CTC GI Flashcards
What are the A Ring, B Ring, and Z Line of the esophagus?
A Ring = Muscular ring above the vestibule
B Ring = Mucosal ring below the vestibule. Thin construction at the EG junction. Dysphagia can happen if it’s <13 mm in diameter. If it’s narrowed you call it a Schatzki.
Z Line = Squamocolumnar junction (boundary between the esophageal and gastric epithelium). Doesn’t necessarily correspond with the B-ring. Endoscopic finding.
What is a Schatzki Ring?
Narrowed B Ring - mucosal line at the GE junction.
What is the true upper esophageal sphincter?
Cricopharyngeus muscle - start of the esophagus - boundary between the cervical esphagus and the pharynx.
What is Eosinophilic Esophagitis?
Young man with long history of dysphagia (and atopia, and peripheral eosinophilia).
Barium shows concentric rings (distinct look).
fail treatment with PPIs, but get better with steroids.
What is esophageal candidiasis?
Discrete plaque-like lesions.
Nodularity, granularity, and fold thickening b/c of mucosal inflamation and edema.
Most severe, shaggy, irregular luminal surface.
Glycogen Acanthosis: Mimic- multiple elevated nodules in an asymptomatic elderly patient.
Cause of esophageal ulcers
Herpes - multiple with halo of edema (Herpes has a halo)
CMV and HIV: Large flat ulcer - look the same.
High stricture with associated hiatal hernia?
Barretts.
Reticular mucosal pattern.
Scenarios of squamous esophageal cancer vs adenocarcinoma
Need to distinguish between stage 3 (adventitia) and stage 4 (invasion into adjacent structures)
Squamous: Black guy who drinks and smokes, tried to kill himself with an alkaloid ingestion (drank lye). Stricture/ulcer/mass is in the mid esophagus
Adeno: White guy, stressed all the time. Chronic reflux (history of PPI use). Scope years ago that showed Barretts and he did nothing. Stricture/ulcer/mass is in the lower esophagus.
Uphill vs Downhill Varices
Uphill - portal HTN. Confined to bottom half of esophagus.
Downhill - SVC obstruction (catheter related or tumor related). Confined to top half of esophagus.
Area of weakness in Zenker Diverticulum?
Killian Dehiscence or triangle
Arises from the hypopharynx, not the cervical esophagus.
Difference between traction and pulsion diverticulum?
Traction = Triangular and will empty
Pulsion = Round and will NOT empty (contain no muscle in their walls).
What are epiphrenic diverticula?
Located just above the diaphragm - usually on the right.
Pulsion types - associated with motor abnormality.
What is Esophageal Pseudodiverticulosis?
Dilated submucosal glands that cause multiple small out pouchings.
Chronic reflux esophagitis
What are esophageal webs?
MC located at the cervical esphagus (near the cricopharyngeus)
Basically a ring caused by a thin mucosal membrane.
Risk for esophageal and hypopharyngeal carcinoma.
Plummer-Vinson Syndrome: Iron deficiency anemia, dysphagia, thyroid issues, “spoon-shaped nails”
What is Vigorous Achalasia?
Early/less severe form with the addition of repetitive simultaneous non-propulsive contractions.
What is Pseudoachalasia?
Secondary achalasia - has the appearance, but 2/2 a cancer at the GE junction.
Achalasia will eventually relax, but pseudo won’t.
Locations of lesions in the stomach?
H Pylori: Antrum
Zollinger-Ellison: Ulcerations in the stomach (jejunal ulcer is the buzzword). Duodenal bulb is actually the MC location in ZE.
Crohns: Uncommon in stomach, but when it is, in the antrum
Menetrier’s: Fundus (classically spares the antrum)
Lymphoma: “Crosses the Pylorus” - although adenocarcinoma does it more.
What is Gardner Syndrome?
FAP (hyperplastic stomach, adenomatous bowel polyps) + Desmoid tumors, osteomas, papillary thyroid cancer
What is Turcots?
FAP (hyperplastic stomach, adenomatous bowel polyps) + gliomas and medulloblastomas.
What is Hereditary nonpolyposis syndrome (Lynch)?
