SECTION 03

EPISODE 22

THE TUFFEST STUFF

CT REGISTRY REVIEW
SEMINAR SOLUTION
ABDOMEN & PELVIS CT IMAGING PROCEDURES
MIKE ENRIQUEZ, MPA, BSRT(R)(CT)
ABDOMINAL VASCULATURE

SECTION 03, EPISODE 22 2

Abdomen Anatomy Review

SECTION 03, EPISODE 22 3

SECTION 03, EPISODE 22 4
KEY ASPECTS ABDOMEN & PELVIS CT
SCANNING
• MUST PAY GREATER ATTENTION TO PATIENT PREP THAN WITH ANY
OTHER BODY AREA
• ORAL CONTRAST REQUIRED TO DEMONSTRATE:
• Intestinal lumen
• Distend the GI tract
• ORAL CONTRAST USED TO DIFFERENTIATE:
• Fluid filled bowel loops from a mass or abnormal fluid collection
• EQUAL EFFECTIVENESS:
• Dilute barium solution or dilute water soluble agent
• 600 ml is key volume to maximize bowel opacity

SECTION 03, EPISODE 22 5

KEY ASPECTS ABDOMEN & PELVIS CT SCANNING
• 2 HOURS OF CLEAR FLUIDS PRIOR TO SCANNING TO ENSURE
STOMACH IS EMPTY
• Contrast coated food resembles pathology
• LOW ATTENUATION CONTRAST AGENTS
• Air, carbon dioxide, water
• Air or carbon dioxide used for CT Colonography providing high
negative contrast
• Volumen is a low-HU oral barium sulfate suspension used in place of
positive contrast agents
• Does not
• Obscure mucosal surfaces
• Superimpose abdominal vessels om postprocessed images
• Mask radiopaque common bile duct or urinary tract calculi
SECTION 03, EPISODE 22 6
• LOW CONTRAST BARIUM SOLUTIONS

SECTION 03, EPISODE 22 7

MORE KEY ASPECTS
• MOST COMMON INDICATION FOR RECTAL CONTRAST
ADMINISTRATION IS COLON CANCER STAGING
• THE BLADDER IS BEST APPRECIATED ON CT WHEN FILLED WITH
CONTRAST OR URINE
• IDENTIFICATION OF THE VAGINAL CANAL BEST ACCOMPLISHED
WITH THE INSERTION OF A TAMPON
• IMPORTANCE OF IV CONTRAST
• Opacify blood vessels
• Increase the CT density of vascular abdominal organs
• Improve image contrast between normal structures & lesions
SECTION 03, EPISODE 22 8
MORE KEY ASPECTS

• SPECIFIC INDICATIONS FOR NON-IV CONTRAST SCANS

• Fatty infiltration diagnosis
• Alteration of parenchymal attenuation
• MULTIPHASIC IMAGING USED FOR SPECIALIZED
STUDIES
• Pancreas, liver, kidney

SECTION 03, EPISODE 22 9

Portal Vein Air Embolism-
rare & fatal condition caused
by necrotizing colitis, trauma
& as a complication of
abdominal anastomosis
surgery

SECTION 03, EPISODE 22 10

 Acute
Cholecystitis Axials

Thickening of gallbladder wall

Non-contrast enhanced halo
appearance

Non-calcific calculus
within the wall
enhanced gall bladder

SECTION 03, EPISODE 22 11

Etiologies:
Acute cholecystitis is usually associated with
Acute Cholecystitis
Sudden onset inflammation of the gall bladder
blockage of the cystic duct by a stone.

•Mechanical obstruction, chemical

inflammation, and bacterial infection are
believed to play a role.

