Pitfalls of Bowel Interpretation on Routine/Emergency Abdominal and Pelvic CT, Dr. Douglas Katz (1-15-26)
HIDEInteractive Transcript
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Hello and welcome to Noon Conference, hosted by modality
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Noon Conference connects the global radiology community
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through free live educational webinars
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that are accessible for all.
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And it is an opportunity to learn alongside top
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radiologists from around the world.
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Today we are honored to welcome Dr. Douglas Katz
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for a lecture entitled, pitfalls
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of Bowel Interpretation on Routine Emergency Abdominal
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and Pelvic ct.
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Dr. Katz is Vice chair
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for research at NYU Long Island's Radiology Department
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and Professor of Radiology.
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He's authored award-winning exhibits,
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co-written multiple books
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and served on the editorial boards of major journals.
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He's also received numerous honors,
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including the RSNA Lifetime Honored Educator Award in 2023.
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Dr. Cass is deeply committed to mentoring students,
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residents, and faculty, and advancing
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radiology education globally.
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At the end of his lecture, please join him in a q
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and a session where he will address questions
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you may have on today's topic.
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Please remember to use that q
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and a feature to submit your questions so we can get to
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as many as we can before our time is up.
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And with that, we are ready to begin today's lecture. Dr.
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Katz, please take it from here.
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Great, thank you, Ashley.
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Again, it's a pleasure to be back.
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This is, I think, my third annual January, uh,
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emergency radiology related talk.
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And I think the first time out of the three
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that I'm not actually under the weather.
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So they say, you know, three times, uh,
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the third time is a charm, um,
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and always get a, a pleasure to be doing this conference.
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So, you know, just a little bit of background information,
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and I have no specific disclosures related to this talk.
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Uh, that's sort of, sort of half joke that I give
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with these, um, emergency related talks, which have,
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in this instance, some something to do
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with the acute abdomen and pelvis imaging with ct, um, is
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that I've been challenged for over three
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and a half decades now, uh, going back to training
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of imaging of the admin
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and pelvis with ct, especially in the emergency setting.
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And some of the cases I'll show today are in the emergency
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setting, but no other disclosures.
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And again, a little help for my friends like the Beatles.
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Um, and I'll acknowledge those individuals, uh,
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when the images that I show are, uh, on the screen.
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So the general concept here is, is of course,
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if you have a adult non-pregnant individual
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and they come into the er, our workhorse is gonna be ct.
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Of course, there are other tests we still do radiography.
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We still do a fair amount of it.
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Um, in my, in my system, we do sonography of course.
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And MRI increasingly has been used over the years for, um,
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either selective problem solving
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or for, uh, in, in some instances primary problem solving.
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But, uh, CT is of course our workhorse.
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And both in the emergency setting, uh, as well
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as in the routine outpatient setting,
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we are often not doing a dedicated bowel protocol,
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meaning we're not doing CT enterography,
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we're not doing a specific bowel prep.
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Of course, they may be NPO if they're, you know,
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getting an outpatient scan,
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but there's no attempt to, uh,
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prepare the colon, for example.
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We're not giving, uh, effervescent crystals
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to blow up the stomach in the ER setting.
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Um, we, we have what we have and,
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and often, not necessarily in all of the parts
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of our system, but in many parts of our system,
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in many other places in the US, Canada, elsewhere
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around the, the world, oral contrast over the years has been
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either completely eliminated
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or has been reduced in its use in the adult setting, uh,
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for ct, uh, in that situation.
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So there's no free lunch.
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And here I show, uh,
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spy versus spy if you get the reference from MAD Magazine.
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Um, so there're gonna be some scenarios here
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where the choices are normal versus abnormal,
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and then if it's abnormal, what is the differential
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or primary, uh, consideration?
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And so there's no free lunch.
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You know, the ER, of course, I get it.
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They want immediate answers.
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They don't want people waiting around for the most part,
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drinking oral contrast for an hour or two hours.
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They wanna scan immediately.
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And so we have under distended bowel, collapsed bowel,
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potentially mimicking pathology or hiding pathology.
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And then the scans come to our packs.
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Often we are nowhere near the actual scanner.
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I'm the outlier. Now I'm about a hundred feet from the
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ERCT scanner.
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I'm embedded in the, uh,
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emergency department in my own reading room in our 600 bed
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community university hybrid portion of my system.
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But that is the exception to the rule now.
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And so we don't have the luxury of going
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to the monitor saying, okay,
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let's do some additional images,
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put the patient into the cubitus position
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or do some other kind of problem solving maneuver.
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We're faced with having to then decide we're bringing the
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patient back, we're doing additional dedicated imaging such
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as CTA or MRE,
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or are we gonna recommend some sort of endoscopic procedure,
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whether it's upper, lower, or capsule.
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And that's sort of the general theme of this presentation.
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So let's start. And there are numerous,
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numerous potential pitfalls and differentials.
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Uh, this is actually the short version
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of this particular talk, uh,
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because I wanted to focus on the things that I think are
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of more importance to the group.
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Uh, but there are many, many, many things
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that I'm not gonna cover, but I'll try
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to hit some of the important highlights.
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And let's start kind of doing what my AP Biology Pro, uh,
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uh, teacher, uh, Mr.
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Lya was also a gym teacher in my high school growing up here
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on Long Island, used to say,
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rowing down the elementary canal.
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That's what we're gonna do. We're gonna go from
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stem to stern here.
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We're gonna start at the GE junction.
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So it was recognized from almost the birth of CT
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that the GE junction, gastro optical junction is a problem.
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And it has to do with the fact that even if you go out
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of your way to give some sort of positive contrast material,
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it is usually collapsed.
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And it also runs obliquely through the course
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of the axial plane.
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And so very problematic
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to determine if there is something there.
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And in fact, in general, the stomach as I'll,
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I'll discuss in some detail, can be very problematic,
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even if there is contrast on board.
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And often, as I said, uh,
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there isn't sometimes even when we give oral contrast,
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the oral contrast isn't
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where we would like it to be in retrospect.
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So again, you have the luxury of being at the CT monitor.
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You could do additional images with effervescent crystals,
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put the patient in oblique position.
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We don't have that luxury. So now what do we do?
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And so we often see hidal hernias, right?
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I see hidal hernias, and you probably do two if you read
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chest or abdominal CT all day long of various sizes.
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I had my last case yesterday on the clinical service was
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about a nine centimeter hidal hernia that was known looking
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for needle in a haystack.
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Which one of those actually have a mass in them, right?
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Very, very difficult to determine
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unless it's obvious and usually it isn't.
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And so truly looking for something very,
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very difficult in a population that is very common.
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And that's one of the other themes of this talk.
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So in general, here's an example
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where we have oral contrast on board,
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and yet the stomach is still collapsed,
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and we still can't determine
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if there's something there or not.
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The radiologist raised the possibility
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of gastric thickening on this.
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This was a normal stomach endoscopy,
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and this is kind of the rule rather than the exception.
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And I would say, you know, a hate hedging,
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but the vast majority of the cts that I interpret every day,
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the comment is made, stomach is collapsed,
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evaluation is suboptimal.
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And that's just the reality.
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Again, unless it's a CTE where we're purposely going out
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of our way to distend the stomach.
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Here's an example. And I see this fairly commonly
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and in fact not commented on often by my colleagues,
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where it really looks like there is some regional thickening
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of the stomach in this case, probably some sort
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of chronic hyperplastic hypertrophic condition.
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There is some contrast on board as we see on the left image,
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and it looks very similar,
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even though the scan on the right is
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non-con eight years apart.
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So chronic condition, is it really wall thickening?
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Again, kind of tough
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to know without having a truly distended
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stomach, but it looks real.
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And then here's the outlier.
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This is the scary kind of a case.
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This is someone who has a hidal hernia,
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but there's fold thickening.
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And is that a mass? Is it not a mass?
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Is it just a redundant collapsed stomach,
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as we've often seen in these varied size hidal hernias?
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Well, unfortunately the answer was on this particular scan
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when we looked at the lung windows.
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And this is a metastatic focus.
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This like looks like a lung cancer,
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but it's actually a metastasis from this primary
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GE junction adenocarcinoma.
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That's what this proved to be.
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And again, this is absolutely outlier.
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So, uh, I've seen cases where, you know,
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you really couldn't even in, you know,
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retrospect knowing there was a mass in the GE junction at a
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hidal hernia, you just couldn't call it, nobody could.
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It can be really, really tough.
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No, if it's bulky and invasive, there's nodes, yes,
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but other cases it can be very difficult.
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Here's one of these sort of Oopsie cases, no harm,
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no foul necessarily
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because it was, uh,
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diagnosed rarely shortly thereafter on endoscopy.
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But this ended up being,
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and I have permission to show this, our former chief
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of surgery from some years ago at my hospital, oopsie,
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kind of a big oopsie.
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So this was not called
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in retrospect, you can see the arrow.
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And again, it's always great when you window the images
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and you, you know, crop them and you put arrows on them.
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But this in retrospect,
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ended up being a GE junction gist tumor sort
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of would've an unusual morphology.
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But the lips of the GE junction are prominent,
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they're bulging into the lumen of the stomach.
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And even though oral contrast was given,
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this was not correctly identified prospectively.
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And the surgeon, uh, came to us
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and said, um, can you re-look at that CT scan
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because I have a gist at my G junction.
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Oops. Yep, you do. There it is.
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In retrospect, again, everybody's a genius in retrospect,
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especially me, one of my favorite sayings.
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So let's talk a little bit about, um, g junction masses.
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If there is an actual mass, you think there's a mass.
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Now the question is, is it benign
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or is it potentially malignant?
