GI Flashcards
posterior impression on esophagus
aberrant subclavian
vascular ring (double aortic arch)
(if high, DISHphagia)
what’s the liver disease associated with ulcerative colitis? What are the risks?
Primary sclerosing cholangitis. May lead to cirrhosis, increased risk of cholangiocarcinoma.
What’s the anatomy of Bilroth I? Bilroth II? What are complications?
Bilroth 1: antrectomy anastomosis to duodenum
Bilroth 2: antrectomy anastomosis to jejunum, risk for aferent loop syndrome
Done for gastric carcinoma
What’s afferent loop syndrome?
uncommon complication following a Billroth II
Most are mechanical obstruction of the afferent loop from adhesions, kinking at the anastomosis, internal hernia, stomal stenosis, malignancy, or inflammation surrounding the anastomosis
Obstruction -> back pressure from dilated -> bil dil and acute pancreatitis.
Dx: hepatobiliary nucs study
Ddx of desmoplastic reaction in mesentary
Retractile mesenteritis
desmoid tumor
(desmoplastic) carcinoid (met)
Ascites with scalloping of organs (liver, spleen, etc.)
Pseudomyxoma peritonei: intraperitoneal accumulation of a gelatinous ascites secondary to rupture of a mucinous tumour. The most common cause is a ruptured mucinous tumour of the appendix / appendiceal mucocoele
Ddx hypervascular splenic lesions
Mets: Melanoma, RCC, endometrial, carcinoid Lymphoma angiosarcoma hemangioma, hamartoma, sarcoid Fungal infxn
Ddx hepatic lesion with central scar
FNH (benign hamartomarous - central scar is AVM) Hepatic adenoma Giant cavernous hemangioma Fibrolamellar HCC Mets
Causes of pneumatosis intestinalis
primary (15%)
ischemia, trauma, infection, pulmonary (COPD), colonic obstruction, artificial ventilation, collagen disease, steroid therapy
Portal venous gas in adult Ddx
mesenteric ischemia (eg occlusion), diabetes, mesenteric vein thrombosis, hemorrhagic pancreatitis, diverticulitis, pelvic abscess, perforated gastric ulcer, necrotic colon cancer, ingestion of corrosive substances
Ddx for solid pancreatic masses
adenocarcinoma islet cell tumor SPEN (young women) lymphoma microcystic (serous) adenoma mets
Ddx echogenic liver masses
Hemangioma (70%)
mets
HCC
fatty change
What liver mass is associated with hormonal contraceptives? What do we do when it’s diagnosed?
Hepatic adenoma
common in young women
remove them - risk of rupture
Ddx hepatic cysts
simple cyst traumatic cyst echinococcal abscess biliary cystadenoma (septa may calcify) (cystadenoma, mesenchymal hamartoma, emryonal sarcoma)
Ddx cystic pancreatic masses
pseudocyst abscess congenital (PCKD, VHL) microcystic adenoma (grandmother) mucinous cystic adenoma/carcinoma (mother) SPEN (daughter) IPMT (grandfather) islet cell
what MRI contrast agent to look for FNH
eovist
Ddx Gastric mass: intramural/extramucosal
GIST, leiomyoma/sarcoma, neurogenic tumor, heterotopic pancreas, carcinoid, fibrous tumor, granuloma
Ddx thickened gastric folds
Gastritis-Hypertrophic, H. Pylori Menetrier’s disease Zollinger Ellison syndrome Varices Lymphoma (post-radiation, Crohn, sarcoid, gastric, mets, eosinophilic gastritis, amyloid)
What’s Zollinger-Ellison?
What syndrome is it associated with?