DNA Mismatch repair
Get cancer everywhere in everything
What is Peutz-Jeghers?
Hamartomas
Mucocutaneous Pigmentation
Small and large bowel CA + GYN CA
What is Cowden Syndrome?
Breast CA, thyroid CA, Lhermitte-Dulcose (posterior fossa noncancerous brain tumor)
What is a GIST?
MC mesenchymal tumor of the GI tract (70% in stomach)
Rare before 40
A 90 degree angle is often formed between the edges of the mass and the normal gastric wall.
Can be nasty and met locally or distally - LN enlargement is NOT a classic feature. Malignant GIST tend to be large (>10 cm)
Syndromes:
Carney Triad: Extra-adrenal pheochromocytoma, GIST, Pulmonary chondroma (hamartoma)
NF-1
What Syndromes is GIST associated with?
Carney Triad: Extra-adrenal pheochromocytoma, GIST, Pulmonary chondroma (hamartoma)
NF-1
Findings of Malignant vs Benign ulcers?
Malignant: Width>Depth Located w/in lumen Nodular, irregular edges Folds adjacent to ulcer Carmen Meniscus Sign
Benign: Depth>Width Project behind the expected lumen Sharp contour Folds radiate to ulcer Hampton's Line
What is Gastric Lymphoma?
Primary (MALT) or 2/2 to systemic lymphoma.
Stomach is MC extranodal site for NHL.
Even with extensive, rarely causes gastric outlet obstruction. Classically “crosses the pylorus,”.
Looks like big, little, ulcerative, polypoid or look like target lesions. Can also look like Linitus Plastica. Can rupture with treatment.
What is Linitis Plastica?
Leather bottle stomach.
Scirrhous adenocarcinoma with diffuse infiltration.
Breast or lung mets.
What is Menetrier’s Disease?
Idiopathic gastropathy. Rugal thickening involves the fundus and spares the antrum.
End up with low albumin from loss into gastric lumen.
What is Ram’s Horn Deformity?
Pseudo Billroth 1: Tapering of the antrum, said to look like a Ram’s horn.
Differential case: scarring via peptic ulcers, granulomatous disease (Crohn’s, sarcoid, TB, syphillis), or scirrhous carcinoma.
Stomach is the MC location for sarcoid in the GI tract.
What is Areae Gastricae?
Normal fine reticular pattern seen on double contrast
Enlarges in elderly and patient’s with H. pylori.
Can focally enlarge next to an ulcer.
Becomes obliterated by cancer or atrophic gastritis.
What does chronic ASA therapy look like?
“Multiple gastric ulcers” - buzzword
ASA does NOT cause duodenal ulcers. If multiple duodenal ulcers think Z-E (most duodenal ulcers are solitary).
What is the Target Sign and what causes single vs multiple?
Single Target: GIST, Primary Adenocarcinoma, Lymphoma, Ectopic pancreatic rest, Met (Melanoma)
Multiple: Lymphoma, Met (Melanoma)
What is Clover Leaf Sign?
Healed peptic ulcer of the duodenal bulb
DDx of thin folds with dilation?
Mechanical obstruction
Paralytic ileus
Scleroderma
Sprue
DDx for segmental thick folds >3 mm?
Ischemia
Radiation
Hemorrhage
Adjacent Inflammation
DDx for diffuse thick folds >3 mm?
Low protein
Venous congestion
Cirrhosis
DDx for segmental thick folds with nodularity?
Crohns
Infection
Lymphoma
Mets
Uniform 2-4 mm nodules = lymphoid hyperplasia
Nodules of larger or varying sizes = cancer (probably mets and therefore probably melanoma)
DDx for diffuse thick folds with nodularity?
Whipples Lymphoid hyperplasia Lymphoma Mets Intestinal Lymphangiectasia
Uniform 2-4 mm nodules = lymphoid hyperplasia
Nodules of larger or varying sizes = cancer (probably mets and therefore probably melanoma)
Causes of loop separation with or without tethering?
Without tethering = ascites, wall thickening (Crohns, lymphoma), adenopathy, or mesenteric tumors
With Tethering = carcinoid
Extrinsic process will spare the mucosa, intrinsic process will alter the mucosa.
