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Gut wrenching: cases of missed gastrointestinal tumors and their mimics on computed tomography

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Abstract

Computed tomography (CT) of the abdomen and pelvis is one of the most common imaging studies ordered through the emergency department (ED). Because these studies are ordered for the detection of acute abnormalities and due to the relatively low incidence in patients presenting through the ED, gastrointestinal tumors are commonly missed. Moreover, many CT findings of malignant tumors overlap with benign entities, which can present a diagnostic challenge. This review article will describe the common CT findings of gastric, small bowel, colon, and appendiceal cancer as well as some of the common benign gastrointestinal conditions with similar imaging findings.

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References

  1. Rui P, Kang K National Hospital Ambulatory Medical Care Survey: 2017 Emergency department summary tables. National Center for Health Statistics. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf

  2. Broder JS, Hamedani AG, Liu SW, Emerman CL (2013) Emergency department contrast practices for abdominal/pelvic computed tomography—a national survey and comparison with the American College of Radiology Appropriateness Criteria®. J Emerg Med 44(2):423–433. https://doi.org/10.1016/j.jemermed.2012.08.027

    Article  PubMed  Google Scholar 

  3. Goldman IA, Cunquiero A, Scheinfeld MH (2019) New CT-based diagnoses of torso cancer is low in the emergency department setting. Emerg Radiol 26(6):633–638. https://doi.org/10.1007/s10140-019-01715-x

    Article  PubMed  Google Scholar 

  4. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. SEER Cancer Stat Facts. https://seer.cancer.gov/statfacts. Accessed July 15, 2020

  5. Horton KM, Fishman EK (2003) Current role of CT in imaging of the stomach. RadioGraphics 23(1):75–87. https://doi.org/10.1148/rg.231025071

    Article  PubMed  Google Scholar 

  6. Solsky I, Rapkin B, Wong K, Friedmann P, Muscarella P, In H (2018) Gastric cancer diagnosis after presentation to the ED: the independent association of presenting location and outcomes. Am J Surg 216(2):286–292. https://doi.org/10.1016/j.amjsurg.2017.10.030

    Article  PubMed  Google Scholar 

  7. Lee MH, Choi D, Park MJ, Lee MW (2012) Gastric cancer: imaging and staging with MDCT based on the 7th AJCC guidelines. Abdom Imaging 37(4):531–540. https://doi.org/10.1007/s00261-011-9780-3

    Article  PubMed  Google Scholar 

  8. Hallinan JT, Venkatesh SK (2013) Gastric carcinoma: imaging diagnosis, staging and assessment of treatment response. Cancer Imaging 13(2):212–227. https://doi.org/10.1102/1470-7330.2013.0023

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kim HJ, Kim AY, Oh ST, Kim JS, Kim KW, Kim PN, Lee MG, Ha HK (2005) Gastric cancer staging at multi–detector row CT gastrography: comparison of transverse and volumetric CT scanning. Radiology 236(3):879–885. https://doi.org/10.1148/radiol.2363041101

    Article  PubMed  Google Scholar 

  10. Hu B, Hajj NE, Sittler S, Lammert N, Barnes R, Meloni-Ehrig A (2012) Gastric cancer: classification, histology and application of molecular pathology. J Gastrointest Oncol 3(3):251–261. https://doi.org/10.3978/j.issn.2078-6891.2012.021

    Article  PubMed  PubMed Central  Google Scholar 

  11. Johnson PT, Horton KM, Fishman EK (2010) Hypervascular gastric masses: CT findings and clinical correlates. AJR Am J Roentgenol 195(6):W415–W420. https://doi.org/10.2214/AJR.10.4575

    Article  PubMed  Google Scholar 

  12. Ba-Ssalamah A, Prokop M, Uffmann M, Pokieser P, Teleky B, Lechner G (2003) Dedicated multidetector CT of the stomach: spectrum of diseases. RadioGraphics 23(3):625–644. https://doi.org/10.1148/rg.233025127

    Article  PubMed  Google Scholar 

  13. Guniganti P, Bradenham CH, Raptis C, Menias CO, Mellnick VM (2015) CT of gastric emergencies. RadioGraphics 35(7):1909–1921. https://doi.org/10.1148/rg.2015150062

