GI DDx Flashcards
Hypo-attenuating Liver
Fatty liver / hepatic steatosis
Hepatic amyloid
Hyper-attenuating Liver
Absolute attenuation > 75HU on non-con.
Iron overload.
- primary haemochromatosis: liver and pancreas
- secondary haemochromotosis: Liver and spleen.
Medications - amiodarone, gold, methotrexate.
- check lung bases for ILD.
Wilsons disease (Copper)
Glycogen excess.
Thoratrast
Multiple tiny hypo-attenuating hepatic lesions:
Candidiasis: immunocompromised. Mets. Lymphoma Biliary hamartomas. Caroli Disease. Sarcoidosis - check spleen for same.
Hypervascular hepatic Mets:
Neuroendocrine tumours: pancreatic neuroendocrine and carcinoid. RCC Thyroid carcinoma Melanoma Sarcoma
Hepatic Capsular retraction:
Metastatic tumor (commonly post Tx) Fibrolamellar HCC HCC (rare) Epitheloid haemangioendothelioma Intrahepatic cholangiocarcinoma Confluent hepatic fibrosis
Pancreatic Mass without ductal dilation:
Autoimmune pancreatitis Groove pancreatitis Cystic pancreatic tumour Neuroendocrine tumour GIST Peri-pancreatic lymph node Pancreatic Mets: RCC, thyroid, melanoma. Lymphoma
Cystic Pancreatic Neoplasm:
Serous cystadenoma: Senile Grandmother, hypervascular, no duct dilation or tail atrophy, central stellate Ca++. (seen in VHL)
Mucinous cystic neoplasm: mother, benign with malignant potential, single / few large cysts, commonly body / tail, capsule.
Solid Papillary Epithelial Neoplasm (SPEN): daughter, low malignant potential, heterogenous solid cystic mass, haemorrhage, capsule.
Intraductal Papillary Mucinous Neoplasm (IPMN): grandfather, variable - can be malignant, main duct or side branch.
Pancreatic neuroEndocrine neoplasm: commonly central necrosis and Ca++, hypervascular. Hypervascular liver mass with associated pancreatic mass most likely metastatic pancreatic endocrine neoplasm. (Seen in VHL)
Hepatic lesion with a scar:
Focal nodular hyperplasia Fibrolamellar HCC: wild looking, T2 hypointense scar. Cholangiocarcinoma Haemangioma HCC
Liver lesion with a capsule:
Adenoma
HCC
Cystadenoma / cystadenocarcinoma.
Liver lesion with central calcification:
Metastases (especially in colorectal tumors - mucinous)
Fibrolamellar carcinoma (FLC) - wild and large
Cholangiocarcinomas
Hemangiomas
Liver lesion containing fat:
Adenoma HCC Metastatic liposarcoma Angiomyolipoma Glissons capsule lipoma / pseudo lipoma
Consider Dropped gall stone.
Liver lesion containing blood / haemorrhage
Adenoma
HCC
Cystic liver lesion:
Simple cyst Traumatic cyst Bilioma Caroli's disease Cystic Mets Abscesses Hydatid disease Biliary cystadenoma
Hypervascular liver lesion:
Benign:
Focal nodular hyperplasia
Adenoma
Haemangioma (looks like fire on PV, peripheral discontinuous nodular enhancement)
Aggressive:
HCC
Hypervascular Mets: RCC, thyroid, melanoma, neuroendocrine, breast, sarcomas.
Common causes liver capsule retraction:
Cholangiocarcinoma
Mets - commonly treated breast.
Focal atrophy due to biliary or venous obstruction.
Stomach Rams Horn Deformity:
Scarring from peptic ulcer disease.
Granulomatous disease: Crohns, sarcoid, TB, Syphillis.
Scirrhous Carcinoma.
Dilated oesophagus:
Achalasia
Pseudoachalsia
Scleroderma.
