Hi everyone, my name is Asma Ahmed. I am an assistant professor of cardiopulmonary imaging at the UEB. And today we are going to discuss some of the incidental abdominal findings on the CT attenuation correction images. And we will start by discussing the incidental findings of the liver and spleen, like liver lesions or cysts, fatty liver, liver cirrhosis, as well as liver and splenic granulomas. So sometimes we find these hypoattenuation lesions within the liver. If they are rounded and well circumscribed, as you can see in this case, we assume that these are or might be hepatic cysts. As you can see in this patient, there is another well circumscribed, rounded hypoattenuation lesion within the liver here that usually is not very clear to visualize. You might need to play with the Hounsfield unit a little bit to visualize them more. This is another example of a large hypoattenuation lesion within the liver that is well circumscribed and rounded. And that's why we assume that these lesions are hepatic cysts. In this case, it is more obvious than before. This is another example of hypoattenuation hepatic lesions that is not, you cannot clearly identify the border. It is not well circumscribed or rounded lesion. It is more of a diffused border. And this ended up being liver metastasis. So not every hypoattenuation lesion that you will find in the liver is going to be assessed. It might be assessed or might be something else. So all what you need to recommend is do a specific liver test or abdominal test, like abdominal ultrasound or dedicated abdominal CT for evaluation of the hepatic lesions. We have another example here for incidental abdominal findings, which is liver cirrhosis and with or without ascites. And this is another example of a patient with shrunken liver and the liver has an irregular margin, as you can see. And there is a fluid density surrounding the liver and the spleen and the upper abdomen, which is ascites. And this is a partially visualized spleen omegaly, which is commonly seen in those patients with liver cirrhosis. This is another example that's not an attenuation correction CT image. That's actually a delayed contrast enhanced image that I just brought for more clear image or visualization of what are the findings exactly. So that's a shrunken liver with a regular outer border. And this is all that fluid density is just ascites. And this is a partially visualized spleen omegaly in a patient with hepatic cirrhosis. This patient has what we call a diffuse hepatic steatosis or fatty liver. And as you can see, the liver here is almost coming closer to the density of the subcutaneous fat and the Helmsfield unit for that liver was minus 10. The fat is usually in the minus from tens to hundred. It does not exceed, rarely exceed 100 because the air is the one Helmsfield unit is this more than minus 100. But the fat is usually in the range between minus 10 and minus 100. And this liver was measuring minus 10. And it is diffusely affected. That's another example of a diffuse hepatic steatosis. And even if the density does not measure as attenuation and as hypo attenuating as the subcutaneous fat, you can still see that this liver parenchymal density is not the normal one. And the easiest way to describe that is to compare it to the splenic density. So here the splenic density was mean of 47 and here was mean of 23. So the spleen was almost double the density of the liver. And this is an indication for diffuse hepatic steatosis, usually the attenuation of the liver and spleen are one to one. This is an example of a calcified hepatic granuloma. I have another example of calcified hepatic and splenic granuloma, as you can see. And for calcified hepatic and splenic granuloma, you cannot, you don't actually have to do any further investigation. You just mention about them. For gallbladder, we are going to show some examples for gallbladder stones as well as cholecystectomy surgical clips. So we have this patient here with large gallstones noted on the CT attenuation prediction with patient presented with chest pain. As you can see, this is the gallbladder here, that's the liver. And the arrow is pointing to a hyperdense lesion within the gallbladder, which means that these are gallstones. Another example of gallstones. So again, hyperattenuation lesions within the gallbladder, which is usually inferior to the liver at the gallbladder fossa. And they are more dependent, as you can see, the gallbladder stones are usually dependent and that's to differentiate them from other gallbladder entities. That's an example for what is called gallbladder sludge, or like these are usually multiple minute stones that are dependently layering over each other, making the layering appearance of the hyperdense lesions. And this can be called gallbladder sludge. Of course, in patients with, you know, chronic cholecystitis or acute cholecystitis, they now do a lab cholecystectomy and they leave behind these surgical clips. These surgical clips might be one or more than one, like this patient had one surgical clip, another patient had two surgical clips in place. This is just to show you an example of how the post-cholecystectomy surgical clips look like. For the pancreas, one of the standout pancreatic abnormalities is pancreatic calcifications, as in this patient who had multiple other abnormalities like hepatic cirrhosis, ascites, gallbladder stones, but he does also have a lot of calcified, a lot of pancreatic calcifications, and this patient had alcoholic cirrhosis, as you can see here. For the stomach, we have, either you can find some prior surgical-related changes