case s Dr Payal Damor R 1 Radiodiagnosis

case s Dr Payal Damor R 1 Radiodiagnosis S. S. G. H BARODA 1

CASE 1 2

A 23 -year-old man presented to casualty dept with 8– 10 episodes per day of diarrhoea with intermixed blood & mucus. By day 9 of hospitalization, the frequency of episodes of diarrhoea had increased to 12 times per day. He underwent CT abdomen & pelvis. 3

Supine topogram obtained at abdominal CT demonstrates dilated loops of large and small intestine in a pattern suggestive of adynamic ileus. The transverse colon appears ahaustral, contains pseudopolyps (arrow), and has a diameter of 8 cm. 4

Coronal reformatted CT image of the abdomen and pelvis shows wall thickening and marked irregularity of the remaining mucosa in the ascending and descending colon (arrows). Coronal reformatted CT image of the abdomen and pelvis shows pseudopolyps (arrow) that extend into the lumen of the 5 transverse colon.

Axial CT image shows mural stratification and a target sign (arrow) in the ascending colon. Gas bubbles adjacent to the caecal wall are suggestive of pneumatosis (arrowhead). The small intestine is mildly dilated, but its wall is normal in thickness. Ascites also is present. 6

Axial CT image obtained at the level of the upper pelvis shows dilatation of the 7 perisigmoid vasculature (arrow), hyperattenuation of adjacent fat, and ascites

ULCERATIVE COLITS 8

DISCUSSION § Common idiopathic inflammatory bowel disease with continuous concentric + symmetric colonic involvement § Etiology : hypersensitivity/autoimmune § Age peak: 20 -40 years & 60 -70 years; § M: F = 1: 1 § Alternating periods of remission + exacerbation 9

C/F: Bloody diarrhea, electrolyte depletion, fever, systemic toxicity, abdominal cramps Extra colonic manifestations: v Fatty infiltration of the liver v Gallstones (28 -34%) v Sclerosing cholangitis v Bile duct carcinoma v Amyloidosis v Urolithiasis: oxalate/uric acid stones v Migratory arthritis v Sacroiliitis and ankylosing spondylitis v Erythema nodosum and uveitis 10

Location: Begins in rectum with proximal progression , relatively uniform symmetric involvement of bowel Plain film: § Diffuse dilatation with loss of haustral markings § § Hyperplastic mucosa, polypoidal mucosa, deep ulcers Toxic megacolon Free intraperitoneal gas Complete absence of fecal residue (due to inflammation) 11

Plain abdominal radiograph on a patient with known ulcerative colitis who presented with an 12 acute exacerbation of his symptoms. Image shows thumb-printing in the region of the splenic flexure of the colon.

USG FINDINGS: CT FINDINGS: Moderately thick, hypoechoic wall Typical wall stratification maintained Loss of haustration Absent peristaltic motion Mural thickening < 1. 5 cm Target appearance of wall – submucosal edema( acute) Target appearance of wall – submucosal fat ( chronic) Increased perirectal and presacral fat 13

longitudinal image of the colon showing circumferential continuous thickening of the colon wall. Cross-section of the transverse colon with stratification. mucosa, sub mucosa 14 & muscle layers are visible.

CT scan of a patient with long-standing ulcerative colitis shows a submucosal halo of fat within the rectum (arrow). There is also perirectal fibrofatty proliferation (*). Ulcerative colitis in a 27 -year-old man. Contrast-enhanced CT scan shows minimal diffuse thickening of the sigmoid colon with minimal 15 inflammatory stranding.

ULCERATIVE COLITIS – BARIUM FINDINGS ACUTE CHANGES CHRONIC CHANGES §Mucosal granularity §Mucosal stippling §“collar button’’ ulcers §Haustral thickening or loss §Confluent, contiguous, §Circumferential diesase §Haustral loss §Luminal narrowing §Lead pipe app §Loss of rectal valves §Widening of presacralspace §Backwash ileitis §Post inflammatory Pseudopolyp 16

Double-contrast barium enema studies show granular mucosa 17

Singlecontrast enema study in a patient with known ulcerative colitis in remission shows a benign stricture of the sigmoid colon. 18

Ulceration with Polypoid changes Postinflammatory polyposis 19

Barium enema examination demonstrates loss of haustral folds in the entire descending colon with small ulcerations suggested. The colon has a "leadpipe" appearance. The distribution and appearance are suggestive of ulcerative colitis. 20

Instant enema shows that total involvement with a granular mucosa, complete absence of haustration & narrowing of the bowel. The terminal ileum is dilated & featureless 21 secondary to reflux ileitis.

