RD GI formatted Flashcards
AUGUST 20111. Cancer felt on PR, MRI shows that the muscularis is intact with periaortic nodes. (exact recall) [also recalled as: Rectal cancer. Eccentric mass on MRI. Muscular layer intact. No perirectal LN. Para-aortic lymphadenopathy. No mets. Radiological staging:)
a. Stage I
b. Stage II
c. Stage IIIB
d. Stage IIIC
e. Stage IV
e. Stage IV
Radiology Jan 2010 (McMahon)“For rectal cancer, paraaortic nodes are nonregional, and spread to these nodes constitutes M1 (stage IV) disease (24).
Inguinal nodes also represent a nonregional site of nodal metastasis in these patients. This is associated with a very poor prognosis and is generally indicative of diffuse disease.”RG 2006
- 70yo man with previous Dukes C CRC (rectal carcinoma). Presents with presacral soft tissue mass on CT done 2 years after surgery, because of rising CEA. (No previous available to compare). Most appropriate imaging?
a. PET-FDG
b. MRI
c. Surgical biopsy
d. Percutaneous biopsy (CT-guided)
e. Re-image with CT in 3 months
a. PET-FDG T if PET-CT
b. MRI T see below
Answer remains controversial (see below) – either A (PET, though needs PET-CT) or B.
If pure PET without CT correlate, then B MRI is best option. CEA = raised in 60-90% of CRC; also can be raised in breast, lung, gastric, pancreatic, bladder, medullary thyroid, etc. malignancies; also can be raised in smokers, PUD, IBD, pancreatitis, cirrhosis, biliary obstruction, etc.Radiology 2004 (Recurrence in patients with rectal carcinoma)
The diagnosis of pelvic recurrence and the differentiation of tumor recurrence and changes associated with previous surgery and/or radiation therapy in the pelvic region constitute a diagnostic challenge for CT, MR imaging, and PET (20–25). Most patients undergoing abdominoperineal resection develop a fibrotic mass in the presacral operative bed. Radiation therapy causes an inflammatory reaction in the pelvic tissues and induces thickening of the perirectal fascia; these changes may appear on CT images for many years and be indistinguishable from tumor recurrence (21).
PET/CT allowed us to differentiate a benign lesion from a tumorous presacral abnormality with a sensitivity of 100% and a specificity of 96%. PET/CT images also provided data that pertained to the involvement of pelvic structures; this information was clinically relevant in selecting an appropriate treatment approach.
AJR March 2010 vol. 194 no. 3 766-771FDG PET/CT has higher sensitivity than MDCT in the identification of sites of recurrent and metastatic disease in patients with colorectal cancer and an elevated CEA level. The two techniques appear to have similar specificity.
Detection of recurrent rectal cancer with CT, MRI and PET/CT – European Radiology 2007, Volume 17, Number 8, Pages 2044-2054
To date, CT is the preferred method for diagnosing local recurrence of CRC. MRI was the superior imaging method with a sensitivity of 91%, a specificity of 100%, and an overall accuracy of 95%. CT reached a sensitivity of 82%, a specificity of 50%, and an accuracy of 68%.MRI is one of the leading imaging modalities for detecting pelvic recurrence of CRC [40–43], in our opinion currently the best, due to its excellent soft-tissue resolution, providing detailed anatomic information. … the positive (PPV) and negative (NPV) predictive values were 87%, 86%, 48% and 98%, respectively.PET is an accurate modality for detecting pelvic recurrence in rectal cancer patients [45], and may have advantages over CT and MRI in differentiating scar from viable tumor. The sensitivity, specificity, overall accuracy, PPV, and NPV were 84%, 88%, 87%, 76% and 92%, respectively. In the study, PET/CT allowed to differentiate benign lesions from presacral recurrences with a sensitivity of 100% and a specificity of 96%.
