Abdominal Imaging

I. Liver
1. Anatomy:

A. Falciform ligament (peritoneal reflections) ligamentum teres (obliterated umbilical vein) divides left hepatic lobe into medial (aka quadrate lobe) and lateral segments B. Caudate lobe demarcated by IVC and fissure of ligamentum venosum (contains hepatogastric lig); papillary process may extend into lesser sac, simulating a mass or lymph node C. Anatomic segments of liver: separated by hepatic veins; contain portal triads (portal vein periportal fibrosis; hepatic artery; biliary ducts) Caudate (I) Left lateral (II = superior; III = inferior) Left Medial (IV) Right Anterior (V = inferior; VIII = superior) Right Posterior (VI = inferior; VII = superior) D. Size: normal < 17 cm craniocaudal dimensions; above iliac crest on supine KUB E. U/S echogenicity: kidney < liver < spleen/ pancreas doppler waveforms: 1) HV= triphasic; 2) PV= low velocity (1020cm/s)+ resp variation+ pulsation d/t tricuspid regurg; 3) HA= low impedance+ arterial flow D. CT-density: liver(55-60 HU) > spleen(45-50 HU) > kidney/pancr(35 HU) F. MRI: T2 = 45-55 msec 2. Cirrhosis: A. Risks: EtOH = Laennecs cirrhosis (micronodular < 3 mm) Hepatitis: hepatitis A/B/D; CMV/ EBV/ HSV (macronod. > 3 mm) Toxins: INH; halothane; chlorpromazine; diphenylhydantoin; methyldopa; acetominophen; CCl4

 Hemochromatosis: DM + pigmentation (= bronze diabetes); echogenicity of liver; overall density WNL ( fat/ glycogen) Other: Wilsons disease; -1 AT deficiency; biliary cholestasis B. Radiographic: Early: fatty infiltration; heterogeneous attenuation; lobulated contour Late: regenerating nodules dysplastic (low-high grade) HCC focus; atrophy of right lobe with hypertrophy of left lateral + caudate lobes; overall liver volume; portal HTN collaterals (left gastric, paraesoph, mesenteric, retroperitoneal, splenorenal) +splenomegaly + ascites; confluent fibrosis with capsular retraction ( T1 + T2) and late enhancement Siderotic nodules: T2; hyperdense NECT (contain Fe) Nodules Regenerating Dysplastic HCC NC = = HAP = = PVP = = T1 / T2 Enhancement +

C. Complications: Portal HTN esophageal varices ( bleeding) + ascites Liver failure: encephalopathy; anasarca HCC: 10% 3. Hepatic steatosis: A. Clinical: risks = EtOH, obesity, DM, steroids/ Cushings syndrome, hepatitis, chemotx, hyperalimentation, and malnutrition B. Radiographic: echogenicity; normal 99mTc-sulfur colloid scan; < 40 HU; 1 mg TG/cm3 liver density by 1.6 HU C. Patterns: Diffuse: vessels stand out in relief; enlarged liver Focal: geographic or fan-shaped (segment IV; adjacent to falciform ligament; adjacent to portal bifurcation + GB-fossa); due to aberrant draining veins (internal mammary; periumbilical; cholecystic) Multifocal: angulated, geometric margins; no mass effect; changes over time (weeks); DDX = hepatoma, metastases Fatty sparing: segments I and IV 4. Hepatic hyperattenuation (> 80 HU): A. Iron deposition: T2; T1 (GRE) Hemochromatosis: autosomal recessive Fe2+-absorption parenchymal deposition (liver, pancreas, heart, pituitary

gland) as ferric oxyhydroxide develop cirrhosis + DM + CHF (cardiomyopathy) Hemosiderosis: due to mutiple blood transfusions (> 40 units or 10 g Fe2+) deposition in RES (liver, spleen, bone marrow, and lymph nodes) NO cirrhosis Other: intravascular hemolysis; PNH (parox noct hemoglobinuria) B. Drugs: amiodarone; gold; arsenic; Thorotrast (= thorium dioxide (223Th; -emitter); heterogeneous/ reticulated angiosarcoma; HCC; cholangioCA) C. Metabolic: von Gierkes disease (hepatomegaly with echogenicity; nephromegaly; hepatic adenoma + HCC) Type I-von Gierke II-Pompe III-Forbes/ Cori IV-Anderson V-McCardle VI-Hers VII-Tarui Glycogen Storage Diseases Enzyme Deficiency Organ Involvement Glucose-6-phosphatase Liver, kidney, intestine Lysosomal glucosidase All organs (heart !) Debrancher enzyme Liver, muscle, heart Brancher enzyme Generalized amylopectin Muscle phosphorylase Muscle Liver phosphorylase Liver Phosphofructokinase Muscle

5. Primary Sclerosing Cholangitis (PSC): A. Clinical: autoimmune (?); associated with IBD (UC >> Crohns) B. Radiographic: Lobulated contour with caudate hypertrophy and atrophy of right lobe; deep lobules Numerous lymph nodes Intra-/ extrahepatic biliary ductal strictures +/- stones 6. Primary Biliary Cirrhosis: A. Clinical: females ; idiopathic vs. autoimmune (?); associated with Sjoegrens, RA, scleroderma, celiac sprue, etc. B. Radiographic: Caudate hypertrophy; mildly heterogeneous parenchyma Numerous lymph nodes; perivascular cuffing Only intrahepatic strictures 7. Gauchers Disease: A. Clinical: glucocerebrosidase deficiency ceramide in RES HSM + splenic infarcts B. Radiographic: Erlenmyer deformity of femur; diffuse osteopenia; lytic bone lesions; AVN; HSM late splenic infarcts 8. Sarcoidosis:

A. Clinical: black females; idiopathic; noncaseating granulomas lungs > skin/ eyes > GI (spleen > liver) B. Radiographic: Noncaseating granulomas: usually < 2 mm; up to 5 mm Portal HTN; hepatosplenomegaly LAD: periportal + perisplenic 9. Peliosis hepatis: A. Clinical: rare benign intrahepatic vascular disorder (endothelial-lined vascular spaces (= extreme phlebectasia) and sinusoids); risks = chronic infection (TB; Bartonella henselae); steroids (androgens); chemotx; DM; CRF; often reversible B. Radiographic: Multiple small hypodense/ hypoechoic lesions (up to 1.5 cm) Enhance in late arterial/ early portal-venous phase 10. Normal hepatic hemodynamics: A. Portal vein hepatopedal with little pulsatility (20-30 cm/sec) B. Hepatic veins hepatofugal with pulsatility (atrial contraction flow reversal); measure at end-expiration C. Hepatic arteries hepatopedal; low resistance (maintained diastolic flow) 11. Portal HTN: A. Portosystemic collaterals Coronary (= left gastric)/ azygos GE varices IMV collaterals hemorrhoids Recanalized paraumbilical vein (vasa vasora) caput medusae Splenorenal B. Etiologies: Presinusoidal: portal thrombosis/ compression; hepatic fibrosis (myelofibrosis; Wilsons; sarcoid; PVC); infection (malaria; schistosomiasis tortoise-shell Ca2+ along capsule + parenchyma) Sinusoidal: cirrhosis (#1); sclerosing cholangitis Postsinusoidal: Budd-Chiari Syndrome: idiopathic (70%); hypercoagulability; malignancy (HCC/ pancreatic/ RCC/ adrenal CA); T2-thrombus; peripheral hypoenhancement (early; poor HV drainage) flipflop (peripheral enhancement on delayed imaging) Hepatic veno-occlusive disease (= progressive non-thrombotic occlusion of hepatic venules): toxins (Jamaican bush tea); chemotherapy; GVHD CHF: passive hepatic congestion (= cardiac cirrhosis) enlarged IVC/ hepatic veins; prominent pulsatility

 Constrictive pericarditis Idiopathic: Banti syndrome ( middle-aged females; portal fibrosis portal HTN + splenomegaly + esophageal varices; normal LFTs) C. Radiographic: hepatofugal flow; HSM; ascites; enlarged periportal veins (cavernous transformation of vasa vasora); varices D. Complications: Variceal bleeding, encephalopathy, ascites, splenomegaly Thrombosis: hypercoagulable states, inflammation, or tumor E. Treatment: Surgical portosystemic shunts SMV/ portal + IVC; splenorenal TIPS (= transjugular intrahepatic portosystemic shunt): failure due to restenosis or neointimal hyperplasia; normal velocities 90200 cm/s (hepatopedal)

12. Hepatic transplant complications: A. Biliary necrosis: due to arterial lesions (normally supply bile ducts); arterial stenosis resistive index > 0.5 (= pulse pressure/ systole); peak systolic velocities > 200 cm/sec B. Arterial dehiscence: hemorrhage/ exsanguination C. Biliary leak: biloma, etc. 13. Solid focal hepatic masses: A. Metastases: Common primaries from GI tract (mucinous colon > stomach > pancreas); breast; ovary Well-defined, low density mass (may appear hyperdense if fatty replaced); hypoechoic Cystic/ necrotic: mucinous colon/ gastric; breast; small cell lung;

melanoma ( T1 melanin); ovarian; endometrial; choriocarcinoma; sarcomas (spindle cell #1) Ca2+: necrosis, mucinous CA (ovary, colon, stomach, breast) Hypervascular: carcinoid; islet cell; thyroid+ pheochromocytoma (RBC-ITP); RCC (small #); ?breast/melanoma Hypovasc: H&N+ lung+ panc+ colon/rectum+ urothelium+ prostate+ gyn Hemorrhagic: melanoma; thyroid; RCC; choriocarcinoma Diffuse mets: small cell lung; melanoma; breast; endocrine tumors B. Hepatoma: Clinical: 80% in cirrhosis ( 10% develop HCC); FP (6070%); Ca2+/ necrosis; risks = cirrhosis; aflatoxin; Thorotrast; galactosemia; von Gierkes; Wilsons; hemochromatosis Composition: hepatocytes+kuppfer cells+capsule (3-4mm thin fibrous; broken)+fat+central scar; NO bile ducts Patterns: solitary, diffuse/ infiltrative, multinodular non-cirrhotic= younger+ lgr (mean 12cm)+ calc 25%+ central scar 50% ( incid fibrolamellar) + solitary 72%+ capsule (25%) + + T1 50%+ invasive cirrhotic= solitary 27%+ central scar 6%+ capsule (25%)+ T1 50% Fibrous capsule 30-50%; locally inv (HV+PV+GB+bile ducts Radiographic: CT: iso/hypodense; = or hyperenhancing (arterial); PVP =; delayed = (wash out more quickly than parenchyma); capsule MRI: T1 (unless hemorrhage)/ T2 Nucs: photopenic (cold) on 99mTc-SC scan Complications: vascular invasion (hepatic > portal veins); fatty metamorphosis; metastases (lung > adrenal > LN > bone; vascular shunts (arterio-portal; portal-venous) C. Fibrolamellar HCC (<10% HCCs): Clinical: younger patients; normal FP; better prognosis Radiographic: hyperechoic; central scar (Ca2+; T1/ T2) D. Hepatic adenoma (rare): Clinical: females (90%); risks = OCPs >5yrs, von Gierkes disease (type I), mult androgens; mult 50%; composed of hepatocytes with few Kuppfer Cells ( uptake of 99mTc-SC); NO bile ducts Radiographic: U/S: hypoechoic; heterogeneous; well-circumscribed

 CT: iso/hypointense x with acute hem; arterial hyperenhancement; PVP ; delayed ; capsule; hemorrhage/ necrosis (50%); multifocal (30%) MRI: variable signal (often isointense) in the absence of hemorrhage; fibrous capsule Nucs: photopenic on 99mTc-SC E. Focal nodular hyperplasia (2-5% incidence): Clinical: all normal histologic elements of liver but no capsule or fat; fibrous bands and stellate scars 50% ( T1/ T2); multifocal (7-20%) 85% women; not a/w OCP; no malig potential Radiographic: U/S: hyperechoic; homogeneous; less well circumscribed CT: iso/hypodense to liver parenchyma (CT); arterial hyperenhancment; PVP =; delayed =; central stellate scar MRI: isointense T1/ slightly T2 with prominent enhancement; stellate scars ( T1/ T2) Nucs: normal/ 99mTc sulfur-colloid uptake (60%)

F. Cavernous hemangioma: Clinical: incid= 4-7%; #2 solid mass (after mets); #1 benign lesion (after cysts); females (5:1); 10% multiple thin-walled endothelial lined spaces supplied at periph by HA; usu <3cm (>5cm giant); uncommon in cirrhotics; spont hem rare Radiographic: U/S: well-defined; homogeneous and hyperechoic (+/enhanced through-transmission 60%); may change appearance) CT: peripheral, broken nodular enhancement aorta central confluence/ isodense fill-in unless central scar persists for 30 min MRI: T1/ T2 (lightbulb) Nucs: uptake 99mTc-RBC scan (> 2 cm) Other features: Giant hemangiomas (> 5 cm) central scar capillary hemangioma: <1.5cm; HAP flash E = vessels Kasabach-Merritt syndrome: giant hemangioma + PLTs

G. Kaposis sarcoma: periportal thickening (echogenic

starry-sky)

H. Lymphoma: often anechoic (appear cystic) due to tumor homogeneity (sheets of cells) I. Peritoneal-based metastases: ovarian > GI tumors; may appear intrahepatic (along falciform ligament/ GB fossa/ etc.); +/- malignant ascites J. Other lesions: Liposarcoma: rare; speed-propagation artifact (U/S); fatcontaining; infiltrative Angiosarcoma: reticulated enhancement; risks = PVC; Thorotrast Hemangioendothelioma: hypoechoic; nodular; heterogeneous enhancement; SXS = output heart failure (neonate) K. DDX for homogeneous hyperechoic liver lesions: Focal fat (#1) Hemangioma (#2) Others: metastases, HCC > adenoma, FNH (rare) L. DDX <1cm lesions : cysts+ biliary hamartoma+ hemangioma+ mets; 80% benign & 60% benign c known mets M. DDX hypovasc mets: 14. Cystic hepatic masses: A. Simple hepatic cysts Clinical: often congenital; ADPKD; autosomal dominant polycystic liver disease (rare; 50% with renal cysts; normal renal function) U/S criteria = anechoic with smooth/ thin walls and throughtransmission B. Complex cysts: hematomas; abscesses; cystic metastases C. Pyogenic abscess: E. coli, streptococci, anaerobes Risks = cholangitis; diverticulitis; appendicitis; typhlitis; IBD; thrombophlebitis Multiloculated; gas (20%); double target sign = surrounding edema; enhancing walls D. Amebic abscess: Entamoeba histolytica Right lobe; irregular, nodular, enhancing walls; 20-30% with pleuro-parenchymal involvement; internal septations; multiple abscesses anchovy-paste debris TX = metronidazole E. Schistosomiasis:

 Periportal echogenic fibrosis due to granulomatous reaction Complications: cirrhosis; splenomegaly; ascites F. Echinococcal cysts (= hydatid cyst disease): dog tapeworm (Taenia echinococcus) E. granulosus: daughter cysts (smaller cysts within larger cyst); rimlike Ca2+ (50%); double rim sign = pericyst/ endocyst; Waterlilly sign; enhancing wall E. multilocularis (alveolaris): rodent host; hypodense lesion (infiltrative); tiny cysts not visualized radiographically (appears solid); punctate Ca2+ G. Fungal: Candida; Aspergillus Multiple small (< 5 mm) lesions = target/ bulls eye sign spleen; wheel-within-a-wheel appearance H. Pneumocystis carinii: Multiple echogenic foci scattered throughout the liver (= granulomas) starry-sky appearance I. Cystic/ necrotic liver tumor: Thick, nodular walls; internal debris Contrast enchancement DDX = metastases > HCC > cystadenomas/ cystadenocarcinoma J. Vascular malformations: appear cystic; aneurysms; aortoportal fistulae K. Biliary cystadenoma/ cystadenocarcinoma: Middle-aged females Multiloculated intrahepatic lesions Septal + mural nodularity malignancy (cystadenocarcinoma) 15. Hepatitis: A. Radiographic: echogenicity of portal triads (venules); often normal sonographic appearance; GB wall thickening + periportal LAD B. DDX for starry-sky: Acute hepatitis Leukemia/ lymphoma/ Kaposis Toxic shock syndrome Infections: PCP > MAI, CMV; candidiasis; aspergillosis Granulomatous disease: TB; histoplasmosis; schistosomiasis 16. Portal vein thrombosis: A. Etiology: malignancy; chronic pancreatitis; hepatitis; trauma; shunts; hypercoagulability B. Findings: echogenic thrombus; hepatofugal flow; splenomegaly; ascites liver +

