Eosinophilic Gastroenteritis

Case: 40Y Male patient presented with abdominal pain and diarrhoea. 

Plain CT image shows thickened appearing colon (orange arrows) with surrounding fat stranding. Thickening of anterior pararenal fascia is also seen bilaterally (blue arrows). 

Contrast CT images showed edematous thickening of the terminal ileum (not shown) and large bowel upto distal descending colon. Peri-colonic inflammatory fat stranding is noted. The SMA-SMV, IMA-IMV showed normal contrast opacification. 

Contrast CT images showing mild right pleural effusion (yellow arrow) and ascites (green arrows). 

Differential Leukocyte count revealed Eosinophil count of 18% initially and rose upto 68% within 3 days. Peripheral smear showed normocytic normochromic picture with marked eosinophilia. 

Colonic biopsy showed dense chronic inflammation with predominance of eosinophils - features compatible with Eosinophilic enterocolitis.

Patient was treated with Steroids and Azathioprine, improved and was asymptomatic with normalized lab parameters in the last visit.  

Eosinophilic gastroenteritis  is a rare inflammatory disorder of the gastrointestinal tract, characterized by focal or diffuse eosinophilic infiltration of the gastrointestinal tract. Clinical features and radiological findings are non-specific, so a high index of suspicion is needed, in cases of peripheral eosinophilia (seen in >60%). This usually presents with dyspepsia and diarrhoea. It may rarely cause GOO / SBO and pancreatitis. This disease was first described by Kaijser in 1937.

Although any age group can be affected, majority of patients are in the 3rd to 5th decades, with a slight male preponderance. Most patients have history of seasonal allergies, asthma, food sensitivity, eczema, elevated IgE levels. 

EG is a self-limiting disorder in most cases and usually responds well to steroids. 

Three types of EG have been mentioned, 

1. Mucosal EG (most common) : presents with fecal blood loss, anemia, weight loss due to malabsorption or protein losing enteropathy.
2. Muscularis EG : presents with obstruction (GOO/SBO).
3. Subserosal EG : manifests as eosinophilic ascites. 

Definitive diagnosis of EG requires bowel biopsy correlation demonstrating the eosinophil infiltration. In cases of the subserosal EG, high eosinophil count in a sterile ascitic fluid by paracentesis can also be demonstrated. 

Major DD would be a intestinal parasites, which necessitates stool examination to look for ova and parasites. 

Hypereosinophilic syndrome (HES) is an idiopathic condition associated with marked peripheral eosinophilia (>1500/uL for >6months) and gastroenteritis. Heart, lungs, brain and kidneys are also affected in HES. 

Imaging features are non-specific, can show edematous wall thickening. Ascites and pleural effusion can be seen. Esophagus, stomach, small bowel and also colon can be affected. 

References:

• A Review of Eosinophilic Gastroenteritis.
• Radiopaedia. 

Thanks to Dr. GP. 

Radiation enteritis

Below are the CT images of a 60y female patient, post surgery, post chemo-radiotherapy for Ca Rectum 3 months before the CT. 

CT images show 'long segment, contiguous, mild circumferential wall thickening of distal and terminal ileum, measuring length of ~30cm and maximum wall thickness of ~6mm. No peri-enteric fat stranding or lymph node enlargement seen'.  There were no sinuses or fistulae or any features of bowel stricture or obstruction.  

The blue arrows point to the thickened ileal loops. 

Radiation induced enteritis, especially of the small bowel is less often seen even though small bowel is very radiosensitive, because of its relatively increased mobility. Among small bowel the terminal ileum is the most sensitive, as it is more or less fixed. Fixation due to adhesions from a previous surgery or previous inflammation (including PID) can increase the risk of radiation induced bowel damage. Thin habitus, diabetes and hypertension can also influence the post radiation injury. 

