W. Garik. Bentley College.
Nonspecific benign Usually single (20% are multiple) ulcer prima- Associated intense inflammatory reaction produces ulceration of colon rily involving the cecum and ascending colon in a mass-like effect simulating carcinoma cheap misoprostol 100mcg otc gastritis diet öööþïùùïäóþñùü. Histologic material and special amyloid stains (Congo red) required for diagnosis purchase misoprostol 100 mcg online gastritis diet in dogs. Cancer chemotherapeutic agents order misoprostol 200mcg free shipping gastritis remedios, methyldopa, nonsteroidal anti-inflammatory agents, cimetidine, the antifungal agent flucytosine, and elemental gold. Collagenous colitis Fine mucosal granularity that predominantly Chronic or intermittent watery diarrhea, often with involves the rectosigmoid region. Inflammation in a segment of colon that has been surgically isolated from the fecal stream by placement of a proximal colostomy or ileostomy. Postrectal biopsy Shallow, ring-like ulcer surrounded by a radiolu- May be seen on barium enema examinations cent elevation. Area of narrowing in the proximal transverse colon with ulceration along its infe- rior aspect and marginal spiculation (arrow). Schistosomiasis Segmental narrowing, primarily involving the Stenosing granulomatous process simulating sigmoid colon. Repeated episodes can produce a pattern simulat- dysentery ing chronic ulcerative colitis. In addition to the severe and loss of haustra involving the colon shortening and rigidity of the colon narrowing in the sigmoid colon (closed distal to the hepatic flexure simulate the and a loss of haustral markings. Varies from a short isolated narrowing to a long venereum stenotic segment with multiple deep ulcers. Radiation injury Long smooth stricture of the rectum and sig- Develops 6 to 24 months after irradiation. A stricture in the descending colon (arrow) followed healing of the ischemic episode. Without previous evidence of mucosal nodularity syndrome or ulceration, it may be impossible to differentiate this condition from inflammatory bowel disease, lymphogranuloma venereum, or rectal malignancy. Nonspecific benign ulcer Smooth or irregular area of narrowing, most fre- May be radiographically indistinguishable from of colon quently involving the cecum. Colonic âsphinctersâ Transient areas of narrowing, primarily in the Areas of spasm that probably reflect localized nerve transverse, descending, and sigmoid portions. Unlike annular carcinoma, colonic sphincters change on sequential films, have tapering margins and intact mucosa, and usually can be relieved by intravenous glucagon. In the sigmoid, an apple-core le- sion may be difficult to distinguish from diverticuli- tis (annular carcinoma tends to be shorter with more sharply defined margins and mucosal de- struction). The relatively short lesion (arrow) with irregular areas of narrowing pri- detergent enema. The long, circumferentially narrowed area (arrow) simulates segmental colonic encase- ment due to metastatic disease. The nodular mass in the region of the pouch of Douglas (arrows) was clinically palpable (Blumerâs shelf). There is a mass effect and tethering local- ized to the superior border of the sigmoid colon (arrow). Pancreatitis Narrowing primarily involving the distal trans- Reflects the spread of liberated digestive enzymes verse colon and splenic flexure. Amyloidosis Narrowing and rigidity, primarily in the rectum Thickening of the bowel wall due to direct mural and sigmoid. Endometriosis Smooth constriction, usually involving the rec- Occurs in women of childbearing age. Note the thin projection of contrast material (arrow) representing extravasa- tion from the colonic lumen. Adhesive bands Short, smooth areas of circumferential narrow- Most bands are due to previous abdominal or pelvic ing with normal mucosal contours. Distensibility of the narrowed area and a history of previous surgery permit distinction from a malig- nant process. Adenomatous polyp Sessile, protuberant, or pedunculated appear- Premalignant condition. An increasing incidence 9 mm have a 1% probability of containing invasive with advancing age. There is a 1% risk of multiple synchro- colon wall on profile view; interval growth or nous colon cancers and a 3% risk of metachro- change in shape; and short, thick, irregular stalk nous cancers. There may be mucous diarrhea causing severe fluid, protein, and electrolyte (especially potassium) depletion. Lipoma Smooth submucosal filling defect that is usually Second most common benign colonic tumor. The tumor (arrow) ap- pears to sit on the upper margin of the distal transverse colon like a saddle on a horse. Most are asymptomatic and found inciden- tally (rarely cause the carcinoid syndrome). Ascending colon mass that is extremely lu- filling the deep clefts between the multiple fronds. Peutz-Jeghers syndrome Multiple hamartomatous polyps (primarily in- Inherited