Body CT
UNC Radiology Residency Educational Scholarship
University of North Carolina School of Medicine
Department of Radiology 2020
Carrie Anne Orlikowski, MD
Jeremy Kim MD Sheryl Jordan MD
Learning objectives
By the end of this activity, participants will be able to:
I. Describe basic of CT to include common indications for body
CT
II. Identify basic abdominal CT anatomy
III. Recognize classic CT cases
Outline
[Link] Back
[Link] & Indications
[Link] CT Anatomy
[Link]
[Link] Up/Questions
Think Back Q1
RADY Resident
When you Symposium:
suspect acute cholecystitis, what imaging test should
CXR #1in the W
you order?
Correct! GB ultrasound
Think Back Q2
Erect
What is the
diagnosis?
Correct! Small
bowel
obstruction
Supine
Think Back Q3
RADY Resident
When would Symposium:
you order MRI as the first line study for abdominal
CXR
pain? #1in the W
Correct! Suspected Appendicitis in a
pregnant woman!
Outline
[Link] Back
[Link] & Indications
[Link] CT Anatomy
[Link]
[Link] Up/Questions
CT Basics
RADY Resident Symposium:
Ionizing radiation (x-rays)
CXRthat#1in
Basically CT is an x-ray tube rotatesthe World
around
the patient with detectors on opposite side
CT Basics
Multidetector
• 8, 16, 64, 128, 320 rows of detectors
RADY Resident Symposium:
• 64-slice scanner = 64 detector arrays in 40 mm width =
CXR #1in the World
0.6 mm slice thickness
• Faster scans than single row
• More detectors helpful for breath hold studies, non-
cooperative patients, and cardiac imaging
Pros: Fast and High detail
Cons: Radiation, Contrast reactions, and Expensive
CT Basics - Contrast
Types of CT Scans
• CT with Contrast
• RADY Resident Symposium:
IV and PO Contrast (More Later!)
• CT without contrast
•
CXR
CT Angiography (CTA)
#1in the World
Pearl: Never order a CT with and without: limited indications to do so.
Plus, we must then call you / you will be interrupted in your daily tasks
CT Basics - Contrast
WHAT IS CONTRAST?
RADY Resident Symposium:
IV and PO administered and used to highlight organs
CXR #1in the World
Allows better visualization, differentiates structures
CT contrast is iodine based
Ex: omnipaque 350
ORAL CONTRAST OMNIPAQUE 240
Water soluble, safe in case of bowel perf
Include oral contrast in nearly all standard CT AP exams
Exceptions: retroperitoneal and vascular studies
Contrast Myths
CT Basics - Contrast Shellfish Allergy is not a contrast allergy!
‘Iodine allergy’ or topical iodine
Iodine is an essential substance
Present in thyroid hormone
ALLERGIES PREMEDS
RADY
Contrast allergies Resident Symposium:
Contrast allergy
Hives/rash premedication
Laryngeal edema CXR At#1in
UNC: the World
Bronchospasm 50 mg po prednisone 13, 7, 1 hour
Vasovagal (not really an prior to study
allergy) 25-50 mg po benadryl 1 hour prior
True anaphylaxis
Reasons to premedicate:
Severe hives
Note: True anaphylaxis from
prior contrast is Edema
CONTRAINDICATION to Bronchospasm
EVER receiving contrast
again!
3 Planes may be included: Axial (or transverse),
CT Basics - Anatomy Coronal, and Sagittal. For body work, axial and
coronal are today’s scan hallmarks (prev axial)
Anterior
RADY Resident Symposium:
CXR #1in the World
Right Left
Posterior
CT Basics - HU and Window-Level
HOUNSFIELD UNITS WINDOW & LEVEL
Water = 0 HU RADY Resident
Window Symposium:
and Level: allow for
tissue contrast
CXR #1in the World
All other densities relative
to water
Air -1000 Window width = width of
Lung -600 to -400 values
Fat -100 to – 40 • Depends on the area of
Soft tissue 40 to 80 interest on the scan (lung and
bone are not the same!)
Bone 400 to 1000
• Ex: bone windows: 3000
Level = set point
Ex: bone level: 500
CT Basics - Window Settings
Soft tissue/
Lung Bone
Vascular
CT Basics - Densities
Fat
RADY Resident Symposium:
CXR #1in the World
Contrast
Soft Bone Air
tissue
Fluid
CT Basics - Radiation Dose
Annual background radiation
3 mSv RADY Resident Symposium:
CT Effective Doses CXR #1in the World
10 mSv for AP (3 years background)
5-6 mSv for chest only (1.5-2 years background)
1.5 mSv CT chest lung cancer screening
12 mSv coronary CTA (4 years background)
CT Basics - Indications
Trauma
RADY Resident Symposium:
Pain CXR #1in the World
Mass
Cancer staging & surveillance
Pre & post operative
Complications AND SO MANY MORE . . .
