Discussion
Background
GISTS are the most common mesenchymal tumags arising from the
gastrointestinal (GI) tract wall. Nevertheless, they are
uncommon, accounting far only 1 to 3% of all GI
neoplasms, and usually patients >50 years of age without
any gender predilection. These tumors are also reported
to occur in 10 to 25% of patients affected by
neurofibromatosis 1. Previously mistake for smooth and
neural tumors, GISTS show distinctive genetic and
histologic features. They can occur anywhere from the
rectum to the esophagus, the stomach being the most
common located site of origin: they can also be located
in the mesentery omentum, and retroperitoneum.
Clinical Findings

The clinical presentation relies on the location, size, and pattern of

growth of the tumor and is mainly characterized by
abdominal pain or distention, anemia or melena, or
bowel obstruction.

Complications

Malignant GIST can be aggressive and spread to the liver,

retroperitoneum. and mesentery, and less frequently to
the bones, lungs, and lymph nodes. Intraluminal GISTs
can cause bowel obstruction.

Etiology

GISTs have distinctive immunohistochemical properties, the most

important being the expression of KIT (CD1I7), a
tyrosine kinase growth factor receptor, which promotes
the growth of mesenchymal neoplastic cells.

Imaging Findings

19
Although tumor expression of the KIT receptor is needed for a
definitive diagnosis of GIST, imaging, especially CT,
has proved to be instrumental. GISTs are usually seen as
exophytic, heterogeneously enhancing, rarely calcified
masses arising from the GI tract wall. Most of them,
especially larger ones, show heterogeneous density due
to the presence of intratumoral necrosis (Fig. 80.2),
hemorrhagic foci, and cystic degeneration.

Treatment

Surgical removal is recommended, but despite complete resection, the

recurrence rate is high, especially in the setting of less
well differentiated lesions.
New drugs targeting the growth factor receptor KIT appear promising,
but so far they have been used only for unresectable
tumors.

Prognosis
- Recent advancements in therapy have increased the
average survival rate, especially in malignant
nonmetastatic GISTs.

Fig. 80.2 Contrast-enhanced CT in a different patient shows a large

heterogeneous mass arising from the stomach. Multiple
hepatic cysts are present.

CASE 5

Clinical Presentation

A middle-aged man presents for evaluation of long-standing

dysphagia with episodic periods of more intense
discomfort.

Fig. 81.1 (A) Contrast-enhanced axial CT image

demonstrates a large hiatal hernia. The distal esophagus
is midline, and the gastroesophageal (GE) junction as
well as a portion of the stomach is located within the
intrathoracic hernia. (B) Overhead radiograph and (C)
spot fluoroscopic image from an upper gastrointestinal
series show a large hiatal hernia. The radiograph
illustrates that the Uconcave greater curvature of the
gastric body is located
cephalad to the “convex” lesser curvature, the GE

20
 junction and pylorus. The GE junction and pylorus
maintain their normal relationship.

Radiologic Findings
Contrast-enhanced axial computed tomography (CT)
image demonstrates a large hiatal hernia (Fig.81.1A).
The distal esophagus is midline, and the
gastroesophageal (GE) junction as well as a portion of
the stomach is located within the intrathoracic hernia. An
overhead radiograph and spot fluoroscopic image (Fig.
81.1B,C) from an upper gastrointestinal (GI) series show
a large hiatal hernia. The radiograph

Diagnosis
Organoaxial gastric volvulus in a large hiatal hernia
Differential Diagnosis
Sliding hiatal hernia
Paraesophageal hernia
Large intra-abdominal mass with superior displacement of the
stomach
Discussion
Background
Gastric volvulus represents abnormal torsion of the stomnach, usually
> 180 degrees. If the greater curvature rotates superior to
the lesser curvature along the long axis of the stomach.
This is termed an organoaxial volvulus and accounts for
-60% of gastric volvulus case. If the antrum and pylorus
rotate. Anterosuperior to the fundus and GE junction,
this is termed a mesenteroaxial volvulus, representing -
30% of volvulus cases. The volvulus is also classified
with respect to the diaphragm: supradiaphragmatic (two
thirds) or subdiaphragmatic / intraperitoneal (one third)
Clinical Findings
In cases of chronic volvulus, patients typically present with
nonspecific abdominal complaints, including vague
abdominal or chest pain early satiety or fullness
dysphagia, or dyspnea. Chronic volvulus may be noted

21
 incidentally on chest radiographs or an upper GI series or
esophagram. Acute volvulus demonstrates more dramatic
presentations, including severe pain, an inability to
ingest liquids or solids or pass, an enteric tube, gastric
outlet obstruction, and peritonitis when there is gastric
ischemia or perforation Purportedly diagnostic of acute
obstructing volvulus, the classic Borchardt triad
describes severe constant chest or epigastric pain, nausea
with inability to vomit, and difficulty passing a
nasogastric tube.