Liver mass with capsule retraction
Focal confluent fibrosis Peripheral cholangiocarcinoma Mets / lymphoma. HCC Epithelioid haemangioendothelioma
Fat containing liver mass
Steatosis (normal traversing vessels) Pericaval fat deposition HCC (small foci) Hepatic adenoma Hepatic Mets Hepatic angiomyolipoma (TS, renal AMLs) Alcohol ablated liver tumour Teratoma Liposarcoma
Mosaic / patchy hepatogram:
Passive hepatic congestion Hepatitis Cirrhosis Steatosis Budd Chiari syndrome Hereditary Haemorrhagic Telangiectasia Congenital Hepatic Fibrosis Hepatic sarcoidosis
Hepatic Ca++:
Calcified granuloma (histoplasmosis > Tb)
Hepatic Mets (mucinous colon, breast, ovary, stomach)
Arterial Ca++
Ethiodol treated lesions
Cavernous Haemangioma
Hydatid cyst
Fibrolamellar HCC
Dysmorphic Liver with abnormal Bile Ducts:
PSC Cholangiocarcinoma Cholangitis AIDS cholangiopathy Fibropolycystic liver disease (Caroli disease)
T1 hyperintense Liver lesions:
Steatosis Hepatic adenoma HCC Haemorrhagic hepatic cyst Dysplastic and regenerative nodules Liver haematoma Hepatic Mets Pyogenic abscess Focal nodular hyperplasia Hepatic angiomyolipoma Peliosis
Liver lesion with capsule / Halo:
Hepatic Mets Pyogenic abscess HCC Haematoma Adenoma Hydatid cyst Amebic abscess Focal nodular hyperplasia
Focal Hyperdense Hepatic Mass on Non enhanced CT
Cirrhotic Regenerating Nodule Mass within fatty liver Focal sparing in fatty liver Mets Haematoma Haemorrhage within adenoma / HCC
Focal hepatic echogenic lesion +/- acoustic shadowing:
Focal steatosis Calcified granuloma Haemangioma Mets Pneumobilia Intra hepatic biliary calculi Pyogenic hepatic abscess Portal venous gas HCC Fibrolamellar HCC Cholangiocarcinoma
Pancreatic duct dilation
Chronic pancreatitis
Pancreatic ductal adenocarcinoma
Periampullary tumour
Obstructing distal common bile duct stone
Intra ductal papillary mucinous neoplasm.
Hypovascular Pancreatic Mass:
Pancreatic ductal adenocarcinoma Chronic pancreatitis Mucinous cystic neoplasm Serous cystadenoma Ampullary carcinoma.
Hypervascular Pancreatic Mass:
Pancreatic neuroendocrine tumour Pancreatic Met (RCC) Pancreatic serous cystedoma with multiple enhancing septations.
Cystic Pancreatic Mass:
Intraductal papillary Mucinous Neoplasm (elderly men)
Pancreatic psuedo cyst
Pancreatic serous cystadenoma (“senile head of family”)
Mucinous cystic neoplasm (Mother, body/tail)
Solid Psuedopapillary Neoplasm (Daughter, Race minor)
Atrophy or Fatty replacement pancreas:
Chronic pancreatitis Senescent change Obesity Cystic Fibrosis Cushing syndrome / steroid use Lipomatous pseudohypertrophy Shwachman-Diamond syndrome Agenesis dorsal pancreas.
Infiltration of peripancreatic fat planes:
Acute pancreatits Pancreatic ductal carcinoma Anascara and portal HTN Traumatic pancreatitis Duodenal / gastric ulcer Shock pancreatits Sclerosising mesenteritis Autoimmune pancreatitis Lymphoma
Pancreatic calcifications:
*Pancreatic adenocarcinoma alsomost never shows Ca++.
Chronic pancreatitis
Senescent change
Peripancreatic vascular calcification - splenic artery
Choledocholithiasis
Pancreatic neuroendocrine tumour
Pancreatic serous cystadenoma - central Ca++
Pancreatic muscinous cystic neoplasm - septation Ca++
Solid pseudopapillary Neoplasm - Ca++ common.