What is Whipples?
Tropheryma Whipplei - White men in their 50s.
Bug infiltrates the lamina propria with large macrophages infected by intracellular whipple bacilli leading to marked swelling of intestinal villi and thickened irregular mucosal folds primarily in duodenum and proximal jejunum.
Buzzword - “sand-like nodules” referring to micronodules in the jejunum - thickened jejunal folds.
Cause of low density (near fat) enlarged lymph nodes
What is Pseudo Whipples?
MAI infection. AIDS patients with CD4 <100. Nodules in jejunum just like regular Whipples is the finding. Plus big spleen and retroperitoneal lymph nodes.
What is Celiac Sprue?
Small bowel malabsorption of gluten
Can cause malabsorption of iron, and lead to iron deficiency anemia.
Associated with idiopathic pulmonary hemosiderosis (Lane Hamilton Syndrome)
Increased risk of bowel wall lymphoma
Gold standard is biopsy
Dermatitis Herpetiformis
Fold reversal - Jejunum like ileum, ileum like jejunum.
Moulage Sign - dilated bowel with effaced folds (tube with wax poured in it)
Cavitary lymph nodes (low density)
Splenic atrophy
Findings of Celiac Sprue?
Fold reversal - Jejunum like ileum, ileum like jejunum.
Moulage Sign - dilated bowel with effaced folds (tube with wax poured in it)
Cavitary lymph nodes (low density)
Splenic atrophy
Buzzword for graft vs host disease?
Ribbon Bowel
Patients after bone marrow transplant. Skin, liver and GI tract get hit. Small bowel is usually the most severely affected. Bowel is featureless, atrophic, and has fold thickening (ribbon like)
Infections that like the duodenum and proximal small bowel vs infections that like the TI?
Duodenum and proximal small bowel: Giardia and Strongyloides
TI: TB and Yersinia
Barium Bowel Buzzwords
Fold Reversal = Celiac Sprue Ribbon Bowel = GVH Lead Pipe = UC String Sign = Crohns Hide Bound = Scleroderma Cone Shaped Cecum = Amebiasis
What is intestinal lymphoma?
NHL.
Patients with celiac, Crohns, AIDS, and SLE are higher risk.
Can look like anything - NOT obstruct, even with massive circumferential involvement.
Hodgkin subtype is more likely to cause a desmoplastic reaction.
What is a lumbar hernia?
Superior (Grynfeltt-Lesshaft) - through the superior lumbar triangle, or inferior (Petit) through the inferior lumbar triangle.
Superior is more common than inferior.
Congenital or acquired
What is a Spigelian Hernia?
Located along the semilunar line through the transversus abdominus aponeurosis close to the level of the arcuate line.
What is a Littre Hernia?
Hernia with a Meckle Diverticulum in it
What is an Amyand Hernia?
Hernia with appendix in it.
What are the sites of internal hernias after bypass?
Laparoscopic vs open - laparoscopic creates less adhesions = more mobility. More weight loss = less protective fat.
At the defect in the trasverse mesocolon through which the Roux-loop passes (if it’s done in the retrocolic position)
At the mesenteric defect at the enteroenterostomy
Behind the Roux limb mesentery placed in a retrocolic or antecolic position. (retrocolic Petersen and antecolic Petersen type)
What is a paraduodenal hernia?
MC type of internal hernia. Usually left or right.
75% of the time they are on the left. The duodenojejunal junction (“fossa of Landzert”). The herniated small bowel can become trapped in a “sac of bowel” between the pancreas and stomach to the left of the Ligament of Treitz. The sac characteristically contains the IMV and the left colic artery.
Right-sided PDHs are located behind the SMA and just below the transverse segment of the duodenum, at the “Fossa of Waldeyer.” Non-rotated small bowel with normally rotated large bowel.
Buzzwords for Crohns
Squaring of the folds - Early manifestation from obstructive lymphedema
Skip Lesions - Discontinuous involvement of bowel
Proud loops - Separation of the loops caused by infiltration of the mesentery, increase in mesenteric fat and enlarged lymph nodes.
