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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_770_Библиотеки_им_академика_М_И_Перельмана
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J. H. Bortz
c
e
g
d
f
h
Fig. 18.3
(d) Angiomyolipoma (open white arrow) showing a ‘rateaten appearance’ due to invasion by fatty tissue, vascular
and muscle tissue. Cyst left kidney (open black arrow).
GB=gallbladder; P=pancreas; S=spleen; A=aorta. (e)
Polycystic kidneys (open white arrows) with rim calcication (1) in right kidney (RK). LK = left kidney. (f)
(c) Lobular liver (1) due to cirrhosis. A=aorta.
Hydronephrotic change right kidney (1); A = aorta;
LK= left kidney. (g) Calculus in ureteropelvic junction
(UPJ) of right kidney (open white arrow). LK=left kidney. Mild hydronephrosis. (h) 2D axial view shows a dermoid cyst of the right ovary (open black arrow) containing
fat and soft tissue.
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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i(i)
i(iii)
k
i(ii)
j
l
Fig. 18.3
incarcerated hiatus hernia containing part of stomach. (iii)
Large hiatus hernia. (j) Density inguinal canal (open
white arrows) due to testis. (k) 2D axial showing entero-
(i) (i) Incarcerated hiatus hernia. (ii) Large
18.5.4 E4: High Clinical Importance
Figure 18.4a (i)–i (ii) are examples of ECFs of
high clinical importance.
Potentially important (E4) ECFs of asymptomatic patients (n=7952) who underwent rst
time screening CTC for CRC from 1 April 2004
to 30 June 2012 were analysed in a retrospective
coele (open white arrow) post hysterectomy. Rectum displaced to the left. Rectal catheter (circle). (l) Femoral
hernia (open black arrows). Rectal catheter (open white
arrow); 1=bladder; 2=pectineus muscle
study [23]. The results were that only 2.5% of
patients had a signicant ECF (E4). Almost 70%
of these ndings proved to be clinically signicant and required treatment or surveillance:
malignancies and aneurysms, for example [23].
Table 18.2 is a summary of the ndings of the
study.
a(i)
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J. H. Bortz
a(ii)
b
c(i) c(ii)
Fig. 18.4 (a) (i) 2D axial view showing pancreatic mass
1 = with calcication of part of the wall (open white
arrow). 2= right lobe of liver; 3= inferior vena cava;
4= right kidney; 5 = abdominal aorta; 6 =left kidney;
7=spleen; 8=quadratus lumborum muscle. (ii) 2D sagittal view showing large pancreatic cyst 1 = with wall
calcication (closed white arrow). 2 = spleen; 3 = left
kidney; 4=psoas muscle; 5=quadratus lumborum mus-
cle; 6=anterior abdominal wall muscles. (b) Open white
arrow = abdominal aortic aneurysm (AAA) measuring
35mm (3.5cm). Note partial calcication (closed black
arrow). (c) (i) AAA (open white arrow) measuring 53mm
(5.3cm) with partial calcication (closed black arrows).
(ii) Sagittal view of the AAA (open white arrows) show-
ing partial calcication (closed black arrows).
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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d
ef
261
g(i) g(ii)
Fig. 18.4
arrows) measuring 54.4mm (5.44cm) with slight calcication (open green arrows). (e) 2D axial view showing
pressure effect on rectus abdominis muscle (1). Dilated
small bowel (2) trapped in a direct inguinal hernia causing
obstruction. Green arrow = transition point. Granules
from ingested tablets (3). (f) Loop of bowel in scrotum
(d) Left iliac artery aneurysm (open white
(open white arrow). Rectal catheter (open green arrow).
1= corpus cavernosum; 2=obturator externus; 3=gluteus maximus. (g) (i) No pathology evident on 2D axial
supine view. (ii) 2D axial prone view of same patient
showing a non-calcied lesion in left lung (open white
arrow). This is due to greater coverage of the lung elds in
the prone position.
