Anatomy and Pattern recognition of the digestive system – abnormal pathologies Flashcards
Pathologies covered
Appendicitis
• Gallstones
• Pancreatic
calcifications
• Ulcerative colitis
• Crohn’s
• Diverticular disease
• Volvulus – sigmoid,
caecum, gastric
• Colonic cancer
• Salivary gland stones
• Foreign bodies
• Oesophageal cancer
• Barretts
oesophagus
• Gastric cancer
• Pancreatic cancer
• Liver cancer
• Small bowel
obstruction
• Large bowel
obstruction
• Toxic megacolon
• Coeliac disease
Salivary gland calculi
(Sialolithiasis): description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•Describes the formation of calculi inside the salivary glands, most commonly the
submandibular ducts and glands
Causes
•May be no known cause but dehydration, smoking, and some autoimmune diseases are linked
Symptoms
•History of recurrent swelling and pain in the involved gland usually associated with
eating.
•May also be infection
Diagnosis
•Plain film – not normally used. Not all stones can be seen, and oblique views are needed
to project the stones away from the bones and teeth
•Sialography – normally fluoroscopy but CT and MRI can also be used
•CT – excellent at visualising the stones.
•MRI – can help to map the duct anatomy and gland
Complications
•Infection and pain
Treatment
•Often conservative – hydration and heat. Sometimes sucking on something sour
•May need surgical removal
Differential diagnosis
•Vascular calcification.
GORD: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•Reflux of gastric acid from the stomach into the lower oesophagus across the
oesophageal sphincter
Causes
•Hiatus hernia, smoking, alcohol, pregnancy, certain medications such as
NSAIDs, certain asthma medications etc.
Symptoms
•Epigastric and retrosternal burning, acidic taste in mouth, chronic dry cough
Diagnosis
•Barium swallow – will see reflux, sometimes a hiatus hernia, impaired motility
Complications
•Exposure of the oesophagus to acid causes inflammation that leads to Barretts
oesophagus and then can result in cancer
Treatment
•Drugs to inhibit gastric acid production
•Surgery for severe cases – Nissens fundoplication
Differential diagnosis
•Oesophageal cancer or stricture
Barretts oesophagus: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• A change in the type of cells in the oesophagus (squamous epithelium to
columnar epithelium). It is generally considered to be pre oesophageal
adenocarcinoma
Causes
• Seen more in patients with oesophagitis. Risk factors include: being male,
smoking
Symptoms
• Normally asymptomatic and seen incidentally when patients present with GORD.
Diagnosis
• Endoscopy is the gold standard for visualisation and biopsy
• May not be seen on imaging until its advanced – most likely to see a stricture
• Barium swallow – may see a long stricture in the mid or lower oesophagus,
thickened and irregular mucosal folds
Complications
• Patients have a 30x risk of developing oesophageal adenocarcinoma.
Treatment
• Patients will be monitored with endoscopy every 3,6 or 12 months depending on
severity
Differential diagnosis
• Other causes for a stricture e.g. adenocarcinoma
Oesophageal cancer : description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•7th most common cancer in 2023
Causes
•Alcohol and smoking, Barrett oesophagus, coeliac disease, radiation, HPV
Symptoms
•Dysphagia, weight loss, reflux, hoarseness and cough
Diagnosis
•Normally diagnosed by endoscopy but we will be involved in the staging
•CXR – widened mediastinum, posterior mediastinal mass, tracheal deviation
•Barium swallow – irregular stricture, shouldering
•US – most accurate for staging as can define the oesophageal wall layers.
•CT – wall thickening, soft tissue mass, dilated lumen due to an obstructing lesion
•PET-CT – good for identifying metastases
Complications
•Normally advanced at presentation. Localised – 40% 5-year survival, distant mets – 5%
Treatment
•Surgery – oesophagectomy
Differential diagnosis
•Inflammation
•Benign mass
Gastric adenocarcinoma
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Is a primary malignancy arising from the gastric epithelium. Most common
gastric malignancy (95%)
Causes
• Rare before 40. Causes nonspecific anaemia, gastritis, smoking, H-pylori
infection, relfux
Symptoms
• Often non specific, weight loss and vague pain, nausea and vomiting in late
stage. Tumours highly vascular- blood. common symptom.
Diagnosis
Gastric
adenocarcino
ma
• Endoscopy is the gold standard
• CT – staging modality of choice because it can assess the tumour, and look for
local and distant spread. Findings include – a mass, wall thickening with
irregularity, ulceration and loss of rugae
Complications
• Its an aggressive cancer with a low 5 year survival of less than 20%. Need
accurate staging.
Treatment
• Surgery and chemotherapy and radiotherapy
Differential diagnosis
• Other gastric cancers, peptic ulcer
Small bowel obstruction
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•Is a mechanical blockage (tumour, foreign body) of the transit of food through the small bowel.
•Can be complete or incomplete (high grade or partial)
Causes
•Adhesions (scarring) inflammatory bowel disease, cancer, hernias, foreign body.