Radiation doses >50Gy administered over 6 weeks can produce radiation induced bowel injury, which in 10% of cases might require surgical intervention. ~5-15% patients receiving >45Gy develop chronic radiation enteropathy.

The three stages of radiation enteritis are acute, subacute (2-12 months) and late phase. Acute phase is usually the mucosal inflammation, crypt abscesses, superficial ulcerations. Subacute phase, is a phase of regeneration, arteriolar sclerosis. Late phase is usually due to fibrosis. This phase can result in strictures, obstruction, fistula and sinus formation. 

👉  Point to remember : Keep in mind the differential of radiation induced bowel injury, in cases of bowel wall thickening. Especially in a post op patient, ask for history of radiotherapy. 

Calyceal Diverticulum

Calyceal diverticula are outpouchings of renal calyces or even renal pelvis (pelvi-calyceal diverticula) into the renal cortex connected by narrow neck. These are lined by non-secreting urothelium (transitional cell epithelium).

Incidence: 0.2-0.6% of patients undergoing renal imaging.

Usually these are incidental findings and are mostly asymptomatic. Due to stagnation of urine within the diverticulum, these are prone for stone formation. Stones can be found in upto 50% of the calyceal diverticula.

Exact etiology of the formation of calyceal diverticula are not known, may be congenital or acquired due to infections, VUR, or rupture of a cortical cyst.

These are subdivided into two types:¹
Type 1 communicating with a calyx, usually found in upper pole.
Type 2 communicating with renal pelvis, larger, usually found in mid-pole (also called pyelo-calyceal diverticula). Radiopaedia adopts a slightly varied types, with type 1 from minor calyx and type 2 from major calyx or renal pelvis.²

There may be internal calcifications, either in the form of stones or of milk of calcium. In one small ultrasound series, 7 of 11 cases of calyceal diverticula demonstrated mobile echogenic material. It is suggested that the presence of mobile hyperechogenic material within a cystic structure is diagnostic of a calyceal diverticulum. ³

Differential considerations of a calyceal diverticulum would include complex cyst, dilated calyx, cystic renal neoplasm and abscess. Unless an excretory (or urogram) phase is acquired diagnosis of calyceal diverticulum is not possible. Dilated calyx can be due to obstructing stone, tumor or due to infundibular stenosis in TB.



The following plain and contrast CT images are of a 40 year old male patient who was evaluated for left lumbar pain and tenderness.

Plain CT Axial sections showing calcific focus within a subtle hypodense area in the bilateral renal parenchyma. 

Type I Bosniak cyst is noted medially (not marked).

The above three images shows the Plain CT, venous phase and excretory phase axial sections of both kidneys, which shows contrast filling of the cystic appearing area in the venous phase - consistent with the diagnosis of Calyceal Diverticulum of both kidneys. Calculus formation is noted in both these calyceal diverticulum. 

Oblique coronal MIP image showing the contrast filled bilateral calyceal diverticulum (Green arrows). The yellow arrow points to the pathology for which the patient underwent the CT examination (colitis). As in most cases, this case of bilateral calyceal diverticulum was also asymptomatic.  

3D VRT image demonstrating the calyceal diverticula. 

References
1. Mullett, Rebecca et al. “Calyceal diverticulum - a mimic of different pathologies on multiple imaging modalities.” Journal of radiology case reports vol. 6,9 (2012): 10-7. doi:10.3941/jrcr.v6i9.1123

2. Stunell, H et al. “The imaging appearances of calyceal diverticula complicated by uroliathasis.” The British journal of radiology vol. 83,994 (2010): 888-94. doi:10.1259/bjr/22591022

3. Reynard J, Brewster S, Biers S. Oxford Handbook of Urology. Oxford: Oxford University Press; 2006. p. 328.

4. Leveillee RJ, Bird VG. Treatment of Caliceal Diverticula and Infundibular Stenosis. In: Smith AD, Badlani G, Bagley D, et al., editors. Smith’s Textbook of Endourology. 2nd ed. Ontario: BC Decker; 2007. pp. 171–185.

