GI Flashcards
Barretts-buzzword, typical appearance, dx, rx
- buzzword: Reticular mucosal pattern
- appearance: mucosal ulceration several centimeters above the gastroesophageal junction
- diagnosis- muc bx
- rx: Aggressive medical treatment for gastroesophageal reflux is mandatory along with close monitoring to detect possible transition into adenocarcinoma of the esophagus.
feline esophagus vs esuinophilic esophagitis
feline= thin TRANSIENT folds, lower 2/3, normal but also high ass with reflux esophagitis
Critical staging for Es CA
T3 (Adventitia) vs T4 (invasion into adjacent structures. Need CT (others staged by endoscopy)
Name for fundoplication 360˚ and < 360˚
nissen=360. Toupe = <360
Ivor lewis
transthoracic esophagectomy usually through right intercostal approach (Ivor lewis)
“short esophagus”
hiatal hernia that is fixed/non-reducible and >5cm
MCC recurrent reflex s/p fundoplication
Slipped Nissen
MCC slipped Nissen
short es
earliest mc complication fundoplication. when does it peak?
obstruction (edema or too tight). peak at 2wks.
Treatment for short esophagus
Collis gastroplasty
Diagnosis slipped nissen
narrowed esophagus >2 cm
odynophagia + immunocompromised
esophageal candidiasis
elevated benign esophageal nodules + elderly
glycogenic acanthosis (asymptomatic.)
When do you see esophageal involvement with Crohn’s? What is the buzzword?
Severe disease. Apthous ulcer.
clusters of nodules on esophagram
hpv squamous papillomatosis
MC location esophageal duplication cyst
ileum
Killian Dehiscence
between thyropharyngeus and cricopharyngeus muscles
ddx epiphrenic diverticula
- paraesophageal hernia (MC left)
- traction-mc mid es, tented/triangular
- fluid collection-history, less well defined.
Epiphrenic diverticula
pulsion diverticula in distal es, mc on right. Ass with dysmotility
Plummer-vinson syndrome
Fe def anemia, dysphagia (es web), thyroid issues, “spoon-shaped nails”, glossitis
esophageal webs are a RF for what?
hypoph and es CA
long esophageal stricture
radiation, NGT, caustic
medication induced esophagitis-mcc & loc
- sites of es narr (AA, LMB, retrocardiac, distal es)
- abx (tetracycline), anti-inflamm, cardiac (quinidine, K), BisP
glycogenic acanthosis
asymptomatic benign esophageal nodules in elderly. Look like candidiasis
buzzword eosinophilic esophagitis
ringed esophagus
“vigorous achalasia”
early/less sev form. repetitive simultaneous non=propulsive contractions. MC in women, 2˚ CA MC in men
achalasia vs pseudoachalasia
GEJ will eventually relax with achalasia
increased risks of achalasia
SCC, candidiasis
increased risks of scleroderma
chronic reflux, scarring, barretts, adenoCA, (also candidiasis?)
how will scleroderma appear on exam?
dilated es with birds beak (ID to achalasia) + lung changes (NSIP)
Hampton’s Line
Benign gastric ulcer AM. Thin radiolucent line separating barium in gastric lumen from barium in crater
Carmen meniscus sign
Malignant gastric ulcer AM. Ulcer crater and radiolucent elevated border
GIST location frequency
stomach (70%), duo, colon
Carney’s triad
Carney’s Eat Garbage: chondroma (pulmonary), extra adrenal pheo, GIST.
where do GIST usually met?
They don’t. But if so, to liver
Sarcoma-spreads hematogenously, rarely to LNs
what syndromes are GIST ass with?
Carney’s triad & NF1
Areae gastricae-what is it, when does it enlarge and when is it obliterated
normal fine reticular pattern on double contrast. Enlarges in elderly, H pylori and focally next to ulcer. Obliterated by cancer.
Types of gastric volvulus
organoaxial (gastric antrum below GEJ) & mesenteroaxial (gastric antrum above GEJ.)
Menetrier’s disease
idiopathic hypoproteinemic gastropathy with rural thickening. Fundus, spares antrum. Protein loss (low alb). Ass with CMV in kids?