•A vast majority of patients are believed to

become symptomatic due to bacterial
infection. Coronal
•Organisms cultured from the gallbladder
include Escherichia coli, Klebsiella species,
group D Streptococcus, Staphylococcus, and
Clostridium.
SECTION 03, EPISODE 22 12
 COMMON ABDOMEN WINDOW SETTINGS
• ROUTINE SOFT TISSUE ABDOMEN
• WW = 450, WL = 50
• Adequate display of most abdominal anatomy
• “LIVER WINDOWS” USED TO IMPROVE VISIBILITY OF SUBTLE LIVER
LESIONS
• WW = 150, WL = 70
• LUNG BASE VISUALIZED WITH LUNG WINDOWS
• WW = 1500, WL = 600
• ABNORMALITY REVEALING BONE LESION WINDOWS
• WW = 2000, WL = 600

SECTION 03, EPISODE 22 13

• NORMAL ABDOMEN- ENHANCED; CORONAL, AXIAL PLANE

SECTION 03, EPISODE 22 14

WHAT ABOUT DFOV?

•AN APPROPRIATE DFOV:

• Just large enough to include the skin surface
over key body areas
• Should use the same DFOV as previous studies

SECTION 03, EPISODE 22 15

LIVER CT ESSENTIALS
• NORMAL CT ATTENUATION OF UNENHANCED LIVER RANGES
FROM 38 – 70 HU
• NORMAL ATTENUATION OF THE LIVER IS AT LEAST 10 HU
GREATER THAN THE SPLEEN
• Fatty infiltration defined:
• Liver attenuates at least 10 HU less than the spleen
• When ROI analysis reveals the spleen to attenuate 10 HU more than the liver
• CAVERNOUS HEMANGIOMA
• Benign tumor often discovered incidentally
• Unenhanced appearance: well-defined hypodense mass similar to the
IVC
• Enhanced appearance: progressive contrast filling from periphery
SECTION 03, EPISODE 22 16
• NORMAL LIVER UNENHANCED

SECTION 03, EPISODE 22 17

 • FATTY LIVER INFILTRATION

If the spleen
measures 10 or
more HU greater
than the liver, a fatty
liver is indicated

SECTION 03, EPISODE 22 18

 MORE LIVER CT ESSENTIALS
• LIVER PERFUSION
• 25% from the arterial hepatic artery which branches from the celiac axis
• 75% from the venous portal vein which receives blood from the SMV,
IMV, SV
• PHASES OF LIVER ENHANCEMENT
• Arterial phase: occurs 15 – 25 seconds post contrast bolus
• Can be further divided
• Portal venous phase: occurs 60 – 70 seconds post contrast bolus
• For routine studies, most scanning is accomplished during the Portal venous
phase
• However, scanning in Early arterial, late arterial & Portal venous phases is
accomplished in some facilities

SECTION 03, EPISODE 22 19

CAVERNOUS HEMANGIOMA
• PORTAL VENOUS PHASE

SECTION 03, EPISODE 22 20

 Metastatic Cancer Lesions
• Secondary liver cancer occurs as a direct result of primary cancer
elsewhere in the body.
• Lung, kidney, breast, stomach and colon cancers are the primary
sites from which “mets” tumors in the liver may originate.
• 50 percent of secondary liver cancer results from the spread of
primary colorectal cancer.
• In many cases, the origin of metastatic liver cancer cannot be
found.
• The primary tumor may be too small to detect and is not causing any
symptoms.
• This is occasionally referred to as unknown primary cancer.
• Because of the important functions the liver performs, “mets” liver
cancer has many possible origins
SECTION 03, EPISODE 22 21
Metastatic Lesions
Lung lesion Lung lesion

Lung lesion

Liver
lesions
plus
Lymph
Node

SECTION 03, EPISODE 22 22

PANCREAS CT ESSENTIALS
• NORMALLY LOCATED BETWEEN THE 12TH THORACIC VERTEBRA
& THE 2ND LUMBAR VERTEBRA ALONG THE MIDLINE
• VISUALIZATION OF THE MAIN PANCREATIC DUCT
• IV contrast enhancement
• Thin slices
• Jaundiced patient
• Non-contrast scans to visualize CBD calculi
• Water or Low contrast oral used to avoid obscuring small
calculi