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h(i) h(ii)
h(iii) h(iv)
J. H. Bortz
i(i) i(ii)
Fig. 18.4
right inguinal region and left kidney area. He declined an
optical colonoscopy and chose to undergo a screening
CTC study. 2D coronal view shows multiple cysts (1 and
2) in polycystic kidneys. RK=right kidney. LK=left kidney. (ii) 2D coronal view shows bilateral polycystic kidneys. RK = right kidney; LK = left kidney with a
haemorrhagic cyst (open white arrow). Note the normal
transplanted kidney in the right pelvic area. (iii) 2D axial
view shows the haemorrhagic cyst (open white arrows).
RK=right kidney. LK=left kidney. (iv) 2D sagittal view
(h) (i) This patient presented with pain in his
shows the haemorrhagic cyst (open white arrows) in the
left kidney (LK). (i) (i) 2D axial view of liver showing
shrunken and lobulated right lobe of liver (open white
arrows). The lobulated appearance of the liver margin is
secondary to infarction of the liver following selective
catheterisation of the hepatic artery with chemotherapeutic agents for hepatocellular carcinoma. (ii) 2D axial view
shows a markedly enlarged spleen (splenomegaly) due to
portal hypertension with associated splenic varicosities
(open white arrows). RK=right kidney
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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a
Table 18.2
System and organ
Vascular system (e.g., abdominal aortic
aneurysms, iliac aneurysms)
Genitourinary system 18%
Liver 15%
Gastrointestinal system 10%
Lungs 9%
Gynaecologic system 7%
Pancreas, adrenal glands, and breast 4%
Others (e.g. lymphoma, sarcoidosis,
early acute appendicitis)
a
Adapted from the text of Pooler etal. [23]
Main organs and systems in the E4 ndings
Percentage of
n=7952
26%
11%
Table 18.3
BMD HU
Normal >160
Osteopenia >100 to <160
Osteoporosis <100
sex [31]. A trabecular bone score (TBS) is a tool
which adds to predicting risk of fracture in persons who are in the osteopenia or normal range
[32, 33]. Furthermore, this tool may be used to
adjust FRAX (fracture risk assessment tool) probabilities of fracture [33]. Literature reports that
novel application of articial intelligence (AI)
HU range of BMD
and machine learning (ML) may be useful for
18.6 Bone Mineral Density
Assessment
diagnosis of osteoporosis [34]. Chapter 25 presents a discussion of AI and ML in imaging.
Concurrent screening for osteoporosis and
Usually opportunistic has negative connotations
[24] (e.g., unprincipled, exploitation). In 1995,
opportunistic screening was described as offering a
test for an unsuspected pathology which is not
related to the reason for the examination [25]. In
radiology, opportunistic screening, according to
Pickhardt [24], is the practice of maximum use of
imaging data, unrelated to the clinical indication,
for risk proling and prevention of relevant disease.
According to Boutin and Lenchik [26], the use of
opportunistic screening for osteoporosis and sarcopenia at CT is a value-added benet for patients.
Opportunistic screening at screening CTC benets
men and women if an early diagnosis of osteoporosis is made [26–28]. Men and women who present
for screening CTC would benet if an early diagnosis of osteoporosis is made. Osteoporosis is a
silent disease and pathological fractures impact on
health services and the mortality of the elderly [29].
Literature reports that testing and treatment rates in
men are low despite them having high prevalence
of osteoporosis, osteopenia, and fractures; morbidity and mortality are signicant in men with osteoporotic hip fractures [30].
Dual-energy X-ray absorptiometry (DXA or
DEXA) is the most used modality to determine
BMD.Two scores (i.e., T-score and Z-score) are
usually presented. Both are used for women and
men. A T-score indicates a comparison of the
BMD of healthy 30year old: −1.0=normal, −1.0
to −2.5=osteopenia, and ≥−2.5=osteoporosis;
and a Z-score compares amount of bone present
with that of others in the same age group, size and
CRC at CTC adds to service delivery to patients.
By using the region of interest (ROI) to measure
trabecular bone mineral density (BMD) of L1 of
2D CT scans does not increase radiation dose to
a patient [24, 28]; if there is a compressed
fracture of LI the Hounseld unit (HU) of L2 is
measured. It is recommended that the HU measurements are included in CTC reports (see
Table 21.2 in Chap. 21).
