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MCQs Flashcards

1
Q

Small bowel carcinoid

A

Calcifies in 70%
40% are in small bowel, mostly in terminal ileum > rectum > appendix
Take up octreotide - 15% don’t
Otherwise take up MIBG
Potentially malignant
Enterochrommafin cells, crypts of Leiberkuhn
(Pulmonary from Kulchitsky cells)
More common in small bowel than primary adeno in small bowel
Solid yellow tan

Size relates to malignant potential
And to met incidence - <1cm 2%, >2cm 85%

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2
Q

Xanthogranulomatous pyelonephritis

A

Chronic granulomatous pyelonephritis
Associated with staghorn calculus
Also pelvic contraction (with pelvicalyceal obstruction), perinephric infolvement, and multiloculated appearance.
Foamy macrophages, plasma cell, lymphocytes, PNLs, giant cells
May produce yellowish nodules, confused with RCC

E. coli and proteus most common (note E coli usually urease negative)
Female predominance 2:1 (presumably as higher rates of UTI)

Fatty infiltration
Hypoechoic infiltration of soft tissues
Rim enhancement on CT

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3
Q

UC v Crohns

A 
Toxic megacolon more common in UC
Crohns 10% colon involved
Crohns skip lesions
UC male predominant
Perianal not common in UC, but is in Crohns
Creeping fat Crohns
Gallstones common in Crohns
PSC more common in UC
Erythema nodosum and pyoderma gangrenosum
Apthous ulcer and Cobblestoning - Crohns
Crypt abscess and pseudopolyps - UC
Collar button ulcer - UC

Linear ulcer mesenteric border almost pathognomonic of Crohns

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4
Q

Serous cystadenoma pancreas

A 
Central calcification
Numerous small cysts
Oligocystic varian in 10%
Elderly
Benign
Associated with VHL
Favour pancreatic head

Hyperechoic on ultrasoun.

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5
Q

Mucinous cystadenoma of pancreas

A 
Younger
Uni / multilocular
Usually body or tail (head in 20%)
Peripheral calc
Elevated CEA, CA19-9
Malignant or premalignant
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6
Q

Cholangiocarcinoma

A 
Typically obstructs bile ducts
Progressive enhancement - early rim, with patchy central fill in and delayed (different enhancement pattern to HCC)
Capsular retraction (characteristic)
Klatskin - periductal infiltrating
1 - distal to confluence (i.e. Common hepatic duct)
2 - involves confluence
3 - involves left or right duct
4 - involves both ducts
90% are extrahepatic

DWI peripheral hyperintensity, target pattern, favours cholangiocarcinoma over HCC

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7
Q

Haemachromatosis

A

Iron deposits in liver
Later in pancreas
Not in spleen
Diffuse low T2 signal in liver

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8
Q

Prostate cancer

A

70% peripheral
Primary indication for MRI is to determine capsular extension if biopsy proven
May also be used when biopsy negative but persistent raised PSA
TR USS mainly to guide biopsy - otherwise poor
Mostly hypoechoic
Low T2 in normally high signal peripheral zone
Dynamic contrast enhancement can also be used - early enhancement with washouy

19-30% have normal PSA - need PSA >40 for bone mets
Rarely causes haematospermia

MR spectroscopy - increased choline and decreased citrate

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9
Q

Focal smooth thickened small bowel folds

A

Radiation in differential

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10
Q

Pancreatic ca resectability

A

CT good at prediciting unresectability
If tumour surrounds SMA or coeliac axis >180, unresectable (T4, stage 3. T3 if exends beyond pancreas but doesn’t surround vessels)

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11
Q

Rectal cancer staging

A

Stage 1 is T1 or 2
Stage 2 is T3 or 4
Stage 3 has nodes, 4 mets.
T1 Submucosa, T2 muscularis propria, T3 through muscularis into subserosal or non-peritonealised tissues, T4 invasive of organs/structures or visceral peritoneum

N1 1-3 nodes
N2 4 or more

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12
Q

Colon cancer staging

A

T1 submucosa
T2 muscularis propria
T3 through muscularis into subserosa or non-peritonealised tissues
T4 through visceral peritoneum or invading
N based on number of nodes - 1 1-3, 2 4 or more

Dukes
A mucosal
B muscularis propria
C lymph nodes
D mets
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13
Q

Anomalous biliary drainage

A

Most common is right posterior duct into left hepatic duct above confluence

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14
Q

Renal artery stenosis

A

Atherosclerosis involves proximal artery
FMD involves distal artery
PSV > 1.5 in transplant indicates stenosis

> 3.5 renal artery to aorta ratio
150cm/s if insonation <60 degrees, 180cm/s for >70

2:1 stenotic:poststenotic

Intraparenchymal RI >0.8
Intraparenchymal acceleration >0.07s

(RI may be increased in obstruction)

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15
Q

Cerebriform appearance of small bowel

A

Shock bowel

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16
Q

WDHA syndrome

A

Watery diarrhoea, hypokalaemia, anchlorhydria

VIPoma

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17
Q

Gastrinoma

A

10-15% occur in duodenum

In ZES and MEN1, usually multiple and in duodenum, <5mm, 75% in D1

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18
Q

Gallstones

A

Increased risk in chronic haemolysis (pigment stones)

Increased risk in Crohns disease - malabsorbed bile salts (TI) alter bilirubin reasorbtion (large bowel).

