Grainger & Allison's Diagnostic Radiology Essentials. Part 2

355 Pages·2016·176.38 MB·English

by  Grant L.

&
Grainger Allison's
DDiiaaggnnoossttiicc
RRaaddiioollooggyy
Essentials
Lee Alexander Grant BA (Oxon) FRCR
Consultant Radiologist
The Royal Free NHS Foundation Trust
London, UK
Nyree Griffin MD FRCR
Consultant Radiologist
Guy’s and St Thomas’ NHS Foundation Trust
London, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013
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Foreword
I am delighted to be able to write the foreword to this which are needed for day-to-day radiological practice.
book prepared by two outstanding young radiologists Thus,inonesimpletextbook,mostoftheessentialinfor-
who worked with me here in Cambridge. While they mation required for practising radiology becomes
wereatmysidereporting,theypolitelypointedoutthat available.
a list-like textbook was what candidates for examina- Justtotakeoneexample,thesectiononlobarcollapse
tions required, even if there is still a need for the defini- is extremely well presented. For old-stagers like me it is
tive‘authorizedbible’.Thustheysetaboutreviewingthe excellent to see the plain CXR findings so well matched
fifth edition of Grainger & Allison’s Diagnostic Radiology, with their CT equivalents. But more importantly the
one of the largest multi-author textbooks of radiology commonest causes are listed, rather like a bookmaker’s
in the world, with a view to presenting the data in a list: but not with the odds attached! Then come the all
more examination-orientated format. To this end they important teaching pearls. Even in the legends to the
have used much of the text and several of the illustra- images there are additional teaching points, such as is
tionswithinthebook butembellishingthecrucial teach- seen in a patient with left upper lobe collapse: ‘the jux-
ing points with the minimum amount of text. Thus the taphrenic peak sign: A small triangular density (arrow)
organization of this new shortened version still adopts is seen; the sign is due to reorientation of an inferior
the same form of organization as the main textbook but accessory fissure.’
with a more graphic and more modern feel. They Theeditorsofthemaintextbookverymuchhopethat
acknowledge the help that Michael Houston and all this new single textbook will be seen as an essential
those from Elsevier have given them and they acknowl- add-on to its big brother. As Doctors Griffin and Grant
edge the work that the four editors of the fifth edition suggest,itisverymuchanticipatedthatthesmallertext-
(Professors Ronald G. Grainger, David J. Allison, Andy book will be a bench book which becomes dog-eared
Adam and myself) have put into this book. Of course close to the reporting station, whilst the definitive bible
we, in turn, all owe an enormous debt to Professors is in a more sacrosanct place within the department or
Grainger and Allison for having had the vision of start- on the bookshelf of the radiologist’s office. They should
ing the whole process all those years ago. be congratulated on their enormous energy to harness
In any event, the presentation of this single-volume such a huge amount of data on top of their very busy
textbook is much more suitably aimed at the young lives while they metamorphosed from Senior Registrar
radiologist/examination candidate. It has an attractive to Consultant status. I wish both them and this remark-
layout, easy referencing, excellent images and the mini- able book every success.
mum of text. It also includes appendices with the latest
TNM staging, new RECIST criteria for following Adrian K Dixon
response to chemotherapy and other ‘pearls’, all of Cambridge, 2013
xi
Preface
We are extremely grateful to Michael Houston for the However, our greater vision was for it to become an
opportunity to write our ‘dream’ book and the support invaluable tool for practising consultants as well. With
given to us by all four editors of the Grainger & Allison’s this in mind, we have added a new Appendices section
Diagnostic Radiology series (Profsessors Andy Adam, incorporatingthelatestTNMstaging,RECIST1.1criteria
AdrianK.Dixon,RonaldG.GraingerandDavidJ.Allison). and other important pearls in anatomy and imaging,
We would also like to single out Joannah Duncan for that we felt would be of immense value in day-to-day
special praise, as without her hard work and tireless radiological practice. These will hopefully provide
dedication this book would never have been completed. essential aide memoirs for those things that somehow
Theoverridingvisionwastosatisfyaneedthatisnot always seem impossible to commit to memory!
