Small Intestine

Question 1

A 25-year-old male presents following blunt abdominal trauma following a motor vehicle accident. Which is the most common CT finding in the ‘shock bowel’?

A. Small bowel luminal dilation

B. Fluid-filled loops of small bowel

C. Colonic involvement greater than small bowel

D. Increased small bowel mucosal enhancement

E. Focal involvement of the small bowel

Answer 1

D. Increased small bowel mucosal enhancement

Increased small bowel mucosal enhancement (HU > psoas) and mural thickening > 3mm are the most common signs. Colon involvement is infrequent and the small bowel is typically diffusely involved.

Question 2

The CT of a 50-year-old man with abdominal pain shows a stellate enhancing mesenteric mass with a radiology pattern of linear densities emanating from the mass. Adjacent small bowel loops show tethering and thickening. Which is the most likely diagnosis?

A. Primary mesenteric mesothelioma

B. Desmoid tumour

C. Non-Hodgkin’s Lymphoma (NHL)

D. Metastatic carcinoid tumour

E. Abdominal TB

Answer 2

D. Metastatic carcinoid tumour

The stellate pattern is characteristic for carcinoid tumor.

Question 3

A duodenal diverticulum is noted on CT as an incidental finding. Which is the single best answer?

A. Commonly symptomatic with high risk of inflammation

B. Reported in up to 5% of upper Gastrointestinal (GI) fluoroscopic studies

C. Mostly located on the lateral wall of the duodenum

D. Mostly arise from the third or fourth part of the duodenum

E. If perforated is easy to distinguish from a perforated duodenal ulcer

Answer 3

B. Reported in up to 5% of upper Gastrointestinal (GI) fluoroscopic studies

Common acquired outpouchings of the mucosa and submucosa located along the medial wall of the duodenum within 2cm of the ampulla of Vater.

25% arise from D3/4.

Reported in 1-5% of upper GI fluoroscopic studies.

Question 4

Which of the following is a cause of smooth, regular and thickened folds in non-dilated small bowel?

A. Crohn’s

B. Zollinger-Ellison

C. Intraluminal haematoma

D. Tuberculosis

E. Carcinoid

Answer 4

C. Intraluminal haematoma

B-D are cases of irregular and thickened distal folds in non- dilated small bowel.

Question 5

Which of the following is a case of decreased/absent duodenal folds:

A. Pancreatitis

B. Lymphoma

C. Melanoma metastases

D. Whipples disease

E. Scleroderma

Answer 5

E. Scleroderma

Scleroderma, strongyloides, and cystic fibrosis are causes of decreased/absent folds. Crohn’s and amyloidosis can cause decreased or increased folds.

Question 6

1. A 34-year-old woman with a history of steatorrhea and weight loss undergoes a small bowel follow-through examination that demonstrates dilatation of the proximal small bowel with flocculation and segmentation of the barium column. Fold thickness is normal. What is the most likely diagnosis?

A. Crohn’s disease

B. Zollinger–Ellison syndrome

C. coeliac disease

D. small bowel lymphoma

E. Whipple’s disease

Answer 6

C. coeliac disease

Coeliac disease is characterized by malabsorption due to intolerance to the alpha-gliadin component of gluten, which causes small intestinal villous atrophy.

Typical findings are of dilatation of the proximal small bowel, together with dilution of the barium column due to hypersecretion of fluid.

Artefacts such as segmentation (breaking up of the barium column) or flocculation (clumping of disintegrated barium) were traditionally classic features of coeliac disease, but are less often seen nowadays with improved barium suspensions.

In Whipple’s disease the small bowel is typically non-dilated, and shows moderate fold thickening.

Crohn’s disease usually causes nodular fold thickening, and predominantly involves the distal small bowel.

Zollinger–Ellison syndrome results in dilatation of proximal small bowel due to hypersecretion, but typically causes thickened folds.

Small bowel lymphoma is usually associated with fold thickening.

Question 7

2. A 25-year-old woman presents with cramping abdominal pain and bleeding per rectum. On examination she has mucocutaneous pigmentation of her mucous membranes and face. A small bowel follow-through examination demonstrates small-bowel intussusception. Which other finding is most likely to be demonstrated?

A. separation and displacement of small bowel loops

B. localized outpouching of the antimesenteric border of the distal ileum

C. generalized irregular fold thickening

D. multiple filling defects in the small bowel

E. generalized dilatation of the small bowel

Answer 7

D. multiple filling defects in the small bowel

Peutz–Jegher syndrome is characterized by multiple benign hamartomata’s intestinal polyps and mucocutaneous pigmentation. It is familial in 50% of cases, with an autosomal dominant inheritance, and sporadic in 50%. It is the most common polyposis syndrome to involve the small intestine, and frequently presents with intussusception.
Typical findings are of multiple hamartomatous polyps in the small bowel, and less commonly the colon and stomach. Patients are at increased risk of gastrointestinal malignancy, but also of tumours of the pancreas, breast, ovary, endometrium and testis.

