Practical Radiological Pathology PDF

1 PRACTICAL RADIOLOGICAL PATHOLOGY By: Mohamed Mubarak Hassan TA of Radiology & Medical Imaging - Sphinx University  2 Contents:  Introduction to Pathology  Skeletal System  Respiratory System  Cardiovascular System  Nervous System  Urinary Sys...

1 PRACTICAL RADIOLOGICAL PATHOLOGY By: Mohamed Mubarak Hassan TA of Radiology & Medical Imaging - Sphinx University  2 Contents:  Introduction to Pathology  Skeletal System  Respiratory System  Cardiovascular System  Nervous System  Urinary System  Reproductive System  Gastrointestinal System  Hepatobiliary System  Trauma Radiography  3 Contents:  Introduction to Pathology   Disease  Pathology  Skeletal System  Pathogenesis  Respiratory System  Inflammation  Cardiovascular System  Inflammatory Reactions  Nervous System  Edema  Abnormal Fluids  Urinary System  Ischemia  Reproductive System  Infarct  Gastrointestinal System  Hemorrhage  Hepatobiliary System  Aplasia  Trauma Radiography  Atrophy  Hypertrophy  Neoplasm  4 Introduction to Pathology: Disease:  Simply put, pathology is the study of disease.  Disease is a term that literally refers to a lack of “ease.”  It is a condition that is marked by an abnormal disturbance in the function and or structure of the human body as a result of some type of injury or trauma.  5 Introduction to Pathology: Pathology:  The study of disease and how it impacts the human body.  The following is a partial list of sources for pathology:  Hereditary or Congenital  Tumors  Iatrogenic o Any adverse conditions that results from medical treatment. o An example would be a pneumothorax that occurs as the result of a thoracentesis.  Infections o A nosocomial infection is acquired from a health care environment.  6 Introduction to Pathology: Pathogenesis:  The study of the origin and development of a disease.  Pathogenesis will lead to observable changes that are known as manifestations.  Sign: o This is a manifestation that is observable by the health care worker. o Examples would be swelling or a skin rash.  Symptom: o This pertains to the patient’s perception of what is wrong and is subjective. o An example would be a headache.  7 Introduction to Pathology: Pathogenesis:  Syndrome:  This is a group of signs and symptoms that characterize an abnormal disturbance.  An example would be Marfan’s Syndrome. o This is a genetic disorder of connective tissue. o It is characterized by a predisposition to cardiac disorders, long limbs, long fingers, and a tall stature. o Abraham Lincoln had Marfan’s Syndrome.  Etiology:  This is the study of the cause and origin of a disease.  8 Introduction to Pathology: Pathogenesis:  Idiopathic:  This refers to the fact that there may be no real cause for the disease.  Examples would be hypertension and a spontaneous pneumothorax.  9 Introduction to Pathology: Inflammation:  Inflammation refers to the body’s ability to wall-off and sequester an injurious agent.  The ultimate goal of this process is the safe removal of said injurious agents.  Hyperemia is the process of dilating capillaries to allow fluids and leucocytes to infiltrate the infected area.  The leucocytes will act to remove cellular debris through a process known as phagocytosis.  The cardinal signs of inflammation include heat (results from hyperemia), redness, pain, and often a decrease in function.  10 Introduction to Pathology: Inflammatory Reactions:  Abscess:  This type of inflammatory reaction causes the injurious agent to become a walled-off ball of pus.  Antibiotics cannot penetrate an abscess since they do not contain a blood supply like a neoplasm.  As a result, an abscess must be aspirated with a needle and drained.  11 Introduction to Pathology: Inflammatory Reactions:  Ulcers:  This is another type of inflammatory reaction that is the result of a healing wound that is located on the skin or a mucous membrane.  12 Introduction to Pathology: Inflammatory Reactions:  Cellulitis:  This is an acute bacterial infection of the skin and is a third example of an inflammatory reaction.  