C. Complications: cavernous transformation; extension of thrombus 17. DDX for liver lesions with central scars: Fibrolamellar HCC FNH Adenoma: rare Hemangioma (giant) 18. Liver trauma: A. Clinical: blunt/ penetrating trauma contusions; lacerations (linear, stellate); subcapsular hematomas (blunt trauma) B. Subtypes/ grades: Grade I: Hematoma: subcapsular (< 10%) Laceration (< 1 cm deep; linear/ extends to liver margin) Grade II: Hematoma: subcapsular (non-expanding; 10-50%) or intraparenchymal hematoma (< 2 cm) Laceration (< 3 cm deep; < 10 cm long) Grade III: Hematoma: subcapsular (> 50%) or expanding or intraparenchymal hematoma (> 2 cm) Laceration (> 3 cm deep) Grade IV: Hematoma: central intraparenchymal Laceration with parenchymal destruction (25-75% of lobe) Grade V: Parenchymal destruction (> 75% of hepatic lobe) Juxtahepatic venous injury (portal > hepatic veins) Grade VI: Hepatic avulsion

II. Biliary Tree and Gallbladder

1. Anatomy: A. Common bile duct < 7 mm B. Hepatic artery between CBD + portal vein (80%); 20% anterior to CBD C. GB: maximum = 5 x 10 cm; wall < 3 mm D. Cystic duct: spiral valves of Heister E. Phrygian cap: fold within gallbladder fundus (normal variant) 2. Biliary obstruction: A. Etiology: gallstones, tumor (pancreatic carcinoma, ampullary carcinoma, cholangiocarcinoma), stricture, pancreatitis, Mirrizzis syndrome (impacted stone within cystic duct with surrounding edema)

B. Criteria: CBD > 7 mm; gallbladder > 5 cm 3. Cholangiocarcinoma: A. Clinical: most within CBD; jaundice; Klatskin tumor at hepatic duct junction (DDX = HCC; GB carcinoma) B. Risk factors: UC; benzene; Clonorchis; Carolis disease; Thorotrast C. Radiographic: proximal intrahepatic ductal dilatation; often too small to identify on CT; portal vein encasement; short annular constricting lesion; delayed enhancement (> 10 min) 4. Acute cholangitis: E. coli > Klebsiella > Pseudomonas A. Etiologies: choledocholithiasis; strictures; sclerosing cholangitis; ampullary CA B. Findings: intrahepatic ductal dilatation; pigment stones + sludge 5. Choledochal cysts: classic triad = jaundice + palpable mass + abdominal pain Type I: fusiform dilatation of extrahepatic duct (most common) Type II: diverticular outpouching of extrahepatic duct Type III: choledochocele (dilatation of distal CBD which protrudes into duodenum); cholangiocarcinoma Type IV: multifocal intra-/ extrahepatic dilatation Type V (= Carolis disease): Saccular dilatation of intrahepatic biliary ducts; central dot sign dilated bile duct surrounds adjacent HA and PV Complications: cholangitis; cholangiocarcinoma; hepatic fibrosis Associations: medullary sponge kidney (80%), IPCKD, gallstones

6. DDX for biliary gas: A. Postoperative: sphincterotomy, choledochoenterostomy B. Fistulae: gallstone (cholecystoduodenal); perforated ulcer (choledochoduodenal); carcinoma (choledochoenteric) 7. Biliary cystadenomas/ adenocarcinomas: A. Clinical: middle-aged women; SXS = abdominal mass; N/V; jaundice B. Radiographic: large, multilobulated mass; Ca2+ within walls/ septations; malignancy with mural nodules or irregular/ thickened walls C. DDX = abscess (pyogenic; echinococcal); necrotic mets; cystic mesenchymal hamartoma (< 20 years) 8. Gallstones: A. Subtypes: low density cholesterol ( older women); high density

Ca2+ (30%); pigment stones (calcium bilirubinate Asian population; hemolytic anemia); risk factors = DM, cirrhosis, Crohns disease, PTH B. Findings: posterior shadowing; mobile; wall-echo-shadow triad; floating stones cholesterol stones or HIDA scan C. DDX: Sludge echogenic without posterior shadowing; fasting, hyperalimentation, obstruction (tumefactive if non-mobile/ mass-like) Milk of calcium bile: intravesical calcium salts; dense GB contents Polyps: non-mobile and non-shadowing Other: Ca2+ in hepatic artery/ pancreatic head or gas in duodenal diverticulum 9. Acute Cholecystitis: A. Types: Gangrenous perforation, abscess, fistula, peritonitis (Nucs rim-sign) Acalculous cholecystitis critically ill patients (trauma, burns, hyperalimentation, DM, AIDS, postoperative) Emphysematous: rare; 40% DM; elderly; perforation B. Radiographic: gallstones; gallbladder > 5 cm; gallbladder wall > 3 mm; pericholecystic fluid; bile density; emphysematous cholecystitis; sonographic Murphys sign C. Complications: Mirizzi syndrome: impacted stone within cystic duct surrounding inflammation CHD obstruction Biliary-enteric fistulas: biliary-duodenal > colonic, ileo-jejunal; trauma; tumor; penetrating posterior duodenal ulcer Gallstone ileus: Rieglers triad = obstruction (85%) + pneumobilia (70%) + Ca2+ stone (25%) Bouverets syndrome: gallstone ileus with stone impacted in the duodenum or pylorus 10. Oriental Cholangiohepatitis (= recurrent pyogenic cholangitis): A. Clinical: younger Asians (20-50 years); SXS = fever; jaundice; abdominal pain; Clonorchis sinensis or Ascaris lumbricoidis B. Findings: biliary strictures + central dilatation; arborization with abrupt tapering; hepatolithiasis (intrahepatic) C. Complications: hepatic abscess; hepatic atrophy; cholangiocarcinoma 11. Xanthogranulomatous cholecystitis: staghorn calculi; marked GB wall thickening; adjacent hepatic inflammatory changes 12. Sclerosing cholangitis: primary vs. secondary

A. Etiologies (2): IBD (UC >> Crohns); cirrhosis; chronic active hepatitis; pancreatitis; Riedels thyroiditis (fibrosing thyroiditis); Peyronies disease (penile fibromatosis) B. Findings: string of beads dilatation of intra-/ extrahepatic bile ducts; pruned-tree (obliterated peripheral ducts); left hepatic lobe hypertrophy with nodular contour C. Complications: cholangiocarcinoma; biliary cirrhosis; portal HTN D. DDX = primary biliary cirrhosis (PBC): only intrahepatic biliary strictures 13. Hyperplastic cholecystoses: A. Adenomyomatosis: #1 hyperplastic cholesterolosis; RokitanskyAschoff sinuses containing cholesterol crystals (comet tail artifacts); adenomyoma (localized form with sessile/ smooth filling defect in fundus) B. Cholesterolosis: strawberry gallbladder; TGs and cholesterol (< 1 mm) deposited in macrophages within GB wall; no shadowing 14. GB carcinoma: A. Clinical: #5 GI cancer; risks = cholelithiasis; IBD (UC > Crohns); porcelain GB (risks = chronic cholecystitis; gallstones) B. Radiographic: GB thickening; invasion of liver, gastrohepatic and hepatoduodenal ligaments; LN mets; peritoneal carcinomatosis 15. DDX for GB wall thickening: Cancer: focal > diffuse Metastases: focal; melanoma; pancreas Adenomyomatosis: focal (adenomyoma) vs. asymmetric > diffuse Polyps: focal; remove if > 1 cm ( risk of GB carcinoma) Tumefactive sludge: focal Edema: diffuse Inflammation: cholecystitis > hepatitis, pancreatitis (diffuse/ asymmetric) Other: AIDS cholangiopathy; sclerosing cholangitis (diffuse)

III. Spleen
1. Anatomy: A. Splenic density < hepatic density B. Heterogeneous arterial enhancement C. Accessory spleens: 10-30% (around splenic hilum and pancreatic tail; < 3 cm); detect with 99mT-SC or heat-damaged 99mT-RBC scans D. Wandering spleen: laxity of suspensory ligaments (children) E. Polysplenia: bilateral left-sidedness, absent GB, left-sided liver, interrupted IVC, CHD 2. Trauma: A. Clinical: blunt > penetrating trauma subcapsular hematoma, lacerations, fragmented spleen; intraperitoneal blood (> 95%)

B. Subtypes/ grades (not very predictive of outcome): Grade I: Hematoma: subcapsular, nonexpanding (< 10%) Laceration: capsular, non-bleeding (< 1 cm deep) Grade II: Hematoma: subcapsular, nonexpanding (10-50%) Laceration: 1-3 cm deep; bleeding Grade III: Hematoma: subcapsular (> 50%) or expanding/ bleeding Laceration: > 3 cm deep Grade IV: Hematoma: ruptured intraparenchymal +/- bleeding Laceration: crushed or fragmented region (< 25%) Grade V: Laceration: diffuse fractured/ shattered spleen Vascular: hilar vessel injury; devascularized spleen C. Complications Splenosis (autotransplantation) mesentery, peritoneum, omentum; image with heat-damaged 99mTc-RBC or 99mTc-SC 3. Splenomegaly: A. Criteria: > 12 cm; splenic index (multiply 3 dimensions; normal 120-480 cc); extending below costal margin B. Etiologies: Myeloproliferative: lymphoma, leukemia Infectious: EBV, CMV, HIV ( Kaposi, lymphoma, MAI, MTB, fungal, Pneumocystis) Congestive: CHF, portal vein thrombosis Infiltrative: Gauchers disease C. Complications: thrombocytopenia; spontaneous hemorrhage 4. Low density/ cystic lesions: A. Infarction: wedge-shaped areas with capsular extension without mass effect; late fibrosis + scarring; risks sickle cell, cardiac disease (endocarditis, atheroma, MS), lymphoma, mets, polycythemia, pancreatitis B. Lymphoma: splenomegaly (often reactive) vs. solitary mass vs. multifocal nodules; LAD splenic hilum C. Hematoma: subcapsular; lacerations with extension to capsule; intrasplenic contusions and hematomas fibrosis + Ca2+ D. Abscess: Candida; Aspergillus; Pneumocystis: ill-defined thick walls; +/gas or fluid (DDX = sarcoid) Echinococcus: thick/ mural Ca2+ with daughter cysts

E. Metastases: primaries = melanoma, lung, breast, ovarian, stomach; occasionally cystic F. Cysts: Final stage of intrasplenic hematomas; 10% wall Ca2+ Congenital epidermoid cysts: spherical, thick walls with trabeculations Echinococcal cysts: multi-septated; Ca2+ common Cystic lymphangioma G. Epidermoid: peripheral septations/ trabeculations; contains fat/ cholesterol/ etc. H. Splenic peliosis: multiple low-attenuation lesions (1-3 cm); late enhancement 5. DDX for splenic Ca2+: Granulomatous disease: TB; histoplasmosis; sarcoidosis Hematoma Metastases: melanoma; breast; lung Infarction 6. Primary tumors: rare Hemangiomas (#1): benign; central/ mottled or peripheral curvilinear Ca2+ Hemangiosarcomas: heterogeneous with solid and cystic components Hamartoma: rare; usually asxs, anemia, PLTs Littoral cell angioma: benign hypervascular tumor of the red pulp; rare; intra-abdominal malignancies (lymphoma; GI tumors; etc.) DDX = lymphangiomatosis: multiple round lesions ( T1/ T2) 7. Gamna-Gandy bodies: Aka siderotic nodules; hemosiderein-calcium complex deposits in spleen > liver; cirrhosis Undetectable by U/S or CT; MRI T1/ T2 foci (GRE blooming)

IV. Kidneys
1. Anatomy:

A. Anterior pararenal space contains pancreas, duodenal loop (2nd-4th portions), and ascending/ descending colon; anterior renal fascia = Gerotas fascia B. Posterior pararenal space = potential space which is contiguous with properitoneal flank stripe laterally; posterior renal fascia = Zuckerkandles fascia 2. Tumor Classification: A. Parenchymal: RCC; Wilms; adenoma; oncocytoma; nephroblastomatosis; mesoblastic nephroma B. Mesenchymal: angiomyolipoma; malignant fibrous histiocytoma (MFH); hemangioma C. Renal pelvis: transitional cell; squamous cell; papilloma; fibroma; polyp 3. Renal cell carcinoma: A. Clinical: 85% of renal tumors; males; hematuria; flank pain; mass; risk factors = tobacco; phenacetin; vHL; chronic dialysis (papillary RCC with better prognosis); predominantly solid with cystic components B. Staging (Robson): resectable < stage IIA; unresectable > stage IIB Stage I: confined to kidney Stage II: extension through capsule into perirenal space Stage III: regional extension A: extension into main renal vein/ IVC B: regional lymph node involvement C: renal vein + regional lymph nodes Stage IV: A: spread to adjacent organs B: distant metastases

C. Radiographic: 10% stippled central egg-shell Ca2+; hypervascular tumors strong heterogeneous enhancement; vascular invasion (30% renal vein; 5-10% IVC; rarely into right atrium); DDX = column of Bertin; usually hypoechoic (hyperechoic if < 3 cm; DDX = AML) D. Tumor spread: Local extension Lymphatic: hilar, pericaval, periaortic nodes (> 1.5 cm) Hematogenous: lung > liver > bone, adrenals > opposite kidney; long latency (> 20 years) E. Paraneoplastic syndromes: HTN (renin) HCT (erythropoietin) Ca2+ (PTH) 4. Angiomyolipoma: A. Clinical: 20% multiple, bilateral tuberous sclerosis; 80% solitary, unilateral; middle-aged women B. Radiographic: fatty regions (-80) to (-120) HU; smooth muscle components (nodules/ whorls); hypervascular enhancement; size = 1-30 cm 5. Transitional cell carcinoma: A. Clinical: 5-10% renal tumors; presents earlier with hematuria; risks = aniline dyes (azo-/ aryl amines); NSAIDs; bladder TCC (> 50%) B. Radiographic: soft tissue filling defects; central/ infiltrative with distortion of collecting system; poor enhancement; rare Ca2+; 10% metachronous/ synchronous lesions C. DDX (filling defects) = blood clots; mycetoma; fibroepithelial polyps; malacoplakea; calculi; sloughed papillae D. Tumor spread: local, lymphatic regional nodes; synchronous tumors ipsilateral ureter + bladder E. TX = ipsilateral neuphroureterectomy + bladder resection 6. Oncocytoma: A. Clinical: males in 60s; benign solid tumor; orginates from distal renal tubules B. Radiographic: sharply defined hypodense mass with central stellate scar (non-enhancing) and spoke-wheel appearance 7. Renal Lymphoma: NHL >> Hodgkins lymphoma A. Radiographic: multiple parenchymal nodules (60%) > solitary mass > diffuse infiltrating > perinephric (rare) B. Associated findings: bilateral, extensive LAD, splenomegaly; hypoechoic masses (often anechoic mimic cysts) C. DX = biopsy (DDX = metastases, primary CA)

8. Squamous cell carcinoma: with schistosomiasis; leukoplakia (= premalignant) 9. Juxtaglomerular Tumor (= reninoma): A. Clinical: females; HTN, Na+, K+ B. Radiographic: small, hypovascular & hyperechoic lesions 10. Other neoplasms: A. Medullary carcinoma: younger patients; sickle cell trait or other hemoglobinopathies; poor survival B. Bellini duct carcinoma: tubular carcinoma; older patients; often hypoechoic; poor prognosis/ survival C. Rosai-Dorfmann syndrome: sinus histiocytosis; S-100 positive cells; pediatric population; often large bilateral masses (DDX = lymphoma) D. Erdheim-Chester disease: bilateral perinephric xanthogranulomas; also with metadiaphyseal osteosclerosis 11. Cystic Renal Masses: Classification I II IIF III IV BOSNIAK CLASSIFICATION Features Simple cyst (anechoic; no septations); claw/ beak sign Paper-thin septations ( 3); minimal Ca2+ Additional Ca2+ / septations Complex cysts with thick/ enhancing septations; heavy Ca2+ Solid/ enhancing component; nodular Follow-up None CT/ US follow-up study Follow-up q 3 mths Partial nephrectomy Nephrectomy

