GI 2 Flashcards
What are choledochal cysts?
Dilatation of the EXTRA-hepatic bile ducts.
T/F 30-40% of pts with choledocal cysts present before 1 year of age?
True
What is the clinical triad seen in 25% of pts presenting with choledochal cysts?
- Intermittent obstructive jaundice,
- Recurrent RUQ pain,
- RUQ mass.
What are the US features of choledochal cysts?
- cyst adjacent to the gallbladder,
- intra-hepatic bile duct dilatation caused by pressure on the CHD,
- may be seen on antenatal scans.
What are the HIDA features of choledochal cysts?
- Delayed filling of the cyst. Differential dx includes hepatic cysts, pancreatic pseudocysts and enteric duplication cysts.
T/F cholesterol stones are radiolucent?
True
T/F pneumobilia can be seen with emphysematous cholecystitis?
True, dirty shadowing on US
What is xanthogranulomatous cholecystitis?
- inflammation of the gallbladder with intramural nodules,
- peak age 70-80.
What are the US features of xanthogranulomatous cholecystitis?
- thick gallbladder wall and intramural hypo echoic nodules.
- focal fatty inflammation,
- biliary obstruction.
What are the US features of intra-hepatic cholangiocarcinoma?
Dilated biliary tree with hyper echoic mass.
What are the CT features of intra-hepatic cholangiocarcinoma?
Homogenous delayed enhancement, dilated ducts.
What are indirect signs of Klatskin tumour?
- segmental dilatation of the main ducts,
- portal vein obstruction,
- lobar atrophy.
T/F PSC Intra-hepatic ducts more often involved than extra-hepatic ducts?
True
Name some associations f PSC?
IBD, pancreatitis, Sjogrens, RPF, Peyronies
What space does the pancreas lie in?
Anterior pararenal space at T12-L1
T/F the pancreas lies anterior to the lesser sac?
False- it lies posterior to the lesser sac and mesentery of the transverse colon.
What is the blood supply of the pancreas?
- superior pancreaticoduodenal artery (branch of gatroepiploic artery)
- inferior pancreaticoduodenal artery (branch of SMA).
T/F the dorsal Santorini duct drains the body and tail of the pancreas?
True- the ventral (Wirsung’s duct) drains the uncinate process via the major papilla. The distal dorsal duct regresses and drains via the minor papilla.
What is pancreas divisum?
Failure of the ventral and dorsal pancreatic ducts to fuse- the dorsal and ventral ducts drain separately.
In pancreas divisum, what does the dorsal duct drain and where does it drain to?
The dorsal duct drains the body and tail and the superior aspect of the head and uncinate process through the minor duodenal papilla. The ventral duct drains the inferior aspect of the head and uncinate process into the major papilla.
T/F annular pancreas can give rise to the double bubble sign in neonates?
True- due to duodenal obstruction.
How long does a pancreatic pseudocyst take to form?
4 weeks
2/3 of pancreatic pseudocysts are in the pancreas- where is the next commonest site?
Omental bursa
T/F rupture of a pancreatic pseudocyst can result in peritonitis?
True
What are other complications of pancreatic pseudocysts?
- infection,
- fistula formation,
- pseudoaneurysm.
T/F pancreatic pseudocysts can result in gastric outlet obstruction?
True
What organism is most commonly implicated in pancreatic abscesses?
E coli
T/F pseudoaneurysms occur in 10% of pancreatic pseudocysts?
True- splenic artery most common then GDA.
What is the most common organism in emphysematous pancreatitis?
E Coli
Name 4 causes of calcifying chronic pancreatitis?
- juvenile tropical pancreatitis,
- hereditary pancreatitis,
- Hyperlipidemia,
- Hypercalcemia.
Name 6 causes of obstructive type chronic pancreatitis?
- trauma,
- renal failure,
- CF,
- sclerosing cholangitis,
- ampullary tumour,
- ampullary stenosis.
What are MRI features of chronic pancreatitis?