Complications
Organoaxial volvulus can be complicated by strangulation in-5 to 20%
of cases secondary to twisting of the left gastric artery
and occlusion of venous drainage. Ischemia in
mesenteroaxial volvulus is rare. Any type of gastric
volvulus can be associated with gastric outlet
obstruction. Obstruction with strangulation is usually
seen only in cases of acute volvulus. Mortality ranges
from < 10% for chronic cases to > 40% for acute
volvulus
Etiology
Organoaxial volvulus is usually seen in adults and is associated with a
diaphragmatic defect in 50% of cases, including hiatal
hernia, paraesophageal hernia, eventration, and
diaphragmatc rupture. This defect allows for abnormal
movement of the gastric body into the thorax with
resultant o this way, the majority of organoaxial volvulus
in this way, the majority of organoaxial volvuls case also
represent the supradiaphragmatic variety in comparison,

22
 mesenteroaxial volvuli are over whelmingly
subdiaphragmatic and most often seen in children.
Thought to be de to abnormal laxity of the suspensory
ligaments of the stomach, mesenteroaxial volvulus can
be also be associated with a “wandering” ectopic spleen
Treatment
Acute gastric volvulus is initially treated with attemted nasogastric
tube decompression.
Surgical repair is indicated for all cases of volvulus and involves
untwisting of the volvulus, return of the stomach to a
subdiaphragmatic position, gastropexy in an anatomical
position, and repair of any predisposing diaphragmatic
defect. Surgical access may be via thoracotomy,
laparatomy, or peritoneal laparscopy.
Prognosis
Following successful repair with gastropexy, the risk of recurent
gastric volvulus is low and is related to failure of
gastropexy and adequancy of repair of any known
diaphragmatic defect

PEARL
Acute gastric valvulus is a surgical emergency because of the
moderate risk of ischemic strangulation and gastric outlet
obstruction and requires diaphragmatic repair of both the
gastric torsion and any defect
PITFALLS
Chronic volvulus can be intermittent, and the upper GI series may
only demonstrate hiatal or araesophageal hernia during
an asymptomatic period

CASE 6

23
Clinical Presentation

A 42-year-old man presents with postprandial epigastric discomfort.

Fig. 82.1 Ultrasound image shows

a well-defined cystic structure with
a gut signature in continuity with
the lateral duodenal wall and the
lumen of the vertical part of the
duodenum. The lumen and the wall
of the lesion are contiguous with the
lateral wall of the second part of the
duodenum.

Radiologic Findings

Upper abdominal ultrasound shows a well-demarcated hypoechoic

structure (Fig. 82.1) in close proximity to the second
portion of the duodenum. The structure has a gut
signature on ultrasound with alternating hyper- and
hypoechoic layers in the wall.

Diagnosis

Duodenal diverticulum arising from the lateral wall of the duodenum

Differential Diagnosis

Postbulbar duodenal ulcer

Pancreatic pseudocyst
Cystic pancreatic tumor
Duodenal duplication

Discussion

Background

The duodenum is the second most common site for diverticula

formation after the large bowel. The incidence of
duodenal diverticula is 5 to 15g on barium examinations,
20 to 25% at autopsy. The peak incidence of duodenal
diverticula is found in the 5th to 6th decades of life. They
typically arise from the medial wall of the second and

24
 third pacts ot the duodenum within 2 cm of the a Vat
Intraluminal dundenal divecticula are sare Deticua a
Large in size and ane Iess cummn iv ula can alo be
classified as pimary o secondary (due to postbullar uloy
ampula o tend to be Lateral wall from the medial wall of
the second and third parts of the duodenum within 2 cm
of the ampulla of vater. Intraluminal duodenal diverticula
are rare. Diverticula arising from the lateral wall tend to
be larger in size and are less common. Diverticula can
also be classified as primary or secondary (due to
postbulbar ulcer)