It can be found anywhere in the body but it is more often seen in areas where the skin can be damaged and thus allow a portal of entry for bacteria.  A byproduct of bacterial reproduction within the tissue is the excretion of methane.  This can sometimes be demonstrated on a radiograph as depicted on the next slide.  13 Introduction to Pathology: Inflammatory Reactions:  Cellulitis: Demonstrated as a formation of air within the tissue  14 Introduction to Pathology: Edema:  This is an abnormal accumulation of fluid in body cavities or intercellular spaces.  The increase in fluid can be localized within a structure or dispersed throughout the body.  An example of a localized edema would be ascites which is essentially edema of the peritoneal cavity.  Generalized edema can be caused by congestive heart failure. This is characterized by peripheral edema, pulmonary edema, pleural effusions, and ascites.  15 Introduction to Pathology: Edema: CXR – PA view  16 Introduction to Pathology: Edema: CT chest – axial cut – mediastinum window  17 Introduction to Pathology: Abnormal Fluids:  Transudates:  This abnormal, extracellular fluid essentially consists of water that contains a low cell count.  As a result, they are usually clear.  A good example would be a pleural effusion.  Exudates:  This fluid filters from the circulatory system into lesions and generally contains water, pus, and/or blood.  Since exudates contain infected fluid (pus/bacteria), they are therefore not clear.  18 Introduction to Pathology: Ischemia:  This term refers to an obstruction of the normal blood flow to an organ or structure.  It usually results from either a narrowing of blood vessels from plaque formation (fatty cholesterol deposits) or as the result of a thrombic occlusion.  As humans age, primary blood vessels into an organ may become stenotic due to plaque formation within their lumen.  As a response to this gradual change, secondary blood vessels may enlarge and play an increasingly important role in that organ’s blood supply. o This process is called collateral circulation and it is the body’s natural defense against ischemia.  19 Introduction to Pathology: Ischemia:  20 Introduction to Pathology: Infarct:  Loss of blood supply to an organ or structure will cause the surrounding tissue to become necrotic.  This process is referred to as an infarct.  The following is a list of diseases that are either caused by an infarct or may result in an infarct:  Myocardial Infarction (Heart Attach)  Pulmonary Embolus  Cerebrovascular Accident (Stroke)  Hernia (Mechanical Obstruction)  Volvulus (Mechanical Obstruction)  21 Introduction to Pathology: Infarct:  22 Introduction to Pathology: Infarct:  23 Introduction to Pathology: Hemorrhage:  Hemorrhage or bleeding is simply the loss of blood from the circulatory system.  The following is a list of a few examples of a hemorrhage:  Hematoma: o This occurs as the result of a break in a blood vessel that causes a pooling of blood below the surface of the skin, organ, or structure.  Ecchymosis: o This is a type of hematoma that is commonly referred to as a bruise or contusion. o Capillaries below the skin are damaged usually as the result of some type of trauma.  24 Introduction to Pathology: Hemorrhage:  Hemorrhage or bleeding is simply the loss of blood from the circulatory system.  The following is a list of a few examples of a hemorrhage:  Hematoma: o This occurs as the result of a break in a blood vessel that causes a pooling of blood below the surface of the skin, organ, or structure.  25 Introduction to Pathology: Hemorrhage:  Ecchymosis: o This is a type of hematoma that is commonly referred to as a bruise or contusion. o Capillaries below the skin are damaged usually as the result of some type of trauma.  Purpura: o These are red or purple spots on the body that are caused by a hemorrhage. o They are often the result of some type of platelet or coagulation disorder.  