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And ultimately it's gonna require, you know, some sort
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of biopsy, endoscopy biopsy.
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But the main differential here is gonna be a
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OMA versus a gist.
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And they have various levels of activities, STIG,
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variety of papers in this.
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And again, some of these slides are a bit
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dense in terms of text.
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My understanding is you'll have access
10:14
to this presentation well after it is given live.
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And again, a shout out to everybody who's watching this live
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and those who are gonna be watching this down the road,
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either later today or in the future.
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Uh, but you can look at the references,
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you can look at the detailed information in terms of some
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of the data, but no surprise, the gist tend to be bigger.
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They're bulkier, they're more heterogeneous.
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We know they can become cystic necrotic to various extents,
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and they tend to be off the midline as opposed to the,
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my leiomyomas, which tend to be a bit smaller, tend
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to be more, uh, in the midline.
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But again, these can be tough when they're smaller.
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Here is a 33-year-old with abdominal fullness,
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and you can see there is oral conscious on board.
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This is an older case, uh, for my institution.
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You know, is this an actual mass?
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Is this food that's warming a pseudo mass? Is this a bizo?
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In fact, this is a true mass.
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This ends up being a tumor in the proximal stomach.
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So with the stomach being collapsed, as I mentioned in,
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in many practices, even if you sometimes give
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or oral contrast, or if you're not giving it,
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it really can make life very difficult.
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As I said, there's no free lunch.
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Um, and so if you see gastric contents, you need to try
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to make a determination whether there is
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or is not something there, whether you think it's food,
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whether you think it's confluent food or a bezo,
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or whether it's an actual mass.
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And again, these things go from, uh, you know, pretty,
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pretty uncommon to see them, but they obviously do occur.
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So Bezos, we don't see Bezos very often,
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but there are several well-described categories of them.
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Of course, the classic Trico Bezos,
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so-called Rapunzel syndrome, where there's ingested hair
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that becomes confluent phyto Bezos fruit
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or vegetable material, um,
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persimmon being sort of the prototype.
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But there are a variety of, of of food material
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that can cause Bezos lacto Bezos undigested milk,
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and then pharmaco Bezos,
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where ingested medications can become a bezo.
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Now, when I was at the RS NA meeting in a session that I,
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uh, was, uh, speaking at one of my colleagues
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who was from Singapore on the panel, showed a case of a
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dehydrated mushroom small B bizo,
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something I had never heard of.
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And so, sort of the joke I made was that
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as a strict vegetarian who had recently been to Japan
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and actually bought, uh, a a, uh, uh, a small, uh, amount
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of dried mushrooms, I really have to be on the watch.
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You know, there's dangerous for us, even us vegetarians.
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So, um, bezo, uh, may
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or may not be mobile, may have a modeled appearance.
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Um, and it, it, it can, you know, be tough
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to distinguish unless it's obvious.
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So history, of course, is important.
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Again, bringing the patient back,
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repeating the imaging in different positioning,
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given oral contrast,
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and of course, doing other things such
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as fluoroscopy and endoscopy.
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And of course, always, always comparison
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with priors if available.
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The general rule of thumb is when you need a prior,
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you don't have it, but of course you need
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to go out of your way to look for them.
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And sometimes it's not that obvious what the prior is.
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It may necessarily be a, uh, direct, you know,
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one-to-one ct, abdominal abdominal comparison, make sure
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that you're looking at everything radiography, et cetera.
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This is a case sent to me about, uh, two years ago by one
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of my senior colleagues who was questioning whether there
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was or was not something in the proximal stomach.
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And it, you know, sort of, is that a polyp? Is that food?
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Is it, is it, is it, you know, what is that?
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So on, you know, careful review
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of the images in different planes.
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It really looked like, particularly if you look at this
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coronal image here on the lower right,
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it really looks like ill-defined food.
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And that's what the, that proved to be.
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So, you know, he said, what do you do?
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I said, well, I would actually bring this patient back and,
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and have them be NPO 'cause this was done for endometriosis.
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Now, gastric endometriosis is pretty rare.
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Um, and, uh, you know, have them be NNPO status and,
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and give them water and effervescent crystals, do imaging
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and, and, uh, supine and,
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and decubitus positioning and, and see what you get.
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And it was negative. So here's a case from Cookie Arminius,
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the editor of radiographics,
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where there is a very large trico bor.
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This young woman had a, uh, a,
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a correlative psychiatric history.
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You can see this large heterogeneous mass like process
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filling the stomach, explaining her acute abdominal pain.
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So let's talk about something that does kind
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of keep me up at night,
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and that's Linus plastic A, which is again, looking
14:40
for a needle in a haystack.
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This can be a really tough call,
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but I'll show you cases where I have personally made this
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diagnosis prospectively.
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Um, it, it is, it's really difficult.
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The bottom line is
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that we often will have a hard time determining if there is
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gastritis or not in the first place.
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And then if there is gastritis,
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is there in fact a malignancy
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that is making it look like there's gastritis?
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So you can under call and over call.
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Obviously you want to get things correct as best as you can,
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but worst case scenario is when you blow by a, uh,
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adenocarcinoma of the stomach
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and you, you don't appreciate it at all,
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which is potentially possible
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because these things can be difficult.
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Um, if the entire stomach is abnormal as opposed
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to regional abnormality may also make things difficult.
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Of course, with all of these processes, we're looking
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for the wall, um, architecture,
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is there so-called stratification implying a benign process
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where the wall may be emus, but the anatomy is preserved?
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Or is there loss of the architecture
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as we should see in Linus plastic?
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Is there edema of the adjacent fat and is there adenopathy?
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And what is the nature of the adenopathy?
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So here's an example, um, where this is a young individual.
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There's oral conscious on board.
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Notice it's not in the stomach,
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and we have a diffusely
15:59
substantially edematous, uh, stomach.
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This is gastritis
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and there is some adenopathy if you look here in the
16:05
gastro pad ligament region.
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But this is reactive, this is benign. There is no tumor.
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Um, we all know about the most common causes of gastritis,
16:14
h pylori, NSAIDs, alcohol, et cetera.
16:17
And the paradox with, with some of these upper itises is
16:20
that if we knew there was gastritis,
16:22
unless we were suspecting perforation
16:25
or other complications,
16:26
we wouldn't have done the CT in the first place.
16:28
But I'll absolutely tell you we see these kinds of regional
16:32
and diffuse bowel edematous states, um,
16:34
including gastritis all the time in the er.
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And there is overlap because you can have a malignancy
16:41
that's causing secondary edema
16:43
and it may be tough to sort out.
16:44
So we're looking for areas of nodular thickening, um, loss
16:48
of the architecture, nodal disease, that's a red flag
16:52
that's bulkier or something like this.
16:54
And this is one of those cases
16:55
where I did correctly prospectively call
16:58
this adenocarcinoma.
16:59
If you look at it, you might think it's okay,
17:02
it's just an under distended stomach, um,
17:05
or maybe it's gastritis.
17:06
But notice we have a substantially diffusely enhancing
17:09
stomach wall that's really thick.
17:11
There's also some nodes here that's a red flag.
17:14
And the architecture, if you look at it carefully,
17:16
really looks off.
17:18
Additionally, notice there's oral conscious on board,
17:20
but there is no, uh, substantial distension of
17:23
that distal stomach compared with the proximal stomach,
17:26
which is actually becoming a little bit obstructed.
17:28
So this is unfortunately a young woman with adenocarcinoma
17:33
that was a Linus picture, proven an endoscopy.
17:36
Here's an even sadder case.
17:37
This was a pregnant postpartum woman, 25 years old.
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Um, a bit of a different sort of picture in terms
17:43
of the extent of edema of the, uh, uh,
17:47
more outer layers of the stomach.
17:48
But again, the architecture is really off that mucosal
17:52
to submucosal looks really thickened and enhancing,
17:55
and this again, proved to be adenocarcinoma.
17:58
So leitis tends to, uh,
17:59
display regional diffuse loss of architecture.
18:02
The folds are gone, it doesn't distend,
18:06
but again, you really have to be paying attention.
18:08
And so though, if you aren't sure, again,
18:11
maneuvers include repeating the CT with neutral contrast,
18:15
positive contrast water, some combination of
18:18
that fluoroscopy.
18:20
And I should say that I do a day a week of fluoroscopy
18:24
with a radiology assistant.
18:26
So fluoroscopy is far from dead at my institution.
18:29
I do a ton of it. I was on fluoroscopy yesterday,
18:32
probably reported out about 20 cases.
18:35
So it is quite alive and well.
18:37
Um, and, uh, of course various endoscopic approaches.
18:41
So gastric ulcer disease. So there's a lot of overlap.
18:44
Again, you can have gastritis with tumor, you can have
18:47
of course, gastritis with ulcer disease,
18:49
most commonly gastric gastritis alone.
18:52
So upwards of about 50%
18:53
of gastric tumors can have some degree
18:55
of mucosal ulceration.
18:58
And the trick is to try to distinguish this, uh,
19:00
from benign processes, what's benign, what's malignant.
19:03
Of course, benign is much more common than malignant.
19:07
So again, we're looking for an ulcer in association
19:10
with architectural distortion, nodular mass,
19:13
like processes marked thickening of the wall,
19:16
and again, adjacent adenopathy.
19:18
So going back to classic, uh, fluoroscopic signings,
19:22
things like the Hamptons hump, um, and those sort of things.
19:25
If you see, um, a focal outpouching that is extending
19:30
beyond the wall of the stomach
19:31
and there is no associated mass that you can see,
19:34
more likely than not, you are dealing with a benign
19:36
as opposed to a malignant ulcer.
19:38
And here's an older example of that from my practice.
19:40
This was someone with a known distal gastric ulcer
19:44
that was non-healing.