Clinical Findings
Asympromatic
Abdominal discomfort
Pain in the epigastric ar umbilical region
Central abdominal pain radiating to the back
Jaundice in the case of compression of the biliary channels
Pain and fever in cases of diverticulitis

Complications
Diverticulitis
perforation
Pancreatitis secondary to perforation
Bleeding
Obstructive jaundice due to compression of the biliary channels
Cholangitis
Failure of endoscopic retrograde cholangiopancreatography if the
common bile duct drains into the diverticula
Increased incidence of cholelithiasis
Neoplastic change

25
Bezoar formation

Etiology
Primary diverticula are thought to arise because of the presence of a
weakened wall in the duodenum at the vessel's entry site.
biliary ductal entry sites, muscular weakness in the wall,
or heterotopic pancreatic tissue.

Imaging Findings
. On an upper gastrointestinal series with barium, the diverticula are
seen as typical outpouchings arising drom the duodenum
without any distortion of mucosal folds, which changes
their configuration with time (fig82.2). delayed retention
of barium in the diverticula is a diagnostic finding.
Intraluminal diverticula appear as intraluminal
projections of barium-filled linear structures with
surrounding lucency, giving a “typical wind sock”
appearance
Ultrasound demonstrates a clear fluid- or food-containing structure
with the presence of gas in the nondependent portion of
the lesian. The wall of the duodenal diverticula typically
shows the multilayered gut signature on ultrasound. Use
of real-time ultrasound imaging helps, and diverticula
can be better demonstratted after the ingestion of large
quantities of fluids
CT shows gas-containing diverticula (Fig. 82.3) In cases where gas s
absent, diverticula can be confused with cystic
neoplasms, pseudocysts, or abscess. In such cases,
repest scans may demonstrate the presence of gas within
the structure.

26
Fig. 82.2 Upper gastrointestinal series image in a different patient
shows the presence of diverticula arising from the medial
wall of the second and third parts of the duodenum
(arrows).

Fig. 82.3 Axial contrast-enhanced CT image in a 63-year- old man

shows the presence of a gas-filled diverticulum arising
from the lateral wall of the third part of the duodenum
(arrow).

T2-weighted magnetic resonance images show a hyperintense fluid-

containing structure and
hypointense gas within the nondependent portion of the
lesion.

Treatment

Conservative treatment is preferred in asymptomatic primary

duodenal diverticular disease without any complications.
The patient can be advised to adopt a position that favors
diverticular emptying. Surgical treatment in symptomatic
primary diverticular disease is undertaken only in
patients with complications and persistent symptoms
despite conservative management. In patients with
secondary disease because of an ulcer, the treatment of
the ulcer by medications and surgery is recommended.

Prognosis

The prognosis for primary duodenal diverticular disease is excellent

with lesser incidence of complications. In patients with
secondary diverticula due to a postbulbar ulcer who are
treated, the prognosis is good; however, the rates of
complications are higher.

PEARL
The presence of gas and continuity with the duodenum
help to differentiate duodenal diverticula from other
pathologies.

PITFALL
Duodenal diverticula filled with fluid can be mistaken

27
 for cystic neoplasms from the head of the pancreas, in
which case barium examination should be considered.

CASE 83

Clinical Presentation

A 57-year-old man presents with abdominal pain and discomfort.

Physical examination reveals a palpable mass in the
anterior abdominal wall, in the midabdomen.

Fig. 83.1 (A,B) Axial CT image show small bowel loops herniating
through the abdominal wall and surrounded by arim of
soft tissue density with stranding, consistent with mild
inflammation. There is mild distention of the small
bowelproximally to the herniated loops.

Radiologic Findings

Axial computed tomography (CT) images (Figs. 83.1) show small

bowel loops herniating through the abdominal wall and
surrounded by a rim of soft tissue density with stranding,
consistent with mild inflammation. There is mild
distention of the small bowel proximally to the herniated
loops.

Diagnosis

Abdominal wall hernia

Differential Diagnosis

Abdominal wall tumors (desmoid, lymphoma, hemangiomas, lipoma,

metastases, etc.)
Rectus sheath hematomas (posttraumatic, associated with
coagulopathy)
Enlarged lymph nodes (infections, lymphomas, etc.)
Enlarged, prominent vessels (as seen in cirrhotic patients with portal
venous shunts)
Undescended testis
Abdominal wall endometriosis

Fig. 83.2 An axial contrast-enhanced CT image through

the pelvis demonstrates a direct left inguinal hernia.