Question 8

A 46-year-old man presents with severe abdominal pain. An erect chest radiograph shows free intraperitoneal air below the diaphragm. What is the most likely cause?

A. perforated anterior wall duodenal ulcer

B. perforated posterior wall duodenal ulcer

C. perforated gastric ulcer

D. perforated appendix

E. diverticulitis with perforation

Answer 8

A. perforated anterior wall duodenal ulcer

The commonest cause of a free intraperitoneal perforation is an anterior wall duodenal ulcer.

However, free peritoneal air is only apparent on an erect chest radiograph in 60%of perforated duodenal ulcers. Possible causes include sealing of the perforation, adhesions preventing the gas reaching the subphrenic space or insufficient time being allowed for gas to collect under the diaphragm.

Anterior wall gastric ulcers also perforate into the peritoneal cavity but are a less common cause of pneumoperitoneum.

Posterior wall duodenal and gastric ulcers perforate into the lesser sac or retroperitoneal region rather than the peritoneal cavity.

Perforated appendix and diverticulitis may produce localized collections of extraluminal gas, but pneumoperitoneum is rare.

Question 9

3. A 20-year-old woman with anorexia nervosa presents with intermittent abdominal pain and vomiting relieved by lying prone. Barium meal examination reveals a vertical band-like narrowing of the third part of the duodenum, with proximal duodenal dilatation and vigorous to-and-fro peristalsis. What is the most likely diagnosis?

A. duodenal duplication cyst

B. annular pancreas

C. Ladd’s bands

D. superior mesenteric artery syndrome

E. duodenal atresia

Answer 9

D. superior mesenteric artery syndrome

The third part of the duodenum is bounded posteriorly by the aorta, and anteriorly by the root of the mesentery carrying the superior mesenteric artery.

In superior mesenteric artery syndrome, the third part of the duodenum is compressed by the superior mesenteric artery, and the angle between it and the aorta narrows to 10–22° (normal 45–65°).

The condition is associated with severe weight loss, prolonged bedrest (particularly in a body cast), lumbar lordosis and pregnancy.

Patients report intermittent abdominal pain and vomiting, relieved by lying prone or in the knee–elbow position.

Duodenal atresia causes complete obstruction usually distal to the ampulla of Vater, and presents in neonates with a ‘double-bubble’ sign on plain abdominal radiograph.

Annular pancreas is usually asymptomatic but may present with abdominal pain and vomiting, and barium meal demonstrates narrowing of the second part of the duodenum.

Duodenal duplication cysts cause extrinsic compression of the first and second portions of the duodenum.

Ladd’s bands are congenital peritoneal bands occurring in association with malrotation that may cause obstruction of the second part of the duodenum, but presentation is usually in infants and children.

Question 10

4. A 67-year-old man presents with abdominal pain, distension and vomiting. Multiple dilated loops of small bowel are seen on plain abdominal radiograph. A contrast-enhanced CT of the abdomen and pelvis is performed, which shows small bowel dilatation to the terminal ileum, where there is a nodular calcified mass with surrounding desmoplastic reaction. What is the most likely cause of small bowel obstruction?

A. adhesions

B. carcinoid tumour

C. Crohn’s disease

D. previous irradiation

E. small bowel lymphoma

Answer 10

B. carcinoid tumour

The commonest cause of small bowel obstruction in adults is adhesions, which are diagnosed on CT when there is an abrupt caliber transition without an associated mass, surrounding inflammatory changes or bowel wall thickening. Carcinoid tumours comprise 25% of all tumours of the small bowel. They are commonly asymptomatic but may present with pain or obstruction, or with carcinoid syndrome in 7% of patients. Most occur in the ileum, and typical appearances are of a calcified mass with surrounding desmoplastic reaction, retraction of the mesentery and thickening of surrounding loops of bowel. Small bowel obstruction complicates Crohn’s disease in approximately 15% of patients, due to thickening and submucosal oedema of the bowel wall. Previous irradiation may result in adhesions and fibrotic changes in the mesentery that can cause bowel obstruction. Lymphomatous involvement of the small bowel causes circumferential bowel wall thickening, but this rarely results in obstruction.

Question 11

@# 5. A 60-year-old woman presents with weight loss and diarrhoea. CT of the abdomen demonstrates multiple, enlarged, low-attenuation mesenteric lymph nodes containing fat–fluid levels and splenic atrophy. What is the most likely diagnosis?

