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The Patient Pathway > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

Sialolithiasis – INITIAL/REFERRING Patient Pathway

A

Likely route via GP, or possibly dentist

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2
Q

What imaging modalities are used for Sialolithiasis?
Positives and limitations

A

Plain X-rays will show radiopaque calculi

sialography:
fluoro with contrast
exact size and location
calculi will show as a filling defect
contraindication with infection

US:
visualise stone and gland
hyperechoic lesion (stone) + shadow
Can visualise radiolucent stone
acute obstructive cases, appearance of enlarged glands and dilated ducts

CT:
visualise stones within ducts and glands
Acute presentation may identify gland enlargement and inflammation
potential artifact from filling

MRI:
Excellent demonstration of the gland and the ductal architectural, especially when there is intra-glandular duct dilatation

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3
Q

INITIAL/REFERRING Patient Pathway for oral carcinoma?

A

Referral often via dentist, but could also be via GP

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4
Q

What imaging modalities are used for oral carcinoma?

A

MRI:
depiction of the tumour and staging

CT:
Useful for depiction of the tumour and for staging

PET/CT:
Much clearer depiction when CT is combined with PET

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5
Q

oesophagal pathology initial/referral pathway?

A

GP referral to specialist services,
e.g. for endoscopy, or possibly straight to oncology

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6
Q

What imaging can be done to diagnose pathologies of the oesophagus?

A

Endoscopy is used for initial diagnosis (biopsies can be taken)

Barium Swallow when endoscopy not a viable option

If abnormal, whole-body CT (WBCT) carried out for staging, +/- PET

If suitable for radical treatment,
PET-CT is useful for treatment planning (helps to detect metastatic disease)

Endoscopic ultrasound (EUS) can also be performed (biopsies can be taken)

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7
Q

What is the initial/referring pathway for stomach carcinoma?

A

GP referral to specialist services,
e.g. for gastroscopy, or possibly straight to oncology

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8
Q

What imaging is done for stomach carcinoma?

A

Very similar to oesophageal carcinoma imaging pathway

First line is endoscopy (gastroscopy) – readily available and biopsies can be taken

Radiological examinations usually for staging and/or treatment planning:
CT
PET
EUS

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9
Q

What is adenocarcinomas radiographic appearance?

A

CT image:
mass which has thickened walls
and central ulceration

EUS:
infiltration of serosa (membrane)
enlarged lymph nodes

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10
Q

Small bowel obstruction initial/referrring pathway?

A

Medical emergency – requires early diagnosis and intervention

Emergency referral to ED

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11
Q

What imaging is done for small bowel obstruction?
Radiographic appearance?

A

AXR
SBO:
- distended/dilated bowel
- central location
- Large bowel at the periphery is collapsed
- Valvulae conniventes can be identified across the full width of the dilated loops confirming it to be small (not large) bowel

CT (abdo/pelvis +C; no oral)
much more sensitive
aetiology
determine treatment pathway, e.g. immediate surgery when there is a risk of ischaemia, etc.
- Multiple dilated loops of small bowel
- large caecal mass

US can be used (“bedside test”)
- dilated small bowel loop
- considered dilated > 2.5cm

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12
Q

What is the imaging pathway for small bowel carcinoma?

A

Endoscopy first line

(No specific imaging pathway as rare in occurrence)

CT to assess spread small bowel tumours

CT findings are unclear:

CT or MR enterography or enteroclysis

PET-CT - metastatic disease

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13
Q

What are the advantages of a CT and MR Enterography for imaging small bowel carcinoma/IBD?

comparison of MRI and CT

A
  • Minimally invasive
    compared to small bowel enema/enteroclysis
  • evaluation of bowel wall thickness/demonstrate thickened bowel wall

-detect extra-intestinal

  • assess small bowel lesions
  • determine an aetiology for occult gastrointestinal bleeding
  • evaluate known or suspected IBD, usually Crohn’s disease

MRI has no radiation dose
Takes longer than CT

MR generally has lower resolution than CT,
greater sensitivity/specificity for abnormalities,
esp. within the bowel walls

CT is a high dose examination
IBD affects younger people more, it’s preferable to use MRI as no ionising radiation

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14
Q

comparison of CT and MR enteroclysis to enterography:

A

Invasive – poor patient satisfaction

Conventional enteroclysis (SBE) still allows better bowel distention

Can be 3D reconstructed - superior images

Extrinsic structures are better visualised

quicker examination

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15
Q

What is Chrins disease?