currentlyaddressedbyanyradiologytextbookpresently Inevitably due to the limitations of space, not every
onthemarket.Wewantedtocreateasinglevolumetext- detailorasmanyfigurescouldbeincludedaswewould
book based on the 5th edition of Grainger & Allison that have liked. However, we hope that we have achieved,
has all its information presented in a standardized within the space limitations, what we set out to do. At
way. We wished to avoid long descriptive sentence con- present there is no single volume, comprehensive gen-
structions that would make information retrieval ineffi- eral radiology textbook that has attempted to do this.
cient. Furthermore, images within this book have been Wehopethatthisbookiswellthumbedbyatrainee-
directlylinkedtotherelevanttextandplacedonthefac- to be then promoted to the workstation as a consultant
ing page. The use of colour was essential in making this radiologist - rather than gathering dust on a bookshelf
book more accessible to the reader and to facilitate at home!
quicker referencing.
As relatively recent trainees that have sat the FRCR Lee Grant BA FRCR
examinations, we wanted this book to provide as close Nyree Griffin MD FRCR
as is possible a ‘one-stop reference guide’ for trainees. 2013
xiii
Dedication
To Malcolm and Hilary, from both of us.
You know why.
Acknowledgements
Listed below are the sources for borrowed and adapted #32 Eisenhauer EA, Therasse P, Bogaerts J, et al. New
material. Due to space limitations within the book sym- response evaluation criteria in solid tumours: revised
bols have been used instead of full citations after figure RECIST guideline (version 1.1). European Journal of
and table legends. Below is a list of the symbols and Cancer 2009;45(2);228–247
their corresponding citations. #33 Royal College of Radiologists; Standards for intra-
#1 Edey AJ, Hansell DM. Incidentally detected small vascular contrast agent administration to adult patients,
pulmonary nodules on CT. Clinical Radiology 2009;64: 2nd edn. The Royal College of Radiologists, April 2010
872–884 #34 El-Khoury GY, Bennett DL, Stanley MD. Essentials
#2 Hansell DM, Lynch D, McAdams HP, Bankier AA. of MSK imaging, 1st edn. Churchill Livingstone, 2002
Imaging of diseases of the chest. Mosby, 2009 #35 Pope T, Morrison WB, Bloem HL, et al. Imaging of
#10 O’Connor JH, Cohen J. Dating fractures. In: the musculoskeletal system. Saunders, 2008
Kleinman PK (ed). Diagnostic imaging of child abuse. *AdamA,DixonAK,GraingerRG,AllisonDJ.Grainger
Williams & Wilkins, 1987, p.112 & Allison’s diagnostic radiology, 5th edn. Churchill
#11 Kleinman PK (ed). Diagnostic imaging of child Livingstone, 2007
abuse. Williams & Wilkins, 1998, p.179 † Sutton D. Textbook of radiology and imaging, 7th edn.
#12ChapmanS,NakielnyR.Aidstoradiologicaldiffer- Churchill Livingstone, 1998
ential diagnosis, 4th edn. Saunders, 2003 ‡ McLoud T. Thoracic radiology: The requisites. Mosby,
#13 Abrams HL, Sprio R, Goldstein N. Metstases in 1998
carcinoma. Analysis of 1000 autopsied cases. Cancer ¶
Middleton WD, Kurtz AB, Hertzberg BS. Ultrasound:
1950;3:74–85
The requisites. Mosby, 2004
#20 Gore RM, Levine MS. Textbook of gastrointestinal ¶¶ Kaufman J, Lee M. Vascular and interventional radi-
radiology. Saunders/Elsevier, 2007 ology: The requisites. Mosby, 2003
#21 Lim JS, Yun MJ, Kim MJ, et al. CT and PET in §
BlickmanJ,ParkerB,BarnesP.Pediatricradiology:The
stomach cancer: preoperative staging and monitoring
requisites. Mosby, 2009
of response therapy. RadioGraphics 2006;26(1): §§
Ziessman HA, O’Malley JP, Thrall JH. Nuclear medi-
143–156
cine: The requisites. Mosby, 2006
#24 Slovis TL. Caffey’s pediatric diagnostic imaging, (cid:1)
Zagoria R. Genitourinary radiology: The requisites.