19:45
This was shown an endoscopy,
19:47
and the CT was done, uh, to exclude an associated mass.
19:51
And we see, um, relatively uniform, uh, edema
19:54
and thickening of that distal stomach.
19:56
We can see the out patching, no evidence for malignancy,
19:59
no evidence for perforation.
20:01
Now here's another oopsie.
20:03
This was an 82-year-old where there was a, uh,
20:07
raging case of cholecystitis.
20:09
We see that on the right.
20:10
So that explains the edema
20:11
and the marked edema of the wall, the gallbladder.
20:13
But believe it or not, this was mist perspectively
20:17
'cause of search of satisfaction.
20:19
There's actually a fairly large ulcerating
20:22
g junction adenocarcinoma,
20:24
and if you look at it kinda looks like,
20:26
if you would imagine if this was on fluoroscopy
20:28
and you used a compression paddle,
20:30
would give us findings very similar to
20:32
that described in the classic Carmens meniscus sign
20:35
where you have the sort of lips of the tumor
20:37
that's ulcerating, and the the falls kind of coapt
20:40
and it traps barium.
20:41
That would be very likely what we would see here.
20:43
So this was then recognized, uh,
20:45
retrospectively shortly thereafter, even again
20:48
with the presence of oral contrast on board.
20:50
So peptic ulcer disease alive
20:52
and well on the er,
20:54
it is a relatively common cause of presentation.
20:56
There may or may not be a prior history and uncommonly,
21:00
but certainly we do see it.
21:01
Perforation may be concurrent.
21:02
And depending upon where the perforation occurs,
21:05
there may be oral contrast if given water, gas
21:09
and retroperitoneal or peritoneal locations or both.
21:13
Here's a case where you would think, you know,
21:15
how is this really the problem?
21:17
But there's a, a small outpouching at the second portion
21:20
of duodenum at the ULA differential being a duodenal tick.
21:24
But this ended, ended up actually being an ulcer.
21:27
And this patient was in septic shock,
21:29
was immunocompromised chemotherapy given
21:31
for metastatic prostate cancer.
21:33
And even though this thing looks relatively innocent,
21:36
this was actually believed to be the source of, of sepsis.
21:39
So a small, uh, proximal duodenal ulcer.
21:42
Here's an example where an older case
21:44
where there's duodenitis,
21:46
but we do not see an actual al pouching.
21:48
So important to look at different planes.
21:50
Um, try to determine if you see an associated ulcer
21:53
and if you see an associated mass.
21:55
So of course, seeing the direct sign of the, uh,
21:57
ulcer itself, seeing the indirect signs, uh,
22:00
of the associated edema, um, if there, again,
22:04
if there's perforation fluid gas
22:05
or contrast depending upon
22:07
where the perforation is occurring.
22:09
And so the point is that,
22:11
and it's been well described, the, the,
22:12
the references here from Doug Kitchen from some years ago
22:15
from the group at Indiana University, um, that there, uh,
22:20
really even fairly large, um,
22:24
ulcers can be missed.
22:25
Um, if you're not paying, uh,
22:27
careful attention really can be tough.
22:32
So let's talk next about, uh, normal, uh,
22:37
jejunum versus abnormal.
22:38
This really can be challenging.
22:41
Uh, and, and I would say, you know, one
22:43
of the surprising things about this topic
22:46
when I put this lecture together is that I,
22:48
I really hadn't ever heard a talk on pitfalls put together
22:52
in a cohesive manner, hopefully cohesive like this
22:55
until I did it myself.
22:56
And it's really, I had to really struggle
23:00
to find some of the references.
23:01
There's not as much evidence-based
23:03
information as we would like.
23:05
So some of it's just observational.
23:07
But a lot of these things, you know, we, we struggle with,
23:10
if you, you interpret abdominal
23:12
and pelvic CT on a routine basis, we struggle
23:14
with this things all the time.
23:16
Even if you're very experienced, we still struggle.
23:19
So identifying whether there is actual jejunal fold
23:22
thickening or not can be really tough
23:24
because normally the jejunum has prominent folds.
23:29
Uh, and again, enteritis in the ER setting,
23:32
if we were thinking an neuritis in the er, uh, end
23:36
of things, they wouldn't necessarily get a CT
23:39
unless they think something else is going on.
23:41
But we often suggest
23:43
that diagnosis on a fairly routine basis.
23:46
So here's an example where I just don't have an answer,
23:48
and that's often the case with these areas
23:50
of regional fo thickening where there is no actual diagnosis
23:53
that comes out of a workup.
23:56
Um, this is someone who has just prominent foes
23:59
of the duodenum.
24:00
And I, I had a case literally
24:01
that looks just like this yesterday,
24:03
and I said, prominent folds of the duodenum,
24:05
nonspecific really, there's no mass.
24:07
It's, it's kind of too long to be a tumor.
24:09
Wouldn't be concerned about that,
24:11
but it doesn't look normal, it just looks,
24:13
there's definitely prominent folds.
24:15
Here it is again in the, uh, coronal plane.
24:18
So here's an example where I think one should no question
24:22
say that these folds are way too thick,
24:24
even though the jejunum, as I mentioned, is the area
24:27
of the small bowel
24:28
where the folds are normally the thickest.
24:30
This is beyond that.
24:32
This is a case from Khi at the Lahey Clinic where there is,
24:35
uh, diffuse small bowel edema
24:38
and this case related to campylobacter.
24:40
Now there's of course, no in earth, you can look at this
24:42
and go, it's campylobacter,
24:43
that's a microbiologic diagnosis.
24:46
But you can look at this
24:47
and say, in the acute setting,
24:48
there's definitely something substantial going on.
24:52
And this proved to be, you know,
24:53
an acute infectious enteritis.
24:56
So small bowel often is, uh, indiscernible when, um,
25:01
normal scenarios in terms of individual folds, um,
25:06
when it's partially collapsed.
25:07
Upper limit should be in the two to three millimeter range.
25:11
But again, these are just sort of,
25:12
you know, general guidelines.
25:14
And if the entire bowel is abnormal again,
25:17
like if the entire stomach is abnormal, it may be harder
25:20
to appreciate that there's something wrong as opposed
25:23
to when you have a very focal air of abnormality
25:25
that is easier to appreciate.
25:27
Now, Mike McCarey, um, who, uh, would love to have had him
25:31
as my colleague, unfortunately he's not with us anymore.
25:34
Um, uh, he, he passed really very, uh,
25:38
prematurely sadly,
25:39
but, uh, when he was in NYU with some of his mentors, uh,
25:44
wrote some really wonderful papers
25:45
that I think really hold water 25 years later.
25:49
And this was a paper that I'm citing from the A JR here on,
25:53
uh, a se uh, evaluating regional diffuse, uh, bowel
25:58
abnormalities on ct, uh,
26:00
extremely helpful basic concepts in terms of, again,
26:03
looking at the fat, looking for edema, looking
26:05
for the regional nodes.
26:07
Is there adenopathy or not looking at the patterns
26:09
of enhancement in terms of trying to sort through a narrow,
26:12
first of all, determine is there,
26:14
is there not an abnormality, number one?
26:16
And number two, what is the differential consideration?
26:20
So some focal things that can happen.
26:23
You can have gas bubble that bubbles that move,
26:26
especially when they're in the proximal stomach.
26:28
That's causes some, you know, common artifacts.
26:32
We also see contractions.
26:33
We see contractions of colon
26:36
or small bowel that can, uh,
26:39
create an artifactual stricture or look like a mass.
26:42
And so looking at these in, uh,
26:45
multiple planes, uh, is helpful.
26:47
But again, you're just capturing a snapshot in time
26:49
unless you happen to have multiphasic
26:51
imaging for whatever reason.
26:52
So again, you may need, if you're not sure,
26:54
is there really a stricture there,
26:55
is there a focal mass you
26:56
may need to bring the patient back?
26:57
In this case, I would repeat the CT probably
27:00
with a CT enterography technique, thin cuts iv, you know,
27:04
optimized neutral contrast
27:05
and IV contrast problem solve in the short term interval.
27:09
Um, you could also do Mr MRE as an alternative as well.
27:13
And of course, capsular endoscopy in the
27:15
armamentarium as well.
27:16
So here's an example where you might struggle with is this,
27:20
you know, also a fake out.
27:22
Is this just retained food
27:23
that's coating the proximal
27:25
duodenum as they're really thickening?
27:26
Well, this is true thickening,
27:28
and this actually proved to be diffuse adenoma,
27:32
ptosis of the duodenum.
27:34
You can see it's extending out of the, uh, the stomach.
27:36
And, and the MRI was very helpful here
27:39
because, you know, clearly this is bowel and,
27:42
and shows as shown in multiple sequences and not food and,
27:45
and it's sort of the mother of all duodenal a adenomas.
27:48
I've never seen this sort of, you know, this kind
27:50
of carpet appearances described in
27:52
processes in the, in the colon.
27:53
I've never personally seen this before in the duodenum,
27:56
but, but here it is.
27:59
Let's talk about our next topic as we continue our, uh,
28:02
our rowing, uh, down the elementary canal.
28:05
We've now made it to the jejunum, um,
28:09
and mid small bowel.
28:10
And one thing that we see on a very frequent basis are these
28:14
small bowel inceptions.
28:15
And again, it's like a needle in a haystack we're looking
28:18
for because the vast majority of them are transient
28:20
and innocent and have no clinical meaning
28:23
and probably have nothing to do
28:24
with why the patient was imaged.
28:27
But every once in a while, there is a more
28:29
concerning small bot of deception
28:31
and there is an underlying leading point.
28:34
So how do we find that needle in the haystack?
