7/12/2017 GastrointestinalTuberculosisImaging:Overview,EsophagealTuberculosis,GastricandDuodenalTuberculosis

GastrointestinalTuberculosisImaging
Updated:Oct15,2015
Author:MaheshKumarNeelalaAnand,MBBS,DNB,FRCRChiefEditor:EugeneCLin,MDmore...

OVERVIEW

Overview
Eachyear,tuberculosis(TB)resultsinthedeathof3millionpeopleglobally.In20002020,an
estimated1billionpeoplewillbeinfected,200millionpeoplewillbecomesick,and35millionwilldie
fromTB,ifcontrolisnotstrengthened.Radiologicfeaturesandpathologiccorrelationtothepatternof
tuberculousinfectionintheGItractisdiscussedinthisarticle(seetheimagesbelow).

Chestradiographrevealscalcifiedhilartuberculouslymphadenitis.
ViewMediaGallery

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7/12/2017 GastrointestinalTuberculosisImaging:Overview,EsophagealTuberculosis,GastricandDuodenalTuberculosis

Plainradiographofabdomenwithdiffusecalcifiedmesentericlymphadenopathyinapatientwithtuberculosis.
ViewMediaGallery

Bariumstudyshowsmarkednarrowingofthebodyofstomach,whichwasproventobegastrictuberculosis.
ViewMediaGallery

Overall,onethirdoftheworld'spopulationisinfectedwiththeTBbacillus,butnotallinfected
individualshaveclinicaldisease.Thebacteriacausethediseasewhentheimmunesystemis
weakened,asinolderpatientsandinpatientswhoareHIVpositive.ThecontrolofTBhasbeen
challengingbecauseofthenaturalhistoryofthediseaseandthevaryingpatterninwhichitmanifests
indifferentgroups.

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GITBisamajorhealthprobleminmanyunderdevelopedcountries.Arecentsignificantincreasehas
occurredindevelopedcountries,especiallyinassociationwithHIVinfection.Autopsiesofpatients
withpulmonaryTBbeforetheeraofeffectivetreatmentdemonstratedintestinalinvolvementin55
90%offatalcases.ThepreviouslynotedfrequentassociationbetweenpulmonaryTBandintestinal
TBnolongerprevails,andonlyaminorityofpatients(<50%)withabdominalTBnowhaveabnormal
chestradiographicfindings.However,approximately2025%ofpatientswithGITBhavepulmonary
TB.AnypartoftheGIsystemmaybeinfected,althoughtheileumandcolonarecommonsites.

Ongrosspathologicexamination,intestinalTBcanbeclassifiedinto3categories:

1.TheulcerativeformofTBisseeninapproximately60%ofpatients.Multiplesuperficialulcers
arelargelyconfinedtotheepithelialsurface.Thisisconsideredahighlyactiveformofthe
disease,withthelongaxisoftheulcersperpendiculartothelongaxisofthebowel.
2.Thehypertrophicformisseeninapproximately10%ofpatientsandconsistsofthickeningofthe
bowelwallwithscarringfibrosisandarigid,masslikeappearancethatmimicsthatofa
carcinoma.
3.Theulcerohypertrophicformisasubtypeseenin30%ofpatients.Thesepatientshavea
combinationoffeaturesoftheulcerativeandhypertrophicforms.

TripathiandAmarapurkarstudied110casesofGITBtoidentifythemorphologicspectrumofthe
disease,andaccordingtotheauthors,animportantfindingwasthecoexistenceofdifferenttypesof
granulomas.Inasignificantnumberofcases,granulomaswereseeninasubmucosallocation,and
thepredominanttypeofinflammationinthelaminapropriawaslymphoplasmacytic.Ongross
examination,inadditiontothetypicalTBlesions,intestinalperforationwasseenwithhigher
frequency,andischemicbowelwasalsoidentified.Morphologicpatternsofcaseating,noncaseating,
confluent,discrete,andsuppurativegranulomaswereidentifiedonhistopathology.[1]