Symptoms
•Depends on many factors, but pain, no / few bowel movements, vomiting
Diagnosis
•AXR most common primary imaging method. Sensitivity of around 55%.
•Will see – dilated loops of small bowel (more than 3cm), mainly centrally located loops,
will see valvulae conniventes. May also see a gasless abdomen.
•CT – more sensitive and mostly demonstrates cause. Will see dilated loops of bowel, may
see the small bowel faeces sign,
•Oral contrast is not always useful in SBO as can be very diluted.
•MRI generally not used unless the patient is pregnant
Complications
•Perforation, ischaemia
Treatment
•Non operative – bowel rest and NG tube. IV nutrition
•Operative – bowel resection
Differential diagnosis
•Ileus
What is Small bowel follow through /Gastrografin challenge?
Often performed on inpatients with a
suspected SBO
Are diagnostic and therapeutic
Patient drinks 100mls of water-soluble
contrast orally or down the NG tube
AXR performed 6-12 hours later to see
if the contrast has reached the large
bowel.
If not contrast at 24 hours – indication
for surgery
Large bowel obstruction
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Less common than small bowel. Mechanical blockage again
Causes
• Most common cause is colonic cancer, then diverticulitis, volvulus, hernias,
faecal / foreign body impaction
Symptoms
• Again, can be complete or incomplete / partial. Same symptoms
Diagnosis
• Will see colonic distension proximal to the obstruction with collapse distally.
• Over 6cm, 9cm in the caecum
• AXR – gaseous distension, collapsed distal colon and rectum, small bowel
dilatation.
• CT – more accurate for diagnosis and localising the transition point.
Complications
• Perforation, ischaemia
Treatment
• Depends on cause.
• Surgery, colonic stent.
Differential diagnosis
• Toxic megacolon, pseudo obstruction
Volvulus: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•There is torsion of the bowel around its mesentery. This results in narrowing of the lumen at the point of rotation and compromise of the blood vessels that supply the bowel / stomach at that point Causes
•Links to some medications for psychiatric conditions and neurological conditions like MS,
Parkinson’s etc. Chronic constipation
Symptoms
•Same as an obstruction. In the stomach – sudden epigastric pain, retching but no
vomiting, can’t pass an NG tube
Diagnosis
•Gastric – AXR – unexpected location of gastric bubble, large distended stomach,
collapsed small bowel. CT – distended stomach with transition point, herniation of the
stomach
•Caecal – 10% of all cases in the bowel. AXR – distension of a loop of large bowel
extending from the RLQ to the LUQ, distal colon collapsed and gas in the small bowel
•Sigmoid – AXR - coffee bean sign, no rectal gas. CT – whirl sign, distended bowel
Complications
•Bowel ischaemia
Treatment
•Flatus tube at endoscopy. Surgery if this does not work
Differential diagnosis
•Other obstructions
Ulcerative colitis
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Type of inflammatory bowel disease that primarily affects the large bowel
Causes
• No known cause. May be associated with stress, poor immune system, family
history, other environmental and genetic factors
Symptoms
• Chronic diarrhoea, pain, fever
Diagnosis
• Involvement of the rectum is nearly always present. May involve the whole colon
• AXR – non specific, may see mural thickening with thumbprinting / lead pipe
colon
• CT – more accurate, can assess extracolonic complications and strictures.
• MRI – increasing use in severe disease.
Complications
• Patients are at increased risk of cancer.
Treatment
• Drugs
• May require surgery – complete proctocolectomy
Differential diagnosis
• Crohn’s disease
Crohn’s disease
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•Inflammatory bowel disease that can affect anywhere in the GI tract. However, terminal ileum and proximal colon are most commonly affected.
Causes
•Similar to UC
Symptoms
•Depend on location but pain, fever, bloody diarrhoea
Diagnosis
•Faecal calprotectin
•Endoscopy
•Characteristic of Crohn’s is skip lesions and ulcers.
•AXR – non specific, similar to UC
•CT and MRI – better and assessing active inflammation.
•US useful for looking for treatment response
•SBFT – can see ulcers, partial obstructions, cobblestone appearance
Complications
•It has many extraintestinal manifestations
•Perforation
Treatment
•Corticosteroids, immunosuppression, surgery in severe cases
Differential diagnosis
•UC
Coeliac disease
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Gluten intolerance characterised by loss of villi in the proximal small
bowel and GI malabsorption
• Is a chronic autoimmune disease
Causes
• Less common in Asian and black population. Associated with
inflammatory bowel disease
Symptoms
• Iron deficiency anaemia, abnormal bowel habit, malabsorption,
weight loss
Diagnosis
• Gold standard is duodenal biopsy at endoscopy
• SBFT – small intestinal dilatation ad dilution of contrast
• CT/MRI enterography – small bowel dilatation, strictures.
Complications
• Increased risk of small bowel cancer and oesophageal cancer
Treatment
• Gluten free diet
Acute Appendicitis
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Acute inflammation of the appendix.
Causes
• Blockage of the opening of the appendix, family history, viral infections
Symptoms
• Pain in the periumbilical area (T10) which moves to the right iliac fossa.
