Differential diagnosis

The nomenclature becomes somewhat confusing due to discrepancies between the technically correct terms and the more commonly used terms. For example, strictly speaking, the term duplex Doppler refers to an examination consisting of two levels (gray-scale and color Doppler US). However, the term is commonly used by referring physicians when ordering an examination with spectral Doppler, which technically would be more accurately termed triplex Doppler. To avoid confusion, it is probably better to use terms that describe the examination more precisely. Such terms include gray-scale, color Doppler, and spectral Doppler.

simple cysts simple hepatic cyst biliary hamartoma Caroli disease adult polycystic liver disease ciliated hepatic foregut duplication cyst 6 infectious: inflammatory conditions hepatic abscess pyogenic hepatic abscess amoebic hepatic abscess hepatic hydatid cyst neoplastic: tumors biliary cystadenoma biliary cystadenocarcinoma cystic hepatic metastases cystic cavernous hemangioma hepatic lymphangioma necrotic neoplasm 5 embryonal sarcoma 5 others liquified hepatic hematoma biloma

Radiology report

neuroendocrine tumors non-functional neuroendocrine tumors functional neuroendocrine tumors gastrinoma glucagonoma insulinoma somatostatinoma VIPoma

high risk of malignancy pancreatic acinar cell carcinoma (ACC) hypervascular pancreatic metastases neuroendocrine tumors

Complications pancreatic fluid collections are defined by presence or absence of necrosis (as described by the Revised Atlanta Classification): necrosis absent (i.e. interstitial edematous pancreatitis) acute peripancreatic fluid collections (APFCs) (in the first 4 weeks) pseudocysts: encapsulated fluid collections after 4 weeks necrosis present (i.e. necrotizing pancreatitis) acute necrotic collections (ANCs): develop in the first 4 weeks walled-off necrosis (WON): encapsulated collections after 4 weeks liquefactive necrosis of pancreatic parenchyma (e.g. necrotizing pancreatitis) increased morbidity and mortality may become secondarily infected (emphysematous pancreatitis) vascular complications hemorrhage: resulting from erosion of blood vessels and tissue necrosis pseudoaneurysm: autodigestion of arterial walls by pancreatic enzymes results in pulsatile mass that is lined by fibrous tissue and maintains communication with parent artery splenic vein thrombosis portal vein thrombosis fistula formation with pancreatic ascites: leakage of pancreatic secretions into the peritoneal cavity abdominal compartment syndrome

pancreatic fluid collections are defined by presence or absence of necrosis (as described by the Revised Atlanta Classification): necrosis absent (i.e. interstitial edematous pancreatitis) acute peripancreatic fluid collections (APFCs) (in the first 4 weeks) pseudocysts: encapsulated fluid collections after 4 weeks necrosis present (i.e. necrotizing pancreatitis) acute necrotic collections (ANCs): develop in the first 4 weeks walled-off necrosis (WON): encapsulated collections after 4 weeks

There are two subtypes of acute pancreatitis as described by the Revised Atlanta Classification 1:  interstitial edematous pancreatitis vast majority (90-95%) most often referred to simply as "acute pancreatitis" or "uncomplicated pancreatitis" necrotizing pancreatitisnecrosis develops within the pancreas and/or peripancreatic tissue

A catchy and early learnt mnemonic for recalling some of the causes of pancreatitis is:I GET SMASHEDMnemonic I: idiopathic G: gallstones, genetic - cystic fibrosis E: ethanol (alcohol) T: trauma S: steroids M: mumps (and other infections)/malignancy A: autoimmune S: scorpion stings/spider bites H: hyperlipidemia/hypercalcemia/hyperparathyroidism (metabolic disorders) E: ERCP D: drugs (tetracyclines, furosemide, azathioprine, thiazides and many others) The first four letters also represent the most common causes of pancreatitis.

