GIT 3 Flashcards
Gardner syndrome
- hyperplastic stomach polyps - adenomatous bowel polyps - desmoid tumors - osteomas - papillary thyroid cancer
Turcot syndrome
- hyper plastic stomach polyps - adenomatous bowel polyps - gliomas and medulloblastomas
Peutz Jegher’s syndrome
- small and large bowel cancer - pancreatic cancer - GYN cancer - sertoli cell tumors - mucocutaneous pigmentation
Cowden
- breast cancer - thyroid cancer - lhermitte-duclos
Carney’s traid
- extra-adrenal pheochromocytoma - GIST - pulmonary chondroma
Bilroth 1 - complications?
pylorus removed, proximal stomach is sewed to the duodenum - less post -op gastritis compared to bilroth 2 - more early post-op complications
billroth 2 - complications?
- partial gastrectomy, and stomach is attached to jejunum - dumping syndrome - afferent loop syndrome - increased risk of gastric cancer 10-20 years after surgery
Celiac sprue associations
- iron deficiency anemia - idiopathic pulmonary hemosiderosis (Lane Hamilton syndrome) - dermatitis herpetiformis - increased risk of bowel lymphoma - fold reversal - Moulage sign - dilated bowel with effaced folds - cavitary lymph nodes (low density) - splenic atrophy
Grynfeltt-Lesshaft
- hernia through superior lumbar triangle
Petit hernia
hernia through inferior lumbar triangle
3 sites for internal hernia after Roux-en Y gastric bypass
- defect in transverse mesocolon, through which the Roux limb passes (if done in retrocolic position) - mesenteric defect at enteroenterostomy - behind roux limb mesentery placed in a retrocolic or antecolic position - Petersen type hernia
Paraduodenal hernia
most common type of internal hernia;
- 75% on the left (This case)
- occurs at duodenojejunal junction (Foss of Landzert)
- sac contains IMV and left colic artery
- right sided occur just below transverse segment of duodenum
- Fossa of Waldeyer and behind the SMA
Case courtesy of Dr Ryan Logan Webb, Radiopaedia.org, rID: 52006
Case Discussion
Abnormal location of small bowel loops within the left hemi-abdomen, lying in the left anterior pararenal space. The ectopic small bowel is contained within a hernia sac, which is outlined by ascites. Associated stretching and distortion of mesenteric vessels. Findings are consistent with left paraduodenal hernia.
Additionally, some of the small bowel loops demonstrate severe wall thickening and abnormal enhancement pattern consistent with ischaemia in the setting of elevated lactate.
At surgery, abnormal location of bowel was noted with the additional finding of twisting of the mesentery resulting in venous occlusion and bowel ischaemia. After devolvulizing, the bowel was deemed viable and no bowel was resected. Additionally, congenital bands were seen near the ligament of Treitz, which were lysed. Postoperative course was uncomplicated.
DDx Diverticular disease
Esophagus
6 ddx
2 mimicks
- Pharyngocele:
- usually lateral in hypopharynx
- Zenker diverticulum:
- pulsion diverticulum
- Traction diverticula
- all layers involved.
