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CURRENT PATHOLOGY IMAGING GUIDELINES

CONTENTS

A. Neck and thorax

B. Upper abdomen

Imaging resources

Problem management

1. Trauma
2. Painful syndrome with fever
3. Painful syndrome without fever
4. Anorexia, weight loss, nausea, emesis
5. Liver function tests disturbance
6. Upper digestive tract haemorrhage
7. Upper intestinal occlusion

C. Genitourinary system

D. Vascular system

E. Central nervous system

F. Spine

G. Extremities

H. Nuclear Medicine

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IMAGING RESOURCES

Abdominal plain film, supine

  • calcifications (vascular, biliary), foreign bodies, surgical clips
  • mass effect
  • extraluminal gas, intestinal distension
  • bone abnormalities

Abdominal plain film, upright or left lateral decubitus

  • sometimes useful (pneumoperitoneum, hydroaeric levels, calcification shift)

Barium meal

  • swallowing dysfunction, dysphagia, hiatal hernia, reflux, gastro-duodenal pain
  • anastomosis patency: use of water soluble contrast medium only when any risk of bronchoaspiration is excluded (chemical pneumonitis)
  • barium follow-through: less accurate than enteroclysis.

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Enteroclysis

  • malabsorption, intestinal adhesions, suspicion of Meckel diverticulum, of small bowel neoplasia, of ileitis

Barium enema

  • intrinsic colonic diseases, extrinsic compression (pancreatitis, tumoral mass, metastases), suspicion of fistula
  • double contrast: allows better mucous membranes surfaces depiction
  • contraindications: toxic megacolon, impending perforation, pseudomembranous colitis, recent endoscopic biopsy, pregnancy, poor intestinal preparation, recent barium meal, scheduled CT-scan for the few next days

Ultrasound

  • first step examination for solid organ diagnosis (liver, gallbladder, spleen, pancreas, kidneys) and vascular diseases, retroperitoneum, ascites, collection
  • Doppler: portal hypertension, Budd-Chiari, thromboses, aneurysm, artery stenosis
  • elastography: hardness liver test for fibrosis diagnosis
  • abdominal wall (eventration, umbilical hernia, abscess)
  • hollow organs: less accurate; ultrasound is often able to show parietal thickening or a mass attached to the digestive tract
  • guided puncture or drainage

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CT-scan

  • first choice work-up tool of neoplasia before treatment
  • obese patients with low diagnostic quality ultrasound
  • better than ultrasound for: retroperitoneum (included pancreas, kidneys and adrenals), digestif tract, mesentery, peritoneal surfaces
  • equivalent accuracy to US (complementary): liver and spleen
  • less accurate than US for: gallstones
  • angio-CT, CT colonoscopy (virtual endoscopy), CT-enterography
  • guided punctures or drainages

MRI

  • as a complement to CT: neoplasic local extension work-up, lesion detection and analysis in liver, kidneys, pancreas
  • preferred to CT-scan in: pregnant women, patients with iodine contrast media allergy, children
  • MR-cholangiopancreatography: biliary tract obstruction; as accurate for diagnosis than ERCP
  • MR-angiography, MR-colonoscopy, MR-enterography
  • MR elastography of the liver (fibrosis, cirrhosis)
  • iron and fat overload measurement

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PROBLEM MANAGEMENT

1. Trauma

  • Ultrasound: peritoneal effusion, liver / spleeen / kidney lesion
  • CT: polytrauma work-up, retroperitoneum and great vessels lesions, mesentery
  • Abdomen plain film: skeletal lesion, pneumoperitoneum, retroperitoneal air, masse effect, foreign body

2. Painful syndrome with fever

  • Ultrasound: cholecystitis, liver abscess, kidneys, ascitis, splenomegaly
  • CT complementary to US: deep abscesses, retroperitoneum, pyelonephritis, inflammation of or digestive tract perforation, perihepatitis, septic thrombosis, mesenteric infarct

3. Painful syndrome without fever

  • Ultrasound: gallstone, bile duct stone, liver, splenic, pancreatic lesion, aortic aneurysm
  • CT-scan: retroperitoneal lesion, pancreas, digestive tract, internal hernia, nephrolithiasis
  • Barium meal (enteroclysis): peptic or reflux disease, oeso-gastro-duodenal tumors, stenoses (pylorus, small bowel, adhesions), internal hernia of the small bowel
  • CT colonography (water, barium, or hydrosoluble contrast enema): tumor, diverticulitis, ischemia, irritable bowel syndrome
  • MRI: added to CT (retroperitoneum / kidney tumor extension)

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4. Anorexia, weight loss, nausea, emesis

  • Ultrasound: cirrhosis, portal hypertension, liver neoplasic invasion, biliary tract stone, pancreas, ascitis, pyloric stenosis (paediatrics), etc.
  • CT-scan: pancreas, retroperitoneum, liver, stomach, oesophagus, colon
  • Barium meal (enteroclysis): peptic or reflux disease, oesophagus or gastric tumor, stenoses (pylorus, small bowel, adhesions), enteropathy
  • CT-enterography or MR-enterography
  • MRI: if needed as complement after CT

5. Liver function tests disturbance

  • Ultrasound (+/- Elastography): fatty liver infiltration, fibrosis, cirrhosis, portal hypertension (Doppler), ascitis, biliary tract stone, acute hepatitis
  • CT-scan: complementary to ultrasound, pancreatic diseases
  • MRI: same as CT + MR cholangiography

6. Upper digestive tract haemorrhage

  • Gastroscopy (ulcers, tumors, varices)
  • CT-scan and/or ultrasound : portal hypertension, liver lesion, upper digestive tract tumor
  • Arteriography: active bleeding > 0,5 ml/min. Embolisation of a bleeding artery.
  • Barium meal: second look when hemorrage under control, and only if no angiography is to be done later

7. Proximal intestinal occlusion

  • CT-scan
  • Abdomen plain film supine and upright: intestinal dilatation, digestive gas in an abnormal location, pneumoperitoneum, air-liquid levels, mass effect, lung bases infiltration
  • Water soluble contrast study uf the upper digestive tract, enteroclysis
  • US: pylorus stenosis (infants), intussusception

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Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018

References:

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