A. Simple cysts: 50% over 55 years of age; small usually asxs; large (> 4 cm) HTN, hematuria, pain, obstruction; criteria: sharp margins without perceptible wall, homogeneous without enhancement; < 10 HU (precontrast); < 15 HU with contrast B. Complicated cyst: simple cyst with hemorrhage, infection, or Ca2+; multiple septations C. Renal abscess: thick walled with enhancement; +/- gas; extension into perirenal space D. Renal cell carcinoma: occasionally multiple non-communicating cysts E. Multilocular cystic nephroma: rare; benign; variably-sized cysts; seen in infants, young boys, and middle-aged women; DDX = RCC/ Wilms tumor (Bosniak III) requires surgical excision F. DDX = calyceal diverticulum; aneurysm; pseudoaneurysm; AVM; papillary necrosis; obstructed upper pole duplication; lymphoma

11. Multiple renal cysts: A. Multiple simple cysts: with age; no other organs involved; no FHX B. Adult polycystic kidney disease: Multiple non-communicating large cysts; autosomal dominant (chromosome 16); renal failure by 30-50 years Multiple liver (30-50%) pancreatic cysts (10%) Berry aneurysms within circle of Willis (10-15%) Complications: hemorrhage/ infection within cysts; HTN; CRF C. Multicystic dysplastic kidney (MCDK): Nonhereditary but congenital; nonfunctioning parenchyma; at birth markedly enlarged; late fibrotic/ Ca2+ Complications/ associations: contralateral UPJ obstruction/ renal anomaly (30%); bilateral fatal in utero D. von Hippel Lindau Syndrome: Autosomal dominant (chromosome 3) Retinal angiomas and cerebellar hemangioblastomas Multiple renal and pancreatic cysts Renal adenomas; bilateral renal adenocarcinomas (RCC) Pheochromocytomas E. Tuberous Sclerosis (= Bourneville disease): Autosominal dominant (chromosome 9 + 16) Multiple renal cysts + multiple bilateral angiomyolipomas Cutaneous/ retinal/ cerebral hamartomas; periventricular subependymal/ glial nodules and giant cell astrocytomas Cardiac rhabdomyomas Other: LAM; skeletal/ skin lesions F. Uremic Cystic Disease (UCD): 2/2 renal dialysis; multiple cysts adenomas + papillary carcinomas (9%; less aggressive lesions with better prognosis) G. Medullary Cystic Disease (MCD): Clinical: azotemia; anemia; ESRD; subtypes = familial nephronophthisis (AR; 70%) > adult MCD (AD; 15%) > renal-retinal dysplasia (15%) Radiographic: multiple small (< 2 cm) medullary cysts medullary echogenicity; thin cortex without cysts; rare Ca2+ 12. Stones: A. Calcium oxalate: 65% B. Calcium phosphate: 10% C. Uric acid: 5-10%; with salicylates; thiazides; hyperuricemia D. Xanthine E. Cystine: 3%; detectable with CT F. Struvite: = Mg2+-ammonium phosphate; =staghorn calculus; Proteus, Pseudomonas, Staphylococcus, Klebsiella (urease +) G. Matrix: glycoproteins and/ or mucoproteins (antiretroviral therapy)

13. Metastases: lung; breast; GI (stomach, colon, pancreas); cervix; melanoma (DX requires BX); perirenal metastases (breast, lung, melanoma) 14. Papillary necrosis: P Pyelonephritis O Obstruction S Sickle cell disease T Tuberculosis C A R D Cirrhosis Analgesics Renal vein thrombosis Diabetes

15. Renal Trauma: A. Category I (75-85%): contusion (patchy; moth-eaten enhancement); subcapsular hematoma (blunt trauma; flattened renal parenchyma; normal perirenal space) segmental infarction; intrarenal hematoma B. Category II (10%): large subcapsular hematoma; corticomedullary contusion; renal fracture (single transection with blood in perirenal space); multiple cysts or fragments; renal vein laceration C. Category III (5%): shattered kidney; renal vascular injury (renal artery occlusion or avulsion); no enhancement intimal flap or transection D. Category IV (rare): limited to children; UPJ avulsion/ laceration no excretion of contrast into ureter 16. Nephrocalcinosis: A. Medullary nephrocalcinosis: Medullary sponge kidney RTA (types IV + II) Ca2+: hyperparathyroidism, etc. Papillary necrosis Drugs: Amphotericin B; Lasix; steroids B. Cortical nephrocalcinosis: Chronic GN Cortical necrosis AIDS Other: oxalosis (prominent echogenicity); Alports syndrome 17. Hydronephrosis: A. Etiologies: obstruction; prior longstanding obstruction; distended bladder; pregnancy; active diuresis; DI; reflux nephropathy B. Grades: Mild: mild dilatation of collecting system Moderate: marked dilatation of collecting system without cortical atrophy Severe: marked dilatation with cortical atrophy C. DDX = parapelvic cysts; extrarenal pelvis; TCC/ lymphoma D. Acute obstruction: RI > 0.7 (nonspecific; normal renal RI < 0.7)

18. Renal vein thrombosis: enlarged kidney; diminished arterial blood flow (high resistance) with pan-diastolic flow reversal; venous collaterals; filling defect 19. Pyelonephritis: A. Clinical: retrograde migration of bacteria >> hematogenous; WBC casts; flank pain; fever; WBC; pyuria; + CX C. Radiographic: urothelial thickening; heterogeneous renal parenchyma (hyper-/ hypoechoic regions); focal enlargement (focal nephronia; lobar nephritis); acute bacterial nephritis (more severe infection; seen with DM; immunosuppression; steroids) D. Xanthogranulomatous pyelonephritis (= XGP): (-10 to +30 HU); chronic inflammatory process with lipid-laden macrophages due to Proteus mirabilis and Escherichia coli (#1); large staghorn calculus with renal enlargement; late nonfunctioning; perinephric abscess; DDX = fibrolipomatosis (replacement lipomatosis of kidney fatty deposition in renal sinus with age; likely due to chronic calculi/ inflammation) E. Emphysematous pyelonephritis: DM; females; due to Escherichia coli; ring-down artifact; DDX = emphysematous pyelitis (less severe) F. Tuberculosis (TB): hematogenous spread; papillary necrosis calyceal clubbing; strictures; Ca2+; end-stage = putty kidney; beaded/ corkscrew/ pipestem ureter 20. Renal artery stenosis (U/S): MRA/ CTA ( sensitivity/ specificity) Peak systolic velocity > 100 cm/sec (Peak renal systolic velocity/ peak aortic velocity) > 3.5 Intrarenal arteries: (pulsus) parvus et tardus effect (delay > 0.08 s) Systolic acceleration < 300 cm/sec2 (pulsus lentus) 21. Vascular anomalies: A. AVF: #1 cause = renal biopsy; velocity + resistance flow; perivascular soft tissue vibration (soft tissue bruit) B. Pseudoaneurysm: s/p trauma/ intervention; swirling internal blood flow 22. Renal Transplants: A. Hydronephrosis B. Peritransplant fluid collections: hematomas; lymphoceles (> 4-6 weeks); urinomas; abscess C. Vascular complications: renal artery stenosis; renal vein thrombosis; AVM; pseudoaneurysm; segmental infarction (rim perfusion maintained due to capsular collaterals) D. Transplant rejection: renal swelling with hypoechoic pyramids; PI > 1.8 (normal < 1.5; borderline = 1.5-1.8); DDX = ATN; cyclosporin toxicity; infection F/U exam or BX

23. DDX for Striated Nephrograms: C Contusion H Hypotension O Obstruction I Intratubular obstruction (Tamm-Horstfall proteinuria) R Renal vein thrombosis B Bacterial nephritis O Obstruction Y Yes, cystic disease: PCKD; medullary sponge kidney; medullary cystic disease 24. Hemolytic-Uremic Syndrome (HUS): A. Clinical: risks = GI infections (E. coli; Shigella; Salmonella; etc.); pregnancy; collagen-vascular disorders (SLE; etc.); HTN; drugs (OCPs; cyclosporin; 5-FU; mitomycin); triad = hemolytic anemia + thrombocytopenia + acute renal failure B. Radiographic: Hyperechoic, enlarged kidneys Diastolic flow; RI Hepatomegaly Pseudomembranous colitis; intussusception; perforation 25. Anatomic variants/ pseudotumors: A. Dromedary hump: focal bulge; mid-left kidney B. Column of Bertin: projection of cortex into renal sinus; isoechoic to cortex C. Hilar lip: supra-/ infrahilar bulge along medial kidney; left D. Fetal lobulation (= ren lobatus): persistent cortical lobules ( 14) E. Lobar dysmorphism: diminutive lobe deep within parenchyma with own calyx; due to nonresorbed junctional parenchyma F. Junctional parenchymal defect: triangular echogenic structure near mid-kidney; due to partial fusion of upper and lower poles G. Pseudo-kidney sign: due to bowel; lymph nodes; mesentery/ omentum

V. Adrenal glands
1. Anatomy: inverted Y configuration; each limb < 1 cm thick, 3 cm long 2. Adrenal hyperplasia: symmetric involvement; +/- functional; DDX metastases, granulomatous disease (TB or histoplasmosis), bilateral adenomas (MEN syndromes) 3. Adrenal masses: adenoma; pheochromocytoma; myelolipoma; cyst; pseudocyst; metastases; neuroblastoma; ganglioneuroma; < 3 cm (87% benign); > 3 cm (95% malignant) 4. Adrenal Adenoma: A. Risks: with age, DM, HTN; usually benign; surgical excision if > 6 cm ( risk of carcinoma) B. Findings: smooth, round; < 3 cm; uniform density; little necrosis or hemorrhage; minimal enhancement; uncommon Ca2+; < 10 HU (precontrast); > 50% wash-out at 10 minutes (or < 30 HU) 5. Adrenocortical Carcinoma: A. Clinical: highly malignant with poor prognosis; < 50% functional (usually Cushings syndrome); 10% bilateral B. Radiographic: Usually very large (> 12 cm); irregular contour; rapic growth Areas of hemorrhage/ necrosis/ Ca2+ (50%) Vascular invasion ( renal vein, IVC, RA) Metastases lung, bones 6. Cushings syndrome: A. Clinical: cortisol or related glucocorticoids; women, 20-40 years Adrenal hyperplasia (70%): pituitary adenoma (Cushings disease) or ectopic ACTH (small cell lung CA, bronchial carcinoid, islet cell, medullary thyroid) Adrenal adenoma (20 %) Adrenal carcinoma (10%): 2-3 cm B. Radiographic: bilateral adrenal hyperplasia or focal mass; SQ fat deposition; hepatic steatosis 7. Conns syndrome: A. Clinical: primary hyperaldosteronism HTN; Na+/ K+; aldosterone; renin B. Radiographic: 80% solitary adrenal adenoma (usually < 2 cm; TX = surgery); 20 % due to bilateral hyperplasia (TX = medical therapy)

8. Adrenal Metastases: variable appearance; lung (40%) > breast (25%) > renal cell carcinoma, GI tumors, melanoma 9. Pheochromocytoma A. Clinical: risks = phakomatoses (vHL, tuberous sclerosis, NFT-1); MEN II a/b; adrenal medulla; SXS = HTN, headaches, palpitations, sweating B. Radiographic: 10% extra-adrenal/ bilateral/ malignant/ familial; welldefined; > 2 cm; prominent enhancement (hyperintense on T2); cystic degeneration, hemorrhage, necrosis, Ca2+ 10. Adrenal Cysts: rare A. Subtypes: True cysts (40%): with epithelial lining; lymphangiectatic or angiomatous Pseudocysts (40%): w/o epithelial lining due to hemorrhage +/Ca2+ rim Epithelial cyst (10%): cystic adenoma; retention cyst; cystic transformation of embryonal remnant Parasitic cysts (5%): Echinococcus B. Radiographic: Ca2+ (20%); fluid density 11. Adrenal myelolipoma: rare; 85% unilateral; well-defined; up to 30 cm; central fat density (-30) to (-100) HU; relatively avascular variable contrast enhancement 12. Adrenal lymphoma: NHL; 50% bilateral; associated with renal and retroperitoneal lymphoma 13. DDX for adrenal calcification: Hemorrhage Tumors: carcinoma; ganglioneuroma, pheochromocytoma Infection: TB/ histoplasmosis, meningococcus Wolmans disease: familial xanthomatosis; fatal < 1 year 14. DDX for bilateral adrenal masses: Hyperplasia Metastases Pheochromocytoma (10%) Other: hemorhage; granulomatous disease

14. Adrenal hemorrhage: A. Etiologies: trauma; perinatal; right (70%); 50-90 HU; coagulopathy; sepsis (Waterhouse-Friedrichsen meningococcemia); HTN; renal vein thrombosis; bilateral (10% neonates; 25% adults) B. Findings: heterogeneous mass; initial density hematoma water density later; late Ca2+

VI. Pancreas
1. Anatomy:

A. Anatomy: head < 3 cm; body < 2.5 cm; tail < 2 cm; pancreatic duct < 4 mm B. Duct of Wirsung main papilla (dorsal + ventral); duct of Santorini minor papilla (dorsal) C. Pancreas divisum: failure of fusion or ventral and dorsal anlagen dorsal pancreatitis D. Annular pancreas: abnormal migration of ventral anlage compression of D2; pancreatitis and PUD E. Cystic fibrosis: atrophic, fatty pancreas; small cysts (1-3 mm) 2. Acute Pancreatitis: A. Etiologies: EtOH; gallstones; hypercalcemia; hyperlipidemia; trauma; drugs (steroids; tetracycline; sulfa abx; estrogen; lasix); infections (viral; parasitic); structural (pancreas divisum; choledochocele) B. Radiographic: colon-cutoff sign; sentinel loop; left pleural effusion; pancreatic enlargement with blurred margins; peripancreatic stranding; peripancreatic fluid; ERCP chain-of-lakes/ sidebranch ectasia C. Staging (Balthazar): Grade A: normal Grade B: enlargement Grade C: pancreatic and peripancreatic inflammation Grade D: peripancreatic fluid collections Grade E: 2 fluid collections +/- gas (necrosis) D. Complications: Necrosis: 30% mortality Phlegmon: mass-like enlargement due to inflammation + edema Abscess: bacterial overgrowth with necrosis Pseudocyst: surgical definition > 6 weeks; 50% resolve spontaneously Other: hemorrhage; pancreatic ascites; splenic vein obstruction

3. Chronic Pancreatitis: A. Clinical: recurrent episodes of acute pancreatitis; course > 6 months B. Radiographic: fibrosis; dilated/ beaded pancreatic duct; pancreatic atrophy; Ca2+ (stippled or coarse; with EtOH); fluid collections; CBD dilatation; peripancreatic stranding 4. Pancreatic Carcinoma: A. Clinical: 5-year survival < 5%; only 10-15% resectable; Courvoisiers sign (palpable, nontender GB) B. Radiographic: hypodense mass; blunted uncinate process; dilated pancreatic/ CBD double duct sign; evidence of pancreatitis C. Resectability: Isolated pancreatic mass without ductal dilatation Combined pancreatic (> 5 mm in head or > 3 mm in tail) + CBD dilatation (> 9 mm) without identifiable mass D. Unresectability: Extension beyond pancreatic margins Invasion into adjacent organs (spleen; stomach; duodenum) Enlarged lymph nodes (> 1.5 cm) Involvement of celiac axis: vascular encasement (artery > vein) Other: hepatic metastases; ascites (peritoneal carcinomatosis) 5. Islet cell tumors: A. Functional: Subtypes: Insulin (#1; 70%): -cells; Whipples triad = hypoglycemia (< 40 mg/dl) + SXS (presyncope, etc.) + resolution of SXS with IV glucose; 5-10% malignant Gastrin (#2): -cells; ZE-syndrome/ MEN; 50-60% malignant Glucagon: -cells; diarrhea, DM, glossitis, necrolytic erythema migrans; malignant (80%) Somatostatin: rare; suppress insulin, TSH, GH; SXS = DM; GB-disease; steatorrhea; > 90% malignant VIP: WDHA syndrome (watery diarrhea, hypokalemia, achlorrhydria = Verner-Morrison syndrome); 60% malignant Imaging: hypervascular transient enhancement/ rapid washout; cystic changes or necrosis; often benign; small (< 4 cm) B. Nonfunctional: Larger (6-20 cm) 80-90% malignant transformation Cystic degeneration/ necrosis; coarse Ca2+ (20%); mild enhancement

