CASE 21

History .\ 28-year-old pariem prcscnlcd with oXrcriorating chronic d)'Spnoca.

CASE 22

History A 45 -year-old 1n3ic presented with ':,udiac arrhythmia and shortness of breath.

Chest Imaging Cases 21, 22

45

"

Answer 21 Chest Imaging

ANSWER 21

Olao",atlo ns I2 I a) Th;' ... ,.,~ d",,, .. , I,,,,,'ph .h,,~, '\'., h'f'<J · ~,~ ,;.-",. or"';';" .""' ... ,I<, k h hilum tI"" "" lik<~' ' 0 "r"'''o' """' .... " r ' u~,;" J~."J " ",, .. I """"h •. :-;<> "g"",",., mlJ",!", ~ <ri.k",. Thi, .. pp." ...... " ~ .I<"nb<J ... 'Iin~" ;., "",,' ... J ~ .. d""'''' 'f'I'<"~K< uf .,k.po Ioro.,,,,," r ul","" U}' .. po ,~'Iooi..

Oilgno. i. AI',<I~i< "" .... hor<' I "''', .. ,.,. "I'<.pl~ ~~ ( ... BI" AI.

Om . ron,i,( dl,gnos;, F,,, •. n .. ;.,~ · r", .. um".i"

~""""'!'"~,, I"""'~"" ~ • ",,,, .. ,,,,," p,,,u",,,,,i •.

AR P .... • Qyr"";<"~ ""","", in~ .""",non" (COn

Oi.cu •• ion Th~ ~ • h,I'<"""'";' i')' ",".Ih.,. ,...,,, ;,. k,,~ .... "'in~ ... h,n .. '" ~· 'h "'"'." i'l' " '~'"J' ''I'<'1.ill i. I, .~·,·u " ;,. I_a .>f ,,'hm"'" .oJ m .... "'mm,,,,ly 1·1 ""1 "' r"""" ""h ,·)"i, 'ib",,". rU ',. ,,",,)' f<'M" of 'h< d;"_ ,..-

l'ul."",,,! ",fih,,,ion ~ ;,h ,,,,.><>ph Wo. " h~'h r"" "" .. , mif..-'t<><y/ ']ittins p","mQft"" of r'''h)' ." .. ~.,. in,~" .. , .. "" ~, """ .. ,~y ",," .. ,,,. ".~"" ~.

C,,,~ I .... ,h""'''' •• I,,, ,. " 1' 1"" k"" p"'do..,,",....,< ,h" b ",U, U,' ... ",,,..,, ,'ro.l,,",in~ ""'~ ,hodo.,.·.· "" ph" ,oJ.W."""

• M ",,,,,I "'r"""" i" dil",,1 "," 'll """"h ;lk" f""'I""'S ,t-.. ""'S" in ~k",, ' 'rl'<"" .'" '1'1" , <on ""'." ; , "S" "",oI/'"b" ,on.po<

• LoN. "",,.,,;J,,,,,",

... ,,., c r "'''~" of . '''''''~ "'m'" r,,;"n, wrth ABI'''' '" """'" • 21b. 1 ' ,,_ ~;~u " 2 1b .h .... J ;r ,,<J ." " " ,". _ f.U,d/plul'l',J up,,,, lob< "",,"'hi. ~h~h "" I" 1>< .. ..," " " ~,«.J • ., "",. ,,1 '" f",," .. ~ 1'""," ", 11 < .1< .. """", ,IK " l""~ .'" t" J iI.>!,J ''''''''hi ~ ith fu 1110,,, ,,'i<k,~"< "f .""''''' -p l ,,u.'''~

Prlt1 lc. ' l ip . ... 'I'''' O\J ,,,to"" ,,, Th. ,,".I, rl ,;"" < ..... "r ""--'n • .-I>"", "l­'''' '" m,J, f""" i" .1",,,10,,,,,,,, ' Od 1)'1'<'

A~ r ... _ «",,,I . • """/."~''' ''' . .,...""";"""'r;" ,,., ~N'" 10",,_

c ) "'" fi~""", _ 1"'" """' •• ffi"" ,Ix urr")Qb" mo", ,h." ""'~, 100<. (2 1dl rv,.,-r<n '''''~ in"""," - 'l"i<. lin~'~. ;" i, i,N, .tl;',,,J HI ro-",,,,"," ~*,'I ,"<,,,,, - <1"~I';,;", 1,.-.. « H>< I""J"mi.,,,,,,

Furth r manall"m~nt Rd"u' <0 ,,, .. , r 0Y'~;"" .. '~rro~,i>.1< with fu <t o" im ,~"~ ""-""'.ur ~' i ,~ H RC r.

Furth. readin g Will;"., S_\ I. I,",,, f.T (1 99 71- (',,""~ .. '" ,~-, ,,, J'I'

""k"",' (," hYr<"""'''~''~l l'''_''',!,''I ...... 'l' "I",,¥i",,~ I "'~I'~ ) _ J!U;'''",/,hi<, 11, I ;~1_1600_

Answer 22 Chest Imaging Case 23

ANSWER 22

Ob" ,"'lions (22) Th~ ~ ...... .. '"'~ "" ,"~· "f, t.. .. ,; '<n1";"-;' "dol ..... ! ~.JoI",",m ."I" .",m"" 1'/"'" Th< ,m",&, """,, .k l.)<d <"h m," .. ' " ' ,,( 'h' ""," .. I. ' r "" I .".! "..,,,1 "')'" onl""" .ith oporin. of t l>< , ...oo.., .. J;",~. 1b;'I"," m o f d" .)~d

.. " .... yu<..w .. <nh ..... ~m<"' ~.;u, •• "n"~ ,"""" .... ;.,'" "'~." .. .., inm, .. ' i ,~.r."wum"o')' P""'<O •.

Di.ynosis (;.w~"" "", .. I.

Discussion ~, .. "' .... r < .. 01;..- "",·;'1 ~ .... n .. In _H" "f ",,;"n, • • ith _cu...._ HOH"", ,. t, ..... 5" .. h>Nt ' ''!' d ... · .. ,iV' •. CIi " "," r""'"'''"'" of ,,=id ;. ~·" k ,..,-J I" .,myth", i ... wdk-ru!"I''''ky..-.l hu" f,, ",,_

CASE 23

HillOry A 50. )< ... ,~J ,.,k !'''.'''' p,.,,,,,,,,J ~;, n """",,'k><"

Im'll"~ "",ling. of <>,.1 ... _001 .. dud" , Cmll " ",m"h ,,.. ","', io~ ,t.. '",n,n,,"'"I ..

"P'""' (h)'['"Oin,,"~'J' o. 1'1 ~';sh,«l .... S'.). • " 1,,,, .... i.1 '" h.q"'"",.' "" ,ld.)",01 g'""-"io;' '"

,nhID"'",'" """'I""id". ' 0 ".". of6bruoio. ~i,h "I' .... ~ .,ftlK ,.oo< • .-.Ii" m . ....... ~ .,. d itf",nt;""q [.urn ,J-,., " f"""J '"lo<.ru;um .of it< 10 ... ",", "" "" d;""K ,

_ ~ "' .. "f h)",,,,",,~ , "f '"" ,n),,,,.-.I ; , I ~., II .

P,.ctIClllllps SI''''''S ,"-rt>< ,"01,,,,.~ , ;" ,, '"11&"''' " " ''''',"''''' """'l' ,I.,., ,... ~ "n, 'n, ",,,, .. I);" ~ ,I,'S"''';' '

Furthe, mln_gem.nl lo.M " CXIl M r<'I'~""'l' ,h ", ~" of .omoiJ .

"

48

Answer 23 Chest Imaging

ANSWER 23

Observations (23a) This chest radiograph shows evidence o f previous surgery - there arc sternotom y wires and :l metallic mitr:!l v,ll\'e replace ment . The heart is enlarged with a cardio thor.lcic ratio of 2 1 :32. There is a ' double density' seen through the right hean - a sign a flert atrial enlargement . Multiple, small ( 1- 5 mill ) calcium density nodules arc seen in both lungs with mid and lower zone predominance. Upper ZOne

venous diversion and a tiny light pleur:!] cffilsion suggest pulmonal)' veno us hypertension .

Appearances ind icate that the patient has had surgical lllitr:ll valve rcpi3cemcllt, but there arc persisting Icaturcs of mitral vake disease and signs o f left heart failure. He should undergo furt her asscssmcnr o f "ake and lefr heart function . Th e high ·density pulllloll3ry nodules indicu c pu lmonary haemosidcrosis, a consequence of elevated pulmon3ry ve nous pressure over many ye3rs.

Diagnosis Mitral ,'al\'e discasc.

Discussion The most co mlllOIl GUIse of mirral valve dise:lse is rheumatic h<.:arr disease, widl presentation most cumnlonly seen in middk ,Igcd fcm;\ks. It results in kll ,ltriJI cnbrgemcnt J.nd pulmonary Vl!1l0US hypertension/heart f-ailure

Radiographic SigllS of mitral \'al"c disease arc: ' Double density' behind the right heart border due to left atrial enlargement. Splaying o rlhe carina by the large kft atrium . Oesophagus displaced to the right.

23b Chest radiograph shows enlargement of the left atrial appendage in a patient w ith mitral stenosis.

ldt .anal "'PfICnd.agc CII\,U"ge lllenr. The norm;11 kIt mcdu!brul comour hJ.s tWO convcxities above th<.: \'C:IIUldC - rhc X>nK: arell 3nd the main pulmonal)' MttT\ Enbrgcmc::nt of the k ft 3tri313ppend3ge produ.:cs.amlrd "bu mp' below the pulmon3ry 23b n..s IS sometimes calk d the ' third mogul [he term mogul is one uscd by skiers to describe

bumps In [he snow!). Caktfiarioo of thrOlll bus in lile !cll: 3trium (23c). Right "'cntricular hypertrophy, Pulmoru.n \~nous hypertension , intcrstitial and pulnlOrUJ)" oedema. Pulfl"lOfUry h.lemosid<.:rosis - longstanding clev3tion of pulmonary "'enous prl!ssure results in oozing of serum into the incers titium. Blood products within this will ultimately be broke n down to ,.