fine 3 mm slices axial and coronal T2 FS or STIR axial and coronal T2 are helpful in the delineation of sphincter anatomy axial and coronal T1 FS with gadolinium-based intravenous contrast material axial T1 Some authors recommend 1: short-inversion-time inversion recovery (STIR) gradient-echo T1-weighted with or without gadolinium-based intravenous contrast material spin-echo T1-weighted spin-echo T2-weighted with saline instillation (MR fistulography)

fine 3 mm slices axial and coronal T2 FS or STIR axial and coronal T2 are helpful in the delineation of sphincter anatomy axial and coronal T1 FS with gadolinium-based intravenous contrast material axial T1 Some authors recommend 1: short-inversion-time inversion recovery (STIR) gradient-echo T1-weighted with or without gadolinium-based intravenous contrast material spin-echo T1-weighted spin-echo T2-weighted with saline instillation (MR fistulography)

The order of frequency of primary retroperitoneal malignancy is as follows: liposarcoma undifferentiated pleomorphic sarcoma leiomyosarcoma rhabdomyosarcoma fibrosarcoma malignant peripheral nerve sheath tumor solitary fibrous tumor extragonadal germ cell tumor primary retroperitoneal adenocarcinoma Causes include radiotherapy, e.g. neuroblastoma treatment as a child.

Primary retroperitoneal neoplasms arise from outside the major organs, and are divided according to histological types: mesenchymal origin: skeletal muscle, fat, peripheral nerve, vessels, fibrous tissue extragonadal germ cell tumors primary retroperitoneal adenocarcinoma

Metastases lymphatic anterior jugular chain and supraclavicular nodes (primary in upper 1/3) para-esophageal and subdiaphragmatic nodes (primary in middle 1/3) mediastinal and paracardiac and celiac trunk nodes (primary in lower 1/3) hematogenous: lung, liver, adrenal glands

Three (some say four) forms can be distinguished: diffuse adenomyosis: most common focal adenomyosis and adenomyoma: sometimes considered distinct (see below) cystic adenomyosis and adenomyotic cyst: rare

Based on histology uterine lipoleiomyoma myxoid uterine leiomyoma

Any fibroid may undergo atrophy, internal hemorrhage, fibrosis, and calcification.They can also undergo several types of degeneration: hyaline degeneration: focal or generalized hyalinisation: this is the most common type of degeneration (can occur in ~60% of cases) 6 cystic degeneration: ~5% myxoid degeneration: generally considered uncommon although reported as high as 50% by some authors 14 red (carneous) degeneration: due to hemorrhagic infarction, which can occur particularly during pregnancy, and may present with acute abdominal pain

Fibroids may have a number of locations within or external to the uterus: intrauterine intramural leiomyoma: most common, centered within the myometrium subserosal leiomyoma: projecting outwards from the uterus submucosal leiomyoma: least common (10-15%), projecting into the uterine cavity extrauterine broad ligament leiomyoma cervical leiomyoma parasitic leiomyoma 7 diffuse uterine leiomyomatosis

The acronym VACTERL derives from: V: vertebral anomalies hemivertebrae congenital scoliosis caudal regression spina bifida A: anorectal anomaliesanal atresia C: cardiac anomalies; cleft lip TE: tracheo-esophageal fistula +/- esophageal atresia R: renal anomalies; radial ray anomalies L: limb anomalies polydactyly oligodactyly

Esophageal atresia is closely related to tracheo-esophageal fistula and can be divided into1: type A: isolated esophageal atresia (8%) type B: proximal fistula with distal atresia (1%) type C: proximal atresia with distal fistula (85%) type D: double fistula with intervening atresia (1%) type E: isolated fistula (H-type) (4%)

It is frequently associated with a tracheo-esophageal fistula. As such, the types of esophageal atresia / tracheo-esophageal fistula can be divided into 4: proximal atresia with distal fistula: 85% isolated esophageal atresia: 8-9% isolated fistula (H-type): 4-6% double fistula with intervening atresia: 1-2% proximal fistula with distal atresia: 1%