A. tuberculosis

B. coeliac disease

C. Whipple’s disease

D. lymphoma

E. metastatic squamous cell carcinoma

Answer 11

B. coeliac disease

Cavitating mesenteric lymph node syndrome is a rare complication of coeliac disease, in which multiple enlarged lymph nodes are seen in the jejunoileal mesentery.

The nodes have central low attenuation and may contain fat or fluid, or fat–fluid levels.

Splenic atrophy is usually seen,

and jejunal or duodenal biopsy confirms villous atrophy of the small bowel mucosa.

Low-attenuation lymphadenopathy may also be seen in tuberculosis, Whipple’s disease, lymphoma & necrotic mets,

but fat–fluid levels have been reported only in coeliac disease.

Question 12

6. A 68-year-old woman presents with abdominal pain, distension and vomiting. Plain abdominal radiograph demonstrates bowel obstruction, gas within the biliary tree, and an ectopic, calcified, 3 cm gallstone. What is the most likely site of bowel obstruction?

A. pylorus

B. duodenum

C. proximal ileum

D. terminal ileum

E. sigmoid

Answer 12

D. terminal ileum

Gallstone ileus accounts for up to 5% of intestinal obstruction, increasing in prevalence with age. It involves erosion of a large gallstone from the gallbladder or common bile duct into the bowel, which goes on to cause obstruction.

The classic appearance on plain film (Rigler’s triad) is only seen in 10% of cases, and consists of partial or complete intestinal obstruction (usually small bowel), gas in the biliary tree and an ectopic calcified gallstone.

The most common site of fistulous communication is between the gallbladder and the duodenum, seen in 60%, and this may be demonstrated on barium meal as a contrast collection lateral to the first part of the duodenum representing barium within the gallbladder.

Fistulas occur less commonly between the common bile duct and duodenum, gallbladder and colon.

The ectopic gallstone most often causes obstruction at the terminal ileum (60–70%), followed by the proximal ileum, distal ileum, pylorus, sigmoid and duodenum.

Question 13

7. What is the most common site of involvement in tuberculosis of the gastrointestinal tract?

A. stomach

B. duodenum

C. ileocaecal region

D. splenic flexure

E. rectum

Answer 13

C. ileocaecal region

Tuberculosis of the gastrointestinal tract may occur through ingestion of infected sputum, or by haematogenous spread to submucosal lymph nodes from a pulmonary tuberculous focus. It most commonly affects the ileocaecal region due to its abundance of lymphoid tissue and relative stasis of gut contents. Typical features at this site include circumferential thickening of the terminal ileum and caecum, a thickened ileocaecalvalve and ulceration following the orientation of lymphoid follicles (longitudinal in the terminal ileum and transverse in the colon). Marked enlargement of adjacent mesenteric lymph nodes with central areas of low attenuation may be seen.

Question 14

Enteropathy-associated T-cell lymphoma is most commonly associated with which of the following conditions?

(a) Coeliac disease

(b) Crohn’s disease

(c) Lymphangiectasia

(d) Whipple’s disease

(e) Peutz-Jegher’ssyndrorme

Answer 14

(a) Coeliac disease

This is invariably seen in the underlying bowel in patients this condition, although it may not have been diagnosed prior to the lymphoma. The other conditions do not predispose to lymphomas.

Question 15

With regard to radiation enteropathy, which of the following is not true?

(a) Acute changes occur in patients have received 1,000cGy or more

(b) Acute changes are due to damage to the blood supply

(c) Chronic changes may be seen in up to 15% Of patients

(d) Multiple stenoses are a feature of chronic disease

(e) Acute radiation enteropathy refers to changes within the first 2 months

Answer 15

(b) Acute changes are due to damage to the blood supply

Acute radiation enteropathy is due to death of the mucosal cells which are dividing rapidly. Chronic enteropathy is due to the effect on the vasculature, resulting in strictures, adhesions and fistulae.

Question 16

A 45-year-old with a history of diarrhoea and weight loss undergoes endoscopy and has a duodenal biopsy. The biopsy is reported to show foamy macrophages. Granules the cytoplasm of these macrophages stain positively with periodic acid-Schiff (PAS) stain. What additional feature might you expect on a SI enema in this patient?

(a) Multiple polyps

(b) Ulceration of the mucosa

(c) Reduced mucosal folds with dilatation of the small bowel

(d) Pseudosacculation

(e) Thickening of the mucosal folds

Answer 16

(e) Thickening of the mucosal folds

These are the clinical, pathological and radiological features Of Whipple’s disease. This is an uncommon condition of the small bowel caused by a bacterial infection, thought to be Tropheryma whippelli. Antibiotic therapy needs to continue for at least a year and relapses may involve the CNS.