Practical tips h is diAicult to distinguish trom plain lilm is mitrJ.1 "3[\"e stenosis o r n:gurgi tation -eonscqu <.: ncC$ and signs arc t he S3111e and cocx i ~t. Howe"er, if there is gross kfl atrial ' rhcrc must he a component of stenosis prescnt.

Further management Cardiac !'efen al with a " iew [(l c<h'"""diol~"'" assessmen t is required . Tr<.:a lmen£ il1\'ol\'es fo r arrh ythmi as (3£rial t"lbrillatio ll - AF) and cardiac funnion . Surg ical intervcntion pCrelltall COllS v,llvc balloon dil at3tion (high r.lrcs), valvotomy and v:llv<.: repbc<.:mcllt.

23c lateral chest radiog raph shows curvilinear calcification of the left atrial wall.

u r·old f1ule W:I,S rdured for m"cstiguiofl rollowing m;! ;:!.l

g showing a right lower lobe k-I.iofl .

Chest Imaging

I,.,.' .'

Case 24

49

50

Answer 24 Chest Imaging

ANSWER 24

Observations (24) These PET scan images from 3. PET CT dcmonsnatc a 1;lrgc right lower lobe highly FDG ( 18 fluoro-2-dcoxy­glucose) avid lesion. There is a smaller lett upper lobe FDG avid lesion. Thc.rc is also rigln hilar uptake as well as uptake in the subcarinal region. Uptake in the region of the oesophagus is also dcmonsu ;ucd. There is 110 FDG avid lesion in li"cr or adrcnals. No bony lesions arc demonstrated.

Diagnosis l\'lct3static right lower lobe bronchogenic carcinoma.

Differential diagnosis The left upper lobe lesion represent's either metastases or a synchronous lesion.

Discussion PET scanning rdics o n increased upl3kc of FDG in cell populations with higher metabolic turno\'cr. The main application is oncological imaging; other, less utilized applications include CNS and cardiac imaging. h is essemial that PET scans arc compared with cross-sectional imaging if no PET CT scan has been performed. Assessing only PC:f illl;lges alone can lead to diagnostic crrors, mainly incorrect st:lging of malignant disease, The cr images (not shown ) of this PET/CT scan demonstrated a right sided pleural effusion that turned out to be malignant. Pleural cffilsions do nOt demonstrate increased FDG activity.

Among Other areas, normal FDG uptake is demonstrated in the brain , heart, sal ivary glands, liver, spleen as well as upper renal tracr and it is also excreted in the urine, Nomlal bowel uptake is also often demonstrated. Pirfulls include increascd FDG uptake in fut (brown f.my tissuc); this can simulatc malignant nodal diseasc. In the current study, the increased oesophageal uptake is due to a coexisting reflux ocsophagitis.

rET scans can be false negative for small lung metaStases or solitary lung nodules, False positivc diagnosis o n PET scanning also occurs due to infection and intlammation - conditions that arc associated wid1 in ­creased glucose turnover.

Practical tips In the UK, PET scanning is used mainly as a staging tool. Neurological and cardiac applications arc not utilized widely. Among others, PET is used for initial

~:~~::~~I~ll~~ rcstaging of bronchogenic or oesophageal

Cancer networks arc increasingly utilizing PET prior [Q planning for curati\'c surgel)', A growing application is the assessment of sol itary nodules. This is particularly useful in centrallesiolls tor which histological confirmation is more challenging and the complication rate is increased. A well documcmed pitfull is a fu lsc negative scan for small IUllg nodules or mcmsmscs. Lesions measuring less than 7-8 mm do ha,'c a higher fillse negati,'c rate. Lymphoma staging is also widely undertaken. This is \'el)' useful for assessment of activity in residual lymphoma masses and also for assessment of early rcsponse to chemotherapy. Inflammatol)' or infected nodal mediastinal masses (histoplasmosis) can also give rise to false positive s~ans. Corrclation with cross· sectional imaging is importallt in all cases where FDG imaging is undertakcn.

Further management PET CT resulrs should be discussed within a multi­disciplinary team \,ith the purpose of deciding whether the patient would be a candidate for surgical disease clearance.

248 Right lower lobe bronchogenic carcinoma (left) and likely metastasis (right).

25

fe male, prc\'iollsly - the USA, presented for a

t chest mdiograph .

E 26

ry :+-year-old male presented with

gia .

51

52

Answer 25 Chest Imaging

ANSWER 25

Observations (25a) This iron tal chest rndiograph demonstrates widespread 1- 3 nUll diarnclcr miliary nodules seen Ihroughom barh lungs with no zonal predominance. The miliary nodules arc of cakifk density. Popcorn calcification ofthc kIt hilar lymph nodes is $Cen. In addition, there is amorphous calcification $Cen under the lell: hcmidiaphragm, which is likely to be in the $plccn.

Diagnosis Histoplasmosis.

Differe ntial diagnosis For increased density miliary opacities: • MiliarYlllcrastascs

Pneumoconiosis - silicosis, si.dcrosis, baritosis. Varicclb-zostcr (25b). H:lcmosidcrosis - due to chronic pulmonary venous hypertension, pu]mon:,uy haemorrhage, o r idiopathic. H istoplasmosis.

For popcorn calcification oflymph nodes: • Sarcoidosis. • Silicosis.

Hisropbsmosis. • Coal workcr's pncumoconiosis «(,,,\VP). • L}'lllphoma - post radiotherapy .

Forsplcnic calcification: • Tuberculosis.

Histoplasmosis. In F.lrcts secondary to sickle cell discase.

• H rd:nidcysts, • Haematoma.

Discussion Histoplasma cnpSlllnwm is a fungus usually found in temperate clim:tres and most commonly in thc northern USA. Infection is by inhalation of air bornc fungal sporcs. These g..:rmin:ltc in the :l1vcoli and then spre;ld via the pulmonary Iymph:llics [0 the hilar/Illediastinallymph nodes

25b Multiple calcified tiny nodules at the left lung base in a patient with old varicella pneumonia,

and haematogenously to the spleen. Acme infection usually presents with few nonspecific symptoms, and radiological findings include gencralizcd lymphadenopathy, flitting nonscglllental bronchopneumoni:l, multiplc miliary nodules, popcorn calcification ofhihlr/mediastinallymph nodes and splcnic calcification. Chronic hislOpiasrnosis is seen in patienrs with chronic obstructi\'c airways disease and has r:l.diological features of peripheral consolidation and apical fibrosis, Disseminated infcction can occur in immunocompromised patients.

Nonpulmonary features of hisroplasmosis include pericarditis (5- 10%) and rheumatologic syndromes (-6%), c.g. arrhrnlgia, erythcma nodosum.

Practical tips In cases whcre there arc multiple radiolosical findings, consider the diflcrential diagnosis liST for each finding and idemi!)' an ovcrlapping diagnosis (easier said than done in a \'h'asilllalion! ).

Further management Clinicll/occupational history and I-IRCf can be useful to dillcrcntiate the possible undcrlying d!;\gnoscs. Respiratory referral with a \'icw to antifunSll trcatmcnt would be required ill the acute infcction.

Further reading Brown K, Mund OF, Aberle DR, ct at. (1994 ).

Imrathor;lcie calcifications: radiographic fcatures and diflCrential diagnoses. RndioGrnpIJies 14: 1247-1261.

Whelt LJ, Wass J, Norton J ( 1984). Cavitary histoplasmosis occurring during tWO large urban outbrcaks, Analysis of elinical, epidemiologic, roentgcnographic, and Jaboratot)· fe:ltures. Mtdici"t ( Baltimore ) 63(4 ): 20 1-209.

'Vilear LJ, Connolly-Stringfield PA, Bakcr RL ( 1990), Disseminated histoplasmosis in the acquircd immune ddiciellC)' syndrome: clinical findings, diagnosis and trcat'lllcllI,and rcvlcwof\hclil'erarurc. Mcdicim (Baltimore) 69(6 ): 361.

er 26 Chest Imaging Case 27

ations (26a) IIOntal chest radiogr-aph dcmons[r.ltcs a right sided .arch. No left sided aortic knuckle is seen . The hean enlarged. No IOcal1ung parenchymal abnonnaliry is

_ is can be contirmed wirh arterial phase contrast -ed CT chest (26b). Right sided aortic arch can be ed with scveral congenital cardiac abnormalities but .I.lso be see n in p:nicms without cardiac abnor­

The lau er group of p:l.IiclHS usually h:l\'c :J. right .Ionic arch with :In aberrant Jeft subclavian artery g as the most distal branch ort he aortic arch ), which behi nd the ocsophagll~. This can be seen on a swallow examination as a posterior indcmation in

t:wium column of the mid oesophagus. Patients with sided aortic arch with mirror i1ll3gC branching, such

the leti: subclavian arises as a branch of the first ,"esse! dlc Jo rtic arch, arc the group usually associated with

tic heart disease. The aorta descends in the right crior mediastinum (although in a small proportion,

.;; this is 011 the lett).

eASE 27

tory 34-year-old smoker presents with

ressivel)' worsening shortness of ath.

Practical tips Right sided aortic arch call gin: a notch in the posterior aspect of the upper oesophagus on COntr:lSt swallow examination .

Further management No further managemem is required in this condition.

26b Axial CT image demonstrates the right sided aortic arch.