- pulling usually by adhesions to mediastinal structures because of malignancy to TB
- Typically at level of bifurcation
- Pulsion
- all layers, secondary to increased intraluminal pressure
- Pseudodiverticula
- small outpouchings caused by dilated mucus glands
- a/w diabetes, alcoholism, candidiasis, obstruction, cancer
- Epiphrenic diverticulum
- Mimicks
- paraesophageal hernia
- oesophageal perforation with contrast extravasation
DDx Luminal Narrowing Esophagus
- Webs
- 2
- rings
- 2
- stricture
- 5
- Extrinsic compression
- 3
- Webs
- Idiopathic
- Plummer-vinson syndrome
- Rings
- Congenital: Vascular or muscular rings
- Schatzki ring
- Stricture
- Skin lesions
- epideermolysis
- pemphigoid
- Proximal 1/3 of oesophagus
- tumour
- oesophagitis
- lye
- barrett
- infection
- radiation
- oesosinophilic
- Intubation
- Achalasia, scleroderma, chagas disease
- Skin lesions
- extrinsic compression
- vascular aortic arch
- arch anomalies
- aneurysm
- left atrium
- left bronchus
- mediastinal tumours
- vascular aortic arch
DDx Megaeosophagus
6 ddx’s
- Achalasia
- Scleroderma
- dilatation 2ndary to distal narrowing
- tumour
- stricture
- Chagas disease
- diabetic or alcoholic neuropahty
- Bulbar palsy
Ddx oesophageal tears
6
- Esophagitis
- Tumour
- Vomiting
- Mallory-Weiss syndrome: only mucosa is disrupted. Longitudinal superficial tear. rarely visualised
- Boerhaave syndrome: the entire wall is ruptured. Pneumomediastinum, extravasation of contrast
- Tracheoesophageal fistulas (paediatrics)
- Bronchopulmonary foregut malformations with communication to esophagus
- bronchogenic cysts
- extra lobar sequestration
- Endoscopy.
DDx Of oesophageal filling defects/mass lesions
- Neoplasm
- Extrinsic lesions
- Submucosal masses
- Neoplasm
- benign
- leiomyoma - 50%
- pedunculated fibrovascular polyp (esp. upper oesophagus) 25%
- Cysts, papilloma, fibroma, hemangioma
- Malignant
- SCC - 95%
- Adenocarcinoma - 5%
- Carcinosarcoma
- Lymphoma
- Metastases
- FB
- Varices
- benign
- Uphill varices
- portal hypertension, predominantly inferior location
- Downhill varices
- SVC obstruction, predominantly superior location
- Extrinsic lesions
- LNs
- Engorged vessels
- aneurysms
- cysts
- Submucosal masses
- GIST
- Fibroma, neurofibroma, lipoma, hemangioma
- Duplication cyst
- Lymphoma
DDx thickened Oeophageal folds
3
- Early form of oesophagitis
- Neoplasm
- lymphoma
- Varicoid carcinoma
- Varices
DDx Air Fluid Level
3
- Hiatal hernia
- Oesophageal diverticulum
- Any oesophageal lesions caused by a motility disorder or a stricture
- cancer
- achalasia
- scleroderma
DDx Gastritis
7
- Erosive
- Granulomatous
- Eosinophilic
- Hypertrophic
- Recurrent Gastric ulcer
- Misc
- Rare
- Errosive
- Corrosives
- alcohol
- stress
- drugs
- granulomatous
- Crohns
- sarcoid
- suphilis
- TB
- Histoplasmosis
- eosinophilic
- peripheral eosinophilia - 60%
- hypoalbuminemia
- hypogammaglobulinemia
- hyperplastic polyps
- hypertrophic
- menetrier disease
- Zollinger-Ellison syndrome
- Idiopathic
- recurrent ulcer
- Zollinger-ellison syndrome
- PUD
- Retained tastric antrum
- Drugs
- misc
- radiation
- ulcer
- corrosives
- rare
- Pseudolymphoma
- Suture line ulceration
- Intraarterieal chemotherapy