Cobblestoning - Irregular, appearance to bowel wall caused by longitudinal and transverse ulcers separated by areas of edema
Pseudopolyps - Islands of hyperplastic mucosa
Filiform - Post-inflammatory polyps - long and worm like
Pseudodiverticulosis - Found on anti-mesenteric side. From bulging area of normal wall opposite side of scarring from disease.
String-sign - Marked narrowing of TI from combination of edema, spasm, and fibrosis.
Things seen in Crohns vs UC
UC has increased risk of cancer and it doesn’t classically have enlarged LNs (like Crohns does) so if you see a big LN in a UC patient think it might be cancer.
Gallstones = Crohns
PSC = UC
Hepatic abscess = Crohns
Pancreatitis = Crohns
What is Entamoeba Histolytica?
Parasite that causes bloody diarrhea. Can cause liver abscess, spleen abscess, or even brain abscess. One of the causes of toxic megacolon.
“Flash-shaped ulcers” on endoscopy.
“Cone Cecum” on barium referring to a change in the normal bulbous appearance of the cecum to that of a cone - also caused by colonic TB.
Affects the cecum and ascending colon most commonly, and unlike many other GI infections spares the TI.
What is colonic TB?
Another cause of “coned cecum” like Entamoeba Histolytica, but spares the TI. Causes both ulcers and areas of narrowing.
Fleischner Sign - Enlarged gaping IC valve
Stierlin Sign - Narrowing of the TI.
What is Colonic CMV?
Seen in patients who are immunosuppressed. Causes deep ulcerations which can lead to perforation.
Cowdry Type A intranuclear inclusion bodies.
Which colon adenoma has the largest risk of malignancy?
Villous Adenoma
Things to know about rectal cancer?
Nearly always adenocarcinoma
If squamous = HPV
Total mesorectal excision is standard surgical method
Lower rectal cancer (0-5 cm from the anorectal angle), has the highest recurrence rate.
MRI is used to stage
Stage T3 - when tumor breaks out of the rectum and into the perirectal fat.
What is a Cecal Bascule?
Anterior folding of the cecum, w/o twisting.
Dilation of the cecum in an ectopic position in the middle abdomen, w/o a mesenteric twist.
What is Behcets?
Ulcers of the penis and mouth. Can also affect the GI tract (and looks like Crohns) - MC affects the ileocecal region.
Can also cause PA aneurysms.
What is Diversion Colitis?
Bacterial overgrowth in a blind loop through which stool does not pass.
What is Colitis Cystica?
Cystic dilation of the mucus glands
Superficial: Cysts that are small in the entire colon. Vitamin deficiencies, and tropical sprue. Can be seen in terminal leukemia, uremia, thyroid toxicosis, and mercury poisoning.
Profunda: Cysts may be large and are seen in the pelvic colon and rectum.
What is Rectal Cavernous Hemangioma?
Associated with Klippel-Trenaunay-Weber and Blue Rubber Bleb. Might show a ton of phleboliths.
What is Barium Intravasation?
Barium ends up in the systemic circulation it results in death about 50% of the time (often immediate - from PE). Risk is increased with inflammatory bowel or diverticulitis (altered mucosa).
What is Cystic Peritoneal Mesothelioma?
More rare than benign mesothelioma, that is NOT associated with prior asbestosis exposure.
Women of child bearing age (30s).
What is Mesenteric Lymphoma?
Usually NHL - involves the mesentery 50% of the time.
Buzzword = “sandwich sign”.
Typically appearance is a lobulated confluent soft tissue mass encasing the mesenteric vessels “sandwiching them”
Pressure to be called portal venous HTN?
Portal venous pressure exceeds hepatic venous pressure by 8 mmHg.
In pre-hepatic portal HTN, collaterals will form above the diaphragm and in the hepatogastric ligaments to bypass the obstruction.
MRI of Regenerative vs Dysplastic Nodules vs HCC
Regenerative: Contains iron; T1 Dark/T2 Dark; Does NOT enhance.
Dysplastic: Contains fat, glycogen; T1 Bright/T2 Dark; Usually does NOT enhance
HCC: T2 bright; Does enhance.
