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

Diverticulitis<br />

Diagnoses: Bowel<br />

TERMINOLOGY<br />

• Evidence of inflammation in thick-walled colonic segment<br />

centered around colonic diverticulosis<br />

IMAGING<br />

• Hypertrophy of muscularis propria with sac-like<br />

outpouchings represents underlying colonic diverticulosis<br />

• Diverticulitis<br />

○ US: Colonic diverticulosis with adjacent inflamed<br />

echogenic pericolic fat<br />

○ CECT: Significant fat str<strong>and</strong>ing centered around<br />

diverticula with background mural hypertrophy<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Colon cancer<br />

• Colitis<br />

• Acute appendicitis<br />

• Epiploic appendagitis <strong>and</strong> segmental omental infarction<br />

KEY FACTS<br />

PATHOLOGY<br />

• Due to localized microperforation of inflamed colonic<br />

diverticulum secondary to impacted fecalith<br />

CLINICAL ISSUES<br />

• Clinical presentation<br />

○ Acute lower abdominal pain, localization dependent on<br />

site of inflammation<br />

○ Fever, diarrhea, <strong>and</strong> rectal bleeding<br />

• Majority settle with conservative management<br />

• Complications: Abscess, fistula, stricture, obstruction,<br />

perforation with purulent or fecal peritonitis<br />

DIAGNOSTIC CHECKLIST<br />

• Consider diverticulitis in differential diagnosis of acute<br />

abdomen presenting with lower abdominal pain<br />

• Typical US <strong>and</strong> CECT diagnostic of diverticulitis<br />

• Look for complications, <strong>and</strong> beware of mimics, e.g., colon<br />

carcinoma<br />

(Left) Diverticulosis can be<br />

identified by thickened colon<br />

with a pronounced hypoechoic<br />

muscularis propria layer <br />

containing diverticulum; note<br />

focal outpouching containing<br />

gas . Note the linear<br />

echogenic foci with posterior<br />

reverberation artifact . No<br />

surrounding acute<br />

inflammation can be seen.<br />

(Right) Acute diverticulitis can<br />

be identified by hypoechoic<br />

outpouching arising from<br />

the adjacent colon with<br />

surrounding inflamed<br />

echogenic fat . Patient had<br />

localized peritonism.<br />

(Left) Hypertrophied<br />

muscularis propria of<br />

colonic wall shows acute<br />

sigmoid diverticulitis. Linear<br />

arc-like echo projects<br />

beyond colonic wall, showing<br />

gas. Note surrounding<br />

echogenic fat . (Right)<br />

Acute sigmoid diverticulitis is<br />

shown by thick-walled sigmoid<br />

colon containing multiple<br />

diverticula with surrounding<br />

fat str<strong>and</strong>ing <strong>and</strong> hyperemia<br />

. Note the adjacent reactive<br />

thickening of the parietal<br />

peritoneum . The mobile<br />

position of sigmoid colon<br />

mimics clinical presentation of<br />

acute appendicitis.<br />

664

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