AccordingtoastudybyLinetal,principalcomorbiditiesassociatedwithlowerGItractTBaretypeII
diabetesmellitus(23%)andalcoholism(23%).Ofthe30patientsfollowed,22hadradiographic
findingssuggestiveofpulmonarytuberculosis,ofwhich13wereconfirmedbyculture.Diagnosticyield
ofmycobacterialculturesofstoolorsputumwasapproximately50%,aratecomparabletothatof
histologicstudiesofcolonoscopicorsurgicalbiopsies.MultidrugresistantTBwaspresentin4ofthe
patients,2ofwhomhadalcoholism.The1yearmortalitywas20%,butmortalitywas50%inpatients
withmultidrugresistance.[2]

InastudybyParketal,6monthsoftherapywasfoundtobeaseffectiveas9monthsoftherapyin
patientswithintestinalTB.Theauthorsnotethatshorterdurationtherapymayhavetheadded
benefitsofreducedcostandincreasedpatientcompliance[3]

SeealsothefollowingMedscapeReferencetopics:

RapidTuberculosisTest
GenitourinaryTractTuberculosisImaging
ImaginginCNSTuberculosis
PostprimaryTuberculosisLungImaging
PrimaryLungTuberculosisImaging

Differentialdiagnosis

Extraluminalabdominaltuberculosis[4]

Patienteducation

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Forpatienteducationinformation,seetheBacterialandViralInfectionsCenter,aswellas
Tuberculosis.

EsophagealTuberculosis
Clinicalfeatures
EsophagealTBisrare,usuallyoccurringbecauseofspreadfromTBinthethoraxeitherfrom
mediastinalnodes,thelungs,orthespine.[5]EsophagealTBistheleastcommonsiteofTBintheGI
tract.Dysphagiaandretrosternalpainindicateesophagealinvolvement,withulcerationsjustabove
thetrachealbifurcation.AraregranularformofTBoccursinmiliaryspreadofprimaryTB.

Radiologicfeatures

Commonradiologicfeaturesincludedeepulceration,intramuraldissection,andfistulaformation,
especiallyinpatientswithAIDS.Theulcerationcanmimicesophagealmalignancywithnodularityof
themucosaonbariumexamination.Massandsinustractformationcanbebetterappreciatedby
usingCTtoassessextentofmediastinalinvolvement.

Otherdiagnosticstudies
Biopsyoftheulceratedmucosarevealsepithelioidgranulomas.

GastricandDuodenalTuberculosis
Clinicalfeatures

StomachandduodenalinvolvementbyTBisrarebecauseof(1)thesparsityoflymphoidtissueinthe
upperGItract,(2)thehighacidityofpepticsecretions,and(3)therapidpassageofingested
organismsintosmallbowel.Symptomsofstomachandduodenalinvolvementincludeabdominalpain
andupperGIbleeding.Nauseaandvomitingisafeaturewhengastritisandoutletobstructionare
present.

Radiologicfeatures

GastricTBmayshowmultiplelargeanddeepulcersinthestomach,mostfrequentlyonthelesser
curvatureoftheantrumorinthepyloricregion.Scarringfromulcersleadstodiffuseantralnarrowing
resultingingastricoutletobstruction.Thestomachmaybediffuselyinvolvedandshowirregular
contour,simulatingalinitisplasticaofprimaryscirrhouscarcinomaofthestomach.Multiplefistulous
tracksmaydevelopasthediseaseadvances(seetheimagebelow).[6]

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Bariumexaminationrevealsalongstrictureoftheduodenumcausedbytuberculosis.
ViewMediaGallery

Duodenalinvolvementisseenwithdiffusemucosalfoldthickening,ulcers,orstrictureformationoris
complicatedbyfistulae.Simultaneousinvolvementofthepylorusandduodenumisafeaturebutis
nonspecificforTB,becausethisfeatureisalsoseeninCrohndisease,lymphoma,andcarcinoma.