- loss of signal on fat sat T1 W imaging,
- poor contrast enhancement of the pancreas,
- duct dilatation and beading.
What % of pancreatic malignancies are duct adenocarcinomas?
80%, head most common site
What sign a/w panc head malignancy on barium meal?
inverted 3 sign
T/F pancreatic adenocarcinomas commonly calcify?
False- they rarely calcify. non-functioning islet cell tumours commonly calcify.
T/F branch type IPMN commonly seen in uncinate process?
True
T/F with mucinous cystadenocarcinomas, solid papillary projections may be seen in the cyst?
True
T/F mucinous cystadenocarcinomas can invade other organs?
True
T/F islet cell tumours are functional in
False- they are functional in 80-90%
T/F insulinomas are usually >3cm?
False- usually
What is the 2nd commonest islet cell tumour?
Gastrinoma
Where do gastrinomas usually occur?
Head of pancreas
What % of all benign non-functioning islet cell tumours eventually turn malignant?
80-100%
T/F non-functioning islet cell tumours may calcify?
True
Where do non-functioning islet cell tumours usually arise?
Pancreatic head
What % of glucagonomas are malignant?
75%
What syndrome are glucagonomas associated with?
MEN 1
Necrolytic erythema migraines is a/w what pancreatic tumour?
Glucagonoma
T/F glucagonoma may present with unexplained thrmboembolic complications?
True
Liver mets occur in what % of cases of glucagonomas?
50%
T/F VIPomas are mrs common in men?
False F:M 2:1
In the pancreas, where are VIPomas usually located?
Body and tail
Name 2 extra-pancreatic sites of VIPomas?
Retroperitoneum and mediastinum in children usually from a neurogenic tumour e.g. neuroblastoma, ganglioblastoma
What is Verner Morrison syndrome?
VIPoma presenting with hypokalemia, achlorhydria and watery diarrhoea
In pts with VIPoma what can happen the gallbladder?
It can dilate due to paralysis of smooth muscle
T/F VIPomas are rarely malignant?
False- liver mets in 59%
Where are somatostatinomas most commonly located in the pancreas?
Head
How do somatostatinomas present?
Diabetes, steatorrhoea
What is the commonest site in the pancreas for a met?
Head
What are the features of MEN 1?
- parathyroid hyperplasia,
- pancreatic islet cell tumour,
- pituitary tumour,
- angiofibromas,
- multiple lipomas.
What are the features of MEN 2a?
- parathyroid hyperplasia,
- medullary thyroid cancer,
- phaeochromacytoma (bilateral in 70%),
- carcinoid,
- Cushing’s syndrome.
What are the features of MEN 2b?
- medullary thyroid cancer,
- phaeochromacytoma,
- marfanoid features with mucosal neuromas.
What is Carney’s complex?
Rare type of MEN,
- primary pigmented adrenocortical disease,
- pituitary adenomas,
- Sertoli cell tumours,
- thyroid nodules,
- non-endocrine features including cardiac myxomas and schwannomas.
What is the most common type of TOF?
Type C (85%) oesophageal atresia with distal TOF
Describe types A-F TOFs
Type A: oesophageal atresia without a fistula (10%).
Type B: oesophageal atresia with proximal TOF (
What sign on CXR is a/w type A or B TOF?
Absence of gastric air bubble.
What is the VACTERL syndrome?
Occurs when 3 or more of the following anomalies are present:
Vertebral: multiple or single hemi-vertebrae, scoliosis or rib deformities,
Anorectal malformations: imperforate anus, cloacal deformities,
CVDs: VSD, Tof Fallot, PDA, ASDs, AV canal defects, coarctation, rt sided arch, single umbilical artery.
Tracho-oesophageal defects: oesophageal atresia,
Renal anomalies: agenesis (incl Potter syndrome), PKD, horseshoe kidney, urethral atresia, ureteral malformations,
Limb deformities: radial dysplasia, absent radius, radial ray deformities, syndactly, polydactly, lower limb tibial deformities.