A

Chronic IBD

Full thickness of intestinal wall is inflammed

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16
Q

What imaging is used to image Chrons disease?

A

Plain abdominal X-rays:
- identify small bowel or colonic dilatation, which may indicate obstruction

Colonoscopy +biopsy

children and young people:
Upper intestinal endoscopy

small bowel capsule endoscopy + US:
when endoscopy and conventional imaging have been non-diagnostic

Abdominal ultrasound:
- assess bowel thickness + dilatation (suggesting obstruction),
- abscesses, fistulas, and strictures

CT/MR enterography
- Stage Crohn’s disease
- look for extraluminal complications (such as abscesses and fistulas)

Pelvic MRI
- definition of the extent and location of abscesses and fistulas

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17
Q

What are the radiographic signs for chrons disease?

A

small bowel US:
- Thickened and stiff bowel wall
- Narrow lumen
- Proximal dilatation of more than 25mm

MR Enteroclysis:
- thickened wall of terminal ileum – Crohn’s disease

CT + C:
- Small bowel with wall thickening
- Prominence of the mesenteric vasculature - comb sign

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18
Q

Radiographic appearance of Hepatitis on US?

A

starry sky pattern
characterised by increased brightness portal venules and diminished parenchymal echogenicity

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19
Q

Transient Elastography (“sonoelastography”) how does it provide a use in diagnostic purposes?

A

Elastography techniques:
Takes advantage of changed soft tissue elasticity in various pathologies to yield qualitative and quantitative information that can be used for diagnostic purposes

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20
Q

Transient Elastography (“sonoelastography”) how is it used when imaging the liver?

A

Used to assess:
- tissue elasticity/stiffness in the assessment of liver fibrosis, as found in cirrhosis

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21
Q

Transient Elastography (“sonoelastography”)

benefits
and
limitations

A

US is widely available with equipment having elastography capabilities

Lack of ionising radiation,
non-invasive
low cost,

but operator dependent
Liver biopsy used to diagnose cirrhosis where elastography is not suitable

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22
Q

How does liver cirrhosis present on US?

A

free fluid surrounding
increased density
nodules??

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23
Q

Hepatocellular carcinoma radiographic appearances?

A
  • Vast majority have liver cirrhosis
  • hepato-cellular carcinoma (HCC) may be: - solitary
  • multifocal
  • diffusely infiltrating.

Larger HCC lesions typically have a mosaic appearance due to haemorrhage and fibrosis

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24
Q

Initial/referring pathway for Hepatocellular carcinoma?

A

GP referral to specialist services
or
possibly straight to oncology

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25
Q

What imaging is used for Hepatocellular carcinoma?

A

Initial CT assessment – highly sensitive and specific (possible to include chest if ?mets)
(2-3 phase liver CT)
late arterial phase - hypervascular tumor - 30 secs

MRI may be an additional tool in some cases (can assess primary and metastases, often with IV contrast – gadolinium)

US has a better sensitivity with larger lesions (3-5cm) - HCC can be hyper- OR hypo-echoic

NM – minimal input

26
Q

What is Hepatic Haemangioma?

A

benign liver tumour

27
Q

what imaging is used for a Hepatic Haemangioma?
Radiographic appearances?

A

CT or MRI are the most commonly used imaging modalities,
alongside US (often used as follow-up)

CT:
contrast - seen on arterial and post

MRI:
A: T1-W, lesion is hypointense
B: T2-W, lesion is hyperintense
Also enhances with Gadolinium

28
Q

liver metastases appearance?

A

Normally multiple,
maybe more peripheral
varying sizes

29
Q

what imaging modalities are used to image liver metastasis?

A

CT
NM - PET/CT

30
Q

what imaging modalities are used to image polycystic liver?

A

US
CT

31
Q

What are the radiographic appearances of a liver abscess?

A

May have similar appearances to cyst

Within liver tend to have thick walls and fluid centres

Wall also more irregular (different to simple cyst appearance)

31
Q

what is the treatment for a polycystic liver?