IntestinalTuberculosis
Clinicalfeatures
ClinicalfeaturesofintestinalTBincludeabdominalpain,weightloss,anemia,andfeverwithnight
sweats.Patientsmaypresentwithsymptomsofobstruction,rightiliacfossapain,orapalpablemass
intherightiliacfossa.HemorrhageandperforationarerecognizedcomplicationsofintestinalTB,
althoughfreeperforationislessfrequentthaninCrohndisease.[7]

Malabsorptionmaybecausedbyobstructionthatleadstobacterialovergrowth,avariantofstagnant
loopsyndrome.Involvementofthemesentericlymphaticsystem,knownastabesmesenterica,may
retardchylomicronremovalbecauseoflymphaticobstructionandresultinmalabsorption(seethe
imagebelow).

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Delayedimagefromfollowthroughseriesshowsacollapsedcolonandmarkedlydistendedlongsegmentofileum
fromchronicobstruction.Thismayrepresenttabesmesenterica.
ViewMediaGallery

Theileumismorecommonlyinvolvedthanthejejunum.Ileocecalinvolvementisseenin8090%of
patientswithGITB.Thisfeatureisattributedtotheabundanceoflymphoidtissue(Peyerpatches)in
thedistalandterminalileum.

ProximalsmallintestinaldiseaseisseenmorecommonlywithMaviumintracellulare(MAI)complex
infection,predominantlyinfectioninvolvingthejejunum.Intestinalobstructionmaybepartialor
completewithTB.Segmentalinvolvementusuallyisinastenoticform.

Radiologicfeatures
Earlychangesonbariumexaminationsrevealnodularthickeningofmucosalfolds,withlossof
symmetryinthefoldpattern(seetheimagebelow).AswithCrohndisease,deepfissures,sinus
tracts,enterocutaneousfistulae,andperforationcanoccur,althoughlesscommonly.Acobblestone
appearanceofthemucosaisafeatureseeninCrohndiseasethatisnotseeninTB.Ulcerationmay
bedemonstratedondoublecontrastexaminations,typicallyperpendiculartothelongaxisofthe
bowelthesehealwiththeformationofshortannularstrictures.Becauseofpersistentirritabilityfrom
inflammationintheterminalileum,rapidemptyingofthatsegmentmayoccur(Stierlinsign).The
ileocecalangleisobliteratedwithawidelypatentileocecalvalve.[8,9,10,11]

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Crohndisease.TheradiologicpatternshowscobblestoningofthemucosalsurfacecharacteristicofCrohn
disease.Thisisnotafeatureoftuberculosis.
ViewMediaGallery

Characteristicultrasonographic(US)featuresthatindicateearlychangesofTBhavebeendescribed.
USfeaturessuggestiveofintestinalTBaremesentericthicknessof15mmormoreandanincreasein
themesentericechogenicity(fromfatdeposition)combinedwithmesentericlymphadenopathy.
However,thesefeaturesalsomaybeseenonsonogramsinpatientswithCrohndiseasetherefore,
theybecomelessspecificforTBinaWesternpopulation.

RadiologicfeaturesofintestinalTBinHIVinfectedpatientsaresimilartothoseinotherpatients(see
theimagesbelow).[12,13]Theileocecalregionisthemostcommonsiteofinvolvement,with
thickeningoftheileocecalvalve,adjacentileum,andcolonicwall.

CTscansshowmesentericlymphadenopathywithahypoattenuatingcentersuggestiveofnecrosis.
DistinguishingMtuberculosisfromMAIcomplexinfectionsinpatientswithAIDSmaybepossible.
Diffusejejunalwallthickeningandenlargedsofttissueattenuatinglymphnodeswith
hepatosplenomegalysuggestdisseminatedMAIcomplexinfection,whereasfocalabdominallesions
withlowattenuatinglymphnodessuggestdisseminatedMtuberculosis.MAIcomplexinfectionisalso
calledpseudoWhipplediseasebecauseofthediffusemucosalfoldthickeninginthejejunumand
histiocyticaggregatesinfectedwithMAIthatstainpositivewithperiodicacidSchifftesting.