Pseudocyst
Distended Gall bladder:
Cholecystits Obstruction of CBD: choledocholithiasis, pancreatic ductal carcinoma, ampullarf carcinoma. Acute pancreatitis. Hepatitis. Gall bladder empyema AIDs Cholangiopathy
Pneumobilia / Pneumo-gall bladder:
Sphincterotomy Choledocholithiasis Patulous Sphincter of Oddi Biliary Enteric Anastomosis Emphysematous cholecystitis. Gass within gall stones. Gall stone ileus / cholecysto-enteric fistula Pyogenic cholangitis.
*Portal venous gas mimic: gas flows toward and collects in periphery of liver, on US causes spiky appearance on portal vein doppler. Biliary gas collects near porta hepatis.
Hyper dense bile within Gall bladder:
Vicarious excretion Layering of small gall stones. Gall bladder sludge. Hepatic / biliary trauma. Milk of calcium bile.
Asymmetric Dilation of Intrahepatic Bile Ducts:
PSC Cholangiocarcinoma ascending cholangitis HCC Hepatic mets or lymphoma AIDs cholangiopathy Recurrent pyogenic cholangitis. Gall bladder carcinoma, with infiltration.
IgG4 disease causes a more diffuse picture of biliary involvement.
Hypointense Lesions in biliary tree on MRCP:
Choledocholithiasis
Pneumobilia
Surgical clip
Post transplantation biliary stricture.
Hypervascular Liver Mets:
Islet cell tumour Carcinoid Thyroid Renal Pheochromocytoma
Liver mass with scar:
FNH: scar T2 bright, delayed enhancement.
Haemangioma
Fibrolamellar HCC: scar T2 dark, delayed partial C+, large wild looking.
HCC
Peripheral cholangiocarcinoma
Focal liver lesion with haemorrhage:
Trauma Hepatic adenoma HCC Hepatic cyst AD polycystic disease
Cystic hepatic Mass:
Hepatic cyst AD polycystic disease Pyogenic abscess Amebic abscess Biliary hamartoma Bilioma Mets.
Focal Hypervascular Liver lesion:
Haemangioma FNH arterial portal shunt THAD HCC Hepatic Mets Hepatic adenoma Hepatic AV malformation (Osler Weber Rendu) Dysplastic Nodular Regenerative nodules Fibrolamellar HCC Peliosis Hepatitis
Periportal lucency:
Hypervolaemia Passive hepatic congestion Acute hepatitis Ascending cholangitis POst transplant biliary necrosis.
Diffuse gall bladder wall thickening: (>3mm)
Fluid overload / oedema:
- Cirrhosis
- CHF
- Protein wasting nephropathy
Inflammatory / Infectious:
- Cholecystitis
- Hepatitis
- Pancreatitis
- Diverticulitis
Infiltrative neoplastic diseases:
- GB carcinoma
- GB mets - melanoma (rare)
Focal GB wall thickening
Adenomyomatosis and cholesterol polyp
Varices
Adenomatous polyp
GB carcinoma
Xanthogranulomatous cholecystitis.
Porcelain GB
Melanoma Mets.
Hypervascular pancreatic Mass:
Pancreatic islet cell tumour
Pancreatic Met
Serous cyst adenoma
accessory spleen.
Multiple Biliary strictures:
PSC Ascending cholangitis AIDS cholangiopathy Post transplant liver Recurrent pyogenic cholangitis Caroli disease. Chemotherapy cholangitis.
Pancreatitis Complications
Interstitial oedematous pancreatitis.
Necrotising pancreatitis.
Infected pancreatic necrosis
Central necrosis (disconnected duct syndrome)
Extra hepatic fat necrosis
Pseudoaneursym (splenic, gastroduodenal, pancreaticoduodenal arteries).
Venous thrombosis (splenic vein, portal vein, SMV).
Fluid collections:
- Acute peripancreatic fluid collection: < 4 weeks post oedematous pancreatitis.
- Pseudocyst: persisting > 4 weeks post oedematous pancreatitis.
- Acute post necrotic fluid collection: <4weeks post necrotising pancreatitis.