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19
Q

Barretts oesophagus

A

Reticular mucosal pattern in distal oesophagus on barium swallow (most sensitive finding)
Columnar (intestinal) metaplasia - need Goblet cells

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20
Q

Solitary rectal ulcer syndrome

A

Misnomer
35% solitary, 22% multiple, 43% no ulcer
Benign abnormality of rectal mucosa from straining - invaginates into lumen
Marked muscularis thickening
Failure of anorectal angle to open, incomplete emptying, rectal prolapse

May have inflammatory polyp (inflamed and elevated mucosa surrounded by granular muscosa)

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21
Q

Menetriers

A 
Idiopathic hypertrophic gastropathy
Bimodal - <10, 30-60, peak 55
Male predominant
Fundus, relative antral sparing
Differential lymphoma, other gastritis
Clinical triad achlorhydria, hypoproteinaemia, oedema
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22
Q

Strongyloidiasis

A

Ulceration and stricture (stenosis) of D3 and 4, rigid pipestem
Dilatation of proximal duodenum with oedematous folds
Helminth parasite
Via skin, lung via lymphatics, then ascends and swallowed.

Can cause a colitis in immunocompromised

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23
Q

Amoebiasis

A

Protozoan
May cause toxi megacolon
Loss of haustral pattern
Collar button ulcers
Apthous ulceration
Right colon and caecum > flexures > rectosigmoid
May mimic Crohns, but spares TI unlike Crohns, TB
Invades crypts, burrows into tunica propria

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24
Q

Amyloid

A

Primary
Duodenum > stomach > colon, rectum > oesophagus
May cause linitis plastica, or submucosal mass
Can cause GI bleeding

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25
Q

Diabetes

A

Can cause gastric dilatation secondary to autonomic neuropathy

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26
Q

Adenomyomatosis

A 
Localised, segmental, or diffuse
Localised often in fundus
Segmental often in waist
Not premalignant
Gallstones in 25-75%
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27
Q

TB peritonitis

A

Dense ascites - wet peritonitis
Omental caking - fibrotic peritonitis
Mesenteric caking, fibrous adhesions, caseous nodule - dry peritonitis

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28
Q

Buscopan, contraindications

A 
Anticholinergic
Closed angle glaucoma
Tachyarrythmias
Megacolon
Myasthenia
Urinary retention
Bowel obstruction
Paralytic ileus
Urinary retention
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29
Q

Cathartic colon

A 
Prolongued stimulant laxative use
Neuromuscular incoordination
Right predominant
Absent haustration
Patulous Ileocaecal valve
DD UC - recutm spared, no pseudopolyps. no ulceration
No increased cancer risk
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30
Q

Acanthosis nigricans

A

Skin changes
Mostly from insulin resistance, obesity
May be due to malignancy GI - gastric, HCC, lung, uterine

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31
Q

Coeliacs

A

Decreased jejunal folds, increased ileal
Low density nodes
Increased risk of T cell lymphoma, small bowel adeno, oesophageal SCC, HCC, colorectal ca, breast

Healing of villous atrophy reduces somewhat the lymphoma risk, but an increased risk remains

Antigliadin antibody 10-20% false positive
EMA 100% specific, 90-95% sensitive
Transglutaminase antibody 98% specific, 95% sensitive

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32
Q

Colovaginal fistula

A

Diverticulitis most common cause

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33
Q

Oesophageal rings

A

A transient muscular contraction
B squamocolumnar junction
C diaphragm crura

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34
Q

Afferent loop syndrome

A

Obstruction to upstream limb of side to side gastrojejunostomy
May have bilious vomiting
Causes: anastomotic kinking, radiation stricture, recurrent tumour

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35
Q

Recurrent rectal Ca

A

Distinguish from scar by PET

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36
Q

CEA

A

Up in 60-90% of colorectal Ca
Also other malignancies - breast, lung, bladder, pancreatic, thyroid
And non malignant - smoker, PUD, IBD, pancreatitis, ccirrhosis

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37
Q

Scleroderma small bowel

A

Hidebound bowel - bunching and crowding of folds (which aren’t thickened - also seen in sprue [coeliacs and tropical sprue]) [not the same as stack of coins, from intramural haematoma, where folds are thickened - coagulopathy and vasculitides]
Antimesenteric sacculations / pseudodiverticula
Dilated duodenum, jejunum
Prolonged small bowel transit time

Also affects colon in 40-50% with pseudosacculations, loss of haustra, marked dilatation, stercoulceration from retained faeces

Women, 30-50 (3xmen)
Arthropathy fingers, wrists ankles 70-97%
Oesophageal involvement 80%
Respiratory histologically in all, but only minority / 25% have symptoms
UIP or NSIP, pulmonary artery HTN

Dilatation of distal 2/3 of oesophagus
Fusiform stricture 4-5cm above GE junction
High risk of adenoCa
Progression to Barrets

Small bowel in 60%
Dilatation which can be massive
Crowded folds / hidebound bowel
Antimesenteric pseudosacculations

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38
Q

Peutz Jager

A

Hamartomatous polyps
Increased risk of GIT carcinoma, breast, adenoma malignum (an adenoCa of cervix)
Pancreas, ovaries, testes, lung, uterus

Polyps mostly small bowel
Mucocutaneous pigmentation
Continuous smooth muscle core with the muscularis differs from other hamartomatous polyposes. The hamartomas are non-neoplastic.