11th edn. Elsevier, 2008
Mosby, 2004
#27 De Bruyn R. Paediatric ultrasound: how, why (cid:1)(cid:1)
Weissleder R, Wittenberg J, Harisinghani M, Chen J.
andwhen,2ndedn.Elsevier/ChurchillLivingstone,2010
Primer of diagnostic imaging, 4th edn. Mosby, 2007
#28 Bates J. Abdominal ultrasound: how, why and
(cid:129) Miller S. Cardiac imaging: The requisites. Mosby, 2004
when. Churchill Livingstone, 2011
(cid:129)(cid:129) Halpert R. Gastrointestinal imaging: The requisites,
#30TurgutAT,AltinL,TopcuS,etal.Unusualimaging
3rd edn. Mosby, 2006
characteristicsofcomplicatedhydatiddisease.European
1
Journal of Radiology 2007;63(1):84–93 Grossman R, Yousem D. Neuroradiology: The requi-
sites. Mosby, 2003
#31 Parizel PM, Makkat S, Van Miert E, et al. Intracra-
11
SotoJ,LuceyB.Emergencyradiology:Therequisites.
nial hemorrhage: principles of CT and MRI interpreta-
Mosby, 2009
tion. European Radiology 2001;11:1770–1783 xv
Dedication
To Malcolm and Hilary, from both of us.
You know why.
Acknowledgements
Listed below are the sources for borrowed and adapted #32 Eisenhauer EA, Therasse P, Bogaerts J, et al. New
material. Due to space limitations within the book sym- response evaluation criteria in solid tumours: revised
bols have been used instead of full citations after figure RECIST guideline (version 1.1). European Journal of
and table legends. Below is a list of the symbols and Cancer 2009;45(2);228–247
their corresponding citations. #33 Royal College of Radiologists; Standards for intra-
#1 Edey AJ, Hansell DM. Incidentally detected small vascular contrast agent administration to adult patients,
pulmonary nodules on CT. Clinical Radiology 2009;64: 2nd edn. The Royal College of Radiologists, April 2010
872–884 #34 El-Khoury GY, Bennett DL, Stanley MD. Essentials
#2 Hansell DM, Lynch D, McAdams HP, Bankier AA. of MSK imaging, 1st edn. Churchill Livingstone, 2002
Imaging of diseases of the chest. Mosby, 2009 #35 Pope T, Morrison WB, Bloem HL, et al. Imaging of
#10 O’Connor JH, Cohen J. Dating fractures. In: the musculoskeletal system. Saunders, 2008
Kleinman PK (ed). Diagnostic imaging of child abuse. *AdamA,DixonAK,GraingerRG,AllisonDJ.Grainger
Williams & Wilkins, 1987, p.112 & Allison’s diagnostic radiology, 5th edn. Churchill
#11 Kleinman PK (ed). Diagnostic imaging of child Livingstone, 2007
abuse. Williams & Wilkins, 1998, p.179 † Sutton D. Textbook of radiology and imaging, 7th edn.
