GI Flashcards
DDx esophagitis
GE reflux Infectious (e.g. candida, CMV) Eosinophilic Drugs Caustic ingestion XRT
What is Boerhaave’s Syndrome?
Post-emetic esophageal rupture. If untreated, mortality rate nearly 100%.
What are 3 types of adenomatous polyposis syndromes?
Gardner syndrome
Familial adenomatous polyposis
Turcotte syndrome
What are 3 types of hamartomatous polyposis syndromes?
Peutz-Jegher
Cowden syndrome
Juvenile polyposis
DDx for fat-containing liver masses
HCC Adenoma (micro or macro) Liposarcoma mets Teratoma (primary or secondary) FNH (micro or macro fat) Focal steatosis AML (rare)
DDx for small bowel polypoid mass
GIST
Small bowel adenocarcinoma
Carcinoid
What are symptoms of carcinoid syndrome?
Flushing
Diarrhea
Palpitations
Shortness of breath, wheezing
What blood or urine tests can be used to dx carcinoid syndrome?
- Urine 5-HIAA (related to serotonin)
- Serum chromogranin A
What nuclear medicine scan is most useful for imaging carcinoid tumors?
Octreotide scan
DDx splenic cystic lesions
Simple splenic cyst Epidermoid cyst Echinococcal cyst Pancreatic pseudocyst (lymphangioma?)
What are MRI features of hepatic adenoma?
- Variable T1 (usually mildly hyperintense)
- Mildly T2 hyperintense
- may drop SI on IP/OOP images
- Adenomas show early arterial enh and become nearly isointense relative to liver on delayed images; may show even show washout
- If hemorrhagic, blood products may alter signal characteristics
What are risk factors for hepatic adenoma?
- Young women on OC
- Glycogen storage disease
- Anabolic steroids
What infectious etiologies should you consider in terminal ileitis?
- Yersinia
- TB
- Amebiasis
- Actinomycosis
DDx for micronodularity of the spleen
- Lymphoma/Leukemia
- Fungal infections (Candida, histo)
- TB
- Sarcoidosis
- Mets usually cause larger nodules
What is the risk of malignant degeneration of Barrett esophagus?
10% (adenocarcinoma)
What is considered splenomegaly (measurements)?
Greater than 13 cm in length
Greater than 6 cm in width and 8 cm in breadth
What are radiographic signs of pneumoperitoneum?
Rigler sign Football sign Cupola sign Triangle sign Falciform ligament, umbilical ligament (inverted "V"), ligamentum teres, or urachus signs
What is an amyand hernia?
Inguinal hernia containing the appendix
What is a littre hernia?
Hernia containing a Meckel diverticulum
What is Mirizzi syndrome?
Occurs when a gallstone lodges in the neck of the GB or cystic duct and causes compression of the CBD.
What is a Todani type 1 choledochal cyst?
1A: saccular, majority of the extrahepatic CBD
1B: saccular, limited segment of the CBD
1C: fusiform, majority of the CBD
What is a Todani type 2 choledochal cyst?
isolated diverticulum; often a narrow-necked CBD
What is a Todani type 3 choledochal cyst?
duodenal wall, CBD (aka choledochocele)
What is a Todani type 4 choledochal cyst?
4A: multiple intrahepatic and extrahepatic
4B: multiple extrahepatic
What is a Todani type 5 choledochal cyst?
Multiple intrahepatic (Caroli disease)
What disease causes the cocoon sign?
Sclerosing encapsulating peritonitis (classic)
Other causes: TB, sarcoidosis, familial Mediterranean fever, GI malignancy
What causes sclerosing encapsulating peritonitis
Idiopathic
Secondary to chronic ambulatory peritoneal dialysis or VP shunts
DDx for coned cecum with involvement of the TI
Lymphoma
Abscess from appendicitis or diverticulitis
Crohn disease
Infection (TB, Amebiasis, Yersinia)
What is the typical CT appearance of FNH?