53

Answer 27 Chest Imilging

AN SWER 27

ObH rvllions l27"1 Th, ,h,,' , .. I"5''I'h .t.~, !oi 1"",1 'hkl .",1 'hm ",1,,1 'l'" ' ""'. S""U' ""'h I. "S' ~ ; ' " P"''''''''''' afl.,,! ,,-,jo,,,<,, s,.,.,,, ' on.1I ",.jo'n.", .,,,, .. ," p .... "ul«l' wi,h .. ,I .. ,;~h ' .P I'" zoo ... ),'a pi, . .. , ,nu.;.," "' f"'<""""m."" ~ w,n. :<u """r .bnunn~", .... ..,fi ,;,,"' n, .. "' .. ,,, '"UO" ,,,,.""'1>rom,,0<i~ ' 0 'f'il< af 'h, p.I<~"'" ''', '"' ~'.," ..... '" J;"rih,,,,,," ",d "''').''' ''1 w<o. 1J m'~< I~"~,,h,", " II h;"' ''l''''~ ,I" "M'" Iii-d)' J i'",,~~_

Oi.gnosl. ,,,,,,>;<',,,,", "u h"';'~'!""'~'

Oiff".nti., dllgno.ls F", 'Y"" I ."~ ";0<," ~';,h "",,,,.1 0> ;n", ... J I.nt

'''' ' m<'' L)m,~,.o,~' ,H .. ,), .. ", ... _ "1<,.,, .... ""'" in l nd---<>, ', ,I«~k~ n,,< ." m"l<;rk ')'" ""''' ,,, .... """', '"' h.'3' "f ",1"",1)' ,,,,;i,,,,, " " I ·~ " " .) ' "" -.II.,...., ~· i'l> "', "oJLlk fv<on,,;'-.. , O".'""y .o<~.n ",,1 _on 'h, ~ .~ rI'.'" ,Ib,"" .00 ",."'''' pn<U""" ..... ,,'"',

• ),;"'00';00-"",,,,,,,, - r ....Jomin."tlj· 'r"" 'lV>. Tu"'''''''."k" ....

• C)"" _h~<f"'"

Oi..,u .. ion I .. "~"h,,,, " II h~"><p,,,i, " , mul';'I"" " '" ",.Ie n,,"m, ,I . ",,,, . _."" h 0« un ""-'''' """"on I,' ., I""~ p,J-..f," J " ·,,k>1 oJ." m l" . .okl h" ,n ... ~",i,,"'" ~'.h <~"''''< ~'''/'''II . 1'11""' '''' '1' <h~I~'~ ,,' C;H in, ,-,j,,,, , "q"'"" ,f<h."~,,_ inHW "S"' '" <ti """,uk' 'hn 1""&',,,;,, ly e .... ' ''' ,~ ..... 0" ., ,h"· • ....J ,n." then ~-.lk..l,l" fiKm"""" L""~",ju.,... u. ",",Uy

"""" .. , .. "",,,,,,1 in uP"' .'''''' . r""umn',"""", .. '" """,""" ""I <0" I'< ","""", \'1",,,1 .1Ii,,'." "" , .... Ir ...... · .. "d. H ~CT "l'f""'''''''' '"" of ""'~ .oouk. ' orl ''''" el., ,hin ~"k" '\'" 'h" ... ,0/",,..,..... ."" ..... ~"I" on" .00.' .. I"", 'I"'in~ <of , he "1' ''' ' mJ 'uotop""n ~ ,,<c ... , (1 71)1 .

P •• OIic.llip. On • CU, <)"'''' ""'I' J .. ..., _ .~ ...... V""",.,.,j 1un3 ,,,h.,,, "" he ,,,11<,,,,,, ~,,4 \>y io<"'i"~ " 1",,,,,, ', ""' "" I ",. Ok"'Wj'in, .","" ,,,I."',,,," "'I",~"

1.\ "'p" ."~d<;,"" \ """""" ,."",, '" I "' ;w~' " ~'""'" )';,",,>fobmrn""'6 .h'"'8" on • eX k ""Iuok rih/-.on .n; ..,~ , ..... m . .... ( """,,,f,brom,,) ,«" in 1'''''<00, • ...t .... o,.'" and ,,;,,_ TO'",,,,,,, "k",,;, ;, ,..ill' o.kn,;tKJ lor ,n. hi>tu<y _ b<io,~ ,h ...... " d"J lor ,\" ,Oi.OJ .. rm,,,'" ",,"' ...... """"', .",1 "'k ...... "1'J«,,,n. IImo,h.",.,;, 1"'''''''''' ,h" l ... -. II, J ')'" ",.j '", , " ~~,,,<d '''~''r ~"h '"'\' . bo , '" '-";~k '~ "I ,n." k ,,~'"< '" '"..,., ""'inS'

F~rthr managemlnt HKCT "" '" .«';"1;" 'h, f"lID~ _"P or ,,", ,, r"'""" _·n.n iDo)';"~ r.,. 1"","6.01 "'"'pi ;''' .. ", of ... "'.' , .... / ... )"',,,,,,, ;. ,t<". ,~> ''';' .' ' 'g ... .Iuk, .. .I r 0 ,.""""","",,,,

F~rthe, , .. ding .'1""" ~ n, ,,,,,) ... 'I>, .II"!" SL." oJ 11 9'~ ) .

''' '''''"'It)'I>'''i<'''~''~~ ~ : ''''''I'''''.' "r ,..J"W.ph~ .00 cr find;"S' . ~""." 17), H9-:;~_

CASE 28

Histo ry A l~·",,,·,~,, m.l, p" ... n"" .~h ""'m" ... t r'" '' oc.h "m~ 1m"&,, lAh,.,.. llk _.,., .. ..,,,;..,, I "' .. " .. 'p'" _ . ·h" h .. h'rp<n<J "'.u. ,I,,,,n'

CASE 29

History A 65.)'<,,..~J ""I, I""""" J .;'h ~wJ«,,;,~lr .·""".i •• ~ ..... "'».,{ ,," .... h

Chest Imaging Cases 28, 29

Answers 28, 29 Chest Imaging

ANSWER 28

OI>& .. ".lIono i2b. b._I ><k"," ;",'s" "" .. ,n m~ "'''''N.m '1'1,,' fi", ;",,",' P "") ~ • P"'-'""'''''' .. "" ~hkh d.mo",,,,',, t.!",,,~ ,,,",,.; n~" 1h< W,,'o" ... ,.,. p .... ) ,)",_., • p,g"i' ",h"" io , ... "",h . hh "',",," ... """J . nJ "" ,,~>l 'r""""." uf ,I" ,.,rt;" ,,'~ ,n" , ... P'o,,,,,' m.;" ~''''''' ... ~ Th. ,hWol ""1'< {1&) .00_" ""'",.; ""d","," ..... , ... ,,,lxl",10 ./t,,,",, " ,I>< k .. l ,,(,1>< ,"'~ .. ~ ,-""k,. G;,," , ... ,...,w,'" of ",,~. I ';"', ~ ~ ,"~,,~"d 'h" ,I", ,", .. I ",g,~", "-.IU~,J ~;,h ' h' .. ", ""~.,,, ""' ,I>< ,hi,.! 1m •• , ~;,~ 'h, ..... , .k.',",,!.

1'" ~""'" h,.,Ik""", ""'" .~""n",,, Dllg"".I . Tho,.,;" "",II" 'p.Jrom •• ,,,onJ,,), '0 1kJ,t<," ""';',1 ,;b>

Diffe r.nti, 1 di . gno." 0, """" "I tI ... "';, ".,k, ')"'I~ . It, : C~.'U"i'" _ 'mi.-" rh, fi~n .. , NoJ " • .oo."", ~ I" "b.

• ""'"",,,,,1 _ r"" ,;~ ",.,,";.. , w ""-",,rr. "',.j~' >,r".u'.

ANSWER 29

ObSflrv •• lon.12So, 29bl '1".'" "" I cr ... ~" "' ,h. ,h,,' .h",,· ">1,,«, or • ·'''!'' .. '"~r, ~".". .,r",,~ ,1\tl," .... ",,' ""'~~' .~ j<I .. , or><"' ~ ... h .n",,"'" u. ",tIo~YI" "1"01 'h"'h ,,"~. ' j h~ ,0., ,,,1'; ... ;. .. "f i."~"~ r, ,, J"'i\> ."uIJ fi, . ·;o h •

J"~no'" oJf 1"""""'0<)'..00.,""

Oi.gno. l. \~""""''''Y ,,,,\fm, ,t,,, to, '''''IT f, ,,'" ,

Diff. ,entlll dilgno.ls ............ ,' ."~' """-")' • l'ulmoooM)·",J.m.,

1"(.,,".,, , H ..,""""',~., 1 , ,,«~.i,1 '''''un'' ......

• E'.>,rin,., oIk,." ,[",,!;,"­A~"~,, r ""';~"'" · .... """"' .. f",," .... " nf ·s"x .. ' gI .... - >I>'<OI,,«~ ,· ..... "" '/I)mph"' .. ,

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• s.."uOlo~ •.

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Answer 29 Chest Imaging Case 30

Tbcsc same lindings 3fe visible all CT. Alveolar Ollid often ~nrs as 'ground glass' opacity, which is an increased ::u.zincss/ attc.nuation in the lling - and which can be

chy in distribution. 'Ground glass' opacity is a relatively ..onspccific imaging finding due [0 many conditions that .::aISC an overall increase in density within the segmellt of

g displayed as a pixel on the CT image. There is a long ( remia! diagnosis including any cause of alveolar

. j collsolidation.

CASE 30

iistory ~ 65 -vear-old male was referred tor :l ardiac MRJ to assess cardiac viability.

Practical tips A combination of cardiomegaly, pleural clTusion and airspace opacity suggests cardiac f."tiluTe with pulmonary oedema.

Further management Medica! management with eXR radiological tollow-up as appropriate .