- Young women (32 years). Barium swallow. Sliding hiatus hernia and stricture to 5mm over 2cm (LAS – narrowing at T6 level), nodular mucosal pattern. Most likely diagnosis:
a. Barrett oesophagus
b. Eosinophilic oesophagitis
a. Barrett oesophagus
A = Barrett oesophagus = T (Gore p55)
• Classic = mid-oesophageal stricture or ulcer or reticular pattern assoc/ w/ sliding hiatus hernia
• Innumerable tiny, barium-filled grooves or crevices adjacent to distal side of stricture
**SCS: statdx: mid oesophageal stricture with hiatus hernia and reflux is essentially pathognomonic,
B = Eosinophilic oesophagitis = F (Gore p83)
• Segmental strictures in oesophagus
• Ringed oesophagus
• Diffuse oesophageal narrowing
• Abnormal motility with ↑ non-peristaltic contractions
• Primer – proximal or mid oesophagus
- 35 year old Asian (Chinese) woman with enlarged hypodense mesenteric lymph nodes on CT, thickening of the terminal ileum and caecum (LAS – hyperdense ascites). Most likely:
a. TB
b. Amoebiasis
c. Crohn disease
d. Lymphoma
a. TB
- Male patient post alcohol binge with blood-stained vomiting. Contrast leakage just above GOJ on barium swallow. Most likely complication of the examination:
a. Mediastinal abscess
b. Fibrosing mediastinitis
c. Fistula
d. Aspiration pneumonia
e. Septicemia
b. Fibrosing mediastinitis a small theoretical risk, see below
- Male patient post alcohol binge with blood-stained vomiting. Contrast leakage just above GOJ on barium swallow. Most likely complication of the examination:
a. Mediastinal abscess certainly a possibility, however wouldn’t be specifically caused by “the examination”
b. Fibrosing mediastinitis a small theoretical risk, see below
c. Fistula
d. Aspiration pneumonia
e. Septicemia
Barium:- granulomatous reaction- mediastinitis- mediastinal fibrosis- in lung : internet -> normally doesn’t not cause aspiration pneumonitis. However stays forever in lung Gastrograffin- aspiration pneumonitis- fatal respiratory failure
Omnipaque- water soluble- safer
A water-soluble contrast agent is generally used as the contrast medium of choice for the initial radiographic evaluation of patients with possible upper gastrointestinal perforation. Water-soluble contrast agents are recommended because they have no known deleterious effects on the neck, mediastinum, pleural cavity, or peritoneal cavities and are absorbed rapidly from these extraluminal spaces if a leak is present. Most authors therefore believe that the radiographic examination should be repeated immediately with barium if no leak is seen with a water-soluble contrast agent in patients with a possible esophageal perforation.Water-soluble contrast agents such as Gastroview are generally administered as the initial contrast medium for the detection of esophageal perforation because of a small theoretic risk that extravasated barium in the mediastinum may cause a granulomatous reaction with mediastinitis or mediastinal fibrosis, as previously shown in studies on laboratory cats.Because water-soluble contrast agents are hyperosmolar and can draw fluid into the lungs causing pulmonary edema if aspirated into the tracheobronchial tree [2–4], some investigators even recommend that barium be used as the initial contrast medium to rule out anastomotic leaks after esophagogastrectomy.
- Young woman with diarrhea for 3 months. Small bowel follow through. Jejunum dilated with crowded thin folds. Most likely diagnosis:
a. Scleroderma
b. Sprue (Coeliac)
c. Crohn
a. Scleroderma
- Young woman with diarrhea for 3 months. Small bowel follow through. Jejunum dilated with crowded thin folds. Most likely diagnosis:
a. Scleroderma
b. Sprue (Coeliac)
c. Crohn
A = Scleroderma = T (Gore & Levine p304, Mayo ebook p226)
• Dilatation of duodenum & jejunum (Type I folds = thin, straight folds with dilated lumen)
• Prolonged SB transit time
• Hidebound bowel = bunching & crowding of SB folds with ↑ no. of folds (virtually pathognomonic of scleroderma)
• Pseudodiverticula/sacculationso Gore/Levine & Dahnert = mesenteric sideo Mayo GI = antimesenterico StatDx & Eisenberg = not specified which side!o Top 3 = antimesenteric
B = Coeliac = F (Gore p306)
• Classified as type I folds, but…
• Decreased number of folds in proximal jejunum, with jejunisation of ileum
• Finely reticular mucosal surface
• Look for cavitary nodes & lymphoma (T-cell)
C = Crohn = F (see above)
DDx for Type 1 folds = dilated lumen with thin (<3mm) straight folds “SOS”
• Sprue (coeliac disease)
• Obstruction (mechanical)
• Scleroderma
• Paralytic ileus
• Other – medications (morphine, atropine), vagotomy
- Man with small bowel follow through, thickening of terminal ileum, fistula
Crohn’s
Woman with previous gastric surgery presents with vomiting. Tubular stomach with central narrowing. Stapples extending from LUQ to epigastrium. Most likely cause:
a. slipped band
b. sleeve gastrectomy
c. partial gastrectomy with anastomotic strictures
d. Bilroth 2 with afferent loop syndrome
b. Sleep gastrectomy
A = F = stomach distal to band should be normal
B = T = tubular stomach could be sleeve gastrectomy = narrow tube of residual stomach, the appearance of which has been likened to a “half-moon” or “banana” with a thin string-like lumen (Abdominal Imaging, 2011) – however if laparoscopic, no staples
C = unlikely
D = unlikely
Patient transferred from elsewhere following unsuccessful resuscitation. Had massive duodenal bleed. All tubes have been removed. 2 ribbon shaped densities in RUQ. Most likely explanation is:
a. embolisation material
b. T-tub
c. Gossypiboma / textiloma
d. penrose drain
A = F
B = F
C = ?T = Gossypiboma or textiloma is the technical term for surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient’s body *LW: favoured answer (AJL agrees, the stem says all drains are removed which presumably includes penrose drains)
D = ?T – can be tubular or ribbon-like (can’t find an x-ray of these though!)