SECTION 03, EPISODE 22 23

Hepato-biliary Pancreatic Anatomy

SECTION 03, EPISODE 22 24

• NORMAL PANCREAS- AXIAL, ENHANCED

SECTION 03, EPISODE 22 25

Pancreatic Anatomy

SECTION 03, EPISODE 22 26

SECTION 03, EPISODE 22 27
SUPERIOR MESENTERIC ARTERY

SECTION 03, EPISODE 22 28

PANCREATIC CT ESSENTIALS
• MULTIPHASIC IMAGING
• Data acquisition most commonly timed to
• late arterial phase (35 – 40 seconds post IV contrast
bolus); and,
• Portal venous phase (65 – 70 seconds post IV contrast
bolus)

SECTION 03, EPISODE 22 29

Pancreas Essentials
• Differentiating pancreas & duodenum margins
• Additional oral CM
• Axial scans with the patient in right lateral decubitus
position

SECTION 03, EPISODE 22 30

SECTION 03, EPISODE 22 31
CT ESSENTIALS: KIDNEYS & URETERS
• MOST ABNORMALATIES VISUALIZED WITH IV
CONTRAST ENHANCEMENT
• REASONS FOR UNENHANCED SCANS:
• Demonstrate calcifications, calculi that may be obscured
with IV contrast
• Determine baseline attenuation measurements as a
feature of renal mass characterization
• 2D & 3D REFORMATIONS HELPFUL IN DEFINING
RENAL CELL CARCINOMA & URETEROPELVIC
JUNCTION OBSTRUCTION
SECTION 03, EPISODE 22 32
NORMAL KIDNEY

SECTION 03, EPISODE 22 33

CORTICO-MEDULLARY NEPHROGRAM EXCRETORY

30-70 sec. POST-Bolus 100-120 sec. POST-Bolus 3-16 min. POST-Bolus

SECTION 03, EPISODE 22 34

Kidney Essentials
• Unenhanced scans emphasize visibility of calcium and
calculi
• Most exams use IV contrast
• Enhancement phases
• Corticomedullary: 30-70 sec. post CM bolus
• Nephrogram: 100-120 sec. post CM bolus
• Excretory : 3-16 minutes post CM bolus

SECTION 03, EPISODE 22 35

Kidney Essentials
•Contrast administration
• Single bolus technique
• 100-150 mL LOCM at 2-3mL/sec
• Split bolus technique
• Goal is to image a combined nephrographic-
excretory phase
• Two injections of equal mL with a delay of 2-15
minutes between injections
SECTION 03, EPISODE 22 36
 EVALUATING RENAL MASS
• CT IMAGING PROTOCOL
• Round 1: unenhanced scans
• Round 2: IV contrast enhanced post-bolus
• Images obtained from selected phases
• CARDIAC OUTPUT is the major controlling factor
regarding the time of phases
• CORTICOMEDULLARY- 30-70 seconds post-bolus
• NEPHROGRAM- 80-120 seconds post-bolus
• EXCRETORY- 3-16 minutes post-bolus

SECTION 03, EPISODE 22 37

CTU EXAMINATION KEYS
• Kidneys, ureter & bladder imaging
• MDCT- thin slice
• IV contrast
• Excretory phase imaging emphasized but may include all 4
phases
• Unenhanced
• Corticomedullary- 60 seconds post-bolus
• Nephrogram- 110 seconds post-bolus
• Excretory- 3-16 minutes post-bolus
• Other techniques to improve KUB enhancement
• Compression band
• IV saline hydration
• Low-dose furosemide (Lasix) injection
SECTION 03, EPISODE 22 38
CTU CONTRAST
ADMINISTRATION TECHNIQUES
• SINGLE BOLUS
• 100-150 ml LOCM
• 2-3 ml/sec injection rate
• SPLIT-BOLUS
• Goal is to image a combined nephrographic & excretory
phases
• Two bolus injections
• Delay between injections: 2-15 minutes possible
• Recognized as a lower dose technique
SECTION 03, EPISODE 22 39
CT Urography

•Many different protocols

•Split-bolus technique
• Two bolus injections with a delay of between 2
& 15 minutes between injections
• Goal: image combine nephrographic-excretory
phase