The use of ROI to measure BMD provides
information to identify fracture risk of patients
who undergo screening CTC for CRC [35]. This
means that more patients can be assessed for
osteoporosis. This is important as there has been
underutilisation of preventive osteoporosis strategies [30]. CTC is a cost-effective study for
screening of CRC [36]; hence, there are no additional costs in opportunistic screening. Table18.3
shows Hounseld unit (HU) range for BMD.
The ROI must only include the trabecular bone
of a vertebra to obtain an accurate HU reading.
Figure18.5a (i, ii) shows incorrect ROI placement.
It is important that ROI placement is correct to
obtain the HU values of trabecular bone. Correct
ROI placement is illustrated in Fig.18.5b (i, ii).
Figure18.5c (i) shows osteoporosis at CTC on a
female patient and Fig.18.5c (ii) shows osteoporosis in a male patient. As evident in Fig.18.5d, the
HU value is <100 indicating osteoporosis.
Figure 18.5e shows a grade 3 fracture of lumbar vertebra. There is ≥40% loss of vertebral
height according to the Genant classication
which is based on vertebral shape, and loss of ver-
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J. H. Bortz
tebral height involving anterior, posterior, and/or
middle vertebral body. Grade 0 =normal; grade
1=mild fracture (20–25%) loss of height; grade
2 = moderate fracture (25–40% loss of height),
and grade 3 = severe fracture (>40% loss of
height). Figure18.5f (i, ii) illustrates osteopenia,
namely a HU reading of >100 to <160. Osteopenia
can be a risk fracture in males and females.
a(i) a(ii)
b(i) b(ii)
Fig. 18.5 (a) (i) Incorrect ROI placement on coronal 2D
image at CTC as it extends beyond trabecular bone. (ii)
Incorrect ROI placement on sagittal 2D image at CTC as
it extends beyond trabecular bone. (b) (i) Correct ROI
placement to measure BMD of lumbar vertebra at
CTC.There is a vertebral venous plexus in the posterior
portion of the vertebral body. To ensure correct placement
the ROI should not touch cancellous bone. Red arrow
c(i) c(ii)
shows average HU reading of 203. (ii) Correct ROI placement to measure BMD of L1 on sagittal 2D scan at
CTC.Red arrow shows average HU reading of 210. (c) (i)
HU -5 (red arrow) showing osteoporosis at CTC in a
female patient. (ii) HU 49 (red arrow) showing osteoporosis in a male patient with a history of respiratory pathology and prolonged corticosteroid treatment.
de
18 Extracolonic Findings, Their Clinical Signicance, andtheRole ofOpportunistic Screening
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f(i) f(ii)
265
Fig. 18.5
on sagittal 2D scan at CTC showing osteoporosis. (e) 2D
sagittal view of male patient in Fig. 18.5c (ii) showing
grade 3 fracture of L1 (red arrow). (f) (i) 2D coronal view
(d) Average HU reading 58 (red arrow) of L1
18.7 Calcic Score: Abdominal
Aortic Calcication
A recent prospective study over 14years of bone
mineral density screening and monitoring of elderly
women focussed on abdominal aortic calcication
(AAC) on lateral spine DXA scans [37]. The study
measured the amount of calcium present in the wall
of the aorta and scored the amount of calcium present as: low, moderate, and extensive. The ndings
were that those patients with moderate and extensive calcication had a higher incidence of demen-
at CTC showing osteopenia in a male patient. HU 135 (red
arrow) of L1. (ii) Sagittal view showing osteopenia in a
female patient. HU 140 (red arrow)
tia and hospitalisation compared to those with a low
score [37]. This shows that extra-coronary vascular
calcication in patients may be a marker for late-life
dementia. The study only included lateral spine
DXA scans. In terms of ECFs, the abdominal aorta
is one of the sites where calcication is seen at
CTC: AAC is common in both men and women.
Late-life dementia (>80years of age) may be related
to vascular or nonvascular causes and is a major
global health issue. Figure18.6a–d shows normal
abdominal aorta and abdominal aortic calcication
at CTC.