28
 Small
bowel loops are present along the left spermatic cord.
Neither inflammatory changes nor signs of strangulation

Fig. 83.3 Axial contrast-enhanced CT image shows a left

ventral hernia containing small bowel loops and
mesentery.
are present.

Discussion

Background

A hernia is commonly defined as the protrusion of any viscus from its

proper cavity into a saclike structure formed by the same
membrane with which the cavity is usually lined.
Different types of hernias have been described according
to their anatomical distribution, the most frequent in both
men and women being inguinal hernias (direct Fig. 83.2
and indirect). Others include

Femoral hernia: occurs medial to the femoral vein and posterior to the
inguinal ligament: com monly right-sided
Ventral hernia:
a. Midline defects: umbilical, paraumbilical, epigastric, and
hypogastric hernias. Umbilical is the most common type,
usually occurring in women (risk factors: obesity,
multiple pregnancies, ascites, intra-abdominal masses)
b. Lateral defects—spigelian hernia (Fig. 83.3): occurs
along the lateral aspect of the rectus muscle through the
hiatus semilunaris
Posterior defects—lumbar hernia: occurs either through defects in the
superior (Grynfeltt) (Fig.83.4) or inferior (Petit) lumbar
triangle

Fig. 83.4 (A.B) Lumbar hernia of Grynfeilt seen on CT (arrow). Note

that this hernia contains a portion ofGerota fascia. The
contents of these hernias can be confused with a
lipomatous tumor.

29
Fig. 83.5 Axial CT image of the pelvis shows a herni
ated bowel loop in the left obturator fossa (arrow).

Obturator hernia: occurs through the obturator foramen, usually in

elderly multiparous women (Fig. 83.5)
lncisional hernia: represents a delayed complication of abdominal
surgery

Abdominal wall hernias are very common, with more than 500,000
operations performed in the United States every year.
Unfortunately, surgical repair is associated with a high
rate of complications (up to 20%), such as recurrence,
fluid collections, and infection of prosthetic materials.
The clinical diagnosis may be difficult in cases of
obesity or abdominal scarring from a previous surgery:
hence imaging plays a central role in recognizing this
pathologic entity and decreasing the morbidity associated
with complications.

Clinical Findings

Clinical presentation depends on the anatomical location and severity

of abdominal hernias. Patient presentation can range
from vague abdominal tenderness and discomfort with a
palpable abnormality to a bowel obstruction.

Complications

Major complications include strangulation (Fig. 83.6) and

incarceration (Figs. 83.1), both leading to bowel
obstruction or perforation in case of missed or delayed
diagnosis. Incarceration refers to those hernias that
cannot be manually reduced because of progressive
narrowing of the neck of the hernia sac. Strangulation
refers to ischemia of the protruded organ due to impaired
blood supply. Other, less frequent complications include
herniation of other organs, either solid (liver, kidneys) or
nonsolid (stomach, bladder).

Fig. 83.6 Axial contrast-enhanced CT image shows a ventral

hernia in the left lower quadrant, which contains a loop
of
descending colon. There is a small amount of fluid in the
her
nia sac. The bowel within the colon demonstrates mild
wall

30
 thickening. The colon distal to the hernia is
underdistended.
These findings are consistent with strangulation.

CASE 8
Clinical Presentation
A 72 year-old woman presents with abdominal distention, fullness,
and pain in the right iliac fossa
Fig. 90.1 (A) Axial contrast-enhanced CT image shows the presence
of a cystic lesion with thick walls in the right illac fossa
with surrounding fat stranding and free fluid. (B) Axial
contrast-enhanced CT image of the liver in the same
patient thows scalloping of the liver margins and ascites
with peritoneal thickening
Radiologic Findings
Contrast computed tomography (CT) images show the presence of a
cystic lesion in the right lower quadrant with ascites and
scalloping of the liver margins (Fig. 90.1)
Diagnosis
Malignant mucocele of the appendix with pseudomyxoma peritonei
Differential Diagnosis
Abscess
Normal fluid-filled ileal loop
Tuberculous ascites
Peritoneal metastases
Malignant ascites
Ovarian cystic lesions
Bowel perforation
Peritoneal mesothelioma
Meckel diverticulitis with perforation
Discussion
Background