    Article  PubMed  Google Scholar 

  14. Chen CY, Jaw TS, Kuo YT, Hsu JS, Liu GC (2007) Differentiation of gastric ulcers with MDCT. Abdom Imaging 32(6):688–693. https://doi.org/10.1007/s00261-006-9162-4

    Article  PubMed  Google Scholar 

  15. Chen CY, Wu DC, Kuo YT, Lee CH, Jaw TS, Kang WY, Hsu JS (2008) MDCT for differentiation of category T1 and T2 malignancy lesions from benign gastric ulcers. AJR Am J Roentgenol 190(6):1505–1511. https://doi.org/10.2214/AJR.07.2940

    Article  PubMed  Google Scholar 

  16. Stabile Ianora AA, Wolowiec A, Francioso G, Scardapane A, Rotondo A, Angelelli G (2001) Benign and malignant gastric ulcer: CT findings. Radiol Med 102(1–2):32–26

    CAS  PubMed  Google Scholar 

  17. Urban BA, Fishman EK, Hruban RH (1991) Helicobacter pylori gastritis mimicking gastric carcinoma at CT evaluation. Radiology 179(3):689–691. https://doi.org/10.1148/radiology.179.3.1888360

    Article  CAS  PubMed  Google Scholar 

  18. Mayor S (2012) One in four cases of bowel cancer in England are diagnosed only after emergency admission. BMJ 345:e7117. https://doi.org/10.1136/bmj.e7117

    Article  PubMed  Google Scholar 

  19. Amri R, Bordeianou LG, Sylla P, Berger DL (2015) Colon cancer surgery following emergency presentation: effects on admission and stage-adjusted outcomes. Am J Surg 209(2):246–253. https://doi.org/10.1016/j.amjsurg.2014.07.014

    Article  PubMed  Google Scholar 

  20. Inra JA, Syngal S (2015) Colorectal cancer in young adults. Dig Dis Sci 60(3):722–733. https://doi.org/10.1007/s10620-014-3464-0

    Article  PubMed  Google Scholar 

  21. Klang E, Eifer M, Kopylov U, Belsky V, Raskin S, Konen E, Amitai MM (2017) Pitfalls in diagnosing colon cancer on abdominal CT. Clin Radiol 72(10):858–863. https://doi.org/10.1016/j.crad.2017.06.007

    Article  CAS  PubMed  Google Scholar 

  22. Lee SA, Poh A (2015) Unsuspected colorectal carcinoma on routine abdominopelvic computed tomography. Singap Med J 56(5):248–257. https://doi.org/10.11622/smedj.2015072

    Article  Google Scholar 

  23. Wray CM, Ziogas A, Hinojosa MW, Le H, Stamos MJ, Zell JA (2009) Tumor subsite location within the colon is prognostic for survival after colon cancer diagnosis. Dis Colon Rectum 52(8):1359–1366. https://doi.org/10.1007/DCR.0b013e3181a7b7de

    Article  PubMed  Google Scholar 

  24. Lee J, Voytovich A, Pennoyer W, Thurston K, Kozol RA (2010) Accuracy of colon tumor localization: computed tomography scanning as a complement to colonoscopy. World J Gastrointest Surg 2(1):22–25. https://doi.org/10.4240/wjgs.v2.i1.22

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ponz de Leon M, Marino M, Benatti P, Rossi G, Menigatti M, Pedroni N, Di Gregorio C, Losi L, Borghi F, Scarselli A, Ponti G, Roncari B, Zangardi G, Abbati G, Ascari E, Roncucci L (2004) Trend of incidence, subsite distribution and staging of colorectal neoplasms in the 15-year experience of a specialised cancer registry. Ann Oncol 15(6):940–946. https://doi.org/10.1093/annonc/mdh224

    Article  CAS  PubMed  Google Scholar 

  26. Horton KM, Abrams RA, Fishman EK (2000) Spiral CT of colon cancer: imaging features and role in management. RadioGraphics 20(2):419–430. https://doi.org/10.1148/radiographics.20.2.g00mc14419

