GIT Flashcards
GIT
A 40-year-old man on the third cycle of chemotherapy for non-Hodgkin’s lymphoma presents with dysphagia and odynophagia. A recent blood count revealed neutropenia. He is referred for a barium swallow, which shows several linear ulcers with ‘shaggy borders’ in the upper oesophagus. What is the most likely diagnosis?
A. Candida oesophagitis
B. CMV oesophagitis
C. Post-radiotherapy stricture
D. TB oesophagitis
E. Pharyngeal pouch
A. Candida oesophagitis
Candida oesophagitis occurs in patients whose normal flora is altered by broad spectrum antibiotic therapy and in patients whose immune systems are suppressed by malignancy, immunosuppressive agents like chemotherapy and radiotherapy, and immunodeficiency states such as AIDS. When the disease is superficial, the oesophageal mucosa may appear norma lradiographically.
Early in the course of Candida oesophagitis, mucosal plaques are the most frequent finding. Later erosions and ulcerations may develop, which together with intramural haemorrhage and necrosis result in the ‘shaggy’ margin seen on esophagograms.
GIT
A 65-year-old diabetic with a history of alcohol excess is referred for a barium swallow following a history of dysphagia. The study shows several small, thin, flask-shaped structures along the cervical oesophagus oriented parallel to the long axis of the oesophagus. What is the most likely diagnosis?
A. Feline oesophagus
B. Pseudo-diverticulosis
C. Glycogenic acanthosis
D. Traction diverticulum
E. Idiopathic eosinophilic oesophagitis
B. Pseudo-diverticulosis
Oesophageal intramural pseudo-diverticulosis is a condition of unknown cause characterized by flask-shaped outpouchings of the mucosa that extend into the muscular layer and show characteristic findings on oesophagograms. They are dilated excretory ducts of deep oesophageal mucous glands resulting from obstruction of excretory ducts by plugs of viscous mucus and desquamated cells or by extrinsic compression of the ducts by periductal inflammatory infiltrates and fibrotic tissue. It occurs in all age groups predominantly in the sixth and seventh decades with slight male preponderance. It has been reported as a separate entity or in association with diseases such as diabetes, peptic strictures and oesophagitis.
GIT
A 50-year-old secretary presents with epigastric pain, nausea and weight loss. She also complains of bilateral swollen ankles. She is referred for a barium meal as she is unable to tolerate an oesophago-gastroduodenoscopy (OGD). The examination shows thickened folds in the fundus and body of the stomach; the antrum was not involved. What is the most likely diagnosis?
A. Nephrotic syndrome
B. Lymphoma
C. Eosinophilic gastroenteritis
D. Leiomyoma
E. Ménétrier’s disease
E. Ménétrier’s disease
The hallmark of Ménétrier’s disease is gastric mucosal hypertrophy, which may cause the rugae to resemble convolutions of the brain. The thickening of the rugae is predominantly caused by expansion of the epithelial cell compartment of the gastric mucosa. Patients with Ménétrier’s disease most often present with epigastric pain and hypoalbuminemia secondary to a loss of albumin into the gastric lumen. Signs and symptoms of Ménétrier’s disease include anorexia, asthenia, weight loss, nausea, gastrointestinal bleeding, diarrhoea, oedema and vomiting. The disease has a bimodal age distribution. The childhood form is often linked to cytomegalovirus infection and usually resolves spontaneously. It usually occurs in children younger than 10 years (mean age 5.5 years), predominantly in boys (male-to-female ratio 3:1).The second peak occurs in adulthood, and the disease in adults tends to progress over time. The average age at diagnosis is 55, and men are affected more often than women. A diagnosis of Ménétrier’s disease is made by using a combination of upper gastrointestinal fluoroscopic imaging, endoscopic imaging and histologic analysis. On fluoroscopic images, Ménétrier’s disease is characterized by the presence of giant rugal folds. Rugal folds should normally measure less than 1 cm in width across the fundus and 0.5 cm across the antrum, and they should be parallel to the long axis of the stomach.
GIT
A 50-year-old man is referred to a gastroenterologist with a 6-month history of intermittent epigastric pain and nausea. He is referred for a barium meal test due to a failed OGD –oesophago-gastroduodenoscopy-. The study shows an ulcer along the lesser curve of the stomach. Which of the following is a malignant feature of a gastric ulcer?
