Lecture 9: Radiology of the Upper GI Tract

Question 1

What is GERD?

Answer 1

Gastroesophageal reflux disease

Question 2

What is the pathogenesis of GERD?

Answer 2

1. Decreased LES tone
2. abnormal LES relaxations
3. abnormal motility due to scleroderma
4. Increased acidity of refluxate (ZES increases acid production) or Billroth II (bile)
5. resistance of mucosa that decreases with age and debilitation

Question 3

What are the clinical findings of GERD?

Answer 3

1. heartburn and regurg
2. epigastric and RUQ pain
3. Upper GI bleeding
4. Dysphagia

Question 4

What are the infectious causes of esophagitis?

Answer 4

1. Candida
2. Herpes
3. CMV
4. HIV
5. drug-induced

Question 5

What are the characteristics of candida caused esophagitis?

Answer 5

Most common
Manifested in barium studies by presence of plaques (also shaggy esophagus if AIDS patients have candida)
Dysphagia or odynophagia
Thrush in 50% of patients so thrush is NOT pathognomonic

Question 6

What are the characteristics of herpes esophagitis?

Answer 6

2nd most common infection
Dysphagia or odynophagia
Radiologically, no plaques but a shitload of discrete SMALL ulcers

Question 7

What is punctate?

Answer 7

Means tiny

Question 8

What are the characteristics of CMV esophagitis?

Answer 8

Associated with AIDS patients

Radiologically, have HUGE fucking ulcers

Question 9

What are the characteristics of HIV espophagitis?

Answer 9

Maculopapular rash

Giant ulcers like CMV so you have to test for CMV vs. HIV

Question 10

What drugs cause esophagitis?

Answer 10

If they take it before you go to sleep, then you are fucked
Contact esophagitis
You need to take water BEFORE you take the pills to prevent contact esophagitis

Question 11

What is the ringed esophagus?

Answer 11

Seen in eosinophilic esophagitis
Idiopathic eosinophilic esophagitis
Allergic history
Use steroid to treat
You can see in the radiography presence of rings (feline appearance)

Question 12

What are the types of esophageal cancer?

Answer 12

1. squamous cell carcinoma
   
   • upper or mid esophagus
2. Adenocarcinoma (due to Barrett’s)
   
   • distal esophagus

Question 13

Where are gastric ulcers usually located?

Answer 13

Antrum or body

Question 14

How many gastric ulcers are benign?

Answer 14

95%

Question 15

What are the characteristics of benign ulcers?

Answer 15

Radiologically
1. Round or ovoid crater (of barium)
2. Smooth mound of edema
3. Symmetric radiating folds
After radiology, you do NOT need endoscopy

Question 16

What are the characteristics of malignant gastric ulcers?

Answer 16

1. IRREGULAR crater of barium in tumor mass, eccentric
2. nodularity or clubbing of radiating folds
3. projects into lumen
   Endoscopy is required

Question 17

What are erosions?

Answer 17

Very small and shallow ulcers
They do not penetrate past muscularis mucosae
Always benign
EROSIVE GASTRITIS
Caused by NSAIDS and stress

If you get pain after aspirin ingestion, then you might have erosive gastritis…stop that shit

Question 18

What are ulcers of the greater curvature of the stomach always caused by?

Answer 18

High dose of NSAIDS
So if you see a radiology picture of greater curvature ulcer, you say “elderly women who is taking high doses of NSAIDS for her severe arthritis”

Question 19

If you puke out shit, what might you have?

Answer 19

Stomach-transverse colon fistula due to gastric ulcers

Question 20

If you see a shitload of ulcers in the intestine, what does that suggest?

Answer 20

A lot of acid production

ZES

Question 21

What are the characteristics of DU?

Answer 21

1. vast majority in bulb
2. pain or upper GI bleeding
3. benign, noon need for endoscopy

Question 22

What is the prevalence of H. pylori in GU and DU?

Answer 22

80% and 95%

Question 23

What is hypertrophic GU suggestive of?

Answer 23

H pylori

Increased risk of gastric cancer

Question 24

What is erosive gastristis suggestive of?

Answer 24

NSAIDs

Question 25

Which type of infectious esophagitis is most likely to be associated with the development of small ulcers?

Answer 25

Herpes esophagitis

Candida has plaques not ulcers

Question 26

Which one of the following radiographic findings is least likely to be associated with eosinophilic esophagitis?

Answer 26

Shaggy esophagus (because that means candida)

Question 27

What are the radiographic findings of eosinophilic esophagitis?

Answer 27

1. esophageal stricture
2. ringed esophagus
3. small-caliber esophagus

Question 28

What is the best way to followup a benign appearing GU?

Answer 28

Repeat Ba study in 8 weeks (play it safe)

Question 29

Which one of the following abnormalities is caused by H. pylori?

Answer 29

1. gastritis
2. GU
3. DU
4. Gastric cancer
   ALL 4

Question 30

What is the etiology of GU and DU?

Answer 30

1. GU is 80% H. pylori and 20% NSAIDS

2. DU is 99% H pylori and 1-5% from ZES and Crohns

Question 31

What differentiates benign vs. malignant GU?

Answer 31

2/3 can be differentiated by double-contrast Ba studies
Benign-appearing GU followed by repeat Ba study in 8 weeks
Equivocal/malignant appearing Gus require early endoscopy

Question 32

What are the appropriate follow-ups for the following?

Answer 32

1. Gastritis/duodenitis?
   
   • treatment with PPI
2. Benign GU/DU?
   
   • noninvasive H pylori testing to guide treatment
3. Equival/malignant appearing GU or suspicious lesions?
   
   • endoscopy