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J. H. Bortz
nias causing small bowel obstruction [39]. Obstruction of the colon by abdominal wall her­nia is uncommon. Obstruction of small bowel is best diagnosed on multi-detector CT (MDCT) scans showing dilated bowel proximal to the her­nia and normal or reduced calibre or collapsed bowel distal to the obstruction [39].
• Strangulation may be caused by incarceration
when there is free uid within the hernia sac, bowel wall thickening is present or bowel is dilated. If the blood supply is compromised, then ischaemia or strangulation occurs. This happens when there is obstruction to the afferent and efferent loops by the hernia defect [39].
• Incarceration occurs when a hernia cannot be reduced or pushed back manually and diagnosis
18.8.5 Surgical Repair Procedures
may be suggested if a hernia occurs through a small defect and the hernial sac has a narrow neck. Incarceration may predispose to obstruc­tion, inammation or ischaemia. The latter occurs due to a compromised blood supply [39].
Surgical procedures for abdominal wall hernias repair vary from open repair to laparoscopic suture repair with or without the use of mesh. Figure18.7 g shows repair of an inguinal hernia.
a(i) a(ii)
b(i) b(ii)
Fig. 18.7 (a) (i) 2D supine axial view showing left femo- ral hernia containing loops of small bowel (Courtesy of Prof D Kim, Wisconsin University). E4 classication: high clinical importance. (ii) 2D coronal supine view showing a loop of small bowel in a left femoral hernia. Mild proximal dilation of small bowel is present indicat-
ing partial obstruction (Courtesy of Prof D Kim, Wisconsin University). E4 classication. (b) (i) 2D axial view showing the presence of small bowel hernias in both inguinal canals (yellow and red circles). (ii) 2D right supine sagittal view showing small bowel hernia (yellow circle).
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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b(iii) b(iv)
b(v) b(vi)
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c(i) c(ii)
Fig. 18.7
small bowel hernia (red circle). (iv) 2D right decubitus view showing left hernia (red square) and right hernia (yellow circle). (v) 2D supine coronal view showing bilat­eral small bowel hernias (yellow and red arrows). (c) (i)
(b)
(iii) 2D left supine sagittal view showing
2D supine axial view showing bowel in left inguinal her­nia (white hexagon) and fat in right inguinal hernia (red hexagon). (ii) 2D supine sagittal view showing bowel in the scrotum (red arrow) and small area of narrowing as it exits the inguinal canal (green arrow).
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d e(i)
e(ii) e(iii)
J. H. Bortz
Fig. 18.7
showing collapsed small bowel loops containing barium in a right direct inguinal hernia (red arrow). Left side shows a small direct inguinal hernia containing fat (red circle) with vessels displaced medially (white lines). (e) (i) Colon-map supine showing small bowel inguinal her­nia (white arrow) on the right. (ii) Supine colon-map of
(d) 2D axial scan of an abdominal CT study
large bowel with small bowel removed. (iii) Colon-map with small bowel removed showing herniation of sigmoid colon (S). R=rectum; DC=descending colon; TC=trans­verse colon; AC = ascending colon; C = caecum. Red arrows indicate direction of ow of CO sigmoid colon.
from rectum to
2
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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f(i) f(ii)
g
271
Fig. 18.7
bowel in right inguinal hernia (red hexagon). E4 classi­cation: high clinical importance. (ii) 2D axial supine view showing a right inguinal containing fat (red hexagon) and
(f) (i) 2D axial supine image showing small
The most commonly used method is ‘tension­free’ mesh repair and is regarded as the standard surgical technique for the majority of cases. Complications of surgical repair may involve up to 50% of cases. Hernia recurrence is the most common one irrespective whether mesh is used or not. Fluid collection after surgery may occur as well as infection [39].