28:37
Well, we're looking for the associated findings. Now.
28:39
There's no hard and fixed number in terms of length
28:42
or width of the interoception in the literature.
28:44
There's no a CR appro criteria
28:47
to my knowledge on interoceptions in terms
28:49
of sorting this through.
28:51
But basically you're looking at the morphology.
28:54
Is it longer than what we expect
28:57
to see in these trans inceptions?
28:58
Is there a clear cut associated mass or masses?
29:01
Is there edema of the fat? Is there a small bowel structure?
29:04
Is there evidence for bowel ischemia? Is there adenopathy?
29:07
Is there any other red flag that will tell us this is
29:10
that outlier that we do need to pursue as opposed
29:13
to the usual proximal jejunal short segment,
29:16
transient small onus deception.
29:18
That in my experience, gets worked up a lot
29:20
and has very low yield questions to ask,
29:23
does a patient have a motility problem?
29:25
They have celiac disease.
29:26
Do they have chron Crohn's disease?
29:28
Some also leads to an increased incidence
29:31
of these inceptions that's described in the literature.
29:34
Or is there actually something else going on?
29:36
Is there a polyp, a mass, a lipoma,
29:39
or something else that's causing inception?
29:42
Um, again, there's no hard
29:43
and fast numbers in terms of length or width.
29:46
Look at the, uh, look at the
29:48
bowel, look at the secondary finding.
29:49
So here's the usual kind of short segment,
29:51
transient jejunal inception.
29:53
You see it on a couple of images.
29:55
You see a little bit of fat going in here, being, uh,
29:58
drawn into the, by the incept.
30:00
The ends, the intercept going into the intercept, the ends,
30:03
and there's no evidence for any mass.
30:05
There's no edema, there's no obstruction.
30:07
It looks innocent because it is innocent.
30:09
Here's a 95-year-old with it may be a little bit longer, uh,
30:12
segment of proximal al incept on a non-con ct.
30:16
Patient was brought back for a CTE two days later,
30:19
which I guess was reasonable and it went away.
30:22
There's nothing there. So end of workup.
30:24
In contrast, here's an older case where we have a patient
30:28
with a known predisposing condition.
30:30
They have a polyposis po jagers,
30:33
and we see two, uh, segments of inception.
30:36
This one is ileal sequel here on our right.
30:38
This one is more proximal
30:40
to midal on our left long segments.
30:44
You can see the thickened bowel,
30:45
you can see the bowel enhancement that's abnormal.
30:48
You can see the length of this is more than the usual.
30:50
These are again, the outliers in this case,
30:52
not a diagnostic dilemma.
30:55
We occasionally see this particular scenario.
30:57
This is someone who has had a gastric bypass.
31:02
And we see the, uh, more distal aspect,
31:06
uh, is partially intercepting intu itself.
31:10
But notice oral conus was given kind
31:13
of probably comes and goes.
31:14
There's absolutely no evidence for obstruction at all here.
31:18
And this was, again, believed not to be the source of,
31:21
of symptomatology, just sort
31:23
of sitting there sub acutely or maybe chronically.
31:26
And here it is, you can see that partial swirl nicely
31:29
demonstrated, uh, with some focal dilatation
31:31
as we often see at the jejunal anastomotic site.
31:35
But nothing else going on on the mr a few weeks later.
31:40
So continuing our rowing down the canal,
31:43
we're now reached at the distal
31:45
small bowel and the appendix.
31:46
Now, we could spend several hours
31:48
talking about the appendix.
31:49
We're just gonna mention a few things about some
31:51
potential pitfalls.
31:52
And the one that I really wanna highlight here
31:55
is when you have a big-ish or big appendix,
31:59
and whether you think it is in the ER setting,
32:03
just a appendix that is perforating
32:06
or is there a mucus seal that's underlying it?
32:09
And there's appendicitis
32:11
or sometimes we see in the outpatient setting a
32:15
unanticipated mucosal.
32:16
So there's overlap in all these things.
32:19
Um, the bottom line is I tend to
32:23
over call a bit here, meaning that, um,
32:26
if I have a two centimeter appendix
32:30
and there's evidence of appendicitis, um,
32:34
I might at least raise the possibility that
32:37
although I'm still most likely dealing with a
32:40
very abnormal appendix without an underlying neoplastic
32:43
process, it could be a mucosal.
32:46
Again, there's no hard and fast number,
32:48
but the known number thrown at in the literature, uh, by,
32:51
by peri Picard, uh,
32:53
some years ago when he was in the military in the us, uh,
32:56
is 15 millimeters.
32:57
Certainly if you have a big mass
33:01
and it has calcification in its walls
33:03
or occasionally even in the lumen.
33:05
Um, and it's clearly arising from the secum.
33:08
And there's no normal appendix, no history
33:10
of an appendectomy, and it's not a female.
33:13
It is a female. And you could clearly see
33:15
a separate appendix.
33:17
You have something like this.
33:19
Um, this was, believe it
33:21
or not, incidental, there's no
33:22
appendicitis that we see acutely.
33:24
The, the fat around the appendix looks fine.
33:26
A lot of peripheral wall calcification.
33:28
This was an incidental muco cell.
33:30
And so we do see these every once in a while.
33:32
And then not it would tell you that every single CT
33:35
that I look at, every one I look for the appendix,
33:38
it's a hundred percent in my search pattern.
33:41
And although I don't use templates from my reporting,
33:44
I have templates in my head.
33:45
So, you know, I, every,
33:47
every single patient, I look for the appendix.
33:49
And so the yield is gonna be really low, right?
33:50
I mean, it's like, you know, 5% of the,
33:52
of the cts are gonna have muco seals.
33:54
It's really, really small, but it is certainly not zero.
33:57
And I, I could say I probably picked up three
33:59
or four in the last two or three years.
34:01
It happens. Here's a case that very astutely, one
34:04
of my colleagues, uh, some years ago
34:06
correctly said prospectively.
34:07
This was both appendicitis and a mucosal.
34:11
And here's why this appendix is really big.
34:14
Um, it's probably pushing, you know, three centimeter.
34:17
So that's well beyond that 15 millimeter, uh,
34:20
from peri picard's research.
34:21
And notice how large this append quali is really unusual
34:25
to have an append quali that big.
34:27
Um, and of course there's inflammation
34:29
and there's wall thickening
34:30
and there's increased enhancements.
34:31
So this was correctly called mucosal with appendicitis.
34:35
Every once in a while we see something else
34:37
really weird going on.
34:38
It, it, it can be tough to sort this one out.
34:41
If you're looking at this prospectively,
34:43
you can see there is a degree of inception here.
34:45
It looks like there's some sort of a mass fluid
34:48
or mucinous mass here that's involved in this.
34:51
You can see it in the axial cron plains.
34:53
This ended up being an appendic mucosal
34:55
that was intercepting something I've seen
34:58
a few times in my career.
34:59
It's certainly very unusual,
35:00
but again, well described in the literature.
35:03
So, um, if you have an appendix that's big,
35:06
especially in a middle age to older individual,
35:10
and the bigger the appendix is,
35:11
the more you should be thinking mucosal,
35:13
at least raise that possibility.
35:15
One of my other favorite expressions is surgeons do
35:17
not like surprises.
35:18
So yes, you could potentially over call it
35:21
and being a false negative call in terms of mucosal,
35:24
but if you're thinking mucosal, the surgeon needs to know
35:27
that because they need to be checking carefully for
35:32
the omentum, eCenter
35:33
and adjacent structures for any subtle tumoral spread
35:36
that you might not necessarily pick up on the CT you
35:40
want, of course, look for that.
35:41
Um, and it may potentially change their approach.
35:44
They might, you know, get fresh,
35:45
frozen in the operating room.
35:47
They may consider doing a bit of a wider resection.
35:50
Uh, and taking the SQL base if you really believe that you,
35:53
you may be dealing with a mucus cell rather than just
35:56
appendicitis that's, uh, perforating or about to perforate.
35:59
Continuing our, uh, rowing down the elementary canal here.
36:03
We've now made it to the colon.
36:05
And I'll tell you, I think of all of the body parts in terms
36:10
of, uh, you know, routinely causing challenges
36:14
of interpretation, I would have to rank this.
36:17
Number one, I would say stomach is number two
36:19
and colon is number one.
36:21
And the reasons for this are obvious, right?
36:23
We're, we're never doing bowel preparation other than the
36:26
scenario where we're doing a CT colonography exam.
36:29
Um, you have a a, a often collapsed colon.
36:33
Again, oral contrast, even if it's given,
36:36
it's not like the ER is gonna be waiting around, you know,
36:38
three, four hours to have oral contrast go in there.
36:41
And then there have been various approaches.
36:43
Uh, the, the group at the University of, of, uh, Wisconsin
36:46
and Madison have advocated using a combined, uh, barium
36:50
and gastrografin iodine based conscious material to get
36:54
to the distal, uh, bowel, uh, more, uh, rapidly in, in terms
36:58
of them using oral contrast.
37:00
Still fairly frequently in their practice.
37:03
Um, but you know, in our setting often, you know,
37:06
I'll write in the protocols, you know,
37:08
give oral if it's not truly, truly emergent,
37:10
give oral wait two hours, that that often doesn't happen.
37:14
And so you are faced with the scenario
37:17
of is there a colitis, is there a regional colitis?
37:21
Is it a stool I'm looking at? Is there an actual mass there?
37:24
So there are a host of potential, uh,
37:27
traps you can fall into.
37:29
Um, again, that paper from Mike McCarey super and
37:32
and colleagues at NY years ago, super helpful in terms
37:35
of going through the pattern approach
37:38
and the differential considerations.
37:39
Again, I think that paper absolutely holds water
37:42
even in 2026.
