GI imaging Flashcards
What is Murphy’s sign?
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.
What is your first line investigation for RUQ pain suspected liver/gallbladder disease?
USS
What would you see on US with Gallstones?
Liver, fluid filled gallbladder and nodules .
Posterior shadow showing radio waves cannot pass through stones.
Can you get cholectystitis without gallstones?
Yes- Acalculi cholecystitis.
Often blood born
If the pain form cholecystitis exacerbated by eating?
Yes because that causes the gall bladder to contract
Can you identify a dilated bile duct on USS?
Yes
If you see a dilated bile duct on USS what is your next investigation?
MRCP to clarify where the stone is and then follow up with therapeutic ERCP.
If there is a stone in the gallbladder what is the treatment?
Remove it with ERCP urgently. Let the inflammation reduce and then you can do a prophylactic elective lap cholycystectomy to remove the gallbladder later.
If you have cholecystititis without a dilated CBD what is the treatment?
IV antibiotics and then remove the gallbladder
What imaging is used for the diagnosis of pancreatitis?
Nothing. Its a clinical diagnosis- amylase.
When would you use imaging in pancreatitis and what would you chose?
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
What are the signs of perforation of the bowel?
Localised or generalised puritanism (ridgid abdomen)
Guarding if its a small walled off perforation.
If you suspect perforation, what is your first line investigation?
Erect CXR to look for air under the diaphragm
If you see air under the diaphragm on a CXR what is your next imaging step?
CT scan to look for where the perforation (see air and fluid) is before sending for surgery.
When would you use an USS scan if you suspect appendicitis?
Children
Pregnancy women
Thin people
What may you see on USS in apendicitis?
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.
What is the clinical presentation of diverticulitis?
LIF pain
Diarrhoea +/- blood PR
What investigations would you consider in diverticulitis and when?
Sigmoidoscopy to check for diverticulosis initially.
CT only if you suspect complicated diverticulitis with abcess/rupture/fistula/haemorrhage
What does abnormal fat on CT suggest?
Surrounding inflammation
What are other common causes of abdominal pain?
Renal calculi
AAA
Gynae causes
What is the first line investigation if you suspect bowel obstruction?
AXR Supine- this will only help if the dilation is gas rater then fluid filled.
How can you tell the difference between large and small bowel on AXR?
Large bowel- bigger- lines do not go all across
Small bowel- more central and lines go all across
What are the AXR findings of ileus?
Dilated small, large bowel and rectum with no visible obstruction.
You see dilated bowel on a AXR what is you next investigation and why?
CT to determine the cause- looking for transition area or a hernia in the inguinal region.
Also see air/fluid levels
What is the first line investigation in ascites or if fluid is suspected?
UUS- fluid will show black
You have a patient with haematemitis and you cannot see the source of bleeding on OGD what next?
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)
You have a patient with an upper GI bleed but you have failed twice to stem the bleeding with an endoscope, what next?
Interventional radiology
same protocol for lower GI bleed
OJD is initial investigation for dysphagia. What further investigations are possible to assess functionality of swallow in addition to anatomical pathological features of oesophagus?
Fluoroscopic studies.
Either barium or water soluble (if there is any risk of aspiration) contrast swallowed.
Helps to view abnormal peristalsis.
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?
Ct virtual colonography Barium enema (rare) (can miss 1 in 5 cancers)
What are the disadvantages for CT colonography?
Less available, more expensive, higher radiation dose, cannot biopsy
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?
Fluoroscopic contrast studies. Can see stricturing, wall thickening and fistulation.
When is MRI used in IBD?
Known cases of chron’s
How can you tell if IBD is currently active in the small bowel?
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
What is the first line investigation in jaundice?
USS- help to determine post hepatic or hepatic cause
What does irregular contours on USS in the liver suggest?
Cirrhosis
If the liver is bright on USS what does this suggest?
NAFLD
What can a liver USS show?
Dilated bile duct (intra or post hepatic)
Look at portal triad
Cirrosis
Metastasis
If you suspect post hepatic jaundice after bloods and USS, what is your next investigation?
MRCP +/-ERCP
If you identify target metastasis on USS of liver, what is the next investigation?
CT scan to find the primary cancer- likely in the abdomen
If you see cirrhosis and little ascities on the liver USS, what is you next investigation?
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)
