Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 386 - файл
.pdf
374
h(i)
h(ii)
h(iii)
https://t.me/medicina_free
J. H. Bortz et al.
Question 8
The images are of the valves of Houston in the rectum. 3D view (Fig.28.2h(i)) shows a polypoidal
swelling on the valve of Houston fold (black circle). TD (Fig.28.2h(ii)) conrms that it is a polyp
(arrows). 2D sagittal view (Fig.28.2h(iii)) shows a soft tissue polyp (red arrow) on the inferior valve
of Houston.
Comment
Histology was that of a tubular adenoma. Colour attenuation values of TD are discussed in
10.5in Chap. 10. The anatomy of the valves of Houston is described in Chap. 11 (see 11.3.1 and
Fig. 11.2(i, ii)).
Question 9
The appearance on Fig.28.2i(i) is that of 8mm sessile polyp on the 3D view (black circle). However,
a small stalk (red arrows) is noted on Fig.28.2(ii) depicting a pedunculated polyp.
i(i)
i(ii)
Comment
It is important to carefully look at the features of polyps on 2D views and to check for a stalk,
if visualised. How to measure sessile and pedunculated polyps is described in Chap. 10.
28 Self-Assessment ofCT Colonography Images
https://t.me/medicina_free
375
Question 10
Colon-map (Fig. 28.2j) simulating a doublecontrast barium enema image shows markedly
redundant sigmoid colon (SC) and transverse
colon (TC), which dips into the pelvic region.
AC=ascending colon. DC=descending colon.
R=rectum.
j
Question 11
As shown on Fig. 28.2k, there are secondary
deposits in the liver (black circles). Gallbladder
(GB) appears normal. The tail of the pancreas
(green arrow) dips vertically towards the renal
bed, and the spleen is in a horizontal position.
Red arrows=calcication of wall of the aorta in
keeping with atherosclerosis. E4. Patient had a
left nephrectomy; hence, the position of the
spleen and tail of the pancreas. Patient probably
had cancer of the kidney in view of secondary
deposits in the liver.
k
Comment
It is easy to understand how an optical
colonoscopy may be unsuccessful in a
patient with this bowel conguration.
Redundancy is discussed in Chap. 20, and
the average colon length is presented in
11.3in Chap. 11.
376
https://t.me/medicina_free
Comment
J. H. Bortz et al.
Note the position of pancreas and spleen in Fig.28.2l(i, ii). Most spleens are in the left upper
quadrant. The position of the spleen usually shifts in a patient who has had a left nephrectomy. It
shifts to the area of the left renal bed where the kidney used to be positioned. Its orientation also
changes, and it tends to lie in a horizontal position as evident in Fig.28.2k. The position of the
pancreas also changes in these patients. Its body and tail tend to dip vertically towards the renal
bed as evident in Fig.28.2k. The splenic artery and vein accompany the pancreas in this move.
l(ii)
l(i)
Question 12
As shown on Fig.28.2m, there is a right transplanted kidney containing calcication (red arrow) and
a left transplanted kidney (green arrow). E2 classication.
m
Comment
Both kidneys were not functioning (failed
transplants). The patient had a successful
third transplant as shown in Fig.28.2n.
n
28 Self-Assessment ofCT Colonography Images
https://t.me/medicina_free
377
Question 13
Typical kidney appearance in each renal fossa is not seen in Fig.28.2o. The two kidneys have fused
anteriorly (red arrow). Green arrow = IVC. Red circle = aorta. Orange arrows = psoas muscle.
Horseshoe kidney (aka renal fusion). E 2.
o
Comment
During foetal development the kidneys rise from the pelvic region and move into their normal
position. However, if they become attached during this process they become ‘fused’ and take on
a shape resembling a horseshoe. Figure28.2p is of a different patient. The shape on each side
resembles a kidney joined by a bar of tissue anterior to aorta (green arrow). Yellow
arrow=IVC.Red arrow=L kidney. Purple arrow=R kidney.
p
378
https://t.me/medicina_free
J. H. Bortz et al.
Question 14
On the 2D axial view (Fig.28.2q(i)), the rectum is displaced to the left. There is unopacied small
bowel (yellow arrows) to the right of the rectum extending to the tip of the sacrum. This is in keeping
with an enterocele. The 2D prone axial (Fig.28.2q(ii) shows the rectum in a more central position.
Reduction of enterocele (yellow arrow) anteriorly. There is a streak artefact from a pin in R femoral
neck. The 2D sagittal prone view (Fig.28.2q(iii)) shows rectum in normal position with the small
bowel now reduced and lying anteriorly (yellow arrow) to the rectum. E2 classication.
q(i)
Comment
q(ii)
q(iii)
Streak artefacts are discussed in 12.2.9in Chap. 12. An enterocele is uncommon in males. It is
a prolapse of small bowel which descends into the lower part of the pelvic cavity and displaces
the rectum usually to the left. In a sagittal view, loops of small bowel may be seen between the
rectum and the sacrum. It is caused by weakness of the muscles and ligaments of the pelvic
oor. It may occur after pregnancy and childbirth and is more common in women who have had
a previous hysterectomy.