Pancreatic pseudocyst with duct communication (CT)

Pancreatic pseudocysts are the most common (85% to 90%) cystic lesions of pancreas, which are encapsulated peripancreatic or remote fluid collections developing after 4 weeks of an episode of acute pancreatitis. These are called pseudocysts as cyst lining is formed of fibrous tissue and not true epithelium. Cyst contents are rich in amylase.

Causes of pancreatic pseudocysts include Acute or chronic pancreatitis (most common), pancreatic trauma and rarely iatrogenic (e.g. partial gastrectomy). In cases of acute pancreatitis with inflammatory changes and seeing fluid collection developing wall or capsule in the peri-pancreatic region in follow-up imaging, is usually diagnostic of a pseudocyst. These usually arise 4 to 6 weeks after an acute episode. Pseudocysts can be followed up if the patient is asymptomatic or the cyst is smaller than 6cm as there is a chance of spontaneous resolution in smaller cysts.¹

Complications include secondary infection, hemorrhage, rupture and mass effect on adjacent structures.¹

Above axial images of contrast CT shows a large, peripherally enhancing cystic area (green arrow) in relation to the pancreas, consistent with a pseudocyst. Yellow arrow points to the pancreatic head head and orange arrow points to the distal CBD.

 

Green arrows mark the pancreatic pseuocyst and blue arrow points to the stretched residual pancreatic parenchyma of body region.


 

Sagittal reformats showing the duct (yellow arrows) in tail region.

Sagittal MPR and Sagittal Minimum Intensity Projection, showing the PD and the pseudocyst.

A communication between the PD and the pseudocyst is demonstated in the above image. 

Cysts communicating with PD are difficult to treat and tend to recur.

Presence of internal dependent debris level is regarded as highly specific for the diagnosis of pancreatic pseudocysts in MRI ².




References:
1. Imaging Diagnosis of Cystic Pancreatic Lesions: Pseudocyst versus Nonpseudocyst
Young H. Kim, Sanjay Saini, Dushant Sahani, Peter F. Hahn, Peter R. Mueller, Yong H. Auh
Radiographics, May 2005.

2. Differentiating Pancreatic Cystic Neoplasms from Pancreatic Pseudocysts at MR Imaging: Value of Perceived Internal Debris.
Michael Macari, Myra E. Finn, Genevieve L. Bennett, Kyunghee C. Cho,
Elliot Newman, Cristina H. Hajdu, James S. Babb.
Radiology April 2009.

3. Radiopaedia.

Plain CT Brain findings in an adolescent patient with Tuberous Sclerosis

Tuberous Sclerosis (TS) or Bournville disease is a rare Autosomal Dominant (AD) neurocutaneous syndrome (phakomatoses) characterized by development of multiple benign tumors of in various organs. Since the characteristic clinical triad mentioned is mental retardation, adenoma sebaceum and seizures is uncommon, imaging plays an important role in diagnosis of this condition.Sometimes intrauterine diagnosis of TS of the fetus can be suspected with visualization of cardiac rhabdomyomas in ultrasound.

Below are some of the features of TS detectable in plain CT, in a 16yr old patient.

Above image shows the presence of characteristic calcified and non-calcified sub-ependymal nodules (red arrows). Calcification of these subpendymal hamartomas is less frequent in early childhood, where as cortical/subcortical tubers can calcify as early as 2yrs of age.

Image showing multiple cortical and subcortical hypodensities suggestive of cortical tubers (blue arrows). Most of the tubers in TS are located in frontal lobe.

Left foramen of Monro region shows a relatively homogenous, non-calcified lesion (blue arrows) measuring AP dimension of ~13mm - suspicious of a Subpendymal Giant Cell Astrocytoma (SGCA / SEGA). These are considered WHO-Grade 1 tumors, eventhough there is a potential of causing obstructive hydrocephalus. These are theorized to evolve from the subpendymal nodules. Histologically both SGCA and subpendymal hamartomas show same appearance.SGCAs can show intense enhancement, and may show calcifications and heterogeneity.