disorder (autosomal dominant) with no volving the small bowel). Characteristic ab- normal mucocutaneous pigmentation (especially affecting the lips and buccal mucosa). Condition Imaging Findings Comments Cronkhite-Canada Multiple hamartomatous juvenile polyps. Associate hyperpigmentation, alopecia, and atrophy of the fingernails and toenails. Childhood disorder with no malignant potential (polyps tend to autoamputate or regress). Surgery is indicated only if there are significant or repeated episodes of rectal bleeding or intussusception. Rare hereditary disorder associated with multiple malformations and tumors of various organs. Typ- ically, there is circumoral papillomatosis and nodu- lar gingival hyperplasia. Rare inherited disorder (autosomal dominant) with syndrome macrocephaly and pigmented genital lesions. Inflammatory Islands of hyperplastic, inflamed mucosa Most commonly a manifestation of ulcerative pseudopolyposis (between areas of ulceration) mimicking multi- colitis and Crohnâs colitis. Occasionally a large single diographic evidence of the inflammatory process inflammatory pseudopolyp. A similar pattern may develop in infec- tious colitis (amebiasis, schistosomiasis, strongy- loidiasis, and trichuriasis). Focal hyperplastic granuloma (secondary bacterial infection of an amebic abscess in the bowel wall). Usually produces an annular, nondistensible lesion with irregular mucosa simulating colonic carcinoma. Innumerable adenomatous polyps throughout the colon present a radiographic appearance indistinguishable from that of familial polyposis.
Ascertain that the nasogastric tube has been withdrawn and Submit the proximal and distal margins of the specimen to divide the stomach with a long linear cutting stapler or with frozen section examination buy misoprostol 200 mcg amex gastritis diet àâòî. Clean the lumen of the proximal two 90-mm linear staplers applied in a parallel fashion discount misoprostol online amex gastritis diet 8i. The incision should be Enlarging the hiatus is rarely necessary if the crura of sufficient magnitude to allow the gastric pouch to pass have been skeletonized as described by division of the into the mediastinum without constriction of its venous phrenoesophageal ligament buy discount misoprostol on-line gastritis upper back pain. If the exposure is still inadequate, a A properly fashioned end-to-side esophagogastric anastomo- segment of the fourth rib may also be excised, but this is sis requires the presence of 6â8 cm of esophagus below the rarely necessary. If there is not 6â8 cm of esophagus below Enter the space between the anterior wall of the esophagus the aortic arch, the surgeon should not hesitate to enlarge the and the aortic arch with the index ï¬nger (Figs. This makes the anastomosis ger emerges cephalad to the aortic arch behind the mediasti- far simpler and safer to perform and requires only a few min- nal pleura. Now dissect the esophagus the skin incision up from the tip of the scapula in a cephalad free of all its attachments to the mediastinum in the vicinity of direction between the scapula and the spine. Avoid damage to the left recurrent laryngeal cautery divide the rhomboid and trapezium muscles medial nerve, the thoracic duct, and the left vagus nerve located to the scapula. Retract the scapula in a cephalad direction medial to the esophagus above the aortic arch. One or two and free the erector spinal muscle from the necks of the sixth vessels may have to be divided between hemostatic clips. Free a short (1 cm) segment of the sixth (and Deliver the esophagus from behind the aortic arch up often of the ï¬fth) rib of its surrounding periosteum and through the window in the pleura between the left carotid excise it (Fig. Insert one fork of the gus out through a pleural incision lateral to the subclavian cutting linear stapler through the stab wound into the stom- artery. Insert the stapling device to a depth should be constructed in a position lateral and anterior to the of 3. Exposure for the anastomosis in this location is step leaves both the end of the esophagus and a large open- excellent. Bring the esophagus down over the anterior wall of ing in the stomach unclosed (Fig. An overlap of 6â7 cm layer of the anastomosis has already been accomplished by is desirable. Complete the anastomosis in an everting without undue trauma, the esophageal segment has an excel- fashion by triangulation with two applications of the 55-mm lent blood supply even though its distal 10 cm has been liber- linear stapler. To facilitate this step, insert a 4-0 temporary ated from its bed in the mediastinum. The anastomosis can guy suture through the full thickness of the anterior esopha- readily be performed as high as the apex of the thorax by this geal wall at its midpoint, carry the suture through the center method, and a level of resection comparable to that achieved of the remaining opening in the