- Walled off necrosis: > 4 weeks post necrotising pancreatitis.
Multiple splenic Ca++:
Histoplasmosis TB arterial Ca++ and aneurysm Pneumocystis Carinii Splenic infarction Splenic cyst Hydatid cyst
Solid Splenic Mass or Masses:
Splenic trauma Splenic infarction Splenic mets Lymphoma Sarcoidosis Infection / abscess.
Cystic Splenic Mass:
Splenic cyst: acquired or congenital. Splenic trauma Splenic infarction Splenic Mets Splenic lymphoma Infection / abscess.
Diffuse increased spleen attenuation:
Haemochromatosis secondary form.
Splenic infarction: sickle cell anaemia.
Opportunistic infection.
Multiple Colonic Filling Defects:
Feacal material Colonic Polyps Colon Carcinoma UC Familial polyposis Gardner syndrome
Colonic Fistula:
Diverticulitis Colon Carcinoma Cervical Carcinoma Endometrial Carcinoma Ovarian Carcinoma Cystitis Crohn Disease
Segmental Colonic narrowing:
Colon Carcinoma Diverticulitis Ischaemic colitis Colonic Mets colonic Spasm Infectious colitis Ulcerative colitis. TB Radiation colitis
Smooth Ahaustral Colon
UC Cathartic abuse Crohn Disease Senescent change Toxic megacolon Ischaemic colitis Radiation Colitis
Multiple masses or filling defects in Small Bowel:
Lymphoid follicles Intestinal parasitic disease Intestinal Mets Intramural benign intestinal tumours. Hamartomatous polyposis syndromes Gardner syndrome.
Aneurysmal dilation of small bowel lumen:
Small bowel lymphoma. Small bowel Mets. Bowel-bowel anastomosis. GIST. Small bowel diverticula. Meckel diverticulum.
Irregular Diffuse Small Bowel Fold Thickening:
Celiac disease Oppurtunistic intestinal infections. Whipple disease. Portal HTN varices. Ischaemic enteritis. Mets.
Occult GI bleeding:
Intestinal Vascular ectasia Crohn Disease Mets / lymphoma GIST Carcinoid. Small bowel carcinoma. Small bowel vasculitis. Ischaemic enteritis.
Splenomegaly:
Massive:
- Myeloproliferative disorders, CLL, Hairy cell leukaemia
- Lymphoma
- Malaria
- Gaucher disease.
Moderate:
- Chronic congestive: portal HTN, splenic vein obstruction.
- Hereditary spherocytosis
- Thalassemia
- Autoimmune haemolytic anaemia
- Acute leukaemia
- Amyloidosis
- Niemann Pick disease
- LCH
- TB
- Sarcoidosis
- Mets.
Mild to moderate:
- Cirrhosis with Portal HTN.
- Acute Congestion.
- Inflammatory / infection: mononucleosis, hepatitis, SLE.
Duodenal filling Defects:
Prolapsed astral mucosa Duodenal polyps Brunner Gandhi hyperplasia. Pancreatic ductal carcinoma Duodenal lipoma. Duodenal haematoma Duodenal carcinoma.
Gastric antral narrowing:
Gastritis Gastric ulcer Gastric carcinoma Pancreatitis Post surgery. GIST.
Target / Bull’s Eye lesion stomach:
Gastric Mets Gastric lymphoma Kaposi Sarcoma Gastric carcinoma Ectopic pancreatic tissue GIST.
Gastric Ulceration without mass:
NSAID induced gastritis Gastritis Gastric ulcer Gastric carcinoma Zollinger Ellison syndrome. Crohn disease.
Linitis PLastica:
Gastric carcinoma Mets Caustic injury Gastritis Peritoneal mets. Crohns disease Oppurtunistic infection.
Oesphageal ulceration:
Reflux oesophagitis.
Candida Oesophagitis.
Viral oesophagitis:
- CMV and HIV are large: “V” = Very large and ‘V” go together.
- Herpes multiple small and discrete and focal, with Halo.
Drug induced, caustic, radiation oesphagitis.