6. Pancreatic lymphoma: rare; Burkitts, NHL; large focal mass; LAD 7. Cystic Lesions: A. Pseudocyst: #1 cystic lesion; fibrous well-defined walls +/- Ca2+ B. Abscess: less distinct walls; +/- air C. True cyst: inner lining of epithelium; well-defined; present with vHL and APCKD D. Cystic tumors: Islet cell tumors Cystic teratomas Microcystic (serous) adenoma: risks = elderly females + vHL; multiple small cysts (< 2 cm; > 6 total); no malignant degeneration with central scars/ Ca2+ (20%); head of pancreas; hypervascular Mucinous cystic neoplasms: cystadenoma or cystadenocarcinoma; large cysts (> 2 cm; mean > 12 cm); females; multilocular; hypovascular; body or tail; peripheral Ca2+ 8. Other pancreatic malignancies: A. Solid and papillary carcinoma (= epithelial neoplasm): young females; tail; cystic with peripheral solid components + curvilinear Ca2+; better prognosis (often with surgical cure) B. Mucinous duct-ectatic (= intraductal papillary mucinous tumors = IPMT): prominent ductal dilatation filled with mucin; often microscopic tumor (non-detectable radiographically) C. Acinar cell cystcarcinoma: older patients; large mass (< 15 cm); systemic lipase fat necrosis (skin erythematous rash; bone lytic lesions; joints arthralgia); poor prognosis ( liver metastases) 9. Metastases: breast, lung, RCC, melanoma; associated LAD 10. Trauma: usually due to knife and GSW; blunt abdominal trauma contusion vs. laceration vs. focal hemorrhage vs. necrosis child;

VII. Gastrointestinal Tract

1. Bowel wall thickening: A. Normal: < 2 mm (distended bowel); < 4 mm (compressed bowel) B. Benign thickening: < 2 cm; symmetric; circumferential; double halo sign dark inner/ bright outer rings; target sign bright-darkbright rings C. Malignant: heterogeneous; eccentric; asymmetric; > 2 cm; focal mass; lobulated; spiculated; enlarged lymph nodes 2. Esophagus: A. Anatomy: no serosa early invasion of tumors; striated muscle in upper third; smooth in lower third; mixed in middle; wall thickness < 3 mm B. Hiatal hernia: widened hiatus (> 15 mm) C. Esophageal carcinoma: Squamous (90%): irregular wall thickening > 3 mm; periesophageal invasion fat, aorta, trachea; liver metastases; risks = head & neck CA; EtOH; TOBA; achalasia; sprue; tylosis; Plummer-Vinson syndrome (= Patterson-Kelly) Adenocarcinoma (10%): Barretts esophagus: chronic reflux mid-esophageal stricture adenocarcinoma Spindle-cell (=carcinosarcoma; 1%): pedunculated/ polypoid; mid-esophagus D. Leiomyoma (#1 benign tumor): submucosal (DDX = fibroma; lipoma; duplication cyst; etc.); eccentric thickening; < 5% multiple E. Esophageal varices: scalloped thickening of wall; other signs of portal HTN; left gastric azygos vein (uphill vs. downhill SVC obstruction below azygos); DDX = varicoid carcinoma F. Esophagitis: Radiographic: circumferential thickening ulcers, perforation, mediastinitis, abscess; feline esophagus = fine transverse striations due to longitudinal muscularis mucosae contractions Risks: Infections: Herpes; Candida (shaggy plaques); CMV/ HIV (giant ulcers) Caustic: gastroesophageal reflux; lye Medications: K+-tablets; tetracycline Other: radiation (> 4000 rads); scleroderma; Crohns/ Behcets; eosinophilic gastroenteritis; epidermolysis bullosa; pemphigoid G. Esophageal perforation: due to trauma, CA, instrumentation, inflammation; hydropneumomediastinum; Boerhaaves syndrome (left posterolateral; above GE junction) vs. Mallory-Weiss tear (mucosal)

H. Diverticula: Zenkers (pharyngoesophageal): posterior at Killians dehiscence (above cricopharyngeus) Killian-Jamieson: lateral, below Zenkers Pulsion diverticula (interaorticobronchial): left anterolateral between aortic arch and LMSB (false diverticula) Traction diverticula (interbronchial): true diverticulum; TB Epiphrenic: R > L; lateral; hiatal hernia Pseudodiverticulosis: dilated submucosal mucous glands (1-3 mm); Candidiasis + CA I. DDX for esophageal strictures: Schatzki ring: B-ring; 1-2 mm thick; usually due to reflux; symptomatic if lumen < 13 mm (12.5 mm tablet) Long strictures: reflux; XRT; post-NGT Medications: K+; tetracycline; NSAIDs; quinidine Caustic ingestion: lye; etc. Plummer-Vinson Syndrome (= Patterson-Kelly): cervical strictures + Fe2+-deficiency anemia; risk of CA Cancer; surgery; chemotherapy J. Dysmotility/ dilatation: Scleroderma: patulous GE junction (= chalasia) reflux; DDX = SLE/ Raynauds Achalasia: idiopathic; failure of LES relaxation (aganglionosis of Auerbachs plexus); birds-beak on esophagogram; CA Secondary achalasia: pseudoachalasia (cancer); DM; EtOH; post-vagotomy; myasthenia gravis, Chagas disease (neurotoxin myenteric plexus megacolon, megaesophagus, megastomach, etc.) Presbyesophagus: fewer primary peristaltic waves; tertiary contractions Esophageal spasm: corkscrew esophagus; severe chest pain Other: DM-neuropathy/ myopathy; EtOH; post-vagotomy K. Polyps: fibrovascular (#1; pedunculated; proximal esophagus) > inflammatory (#2; sessile; distal esophagus), adenomatous; DDX = papilloma, lymphoma ( NHL; GE-junction; ulceration) L. DDX for small polyps: Papillomatosis Candida: shaggy mucosa; DDX = glycogen acanthosis Acanthosis nigrans Bullous pemphigoid Cowdens disease: hamartomas + skin lesions + breast/ thyroid CA

3. Stomach: A. DDX for gastric wall thickening (> 5 mm): Neoplasm: carcinoma; lymphoma Inflammation: radiation; granulomatous disease; eosinophilic gastritis; ZE-syndrome; Menetriers; pseudolymphoma (due to inflammation) Other: amyloidosis; varices B. Gastric carcinoma: Clinical: 95% of gastric malignancy; risks = pernicious anemia; adenomatous polyps; chronic atrophic gastritis; Billroth II > I Radiographic: focal, nodular thickening vs. diffuse thickening with luminal narrowing (linitis plastica); stippled Ca2+ (mucinous CA); extension into perigastric fat; peritoneal carcinomatosis; liver metastases C. Gastric lymphoma: #1 site of primary GI lymphoma; 95% NHL; findings similar to adenocarcinoma with thickening (> 3 cm) + more widespread LAD; body/ antrum with extension into duoden. D. Gastric leiomy-(oma)/-sarcoma/-blastoma: submucosal/ subserosal Benign: leiomyoma (#1) > neurofibroma, lipoma; small (< 4 cm), homogeneous, mottled Ca2+ Malignant: leiomyosarcoma > leiomyoblastoma; large (> 12 cm), intramural or exogastric with cysts + deep ulcerations + cavitation; hematogenous mets (liver/ lung) >> direct extension/ lymphatic mets E. Metastases: bulls-eye lesions (ulceration) or linitis plastica Beast CA: linitis plastica Melanoma: ulceration Kaposis sarcoma: submucosal masses with ulcerations/ polyps Other: esophagus; pancreas; colon F. DDX for linitis plastica: Gastric adenocarcinoma (#1) Lymphoma: may cross pylorus Metastases: breast (#1) > pancreas, colon, Kaposis Atrophic gastritis: diffusely narrowed/ tubular stomach; risk = pernicious anemia Eosinophilic gastritis: antrum; thick folds with cobblestoning; 50% with small bowel involvement ( jejunum) Granulomatous gastritis: Crohns disease (rams horn); sarcoidosis; syphilis (tertiary); TB G. Polyps: Hyperplastic (> 90%): < 1 cm; body/ antrum; risk = chronic gastritis Adenoma (#2): antrum; risk = familial polyposis; CronkhiteCanada Hamartoma (#3): non-malignant; risks = Peutz-Jeghers; Cowdens

H. Diverticula: rare; posterior gastric fundus/ cardia I. Other filling defects: Ectopic pancreas: 1-2 cm submucosal nodule along greater curvature; 3-6 cm from pylorus; central umbilication Bezoars: tricho-/ phyto-/ lactobezoars Pseudotumor: Nissen fundoplication; hiatal hernia with esophagogastric invagination Gastric duplication: rare J. Gastric varices: portal HTN or splenic vein thrombosis; ill-defined tubular densities fundus; bright enhancement K. Peptic Ulcer Disease (PUD): Clinical: H. pylori; risks = ZE; NSAIDS; TOBA; PTH; steroids; Curlings/ Cushings ulcers Benign: extends beyond lumen; Hamptons line (1-2 mm; traverses orifice in profile); crescent sign (concave ulcer margin); central Malignant: irregular; Carmans meniscus (concave ulcer margin-towards lumen); Kirklins complex (= Ba+-filled ulcer crater with heaped-up mound of tissue irregular lucent halo) Complications: Bleeding (15-20%) Gastric outlet obstruction (< 5%) Perforation (5-10%) Penetration: into pancreas; omentum; liver; etc. L. Gastritis: rugal thickening Menetriers disease: triad = achlorhydria + hypoproteinemia + edema; rare; due to dilatation of mucus glands; greater curvature (fundus/ body); CA risk Eosinophilic gastroenteritis: gastric outlet obstruction; pain; diarrhea; jejunum ZE syndrome: diarrhea, PUD; MEN I Lymphoma: NHL >> Hodgkins; 10% primary; desmoplastic Metastases: melanoma > kidney, lung Granulomatous disease: Crohns; sarcoid; TB; syphilis Other: EtOH; XRT; corrosives M. Volvulus: Organoaxial: with large HH; rare complications Mesenteroaxial: with diaphragmatic rupture trauma; ischemia N. DDX for erosive gastritis (aphthous lesions): Medications: NSAIDS; steroids; EtOH Inflammation: Crohns disease Infections: HSV; CMV; Candida

4. Duodenal ulcers: A. Clinical: risks = PUD, malignant tumors, mets, Crohns, TB; 95% bulbar; 50% anterior; ZE multiple post-bulbar ulcers B. Radiographic: cloverleaf deformity; hourglass stenosis 5. DDX for duodenal filling defects: Prolapsed antral mucosa Flexural pseudotumor: redundant mucosa at superior duodenal flexure Heterotopic gastric mucosa: choristoma Brunners gland hyperplasia: duodenitis; DDX = lymphoid hyperplasia Neoplasms: Benign: adenomatous polyp; villous adenoma; lipoma; leiomyoma Malignant: adenocarcinoma (#1) > lymphoma, leiomyosarcoma, metastases, Kaposis, carcinoid ( bulb) Other: duplication cyst; hematoma 6. DDX for duodenal narrowing: Atresia/ stenosis Annular pancreas Ladds bands (malrotation) SMA syndrome (= Wilkies syndrome): aorto-mesenteric compression of D3; anorexia; pregnancy Trauma: duodenal hematoma Inflammation: Crohns; pancreatitis Other: XRT; CA 7. Small bowel: A. Normal anatomy: Jejunum feathery with distinct folds; < 3 cm; 4-7 (vavulae/inch) Ileum featureless with thin walls; diameter < 2.5 cm; wall thickness < 3 mm; 2-4 (valvulae/inch) B. Thickening: < 15 mm inflammation, trauma, hypoalbuminemia, lymphatic obstruction > 15 mm neoplasm 8. DDX for thickened SB folds: Edema: proteinemia; CHF; renal failure; cirrhosis Inflammation: Crohns disease; XRT; GVHD ZE syndrome Infections: Giardiasis; Strongyloidiasis Other: ischemia; trauma; hemorrhage (stack-of-coins)

9. DDX for nodular thickening of SB folds: Eosinophilic gastroenteritis: jejunum/ gastric antrum Whipples disease: Tropheryma whipelii; malabsorption; arthralgia; diffuse LAD (hypodense); proximal small bowel Mastocytosis: bulls eye lesions; sclerotic osseous lesions Infections: Giardiasis; MAI; Cryptosporidiosis Brunners gland hyperplasia: 2/2 PUD; nodular filling defects in proximal duodenum Other: amyloidosis; polyposis syndromes; lymphangiectasia 10. DDX for dilated SB with normal wall thickness: Obstruction; ileus Sprue: ilealization of jejunum + jejunization of ileum Scleroderma: hidebound mucosa 11. Upper GI Surgery:

12. Small bowel tumors: A. Lymphomas: #1 malignant SB tumor; distribution = stomach > ileum > jejunum; up to 9 cm; nodular wall thickening vs. aneurysmal dilatation; ulceration; mesenteric LAD; possible lead-point for intussusception; HIV NHL with splenomegaly; LAD; ascites B. Carcinoids: appendix (50%); distal ileum (20%); dramatic desmoplastic reaction tethering = spoke-wheel pattern (DDX = mesenteric lipodystrophy); liver metastases required for carcinoid syndrome (diarrhea, right-sided fibroelastosis TI + PS; bronchospasm; flushing) C. Adenocarcinoma: duodenum/ proximal jejunum; < 8 cm; risks = sprue; Crohns D. Leiomyosarcoma: stomach; large (> 11 cm); exophytic with central necrosis; metastases (liver; lung; bone) E. Metastases: melanoma; lung; breast; ovary; GI; Kaposis F. Benign tumors: Leiomyoma (#1): jejunum Adenoma: tubular > villous Lipoma: ileum Brunners gland adenoma

13. DDX for tiny (sand-like) filling defects: Macroglobulinemia: plasma cell dyscrasia; anemia; LAD; HSM; bleeding Nodular lymphoid hyperplasia: IG-deficiency; giardiasis (> 90%); diarrhea; malabsorption 14. DDX for terminal ilial disease: IBD: Crohns disease; UC (back-wash ileitis) Infections: TB; Yersinia (enterocolitica mesenteric adenitis); Salmonella (typhosa tyhpoid fever; splenomegaly); CMV ( ulcers/ fistulae) Neoplasms: lymphoma; carcinoid 14. Amyloidosis: A. Types: hereditary, chronic HD, senile B. Associations: TB; osteomyelitis; spondyloarthropathies; Hodgkins disease; RCC C. Findings: RTA; renal vein thrombosis; diffuse irregular bowel wall thickening; HSM; macroglossia; pseudodiverticulosis; restrictive cardiomyopathy 15. Sprue: A. Clinical: = tropical/ celiac disease; SXS = steatorrhea; glossitis; hyperpigmentation (dermatitis herpetiformis); TX = gluten-free diet B. Radiographic: SB dilatation; ulcerative jejunoileitis; ilealization of jejunum + jejunization of ileum; transient intussusceptions C. Complications: ulcerative jejunoileitis; lymphoma and adenocarcinoma (esophagus + SB) 16. Mastocytosis: histamine; diarrhea; flushing; tachycardia; pruritus; irregular fold thickening; small nodules; sclerotic bone lesions; HSM; PUD; LAD 17. Scleroderma: A. Clinical: hypomotility; #1 cause of chronic intestinal pseudo-obstruction B. Radiographic: hidebound mucosa (= tight folds); antimesenteric pseudo-sacculations (broad-neck); esophageal and colonic dilatation C. Complications: pneumatosis; benign pneumoperitoneum; bacterial overgrowth malabsorption D. Other manifestations: pulmonary fibrosis; acro-osteolysis 18. Crohns disease: circumferential thickening (7-11 mm); double halo sign (submucosal edema); mesenteric stranding; skip areas; fistulae and sinus tracts; mesenteric abscesses

19. Intestinal lymphangiectasia: A. Types: Congenital: lymphedema; chylous effusions; diarrhea; WBC Acquired: thoracic duct obstruction; small bowel lymphoma; pancreatitis B. Findings: diffuse fold thickening; hypersecretion (dilute contrast) 20. Small bowel obstruction: A. Findings: transition point (dilated decompressed bowel; collapsed descending colon, however, is NORMAL) B. Etiologies: adhesions > tumor, intussusception, inflammation, hernias C. Closed loop obstruction: two adjacent points of obstruction; volvulus; strangulation (ischemia) D. Intussusception: lipoma; leiomyoma; mets; lymphoma; donut sign intussuscipiens within intussusceptum + mesenteric fat 21. Diverticula: A. Jejunal diverticulosis: Clinical: 2% adults (> 40 years); bacterial overgrowth malabsorption + folic acid deficiency; pneumoperitoneum (benign); rare obstruction/ hemorrhage Radiographic: mesenteric border with narrow neck; DDX = pseudo-sacculations in scleroderma (antimesenteric border/ broad neck) + pseudodiverticula in Crohns disease B. Meckels Diverticulum: Clinical: antimesenteric border; 2% population; < 2 years of age; < 2 feet from ileocecal valve; heterotopic gastric mucosa (= choristoma) Radiographic: intussusception; obstruction; perforation; ulceration (gastric mucosa) 22. Small Bowel Infections: A. Giardiasis: Giardia lamblia; duodenum > jejunum; irregular fold thickening; hypermotility; hypersecretory B. Strongyloidiasis: Strongyloides stercoralis; SXS = N/V/D/F; proximal small bowel fold thickening + pulmonary disease (DDX = TB) C. Cryptosporidiosis: #1 in AIDS thickened proximal small bowel folds; SB dilatation D. MAI: AIDS; mid-distal SB; hypodense LAD; HSM E. CMV: AIDS; ileum F. Ascariasis: Ascaris lumbricoides; #1 parasitic infection world-wide; jejunum > ileum; tubular filling defects; complications = obstruction; peritonitis; biliary colic; hemoptysis [larvae stomach lung tracheobronchial tree bowel (worms)]