A

Dialysis/transplant

32
Q

What is the treatment for a liver cyst?

A

Aspiration and drainage is immediate treatment (under imaging guidance)

33
Q

Liver trauma imaging and treatment?

A

Liver is the most commonly affected intra-abdominal organ in trauma (blunt and penetrating)

High risk of uncontrolled bleeding and delayed complications

Immediate assessment required – FAST and CT

Minor trauma self resolves (CT avoids surgery):
- as many as 86% of liver injuries have stopped bleeding by the time surgical exploration is performed
- 67% of operations performed for blunt abdominal trauma are nontherapeutic

34
Q

imaging modalities and radiographic appearance of subcapsular haematoma?

A

US assessment may be possible – potential issues with direct contact of transducer and trauma site(s)

CT +C demonstrates:
small,
crescent-shaped subcapsular
parenchymal hematoma (less than 1 cm thick)
crescent-shaped hyperechoic collection

MRI:
- good at demonstrating fresh blood because of the difference in signal intensity,
however minimal role as initial imaging modality (useful for follow-up assessment)

35
Q

What is the imaging pathway for cholecystitis?

A

people with suspected gallstone disease:
liver function tests
ultrasound

people with abdominal or gastrointestinal symptoms that have been unresponsive to previous management:
- magnetic resonance cholangiopancreatography (MRCP)

If ultrasound has not detected common bile duct stones but the:
bile duct is dilated and/or
liver function test results are abnormal:
- endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made

36
Q

US radiographic appearances cholecystitis?

A

US (fast so full of bile) – usually detect
stones larger than 1 or 2mm

Wall thickening (>3mm)

Common hepatic or common bile duct should not be more than 7mm in size (unless have had cholecystectomy)

37
Q

magnetic resonance cholangiopancreatography radiographic appearances cholecystitis?

A

A non-invasive alternative to ERCP:
- excellent images
- however, as no endoscope is used it is not therapeutic (and patient may need ERCP to e.g. remove any gallstones that are found!)
- Used to visualise biliary and pancreatic ducts
- fast for at least 6 hours before the procedure, as this allows better demonstration of gall stones
- may use IV Gadolinium

38
Q

what is Intrahepatic Cholangiocarcinoma?

A

Carcinoma arising in any part of the:
- biliary tree
- from the small intrahepatic bile ducts to the Ampulla of Vater at the distal end of the common bile duct

39
Q

What imaging is used for pancreatitis?

A

US - first line
- chronic and acute
Enlarged heterogeneous pancreas anterior bowing and surface irregularity surrounded by a rim of peri-pancreatic fluid

CT:
can differentiate acute and chronic
Chronic Main features:
Pancreatic duct dilatation
Parenchymal atrophy
Pancreatic calcification
Best visualised with water as contrast agent

40
Q

What imaging is used for Pancreatic cancer?

A
  • essential to assess and stage pancreatic tumours
  • differentiate those who are suitable (or not) for surgery
  • Can accurately stage pancreatic cancer
  • Can identify cysts
  • pseudocysts,
  • necrosis
  • abscesses
    Use of tailored CT protocol is essential (using pre contrast, arterial and portal venous phases)
41
Q

What is the treatment of pancreatic cancer?

A

(Whipple’s procedure:
- removal of the head of pancreas,
- the first part of the small intestine,
- the gallbladder
- the bile duct,
aka pancreaticoduodenectomy

42
Q

what is the imaging pathway for pancreatic pathways (all the same) - NICE guidelines?

A

Depends on patient presentation, in relation to whether they have:
Obstructive jaundice
Pancreatic abnormalities on imaging
Pancreatic cysts
Inherited high risk of pancreatic cancer

Regardless, the imaging modalities of choice for all are:
CT scan (pancreatic protocol – likely to include water instead of oral contrast)
PET-CT and/or EUS (with US guided biopsy)
In addition:
For obstructive jaundice – ERCP (relieve biliary obstruction)
For pancreatic cysts – MRI/MRCP

43
Q

What are Pancreatic Pseudocysts?
what are the appearances?

A

Small pancreatic cysts and pseudocysts are common features of both acute and chronic pancreatitis;

Pseudo-cysts greater than 6 cm in diameter seldom disappear spontaneously

Large pseudocysts:
can produce abdominal mass
may compress or erode surrounding structures.