Gastrinoma with excessive secretion of acid into the stomach, initial manifestations is with peptic ulcer disease (PUD) with multiple recurrent and intractable ulcers, often in unusual locations
Also get diarrhea
assoc. with MEN I
What’s menetrier disease?
a form of rare idiopathic hypertrophic gastropathy, most commonly affecting fundus with massively thickened folds -
it causes protein loss
*increased risk of gastric cancer
Ddx pancreatic lipomatosis
CF, obesity, malnutrition, steroids/Cushing syndrome
Gastric polyps - what types and what would each be associated with?
adenomatous (usually antral)
Hyperplastic (gastritis)
Hamartomatous (Peutz-Jeghers)
Fundic Gland (FAP)
What’s Peutz–Jeghers syndrome?
multiple hamartomatous polyps, most commonly involving the small intestine, but also colon and stomach
mucocutaneous pigmentation involving the mouth, fingers and toes
Ddx for mid-esophageal stricture
caustic injestion reflux esophagitis radiation prolonged tube eosinophilic esophagitis carcinoma (primary or mets) pill esophagitis
Ddx thickened bowel wall / bowel wall thickening
enteritis, radiation, ischemia (including shock bowel), hemorrhage, ACE angioedema
Ddx for aneurysmal dilatation prior to small bowel stricture
lymphoma, Crohn’s dz, TB
Ddx gastric antral stenosis
TB, sarcoid, caustic, gastric cancer, mets, lymphoma, eosinophilic gastroenteritis, radiation
Ddx multiple gastric antral ulcers
erosive gastritis (meds, H. pylori), mets (melanoma, breast, Kaposi’s, lymphoma), Crohn’s dz
Ddx colonic “thumbprinting”
C. diff colitis, Crohn’s, UC, ischemic bowel, (if also in small bowel, graft-vs-host)
Organs involved in primary hemachromatosis:
Liver, pancreas, heart
GE junction polyps are associated with what?
reflux
Ddx for large gas-filled cyst in the lower abdomen on plain film:
cecal or sigmoid volvulus
giant sigmoid diverticulum
What are the types of groin hernias? How do you distinguish them?
Inguinal hernia - anterior to pubic tubercle
Indirect is lateral to the inferior epigastric vessels and congenital
direct is medial and found in adults
Lateral to pubic tubercle:
Femoral hernia - anterior to pectineus
Obturator hernia - posterior to pectineus (characteristic in old ladies)
What hernia are gastric bypass patients prone to?
internal hernia through the mesocolic window created during surgery
Small bowel tapeworm is called
Ascaris lumbricoides
Ddx small esophageal ulcers
Herpes, Crohn’s, medication
Ddx large esophageal ulcers
CMV (late HIV), HIV (at seroconversion)
Ddx for multiple calcifications in the liver and spleen
Treated systemic PCP, treated granulomatous disease
Ddx “target” lesions in small bowel
Mets (melanoma, breast, lung)
Immunocompromised: Kaposi, lymphoma
What’s a “carpet lesion” in the colon?
Villous adenoma
Posterior esophageal diverticulum =
Zenker’s
Lateral esophageal diverticulum =
Killian-Jamieson
Pseudopolyps in the colon indicate
Chronic IBD/colitis (look at distribution for Crohns vs UC)
Ddx for intramural bowel fistula
Crohns (especially if long), diverticulitis, cancer
Ddx numerous small esophageal outpouchings
Esophageal pseudodiverticulosis (Aunt Minnie)
Describe flouro findings of Barrett’s esophagus
may be normal
ulcer
stricture
reticular mucosa
Ddx large / mega esophagus
achalasia, scleroderma, Chagas disease (Tripanosoma cruzi), pseudoachalasia (ca/mets)
Esophageal ulcers tracking longitudinally into the wall
TB
What’s Hampton’s line (relating to the stomach)?
Line of intact mucosa around a benign ulcer
Ddx for double pyloric channel
Ulcer/peptic ulcer disease
Crohns
Cancer with ulceration
Duodenal adenoca - what should you think of/look for?
FAP - look for a stoma or absence of colon from prior total colectomy
Reduced/absent gastric folds:
Atrophic gastritis: causes vitamin B12 deficiency, and megaloblastic anemia
can be caused by persistent infection with Helicobacter pylori, or can be autoimmune in origin
What’s Cowden syndrome?
multiple hamartoma syndrome
large and small bowel hamartomatous polyps
associated with Lhermitte-Duclos (hamartoma in cerebellum)
increased risk of breast cancer
Imaging features of cholangiocarcinoma
Central (Klatskin) or peripheral, masslike or infiltrating
slow enhancement, retains contrast
capsular retraction
distal bile duct dilatation
Imaging features of recurrent pyogenic cholangitis
Infection with chlonorchis (“Oriental”)
strictures, especially (98%) in LEFT lobe with atropy
Ducts get strictures and *stones, sludge
increased risk for cholangioca
What are the types of bile duct cysts? What’s the classification called?