Petechia: o This is a type of purpura that consists of very small red or purple spot on the body.  26 Introduction to Pathology: Hemorrhage:  27 Introduction to Pathology: Aplasia:  This is the inability of an organ or structure to form properly.  The defective development of an organ can result in the partial or complete loss of an organ.  28 Introduction to Pathology: Atrophy:  Atrophy is the decrease in size of the cells within an organ or structure.  The following is a list of some of the common causes of atrophy:  Lack of Physical Activity  Poor Nourishment  Nerve Damage  Poor Circulation.  29 Introduction to Pathology: Hypertrophy:  This is the opposite of atrophy in that there is an abnormal increase in cell size.  This condition is also sometimes referred to as hyperplasia or hypergenesis.  The following is a list of some of the common causes of hypertrophy:  An Increase in Physical Activity  Hormonal Changes  Chronic Inflammation  30 Introduction to Pathology: Hypertrophy: The arrow on this CT scan of the The arrows on this CT scan of the abdomen abdomen is pointing to a normal spleen. are pointing to an enlarged spleen. This condition is referred to as splenomegaly.  31 Introduction to Pathology: Neoplasm:  This is the abnormal proliferation of foreign cells that form a mass of tissue within an organ or structure.  A neoplasm will compete for nutrients from the cells that normally comprise the host organ and it is often referred to as a mass or tumor.  Oncology is the study of neoplasms.  A benign neoplasm: o Is one that is self-limited and will not spread or seed to distant sites within the host organism.  32 Introduction to Pathology: Neoplasm:  33 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o On the other hand, does possess the ability to spread to distant sites in the body.  This type of tumor will seed by employing either the lymphatic system (primary method) or by using the circulatory system (hematogenous spread). o Cachexia  If left untreated or undetected, malignant neoplasms will ultimately result in this condition.  It is characterized by fatigue, atrophy, weakness, and anorexia.  Cachexia is often seen as an end-stage to cancer.  34 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer):  35 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o Four major cancer categories are as follows:  Carcinoma/Adenocarcinoma: This type of cancer will arise from epithelial cells or tissues such as the breast, colon, or pancreas.  Sarcoma: Relatively rare but highly malignant. This is cancer of soft tissue or connective tissue such as bone, cartilage, muscle, and fat.  36 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o Four major cancer categories are as follows:  Leukemia: This is cancer of the blood and blood forming tissues. Acute leukemia is characterized by an abnormal proliferation of immature blood cells that do not possess the ability to fight infection. Chronic leukemia is characterized by an abnormal proliferation of mature blood cells that do not possess the ability to fight infection.  37 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o Four major cancer categories are as follows:  Lymphoma: This type of cancer originates in lymphatic tissues and affects the production of lymphocytes (white blood cells). There are two major categories. Non Hodgkin’s Lymphoma (NHL): This is the most common type of lymphoma and it is found in the spleen, liver, bone marrow, lymph nodes, and GI tract. NHLs are a diverse group of diseases that can develop in any organ that is associated with the lymphatic system and has an unknown etiology.  38 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o Four major cancer categories are as follows:  Lymphoma: Hodgkin’s Lymphoma/Disease: This type of cancer is also associated with lymphatic tissue and it was first describe by Thomas Hodgkin in 1832. This cancer is characterized by the lymph nodes becoming swollen and rubbery yet they remain pain free. It is definitively diagnosed via lymph node biopsy and finding the presence of Reed-Sternberg Cells. Hodgkin’s disease has an unknown etiology.  