Nodules w/in a nodule - central bright T2 nodule, has a T2 dark border- transformation of a regenerative nodule to HCC.
Liver infection buzzwords
Viral Hepatitis - Starry Sky
Pyogenic Abscess - Double Target
Candida - Bull’s Eye
Amoebic Abscess - “Extra Hepatic Extension”
Hydatid Disease - Water lilly, sand storm
Schistosomiasis - Tortoise Shell
Hepatitis is chronic in B and C and acute in the rest. HCC in the setting of hepatitis can occur in the acute form of Hep B (as well as chronic).
FNH vs FL HCC
FNH: T2 bright, Enhances on delays (scar), Mass is sulfur colloid avid (sometimes)
FL HCC: T2 dark (usually), Does NOT enhance (scar), Mass is Gallium avid.
Multiple hepatic adenomas?
Glycogen storage disease (von Gierke) or liver adenomatosis
Female on OCPs
Male on anabolic steroids.
What is the doubling time of HCC?
Slow, medium, and fast.
Short - 150 days, medium is 150-300, and long >300
300 is in the middle.
What is Fibrolamellar HCC?
Younger patients (<35) w/o cirrhosis and a normal AFP.
Central scar, similar to FNH, but scar does NOT enhance and is T2 dark.
Gallium avid
Calcifies more than conventional HCC.
Risk factors for Cholangiocarcinoma?
Elderly male (70s)
Primary sclerosing cholangitis, recurrent pyogenic cholangitis, clonorchis senesis (liver fluke), HIV, Hep B and C, EtOH, and thorotrast)
Infiltrative growth pattern and will not have a capsule. Dilation of the biliary system, and possible persistent enhancing soft tissue on delayed phase (the scar enahnces). Capsular retraction is a buzzword.
Delayed enhancement
Perihilar biliary dilation
Capsular retraction
What is a Hepatic Angiosarcoma?
Thorotrast.
MC primary sarcoma of the liver.
Associated with toxic exposure - arsenic use (latent period is about 25 years), polyvinyl chloride exposure, radiation, and thoratrast.
Hemochromatosis and NF patients.
Multifocal and has propensity to bleed.
What is Biliary Cystadenoma?
Uncommon benign cystic neoplasm of the liver. Middle aged women. Can sometimes present with pain or even jaundice.
Multilocular or unilocular - no reliable methods for distinguishing from biliary cystadenocarcinoma.
AIDS with diffuse periporal hypoechoic infiltration
Kaposi
Looks similar to biliary duct dilation
Arterial and Portal venous timing
Arterial: 25-30 sec
Portal Venous: 70 seconds
Who gets massive caudate lobe hypertrophy?
Budd Chiari
PSC
Primary biliary cirrhosis
What is Hemochromatosis
Liver and spleen dark on T1 and T2
In and out of phase - low signal on in phase and high signal on out of phase - opposite of hepatic steatosis.
Primary = inherited = Pancreas - also involves the heart, thyroid, and pituitary. Secondary = spleen
Dense liver DDx
Hemochromatosis
Wilson’s Disease
Colloidal Gold Therapy
Amiodarone
Normal Liver transplant US
Rapid systolic upstroke
Diastolic -> systolic in less than 80 msec (0.08 seconds)
RI between 0.5 - 0.7
HA peak velocity should be <200 cm/sec
PSC vs AIDS Cholangiopathy
PSC: extrahepatic strictures rare >5 mm; Has saccular deformities of the ducts; strongly associated with cholangiocarcinoma; Cirrhotic pattern is “central regenerative hypertrophy”; UC association
AIDS: Focal strictures of the extrahepatic ducts >2 cm; absent saccular deformities of the ducts; Associated PAPILLARY STENOSIS
What is Oriental Cholangitis?
SE Asia - dilated ducts that are full of pigmented stones.
“Straight rigid intrahepatic ducts.” Unknown cause but associated with clonorchiasis, ascariasis, and nutritional deficiency.
What is Primary Biliary Cirrhosis?