SECTION 03, EPISODE 22 40

• UNENHANCED CTU- demonstrating calculi

SECTION 03, EPISODE 22 41

• TRIPLE BOLUS MDCT- demonstrates an enhancing
lesion

SECTION 03, EPISODE 22 42

CT UROGRAPHY
• Unenhanced scans emphasize visibility of calcium and
calculi
• Most exams use IV contrast
• Enhancement phases
• Corticomedullary: 30-70 sec. post CM bolus
• Nephrogram: 100-120 sec. post CM bolus
• Excretory : 3-16 minutes post CM bolus

SECTION 03, EPISODE 22 43

 Demonstrated are a number of Streak Artifact
detectors not ready to receive
information. They are acting as if
this were a bad case of “Ring”
artifact.
Solution:
Remove the patient from the
scanner room. Using the
appropriate phantom recalibrate
the system detectors
Resume scanning only after
testing with phantom indicates all
is working correctly.

SECTION 03, EPISODE 22 44

 UROLITHIASIS
• TERMINOLOGY
• RENAL CALCULI- stones located in the kidneys
• URETEROLITHIASIS- stones located in a ureter
• RENAL COLIC- acute pain associated with the passage of urinary
tract calculi
• HYDRONEPHROSIS- ureteral obstruction resulting in dilatation,
distention, enlargement of the renal pelvis
• 10% of people in the U.S. affected
• 50% recurrence rate within 10 years
• IDIOPATHIC NEPHROLITIASIS- no clear precipitating factor linked to
stone formation
SECTION 03, EPISODE 22 45
• BASIC TYPES URINARY CALCULI
• Calcium salt- most common type; account for 75% of stone cases
• Uric acid
• Struvite (magnesium ammonium phosphate)
• Cystine
• 80%-85% pass simultaneously
• 4 mm size stone has an 80% chance to pass
• 5 mm size stone has a 20% chance to pass
• Factors impacting stone passage:
• Patient size
• Record of previous stone passage
• Prostate enlargement
• Pregnancy
• Stone size SECTION 03, EPISODE 22 46
 Urinary Tract Calculi CT
• Noncontract helical CT (NCHCT)
• More than 99% of stones, including those radiolucent on
plain film imaging, will be visualized on NCHCT
• Nephrolithiasis, urolithiasis
• Protocols use a helical scan mode from the top of the kidneys
to the bladder base
• 3 mm or less slice thickness
• Greatest negative: huge radiation dose particularly to the
gonads
• Complicated due to young patients, many who have stone disease
are young
SECTION 03, EPISODE 22 47
 RENAL COLIC SYMPTOMATOLOGY
• VERY SIMILAR TO MANY CONDITIONS
• From vague to waves of severe flank pain
• It’s when the stone stops that it hurts
• Caudal to medial pain migration relative to the ureter and side
• Pain is not reliably associated with stone size
• Sharp points are painful regardless of size
• Hematuria is common- ureteral wall erosion
• Frequency or experiencing a burning sensation upon urination
are also symptoms- the stone is getting close to leaving the
bladder
SECTION 03, EPISODE 22 48
• CLASSIC PATIENT:
RENAL COLIC SYMPTOMATOLOGY
• SEVERE UNILATERAL FLANK PAIN &/or SEVERE LOWER ABDOMEN PAIN
• CAN’T SIT OR LIE STILL
• Postural changes don’t help relieve the pain
• STIMULATION OF THE CELIAC PLEXUS in some patients:
• Nausea
• Vomitting
• Pain unrelated to trauma
• Febrile state is not a factor
• Noncontrast Helical CT (NCHCT) is the best investigatory diagnostic
tool- MDCT @ 2.5 – 3.0 mm collimation slice thickness
• 99% of all stones visualized including those radiolucent on plain film
• However, it is a high gonadal dose procedure
• Allows evaluation of stone for extracorporeal shock wave lithotripsy (ESWL)
• 1,000+ HU limit to ESWL SECTION 03, EPISODE 22 49
 RENAL COLIC SYMPTOMATOLOGY
• Peritoneal irritation
• A few important symptoms are the opposite of renal
colic
• Maintaining pain-free position
• Location of lesion will determine nausea, vomitting