The esophagus is made up of five layers, noting there is no serosal layer. From outer to inner, these are: adventitia muscularis propria outer longitudinal muscularis propria inner circular muscularis propria (in the upper one-third of the esophagus this layer is composed of striated (voluntary) muscle while the lower two-thirds is smooth muscle) submucosa mucosa stratified squamous epithelium that abruptly changes to columnar epithelium in the lower esophagus

Lymphatic drainageFollows arterial supply: upper third: deep cervical lymph nodes middle third: posterior mediastinal lymph nodes lower third: left gastric and celiac group lymph nodes

Venous drainage upper third: inferior thyroid veins to brachiocephalic veins middle third: azygos vein to SVC lower third: left gastric vein to portal vein (site of portal-systemic collateral pathway)

Arterial supply upper third: inferior thyroid artery middle third: esophageal branches of the thoracic aorta lower third: esophageal branches of the left gastric artery

cervical: continuous with the hypopharynx, commences at the lower border of cricoid cartilage (at level of C5/6) or cricopharyngeus muscle thoracic: from superior thoracic aperture (T1) to the esophageal hiatus (T10) in the diaphragm which covers the inferior thoracic aperture abdominal: from esophageal hiatus and is continuous with the cardia of the stomach at the gastro-esophageal junction

Pathology Three precursor lesions for pancreatic adenocarcinoma have been identified 8: pancreatic intraepithelial neoplasia (PanIN): responsible for more than 90% of pancreatic cancers 12  intraductal papillary mucinous neoplasm (IPMN) mucinous cystic neoplasm

Serum markers CEA (carcinoembryonic antigen) CA19-9

Clinical presentation pain (most common) Courvoisier gallbladder: painless jaundice and enlarged gallbladder Trousseau syndrome: migratory thrombophlebitis  new-onset diabetes mellitus lipase hypersecretion syndrome (10-15%) 9 polyarthralgia and subcutaneous fat necrosis +/- lytic bone lesions elevated serum lipase and eosinophilia

exocrine: ~99% of all primary pancreatic neoplasms pancreatic ductal adenocarcinoma (commonly known as pancreatic cancer) 90-95%  acinar cell carcinoma of the pancreas cystic neoplasm intraductal papillary mucinous neoplasm (IPMN) intraductal tubular neoplasm (ITN) endocrine: were previously referred to as islet cell tumors because they were thought to have originated from the islets of Langerhans, however, new evidence suggests that these tumors originate from pluripotential stem cells in ductal epithelium 6 non-syndromic syndromic mesenchymal tumors although the great majority of both benign and malignant pancreatic neoplasms arise from pancreatic epithelial cells, mesenchymal tumors, while rare, can derive from the connective, lymphatic, vascular, and neuronal tissues of the pancreas 7 they account for 1-2% of all pancreatic tumors and are classified according to their histologic origin 7 other metastases to pancreas

DWI is the best sequence for detection of lymph nodes. T1W series are useful for interpretation of the border contour and signal characteristics of lymph nodes.

Differential diagnosis retropharyngeal cellulitis: i.e. same pathology but no abscess formation retropharyngeal edema: hypoattenuation without a well defined or enhancing rim prevertebral abscess: usually secondary to discitis osteomyelitis retropharyngeal hematoma 5 blood density/intensity on CT/MRI Capps triad usually in adults retropharyngeal effusion secondary to acute calcific prevertebral tendinitis 6 no marginal enhancement calcification may be seen in the longus capitits and longus colli muscles mass involving retropharyngeal space: e.g. hemangioma, tumor retropharyngeal pseudothickening

Differential diagnosisGeneral imaging differential considerations include: gastrointestinal leiomyoma most common in the esophagus, accounting for 75% of mesenchymal tumors 1 rare in the remainder of the GI tract gastrointestinal leiomyosarcoma: rare gastrointestinal lymphoma/gastric lymphoma lymphadenopathy uncommon for GIST more extensive mural thickening there is often associated aneurysmal dilatation gastrointestinal schwannoma typically homogeneous attenuation tend to lack cystic change gastrointestinal carcinoid more common in the small bowel polypoid/plaque-like growth hyperenhancing mesenteric metastases with stranding (characteristic “spoke-wheel” appearance)