- homogeneously hypervascular on AP
- nearly isodense to liver on other phases (stealth)
- central scar is nearly pathognomonic
What is the Milan criteria for liver transplant?
“The Milan criteria stipulate that to be eligible for liver transplantation, pts with HCC should have a single tumor that is
DDx for mass within the cecum containing fat
- Ileocecal valve lipoma
- Lipomatous infiltration
- Intussusception (mesenteric fat)
What is Zollinger-Ellison Syndrome?
Severe peptic ulcer disease a/w marked increase in gastric acid due to gastrin-producing endocrine tumor (gastrinoma) of pancreas. See hypervascular pancreatic mass with multiple peptic ulcers and thickened folds.
What are the boundaries of the gastrinoma triangle?
1) Superiorly: cystic and common bile ducts
2) Inferiorly: 2nd and 3rd parts of the duodenum
3) Medially: junction of pancreatic neck and body
What is Menetrier Disease?
Rare acquired condition characterized by hyperproliferative protein-losing gastropathy of gastric foveolar epithelium. See massively thickened gastric folds (usually spares antrum).
DDx for fatty replacement of the pancreas
- Cystic fibrosis
- Senescent change
- Obesity and DM
- Steroids
- Cushing syndrome
- Shwachman Diamond syndrome
What are typical GI findings of scleroderma?
- Esophageal dilatation
- Marked fecal retention
- Pneumatosis cystoides coli
- Hide-bound small-bowel folds
What is pneumatosis cystoides coli? What are potential etiologies?
- PCC is a benign form of pneumatosis in which predominantly nitrogen gas collects in the subserosal space, often with cystic or bleblike appearance.
- Steroids, CF, scleroderma, COPD
What are characteristics of Cowden syndrome?
- Hamartomas of the tongue, skin and entire GI tract
- AD and extremely rare
- Incr’d risk of thyroid and breast ca
What are characteristics of Cronkhite-Canada syndrome?
- Hyperplastic inflammatory retention polyps: stomch, SB, LB
- Decades 5 to 8; marked weight loss, protein-losing enteropathy, diarrhea, peripheral edema, anemia
- Loss of hair and nails, cutaneous hyperpigmentation
What are characteristics of Peutz-Jegher Syndrome?
- Hamartomas: stomach, SB, LB
- Decades 2 to 3; recurrent abdo pain (intussceptions of SB), orocutaneous hyperpigmentation
- Incr’d risk for ca of the LB, SB, breast, ovaries, pancreas
What are high-risk features of pancreatic IPMN?
High-risk features (MPD ≥ 1 cm, enhancing mural nodularity, or biliary obstruction) warrant resection
What are worrisome features of pancreatic IPMN?
- Lesions with worrisome features (cyst size ≥ 3 cm, MPD dilatation between 5-9 mm, nonenhancing mural nodularity, abrupt change in main duct caliber with distal pancreatic atrophy) should undergo EUS.
- Presence of suspicious cytology or mural nodularity/main duct involvement on EUS in this subgroup warrants consideration of surgery
What are the most frequent small bowel malignant tumors?
-adenocarcinoma: 30-50%
-carcinoid tumor: 25-30%
-lymphoma: 15-20%
-leiomyosarcoma: 10%
(radiopaedia)
What is feline esophagus?
Refers to transient transverse bands seen at the lower esophagus on a double contrast barium swallow. Almost always a/w GERD.
DDx for thickened gastric folds
- Hypertrophic gastritis
- Antral gastritis
- Gastritis (from H. pylori)
- Eosinophilic gastritis
- Menetrier disease (spares antrum)
- Lymphoma
- Chronic gastritis from renal failure
- ZE syndrome
Describe the MR appearance of FNH
-isointense on T1
-slightly hyperintense on T2
-scar is hypointense on T1 and hyperintense on T2
-enhances in AP with delayed enh of central scar
(central scar only present in 50% of cases)
DDx for atonic esophagus
- Scleroderma
- Rheumatoid arthritis
- SLE
- polymyositis/dermatomyositis
- anticholinergic meds
- achalasia may appear similar
What is Budd-Chiara syndrome?