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BariummealfollowthroughseriesrevealsgrossdilatationofdistalilealsegmentsinthisBritishbornpatientof
Asianoriginwithmalabsorption.HehadvisitedPakistanonce15yearsago.Lymphoidmassesfoundatsurgery
wereproventobeintestinaltuberculosis.
ViewMediaGallery

CTscanoftheabdomeninapatientwithAIDSshowsedematousjejunalloopsandextensivelymphadenopathy,
whichwasproventobeaMycobacteriumaviumintracellulareinfection.
ViewMediaGallery

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CTscaninanHIVpositivepatientwithintraabdominaltuberculosis(TB)showsascites,markedomental
thickeninginbothflanks,andstrandinginthemesentery.CourtesyofZahirAmin,MD.
ViewMediaGallery

Plainradiographofabdomenwithdiffusecalcifiedmesentericlymphadenopathyinapatientwithtuberculosis.
ViewMediaGallery

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BariummealfollowthroughseriesrevealsgrossdilatationofdistalilealsegmentsinthisBritishbornpatientof
Asianoriginwithmalabsorption.HehadvisitedPakistanonce15yearsago.Lymphoidmassesfoundatsurgery
wereproventobeintestinaltuberculosis.
ViewMediaGallery

AbdominallymphadenopathyinintestinalTBmaybedemonstratedwithUSandCT.Thedistribution
oflymphadenopathyissometimesdifficulttodifferentiatefromlymphoma.ContrastenhancedCTmay
beusefulindifferentiatinglymphomasfromTB.Mesentericlymphnodesareinvolvedmoreoftenin
disseminatedTB(80%)andinnondisseminatedTB(52%)thaninpatientswithuntreatedHodgkin
disease(6%).[14,15,16]

ColonicTuberculosis
Clinicalfeatures
ColonicTBmostoftenisassociatedwithilealTB.Theinvolvementissegmentalandespecially
involvestherightcolon.Symptomsincludeweightloss,fever,andpainintherightiliacfossa,witha
palpablemassanddiarrhea.

Radiologicfeatures

AsmallbowelbariumstudyisthemainradiographicmethodfortheevaluationofintestinalTBin
regionsoftheworldwherethediseaseisendemic.However,becauseperitonitisiscommoninGITB,
abdominalCTmaybeperformedasapreferredexamination,whichnearlyalwayssuggeststhe
diagnosisinthepresenceofnecroticlymphnodesorchangessuggestiveofTBperitonitis.TheCT
featuressuggestiveofabdominalTBincludeirregularsofttissuedensitiesintheomentum,low
attenuatingmassessurroundedbythicksolidrims,lowattenuatingnecroticnodes,disorganized
appearanceofsofttissuedensities,highattenuatingasciticfluidandbowelloopsformingpoorly
definedmasses,andamultiloculatedappearanceaftertheintravenousadministrationofiodinated
contrastmaterial.[17]

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Radiologicfeaturesincludeacombinationofnarrowing,deepulceration,andmucosalgranulation
producingnodularityandinflammatorypolyps.Lesscommonfindingsareaphthousulcersanda
diffusecolitis.Changesareusuallynotedintheascendingandtransversecolon.Bowelcontourmay
belostwithasymmetrysimulatingCrohndisease.Whenashortsegmentisinvolved,thestrictures
arehourglassshapedratherthantheapplecoredeformityassociatedwithcarcinoma.Insomecases,
theymaybeindistinguishable.