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39
Q

GI lymphoma

A

Gastic > small bowel esp ileum > proximal colon > distal colon > oesophagus and appendix rare

Ileum most common small bowel site (as mentioned above)

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40
Q

Appendicitis in pregnancy

A

Increased risk of perforation

Probably because of delays in diagnosis and treatment

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41
Q

Perianal fistula

A

1 - linear intersphincteric
2 - interspincteric with abscess or secondary fistulous tract
3 - trans-sphincteric
4 - trans-sphincteric with abscess or secondary fistulous tract in ischioanal or ischiorectal fossa
5 - supralevator or translevator disease

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42
Q

Gastric ca risk

A

Chronic atrophic gastritis

Partial gastrectomy - bilroth 2 > 1

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43
Q

Whipple disease

A

Thickened (fine) nodular folds (swollen villi) in distal duodenum and jejunum. Normal calibre bowel. Infiltration by macrophages, and lymphatic obstruction.
Low attenuation nodes
Hepatosplenomegaly, ascites
Sacroiliitis

No ulceration. Normal transit time. No rigidity of folds.
Wild mucosal pattern.

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44
Q

Bilroth

A

1 - gastroduodenostomy - direct attach
2 - side to side anastomosis from gastric to jejnum. Afferent limb (biliopancretic limb) proximal to anastomosis, efferent limb distal
Biroth 2 has higher gastric ca risk than bilroth 1

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45
Q

Hepatorenal syndrome

A

Rapid deterioration in renal function in patients with cirrhosis or fulminant hepatic failure
Liver failure causes altered blood flow to kidneys

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46
Q

Medullary nephrocalcinosis

A 
20x more common than cortical
Hypercalcaemic, hypercalcuric
HPT, MSK, RTA
Vit D, sarcoid, cushings, mets, myeloma
Renal TB, infection
Sickle cell
Renal papillary necrosis
Durgs - furosemide
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47
Q

Upper pole duplex

A

Ectopic and obstructs
Can be into seminal vesicles
May present with epididymo-orchitis

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48
Q

Bilateral increased renal size

A

TB, leukaemia, RTA, HUS

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49
Q

Fish-hooking distal ureters

A

Prostatomegaly

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50
Q

Medial deviated ureters

A

AAA, retrocaval ureter, retroperitoneal fibrosis (proximal)
Iliopsoas hypertophy
Iliac adenopathy
Iliac aneurysm
Hutch diverticulum (VUJ)
Following AP resection and retroperitoneal lymph node dissection
Pelvic lipomatosis

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51
Q

Rim nephrogram

A

Perfusion maintained around rim of devasculrised kidney from capsular vessels
Develops >8 hours

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52
Q

Fluid collections post renal transplant

A

Immediate post-op - haematoma
1-2 weeks - urinoma
3-4 weeks - abscess
2 months and beyond - lymphocoele

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53
Q

Papillary v clear cell RCC

A 
Papillary enhances less
Papillary hypo T2, clear cell hyper T2
Clear cell most common
Papillary better prognosis
VHL - clear cell
Dialysis associated - papilary
Smoking major RCC risk factor

RCC risk factors - smoking, obesity, cyclophosphamide, dialysis cystic disease (mostly papillary)

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54
Q

Renal vein thrombosis causes, child

A 
Dehydration
Sepsis
Sickle cell
Polycythaemia
Maternal diabetes
Indwelling umbilical venous cathether
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55
Q

Renal vein thrombosis causes, adult

A 
Nephrotic synd
SLE
Amyloid
Glomerulonephritis
Diabetes
Renal sepsis
Renal tumour
Trauma
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56
Q

Testicular microlithiasis associations

A 
GCT (debatable increased risk)
Cryptorchidism
Klinefelters
Downs
Male pseudohermaphraditism
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57
Q

Testis teratoma

A

In child benign
In adult malignant

Tend to occur in younger age group than seminoma

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58
Q

PSA for bony mets

A

>

  1. <20 is uncommon

85% NPV for prostate Ca of PSA <4

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59
Q

Testicular radiosensitivity

A

Seminoma senstive
Rest not
NSGCT more aggressive, worse prognosis

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60
Q

Bosniak

A

3 - thick enhancing septa, remove
4 - clearly malignant

1-3% of cysts calcify
3 - 50% chance of malignancy
Thin <1mm septa normal - 2

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61
Q

Epididymal tumour

A

Adenomatoid most common
Slow growing mesothelial neoplasm
2nd-4th decade
Tail particularly

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62
Q

Renal TB

A

Normal CXR in 50%

Moth eaten calyx - necrotizing papillitis

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63
Q

HUS

A

Increased cortical echogenicity from acute cortical necrosis
In differential for bilateral enlarged kidneys

MORE DESCRIBING THE CONDITION

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64
Q

Indinavir stone

A

Renal stone not seen on any modality if pure

HIV treatment

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65
Q

Oxalate stones

A

Crohns without ileostomy increases risk - fat malarbsorption, so more bound calcium by fat, so less oxalate bound by calcium
Radiopaque

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66
Q

HIV nephropathy

A

Normal kidney size

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67
Q

Carney’s triad

A

GIST, pulmonary chondroma, extra-adrenal paraganglioma

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68
Q

Phaeo

A

10% have speckled calc
10% malignant
Familial 10% - VHL, NF1, MEN2, Sturge-Weber
10% extra-adrenal - these are more likely to be malignant
10% bilateral
Extra-adrenal more likely to be malignant

