Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Epiploic Appendagitis (Left) Grayscale ultrasound shows a well-defined echogenic mass with a hypoechoic rim of visceral peritoneal thickening ſt and central ill-defined hypoechoic foci. Note the normal hypoechoic layers representing the muscularis propria of the sigmoid colon . (Right) Color Doppler ultrasound shows the mass to be avascular. Diagnoses: Bowel (Left) Axial CECT in the same patient demonstrates the typical radiological appearances of epiploic appendagitis (EA) with surrounding fat stranding . Note the normal adjacent sigmoid colon. (Right) Corresponding coronal MPR showing the EA and its intimate relationship to the normal adjacent sigmoid colon ſt. (Left) Axial CECT in a patient with suspected diverticulitis shows a focal fat-containing lesion with peripheral hyperattenuation (hyperattenuating ring sign) and central linear hyperdensity (equivalent to the central dot sign when seen en face). Note the adjacent fat stranding. (Right) Follow-up axial CECT in the same patient performed at 8-month interval demonstrates improvement but persistent radiological features . This case illustrates the slow resolution of EA radiological signs. 663

Diverticulitis Diagnoses: Bowel TERMINOLOGY • Evidence of inflammation in thick-walled colonic segment centered around colonic diverticulosis IMAGING • Hypertrophy of muscularis propria with sac-like outpouchings represents underlying colonic diverticulosis • Diverticulitis ○ US: Colonic diverticulosis with adjacent inflamed echogenic pericolic fat ○ CECT: Significant fat stranding centered around diverticula with background mural hypertrophy TOP DIFFERENTIAL DIAGNOSES • Colon cancer • Colitis • Acute appendicitis • Epiploic appendagitis and segmental omental infarction KEY FACTS PATHOLOGY • Due to localized microperforation of inflamed colonic diverticulum secondary to impacted fecalith CLINICAL ISSUES • Clinical presentation ○ Acute lower abdominal pain, localization dependent on site of inflammation ○ Fever, diarrhea, and rectal bleeding • Majority settle with conservative management • Complications: Abscess, fistula, stricture, obstruction, perforation with purulent or fecal peritonitis DIAGNOSTIC CHECKLIST • Consider diverticulitis in differential diagnosis of acute abdomen presenting with lower abdominal pain • Typical US and CECT diagnostic of diverticulitis • Look for complications, and beware of mimics, e.g., colon carcinoma (Left) Diverticulosis can be identified by thickened colon with a pronounced hypoechoic muscularis propria layer containing diverticulum; note focal outpouching containing gas . Note the linear echogenic foci with posterior reverberation artifact . No surrounding acute inflammation can be seen. (Right) Acute diverticulitis can be identified by hypoechoic outpouching arising from the adjacent colon with surrounding inflamed echogenic fat . Patient had localized peritonism. (Left) Hypertrophied muscularis propria of colonic wall shows acute sigmoid diverticulitis. Linear arc-like echo projects beyond colonic wall, showing gas. Note surrounding echogenic fat . (Right) Acute sigmoid diverticulitis is shown by thick-walled sigmoid colon containing multiple diverticula with surrounding fat stranding and hyperemia . Note the adjacent reactive thickening of the parietal peritoneum . The mobile position of sigmoid colon mimics clinical presentation of acute appendicitis. 664

Epiploic Appendagitis<br />

(Left) Grayscale ultrasound<br />

shows a well-defined<br />

echogenic mass with a<br />

hypoechoic rim of visceral<br />

peritoneal thickening ſt <strong>and</strong><br />

central ill-defined hypoechoic<br />

foci. Note the normal<br />

hypoechoic layers<br />

representing the muscularis<br />

propria of the sigmoid colon<br />

. (Right) Color Doppler<br />

ultrasound shows the mass to<br />

be avascular.<br />

Diagnoses: Bowel<br />

(Left) Axial CECT in the same<br />

patient demonstrates the<br />

typical radiological<br />

appearances of epiploic<br />

appendagitis (EA) with<br />

surrounding fat str<strong>and</strong>ing .<br />

Note the normal adjacent<br />

sigmoid colon. (Right)<br />

Corresponding coronal MPR<br />

showing the EA <strong>and</strong> its<br />

intimate relationship to the<br />

normal adjacent sigmoid colon<br />

ſt.<br />

(Left) Axial CECT in a patient<br />

with suspected diverticulitis<br />

shows a focal fat-containing<br />

lesion with peripheral<br />

hyperattenuation<br />

(hyperattenuating ring sign)<br />

<strong>and</strong> central linear<br />

hyperdensity (equivalent to<br />

the central dot sign when seen<br />

en face). Note the adjacent fat<br />

str<strong>and</strong>ing. (Right) Follow-up<br />

axial CECT in the same patient<br />

performed at 8-month interval<br />

demonstrates improvement<br />

but persistent radiological<br />

features . This case<br />

illustrates the slow resolution<br />

of EA radiological signs.<br />

663

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