Theileumemptiesintoadeformedconeshapedcecumatrightangleswithhypertrophyofthe
ileocecalvalve(Fleischnersign).Fistulaeandsinusesmayoccurbutarerare.Thececummaybe
pulledupwardwithfibrosis.

DifferentiatingCrohndiseasefromTBbeforetreatmentisinitiatedisimportant,assteroidtherapycan
becatastrophicinpatientswithundiagnosedTB.CTdemonstratescolonicwallthickeningwith
spiculations,transmuralfibrosis,andlymphadenopathy.Ifdoubtexistsandifimagingfindingscannot
definitivelydifferentiateGITBfromCrohndiseaseandotherinflammatorydisorders,laparoscopywith
atargetedbiopsyiscurrentlyconsideredthemostrapidandspecificmethodfordiagnosingGITB.

TBisawellrecognizedcauseofrectalstrictureintheAsianpopulation.Isolatedrectalinvolvementis
rareandmaybemistakenforrectalmalignancy.

Otherdiagnosticstudies
Themeasurementofasciticfluidadenosinedeaminaselevelsisamajoradvanceinthediagnosisof
tuberculousperitonitis,whichshouldbeconsideredwhendealingwithexudativeascites.
Laparoscopicbiopsysamplesfromtheperitoneumshouldbestainedforacidfastbacilli(AFB),and
culturesshouldbeobtained.Wherelaparoscopyisnotavailable,percutaneousperitonealbiopsyand
diagnosticascitictap(ifascitesarepresent)formicrobiologicandbiochemicalexaminationshould
suffice.Peritonealbiopsyisalsohelpfulinnonasciticcases.Findingsarepositivein42%ofpatients
withabdominalTB.

ThemostcommonsiteofGITBistheileocecalregion,iftheareacanbereachedwithaflexible
endoscope.Arapiddiagnosiscanbeachievedifsmearorcultureresultsarepositiveorifcaseating
granulomasareseeninbiopsysamples.IncountrieswhereGITBisendemic,atherapeutictrialof
antituberculosistreatmentmaybejustifiediftheclinicalpictureiscompatiblewithTB.

References

1.TripathiPB,AmarapurkarAD.Morphologicalspectrumofgastrointestinaltuberculosis.Trop
Gastroenterol.2009JanMar.30(1):359.[Medline].

2.LinPY,WangJY,HsuehPR,LeeLN,HsiaoCH,YuCJ,etal.Lowergastrointestinaltract
tuberculosis:animportantbutneglecteddisease.IntJColorectalDis.2009Oct.24(10):117580.
[Medline].

3.ParkSH,YangSK,YangDH,KimKJ,YoonSM,ChoeJW,etal.Prospectiverandomizedtrialof
sixmonthversusninemonththerapyforintestinaltuberculosis.AntimicrobAgentsChemother.
2009Oct.53(10):416771.[Medline].[FullText].

4.EgeG,AkmanH,CakirogluG.Mesentericpanniculitisassociatedwithabdominaltuberculous
lymphadenitis:acasereportandreviewoftheliterature.BrJRadiol.2002Apr.75(892):37880.
[Medline].

5.WillifordME,ThompsonWM,HamiltonJD.Esophagealtuberculosis:findingsonbariumswallow
andcomputedtomography.GastrointestRadiol.1983.8(2):11922.[Medline].
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6.NagiB,LalA,GuptaP,KochharR,SinhaSK.Radiologicalfindingsinduodenaltuberculosis:a
15yearexperience.AbdomImaging.2015Jun.40(5):11049.[Medline].

7.MakanjuolaD.IsitCrohn'sdiseaseorintestinaltuberculosis?CTanalysis.EurJRadiol.1998
Aug.28(1):5561.[Medline].

8.HussainT,SalamatA,FarooqMA,FarooqA,HassanF,HafeezM.Indicationsforendoscopic
ultrasoundanddiagnosisonfineneedleaspirationandcytology.JCollPhysiciansSurgPak.
2009Apr.19(4):2237.[Medline].