Same lesion in sagittal reformat (golden arrow).

A few calcified cerebellar tubers (green arrows).

Above bone window images show multiple calvarial
small sclerotic areas of hyperostosis (orange arrows).

Acute Cholecystitis with intrahepatic perforation of GB causing secondary liver abscess

Above image shows distended gall bladder with pericholecystic fat stranding (orange arrow) consistent with acute cholecystitis.

Above post contrast CECT portal venous phase images showed focal small defect (yellow arrow) in the GB wall suggesting GB perforation, with abscess formation in segment V of right lobe. Blue arrow points to a single calculus within the GB lumen.

Serial axial sections showing small air pocket (orange arrow) within the liver, with adjacent heterogenous hypodense areas (yellow arrow),  superior to the hepatic abscess in segment V. If looked carefully complete pancreatic atrophy, with smooth duct dilatation and intraductal calculi can also be seen, consistent with Chronic Calcific Pancreatitis.

Eventhough acute cholecystitis is a common entity, GB perforation is rare and rarer still is its intrahepatic perforation. GB perforation is commoner in males. Risk of perforation is more in acalculous cholecystitis due to sepsis and associated co-morbidities.

Obstruction of cystic duct causes increased intraluminal pressure which inturn results in impared lymphatic and venous drainage. This results in vascular impairement leading to wall necrosis and finally perforation.

Niemeier classfied GB perforations into 3 types,
Type 1: Acute : Perforation with generalized biliary peritonitis.
Type 2: Subacute : Perforation with pericholecystic abscess and localized peritonitis.
Type 3: Chronic : Perforation with cholecysto-enteric fistula (Original classification did not include intrahepatic perforation / internal fistulae).

Treatment is with antibiotics and percutaneous drainage initially, followed by interval cholecystectomy. Open drainage and cholecystectomy has also been performed.



References:

Date RS, Thrumurthy SG, Whiteside S et al. Gallbladder perforation: case series and systematic review. Int J Surg 2012; : 63–68

Hibernomas

A hibernoma is a rare benign fatty tumor arising from the vestiges (remnant / trace) of fetal brown fat. It is predominantly seen in 20-40 yrs age group with a slight female predilection. It is named so because of resemblance to brown fat in hibernating animals.

Most often the lesion is located in subcutaneous regions of the back (periscapular /interscapular region), neck, axilla, shoulder, thorax, thigh and retroperitoneum. Rarely these are also seen in scalp, breast, peri-ureteric region and scrotum.

Hibernoma usually manifest as slowly growing painless soft-tissue mass. Sometimes patient can be symptomatic due to compression of adjacent neuro-vascular structures, for example sciatica in a posterior thigh lesion.

In ultrasound these usually appear as hyperechoic lesions. Angiography will reveal lesional vascularity with arterio-venous shunting. These can mislead due to increased uptake in 18-FDG-PET.

In CT these lesions show low attenuating lesion, slightly higher attenuating than the subcutaneous fat. Enhancing septae may be seen, with lesion showing mild enhancement. MRI usually demonstrate lesion to be isointense to subcutaneous fat in most cases, with intervening enhancing sepatations. Reduced T1 and T2 signal intensity is also described in few cases. Contrast enhancement need not be present in all cases.

Additionally prominent lesional vessels may be seen in the ultrasound or as T2 flow voids in MRI, with can cause torrential hemorrhage during biopsy, especially in deep seated lesions.

Case courtesy of Dr Matt A. Morgan, Radiopaedia.org. From the case rID: 37589

Above image shows an intermuscular lesion between the gluteus medius and maximus muscles, with intermediate attenuation between fat and muscle. Prominent feeding vessel is seen along the lateral margin of the lesion.

