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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
Large cavitated mass devoid of mucosal markings with destruction of the bowel wall can be seen with what 3 entities?
Lymphoma, malignant GIST, colon cancer mets
26
Where are the 3 most common sites of intraperitoneal seeding? How does it present radiographically?
Pouch of douglas, ileocecal region, superior aspect of sigmoid Displaced bowel loops with narrowed lumen causing angulation and kinking of loops with fold tethering
27
Where is the most common location of a duplication cyst?
Terminal ileum
28
Biliary gas and mechanical SBO suggests what?
Gallstone ileus
29
Describe the pathphysiloigy of ascariasis infection
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
30
DDx for thin (
Mechanical obstruction Paralytic Ileus Scleroderma Sprue
31
What are the 5 questions to ask with an SBO?
``` 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 ```
32
Most common cause of mechanical SBO?
Adhesions
33
What helps to differentiate paralytic ileus vs obstruction
Gas in the colon distal to obstruction
34
How does scleroderma present in the small bowel?
"hidebound" - dilation and crowding of straight and thin mucosal folds sacculations of antimesenteric border, occasional pneumotosis cystoides intestinalis (can be due to steroid use)
35
Differentiate sprue from scleroderma
Sprue will have hypersecretion and normal peristaltic activity
36
How does sprue present?
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 (
37
DDx for Thick (>3mm) straight folds Segmental? Diffuse?
Segmental - ischemia, radiation enteritis, intramural hemorrhage, adjacent inflammation Diffuse - venous congestion, hypoprotenemia, cirrhosis
38
What are the causes of bowel ischemia? most common?
arterial hypoperfusion (most frequent) embolization venous thrombosis
39
What is the pathophysiologic timescale of events in bowel ischemia? What are the 3 possible outcomes?
Submucosal edema and intramural hemorrhage transmural ischemia necrosis Complete healing Stricture formation Perforation
40
Radiographic findings of ischemia?
Isolated, rigid dilated and unchanging small bowel loop with thickened mucosal folds
41
Which portion of GI tract is most susceptible to radiation? At what dose>
Small bowel >40 Gy
42
What is the pathologic process for radiation? How long before chronic changes? What are the imaging characteristics?
Endarteritis obliterans. >6 weeks Fold thickening and serration, nodularity and thumbprinting later on
43
Stack of coins appearance of the small bowel suggests what?
Intramural hemorrhage.
44
What associated findings suggest hypoproteinemia as a cause of diffuse fold thickening
Ascites, anasarca
45
DDx for segmental, thick (>3mm) nodular folds
Crohns Infection Lymphoma Metastases
46
DDx for diffuse, thick (>3mm) nodular folds
``` Whipple disease Intestinal Lymphangiectasia Nodular lymphoid hyperplasia Polyposis Eosinophilic gastroenteritis Amyloidosis Mastocytosis Lymphoma Metastases ```
47
Which segment of small bowel has best prognosis if affected in crohns? Which has highest rate of complication
Distal small bowel Ileocolic has highest rate of complciation
48
Localized fold thickening in the proximal small bowel suggests what
Infection (giardiasis, whipple)
49
Who is prone to giardia infection?
hypogammaglobulinemia
50
How does giardia present radiographically
Nodular fold thickening, increased secretions, spasm/rapid transit
51
Malabsorption, arthralgia, lymphadenopathy, abdominal tenderness, increased skin pigmentation
Whipple
52
Why is the PAS positive in whipple
glycoprotein deposited in macrophages of the lamina propria
53
What is a key feature of whipple disease?
Lack of hypersecretion, dilation, or distal bowel involvement
54
What non GI CT findings helps suggest whipple disease?
Sacroilitis low attenuation LN
55
What is the pathology of lymphangectasia? What is the usual radiogarphic presentation
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
Tx of lymphangectasia?
Medium chain triglycerides
57
innumerable uniform nodular filling defects throughout small bowel
nodular lymphoid hyperplasia
58
What is nodular lymphoid hyperplasia usually associated with?
deficiency of IgA or IgM
59
Usual presentation of nodular lymphoid hyperplasia? Main DDx?