Oesphageal carcinoma.
Extrinsic mass Oesophagus:
Left main bronchus. Aortic arch. Aortic Aneurysms. Hiatal hernia. Mediastinal nodes. Aberrant RSCA. Enlarged thyroid.
Intraluminal Mass Oesophagus:
Oesphageal Carcinoma Oesophageal FB Intramural Benign Oesophageal tumour. Thrombosed oesophageal varies. Inflammatory polyp. Candida Oesphagitis.
Oesophageal Strictures:
Reflux Barretts Carcinoma Scleroderma Mets Radiation Caustic Drug induced. Phemagoid.
Feline oesophagus: - Fine small rings - Distal 2/3, transient, seen with ruflux. Eosinophilic oesophaus - Thicker Ring like, not transient.
Oesophageal web:
- Anteriorly located.
- assess for Plummer Vinson syndrome.
Oesophageal Dysmotility:
Presbyesophagus Diffuse oesphageal spasm Achalasia Scleroderma Reflux Fundiplocation complication
Oesophageal Outpouching / Diverticula:
Zenker Diverticulum Traction Diverticulum Pulsion Diverticulum Killen Jameson diverticulum Intramural pseudo diverticulosis.
Crohn’s disease Features:
"CROHNS" C: Cobble stone mucosa R: rose thorn ulcers O: Obstruction of bowel H: Hyperplasia of mesenteric nodes N: Narrowing of lumen S: skip lesions
Bowel Sacculations:
"MISC" M: Mets I: Ischaemia S: Scleroderma C: Crohn Disease
Generalised Colitis:
I3 NR: Infectious Colitis (E. Coli, CMV) Inflammatory (Pseudomembranous colitis, Crohn, UC) Ischaemic Neoplastic (lymphoma) Radiation
Cystic lesions of spleen:
"TEAM" T: Trauma E: Echinoccoal A: Abscess M: Mets
Echogenic GB wall
Porcelain GB
GB packed full of stones (wall echo sign)
Emphysematous cholecystitis
Diffuse GB wall thickening > 3mm
Fluid overload: - cirrhosis - CHF - Protein wasting nephropathy Inflammation / infection: - Cholecystits - Hepatitis - Pancreatitis - Diverticulitis Infiltrative Neoplastic Disease: - GB carcinoma - Mets (rare)
Focal GB wall thickening:
Hyperplastic cholecystoses: - Adenomyomatosis - Cholesterol Polyp Varicies Neoplastic Disease: - Adenomatous polyp - GB carcinoma - Adjacent hepatic tumour.
Non shadowing mass in gall bladder lumen:
Tumefactive sludge (mobile) Blood / pus (mobile) GB polyp (immobile) GB carcinoma (immobile)
Hyperechoic Hepatic Mass:
Haemangioma Focal steastosis Hepatic Met (colon, RCC, breast, carcinoid, choriocarcinoma) Pyogenic abscess (Usually anechoic, while early lesions can be echogenic with poorly defined margins) Hyperechoic HCC Calcified granuloma Hepatic adenoma Hepatic angiomyolipoma.
TIPS Stenosis signs on US:
High intra TIPS velocity >190cm/s or low intra TIPS velocity < 90cm/s suggests stenosis.
Intra TIPS velocity change of 50cm/s or more since baseline is concerning for stenosis
Low main portal vein velocity <30cm/s suggests TIPS stenosis.
TIPS occluded shows re reersal of flow in left and right portal veins becoming hepato-peta.
Echogenic GB wall:
Porcelain GB
Gall bladder full of stones - wall echo shadow sign
Emphysematous cholecystitis
Hypoechoic hepatic Mets:
Breast
Pancreas
Lung
Lymphoma
Hyperechoic hepatic mets:
Colon cancer RCC Breast Carcinoid Choriocarcinoma.