Question 17

A 56-year-old patient presents with carcinoid syndrome and is found to have liver metastases. What is the most likely site of the primary lesion?

(a) Stomach

(b) Duodenum.

(c) Small Bowel

(d) Appendix.

(e) Rectum

Answer 17

(c) Small Bowel

Over 40% of carcinoid tumours arise within the small intestine, rectum (27%), appendix (24%) and stomach (8%) next most common. Duodenal carcinoids are rare. Small intestinal carcinoid tumours are often symptomatic.?

Question 18

A 57-year-old man presents with diarrhoea and is noted to have elevated ACTH levels. A small bowel enema demonstrates no ulceration or strictures but there is sharp angulation of loops of distal ileun. What is the most likely diagnosis?

(a) Cushing’s disease

(b) Cushing’s syndrome

(c) Crohn’s disease

(d) Desmoid tumour Carcinoid

(e) Carcinoid

Answer 18

(e) Carcinoid

Carcinoid syndrome commonly presents with non-specific symptoms, with obstruction, bleeding pain or diarrhoea all seen. A polypoid nodule may be seen in the wall of the bowel but the desmoplastic reaction in the adjacent mesentery causes sharp angulation Of bowel loops.

Question 19

In the assessment of small bowel disease, for which of the following criteria is MRI superior to other imaging modalities?

(a) Shorter imaging time

(b) Better depiction of early disease

(c) Superior spatial resolution

(d) Better mucosal detail

(e) Superior tissue contrast

Answer 19

(e) Superior tissue contrast

Small bowel enema has the best resolution and better depicts early disease. CT is the fastest study to perform. MRI has superior tissue contrast.

Question 20

You are asked to supervise a CT enterography study for inflammatory bowel disease which has been protocolled for a single ‘enteric phase’. Approximately how long after the commencement of the i.v. injection of contrast medium should the study be acquired?

(a) 20 secs

(b) 45 secs

(c) 70 secs

(d) l00 secs

(e) 180 secs

Answer 20

(b) 45 secs

This optimises mural enhancement. By contrast, in the evaluation of small bowel neoplasia or obscure GI bleeding, an unenhanced, arterial and portal venous study are usually used. Neutral oral contrast agents are usually favoured, although positive agents may have a role when intravenous contrast medium is contraindicated.

Question 21

A 53-year-old lady undergoes a small bowel enema study. This shows delayed transit with a marked increase in the number of mucosal folds. What is the most likely diagnosis?

(a) Systemic sclerosis

(b) Whipple’s disease

(c) Intestinal lymphangiectasis

(d) Eosinophilic gastroenteritis

(e) Mastocytes

Answer 21

(a) Systemic sclerosis

The ‘wire-sprung’ or ‘hidebound’ appearances are characteristic. Dilatation of the duodenum and jejunum, decreased peristalsis and sacculations (pseudodiverticulae) are also features. The remaining conditions cause a non-specific thickening of the mucosal folds.

Question 22

Which of the following primary tumours is least likely to metastasize to the small bowel?

(a) Bronchus

(b) Thyroid

(c) Melanoma

(d) Renal cell carcinoma

(e) Breast

Answer 22

(b) Thyroid

The remaining are the commonest tumours to have blood-borne metastases to the small bowel. Direct invasion may be seen from the prostate, uterus, ovary, colon or kidney; lymphatic spread is less common but may be seen from caecum to terminal ileum.

Question 23

A 32-year-old man weight loss is referred for a barium follow through. This is reported to show mild jejunal dilatation. There is a reduction in the number of jejunal folds, an increase in the ileal folds, but only very slight fold thickening. What is the most likely diagnosis?

(a) Whipple’s disease

(b) Coeliac disease

(c) Eosinophilic enteritis

(d) Scleroderma

(e) lymphangiectasia

Answer 23

(b) Coeliac disease

This appearance, as jejunisation of the ileum, is typical of coeliac disease. There is an associated increase in the frequency of both epithelial tumours and NHL in patients with coeliac disease.

Question 24

Amyloid deposition in the smooth muscle of the small bowel would most likely present with which of the following?

(a) Pseud-obstruction

(b) Volvulus

(c) Bleeding

(d) Pain

(e) Watery diarrhoea

Answer 24

(a) Pseud-obstruction

Pain, bleeding or diarrhoea might be seen with deposition in the bowel wall. Volvulus is not a feature of amyloidosis. Both primary and secondary amyloidosis may affect the bowel, as well as other organs.

Question 25

What is the most common cause for small bowel intussusception in adults?

(a) Meckel’s diverticulum

(b) Lymphoma

(c) Crohn’s disease

(d) Gastrointestinal stromal tumour

(e) Polypoid tumour

Answer 25

(e) Polypoid tumour

Polypoid tumours are the most common cause for small bowel intussusceptions in adults and these may have one of a number of histopathological diagnoses. Crohn’s disease does not cause an intussusception but the other conditions can on occasion.