A. The margin of the ulcer crater extends beyond the projected luminal surface.
B. Carman meniscus sign.
C. Hampton’s line.
D. Central ulcer within mound of oedema.
E. The ulcer depth is greater than the width.
B. Carman meniscus sign
The Carman meniscus sign is a curvilinear lens-shaped intraluminal form of crater with convexity of crescent towards the gastric wall and concavity towards the gastric lumen.
**Gastric ulcer** * Sign *Benign* *Malignant* * Crater Round, ovoid Irregular * Radiating folds Symmetric Nodular, clubbed, fused * Areae gastricae Preserved Destroyed * Projection Outside lumen Inside lumen * Ulcer mound Smooth Rolled edge
GIT
A middle-aged woman presents with cough and hemoptysis. Her chest X-ray reveals a large ovoid mass in the right lower lobe. She has a known history of Osler–Weber–Rendu syndrome. What is the most appropriate next imaging investigation that you will organize?
A. MRA of the pulmonary artery
B. CTPA
C. CTPA with portal phase images covering the liver
D. Chest HRCT
E. Conventional pulmonary angiography
C. CTPA with portal phase images covering the liver
Hereditary hemorrhagic telangiectasia, also called Osler–Weber–Rendu syndrome, is an uncommon genetic disorder characterized by arteriovenous malformations in the skin, mucous membranes and visceral organs. The brain, gastrointestinal tract, skin, lung and nose are the primary sites affected. It is associated with the classic triad of epistaxis, telangiectasias and a family history. Pulmonary AVMs are often discovered initially as a solitary pulmonary nodule or mass on plain chest films. If a pulmonary AVM is suspected, further imaging evaluation should be CT or conventional pulmonary angiography. Although conventional angiography is the gold standard, considering its invasive nature CT is considered a better method of diagnosis. This is more important when screening for AVM.
Portal venous-phase liver images are often obtained at the same time, in case the lesion does turnout to be a solid nodule.
GIT
A nursing home resident is found to have a lung tumour and undergoes CT staging of the chest and abdomen. This reveals a discrete lesion medial to the second part of the duodenum with a fluid-fluid level. What is the most likely diagnosis?
A. Duplication cyst
B. Duodenal diverticulum
C. Duodenal web
D. Annular pancreas
E. Adenocarcinoma of the duodenum
B. Duodenal diverticulum
Duodenal diverticulosis is a common entity first described by Chomel in 1710. Its prevalence varies depending on the mode of diagnosis. Diverticula are found in 6% of upper gastrointestinal series, 9%-23% of ERCP procedures and 22% of autopsies. Its occurrence has no sex predilection, and the age range for detection varies from 26 to 69 years. Duodenal diverticula may be congenital or acquired, with the latter being more common. Congenital or true diverticula are rare, contain all layers of the duodenal wall, and may be subdivided into intraluminal and extraluminal forms.
The CT appearance of a duodenal diverticulum includes a saccular outpouching, which may resemble a mass-like structure interposed between the duodenum and the pancreas that contains air, an air-fluid level, fluid, contrast material, or debris. A periampullary diverticulum may simulate a pseudocyst or tumour.
GIT
A taxi driver has had recurrent episodes of abdominal pain. On CT, a lesion is seen within the head of the pancreas. Pancreatic duct dilatation is noted with a normal CBD and atrophy of the body and tail of the pancreas. ERCP demonstrates thick mucous material discharging from the bulging papilla. What is the most likely diagnosis?
A. Mucinous cystadenocarcinoma
B. Serous cystadenocarcinoma
C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
D. Pancreatic pseudocyst
E. Pancreatic adenocarcinoma
C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
IPMNs are a group of neoplasms in the biliary duct or pancreatic duct that causes cystic dilatation from excessive mucin production and accumulation. The true incidence of IPMNs is unknown because many are small and asymptomatic. However, in a series of 2,832 consecutive CT
scans of adults with no history of pancreatic lesions, 73 cases of pancreatic cysts (2.6%) were identified. Many of these cases likely were IPMNs, given that IPMNs account for 20%-50% of cystic pancreatic neoplasms. There are three main types of pancreatic IPMNs: main duct, branch duct and combined. A main duct IPMN commonly causes dilatation of the papilla, with bulging of the papilla into the duodenal lumen. Filling defects caused by mural nodules or mucin may be seen at MRCP or ERCP. At CT and MRI, filling defects caused by mural nodules enhance, while filling defects caused by mucin do not enhance.