Calcified hepatic mets (Hyperechoic with acoustic shadowing):
Colon cancer (mucinous)
Gastric adenocarcinoma
Osteosarcoma
Cystic Hepatic Mets:
Ovarian cystadenocarcinoma
Gastrointestinal sarcoma
Sparse liver Calcification on AXR:
Mucinous adenocarcinoma Met
Calcified giant cavernous haemangioma
Granulomatosis: TB, Histoplasmosis, brucellosis
Psuedomyxoma peritonei
Haemochromatosis: primary vs secondary
Liver dark on T1 and T2
Low signal on IN PHASE, high signal on out of phase (Opposite to steathosis / fatty liver)
IRON on IN-phase.
Primary: AR inherited.
- Pancreas involved.
Secondary: transfusions
- Spleen involved, pancreas spared.
- Stem cells of bone marrow involved.
Massive caudate lobe hypertrophy:
Budd Chiari
Primary Sclerosing Cholangitis
Primary Biliary Cirrhosis.
Splenic lesion DDx (Bayley)
Greater than 50% of the time lesions are non-specific
MRI of limited use
Often comes down to followup or biopsy
1) Sarcoidosis
- Usually multifocal lesions
- Very common
- Look at lungs/nodes
2) Metastases
- Most common primary is melanoma
- Usually small
- Look for other metastases elsewhere, rarely the only site
3) SANT (sclerosing angiomatoid nodular transformation)
- Rare as hens teeth
- Strange looking
4) Gamna-Gandy bodies
- Look for cirrhosis and evidence of portal hypertension
- Blood products in the spleen
- Not important pathologically but explains unusual splenic appearance
5) Cyst
- Common
- Normal cyst characteristics with thin wall and no enhancement
- In children differential diagnosis is epidermoid
6)Hamartoma
7) Lymphoma
- Non-specific focal lesions, look a bit like liver metastases
- Look for other signs, nodes, enlargement
- Quite common
Intussesception causes:
Children - no lead point found, likely hyperplastic lymphoid tissue
gastrointestinal malignancy (most common cause in adults, accounting for 65% )
- colorectal carcinoma (most common)
- metastases, e.g. malignant melanoma, breast cancer, lung cancer
- small bowel lymphoma/Burkitt lymphoma
benign neoplasms
- gastrointestinal stromal tumour (GIST)
- intestinal polyps
- intestinal lipoma
- polypoid haemangioma
- appendiceal mucocele
congenital
- Meckel diverticulum: think in distal small bowel!
- duplication cyst
- ectopic pancreas
- inflammatory
- periappendicitis
trauma
- mural haematoma
Nodular liver contour:
Cirrhosis Treated breast metastases Bud Chiari syndrome schistosoma infection Confluent hepatic fibrosis.
Oesphageal pseudodiverticula:
Reflux oesphagitis - assess for hiatal hernia.
Candida - longitudinal plaques.
Superficial spreading carcinoma
Drug induced oesphagitis
Gastric fold thickening:
Gastritis Gastric carcinoma Lymphoma Metastatic disease menetrier disease
Ceacal pole mass:
appendicitis / appendiceal abscess
Ceacal / appendiceal carcinoma
Mucocele of appendix.
Lymphoma.
Colonic wall thickening:
infectious colitis
Inflammatory bowel disease
Colon carcinoma
Ischaemic colitis
Swallow: high stricture with associated hiatal hernia. Reticular mucosal pattern.
Barretts Oesphagus
Swallow: transient fine transverse folds mid-lower oesphagus.
Feline oesphagus.
Ribbon Bowel
Graft v Host
hide bound bowel:
scleroderma
Moulage sign / tube of wax:
Dilated jejunal loop with complete loss of jejunal folds = celiac
Fold reversal:
Celiac
Thread like defect in barium column in small bowel
Ascaris Suum
Clover leaf sign:
Healed peptic ulcer of duodenal bulb
Lemmel syndrome
Lemmel syndrome is defined as obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intrapancreatic common bile duct with resultant bile duct dilatation.
Low density nodes DDx:
Cystic / necrotic:
- metastatic carcinome / lymphoma.
- Infectious: TB or fungal
- Celiac disease.
Fat containing nodes:
- Whipple disease
- Extra adrenal myelolipoma.