or you can find hiatal hernia, and this patient has a very large hiatal hernia, so the stomach is almost completely herniated within the mediastinum, inside the chest, as you can see. This patient had a prior, what is called gastric bending, so you can see, as you are cutting axial here, you are cutting through the band, and this is a coronary obstruction, you can actually see the band, so it's a circular metallic structure that surrounds the proximal stomach, and as you are cutting through, you can see two edges of this circular band. For the kidneys, you can see, similar to the liver, you can see renal cysts. The kidneys with chronic kidney disease, they might be atrophic. You can also see some renal stones, so this is an example of a renal cyst. Again, similar to the liver, there is a well-circumscribed and rounded hypoattenuation lesion within the renal parenchyma. Sometimes it has a partial exophytic component, as you can see here, and we call this a cortical cyst, and this is the liver, of course, and this is the gallbladder here. The left kidney does not show any abnormalities in that image, and I want to drag your attention to how big the kidney is here, and that's the normal size for the kidney. It is surrounded with the fascia or the perinephric fat, which is not very big. It is a reasonable amount relative to the kidney size. This is in comparison to what we will discuss later of kidney atrophy. That's an example of nephrolithiasis or a stone within the right kidney, so you will see, similar to gallstone, you will see a hyperdense lesion within the renal pelvis or renal parenchyma, and as you can see here, it is more towards the renal pelvis. That's an example for renal atrophy, and I want to show you this in comparison to the prior exam. As you can see, there is excess or abundance of surrounding intrarenal fat, and the renal parenchyma itself has become really thinned out, as you can see, bilaterally, so this is an example of renal atrophy. I have collected some cases with multiple lesions, so you are not going to see necessarily each lesion separately. Some patients would have more than abnormality in one patient, like this patient, so I'm going to scroll through the images and describe the abnormalities as we are going down, so that's a small hiatal hernia here, and as you can see, the patient had some sort of prior surgical sutures at the gastroesophageal junction, and as you can see, the patient also has anterior abdominal hernia, postcholestectomy surgical clips. Let me go back and stop at each abnormality, so as we are scrolling down, that's a non-contrast abdominal CT. First of all, we can see part of the stomach here above the diaphragmatic level, which is exactly what the hiatal hernia means, and associated with that is some prior surgical changes or surgical sutures or material along the stomach, and as we are scrolling down, you will notice that the patient actually does not have a gallbladder, and instead of the gallbladder, he has postcholestectomy surgical clips. The patient also has some sort of renal atrophy, so there is a thinned-out renal arrhythmia, as you can see here, left greater than right. So that was the first case I have. The patient also has another abnormality that we did not discuss before, which is some of the bowel loops here, as you can see, has escaped between the anterior abdominal wall muscles, so that's an anterior abdominal wall muscle, and there is a gap in that muscle, and some of the bowel has escaped into the subcutaneous back, and this is an example of anterior abdominal wall hernia. Okay, next patient. So this is another patient who also has multiple lesions, so that's a small hiatal hernia. There is a large hypoattenuating liver lesion in postcholestectomy surgical clips. There is another hypoattenuating lesion here within the liver as well. So again, let me re-scroll through the patient. So first, as we are going down, we notice the large, well-circumscribed and rounded hepatic lesions, most likely hepatic cysts, and as we are going down, there is a small herniating stomach endothelial stynum. There is also postcholestectomy surgical clips, as you can see, and multiple hypoattenuating liver lesions that are cysts, that are most likely cysts. That's another patient. It's a delayed post-contrast images, not necessarily attenuation correction, just to show you the abnormality. So you have a shrunken cirrhotic liver with large ascites. You have also splenomegaly. You have some splenic hypoattenuating lesions. You can also see some sort of vascular calcifications here and some pancreatic calcifications, gallbladder with gallbladder stones. So just keep in mind, this is a renal cyst, for example, cortical renal cyst. Just keep in mind that you are going to, you might be able to see multiple, more than one abnormality in the upper abdomen, not necessarily one. And this is another patient who has a diffused hepatic steatosis. In this case, it is a little bit mild because in comparison to the spleen, it is not very attenuated. The patient has also a small hiatal hernia. So part of the stomach has herniated into the mediastinum. He has also a fat-containing butylic hernia, and butylic hernia is just one type of the diaphragmatic hernias, and it's a congenital hernia, and it's a defect within the posterior diaphragm. And if you can just, most of the time it contains just mesenteric fats. So you can just say, you know, small fat-containing butylic hernia. I hope that review was beneficial, and thank you so much for everyone.

incidental findings

CT attenuation

liver lesions

abdominal ultrasound

hepatic steatosis