Liver metastasis differential

Hypervascular Liver Metastases

• RCC
• Carcinoid
• Islet cell
• melanoma
• thyroid
• choriocarcinoma
• Ovarian cystadenocarcinoma
• pheochromocytoma

Hypovascular Liver Metastases

• Stomach
• Colon
• Pancreas
• Lung
• Breast

Hemorrhagic Liver Metastases

• Colon
• Thyroid
• Breast
• Choriocarcinoma
• Melanoma
• RCC

Calcified Liver Mets

• Mucinous tumors

Dahnert

Liver mass in children

• Hemangioendothelioma (MC B9)
  • <6 months
  • cutaneous hemangiomas
• Mesenchymal Hamartoma
  • <10 y
  • large, multiloculated
  • exophytic
• Hepatoblastoma (MC malignant)
  • Beckwith-Wiedeman syndrome
  • hemihypertrophy
  • mets
• HCC
  • glycogen storage disease
  • biliary atresia
  liver masses in pediatrics

Disease and Bowel location

• Amebiasis = right colon
• Lymphoma = ileum
• Sprue = entire colon
• Giardiasis = proximal small bowel
• Yersinia = terminal ileum
• Crohn’s disease = terminal ileum
• Ulcerative colitis = rectum

Featureless Small Bowel

Toothpaste, tubular

• graft-vs.-host disease (GvH)
• Mycobacterium avium complex (MAC) (in AIDS)
• ischemia
• Crohn disease
• radiation
• Strongyloides
• milk enteropathy
• sprue
• corrosive enteritis
• lymphoma
• amyloidosis
• mastocytosis
• FUDR toxicity

GI Buzz Word

• central scar = FNH
• Light bulb = pheochromocytoma
• Corkscrew = malrotation midgut volvulus
• Leadpipe colon = ulcerative colitis
• Featureless bowel = Graft versus Host
• Cauliflower liver mets = colon mets
• bird beak esophagus = achalasia
• plaquelike mucosa = candidiasis esophagitis
• cloverleaf deformity = healed duodenal ulcer
• spokewheel mass in mesentery = carcinoid
• sunburst angiography = mesenteric carcinoid
• string sign ileium = Crohn’s disease
• Aphthoid/cobblestone ulcers = Crohn’s disease
• ribbon bowel = graft-vs-host disease
• string of beads biliary system = sclerosing cholangitis
• comet tail artifact in GB = adenomyomatosis

Carcinoid

• malignant neuroendocrine tumor
• SB (Ileum) > lung > thyroid/ovary
• MC malignancy of appendix
• carcinoid syndrome = secretion of serotonin:  flushing, diarrhea, wheezing, cramping, peripheral edema
• findings
  • well defined margins
  • lobulated
  • 30% have calcifications
  • intense contrast enhancement
  • lung: typically central location
  • hot on octreotide scan
• surgery, adjuvant chemotherapy

read more

Multiple Small Bowel Lesions Differential

• lymphoma
• polyposis syndrome
• hemangiomas
• neurofibromas
• metastases

Duodenal Narrowing Differential

Benign

• peptic ulcer disease
• pancreatitis
• crohn disease
• hematoma
• SMA syndrome
• annular pancreas

Malignant

• adenocarcinoma
• lymphoma
• malignant GIST
• mets

Duodenal Filling Defects

Malignant

• adenocarcinoma
• ampullary carcinoma
• lymphoma
• malignant GIST
• metastasis

Benign

• villous adenoma (FAP)
• polyps (most are gastric polyps that prolapse into duodenum)
• GIST
• lipoma (submucosal, smooth surface, fat density)

Nonneoplastic

• heterotopic gastric mucosa
• Brunner gland hyperplasia
• Enteric duplication cyst
• flexural pseudopolyp
• annular pancreas

Duodenal Ulcer

• 2-3 times more common than stomach ulcers
• M>F
• increased secretion of acid
• high incidence of H pylori, stress, smoking, caffeine, corticosteroid use
• fixed outpouching of barium that does not change shape
• most along anterior surface of duodenal bulb
  • only 1 in 20 occur beyond bulb
  • think Zollinger-Ellison syndrome or malignant ulcer
• narrowing of distal and proximal duodenum
• complications: perforation, bleeding, obstruction, penetration
• multiple = Zollinger-Ellison syndrome
• clover-leaf barium collection = scar from old ulcer; should change in shape
• two pyloric channels; fistula connects stomach to duodenum through peptic ulcer

Emphysematous Gastritis

• gas within stomach wall
• causes
  • gas forming organisms: e coli, clostridium perfringens
  • gastric obstruction with increased pressure
  • severe vomiting
  • ischemia
  • infection
  • corrosive ingestion
• corticosteroid use risk factor

read more

Postoperative Stomach Differential

• Marginal Ulcer
• Afferent loop syndrome
• Blown duodenal stump
• Jejunogastric intussusception
• Gastric remnant bezoar
• Postgastrectomy carcinoma
• Bile reflux gastritis

Small Bowel Surgery Diagrams

From AJR article.

Whipple Procedure (Pancreaticoduodenectomy)

Puestow Procedure

Roux-en-Y Procedure

Biliopancreatic Diversion

Afferent Loop Syndrome

• post Billroth II
• obstruction of afferent loop by adhesions, ulcer, tumor, internal herniation
• distension, pain, nausea
• nonfilling of dilated, fluid-filled afferent limb on CT
• perforate, peritonitis, death

Adrenal Mass Differential

• Lipid rich adenoma = fat density
• Adrenocortical carcinoma
• Pheochromocytoma = bright on T2; light bulb
• Myelolipoma
• Lymphoma
• Metastasis

read more

Hinchey Classification of Diverticulitis

Hinchey proposed a classification for acute diverticulitis, that has been variously adapted, and is useful not only in accademia but also in outlining successive stages of severity.

Stage 1a: phlegmon

Stage 1b: diverticulitis with pericolic or mesenteric abscess

Stage 2: diverticulitis with walled off pelvic abcess

Stage 3: diverticulitis with generalised purulent peritonitis

Stage 4: diverticulitis with generalised faecal peritonitis

Couinard’s Liver Segments

Splenic Laceration Grading

Grade 1

• subcapsular hematoma <10% of surface area
• capsular tear <1cm deep

Grade 2

• Subcapsular hematoma 10-50% SA
• intraparenchymal hematoma <5cm diameter
• laceration 1-3 cm deep, not involving vessels

Grade 3

• Subcapsular hematoma >50% SA or expanding and ruptured
• subcapsular or parenchymal hematoma
• Intraparenchymal hematoma >5cm or expanding
• Laceration >3cm deep, or involving vessels

Grade 4

• involves hilar vessels with devascularization >25% of spleen

Grade 5

• shattered hilar vascular injury

spleen

Liver Laceration Grading

Grade 1 (either or)

• Subcapsular hematoma <1cm
• Liver Laceration <1cm deep

Grade 2 SH or LL 1-3 cm

Grade 3 SH or LL >3cm

Grade 4 LL or SH >10cm Lobar destruction devascularization

Grade 5 Global destruction or devascularization

Grade 6 Hepatic avulsion

Hypertrophic pyloric stenosis

• M>F, familial predisposition
• nonbilous vomiting
• 2-6 week old infant
• pyloric channel length >17 mm
• pyloric muscle thickness >3 mm
• can give water if difficult to visualize
• differentiate from pylorospasm (findings constant throughout exam, lack of peristalsis)
• Rx: Pyloromyotomy, returns to normal in 3 months postop