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Gastrointestinal > Small Bowel > Flashcards

Small Bowel Flashcards

1
Q

DDx for smooth surfaced filling defect in jejunum

A 
GIST
Hemangioma
Lipoma
Metastasis
Lymphoma
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2
Q

Where in the small bowel do lipoma usually occur? What is a key differentiating feature?

A

Distal in the small bowel

Compressibility!

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3
Q

What is the difference between lipoma and liposarcoma?

A

Lipoma will be homogeneously fat

Liposarcoma will have a soft tissue component

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4
Q

What is the DDx for multiple small bowel lesions on SBFT?

A

Lymphoma, Polyposis, Hemangioma, Neurofibroma, Metastases

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5
Q

Where do hemangiomas usually occur?

What syndromes have an increased incidence?

A

Jejunum

Turner
Tuberous sclerosis
Blue rubber nevus
Rendu-osler-weber

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6
Q

What is CT enterography?

A

IV contrast enhances the bowel wall

Water attenuation luminal contrast enhances the lumen

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7
Q

How do hemangiomas present on CT?

A

CAN have calcifications

Small tufts of enhancement within the bowel wall

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8
Q

What two syndromes are associated with diffuse hemangiomatosis

A

Klipper-trenauny-Weber (varicose veins, cutaneous hemangiomas, soft tissue/bone hypertrophy)

Maffuic (enchondromas, subcutaneous cavernous hemangiomas)

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9
Q

Cauliflower like grouped polyps in the jejunum in a

A

Peutz Jeughers (Hamartomatous polyps)

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10
Q

What cells do carcinoid tumors arise from? What do they produce? What size does malignant transformation occur? Where are they found in the small bowel?

What is the radiographic appearance?

A

Kulchitsky cells (APUD), usually 2-3cm
Serotonin
>1cm
Distal small bowel, within 2 feet of ileocecal valve

Cause a fibrotic reaction leading to kinking of the bowel with obstruction.

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11
Q

Starburst appearance with linear stranding radiating from a central mesenteric mass with calcification indicates what?

A

Metastatic carcinoid to the small bowel

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12
Q

How do carcinoid mets to the liver present?

A

Hypervascular mass with central necrosis

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13
Q

Who is at risk of small bowel lymphoma?

A

AIDS
Celiac disease
Crohns
Lupus

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14
Q

Which lymphoma is most common in the small bowel?

A

NHL

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15
Q

What are the 4 classifications of small bowel lymphoma?

Which is most common?

A

Multiple nodules - most common, can cross IC valve
Infiltrating
Polypoid - can be “pseudopedunculated”
Endo-exoenteric

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16
Q

DDx for a focal segment of small bowel with smooth mucosa and loss of folds.

Differentiate them

A

Ischemia - will have narrowed lumen
Amyloidosis - may cause fold thickening
Lymphoma - wont have associated fibrosis, thus causing dilation (vs narrowing with ischemia)

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17
Q

Differentiate small bowel lymphoma vs ischemia

A

Ischemia will cause lumenal narrowing

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18
Q

Differentiate hodgkins vs nonhodgkins in the small bowel

A

Hodgkins will incite a desmoplastic reaction, causing luminal narrowing

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19
Q

What type of lymphoma in AIDS patients?

A

B-cell lymphoma

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20
Q

What helps to differentiate malignant GIST vs lymphomas?

A

adenopathy

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21
Q

Where is primary adenocarcinoma most commonly found in the small bowel? What is a known risk factors?

A

Proximal, duodenum

Adult celiac disease

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22
Q

How do malignant GIST spread?

A

Hematogenous and peritoneal spread

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23
Q

How common is small bowel mets in metastatic melanoma?

A

50% at autopsy

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24
Q

Bulky intraluminal mass in the retroperitoneal duodenum suggests what?

A

Invasive renal cell carcinoma

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25
Q

Large cavitated mass devoid of mucosal markings with destruction of the bowel wall can be seen with what 3 entities?

A

Lymphoma, malignant GIST, colon cancer mets

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26
Q

Where are the 3 most common sites of intraperitoneal seeding? How does it present radiographically?

A

Pouch of douglas, ileocecal region, superior aspect of sigmoid

Displaced bowel loops with narrowed lumen causing angulation and kinking of loops with fold tethering

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27
Q

Where is the most common location of a duplication cyst?

A

Terminal ileum

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28
Q

Biliary gas and mechanical SBO suggests what?