APRIL 201110. 42 female with known Peutz-Jegher syndrome presents with 3 weeks of nausea and vomiting. CT abdomen shows SBO secondary to intussusception. Which of the following statements is MOST correct?
a. SBO is most commonly caused by intussusception
b. Polyps are benign
c. Carcinoid is the most common cause of distal SBO
d. The most common site of lymphoma in the GIT is in the proximal jejunum
e. Peutz-Jegher is a benign polyposis
LJS edit: I would choose b as the most correct - the polyps are benign (hamartomas) but there is a 40% lifetime risk of malignancy, so it is not a benign condition
*LW: agrees.
*AJL I disagree (on the answer not the underlying principle). The peutz jegher polyps are benign/hamartomatous (therefore a benign polyposis) however it is a stretch to say polyps are benign because some polyps are adenomatous (unrelated to PJ, just related to being a person). I think the problem is mostly question interpretation due to it being a recall.
Previous answer:
e. Peutz-Jegher is a benign polyposis T/F – benign hamartomatous polyps with smooth muscle core predominantly in SB, BUT increased risk of carcinoma in general (2-10% get GIT carcinoma, highest risk is breast Ca)
- 42 female with known Peutz-Jegher syndrome presents with 3 weeks of nausea and vomiting. CT abdomen shows SBO secondary to intussusception. Which of the following statements is MOST correct?
a. SBO is most commonly caused by intussusception F Postoperative adhesions cause the majority of small bowel obstructions.
b. Polyps are benign T/F, but are premalignant. A polyp refers to a protuberance into the lumen from the normally flat mucosa. All adenomas are dysplastic.
c. Carcinoid is the most common cause of distal SBO F – can cause SBO, but not most common cause.
d. The most common site of lymphoma in the GIT is in the proximal jejunum F – stomach is most common site: stomach (55-60%) > small intestine (25-30%, esp. ileum) > proximal colon (10-15%) > distal colon (10%)»_space; appendix & oesophagus (rarely involved)
e. Peutz-Jegher is a benign polyposis T/F – benign hamartomatous polyps with smooth muscle core predominantly in SB, BUT increased risk of carcinoma in general (2-10% get GIT carcinoma, highest risk is breast Ca)
Peutz-Jegher syndrome (UTD)
• Gastrointestinal hamartomatous polyps are present in most patients with PJS. These polyps contain a proliferation of smooth muscle extending into the lamina propria in an arborization-like fashion; the overlying epithelium is normal.
• Up to 69 percent of patients experience an intussusception during their lifetime, most often in the small intestine
• The PJS is associated with an increased risk of gastrointestinal and nongastrointestinal malignancies
- Which best describes grade 5 perianal fistula?
f. Intersphincteric fistula with abscess
g. Linear Intersphincteric fistula
h. Translevator
i. Transphincter with abscess
j. Transphincter without abscess
c. Translevator = grade 5.