57

58

Answer 30 Chest Imaging

ANSWER 30

Observations (3Da, 30b) The first image (3 0a ) is;t shorr <l.\:is scan through the left \'cmriclc during the firs t pass of contrast. There is no contrast enhancement orlhc thinned IeH \'cmricular septal :md anterior walls. The visualized posterior, lateral and inferior walls show 110mlal enhancement and arc of nOnllal thickness . The second im:agc (30b) is a delayed lour chamber ,-jew showing delayed, prolonged cnhanccmcm of the septal, apical and 3lHcrohncr;11 wall of the left ventricle. These appearances :HC of an extensive left "cnrricular infurct wit h no evidence that inl"olved areas arc viable.

Diagnosis Left \'cntricubr inrnrct involving Ihe septal/apical! amcrolatcralwalls.

Discussion Cardiac MRJ has 311 expanding rolc and current uses include asscssmentof:

Cardiac viability prior to re\'ascubrization. Cardiac congenital heart detect Cardiac tumours. Perieardialdiscasc. Canliomyopathics.

Assessing cardiac viability post 1l1~'ocardiaJ infarction is important since re\'ascularization of li\'e tissue reduces morbidity and morraliry. Previously cardiac pcrfilsion was assessed b~' cardiac nuclear medicine ( lIHBG - Illeta­iooobenzylguanidinc [scintiscan }) stress resting but there is now an increased role for cardiac M ItI.

Shorl a.'(is cine images arc acquired at first Pfl~ of a bolus injection of gadolinium to determine perfusion, Infurcted myocardium shows no enhalll::ement on lint-pass imagin! (as demonstrated in this case), In addi t ion, first ­pass imaging can show: • Whether the infarct is transmural or subendocardiaL • Degrce of hypo/akinesia.

Delllycn..cnhancel1lenr sequences al approximately 5 min show enhancement in infarcted tisslle sillce clear:lllce of contrast from fibrotic tiSSlle is slower lh:lll from normal nH'ocardium.

· Ifthere is :lny uncert.linty regarding ditlercntiation of ischaemic from inf.ucted mnxardi um then cardiac MRI stress testing is per!armed \~'ithftNl-PIlJ1 images acquired at stress with adenosine and then repeated afTer 20 min al rest. Areas of hypocnhancement at stress that show recove!)' at rest represent areas of ischaemia rather than in&rction. .,\

Practical tips Cardiac MR.I is a d~'namic test that requires assessment of cine inllges to make a subjecti\'e and objecti\'e assessment of1cfi \'enlricular function (ejection frnction ).

Further management Coronary artery atherosclerotic disease is ch:lr,lCterized using coronary angiography or corona!)' artery CT Patients with isehaemic but \'iable mYOi:ard iulll may be suitable for re\':lscularization with angioplasty or bypass gl'Jfiing,

:.ASE 31

Iis:ory -~~-old female patient prcscmcd

.:best pain.

tASE 32

ry ':'i-ycar-oJd Illale presented with ~naftcrminortral1111a.

Chest Imaging Cases 31,32

59

60

Answer 31 Chest Imaging

ANSWER 31

Observations (31a) This chest radiograph shows e\'idence of a pn:,'ious rigln llIastcctonw. !-lean :lIld mediastinal conrours are normal. No lung 3.b'llormaliry is seen. There is ditnlsc sclerosis of all visible bones, mOSt evident in Ihe ribs, Appearances arc of difli.Isc sclerotic mct:lSI":lSCS from a breast carcinoma primary.

Diagnosis "hstcctomy and sclerotic bone metastases,

Differential diagnosis For causcs of unibtcraJ hypcrtr.lllsr.1dbncy: • Chest wall abnormality - mastectomy, pecroral muscle

atrophy (polio ) or absence (Pobnd's syndrome). Pleur-l1 almorm:tlit), - pncu1l1othor:lx, Lung abnormality - Swyer-James syndrome (consequence of bronchiolitis as a child resulting in a hypoplastic lung with air tT:lpping on expiration ), emphyscma, bulb!.', pulmon:ll)' embolus (3 I b ),

For causes of unilater:tl hyperdensity: Chest wall :lbnormalil)' - gynaecomastia (unilater:tl in 40% of cases), breast impl:\l1I.

• Pleural abnorm:llity - pleurJ.1 dfusion on supine film, pleural thickening. LUl\g abl\orma\it~, - ul\ilatera\ pu\mom.\}' oedema from lying on one side (3 I c), consolidation, lobar collapse (especi:llly left upper lobe ).

31b There is a large central pulmonary embolus on the right with marked reduction in vascula r markings on this side.

Discuss ion '''ith breast cancer being such a common malisnan~·. complications will present frequemly on plain radiographs so it is important to note :I mastectomy. Another 'tell tak' sign of pre\·iolts bre:lst cancer is the presence of a:;:illaTT clips from node sampling.

The mastectomy may first be percei\'ed as a disparity between the o"eral1 densities of the tWO hemithoraces.. There arc many other causes for this, though sometimes may not be e:ls), deciding which side is norm:ll.

Practica l tips In :lny c:lse with a history of breast cancer, the chcsr radiograph should be scrutinized for features of recurrence. These ~lre classical "iva films for exams :lnd also presc frequently in e"el)'ciay practice. Features to look fi include:

Sclerotic/lytic bone metastases (31d). Lung lllet~lstJses. Lymph:lngitis C;J.rdnomafQsa. Pleural effusion. A-.;illary lymphadenopathy. Right hemidiaphragm ele":ltion secondary to li,·er metastases.

• PUilllOnal)' pnelllllonitis/ ilbrosis from radiothcra~·

Further management • In cases where clinical history and examin:ltion do

revcal an olwious cause lor the rdati,"c diftcrenccs chest lucency - CT chest would be appropriate. Isotope bone SCJn may ident"if)r distant bone metastases.

31c Unilateral pulmonary oedema with pleural effusion and airspace opacity on the right.

Answers 31, 32 Chest Imaging

d Multiple poorly defined lytic lesions are seen ;;:TOughout the ribs bilaterally .

SWER32

Observations (32a) chest radiograph shows no ti.xallung abnormality and

rib fracture or pneumothorax from the recent trauma. "e\"er, there is bilateral inferior rib notching involving 3rd- 8th ribs. The aortic knuckle is not well seen bllt

is no other mediastinal conto ur abnormality. The ..art is not cnl:lrgcd. There is no evidence of previous ~Jiac surgery. No other specific bOlly or soft tissue ~rmaliticsarcsccl1.

The most likely diagnosis is coarctation of the aorta -p:nicnr's blood pressure should be checked in both

and compared with that in the legs for confirmatory

:Jiagnosis - 'or rib notching due to coarctation of the aorta.

- erential diagnosis inferior rib notching:

~\n:eriaJ : Coarctation of the aorta .

• Subclavian obstruction after Blalock- Taussig shunt fo r tetralogy of Fallot .

• \·cnous: SVC obstmction. Arteriovenous malformations (AVlvl ). :S-curogcnic, neurofibromatosis.

superior rib notching: Rheumatoid arthritis, sckrodenna and SYSTemic lupus crythcmarosus (SLE ). H~~rparatbyroidism. :S-curofibromatosis. ~larfun's syndrome. ~uicti\'e IUllg disease.

Discussion The most common cause of inferior rib notching is coarctation of the aorta. This can be of [\vo types: • Preductal - the hypoplastic n~rro\\'ed segment is long

These patients present in inf3ncy and early childhood with congestive c~rdiac fJilurc. Prognosis is worse than lor those who present with t.he postduct"al type . I'ostductal - this Ilsuallv consists of a short narrowed segment, immediately distal to the site of the ligamentum artenosulll (32b). Presentation is llsllally in latef childhood, and is with hypertension, diftcrential blood pressures in the upper and lower limbs and/ or a heart IllUfmur.

( COIlt.)

32b Single angiographic image shows postductal stenosis of the descending thoracic aorta, with poststenotic dilatation.

62

Answer 32 Chest Imaging

On chest radiographs, the focal Il:J.ITowing of the aorta is cbssically made more (vident because of pre- and posl'Stcnoric dilatation producing a classic ' tigure of 3' sign. Obscuration orthe arch, as in this case, is also recognized. Rib 1l00ching on the inferior surfucc of the 3rd-8th ribs can llsuall}, be seen in untrc:ltcd patients by 8 years. Rib notching occurs due [0 dilatation of the posterior imcrcostal arteries, which act as collateral vessels. Since the 1st and 2nd posterior intercostal arteries arise from the COsfoccl"l'ical trunk of subcbvian artery rather than descendi ng aorta, they do nOt form a collateral path and hence do not cause rib erosion.

Coarctation of the :10m is associated with sc\'eral orher congenital anomalies such as bicuspid aortic valve, patent ductus arteriosus (PDA), \'ctHricular septal dcfcC[ (VSD), tricuspid atrcsia and transposition of the gre;lt \·csscls. There is also an association with Turner's syndrome.

Practica l t ips When suspected from plain fi lms and clinical findings, t.'IR or CT angiograph~' has now largely replaced com'emional angiograph~' as the next im'cstigatioll of choice (32c).

When inferior rib nmching is noted check: The aortic comour for the 'figure of 3' sign. Is therc evidence of previous repair, e.g. thoracotonw scar? The hcart fo r e\'idence ofldi: ventricular hypertrophy, i.c. elevation of the apex . Arc there features to indicate neurofibromatosis, e.g. cutaneous soft tisslle nodules?

When rib Ilmching is unilateral, suspect an aberrant $ulxla\'ian artery origin on the unaflected side.

Further management Surgical treatment for coarctation of the aorta in\,oh'es resection and end to end anastomosis, prosthetic patch graft, sulxlavian fbp aOrToplasry or balloon angioplasty.

