GI imaging

Question 1

What is Murphy’s sign?

Answer 1

a test for gallbladder disease in which the patient is asked to inhale while the examiner’s fingers are hooked under the liver border at the bottom of the rib cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed.

Question 2

What is your first line investigation for RUQ pain suspected liver/gallbladder disease?

Answer 2

USS

Question 3

What would you see on US with Gallstones?

Answer 3

Liver, fluid filled gallbladder and nodules .

Posterior shadow showing radio waves cannot pass through stones.

Question 4

Can you get cholectystitis without gallstones?

Answer 4

Yes- Acalculi cholecystitis.

Often blood born

Question 5

If the pain form cholecystitis exacerbated by eating?

Answer 5

Yes because that causes the gall bladder to contract

Question 6

Can you identify a dilated bile duct on USS?

Answer 6

Yes

Question 7

If you see a dilated bile duct on USS what is your next investigation?

Answer 7

MRCP to clarify where the stone is and then follow up with therapeutic ERCP.

Question 8

If there is a stone in the gallbladder what is the treatment?

Answer 8

Remove it with ERCP urgently. Let the inflammation reduce and then you can do a prophylactic elective lap cholycystectomy to remove the gallbladder later.

Question 9

If you have cholecystititis without a dilated CBD what is the treatment?

Answer 9

IV antibiotics and then remove the gallbladder

Question 10

What imaging is used for the diagnosis of pancreatitis?

Answer 10

Nothing. Its a clinical diagnosis- amylase.

Question 11

When would you use imaging in pancreatitis and what would you chose?

Answer 11

Determine the cause: USS scan to look for gall stones.
Or to look for complications of necrosis, abscesses, pseudocystsor vascular.Use a CT scan. Performed 1 weeks following symptom onset if no improvement or worsening

Question 12

What are the signs of perforation of the bowel?

Answer 12

Localised or generalised puritanism (ridgid abdomen)

Guarding if its a small walled off perforation.

Question 13

If you suspect perforation, what is your first line investigation?

Answer 13

Erect CXR to look for air under the diaphragm

Question 14

If you see air under the diaphragm on a CXR what is your next imaging step?

Answer 14

CT scan to look for where the perforation (see air and fluid) is before sending for surgery.

Question 15

When would you use an USS scan if you suspect appendicitis?

Answer 15

Children
Pregnancy women
Thin people

Question 16

What may you see on USS in apendicitis?

Answer 16

If you’re lucky you may see distended appendix with inflamed walled and fluid filled. Calcified appendicolith
Otherwise you may see surrounding features like, fluid in abdoment, inflamed lymph nodes.

Question 17

What is the clinical presentation of diverticulitis?

Answer 17

LIF pain

Diarrhoea +/- blood PR

Question 18

What investigations would you consider in diverticulitis and when?

Answer 18

Sigmoidoscopy to check for diverticulosis initially.

CT only if you suspect complicated diverticulitis with abcess/rupture/fistula/haemorrhage

Question 19

What does abnormal fat on CT suggest?

Answer 19

Surrounding inflammation

Question 20

What are other common causes of abdominal pain?

Answer 20

Renal calculi
AAA
Gynae causes

Question 21

What is the first line investigation if you suspect bowel obstruction?

Answer 21

AXR Supine- this will only help if the dilation is gas rater then fluid filled.

Question 22

How can you tell the difference between large and small bowel on AXR?

Answer 22

Large bowel- bigger- lines do not go all across

Small bowel- more central and lines go all across

Question 23

What are the AXR findings of ileus?

Answer 23

Dilated small, large bowel and rectum with no visible obstruction.

Question 24

You see dilated bowel on a AXR what is you next investigation and why?

Answer 24

CT to determine the cause- looking for transition area or a hernia in the inguinal region.
Also see air/fluid levels

Question 25

What is the first line investigation in ascites or if fluid is suspected?

Answer 25

UUS- fluid will show black

Question 26

You have a patient with haematemitis and you cannot see the source of bleeding on OGD what next?

Answer 26

CT with IV contrast (not oral if vomiting) Triple phase scan- precontrast, arterial and venous phase. +/- angiography with intervention to stop the bleeding. (same protocol for lower GI bleed)

Question 27

You have a patient with an upper GI bleed but you have failed twice to stem the bleeding with an endoscope, what next?

Answer 27

Interventional radiology | same protocol for lower GI bleed

Question 28

OJD is initial investigation for dysphagia. What further investigations are possible to assess functionality of swallow in addition to anatomical pathological features of oesophagus?

Answer 28

Fluoroscopic studies. Either barium or water soluble (if there is any risk of aspiration) contrast swallowed. Helps to view abnormal peristalsis.

Question 29

WHat can be done for a patient who is unfit for colonoscopy or the obstruction in the colon will not allow the passage of a scope, to visulalise the bowel?

Answer 29

``` Ct virtual colonography Barium enema (rare) (can miss 1 in 5 cancers) ```

Question 30

What are the disadvantages for CT colonography?

Answer 30

Less available, more expensive, higher radiation dose, cannot biopsy

Question 31

If you suspect IBD this is usually investigated by endoscopy as biopsies are required. What investigation can be used to visualise most of the small bowel which cannot be veiwed on endoscopy?

Answer 31

Fluoroscopic contrast studies. Can see stricturing, wall thickening and fistulation.

Question 32

When is MRI used in IBD?

Answer 32

Known cases of chron's

Question 33

How can you tell if IBD is currently active in the small bowel?

Answer 33

No endoscope can get there. Use a nuclear 'Radio-labelled white cell scan' this will show where the WBCs are going. Normally nothing should be seen in the bowel but the liver and spleen should show up. In active IBD the bowel will show up

Question 34

What is the first line investigation in jaundice?

Answer 34

USS- help to determine post hepatic or hepatic cause

Question 35

What does irregular contours on USS in the liver suggest?

Answer 35

Cirrhosis

Question 36

If the liver is bright on USS what does this suggest?

Answer 36

NAFLD

Question 37

What can a liver USS show?

Answer 37

Dilated bile duct (intra or post hepatic) Look at portal triad Cirrosis Metastasis

Question 38

If you suspect post hepatic jaundice after bloods and USS, what is your next investigation?

Answer 38

MRCP +/-ERCP

Question 39

If you identify target metastasis on USS of liver, what is the next investigation?

Answer 39

CT scan to find the primary cancer- likely in the abdomen

Question 40

If you see cirrhosis and little ascities on the liver USS, what is you next investigation?

Answer 40

History dependant. Do blood tests (Alcohol, Iron, Copper) and virology (hep B) and immunology (AMA (PBC) or ANCA (PSC)) May require liver biopsy (US guided)