Differential diagnosisGeneral imaging differential considerations include: cirrhosis from other causes caudate lobe not as frequently or as markedly enlarged left lobe usually also hypertrophied IgG4-related sclerosing cholangitis these patients tend to be older and more symptomatic with involvement of other systems besides the bile ducts 17 IgG4 levels 4x normal; ratio of IgG4 to immunoglobulin 1 of >0.24 17 responds to steroid therapy secondary sclerosing cholangitis AIDS-associated cholangitis biliary strictures from other causes, e.g. surgery, ischemia cholangiocarcinoma (can also occur as a later complication) primary biliary cholangitis especially difficult to distinguish when PSC is limited to the intrahepatic biliary tree young women more frequently affected high antibody titers 4 Alagille syndrome (arteriohepatic dysplasia) hepatic sarcoidosis: see abdominal manifestations of sarcoidosis

Complications hepatic osteodystrophy cholangiocarcinoma develops in ~15% of patients 6 colorectal cancer 14 4x greater risk compared to IBD patients without PSC 10x greater risk compared to general population hepatocellular carcinoma: appears to be not increased beyond other causes of cirrhosis 14 gallbladder carcinoma

ulcerative colitis 70-80% of patients with PSC develop inflammatory bowel disease87% of these develop ulcerative colitis 18 autoimmune hepatitis (AIH-PSC overlap) Sjogren syndrome 6 retroperitoneal fibrosis 6 mediastinal fibrosis Riedel thyroiditis orbital pseudotumor

The characteristic feature is that these tumors communicate with the main pancreatic duct or its branches, which helps to distinguish these tumors from mucinous cystadenoma/cystadenocarcinoma, which do not.

Reported locations of IPMN include 15: head ~50% tail ~7% uncinate process ~4%, elsewhere throughout pancreas ~39%

Macroscopic appearanceDivided macroscopically: main duct reminiscent of chronic pancreatitis segmental or diffuse distribution highest malignant potential 6~60% are malignant 10 branch duct type mostly seen in the head and uncinate process more localized and mass-like may be multifocal 13 may be macro or microcystic in appearance 5 typically indolent behavior 6~5% (range 2-10%) are malignant 11,12 mixed-type lesionssimilar to the main duct type in terms of prognosis and overall survival Solid components, as well as bile duct dilatation 14, are suspicious of malignant transformation.

En la Rx lateral cervical puedenverse datos patognomónicos: desplazamiento anterior de latráquea, ensanchamiento del mediastino superior, neumome-diastino (signo de la V de Nacleiro). Puede verse neumotóraxo derrame pleural. Se confirma al pasar contraste hidrosoluble(Gastrografin®) al mediastino (localiza el punto de ruptura).Endoscopia sólo si hay perforación por cuerpo extraño (

Enfermedad localmente avanzada (T3-T4a, N+)Los tumores que afectan a la adventicia (T3), superan la pareddel esófago afectando a estructuras resecables como la pleura oel pericardio (T4a) o presentan adenopatías locorregionales (N+)son indicación de tratamiento neoadyuvante con una combina-ción de RT y QT. El objetivo es reducir el tamaño tumoral para,posteriormente, intentar una cirugía radical. Esta estrategia hademostrado beneficio en términos de resecabilidad, superviven-cia libre de enfermedad y desarrollo de metástasis a distancia,pero no en relación con la supervivencia global.Enfermedad avanzada (T4b, M1)Tumores que invaden estructuras mediastínicas no resecablescomo la tráquea o los grandes vasos (T4b) o con metástasis adistancia (M1). La braquiterapia consigue un control local deltumor en un 30% de los casos. Aunque la QT puede paliarlos síntomas en una proporción significativa de pacientes, noaporta beneficio en términos de supervivencia.

Esofagograma con bario: dilatación del cuerpo esofágico.Estenosis distal en forma de pico de pájaro. En casos avanza-dos: esófago muy dilatado y deformado (forma sigmoidea).