SECTION 03, EPISODE 22 50

SECTION 03, EPISODE 22 51
SMALL BOWEL
THREE PARTS: 20 FEET LONG, 2.5 INCHES
IN DIAMETER
1. DUODENUM
2. JEJUNUM
3. ILEUM

ISCHEMIC COLITIS
SECTION 03, EPISODE 22 52
ADRENAL GLAND CT
• Technologist identification of INCIDENTELOMA
• An unexpected finding
• Can be related to adrenal mass
• Slight adjustment in protocol may save a repeat
exam
• Addition of delayed images
• CT is the gold standard regarding the
investigation of adrenal mass
SECTION 03, EPISODE 22 53
Adrenal Gland CT
•Imaging goal
• Reduce…
• …The number of unnecessary biopsies
• …The number of follow-up studies needed for an
accurate diagnosis
• …the cost of care

SECTION 03, EPISODE 22 54

 INCIDENTALOMA
• The majority are benign
• Further investigation, possibly including biopsy, is warranted
• BIOPSY:
• Invasive
• Risk of complication
• CT can be used to differentiate benign versus malignant
• Assess attenuation details
• Less than 10 HU is lipid rich and benign (adenoma)
• Greater than 10 HU is problematic
• Evaluate IV contrast washout from the mass on delayed images
• HU contrast enhancement at portal venous phase compared to 15
minute delayed images to determine washout percentage
• Less than 60% washout indicates malignancy
SECTION 03, EPISODE 22 55
 MALIGNANT LESION CHARACTERISTICS
• LESIONS greater than 4 cm in diameter
• LESIONS that change size in a notable fashion
• Metastatic lesions are heterogeneous & have an irregular shape
• A HU value of greater than 10
• Means that there is a minimum of fat which points to malignant mass
lesion
• Malignancy according to formulas:
• Washout of less than 60% when enhanced images are available
• Relative washout formula used when unenhanced images are not
available
• When less than 40% malignancy is indicated
SECTION 03, EPISODE 22 56
ADRENAL ANATOMY

• Named according to their location at the top of each kidney, aka,

“Suprarenal gland”
• Triangular in shape and normally weigh approximately 5 grams
SECTION 03, EPISODE 22 57
ADRENAL MALIGNANCY

SECTION 03, EPISODE 22 58

Axials
Adrenal Mass
• Etiology facts:
• Often discovered incidentally during
the performance of CT procedures and
are termed “incidentaloma.”
• Usually, the patient has no signs of
hormonal excess or obvious underlying
malignancy.
• Less commonly, adrenal masses are
discovered as part of the clinical
workup for suspected adrenal disease
(eg, Cushing syndrome).

SECTION 03, EPISODE 22 59

 Sagittals
Coronals

SECTION 03, EPISODE 22 60

CT & ACUTE APPENDICITIS
• MOST POPULAR CT PROTOCOL
• Scan entire abdomen and pelvis with both IV and oral contrast materials
• MOST COMMON CT FINDINGS
• Dilated nonopacified appendix
• Soft tissue stranding into adjacent periappendiceal fat
• Appendicolith
• MOST COMMON ETIOLOGY
• Fecalith
• MOST COMMON INCIDENCE
• Most common in ages 10 – 40
• Occurs in 7% of the population in some time of their lives

SECTION 03, EPISODE 22 61

 ACUTE APPENDICITIS DIAGNOSIS
• MOST COMMON DIAGNOSTIC TOOL
• Appendiceal CT
• REVIEW OF IMAGING STUDIES
• Plain film imaging not useful
• Barium enema no longer commonly used
• Ultrasound very useful but also very non-specific
• Children
• Young women
• Pregnant women
SECTION 03, EPISODE 22 62
ACUTE APPENDICITIS CLINICAL PRESENTATION
• Variable position contributes to the diverse clinical presentation
• Base fixed to cecum but variable location of tip
• Challenging to localize on cross-sectional images
• Can be duplicated structurally
• Easily mistaken for diverticula
• No single clinical finding can effectively rule out or confirm acute
appendicitis diagnosis
• Acute gynecologic conditions may mimic acute appendicitis
• Abdominal pain, anorexia, nausea & vomiting are the most common
symptoms
• Appendix position affects clinical presentation
SECTION 03, EPISODE 22 63
ACUTE APPENDICITIS