GIT
A neonate presents with non-bilious vomiting with a palpable upper abdominal lump. Which of the following US findings would not be in keeping with pyloric stenosis?
A. Pyloric muscle thickness 3.5 mm
B. Target sign
C. Pyloric canal length 14 mm
D. Antral nipple sign
E. Cervix sign
C. Pyloric canal length of 14 mm
Ultrasound is the modality of choice because of its advantages of directly visualising the pyloric muscle and no ionising radiation. The hypertrophied muscle is hypoechoic, and the central mucosa is hyperechoic. Normal measurements of the pylorus are as follows:
Pyloric muscle thickness (i.e., the diameter of a single muscular wall on a transverse image): <3 mm (most accurate)
Length (i.e., longitudinal measurement): <15-17 mm
Pyloric volume: <1.5 cc
Pyloric transverse diameter: <13 mm
Abnormal features on US includes target sign (hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross section), cervix sign (indentation of muscle mass on fluid-filled antrum on longitudinal section) and antral nipple sign (redundant pyloric channel mucosa protruding into gastric antrum). Other features include increased antral peristalsis and delayed gastric emptying.
Infantile pyloric spasm also shows increased peristalsis and delayed gastric emptying with pyloric muscle thickness between 1.5 and 3 mm.
GIT
A 50-year-old man presents with recurrent episodes of abdominal pain. Blood amylase is normal. Chronic pancreatitis is suspected. All of the following statements regarding MRI imaging in chronic pancreatitis are true, except
A. MRI has a poor sensitivity for detecting parenchymal calcification in chronic pancreatitis.
B. MRI allows evaluation of the ductal system for strictures and stones, debris within pseudocysts and fistula.
C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis from pancreatic carcinoma.
D. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate abnormal post-contrast enhancement on MRI.
E. Both focal chronic pancreatitis and pancreatic carcinoma demonstrate low signal intensity of the pancreas on T1W fat-saturated images.
C. MRI shows good sensitivity for the differential diagnosis of focal chronic pancreatitis
from pancreatic carcinoma.
The diagnosis of chronic pancreatitis on MRI is based on signal intensity and enhancement changes as well as on morphologic abnormalities in the pancreatic parenchyma, pancreatic duct and biliary tract. The imaging features of chronic pancreatitis can be divided into early and late findings. Early findings include low-signal-intensity pancreas on T1 -weighted fat-suppressed images, decreased and delayed enhancement after IV contrast administration, and dilated side branches. Late findings include parenchymal atrophy or enlargement, pseudocysts, and dilatation and beading of the pancreatic duct often with intraductal calcifications.
Differentiating between an inflammatory mass due to chronic pancreatitis and pancreatic carcinoma on the basis of imaging criteria remains difficult. Decreased Tl signal intensity with delayed enhancement after gadolinium administration as well as dilatation and obstruction of the pancreaticobiliary ducts can be seen in both diseases. Irregularity of the pancreatic duct, intraductal or parenchymal calcifications, diffuse pancreatic involvement, and normal or smoothly stenotic pancreatic duct penetrating through the mass (‘duct penetrating sign’) favour the diagnosis of chronic pancreatitis over cancer. In distinction, a smoothly dilated pancreatic duct with an abrupt interruption, dilatation of both biliary’ and pancreatic ducts (‘double-duct sign’) and obliteration of the perivascular fat planes favour the diagnosis of cancer.
GIT
Barium enema of a neonate shows an inverted cone shape at the rectosigmoid colon. There is marked retention of the barium on delayed post-evacuation films after 24 hours.
The cause for this is
A. Meconium ileus
B. Meconium plug syndrome
C. Hirschsprung’s disease
D. Imperforate anus
E. Hyperplastic polyp of colon
C. Hirschsprung’s disease
Hirschsprung’s disease, also called aganglionosis of the colon (absence of parasympathetic ganglia in muscle and submucosal layers secondary to an arrest of craniocaudal migration of neuroblasts), results in relaxation failure of the aganglionic segment. It affects full-term infants during the first weeks of life, mainly boys. It is extremely rare in premature infants. It usually affects the rectosigmoid junction and results in short-segment disease (80%). Long-segment disease (20%) and total colonic aganglionosis (5%) are less common.