Autoimmune disease that results in the destruction of small bile ducts. Middle aged women often asymptomatic.
Irregular dilation of the intrahepatic ducts with normal extrahepatic ducts.
Increased risk of HCC.
Antimitochondiral antibodies.
What are the types of Choledochal Cysts
Type 1 is focal dilation of the CBD and is MC. Type 2 is diverticulum Type 3 is a "choledochocele" Type 4 is intra and extra Type 5 is Carolis - intrahepatic only.
What is Caroli’s Disease?
AR associated with polycystic kidney disease and medullary sponge kidney.
Intrahepatic duct dilation that is large and sacular.
Central dot sign which corresponds to the portal vein surrounded by dilated bile ducts.
Cholangiocarcinoma
Cirrhosis
Cholangitis
Intraductal Stones
What is Duct of Luschka?
Accessory cystic duct
Accessory subvesicular (MC)- connects to common hepatic duct Hepatocystic - Connects to GB.
Duplex vs Spectral
Duplex = color Spectral = color with waveform
Calculation of RI
Peak systolic - Peak diastolic/Peak systolic
Causes of Low RI
<0.5
Proximal arterial narrowing: Atherosclerotic disease, stenosis at anastomosis, median arcuate ligament compression (severe), peripheral vascular shun
Peripheral Vascular Shunts: Shunting seen in cirrhosis, post traumatic (liver biopsy), Osler-Weber-Rendu
Causes of High RI
> 0.7
Postprandial Advanced age Cirrhosis Hepatic congestion (Acute or chronic) Transplant rejection
Causes of increased and decreased hepatic vein pulsatility
Increased: tricuspid regurg and right-sided CHF
Decreased: Cirrhosis and hepatic venous outflow obstruction
Tricuspid regurg: Increased pulsatility, very tall V, D wave deeper than S.
Right sided CHF: Increased pulsatility with normal wave relationship.
Causes of Portal Vein Pulsatility?
Right-sided CHF
Tricuspid regurgitation
Cirrhosis with vascular AP shunting.
What is Fibrosing Colonopathy?
Wall thickening of the proximal colon as a complication of enzyme replacement therapy.
What is Shwachman-Diamond Syndrome?
2nd MC cause of pancreatic insufficiency in kids (CF = #1).
Kid with diarrhea, short stature (metaphyseal chondroplasia) and eczema.
Will also cause lipomatous pseudohypertrophy of the pancreas.
What is Dorsal Pancreatic Agenesis?
Sets you up for DM b/c most of your beta cells are in the tail.
Associated with polysplenia.
Vocab for Pancreatitis
Interstitial Pancreatitis = no necrosis, no fluid collections
Exudative Pancreatitis = No necrosis, yes fluid collections
Necrotizing Pancreatitis = Yes necrosis, usually fluid collections
Acute peripancreatic fluid collection = <4 weeks, no necrosis
Pseudocyst = >4 weeks encapsulated, no necrosis
Acute necrotic collection= <4 weeks + necrosis
Walled off necrosis = >4 weeks, encapsulated + necrosis
Intraparenchymal fluid collections - not a term used anymore. Instead use acute necrotic collection or walled off necrosis - NOT pseudocyst.
Anatomy in Pancreatic Divisum
Major Duct - Wirsung - Back of the alphabet
Minor Duct - Santorini - Superior - Superior
What is Groove Pancreatitis?
Duodenal and biliary obstruction, symptoms overlap with pancreatic cancer.
Duodenal stenosis and/or strictures of the CBD in 50% of the cases
Soft tissue w/in the pancreaticoduodenal groove, with or w/o delayed enhancement.
What is Tropic Pancreatitis?
Young age at onset, associated with malnutrition
Increased risk of adenocarcinoma
Multiple large calculi w/in a dilated pancreatic duct
What is Hereditary Pancreatitis?
Young age at onset
Increased risk of adenocarcinoma
SPINK-1 gene
Similar to tropic pancreatitis
What is Ascaris Induced Pancreatitis?
MC implicated parasite in pancreatitis
Worm may be seen w/in bile ducts.
IgG4 associated diseases?