Todani classification 1 - CBD - fusiform 2 - CBD diverticulum 3 - choledochocele 4 - multiple extrahepatic +/- intrahepatic (type A) 5 - Caroli's disease
Features of Crohn’s dz
ulcers - apthous or deep
cobble stone mucosa
comb sign
wall thickening and enhancement
strictures
LAN
fat separating bowel loops ("fat halo")
pseudodiverticula ("omega sign") on anti-mesenteric border
fistula and abscess formation
ram's horn sign (antrum-duodenum)Features of Scleroderma in the small bowel:
hidebound/saran-wrapped: crowded, sharp folds
pseudosacculations along the mesenteric border with more folds along the antimesenteric border
(check lung bases for fibrosis and esophagus for dilatation)
Features of celiac disease
reversal of jejunal and ileal fold pattern
delayed transit
duodenitis
mesenteric LAN
Features of small bowel lymphoma
aneurysmal dilatation - no obstruction!
wall thickening without luminal narrowing
splenomegaly
LAN
Ddx small bowel stricture
NSAID enterocolitis, Crohn’s, ischemia, radiation, lymphoma, TB, eosinophilic enteritis
Ddx for fatty/low density LAN
Whipple disease, TB or fungal, mets (incl lymphoma)
Ddx for pancolitis
Infectious, IBD
not ischemic
Ddx for proctitis
Herpes, CMV, Crohn’s, UC, chlamydia (lymphogranuloma venereum)
Locations in the colon prone to ischemia:
Splenic flexure, sigmoid
What are filiform colonic polyps and what are they caused by?
Small islands of residual mucosa which appear as thin, worm-like structures
UC, Crohn’s, TB
What’s the term for colitis caused by fecal impaction?
Stercoral colitis
can rupture
What are some things to consider if the patient has no colon?
Total colectomy:
UC (look for liver lesion eg missed metastatic lesion from colon ca, PSC and/or cholangioca)
FAP - look for duodenal mass or desmoid in mesentery
Occasionally 2/2 Crohn’s or C. diff colitis
What’s a tail gut duplication cyst?
aka retrorectal cystic hamartoma
seen in adults (~30-60 yo)
discrete, well-marginated, pre-sacral mass with water or soft-tissue density, depending on the contents of the cyst. Calcifications may be seen
What’s a Spigelian hernia?
Lateral to the rectus femoris m.
tends to cause bowel strangulation
What other issue is associated with wandering spleen?
Gastric volvulus
Describe the types of gastric volvulus
organoaxial - along long axis, so greater curvature is now superior and to the right
mesenteroaxial - across short axis, so GE jctn on right and pylorus on left - more severe
both can cause ischemia
What is a waterlily sign and what does it mean? What are other features of this disease?
detachment of the endocyst membrane which results in floating membranes within the pericyst Hydatid cyst (Echinococcal infection) Daughter cysts are also diagnostic
Ddx dense liver
defined as >70 HU
Amiodarone, hemosiderosis, hemochromatosis, Wilson’s
Liver lesions that can contain calcium:
Mets (mucinous GI, osteosarcoma, treated lymphoma)
Low density lesions in the spleen
Fungal infxn, lymphoma, mets, TB, hemangioma (fills in post contrast)
What’s the name for complications resulting from foreign objects / material left inside a patient’s body, usually following surgery
Gossypiboma
Ddx varioliform gastric ulcers
NSAIDS, Crohns, EtOH, infxn (CMV, candida)
Note - these are smaller than target lesions, which are >1 cm
What are Gamna gandy bodies? What do they look like? What organ? What does it mean?
aka siderotic nodules = microhemorrhages + fibroblastic rxn in the spleen Dark on T2 / heterogeneous on US Portal HTN (rarely other causes)
What’s cavernous transformation of the portal vein?
portal vein thrombosis and is the replacement of the normal single channel portal vein with numerous tortuous venous channels. (there’s portal HTN)
Ddx massive gallbladder wall thickening
(acute cholecystitis)
hepatitis
hypoproteinuria
CHF