31
Mucocele of the appendix is the accumulation of mucus with luminal
distention of the appendix. The reported incidence is 0.2
to 0.5% of appendectomies, It can be benign or
malignant. The variety results from occlusion of the
appendiceal luminal opening into the cecum from a
phlebo-lith or impacted feces. A malignant mucocele
results from mucin-secreting adenocarcinoma of the
appendix. Either a benign or a malignant mucocele can
result in the development of pseudomyxoma peritonei on
rupture.
Clinical Findings
Chronic pain in the abdomen
Abdominal distention
Mass in the right iliac fossa
Intermittent colicky pain due to intussusception
Vomiting
Complications
Rupture of the mucocele
Development of pseudomyxoma peritonei
Intestinal obstruction
Intussusception
Etiology
Obliteration of appendiceal lumen from any cause
Imaging Findings
On ultrasound, the mucocele may appear as a thin-walled cystic mass
in the right iliac fossa, attached to the cecum, filled with
diffuse internal echoes in the dependent portion with or
with- with out septa and polypoidal luminal projections,
and with posterior acoustic enhancement. The pres- ence
of a solid mass within the nondependent portions of the
lesion indicates the possibility of adenocarcinoma.

32
 Similar findings are seen with CT, with the mucocele
appearing as a low-attenu- ating structure in the right
lower abdomen.
Calcifications within an unruptured mucocele can be curvilinear or
plaquelike and can be appreciated on plain radiographs
of the (Fig. 90.2) The size of the lesion varies, with
lesions measuring up to 15 cm reported in the literature.
A ruptured mucocele show fluid-density ascites with
internal echoes and fixed bowel loops. In patients with
the development of pseudomyxoma peritonei, diffuse
coarse internal echoes within the ascitic fluid can be seen
with scattered calcifications and scalloping on the
peritoneal surfaces of the abdominal organs. Multiple
solid translucent globules of uniform size that calcify in
the course of time and shift with movement are
pathognomonic of the myxoglobulosis variant of a
mucocele.
The presence of mucinous nodules within the remnant umbilical vein
is a feature that the nondependent portions of the lesion
indicates the possibility of with lesions mucocele shows
fluid-density ascites with the development of
pseudomyxoma Multiple solid trans- differentiate
pseudomyxoma peritonei from ascites.

Fig. 90.2 Asial contrast - enhanced CT image in a different patient

reveals a cystic lesion with thick walls in the right illiac
fossa. The lesion shows the presence of calcifications in
its wall
Treatment
Surgical resection of the appendix is the treatment of choice for an
unruptured mucocele of the appendix. In patients with a

33
 ruptured mucocele with the development of
pseudomyxoma perito nei, wide peritoneal stripping is
done for cytoreductive surgery, followed by heated
intraoperative intraperitoneal chemotherapy with
mitomycin C, doxorubicin, and fluorouracil (5-FU)
Systemic chemotherapeutic agents can be used in resistant discase
and recurrent disease.
Prognosis
Patients with an unruptured mucocele of the appendix have an excellet
prognosis. Patients with pseudomyxoma peritonei and
mucinous adenocarcinoma have a worse prognosis with
treatment resistant disease, higher mortality, and
posttreatment complications
PEARLS
A cystic oblong mass in the right iliac fossa should include mucocele
in the differentia
Scalloping of the peritoneal l surfaces of abdominal organs represents
pseudomyxoma peritonei
PITFALL
between benign Imaging cannot always differentiate appendix and
pseudomyxoma peritonei. and malignant causes of
mucocele of the

CASE 10

Clinical Presentation

A 74-year-old man presents with lower abdominal pain and

discomfort associated with a recent change in bowel
habits.

34
Fig. 91.1 An axial contrast-enhanced CT image shows dif
fuse diverticulosis, most significant in the sigmoid colon,
with evidence of related mild muscular hypertrophy. No
pericolonic inflammatory changes are noticed.

Radiologic Findings
An axial contrast-enhanced computed tomography (CT) image (Fig.
91.1) shows diffuse diverticulosis, most significant in the
sigmoid colon, with evidence of related mild muscular
hypertrophy. Nopericolonic inflammatory changes are
noticed.