Cx: Toxic megacolon ± perforation in 5 -10% Ø (DDx: granulomatous/ischemic/amebic colitis) Most common cause of death in ulcerative colitis! Colonic adenocarcinoma (3 -5%) Ø Ø Risk starts after 8 -10 years of onset of disease Higher risk with pancolitis Onset of disease in <15 years of age Narrowed segment of 2 -6 cm in length with eccentric lumen + irregular contour + flattened rigid tapered margins Colonic strictures (10%) Ø Smooth contour with fusiform pliable tapering margins, usually short + single stricture; Ø Commonly in sigmoid/rectum/transverse colon Ø Usually after minimum of 5 years of disease; rarely cause for obstruction (DDx: colonic carcinoma) Perforation 22

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HOW TO DIFFERENTIATE UC FROM CROHN’S DZ…. 24

UC Symmetrical CROHN’S Asymmetrical Inflammatory changes limited to the mucosa. Transmural Normal thickness is less than 3 mm 5– 8 mm Grossly thickened Location Left side Right side Ulcers Shallow Deep Disease invovlement 25

UC CROHN’S Contraction Yes No Ileocecal valve Fistulae Gaping Thickened No Yes Eccentricity Rate of carcinoma No Yes Marked increase Slight increase Yes Unusual Megacolon 26

Crohn disease in a 41 -year-old man. (a) Multi–detector row CT scan shows an enlarged appendix (black arrow), stratified symmetric thickening of the terminal ileum (arrowheads), and adjacent creeping fat (white arrow). (b) Sagittal reformatted multi–detector row CT image demonstrates hypoattenuating symmetric thickening of the 27 cecal wall (arrowheads) and stratified thickening of the terminal ileum (arrows).

Crohn disease in a 33 -year-old man. Sagittal oblique reformatted multi–detector row CT image shows a thickened, inflammatory terminal ileum (arrowheads) with a fistula and retroperitoneal abscess posteriorly (arrows). 28

Aphthoid ulceration 29

30 -year-old man with Crohn's disease involving colon. Image from double-contrast barium enema reveals aphthoid lesions (arrowheads) in sigmoid colon. 25 -year-old woman with Crohn's disease involving colon. Image from double-contrast barium enema reveals longitudinal and perpendicular ulcerations (arrows) in right colon. 30

Cobble stone appearance typical of crohn’s disease 31

Fissuring ulceration with thorn-like cuts into the bowel wall is a classic feature of Crohn’s disease. 32

Case 2 33

45 -year-old woman who has recently noticed a lump on her head. 34

Plain Xrays reveal a solitary, predominantly lytic expansile lesion arising from the left parietal bone. 35

Axial CT scan shows no involvement of the underlying brain. The bone windows from the CT images reveal a truly intraosseous lesion, which is 36 predominantly lytic, but has prominent thick trabeculae.

Axial CT scan shows no involvement of the underlying brain. The bone windows from the CT images reveal a truly intraosseous lesion, which is predominantly lytic, but has prominent thick trabeculae. 37

Findings Plain Xrays reveal a solitary, predominantly lytic expansile lesion arising from the left parietal bone. Axial CT scan shows no involvement of the underlying brain. The bone windows from the CT images reveal a truly intraosseous lesion, which is predominantly lytic, but has prominent thick trabeculae. 38

Diagnosis Hemangioma of the skull 39

Discussion Osseous hemangiomas are usually asymptomatic, incidentally discovered benign lesions. They are more frequently seen in men than women, and are usually found in the 4 th and 5 th decades. Calvarial hemangiomas comprise 20% of all osseous hemangiomas, and 10% of primary benign skull neoplasms. 40

They are most frequently found in the frontal and parietal bones, arising in the diploic space. They are slow-growing lesions and the outer table tends to expand more than the inner table, with a resultant assymetric shape, as in this case. On plain films and CT, the hemangioma appears as an expansile lytic lesion with radiating, or spoke-wheel-like, thickened trabeculae. 41

Pathologically this trabecular thickening is due to bone formation adjacent to angiomatous channels that are characteristic of the vascular lesion. There may be a soft tissue component in association with the bone lesion, which will be best identified with contrast enhancement or MR imaging. The signal intensity on MR can vary but it is classically of high T 1 and T 2 signal. 42

Noncontrast axial T 1 weighted MR image (A) reveals a wellcircumscribed mass, in the right frontal bone with intra- and extracranial extension. The lesion is well defined, and the signal intensity is of mixed intensity with some central hyperintensity and bone destruction. 43

T 2 -weighted image shows a lesion of high signal intensity with central areas of hypointensity. The lesion is well demarcated from the galea extracranially (outer uniform dark line) and the underlying dura intracranially (inner dark line). There is no surrounding edema. 44

After gadopentetate dimeglumine administration strong and homogeneous enhancement of the mass, relative enhancement of the bone marrow, and a dural tail sign are observed. The lesion extends intracranially and appears to compress the underlying brain, but without intraparenchymal extension. On the inner table in the parietal area, the small enhancing nodule corresponds 45 to a vessel.