gastric wall (Fig. Apply Allis clamps to approximate the circular stapling technique to perform the anastomosis high in everted walls of the esophagus and stomach. Apply the ï¬rst the chest is an excellent alternative to sutured intrathoracic or Allis clamp just behind termination of the ï¬rst staple line on cervical anastomosis. Hold the suture and the Allis clamps so the in front of the esophagus for the end-to-side anastomosis. Excise the esophageal and gastric tissues ï¬ush with the sta- Esophagogastric Anastomosis, pling device with Mayo scissors. Use an identical procedure to approximate the lateral side The technique for sutured esophagogastric anastomosis is of the esophagogastric defect. Then place the 55-mm linear stapling device into position deep to the Allis clamps and the previously placed guy suture. Close and ï¬re the stapler and remove the redundant Esophagogastric Anastomosis, Stapling tissue with Mayo scissors (Fig. It is essential that a Technique (Surgical Legacy Technique) small portion of the lateral termination of the stapled anasto- mosis be included in the ï¬nal linear staple line. Include the In 1978, Chassin described a linear stapling technique for guy suture also in this last application of the linear stapler. Although circular staplers are These measures eliminate any possibility of leaving a gap more commonly used currently, this method is still occasion- between the various staple lines. Test the integrity of the ally useful and applicable when other methods are difï¬cult. It requires an overlap appearance of the completed stapled anastomosis is shown in to enable 7â8 cm of the esophagus to lie freely over the front Fig. If a 7- to 8-cm overlap is not available, this Whether a Nissen fundoplication is to be constructed fol- stapling technique is contraindicated. In some cases of the gastric pouch at a point 7â8 cm from the cephalad partial fundoplication can be done. If a tear is detected, resect an additional segment of the The circular stapling technique is especially suitable for esophagus to remove the laceration. If the tear is not detected patients in whom the lumen of the esophagus is large enough and a stapled anastomosis is constructed, postoperative leak- to admit a 28- or 31-mm circular stapling device. It is dangerous the 28-mm sizer passes easily, the circular stapling technique to stretch the esophagus with these sizers, because it can is a good one. If only the 25-mm sizer can be inserted, there result in one or more longitudinal tears of the mucosa and is danger of postoperative stenosis when this size staple car- submucosa. Although this type of stenosis frequently the safest way to achieve lumen of adequate size for anasto- responds well to postoperative dilatation, we prefer to utilize mosis. Use a 16-F Foley catheter with a 5-cc balloon attached the alternative technique described above (Figs. Withdraw the inï¬ated balloon slowly Use a purse-string suture to tighten the esophagus around the after each inï¬ation. After inserting a 28- or 31-mm sizer, always be inserted with ease (use the largest size that can be place one or two purse-string sutures of 0 or 2-0 Prolene, inserted easily). Place four long Allis clamps or guy sutures making certain to include the mucosa and the muscularis in equidistant around the circumference of the esophagus to each bite. We generally prefer to use the posterior wall if the anastomosis is high in the chest, as it allows an easy anterior hemifundoplication. Make a 3-cm linear incision somewhere in the antrum of the gastric pouch utilizing electrocautery. Through this open- ing in the anterior wall of the gastric pouch, insert the car- tridge of a circular stapling device after having removed the anvil. Then choose a point 5â6 cm from the proximal cut end of the gastric pouch and use the spike of the stapler to puncture it. Advance the shaft as far as it will go and then insert a small purse-string suture of 2-0 Prolene around the shaft. Alternatively, place the purse-string suture ï¬rst; then make a stab wound in the middle of it (Fig. When this has been accomplished, tie the purse-string suture around the instrumentâs shaft, ï¬xing the esophagus in position (Fig.