32c A maximum intensity projection (MIP) image from an MRA exam ination of the thoracic aorta.

SE 33

ory 38-year-old man was Ixing tigatcd for transient neurological

".

CASE 34

ory 51-year-old woman with oesophageal

er presented complaining of chest

Chest Imaging Cases 33, 34

63

64

Answers 33, 34 Chest Imaging

ANSWER 33

Observations (33a) There 3TC some incrc3.scd tubular sofi: tisslie dcnsitv opJCitics in the right lower zone, suggcstiyc of abnormal vessels, leading TO a faim pulmonary nodule. There is a funhcr nodular opacity in the right lIplXT zone, again \Iith Ihe suspicion of vessels running to it from the right hilum. The left lung is CicJT and the mediastinal outline normal.

Given the clinical details, pulmonary ancrion:nous mallormations giving rise to paradoxical emboli and TIAs l1msr be presumed. Contrast cllh:lllccd CT would confirm.

Diagnosis Pulmonary :lrtcrio\'cnOllS m3ltonm.tion (AVM ).

Differential diagnosis Single or multiple pulmon;uy nodules frOIll other causes.

Discussion Pulmonary AVMs arc abnormal \'Jscular communications between pulmonary arteries and \·eins (95%) or systemic arteries and pulmon:lry veins. 1\10st commonl~', they arc of the simple type, with :I single artery feeding :I focal aneurysmal segment and a single dn)ining vein. Compkx lesions ha\"e more than one artery and/or vein. Figure 33b is a single angiographic image tll;lt demonstrates the large feeding vessel to a solitary AVl'vl

Multiple pulmoll:lr)' AVMs may be associated with Osler-Weber- Rcndu syndrome. They arc usuall~' asymp­tomatic until the 3rd-4th decade when they can present with local effects - haellloptysis, d)'spnoca on exertion and cyanosis with clubbing (due to right LO lefi: shunt); or \\~lh distal eflects - cerebrovascular accident (CVA ) or brain abscess due TO paradoxical emboli. Lesions enlarge with age.

Practical tips The 'finger in glm·e' appearance from mucoid impaction of cemfal ;lirways in allergic bronchopu lmonary asper­gillosis can look similar in some ways to the vessels supplying an AVM. H owever, there is a nodule at the end of these \·cssels in AVI'.,.\

ANSWER 34

Observations (34) T his chc:st radiograph shows a normal sized heart and clear lungs. There is, however, c\·idcnce of air within the mediastinum - best seen aTOund the leli heart border and aortic arch. Helow the medialldi: di;lphragm, a stent is just about visibic across the gastro-ocsophageal junction.

It is likely that there has been oesophageal perforation from the stemed oesophageal tumour

Diagnosis Pneumomediastinum from perforation of stented oesophageal cancer.

Further management Angiographic assessment and treatment with embolization or balloon occlusion is now the preferred management.

Further reading Coley SC, Jackson JE ( 1998). Pulmonary arteriovenous

maltormations. C/jIJicn/ Radi%gy 53(6): 396-404. Pick A, Deschamps C, $tallSOIl AW ( 1999). Pulmonar)'

arteriovenous tistula: presentation, diagnosis, alld treatment. World journal ofSllrgery 23( 11 ): IIIS- II22.

33b Single image from an angiographic investigation demonstrating a large feeding vessel to the pulmonary AVM .

Differential diagnosis For causes of pneumomediastinul\J: • Al,'eolar rupture in acute asthma. • Oesophageal rupture due to malignancy, trauma,

l"iolent vomiting (Boerhaa\·..:>s syndrome - usually associated with a left sided pleural effusion). Extension from peritoneum - pneumoperitoneum. Iatrogenic - following oesoph ageal balloon dilatatioJl/stenting, bronchoscopy, ll1cdiastinoscopv. positil·e pressure \'emiJalion. .

Chest Imeging Case 35

nnum is an uncommon condition that is m.nic but can present \I'ilh ncdcor ches!'

11 rarely leads to any complications bur it can dUgnostic sign for an underlying medical

th.u does need trcarmen!. Although a ['an::

_ ~iuhs, it is see n in children and masa

tips rlx' ribs for any sign of trauma. lAX lung fields for a lesion that might hal·C

bronchoscopic/ surgical investigation. 4fr under the diaphragm to indicate

·toneum .

.old male presented to A& E 1'a:Urrenr acute-on -chronic

• Look for an cffilsion to suggest oesophageal injury, or oesophageal stem, as in this case .

Further management Chcst CT after the patient has drunk some water-soluble contraSt , o r a water-soluble contrast swallow, can confirm an oesoph:ageal tear and leak and help to idcntif}' the si te.

Further readi ng Gcrazounis 1\.\, Arhanassiadi K, Kalantzi N, Mousr:m ias

M (2003 ). Spontaneous pneumomediastinum: a rare benign entity. J01I'-"(I/ of711omcic alld Cnrdiol'aJw/flT Surgery 126(3): 77~776.

65

66

Answer 35 Chest Imaging

ANSWER 35

Observations (3Sa) There is a large area of increased lucency in the right mid and upper zone with no visible.:: lung markings. There is no visible lung edge, however, to suggest this is a pneumo­thorax. Moreover, there is crowding of"csscls in the lower zone. The appearances arc likely ro indicate a large upper lobe bulla. There arc no focal pulmol131")' opacities to indicate superadded infcClion . ComparisOI;I with an}' ;l\>;lilable old films should help confirm this interpretation. A general reduction in density in the left upper zone suggcSlS rhal similar pathology is del'doping here tOO

Diagnosis Large right sided bulla.

Discussion A bulla is a large dila ted airspace within the hmg Witll a \\"JJl

less than I mill thick. They arc usuallY' produced byah'colar dcstruction in "'mphyscUlII, Impaired ventilation ofrhe rest of the lung can result in dyspnoea, as well as that due to rhe background chronic lung disease.

Confusion Cln lrise when the absence oflung mukings leads to the erroneous diagnosis of pneumothorax. This

35b Image demonstrates a small pneumothorax with no lung markings lateral to the lung edge.

can have dire conscquences if an intercostal chest drain is then mistakenl~' placed in the bulla! An expiratory fi lUl makes a pneumothorax easier to detect (because it en­hances the contrast di ffe rem ial between pleural air and lung parenchyma) but probably won't help resolve diag­nostic confusion with a bulla. Patients with chronic lung disease may well ha\'e pre\'ious filrns that show a bulla TO be longstanding.

Practical tips A pneumothorax leads to two findings: a visible lung edge and hypodensity with absent lung markings il teral to this (35b). A bulla has absent lung markings but not the discrete lung edge. COIlI'ersciy, skin fo lds (seen mOST freqlleml~' in babies and the elderly) can produce a pseudo lung edge but there \\~II be lung markings lateral to iT (35,).

Further management If diagnostic uncertainty continues after expert review of the films, then occasionllly CT of the thorax may be needed to diflerentiate bullae from pneumothorax.

35c Chest radiog raph demonstrates a skin fold giving an apparent lung edge but lung markings are visible lateral to it.

Chest Imaging Case 36

... lib Sequential chest radiographs taken 4 months apart.

36c HRCT thorax of the same patient at a later dale.

6i

68

Answer 36 Chest Imaging

ANSWER 36

Observat io ns (36a, 36b, 36c) This frontal chest rldiograph (36a) demonstrates wide ­spreld, fairly symmetTicll lung plrcnchymll abnormality that is central in distribution and chnr.lo.:terized bv bronchial \\'all thicken ing and cystic bronchiectatic chl;'ge, Some larger soft tissue density nodules arc seen in the lower zones, which likely represent mucous plugs. Bibteral lobull!ed hibr enbrgement is seen with the right sided

R:adiological features ofCF on a chest r.ldiograph arc: Cystic/cylindrical bronchiectasis. Peribronchial cuffing/thickening. Mucous plugging with secondlry lte1cctlsis due to obstruction.

• I-lilar lymphadenopafhy. • Allergic bronchopul"lonaryilslX'rgil losis (ARPA).

Irmphadenopathy being more evident. Appearances arc of Respiratory complications or CF include pneumothorax. cystic fibrosis. haemopt)'sis and cor pulmonale. Chronic pulmonary

Chest radiogrlph (36b) from the same plticnr t:l.ken at infecrion can lead to hypertrophic pulmonary osteo-a latcr date demonSlrat"es more ad\'anced disease with more arthropathy ( H POA ). mucous plugging and hyperinfbtcd lungs secondary to air • Cystic fibrosis is a multisystem disease: as wdl as causing trapping. Peribronehill culling and thickencd 1.1Ontapering ~ meconium ileus (in, chi ldren) and meconium ileus bronchi arc e\'idem. A right subclal'i;lIl central hne is noted, e(luivalent (in adults), It Clll also callse pancreatic insuffici-presumabl}' for the administration of IV antibiotics, eney, biliary cirrhosis, portal hypel'lension, malabsorption

A c r image (36e) of the chest on lung windows shows due to gallbladder disease, cholelithiasis lnd dubbing typical reatures of CF with cylindrical brollchie([asis and a (36d). central distribution, peribronchial euning. mucous plugging :and lOCal :nclectasis. It also shows the most common complic:ation of:a pneumothorax on the lci't side.

Diag nosis Cystic fibrosis (CF).

Discussio n Cystic fibrosis is an :autosolll:ll recessi\'e Illultisystem condition that is chlrl(terized by exocrinr gbnd dysrunction due to mucous plugging arising sccondlry to a fuull in rell chloride transport. The condition aHects whites with a geographical distribution :affecting Europeans and Ashken:azi Jews. Di:agnosis is usually made in children, \\;th the majority being diagnosed within the first year of life with the clinical presentation of meconium ileus and respiratory symptoms. Pulmonary complic:ations are the predom inant cause of de:ath and sun'ival is limited to -30-40 rears.