T2 hyper to liver (unlike adenoma which are similar to liver) (markedly hyperintense - lightbulb sign)
Avid enhancement, may washout
Calc in 7% (cortical carcinoma in 30%)

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69
Q

MIBG

A

to detect phaeo mets

taken up by small bowel carcinoid

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70
Q

Transjugular liver biopsy

A

Good when bleeding risk, as minimised

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71
Q

PBC

A

Has adenopathy more than other causes of cirrhosis
AMA (antimitochondrial antibody) sensitive and specific
Middle aged women

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72
Q

Chlonorchis sinensis

A

Chinese liver fluke

Intrahepatic calculi

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73
Q

Solid bening hepatic

A

Haemangioma most common

Then FNH

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74
Q

Budd-Chiari cause

A

Idiopathic 2/3 (or 1/3 depending on source)
Thrombotic - pills, pregnancy, PCV, PNH paroxysmal nocturnal haematglobinuria
Vessel wall injury - radiation, chemo/immunosupression in BMT patients, jamaican bush tea
Tumour extension - RCC, HCC, adrenal, leimyosarc of IVC
Treat - medical, thrombolysis, angioplasty / stent, TIPS,
Caudate hypertrophy (in some - not seen in majority on NM), spider web hepatic venous collaterals

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75
Q

VHL pancreatic associations

A

Cysts, cancer, serous cystadenoma, islet cell tumours (tend to be non-functioning), NOT MUCINOUS

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76
Q

Choledochal cysts class

A 
1  fusiform dilatation extrahepatic
2 diverticulum
3 within duodenal wall
4 multiple
5 intrahepatic only - Caroli disease
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77
Q

Bile stasis

A

Cholangitis, bilirubin stones, liver abscesses

78
Q

Anabolic steroids

A

Can cause pure cholestasis and NASH

Also risk factor for heaptic adenoma

79
Q

Hepatic adenoma

A

Heterogeneous (enhancement and ultrasound)
OCP, anabolic steroids, glycogen storage disease
Negative sulphur colloid and hepatobiliary contrast MR
Commonly T1 dropout
Fat or haemorrhage - may have calcium (5-10% in areas of old haemorrhage)
Can malignantly transform, haemorrhage, rupture

Less common than FNH, haemangioma

USS may show flat trace -perilesional sinusoids

TYPES:
.

80
Q

Pancreatic endocrine tumours

A

2% MEN1
Also VHL, TS
Syndromic and non-syndromic tumours
Insulinoma > gastrinoma > glucagonoma, VIPoma, somatostatinoma
Vascular, may be cystic
10% of insulinoma malignant
Others around 75%
DD met RCC, splenule, solid serous cystadenoma
80% take up octreotide - gastrinoma best, insulinoma worst
70% of insulinoma <1.5cm, less than 1% extrapancreatic (gastrinoma ectopic 7-33%).

81
Q

Mucinous cystadenoma pancreas

A

Peripheral egg-shell calc specific for malignancy

82
Q

Chronic pancreatitis

A

Alcohol

2-4% get cancer

83
Q

Pancreatic pseudocyst

A

10-20% of acute pancreatitis

Spontaneously resolve 25-40%

84
Q

OCP use

A

Increases risk of HCC slightly

85
Q

Peliosis hepatis

A

Blood filled cavities in liver
Steroids, OCP, tamoxifen, oestrogens
HIV AIDS, transplantation, haem/onc disorders, some infections - bartonella
Toxins
May haemorrhage, hepatomegaly, liver impairment

86
Q

Hepatic pseudotumour

A

Young asian males
Associated with recurrent pyogenic cholangitis
Right lobe
Not typical imaging - biopsy or surgery required
More common in lung and orbit

87
Q

Secondary sclerosing cholangitis

A

AIDS cholangitis
Or stricture from previous surgery, ischaemia
AIDS - cryptosporidium, CMV

88
Q

Regenerative liver nodule

A

Non-neoplastic nodule in cirrhotic liver
If not cirrhosis, NRH
If iron, siderotic
Cirrhotic nodules range from benign regenerative to dysplastic to HCC

89
Q

TIPS

A

Change in velocity >50cm/s relative to baseline may indicate significant stenosis
Flow should be 50-150
Also elevated maximum and depressed minimum
Biliary dilatation may be an acute complication - fistula
Contraindicated in RHF, pulmonary HTN, hepatopulmonary syndrome
Is a treatment for refractory ascites, Budd-Chiari, portal HTN / varices, hepatorenal syndrome, portal hypertensive gastropathy, hepatic hydrothorax, malignant compression of portal or hepatic veins

Contraindications: fulminant failure, encephalopathy, severe right heart failure, sepsis
(because 1 liver may not tolerate lack of portal nutrients, 2 more toxins may get to brain, 3 increased preload, 4 stent may get infected

90
Q

Hypervascular liver mets

A

Renal, lung, breast, thyroid, carcinoid, melanoma, HCC, choriocarcinoma

91
Q

Hyperechoic liver mets

A

Colon, RCC, carcinoid

92
Q

Hypoechoic liver mets

A

Lung, breast, pancreas, lymphoma

93
Q

Tamm-Horsfall protein

A

In urine, from renal casts in ATN

94
Q

GI bleeding

A

0.5mL/minute to detect on angiography
0.1mL/minute on muclear medicine
Diverticula in right colon are more likely to bleed than on the left - 3x