39 Introduction to Pathology: Neoplasm:  A malignant neoplasm (cancer): o Cancer treatment varies according to the type of cancer that is diagnosed and what stage it is in. o The three primary methods of treating malignancies are as follows:  Surgery  Chemotherapy  Radiation Therapy In some instances, a combination of these treatments may be indicated.  40 Contents:  Introduction to Pathology  Butterfly Vertebra  Spondylosis  Cervical Rib  Spondylolysis  Skeletal System   Osgood-Schlatter Disease  Spondylolisthesis  Respiratory System  Osteogenesis Imperfecta (OI)  Retrolisthesis  Cardiovascular System  Osteopetrosis  Osteopoikilosis  Nervous System  Osteoporosis  Bone Cysts  Osteomalacia  Bone Tumors  Urinary System  Osteomyelitis  Enchondroma  Reproductive System  Rheumatoid Arthritis (RA)  Osteochondroma  Gastrointestinal System  Ankylosing Spondylitis  Multiple Myeloma  Hepatobiliary System  Gout  Osteosarcoma  Trauma Radiography  Osteoarthritis  Chondrosarcoma  Paget’s Disease  Fibrosarcoma  Avascular Necrosis (AVN)  Secondary Bone Cancer  41 Skeletal System: Butterfly Vertebra:  A congenital defect of a vertebra.  Produces the radiographic appearance of a butterfly on an AP projection.  Most are of no significance but they do have the potential for causing instability or altering the shape of the spinal canal.  42 Skeletal System: Butterfly Vertebra: CT Dorsal spine – X-ray LS Spine – AP view X-ray LS Spine – Lateral view coronal cut  43 Skeletal System: Cervical Rib:  This Is a supernumerary or extra rib that is attached to C7.  It is usually unilateral but in some cases, they can be bilateral.  The concern with a cervical rib is that it may compress the brachial nerve plexus or the subclavian artery and thus require surgical removal.  44 Skeletal System: Cervical Rib: X-ray on left upper ribs – AP view  45 Skeletal System: Osgood-Schlatter Disease:  Inflammation of the tibial tuberosity following exercise.  Patellar tendon has avulsed a portion of the tibial tuberosity away from the tibia.  This disease is one of the most common causes of knee pain in young athletes. The arrow on this diagram demonstrates how the patellar tendon is attached the the tibial tuberosity of the tibia.  46 Skeletal System: Osgood-Schlatter Disease: this image depicts how the patellar tendon has avulsed a portion of the tibial tuberosity away from the tibia X-ray Rt knee ( lateral view ) CT knee – sagittal cut – bone window  47 Skeletal System: Osteogenesis Imperfecta (OI):  Congenital bone disorder characterized by bones that easily break “brittle bone”.  People with this OI are born with insufficient amounts of a protein called type I collagen which plays an important role in bone formation.  This collagen deficiency will result in osteopenia which is a decrease in the number of osteocytes.  The net result is the formation of fragile or severely deformed bones.  Bones appear fragile, bowing or severely deformed.  48 Skeletal System: Osteogenesis Imperfecta (OI): X-ray lower limbs - AP view X-ray both femurs AP view X-ray rt lower limb – lat. view  49 Skeletal System: Osteoporosis:  A reduction in bone density.  “washed-out” radiographic appearance (dark).  Patients with this condition are prone to hip fractures, compression fractures of the vertebral bodies, and Colles’ fractures of the wrist.  50 Skeletal System: Osteoporosis: X-ray lt hip –AP view CT L.S. – sagittal cut – bone window  51 Skeletal System: Osteopetrosis:  Patients with this very rare condition possess bones that are very hard and dense “marble bone”.  marbled radiographic appearance (more bright).  52 Skeletal System: Osteopetrosis: X-ray ribs – AP view CT L.S.S. – sagittal view – bone window  53 Skeletal System: Osteomalacia:  This disease is characterized by a softening of bones that results from insufficient mineralization.  It can be caused by a decrease in absorption of either vitamin D or calcium.  It can also be manifested in children who ingest an insufficient amount of vitamin D or who are not exposed to enough sunlight.  