A

Gallstone ileus

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29
Q

Describe the pathphysiloigy of ascariasis infection

A

Ingested eggs hatch in the small bowel and penetrate the mucosa

Travel up to lungs by lymphatics/portal system

Travel up bronchi and are swallowed and shed infections eggs

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30
Q

DDx for thin (

A

Mechanical obstruction
Paralytic Ileus
Scleroderma
Sprue

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31
Q

What are the 5 questions to ask with an SBO?

A 
1 - is there an SBO
2 - where is the obstruction
3 - What is the cause of the obstruction
4 - Are there complications
5 - How should they be treated
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32
Q

Most common cause of mechanical SBO?

A

Adhesions

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33
Q

What helps to differentiate paralytic ileus vs obstruction

A

Gas in the colon distal to obstruction

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34
Q

How does scleroderma present in the small bowel?

A

“hidebound” - dilation and crowding of straight and thin mucosal folds

sacculations of antimesenteric border, occasional pneumotosis cystoides intestinalis (can be due to steroid use)

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35
Q

Differentiate sprue from scleroderma

A

Sprue will have hypersecretion and normal peristaltic activity

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36
Q

How does sprue present?

A

Jejunization of the ileum - adaptive response to loss of absorptive surface in proximal small bowel by villous atrophy

Decrease in number of proximal jejunal folds (

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37
Q

DDx for Thick (>3mm) straight folds

Segmental?
Diffuse?

A

Segmental - ischemia, radiation enteritis, intramural hemorrhage, adjacent inflammation

Diffuse - venous congestion, hypoprotenemia, cirrhosis

38
Q

What are the causes of bowel ischemia? most common?

A

arterial hypoperfusion (most frequent)
embolization
venous thrombosis

39
Q

What is the pathophysiologic timescale of events in bowel ischemia?

What are the 3 possible outcomes?

A

Submucosal edema and intramural hemorrhage
transmural ischemia
necrosis

Complete healing
Stricture formation
Perforation

40
Q

Radiographic findings of ischemia?

A

Isolated, rigid dilated and unchanging small bowel loop with thickened mucosal folds

41
Q

Which portion of GI tract is most susceptible to radiation? At what dose>

A

Small bowel

> 40 Gy

42
Q

What is the pathologic process for radiation? How long before chronic changes?

What are the imaging characteristics?

A

Endarteritis obliterans. >6 weeks

Fold thickening and serration, nodularity and thumbprinting later on

43
Q

Stack of coins appearance of the small bowel suggests what?

A

Intramural hemorrhage.

44
Q

What associated findings suggest hypoproteinemia as a cause of diffuse fold thickening

A

Ascites, anasarca

45
Q

DDx for segmental, thick (>3mm) nodular folds

A

Crohns
Infection
Lymphoma
Metastases

46
Q

DDx for diffuse, thick (>3mm) nodular folds

A 
Whipple disease
Intestinal Lymphangiectasia
Nodular lymphoid hyperplasia
Polyposis
Eosinophilic gastroenteritis
Amyloidosis
Mastocytosis
Lymphoma
Metastases
47
Q

Which segment of small bowel has best prognosis if affected in crohns? Which has highest rate of complication

A

Distal small bowel

Ileocolic has highest rate of complciation

48
Q

Localized fold thickening in the proximal small bowel suggests what

A

Infection (giardiasis, whipple)

49
Q

Who is prone to giardia infection?

A

hypogammaglobulinemia

50
Q

How does giardia present radiographically

A

Nodular fold thickening, increased secretions, spasm/rapid transit

51
Q

Malabsorption, arthralgia, lymphadenopathy, abdominal tenderness, increased skin pigmentation

A

Whipple

52
Q

Why is the PAS positive in whipple

A

glycoprotein deposited in macrophages of the lamina propria

53
Q

What is a key feature of whipple disease?

A

Lack of hypersecretion, dilation, or distal bowel involvement

54
Q

What non GI CT findings helps suggest whipple disease?

A

Sacroilitis

low attenuation LN

55
Q

What is the pathology of lymphangectasia?

What is the usual radiogarphic presentation

A

Dilated lymph channels in the lamina propria and submucosa of bowel wall with associated enlarged villi

Channels may rupture and spill into lumen causing barium dilution

Thickened folds with nodules
or
Nodular filling defects

56
Q

Tx of lymphangectasia?

A

Medium chain triglycerides

57
Q

innumerable uniform nodular filling defects throughout small bowel

A

nodular lymphoid hyperplasia

58
Q

What is nodular lymphoid hyperplasia usually associated with?

A

deficiency of IgA or IgM

59
Q

Usual presentation of nodular lymphoid hyperplasia? Main DDx?