23. DDX for mesenteric masses: A. Lymphomas: circumferential, aneurysmal bowel wall thickening; masses sandwich mesenteric vessels B. Other: metastases; carcinoid tumor; desmoid; TB; XRT; mesenteric fibromatosis well-defined homogeneous mass 24. Appendix: < 6 mm in length; ipsilateral to ileocecal valve; 65% retrocecal A. Appendicitis: Findings: > 6 mm length; wall > 3 mm; periappendiceal inflammatory changes; appendicolith (< 25%); lymphoid hypertrophy Complications: phlegmon, abscess, fluid collection, peritonitis DDX: Crohns; diverticulitis; perforated cecal CA; mesenteric adenitis (children); PID B. Mucocele: cystic mass < 15 cm; due to obstruction or mass (cystadenoma or cystadenocarcinoma); complication = pseudomyxomatous peritonei C. Myxoglobulosis: Ca2+ mucin globules multiple stones in RLQ D. Carcinoid tumor: #1 site; liver involvement carcinoid syndrome 25. Colon and rectum: A. Anatomy: sigmoid rectum at S3; rectovaginal pouch of Douglas (females); rectovesical pouch (males); lower 2/3 of rectum are extraperitoneal B. Colorectal Carcinoma: Clinical: 70% rectosigmoid region; metastases direct extension, lymphatic, hematogenous, intraperitoneal; risks = polyposis syndromes; IBD (UC > Crohns); FHX (colon; breast; endometrial CA); ureterosigmoidostomy Staging: Duke A: bowel wall Duke B: serosa/ mesenteric fat Duke C: LN Duke D: distant mets (liver > lung > adrenal) Radiographic: focal lobulated wall thickening (> 3 mm); ulcerations; polypoid mass; apple-core lesion; pericolic soft tissue densities; regional LAD; metastases liver (75%) > lung (50%) > adrenal (15%) Complications: desmoplastic obstruction; hemorrhage; perforation; intussusception Prognosis: > 33% recurrence with 80% recurrence within 2 years; 50% at anastamosis site; low synchronous (1%)/ metachronous rates (3%)

C. Colon lymphoma: less common than gastric/ small bowel; marked bowel wall thickening (> 4 cm) with dilated lumen (rare obstruction); homogeneous; minimal enhancement; regional LAD; risks = immunosuppresion (AIDS); 2 NHL involvement most common (> 100 nodules; 2-25 mm; rarely imaged) D. Metastases: melanoma; breast; lung E. Lipoma: fat density (-80) to (-120) HU; size 2-3 cm; colon (> small bowel > stomach) F. Diverticulitis: mesenteric surface of colon perforation initially contained within mesocolon (extraluminal and extraperitoneal); sigmoid colon (95%); focal symmetric bowel wall thickening (> 3 mm); pericolonic inflammatory changes [mass, linear stranding, sinus tracts (also intramural), fistulae]; giant diverticulum (> 5 cm; ball-valve mechanism); bleeding (usually right-sided) G. Ischemic bowel disease: Etiologies: arterial occlusion; low flow states; venous thrombosis Evolution: submucosal edema pneumatosis portal venous gas free air Radiographic: thumbprinting; pneumatosis; portal venous gas; etc. Sites: SMA mortality; IMA mild, mimics diverticulitis H. Volvulus: Clinical: sigmoid >> cecum >>> transverse colon; sigmoid elderly; up to 80% recurrence Radiographic: dilated proximal colon; cecal points towards LUQ, SB dilatation; birds-beak DDX = cecal bascule (folded mobile cecum, mimics cecal volvulus) J. Toxic megacolon: severely dilated transverse colon (> 8 cm); 30% mortality; spontaneous perforation (50%); risks = UC >> Crohns disease; pseudomembranous colitis; ischemia; infection (amebiasis/ CMV); BE contraindicated I. Pseudo-obstruction (= Ogilvies syndrome): elderly, cathartic abuse; dilated, ahaustral colon K. Extrinsic masses: Neoplastic: peritoneal metastases; peritoneal carcinomatosis; endometrioma Inflammatory: appendicitis; mucocele; cholecystitis; pancreatitis; PID; tubo-ovarian abscess

26. Polyposis Syndromes: Type Trait Gastric AD < 5% Familial Polyposis AD 5% Gardner SB < 5% 5% Colon 100% 100% Histology Adenoma Adenoma Extraintestinal None Osteoma, sarcoma, ovarian/ ampullary CA Glioma Perioral pigmentation Oral papilloma, breast/ thyroid CA

Turcot PeutzJeghers Cowden

AR AD AD

25% Esophagu s (100%) Yes

95%

100% 30% Rare

Adenoma Hamartoma Hamartoma

Ruvalcaba -Myhre Juvenile Polyposis Cronkhite -Canada

AD AD NH

Yes

Yes 100%

Macrocephaly; MR; SQ lipomas Inflammatory None Inflammatory Ectodermal changes (nails, alopecia)

Hamartoma

100%

50%

100%

A. Polyps: Adenomatous: subtypes = tubular/ tubulovillous/ villous; risk of malignancy with size 40% (> 2 cm) vs. 10% (1-2 cm ) vs. 1% (< 1cm) Hyperplastic: usually sessile; rare malignant transformation Post-inflammatory (= pseudopolyposis/ filiform polyps) UC; Crohns; infectious colitis B. Familial Polyposis: #1 intestinal polyposis (1: 8000); > 100 polyps; 100% malignant degeneration; adenomatous polyps C. Gardner Syndrome: stomach adenomas; soft tissue tumors (inclusion cysts, desmoids, fibrosis); 100% malignant degeneration D. Peutz-Jeghers: #2 intestinal polyposis; mucocutaneous lesions/ pigmentation; rare malignant potential (least common in SB) E. Juvenile Polyposis: usually single large rectal polyp bleeding, prolapse, obstruction; CA (gastric/ duodenum/ colon/ pancreas); death < 2 years F. Lynch syndrome: types I (no associated extracolonic CA) and II (extracolonic CA TCC; endometrial CA; GI-CA; skin CA; breast CA); autosomal dominant (chromosome 2); 5 x more common than familial polyposis syndrome; proximal to splenic flexure (70%)

27. Colitis: A. Ulcerative colitis: Colon continuous spread proximally; lead pipe/ ahaustral appearance (DDX = cathartic abuse); mucosal granularity Extra-intestinal: arthritis; sclerosing cholangitis; pyoderma gangrenosum; erythema nodosum; uveitis Complications: toxic megacolon; malignancy (1%/yr > 10 yrs) B. Crohns disease: Terminal ileum (80%) > colon (70%); perianal disease (DDX = lymphogranularum venereum Chlamydia trachomatis) Fold thickening; string sign; cobblestoning; sinus tracts; fistulae; skip lesions; collar-button ulcers Fibro-fatty proliferation: creeping-fat Aphthoid lesions: colon > duodenum > stomach > esophagus Extra-intestinal features: gallstones; sacroiliitis; AVN; lymphoma/ GI tumors; renal oxalate stones C. CMV colitis: aphthoid ulcers; bowel wall thickening; terminal ileum + cecum D. Typhlitis: neutropenic colitis; diarrhea; perforation; also terminal ileum + appendix E. Pseudomembranous colitis: Clostridium difficile; after ABX (clindamycin/ lincomycin > tetracycline, ampicillin); thumbprinting; megacolon; accordion sign = thickened folds F. Amebiasis: Entamoeba histolytica; dysentery; cecum > transverse colon/ rectosigmoid; flask-shaped ulcers; ameboma (hyperplastic granuloma 1%); fistula; liver/ brain/ pleural abscess G. Intestinal tuberculosis: TB > MAI > M. bovis; Stierlins sign (narrowed terminal ileum loss of demarcation between ileum and cecum); Fleishners sign (narrowed cecum due to hypertrophied ileocecal valve); bowel wall thickening; ulcers; fistulae; strictures H. Colitis cystica profunda: submucosal fluid-filled cysts; rectum (85%); < 3 cm; DDX = cystic mucinous adenocarcinoma 28. DDX for submucosal ulcerated lesions (bulls eye): Melanoma Lymphoma Carcinoma Kaposis sarcoma Carcinoid 29. DDX for thumbprinting: Ischemia: vaso-occlusive; hypotension Hemorrhage: trauma; bleeding diathesis; HUS, TTP Colitis: infectious, pseudomembranous (C. difficile) Neoplastic: lymphoma, metastases

30. Collateral vessels: A. Arc of Buehler: embryonic ventral communication between celiac axis and SMA B. Arc of Barkow: right left epiploic connections (via gastroepiploic arteries) C. Arc of Riolan: direct, short SMA (middle colic) IMA (left colic) connections D. Marginal artery of Drummond: arcade along mesenteric border of colon (middle left colic) E. Rectal arteries: Superior rectal artery: IMA Middle rectal artery: internal iliac artery Inferior rectal artery: pudendal artery

VII. Pelvis
1. Anatomy:

A. Extraperitoneal cavity: contiguous with retroperitoneal space B. Retropubic space of Retzius: contiguous with posterior pararenal space + extraperitoneal fat C. Perineum: below pelvic diaphragm D. Parametrium: contained within broad ligament E. Denonvilliers fascia: positioned between prostate and rectum 2. DDX for ureteral filling defects: Stones Tumor: TCC > squamous cell, adenocarcinoma Ureteritis cystica: epithelial/ subepithelial cysts due to inflammation or irritation (metaplasia of Brunns nests) Leukoplakia: associated with Schistosomiasis; premalignant squamous cell carcinoma Malakoplakia: chronic gram (-) infection (E. coli #1); DM foamy macrophages (Hansemann) with PAS (+) inclusions (MichaelisGuttman bodies); raised yellow lesions Other: thrombus; sloughed papilla; mycetoma DDX: pseudodiverticulosis: 1-3 mm outpouchings calculi/ infections/ CA (#1 = TCC) 3. Ureteral TCC: A. Risks: azo-dyes, cyclophosphamide, phenacetin B. Radiographic: Wine glass/goblet deformity (dilated distal ureter) Bergman sign (coiled retrograde catheter)

4. Ureteral displacement: A. Distribution: Above Pelvis Medial Retroperitoneal fibrosis Retrocaval ureter (right; at L3) Pelvic lipomatosis Iliac LAD/ aneurysm Iliopsoas hypertrophy Hutch diverticulum Lateral Psoas hypertrophy LAD AAA Central tumor Fibroids Ovarian masses

Below Pelvis

B. Medial: Retroperitoneal fibrosis: drugs (methylsergide, ergotamine); XRT; prior surgery; malignancy; connective tissue disorders Retrocaval ureter (right only) Pelvic lipomatosis: black males; tear-drop or pearshaped bladder; associated with ureteritis cystica Other: hematoma; iliac LAD or aneurysms; adnexal mass; surgery C. Lateral: AAA LAD; psoas hypertrophy Central pelvic mass Retroperitoneal fat ( pelvic lipomatosis) 5. DDX for ureteral stricture: Infection: TB; Schistosomiasis; abscess; fistula CA: metastases; local extension; TCC; lymphoma XRT Inflammation: calculi; instrumentation; stent; endometriosis 6. DDX for ureteral dilatation: Obstruction Reflux Primary megaureter (beak sign) 7. DDX for bladder filling defects: Tumor: TCC; adenocarcinoma; squamous cell carcinoma; metastases (pheochromocytoma) Extrinsic masses: BPH; uterus (fibroids); etc. Other: calculus; thrombus; ureterocele (pseudoureterocele due to inflammation/ tumor); foreign bodies 8. Hutch diverticulum: adjacent to UVJ; vesicoureteral reflux

9. Bladder carcinoma: A. Clinical: transitional cell (90% malignant); risks = azo-dyes; phenacetin; cyclophosphamide; focal thickening of bladder wall; perivesical spread; LAD (> 10 mm) B. Staging: Stage A: limited to mucosa + submucosa Stage B1: superficial muscular layer Stage B2: deep muscular layer Stage C: perivesical fat Stage D: seminal vesicles, prostate, or rectum 10. Bladder trauma: contusion; interstitial A. Extraperitoneal: due to pelvic fracture, dissection into retroperitoneum + scrotum + thigh B. Intraperitoneal: usually blunt trauma with distended bladder; DX requires adequate bladder distention (> 250 ml) 11. DDX for bladder Ca2+: S Schistosomiasis ( squamous cell carcinoma) C3 CA; Cytoxan; calculus R Radiation T TB 12. Urethral anatomy/ injuries: A. Anatomy (male): Anterior = penile + bulbous (penoscrotal junction) Posterior = membranous (between inferior margin of verumontanum + tip/ cone of bulbous urethra) + prostatic Cowpers glands: contained within membranous urethra with ducts entering the bulbous urethra Glands of Littr: located primarily along dorsal penile urethra infections (gonococcus; chlamydia)

B. Clinical: risks = pelvic trauma (especially multiple pelvic fractures); absence of blood at meatus does not exclude urethral injury RUG C. Subtypes: Type I: posterior urethra stretched Type II: posterior disruption (above urogenital diaphragm) Type III: anterior + posterior disruption Type IV: bladder neck injury with extension to urethra Type IVa: periurethral extravasation with intact urethra Type V: anterior disruption (saddle injury); bulbous urethra 13. Female urethral diverticulum: A. Clinical: most often acquired due to infection of Skenes glands; posterior wall; SXS = dysuria + dribbling + dyspareunia (3 Ds); TX = surgical resection (diverticulectomy) B. Radiographic: focal outpouching along posterior urethra; impression along inferior bladder (= male prostate); best seen on MRI C. Complications: infection; calculi; CA (squamous cell) 14. DDX for urethral strictures: T Trauma I 2 Inflammatory; infections (prostatitis; phlegmon; etc.) C Calculus B BXO (= balanitis xerotica obliterans): variant of lichen sclerosis et atrophicus (white plaques) phimosis/ meatal stenosis; premalignant (penile squamous carcinoma) 15. Hypospadias: cryptorchidism (30%) + inguinal hernias (10%) 16. DDX for urethral tumors: A. Benign: Fibroepithelial polyp: solitary; pedunculated; attached near veru montanum; child/ young adult Transitional cell papilloma: prostatic/ bulbomembranous urethra; bladder papillomas; older adults Adenomatous polyp: young men; adjacent to veru montanum Penile squamous papilloma/ condyloma acuminata: verrucous lesion in penile urethra; associated with cutaneous disease B. Malignant: Squamous cell carcinoma (70%): distal 2/3 of urethra; risks = venereal disease; stricture (> 80%) TCC (10-20%): posterior 1/3 of urethra; multifocal Adenocarcinoma (10-20%): arise from periurethral glands (Skene; female) and glands of Cowper/ Littr (male)

17. Benign adnexal masses: A. Functional ovarian cyst: follicular or corpus luteum cysts; thin/ thick walled; homogeneous; echogenic B. Hemorrhagic cysts: nearly solid (sponge-like) vs. multiseptated/ nodular vs. fluid-fluid levels; rarely hypoechoic C. Para-ovarian cysts: Wolffian duct remnant (also Gartners duct cyst lateral to uterus/ vagina); 10% of adnexal cysts ( broad ligament); thin-walled; unilocular; large (< 18 cm) torsion; no hormonal dependence D. Benign cystic teratoma (#1 tumor): < 15 years; composed of fat ( T1; fat-fluid levels); teeth; bone; hair; dermoid plugs E. Ovarian cystadenoma: regular thin walls; fine septations; NO solid components; older age group F. Endometriosis/ tubo-ovarian abscess: identical CT appearances complex cystic masses; inflammatory changes and fibrosis G. Polycystic ovarian disease (= Stein-Leventhal syndrome): hirsutism + amenorrhea + anovulation; large ovaries with small peripheral cysts H. Ovarian torsion: risks = masses; hyperstimulation; pregnancy; adnexal mass with hyperechoic + peripheral cystic components; variable blood flow I. Ovarian hyperstimulation syndrome: 2/2 ovulation induction/ assisted reproduction; enlarged bilateral cystic ovaries with ascites + pleural effusions; complications = shock (multi-organ failure); ARDS; torsion 18. Endometriosis: A. Clinical: ectopic endometrium (stratum functionalis) bleeding; sites = ovaries (#1) > broad ligament; peritoneum B. Radiographic: mutifocal/ multiloculated T1/ T2 lesions without fatsaturation (hemorrhage); HCT-level; often homogeneous/ low-level echoes; DDX = hemorrhagic cyst (unilateral; unilocular) 19. Ovarian Cancer: A. Clinical/ subtypes: 65% cystic; 25% bilateral; 85% nonfunctional Epithelial (#1): Cystadenoma (serous/ mucinous)/ -carcinoma Endometrioid carcinoma Brenner tumor: 40-70 years; 1-2 cm; solid/ hypoechoic; +/- Ca2+; may produce estrogen Clear cell neoplasm: unilocular cyst with mural nodule; usually invasive