MC GI tract loc for sarcoid?
stomach
Ram’s Horn Deformity
aka Pseudobillroth 1. tapering of antrum. Ddx= peptic ulcer scarring, granulomatous dx, scirrhous carcinoma.
in what setting does splenic v thrombus occur?
isolated gastric varices (which can be ass with pancreatic cancer, pancreatitis)
gastric band-1) MC complication 2) MC comp to be tested
1) stomal stenosis 2) slippage
billroth 1 vs 2
1) Pylorus removed, remaining stom att to duo. (-) post op gastritis, (+) early compl
2) Partial gastrectomy, remaining stom att to jej.
risks billroth 2
1) dumping syndrome
2) afferent loop syndrome
3) gastric CA 10-20 yrs
Afferent loop syndrome
- Obstr of afferent limb –> dil loop, BD dil, chole/pancreatitis.
- Pot compl of billroth 2, REY, Whipple.
dumping syndrome
-classically billroth 2. also REY
what is suspected cause of gastric fold thickening and filling defects s/p Billroth?
bile reflux gastritis
jejunogastric intussusception
post-op compl w/ jejunal herniation into stom. High mortality when acute.
mcc sbo s/p REY
open=adhesions. laparoscopic= less ads –> more mobility –> closed loop.
3 potential sites for internal hernia s/p REY
1) transverse mesocol 2) JJ anast mesentery 3) behind roux limb mesentery
buzzword: ribbon bowel
graft vs host. Featureeless, atrophic, fold thickening
-vascular granulation tissue replacing destroyed mucosa
buzzword: hidebound
scleroderma-narrow sep of normal folds w/ mild bowel dil
buzzword: moulage sign (tube of wax)
Celiac-dilated jejunal loop w/ compl loss of jejunal folds. opacified like a tube of wax
buzzword: fold reversal
Celiac-jejunum loses folds to look more like ileum, ileum gains folds (in RLQ) to look like jej. Ie: atrophied jej, thickened ileum
buzzword: thread-like defect in barium column
ascaris suun worm
clover leaf sign
AM: healed peptic ulcer of duodenal bulb
which bug is responsible for whipples?
Tropheryma Whipplei
Buzzword: sand-like nodules
Whipple (and MAC “pseudo-whipples”)
SMA syndrome
compression 3rd pt duo by SMA. 2/2 sudden wt loss
other diseases ass w. celiac
- idiopathic pulmonary hemosiderosis (Lane Hamilton syndrome)
- Dermatitis herpetiformis
- bowel lymphoma
Meckel’s diverticulum
True diverticulum, remnant of omphalomesenteric duct
Complications of Meckel’s
- diverticulitis
- bleed (30% syx)
- intuss
- obstr
chronic dialysis its suscp to which bowel path?
thickened duo folds
jejunal diverticulosis
occ along mesenteric border, ass w/ bacterial overgrowth & Malays. V rare.
Riglers sign vs triad
Riglers sign- free air
Riglers triad- pneumobilia, obstruction, ectopic gallstone
Dir & indir sgx’s bowel trauma
- direct=spilled oral contrast, active mesenteric bleed
- indir=mes fat stranding fluid layering along bowel
MC type of small bowel lymphoma
non-hodgkin
sm bowel tumors ass w/ desmoplastic rxn
carcinoid (classically), HL
spigelian hernia
AKA lateral ventral hernia. Loc along Semilunar line (lat border RA) –> MC above arcuate line (caudal to umbilicus)
- defect in the aponeurosis of the internal oblique and transverse abdominal
- It is often covered by external oblique muscle and aponeurosis, as seen here, which helps to distinguish it from an incisional hernia.
lumbar hernia
- superior lumbar (grynfeltt-Lesshaft)-12th rib (super), int obl (inf), quadratus lumborum (med)
- inferior lumbar (petit)- latissimus dorsi, iliac crest, external obl (lat)
litter hernia
contains MD
amyand hernia
contains appendix
Howship-Romberg Sign
inner thigh paresthesia 2/2 obturator hernia
Richter hernia
only 1 bowel wall herniates, (+) strangulation
mc type of internal hernia
paraduodenal (through song defect)
paraduodenal internal hernias-2 types
1) Fossa of Lanzert-on Left (desc colon mesentery/LUQ). Sac-like cluster dil loops in left ant pararenal space behind IMV & asc L colic a
2) Fossa of Waldeyer- Right (asc colon, RLQ). ass w/ malrotation (non rotated small bowel, normally rotated large bowel). Occ below 3rd pt duo, behind SMA
What is the most common imaging finding in adult CF?
fatty replacement
Pancreatic agenesis vs lipomatosis
Agenesis: no duct. Lipomatosis: duct.
How does annular pancreas present differently in adult vs child?
Adult-pancreatitis.