Acute or chronic obstruction of the venous outflow of the liver, which may result from obstruction of the hepatic veins, IVC, or both
What biochemical tests help diagnose pheochromocytoma and paraganglioma?
- plasma free metanephrines
- urinary fractionated metanephrines
- can use serum chromogranin A
What scintigraphic test is used to detect pheochromocytoma?
I-123 MIBG. Reserved for cases in which a pheochromocytoma is confirmed biochemically but CT scanning or MRI does not show a tumor
DDx for cystic liver lesion
- Biliary cyst adenoma (multilocaulated, smooth margins)
- Hepatic cyst
- Echinococcal cyst
- Abscess (pyogenic)
What are associated clinical features of hemochromatosis?
Hyperpigmentation, diabetes, OA, hepatomegaly, cardiomyopathy
What are the 4 types of hepatic adenoma?
1) HNF 1 alpha inactivated (35-40%), lowest risk for malignant transformation
2) Inflammatory (45-60%)
3) Beta-catenin-activated (10-15%), highest risk for malignant transformation
4) Unclassified (10%)
What is the T staging for Gallbladder cancer?
T1: invades lamina propria or muscular layer
T2: invades perimuscular connective tissue, no extension beyond serosa into liver
T3: perforates serosa OR directly invades into one adjacent organ OR both (2 cm into liver and/or into two or more adjacent organs (stomach, duodenum, colon, pancreas, omentum, extra-hepatic bile ducts)
What is the T staging for colon carcinoma?
T1: submucosa
T2: muscular mucosal
T3: transmural
T4: invades adjacent organs/visceral peritoneum
What are the management guidelines for GB polyps?
-
What conditions make pancreatic cancer unresectable?
- Invasion of peripancreatic vessels (>180 degree contact)
- -Celiac artery, SMA, common and proper hepatic artery
- -Portal vein & amp; SMV = some surgeons will operate
- Invasion of the neural plexus around the celiac axis and SMA
- Invasion of local contiguous structures other than the duodenum
- Distant metastases (Lymph nodes outside the margin of resection, Liver metastases, Omental and peritoneal metastases)
What is the recommended mgmt for colonic polyps at CT colonography?
10 mm: Colonoscopy
DDx for thumb printing
- Ischemic colitis
- IBD
- Infectious colitis
- Lymphoma
- Pseudomembranous colitis
What is median arcuate ligament syndrome?
MALS is compression of the celiac artery by the median arcuate ligament of the diaphragm, most common in young women (median age 35 years). The clinical presentation is chronic intermittent nausea and diarrhea, significant weigh loss (>20 lb), and mild-to-severe abdominal pain, particularly during exercise and eating. An epigastric bruit may be detected during exhalation.
DDx for causes of mesenteric ischemia
- atherosclerosis/stenosis
- arterial thrombosis
- venous thrombosis (e.g. SMV)
- retroperitoneal fibrosis
- fibromuscular dysplasia
- Takayasu’s arteritis
By LI-RADS criteria, what is considered threshold growth?
–>diameter increase of a mass by a minimum of 5 mm
Also:
-if prior exam 50% increase
-if prior exam >6 months, diameter >100% increase
- ->a new 10 mm lesion represent threshold growth, regardless of time interval
- ->threshold growth only applies to masses
- ->threshold growth should be compared on similar sequences between studies
Broad ddx for splenic pathology:
- Congenital (asplenia, polysplenia, accessory spleen)
- Trauma
- Infection/inflammation (histo, sarcoidosis, candidiasis, abscess)
- Vascular (infarction, AVM, diseases affecting splenic vasculature)
- Hematologic disorders (sickle cell, extramedullary hematopoiesis)
- Benign tumors (cysts, hemangioma, diffuse hemangiomatosis, hamartoma)
- Malignant tumors (sarcoma, lymphoma, mets)
- Other diseases that affect the spleen diffusely (portal HTN, Gaucher disease, sickle cell) or focally (Gamna-Gandy nodules)
What is the most common malignant tumor of the spleen?
lymphoma
What is typically used as a size cutoff for consideration of endovascular tx of splenic artery aneurysm?
