Gastrointestinal Imaging A Teaching File Editors Courtney Coursey Moreno, MD Assistant Professor of Radiology Director of Ultrasound Department of Radiology and Imaging Sciences Emory University School of Medicine Atlanta, Georgia Pardeep Kumar Mittal, MD Assistant Professor of Radiology Director of MRI Body Imaging Department of Radiology and Imaging Sciences Emory University School of Medicine Atlanta, Georgia iii 73376_fm-Book_pi-xiv.indd 3 11/04/14 7:02 PM Senior Executive Editor: Jonathan W. Pine, Jr. Acquisitions Editor: Ryan Shaw Product Development Editor: Amy G. Dinkel Product Production Manager: David Orzechowski Senior Manufacturing Coordinator: Beth Welsh Marketing Manager: Dan Dressler Senior Designer: Stephen Druding Production Service: Integra Software Services Pvt. Ltd. © 2014 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Gastrointestinal imaging (Moreno) Gastrointestinal imaging : a teaching lfie / editors, Courtney Coursey Moreno, Pardeep Kumar Mittal. p.; cm. Includes bibliographical references and index. ISBN 978-1-4511-7337-6 ISBN 1-4511-7337-7 I. Moreno, Courtney Coursey, editor of compilation. II. Mittal, Pardeep Kumar, editor of compilation. III. Title. [DNLM: 1. Digestive System Diseases—diagnosis—Case Reports. 2. Diagnosis, Differential—Case Reports. 3. Diagnostic Imaging—methods—Case Reports. WI 141] RC804.D52 616.3'30754—dc23 2014003469 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. 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Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 73376_fm-Book_pi-xiv.indd 4 11/04/14 7:02 PM To my son, Ricky, who amazes me every day. To my husband, Ricardo, for his support and ideas. To my parents, Martha and Jeff Coursey, for encouraging me to follow my dreams. Courtney Coursey Moreno It is with great pleasure that I dedicate this book to my family, mentors, colleagues, residents, fellows, and students for their guidance and contribution in both my personal and professional life. Pardeep Kumar Mittal 73376_fm-Book_pi-xiv.indd 5 11/04/14 7:02 PM Publisher’s Foreword Teaching Files are one of the hallmarks of education in radiology. When there was a need for a comprehensive series to provide the resident and practicing radiologist with the kind of personal consultation with the experts normally found only in the setting of a teaching hospital, Lippincott Williams & Wilkins was proud to have created a series that answers this need. Actual cases have been culled from extensive teaching files in major medical centers. The discus - sions presented mimic those performed on a daily basis between residents and faculty members in all radiology departments. This series is designed so that each case can be studied as an unknown. A consistent format is used to present each case. A brief clinical history is given, followed by several images. Then, relevant findings, differential diagnosis, and final diagnosis are given, followed by a discussion of the case. The authors thereby guide the reader through the interpretation of each case. This year we’ve made additional changes to the series. Cases have been randomized to better pre- pare the reader for the challenges of the clinical setting. In addition, to answer the growing demand for Web-based product, we have included more cases online, which has left us, in turn, able to offer a more cost-effective product. We hope that this series will continue to be a trusted teaching tool for radiologists at any stage of training or practice, and that it will also be a benefit to clinicians whose patients undergo these imaging studies. The Publisher vii 73376_fm-Book_pi-xiv.indd 7 11/04/14 7:02 PM PreFace In compiling the cases for this volume, we sought to create a high-value resource for trainees learning the basics of gastrointestinal imaging (fluoroscopy, CT, and MR) and also for those studying for board and certifying examinations. To that end, we have included all of the topics listed at the time of this writing in the Gastrointestinal Imaging section of the publicly available American Board of Radiology Core Exam and Maintenance of Certification study guides. To round out the 300 cases in this teaching file, we included additional fluoroscopy, CT, and MR cases that we hope you will find interesting and educational. Cases are grouped into three chapters based on modality so that trainees can use this teaching file efficiently during modality-based rotations. We hope that you will find this collection of cases to be a helpful resource as you train your eye to recognize findings at fluoroscopy, review the variety of diagnoses that can be made at CT, and get your feet wet with the basics of body MR. Courtney Coursey Moreno Pardeep Kumar Mittal ix 73376_fm-Book_pi-xiv.indd 9 11/04/14 7:02 PM acknowledgments Thank you to Drs. Carl Ravin and Linda Gray Leithe for giving me my start in radiology. Thank you to mentors present and past including Drs. Rendon Nelson, Don Frush, Erik Paulson, Tracy Jaffe, George Bisset, Caroline Hollingsworth, Sal Martinez, John H.M. Austin, Dean Danner, Bill Small, Bill Torres, Deb Baumgarten, and Carolyn Meltzer. Thank you to all of the attendings at Duke who taught me so much during residency and fellowship, with special thanks to those in the abdominal imaging division. Thank you to Deb Baumgarten for sharing the opportunity to complete this project with our division. Thank you to Eric Jablonowski and Kevin Makowski for converting some of the films to digital images for this volume. Thank you to Amy Dinkel and the late Jonathan Pine from Wolters Kluwer for making putting this project together such a pleasant experience. Courtney Coursey Moreno Thank you to all of my mentors, past and present, at New York Methodist Hospital in Brooklyn, NY, University of Connecticut Health Center, Medical College of Georgia, and Emory University School of Medicine who helped me when I was a resident in nuclear medicine and diagnostic radiology and dur- ing my abdominal imaging fellowship. I also want to thank my staff, mentors, and colleagues at Emory University School of Medicine Department of Radiology and Imaging Sciences for their immense sup- port and guidance. Kevin Makowski and Eric Jablonowski’s diligent efforts to convert old hard copy radiographs to digital images were necessary to complete this gastrointestinal teaching file project. Finally, this project would not have been possible without the expert guidance of Amy Dinkel and the late Jonathan Pine from Wolters Kluwer. Pardeep Kumar Mittal xi 73376_fm-Book_pi-xiv.indd 11 11/04/14 7:02 PM contents Publisher’s Foreword vii Preface ix Chapter 1 Fluoroscopy...........................................1 Chapter 2 Computed Tomography (CT) Imaging.....................89 Chapter 3 Magnetic Resonance (MR) Imaging......................141 Appendix (List of Cases) 187 Index 191 xiii 73376_fm-Book_pi-xiv.indd 13 11/04/14 7:02 PM 73376_fm-Book_pi-xiv.indd 14 11/04/14 7:02 PM 1 C h a p t e r Fluoroscopy 1 73376_Case-Book_Ch01.indd 1 10/04/14 11:25 AM