    Article  CAS  PubMed  Google Scholar 

  27. Jaffe T, Thompson WM (2015) Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology 275(3):651–663. https://doi.org/10.1148/radiol.2015140916

    Article  PubMed  Google Scholar 

  28. Smith N, Bees N, Barbachano Y, Norman AR, Swift RI, Brown G (2007) Preoperative computed tomography staging of nonmetastatic colon cancer predicts outcome: implications for clinical trials. Br J Cancer 96(7):1030–1036. https://doi.org/10.1038/sj.bjc.6603646

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Zaidi E, Daly B (2006) CT and clinical features of acute diverticulitis in an urban U.S. population: rising frequency in young, obese adults. AJR Am J Roentgen 187(3):689–694. https://doi.org/10.1038/sj.bjc.6603646

    Article  Google Scholar 

  30. American College of Radiology. ACR appropriateness criteria®: Left lower quadrant pain-suspected diverticulitis. Available at: https://acsearch.acr.org/docs/69356/Narrative/. Accessed March 17, 2020

  31. Dickerson EC, Chong ST, Ellis JH, Watcharotone K, Nan B, Davenport MS, Al-Hawary M, Mazza MB, Rizk R, Morris AM, Cohan RH (2017) Recurrence of colonic diverticulitis: identifying predictive CT findings—retrospective cohort study. Radiology 285(3):850–858. https://doi.org/10.1148/radiol.2017161374

    Article  PubMed  Google Scholar 

  32. Kircher MF, Rhea JT, Kihiczak D, Novelline RA (2002) Frequency, sensitivity, and specificity of individual signs of diverticulitis on thin-section helical CT with colonic contrast material: experience with 312 cases. AJR Am J Roentgen 178(6):1313–1318. https://doi.org/10.2214/ajr.178.6.1781313

    Article  Google Scholar 

  33. Horton KM, Corl FM, Fishman EK (2000) CT evaluation of the Colon: inflammatory disease. RadioGraphics 20(2):399–418. https://doi.org/10.1148/radiographics.20.2.g00mc15399

    Article  CAS  PubMed  Google Scholar 

  34. Peery AF, Keku TO, Martin CF, Eluri S, Runge T, Galanko JA, Sandler RS (2016) Distribution and characteristics of colonic diverticula in a United States screening population. Clin Gastroenterol Hepatol 14(7):980–985. https://doi.org/10.1016/j.cgh.2016.01.020

    Article  PubMed  PubMed Central  Google Scholar 

  35. Chintapalli KN, Chopra S, Ghiatas AA, Esola CC, Fields SF, Dodd GD (1999) Diveriticulitis versus Colon Cancer: differentiation with helical CT findings. Radiology 210(2):429–435. https://doi.org/10.1148/radiology.210.2.r99fe48429

    Article  CAS  PubMed  Google Scholar 

  36. Padidar AM, Jeffrey RB, Mindelzun RE, Dolph JF (1994) Differentiating sigmoid diverticulitis from carcinoma on CT scans: mesenteric inflammation suggests diverticulitis. AJR AM J Roentgen 163(1):81–83. https://doi.org/10.2214/ajr.163.1.8010253

    Article  CAS  Google Scholar 

  37. Shen SH, Chen JD, Tiu CM, Chou YH, Chiang JH, Chang CY, Lee CH (2005) Differentiating colonic diverticulitis from colon cancer: the value of computed tomography in the emergency setting. J Chin Med Assoc 68(9):411–418. https://doi.org/10.1016/S1726-4901(09)70156-X

    Article  PubMed  Google Scholar 

  38. Sai VF, Velayos F, Neuhaus J, Westphalen AC (2012) Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review. Radiology 263(2):383–390. https://doi.org/10.1148/radiol.12111869

    Article  PubMed  PubMed Central  Google Scholar 

  39. Daniels L, Ünlü C, de Wijkerslooth TR, Dekker E, Boermeester MA (2014) Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review. Gastrointest Endosc 79(3):378–389. https://doi.org/10.1016/j.gie.2013.11.013

    Article  PubMed  Google Scholar 

  40. de Vries HS, Boerma D, Timmer R, van Ramshorst B, Dieleman LA, van Westreenen HL (2014) Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review. Surg Endosc 28(7):2039–2047. https://doi.org/10.1007/s00464-014-3447-4