36c HRCT thorax of the same patient at a later date.

Practica l tips • Typical presentation is of\\;despread pulmonary

disease in a young patient. • Tunnelled cenrrallines in patient's arc used for long

term drllg treatment with antibiotics or ":i­chemotherapy. Again this is a clue 1'0 the underlying diagnosis, Look for complicltions ofCF - pneumothoraces and secondary infections. Though nor a common site, I-I POA Clll occur in the humerus and may thus be visible on the edge ofthr film.

Fu rt her ma nage me nt Follow-up in these patients is bc5t lX'rformed with HRCf which can answer the important quest ions when lunf transplant is considered - is there coexistent Aspergill infection? Arc there complicating felttlTeS, e.g. pneurrx thomces?

36d Sing le axial CT image demonstrates significant splenomegaly due to portal hypertension and pancreatic calcification secondary to recurrent bouts of acute pancreatitis.

Chest Imaging

- rar-old IV d rug user presented with cough and rtncss ofbrcarh. He is nored to be signific:lOtly

- on prescluation. This series of chest radiographs n at presentation, day 3 and day 7.

Case 37

69

70

Answer 37 Chest Imaging

ANSWER 37

Observations (37a, 37b, 37e) The firs t chest film taken at presentation (373) shows no obvious radiologic:tl 3bnorm3lity. The next radiograph from 3 days later (37b) shows bilateral mid and lower zone rcricu!ar/gr:lIlular inrcrstitial infiltrate with no evidence of volume loss. The third film trom 7 days after presentation (37c) shows bilateral consolidarjvc change affecting both lungs. There is :J. pneumothorax on the left with subtotal collapse of the left lung. Surgical emphysema is noted.

It is notable that the patiellt was initially vcry symptomatic with a relatively normal chest film and then showed rapid pulmonary changes over several days. The history of IV dmg abuse raises the possibility of background HIV infection and the sequence of radiological appearances is typical for Pllwllloeystis e""illii pneumonia.

Diagnosis Pncumocystis carinii pneumonia (PCP).

Discussion P. carillii pneumonia is the mOSt common cause of interstitial pneumonia in immullocompromised patients Radiological find ings can be very variable but the typical pattern of development is as follows: • Normal chest radiograph is seen in up to 40% of

patients, especially carlyon in the infection. Bilateral diffuse perihilar airspace/granular/reticular opacities is the typical appearance. Progression to diffuse airspace consolidation with air bronchograms. Pleural effusions arc seen in -20% of cases. Response to treatment occurs over a period of - 1 week Atypical features (seen in - 5%) include upper lobe thin and thick walled cysts, IUllg nodules, mediastinal and hilar lymphadenopathy. Treatment with aerosolized pentamidine alone results in the d isease af1ccting upper lobes.

Complications of PC P arc common, e.g- pneumothorax and superimposed TB/fungal infections.

Appearances on CT include a patchy mosaic/'ground glass' pattern with subsegmental sparing and coexistent thin walled cyStS and pneumatoceles. Appearance of nodules on CT imaging is suggestive of a second disease process being involved - metastases, l)'mphoma, septic emboli or Kaposi's sarcoma.

Bilateral gallium uptake is seen prior to radiological changes being evident.

Practical tips A strong index of suspicion for PCP should be maintained when an immunocompromised patient presents with dyspnoea. As in this case, symptoms can be OLit of proportion to the initial radiographic changes.

Further management Diagnosis is confirmed with sputum cytology or bronchoscopy and lavage. Treatment is with IV co­trimoxazole.

Further reading Kuhlman JE, Kavum M, Fishman EK, Siegelman $S

( 1990 ). PIIClllI/oeystis carinii pnellmonia: spectrum of parenchymal CT findings. Radiology 175: 7 11 -7 14.

Chapter 2

ABDOMINAL IMAGING

IN ABDOMINAL RADIOGRAPHS ays, a s)'Stcmltic approach is required to be able to

:t lhc mOSt information from a radiograph. T he order • led is a guide and should be adapted to your own lliettnccs and adjusted for each individual case.

- era l assessment r assess the qu:..ti t)' or the film, ensuring that there

.kquarc cQ\'cragc - arc the hernial orifices cQ\'cred in p.uicm who appears to h:wc small bowel oOOmtetian?

..dtition, make a quick assessment of the film to exclude important di:tgnoses that arc surgical emergencies and rt'qui rc immediate management:

• PtttOration. • Tone Illcgacolol.l ,

es ufy any lines that arc present, e.g. postsurgical dnins, tubes, urill:!r)' catheters and peritoneal dialysis ters. The pre$Cnce of peritOnea! dialysis catheters or rgical drains may offer a simple explanation for free

.a.pcriwneal gas.

Gas pattern erentiating sma ll from large bowel is \'ery difficult in ng chi ldren and one can usually only say whedler a k m is in d ll: pro.~i mal or distal bowel. In adults,

raures uscd to distinguish the two include position in the o men; d iameter (I:uge bowel <5 cm, small bowel <3 ; \'alvube conni\'t:ntcs travcrse the whole \\~dth of small 1::1 but this is nor so with the colonic haustralions; solid es onl\' scen in colon.

The ra~ge of ' nor mal' bowd gas pattems is rather wide, t from experience, o ne should quickly know whether

amount and dist ribution of bowel gas arc. \·cry ormal. Unusually shaped collections of g:liS (e.g.

~ngular ) should raise suspicion of gas outside the GI :no- and lead rou to examine thc area very dosely. Check .:Mefully for gas in areas of the abdomen where it is not wormally seen, e.g. o\'er the liver (either as pockets of g3S 'JI"\\; thin the biliary tree ) or in the relroperiwncum. Don't

forget 10 check for bowel loops extending be low the < '-\ inguinal ligament indicative of hernia.

Exclude bowel dilatation and wallthiekening. If there is dilatation, decide whether it is small or large bowel and then try to cst:l.blish the 'cut ·oW point. wter ClSCS illustrate specific features to check for when one suspeCtS small o r large bowel obstruction .

Soft tissue organs Check the size and outline of the liver, spleen and kidnq'S. Also check the psoas outlines which ma~' be obscured by ~'\., retroperitoneal pathology .

Calcification Look at the rest of the film for calcified densities such as gallstones ( onl~' 5- 10% visible on plain radiographs) and renal tract calculi (80-85% "isiblc on plain radiographs). Common incidental calciftc opacit ics include mesenteric nodes, phleboliths , ,·ascular calcification and uterine fibroids. Calcification within the solid Ofb':lns may be more significant however. Unusual calcified opacities may allow fOf a specific diagnosis such as a pelvic dermoid.

Bones Assess thc bones of the vertebral column and pe lvis fo r incidental pathology or findings that might be rclc\'ant to intra· abdominal disease such as sacroiliac joint changes associated with inflammatory bowel disease.

Periphery of the film Conclude by looking at peripheral stmcmrcs. For example, patholog), at the lung bases that might mimic abdominal patholoID', incident:l.llcsions in the abdominal wall.

ABDOMINAL CT The first qucstion to ask yourself when looking at all abdominal cr is what type of comrasr has the patient been gh'en, i.e. oral/IV/ both and during what phase has imaging been carried Out. T he typical phase for abdominal

71

72

Abc!ominal Imaging

imaging is portal-\'enous (60-70 seconds delay) bur other phases, e.g. pre-contrast, :mcrial, delayed, arc useful in characterizing spedfic lesions.

Axial im::agcs will commonly be presented and you can proceed in one of two ways - either :lSSCSS all stmctures on each ax ial image then proceed to the next image, or, alternatively, assess each org:m in mm o\'er a series of slices before moving on to the next organ. in rcalit ... , a combination of the tWO is often used but the J:mcr ensures nothing is missed.

As well as searching for tOcal lcsions within the organs, other features to check include the fo llowing: • Li\'cr:

O verall attenuation (e.g. reduced in fatty change) and enhancement homogeneity. Size :Illd comour (e.g. irregular contour in cirrhosis). Patency of normal vascul::lrstrucrures. $mte of intrahepatic bile ductS.

Gallbladder - check for stolles, the density ofbilc, wall thickening and perieholecystic fluid. Carefully assess the extrahepatic bile ducts.

Pancreas - check lor calcification; the state of the pancreatic duct, pcripancreatic collections and infl:lnlmatofY changes. Spleen - check sizc and adjacent \'::Irices. Kidneys - is the :menuation orthe kidneys correct for that phase of scan? Is there:: collecting s~'Stem dilamtion? Check the adrenals abo\'e.

Then systematically evaluate the non·solid organs: • Aorta - as well as o\'erall size, du:ck for dissection and

patency of main branches. Check major venous patency at the same time, excluding deep vein thrombus. Bladder, ovaries/ut erus. Lymphadenopathy. Intra -abdomi nal fat - peritoneal soft tisslle deposits arc easily overlooked unless the abdominal fur is careful!vscrulinized. Colon, 'ileum and stomach. Free gas/fluid. Bones and lung bases.

- :car-old male presented with a of gradually progressive .,.

SE 39

ory - -year-old female presellted with

bkcding.

Abdominal Imaging Cases 38, 39

73

GENERAL INTRODUCTION

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74

Answer 38 Abdominal Imaging

ANSWER 38

Observations 138a) Single AP image from a double cammst barium swallow examination shows a short, smoothly i.lpcrcd narrowing in rhe lower ocsoph<lgus juSt superior to the gastro­oesophageal junction and a small hiatus hernia. The OCsoph3guS proximal to rhis h:l.S delicate tr,Ulswrse mucosal folds, the so-called fcline oesophagus. This 3.ppe31"311CC is 35S0Ciatcd with gastro-ocsophagcal rdlux and leads to the conclusion that the shon stricrun: is a peptic stricmrc.