Question 26

A 67-year-old man presents with abdominal pain, weight loss, fever and diarrhoea. The small bowel demonstrates discrete ulcers, both circumferential and longitudinal, with mucosal fold thickening. Which of the following conditions is most likely?

(a) Actinomycosis

(b) Tuberculosis

(c) Giardiasis

(d) Yersiniosis

(e) Strongyloidiasis

Answer 26

(b) Tuberculosis

Lesions are often multiple, and stricture formation is also commonly seen. When the terminal ileum is involved, a rigid and gaping ileocaecal valve may be seen. Cross-sectional imaging may low attenuation lymph nodes (due to caseous liquefaction), ascites and peritoneal nodules.

Question 27

A 27 year old male has recurrent admissions for intermittent low-grade small bowel obstruction of unknown cause. Which one of the following investigations would be most appropriate?

a. Contrast-enhanced CT abdomen and pelvis

b. Barium meal

c. Small bowel enteroclysis

d. Serial abdominal plain films

e. Barium follow-through

Answer 27

c. Small bowel enteroclysis

Small bowel enteroclysis is the most appropriate examination. CT is sensitive for high-grade obstruction as it will readily identify the level of obstruction and can demonstrate complications such as ischaemia and perforation. Enteroclysis is the preferred investigation for recurrent low-grade obstruction as it is more likely to demonstrate the presence of a transition point (for example from non-obstructing adhesions) because the bowel is distended. The examination involves passing a nasojejunal tube just distal to the duodenojejunal flexure and distending the small bowel using either dilute barium or a double-contrast examination with high-density barium and methylcellulose.

Question 28

A 31 year old male is investigated as an outpatient for diarrhoea. A small bowel meal study reveals jejunal dilatation with thickened valvulae conniventes. In the ileum an increased number of mucosal folds are seen. Which of the following diagnoses is most likely?

a. Lymphoma

b. Crohn’s disease

c. Coeliac disease

d. Whipple disease

e. Behcet syndrome

Answer 28

c. Coeliac disease

Jejunal dilatation and jejunisation of the ileal loops are characteristic features of coeliac disease. This is an immunological intolerance to gluten that causes villous atrophy in the small intestine. In Whipple disease there is thickening of the jejunal and duodenal mucosal folds but typically no luminal dilatation. Dilatation of the small bowel does occur with lymphoma but jejunisation of the ileum is not a feature.

Question 29

A 34 year old female is investigated for intermittent abdominal pain and malabsorption. Small bowel meal shows dilatation of the proximal small bowel loops but a normal mucosal fold pattern. Which one of the following is the most likely underlying diagnosis?

a. Coeliac disease

b. Amyloid

c. Whipple disease

d. Giardiasis

e. Eosinophilic gastroenteritis

Answer 29

a. Coeliac disease

All of these may cause malabsorption. Amyloid can cause dilatation but also causes diffuse thickening of the valvulae conniventes throughout the small bowel. With Whipple disease and eosinophilic gastroenteritis, one would not see dilatation of the bowel, but thickening of the mucosa is again a prominent feature. Giardiasis causes thickening and marked distortion of the mucosal folds in the duodenum and jejunum. One of the hallmark features of untreated coeliac disease is jejunal dilatation. Typically the mucosal folds are of normal thickness

Question 30

A 38 year old patient with AIDS presents with diarrhoea and steatorrhoea. As part of the work-up, small bowel enteroclysis shows thickened jejunal folds with nodularity and evidence of marked jejunal spasm. The ileum has normal appearances. Which one of the following is the most likely underlying cause?

a. Cytomegalovirus

b. Tuberculosis

c. Mycobacterium avium intracellulare

d. Cryptosporidium

e. Giardiasis

Answer 30

e. Giardiasis

All the stems are potential causes for these symptoms in a patient with AIDS, however giardiasis is the most likely cause given these imaging appearances. Cytomegalovirus most typically affects the caecum, and tuberculosis affects the caecum and ileocaecal valve. Mycobacterium avium intracellularecan affect the ileum and jejunum but does not usually cause spasm. Cryptosporidium affects the duodenum and the jejunum can be affected, but dilatation is more common than spasm.

Question 31

A 45 year old female has a CT for abdominal pain and weight loss. Findings include a soft-tissue mass at the root of the small bowel mesentery with eccentric calcifications and tethering of adjacent small bowel loops resulting in a moderate degree of small bowel obstruction. There is a desmoplastic reaction within the surrounding mesentery. Which one of the following is the most likely diagnosis?

a. Lymphoma

b. Carcinoid tumour

c. Melanoma metastases

d. Tuberculosis

e. Paraganglioma

Answer 31

b. Carcinoid tumour

These features are typical of carcinoid tumour. The desmoplastic reaction appears on CT as thickened mesentery in a radiating pattern away from the soft-tissue mass, with beading of the mesenteric vascular bundles.