DDx Target/Bull’s eye lesions
- Ulcer surrounded by a radiolucent halo. Multiple
- Gastritis (aphthoid type, tiny ulcer)
- erosive
- NSAID, Alcohol
- Granulomatous
- Crohn’s Disease
- Infectious
- Candidiasis
- herpes
- syphilis
- CMV
- erosive
- Submucosal Metastasis (Large ulcer)
- melanoma
- kaposi sarcoma
- Lymphoma
- Solitary, giant bull’s eye (very large ulcer)
- Leiomyoma
- sarcoma
- Gastritis (aphthoid type, tiny ulcer)
Ddx Stomach Filling Defect/mass lesion
4
- Mobile filling defects
- bezoar
- phytobezoar
- trichobezoar
- phytotrichobezoar
- bezoar
- Fixed filling defects
- Neoplasm
- adenocarcinoma
- lymphoma
- leiomyosarcoma
- metastases
- kaposi sarcoma
- Other
- endometriosis
- carcinoid
- benign tumours
- Leiomyoma > lipoma, fibroma, schwannoma
- Polyps
- Varices
- Extramedullary hematopoiesis
- Ectopic pancreas
- Extrinsic compression
- Spleen
- Pancreas
- Liver
- Neoplasm
DDx Stomach submucosal lesions
4
- GIST
- Lipoma
- ectopic pancreas
- Lymphoma
DDx Stomach Giant rugal Folds
6
- Tumour
- Lymphoma
- Inflammation
- Menetrier disease
- ZES
- Gastritis a/w pancreatitis
- Bile Reflux Gastritis
- Eosinophilic Gastroenteritis
DDx of this appearance
- Ddx Stomach
Linitis Plastica
4 categories
11 ddx
AKA - Leather bottle stomach
* Marked thickening and irregularity of the gastric wall (diffuse infiltration)
* Rigidity, narrowing and nondistensibility
* peristalsis does not pass through linitis * DDx
* Tumour
* Inflammation
* Infiltrative disease
* Infection * DDx
* Tumour
* Scirrhous cancer (most common cause)
* Lymphoma
* Metastases (most commonly breast cancer)
* Pancreatic carcinoma
* Inflammation
* Erosive gastritis
* Radiation therapy
* Infiltrative disease
* Sarcoid
* Amyloid - rare
* Intramural gastric hematoma (rare)
* Infection
* TB
* Syphylis
https://radiopaedia.org/cases/linitis-plastica-2
DDx stomach Antral Lesions
3 categories
10 ddx
- Tumour
- Inflammatory
- Other
- Tumour
- Andromcarcinoma
- mets
- lymphoma
- Inflammatory
- Crohn’s disease
- PUD
- TB
- Sarcoid
- Other
- Hypertrophic pyloric stenosis
- Pulorospasm
- Antral web
DDx Stomach Ram’s Horn Antrum
8
- Blunting of antral fornices with progressive tapering from antrum to pylorus
- DDX
- Chronic PUD
- Scirrhous carcinoma
- Granulomatous Disease
- Crohn’s disease
- TB
- Sarcoid
- Eosinophilic gastroenteritis
- Caustic ingestion
- DDX
DDx stomach Intraperitoneal Air
6
- Surgery and laparoscopy and other radiologic interventions (most common cause
- Perforated gastric or duodenal ulcer (second most common cause)
- Cecal perforation from colonic obstruction
- pneumatosis coli
- air through genital trach in females
- perforated distal bowel (usually a/w abscess and lesser amounts of free air
- IBD
- Diverticulitis
- Tumour
DDx Duodenum Filling defects
- Neoplastic
- benign
- Malignant
- Other
- Bulb
- Distal
- Neoplastic
- benign
- often in first portion, asymptomatic
- adenoma (usually <1cm)
- Leiomyoma
- Carcinoid
- Villous Adenoma
- Near Papilla, high malignant potential
- often in first portion, asymptomatic
- Malignant
- Often distal to first portion, symptomatic
- adenocarcinoma at or distal to papilla - 90% of malignant tumors
- Metastases
- Direct invasion from stomach, pancreas, colon, kidney, or hematogenous such as melanoma