Te childhood form is characterized by recurrent pyo- Syndrome genic infections and hepatosplenomegaly buy misoprostol cheap gastritis diet 974. In contrast trusted misoprostol 100mcg gastritis symptoms bleeding, the adult form presents in early adulthood with various neuro- Infection-associated hemophagocytic syndrome is a disease logical manifestations that include Parkinsonism buy misoprostol with a mastercard gastritis diet øàðèêè, dementia, characterized by histiocytes hyperplasia (increased num- spinocerebellar degeneration, and peripheral neuropathy. Extranodal manifestation like any other histiocyto- sis disease can involve any part of the body. Pathologically, the enlarged lymph nodes show infltra- tion of the sinuses by large histiocytes. Te histiocytes con- tain engulfed lymphocytes and plasma cells (emperipolesis), which is the hallmark of this disease. Laboratory investiga- 7 tions show leukocytosis, high erythrocyte sedimentation rate, and hypergammaglobulinemia. Patients with Griscelli disease are typically children presenting with characteristic silver hair in addition to febrile episodes, lymphadenopathy, hepatosplenomegaly, anemia, and pancytopenia. Neurological abnormalities in Elejalde syndrome include severe hypotonia or hyperrefexia, spastic hemi- or quadriplegia, ataxia, seizures, and profound developmental delay. Some investigators believe that Elejalde syndrome and Griscelli syndrome type 1 are the same disease. However, Elejalde syndrome lacks the immunological abnormalities commonly seen in patients with Griscelli and ChÃ©diakâHigashi. Xanthoma disseminatum: a case report the retroperitoneal structures), and pathological fndings. Elejalde syndrome: report of a case and Signs on Plain Radiographs review of the literature. Neuroradiologic aspects of of long bones (98 %), with relative sparing of the Chester-Erdheim disease. Bone involvement in Erdheim-Chester disease: blurred, and the bone marrow is obliterated by imaging fndings, including periostitis and partial epiphy- dense bone. Imaging of multisystem Langerhans cell his- 5 Radiolucent bands separating the sclerotic tocytosis in an adult. Extranodal sinus histiocytosis (Rosai-Dorfman of the periosteum is seen as a white line along the disease) of the brain parenchyma. Langerhans cell histiocytosis in the mandible: images affecting the meninges, eye, and pituitary computed tomography and magnetic resonance imaging. Langerhans cell histocytosis: presentation and evolution of radiologic fndings with clinical correlation. Xanthoma disseminatum: a rare cause of dia- Hemoptysis is a term used to describe the pathological con- betes insipidus. Hemoptysis can be a life-threatening condition, immunodefciency syndrome: diagnostic considerations and the condition needs urgent evaluation. Multisystem Langerhansâ cell histocytosis supply the lungs and take part in gas exchange. In contrast, (Hand-SchÃ¼ller-Christian disease) in an adult: a case the bronchial arteries are small arteries (2 mm or less in diam- 7 report and review of the literature. Eur Arch eter) that arise from the descending thoracic aorta and sup- Otorhinolaryngol. Langerhans cell histiocytosis presenting as esophagus, and part of the mediastinal lymph nodes. Te Langerhansâ cell histocytosis (eosino- T e right bronchial artery arises at the level of the ffh philic granuloma) of the cervical spine: a rare diagnosis of or sixth thoracic vertebra posteriorly and usually forms a cervical pain. Congenital Letterer-Siwe disease associated with a second lef bronchial artery found in up to 70% of with protein losing enteropathy. Cerebral Erdheim-Chester disease: case in the retrotracheal, retrobronchial, and retroesophageal report and review of the literature. The scan shows a hyperdense pulmonary mass that may T e diferential diagnosis of hemoptysis is diverse and contain cystic changes or airâï¬uid level. Cryptogenic hemoptysis is a term seen penetrating the mass, which is a pathognomonic used to describe hemoptysis with no identifable cause, and it ï¬nding (. The sequestered mass may show is responsible for up to 42% of hemoptysis episodes, espe- homogenous or inhomogeneous contrast enhancement. T is topic discusses some of the causes of hemoptysis, in which radiology plays an important role in establishing their diagnosis. Te term sequestration describes disconnected lung tissue with its own anomalous b systemic artery. Most cases are diagnosed before the age of 10 years, where the child presents with chronic cough, hemoptysis, and recurrent pneumonias. Hybrid lesion is a term used to describe a lesion, where the sequestered lung mass has a congenital cystic adenomatous malformation lesion within it. Te mass is located on the lef side in the posterior basal segment in 98% of cases. Te mass has its arterial supply from the descending aorta and its venous drainage from the azygos or systemic veins. It accounts for 1â6 % of the seques- lower lobe intralobar bronchopulmonary sequestration mass tration cases. Te mass receives its arterial supply from the (arrowheads) with its abnormal arterial supply arising from the descending thoracic aorta (arrows ) thoracic or the abdominal aorta in 80% of cases and is usu- ally found between the lower lobes and the diaphragm. Most cases present within the frst 6 months of life with dyspnea, cyanosis, and feeding difculties. Unlike bronchopulmonary parenchyma through the pulmonary ligament or sequestration, there is no abnormal tissue mass, and the ves- the adherent pleura. Te con- vessels within extrapleural fat associated with dition is sometimes referred to as