95
Q

GI ischaemia

A

If good collaterals, so doesn’t perforate bowel, may result in a stricture
SMA occlusion:
Embolic 60%
Thrombosis superimposed on atherosclerosis 30%
Aortic dissection
Embolism - 15% at origin, 50% just distal to middle colic artery
Venous thrombosis 5-15% of cases

96
Q

Haematogenous small bowel mets

A

Prediliction for antimesenteric wall

97
Q

Testicular cysts

A

Seen on USS in 10%

98
Q

Cushings

A

5% from carcinoma, most in children (66%)

20% from adenoma (or carcinoma) secreting cortisol
80% from increased ACTH production by a tumour - pituitary mostly, but also ectopic - small cell lung, carcinoid, pancreatic neuroendocrine, phaeo, ovarian benign
Rarely ACTH independent hyperplasia

99
Q

Adrenal mass

A

Large size and calc suggest malignancy

Carcinoma calc 30%, phaeo 10%

100
Q

Adrenal hyperplasia

A

Occurs more commonly in malignancy

101
Q

Paraduodenal hernia

A

The most common type of internal hernia
Left more common than right
Failure of fusion of ascending / descending colon mesenteries
R is associated with small bowel malrotation

102
Q

Pancreatitis, SLE

A

May be secondary to vasculiti, small vessel ischaemia, immune complex deposition or a combination

103
Q

Most common splenic benign lesion

A

Haemangioma

104
Q

CF

A

Increased risk of colon, pancreatic, biliary malignancy and lymphoma

105
Q

PNH

A

Paroxysmal nocturnal haemoglobinuria
A haemolytic anaemia - complement destroys rbcs.
May be primary, or secondary to another bone marrow disorder
26% have red urine in morning
May cause thrombosis - legs (DVT), hepatic veins (Budd-chiari) portal vein, mesenteric veins, cerebral

106
Q

Colonic lipoma

A

Benign, caecum and ascending colon, don’t degenerate

107
Q

Achalasia

A

1000x risk of adenocarcinoma
(also increased risk of SCC)
Vestibule is the region of the lower oesophageal sphincter which fails to relax
5% risk of perforation from pneumatic dilatation
May have nocturnal reflux and aspiration

108
Q

Spindle cell ca oesophagus

A

A type of SCC

Relatively little obstruction

109
Q

AIDS abdominal manifestations

A

MAI infection - bowel dilatation
Toxic megacolon (pseudomembranous colitis)
Perirectal abscesses, lymphoma
Reactive hyperplasia is the most common cause of lymphadenopathy
Kaposi shows strong enhancement

110
Q

Schistosomiasis

A

Bladder wall calcs, can lead to SCC

111
Q

Wolman disease

A

AR
Deposition of fat in various organs
May have bilateral enlarged calcified adrenal glands, hepatosplenomegaly, and enlarged nodes

112
Q

Hydatid cyst

A

Daughter cyst in 70%
Echinococcus granulosa
Death of parasite implied by complete calcification

113
Q

ADPKD

A 
Do not invariably have liver cysts, but majority and increasing incidence with age
Associations:
Bicuspid valve
Berry aneurysms
HTN
Diverticulosis
Cranial dolichoectasia
Multiple biliary hamartomas
Aortic dissection
Mitral valve prolapse
Liver cysts 75% by 60
Seminal vesicle cysts 60% by 40
Pancreatic, prostate
114
Q

Lipiodol

A

Taken up by HCC and normal hepatocytes, not cleared by HCC so do delayed scanning

115
Q

Pancreatic duct

A

3mm young, 5mm elderly

Divisum in 5%

116
Q

Caroli disease

A

Stones, cholangiocarcinoma, bacterial cholangitis, renal cystic disease associations

Multifocal cystic dilatation (sacular often - recurrent pyogenic cholangitis gives fusiform dilatation) of intrahepatic bile ducts
Central dot sign of enhancing portal radicles within the dilated bile ducts

117
Q

Hepatic attenuation

A

Decreased in Wilsons as steatosis (can be increased from Copper, but not majority)
Increased in amiodarone, gold, iron (haemochromatosis, haemosiderosis), glycogen storage disease

118
Q

CT cholangiography

A

No good if serum bilirubin 3x normal because impaired excretion of contrast agent
95% sensitive if bilirubin normal

119
Q

FNH

A

20% will be decreased uptake on sulfur colloid. 33% have increased uptake.
Adenomas are photopenic on sulfur colloid

120
Q

Chagas

A

Mega oesophagus or colon in 1/3

Also myocarditis

121
Q

Dermatomyositis

A

Disordered peristalsis of oesophagus

122
Q

Infectious oesophagitis

A

Candida: mucosal nodularity and longitudinal plaques, may be shaggy in severe cases (also granularity, fold thickening)
CMV: one or more large ovoid ulcers (although can have multiple small superficial ulcers, more like HSV). A giant ulcer is more suggestive of CMV. May be indistinguiable from HIV, HSV

123
Q

Adrenal adenoma

A

Chemical shift MR most accurate in differentiating from mets.
Absolute washout >60%
Relative washout >40%