Barium enema shows a ‘transition zone’ (aganglionic segment), which appears normal in size with dilatation of large and small bowel proximally with marked retention of barium on delayed films after 24 hours. Normal children show a rectosigmoid ratio of >1, as the rectum is larger in diameter than the sigmoid; in the case of Hirschsprung’s disease, the ratio is reversed (rectosigmoid ratio <1).
GIT
A 40-year old woman presents to her GP with right upper quadrant pain and is referred for an ultrasound of the abdomen. The scan demonstrates a thickened gall bladder wall with several intramural small echogenic foci showing ‘comet tail artefacts’. A few gallstones
are also noted. What is the most common diagnosis?
A. Xanthogranulomatous cholecystitis
B. Strawberry gallbladder
C. Porcelain gallbladder
D. Gallbladder adenomyomatosis
E. Acute cholecystitis
D. Gallbladder adenomyomatosis
Adenomyomatosis is a benign hyperplastic cholecystosis. Tt is a relatively common condition, identified in at least 5% of cholecystectomy specimens. There is no definite racial or sex predilection. Most diagnoses are made in patients in their fifties, but the age range is wide and case reports exist of paediatric adenomyomatosis. Adenomyomatosis is most often an incidental finding, has no intrinsic malignant potential, and usually requires no specific treatment.
It frequently coexists with cholelithiasis, but no causative relationship has been proved. Adenomyomatosis occasionally produces abdominal pain, and in some cases cholecystectomy may be indicated for relief of symptoms. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses, intramural diverticula lined by mucosal epithelium. Gallbladder wall thickening and intramural diverticula containing bile with cholesterol crystals, sludge, or calculi are the radiologic correlates of the distinctive multimodality imaging features of adenomyomatosis.
US is a primary modality for biliary imaging, and adenomyomatosis of the gallbladder is frequently identified at sonography. The non-specific finding of gallbladder wall thickening is well demonstrated with US, as are sludge and calculi, when present. Echogenic intramural foci from which emanate V-shaped comet tail reverberation artefacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses.
GIT
A child presents with vomiting and sudden onset abdominal pain. Plain X-rays show a target sign in the right upper quadrant. US shows a pseudo kidney sign in keeping with intussusception. Which of the following is false regarding hydrostatic reduction?
A. Free intraperitoneal air is a contraindication.
B. A maximum of two attempts can be made.
C. Air is preferred to Gastrografin water solution in some institutions.
D. The perforation rate is 0.4%-3%.
E. Air enema is associated with a higher perforation rate.
B. Maximum of two attempts can be made.
Intussusception is one of the most common causes of acute abdomen in infancy.
Perforation may already have occurred before enema therapy or may occur during the reduction process.
There is no agreement on the number and duration of reduction attempts, the efficacy of premedication or sedation, the use of rectal tubes with inflatable retention balloons, or the use of transabdominal manipulation. The classic ‘rule of threes’ is that the number of reduction attempts is capped at three, lasting 3 min each. This rule has been discarded at some institutions, and some authors use a nearly unlimited number of attempts. Use of sedation, rectal tube with balloons and the Valsalva maneuver are said to improve the reduction rate achieved.
Absolute contraindications to enema therapy are shock not readily corrected with IV hydration and perforation with peritonitis. Criteria that are linked to a lower reduction rate and a higher perforation rate are age less than 3 months or greater than 5 years, long duration of symptoms, especially if greater than 48 hours, passage of blood via the rectum, significant dehydration, small bowel obstruction and visualization of the dissection sign during enema therapy. Air enema produces excellent results but is also associated with maximum perforation rates.
GIT
Plain X-ray of a newborn shows a large tubular air shadow behind the trachea. The lungs are clear. The bowels are grossly distended with air. What is the likely type of tracheo-oesophagcal fistula?
A. Type A
B. Type B
C. Type C
D. Type D
E. Type E
C. Type C
Different types of oesophageal atresia are identified on the basis of the presence (and location) or absence of a tracheo oesophageal fistula.