Diagnosis Peptic stricture fcline oesophagus.

Differential diagnosis For oesophageal strictures: • Lower oesophagus:

Peptic stricture secondary to gastro-oesophageal renux, Scleroderma - aflccted patients have an incompetent lower oesophageal sphincter and reduced pcrisl::Ilsis resulting in marked gastro­oesophageal reflux. NG intubation - pre\'cnrs'closure orthc lower oesophageal sphincter. Zollinger-Ellison syndrome_

Upper and mid oesophagus: Harrett oesophagus - acquired condition characterized b)' columnar Illel::lplasia secondary to chronic gasrro-oesophageal rcflux/ oesophagitis. Prcmalignam condition with an increased risk of adenoearcinoma of the oesophagus. Caustic ingestion - usually long, smooth narrowing forms 1-3 months l)Osl ingestion. Mediastinal rJdiOtherap), - usuaJJy long, smooth narrowing forms 4-8 momhs post radiotherapy. Skin diseases - epidermolysis bullosa, pemphigoid, ery thema multi forme.

Other less common causes of strictures include Crohn's disease, Candidn oesophagitis and Behr;el's disease.

Discussion Peptic strictures have this typical appearance of short (1-4 cm), smooth, tapered, concentric narrowing in the IOll'er oesophagus. Associated radiological findings include intramural pscudodi\'eniculosis (38b) and feline oesopha­gus (so called occause this is the normal appearance in cats). Longitudinal scarring can cause fixed [ranS\'ersc folds but these can be diflerentiatcd from fcline oesophagus sincc lhe), arc only seen in the region of the strictur;: and do not extend more than half way across the oesophagus, giving a 'step bddcr' appearance.

Practical tips Previous CXRs call ~ useful in identifying a cause for a stricture - look for a tlll110UT that might have been irradiated or fratures of aspiration pneumonia/hiatus hernia.

Further management GastrOenterology referral \\~th a view to direct \;sualization and confirmation of diagnosis with endoscopy,

Further reading Luedtke P, Lc\-illc MS, Rubcsin SE, tt nl. (2003 ).

R.,diologic diagnosis ofbcnign esophageal strictures: a paltern approach. RadioGrnplJics 23: 897-909.

38b Contrast barium swallow shows flask shaped outpouchings with a narrow neck of intramural pseudodiverticulosis.

swer 39 Abdominal Imaging Case 40

rvations (39) image from a mesen teric angiogram examination an abnormal duster ofvcssds and contrast 'blush'

_ ysplasia is the most common cause of occult "ng in the large bowd, predominantly aflCcting the y population. The condition is characterized by ar ectasia of the colonic circulation, most commonly

- :ring rhe caecum and ascending colon. The condition to chronic low-gr3dc blood loss but can also lead to cs of severe lower G I bleeding. There is an associa­

\\ith valvular heart disease, specifically aortic stenosis

SE 40

ory 35-year-old farmer presented with

ache in the right upper abdomen sc ... cralmonths.

Di agnosis can be made with selective mesenteric angiography or CT angiography. Both arc :a ble to idcnrif)' bleeding when the rate is as little as I mljmin. Three levels of abnormalit\, afC identified:

In carly disease, a densel)' contrast filled dilated \'ein is seen within the bowel wall. As the disease progresses, a vascular tuft can be seen at the lesion site. Fmther progression shows an early filling vein during the arterial phase of scanning.

;vlcsenteric angiography has the adv,lntage of proceeding directly to treatment with embolization. '1. ,

Practical tips y-r ; J CT is exce.Hem at ider.1tit~'ing the bleeding point when "\V; there is actIve GI blcedll1g. Always perform a pre -contrast f scan prior to the arterial phase scan so that high­contrast intraluminal blood can be diftcrentiated from high -contrasT bowel tOad content/debris.

Further management Surgical resection is the definitive treatment when endoscopic treatments have not controlled bleeding.

75

76

Answer 40 Abdominal Imaging

ANSWER 40

Observations (40a) There is a large, well defined lesion in the right upper quadr:l!ll, which has thin, curvilinear calcification of its wall. This is projected over the li,'cr and is probably inrrahcp3tic, though a calcified gallbladder cannot be excluded from this film. This is a solitary lesion with no orher abnormality seen. Gi\'cn the appearances and paticnI's young 19C and occupation, a hydatid q'Sl of the li\'cr is most likely. Funhcr imaging with CT would help confirm the location of the lesion and the likcl~' diagnosis. Serological tests for hydatid disease should also be undertaken.

Diagnosis Hydatid disease.

Differential diagnosis Ofca1citicd Ji\'crlcsion:

Metastasis - especially colorcctal cancer. • Primaryli\'crlUmOl1T. • In fection - hydatid, TB.

Discussion Hyd~tid disease is ac~uired through infection by the parasitic tapeworm EcJllllO,o'CIIsgr(lllllloSlls. Dogs are the definite host with the human acting as an accidental host following lcddental ingestion of eggs from canine faeces. The li,·er is the mOSt commonly im·oln:d organ and presentation is with abdominal pain, jllllldice, bilia~' colic with eosinophilia in 20-50%.

In the lil'er, inlection results in the fomlltion ofa cyst, which is more commonly found in thc right lobe; the size of the cyst ranges up to 50 Clll bur is - 5 em on average and mu lt iple in 20% of cases. The cyst is composed of three layers - the Outer pericyst, middle laminated ectocyst and the inner endocyst.

Radiological features ;lfe: Variable appearance ranging frOIll a simple unilocular cyst to a complex hct"Cfogclleolls cystic mass. D:lIlghtcr cysts arc char;lCterislic bllt arc a r;1re finding Their presence is noted by a 'racemose' appearance. Initially <hmghter cyStS arc \\'ell defined and round and aTe seen at tile periphery of the mother cystS. They progress to !orm large, irregular shaped cysts filling the Illother cysl. Can also contain debris (hyd.1tid sand), internal septations and wall calcification.

• Calcification is seen in 20- 30% of hydatid cyStS and is usua ll ~' cUrI·ilinear or ring like. Dense calcification is seen as the e,·st Start.s to heal.

• On cr, the appearance is of a l~'st \\'ith a high attenuation wall on Ilncnhanccd CT cvcn without calcification.

• ,\·IRI appearance is of a cyst with a low signal rim. • On C f /MRI!, thc wall and septac enhance with

contrast, which can aid in the diflercntiation betwecn hydatid cyst and a simple liver cyst.

Complications arc of cySt rupture (50- 90% of cases) and infection.

The lun gs arc th e second most common site of involvement in adu lts and the mOSt common in children.

There is a predilection lor the lower lobes and disease is Illore cOlllmonly seen on the right. CySts arc multiple in 2~ and bilateral in 2~ of cases. Figure 40b shows several left sided, well defined round intrapulmonary lesions. Calcification is rare. When ai r infiltrates between the layers of the cySt wall it can give the appearance of:a 'meniscus' sign, 'onion peel' sign and fin:atly thc 'watcr lily' sign, when there is complete separation of the endocyst from the pericysr. Rupture of the cySt can resul t in surrounding consolidation.

Practical tips • Benign liver cysts afe common, but all cySts should be

closely inspected lor atypical features, e.g. h)'l)cTattenllating wall Of wall calcification suggestive of abscess/hydatid; poorly dcfined edgcs, which may suggest the lesion is in fact a metastasis. Cystic lesions involving lil"Cr and lungs should suggest infectivc/malignant underlying diagnosis until proven otherl\"ise.

Further management )\bnagement can be cither medical (t\\"o benzimidazoles arc commonly used, albcndazole and mcbend:azolc) or surgical (cystectomy or partial organ resection).

Further reading Pedrosa I, Saiz A, Arrazola 1, It nl. (2000). Hydatid

disease: radiologic and pathologic features and complications. RndioGrnphics 20: 795-817.

Polat P, Kantard M, Alper F, It nl. (2003 ). Hydatid disease frolll head to toc. R..ndioGrnplJicJ 23: 475-494.

40b Patient with pulmonary hydatid presented with several large. well defined nodules in the left lung with no calcification.

Abdominal Imaging

CASE 41

History .\ 67-year-old, o\'crwcight female p,nicnt, with no past medical history, pr('scnrcd with \'ague abdominal pain, nausea and \·ol1li[lng.

Case 41

77

78

Answer 41 Abdominal Imaging

ANSWER 41

Observations (41a, 41b) AI' :abdominal radiograph shows distended loops of gas­filled small bowd but absent colonic gas. TogClhcr with the clinical history, appearances 3fC consistent with small bowel obstruction. There is no evidence of free gas on these films but on the second image there is an abnormal collection of air o\'er the ce!Urnl liver that has a somewhat li near/branching configuration. This is consistent with air in the biliary tree. In the right side of pelvis, there is a round opacity showing peripheral calcification - this is likely to ind icate an obstructing gJ.llstone.

Diagnosis Gallstone ilcus.

Discussion Gallstolle ileus is rchlti\'ely rare, accounting for 1-2% of all mcch;mic;ll obstructions (though more in the elderly). The most common scenario is of a stone eroding through from gallbladder to duodenum - the cholecysroduodenal fistula leads to pneumobi lia and the Stone then impacts in the Slllall bowel. The fistula can also be !Tom the comOlon duct, and can enend to thc colon or stomach instead of the small bowel.

Occasionally, the diagnosis can be made on plain films \\;th Rigler's triad t>f small bowcl obstruction, pneumobilia and ectopic gallstOnes. Oncn, however, the gallstone is nor seen on plain film since rhe stoncs frequently have a predominant composition of cholcsterol with little

calcilication. An axial CT scan of the abdomen (41 e conlimled a gallstone ilcus \\;th a 5 em diameter laminated gallstone found in the distal ileum. The bowel was collapsed disral to rhe site of stone impaClion. At laparotomy, the stonc was milked back to thc jcjunum and rcmo\·cd.