- Lymphoma
- Often distal to first portion, symptomatic
- benign
- Other
- Bulb
- ectopic gastric mucosa
- prolapsed antral mucosa
- Brunner gland hyperplasia
- varices
- Distal
- Benign lymphoid hyperplasia
- ectopic pancreas
- Annular pancreas
- papilla of vater
- tumour
- edema with impacted or passed gallstone
- choledochocele
- duplication cyst
- intraluminal diverticulum
- Bulb
Malignancy of duodenal lesions depending on location
- Duodenal Bulb
- 90% are benign
- 2nd and 3rd portions
- 50% are malignant
- 4th portion
- 90% are malignant
ddx Duodenal luminal outpouchings
- Ulcer
- ulcer with contained perforation
- malignant ulcer (rarely primary)
- Diverticulum
- pseudodiverticulum: ulcer scarring
- Choledochoduodenal or cholecytoduodenal fistula
- True diverticulum
- medial
- 2nd part duodenum
Ddx duodenal Post bulbar narrowing
- Neoplastic
- adenocarcinoma
- lymphoma
- metastases
- direct invasion from colon, kidney, pancreas, GB
- GIST
- Inflammatory
- Intrinsic
- post bulbar ulcer
- duodenitis
- crohn’s disease
- extrinsic
- pancreatitis
- annular pancreas
- intramural diverticulum
- duodenal duplication cyst
- duodenal hematoma
- aortic aneurysm (3rd portion)
- SMA Syndrome
- Supine position causes partial obstruction of the 3rd portion of the duodenum by SMA
- may be exacerbatedby weight loss
- Intrinsic
DDx duodenal Fold thickening
9
- H. Pylori
- Crohn’s
- Giardiasis
- Sprue
- Whipple disease
- Brunner gland hyperplasia
- Lymphoma
- Hematoma/trauma
- Pancreatitis
DDx duodenal Papillary enlargement
9
- Normal variant
- choledochocele
- papillary edema
- pancreatitis
- acute duodenal ulcer
- impacted stone
- Ampullary tumour
- adenomatous polyp
- carcinoma
Findings of Small Bowel Obstruction
- Disproportionate distribution of gas is the key finding
- much more gas and fluid in SB compared with colon
- much more gas in proximal; SB compared with distal SB
- Fluid retention parallels gas distribution:
- no fluid no obstruction
- Closed-loop obstruction
- lumen occluded at two adjacent sites
- obstructed loops distend with fluid
- loop may twist
- the bowel may or may not be infarcted
- Additional examinations in presumed acute SBO include
- if very dilated or abundant fluid
- CT - the fluid acts as an intrinsic contrast material
- if mild dilatation
- CT with oral contrast or SBFT
- Enteroclysis:
- need to decompress bowel before the study, best applied to nonacute situations
- if very dilated or abundant fluid
Colonic Obstruction
Key radiographic finding
- cecal dilation is the key radiographic Finding
- cecum is invariably most dilated in colonic obstruction. however it may also be very dilated in paralytic ileus
- If the transverse colon is more dilated than the caecum, there is rarely an obstruction
- exception: concomitant disease that intrinsically narrows the cecum (IBD)
- Fluid retentiaion not necessarily seen in colonic obstruciton
- A useful initial screening procedure to rule out distal colonic obstruction is a prone KUB. IF there is no obstruction, gas passes to the rectum.
- BE is the definitive study.
- Do not perform UGI series in a patient with possible colonic obstruction (contraindicated bc barium impacts in the colon.