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Fig. 18.6 (a) Sagittal view showing normal abdominal
aorta (black arrows). (b) Sagittal view showing mild calcication in the abdominal aorta (black arrows). (c)
Sagittal view showing moderate calcication in the
abdominal aorta (black arrows). (d) Sagittal view showing
extensive calcication in the abdominal aorta (black
arrows)
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18.8 Inguinal Hernias
asExtracolonic Findings:
AnOverview, Types ofHernia,
Complications, andRepair
Inguinal hernias are commonly present in males
and rare in females. They often remain undiagnosed
as many patients do not complain of symptoms or
swelling in the groin region. Hernias at CTC are
reported as ECFs. Abdominal herniation may be
dened as the protrusion of part of its content from
the abdominal cavity through a normal or abnormal
aperture or from wall weakness [38]. Hernias may
be reducible (i.e., can be safely pushed back into the
abdominal cavity) or irreducible. The latter may
then result in vascular compromise and possible
ischaemia and ultimately gangrene [39]. A hernia
may cause obstruction resulting in failure of intestinal content to pass through the obstructed area [39].
18.8.1 Types ofHernias
Hernias may be congenital or acquired. A congenital malformation occurs in new-borns whilst in
adults a hernia is due to stress on the abdominal
wall, or a weakness in the elderly [40]. Indirect
inguinal hernias are the most common and protrude through the patent internal (deep) inguinal
ring lateral to the inferior epigastric vessels. In
men, the hernia may extend together with the spermatic cord into the scrotum. In women, the hernia
may follow the course of the round ligament into
the labia majora [41]. The peritoneal sac containing
bowel loops may protrude through the inguinal
canal and emerge at the external inguinal ring.
Direct inguinal hernias behave differently: they
extend through an acquired weakness in the posterior wall of the canal, known as the Hesselbach triangle, and pass medially to the inferior epigastric
vessels. A femoral hernia on the other hand passes
through the femoral canal, which is medial to the
femoral vein and below the inguinal canal and lateral to the pelvic tubercle. Women have a wider
bony pelvis compared to men thus femoral hernias
are more common in women. Figure18.7a (i, ii)
shows a femoral hernia in a female. Figure18.7b
(i)–(vi) depicts small bowel bilateral inguinal hernia (E4 classication). Figure18.7c (i, ii) shows a
large bowel inguinal hernia (E4 classication).
18.8.2 Tips toDetermine Whether
Small or Large Bowel Is
Trapped inanInguinal Hernia
• If valvulae conniventes are seen within the
trapped bowel, the diagnosis is small bowel as
shown in Fig.18.7d. If haustral markings are
observed, then it is large bowel.
• The most accurate way of deciding whether it
is small or large bowel is by looking at the
colon-map, initially with small bowel included
and then removing the small bowel which is
usually an automatic process.
• If the contour of the large bowel remains intact,
then no large bowel has herniated and the content is small bowel as shown in Fig.18.7e (i, ii).
• When large bowel herniates, it is usually sig-
moid colon. A colon-map will show displacement of sigmoid colon inferiorly, making it a
left-sided hernia entering the scrotum in the
male (Fig.18.7e (iii)) and possibly in the labia
of the female.
• Colon hernias are usually left-sided.
18.8.3 Frequency ofInguinal Hernias
Inguinal hernias are 20 times more common in
men than women [42, 43]. Dabbas et al. [44]
underscore that inguinal hernia repair was carried
out almost 15 times more in men than women.
They state that there has been a reduction in inguinal hernias over time accompanied by an increase
in the proportion of midline abdominal wall hernia repairs. Inguinal hernias are a more common
cause of groin pain, and their repair is the commonest one for hernias. Dabbas etal. [44] report
that 96.8% of repair cases were in men and 3.2%
in women. Figure 18.7f (i) is an ECF of small
bowel in a right inguinal hernia and Fig.18.7f (ii)
is an ECF of bilateral inguinal hernias.
18.8.4 Complications
Complications of abdominal wall hernias include
obstruction, incarceration and strangulation, and
clinically include abdominal pain, vomiting, and
distension. Adhesions are the leading cause of
bowel obstruction, followed by abdominal her-
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