Type A is pure oesophageal atresia without fistula, and Type B is oesophageal atresia with a fistula between the proximal pouch and the trachea. Type C is oesophageal atresia with a fistula from the trachea or the main bronchus to the distal oesophageal segment. Type D is oesophageal atresia with both proximal and distal fistulas, and Type E is an H-shaped tracheo-oesophageal fistula without atresia. Of these five types, Type C is by far the most common. Oesophageal atresia is generally suspected on the basis of polyhydramnios, inability to swallow saliva or milk, aspiration during early feedings, or failure to successfully pass a catheter into the stomach. Feeding difficulties with choking occur in infants with Type E (fistula without atresia), but the
diagnosis may not be made until several years later when the patient presents with a cough while swallowing, recurrent pneumonia and a distended abdomen.
In Types A and B, there is a complete absence of gas in the stomach and intestinal tract, whereas in Types C and I) the gastrointestinal tract commonly appears distended with air.
GIT
A 70-year-old pensioner has been referred for an abdominal ultrasound as part of a routine medical examination. He is fit and well with no significant past medical history. The scan demonstrates a small focal well-defined hyperechoic area in the right lobe
of the liver showing posterior acoustic enhancement. The most likely differential diagnosis is
A. Metastasis
B. Fatty infiltration
C. Liver cyst
D. FNH (Focal nodular hyperplasia)
E. Capillary haemangioma
E. Capillary haemangioma
The classic haemangioma is an asymptomatic lesion that is discovered at routine examination or autopsy. At US, the typical appearance is a homogeneous, hyperechoic mass with well-defined margins and posterior acoustic enhancement.
The CT findings consist of a hypoattenuating lesion on non-enhanced images. After intravenous administration of contrast material, arterial-phase CT shows early, peripheral, globular enhancement of the lesion. The attenuation of the peripheral nodules is equal to that of the adjacent aorta. Venous-phase CT shows centripetal enhancement that progresses to uniform filling. This enhancement persists on delayed-phase images.
At MRI, haemangiomas are characterised by well-defined margins and high signal intensity on T2-weighted images, which is identical to that of cerebrospinal fluid. Specificity is improved by using serial gadolinium-enhanced gradient-echo imaging. The gadolinium intake is similar to the intake of iodinated contrast material during enhanced CT. With T2-weighted spin-echo and dynamic gadolinium enhanced T1-weighted gradient-echo sequences, the sensitivity and specificity of MRI are 98% and the accuracy is 99%. The imaging features of a haemangioma depend on its size; typical haemangiomas are mostly less than 3 cm in diameter.
GIT
A 40-year-old man undergoes a CT KUB for renal colic, which shows an incidental finding of an 8-mm lesion in Segment VIII of the liver. Further characterisation of this lesion with MRI shows it to be low signal on T1W and high signal on T2W. On the dynamic phase, it shows peripheral nodular enhancement with centripetal filling.
What is the most likely diagnosis?
A. FNH
B. Adenoma
C. Haemangioma
D. Early appearance of Hepatocellular Carcinoma (HCC)
E. Cholangiocarcinoma
C. Haemangioma
The classic haemangioma is an asymptomatic lesion that is discovered at routine examination or autopsy. At US, the typical appearance is a homogeneous, hyperechoic mass with well-defined margins and posterior acoustic enhancement.
The CT findings consist of a hypoattenuating lesion on non-enhanced images. After intravenous administration of contrast material, arterial-phase CT shows early, peripheral, globular enhancement of the lesion. The attenuation of the peripheral nodules is equal to that of the adjacent aorta. Venous-phase CT shows centripetal enhancement that progresses to uniform filling. This enhancement persists on delayed-phase images.
At MRI, haemangioma are characterised by well-defined margins and high signal intensity on T2-weighted images, which is identical to that of cerebrospinal fluid. Specificity is improved by using serial gadolinium-enhanced gradient-echo imaging (6). The gadolinium intake is similar to the intake of iodinated contrast material during enhanced CT. With T2-weighted spin-echo and dynamic gadolinium-enhanced T1-weighted gradient-echo sequences, the sensitivity and specificity of MRI are 98% and the accuracy is 99%. The imaging features of a haemangioma depend on its size; typical haemangiomas are mostly less than 3 cm in diameter.