Diagnosis

Diverticulosis

Differential Diagnosis

Inflammatory bowel disease (Crohn disease and ulcerative colitis)

Colonic carcinoma

Small bowel diverticulosis

Discussion
Background

Diverticula are outpouchings of the intestinal walls, involving either

all the layers (true diverticula) or just the mucosal and
submucosal layers (false diverticula). Diverticular
disease has been described anywhere in the
gastrointestinal (GI) tract but is most frequently present
in the sigmoid colon (95—98%) due to the higher
segmental intraluminal pressures. These diverticula
usually form through weaker points of the colonic walls,
which represent the natural openings for the vasa recta
and other nutrient vessels.

35
Fig. 91.2 (A.B) Axial contrast-enhanced CT images show diffuse
bowel wall thickening of the sigmoid colon with
surrounding inflammatory mesenteric fat stranding.
These findings are consistent with severe diverticulitis.

Clinical Findings

Diverticulosjs is a common, usually asymptomatic condition. Patients

with multiple diverticula may present with different
symptoms according to their location; clinical
presentation most frequently includes left lower
abdominal pain, nausea, and changes in bowel habits,
including diarrhea, constipation, and tenesmus.

Complications

Major complications include GI bleeding (melena, hematochezia) and

diverticulitis due to occlusion of the neck of a
diverticulum by stool, inflammation, or ingested
material, causing subsequent micro perforation of a
diverticulum and associated pericolic inflammation (Fig.
91.2). Inflammation may resolve or progress, causing
abscess formation, fistulas (to local structures, e.g., the
bladder, uterus, or vagina), abdominal obstruction, or
free perforation.

Etiology

Diverticulosis is related to the low-fiber/high-fat diet typical of

industrialized countries leading to abnormal peristalsis,
intestinal dyskinesia, and increased intraluminal
pressures, Its incidence increases with age; in fact.
colonic diverticular disease is uncommon in people
younger than 40 years. Genetics may play a predisposing
role, as left-sided diverticula are usually described in
Caucasian populations, whereas right-sided diverticula
are typically seen in persons of Asian descent.

Imaging Findings

Water-soluble contrast enemas represent a safe but somewhat

outmoded imaging study for diverticulosis.

On CT, diverticula appear as multiple, air-filled outpouchings of the

intestinal walls ranging in size from 2 to 3 mm to 2 cm
(giant diverticula have been reported but are rare) and

36
 usually located in the sigmoid colon: the affected
intestinal segment may have thickened walls due to
muscular hypertrophy. CT is also useful to evaluate the
complications of diverticular disease, such as acute
diverticulitis (wall thickening and pericolic fat
stranding), abscesses (fluid collections with peripheral
enhancing rims), and perforation (extraluminal free air).
Colovesicular fistulas are suggested by the presence of
gas in the bladder or focal bladder wall thickening ¡n
close proximity to the affected segment of the bowel
with loss of dividing fat planes.

CASE 11

Clinical presentation
Nonspesific abdominal pain

Fig. 99.1 Upper gastrointestinal series shows an outpouching (arrow)

arising from the gastric fundus.

Radiologic Findings
Upper gastrointestinal (GI) series shows an outpouching arising from
the gastric fundus (Fig. 99.1).

Diagnosis

Gastric fundal diverticulurn

Differential Diagnosis
Cystic adrenal, renal, or pancreatic lesions
• Necrotic lesions or abscess in cases where air—fluid levels are
present
• Duplication cysts

Discussion

Background

Fundal diverticula are the most common gastric diverticula arising

from the cardiofundic region. They are congenital and
usually seen on the posterior wall of the stomach. These
are true diverticula and contain all layers of the stomach

37
 wall: they are variable in size, ranging from 1 to 10 cm.

Fig. 99.2 Axial CT image of the upper abdomen shows a

contrast-filled fundal diverticulum (arrow).

Clinical Findings
Patients are often asymptomatic Some patients may present with
intermittent pain, worse when supine.

Complications
Usually these are asymptomatic; however, cases of bleeding and
ulcerations exist. Patients may present with pain and
abdominal discomfort If diverticu are large, impaired
emptying may occur. Additionally, the condition may
lead to excessive workup due to misinterpretation of a
diverticulum as an adrenal mass.

Imaging Findings

Lateral view of a barium swallow and upper GI studies may

demonstrate an Outpouching on the posterior aspect of
the gastric cardia, with a characteristic finding of a
fundal diverticulum
Computed tomography may show a collection of contrast material
arising from the posterior aspect of the gastric fundus. ¡t
usually projects in the retroperitoneal cavity.
Occasionally, when poorly opacifje with oral contrast, a
fundal diverticujum may mimic an adrenal mass and is
considered in the differential for an adrenal pseudomass
(Fig. 99.2).