 Germ cell tumors: Teratoma Choriocarcinoma Yolk sac tumor Embryonal carcinoma Dysgerminoma (seminoma equivalent) Stromal tumors: Fibroma Meigs syndrome (ascites + pleural effusion, R > L) Estrogen-producing: granulosa cell; thecoma Androgen-producing: Granulosa cell tumor Arrhenoblastoma: large (< 27 cm) with cysts/ hemorrhage; unilateral; malignant transformation B. Radiographic: direct extension ( uterus, colon, bladder); peritoneal implants (omental cake); malignant ascites; hematogenous metastases ( lung, liver, bone); RI < 0.4; PI < 1.0 C. Staging (FIGO): Stage I: limited ovaries +/- malignant ascites (C) A: unilateral B: bilateral Stage II: pelvic extension +/- malignant ascites (C) A: uterus/ fallopian tubes B: pelvic side walls Stage III: A: microperitoneal extension beyond pelvis B: < 2 cm extrapelvic peritoneal extension C: > 2 cm peritoneal extension or regional lymph nodes Stage IV: distant metastases 20. Uterus: A. Endometrial stripe: Premenopausal: 2-3 mm (end of menses) 8 mm (proliferative) 15 mm (secretory) Postmenopausal: 4 mm (WNL) 5-7 mm (borderline; HRT) 8 mm (abnormal) B. MRI (T2): hyperintense endometrium (see above) + hypointense junctional zone (< 8 mm) + intermediate myometrium

C. Uterine anomalies: evaluate for concomitant renal anomalies Subtypes: Agenesis (rare): Mayer-Rokitanski-Kuster-Hauser syndrome = agenesis of uterus + cervix + vagina (superior 2/3) + fallopian tubes (mullerian duct) Didelphys (< 1%): two complete uteri + cervices + vaginae Bicornuate (< 10%): bicollis subtype two cervices Septate: most common (> 90%); highest complication rate Others (rare): unicornuate; arcuate; DES-exposure (hypoplasia or T-shaped) Findings: MRI; laparoscopy = gold standard > 4 cm separation of uterine horns bicornuate > 75 angle bicornuate > 1.5 cm fundal cleft bicornuate D. Leiomyoma: 40% of females > 30 years Subtypes: submucosal; intramural; subserosal Well-circumscribed; homo-/ heterogeneous; iso-T1/ T2; coarse T1/T2) Ca2+; degeneration (cystic, hyaline, or carneous E. Endometrial carcinoma: Clinical: adenocarcinoma; invasion or myometrium postmenopausal bleeding; lymph nodes, parametrium; metastases lung, bones, brain, liver common Radiographic: hypodense mass; hematometra; widened endometrium; variable signal intensities (MRI) Staging: Stage I: confined to uterine corpus (A = endometrium; B = < 50% myometrium; C = > 50% myometrium) Stage II: cervix Stage III: beyond cervix; within true pelvis Stage IV-A: bladder, rectum, beyond pelvis Stage IV-B: distant metastases F. Carcinoma of the cervix: squamous MRI (T2): Normal: hyperintense cervical mucus + intermediate cervical mucosa + hypointense fibrous stroma + intermediate smooth muscle (contiguous with uterine myometrium) Cancer: intermediate/ T2 (DDX = XRT < 12 months) Staging (FIGO): resectable stage IIA Stage I: confined to cervix Stage II: beyond cervix A: superior 2/3 vagina B: parametrium

 Stage III: A: inferior 1/3 vagina B: pelvic side-wall/ hydronephrosis Stage IV: further extension/metastases A: bladder or rectum B: distant mets Radiographic: enlarged cervix (> 3 cm); direct extension; LAD; hematogenous metastases lung, bone, brain G. Adenomyosis: heterotopic endometrium within myometrium (stratum basalis); junctional zone ( T2 > 12 mm; normal < 8 mm; borderline = 8-12 mm); +/- T2 foci; heterogeneous/ shadowing regions (U/S; DDX = leiomyoma); adenomyoma = focal adenomyosis H. DDX for uterine filling defects (HSG): Neoplasms: leiomyoma; endometrial polyp (echogenic); carcinoma Synechiae: Ashermans syndrome (intrauterine adhesions status post D&C with hypo-/ amenorrhea) Adenomyoma Other: foreign body (IUD; etc.); retained POC; blood clot; etc. I. Myometrial Ca2+: usually arcuate vessels; DM; HTN; renal failure J. Fallopian tubes: Tubal obstruction: post-operative; PID; cornual spasm; plica (cogwheel or sawtooth sign) Salpingitis ischmica nodosa (SIN): 50% bilateral; infertility; PID; ectopic pregnancies; multiple small isthmic diverticula; DDX = TB; tubal endometriosis Hydro-/ pyo-/ hematosalpinx: due to PID; ampulla 21. Testes: A. Testicular Cancer: Clinical: seminomas orchiectomy + XRT; nonseminomas (radioresistant) orchiectomy + chemotherapy Staging: Stage I: limited to testes and spermatic cord Stage II: lymph nodes below the diaphragm Stage III: lymph nodes above the diaphragm A: lymph nodes only B: extranodal mets Lymphatic spread: along gonadal veins renal hilar nodes; external iliac nodes para-aortic nodes Hematogenous spread: uncommon except for choriocarcinoma B. Cryptorchidism: located from inferior renal pole to superficial inguinal ring; risk of torsion ( 10x) + malignancy ( 50x); usually atrophic

22. Prostate: A. Anatomy: U/S hyperechoic central gland = transitional + central zones Transition zone (5%): periurethral BPH Central zone (25%): ejaculatory ducts Peripheral zone (75%): carcinoma (> 80%); hypoechoic B. BPH: periurethral transitional zone; enlarged, lobulated gland; cystic degeneration; Ca2+; elevation of bladder base; bladder wall thickening and trabeculation C. Prostatic cysts: Midline: Mullerian duct: larger; extend superiorly Utricular cyst: smaller; communicate with urethra; hypospadias Ejaculatory duct cyst: acquired; due to obstruction Eccentric: Cystic prostatitis/ carcinoma Cystic BPH DDX = seminal vesicle cysts unilateral; ipsilateral renal agenesis (= Zinner syndrome) > cystic renal disease (APKD), renal ectopia, duplication, ectopic renal insertion D. Prostate carcinoma: Clinical: # 2 male CA; enlarged gland with nodules; periprostatic stranding; regional nodes; direct extension to seminal vesicles, bladder; mets to axial skeleton Radiographic: hypoechoic; T2 lesions in peripheral gland (DDX = prostatitis; fibrosis; hemorrhage) Staging: Stage A: nonpalpable Stage B: confined to prostate Stage C: capsular involvement a: invasion b: penetration c: seminal vesicles Stage D: metastases a: pelvic LN b: bone; distant LN Treatment: Stage A/B radical prostatectomy +/- XRT; Stage C/D hormone therapy +/- XRT

VIII. Peritoneal Cavity, Vessels, and Nodes

1. Anatomy:

QuickTime and a None decompressor are needed to see this picture.

2. Fluid in peritoneal cavity: A. Ascites: serous; due to CHF, cirrhosis, hypoproteinemia, venous obstruction; accumulates in greater peritoneal space; density = 1015 HU B. Exudative ascites: pancreattis accumulates within lesser sac; peritonitis; bowel perforation C. Hemoperitoneum: density > 30 HU; sentinel bleed accumulates at site of hemorrhage D. Pseudomyxoma peritonei: due to appendiceal mucocele or mucinous cystadenocarcinoma of the ovary (> urachal/ endometrial CA); peritoneum filled with gelatinous mucin; Ca2+ 3. Pneumoperitoneum: due to bowel perforation, pneumothorax, or mechanical ventilation 4. Peritoneal tumors: A. Peritoneal carcinomatosis: Etiologies: ovarian, pancreatic, gastric, and colon carcinoma Radiographic: malignant ascites; tumor nodules/ Ca2+ bowel wall nodularity; mesentery; omental cake; pouch of Douglas (Blumers shelf); adnexa/ ovaries (Krukenberg tumor) B. Peritoneal (cystic) mesothelioma: 20-40% in abdomen; women 3040 years; irregular thickening of peritoneal surfaces; multilocular cysts; ascites; bowel compression without obstruction C. Mesenteric lipodystrophy (= retractile mesenteritis): fat-density mass with tethering/ kinking/ angulation of adherent bowel loops 5. Abscess: A. Clinical: complications of trauma or surgery; pancreatitis; bowel perforation; commonly located within pelvis, subhepatic and subphrenic spaces B. Radiographic: loculated fluid collection; thickened walls; gas; thickening

of fascia; obliteration of fat planes; ascites; pleural effusions 6. DDX for cystic abdominal masses: Abscess Loculated ascites Pancreatic pseudocyst Ovarian cyst/ tumor Cystic teratoma: fat, water, Ca2+ Enteric duplication cysts: lined by GI mucosa Lymphocele: complication of surgery/ trauma Cystic lymphangioma: mesenteric/ omental 7. DDX for pelvic cystic masses: Ectopic pregnancy: adnexal/ tubal ring TOA: tubo-ovarian abscess Endometrioma Ovarian neoplasms Ovarian cysts Extra-GU origin: abscess; urinoma; duplication/ mesenteric cyst; etc. 8. Lymph nodes: A. Pathology: lymphadenopathy: > 10 mm in abdomen and pelvis; > 6 mm in retrocrural and porta hepatis regions B. Hodgkins lymphoma: 40% of total; contiguous spread; discrete, noncomglomerate C. Non-Hodgkins lymphoma: 60% of total; noncontiguous spread; GI involvement 9. DDX for hypodense intra-abdominal/ retroperitoneal LAD: Infection: MAI > TB ( AIDS), histoplasmosis Whipples disease: glycogen deposition Tumors: lymphoma (post-therapy); nonseminomatous testicular CA; mucinous adenoCA (rare) 10. Trauma: A. Hemoperitoneum: density (30-45) HU; (60-80) HU active bleeding (> 100 HU with contrast); sentinel clot adjacent to injured organ (> 60 HU); free intraperitoneal contrast bowel/ bladder perforation B. Pneumoperitoneum: perforated viscous; PTX; mechanical ventilation; post-op C. Subcapsular hematomas: crescentic flatten parenchyma D. Lacerations: jagged, linear low density areas E. Intraparenchymal hematomas: rounded, low density areas

11. Vascular anatomy: A. Normal anatomy: aorta/ IVC bifurcate at iliac crest; common iliac vessels bifurcate at pelvic brim; celiac axis originates below the aortic hiatus SMA originates 1 cm below and renal arteries 2 cm below B. Anomalies: Duplication of IVC: left common iliac vein left renal vein (< 1%) Retroaortic (1-2%) or circumaortic (2-5%) left renal vein (retroaortic component more inferior) Absent intrahepatic IVC azygos continuation (< 1%) C. True aneurysm: all three layers (intima, media, adventitia); saccular, fusiform, or spherical dilatation Aorta > 3 cm (risk of rupture = 5% if < 5 cm; 15% if > 6 cm; and 76% if > 7 cm; 90% infrarenal) Iliac > 1.5 cm D. Pseudoaneurysm: hematoma confined within adventitia/ surrounding tissue Iatrogenic, traumatic Infectious (mycotic) irregular contour without Ca2+; gas; adjacent vertebral osteomyelitis, suprarenal location Inflammatory: perianeurysmal fibrosis (posterior wall spared); due to autoimmune process Dissecting: true and false lumens separated by intimal flap; thrombosis within false lumen; risk factors include HTN, Ehlers-Danlos, and Marfans Ruptured aortic dissection: mortality > 75%; adjacent retroperitoneal hematoma; dissection into psoas muscle and peritoneal cavity E. Venous thrombosis: bland, septic, neoplastic (hepatic; adrenal; renal) 12. AIDS: A. Extensive LAD: MAI; lymphoma; Kaposis lymphoma B. HSM: MAI; histoplasmosis; hepatocellular disease C. Focal LAL within liver: MTB; MAI; Coccidiomycosis; Candidiasis; bacillary peliosis; Kaposis; lymphoma; PCP D. Focal bowel wall thickening: lymphoma E. Calcifications in spleen, liver, lymph nodes Pneumocystis carinii infection F. Nephromegaly (echogenic) and striated nephrogram HIV nephropathy G. Mycobacterial infections: LAD; LAL in spleen/ liver; HSM; bowel wall thickening H. Pneumocystis carinii infections: punctate/ nodular Ca2+ in solid organs; LAL in spleen

I. Kaposis sarcoma: LAD; HSM; focal bowel wall thickening; hepatic LAL; low density bands in periportal region J. AIDS-related lymphoma: solid masses in abdomen; LAD; bowel wall thickening; focal masses in spleen, liver, kidneys 12. Abdominal hernias: A. Incisional B. Inguinal: direct (through Hesselbachs triangle)/ indirect (along canal) Pantaloon: direct + indirect Littres = inguinal hernia containing Meckels diverticulum C. Paraumbilical: through linea alba D. Spigelian: through linea semilunaris at lateral edge of rectus abdominis E. Lumbar hernias: Superior: triangle of Grynfelt and Lesgaft (borders = 12th rib + internal oblique muscles + erector spinae muscles); hernias contain kidneys/ adrenals/ fat Inferior: Petits triangle (borders = external oblique muscles + latissimus dorsi + iliac crest); contains retroperitoneal fat >> kidney, ascending/ descending colon F. Paraduodenal hernias (= mesocolic hernias): #1 internal hernia (> paracecal; lesser sac; transmesenteric hernias) Right paraduodenal: behind hepatic flexure; fossa of Waldeyer; associated with cecal malrotation + Ladds bands; usually small contains portions of mesentery + vessels (middle colic artery + IMV) Left paraduodenal: fossa of Landzert near splenic flexure; often large; contain jejunal loops mary become incarcerated obstruction/ ischemia G. Obdurator: SB herniation/ strangulation; Howship-Romberg sign (compression of obdurator nerve pain along superomedial thigh) 13. Retroperitoneal fibrosis: ST-encasement of retroperitoneal vessels/ ureters without anterior displacement (DDX = lymphoma); prominent enhancement Drugs: methylsergide; hydralazine Lymphoma Metastases: lung; breast; carcinoid Other: AAA; trauma; surgery; instrumentation Ormonds disease: idiopathic 14. DDX for retroperitoneal masses: A. Malignant: MFH (#1) Liposarcoma (#2)

 Other: leiomyosarcoma; metastases; RCC/ adrenal extension B. Benign: XGP; DDX = Erdheim-Chester disease Neural tumors Lymphangioma; hamangioma; lipoma Teratoma (dermoid)

IX. Vascular System

1. General considerations: A. Parenchymal organs: low resistance arterial waveforms B. Extremities: high resistance, triphasic arterial waveforms C. Turbulent blood flow: soft tissue bruit; spectral broadening D. Stenosis: pan-diastolic flow reversal, aka to-and-fro blood flow E. Basic Doppler equation: Fd = Ft x (/C) x cos() x 2 Fd = doppler frequency shift Ft = transmitted frequency = blood flow velocity C = speed of sound = Doppler angle F. Resistive index: RI = (S-D)/S G. Pulsatility index: PI = (S-D)/M M = mean pressure 2. Carotid arteries: A. Surgical candidates: Symptomatic patients with stenosis > 70% (NASCET = North American Symptomatic Carotid Endarterectomy Trial) Asymptomatic patients with stenosis > 60% (ACAS = American Carotid Atherosclerosis Study) B. Anatomy: Features Location Size Branches Waveform Temporal tap ICA Posterolateral Larger None resistance No ECA Anteromedial Smaller Several resistance Yes