Question 32

A 57 year old diet-compliant male patient with coeliac disease has a CT abdomen and pelvis for the investigation of cachexia and two stone weight loss over six months. A 7 cm segment of ileum shows mild dilatation and circumferential thickening, with multiple low-attenuation mesenteric and para-aortic lymph nodes. Which one of the following is the most likely diagnosis?

a. Tuberculosis

b. Gastro-intestinal lymphoma

c. Coeliac disease

d. Whipple disease

e. Crohn’s disease

Answer 32

b. Gastro-intestinal lymphoma

Hypoattenuating lymph nodes can be attributed to many causes, but lymphoma and tuberculosis are the most common. Lymphoma of the gastro-intestinal tract most commonly affects the ileum, although lymphoma associated with coeliac disease most commonly affects the jejunum. Although 90% of tuberculosis of the gastro-intestinal tract occurs in the ileum, lymphoma is most likely in this scenario. Dilatation of the small bowel with lymphoma is common but obstruction is rare due to the soft pliable nature of the tumour.

Question 33

1. A 30-year-old male patient arrives at the Radiology Department for a barium follow-through examination. He has experienced chronic lower abdominal pain with weight loss and intermittent diarrhoea. Optical colonoscopy was normal. As the Specialist Registrar in the department, it is your responsibility to supervise this investigation and the radiographer asks how you would like the examination performed. Which statement is true regarding the barium follow-through examination?

A A 250% weight-to-volume barium sulphate should be used.

B Barium reaches the caecum within 30 minutes in the majority of patients.

C Barium sulphate suspensions are nonionic to avoid clumping of particles.

D Oral metoclopramide may be used to delay gastric emptying.

E The first radiograph should be a supine film after 60 minutes.

Answer 33

C Barium sulphate suspensions are nonionic to avoid clumping of particles.

Barium sulphate preparations consist of tiny particles (less than 1 pm) in a nonionic suspension.

Question 34

QUESTION 23
A 52-year-old female patient is under the care of a rheumatologist with a diagnosis of diffuse scleroderma. She resents to her GP with vomiting, intermittent abdominal pain and reduced bowel habit. An abdominal radiograph demonstrates several loops of gas-filled bowel but there is no evidence of mechanical obstruction. A barium follow-through examination is performed. In view of the clinical history, what are the most likely findings?

A Dilated small bowel with increased number of valvulae conniventes

B Extraluminal mass in the ileum, causing ulceration and a shouldered stricture

C Long irregular ileal stricture with antimesenteric mucosal thickening

D Nodular thickening of the valvulae conniventes of the duodenum only

E Short stricture in the terminal ileum with ‘cobblestoning’ of the mucosa

Answer 34

A Dilated small bowel with increased number of valvulae conniventes

This describes the characteristic ‘hide bound’ appearance of the small bowel in scleroderma.

Question 35

QUESTION 27
A 47-year-old woman presents with a 2-day history of lower abdominal pain and reduced bowel habit. Dilated loops of small bowel are evident on an abdominal radiograph and a barium small bowel follow-through examination is performed. This demonstrates a stricture in a pelvic loop of small bowel. The patient’s symptoms improve on conservative management and further history reveals pelvic radiotherapy for cervical cancer 21 years ago. Which one of the following statements is true regarding radiation enteritis?

A Acute symptoms following radiotherapy are a poor predictor of chronic enteritis.

B The proximal jejunum is the most common site of small bowel involvement.

C There is characteristic dilatation of affected small bowel in chronic radiation

D There is flattening of the valvulae conniventes in the acute stage.

E There is typically ‘cobblestoning’ of the small bowel mucosa.

Answer 35

A Acute symptoms following radiotherapy are a poor predictor of chronic enteritis.

Acute symptoms are not an accurate predictor of chronic radiation enteritis. The valvulae conniventes are typically thickened in acute radiation enteritis and the distal jejunum and ileum are the most frequent sites of small bowel involvement. In chronic phase, the small bowel develops submucosal thickening and adhesions and fistulae may develop. The most common cause of radiation enteritis is pelvic radiotherapy for gynecological malignancy or rectal cancer.

Question 36

QUESTION 78
A 23-year-old man presents with a 2-day history of vomiting and generalized abdominal pain. Two years ago, he underwent a small bowel resection for an ileal stricture due to Crohn’s disease. Initial blood tests reveal a raised CRP and white cell count and an abdominal radiograph demonstrates dilated loops of small bowel. Small bowel obstruction is suspected and a contrast-enhanced CT of the abdomen is performed. Which one of the following statements is true regarding the role of multidetector CT in small bowel obstruction?