18.9 Air inVagina
Vaginal air may be seen on 2D images; thus, it is important to carefully examine these images to exclude pathology causes as an ECF [45]. Table18.4 lists normal causes of air in the vagina. Figure18.8a (i, ii) shows no air in the vagina. Figure18.8a (iii) shows air between vulva folds. Figure18.8a (iv, v) shows air in the vagina due to yoga stretching.
a small left inguinal hernia containing fat (yellow hexa­gon). E3 = moderate clinical importance. (g) 2D axial supine view showing repair of right inguinal hernia (red hexagon). Red arrow=left inguinal hernia
Table 18.4 Normal causes of air in vagina
Sexual intercourse Insertion of objects into the vagina (e.g., pessaries or
speculum) Tampon insertion Exercise or stretching (e.g., stretching in yoga)
a
Adapted from Bortz [45]
a
It is important not to not mistake air between vulva folds as air in the vagina. If air is present it may be one or two bubbles that are rounded, hori­zontal, vertical, or curvilinear (Fig. 18.8b (i)– (v)). A cluster of bubbles may indicate an underlying infection or malignancy. Pathological conditions that show air in the vagina are pre­sented in Table18.5. Figure18.8c (i)–(iii) shows a rectovaginal stula at a CTC study.
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a(i) a(ii)
a(iii) a(iv)
a(v)
Fig. 18.8 (a) (i) 2D axial viewing showing normal vagina without air (open black arrows) and rectal catheter. (ii) Sagittal view showing no air in the vagina (V). Rectal catheter (C). Rectum (R). (iii) Axial supine view showing air between vulval folds. White circle= rectal catheter.
(iv) 2D axial view showing a large amount of air in the vagina (white arrow). R=rectum; circle=catheter. This air was caused by yoga exercises. (v) Sagittal view show­ing a large amount of air in the vagina (white arrow) post yoga exercises
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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b(i)
b(iii)
b(v)
b(ii)
b(iv)
Fig. 18.8
the vagina (open white arrow). Circle=rectal catheter. (ii) 2D axial view showing two small air bubbles in the vagina. Circle=rectal catheter. (iii) 2D axial view show­ing curvilinear air in vagina (open white arrow).
(b) (i) 2D Axial showing solitary air bubble in
Circle=rectal catheter. (iv) 2D axial showing a triangular shape air bubble air (open white arrow). Circle= rectal catheter. (v) 2D view showing air in the vagina (open white arrow)
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c(i) c(ii)
c(iii)
Fig. 18.8
(c) (i) Sagittal view showing air in the vagina (A). Rectovaginal stula = bottom white line. Rectum (R); Uterus (U). (ii) 2D prone axial demonstrates a stu­lous tract (open black arrow) between the rectum (C=rec-
Table 18.5
Inammatory bowel disease, especially Crohn’s disease inammatory bowel disease
Pelvic malignancies arising from the cervix or uterus; vaginal secondaries from breast cancer or melanoma
Radiotherapy to the pelvis Recto or colo-vaginal stula Pelvic oor dysfunction or prolapse following
childbirth, enterocoele, rectocoele, or vaginal prolapse
a
Das and Snyder [46]
b
Bortz [47]
c
Bortz [45]
d
Krissi etal. [48]
Air in the vagina due to pathology
a
. CTC is not performed on patients with
b
a
a
c
d
18.10 Comparison ofECFs
andClinical Outcomes at Screening andDiagnosticCTC
A recent comparative study was done to determine the distribution of ECFs and clinical outcomes in 388 patients who underwent screening and diag-
tal catheter) and the vagina (open white arrow).(iii) 2D close-up view showing the rectovaginal stula. Open black arrow=stulous tract; open white arrow=air in the vagina; C=rectal catheter
Table 18.6
Total ECFs
a
E classication Percentage of n=388 E1 and E2 88.4% (n=347) E3 4.4% (n=17) E4 7.2% (n=28)
a
Adapted from the text of Taya etal. [49]
nostic CTC studies [49]. The majority (262/68%) had screening CTC studies compared to the diag­nostic CTC cohort (126/32%). The majority (84.%) had E1 and E2 ECFs as shown in Table18.6. The distribution of ECFs distribution and clinical out­comes showed there was no statistically signicant difference between the screening and diagnostic CTC population (4.4%/4.0%) [49].
Key Messages
• Extracolonic ndings are an integral part of a CTC examination and must be reported on even if the examination is considered non-diagnostic.