C. ICA occlusion: absence of blood flow; externalization of CCA

D. Duke sonographic criteria for stenosis: Degree of Stenosi s 0-39% 40-59% 60-69% 70-79% 80-99% Peak Systolic velocity (cm/sec) < 110 > 120 > 150 > 210 > 280 Peak diastolic velocity (cm/sec) < 40 < 40 > 40 > 70 > 100 Systolic velocity ratio (ICA/CCA) < 1.5 < 1.8 > 1.8 > 3.0 > 3.7 Diastolic velocity ratio (ICA/CCA) < 2.6 < 2.6 > 2.6 > 3.3 > 5.5

3. Vertebral arteries: detect cephalad blood flow; flow reversal suggests subclavian steal phenomenon; L = dominant 50% 4. Pseudoaneurysms: s/p catheterization; swirling blood flow; mural thrombus; to-and-fro flow within aneurysm neck; TX = compression or thrombin injection 5. AV fistulas: soft tissue bruit; localized low resistance arterial blood flow + localized turbulent/ arterialized venous blood flow 6. Deep venous thrombosis: A. Findings: Non-compressible Filling defects Absent blood flow or phasicity Venous enlargement (acute/ malignant) B. Additional maneuvers: Evaluate pelvic venous system with Valsalva maneuvers (normal augmentation) Calf veins with calf compression ( venous return) 7. DDX for resistance waveforms: Peripheral artery; distal aorta Proximal to stenosis/ occlusion Renal transplant rejection 8. DDX for resistance waveforms: Organs: brain; liver; kidney; etc. Placenta AVM/ AVF

X. Superficial Parts
1. Scrotum: A. Extra-testicular masses: Spermatocele: most common extratesticular mass; head of epididymis Epididymal cysts: head or tail of epididymis Adenomatoid tumor: #1 extra-testicular neoplasm; most common tumor of epididymis (> sarcoma; leiomyosarcoma; metastases) Rhabdomyosarcoma: children Hydroceles: fluid within tunica vaginalis; may develop cholesterol crystals internal echoes (DDX = pyocele; hematocele) Varicocele: dilated peritesticular veins (= pampiniform plexus); left (85%) > right (venous drainage); infertility Tunica albuginea cysts B. Intra-testicular masses: Testicular cysts: rare; elderly; near mediastinum (tunica albuginea) Tubular ectasia of rete testis: usually bilateral; spermatoceles and intratesticular cysts Seminoma: most common germ cell tumor; radiosensitive; young males; homogeneously hypoechoic Teratomas: complex cystic masses; benign (children) or malignant (adult) Embryonal cell carcinoma and choriocarcinoma: malignant; heterogeneous Sertoli-Leydig cell tumors: rare; non-germ cell (= stromal) tumors; solid masses; < 6 years Epidermoid cysts: benign; only ectodermal derivatives Metastases: lymphoma; leukemia; prostate > lung, colon Other lesions: focal orchitis; infarcts; atrophy; hematomas; abscesses C. Testicular microlithiasis: > 5 Ca2+ per image; germ cell tumors D. Testicular torsion: risk with bell-clapper deformity (abnormal tunica vaginalis suspended by spermatic cord); venous obstruction arterial obstruction ischemia; DX within 6 hrs; blood flow E. Epididymo-orchitis: inflammatory hyperemia with testicular enlargement and echogenicity 2. Appendix: A. Anatomy: blind-ended tubular structure; < 6 mm diameter B. Appendicitis: > 6 mm; non-compressible; non-peristaltic; hyperemia; periappendiceal fluid collections

3. Thyroid: A. Anatomy: bilateral lobes (4.0 x 2.5 x 2.0 cm); isthmus (< 3 mm) B. Nodules: Benign: multiple; cystic; hyperechoic; well-defined margins; thin halo (hypoechoic); large peripheral egg-shell Ca2+; < 1.5 cm Malignant: single; solid; ill-defined margins; thick halo; central micro-Ca2+; > 1.5 cm C. Graves disease: homogeneous hyperechoic gland with intense hypervascularity (thyroid inferno) D. Hashimotos thyroiditis: heterogeneous and hypoechoic; micronodular 4. Parathyroid: A. Anatomy: 4 glands; up to 3% ectopic (inferior neck carotid sheath; superior mediastinum) B. Primary hyperparathyroidism: single adenoma (85%) > diffuse bilateral hyperplasia (10%) > carcinoma (< 5%); homogeneous, hypoechoic 5. Prostate: A. Anatomy: peripheral zone (hyperechoic; develops into carcinoma); transitional zone (periurethral; hypoechoic; BPH) B. Prostate carcinoma: hypoechoic lesion in peripheral gland (70%); nodular or diffusely infiltrative; DDX = prostatitis; fibrosis; infarct; BPH; correlate with PSA/ DRE and BX C. BPH: enlargement of transitional zone; inhomogeneity; Ca2+ D. Prostatic cysts: Midline: utricle cyst; Muellerian duct cysts; ejaculatory duct cysts Eccentric/ paramedian: seminal vesicle cysts; retention cysts; cystic BPH

XI. Obstetrics
1. First Trimester: A. Indications: confirm and date IUP; determine fetal number and placentation; evaluate bleeding B. -FP: synthesized by fetal liver, yolk sac, and gut; measure MS-FP (maternal) at 16 weeks Elevated: neural tube defects and fetal swallowing defects (abdominal wall defects; GI obstruction); multiple gestations; fetal demise (early); incorrect dates Depressed: Downs syndrome; trisomy 18; incorrect dates; fetal demise (late) C. -HCG: correlates with size of gestational sac; doubles every 2-3 days; declines after 10 weeks; 3rd IRP = 1.84 x 2nd IRP (= International Reference Preparation); triple screen = -FP + -HCG + estradiol D. Amniocentesis: perform at 15-16 weeks; desquamated cells cultured and karyotyped; indications = maternal age > 35 years; abnormal MS-FP; fetal anomalies; history of chromosomal/ genetic disorders; 0.5% fetal loss E. Chorionic Villus Sampling (CVS): perform at 10-12 weeks; transcervical or transabdominal approach F. Fetal Blood Sampling: percutaneous sampling of umbilical vessels (PUBS) near placental insertion 2. Normal Pregnancy: A. Amniotic and chorionic membranes: amnion contains fetus, but NOT yolk sac; apposed by 12-14 weeks; fuse within 14-16 weeks B. Double decidual sac sign: three layers decidua parietalis (hyperechoic) + uterine cavity (hypoechoic) + decidua capsularis (hyperechoic) C. Intradecidual sign: earlier; implanted ovum in endometrium = small cyst D. Double Bleb sign: amnion + yolk sac separated by embryo E. Yolk sac: < 5.6 mm; provides nutrients; site of angiogenesis/ hematopoiesis; connected to primitive gut via omphalomesenteric (vitelline) duct; involutes by 10-12 weeks F. Gestational sac: MGSD (mm) = [(length + width + height)/ 3]; inner-to-inner margin Estimated gestational age (EGA; days) = [MGSD (mm) + 30]; normal increase = 1.1 mm/day [MSD - CRL (mm) < 5 mm] indicates likelihood of pregnancy loss (= 1st trimester oligohydramnios) Empty gestational sac: early IUP; blighted ovum or pseudogestational sac (no yolk sac; absent double decidual sign) Only use MSD prior to crown-rump length (more accurate); EGA = CRL (mm) + 42

G. Abnormal findings: Abnormal Finding No yolk sac Embryonic/ fetal pole MSD (TV) 8 mm 16 mm MSD (TA) 20 mm 25 mm

H. Fetal heart: heartbeat detectable if CRL > 5 mm I. Transvaginal U/S landmarks: Age (wks) 5 5.5 6 >6 -HCG (2nd IRP) 500-1000 > 3600 > 5400 > 6000 Gestational Sac + + + + Yolk Sac + + + Heartbeat + + Embryo +

3. Threatened abortion: A. Subtypes: blighted ovum; ectopic pregnancy; inevitable, incomplete or missed abortion B. Signs and symptoms: bleeding; pain; contractions; open cervix C. Threatened abortion: vaginal bleeding with closed cervical os; 25% of 1st trimester pregnancies; 50% survival D. Inevitable abortion: vaginal bleeding with open cervical os E. Incomplete abortion: retained products of conception with persistent vaginal bleeding F. Spontaneous abortion: vaginal bleeding with passage of tissue G. Missed abortion: retention of dead fetus > 2 mths 4. Endovaginal (EV) U/S criteria for embryonic demise: CRL > 5 mm without cardiac activity MSD > 8 mm without yolk sac MSD > 16 mm without embryo 5. Bradycardia: heart rate < 85 BPM at 5-8 weeks spontaneous abortion likely; normal heart rates = 100 (5-6 weeks); 140 (> 8 weeks) 6. Subchorionic hemorrhage: 80% occur during late 1st trimester vaginal bleeding; hypoechoic/ hyperechoic blood separating chorion from endometrium; DDX = retroplacental hemorrhage; abruption 7. DDX for 1st trimester bleeding: Abortion Ectopic pregnancy Gestational trophoblastic disease (GTD) Subchorionic hemorrhage

8. DDX of Empty Sac: Early IUP Ectopic pregnancy Blighted ovum 9. Ectopic pregnancy: A. Location: tubal (ampullary > isthmus; 95%) > interstitial (= cornual; 3%; interstitial line sign; Ruge-Simon syndrome = cornual ectopic mimicking IUP) > ovarian (1%) > cervical, abdominal (< 1% each) B. Presentation: clinical triad = pain, hemorrhage, palpable adnexal mass C. Risk factors: prior ectopic pregnancy; IUD; PID; tubal surgery; in vitro fertilization D. Features: slower rise of -HCG; P4 progesterone; culdocentesis non-clotted blood (> 5 ml) E. Ultrasound: Thick decidual cast without gestational sac; +/- decidual cyst Pseudogestational sac; absent double decidual sac sign Free fluid in cul de sac extending into flanks Simple adnexal cyst or complex adnexal mass Tubal/ adnexal ring sign: echogenic rim; DDX = corpus luteum Live extrauterine embryo (100% PPV) F. Heterotopic pregnancies: concurrent IUP and ectopic pregnancy; incidence due to fertilization techniques (1/ 30,000 1/ 7,000) 10. DDX for intrauterine tissue: A. Positive -HCG: Missed AB Retained products of conception Gestational trophoblastic disease (GTD) B. Negative -HCG: Degenerating submucosal fibroid Endometrial polyp/ hyperplasia/ CA 11. Multifetal pregnancy: A. Subtypes: Dizygotic (fraternal): independent fertilization of 2 ova; always dichorionic and diamniotic; risk factors = advanced maternal age; FHX; ethnicity (Nigerian) Monozygotic (identical): duplication of single fertilized ovum; may be monochorionic or dichorionic (# of placentae); NO RISK FACTORS; risk of complications (monoamniotic > monochorionic/ diamniotic > dichorionic) B. Ultrasound: dichorionicity determined by separate placentae; different fetal sex; thick separating membrane; twin peak sign C. Complications: fetal mortality (3x); neonatal mortality (7x)

D. Twin-twin transfusion syndrome: occurs only in monochorionic twins; due to AV communications within placenta; poor prognosis Recipient twin: larger; polyhydramnios; polycythemia; fetal hydrops Donor twin: smaller; pinned to gestational sac (stuck twin); oligohydramnios E. Twin complications/ demise: Vanishing twin: demise of twin within 1st trimester resorption of dead fetus Fetus papyraceus: demise of twin in 2nd or 3rd trimester with persistence of dead fetus as amorphuous mass premature labor; labor obstruction Twin-twin embolization syndrome: monochorionic twins thrombus propagation via common placenta multiorgan failure Acardiac parabiotic twin: monochorionic twins only ( monoamniotic); acardiac/ acephalic fetus rudimentary lower body; live twin polyhydramnios and hydrops F. Conjoined twins: monoamniotic twins; thoracopagus (thorax fused); omphalopagus/ xiphopagus (abdomen fused); pyopagus (sacrococcygeal fusion); craniopagus (cranium fused) 12. Second and Third Trimester Fetal Survey: A. Brain: hydrocephalus; agenesis of corpus callosum; anencephaly; cystic hygroma; Dandy-Walker malformation; banana and lemon signs; anopthalmia B. Face: facial cleft; proboscis; micrognathia; masses C. Spine: spina bifida; sacral agenesis; sacrococcygeal teratoma D. Thorax: congenital heart disease (VSD; TA; TGA; DORV); dextroposition; lung masses; diaphragmatic hernia E. GI: eophageal/ duodenal atresia; ascites; meconium peritonitis; situs F. Kidneys: renal agenesis; hydronephrosis; MCDK; ectopic kidney G. Abdominal wall: gastroschisis; omphalocele; limb-body-wall complex; 2 vessel cord H. Extremities: dwarfism; clubfoot; polydactyly 13. Ventriculomegaly: Ventricular atria > 10 mm (> 8 mm < 25 weeks); dangling choroid plexus; due to hydrocephalus, brain atrophy, or colpocephaly (large ventricular atria) DDX = Chiari malformations (> 90%) > DW-malformation (5%) > congenital aqueductal stenosis (3-4%) > infections (TORCH), syndromes, encephaloceles

14. Agenesis of Corpus Callosum: develops anteriorly (genu) posteriorly rd (splenium); colpocephaly; enlarged 3 ventricle; sunburst gyral pattern; associated with DW malformation; holoprosencephaly; heterotopias 15. Hydrananencephaly: near total absence of cerebrum with intact cranial vault, thalamus, and brainstem; often secondary to occlusion of supraclinoid ICA (TORCH infections; etc.) 16. Porencephaly: less severe vascular insult; cystic lesion communicating with ventricle or subarachnoid space; 2/2 PVL; DDX = arachnoid cyst; agenesis of CC with interhemispheric cyst; holoprosencephaly with dorsal cyst 17. Fetal Neural Axis: A. Dimensions: ventricles < 10 mm; cisterna magna < 10 mm B. Ultrasound features: Hyperechoic structures choroid plexus; dura; cerebellar vermis Hyoechoic structures white matter; CSF C. Spine: 3 ossification centers (centrum + 2 neural arches) D. Holoprosencephaly: all absent septum pellucidum (SP) + CC; risk = trisomy 13; midline facial anomalies (clefts; cyclopia; hypotelorism) Alobar: monoventricle with dorsal cyst; mantle of brain tissue (horseshoe or boomerang); fused thalami; absent falx + cavum septum pellucidum + corpus callosum Semilobar: monoventricle with rudimentary occipital horns; fused thalami; partial posterior falx; absent CC + SP Lobar: difficult diagnosis (partial fusion) 18. Cystic structures: A. Cystic teratoma: #1 congenital intracranial tumor; solid + cystic components B. Choroid plexus cysts: common 12-24 weeks; if > 10 mm incidence of trisomy 18 (Edwards syndrome) C. Arachnoid cysts: within pia-arachnoid which communicates with subarachnoid space via ball-valve mechanism; congenital vs. acquired (hemorrhage, infection) D. Rhombencephalon: normal hindbrain cyst (8-11 weeks) 19. Neural tube defects: 1/6000 births; risk with prior NTD child; MS-FP A. Anencephaly: acrania + absence of cerebral hemispheres; angiomatous tissue overlying skull base; polyhydramnios; DDX = microcephaly (HC > 3 STDs below mean) B. Encephalocele: herniation of intracranial structures through skull defect; MS-FP usually WNL (skin cover); occipital (70%) > frontal (10%); association with ABS (amniotic band syndrome) and MeckelGruber syndrome; lemon sign