Which best describes grade 5 perianal fissures?
a. Intersphincteric fistula with abscess = grade 2
b. Linear Intersphincteric fistula = grade 1
c. Translevator = grade 5
d. Transphincter with abscess = grade 4
e. Transphincter without abscess grade 3
- Rectal cancer, transmural thickening, ipsilateral peri rectal nodes, no mets, what stage.
a. 1
b. 2a
c. 3b
d. 3c
e. 4
c. 3b True answer is stage 3a (if T2) or stage 3b (if T3)
**SCS: transmural implies AT LEAST T3 disease, possibly T4. Ipsilateral perirectal nodes ( = regional) ->N1. Thus stage IIIB (T3-4, N1,M0).
Stage groupings
stage 0: Tis N0 M0
stage I: T1-2, N0 M0
stage IIa: T3, N0, M0
stage IIb: T4a, N0, M0IIc: T4b, N0, M0
stage IIIa: T1-2, N1, M0
Stage IIIb: T3-4, N1, M0
Stage IIIc: T3-4b, N2, M0
stage IV: any T, any N, M1
- Anal cancer, 2-5cm in size, unilateral internal iliac nodes, no distal mets, what stage.
a. 1
b. 2
c. 3a
d. 3b
e. 4
**LJS - 3A
Primary tumour (T)TX: primary tumour cannot be assessedT0: no evidence of primary tumour
Tis: carcinoma in situ (Bowen disease, high-grade squamous intraepithelial lesion [HSIL], anal intraepithelial neoplasia II-III (AIN II-III)
T1: tumour 2 cm or less in greatest dimension
T2: tumour >2 cm but <5 cm in greatest dimension
T3: tumour >5 cm in greatest dimension
T4: tumour of any size invades adjacent organ(s), e.g. vagina, urethra, bladder (note that direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4)
Regional lymph nodes (N)
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in regional lymph nodes
N1a: metastases in inguinal, mesorectal, and/or internal iliac lymph nodes
N1b: metastases in external iliac lymph nodes
N1c: metastases in external iliac and in inguinal, mesorectal, and/or internal iliac lymph nodes
Distant metastasis (M)
Mx: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis
STAGE
1 - T1
2 - T2-3
3a - T1-3 N1 - T4 N0
3b - T4 N1 - N2,3
4 - m
- Barium follow through, extrinsic filling defect at D2, likely to represent?
f. Pancreas divisium
g. Annular pancreas
h. Pancreatitis
i. Ectopic pancreas
b. Annular pancreas – dorsal & ventral pancreatic tissues encircle & narrow the periampullary duodenum. If obstructed get double bubble sign. (Gore p693 / Mayo GI)Annular pancreas develops due to failure of ventral bud to rotate with duodenum, causing encasement of duodenum.
- Barium follow through, extrinsic filling defect at D2, likely to represent?
a. Pancreas divisium - usually no mass effect on duodenum
b. Annular pancreas – dorsal & ventral pancreatic tissues encircle & narrow the periampullary duodenum. If obstructed get double bubble sign. (Gore p693 / Mayo GI)
c. Pancreatitis – enlarged pancreatic head can widen the duodenal sweep (Gore p263)
d. Ectopic pancreas – intramural or extramucosal broad-based, smooth lesion with central niche/umbilication
- Pregnancy and appendicitis (which is false?)
a. Risk of perforation of appendix is equal in pregnant and non pregnant patients
b. Decreased ultrasound sensitivity for appendicitis late in pregnancy (or “difficult to see in 3rd trimester because displacement)
c. Most common need for emergency surgery besides obstetric cause
d. US first line of imaging
e. Higher rate of preterm labour & other complications
a. Risk of perforation of appendix is equal in pregnant and non pregnant patients F (High-Risk Pregnancy, James) An infected appendix appears more likely to rupture during pregnancy, esp. in 3rd trimester, possibly because of delay in diagnosis & intervention.6.
Pregnancy and appendicitis (which is false?)
a. Risk of perforation of appendix is equal in pregnant and non pregnant patients F (High-Risk Pregnancy, James) An infected appendix appears more likely to rupture during pregnancy, esp. in 3rd trimester, possibly because of delay in diagnosis & intervention.
b. Decreased ultrasound sensitivity for appendicitis late in pregnancy (or “difficult to see in 3rd trimester because displacement) T – UTD: the gravid uterus can interfere with performance of this technique, particularly in the third trimester, leading to a high negative laparotomy rate when ultrasound results are inconclusive [20,21]. There are no large series in pregnant women. In one small series, the appendix could not be visualized with ultrasound in 22 of 23 pregnant patients with suspected appendicitis
c. Most common need for emergency surgery besides obstetric cause T = Acute appendicitis is the most common general surgical problem encountered during pregnancy (UTD). Appendicitis is the most common cause of abdominal pain that requires emergency surgical treatment during pregnancy (Radiology 2006). Occurs at same frequency as in non-pregnant women.