#12ChapmanS,NakielnyR.Aidstoradiologicaldiffer- Churchill Livingstone, 1998
ential diagnosis, 4th edn. Saunders, 2003 ‡ McLoud T. Thoracic radiology: The requisites. Mosby,
#13 Abrams HL, Sprio R, Goldstein N. Metstases in 1998
carcinoma. Analysis of 1000 autopsied cases. Cancer ¶
Middleton WD, Kurtz AB, Hertzberg BS. Ultrasound:
1950;3:74–85
The requisites. Mosby, 2004
#20 Gore RM, Levine MS. Textbook of gastrointestinal ¶¶ Kaufman J, Lee M. Vascular and interventional radi-
radiology. Saunders/Elsevier, 2007 ology: The requisites. Mosby, 2003
#21 Lim JS, Yun MJ, Kim MJ, et al. CT and PET in §
BlickmanJ,ParkerB,BarnesP.Pediatricradiology:The
stomach cancer: preoperative staging and monitoring
requisites. Mosby, 2009
of response therapy. RadioGraphics 2006;26(1): §§
Ziessman HA, O’Malley JP, Thrall JH. Nuclear medi-
143–156
cine: The requisites. Mosby, 2006
#24 Slovis TL. Caffey’s pediatric diagnostic imaging, (cid:1)
Zagoria R. Genitourinary radiology: The requisites.
11th edn. Elsevier, 2008
Mosby, 2004
#27 De Bruyn R. Paediatric ultrasound: how, why (cid:1)(cid:1)
Weissleder R, Wittenberg J, Harisinghani M, Chen J.
andwhen,2ndedn.Elsevier/ChurchillLivingstone,2010
Primer of diagnostic imaging, 4th edn. Mosby, 2007
#28 Bates J. Abdominal ultrasound: how, why and
(cid:129) Miller S. Cardiac imaging: The requisites. Mosby, 2004
when. Churchill Livingstone, 2011
(cid:129)(cid:129) Halpert R. Gastrointestinal imaging: The requisites,
#30TurgutAT,AltinL,TopcuS,etal.Unusualimaging
3rd edn. Mosby, 2006
characteristicsofcomplicatedhydatiddisease.European
1
Journal of Radiology 2007;63(1):84–93 Grossman R, Yousem D. Neuroradiology: The requi-
sites. Mosby, 2003
#31 Parizel PM, Makkat S, Van Miert E, et al. Intracra-
11
SotoJ,LuceyB.Emergencyradiology:Therequisites.
nial hemorrhage: principles of CT and MRI interpreta-
Mosby, 2009
tion. European Radiology 2001;11:1770–1783 xv
3.1 OESOPHAGUS
HIATUS HERNIA
DEFINITION RADIOLOGICAL FEATURES
(cid:129) Protrusion of part of the stomach through the Bariumswallow
diaphragmatic oesophageal opening (cid:129) Sliding hiatus hernia: the Schatski or B ring is
§
Sliding hernia (the commonest type): the gastro- demonstrated above the diaphragmatic hiatus
oesophageal junction (GOJ) slides proximally (cid:129) Rolling hiatus hernia: a part of the stomach (usually
through the diaphragmatic hiatus to assume an thegastricfundus)isprolapsedintothechestanterior
intrathoracicposition▶itisaccompaniedbyreflux or lateral to the oesophagus
and oesophagitis
– The squamocolumnar junction is seen at (cid:1)38cm PEARLS
(the normal is 40cm) from the incisors at
(cid:129) Schatski or B ring: a ring of mucosal tissue at the
endoscopy
§ lower border of the phrenic ampulla marking the
Rolling hernia: the GOJ is in a normal
junction between the squamous and columnar
position below the diaphragm – the proximal
epithelium (the ‘Z line’)
stomach (usually the fundus) herniates through
(cid:129) The ‘A’ ring or inferior oesophageal sphincter:
the hiatus ▶ this is more prone to incarceration
about 2-4cm proximal to the B ring is a thicker ring
and obstruction, and it may undergo torsion,
produced by active muscular contraction
resulting in strangulation, infarction or perforation
(cid:129) The Schatski ring is always associated with a small
– The squamocolumnar junction maintains its sliding hiatus hernia ▶ it can be congenital or