T2 similar to liver, whereas phaeo has higher T2

124
Q

Adrenal cortical carcinoma

A

Associated with congenital hemihypertrophy (Beckwith Wediedeman
And LiFraumini, Carney complex (not the same as Carney Triad), MEN1
30% calcify
Large, extend into liver, IVC, renal vein
May look identical to phaeo on imaging

125
Q

Omental infarct

A

90% right sided

126
Q

Appendicitis diameted

A

> 6mm

127
Q

Portal HTN ultrasound

A

Portal vein >13mm (non-specific)
Flow reduced <35cm/s
Defined as pressure >12mmHg or portosystemic gradient >5mm

128
Q

CBD US

A

<6mm, +1 per decade over 60

129
Q

Mag3 renogram T1/2

A

<10 normal, >20min obstructed (after lasix)

130
Q

Schatzki ring

A

Symptomatic B ring (mucosal squamocolumnar junction)

Symptomatic if <13, sometimes if 13-20mm

131
Q

Renal stone, size, pass

A

4mm will pass, 8mm won’t, 4-8 variable

132
Q

Risk of colon malignancy with polyp size

A

<5mm, <1%
5-9mm, <1-2%
10-20mm, 10%
>20mm 40-50%

133
Q

Colon cancer

A

5% synchronous

55% rectosigmoid. 20% caecum / ascending (including IC valve), 10% transverse, 5% descending

Asbestos is a risk factor

134
Q

IBD genetics

A

10% risk in 1st degree relatives

135
Q

Cronkite Canada

A

Non-hereditary hamartomatous polyposis
Throughout GI tract
Cutaneous manifestations - pigmentation, alopecia, onychodystrophy

136
Q

Cowden

A

Hamartomatous polyps
AD
Polyps mostly skin and mucosal membranes, but also GI tract

Follicular thyroid cancer
Skin, oral, breast and uterine malignancy
Lhermette-Duclos
Fibrocystic disease of breats, thyroid adenomas, glycogenic acanthosis

137
Q

Oesophageal ulcer, table

A

Solitary large flat

138
Q

Oesophageal cancer, gross morphology

A

Polypoid/fungating (most common)
Ulcerating
Infiltrative (obtuse margins)
Superficial spreading / varicoid - thickened nodular folds

139
Q

Zollinger Ellison

A 
FUSED
Folds (thickened)
Ulcers
Secretions
Edema
Diarrhoea
140
Q

Villous adenoma, clinical

A

Can secrete potassium and protein and cause hypokalaemia and hypoproteinaemia

141
Q

Eosinophilic gastroenteritis

A

Unknown aetiology
Common to have atopy
Peripheral eosinophilia

Infiltration of any or all layers of gut wall by eosinophils (one source talked about mucosal and muscular types)
Gastric antrum and proximal small bowel common
Fold thickening and nodularity - may give a cobblestone appearance
Steroids

Usually middle age

142
Q

GVHD

A

Skin, small bowel (and remaining GI tract), and liver most common
Host immune system activates donor T cells, causing inflammatory cascade
GI mucosal fold thickening, may lose folds in ileum
May have strictures and dilatation proximal to these

143
Q

Mastocytosis

A

Mast cell proliferative neoplasm
Diffuse bony sclerosis

Small bowel diffuse nodular irregular thickened folds, sand like nodules (from mast cell / other cell infiltration)

144
Q

Scleroderma, oesophagus

A

Atonic distal 2/3 with patulous sphincter
Dysmotility leads to reflux, Barrets, lower oesophagus stricture, aspiration, candida

Women, 30-50 (3xmen)
Arthropathy fingers, wrists ankles 70-97%
Oesophageal involvement 80%
Respiratory histologically in all, but only minority / 25% have symptoms
UIP or NSIP, pulmonary artery HTN

Dilatation of distal 2/3 of oesophagus
Fusiform stricture 4-5cm above GE junction
High risk of adenoCa
Progression to Barrets

Small bowel in 60%
Dilatation which can be massive
Crowded folds / hidebound bowel
Antimesenteric pseudosacculations

145
Q

Epididymitis

A

20-40% have orchitis

Can look like torsion

146
Q

Renal calculi

A

RTA can cause calcium phosphate calculi

Most calcium containing stones have idiopathic hypercalcuira (or are on loop diuretics or acetazolamide)
Struvite (triple phosphage / magnesium ammonium phosphate stone)- urease bacteria (proteus, klebsiella, pseudomonas, enterobacter. Stones usually mixed with calcium so radiopaque
Uric acid e.g. gout (lucent - mildly opaque on CT)
Cystine e.g. metabolic cyteinuria (lucent - mildly opaque on CT)
Meds e.g. indinavir (radiolucent, HIV)

Crohns - malabsorbed fats bind calcium so calcium can’t bind oxalate, so oxalate stones. Oxalate is resorbed in the colon, so if Ileostomy, don’t have the same risk

147
Q

Malacoplakia

A

Chronic granulomatous inflammation of bladder wall
Common in immunocompromised or chronic disease - AIDS, DM
E coli infection common
Michaelis-Gutmann bodies are histological hallmark - intracellular calcium inclusions

Multiple bladder masses or circumferential thickening, associated with reflux and ureteric dilatation (can commonly obstruct)
Can occasionally be locally aggressive
Medical treatment first line. Vitamin C included. Surgical options.

Gallium scintigraphy can detect clinically silent lesions

148
Q

Renal cortical necrosis

A

May cause cortical nephrocalcinosis, with punctate / dystrophic calc.

