Objectives

To describe the important imaging findings on Multidetector Computed Tomography (MDCT) of duodenal diverticulum and its complications, diagnostic tips that can allow a correct differential diagnosis.

Background

Duodenal diverticulum is outpouching from the duodenal wall, usually located along the medial wall of the second and third portions of the duodenum. Duodenal diverticulum sometimes can be easily missed, but often is an incidental finding in asymptomatic individuals.

Imaging findings OR Procedure findings

The CT appearance of a duodenal diverticulum includes a saccular outpouching, that contains air, fluid, an air-fluid level, contrast material, air-contrast level or food debris, usually interposed between the duodenum and the pancreas. Due them intermittently expand and collapse, the duodenal diverticulum has a fluctuating character, so imaging findings can be limited.

Diverticulitis, abscess formation, perforation, bleeding, intestinal obstruction, obstructive pancreatitis or biliary obstruction (Lemmel syndrome) can complicate the duodenum diverticulum.

The differential diagnosis of duodenal diverticulum include an extraluminal periduodenal gas (caused by periduodenal abscess, duodenal ulcer, duodenal injury iatrogenic or trauma, duodenitis) and an extraluminal periduodenal collection of fluid (head of pancreas cystic lesion or pseudocyst).

Conclusion

The radiologist should pay attention to duodenum and adjacent organs in order to recognize and interpretate the CT imaging characteristics of duodenal diverticulum in the scope of reducing the chances of misdiagnosis and inappropriate treatment.

Objectives

Ultrasound and computed tomography imaging of appendiceal divericulosis in patient with acute appendicitis.

Background

Divertivulosis of the appendix is a rare pathology and usually found in male of age >30 years old and divided to true and pseudodiverticulosis, acquired and congenital types. Clinically it may be asymptomatic or presented with chronic and intermitted abdominal pain, with some differences from acute appendicitis.

There are 4 subtypes of appendiceal diverticulitis:

1 Normal appendix with inflammated diverticuli

2 Acute diverticulitis with surrounding appendicitis

3 Conventional inflammation of appendix with incidental uninvolved diverticulum

4 Incidental diverticulum without inflammation of the appendix

Imaging findings OR Procedure findings

Diagnosis based on clinical evaluation; however ultrasound scan is very useful revealing usually small diverticuli of 2-5mm, larger diverticuli 1-3cm may also occur, rarely they are >8cm. In case of doubt, computer tomography can clear the picture.

Conclusion

Appendiceal diverticulosis should be kept in mind of a doctor because the correct diagnosis is very important, not only to prevent serious complications as perforation, with high mortality, but also appendiceal diverticulosis appears to be associated with neoplasm like carcinoid tumors or mucinous adenomas. For that reason appendectomy must be performed for symptomatic diverticulitis or appendicitis. However, if the patient is asymptomatic prophylactic elective appendectomy is preferred, with histological examination of the specimen.

Objectives

1. To assess the capability of dedicated gastric MDCT protocols in localization and staging of early and advanced gastric cancer.

2. To establish dedicated MDCT criteria for operability or other treatment options of GC, thus facilitating crucial treatment strategy

3. To assess pathways of disease spread by dedicated MDCT.

Background

Gastric carcinoma (GC) is one of the most common and fatal cancers worldwide. Prognosis and treatment depend strongly on disease stage, thus accurate pre-treatment staging is essential. Early GC may be treated by endoscopical resection or surgery, whereas advanced GC requires previous adjuvant chemotherapy. Dedicated gastric MDCT protocols aim to define important steps in treatment algorithm, providing crucial information regarding depth of invasion, lymph node status, perigastric or peritoneal spread.

Imaging findings OR Procedure findings

Dedicated techniques are performed with adequate stomach distention, with negative contrast agents and/or induction of gastric hypotonia. Thin pre- and post contrast image acquisitions in late arterial and portal venous phases with high resolution multiplanar reformations allow evaluation of gastric wall layers and thickness, evidence of multilayer wall disruption, marked transmural or non-trasmural focal wall enhancement, regularity of outer border, obliteration of perigastric fat, lymph node involvement, submucosal, subperitoneal and peritoneal spread, adjacent organ invasion. These findings may serve as criteria for operablility of GC or other treatment options.

Conclusion

Dedicated MDCT gastric protocols apply for accurate staging of both early and advanced GC. MDCT is a widely available modality and dedicated protocols may improve tumor localization and staging. Awareness of MDCT imaging criteria is mandatory in planning therapeutic strategy.