    Article  PubMed  Google Scholar 

  41. Sharma PV, Eglinton T, Hider P, Frizelle F (2014) Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 259(2):263–272. https://doi.org/10.1097/SLA.0000000000000294

    Article  PubMed  Google Scholar 

  42. Vas WG, Seelig R, Mahanta B, Patel B, Salimi Z, Markivee C, Sundaram M (1988) Neutropenic colitis: evaluation with computed tomography. J Comput Tomogr 12(3):211–215. https://doi.org/10.1016/0149-936x(88)90011-2

    Article  CAS  PubMed  Google Scholar 

  43. Thoeni RF, Cello JP (2006) CT imaging of colitis. Radiology 240(3):623–638. https://doi.org/10.1148/radiol.2403050818

    Article  PubMed  Google Scholar 

  44. Kirkpatrick IDC, Greenberg HM (2003) Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology 226(3):668–674. https://doi.org/10.1148/radiol.2263011932

    Article  PubMed  Google Scholar 

  45. Frick MP, Maile CW, Crass JR, Goldberg ME, Delaney JP (1984) Computed tomography of neutropenic colitis. AJR Am J Roentgenol 143(4):763–765. https://doi.org/10.2214/ajr.143.4.763

    Article  CAS  PubMed  Google Scholar 

  46. Wiesner W, Mortele KJ, Hoon J, Ros PR (2002) Normal colonic wall thickness at CT and its relation to colonic distension. J Comput Assist Tomogr 26(1):102–106. https://doi.org/10.1097/00004728-200201000-00015

    Article  PubMed  Google Scholar 

  47. Macari M, Balthazar EJ (2001) CT of bowel wall thickening: significance and pitfalls of interpretation. AJR Am J Roentgenol 176(5):1105–1111. https://doi.org/10.2214/ajr.176.5.1761105

    Article  CAS  PubMed  Google Scholar 

  48. Connor SJ, Hanna GB, Frizelle FA (1998) Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. Dis Colon Rectum 41(1):75–80. https://doi.org/10.1007/BF02236899

    Article  CAS  PubMed  Google Scholar 

  49. Turaga KK, Pappas SG, Gamblin T (2012) Importance of histologic subtype in the staging of appendiceal tumors. Ann Surg Oncol 19(5):1379–1385. https://doi.org/10.1245/s10434-012-2238-1

    Article  PubMed  Google Scholar 

  50. Moertel CL, Weiland LH, Telander RL (1990) Carcinoid tumor of the appendix in the first two decades of life. J Pediatr Surg 25(10):1073–1075. https://doi.org/10.1056/NEJM198712313172704

    Article  CAS  PubMed  Google Scholar 

  51. Pickhardt PJ, Levy AD, Rohrmann CA Jr, Kende AI (2003) Primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation. RadioGraphics 23(3):645–662. https://doi.org/10.1148/radiol.2243011545

    Article  PubMed  Google Scholar 

  52. Amr B, Froghi F, Edmond M, Haq K, Thengungal Kochupapy R (2015) Management and outcomes of appendicular neuroendocrine tumours: retrospective review with 5-year follow-up. Eur J Surg Oncol 41(9):1243–1246. https://doi.org/10.1016/j.ejso.2015.06.010

    Article  CAS  PubMed  Google Scholar 

  53. Maglinte DD, O’Connor K, Bessette J, Chernish SM, Kelvin FM (1991) The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterol 86(3):304–308 https://pubmed.ncbi.nlm.nih.gov/1998312/

    CAS  PubMed  Google Scholar 

  54. Ojha A, Zacherl J, Scheuba C, Jakesz R, Wenzl E (2000) Primary small bowel malignancies: single-center results of three decades. J Clin Gastroenterol 30(3):289–293. https://doi.org/10.1097/00004836-200004000-00017

    Article  CAS  PubMed  Google Scholar 

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Capiro, N., Flink, C., Sai, V. et al. Gut wrenching: cases of missed gastrointestinal tumors and their mimics on computed tomography. Emerg Radiol 28, 389–399 (2021). https://doi.org/10.1007/s10140-020-01832-y

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