SECTION 03, EPISODE 22 64

FINDINGS:
Evaluation of the pelvis demonstrates a Acute Appendicitis
rounded structure seen within the right lower
quadrant with a 7 mm diameter suspicious for
appendicitis. Small fluid is seen. No definite
inflammation is seen in this region.
IV contrast was given. Normal enhancement of
the liver and spleen is seen. The stomach
appears normal. The pancreas is within normal
limits. The kidneys demonstrate normal
enhancement. The upper abdomen is
unremarkable. The retroperitoneum is normal.

SECTION 03, EPISODE 22 65

 Streak Artifact Demonstrated
Four categories of Artifact:
• Physics based: include beam hardening,
photon starvation
and undersampling artifacts.
• Patient based: include metallic and
motion artifacts.
• Scanner based: artifacts caused by
detector sensitivity and
mechanical instability.
• Spiral based: artifacts arise due to spiral
interpolation.

SECTION 03, EPISODE 22 66

 Streak Artifact
Demonstrated are a number of
detectors not ready to receive
information. They are acting as if this
were a bad case of “Ring” artifact.
Solution:
Remove the patient from the scanner
room. Using the appropriate phantom
recalibrate the system detectors
Resume scanning only after testing
with phantom indicates all is working
correctly.
SECTION 03, EPISODE 22 67
Appendix with fecalith; no inflammation is
presented although dilated to 8 mm

“Strandy”mesentery
indicative of inflammation

Appendix

Terminal Ilium
Appendix with fecalith

SECTION 03, EPISODE 22 68

 DIVERTICULITIS or DIVERTICULOSIS
• MAJOR SYMPTOM IS PAIN IN THE LEFT LOWER QUADRANT
• Can sometimes be RLQ
• Other symptoms:
• Tenderness, cramps, fever & chills, bloated feeling, diarrhea or
constipation, nausea, vomiting, loss of appetite
• Recommend high fiber diet components
• DIVERTICULOSIS: The abnormal development of pouches in
the bowel lining
• These can become holding areas for bacteria and cause
inflammation
• Erosion of the walls can cause the development of fistula
SECTION 03, EPISODE 22 69
DIVERTICULITIS or DIVERTICULOSIS

SECTION 03, EPISODE 22 70

Abdomen

SECTION 03, EPISODE 22 71

SECTION 03, EPISODE 22 72
 1. Falciform ligament
2. Left gastric artery & vein
3. Magenblase
4. Barium-filled stomach
5. Spleen
6. Splenic artery
7. Left kidney
8. Left adrenal gland
9. Diaphragm
10. Spinal cord
11. Aorta
12. Inferior vena cava
13. Portal vein
14. Liver
15. Spinal nerve
16. Ribs
17. Transverse colon
18. Splenic vein
19. Cortex, left kidney
20. Medulla, left kidney
21. Vertebra
22. Right adrenal gland
SECTION 03, EPISODE 22
23. pancreas 73
 1. Falciform ligament
3. Magenblase
4. Barium-filled stomach
5. Spleen
8. Left adrenal gland
11. Aorta
12. Inferior vena cava
13. Portal vein
14. Liver
17. Transverse colon
18. Splenic vein
19. Cortex, left kidney
20. Medulla, left kidney
21. Vertebra
22. Right adrenal gland
23. Pancreas
SECTION 03, EPISODE 22 74
 1. Hepatic artery
2. Duodenum
3. Barium-filled stomach
4. Splenic flexure, colon
5. Spleen
6. Pancreas
7. Left kidney
8. Celiac axis artery
9. Aorta
10.Inferior vena cava
11.Portal vein
12.Liver
13.Vertebra
14.Spinal cord
16. Splenic vein

