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DIAGNOSTIC IMAGING
ABDOMEN
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DIAGNOSTIC IMAGING
ABDOMEN
Michael R Federle, MD, FACR
Professor of Radiology
Chief Abdominal Imaging
University of Pittsburgh Medical Center

R. Brooke Jeffrey, MD
Professor of Radiology
Chief of Abdominal Imaging
Stanford University Medical Center

Terry S. Desser, MD
Assistant Professor of Radiology
Stanford University School of Medicine

Venkata Sridhar Anne, MD

Clinical Research Fellow
Radiology Department
Abdominal Imaging Division
University of Pittsburgh Medical Center

Andres Eraso, MD
Assistant Clinical Professor of Radiology
Louisiana State University Health Sciences Center
Radiologist
Veterans Affairs Medical Center
New Orleans, Louisiana

Joseph Jen-Sho Chen, BA

Medical Student; Research Fellow
Radiology Department
Abdominal Imaging Division
University of Pittsburgh Medical Center

Shalini Guliani-Chabra, MD
Radiology Resident
Radiology Department - Abdominal Imaging Division
University of Pittsburgh Medical Center

Karen M. Pealer, BA, CCRC

Clinical Research Coordinator
Radiology Department - Abdominal Imaging Division

.-..
University of Pittsburgh Medical Center

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AMIRSYS'"
Names you know, content you trust®

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AMIRSYS$
Names you know, content you trust®

First Edition
Text - Copyright Michael P. Federle, MD 2004

Drawings - Copyright Amirsys Ine. 2004

Compilation - Copyright Amirsys Ine. 2004

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or media
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from Amirsys Ine.

Composition by Amirsys Inc, Salt Lake City, Utah

Printed by Friesens, Altona, Manitoba, Canada

ISBN: 1-4160-2541-3
ISBN: 0-8089-2316-1 (International English Edition)

Notice and Disclaimer

The information in this product ("Product") is provided as a reference for use by licensed medical professionals and no others. It does not and should not be construed as any form
of medical diagnosis or professional medical advice on any matter. Receipt or use of this Product, in whole or in part does not constitute or create a doctor-patient, therapist-patient,
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or other healthcare professional relationship between Amirsys Ine. CAmirsys") and any recipient. This Product may not reflect the most current medical developments, and Amirsys
makes no claims, promises, or guarantees about accuracy, completeness, or adequacy of the information contained in or linked to the Product. The Product is not a substitute for or
replacement of professional medical judgment. Amirsys and its affiliates, authors contributors, partners and sponsors disclaim all liability or responsibility for any injury and/or
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damage to persons or property in respect to actions taken or not taken based on any and all Product information.

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administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician relying on
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Library of Congress Cataloging-in-Publication Data

Diagnostic imaging. Abdomen / Michael P. Federle ... let al.].- 1st ed.
p.; cm.
Includes bibliographical references and index.
ISBN 1-4160-2541-3
1. Abdomen-Imaging.
[DNLM: 1. Radiography, Abdominal-methods. 2. Diagnostic Imaging-methods. 3.
Digestive System Diseases-radiography. WI 900 D536 2004] I. Title: Abdomen. II. Federle,
Michael P.

RC944.D526 2004
617.5'50754-dc22
2004022701

IV
 This book is dedicated to my wife, Lynne, who graciously endured many
months of late dinners during its writing, and to my colleagues and trainees at
the University of Pittsburgh Medical Center, who enthusiastically joined in my
quest for the "great cases" to include in the book.

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 DIAGNOSTIC IMAGING: ABDOMEN

We at Amirsys and Elsevier are proud to present Abdomen, the fifth volume in our acclaimed Diagnostic Imaging
series. This precedent-setting, image- and graphic-packed series began with David Stoller's Orthopaedics. The next
three books, Brain, Head and Neck, and Spine are now joined by the first of three volumes that will focus on
abdominal imaging issues. Mike Federle and his team lead off with Abdomen. Subsequent topics will include
Obstetrics and Gynecology.

The unique bulleted format of the Diagnostic Imaging series allows our authors to present approximately twice the
information and four times the images per diagnosis compared to the old-fashioned traditional prose textbook. All
the DI books follow the same format, which means the same information is in the same place: Every time! In every
organ system. The innovative visual differential diagnosis "thumbnail" that provides an at-a-glance look at entities
that can mimic the diagnosis in question has been highly popular. "Key Facts" boxes provide a succinct summary for
quick, easy review.

In summary, Diagnostic Imaging is a product designed with you, the reader, in mind. Today's typical practice
settings demand efficiency in both image interpretation and learning. We think you'll find the new Abdomen
volume a highly efficient and wonderfully rich resource that will be the core of your reference collection in
abdominal imaging. Enjoy!

Anne G. Osborn, MD
Executive Vice President and Editor-in-Chief, Amirsys Ine.

H. Ric Harnsberger, MD
CEO, Amirsys Ine.

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 FOREWORD

Those of us who are abdominal imagers have been eagerly awaiting the Diagnostic Imaging: Abdomen book,
having admired the prior volumes in this remarkable series of imaging texts. We are also pleased to see that the editor
of this volume is Michael Federle, MD, who is Professor of Radiology and Chief of Abdominal Imaging at the
University of Pittsburgh Medical Center.

I have been privileged to know Michael for over 20 years. I share his passion for abdominal imaging, but I have
always been in awe of his clinical and teaching skills. He has used all his experience, judgment and expertise to
produce a teaching tool that will be useful at multiple levels of training, from medical student to practicing
radiologist. The format of the Diagnostic Imaging series makes it easy to learn the relevant imaging and clinical
aspects of every major disease or lesion confronting the radiologist, and should facilitate meaningful communication
with referring physicians.