Child-obstruction
CF buzzword
lipomatous pseudohypertrophy of the pancreas (enlarged w/ fatty replacement.)
imaging pancreatic CF
1) fibrosis 2) fatty replacement 3) small 1-3 mm cysts
Fibrosing colonopathy in CF
2/2 enzyme replacement
causes of pancreatic lipomatosis
CF, Cushing syndrome, chronic steroid, HLD, Shwachman-Diamond Syndrome
Shwachman-Diamond Syndrome
diarrhea, short stature (metaphysical achondroplasia), eczema, lipomatous pseudohypertrophy of pancreas (2nd MCC pancreatic insufficiency in children (CF=#1))
key imaging finding annular pancreas
annular duct encircling descending duodenum
What matters the most in pancreatic trauma? Next step if suspected?
- duct integrity-surgical EM.
- MRCP or ERCP if suspected
MC complications pancreatic trauma?
fistula (MC), abscess
Causes pancreatitis
GS, EtOH, ERCP (milder course), mx (VA), trauma (kids), H hyperTG, hyperCa, AI pancreatitis, pancreatic divisum, groove (para-duodenal), tropic, parasite (Ascaris)
How to score pancreatitis
Balthazar
Biphasic course acute pancreatitis
1-2wks=inflammatory (SIRS/ARDS)
3-4wk=anti-inflamm –> (+) susp infection
most common anatomic variant of pancreas
pancreatic divisum
MCC chronic pancreatitis
EtOH
early & late findings chronic pancreatitis
- early- 1) loss of T1 signal 2) delayed enh 3) dilated side branches
- late- 1) atrophic 2) chain of lakes (dilation/beading duct + Ca) 3) pseudocyst (30%)
- fibrotic inflammatory pseudotumor-diff from cancer
most char finding chr pancr
chain of lakes
compl chr pancr
cancer (20 yrs chr pancr = 6% increased risk)
chr pancreas vs malignancy
CP-duct dil=irreg & <50%
-fibrotic inflamm pseudotumor
IgG4
- AI pancreatitis
- retroperitoneal fibrosis
- sclerosing cholangitis
- inflammatory pseudotumor
- riedel’s thyroiditis
What gene is related to hereditary pancreatitis?
SPINK-1 gene
Trousseau’s syndrome
enlarged GB, painless jaundice, migratory thrombophlebitis
imp staging elements of pancreatic adenoCA
SMA/celiac axis involvement-unresectable
pancreatic adenoCA on small bowel follow-through
reverse impression on duodenum (frostburg’s inverted 3 sign or wide duo sweep)
Frostburg’s inverted 3 sign
reverse impression on duo in setting of pancreatic adenoCA seen on sm bowel follow through
Periampullary tumor
within 2 cm of major papilla arising from pancr, duo or CBD
What syndrome is associated with increased incidence of periampullary tumor?
Gardner’s syndrome
buzzword jejunal ulcer
Zollinger-Ellison syndrome
complications whipple
1) delayed gastric emptying 2) pancreatic fistula 3) wound inf
complications pancreatic transplant
1) acute rejection 2) donor splenic vein thrombosis 3) pancreatitis (<4 wks) 4) chronic rejection (shrinking transplant)
buzzword: shrinking transplant
pancreatic transplant chronic rejection, graft progressively gets smaller
Felty’s syndrome
SMG, RA, NP. Abn of granulocytes
Littoral cell angioma
benign vascular tumor of littoral cells lining venous sinusoids of red pulp
MC met to spleen
melanoma
Lane Hamilton syndrome
Celiac dx + Idiopathic pulmonary hemosiderosis (IPH)
IPH is an uncommon form of pulmonary hemosiderosis. It is characterized by the triad of
hemoptysis
iron deficiency anemia
diffuse pulmonary infiltrates, usually represented by diffuse pulmonary hemorrhage
The diagnosis is usually made by exclusion 1.
signs of GIST malignancy?
- mets (most reliable sign)
- size >5m
- irregular enh
- ulceration, cavitation
3 components of levator ani
1) pubococcygeus (pubovisceral ) m
2) iliococcygeus m
3) puborectalis m
inguinal LN pathology
- perineum
- anal canal
- anorectal junction
internal & external iliac LN pathology
- rectal
- urinary bladder
- prostate, cervical CA
obturator LN pathology
early prostate
rectus sheath mets
melanoma
inferior epigastric vessels course through rectus sheath
btw rectus abd and pst layer of rectus sheath
rectus sheath
strong fibrous compartment enveloping rectus m’s, formed by aponeuroses of 3 flat m’s
- contains sup and inf epigastric vess’
- ant: apon EO and ant IO
- pst=pst IO and TA
- below arcuate line (halfway btw umbilicus and pubic symphysis)–> no pst wall!
which liver tumors rupture spon’t
hcc
angiosarcoma
abd wall hernias with highest risk strangulation
femoral=highest
how often does serous cyst adenoma have central enhancing scar and Ca?