Vomiting, raised inflammatory markers
Diagnosis
• AXR – nonspecific. May see an appendicolith
• US – best in younger patients but need specialist training
• CT – highly sensitive and specific and assesses for other causes. May see
enlarged appendix, wall thickening, fat stranding, signs of perforation
• MRI – generally used for pregnant patients
Complications
• Perforation, abscess
Treatment
• Appendicectomy.
Differential diagnosis
• IBD and many others!
Toxic megacolon
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•Acute complication of IBD, and other forms of colitis. The colon loses its tone
which results in severe dilatation and high risk of perforation
Causes
•UC is the most common cause.
Symptoms
•Pain, no bowel movement. If perforated there may be signs of peritonitis
Diagnosis
•AXR – distended transverse colon, may see it increasing over time. Signs of
perforation.
•CT – loss of haustral markings, distension and signs of ulceration
•DO NOT DO colonoscopy due to risk of perforation
Complications
•Perforation
Treatment
•May need bowel rest and surgery is it does not resolve
Differential diagnosis
•Large bowel obstruction
Colorectal cancer
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Cancer of the colon and rectum. 3rd most common cancer worldwide. 98% are
adenocarcinomas from preexisting polyps
Causes
• Lifestyle factors, mainly individuals over 50
Symptoms
• Anaemia, rectal bleeding, change in bowel habit, pain, signs of obstruction
Diagnosis
• Most common in the rectum and sigmoid.
• CTC for diagnosis
• CT for staging
• MRI is the best imaging for the rectum
Complications
• Metastases, perforation and obstruction
Treatment
• Surgery
• Chemo / radiotherapy
Recurrence is common normally at the surgery site
Diverticular disease
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
•General term for any pathology involving diverticula. Can be diverticulosis,
diverticulitis as well
Causes
•A diverticulum is a small outpouching of the GI tract between the haustra.
Most common in the sigmoid. Lack of fibre in diet, increasing age, use of
laxatives are all causes.
Symptoms
•Often asymptomatic. But in acute setting there will be pain, blood stools,
vomiting, signs of obstruction
Diagnosis
•Often seen incidentally at CTC / CT scans. If acute, CT will show mucosal
thickening and signs of perforation.
Complications
•Perforation and obstruction
Treatment
•Bowel rest and diet change. If severe, surgery is often used
Differential diagnosis
•Other causes of obstructive symptoms
Gallstones: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Also called cholelithiasis. Is stone formation at any point along the biliary tree.
Causes
• Female, middle age, obesity, family history, recent rapid weight loss
Symptoms
• Only symptomatic in approx. 25% of cases. Pain – RUQ, nausea, bloating, right
scapula tip pain
Diagnosis
• AXR – may not be visible (only seen in 15-20%)
• Us – gold standard. Can see a highly reflective echogenic focus, and can see
them move with position change
• CT – not as accurate as US
Complications
• Cholecystitis, pancreatitis, jaundice
Treatment
• Laparoscopic cholecystectomy
Differential diagnosis
• Gallbladder cancer
Pancreatic calcifications
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• Calcifications within the pancreas
Causes
• Mainly due to chronic pancreatitis
Symptoms
• Asymptomatic but the cause of them
may be causing symptoms
Diagnosis
• Generally seen incidentally on CT and
AXR
Pancreatic cancer
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• There are many different cancers of the pancreas because of its endocrine and
exocrine functions. 99% are exocrine in origin.
Causes
• Smoking, chronic pancreatitis, obesity, diabetes, family history
Symptoms
• Pain, new onset diabetes
Diagnosis
• Unfortunately, these cancers are aggressive and often present late so prognosis
is poor.
• Most are not resectable due to the involvement of the superior mesenteric artery
• CT is the primary imaging method – can see appearance of the pancreas and
assess for surgery. Can also look for local and distant spread.
• MRI can also be used.
Treatment
• Surgery if possible
Differential diagnosis
• pancreatitis
Liver cancer –hepatocellular carcinoma
(HCC)
: description, causes, symptoms, diagnosis, complications, treatment, differential diagnosis.
Description
• 80-90% of liver cancers. Most common primary cancer of the liver.
Causes
• Strongly associated with cirrhosis from alcohol and viral causes such as hepatitis
B and C
Symptoms
• Jaundice, hepatomegaly, pain
Diagnosis
• They can be a large mass, multiple masses or can be tiny and hard to see.
• US – has a variable appearance depending on the lesion but can see arterial
enhancement and appear hypoechoic compared to the normal liver
• CT – enhanced during a late arterial phase, indistinct in portal venous.
• PET-CT – good for staging, not so accurate at identifying the HCC in the liver
Treatment
• Resection, liver transplantation, chemotherapy and radiotherapy
Differential diagnosis
• Other liver tumours.
What are liver cysts?
• Simple hepatic cysts are common benign lesions with no malignant potential.
• Nearly always seen incidentally.
• Can be isolated or multiple
• On imaging they are typically round or ovoid in shape with well defined margins.
• CT – has homogenous hypoattenuation (like water) of around 0-10 HU.