SECTION 03, EPISODE 22 75

 2. Duodenum
4. colon, splenic flexure
5. Spleen
9. Aorta
10. Inferior vena cava
12. Liver
15. Rectus abdominus muscle
17. Pancreatic head
18. Portal vein confluence
19. Jejunum
20. Superior mesenteric artery
21. Left renal vein
22. Right kidney
23. Psoas muscle
24. Erector spinae muscle
25. Gall bladder
SECTION 03, EPISODE 22 76
Branches of the thoracic and abdominal aorta

SECTION 03, EPISODE 22 77

UPPER ABDOMINAL ARTERIES
CELIAC AXIS ARTERIES
• SPLENIC ARTERY
• COMMON HEPATIC ARTERY

SUPERIOR MESENTERIC ARTERY

RIGHT & LEFT RENAL ARTERIES

INFERIOR MESENTERIC ARTERY

SECTION 03, EPISODE 22 78

SECTION 03, EPISODE 22 79
SECTION 03, EPISODE 22 80
SECTION 03, EPISODE 22 81
SECTION 03, EPISODE 22 82
 Thoracic & Abdominal Veins

SECTION 03, EPISODE 22 83

AZYGOS & HEMI-AZYGOS VEINS
FACTS:
1. Innominate = Brachiocephalic
2. Azygos connects the IVC & SVC
1. Courses the right vertebral column
2. Azygos origin at pre-renal portion of the IVC
3. Azygos drains into the SVC
3. Hemi-azygos:
1. Courses the left vertebral column
2. Communicates with the Azygos at the level
of T-7
4. Accessory Hemi-azygos
1. Receives venous return from:
1. Oblique vein of Lt. Atrium
2. Coronary Sinus
SECTION 03, EPISODE 22 84
 Hepatic-Portal System
H-P SYSTEM CONTRIBUTING
VEINS

• SUPERIOR MESENTERIC VEIN

• INFERIOR MESENTERIC VEIN
• GASTRO-SPLENIC VEIN

SECTION 03, EPISODE 22 85

 Hepatic-Portal System
H-P SYSTEM CONTRIBUTING
VEINS

• SUPERIOR MESENTERIC VEIN

• INFERIOR MESENTERIC VEIN
• GASTRO-SPLENIC VEIN

SECTION 03, EPISODE 22 86

SECTION 03, EPISODE 22 87
Abdominopelvic

SECTION 03, EPISODE 22 88

PELVIS

SECTION 03, EPISODE 22 89

SECTION 03, EPISODE 22 90
CT MALE PELVIS

SECTION 03, EPISODE 22 91

Iliac VEIN thrombosis- why DVT arise from the left leg

The Left Iliac

Vein is located
between the
Right Common
Iliac Artery
anteriorly, and
the Lumbar
vertebral column
posteriorly

SECTION 03, EPISODE 22 92

Internal Iliac Artery Branches
COMMON ILIAC ARTERY
• Located just to the left side of
the body of the 4th lumbar
vertebra
• Located where the abdominal
aorta divides

• THE INTERNAL ILIAC ARTERY is

the main pelvic artery (aka,
hypogastric artery)

SECTION 03, EPISODE 22 93

Common Iliac Artery Branches

SECTION 03, EPISODE 22 94

SECTION 03, EPISODE 22 95
 1. Mesenteric arteries
2. External iliac arteries
3. Gluteus minimus muscle
4. Gluteus medius muscled
5. Gluteus maximus muscle
6. Sacrum
7. Internal iliac arteries
8. Right common iliac vein
9. Fascia
10.Rectus abdominus muscle
11.ilium
19. Left common iliac vein
20. Iliacus muscle
21. Psoas muscle

SECTION 03, EPISODE 22 96

 10. Rectus abdominus muscle
11. Ilium
12. Bladder
13. Sigmoid colon
14. Piriformis muscle
15. Left external iliac artery
16. Left external iliac vein
17. Right external iliac artery
18. Right external iliac vein