Osteomalacia may cause a “bowing” of bones or lead to greenstick fractures.  This is commonly called rickets.  54 Skeletal System: Osteomalacia: X-ray pelvis – AP view  55 Skeletal System: Osteomyelitis:  A bacterial bone infection that causes bone destruction and abscess formation.  Brodie’s abscess and Sequestrum formation (avascular island of bone within the abscess) are indications that the patient has osteomyelitis. X-ray Lt Knee – AP view  56 Skeletal System: Osteomyelitis: X-ray Rt forearm – PA view CT Ankle – Axial Cut  57 Skeletal System: Rheumatoid Arthritis (RA):  Arthritis can involve joints, muscles, tendons, ligaments, and blood vessels.  It begins as a chronic inflammation of synovial membranes that line joints.  Thickened tissue (pannus) forms as a result of the inflammation and this causes erosion of the articular cartilage.  Lead to freezing of the affected joint, ulnar deviation of the fingers and deformities begin in the extremities and progresses toward the trunk  58 Skeletal System: Rheumatoid Arthritis (RA): X-ray lt hand – PA view X-ray elbow – lat. view  59 Skeletal System: Ankylosing Spondylitis:  A chronic, degenerative arthritis that usually begins in the sacroiliac (SI) joints and spreads to the spine.  Characterized by osteoporosis and fusion of the SI joints and vertebral bodies (bamboo spine).  60 Skeletal System: Ankylosing Spondylitis: X-ray l.s.s & pelvis – AP view X-ray l.s.s – lat. view  61 Skeletal System: Gout:  Gout, or metabolic arthritis, is a disorder of purine metabolism that results in an increase in uric acid production.  The excess uric acid is deposited in the blood, kidneys, and joints.  Gout is primarily manifested in the feet (great toe) but it can also affect other areas such as the hands and knees.  62 Skeletal System: Gout: X-ray Rt hand – PA view X-ray Rt foot – PA view  63 Skeletal System: Osteoarthritis:  A natural loss of joint cartilage that is related to but not caused by aging.  Demonstrated as a narrowing of joint space and formation of bone spurs.  64 Skeletal System: Osteoarthritis: X-ray lt knee – AP view X-ray lt knee – lat view  65 Skeletal System: Osteoarthritis: X-ray Rt hip – AP view X-ray lt shoulder – AP view  66 Skeletal System: Paget’s Disease:  Characterized by an abnormal cycle or process of bone destruction followed by excessive bone growth and thickening.  Paget’s disease is also known as osteitis deformans.  Signs and symptoms include bone pain, deformity, arthritis, and fractures.  Demonstrated as a thickening and deformity of bones.  67 Skeletal System: Paget’s Disease: X-ray hand – PA view X-ray Lt Hip – AP view X-ray Skull – Lat view  68 Skeletal System: Avascular Necrosis:  Characterized by bone ischemia followed by bone inflammation and necrosis.  Occur with navicular fractures but is most commonly seen in the femoral head, knee, and shoulder.  MRI is the imaging modality of choice in the diagnosis of AVN. X-ray lt shoulder – AP view  69 Skeletal System: Avascular Necrosis: X-ray pelvis – AP view MRI pelvis – coronal cut  70 Skeletal System: Spondylosis:  Refers to degenerative osteoarthritis of the spine. This essentially means that the space between vertebrae narrows as the protective cartilage that cushins the ends of the vertebrae wears down with age, this causes flexion (forward bending) of the spine.  71 Skeletal System: Spondylosis:  72 Skeletal System: Spondylosis: CT L. Spine – sagittal cut – bone window X-ray c.s – lateral view  73 Skeletal System: Spondylolysis:  This condition is characterized by a cleft (stress fracture) between the superior and inferior articulating processes at the pars interarticularis caused by stress or trauma.  It is usually bilateral and the net result is a loss of the neural arch continuity.  It is commonly found 90% of the time between L5 and S1.  74 Skeletal System: Spondylolysis: X-ray L.S.S. – lateral view  75 Skeletal System: Spondylolisthesis:  This condition is secondary to spondylosis.  