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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• Although the number of ECFs are high, only a small percentage are of signicant clinical importance.
• A low-dose technique without intravenous contrast is used.
• The most common ndings include abdomi­nal aortic aneurysm, renal carcinoma, lymph­adenopathy, and ovarian tumours.
• Opportunistic screening for bone mineral den­sity should be included in a CTC study.
• When a hernia containing bowel is visualised, it is important to determine whether it is reducible or whether obstruction, incarceration, or strangulation has occurred and which bowel (large or small) is involved.
• A cluster of bubbles in a vagina may indicate an underlying infection or malignancy.
18.11 Summary
Detection of ECFs is an unavoidable responsibil­ity of the radiologist or radiographer who inter­prets the CTC images. Most ECFs are determined to be clinically inconsequential on CTC and most patients do not have further testing. A disclaimer should be in CTC reports, namely that the lack of intravenous contrast material and low-dose tech­nique limit the evaluation of CT ndings outside the colon. It is essential to report ECFs in poor quality non-diagnostic CTC studies to ensure that if the abnormalities are deemed to be clinically important this will result in further diagnostic studies or medical/surgical follow-up.
Acknowledgement Professor David Kim from Wisconsin University is thanked for providing examples of a femoral hernia.
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Metabolic-Associated Fatty Liver
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Disease: Opportunistic Screening at CT Colonography
JoelH.Bortz
19
19.1 Introduction
In this chapter, the novel term metabolic­associated fatty liver disease (MAFLD) previ­ously termed non-alcoholic fatty liver disease (NAFDL) [1, 2] is used. According to a group of experts, the term non-alcoholic fatty liver dis­ease (NAFLD) does not reect current knowl­edge associated with fatty liver disease in terms of associated metabolic dysfunction [3]. They suggest the use of metabolic-associated fatty liver disease (MAFLD) as an overarching term to cover specic metabolic conditions in terms of inclusion criteria compared to the exclusion criteria of NAFLD.This suggested term is sup­ported by many international patients because the term NAFLD is not acceptable in terms of their religious, cultural, and spiritual beliefs [4]. The use of alcoholic in the term to describe their clinical condition leads to them being stigma­tised; they therefore support the suggested use of MAFLD [4].
The global prevalence of metabolic-associated fatty liver disease (MAFLD) has increased by 25% [5, 6]. Such a prevalence could lead to a clinical and economic burden [7]. In radiology, opportunistic screening is the practice of maxi­mum use of imaging data, unrelated to the clini­cal indication, for risk proling and prevention of
J. H. Bortz (*) LSG Imaging, Los Angeles, CA, USA
relevant disease [8]. According to Pickhardt [8], opportunistic screening allows for early detection of, for example, liver fat content on unenhanced scan. AI-based CT tools or manual region of interest (ROI) assessment can be used in opportu­nistic screening of the liver [8]. It is therefore important that the liver should be carefully assessed during screening CTC as it allows visu­alisation of the colon as well as extracolonic structures [9, 10]. The examination includes visu­alisation of the liver as an extracolonic organ; un­enhanced images of the liver and spleen are obtained. A reader can compare these two organs’ respective CT attenuation values (Hounseld units/HU) [11]. This allows for differentiation and quantication of visceral and subcutaneous fat; liver fat (steatosis) can be accurately quanti­ed [12]. Moderate steatosis is when unenhanced liver attenuation under 40 HU corresponds to 15% proton fat fraction calculated from MRI [8]. In the absence of multiple blood transfusions, or amiodarone therapy, if the attenuation of unen­hanced liver exceeds 75HU then iron overload must be considered [8].
Steatosis used to be considered a self-limiting and relatively benign condition, but is now recog­nised as a typical feature of MAFLD (formerly NAFLD), which may lead to non-alcoholic ste­atohepatitis (NASH/MASH), and even cirrhosis [13, 14]. Figure 19.1a and b are examples of a normal liver and hepatic steatosis. MAFLD is an extracolonic nding (ECF) which needs to be
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. H. Bortz et al. (eds.), CT Colonography for Radiographers,
https://doi.org/10.1007/978-3-031-30866-6_19
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