9.OzblblNI,OzdemirM,TurhanN.CTfindingsinfatalprimaryintestinaltuberculosisinaliver
transplantrecipient.DiagnIntervRadiol.2008Dec.14(4):2214.[Medline].

10.BarreirosAP,BradenB,SchiefersteinKnauerC,IgneeA,DietrichCF.Characteristicsof
intestinaltuberculosisinultrasonographictechniques.ScandJGastroenterol.2008.
43(10):122431.[Medline].

11.KalraN,AgrawalP,MittalV,KochharR,GuptaV,NadaR,etal.Spectrumofimagingfindings
onMDCTenterographyinpatientswithsmallboweltuberculosis.ClinRadiol.2014Mar.69
(3):31522.[Medline].

12.BrownLP,NelsonAM,BrownAE,etal.Gastrointestinalmanifestationsofacquired
immunodeficiencysyndrome.RadiologicalSocietyofNorthAmerica:.1995.Availableat:
http://www.rsna.org/REG/publications/rg/afip/privateM/1995/0015/00.[FullText].

13.RadinDR.IntraabdominalMycobacteriumtuberculosisvsMycobacteriumaviumintracellulare
infectionsinpatientswithAIDS:distinctionbasedonCTfindings.AJRAmJRoentgenol.1991
Mar.156(3):48791.[Medline].

14.EpsteinBM,MannJH.CTofabdominaltuberculosis.AJRAmJRoentgenol.1982Nov.
139(5):8616.[Medline].

15.JainR,SawhneyS,BhargavaDK.Diagnosisofabdominaltuberculosis:sonographicfindingsin
patientswithearlydisease.AJRAmJRoentgenol.1995Dec.165(6):13915.[Medline].

16.YangZG,MinPQ,SoneS.Tuberculosisversuslymphomasintheabdominallymphnodes:
evaluationwithcontrastenhancedCT.AJRAmJRoentgenol.1999Mar.172(3):61923.
[Medline].

17.HellerT,GoblirschS,BahlasS,AhmedM,GiordaniMT,WallrauchC,etal.Diagnosticvalueof
FASHultrasoundandchestXrayinHIVcoinfectedpatientswithabdominaltuberculosis.IntJ
TubercLungDis.2013Mar.17(3):3424.[Medline].

MediaGallery

Chestradiographrevealscalcifiedhilartuberculouslymphadenitis.
Plainradiographofabdomenwithdiffusecalcifiedmesentericlymphadenopathyinapatientwith
tuberculosis.
Bariumstudyshowsmarkednarrowingofthebodyofstomach,whichwasproventobegastric
tuberculosis.
Bariumexaminationrevealsalongstrictureoftheduodenumcausedbytuberculosis.
Bariumexaminationshowslossofnormalorientationanddisplacementofjejunalandileal
segmentsinayoungAsianboythisfindingsuggestsmesentericdiseaseduetotuberculosis.
BariummealfollowthroughseriesrevealsgrossdilatationofdistalilealsegmentsinthisBritish
bornpatientofAsianoriginwithmalabsorption.HehadvisitedPakistanonce15yearsago.

http://emedicine.medscape.com/article/376015overview#a3 12/14
7/12/2017 GastrointestinalTuberculosisImaging:Overview,EsophagealTuberculosis,GastricandDuodenalTuberculosis

Lymphoidmassesfoundatsurgerywereproventobeintestinaltuberculosis.
Delayedimagefromfollowthroughseriesshowsacollapsedcolonandmarkedlydistendedlong
segmentofileumfromchronicobstruction.Thismayrepresenttabesmesenterica.
Bariummealfollowthroughstudyinapatientwithstrictureoftheileocecalregionextendinginto
proximalascendingcolon.
CTscanoftheabdomeninapatientwithAIDSshowsedematousjejunalloopsandextensive
lymphadenopathy,whichwasproventobeaMycobacteriumaviumintracellulareinfection.
CTscaninanHIVpositivepatientwithintraabdominaltuberculosis(TB)showsascites,marked
omentalthickeninginbothflanks,andstrandinginthemesentery.CourtesyofZahirAmin,MD.
Crohndisease.Theradiologicpatternshowscobblestoningofthemucosalsurface
characteristicofCrohndisease.Thisisnotafeatureoftuberculosis.