149
Q

Medullary, cortical nephrocalc mnemonics

And renal papillary necrosis mnemonic

A

Medullary - HAMHOP
Cortical - COAG
RPN - NSAID

Hypercalcuria/aemia
Acidosis (RTA)
MSK
HPT
Oxalosis
Papillary necrosis

Cortical necrosis
Oxalosis
Alport syndrome (hearing loss, ocular abnormalities, haematuria, leiomyomas)
Glomerulonephritis (chronic)

NSAID
Sickle cell
Analgesics
Infection (pyelo and TB)
Diabetes and dehydration
150
Q

Properitoneal fat strip

A

Anterior extension of the posterior pararenal space

Lost in: appendicitis, ruptured AAA

151
Q

Perirenal abscess, plain film

A 
Loss of renal outline
Loss of psoas shadow
Scoliosis, convex to side of abnormality
Anterior displacement of descding duodeneum
Loss of properitoneal fat strip
152
Q

Intratesticular varicocele

A

Usually in association with an ipsilateral extratesticular varicocele

153
Q

Ureteritis cystica

A

AKA pyelitis cystica (renal pelvis), cystitis cystica (urinary bladder), pyeloureteritis cystica
Multiple submucosal cysts in the ureters
Older women with recurrent UTIs
Perhaps increased TCC risk but probably relates to the underlying cause

?maybe associated with diabetes

154
Q

Renal NM

A

DMSA tubular uptake (cortex) - scarring, differential of renal function
DTPA - GFR, filtered
Mag3 secreted, tubules, and glomerular filtration. Highly protein bound in serum. Accumulates in ATN

155
Q

Renal transplant

A

Dilatation of collecting system without obstruction common in a normal transplant kidney
Vascular compromise in 1-2%
Increased renal size (oedema) may be first sign of rejection

156
Q

Renal leukaemia

A

Hyperdense

157
Q

Endodermal sinus tumour

A

Is a synonym for yolk sac tumour

158
Q

Cholecystostomy

A

Can be complicated by bradycardia and hypotension

159
Q

Hepatic haemangioma

A

F:M 5:1
T1 hypo, T2 hyper
Multiple in about 30%
Progressive fill in

160
Q

Coursouviers law

A

Palpable enlarged gallbladder, with painless jaundice, cause is unlikely to be gallstones
Gallstones are formed over extended period of time, so get fibrotic gallbladder which cannot distend easily

161
Q

Hepatoduodenal ligament

A

CBD anterior and right
Hepatic artery anterior and left
Portal vein posterior

162
Q

Portal vein thrombosis

A

Reduced flow - cirrhosis, malignancy
Hypercoagulable state - V leiden, C, S, antiphosopho. Pregnancy, malignancy, drugs (OCP), dehydration
Endothelial damage - pancreatitis, ascending cholangitis, abdo surgery (actinomycosis in prev question)

163
Q

Cholelithiasis

A

Haemolysis e.g. thalassaemia, sickle cell. Also Cirrhosis with hypersplenism. Wilson’s can thus cause via cirrhosis.
Cystic fibrosis - biliary cirrhosis

Cholesterol stones (>50% cholesterol) - 10%. Diet, weight loss, obesity, contraceptive
Mixed (20-50%) - 80%
Pigement sones - 10%, high bilirubin content from supersaturated unconjungate bilirubin. May have black sontes (cirrhosis, haemolysis, intestinal malabsorption e.g Crohns), or brown (bacterial, parastic infection e.g. clonorchis, and biliary stasis)
164
Q

Haemachromatosis

A

Increased out of phase signal as not susceptible to T2* low signal

165
Q

Multilocular cystic nephroma

A

Bimodal - 3month to 4 years, 75% male, and 40-60, mostly females
Benign
Multilocular cystic on imaging, encapsulated
Calc, haem and necrosis uncommon
Usually remove due to confusion as below
In adults, can look like a multilocular clear cell RCC
In children difficult to tell from cystic Wilms (1-11, peak 3-4)
MCDK is usually diagnosed antenatally whereas this presents later, plus have some normal kidney in this cf MCDK

166
Q

Metanephric adenoma

A

Polycythaemia in 10%, from EPO
Benign, 40-60 peak but can be any age, F 2xM
Difficult to differentiate from other renal tumours
Calc in 20%

167
Q

RCC

A

Calcify 30%
Clear cell T2 hyper
Papillary T2 hypo
Heterogeneous T1 - necrosis, solid, haemorrhage

168
Q

Organ of Zuckerkandl

A

Small mass of chromafin cells by aorta
Highest concentration near IMA origin
Extends from near SMA down to bifurcation

169
Q

Vas deferens calc

A 
Diabetes most common
Idiopathic / aging
Chronic infection:
TB
Syphilis
Shistosomiasis
Gonorrhoea
Chronic UTI
170
Q

PSC

A

Strongly associated with IBD, esp UC
AIDS cholangitis indistinguishable
May have secondary to other cause e.g. surgery causing stricture
Strictures, dilatations, and divertulae of biliary tree
Increased risk of cholangiocarcinoma. Also HCC (as causes cirrhosis). And increased risk of bowel cancer (4x that of IBD without PSC, and 10x general population)
Associated with other IgG4 diseases.