Pre-operatively differentiating from liposarcomas is difficult. Four histological subtypes have been defined: Typical (~80%), Myxoid (8%), Lipoma-like and spindle cell variant. 'Typical' variant has predominantly brown fat. Myxoid variant is seen more often in men with higher water content (increased T2 signal). Lipoma-like lesion is seen more commonly in thigh, more resembling adult fat.


References:
Imaging Findings of a Hibernoma of the Neck
A.C.B.S. da Motta, D.E. Tunkel, W.H. Westra and D.M. Yousem
American Journal of Neuroradiology September 2006, 27 (8) 1658-1659;

CT and MR characteristics of hibernoma: six cases
Dursun, Memduh et al.
Clinical Imaging , Volume 32 , Issue 1 , 42 - 47

From the Archives of the AFIP
Benign Musculoskeletal Lipomatous Lesions
Mark D. Murphey, John F. Carroll, Donald J. Flemming, Thomas L. Pope, Francis H. Gannon, and Mark J. Kransdorf. RadioGraphics 2004 24:5, 1433-1466

Leaking Abdominal Aortic Aneurysm (AAA) in plain CT

Elderly male patient with abdominal pain, with raised Serum Creatinine underwent Plain CT Abdomen, which showed a large fusiform aneurysm of the abdominal aorta, measuring ~12cm in length and 6cm in maximal diameter. Left retroperitoneal massive hemorrhage is noted lifting the left kidney anteriorly (above image).

Aneurysm (orange arrows) and the surrounding hemorrhage (yellow arrows).

Ogilvie Syndrome or Acute Colonic Pseudo Obstruction

Ogilvie Syndrome

Also known as Acute Colonic Pseudo Obstruction, Ogilvie syndrome is a potentially fatal clinico-radiological conditon with features akin to large bowel obstruction without any mechanical obstruction. 

It is most commonly seen in elderly and usually unwell patients, with multiple probable or causative factors like electrolyte imbalances, diabetes mellitus, uremia (renal failure), recent surgery, medications (eg: Opioids) etc. Pathological analysis of resected specimens showed reduced intramural ganglion cells in most cases.

Even though there is no mechanical obstruction  this condition can lead to bowel gangrene and subsequent peritonitis, increasing the mortality risk. Therefore early identification of this entity and nasogastric suction, medical management (anticholinesterases), decompression by rectal tube, colonoscopic exsufflation is needed. Sometimes cecostomy under fluroscopic guidance and rarely cecectomy might be required.

Patients usually present with abdominal pain and distension with preserved bowel sounds on auscultation.

A plain abdominal radiograph usually shows dilated colonic loops (presence of haustra), more often the right colon and transverse colon, with relative lack of air fluid levels (which are more commonly seen with SBO). Rectal gas is usually seen in radiographs, indicating lack of mechanical obstruction.

CT is performed to rule out mechanical obstruction and to assess in detail the location, cause, length of obstruction, presence of vascular compromise, bowel wall thickening if any.

Ogilvie syndrome is characterized by dilated colonic loops, without any significant transition points in CT. An intermediate or gradual transition point may be seen close to the splenic flexure region. Bowel walls are not thickened. Small bowel loops are usually collapsed or non-dilated (In contrast adynamic ileus usually has dilated small bowel loops).

If the caecal diameter is <9cm, medical / conservative management  with anticholinesterases like neostigmine, nasogastric aspiration, rectal tube may suffice to relive the condition. CT enema can sometimes be therapeutic.

Caecal perforation risk is more with diameters >9cm, where a decompressive caecostomy may be required to prevent formation of gangrene and eventual perforation peritonitis.

Acute and chronic forms are recognized, with acute form being transient and associated with acute severe illness. Acute forms respond to neostigmine. Chronic forms rarely perforate, but are usually refractory, sometimes requiring subtotal colectomy for relief.