30%
10%
when to resect serous cystadenoma vs other cystic pancreatic neos
- 4cm (growth accelerates)
- 3 cm
serpiginous filling defects in esophagus
-varices
-varicoid carcinoma
lymphoma
varicose carcinoma of esophagus
mural metastasis of SCC of es
when to treat pancreatic fluid colls
4 wks intractable pain biliary ob suspecting inf con't growth
Myochosis/”cogwheel”
hypertrophy of the colonic circular muscle layer and shortening of the longitudinal layer (taenia) cause irregular narrowing of the colonic lumen.
Non hodgkin lymphoma
Immunosuppressed patients (e.g., those with AIDS or transplant recipients) are at markedly increased risk for developing NHL. Almost any focal abdominal visceral or nodal mass should be considered worrisome for involvement by NHL and evaluated appropriately.
anal cancer-who, ass w/ which virus, mets
- homosexual men, AIDS
- papilloma viral inf
- can spread systemically w/o liver mets due to dual (portal & systemic) venous drainage of rectum
CT criteria for acute appendicitis
thickened wall and/or dilated lumen & periappendiceal inflamm
Brunner gland hyperplasia/hamartoma
- Nonneoplastic hyperplasia of duodenal submucosal glands
- common cause for polypoid filling defects
- ass w. duodenitis, hyperacidity
- Strawberry or cobblestone appearance in proximal duodenum on barium study
Rx GIST
imatinib (Gleevec), tyrosine-kinase inhibitor
mesenteric adenitis-what is it?
inf of distal sm bowel
pancreatic pseudocyst mx
- typically resolve on own in weeks. Decompr into pancreatic duct or stomach/duo
- drain if inf, syx (usually via obstr of bowel or bd)
gastric ulcer vs avm/vascular ectasia on CT
- The term “ulcer” implies erosion into the submucosa or even through the wall of stomach. CT might show extraluminal gas, fluid, or enteric contrast medium, not evident in this case.
- Arteriovenous malformations or vascular ectatic lesions occur throughout the gastrointestinal (GI) tract and are a common cause of GI bleeding. These cannot be diagnosed by imaging, except indirectly as a source of active hemorrhage.
Bochdalek hernia
left post hemidiaph defect
pancreatitis fluid collections-encapsulated vs non
non= <4 wks (acute necrotic collection, acute peripancreatic fluid colelction.)
encaps: >4 wks (walled off necrotic collection, pseudocyst.)
common causes splenic v thrombosis
- acute & chr pancreatitis
- pancreatic malignancy
- aneurysms of celiac/splenic arteries
how does pancreatitis cause gastric varices?
splenic v thrombosis
vascular compl of pancreatitis-what, pathophys, which ones
- enzymes –> erosion –> hemorrhage and pseudoaneurysm via erosion
- splenic > GD > PD arteries
-Vessels we care about in panacreatic adenocarcinoma
- *common hepatic a’s –> GDA –> SPDA
- *celiac a + branches (LGA, SA)
- *SMA –> IPDA
*PV, splenic v
vessel encasement vs abutment
- encasement= > 180
- abutment = <180
benign vs malignant: serous cystadenoCA, mucinous cystic tumor
- serous=benign
- mucinous= low grade mal
small bowel target sign-app, causes
- water or hemorrhage in submuc
- pancreatic rests, GIST, lymphoma, melanoma, primary bowel adenoCA
- if mult: think lymphoma, melanoma
How does afferent loop syndrome cause pancreatitis?
obstruction of afferent limb s/p billroth2 –> obstruction of biliary and pancreatic drainage
img mucinous cystic pancreatic tumor
- large, loculated, thick walled cystic masses
- mural nodules, papillary projections
- TAIL
annular pancreas-pathophys
Failure of ventral pancr bud to rotate (clockwise) with duodenum
annular pancreas-types
- complete-complete encasement of duo
- incomplete-
- extramural: pancreatic tissue from ventral bud drains into main PD
- intramural-VB drains via own small ducts into duo