-2 cm: endovascular therapy should be considered; coil embolization is increasingly used to treat larger aneurysms.
What is the risk of malignancy with a choledochal cyst?
10-15% lifetime risk of cholangiocarcinoma
What is Bouveret syndrome?
Gastric outlet obstruction produced by a gallstone impacted in the distal stomach or proximal duodenum. (need fistula)
DDx filling defect in CDB on ERCP or MRCP
-gallstones
-sludge
-pus
-malignancy (ductal, ampullary, cholangio, pancreatic…)
-air bubbles
-parasites
At MRCP: consider susceptibility artifact, crossing vessel, flow voids, pseuocalculous / sphincteric contraction
What is the risk of cholangiocarcinoma in PSC?
15%
DDx for calcified mesenteric mass
- Sclerosing mesenteritis
- (Metastatic) carcinoid, more common in ileal mesentery
- Treated lymphoma
- TB
- Mets
- Primary carcinoma
What is the duct of Luschka?
Accessory bile duct that tracks alone the gallbladder fossa and usually drains into the extra hepatic bile ducts. It is vulnerable to injury during cholecystectomy.
What is the most common site of sarcoid involvement in the GI tract?
stomach (up to 10% of patients with sarcoid have asymptomatic gastric mucosal granulomas)
DDx for diffuse GB wall thickening
- Acute/chronic cholecystitis
- Patient not fasting
- Chronic hypoalbuminemia
- Hepatitis
- CHF
- Cholangitis (AIDS)
- Frequently not due to primary GB disease
DDx for focal GB wall thickening
- Polyps
- Metastases
- Adenomyomatosis
- Carcinoma
- adenomas
- Cholangitis (AIDS)
- Gangrenous cholecystitis
- Rare miscellaneous disease
- Frequently is due to primary GB disease
What is the T staging for adrenal cortical carcinoma?
T1: diameter 5 cm without local invasion
T3: Any tumor size with local invasion but not involving adjacent organs
T4: Any tumor size with local invasion and extension into adjacent organs.
What syndromes are associated with pheochromocytoma?
- von Hippel Lindau
- NF 1
- MEN 2A and 2B
- Carney syndrome (pulmonary chondroma, gastric leiomyosarcoma, phew)
- Also Sturge-Weber, Tuberous sclerosis
DDx cystic liver lesion
- Simple or complicated benign cyst
- Biliary cystadenoma
- Cystic metastasis
- Abscess
- Hematoma
- Echinococcosis (usually with daughter cysts)
Organisms associated with oriental cholangiohepatitis?
The exact etiology is not well understood but strong association with hepatobiliary infestation with Clonorchis sinensis (liver fluke) or ascaris lumbricoides have been implicated.
DDx target lesions in the liver
- Mets
- leukemia, lymphoma
- Sarcoid
- fungal infection
Which embryologic duct becomes the major duct of the pancreas?
Which duct drains the dorsal pancreas?
- Duct of Wirsung drains the ventral anlage (pancreatic head and uncinate process). Major papilla
- Duct of Santorini drains the dorsal pancreas (pancreatic body) to the minor papilla
DDx thumbprint one
- pseudomembranous colitis
- infectious colitis (salmonella, E. coli, parasitic)
- IBD (CD, UC)
- ischemic colitis
- intramural hemorrhage
- rarely lymphoma
Recommended management for a pancreatic SPEN?
A small percentage (~15%) may undergo malignant degeneration. Surgical excision is commonly recommended to rule out or prevent malignant degeneration.
Most common functioning islet cell tumor?
insulinoma
DDx linitis plastica
1) Neoplastic
- gastric adenocarcinoma (scirrhous)
- metastases (breast, lung)
2) lymphoma: less rigid
3) diffuse gastric diverticula (rare)
4) inflammatory
- radiotherapy
- eosinophilic enteritis
- granulomatous disease (Crohn’s disease, TB, sarcoid)
5) scarring (e.g. ingestion of corrosives)
6) gastric amyloidosis
Pancreatic neuroendocrine tumors are associated with what syndromes?