SECTION 03, EPISODE 22 97

 1. Bladder
2. Left external iliac artery
3. Left external iliac vein
4. Obturator internus muscle
5. Seminal vesicles
6. Rectum
7. Coccyx
8. Ischium
9. Femoral head
10.Pubis
11.Right external iliac artery
12.Right external iliac vein
13.Rectus abdominus muscle
19. Gluteus maximus muscle
20. Gluteus minimus muscle
21. Gluteus medius muscle
SECTION 03, EPISODE 22 98
 1. Bladder
2. Left external iliac artery
3. Left external iliac vein
4. Obturator internus muscle
5. Seminal vesicles
6. Rectum
7. Coccyx
8. Ischium
9. Femoral head
10. Pubis
11. Right external iliac artery
12. Right external iliac vein
13. Rectus abdominus muscle
14. Quadriceps femoris muscle
15. Prostate gland
16. Iliopsoas muscle
17. Sartorius muscle
18. Femoral head
19. Gluteus maximus muscle
20. Gluteus minimus muscle
21. Gluteus medius muscle
22. Tensor fascia lata muscle
SECTION 03, EPISODE 22 99
 1. Bladder
2. Sigmoid colon
5. Gluteus minimus muscle
6. Gluteus medius muscle
7. Ovaries
8. Uterus w/ IUD
9. Ilium
10. Gluteus maximus muscle
11. Sacrum
12. Piriformis muscle
13. Rectum
15. Iliacus muscle
16. Right external iliac artery
18. Rectus abdominus muscle

SECTION 03, EPISODE 22 100

 1. Bladder
4. Left external iliac vein
6. Gluteus minimus muscle
9. ilium
10. Gluteus maximus muscle
13. Rectum
16. Right external iliac artery
18. Rectus abdominus muscle
20. Femoral head
21. Vagina
24. Iliopsoas muscle
25. Sartorius muscle
26. Tensor fascia lata muscle
27. ischium

SECTION 03, EPISODE 22 101

Things to study…
1. Know the arterial branches of the abdominal aorta inferior to the
diaphragm
2. Be able to label an axial slice of the abdomen at approximately the
level of L3, and from this image be able to:
1. Label all pertinent anatomy
2. Accurately describe the Window Width and scale of contrast
3. Accurately describe the demonstrated vascular phase
4. Accurately describe the demonstrated enhancement of the kidneys
3. Review the key aspects of Abdomen & Pelvis CT Scanning
1. Pay attention to the details

SECTION 03, EPISODE 22 102

Things to study…
4. Specific indications for NON-IV Contrast liver scan:
a. Fatty infiltrate diagnosis
b. Parenchymal attenuation alteration
5. Review the Window settings…
a. How is visualization of subtle liver lesions maximized?
b. What is the CT Number relationship that defines fatty liver
infiltrate?
6. Closely review the CT essentials for the following:
a. Liver
b. Pancreas
c. Kidney
d. Adrenal Glands

SECTION 03, EPISODE 22 103

Things to study…
7. Know the enhancement phases for the kidney…
a. By image description
b. By verbal description
c. By time increment
8. What are the details of renal colic?
9. How is renal colic different from peritoneal irritation?
10. Describe the 3 segments of the small bowel.
11. State the details of adrenal gland CT
a. What is the primary method for dealing with suspected
tumor?
SECTION 03, EPISODE 22 104
Things to study…
12. Describe the details of malignant lesion detection regarding the
adrenal gland.
13. Review the CT imaging details of delayed adrenal gland CT
14. Make sure you review the clinical details associated with the
following:
a. Cholecystitis
b. Appendicitis
c. Diverticulitis

SECTION 03, EPISODE 22 105

Things to study…
15. Know the details and be able to label the vascular anatomy associated
with the following:
a. Celiac axis
b. Hepatic-Portal System
c. Azygos-Hemiazygos System
16. Be able to label the following anatomical structures:
a. Liver
b. Abdomen
c. Male Pelvis
d. Female Pelvis
SECTION 03, EPISODE 22 106