A

Innumerable, UNIFORM

60
Q

GIve a DDx for terminal ileal discrete ulcerations.

A

Crohns

Infection (yersiniosis, amebiasis, TB)

61
Q

What stones are crohns patients have increased risk of?

A

Cholesterol gallstones and oxalate renal stones

62
Q

What is the string sign? Where is it seen most commonly?

A

Fixed narrowing with short segmental stricture from intramural fibrosis of crohns. Terminal ileum most commonly affected.

63
Q

Circumferential asymmetry is suggestive of what dx?

A

Crohns

64
Q

Differentiate yersinia/salmonella from crohns of the TI?

A

Yersinia/salmonella can have superficial erosions and fold thickening WITHOUT strictures

65
Q

What is creeping fat

A

Fibrofatty changes in the mesentery adjacent to bowel wall thickening - seen with crohns

66
Q

How/where does recurrent crohns occur?

A

Irregular countouring and nodular ulceration of the neoterminal ileum.

67
Q

Differentiate active vs inactive crohns

A

Active - soft tissue density or contain a central water density ring

Inactive - Fat within the bowel wall (may be due to corticosteroid use)

68
Q

DDx for thick small bowel wall with submucosal edema

A 
Ischemia
Crohns
Lymphoma
Radiation enteritis
ACE-I induced
69
Q

What helps differentiate intramural vs intraluminal gas

A

Intraluminal will be nondependent

Intramural will be nondependent and POSTERIOR and DEPENDENT because it is within the wall

70
Q

name 4 conditions associated with pneumatosis intestinalis

A

Ischemia
Scleroderma
Corticosteroid use
COPD

71
Q

What is a closed-loop obstruction

A

Mechanical small bowel obstruction in which blood supply to the loop can be compromised

72
Q

What are the signs of closed loop obstruction

A

Bowel thickening, vascular engorgement, mesenteric stranding, differential perfusion loop

73
Q

Small bowel and mesentery encircle the SMA in a whorl pattern in what condition

A

Midgut volvulus

74
Q

What is the moulage sign?

A

“molded” or “casted” structure - resembles a tubular cast with paucity of mucosal folds

seen with Celiac

75
Q

Featureless ileum with excessive intraluminal fluid obscures with moulage sign

A

Celiac disease

76
Q

Loss of jejunal fold pattern and flocculation with segmentation of barium

A

Sprue

77
Q

What are the three types of sprue?

A

Non tropical (gluten sensitive) – adult and childhood

Tropical

78
Q

What are the radiologic features of sprue

A

Hyper secretion - excess intraluminal fluid
Clumping and segmentation of barium
Thickened folds

79
Q

tubular and featureless jejunum with focal stricture?

A

Sprue - can develop stricture due to ulcerative jejunoileitis

80
Q

Name 6 associated conditions with celiac disease

A 
Hyposplenism
Cavitary lymph node syndrome
Carcinoma
Lymphoma
Immunoglobulin A deficiency
Dermatitis herpetiformis
81
Q

What part of the GI system does TB affect

A

Distal small bowel and cecum

82
Q

What are the findings of GI TB

A 
Ulcerations
luminal narrowing with segmental involvement
wall thickening
fistulas
shrunken and deformed cecum
83
Q

Prolonged coating of affected bowel segments with barium for several days after the examination

A

Graft vs host disease

84
Q

What are the two main regions of rotation of intestine during fetal life

A

Duodenum-jejunum

Cecocolic

85
Q

What are the different types of malrotation

A

Nonrotation - small bowel in right hemiabdomen, colon in left

Incomplete rotation - incorrect location of cecum

Incomplete mesenteric fixation - mobile cecum

86
Q

What are the 3 main complications of malrotation

A

Midgut volvulus/Obstruction

Congenital diaphragmatic hernia

Omphalocele

87
Q

What is the consequence of small bowel diverticula

A

Usually asymptomatic

Occasionally lead to bacterial overgrowth

88
Q

Hyperenhancement of bowel wall, kidneys, and adrenals

Small or collapsed inferior vena cava

A

Hypoperfusion complex

89
Q

What is a meckels diverticulum

A

Remnant of the omphalomesenteric duct

90
Q

Which tracer is used in a meckels scan

A

Technetium pertechnetate

91
Q

What organs normally take up TcPertechnetate

A

Stomach, salivary glands

92
Q

DDx for Atrophic featureless bowel folds

A 
GVHD
Chronic ischemia
Celiac disease
Radiation enteritis
Amyloidosis
Infectious

Gastrointestinal (13 decks)

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