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ContributorInformationandDisclosures

Author

MaheshKumarNeelalaAnand,MBBS,DNB,FRCRConsultantInterventionalRadiologist,
DepartmentofRadiology,MediclinicMiddleEastHospitals,UAEPreviousConsultantInterventional
RadiologistandClinicalDirectorofRadiology,PennineAcuteHospitalsNHSTrust,UK

MaheshKumarNeelalaAnand,MBBS,DNB,FRCRisamemberofthefollowingmedicalsocieties:
BritishSocietyofGastroenterology,BritishSocietyofInterventionalRadiology,Cardiovascularand
InterventionalRadiologicalSocietyofEurope,EuropeanSocietyofGastrointestinalandAbdominal
Radiology,IndianRadiologicalandImagingAssociation,RadiologicalSocietyofNorthAmerica,Royal
CollegeofRadiologists

Disclosure:Nothingtodisclose.

Coauthor(s)

JinnaJaganMohanReddy,MBBS,MDRadiologist,ClinicalImagingDepartment,MafraqHospital

Disclosure:Nothingtodisclose.

AliNawazKhan,MBBS,FRCS,FRCP,FRCRConsultantRadiologistandHonoraryProfessor,North
ManchesterGeneralHospitalPennineAcuteNHSTrust,UK

AliNawazKhan,MBBS,FRCS,FRCP,FRCRisamemberofthefollowingmedicalsocieties:
AmericanAssociationfortheAdvancementofScience,AmericanInstituteofUltrasoundinMedicine,
BritishMedicalAssociation,RoyalCollegeofPhysiciansandSurgeonsoftheUnitedStates,British
SocietyofInterventionalRadiology,RoyalCollegeofPhysicians,RoyalCollegeofRadiologists,Royal
CollegeofSurgeonsofEngland

Disclosure:Nothingtodisclose.
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7/12/2017 GastrointestinalTuberculosisImaging:Overview,EsophagealTuberculosis,GastricandDuodenalTuberculosis

SpecialtyEditorBoard

BernardDCoombs,MB,ChB,PhDConsultingStaff,DepartmentofSpecialistRehabilitation
Services,HuttValleyDistrictHealthBoard,NewZealand

Disclosure:Nothingtodisclose.

SpencerBGay,MDProfessorofRadiology,DepartmentofRadiologyandMedicalImaging,
UniversityofVirginiaSchoolofMedicine

Disclosure:Nothingtodisclose.

ChiefEditor

EugeneCLin,MDAttendingRadiologist,TeachingCoordinatorforCardiacImaging,Radiology
ResidencyProgram,VirginiaMasonMedicalCenterClinicalAssistantProfessorofRadiology,
UniversityofWashingtonSchoolofMedicine

EugeneCLin,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofNuclear
Medicine,AmericanCollegeofRadiology,RadiologicalSocietyofNorthAmerica,SocietyofNuclear
MedicineandMolecularImaging

Disclosure:Nothingtodisclose.

AdditionalContributors

ZahirAmin,MD,MBBS,MRCP,FRCRConsultingStaff,DepartmentofImaging,UniversityCollege
Hospital,UK

ZahirAmin,MD,MBBS,MRCP,FRCRisamemberofthefollowingmedicalsocieties:BritishInstitute
ofRadiology,BritishMedicalAssociation,RoyalCollegeofRadiologists

Disclosure:Nothingtodisclose.

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