Differential considerations include Adynamic Ileus, Mechanical obstruction, pseudomembranous colitis, toxic megacolon, ischemic colitis and caecal / sigmoid volvulus.


Below is a case of Ogilvie syndrome in a 78yr old male with multiple co-morbidities and electrolyte imbalances, presenting with abdominal distension.

Here a gradual 'transition' point was seen in the proximal sigmoid colon.

The maximal caecal dimension in this case was 8.0cm (not shown).

 

The small bowel loops are seen collapsed. However in some cases of Ogilvie syndrome, due to incompetence of ileo-caecal valve, the distension can extend into the small bowel loops also.

Cavernous Sinus Dermoid Cyst

Clinical History : 60yr old female patient with right 3rd nerve palsy. Suspecting a PCom aneurysm, CT angiogram was performed which showed no intracranial aneurysms.

However a heterogenously hypodense non-enhancing lesion was seen in the right cavernous sinus, with cavernous ICA seen medially displaced. Lesion anteriorly showed markedly hypodense area of negative attenuation varying from -100 to -150HU, suggesting intralesional fat. Posterior rim of the lesion showed small calcfications. Lateral hyperdense rim was thought to represent the thickened dural layer of cavernous sinus.

Solid Pseudopapillary Tumor of Pancreas

Solid Pseudopapillary Tumor (SPT) is a rare, benign, exocrine pancreatic tumor. It is seen in African or Asian females in 2nd or 3rd decade usually. These tumors can be asymptomatic or may present with a gradually enlarging painless mass in abdomen (as in this case), or with vague abdominal pain or discomfort.

SPTs are well encapsulated lesions with varying degrees of hemorrhage, necrosis and cystic degeneration which make them heterogeneous in both plain CT and post contrast images, with hemorrhage and capsule being the most important distinguishing features from other pancreatic neoplasms. 

The larger lesions have peripheral solid areas and central necrotic / cystic areas. The smaller or early lesions can be entirely solid, and can be difficult to differentiate from islet cell tumors. Some even can have internal septations in the cystic areas adding to the confusion.

SPTs are usually benign, but occasionally can rarely have local aggressive features, capsular invasion, metastasis(liver), lymphadenopathy. These aggressive tumors are more seen in older patients with a male gender predilection. Benign SPTs are usually completely cured by surgery. Long term survival is better with surgical treatment even in the presence of liver metastasis.¹

The following case is a 25yr, female with complaints of feeling of mass in abdomen.

Above CT topogram shows a soft tissue density mass lesion in the left upper quadrant, with compression on stomach and displacing the distal transverse colon and splenic flexure inferiorly. No obvious calcifications detected. No rib erosions / lysis / widening seen. DDs would include Renal, Pancreatic, Adrenal, Gastric lesions. If age is given, possibility of SPT of pancreas should be higher in the list of DDs. This can be a good opening image for FRCR 2B viva discussion.

 

Plain CT images show heterogenous lesion involving tail of pancreas, showing attenuation values ranging from 15-25HU in hypodense areas and rest showing mostly 40-45HU. No obvious hemorrhagic density was seen. Small areas of capsular calcfications were noted in the posterior aspect mainly.

The classic 'Claw Sign' in Radiology.

Post contrast images showing gradually increasing enhancement in few peripheral areas in the lesion. The hypodense areas in plain study showed no significant enhancement.

Lesion was showing well defined margins, with mass effect on adjacent structures and without any evidence of perilesional infiltration.This was reported as SPT.  Patient underwent splenectomy and distal pancreatectomy. Pathology report came as SPT.





References:
1: Solid-pseudopapillary tumor of the pancreas: a surgical enigma?
Martin RC, Klimstra DS, Brennan MF, Conlon KC.
Ann Surg Oncol. 2002 Jan-Feb;9(1):35-40. PubMed PMID: 11833495.