T/F right sided aortic arch is seen in what % of pts with TOF?
5%
At what level do acquired TOFs occur?
At the level of the carina
How is achalasia treated?
balloon dilatation or Ramsted’s surgical myotomy.
CXR features of achalasia?
- double mediastinal stripe,
- convex opacity behind right heart border
What is the commonest site for Boerhaave’s?
Posterolateral wall of the lower 1/3 of the oesophagus, 2-3cm proximal to the GOJ.
What is the commonest chest radiograph finding in Boerhaave’s?
Unilateral left sided pleural effusion
What is the V sign of Naclerio?
Seen in 20% of cases of Boerhaave’s- air in the space between the heart and vertebral column, seen as a left paraspinal hyperlucency.
Rupture of the upper or mid-oesophagus is a/w a pleural effusion on what side?
Right
T/F Mallory Weiss tear is a transverse mucosal laceration at the GOJ/gastric cardia?
False- Mallory Weiss tear is a longitudinal mucosal laceration at the GOJ/gastric cardia on the lesser curve.
T/F Oesophageal B ring is actually a web?
True- Schatzski web- consists of mucosa and submucosa.
Where are Schatzski rings usually found?
At the squamocolumnar junction- forms the upper limit of a hiatus hernia
What is an oesophageal C ring?
Rare anatomical variant caused by indentation of the oesophagus by the diaphragmatic crura.
Where do oesophageal webs typically arise?
Anterior post-cricoid area of the proximal oesophagus.
What is the diagnostic test of choice for oesophageal webs?
Barium swallow
Where do smooth inflammatory strictures usually arise?
At the squamocolumnar junction
T/F epidermolysis bullosa and pemphigus are associated with oesophageal strictures?
True
T/F wedged hepatic venous pressure is usually elevated with post hepatic sinusoidal obstruction e.g. Budd Chiari?
True And in veno-occlusive disease where the central hepatic venues are the primary site of injury.
What do para-oesophageal hernias look like?
GOJ remains below diaphragm and the funds herniates superiorly
What are the differences between a Barrett’s stricture and a PUD stricture?
Barrett’s stricture: Eccentric, short and tight.
PUD stricture: concentric and smooth.
What does candida look like on barium swallow?
granular pattern of mucosal oedema. In advanced cases, shaggy appearance of the oesophagus caused by pseudomembranes and confluent plaques. Owing to the friable nature of the lesions, the barium sometimes dissects into the submucosa and gives a double barrel appearance.
Grade 1: few plaques 2mm,
Grade 3: confluent linear plaques with ulceration,
Grade 4: grade 3 with stricturing.
How does tuberculous oesophagitis arise?
Mediastinal nodes are enlarged and erode into the oesophagus.
What do ulcers look like in tuberculous oesophagitis?
Shallow ulcers, heaped up lesions.
What are the features of CMV oesophagitis?
One or more giant superficial erosions in the mid to distal oesophagus.
In which oesophagitis are erosions diamond shaped, ovoid or serpiginous with satellite ulcers and a halo of oedema?
CMV, also look like this in Herpes
T/F CMV ulcers can grow up to 5-10cm
True
T/F advanced HSV oesophagitis may be indistinguishable from candida oesophagitis?
True
What causes giant flat oesophageal ulcers?
HIV oesophagitis
Oesophageal duplication cysts are completely surrounded by what?
muscularis propria, intramural masses, high protein may cause high signal on T1 Wi
Where do oesophageal leiomyomas arise?
Distal 1/3 of the oesophagus where there is smooth muscle. Arise from all layers of the oesophagus.
What are multiple oesophageal leiomyomas a/w?
neural deafness and renal impairment- Alport’s syndrome
T/F oesophageal leiomyomas are commonly a/ hypertrophic osteoarthropathy?
True
T/F Zenker’s are usually posterior and to the right?
False- posterior and to the LEFT
Where do Zenker’s arise?
between fibres of inferior constrictor and cricopharyngeus