Characterized by the forward movement (subluxation) of one vertebral body on the one below it.  This causes the vertebral canal to narrow and thus impinge on the nerve roots. X-ray l.s.s – lateral view  76 Skeletal System: Spondylolisthesis: X-ray l.s.s – lateral view CT l.s.s – sagittal cut – bone window  77 Skeletal System: Spondylolisthesis:  78 Skeletal System: Retrolisthesis:  Is a posterior displacement of one vertebral body on the one below it. MRI l.s. – sagittal cut X-ray l.s.s – lateral view  79 Skeletal System: Osteopoikilosis:  Is an osteosclerotic bone dysplasia that is literally translated as “spotted bones.”  It is appear as a multiple small radiopaque densities. X-ray wrist – PA view  80 Skeletal System: Osteopoikilosis: X-ray pelvis – AP view CT ankle – sagittal & coronal cuts  81 Skeletal System: Bone Cysts:  Bone cysts are common, benign, expansile, radiolucent lesions that are filled with fluid, and may resulted in a pathologic fracture.  82 Skeletal System: Bone Cysts: X-ray Rt leg – AP view X-ray lt leg – AP view  83 Skeletal System: Bone Tumors:  There are two general categories of bone tumors:  Osteolytic: They result in a decrease in bone density and have a lucent radiographic appearance.  Osteoblastic: They result in an increase in bone density and have an opaque radiographic appearance.  84 Skeletal System: Enchondroma:  A cartilaginous, benign bone lesion that is found in bone marrow, and most often located in the bones of the hands, feet, and ribs.  They present with a radiolucent, “cystic” appearance with calcium deposits.  85 Skeletal System: Enchondroma: X-ray lt hand – PA view X-ray lt foot – PA & oblique view  86 Skeletal System: Osteochondroma:  Is a benign projection of bone that has a cartilaginous cap, and generally found in the metaphysis of long bones, the ribs, and the pelvis.  Produce a mushroom or cauliflower radiographic appearance.  87 Skeletal System: Osteochondroma: X-ray Rt knee – AP view X-ray lt knee – lat. view X-ray Rt hip – lat. view  88 Skeletal System: Multiple Myeloma:  The most common type of primary, malignant bone tumor.  Produce “multicentric” or “punched-out” osteolytic (lucent radiographic appearance) lesions with marked osteoporosis and compression fractures of the vertebral bodies.  89 Skeletal System: Multiple Myeloma: X-ray skull – lateral view CT Brain – sagittal cut – bone window  90 Skeletal System: Multiple Myeloma: CT dorsal spine – sagittal cut – bone window X-ray elbow – oblique view  91 Skeletal System: Osteosarcoma:  Is the second most common type of malignant bone tumor.  It is an osteoblastic (opaque radiographic appearance) lesion that may extend into the surrounding soft tissue structures.  92 Skeletal System: Osteosarcoma: X-ray lt shoulder – AP view CT facial bone – axial cut – bone window X-ray lt ankle – AP view  93 Skeletal System: Chondrosarcoma:  A chondrosarcoma is an expansile, osteolytic, primary bone tumor.  They represent approximately 10% of all malignant skeletal cancers.  94 Skeletal System: Chondrosarcoma: X-ray skull – Lat view CT brain – axial cut – bone window  95 Skeletal System: Fibrosarcoma:  A fibrosarcoma is an osteolytic, malignant cancer of the skeletal system that often has a moth-eaten radiographic appearance.  96 Skeletal System: Fibrosarcoma: X-ray proximal tibia – AP & Lat view X-ray lower leg – Lat view  97 Skeletal System: Secondary Bone Cancer:  This is the most common type of bone malignancy.  Cancers originating from the prostate gland, breast, thyroid gland, colon, and kidneys often metastasize to the skeletal system.  These cancers often seed into the long bones, ribs, and spine.  Secondary bone cancer can possess either an osteolytic or osteoblastic radiographic appearance.  98 Skeletal System: Secondary Bone Cancer: This patient has non Hodgkin’s lymphoma and it caused an osteoblastic lesion to metastasize to the body of this lumbar vertebra. This condition is commonly referred to as an ivory vertebra. This osteolytic lesion metastasized to the tibia from the patient’s renal cell carcinoma.