2: Solid Pseudopapillary Tumor of the Pancreas: Typical and Atypical Manifestations.
Jin-Young Choi, Myeong-Jin Kim, Joo Hee Kim, Seung Hyoung Kim, Joon Sok Lim, Young Taik
Oh, Jae-Joon Chung, Hyung Sik Yoo, Jong Tae Lee, and Ki Whang Kim.
American Journal of Roentgenology 2006 187:2, W178-W186.

3: Solid-Pseudopapillary Tumor of the Pancreas.
Kristin M. Coleman, Michael C. Doherty, and Steven A. Bigler.
RadioGraphics 2003 23:6, 1644-1648.

4. CT and MRI of the Whole Body, John.R.Haaga, 6th Edition.

What's your diagnosis? : Case 4 [June 25th, 2017]

25y female, feeling of mass in abdomen.

Post your answers as comment. Case answer and discussion will be posted in few days.

Click here for the ANSWER.

RARE : Extreme case of bilateral massive renal replacement lipomatosis

Renal Replacement Lipomatosis (RRL) a.k.a Replacement fibrolipomatosis, an extremely rare condition, considered as an advanced form of renal sinus lipomatosis.The latter one is a milder form of the spectrum where the normally present renal sinus fat becomes prominent with ageing, obesity or exogenous steroids. Then again, how extreme can it go?

Renal Replacement Lipomatosis (RRL) is usually associated with infection, long term hydronephrosis, calculi and severe renal parenchymal atrophy. Renal calculous disease along with inflammatory changes are present in ~70% of the cases, and these produced symptoms of flank pain and fever.

The patient is a 60 yr old female patient with non-specific abdominal symptoms.

The above image is the non-contrast (plain) CT images which shows diffuse heterogeneous fatty tissue, filling almost the entire abdomen. On further inspection, we can see the fatty tissue is replacing the normal renal parenchyma (orange arrows), and are displacing the retroperitoneal structures like pancreas and duodenum anteriorly. Both kidneys are markedly enlarged, with near complete fatty replacement of the left kidney. Right kidney shows residual parenchyma (green arrow) in lower pole and in the interpolar region (mid-third). A few discrete fatty lesions (blue arrow) are also seen in the residual right renal parenchyma.

Above image shows the mass effect of the enlarged kidneys.

MIP (31mm) image on left shows the bilateral inferiorly oriented renal arteries, residual enhancing parenchyma of right kidney with fatty lesions. On the right, the axial post contrast images show the marked anterior displacement of the ascending colon (blue arrow) and descending colon (orange arrow).

3D VRT right lateral, frontal and left lateral views again shows the mass effect on colon which are seen markedly displaced anteriorly, against the anterior abdominal wall. Contrast filled small bowel loops are seen in RIF region.

3D VRT image showing the orientation of bilateral main renal arteries.

Delayed MIP images showing contrast excretion into the pelvicalyceal system of both kidneys. Right proximal ureter is marked by the orange arrow.

Delayed MIP axial and coronal images showing the right proximal ureter (orange arrow) and green arrows point to the opacification of pelvicalyceal system. No significant delay in contrast excretion was noted in this patient.

3D VRT of delayed excretory phase showing contrast within the pelvicalyceal system of both kidneys.

As expected renal veins showed moderate dilatation, with left renal vein measuring up to 17mm in diameter.





REFERENCES :

Indian J Nephrol. 2010 Apr; 20(2): 92–93. doi:  10.4103/0971-4065.65303, PMCID: PMC2931141, Renal replacement lipomatosis: A rare type of renal pseudotumor, N. A. Choh, M Jehangir, and S. A. Choh. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931141/

Setty N, Uma K, Narvekar V N, Desai R S. Bilateral idiopathic replacement lipomatosis of the kidney with posterior mediastinal lipomatosis. Indian J Radiol Imaging [serial online] 2002 [cited 2017 Jun 21];12:251-2. Available from: http://www.ijri.org/text.asp?2002/12/2/251/28457