El síntoma más frecuente es la disfagia intermitente para sólidos.

La enfermedad en ausencia de tratamiento puede llevar a laaparición de estenosis fibróticas del esófago. Además, estospacientes tienen riesgo de perforación de esófago. No aumen-to el riesgo de cáncer de esófago.

Tiene unacapa mucosa (epitelio escamoso estratificado, lámina propia ymuscularis mucosa); submucosa, formada por tejido conectivoy es por donde discurre el plexo nervioso de Meissner. La capamuscular está constituida por músculo estriado (1/3 superior) ymúsculo liso (2/3 inferiores más el EEI). Tiene una capa circularinterna y una longitudinal externa; entre ambas está el plexomientérico de Auerbach. El esófago carece de serosa.

Solid masses

Hypervascular liver lesions are findings that enhance more or similarly to the background hepatic parenchyma in the late arterial phase, on contrast-enhanced CT or MRI.

Classification according to morphologyPredominantly cystic serous cystadenoma mucinous cystadenoma  mature cystic teratoma serous cystadenocarcinoma mucinous cystadenocarcinoma Predominantly solid Brenner tumor thecoma fibroma endometroid granulosa cell tumors dysgerminoma endodermal sinus tumor (yolk sac tumor) metastatic

PathologySubtypesPrimary ovarian tumorsSurface epithelial-stromal ovarian tumors (60-70%): ovarian serous tumors ovarian serous cystadenoma: ~60% of serous tumors   ovarian borderline serous cystadenoma: ~15% of serous tumors ovarian serous cystadenocarcinoma: ~25% of serous tumors; commonest malignant ovarian tumor ovarian mucinous tumors: ~20% of all ovarian tumors 11 ovarian mucinous cystadenoma: ~80% of mucinous tumors ovarian borderline mucinous cystadenoma: 10-15% of mucinous tumors ovarian mucinous cystadenocarcinoma: 5-10% of mucinous tumors ovarian endometrioid tumor: 8-15% of all ovarian tumors clear cell ovarian carcinoma: ~5% of ovarian cancer Brenner tumor: ~2.5% of ovarian epithelial neoplasms squamous cell carcinoma of the ovary ovarian cystadenofibroma* / ovarian adenofibroma: can be serous, mucinous, endometrioid, clear cell or mixed ovarian cystadenocarcinofibroma: extremely rare ovarian fibrosarcoma undifferentiated carcinoma of the ovary: ~4% of all ovarian tumors * sometimes classified as a separate category rather than under epithelial 7Germ cell ovarian tumors (~20%): ovarian teratoma: the commonest primary benign tumor of the ovary mature ovarian (cystic) teratoma immature ovarian teratoma specialized teratomas of the ovary struma ovarii tumor ovarian carcinoid tumors ovarian dysgerminoma ovarian yolk sac tumor: endodermal sinus tumor ovarian embryonal carcinoma ovarian choriocarcinoma: <1% of ovarian tumors pure primary ovarian choriocarcinoma: extremely rare 2 malignant mixed germ cell tumor of the ovary Sex cord / stromal ovarian tumors (8-10%): ovarian fibrothecoma: ~5% of ovarian tumors ovarian fibroma: ~4% of ovarian tumors ovarian thecoma: ~1% of ovarian tumors sclerosing stromal tumor of the ovary: rare 9 ovarian Sertoli-Leydig cell tumor - ovarian androblastoma: ~0.5% of ovarian tumors granulosa cell tumor of the ovary: commonest malignant sex cord tumor juvenile granulosa cell tumor of the ovary adult granulosa cell tumor of the ovary small cell carcinoma of the ovary 15 MixedThese are uncommon: collision tumors of the ovary ovarian carcinosarcoma <1%  Other ovarian lymphoma primary ovarian lymphoma secondary involvement of the ovary with lymphoma metastases to the ovary Krukenberg tumor other metastatic lesions to the ovary

Alteraciones en las ondasespectrales en patología arterial