normal position
§ secondary to gastro-oesophageal reflux (with
Combined hernia: features of both are present
associated inflammation and fibrosis)
(cid:129) The Schatski ring is usually no more than 2–3mm
CLINICAL PRESENTATION in thickness ▶ despite being mucosal it can be
symptomatic (requiring dilatation)
(cid:129) Asymptomatic or gastro-oesophageal reflux ((cid:3) reflux (cid:129) If the B ring is incomplete, part of it can sometimes be
oesophagitis) ▶ symptoms are more commonly seen
demonstratedastheincisuralnotch(whichisinevitably
with a sliding hernia
seen on the greater curve aspect of the stomach)
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)
gastro-oesophageal polyp (seen as a single linear
DEFINITION
polyp straddling the GOJ)
(cid:129) Refluxoesophagitis:thiscandemonstratemucosaloedema,
(cid:129) GORD follows lower oesophageal sphincter erosivediseaseorfrankulceration▶initiallythe
dysfunction▶thisinitiallyleadstoreflux(withminor
collapsedoesophagusshowsthickenedlongitudinal
irritation and inflammation) but can then proceed to folds(>3mm)▶multiplefineulcersgivethemucosaa
ulceration, fibrosis and stricture formation ▶ it may punctateorgranularappearance▶largerdiscrete
also be associated with a hiatus hernia punched-outulcerscandevelop▶ulcerationismost
CLINICAL PRESENTATION pronouncedimmediatelyabovetheGOJandlocal
circularmusclespasmmayproducetransversefolds▶
(cid:129) Heartburn or dysphagia ▶ the major long-term scarringproducespermanentfoldsthatradiatefromthe
complications are peptic oesophagitis ((cid:3) stricture ulcermargins
formation or Barrett’s oesophagus) (cid:129) Long-term sequelae: stricture formation (typically a
short stricture above a hiatus hernia with smooth
RADIOLOGICAL FEATURES tapered margins) ▶ the development of Barrett’s
oesophagus (in 10% of cases)
Bariumswallow Radionuclide study Reflux of 99mTc-sulphur colloid
(cid:129) Reflux: this may be demonstrated but alone is of
labelled scrambled egg can demonstrate gastro-
questionable significance – minor amounts can occur
oesophageal reflux
in the normal population ▶ gross reflux (up to the
PEARLS
leveloftheaorticknuckleoraboveandnotclearedby
a stripping wave passing down the oesophagus) is (cid:129) 24-hourpHmeasurementisthe‘goldstandard’inthe
likely to be symptomatic
assessment of reflux
§
Associated features: a wide gastro-oesophageal (cid:129) Thereisnodirectrelationshipbetweenahiatusherniaand
junction (> ˚/(cid:2) of the maximally distended
238 GORD:manypatientshaveahiatusherniabutnoGORD
thoracic oesophagus) ▶ an inflammatory
(butmostpatientswithGORDwillhaveahiatushernia)
HIATUS HERNIA AND REFLUX
Rolling(paraoesophageal)hiatushernia.The Contrast studydemonstrating acombined-type Inflammatorypolyp (arrows)lyingat
gastricfundus (H)liesalongsidethelower hiatushernia.Note therollingcomponent witha endofgastricfold (asterisk).{
oesophagus (O).{ largeportionofstomachabovethediaphragm,but
inadditionthegastro-oesophagealjunctionhasalso
migratedcranially.*
Body of oesophagus
Ring A
Vestibule
Ring B
Stomach
Gastro-
oesophageal
junction
A B A B
Diaphragmatic hiatus
Slidinghiatushernia.(A)Bariumswallowshowsahiatushernia(H), Thelower endoftheoesophagus. (A)TheBringmaynormally
morethan3cmwidewithatleast3gastricfoldsseenextending bewithin2cm above(asshownhere)orbelowthehiatus.