Think back to our Emergency
Radiology and Abd Pain Lectures!
CT Basics - Order Entry
How to order in EPIC
RADY Resident Symposium:
CT abdomen and pelvis W contrast
CT abdomen and pelvis WO contrast
CXR #1in the World
CT chest WO contrast
CT chest W contrast
CTA chest W contrast
CT abdomen and pelvis WO contrast renal colic
CT urogram
CT renal mass
Outline
[Link] Back
[Link] & Indications
[Link] CT Anatomy
[Link]
[Link] Up/Questions
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
R Lung Heart, LV
By convention, CT displayed as if
RADY Resident Symposium: you are standing at the foot of the
supine pt – with pt right on left
RA CXR #1in the World side of screen and pt left on right
side of screen
IVC Esophagus
Pulmonary
vessels, RLL Azygous vein Aorta, descending
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Heart,
LV Lung windows for basilar
RADY Resident Symposium: pulmonary findings
RA CXR #1in the World
Esophagus
Pulmonary
Azygous vein Aorta, descending
vessels, RLL
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Stomach
Liver
RADY Resident Symposium: Without IV, PO contrast
Hepatic
CXR #1in the World
Veins
Spleen
IVC
Aorta
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Liver Stomach
w/ PO contrast
With IV, PO contrast
Portal Veins
Spleen
IVC
Diaphragm Aorta
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Stomach, body
Stomach, w/ PO contrast
antrum
Liver
RADY Resident Symposium:
Pancreas CXR #1in the World
Spleen
IVC
Diaphragm
Aorta L Adrenal L Kidney
upper pole
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Small Bowel
Colon
hepatic flexure RADY Resident Symposium:
Liver CXR #1in the World
inferior tip
Colon
descending
IVC
R Kidney
Splenic vein
L Kidney
Aorta
Now on to (axial) Anatomy!
CT Basics - Axial Anatomy
Umbilicus
Mesenteric
fat
RADY Resident Symposium: Small Bowel
CXR #1in the World
Colon Colon
cecum
descending
R gonadal
vessels L Psoas
L Iliac
Iliac
wing
bifurcation
CT Basics - Axial Anatomy
Small Bowel
Ileum
Colon
cecum
Colon
descending
L Iliac wing
L Psoas
Iliac Sacrum
vessels
Outline
[Link] Back
[Link] & Indications
[Link] CT Anatomy
[Link]
[Link] Up/Questions
Now on to (axial) Anatomy!
Case #1 - 45 yo MVA
Now on toCase
(axial)
#1 -Anatomy!
45 yo MVA
What do you see?
Active contrast
Gallbladder
RADY Resident Symposium:
extravasation
CXR #1in the World Axial CT with contrast: free fluid around liver,
splenic lac with active extravasation
Free Fluid
Laceration,
Spleen
Now on to (axial) Anatomy!
Case #2 - 67 yo with dull abdominal pain and a palpable mass
Now on to (axial) Anatomy!
Case #2 - 67 yo with dull abdominal pain and a palpable mass
Axial CT without contrast: aortic aneurysm with active
retroperitoneal extravasation = ruptured AAA. Call
Surgery!!
Case #3 - Flank Pain and a Bladder Mass
Case #3 - Flank Pain and a Bladder Mass – Findings?
CT Axial, delayed phase.
Two right ureters. Two left
ureters, one opacified,
one dilated and not
opacified.
CT axial w/ contrast.
Left hydronephrosis
Case #3 - Flank Pain and a Bladder Mass – Findings?
Coronal CT, delayed phase. Duplicated collecting systems, dilated
left upper pole moiety. Left ureterocele.
Weigert Meyer Rule:
• For duplex kidneys with complete ureteral duplication, the upper
renal ureter will have an ectopic insertion that is located medially
and inferiorly to the lower pole ureter.
• The upper renal ureter will often form a ureterocele
• The lower renal ureter will have an insertion located laterally and
superiorly, and will often be subject to reflux.
Now on to (axial) Anatomy!
Case #4 - RLQ Pain
Now on to (axial) Anatomy!
Case #4 - RLQ Pain
Findings: Dilated tubular structure in the right lower quadrant attached to the cecum.
Few high density round structures at the appendix base - Could be appendicoliths. Diagnosis:
Appendicitis
For CT protocols, think of indication before ordering study
Wrap Up Renal colic - order non contrast
Routine - order IV and PO contrast
• CTA is arterial phase study to evaluate arteries, trauma
• Contrast allergies: shellfish is NOT contraindication
• Contrast allergy premeds: prednisone & Benadryl
• Contrast serum creatinine <1.8, but dialysis pt ok (if they don’t make
urine!)
• Radiation effective dose of CT AP
10 mSv ~3 years background radiation
Questions???
More at [Link] [Link]
and @UNCRadRes
Thank you!