D/D : NEOPLASTIC NON NEOPLASTIC BONE METS LYPHOMA MULTIPLE MYELOMA OSTEOSARCOMA MENINGIOMA PAGET’S DISEASE HISTIOCYTOSIS 46

Case 3 47

A 40 yrs old female presentated with c/o mucopurulent discharge from ear & deafness on left side since 4 months 48

L SCLEROSIS OF MASTOID AIR CELLS 49

SOFT TISSUE MIDDLE EAR, EAC 50

EROSION OF LONG PROCESS MALLEUS 51

EXPANSION OF MASTOID BY SOFT TISSUE 52

EROSION OF LATERAL WALL OF LATERAL SCC WIDENING OF MASTOID 53

EROSION OF DURAL PLATE SOFT TISSUE IN MASTOID ANTRUM 54

POORLY CELLULAR SCLEROTIC MASTOID 55

Left middle ear cholesteatoma extending in mastoid antrum with partial ossicle erosion. 56

Cholesteatoma § Cholesteatoma is a sac of keratinizing squamous epithelium in the middle ear cleft (Skin growing in wrong place). § Acquired chronic inflammatory process of the middle ear cavity and the mastoid. § With superimposed infection and inflammation, the squamous material continues to grow, to form soft tissue mass. § With enlargement, it contacts contiguous bony structures of middle ear, mastoid air cells and petrous pyramid, causing bone erosion from pressure necrosis and enzymatic lysis 57

Classically cholesteatoma expands into § Antrum and mesotympanum, medial displacement of ossicles § Posterior into sinus tympani § Inferior into hypotympanum. § Posterolateral attic § Aditus into antrum and mastoid air cells. 58

Further … § Pneumocephalus, meningitis, and brain abscess. § Brain herniation into the middle ear and mastoid. § Secondary dural sinus thrombosis 59

Diagnosis CT - when the clinical diagnosis difficult, or to look at cholesteatoma in hidden areas and also to look at various anatomical variation just before surgery. 60

Radiological investigations: Conventional x-ray (Schuller’s view): § Sclerosis of mastoid air cells to suggest chronic otitis media § Dural plate (tegmen) or sinus plate erosion may be visualized § Non-visualization of external auditory meatus – cholesteatoma / discharge. 61

WELL PNEUMATIZED SCLEROTIC DURAL PLATE EROSION 62

How HRCT helpful § Decision and timing of surgery § Better advise patient on degree of hearing attainable after surgery § Extent and location of disease, hidden areas § Surgical approach § Potential surgical hazards § Complications § MEDICO-LEGAL VALUE 63

Reconstructed double-oblique coronal image shows the mallear head (MH), manubrium (MM), and neck (MN) and the tensor tympani (TT) tendon. 64

The hallmarks of the cholesteatoma are: § Presence of soft tissue density in middle ear cavity § Ossicular erosions § Smooth erosion of middle ear borders & adjacent structures § Especially when these are associated with bony expansion of middle ear cavity. 65

Can We Differentiate CSOM From Cholesteatoma Radiologically? § When the air cells appear cloudy but maintain their irregular trabecular pattern, or whenever there is obliteration of mastoid antrum and periantral cells by increased reactive bone formation, chronic mastoiditis without cholesteatoma is indicated. 66

The presence of an airfluid level or a soft tissue (fluid) mass in the dependen t part of middle ear – effusion 67

§ Antrum is enlarged with air fluid level – it suggests infected cholesteatoma § Complete opacification of the middle ear with no bony destruction makes radiological differentiation of cholesteatoma from middle ear effusion and granulation tissue difficult. 68

Cholesteatoma in a 26 -year-old woman with right-sided hearing loss. (a, b) CT scan (a) and corresponding 3 D CT reformatted image (b) show erosion of the right malleus and incus (arrow). The stapes (St) is intact and is better appreciated on the 3 D image. The left malleus and incus (arrowhead) are normal. 69

(c) Three-dimensional VR CT image shows pressure erosion of the head of the right malleus (Me) and the body of the incus (BIe), along with nearly complete erosion of the short process of the incus (SPe). Extension of the erosion into the incudomalleolar articulation (IMe) is also noted. (d) Three -dimensional VR CT image shows the normal left side for comparison. IM = incudomalleolar articulation, In = incus, M = malleus, SP = short process of the incus. 70

The role of MRI in the evaluation of middle-ear pathology. 71

The most important contributions of MRI to the study of acquired temporalbone cholesteatoma are the following: § Precisely define the borders of large lesions. § Depict the relationship of the lesion to intracranial structures. § Helps in evaluating intratemporal and extratemporal complications. § IN Follow-up of patients who have undergone middle-ear surgery for a cholesteatoma. § MRI is also indicated when the facial nerve is involved. MRI findings in cholesteatoma : T 1 -W : low signal intensity with no change after contrast administration T 2 -W : high signal intensity 72

Sagittal T 1 -weighted image after gadolinium administration shows partially enhancing mass in right temporal lobe. Coronal T 1 -weighted image after gadolinium administration shows partially enhancing mass in right temporal lobe, in 73 direct continuity with similar-appearing tissue in right middle ear (arrow).

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