acrossit▶S¼stomachformingthehernia▶B¼Bring,the Thustheoesophageal vestibulemaynormally beabove,orstraddle
gastro-oesophagealjunction▶V¼vestibule.TheAringisnot thediaphragmatichiatus.(B)Smallslidinghiatusherniawithnormal
visible.(B)CTscanshowingthecruraofthediaphragm Bring(betweenarrows).{
(arrows)separatedby28mm(normalis<15mm).Thefundus
ofthestomachisseenherniatingthroughthediaphragmatichiatus.{
239
3.1 ¡ OESOPHAGUS
OESOPHAGITIS AND BENIGN STRICTURES
DEFINITION (cid:129) Crohn’s disease: this can present with aphthoid
ulcers or frank ulceration
(cid:129) Oesophageal inflammation ((cid:3) subsequent smooth (cid:129) Nasogastric tube: this renders the lower oesophageal
benign stricture formation) can be caused by the sphincter incompetent, resulting in a reflux
following: oesophagitis and a long tapered stricture within the
§
GORD (see separate section) lower oesophagus ▶ this may occur only 48 h post
§
Infection: especially in the immunocompromised placement ▶ the strictures are often long and
patient Candida albicans ▶ herpes simplex virus extensive
(HSV) ▶ cytomegalovirus (CMV) ▶ human (cid:129) Caustic ingestion: this can lead to mucosal necrosis
immunodeficiency virus (HIV) ▶ tuberculosis with ulceration and mucosal sloughing ▶ the
§ Drugs: potassium chloride tablets ▶ tetracycline ▶ oesophagus may perforate within the 1st 2 weeks or
clindamycin ▶ doxycycline ▶ NSAIDs result in fistulation to the pleural cavity or
§
Radiation: this is often self-limiting pericaridium ▶ it heals with fibrosis and stricture
§
Crohn’s disease: this is very rare and usually formation ▶ strictures occur at the normal sites of
accompanied by extensive GI disease elsewhere oesophagealcompression(e.g.attheleveloftheaorta,
§
Iatrogenic: following prolonged placement of a left main bronchus or diaphragmatic hiatus)
nasogastric tube (NGT)
§
Caustic ingestion of strong acids or alkalis
PEARLS
CLINICAL PRESENTATION
Epidermolysis bullosa dystrophica
(cid:129) Odynophagia ▶ dysphagia ▶ haematemesis (cid:129) A hereditary skin disease affecting children where
minor trauma produces bullae formation ▶ the
RADIOLOGICAL FEATURES oesophagus may be involved (leading to stricture
formation)
Barium swallow
(cid:129) Candidiasis:initiallythereisdysmotilityandatonyof Pemphigoid
theoesophagus▶eventuallyclassicplaque-likefilling
(cid:129) A benign mucous membrane disease of middle age,
defects with ulceration and pseudomembrane
involving the conjunctiva and mucosa of the oral
formation are seen (there are also irregular and cavityandskin▶theupperoesophagealmucosamay
thickened mucosal folds) ▶ occasionally pseudo-
be involved with ulcers, webs and stricture formation
ulcerations may appear as aphthous ulcers
(cid:129) HSV: vesicles in the upper and mid-oesophagus
appear as sessile filling defects ▶ when they burst Intramural pseudodiverticulosis
they leave punched-out superficial ulcers on a (cid:129) The excretory ducts of the oesophageal deep mucous
background of normal mucosa ▶ in advanceddisease glands dilate and fill with barium ▶ they are seen on
there can be diffuse ulceration
barium studies as multiple, flask-shaped mucosal
(cid:129) CMV/HIV: presents with giant oesophageal ulcers outpouchings ▶ this disease is usually diffuse, but
(cid:129) Drugs: potassium chloride causes deep ulceration
may be localized if it is associated with peptic
leading to stricture formation ▶ NSAIDs can cause
stricture formation or an oesophageal carcinoma
contact oesophagitis (cid:129) Fistulation may occur between these
(cid:129) Radiation: > 20Gy results in a transient oesophagitis pseudodiverticula ▶ intramural abscesses may
with aperistalsis or tertiary contractions ▶ >45Gy
develop which can rarely perforate through the
results in obliterative endarteritis after 6 months with oesophageal wall ▶ long tapered strictures may arise
severe oesophagitis and smooth strictures – deep (cid:129) It is associated with oesophagitis (usually due to
ulcers can also form (which may fistulate to the reflux)▶otherunderlyingdisordersincludediabetes,
trachea)
candidiasis and alcoholism
240