pseudosequestration. Patients are typically middle aged presenting with thoracic aorta between the levels of T5 and T6 recurrent attacks of fever, dyspnea, and hemoptysis. Te typical laboratory fndings include marked eosinophilia in the absence of para- sitic disease and high levels of serum rheumatoid factor in 52% of cases. Extrapulmonary vasculitis may be seen in the form of coronary vasculitis, renal-induced hypertension, glo- merulonephritis, cerebral hemorrhage, and purpuric skin lesions. Tere is no specifc serological marker, and erythro- cytes sedimentation rate can be normal in spite of active dis- ease. As the disease progresses, diï¬use alveolar lung disease may be seen bilaterally due to pulmonary hemorrhage (. Up to 80 % of cases present unit shows bilateral diï¬use alveolar lung disease due to pulmonary hemorrhage as multiple, bilateral nodules located within the a b. Dieulafoy disease can be seen with cases of chronic bron- Cardiac bronchus is not identifed on plain chest radio- chitis. Te cosal blood vessels in the presence of mucosal dilatation anomaly is asymptomatic; however, it may result in hemopty- should alert the bronchoscopist of the possibility of Dieulafoy sis when it is infected. Dieulafoy disease can be the case of massive upper gastrointestinal bleeding in 1â2 % of cases.
Te liver characteristically contains few large ducts nodule formation with fbrosis in between (liver and many small bile ducts order misoprostol 200mcg overnight delivery gastritis diet herbs. Tese nodules do not function normally characterized by fbrosis and intrahepatic collagen because the relationship with the portal vein purchase 100 mcg misoprostol gastritis morning nausea, hepatic deposition cheap misoprostol 200 mcg mastercard gastritis symptoms how long does it last. Signs of liver failure include splenomegaly, ascites, and prominent paraumbilical veins yellowish discoloration of the skin (jaundice), develop- (caput medusae). Multiple intra- and extrahepatic porto- ment of central arteriole dilatation with radiating vessels systemic collaterals develop to compensate the loss of the on the face (spider nevi), white nail bed due to hypoalbu- large portal venous fow that cannot be maintained longer minemia, painful proliferative arthropathy of long bones, due to increased intrahepatic venous pressure in portal gynecomastia and palmar erythema due to reduced hypertension. Intrahepatic portosystemic shunts occur estradiol degeneration by the liver, hypogonadism when the portal vein communicates with the hepatic vein in (mainly in cirrhosis due to alcoholism and hemochroma- or on the surface of the liver through a dilated venous sys- tosis), anorexia and wasting (>50 % of patients), and dia- tem. In contrast, extrahepatic portosystemic shunts occur betes mellitus type 2 (up to 30 % of patients). Some when the intrahepatic portal vein runs toward the outside patients with liver cirrhosis may develop palmar fibro- of the liver communicating with the systemic veins. CruveilhierâBaumgarten syndrome is a condition character- Fibromatosis is a pathological condition characterized by ized by patent paraumbilical vein as a consequence of portal local proliferation of fbroblasts which manifests clinically as hypertension, which occurs as a part of portosystemic sof-tissue thickening. Paraesophageal and paragastric varices develop in aponeurosis (Dupuytrenâs contracture), causing limited hand patients with advanced liver cirrhosis and can cause life- extension and possibly bony erosions (. Manifestations of hepatic fbromatosis of the dorsum of the interphalangeal joint encephalopathy include daytime deterioration (grade 1), (Garrodâs nodes ). Te neurological manifestations of Signs on Plain Radiographs hepatic encephalopathy are due to inability of the liver to 5 Hepatic hydrothorax is defined as large pleural detoxify neurotoxins such as ammonia, phenols, short- effusion in a cirrhotic liver disease patient in the chained fatty acids, and other toxic metabolites within the absence of cardiac or pulmonary disease. Tese toxic metabolites cross the bloodâbrain barrier hydrothorax is seen in 10 % of patients. Te diagnosis of hepatopulmonary syn- 5 Noncardiogenic pulmonary edema can be seen in drome requires the following three criteria: chronic liver dis- 37 % in patients with fulminant hepatic failure. Patients with radiographs as focal lateral displacement of the hepatopulmonary syndrome present with liver cirrhosis with mediastinum. This hypox- 5 On abdominal radiographs, ascites is detected as emia occurs due to pulmonary vascular dilatation and subse- loss of the abdominal gases and the normal psoas quent ventilationâperfusion mismatch due to decreased shadows visualization. The abdomen structures are hepatic clearance or increased hepatic productions of circu- blurry due to the overlying fluid shadow lating cytokines and chemical mediators (e. Hypoxic