- MEN type 1
- VHL
DDx calcified liver mets
“BOTOM”
- B: breast cancer
- O: osteosarcoma
- T: papillary thyroid cancer
- O: ovarian cancer (especially mucinous)
- M: mucinous adenocarcinoma (especially colorectal carcinoma)
Others:
- melanoma
- osteosarcoma, chondrosarcoma
- islet cell tumors
- neuroblastoma (pediatrics)
4 sub-types of hepatic adenoma
1) Inflammatory hepatic adenoma: most common, highest rate of bleed
2) HNF 1-alpha mutated hepatic adenoma: second most common, multiple
3) Beta catenin-mutated hepatic adenoma: least common, men on anabolic steroids, glycogen storage disease, familial adenomatous polyposis
4) Unclassified hepatocellular adenoma
Differentiate primary vs. secondary hemochromatosis
- Primary hemochromatosis (hereditary AR): affects parenchymal cells of liver, pancreas and heart
- Secondary hemochromatosis (due to iron intake, transfusions, etc.) results in iron deposition within the the reticuloendothelial system: liver, spleen, lymph nodes and bone marrow
Management of mucinous cystic neoplasm of the pancreas?
- Rate of malignancy 10-40% depending on series
- Traditionally all MCNs have undergone complete surgical excision (usually distal pancreatectomy and splenectomy)
- Lesions in poor surgical candidates may be conservatively managed with close serial imaging follow-up
- Benign MCNs with complete surgical resection do not require further treatment or follow-up
- Malignant MCNs receive adjuvant chemotherapy after surgical resection
Mgmt of serous cystadenoma of the pancreas?
- Vast majority of have no risk of malignancy
- Most lesions are observed without treatment. They are benign lesions and do not recur once resected.
- Asymptomatic small tumors with classic imaging features: Serial imaging follow-up without surgical excision
- Indeterminate lesions without classic imaging appearance: **MR or endoscopic ultrasound
- Complete surgical excision for large tumors (especially > 4 cm) with mass effect or patient symptomatology
- Complete surgical excision for any lesion-causing symptoms
- No size cut-off for resection; based on symptoms
What criteria is used to assess IPMNs and mucinous cystic neoplasms (MCNs)?
What features should be assessed?
Tanaka Criteria (Fukuoka consensus guidelines; formerly known as the Sendai Criteria 2006)
High risk stigmata
- enhancing solid component
- main pancreatic duct ≥10 mm
- obstructive jaundice (biliary obstruction)
Worrisome features
- cyst ≥3 cm
- thickened and enhancing cyst wall
- non-enhancing mural nodule
- main pancreatic duct 5-9 mm
- lymphadenopathy
International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12 (3): 183-97
What serum markers can be used to assess for pancreatic malignancy?
CEA
CA 19-9
Risk of malignancy in side branch IPMN; in main duct IPMN?
1) Side branch IPMN: variable risk of malignancy: ~25% contain high-grade dysplasia and ~17% contain invasive carcinoma
2) Main duct IPMN: High risk of malignancy: ~62% contain high-grade dysplasia and ~58% contain invasive carcinoma
(StatDx)
DDx hyperdense liver
“WHAT G2”
- Wilson disease
- Hemochromatosis
- Amiodarone
- Thoratrast
- Glycogen storage disease
- Gold treatment
What is the normal flow velocity in the portal vein?
20-30 cm/sec
Normal portal vein pressure?
5-10 mm Hg
DDx “starry sky” liver
- Acute hepatitis
- Hepatic congestion
- Infiltrating neoplasm
- toxic shock syndrome
- biliary or portal venous gas
DDx “target lesion” in the liver
- HCC
- Metastatic disease
- lymphoma
- hepatic abscesses
- hepatic pseudotumor