Autoimmune pancreatitis - no duct dilation. Retroperitoneal fibrosis Sclerosing Cholangitis Inflammatory Pseudotumor Riedel's Thyroiditis
What is a Serous Cystadenoma?
Grandma - microcystic adenoma
Benign, heterogeneous mixed-density lesion made up of multiple small cysts, which resembles a sponge.
MC in pancreatic head.
Does NOT communicate with the pancreatic duct
Can have central scar with or without central calcifications.
What is a Mucinous Cystic Neoplasm?
Mother
Pre-malignant and need to come out - body and tail.
No communication with pancreatic duct.
Peripheral calcs are seen 25% of the time.
Typically unilocular, individual cystic spaces tend to be larger than 2 cm
Which as greater chance of malignancy - side branch or main branch IPMN?
Main - considered malignant and resection should be considered.
Main duct >10 mm
Diffuse or multifocal involvement
Enhancing nodules
Solid hypovascular mass
What is a Solid Pseudopapillary Tumor of the Pancreas?
Daughter
Very rare, low grade malignant tumor - young women (30s) - Asian or AA.
Typically large at presentation, predilection for the tail, and has a “thick capsule”
May demonstrate progressive fill in of the solid portions.
Trivia about Pancreatic Adenocarcinoma
CA 19-9
Hereditary Syndromes with pancreatic CA: HNPCC, BRCA mutation, Ataxia-telangiectasia, Peutz-Jeghers
Wide duodenal sweep or inverted 3 sign
MC neuoendocrine tumor associated with MEN
Gastrinoma - 2nd MC overall after insulinoma
ZE syndrome
Pancreatic tumor considerations at 1, 6, and 15
1: Pancreatoblastoma
2: Adenocarcinoma
15: SPEN
Pancreas transplant blood supply
Two arterial inflows:
Donor SMA - supplies the head via the inferior pancreaticoduodenal artery and the donor splenic - supplies the body and tail.
Venous drainage:
Both the donor portal vein and recipient SMV.
Exocrine drainage through bowel or bladder
Acute rejection then splenic vein thrombosis.
Resistive indicies are not of value - no capsule
Right-sided vs Left-sided heterotaxy syndromes
Right-Sided Two fissures in the left lung Asplenia Cardiac Malformations Reversed aorta/IVC
Left-sided One fissure in the right lung Polysplenia Biliary atresia Azygous continuation of the IVC
What is wandering spleen?
Laxity of peritoneal ligaments holding the spleen - associated with abnormalites of intestinal rotation.
Unusual location = risk of torsion and subsequent infarction.
Chronic partial torsion can lead to splenomegaly and gastric varices.
What is Peliosis?
Multiple blood-filled cyst-like spaces in a solid organ - usually liver
When you see spleen, usually also has liver.
Women with OCPs, men on anabolic steroids, people with AIDS, renal transplant patients, and Hodgkin lymphoma.
Spleen infection
MC is histoplasmosis - round calcifications
Splenic TB can have a similar appearance.
Brucellosis, but usually have a bulls eye appearance.
Immunocompetent: Salmonella in the setting of underlying splenic damage (truma, sickle cell)
Immunocompromised: Fungi, TB, MAI, and PCP
Causes of Small vs Big spleen?
Small: Sickle cell, post radiation post thorotrast, malabsorption syndromes (UC>Crohns)
Big: Passive congestion (CHF, portal HTN splenic vein thrombosis), Lymphoma, Leukemia, Gauchers
What is Felty’s Syndrome?
Abnormality of granulocytes - Splenomegaly, RA, and Neutropenia
What are epidermoid cysts of the spleen?
2nd MC to post-traumatic pseudocysts.
They are a “true” cyst and have epithelial lining. Grow slow.
What is Littoral Cell Angioma?
Clinical hypersplenism.
Multiple small foci which are hypoattenuating on late portal phase.
MR shows hemosiderin (low T1 and T2).
MC primary malignancy of the spleen
Angiosarcoma
Poorly defined area of heterogeneity or low density in an enlarged spleen.
Can contain central necrosis and get big enough to rupture.
Contrast enhancement is usually poor.
Prior thorotrast.