44
Q

What is the imaging pathway for Ulcerative colitis/colorectal cancer?

A

Colonoscopy first line imaging

CT and MRI

45
Q

Benefits of CT colonography (CTC)?

A

CT colonography (CTC):
- offers a less-invasive alternative to conventional colonoscopy for imaging colon cancer
- This technique is sensitive for diagnosis of small polyps

46
Q

limitations of CT colonography (CTC)?

A
  • CT colonography (CTC)
  • Some patients cannot tolerate the preparation for a CTC
47
Q

what is the prep and procedure of a CT colonography (CTC)?

A

Full bowel cleansing is preferred (low residue diet and laxatives) but sometimes faecal tagging used
- Colon is insufflated with air or CO2 to fully distend colon
- Protocolled by radiologist for faecal tagging
- Patient will ingest a barium solution up to 24 hours prior to CT
- No laxatives, no low residue diet

48
Q

Radiographic appearance of Ulcerative colitis?

A

CT and MRI:
might show a thickened,
ahaustral colon,
but are not sensitive or specific enough to be diagnostic tools hence the use of colonoscopy

49
Q

Radiographic appearance of colorectal cancer?

A

irregular wall thickening with luminal narrowing

50
Q

What are the advantages of CT virtual colonography?

A
  • less invasive and safer with minimal perforation or sedation risks
  • substantially lower cost than colonoscopy
    offers complete colonic exam in patients with tortuosity or tumour that may prevent passage of a colonoscope
  • can assess colonic wall thickness and structures outside the colonic lumen
51
Q

What are the limitations of CT virtual colonography?

A
  • not entirely noninvasive - requires rectal tube and insufflation
  • Radiation dose!
  • inability to perform biopsy of suspicious findings at time of exam may require additional follow-up conventional colonoscopy
  • less sensitivity for detection of very small polyps and superficial mucosal abnormalities than with colonoscopy
52
Q

What are the advantages of MR virtual colonography?

A
  • No ionising radiation
  • Detailed images
53
Q

What are the limitations of MR virtual colonography?

A

Less availability than CT
Longer scan time
More use in imaging of rectal pathologies

54
Q

What imaging modalities are used for rectal carcinoma?

A
  • MRI for staging of rectal tumour (better than CT for soft tissues)
  • CT used to assess metastases
  • Endorectal US compliments MRI as is better at looking at tumour extension within rectal wall
    -Ultrasound good if local
  • Good for looking at sphincter muscles of the rectum and anus
  • Fistulas
55
Q

What is a CT Virtual Gastroscopy?

A
  • CT with air-filled stomach
  • Transparency-rendered image shows the mass
  • The volume rendering technique can be applied to create transparency-rendered images.
56
Q

What are the limitations of CT Virtual Gastroscopy?

A

cannot pick up flat lesions comparing to conventional gastroscopy

57
Q

what is the dynamic contrast-enhanced magnetic resonance imaging (DCE MRI)?

A
  • Functional imaging technique that can reflect tumour vascularity - largely used in the staging of rectal carcinomas
  • The changes of signal intensity are plotted on a graph
58
Q

what are the limitations of dynamic contrast-enhanced magnetic resonance imaging (DCE MRI)?

A

Downsides of DCE/MRI include:
- high cost,
- limited availability,
- longer exam time,
- as well as contraindication in patients with pacemakers or certain metal implants

59
Q

The use of dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) in crohns disease?

A
  • Increased bowel wall enhancement is an established finding indicative of active inflammation in patients with Crohn’s Disease
  • Using standard post-contrast sequences, enhancement is evaluated as a snap shot in time
  • Studies have shown that, compared with normal bowel, diseased bowel wall demonstrated early and intense uptake of contrast that increases over time until a plateau is reached
  • The difference in enhancement pattern and dynamics was also observed between active disease and inactive disease.
60
Q

What is 3D Ultrasound of the Bowel

A
  • Data from the 2D scan is collected and by collecting known points and references can use the volume data to create a 3D image
  • Adding the three-dimensional modality (3-D) increases the capabilities of this diagnostic tool in rectal cancer patients (particularly in staging)

The Patient Pathway (6 decks)

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