37:43
So here's an example. This oral conscious on board,
37:46
it made it to the colon to the transverse
37:47
colon of those house drugs.
37:49
It's an older case of those house
37:51
prominent, they kind of look prominent.
37:52
But how much of that is retained stool?
37:54
You know, you look at other parts
37:56
and the wall looks kind of thin.
37:57
Is there a colitis here? Is there not a colitis?
37:59
You know, there's no inflammation of the fat,
38:01
really makes it tough.
38:03
So fluid stool
38:06
redundancy under distension all make life a nightmare in
38:10
terms of assessing accurately the colon on a routine
38:13
or emergency CT where there's no special maneuvers or prep.
38:16
And I'll tell you, just like the appendix,
38:19
I look at every single colon with
38:22
axial coronal images in asinine manner with lung windows
38:25
and with abdominal windows in every single patient.
38:29
And again, the yield is not high, it's really quite low,
38:32
but every once in a while I'll find a big
38:34
polyp or a mass or something.
38:35
It is not a zero yield.
38:37
Again, going back to Macy's paper,
38:39
some general concepts in terms
38:41
of the extent of wall thickening.
38:43
Of course, if you have, you know, thickening that's focal
38:46
and it's over three
38:46
centimeter, you need to be concerned about that.
38:48
And again, our options for polyp include dedicated repeat
38:52
imaging with ct.
38:54
You can even use rectal contrast,
38:55
which I'm not a fan of for a variety of reasons.
38:57
CT colonography, um, and then optical colonoscopy.
39:02
So here's an example.
39:03
It's a non-contrast ct, so it's a little bit tough
39:06
to assess, but notice we do have some prominent vessels in
39:08
some mild edema, the fat.
39:10
So even though this is a collapsed colon
39:13
and there's no IV on board, no oral onboard,
39:15
I think we can still at least raise the possibility
39:18
of a mild distal colitis.
39:20
Here's an unusual scenario.
39:22
This is someone who has constipation.
39:25
The initial CT is prior
39:26
to bowel prep that stools a little bit.
39:28
Hyperdense patient has abdominal pain,
39:31
but they've not yet had optic colonoscopy, they've had prep.
39:35
So even though, again, it's a little bit of a sort
39:37
of tricky thing because the, the protocol is different.
39:41
The first one on the left was with iv, this one is
39:44
with looks like IV n oral.
39:47
The IV isn't the greatest bolus, but there's IV and but,
39:51
and the colon's collapse.
39:52
Now their stool is gone, but that will really look thick
39:55
and the vessels are more prominent
39:57
and there's pericolonic edema
39:58
and the patient has lower abdominal pain.
40:00
So it all correlates. This is believed
40:01
to be cathartic colitis
40:03
where there is colitis from the bowel prep.
40:06
The other thing that can happen is the glutaraldehyde
40:10
and other agents that are used to clean scopes
40:12
to sterilize them, um, can actually induce a colitis.
40:16
You can occasionally have a colitis, the patient was fine,
40:19
they get their routine prep, they're fine,
40:21
they get their optical colonoscopy and then they get colitis
40:23
because of the chemicals used to clean the scope.
40:26
That's also uncommon, but, but described in the literature.
40:29
So again, very, very tough.
40:32
It doesn't make a huge difference.
40:34
Well, you know, if you miss a mild colitis,
40:36
obviously it's not a a terrible thing.
40:39
The er, if there's diarrhea, the ER knows there's diarrhea.
40:41
It's not a diagnostic dilemma to them for the most part,
40:45
but it's nice to get it right
40:46
and it's not nice to exclude other things.
40:48
So again, we're looking for our target sign.
40:50
We're looking for the vessels, the fat nodes,
40:53
is there anything focal, et cetera.
40:56
And here's another kind of paper that keeps me up at night.
40:58
This was from a few years ago from the Mayo Clinic Group.
41:01
And this is from none other than Dan Johnson, who
41:05
with Amy Harra were the first folks to describe the use of
41:09
of CT colonography
41:11
after its initial, uh, kind of, uh, uh, description, uh,
41:15
at at Wake Forest, uh, some years ago.
41:18
And what they did is they looked at a, a subset of, uh,
41:22
about a little over 200 patients who had a CT shortly
41:27
before the then new diagnosis of colon cancer,
41:31
where the interpreters
41:33
of the cts did not know there was a colon cancer on board.
41:36
'cause it wasn't diagnosed up until that point in time.
41:39
And no part, presumably no surprise,
41:42
given all the information I've told you.
41:44
And for those who interpret, you know,
41:46
abdominal pelvic teeth, this should come
41:47
as no surprise to you at all.
41:49
Half of the cancers in this, in this group,
41:52
and these are everyone, all, all these, you know,
41:54
209 patients selected, all of 'em had a cancer.
41:58
Half of them weren't, uh, detected prospectively,
42:00
no surprise, those that were not detected were smaller than
42:04
the ones that were detected on the base of,
42:06
of the perspective.
42:08
C two interpretation. The right colon was a problem.
42:10
Polypoid, asymmetric morphologies were a problem.
42:13
And disturbingly about a fifth of the tumors, even knowing
42:16
where to look on then subsequent retro spector view,
42:19
the interpreter could not find the tumor knowing there was a
42:23
tumor and knowing where it was.
42:25
So here's a case,
42:27
oral consciousness onboarded, reached the rectum.
42:29
Again, often the exception. There's no iv.
42:32
Um, this we knew was a cancer. There's no dilemma.
42:36
It's just a good example to show an area of, of, of,
42:38
of focal wall thickening, protrusion into the lumen.
42:41
There's actually maybe some scariest component here.
42:43
It looks like the lumen is being narrowed, um, as well.
42:47
This is a proven cancer.
42:48
But again, the cancer was diagnosed prior to ct.
42:51
Here's a, a scary case from a few years ago at our practice.
42:55
I looked at this, I said,
42:57
you have hydro necrosis on the right.
42:59
There's probably some sort
43:00
of adenopathy along the pelvic sidewall, is that, you know,
43:04
related to an ovarian tumor?
43:05
We had a hard time seeing anything else,
43:07
but this looked concerning.
43:09
And then there's this focal thickening along the proximal
43:12
to mid transverse colon, highly concerning.
43:14
This looks all malignant.
43:15
We said, we're not sure what came first here, um,
43:19
ad nexo versus colon, but this is malignant.
43:21
And, and I said this malignant a few days later, repeat CT
43:25
with, um, oral contrast again, shows the hydro.
43:28
Now there's a stent, and again,
43:30
it really looks like there's either a primary tumor
43:32
or there is serosal based tumoral implants.
43:35
And we call that again correctly.
43:38
And patient, I guess was lost to follow up
43:40
or seen elsewhere at another practice.
43:42
And here they are two years later,
43:43
diffuse all mental caking tumor ascites.
43:46
This is clearly malignant.
43:47
Again, I'm not sure what the primary is,
43:49
but it was correctly called.
43:50
But again, you know, you can imagine if there were subtler
43:53
examples of this might have been really tough
43:55
to call, is this a mass or not?
43:57
This is, you know, fullness in the area
44:01
of the ileocecal region.
44:02
There's, is it fluid? Is it just stool? Is it, what is it?
44:06
It was called suspicious for tumor here a year later.
44:10
Nothing. It's totally normal. It was a fake out.
44:13
So colitis versus diverticulitis is also a problem.
44:16
You can have, uh, longer segment diverticulitis
44:19
that mimics a short segment colitis.
44:21
And again, it may not make a huge difference,
44:23
but ultimately, if you're having repetitive episodes
44:25
of diverticulitis, the treatment is surgery.
44:26
So it does eventually make a difference.
44:29
In general, the colitis tends to demonstrate
44:31
a greater degree of bowel thickening
44:33
as opposed to fat stranding.
44:34
Whereas the reverse is generally true with diverticulitis.
44:38
You can have mesenteric vessels engorged in both the classic
44:41
edema and the root of the mesentery more
44:43
typical for diverticulitis.
44:44
And you can have abscess and fistula, um,
44:47
and diverticulitis.
44:48
Of course, we see that all the time.
44:50
But Crohn's can do it as well.
44:51
And every once in a while we see perforated tumor.
44:54
We've had in the last month, we've had two
44:56
distal colon neoplasms
44:58
and relatively young people walk in the door.
45:00
No prior diagnosis.
45:02
There was abscesses, there was as a mess.
45:04
Everything all over the place. There was ticks as well.
45:08
And you know, we said we think this is perforated neoplasm,
45:11
not diverticulitis, perforated.
45:12
And we were correct in both cases.
45:15
Here's a case where you can also fall into the search
45:18
of satisfaction pitfall.
45:20
There's diverticulitis on the left,
45:22
but, uh, oh, there's a cancer on the right.
45:24
Previously unknown notice. Again, that's sort of reaction
45:27
where it's dragging in the, the lumen narrowing it,
45:30
but also the whole overall diameter is decreased focally.
45:33
So diverticulitis tends to be longer than tumor.
45:37
There's more of a gradual, uh, transition zone.
45:40
The wall thickness doesn't tend to be marked.
45:42
Again, that classic fluid in the mesentery
45:44
that was assigned, um, in part reported by one
45:47
of my mentors, Bob Mendelson at Stanford years ago, absence
45:50
of major adenopathy and vascular engorgement.
45:53
Um, but again, there can be concurrent things.
45:57
You can have tumor that's causing secondary stasis ischemia
46:02
that leads to a regional colitis.
46:04
Um, you can have diverticula just sitting there mining their
46:07
own business, which may be potentially confused with
46:12
it being a primary diverticulitis.