Innumerable, UNIFORM
60
GIve a DDx for terminal ileal discrete ulcerations.
Crohns | Infection (yersiniosis, amebiasis, TB)
61
What stones are crohns patients have increased risk of?
Cholesterol gallstones and oxalate renal stones
62
What is the string sign? Where is it seen most commonly?
Fixed narrowing with short segmental stricture from intramural fibrosis of crohns. Terminal ileum most commonly affected.
63
Circumferential asymmetry is suggestive of what dx?
Crohns
64
Differentiate yersinia/salmonella from crohns of the TI?
Yersinia/salmonella can have superficial erosions and fold thickening WITHOUT strictures
65
What is creeping fat
Fibrofatty changes in the mesentery adjacent to bowel wall thickening - seen with crohns
66
How/where does recurrent crohns occur?
Irregular countouring and nodular ulceration of the neoterminal ileum.
67
Differentiate active vs inactive crohns
Active - soft tissue density or contain a central water density ring Inactive - Fat within the bowel wall (may be due to corticosteroid use)
68
DDx for thick small bowel wall with submucosal edema
``` Ischemia Crohns Lymphoma Radiation enteritis ACE-I induced ```
69
What helps differentiate intramural vs intraluminal gas
Intraluminal will be nondependent Intramural will be nondependent and POSTERIOR and DEPENDENT because it is within the wall
70
name 4 conditions associated with pneumatosis intestinalis
Ischemia Scleroderma Corticosteroid use COPD
71
What is a closed-loop obstruction
Mechanical small bowel obstruction in which blood supply to the loop can be compromised
72
What are the signs of closed loop obstruction
Bowel thickening, vascular engorgement, mesenteric stranding, differential perfusion loop
73
Small bowel and mesentery encircle the SMA in a whorl pattern in what condition
Midgut volvulus
74
What is the moulage sign?
"molded" or "casted" structure - resembles a tubular cast with paucity of mucosal folds seen with Celiac
75
Featureless ileum with excessive intraluminal fluid obscures with moulage sign
Celiac disease
76
Loss of jejunal fold pattern and flocculation with segmentation of barium
Sprue
77
What are the three types of sprue?
Non tropical (gluten sensitive) -- adult and childhood Tropical
78
What are the radiologic features of sprue
Hyper secretion - excess intraluminal fluid Clumping and segmentation of barium Thickened folds
79
tubular and featureless jejunum with focal stricture?
Sprue - can develop stricture due to ulcerative jejunoileitis
80
Name 6 associated conditions with celiac disease
``` Hyposplenism Cavitary lymph node syndrome Carcinoma Lymphoma Immunoglobulin A deficiency Dermatitis herpetiformis ```
81
What part of the GI system does TB affect
Distal small bowel and cecum
82
What are the findings of GI TB
``` Ulcerations luminal narrowing with segmental involvement wall thickening fistulas shrunken and deformed cecum ```
83
Prolonged coating of affected bowel segments with barium for several days after the examination
Graft vs host disease
84
What are the two main regions of rotation of intestine during fetal life
Duodenum-jejunum Cecocolic
85
What are the different types of malrotation
Nonrotation - small bowel in right hemiabdomen, colon in left Incomplete rotation - incorrect location of cecum Incomplete mesenteric fixation - mobile cecum
86
What are the 3 main complications of malrotation
Midgut volvulus/Obstruction Congenital diaphragmatic hernia Omphalocele
87
What is the consequence of small bowel diverticula
Usually asymptomatic Occasionally lead to bacterial overgrowth
88
Hyperenhancement of bowel wall, kidneys, and adrenals Small or collapsed inferior vena cava
Hypoperfusion complex
89
What is a meckels diverticulum
Remnant of the omphalomesenteric duct
90
Which tracer is used in a meckels scan
Technetium pertechnetate
91
What organs normally take up TcPertechnetate
Stomach, salivary glands
92
DDx for Atrophic featureless bowel folds
``` GVHD Chronic ischemia Celiac disease Radiation enteritis Amyloidosis Infectious ```

Gastrointestinal (13 decks)

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