d. US first line of imaging T
e. Higher rate of preterm labour & other complications T = Maternal morbidity following appendectomy is low except in patients in whom the appendix has perforated. In contrast, pregnancy related complications are frequent, particularly when surgery was performed in the first or second trimester. No pregnancy complications were observed in women who underwent appendectomy in the third trimester. (UTD).
- 75 year-old female with a Zenker diverticulum. What is the most common presentation:
a. Halitosis
b. Cachexia
c. Dysphagia
d. Chest infection
e. Regurgitation of undigested foods.
c. Dysphagia T Present in 80-90% of patients (see article below).
SCS: from Dahnert. 98% get dysphagia.
The rest are valid symptoms.
All of these symptoms can/do occur.Diseases of the Esophagus (2008) 21, 1–8. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management.Although several symptoms may be present, 80–90% of patients complain of dysphagia. Regurgitation of undigested foods, halitosis, and hoarseness can also occur. Cervical borborygmi is almost pathognomonic of ZD. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30–40% of patients describe chronic cough and repeated episodes of aspiration, some with aspiration pneumonia. Symptoms may be present for weeks to several years.
Emedicine (Medscape):
The combination of the following symptoms is nearly pathognomonic for Zenker diverticulum:
• Dysphagia
• Regurgitation of undigested food hours after eating
• Sensation of food sticking in the throat
• Special maneuvers to dislodge food
• Coughing after eating
• Aspiration of organic material
• Unexplained weight loss
• Fetor ex ore
• Borborygmi in the neck
Symptoms may last from months to years.The most common life-threatening complication is aspiration. Other complications include massive bleeding from the mucosa or from fistulization into a major vessel, esophageal obstruction, and fistulization into the trachea. Squamous cell carcinoma (SCC) within Zenker diverticulum is extremely rare, occurring in 0.3% of Zenker diverticula worldwide.
AUGUST 201017. 25yo Singaporian immigrant. RLQ pain. Fever. CT shows multiple 1cm areas of fat density with surrounding inflammatory change posterior to ascending colon. Most likely diagnosis:
i) Diverticulitis
ii) Pseudomonas colitis
iii) Crohns
iv) Epiploic appendagitis
v) Appendicitis
iv) Epiploic appendagitis – T - Usually left-sided, can be right-sided. At CT, a 1–4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation is considered to be diagnostic of epiploic appendagitis (RG 2000). However seems to be usually a single epiploic appendage affected (StatDx) & usually anterior to colon.or
i) Diverticulitis – T – Uncommon on the right, but higher incidence of right diverticulitis in Asians (AJR July 1998). Common conventional CT findings of acute diverticulitis are hazy infiltration of pericolic fat, focal thickening of the colonic wall, and diverticula (AJR 2000). Dahnert states usually solitary diverticulum.Group consensus was epiploic appendagitis, although tough one.
1) 25yo Singaporian immigrant. RLQ pain. Fever. CT shows multiple 1cm areas of fat density with surrounding inflammatory change posterior to ascending colon. Most likely diagnosis (SK / group consensus):
i) Diverticulitis – T – Uncommon on the right, but higher incidence of right diverticulitis in Asians (AJR July 1998). Common conventional CT findings of acute diverticulitis are hazy infiltration of pericolic fat, focal thickening of the colonic wall, and diverticula (AJR 2000). Dahnert states usually solitary diverticulum.
ii) Pseudomonas colitis - Relative paucity of pericolonic inflammation + marked colonic wall thickening differentiates PMC from other colitides (StatDx)
iii) Crohns Unlikely.
iv) Epiploic appendagitis – T - Usually left-sided, can be right-sided. At CT, a 1–4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation is considered to be diagnostic of epiploic appendagitis (RG 2000). However seems to be usually a single epiploic appendage affected (StatDx) & usually anterior to colon.