46:13
If you're not paying attention, you might miss the
46:15
underlying neoplasm.
46:16
So here's just a kind of a typical bread
46:18
and butter non-contrast ct, left flank pain, roll out stone
46:22
or capitalist disease.
46:23
And we see, uh, proximal
46:25
to mid sigma colonic diverticulitis, no evidence for cancer.
46:28
But again, it's kind of a tough call
46:29
because there's no contrast on board.
46:32
Um, additionally we see this all the time,
46:34
particularly the sigmoid colon hypertrophy related
46:37
to chronic diverticulosis, which again,
46:39
can complicate analysis.
46:42
So, you know, there's been a lot written, um, as,
46:45
and this, this is covered in the,
46:46
in an acr r props criteria by the way.
46:48
But, um, as to who should get optic colonoscopy,
46:52
and, you know, not to fuel the scoping
46:54
because in my part of the world, um,
46:55
almost everything gets scoped
46:57
for diverticulitis at some point,
46:59
whether they should or shouldn't.
47:00
But the bottom line is, we don't necessarily have
47:01
to fuel the fire here, fuel the engines.
47:04
If things look like straightforward diverticulitis,
47:06
we don't necessarily need to raise the possibility
47:09
of something else going on
47:10
or to suggest follow up with optical colonoscopy.
47:14
Here's the kind of a scary case.
47:16
This is from John Rebels, one of my
47:18
superstar colleagues in the outpatient, uh,
47:20
arm in my practice.
47:22
And again, if we didn't know this was a, a, a tumor
47:25
that was documented, you might think that's stool.
47:26
You might maybe think it's focal diverticulitis here,
47:30
but this is in fact a proven, uh, transverse, uh, uh,
47:34
a descending colonic, uh, tumor.
47:36
Notice the absence of diverticular.
47:38
There's diverticular above, there's diverticular below,
47:39
there's no diverticular in this area.
47:41
The ticks are obliterated. This is neoplasm.
47:44
Um, two final topics.
47:46
Polyp, uh, versus, you know, mass versus stool.
47:51
This can be really tough.
47:52
As I've mentioned, again, we have found a small number of
47:55
cancers prospectively.
47:56
Uh, it's not a zero yield, but it's low.
47:59
But without bowel prep, it really can be tough.
48:01
And stool can look like polyps
48:02
and polyps can look like stool and things can move.
48:05
You can have polyps on stalks that can move, um,
48:09
if you are in fact doing additional imaging in different
48:12
positions, which we usually don't do.
48:14
But here's an example. This was correctly called,
48:16
and it was, uh, an un unrelated
48:18
to the region reason for scanning.
48:20
This ended up being a large villus tumor picked up in a non
48:23
prepared colon in the distal sigmoid,
48:25
and it had areas of, uh, frank malignancy in it.
48:28
Here's this sort of a, a overall kind of, uh, panel
48:33
of, of, of cancer
48:34
and polyps that were picked up in non prepared bowel
48:38
on cts done for related reasons.
48:39
This one has oral onboard. This has oral onboard.
48:42
Um, and sometimes if the colon is fally
48:46
distended with gas, you can see it.
48:48
And here's an example. This was a CT done for hip fracture
48:51
where there's this big mass kind of hiding
48:54
in the right colon that was not previously known.
48:56
Proven cancer subsequently. So this can be really tough.
49:00
So again, I look at every CT of the AB
49:02
and pelvis axial coronal planes with long
49:05
and abdominal windows and um, you know,
49:08
sometimes we, we miss it.
49:09
Sometimes we over call it, but sometimes we get it right.
49:12
Here's a problem solving example.
49:14
This is a non millimeter polyp in the right colon on a
49:17
dedicated CT exam CT colonography.
49:20
So the final thing we'll talk about, uh, for a few minutes
49:23
and then we'll take some questions is the issue
49:25
of pneumatosis versus pseudo and pneumatosis.
49:28
And this really can be very difficult.
49:30
I've, I've sent several cases to quality assurance
49:32
or peer review within my institution where things were
49:36
incorrectly called one way or the other.
49:38
I had one case where there was rectal pseudo pneumatosis
49:42
that was called pneumatosis.
49:43
And reaction was, well, what does it matter?
49:45
And I think it actually does matter
49:47
because if you have rectal ischemia, you really want
49:49
to know about it as opposed to just, you know,
49:51
having some degree of constipation
49:53
with bowels trapping air at the periphery of the lumen.
49:57
So obviously if you have, you know, wall thickening
50:00
and other findings of mesenteric ischemia, you have,
50:03
you know, portal mesenteric, venous gas,
50:06
vascular occlusion, et cetera.
50:07
You know, that'll tell you what's going on.
50:09
But if all you have is question air in the wall versus air
50:12
in the periphery of the lumen, it can be really tough.
50:14
And again, we don't have the luxury of
50:16
putting the patient in different positions, uh, if we're,
50:19
you know, we're not checking the scans real time.
50:20
So here's a, uh, several examples of true pneumatosis
50:25
of bowel related to, uh, different etiologies.
50:28
You can see ischemia, steroids, infection,
50:30
you can throw connective tissue disease.
50:32
I had a recent case of sort of classic scleroderma where,
50:36
you know, there's air in the bowel wall,
50:37
which is quote benign pneumatosis,
50:39
and they all start to look kind of similar.
50:41
You know, the the teaching is
50:42
that if it's true pneumatosis the um, uh,
50:47
the air may go above the level of the fluid
50:50
or stool, uh, you know, sort of meniscus
50:53
because it's, it's actually air in the bowel, uh, wall.
50:56
But that can be variable.
50:57
Um, here I think it's fairly obvious this is well beyond
51:00
what we would see with, with pseudo pneumatosis.
51:03
Again, another example from cookie mean is this is true
51:05
colonic pneumatosis fairly diffuse,
51:08
but it really can be tough.
51:09
And, um, you know, I definitely, you know, could see where,
51:13
uh, there are cases where it, it can be, uh,
51:15
really quite problematic.
51:16
And without having that ability to do different positioning,
51:19
you really wanna, it's gonna make a difference
51:21
and you have that ability bring the patient back
51:24
and scan in different positions
51:25
or short term interval, follow up
51:26
and correlate obviously with things like
51:28
the lactate level and stuff.
51:29
In terms of anything that might point
51:31
to a true ischemic, uh, etiology.
51:33
Here's someone who's constipated.
51:35
And you can see what's happening is the content in the right
51:37
colon is more fluidy and the gas is just being
51:39
trapped at the periphery.
51:40
This is not, uh, you know, true pneumatosis.
51:43
And also that process classically should
51:45
end at the fluid level.
51:47
It shouldn't go superior. If you see mucosal separation,
51:50
that's usually, uh, pretty accurate for diagnosing, um,
51:53
actual pneumatosis.
51:54
So in conclusion, in about 50 minutes or so,
51:57
and I did manage to finish in my timeframe, um,
52:00
we've gone over a, uh, a selected number of
52:03
what I think are very important potential pitfalls,
52:06
differentials, problem solving,
52:08
where we do a either emergency admin pelvis ct, uh,
52:13
or a outpatient pelvis ct.
52:15
And there is some questionable regional
52:19
or focal abnormality of various parts of the GI tract.
52:23
And because of the absence of bowel prep, the absence
52:27
of oral contrast, even if there is oral contrast,
52:30
you may be struggling to say, what do I do with this?
52:32
Is this normal? Is this abnormal?
52:34
And what sort of abnormalities am I considering
52:37
in my differential?
52:38
So options include, you know, and,
52:40
and some of this even with extensive experience,
52:43
you just look at it and you go, I just don't know.
52:45
I don't know. Um, bringing the patient back, um, prone
52:50
decubitus positioning, problem solving
52:52
with things like effervescent crystals, water neutral
52:56
contrast, um, if it's non-emergent, C-T-E-M-R-E.
53:00
And then, you know, fluoroscopy has a
53:02
role depending on the scenario.
53:03
And certainly RGI colleagues doing various kinds
53:06
of endoscopy, upper capsule and lower.
53:09
So important to be familiar with these.
53:11
Um, I, I don't actually have any
53:14
dedicated publications on this specific topic other than a
53:18
syllabus that I contributed to the American Rank
53:21
and Race Society's er course this past April in San Diego.
53:25
So if you happen to have actually attended that meeting
53:27
or get your hands on that, um, syllabus,
53:30
we have a chapter in there on this, uh, material.
53:33
Other than that, it's just sort of all over the place
53:35
so you can, you know, maybe read
53:36
that article from Mike McCarey if you're interested.
53:38
It really holds water 25 years later.
53:41
And again, I thank you for your attention, uh, today.
53:43
If you're watching this live
53:44
or down the road, again, appreciate the privilege
53:47
and honor of doing, uh, noon conferences.
53:49
It's really great to be back
53:50
and it's become kind of an bit of an honor, uh,
53:52
an annual tradition for me.
53:53
So thank you very much.
53:56
Thank you so much Dr. Katz for that wonderful lecture.
53:59
We've got a bunch of questions in the q
54:01
and a box, if you're able to open
54:03
that up and take a look. Yes,
54:05
I do. Okay. So let's
54:06
see. So first question is,
54:07
what do you think about routine distension
54:09
to the stomach with water?
54:10
Well, absolutely that's an option.
54:12
The problem is that, you know, you would need
54:14
to build that into your protocol.
54:15
So, you know, it's pretty innocent.
54:17
Um, you know, to give water.
54:18
I think absolutely water would be, uh,
54:21
helpful if I had it on board.
54:23
More often than not, it is, it is another step
54:25
for the technologist.