Practical tips Always check for air in the biliary tree on the small bowd obstruction :lbdominal film .

• Tilly loculcs of air in the biliary tree tend to be ccntl':llly located in the li\'(r (4Id ) compared with porral \'ein gas, which is seen in the periphery.

• Bili::!')' tree gas can also be seen as a normal finding in paticlll~ who hal'l.: had a previous sphincterotomy or [allowing a recent ERe I' (endoscopic rctrogrndc cholangiopancrcatography),

Further management 1\ lcchanic;rl Sl11all bowel obstruclion is a sm gic&.. emergency.

Further reading Gurlcrik G, Gurlcyik E (2001 ). GallstOne ilclls:

demographic and clinical criteria sllpponing preopcrati\'e diagnosis. UJI/S TrnJ'lIIn Derg 7(1): 32- 34.

Pangan JC, Estrada R, Rosales R ( 1984). Cholecystoduodenocolic fistula with recurrent gallstone ilcus. ArciJjJ'eJo/Surgery 11 9: 1201- 1203.

ry n;:ar-old male is admitted with -encephalopathy.

- SE43

ory llymptomatic 22 -),c;1r-old male nrcd with deTerioraTin g renal

:rion

Abdominal Imaging Cases 42, 43

79

80

Answers 42, 43 Abdominal Imaging

ANSWER 42

Observations 142) Image from a double contrast barium meal examination shows multiple serpiginous filling defects in the lower oesophagus. Normal appearances of the g,tstric nmdus arc observed. Appcar:lllccs arc consistent with oesophageal varices and the distribution suggests that these arc 'uphill'.

Diagnosis Ocsoph:agcal varices.

Differential diagnosis For ocsophagcal ,·ariees: • Varicoid carcinoma of oesophagus.

For gastric variccs (i.c. CJUSCS of thickened gastric folds): • Hypenrophie gastritis.

Mcnctrier'sdiseasc. • Lymphoma. • Splenic \'cin thrombosis,

Discussion Oesophageal ,'a rices ha,'e a ,'cry typical appearancc on contr;lst sw:tllow examination of dilated, smooth, se rpiginous filling defects. Varices collapse in the creer position and are beSt imaged with the patient pronto Thcre arc two types: • Uphill "arices (found in the lower oesophagus); these

are charanerizcd by collatcral blood flow from the portal vein vb the azygous "ein to the superior \"ena cava (SVC ). These arise due to liver cirrhosis and duc

ANSWER 43

Observations (43) This pl:lin abdominal radiograph shows multiple small foci of calcification over both renal areas in thc region of the rCIl:J1 medulla rather than ren:J1 cort·ex. No stones arc seen elsewhere along the course of the renal tracrs.

Diagnosis Rell:J1 medullary llephrocalcinosis.

Discussion Mcdullary nephroc:Jlcinosis represcnrs calcific:Jrion in the distal con\'oluted tubules, i.e. in the renal pyramids, There arc m:Jny causcs :tnd the underlying pathology can rarely be determined on a plain rndiograph - clinical history is fur more important here.

Tlte C:J lISCS arc: Renal tubular :Jcidosis ( RTA ), Endocrine causes - hyperparathyroidism, hyperthyroidism, Cushing's. Medulla!)· sponge k.idne~' . Idiopathic hypercalcuna,

to IVC/hcp;uic vein/splenic vein thrombosis or obstruction. Downhill \'ariccs (found in the mid and upper oesophagus); these arc characterized by coll:ncral blood flow from the SVC \'ia the :azygous vein into the IVe, and arise due to SVC obstruction from conditions such as IUllg tumour, lymphoma and rc[rasternal goi tre.

Gastric varices arc secn in combination with oesophageal "arices in patients with portal hypertension. When seen.tn the absence of oesophageal "arices, splenic vein thrombosis should be suspected. Again, appearances arc of smooth. serpiginous or grape -like filling defects; most commonl~ seen in the gastric fundus.

Practical tips Best images arc obtained with thc patient in a prone position, Further investigation with an ultrasound of the abdomen should be advised to look for cirrhosis and portal hypcrtension.

Further management Treatment is aimed at controlling poml hrpcrtension \Vim medical and surgical (transjugular intrahcp:ttic ponosy~temic shunt - T IPS) means. Treatment of bleeding ":trices and preemptive treatment of non bleeding varices is achie,-cd with endoscopic banding and sclerotherapy.

Renal papill:t!), necrosis. Hypelyir:Jminosis D, Milk-alkali syndrome, M:Jlignancy - bone metastases, multiple myeloma, p:trnneopiastic syndrome. Primary hypcroxaluria,

Practical tips • The most common causcs of symmetrical medullary

nephrocalcinosis are hyperparathyroidism and RTl'.. • T he most common cause of asymmetrical medullary

nephrocalci nosis is medulla!)' sponge kidney".

Further management Underlying causc must be identified - particubrly tre:ttJbk

Further reading Dyer RB, Chen MY, Zagona RJ ( 1998 ). Abnorm:tl

calcifications in the urina!)' trnct. RadioGraphies 18: 1405~ 1 424.

E 45

ry ·n=Jr-old male presented with

dial bloating.

Abdominal Imaging Cases 44, 45

81

82

Answers 44, 45 Abdominal Imaging

ANSWER 44

Observations (44) This is a single AI' image from a double contrast small bowel barium examination. T here is focal, eccentric n:lrrowing of the second part of the duodenum, with predominant notching of rhe latc",! wall. Appearances of the duodell um superior and inferior to this arc completely normal.

Diagnosis Annular pancreas.

Differential diagnosis For 3.nnubr pancreas: • Sphincter orOddi oedema (secondary to impacted

none or pallcrc3tilis)/carcinoma - usually produces an eccentric lesion but this is prcdominantl~' medially located.

• Duodenal adenocarcinoma - usually presems with an annular concemric I<:sion \\;th shouldering and utccr:ltion. There is an association \\~th G:lrdncr~ syndrome and coeliac disca~.

Discussion Annular pancreas is a disOrder characterized by fuilure of rotation of the ventral bud of the pancreas resulting in pancreatic tissue encircling the duodenum. TIll: sccond pan of the duodenum is inmh'ed in 85% of cases, Usually patients are asymptomatic, but the condition can preSCn! at any age , with 48% of cases presenting in adulthood. There is an association wi th other congenital abnormalities when the condition presents in chi ldhood - tracheo­oesophageal atrcsi:l, duodenal atresia, irnperfor:ne anus, Down 's syndrome.

ANSWER 45

Observations (45a) Single image from a percutaneous chol3ngiogram is shol\1l. The percutaneous needle is seen with the tip in a proximal intrahepatic bili3ry duct. There is clcar abnormalit), of the commo n d uct, which has several strictures with duc t dilatation and bead ing. No filling defects arc seen to indic3te gallstones. Contrast is scen in the duodenum with no obstnlcting lesion scen at the lel'cI ofthc sphincter of Oddi.

Diagnosis Primary sclerosing cholangitis ( PSC).

Differential diagnosis ' For PSC: • Sclerosing cholangiocarcinoma. • Acute ascending cholangitis. • Bile duet carci noma - this G ill ran:I)' inl'oll'e the bili;u)'

system in a difruse maImer producing multiple 1l1mour stric1l1res.

•

Clinical presentation can be with: • Pol)'hydramnios - i'l utero. • Persistent vomiting, "double bubble' - in neonates. • :-J:lUsca~ , 'omiting and abdominal pain - in adults.

The condition is complicated by 311 increased incidence 01

acute and chronic p3ncreatitis 3nd periampullary I"P';; ' J ulcer.

Practical tips Crtrcfully examine the fi lm for g:lllstones or sma ll fe;)tu res of cocli3c disease (small bowel flocculation of contrast , featureless smooth small IUlllen/ folds, jeju nization of ileal loops and peristalsis) to suggest :lI101her diagnosis.

Further management · cr \\ill confiml pancreatic tissue encircling the

duodenum. • ERCP (endoscopic retrograde

cholangiopanereatography) or I'vt RCP (magnetic resonance cholangiopancre3togr:lphy) shows a nomlally located main pancre3tic duct in the body 01·

the pancreas, :lIld 3 small duct in the head or the pancreas encircling the duodenum.

Further reading Rizzo RJ, Szucs RA, Turner MA ( 1995). Congenital

abnormalities of the pancreas and biliary tree in adul ts. l{nnioGmplJiu 15( 1): 49-68.

Discussion Prim3!,)' sclerosing cholangi tis is a progressil·e fibr·", ... inflammatory condition 3fTecting both intrahepalic enrahepatic bile ducts. The condition is strongly as"""·,,,_ with inflammatory bowel dise3se (ulecratil·c colitis [l" round in 70%, Crohn's in 15%). Other assocbtions i'",""K retroperitoncal and mediastinal fibrosis, chronic a hepatitis, Riedel's thyroiditis, p3ncrcarit is and Sjogn=fl s)'ndrome.frescntal"ion is Wilh progressive fatigue, ,,"". and jaundice . Biochemical changes :tn: round with clC"I SCrulll bilinrbin and alkaline phosphatase. • Im3ging feat\rres on cholangiogi.lphy

(MRC P/ ERC P ): there arc mtrhifocal strictures aflccting intra- and extrahepatic bile ducts wilh s~ lesions. The classic p311em is or 3 'beaded' appe"" ... with alternating segments of stenosis and dilat":ltia. (45b),

• Im3ging features on CT: ducts have the 3ppcaran.x strictures, dilat;ltion, belding 3nd pruning.

• Imaging on US: usually normal but may show d ua 1\';111 thickening,