C. Spina bifida and myelomeningocele: lumbosacral > thoracic, cervical; clubfoot, hip dislocations; lemon sign (< 24 weeks); banana sign (cerebellum) Arnold Chiari II hydrocephalus (#1 cause) 20. Dandy-Walker syndrome: posterior fossa cyst which communicates with 4th ventricle + hypoplasia of vermis + hydrocephalus; agenesis of CC, CHD (congenital heart disease); DDX = mega cisterna magna; arachnoid cyst 21. Cystic hygroma: A. Anatomy: fluid-filled structures due to lymphatic obstruction B. Associations: Turners syndrome Trisomies (13, 18, 21) Noonan syndrome Fetal EtOH syndrome C. DDX = non-immune hydrops; cephalocele/ meningocele; teratoma (arise anteriorly); nuchal thickening 22. Anomalies of face and neck: A. Cebocephaly: hypotelorism and rudimentary nose B. Cyclopia: one eye with supraorbital proboscis C. Ethmocephaly: hypotelorism + proboscis D. Proboscis: cylindrical appendage near orbits E. Nuchal thickening: > 5 mm; trisomy 21 F. Beckwith-Wiedemann syndrome: macroglossia G. Holoprosencephaly: cyclopia, ethmocephaly, cebocephaly, clefts, hypotelorism 23. Congenital Heart Defects: A. Structural abnormalities: septal defects (ASD, VSD, AV canal); hypoplastic left heart; Ebstein anomaly; aortic stenosis; coarctation; Tetralogy; Transposition; Truncus B. Masses: rhabdomyoma; endocardial fibroelastosis (echogenic myocardium); moderator band (RV); intraventricular echogenic focus (LV Downs); ectopia cordis (Cantrell) C. Risk factors: DM; infection (rubella; CMV); SLE; FHX; drugs (phenytoin; Li2+; trimethadione; EtOH) D. Arrhythmias: PACs (#1); supraventricular tachycardia (> 180 BPM; #1 tachyarrhythmia); bradycardia (< 100 BPM; fetal hypoxia); heartblock (maternal SLE; CHD) 24. Thorax/ lungs: A. Pulmonary hypoplasia: primary vs. secondary (Potters sequence; skeletal dysplasia; CCAM; CDH (diaphragmatic hernia); hydrothorax

B. CCAM: associated with pulmonary hypoplasia; polyhydramnios Type I/II: cysts > 5 mm; rare hydrops; good prognosis Type III: microscopic; cysts < 5 mm; hydrops; poor prognosis C. CDH: 90% on left; mortality (polyhydramnios; hydrops) Bochdalek (90%): posterior on left side Morgagni (10%): anterior on right side D. Sequestration: CDH; foregut anomalies; sternal anomalies; usually posterior LLL; complications hydrops; polyhydramnios Intralobar: pulmonary venous drainage Extralobar: systemic venous drainage E. Bronchogenic cyst: subcarinal/ paratracheal > lung parenchyma F. Pleural effusions: hydrops; chest masses; aneuploidy; TORCH G. Laryngotracheal obstruction: TEF; polyhydramnios; Frasers syndrome (= laryngotracheal stenosis + renal agenesis + micro-ophthalmia + poly-/ syndactyly) H. Mediastinal masses: Anterior/ middle: teratoma; cystic hygroma; thymus; hemangioma Posterior: neurogenic tumors; enteric cysts 25. Abdomen: A. Umbilical vessels: Umbilical vein: UV left portal vein ductus venosus left hepatic vein IVC Umbilical artery: internal iliac arteries umbilical arteries Two-vessel cord: fetal anomalies (4-20%) B. Adrenal glands: prominent ( 20x larger than in adults); oreocookie sign (hypoechoic rim; echogenic center) normal; neuroblastoma (#1 antenatal tumor; hyperechoic; metastases to placenta, liver SQ tissues; hydrops); Wolmans disease C. Normal bowel: stomach seen as early as 14 weeks; reliably seen by 19 weeks; small bowel < 7 mm; large bowel < 15-18 mm D. Duodenal atresia: association with Downs syndrome, malrotation, CHD, VACTERL; features double bubble sign; polyhydramnios E. Meconium: echogenic material within bowel; complications meconium peritonitis (Ca2+; ascites; polyhydramnios); pseudocyst (peritoneal meconium); ileus (inspissation; bowel dilatation) F. Ascites: causes = urinoma; meconium; ruptured ovarian cyst; hydrops; TORCH; DDX = pseudo-ascites (abdominal wall muscles) G. Amniotic band syndrome (ABS): amputation defects (limbs, facial defects) due to amniotic bands; asymmetric encephaloceles; abdominal wall defects; syndactyly; clubfoot H. Limb-Body Wall Complex: eccentric body wall defect (severe form of ABS); large thoracoabdominal defect; NTD; scoliosis; anencephaly; 2 vessel cord; CHD; omphalocele

I. DDX for echogenic bowel: Normal variant CF Chromosomal anomalies: Downs; trisomies 13/ 18 Other: IUGR; TORCH (CMV); swallowed bood J. Anterior wall defects: Normal physiologic herniation of gut (< 12-14 weeks) Gastroschisis: MS-FP; right side; usually < 2 cm; bowel perforation; intestinal atresia; meconium peritonitis Omphalocele: midline; covered by membrane (contains Whartons jelly + peritoneum + amnion); normal MSAFP; 60% anomalies Pentalogy of Cantrell = omphalocele + CDH + sternal cleft + ectopia cordis + CHD Beckwidth-Wiedemann syndrome = omphalocele + macroglassia + gigantism + pancreatic hyperplasia with glucose OEIS: omphalocele + exstrophy + imperforate anus + spinal anomalies Other omphalocele associations: trisomies; Turners syndrome; GU/ GI/ CNS and cardiac anomalies 26. DDX for abdominal Ca2+: Meconium peritonitis: bowel atresia > CF Anal/ colonic atresia: intraluminal Ca2+ TORCH: CMV Gallstones Adrenal: hemorrhage; neuroblastoma; Wolmans disease Teratoma 27. Urinary Tract: A. Anatomy: renal pelvis < 10 mm (< 4 mm < 24 weeks; < 7 mm > 24 weeks); urinary bladder empties every 30-45 mins; most amniotic fluid consists of urine during 2nd/ 3rd trimesters B. Potter syndrome: renal failure urine ouput oligohydramnios pulmonary hypoplasia, Potter facies; etiologies include bilateral renal agenesis, posterior urethral valves, infantile PCKD, MCDK C. Renal agenesis: unilateral >> bilateral (fatal); severe oligohydramnios; small fetal thorax; Potter facies D. Urinary tract obstruction: UPJ obstruction: #1 antenatal cause of hydronephrosis; 20% bilateral; severe hydronephrosis; 25% associated renal anomalies (agenesis; UVJ obstruction); perinephric urinoma

 UVJ obstruction: less common; etiologies include duplicated collecting systems; primary megaureter; distal ureteral atresia; usually unilateral; associations (UPJ; MCDK) Bladder outlet obstruction: posterior urethral valves (#1 cause in males) > caudal regression syndrome (maternal DM) > megacystis-microcolon-intestinal hypoperistalsis E. Cystic renal disease (often echogenic due to small cysts): MCDK: due to in utero obstruction; multiple noncommunicating macroscopic cysts; contralateral renal anomalies (UPJ obstruction; agenesis; MCDK (bilateral) fatal) Infantile PCKD: bilaterally enlarged, hyperechoic kidneys; liver fibrosis; Potter sequence Cystic renal dysplasia: due to collecting system obstruction; small bilateral cortical cysts Meckel-Gruber syndrome: bilateral MCDK + occipital encephalocele + polydactyly; fatal (pulmonary hypoplasia); autosomal recessive Other: trisomy 13 F. Exstrophy: Bladder: defect of abdominal wall and bladder; association of epispadias, cryptorchidism, omphalocele, anorectal atresia OEIS complex = omphalocele, exstrophy, imperforate anus, spinal anomalies Cloacal: 2 hemibladders separated by intestinal mucosa; multiple GI/ GU anomalies 28. Extremity abnormalities: A. Short radial ray syndromes: Fanconis anemia TAR Holt-Oram syndrome VACTERL Klippel-Feil syndrome Cornelia de Lange syndrome B. Limb anomalies: Rhizo-(root)/ mesomelia (middle) Acromelia: distal extremity Adactyly/ amelia: absence of extremity Camptomelia: bent limb C. Sirenomelia: formerly considered severe form of caudal regression syndrome (mermaid syndrome); currently considered distinct entity; fusion of lower extremities; oligohydramnios; bilateral renal agenesis/ MCDK

29. Skeletal dysplasias: A. Thanatophoric dwarf: #1 lethal dysplasia; cloverleaf skull; severe micromelia; polyhydramnios (small thorax); non-immune hydrops B. Achondroplasia: homozygous (autosomal dominant) similar to thanatophoric dwarf C. Achondrogenesis: autosomal recessive; severe micromelia; absent vertebral ossification; ossified calvarium D. Osteogenesis imperfecta II: autosomal recessive; unossified skull; multiple FXs; long bone angulation E. Congenital lethal hypophosphatasia: autosomal recessive; simliar to OI-II; gracile bones, but unossified skull F. Short rib-polydactyly syndromes: severe micromelia; polydactyly G. Camptomelia: mild micromelia with anterior bowing of long bones H. Chondrodysplasia punctata: stippled epiphyses I. Jeune syndrome: asphyxiating thoracic dysplasia; small thorax, polydactyly; simliar to Ellis-van Crevald syndrome J. Ellis-van Crevald syndrome: similar to Jeune syndrome; also with ASD K. Diastrophic dysplasia: Hitchhiker thumb; clubfeet (also associated with trisomy 18, ABS, meningocele) 30. Hydrops fetalis: A. Clinical: 1/ 700 births; U/S ascites, pleural/ pericardial effusions; SQ edema; placental edema; anasarca B. Subtypes: Immune hydrops (10%): Rh- mother with Rh+ child (1st) and subsequent Rh+ child anemia extramedullary hematopoiesis HSM + portal HTN + hydrops; TX = administer Rhogam at 28 wks Non-immune hydrops (90%): mortality (> 90%) Cardiac: arrhythmias, structural defects Shunts/ output CHF: twin-twin transfusion; anemia; placental chorioangioma; vein of Galen malformation; hemangioendothelioma; acardiac twin Chromosomal anomalies: Turners, trisomies (13, 18, 21) Infections: CMV, toxoplasmosis, parvovirus B19 Thoracic: chest masses; skeletal dysplasia Other: lymphatic anomalies (lymphangiectasia = DDX) 30. Arthrogryposis multiplex: neural motor defect deformities; buddha fetus without movement; hydrops; clubfoot; flexion deformities; CDH; DDX = limb-body-wall complex (= severe amniotic band syndrome)

31. Syndromes: A. Trisomy 21 (= Downs syndrome): nuchal thickening (> 6 mm)/ translucency (> 3 mm); cystic hygroma; CHD (endocardial cushion defect); pyelectasis; duodenal atresia; clinodactyly ( space between 1st and 2nd toes); hyperechoic bowel; short humeri/ femora; intraventricular echogenic focus (LV-papillary muscle); iliac angle (60 vs. 75) B. Trisomy 18 (= Edwards syndrome): CHD (90%); IUGR; choroid plexus cysts (30%); two vessel cord; polyhydramnios; dolichocephaly/ strawberry skull; micrognathia; clenched hands; rockerbottom feet; GI anomalies (omphalocele; CDH; atresia) C. Trisomy 13 (= Patau syndrome): CHD (80%; hypoplastic left heart); CNS abnormalities (70% holoprosencephaly); facial clefts; microophthalmia; polydactyly; GU anomalies [polycystic kidneys (hyperechoic/ enlarged); horseshoe kidney] D. Meckel-Gruber syndrome: bilateral MCDK + occipital encephalocele + polydactyly E. Roberts syndrome (= pseudothalidomide syndrome): autosomal recessive; tetraphocomelia; microbrachycephaly; hypoplasia of radius + ulna; cleft lip + palate; MR; capillary hemangiomata; CHD 32. Placenta: A. Anatomy: maternal decidua basalis + fetal chorion frondosum Decidua (maternal endometrium): capsularis + parietalis + basalis Chorion (fetal component): chorion laeve + frondosum B. Variants: Succenturiate lobe (accessory lobe) hemorrhage Extrachorial placenta: fetal membranes fail to extend to edge of placenta; circummarginate (benign) and circumvallate ( hemorrhage) C. Placental grading: Grade 0: smooth; homogeneous Grade 1: scattered Ca2+ Grade 2: Ca2+ in chorionic plate + basal plate Grade 3: continuous Ca2+ D. Placenta previa: Clinical: with age; multiparity; prior C-sections; TOBA; SXS = 3rd trimester bleeding; premature delivery; perinatal death Subtypes: low-lying (within 2 cm); marginal; partial; complete False positives: overdistended bladder; uterine contraction E. Placenta accreta: risk with prior C-sections Subtypes: accreta (80%); increta (15%); percreta (5%) Complications: maternal hemorrhage; post-partum infection (metritis)

F. Placental separation: Clinical: risk of abruption (3rd trimester bleeding); IUGR; DIC; fetal demise Subtypes: Subchorionic hemorrhage: marginal venous bleed; good outcome Retroplacental hemorrhage: arterial; worse prognosis G. Intraplacental lesions: Intervillus thrombosis/ small infarcts (= Breus mole) Maternal/ venous lakes Chorioangioma: benign vascular malformation; #1 neoplasm; complications if large hydrops (AV shunt); polyhydramnios; IUGR; premature labor H. DDX for enlarged placenta: Molar change Hydrops fetalis Infections (TORCH) Isoechoic abruption 33. Measurements: A. 1st Trimester: MSD/ CRL [EGA = {MSD (mm) + 30} or {CRL (mm) + 42}] B. 2nd Trimester: BPD or HC + femur length C. 3rd Trimester: BPD + HC + AC (single best estimate for fetal size) 34. IUGR (intrauterine growth retardation): EFW < 10th percentile @ 34 wks A. Maternal causes: placental insufficiency; HTN; SLE; EtOH; TOBA; teratogens B. Fetal causes: chromosomal anomalies; infections (TORCH) C. Measurements: S/D umbilical artery ratio: resistance MCA-PI (pulsatility index): brain-sparing effect 35. Macrosomia: EFW > 90th percentile; > 4000 g A. Risk factors: DM; obesity; post-term pregnancy B. Complications: asphyxia; meconium aspiration; neonatal hypoglycemia; trauma (shoulder dystocia; Erbs palsy) 36. Gestational trophoblastic disease: A. Subtypes: hydatiform mole; invasive mole; choriocarcinoma B. Risk factors: Low risk: < 4 mths; -HCG < 100,000; lung + vaginal metastases High risk: > 4 mths; -HCG > 100,000; CNS + liver metastases C. Clinical: size > dates; -HCG; molar vesicles; hemorrhage; hyperemesis gravidarum

D. Radiographic: echogenic mass with small cysts; fills uterine cavity; large/multi-septated theca lutein cyst (50%); U/S snowstorm sign (tiny vesicles with through-transmission) Type Partial mole Complete mole Karyotype Fetal Tissue Malignancy Risk 69 (triploidy) Yes Low 46 XX > 46 XY None High

D. Choriocarcinoma: risks = molar pregnancy (50%), abortion (25%), normal IUP (25%), ectopic pregnancy (5%); metastases lung, CNS, liver, bone, vagina E. DDX: Complete mole: hydropic placental degeneration -HCG; seen with missed abortion; rarely degenerating leiomyoma Partial mole: twin pregnancy with normal IUP + complete mole 37. Umbilical cord: A. Velamentous insertion: away from placenta onto membranes B. Vasa previa: velamentous insertion with vessels crossing internal os C. Two-vessel cord: one artery and vein; chromosomal anomalies 38. Uterus and adnexa: A. Incompetent cervix: closed portion < 3 cm; funneling sign; hourglassmembranes +/- fetal parts; risks = prior AB, abortion, D&C, DES exposure; complications: premature labor/ abortion; TX = cerclage (< 24 weeks) B. Complications: 2nd trimester bleeding/ AB C. Uterine fibroids: #1 lesion; DDX = focal contraction D. Corpus luteum cyst: #1 adnexal mass during 1st trimester; resolves by 16 weeks; DDX = cystic teratoma; cystadenoma; endometriosis; appendicitis 39. Amniotic fluid: AFI (amniotic fluid index; based on BEGA) A. Polyhydramnios: AFI > 18; largest single pocket > 8 cm Idiopathic (40%) Maternal (40%): DM, HTN Fetal (20%): CNS lesion; proximal GI obstruction; chest masses; non-immune hydrops; twin-twin transfusion B. Oligohydramnios: AFI < 5; largest single pocket < 2 cm D Demise: absent cardiac motion; Spaldings sign (overlapping skull bones) R Renal abnormalities: Potters syndrome/ sequence I IUGR P Post-maturity P PROM C Chromosomal anomalies

40. DDX for membranes in amniotic cavity: T Twins A Abruption B Bands (amniotic) S Synechiae; separation (amnion-chorion) 41. HELLP Syndrome (hemolysis + elevated liver enzymes + low platelets): A. Clinical: 5-10% of patients with severe pre-eclampsia/ eclampsia; RUQ pain with N/V; HA; edema B. Radiographic: Hepatomegaly; hepatic necrosis Subcapsular hematomas: liver + kidney Ascites + pleural effusions

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