Question 15
White circle in Fig.28.2r indicates umbilical hernia not containing colon. E2.
r
Comment
An umbilical hernia may be congenital or
acquired. Causes of the hernia in adults
include obesity, lifting or moving heavy
objects, and a persistent heavy cough.
28 Self-Assessment ofCT Colonography Images
https://t.me/medicina_free
379
Question 16
Supine axial 2D view of sigmoid colon (Fig.28.2s(i)) showing marked thickening of the wall of the
colon (red arrow). Compare it to the image more posteriorly containing a blue arrow which shows
how thin the wall is in normal bowel. Narrowing of the lumen is also present. Green arrow=air in
stool. The left lateral decubitus view (Fig.28.2s(ii)) shows bowel wall thickening as well as narrowing
in keeping with a stricture (green circle).
s(i)
Comment
s(ii)
Diverticular disease is presented in detail in Chap. 16. The value of a right lateral decubitus to
resolve image interpretation issues is highlighted. In this case, the right lateral decubitus
(Fig.28.2s(iii)) conrms the stricture in the sigmoid colon (red arrow).
s(iii)
380
https://t.me/medicina_free
J. H. Bortz et al.
Question 17
Figure 28.2t shows a normal left adrenal gland (red circle). It has a lambda shape and two limbs.
A=aorta. E1.
t
Comment
Knowledge of the structures in the perinephric space is important. Always check the appearance
of each adrenal gland for possible pathologies. Figure28.2u(i) shows the normal position of the
adrenal glands situated on top of each kidney. RK=right kidney. Black arrow=right adrenal.
LK=left kidney. Red arrow=left adrenal. A=aorta. Figure28.2u(ii) is an enhanced scan demonstrating the right adrenal. It is an inverted y-shape with two limbs (red arrow). A=aorta.
u(i)
u(ii)
28 Self-Assessment ofCT Colonography Images
https://t.me/medicina_free
Question 18
Patent ileocaecal valve (black arrow) visualised on Fig.28.2v.
v
Comment
An open (patent) ICV may result in reux of carbon dioxide. The 2D coronal view (Fig.28.2w(i))
shows the terminal ileum (TI), caecum (C), and open ICV (red arrow), descending colon (DC),
and Fig.28.2w(ii) is a 2D supine axial view showing patent ICV (green circle). Examples of
reux are presented in Chap. 10: Fig. 10.2f; Fig. 10.2g(i, ii). The position of an ICV is constant
relative to the terminal ileum and caecum (see Fig. 11.9b and Fig. 11.9c(ii, iii). Its various
appearances are presented in 11.3.8in Chap. 11.
381
w(i)
w(ii)
382
https://t.me/medicina_free
J. H. Bortz et al.
Question 19
Figure 28.2x shows bilateral inguinal hernias
(red arrows). Neither contain small or large
bowel. E2.
x
Comment
The different types of abdominal hernias as
well as complications are presented 18.8in
Chap. 18.
Question 20
Figure 28.2y shows the liver density is much
darker compared to that of the spleen. This indicates fatty liver. E3.
y
Comment
It is important when you see that the liver
density is darker than that of the spleen to
ask the patient about their alcohol consumption. As discussed in Chap. 19, there
has been a 25% increase in the global prevalence of metabolic-associated fatty liver
disease/non-alcoholic fatty liver disease.
Until recently, fatty liver was considered a
common nding with potential risks. It is
now considered to be of clinical importance hence opportunistic screening should
be routinely performed at CTC by comparing the respective CT attenuation values
(Hounseld units/HU) of the liver and
spleen.
As stated in Chap. 21, a CTC report
must include metabolic-associated fatty
liver disease, if applicable, and the HU
value. Normal HU of liver is 60HU.Do not
call fatty inltration of the liver until the
HU is between 45 and 50 HU. This will
equate on MRI to approximately 15% fatty
inltration. If increased >75HU, think of
iron overload.
28 Self-Assessment ofCT Colonography Images
https://t.me/medicina_free
383
Question 21
Figure 28.2z shows spondylolisthesis of L4 on L5 (red circle). A possible defect through the pars
interarticularis is not demonstrated at this particular level. Slight disc space narrowing is present
between L4 and L5, and there is a calcied intervertebral disc between L5 and S1. E2.
z
Comment
Types of spondylolisthesis include: congenital spondylolisthesis; isthmic spondylolisthesis due to spondylolysis; and
degenerative spondylolisthesis. The latter
is the most common type. There are two
grades of spondylolisthesis: low grade
(Grade 1 and 11) is usually cases of the
degenerative type; and high grade (Grade
111 and IV) may require surgery.
Figure28.2z is Grade 1.
Question 22
Figure 28.2aA(i) is a lateral 2D image showing fairly extensive abdominal aortic calcication (red
arrows) without aneurysm formation. Extensive disc degenerative disease is seen in the lumbar spine
(green arrows). Figure28.2aA(ii) is a coronal view of another patient showing extensive calcication
of abdominal aorta (red oval) and proximal iliac arteries as well as residual barium or omnipaque in
the colon. Both are E2 classication.
aA(i)
aA(ii)
Comment
Aortic abdominal calcication as an ECF is discussed in 18.7 of Chap. 18.
Соседние файлы в папке @xirurgi_2025