Treatment and Prognosis

• Treatment is conservative and expectant.

PEARL

Classic appearance on barium studies

Pitffal
When poirly dioles with oral Congrast pr id collapsed, Hattrick fundal
Diverticula mau mimik adrenal lesions

38
CASE 12

Clinical Presentation

A 73-year-old woman presents with abdominal discomfort and flank

pain.

Fig. 103.1 Coronal reformatted contrast-enhanced CT

image show a heterogeneous, ill-defined mass in the left
perinephric region surrounding the left kidney. The
lesion
shows areas of fat density and foci of calcifications
adjacent
to the left kidney.

Radiologic Findings

Coronal reformatted, contrast-enhanced computed tomography (CT)

image shows a heterogeneous, ill-defined mass in the left
perinephric region surrounding the left kidney. The
lesion shows areas of fat density and foci of
calcifications adjacent to the left kidney (Fig. 103.1).

Diagnosis

Dedifferentiated retroperitoneal liposarcoma

Differential Diagnosis

Malignant fibrous histiocytoma

Retroperitoneal lymphoma
Metastases
Retroperitoneal dermoid
Infection (rare)

Discussion
Background

Liposarcoma is the second most common type of soft tissue sarcoma

in adults and is most commonly seen in the 5th decade of
life.

Clinical Findings

39
Abdominal fullness
Flank pain
Vomiting
Abnormal renal function tests in patients with renal invasion
Hematuria

Complications
Invasion of adjacent organs, mainly kidneys
Metastases (very rare)

Etiology
Unknown

Imaging Findings

On imaging, a retroperitoneal, large, ill-defined, heterogeneous, fat-

containing mass with involvement of adjacent organs
and bridging across the fascial planes is seen. Tumors are
almost always large in size at presentation, and patients
usually present with nonspecific symptoms.
CT may show calcifications that are commonly nodular in
configuration.
Involvement of adjacent organs, mesenteric vessels, and renal vessels
is common and should be carefully assessed at imaging.
Contiguity with an adjacent organ remains an important
issue for complete assessment because tumors tend to
invade adjacent organs without any direct evidence of
involvement on imaging.
The presence of fat on CT and magnetic resonance imaging (MRI)
helps in diagnosing the condition; however, macroscopic
fat is not always present in liposarcomas (Fig. 103.2).

Fig. 103.2 Axial contrast-enhanced CT image in a differ

ent patient shows a hypoattenuating lesion with a thick
enhancing capsule. The lesion is posterior to the kidney,
compressing and displacing the kidney anteriorly. Because
no discrete focus of macroscopic fat was seen, it was dii
ficult to diagnose this lesion as liposarcoma; however, the
lesion was found to be dedifferentiated liposarcoma on sur
gical pathology.

Treatment
Surgical resection of the tumor is the treatment of choice in patients
without metastases. Contiguity with the kidneys
necessitates nephrectomy in adittion to resection of the
primary neoplasm

40
Prognosis
The prognosis is worse in patients with renal involvement and
vascular encasement of the aorta and o/r inferior vena
cava. However, in patients with surgically resectable
liposarcoma without adjacent organ involvement, the
prognosis remains excellent after treatment, althought
long - tern Followup up imaging is important to deret
recurrence

Pearl
Large, ill-defined, heterogenous, fat-density retroperitoneal lesion

Pitfall

Lesions that do not demonstratif macroscopic far on MRI and fat

density on CT candit be differentiated drop Outher
retroperitoneal Sarcomatous lesions, neccesitating a
biopsy

CASE 13

Clinical Presentation

A 60-year-old woman presents with abdominal discomfort.

Fig. 108.1 Axial CT image with oral and intravenous contrast

demonstrates a hazy appearance to the mesentery with
small mesenteric lymph nodes.

Radiologic Findings

Axial computed tomography (Ci) image with oral and intravenous

contrast (Fig. 108.1) demonstrates a hazy appearance to
the mesentery with small mesenteric lymph nodes.

Diagnosis

Misty mesentery

Differential Diagnosis

Mesenteric panniculitis

41
Malignancy, specifically non-Hodgkin lymphoma

Inflammation due to processes such as inflammatory bowel disease

and pancreatitis

Infection

Mesenteric edema/lymphedema

Trauma and hemorrhage

Discussion

Background

The term misty mesentery refers to increased cr attenuation of the

mesenteric fat caused by infiltration with fluid,
inflammatory cells, tumor, or fibrosis.