DDx Paralytic Adynamic Ileus
- post operative - Most common
- Vascular
- IBD
- Inflammatory
- often localised ileus -> sentinel loop
- pancreatitis
- appendicitis
- cholecystitis
- Diverticulitis
- peritonitis
- Metabolic
- hypokalemia
- hypocalcemia
- Hypomagnesemia
- medication
- morphine
- diphnoxylate (lomotil)
- often localised ileus -> sentinel loop
DDX Mechanical SBO
- Adhesions
- hernias
- tumours
- gallstones
- inflammation with strictures
- Gallstone ileus:
- pneumobilia
- SBO
- Stone within bowel lumen (may obstruct ileocecal valve)
Signs of Malabsorption Patterns
- Signs
- dilution of barium (hypersecretion_
- Flocculation of barium
- moulage
- segmentation of barium column
- delay in transit
DDx of Malabsorption Patterns with Predominantly Thick/irregular folds
- MNEMONIC: WAG CLEM
- Whipple disease
- Amyloid
- Giardiasis (largely affects jejunum) GVH retraction, gammaglobulinopathy
- Cryptosporidiosis (largely affects jejunum)
- Lymphoma, lymphangiectasis, lactase deficiency
- Eosinophilic gastroenteritis
- Mycobacterium Avium complex, Mastocytosis
DDx of Malabsorption patterns with predominantly thick/Straight folds
- Ischaemia
- Intramural hemorrhage
- Radiation
- Hypoproteinema
- Venous congestion
- Cirrhosis
Pattern Approach for Diseases of Mesenteric Small Bowel on Barium Studies1
https://geiselmed.dartmouth.edu/radiology/wp-content/uploads/sites/47/2019/04/small_bowel.pdf
DDx of this sign
7
- TARGET SIGN
- Ischaemia
- vasculitis
- hemorrhage
- IBD
- Angioedema
- ACE inhibitors
- Hereditary
- Allergic reaction
- Portal Hypertension
- NSAIDS
VERY GOOD ARTICLE:
https://radiologyassistant.nl/abdomen/bowel/bowel-wall-thickening-ct-pattern
VERY GOOD ARTICLE: https://radiologyassistant.nl/abdomen/bowel/bowel-wall-thickening-ct-pattern
DDx Gracile SB
- Tubular, “Toothpaste” appearance on SB Series
- GVH disease
- Cryptosporidium
https://link.springer.com/article/10.1007/s00247-010-1853-x/figures/1
Intestinal graft-versus-host disease
Sabah Servaes
Pediatric Radiology volume 40, page101 (2010)Cite this article
557 Accesses
Metricsdetails
A 17-month-old boy with acute lymphoblastic leukemia status 61 days post cord blood transplant presented with vomiting, diarrhea and feeding intolerance. Fluoroscopic examination with barium demonstrates diffuse narrowing of the small bowel lumen referred to as toothpaste- or ribbon-like (Fig. 1) and consistent with graft-versus-host disease (GVHD). Despite improvement of intestinal GVHD with immunosuppressive therapy, the boy developed respiratory failure and infection and died 4 months later.
Ddx of Ileocecal Deformities/Coned caecum
- Inflammation (coned cecum)
- Typhlitis: Inflammatory changes of cecum and/or ascending colon in neutropenic (immunosuppressed, leukemia, lymohioma) patients. Caued by infection, bleeding, ischaema.
- TB: narrow cecum (fleischner sign), narrow crohn may produce same appearance, terminal ileum (stierlin sign)
- Amebiasis (predominantly effects the cecum, not terminal ileum)
- UC: valve is wide open (gaping), labia are atrophied, terminal ileum is dilated
- Crohn’s disease (apthous ulcers-> linear fissues -> nodules -> cobblestone -> stricture, spasm (string sign), fistua).
- Tumour
- Lymphoma
- adenocarcinoma
- Carcinoid of the ileum (desmoplastic response) or appendix
- Intussusception
DDx of Liver nodules in cirrhosis
- Regenerative:
- benign
- proliferation of hepatocytes
- Precursor to dysplastic nodule and HCC
- Regenerative nodules with hemosiderine are termed siderotic nodules
- They are isointense on CT, Hyperdense on NCT and hypointense on T1 and T2.
- Dysplastic nodule
- pre-malignant
- hyperintense on T1 and hypointense on T2
- When malignancies develop they often appear as a nodule within a nodule, where the inner nodule has a characteristic appearance
- T1 hypo
- T2 hyper
- Arterial enhancement
- HCC
DDx of Cystic Pancreatic lesions
- Unilocular
- simple cyst
- Pseudocyst post pancreatitis
- muliple unilocular
- VHL
- CF
- ADPKD
- Microcystic lesions
- serous cystadenoma
- Macrocystic lesions
- mucinous cystadenoma
- Mural nodules
- pancreatic adenocarcinoma
DDx of Fatty replacement of the pancreas
- CF
- Aging
- DM
- Obesity
- Steroids
- Shwachman-Diamond Syndrome (picture)