A unique feature of these texts is the abundance of beautiful medical illustrations that virtually animate the
disease process and the accompanying radiographs. The imaging studies are remarkably excellent, carefully selected
and cropped to highlight every major manifestation of every Diagnosis. The illustrated Differential Diagnosis series
and the accompanying text are other unique features, making it easy to distinguish among several diseases that may
have similar clinical or imaging features.

This text covers all of the major gastrointestinal and genitourinary organs and disease processes from congenital
through traumatic, inflammatory and neoplastic. Between the individual "Diagnoses" (chapters) and the Differential
Diagnoses listed for each, you will find a comprehensive coverage of the factual material covered in the multi-volume
encyclopedic prose textbooks. The Anatomic Overview and.Imaging Issues for each section are written by Dr. Federle
to provide the "glue" to pull the individual Diagnoses together, to suggest optimal imaging protocols, and to provide
extensive tables of Custom Differential Diagnoses that the reader will be referring to on a regular basis.

I have often instructed my residents that the successful radiologist understands three aspects of a disease process:
What does the lesion look like on imaging studies? What does the lesion do on a histopathological and clinical level? What
do these pathological results look like on imaging? Apparently, Michael takes the same approach, and this book will
provide the understanding of these aspects of every GI and GU process likely to be encountered in clinical practice.

Modern imaging is very powerful in revealing the source of a patient's symptoms or signs. This book, as with the
others in the Diagnostic Imaging series, succeeds magnificently in conveying the understanding necessary to make
optimal use of our imaging tools.

Alec]. Megibow, MD, MPH, FACR

Professor and Vice Chairman for Education
New York University School of Medicine

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 PREFACE
This is a book that almost did not happen. For many years I have wanted to write a comprehensive text of
abdominal imaging that would serve as a "readable reference" for radiology residents and practicing physicians.
Increasing clinical demands and the frustrations inherent in writing and editing a traditional multivolume-
multi author text seemed to preclude this. Ric Harnsberger approached me several years ago with his vision of an
entirely new type of textbook and method of writing, with senior authors in all fields of radiology being the driving
force. The text and images would be entered into a proprietary computer program (the Amirsys authoring tool) that
would help organize the data into easily accessible, bulleted text rather than traditional prose, saving an estimated
50% of unnecessary verbiage. The reader would find the key facts, not just in imaging, but in clinical, pathological
and treatment options of every important diagnosis, and he would find it in the same place for every diagnosis and
every book in the series. Moreover, we would ignore the usual publishers' discouragement of the use of color images,
and would use color images and original artwork lavishly. I signed on with some trepidation.

The use of the Amirsys "authoring tool" provided and additional benefit of allowing for a certain uniformity of
style and depth of coverage that is usually impossible to achieve in a multi author text. At the University of Pittsburgh,
we assembled a team of bright young people who performed much of the literature review and data entry, freeing me
to concentrate on editing, overview and selecting the best images and illustrations for maximum teaching value. Our
proprietary authoring tool even facilitated the updating and entry of references; you will note many references from
within the past year, previously impossible to achieve with the lag time to publication of a traditional textbook.

The Pittsburgh team of contributors includes Venkata Anne, MD, who also assisted with the research and writing
of our first Amirsys book, the Pocket Radiologist, Top 100 Diagnoses in Abdominal Imaging. Dr. Anne has augmented
his residency in radiology with a thorough review of available texts and journal articles to acquire an encyclopedic
knowledge of abdominal imaging, and he has contributed substantially to the majority of diagnoses included in our
Pocket Radiologist and current text.

This comprehensive work would not have been accomplished without the dedication and efforts of many people:

Andres Eraso, MD, a former resident and fellow at Pitt, was my main assistant in reviewing our teaching files and
medial records to select the most compelling and informative images for the book. Joe Chen is a medical student and
future radiologist who was part of the research and writing team, along with Shalini Guliani, MD a radiologist trained
in India who is gaining additional training in our radiology residency. Their co-authorship of diagnoses is noted in
the table of contents, and their excellent work is both acknowledged and appreciated.

Karen Pealer has been my research assistant for many years and was absolutely instrumental in the success of this
project. Karen used all of her computer and communication skills to help me organize, edit, enter and illustrate each
of the diagnostic "chapters" and introductory sections. She was also the conduit of information and problem solving
between Pittsburgh and Amirsys headquarters in Salt Lake City. I suppose it would have been possible for an old dog
like me to learn all the new computer tricks necessary to complete this project, but it would have been much more
difficult and time-consuming.

The Stanford team was led by my career-long colleague and friend, Brooke Jeffrey, MD, himself the author of
several excellent textbooks and innumerable articles and other contributions. Brooke has always been one of the top
radiologists and educators in the world, and we are proud to have him as part of this project. Terry Desser, MD is the
other Stanford faculty radiologist who contributed dozens of diagnoses that are all beautifully researched, written and
illustrated.

The Amirsys team all contributed their own expertise. I particularly want to acknowledge Ric Harnsberger whose
unfailing vision and enthusiasm have seen this through some difficult times. The medical illustrations, so key to
understanding and such an Amirsys "trademark", are the work of Rich Coombs, MS and James Cooper, MD I
absolutely love what they have done and you will be seeing them in my lectures for many years!

Michael P. Federle, MD, FACR

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ACKNOWLEDGMENTS

Illustrations
Richard Coombs, MS
James Cooper, MD

Art Direction and Design

Lane R. Bennion, MS
Richard Coombs, MS

Image/Text Editing
Angie D. Mascarenaz
Cassie 1. Dearth
Kaerli Main
Roth LaFleur
David Harnsberger

Medical Text Editing

Andre Macdonald, MD
Doug Green, MD
David Avrin, MD
Akram Shaaban, MD

Production lead
Melissa A. Morris

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