PSC men 40, PBC young women, with high AMA sensitive and specific for PBC (PBC typically doesn’t have lots of bile duct signs)

171
Q

Recurrent pyogenic cholangitis

A 
Diagnosis of exclusion
Intraductal pigment stones
Stricutres and dilatations of ducts
More common in SE asia
E coli and Chlornochis (liver fluke) have been implicated by causation not understood
172
Q

Haemochromatosis

A

T2* signal loss
Opposite to fat on in and out of phase imaging - ie higher on out of phase imaging
Spleen and bone marrow signal typically normal
Pancreatic signal only low if cirrhosis

173
Q

Wilsons

A

Copper doesn’t affect MR signal
CT may be up (from copper) or down (as get fat deposition) or normal.
Changes of cirrhosis

174
Q

HCC staging

A

Barcelona clinic liver cancer staging system

Also Milan criteria for liver transplantation

BCLCstaging
Incorporates: tumour extent (size, multiplicity, vascular invasion, nodes and mets), ECOG performance status (0 fine, 5 dead), and Child-Pugh score
0-A-D

The Child-Pugh score is an assessment of liver function in chronic liver diseases and incorporates bilirubin, Albumin, INR, ascites, hepatic encephalopathy

175
Q

Renal cancer staging

A

TNM and Robson

T1 and 2 just in kidney 1<7cm, 2>7cm
3 extends into veins or perinephric tissue, but not beyond Gerota’s fascia or to ipsilateral adrenal gland
4

N1 regional nodes
M1 mets

Robson:
1 kidney
2 perinephric fat
3 veins or nodes
4 mets or invasion or organs/structures
(This is similar to the Dukes staging of Bowel ca)

Mets are most commonly to: lungs, bone, lymph nodes, liver, adrenal, brain

176
Q

Oesophageal cancer staging

A

T1 invades lamina propria, muscularis mucosa or submucosa
T2 invades muscularis propria
T3 invades adventitia
T4 invades adjacent structures, “a” resectable (pleura, pericardium, diaphtram) “b” unresectable (aorta, trachea)

N1 1-2 regional nodes
N2 3-6
N3 - 7 or moe

177
Q

Gastric cancer staging

A

T stage identical to other GI malignancies

N the same as oesophageal

178
Q

Pancreatic cancer staging

A

T mostly sized based, with 4 if SMA or coeliac axis involved - resectability not included in assessment
1 <2cm, 2 2-4cm, 3 >4cm
N same as bowel - number of nodes, 1 1-3, 2 4 or more

179
Q

Retroperiteoneal liposarcoma types

A

Well differentiated (55%, low grade), myxoid (30%, mostly low grade), pleomorphic, round cell, and dedifferentiated (final 3 high grade)

180
Q

Renal trauma grading

A

AAST american association for the surgery of trauma
1-5
1 - contusion or non-enlarging subcapsular haematoma
2 - <1cm
3 - >1cm but not to pelvis or collecting system
4 - Lac extends to renal pelvis or urine leak, or main vascular injury, or enlarging haematoma compressing kidney
5 - shattered or avulsed from vessels or ureter

181
Q

Hepatic trauma grading

A

AAST 1-6

1 lac <1cm or subcap haem <10%
2 lac 1-3cm depth (<10cm long), haem <10cm, or subcam haem 10-50%
3 lac >3cm depth, haem >10cm or subcap haem >50% or ruptured haem
4 25-75% of a lobe or 1-3 segments
5 >3 segments in one lobe or >75% of one lobe, or major venous injury
6 avulsed

(1-3 similar to spleen but a bit different - 10cm rather than 5cm for haem)

182
Q

Splenic trauma grading

A

AAST 1-5

1 Lac <1cm, subcap haematoma <10%
2 Lac 1-3cm depth, Haematoma <5cm, subcap haematoma 10-50%
3 Lac >3cm depth, Haematoma >5cm or subcap haematoma >50%, or ruptured haematoma
4 Lac involves vessles with major devascularisation >25%
5 shattered or devascularised

(1-3 similar criteria to liver but a bit different = 5cm rather than 10cm for haem)

183
Q

Pancreatic trauma grading

A 
AAST 1-5
1  minor contusion or lac
2 major but withoug duct injury
3 distal duct injury
4 proximal duct injury (right of SMV)
5 massive disruption of pancreatic head
184
Q

Small bowel folds

A

.

185
Q

Adrenal cortical v phaeo

A

ACC - large, calc in up to 30%, relative contrast retention, necrosis and haemorrhage. Liver mets tend to be hypervascular
Phaeo may look identical. Differentiated by histology, biochemistry, functional status
Phaeo calc in 10%
Phaeo tends to enhance a lot. May wash out.
Phaeo also large, and heterogeneous with necrosis and haemorrhage

186
Q

Pancreatitis CT grading

A

.

187
Q

Most common small bowel tumour

A

Leiomyoma (GIST)

Malignant: adeno then carcinoid then lymphoma then leiomyosarcoma

188
Q

Small bowel lymphoma risk factors

A

Coeliacs
HIV / AIDS
H pylori
Post transplant

189
Q

GIST

A 
Stomach 70%
Small intestine 20%
Anorectum 7%
Colon
Oesophagus (oesophagus call tumours leiomyoma in general)
190
Q

Phi angle

A

Normally between 4 and 58
Gastric band
Angle between vertical of vertebral column, and long axis of band

191
Q

Splenic metastses

A 
Melanoma
Breast
Ovarian
Colorectal
Gastric 
Lung

Abdo (7 decks)

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