54:28
Um, you know, sometimes when there's a specific
54:31
upper GI issue that I made aware
54:34
of personally in the history, I'll say, you know,
54:36
give water prior to the scan
54:38
or give oral just prior to the scan.
54:41
Um, we were just having a discussion recently about
54:43
esophageal perforation
54:44
and how to handle that, uh, with some of my colleagues at,
54:47
at, at, at several university centers about two weeks ago.
54:51
Um, and again, dedicated to a problem.
54:52
So I think, you know, that's certainly a, a, a way to go.
54:55
It's, it's cheap. The risks are pretty minimal.
54:58
Um, and uh, that would definitely help.
55:01
I think for assessment of the stomach.
55:02
It still wouldn't necessarily solve all the problems.
55:05
There's gonna be collapse of the proximal stomach often,
55:07
or may not go exactly where you want,
55:09
but it's, it's absolutely better than a
55:10
non distended stomach.
55:12
Um, next question about, uh,
55:14
it says about 10 years ago we stopped routinely giving oral
55:17
contrast for most ED cases
55:18
and recently stopped for outpatients.
55:20
What is your practice? So again, it is all over the place.
55:24
I will tell you that maybe 15 years ago now,
55:29
our ER unilaterally said we're not
55:31
using oral contrast anymore.
55:33
And it was like, what?
55:35
And you know, we're, we're kind
55:37
of set in our way as radiologists, right?
55:38
We don't like change, or at least I don't like change.
55:40
We're resistant to that.
55:42
And, um, you know, they were, they had sort of the privilege
55:46
of doing the initial protocols to get the cases through.
55:48
Now that I'm in a, a bigger system,
55:51
we are supervising the protocols a little more carefully.
55:54
Um, so, you know, there there're pros and cons.
55:57
You know, there's, there's, there's no free lunch.
56:00
There's advantages and disadvantages,
56:02
but I was a bit, so for a lot of things, um,
56:06
oral conscious does not have utility, right?
56:08
We know if you have, you know, a solid organ pathology,
56:13
geo track pathology
56:14
and bowel obstruction, it usually, if there's high grade
56:16
of obstruction known as suspected, it's contraindicated.
56:19
So, you know, in the ER setting, it's usually
56:23
if there is a specific concern for low grade perforation
56:27
or for a leak, um, we, we give, you know,
56:29
iodinated water soluble.
56:31
But I'll tell you other parts of my,
56:32
my hospital systems platform, it's all over the place.
56:35
The city hospital, they love it at main campus in
56:38
Manhattan, they use it a lot.
56:39
They use it in outpatients.
56:41
We still using, I I think for the vast majority
56:45
of patients, oral contrast is actually
56:48
not gonna add anything.
56:50
The problem is this needle in the haystack, you know,
56:52
it's like, so is it better to get rid of it?
56:55
'cause there's cost and there's expense and there's time
56:58
and time is money.
57:00
Um, to have a few patients that we are stuck
57:03
with problems than having oral contrast on board
57:06
with all the negatives.
57:07
Probably the answer is yes to that.
57:10
Um, what are your cutoffs for normal bowel thickness?
57:13
So, um, if you look at the lecture, um, again, I,
57:18
there is some variability.
57:20
I hate to give heart and fast rules,
57:21
but like, you know, imperceptible small bowel, uh, for,
57:25
for distended normal bowel, uh, two to three for collapsed,
57:29
um, some of those numbers are in there.
57:31
I think stomach is really problematic.
57:33
I can't give you any numbers for that large bowel.
57:36
Um, I don't have the numbers off the top of my head,
57:39
but it, it really depends on what part
57:41
of the sm the large bowel and, and where it is.
57:44
But a a hundred percent, the,
57:46
the collapsed colon is in particular very difficult.
57:48
Um, I struggle when it's, when there's majorly colitis,
57:51
when you have, you know, the accordion sign,
57:53
whether it's c diff for something else, it's obvious, right?
57:56
There's edema of the fat. It's major league thickened.
57:59
You know, if you have a two centimeter individual wall
58:01
thickness for the colon, even if there's colonic collapse,
58:04
and often there is gonna be colonic collapse in this
58:06
scenario because of this sub substant edema
58:08
of the Lumina, they're gonna collapse.
58:09
It's gonna be apparent, right?
58:11
So, um, but when it's subtle, that's when it's really tough.
58:16
But I'll tell you one of the key points
58:17
that I haven't yet emphasized.
58:18
So thank you for bringing this up.
58:20
And I look now even more so than ever,
58:22
I look at the distal colon contents.
58:24
So again, they don't need me to tell them there's diarrhea,
58:27
but for me, seeing the liquid content
58:29
and absence of solid stool
58:31
and distal colon is very, very reliable in telling me
58:35
that there is an infection,
58:37
most usually an infection going on.
58:38
Now, of course, if they've had bowel prep for a colonoscopy
58:42
or if they're, you know, post-op,
58:43
that's a different sta scenario.
58:45
But if it's someone who hasn't had any of those things
58:47
and there's either initially no solid stool content distally
58:52
or it develops in the, the course of a hospital stay,
58:55
that's usually pretty indicative that you're dealing
58:56
with a enterocolitis of some sort.
58:58
You can't tell what, but that's what the problem is.
59:02
Um, next question. Under what, oh, there's a good question.
59:04
What circumstances would you follow up with a CT MR?
59:06
So FDG pet,
59:07
I would say I almost never recommend FDG Pet almost never,
59:11
with a few exceptions.
59:13
Um, I had, you know, the occasional case
59:16
where someone walks in with a, uh, either, you know,
59:20
pretty clear cut
59:21
or strongly suspected based on the initial CT imaging
59:25
of a malignancy.
59:26
Would I recommend that? I'm trying,
59:28
I don't remember the exact scenario,
59:30
but there was a patient in the last two weeks
59:31
where I did recommend PET CT for staging,
59:33
but that's absolutely very, very unusual.
59:35
MR is more of the problem solver.
59:38
Um, and, you know, 6 0 1 half a dozen, the other in terms
59:42
of M-R-E-C-T-E, I like CTE
59:43
because of the spatial resolution,
59:45
but if it's a younger person, I would do MRE.
59:47
So I think it really kind of depends,
59:49
but I, I like in, in, in patients
59:52
where they haven't had a huge amount of cts to my knowledge.
59:54
I, I really like the CT for e per problem solving.
59:57
I think that's really helpful. But again,
59:58
you may wanna do more than just the CTA,
60:00
you wanna want to target it.
60:01
Like that case I told you about, I showed with the
60:04
question polypoid mass in the proximal stomach
60:06
where you would wanna do even more,
60:08
you wanna do the cubitus,
60:10
I would probably give effervescent crystals in addition
60:12
to the neutral enteric contrast to answer.
60:14
That's very specific question. Next question.
60:17
Do you have any tips on to different transient peristalsis?
60:19
Yeah, so without repeating the ct, well, so again,
60:23
look at the images in different planes.
60:26
If you look at the slide, again,
60:28
I couldn't cover all the text in, in 45, 50 minutes,
60:30
but asymmetric thickening tends to go along
60:35
with a true s stricture as opposed to symmetric, which tends
60:39
to be a peristalsis area,
60:41
but it can really be tough, really be tough.
60:43
And of course, the history, right?
60:45
You know, why would this person have a s stricture?
60:46
Is there a reason for a s stricture?
60:48
Um, so ultimately it may require, um, again,
60:52
typically a CT E or MRE for follow-up
60:56
and then additional, uh, maneuvers if, if that doesn't,
60:59
uh, answer the question.
61:01
Um, okay, next question.
61:04
Do you have any tips on how to, okay, we did that, uh,
61:07
from, uh, serosal implant?
61:08
Yeah, again, serosal implant's a bit of a different animal.
61:11
So those usually you can, I, I, I don't think that's
61:15
so much a pitfall.
61:16
The this, the thing I would say about, and,
61:19
and I I've, we've been having a run,
61:20
unfortunately in the last few weeks of peritoneal
61:22
or mental mesenteric tumor, um, is that, you know,
61:27
sometimes when it's really subtle, once you see one thing
61:30
that you think is a peritoneal implant, it's, it's almost,
61:34
and I know it's, it's kinda lunchtime, so I'm, I apologize
61:36
for the reference, but it's like roaches.
61:39
You never have one roach, right? Never.
61:41
It's always, unfortunately the sentinel roach, if you will.
61:45
So once you see something that you think is
61:47
or could be a peritoneal or mental mesenteric implant
61:51
and you keep looking, you're always gonna find others.
61:53
Always, almost always.
61:54
I had a case about two months ago where, uh, I,
61:58
there was a new, unfortunately new diagnosis
62:01
of pancreatic cancer in the tail.
62:03
It was not previously known.
62:04
And I said, uhoh, you know, this is kind of bulky.
62:08
Let me look carefully.
62:09
And then I found the localized peritoneal met
62:12
and I started looking, I found like seven
62:14
or eight other mets and, you know,
62:15
we were gonna find even more if you were to do an operation.
62:19
Um, so that's sort of my tip in terms of, you know,
62:22
peritoneal, uh, tumor.
62:24
It can be really tough. Do you ret routinely re-image
62:27
or, uh, recommend endoscopy
62:28
older patients, presume appendicitis?
62:30
No, absolutely not. Um, that's only in this,
62:34
and I would say that's it, it's a good question.
62:37
In this scenario of non appendicitis, what what we see, uh,
62:42
happens is that sometimes there is a CT
62:46
and there's mindfulness to the appendix
62:49
and it's like bulging a little bit into the SQL lumen.
62:52
Um, in that scenario, you know,
62:54
optical colonoscopy definitely is, is advised and,
62:57
and sometimes the opposite happens
62:59
where they're doing optical colonoscopy
63:01
and they think they're seeing a mucus seal bulging into the
63:05
SQL lumen on endoscopy
63:06
and they recommend cross-section imaging.