A Five to 15% of small bowel obstructions are due to hernias.

B Twenty to 30% of small bowel obstructions arc due to adhesions.

C Bowel wall thickening and intramural gas indicate the presence of pneumatosis coli.

D Closed loop obstruction is less likely to result in bowel ischaemia than simple obstruction.

E In small bowel obstruction due to adhesions, a transition point will not be seen.

Answer 36

A Five to 15% of small bowel obstructions are due to hernias.

Bowel wall thickening, lack of enhancement, adjacent fluid and pneumatosis intestinalis are all CT signs of ischaemia (strangulation) in small bowel obstruction. Fifty to 80% of small bowel obstruction is attributable to adhesions while 10% is due to hernias. In adhesions, there will usually be a history of previous abdominal surgery with CT demonstrating small bowel obstruction. The transition point may be identified, but the actual adhesive land is usually not visualized.

Question 37

QUESTION 83
A 22-year-old woman attends the Emergency Department with a 10-day history of vomiting and diarrhoea. The symptoms have worsened and are now associated with severe abdominal pain. Initial investigations reveal an elevated neutrophil count and CRP and she is treated with intravenous fluids and antiemetics. In view of increased pain and fever, a contrast-enhanced CT of the abdomen and pelvis is performed and shows that a segment of bowel is significantly thickened. The microbiology laboratory telephones the clinical team and states that Yersinia enterocolitica has been isolated from the patient’s stool samples. Which segment of the bowel is likely to be abnormal?

A Duodenum

B Gastric antrum

C Proximal jejenum

D Sigmoid colon

E Terminal ileum

Answer 37

E Terminal ileum

An increased number of thickened valvulae conniventes are seen in the distal ileum with nodular filling defects due to lymphoid hyperplasia.

Question 38

QUESTION 94
A71-year-old woman has a contrast-enhanced CT of the abdomen and pelvis to investigate lower abdominal pain and reduced bowel habit. An abnormal mesenteric soft tissue mass is present and displaces adjacent loops of bowel. The mass has multiple linear strands that radiate out towards the adjacent bowel loops giving a ‘stellate’ appearance. Which term describes this CT appearance?

A Aneurysmal dilatation

B Desmoplastic reaction

C Omental cake

D Peritoneal seeding

E Sandwich encasement

Answer 38

B Desmoplastic reaction

The word desmoplastic comes from the Greek ‘desmos’ and ‘plasty’, meaning ‘to form a band’. It describes the growth of fibrous bands infiltrating into adjacent tissue and is a recognized feature of GI carcinoid tumours.

Question 39

QUESTION 96
A 30-year-old man attends the Emergency Department with a 2-day history of abdominal pain and vomiting. On examination, he is afebrile with a firm mass palpable in the right lower quadrant of the abdomen. A supine abdominal radiograph is performed and demonstrates dilated loops of small bowel with a large soft tissue mass in the right lower quadrant. On ultrasound, the mass has a ‘pseudotumor’ appearance. What is the most likely diagnosis?

A Colonic carcinoma

B Gallstone ileus

C Intussusception

D Psoas abscess

E Strangulated femoral hernia

Answer 39

C Intussusception

The ‘pseudotumour’, ‘pseudokidney’ and ‘target’ signs all describe the characteristic sonographic appearance of intussusception.

Question 40

4. Which of the following is correct regarding carcinoid of the GI tract?

A. A minority are asymptomatic when discovered.

B. The appendix is the most common site of occurrence, representing 33% of all carcinoids.

C. Over 50% are multiple.

D. Although malignant change is uncommon in appendiceal carcinoid, as this is the most common site, it accounts for the majority of malignant carcinoids.

E. The size of the tumour at diagnosis is related to the risk of metastatic spread.

Answer 40

4. E. The size of tumour at diagnosis is related to the risk of metastatic spread.

Carcinoid is the 33% tumour, as 33% occur in the small bowel, 33% are multiple, 33% are malignant, and 33% are associated with a second malignancy. Appendiceal carcinoid accounts for 50% of all carcinoids and 67% are asymptomatic at presentation. Appendiceal carcinoid accounts for only 7% of metastatic disease, with small bowel carcinoid causing 75%. The size of the tumour at diagnosis is related to the risk of metastatic spread, which is 2% if the lesion is <1 cm, but 85%if the lesion is over 2 cm in size.

Question 41

A small bowel series is requested for a patient who has a history of systemic sclerosis. Which of the following is a feature of small bowel systemic sclerosis?