respiratory failure can occur with cases of massive liver necrosis or fulminant hepatic failure. Liver inferior vena cava, which is in direct right lobe atrophy with enlarged caudate lobe is a communication with the left atrium. Due to the typical finding (caudate lobe/right lobe ratio previous anatomical fact, the normal hepatic veins >0. The fasting mean velocity of normal portal vein is approximately 18 cm/s (range, 13â23 cm/s ),3 and the ï¬ow pattern is normally ï¬at or monophasic (. Mildly pulsatile portal venous ï¬ow pattern can be seen normally in tall, thin patients (. Portal hypertension is detected as hepatic blood ï¬ow away from the liver (hepatofugal) due to increased intrahepatic venous ï¬ow resistance. Portal vein diameter (>13 mm) and splenic vein diameter (>10 mm) are other signs of portal hypertension. The flow pattern normally is monophasic and has low resistance, with high diastolic flow (. The hepatic artery diastolic velocity is less than the peak portal vein velocity, and if the hepatic diastolic velocity is greater than the portal vein, one should suspect hepatic parenchymal disease. The vein can be followed by the probe until identifying its relation to the intrahepatic portal veins passing through the ligamentum teres (. In (a), the varices are visualized as serpiginous ï¬lling defects in the lower esophagus (arrowheads). Up to 50 % of nodules are not detected 5 Regenerative nodules are divided into in the arterial phase because they behave as a micronodules (<3 mm in diameter) and normal liver parenchyma in the triphasic hepatic macronodules (>3 mm in diameter). The nodules become hypodense again in the enhance in arterial phase because they are portal venous phase of the scan (. Also, accumulate iron within them, which will make splenomegaly, dilated perisplenic collateral them seen in noncontrast scans as hyperdense venous channels, and ascites may be found as nodules (siderotic nodules), which are typically signs of portal hypertension (. They enhance homogeneously in both lumen (intraluminal varices) or adjacent to the arterial and portal phases and are usually not seen esophageal wall (paraesophageal varices) in scans. Lastly, a peripheral small wedge-shaped symmetrical high-intensity signal on T1W images area may be seen in the early phases of liver in the basal ganglia, especially in the globus contrast study, which represents arterialâportal pallidus (. Cerebellar atrophy may be seen in show dilated cisterna chyli, which is seen as high advanced stages. T2 signal intensity structure adjacent to the aorta, 5 Regenerated nodules with or without hemosiderin with delayed enhancement several minutes after have low T2 signal intensity. After contrast may be seen as low-intensity signal centered injection, enhancement of the masses can be seen around the portal venous branches on T2W images in approximately 50 % of cases. The masses show marked contrast enhancement after gadolinium injection (b ) Further Reading Colli A, et al. Doppler in hepatic cirrhosis and 5 Fatty liver is visualized as highly echogenic liver. Computed tomography of hepatic venous the echogenicity of the right renal cortex, which hypertension: the reticulated â mosaic pattern. Any type of lipid can accumulate within cells, such as choles- terol, triglycerides, and phospholipids. Fatty liver disease (steatosis) is characterized by accumulation of triglycerides within hepatocytes. Normally, free fatty acids are taken up by the hepatocytes and then converted into cholesterol esters, triglycerides, ketone bodies, or phospholipids. Liver steatosis can result from either excess delivery of free fatty acids into the liver (e. Types of Liver Steatosis 5 Difuse fatty infltration: the liver is usually enlarged with uniform decrease in density in the liver scan. It usually occurs in the same areas that are supplied by the third infow systemic veins (porta hepatic, around ligamentum teres, and adjacent to gallbladder). In contrast, metastases or with nonspherical margins (metastases usually have other hepatic lesions will be cutting off the hepatic round edge). An esophageal ring is a short liver steatosis: Importance of ultrasonographic and annular narrowing of the esophagus <1 cm in diameter. Focal fatty infltration of the liver simulating and is caused by propagation of the gastroesophageal junc- metastastic disease. Esophageal C ring is the normal abdominal retroperitoneal esophageal part (3 cm long) which makes a groove on the liver. Esophageal web is an abnormal thick Epigastric pain is a term used to describe dull achy pain 1â2 mm diaphragm-like membrane that extends partially or located at the area of the epigastrium beneath the xyphoid completely around the esophageal lumen and always indents process. Te lower esophageal sphincter line encountered in both medical and surgical casualty depart- where mucosal change is observed between the esophagus ments.