Clinical FIndings
Clinical FIndings may be nonspecific or secondary to the underlying
condition. FIndings may be incidental in an asymtomatic
patients imaged for Outher respons.

Etiologi
The increased CT attenuatiob may be the result of the mesentric fat
by a barier of causes. Depending on the underlying
condition. Cause include fluid as mesenteric edema dus
to hypoalbuminemic states, cirhosis, inferior vena cava
obstruction, budd-chiari syndrome, or lymphatic
obstruction: hemorrhage; or imflamatory cell as in
mesenteric paniculitis, tumor cell, and fibrosis.

Imaging findings
Minta mesenteric regresi to nonspesific increased CT attenuation of
the mesenteric fat.

Treatment
Close followup with CT is recommended to search for occult
malignancy. Followup examinations may demonstratif
resolution of the imflamatory condition. In cases of
persistent misty mesentery with unknown Cause, biopsy
may be necessary for definitipe diagnosis.

Prognosis

42
The prognosis depends on the underlying condition

PEARL
Misty mesentery refers to increased CT attenuation of the
mesenteric fat and is a nonspecific finding that may
occur in a variety of Clinical situations

Pitfall
Failure to recognize misty mesentery on CT may luas to a delay in
diagnosis and treatment of infiltrating neoplastic
conditions

CASE 1

Clinical Presentation

A 48-year-old man complains of abdominal pain, severe bladder

pressure, and pain with coughing for 2 years.

Fig. 110.1 (A—D) Axial and sagittal images of the abdomen and
pelvis show a large, low-attenuating mass in the right
lower quadrant of the abdomen extending into the pelvis
with internal septations.

Radiologic Findings

There is a large, low-attenuating mass in the right lower quadrant of

the abdomen extending into the pelvis with internal
septations (Fig. 110.1).

Diagnosis

Multilocular mesothelial (peritoneal) inclusion cyst

Differentiated diagnosis
- lymphangioma
- varian cystadenoma/cystadenocarcinoma
- cystic carcinoma
- mesenteric - mental cyst
- visceral cysts

43
Discussion
Background
Multiloculated mesonthelial (peritoneal) inclusion cysts, or
multicystic Mesothelioma of the peritoneum, is a
nonneoplastic proliferation of mesthelial cell lining the
peritoneum, omentum, and abdominal and pelvic
viscera with a predilection for surfaces of the pelvis.
They usually Occur in ujung to middle-aged women.

Clinical findings
Most patients are premenopausal women who present with pelvic
or abdominal pain.
Etiology
Multiloculated mesonthelial (peritoneal) inclusion cysts usually
Develop in the setting of fluid secretion from active
ovaries. The formation of cysts is facilitated by the
presence of peritoneal adhesions, which accumulate
fluid and Cause reactive proliferation of mesonthelial
cells.
Imaging Findings
Crsss-sectional imaging demonstrates Multilocular thin-walled cysts
containing watery secretions. Internal septations may
show enhacement on contrast-enhanced computed
tomography or magnetic resonance imaging.
Treatment
- treatment is achieved by total Surgical excision.
- oral contractive treadment may be useful in suppressing fluid
secretion from the ovaries.

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- Radiation And chemotherapy are not effective.
- in rare cases, laparoscopic or open surgical excision of adhesions
may be necessary

Prognosis
With Surgical excision the rare of reccurance is 30 to 50%

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 BAB III
KESIMPULAN

CT Scan dapat menghasilkan gambar-gambar yang sangat akurat dari objek-objek di

dalam tubuh seperti tulang, organ, dan pembuluh darah. Gambar-gambar ini sangat

berguna dalam Proses mengakkan diagnosa berbagai penyakit, seperti kanker, penyakit

jantung, stroke, kelainan organ reproduktif, dan kelainan gastrointestinal.

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 DAFTAR PUSTAKA
1. Primamedika – Radiology.http://www.primamedika.com/radiology.htm
2. Elektro Indonesia – 3D CT
Scan.http://www.elektroindonesia.com/elektro/no3d.html
3. X-ray computed tomography (CT
Scan).http://en.wikipedia.org/wiki/Computed_tomography
4. NN, Alat Radiologi IV. Akademi Teknik Elektromedik

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