v) Appendicitis Possible
- 15yo Female. RLQ pain. Enlarged mesenteric nodes on US. Appendix not visualised. Most likely:
i) Typhlitis
ii) Crohn’s
iii) Mesenteric adenitis
iv) Diverticulitis
v) Appendicitis
iii) Mesenteric adenitis
2) 15yo Female. RLQ pain. Enlarged mesenteric nodes on US. Appendix not visualised. Most likely:
i) Typhlitis
ii) Crohn’s
iii) Mesenteric adenitis
iv) Diverticulitis
v) Appendicitis
Quotes (various sources)
• Mesenteric adenitis is most common < 15 years old (StatDx Paeds) or < 25 years old (StatDx Abdo)
• Appendicitis is frequently associated with lymphadenopathy, most commonly in the mesentery of the right lower quadrant (RG 2005)
• The presence of enlarged lymph nodes in the mesentery of the right lower quadrant with a normal-appearing appendix may reflect mesenteric adenitis in the correct clinical setting (RG 2005)
• Dahnert – enlarged nodes in appendicitis immediately anterior to right psoas muscle, less numerous & smaller (but must visualize normal appendix to exclude!)
- 30yr old female has barium swallow. Shows 6cm long symmetrical narrowing of the distal oesophagus with 1cm of distal dilatation at level of the vestibule. Likely cause:
i) Achalasia
ii) Barrett’s
iii) Ca
iv) Scleroderma
v) Cricopharyngeal spasm
ii) Barrett’s – T/F Stricture classically mid oesophagus above the Barrett metaplasia assoc/ w/ sliding hiatus hernia (Mayo/Gore). However a more distal stricture can occur with short-segment Barrett oesophagus or in peptic stricture without Barrett (Gore p55).
3) 30yr old female has barium swallow. Shows 6cm long symmetrical narrowing of the distal oesophagus with 1cm of distal dilatation at level of the vestibule. Likely cause: (SK)
i) Achalasia – F 2cm smooth stricture in region of GOJ that transiently relaxes (Mayo Clinic GI)
ii) Barrett’s – T/F Stricture classically mid oesophagus above the Barrett metaplasia assoc/ w/ sliding hiatus hernia (Mayo/Gore). However a more distal stricture can occur with short-segment Barrett oesophagus or in peptic stricture without Barrett (Gore p55).
iii) Ca F – irregular luminal contour with abrupt, shouldered margins
iv) Scleroderma – F/T – dilated oesophagus and patulous GOJ. However could have this finding later in disease course due to superimposed GORD/Barrett with fusiform stricture formation. Age of onset of scleroderma typically 30-50 years however.
v) Cricopharyngeal spasm – F – higher
• Distal oesophagus – fusiform dilatation just above GOJ (oesophageal vestibule)
o Upper part defined by a transiently contractile ring (the A ring)
• Inferior oesophageal sphincter, caused by muscular thickening
• Transient, changes in shape & disappears at fluoroscopy
• Prominent in patients with hiatus hernia, GORD and some motility disorders
o Lower part defined by another transiently contractile ring (the B ring, transverse mucosal fold or lower oesophageal ring)
• Usually located below the diaphragm (esp. in young people) & not identified radiologically unless hiatus hernia present
• Mucosal ring
• Thin, fixed, does not change appearance
• Marks location of GOJ
• Called Schatzki ring when prominent & symptomatic (dysphagia) – B-ring with < 13mm of luminal narrowing; usually a hiatus hernia is present belowo Mucosal junction b/w oesophagus & stomach occasionally seen as a fine line (the ‘Z’ line)
- 40yo bowel wall thickening of terminal ileum with adjacent calcified mass in the mesentery. Best option:
i) Crohn’s
ii) Carcinoid
iii) Lymphoma
ii) Carcinoid T With mesenteric infiltration get calcification within mesenteric mass in up to 70% (StatDx). Spiculated mass in mesentery with calcification, a/w wall thickening of an adjacent bowel loop. Distal 50cm of ileum is most common site of SB involvement (Gore p333)
4) 40yo bowel wall thickening of terminal ileum with adjacent calcified mass in the mesentery. Best option:
i) Crohn’s F
ii) Carcinoid T With mesenteric infiltration get calcification within mesenteric mass in up to 70% (StatDx). Spiculated mass in mesentery with calcification, a/w wall thickening of an adjacent bowel loop. Distal 50cm of ileum is most common site of SB involvement (Gore p333).
iii) Lymphoma T/F Calcification of nodes can occur, usually after treatment (StatDx)
- 30yo female with diarrhoea. 6cm segment of jejunum demonstrating wall thickening with enteric fistula. Likely:
i) Crohn’s
ii) Carcinoid
iii) Lymphomai
v) Coeliac
i) Crohn’s T sinus tracts & fistulas are common & characteristic of CD at advanced stages (Gore/Primer). CD is 3rd most common cause of fistula (after iatrogenic & diverticular disease) (Dahnert).