63:08
So I've seen it both ways in the setting of
63:10
acute appendicitis, um, you know, it,
63:14
it usually is pretty obvious, right?
63:16
Um, once they do the specimen, what they're dealing with,
63:19
it may not be obvious when you're interpreting the imaging,
63:22
but once you know it, it becomes clear
63:25
that it is an underlying tumor.
63:28
Um, you know, typically, uh, some sort of, you know, adeno,
63:32
if, if it's gonna be something involving the cecum, um,
63:37
you know, a as a,
63:39
and so you have a secondary appendicitis, you know,
63:41
the most common primary appendiceal tumors are distal, uh,
63:45
carcinoids, which usually aren't actually the etiology.
63:48
They're usually incidental,
63:49
but if they get bulky enough can be okay.
63:52
Do you think rectal contrast? No.
63:53
So, you know, I'll tell you why we
63:55
don't like rectal contrast.
63:57
I don't like rectal contrast because the patients hate it.
64:01
The technologists hate it, we hate it.
64:04
You know, I'm now in my particular senior,
64:06
we have an our resident, uh, radiology assistant,
64:08
but I now, uh, have to do these procedures of my own and,
64:12
and interrupt a, a very busy working day.
64:15
And so it's inconvenient.
64:17
Um, i, I reserve it for problem solving.
64:19
So we actually did a paper with the University
64:22
of Miami group some years ago looking at this scenario
64:24
pending penetrating trauma,
64:25
where there's been quite an ongoing debate as to the utility
64:29
of so-called triple contrast, oral, rectal,
64:32
and IV in that very specific scenario.
64:33
And actually the data really wasn't particularly
64:36
helpful one way or the other.
64:37
It's still all over the place.
64:38
So for very selected problem solving fists stuff,
64:42
I actually prefer colon, uh, uh, fluoroscopy.
64:46
And, and I, I always have to debate this
64:48
with my clinical colleagues,
64:50
and the reason is, it's an
64:52
uncontrolled sort of thing, right?
64:53
If you're wanting to do a CT colonography,
64:56
but another thing to be injecting rec, rectal contrast, um,
65:01
under some pressure when you don't know what you're dealing
65:02
with and you, you're, you're not using CT fluoroscopy is
65:06
to ct, you put in the contrast, then you scan.
65:08
I don't love that when I'm problem solving.
65:10
So it's a selective role,
65:12
but I i, I really don't love it for kind
65:15
of a routine u utilization, purely problem solving.
65:18
Okay, next question for the evaluat in the stomach.
65:20
Do you ever met an absolutely ne negative oral contrast?
65:22
So, you know, negative oral contrast is basically
65:25
neutral and enteric contrast.
65:27
Not to mention there are, you know,
65:28
two major manufacturers of that.
65:31
Um, and that's inherent in CT enterography, right?
65:33
So when you're doing recommending CT
65:36
or MRE, by definition, using neutral
65:38
or negative contrast, there have been a parade of
65:41
interesting other alternative contrast.
65:43
Everything from milk to blueberry juice.
65:46
So it doesn't even necessarily have to be that.
65:48
And water works fine if it's the stomach, you know,
65:51
if you're trying to problem solve the, you know, the, the,
65:54
the small bowel, that becomes a, a challenge
65:56
because the fluid gets resorbed normally.
65:58
So the neutral enteric contrast, the ideas that are,
66:01
are additives and stuff that,
66:03
that keep the contrast in the lumen.
66:04
So you normally get a degree of bowel distension.
66:06
Then of course when you're interpreting those,
66:08
you have to sort of account for that.
66:09
So I'll go, you know, there's mild dissent,
66:11
generalized distension of the small bowel,
66:13
which is proportionate to the, you know, the protocol used.
66:16
Um, can you elaborate on the normal FO pattern? Absolutely.
66:19
So let's take a step back and,
66:21
and talk about the, uh, c uh, uh, CX disease, right?
66:25
So sru nontropical spr.
66:27
So we learned years ago in training when it gets really bad,
66:30
there's what's called gen generalization of the ileum,
66:34
where the ileum becomes more thickened and more prominent
66:36
and the folds than the jejunum.
66:37
So the way I remember that, I remember
66:39
that is the jejunum normally has the most prominent folds
66:42
and the ileum has the least prominent folds.
66:45
The rugal folds of the stomach are
66:46
often prominent when they're collapsed.
66:48
And that, again, like I said,
66:49
that can be really kind of challenging.
66:51
And having seen, you know, now like four years of, of,
66:54
of continuous fluoroscopy where we have, you know,
66:59
absolutely commonly we see varying degrees
67:01
of fold thickening, rule thickening, it,
67:03
it's a lot easier on, on fluoroscopy than on ct.
67:07
Absolutely a lot more reliable.
67:08
You know, we see hyperplastic polyps, things we just
67:11
absolutely would not see with anything other than endoscopy
67:14
so that the stomach is tough,
67:16
the jejunum is normally prominent.
67:17
You just have to use your sort of judgment
67:20
and discretion regarding that.
67:21
The oleum normally shouldn't be that, that prominent, um,
67:26
and from, from pathology against celiac disease.
67:30
So mitri it is, that's really, you know, a, a,
67:34
a histopathologic diagnosis.
67:36
But again, I I, I'm not necessarily gonna say net nease,
67:39
but um, you know, some sort
67:41
of benign gastropathy of some sort.
67:43
If I really think the stomach has a regional area
67:46
thickening, and it looks like it's not a non-malignant
67:48
pattern, most likely in terms of celiac,
67:51
and remember, there's now fairly
67:53
substantial literature on that.
67:55
My, my, one of my mentors Frank Schultz at the lay clinic,
67:57
he the colleague of Chris Shire, his case I showed, um,
68:01
he's written fairly extensively on celiac
68:03
disease over the years.
68:04
And it, it's really an absolutely underappreciated
68:08
diagnosis, overlooked diagnosis.
68:11
Um, only when it really is severe do
68:13
people even think about it.
68:14
But remember, so remember
68:16
that ju is juniorization occurs late,
68:19
that's a late finding earlier,
68:21
the folds in the Jun are actually more prominent.
68:24
So when you see, you know, prominent fos,
68:26
when you see nodes, um,
68:28
the cavitary lymph nodes syndrome is really unusual.
68:31
We don't see that very often.
68:32
When you see prominent, when you see abnormalities
68:35
of the stool, you see fatty stool,
68:37
you see geos in the stool.
68:39
Um, you see ab loss of separation of bowel loops, uh,
68:43
because of, of, uh, you know, loss of, of body fat, uh,
68:48
liquid contents in the colon, um,
68:50
fatty contents in the colon.
68:53
You splenomegaly, you got osteopenia.
68:55
There's just a a extent we do an entire lecture,
68:57
literally entire lecture on cross-sectional
69:00
imaging of celiac disease.
69:02
Um, next topic can a question,
69:03
can you differentiate a viral gastritis from bacterial?
69:06
So again, one of my favorite lines is I don't have a needle
69:10
or microscope as a non-interventional cross-sectional ma
69:13
juror, but I wish I did.
69:15
So, you know, absolutely I cannot, there,
69:17
there's no way I can in general playing the numbers.
69:21
It, it, it's, you know,
69:23
is it gonna make a difference in management?
69:24
Maybe, maybe not, but I, I, I can't tell.
69:27
All I can tell you is that there, if there is
69:30
prominent folds beyond
69:32
where there should be in the small bowel,
69:34
the stomach folds are prominent.
69:35
If there's increased fluid in the bowel, if there's lack
69:39
of solid stool content distally, we're probably dealing
69:42
with an enteritis without a prior history.
69:44
It's probably not Corona or Crohn's.
69:46
It's probably infectious.
69:48
And unless there's something really particularly specific,
69:52
which there generally isn't,
69:54
I can't tell you the organism, right?
69:55
I can't see the c of the seal to tell me it's, you know,
70:00
that classic cause of pseu remember,
70:02
is colitis versus something else.
70:07
And the last que any role for USG?
70:13
Not sure if that's not sure what USG is ultrasound,
70:17
I'm not, I'm not sure what I'm,
70:21
I'm not sure exactly what the acronym is.
70:24
Oh, we'll, we'll move on.
70:26
But I answered, um, everything else. I think
70:30
You got it all. Dr.
70:31
Katz,
70:33
Great questions. Thanks.
70:34
I I, it's great to have audience involvement.
70:36
Again, you can see the challenges, right?
70:38
I'm not the only one sitting out there thinking
70:40
that these are problematic.
70:41
I think everybody understands these are problematic
70:44
and we just have to sort
70:45
of do our best to sort through them.
70:48
Absolutely. And thank you so much for covering all of
70:50
that in this lecture and answering questions.
70:52
We really appreciate you being here.
70:53
Thank you so much to everyone else for being here
70:56
and asking such great questions.
70:58
You can access a recording of today's conference
71:00
and all our previous noom conferences
71:01
by creating a free account.
71:02
We'll also email out a link to this replay later today.
71:06
Be sure to join us next week on Thursday,
71:08
January 22nd at 12:00 PM Eastern,
71:10
where Dr. Benjamin Strong will deliver a case-based lecture
71:14
entitled Thoracic and Aortic Trauma ct.
71:17
You can register for that@modality.com
71:19
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71:20
for updates on future noon conferences.
71:22
Thanks again for learning with us and have a great day.
Douglas Katz, MD, FASER, FACR, FSAR
Vice Chair of Research
NYU Langone Hospital - Long Island (formerly NYU Winthrop)
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