How to Read Your Abdominal and Pelvic CT Report

Sections of the Radiology Report

Type of exam

This section usually shows the date, time, and type of exam. This is usually dictated by your symptoms or needs.

Example:

• Abdominal and Pelvic CT with intravenous and oral contrast performed January 10th, 2023.

History/Reason for exam

This section usually lists the information that your ordering provider has listed for the radiologist when they ordered your exam. It allows your ordering provider to explain what symptoms you are having and why they are ordering the radiology test. This helps the Radiologist accurately interpret your test and focus the report on your symptoms and past medical history. Sometimes the radiologist who reads your exam will also add information that they find in your chart or in the forms that you fill out before your imaging test.

Example:

• 64-year-old female with a history of colorectal cancer and new abdominal pain.

Comparison/Priors

If you have had relevant prior imaging exams, the radiologist will compare them to the new imaging exam. If so, the radiologist will list them here. Comparisons usually involve exams of the same body area and exam type. It is always a good idea to get any prior imaging exams from other hospitals/facilities and give them to the radiology department where you are having your test. Having these older exams can be very helpful to the radiologist. In some cases, simply having your prior test available will make a difference in what the radiologist recommends if they see something on your scan. The prior exam can help show if a previous finding is unchanged or if there is a new finding.

Example:

• Comparison is made to an Abdominal and Pelvic CT performed August 24, 2018.

Technique

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This section describes how the exam was done and whether contrast was used. Because it is used for documentation purposes, this section is not typically useful for you or your doctor. However, it can be very helpful to a radiologist for any future exam if needed.

Example:

• CT scan was performed from the lung bases through the pubic symphysis following the administration of intravenous and oral contrast. Coronal and Sagittal reformatted images were evaluated.

Findings

This section lists what the radiologist saw in each area of the body in the exam. Your radiologist notes whether they think the area is normal, abnormal, or potentially abnormal. Sometimes an exam covers an area of the body but does not discuss any findings. This usually means that the radiologist looked but did not find any problems to tell your doctor. Some radiologists will report things in paragraph form, while others use a reporting style where each organ or region of the body is listed as a line with the findings. If the radiologist does not see anything concerning it may say “normal” or “unremarkable.”

Example:

• Lung bases: No pulmonary nodules or evidence of pneumonia.
• Cardiac: Base of heart is within normal limits. No pericardial effusion.
• Liver: Normal size and contour. There is a new 2 cm hypoattenuating focus in segment 8.
• Gallbadder is surgically absent.
• Biliary: No intra or extrahepatic biliary dilation.
• Spleen: Unremarkable.
• Pancreas: Normal.
• Kidneys and Adrenals: No masses, stones or hydronephrosis. No adrenal nodules.
• Lymph nodes: No lymphadenopathy.
• Bowel: No dilation or wall thickening.
• Bladder: Normal.
• Uterus and Adnexa: The uterus and bilateral ovaries are within normal limits for age.
• Bones: No aggressive osseous lesions. Degenerative changes are present in the spine.
• Soft Tissues: Bilateral fat and bowel containing inguinal hernias are again noted.
• Other: No free fluid within the pelvis.

Common terms you may see in your CT scan report of your abdomen and pelvis that can be confusing to a patient are:

Hypoattenuating lesion — this is a term that a radiologist uses to describe the appearance of a findings in comparison to the density of the organ around it. It often means the radiologist has detected a benign cyst in an organ. Cysts are very common and are water containing structure’s that are usually of no concern at all. Some radiologists will just state they see some cysts in an organ as well.

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Enhancing lesion — this means the radiologist sees something that gets bright with the IV contrast. It means it is solid and not a benign cyst. Most enhancing lesions detected incidentally in patients with no history of cancer are also being and often will cause you no harm but sometimes they can reflect a more serious diagnosis like a cancer and may need further testing.

Too small to characterize — these are tiny usually incidental findings the radiologist sees in often of your organs that is often seen with tiny benign cysts.

Impression

In this section, the radiologist summarizes the findings and reports the most important findings that they see and possible causes for those findings. It also has recommendations for any follow-up actions. This section offers the most important information for decision-making. Therefore, it is the most important part of the radiology report for you and your healthcare team.

For an abnormal finding, the radiologist may recommend:

• other imaging tests that can help better assess the finding or getting a follow up imaging test to relook at the finding after a period of time.
• biopsy.
• combining the finding with clinical symptoms or laboratory test results.
• comparing the finding with any other imaging studies that the radiologist interpreting your test does not have access to. This is common when you have imaging tests done at different facilities or hospitals.

For a potentially abnormal finding, the radiologist may make any of the above recommendations.

Sometimes the report does not answer the clinical question, and more exams may be needed. More exams may be necessary to follow-up on a suspicious or questionable finding.

Example:

1. No findings on the current CT to account for the patient’s clinical complaint of abdominal pain.
2. There is a new 2 cm lesion in the liver which is indeterminate (cannot be definitively diagnosed by the study).
3. RECOMMENDATION: Given the patient’s history of colorectal cancer, an MRI of the liver is recommended to better characterize the indeterminate liver lesion to exclude the possibility of metastases (or cancer spread).

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