5) 30yo female with diarrhoea. 6cm segment of jejunum demonstrating wall thickening with enteric fistula. Likely:
i) Crohn’s T sinus tracts & fistulas are common & characteristic of CD at advanced stages (Gore/Primer). CD is 3rd most common cause of fistula (after iatrogenic & diverticular disease) (Dahnert).
ii) Carcinoid F
iii) Lymphoma F rarely fistula (StatDx)
iv) Coeliac F
- Middle aged woman fistula between sigmoid and vagina. Exam neglected to specify whether wanted most likely or least likely, so went with most likely:
i) Rectovesical fistulas more common in females
ii) Most common cause diverticulitis
iii) Fistula tract readily visible on CT
iv) Fistula readily visible on sigmoidoscopy
ii) Most common cause diverticulitis T major cause of colovaginal fistula is sigmoid diverticulitis
6) Middle aged woman fistula between sigmoid and vagina. Exam neglected to specify whether wanted most likely or least likely, so went with most likely:
i) Rectovesical fistulas more common in females F because vagina/cervix/uterus in the way; UTD: “colovesical fistulas secondary to diverticulitis has a distinct (2 to 3:1) male predominance”
ii) Most common cause diverticulitis T major cause of colovaginal fistula is sigmoid diverticulitis
iii) Fistula tract readily visible on CT F UTD “the diagnosis is usually made by the combination of local colonic thickening adjacent to an area of thickened bladder, associated diverticula, and oral contrast material or air in the bladder (prior to instrumentation of the urinary tract)”
iv) Fistula readily visible on sigmoidoscopy F The direct yield (eg, visualization of the fistula) from both BE and endoscopy tends to be low (20 to 26 percent and 0 to 3 percent, respectively)
MARCH 201050 yo woman. previous gastric surgery. Present with vomiting. Oral contrast study shows intact gastric fungus and body. Absent antrum and pylorus. Stomach empty into loop of small bowel which courses to RUQ.
a. fundoplication unwrapped?
b. bilroth 2 with afferent loop syndrome
c. partial gastrectomy with stenosis at surgical site
d. sleeve gastrectomy with stenosis
GL : I think probably B: Afferent loop syndrome - an intermittent partial or complete mechanical obstruction of the afferent limb of a gastrojejunostomy.
Occurs in
- partial gastrectomy : Billroth II gastrojejunostomy
- gastric bypass :Roux-en-Y
gastric bypass- pancreaticoduodenectomy
A fundoplication unwrapped = F
B bilroth 2 with afferent loop syndrome = possibly T, although if high-grade obstruction in afferent loop syndrome the afferent loop fails to fill
C = partial gastrectomy with stenosis at surgical site = possibly T, if Bilroth 2 with stenosis of efferent limb & preferential filling of afferent limb
D sleeve gastrectomy with stenosis = F
Afferent loop syndrome (ALS) is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. Creation of an anastomosis between the stomach and jejunum leaves a segment of small bowel, most commonly consisting of duodenum and proximal jejunum, lying upstream from the gastrojejunostomy. This limb of intestine conducts bile, pancreatic juices, and other proximal intestinal secretions toward the gastrojejunostomy and is thus termed the afferent loop.
ALS manifests in acute and chronic forms.
Acute ALS represents complete obstruction of the afferent loop and is a true surgical emergency. It must be diagnosed and corrected expeditiously. Chronic ALS is associated with partial obstruction. It is not a surgical emergency but does require corrective surgery.
Projectile bilious vomiting is a classic manifestation of ALS with partial obstruction.
35 yo women. Barium swallow: posterior indentation at C6.
a. zenker
b. eosinophilic oesophagitis
c. cricopharyngeous spasm
StatDx = cricopharyngeal achalasia
• Prominent cricopharyngeus muscle at pharyngoesophageal junction with retention of barium in pharynx on lateral view
• Pharyngoesophageal junction: C5-6 level