A. Stacked coin appearance due to infiltration of small bowel loops.

B. Pseudo-diverticula affecting the anti-mesenteric side of the bowel.

C. Decreased intestinal transit time.

D. Small bowel systemic sclerosis is only seen in 10% of patients with systemic sclerosis, but the disease is rapidly progressive when it is present.

E. Pneumatosis intestinalis.

Answer 41

E. Pneumatosis intestinalis.

The stacked coin appearance is seen secondary to intramural haemorrhage—the appearances of systemic sclerosis are of tightly packed folds of normal thickness in a dilated portion of bowel, which has been given the title ‘accordion’ or ‘hidebound’ bowel. The pseudo-diverticula (10–40%) are seen on the mesenteric side of the bowel, unlike colonic diverticula. The transit time is prolonged, as there is reduced intestinal motility. Another classical feature is of a markedly dilated duodenum, due to the loss of the enteric innervations—mega duodenum. This classically terminates abruptly at the level of the superior mesenteric artery (SMA). Pneumatosis cystoides scan occur in systemic sclerosis of the small bowel. Small bowel disease is seen in up to 40% of patients with systemic sclerosis and indicates rapidly progressing disease.

Question 42

A 68-year-old male patient has a 20-year history of RA. During a recent flare he was commenced on steroid therapy, although this has now been discontinued. The patient is now complaining of mild abdominal discomfort, diarrhoea, and mild weight loss. A barium meal is performed, but is suboptimal, as the patient is poorly mobile. Within the limitations of the study, there is reduced peristalsis in the oesophagus and mild reflux. The antrum of the stomach is felt to be mildly narrowed and rigid. Thickened rugal folds are noted. A subsequent small bowel series is carried out. The jejunal folds measure 4 mm and the ileal folds appear more plentiful and measure 3 mm. Contrast is present in the caecum at 4 hours. Spot screening of the terminal ileum reveals the same findings as those described above. What is the most likely diagnosis?

A. Gastric erosions.

B. Whipple’s disease.

C. Mastocytosis.

D. Amyloidosis.

E. Crohn’s disease

Answer 42

D. Amyloidosis.

This patient probably has amyloidosis secondary to prolonged RA. GI involvement is more common in primary (70%) than secondary (13%) amyloidosis. Nevertheless, the small bowel is involved in 74% of cases of GI amyloidosis and secondary amyloidosis is the most common type of amyloid disease. Amyloidosis is secondary to the deposition of insoluble amlyoid protein in soft tissues and organs. In primary amyloidosis the heart (90%), followed by the small bowel and the lungs (70%), are the most commonly affected organs. The kidneys are affected in 90% of cases of secondary amyloidosis. Amyloidosis classically causes a diffuse thickening of bowel folds. It may cause dilated bowel folds, if the myenteric plexus is involved. The main differential for amyloid is Whipple’s disease and intestinal lymphangiectasia. Whipple’s disease does not cause bowel dilatation or rigidity, as described in the antrum in this patient. Crohn’s disease can also present with thickened folds, but it is more commonly focal with the most pronounced abnormality in the terminal ileum. Ulceration is also commonly seen in Crohn’s, but 68 years old would be a late first presentation for Crohn’s. Whilst option A is true, this is not what the question asked. Patients with mastocytosis most commonly present in infancy.

Question 43

A patient presents to the surgical team with central abdominal pain and vomiting associated with abdominal distension. The abdominal x-ray (AXR) reveals numerous dilated loops of small bowel. A CT scan is carried out. Which of the following statements with regard to CT imaging in small bowel obstruction is accurate?

A. Small bowel mural hyperdensity is a feature and is due to vasodilatation seen in early ischaemia.

B. Oral contrast is mandatory for the investigation of small bowel obstruction.

C. Small bowel mural thickening is due to increased venous pressure.

D. Absence of small bowel mural enhancement is a feature of ischaemic gut secondary to emboli rather than small bowel obstruction.

E. Lack of small bowel pneumatosis excludes ischaemia of the gut.

Answer 43

A. Small bowel mural hyperdensity is a feature and is due to vasodilatation seen in early ischaemia.

Multi-detector CT (MDCT) has been found to correlate with pathological processes in small bowel obstruction. The earliest appearance is increased mural density due to hyperaemia. Wall thickening is due to increasing capillary permeability, which causes submucosal oedema. Dilatation is secondary to oedema that limits peristalsis. Lack of enhancement occurs when the bowel dilates and compresses the capillary bed. Pneumatosis is secondary to mucosal ischaemicchange, which allows luminal air to track into the wall. Lack of enhancement is also seen in embolic ischaemia, but is not a specific sign of this process. Whilst oral contrast is preferred inmanycentres, as it can help define if complete obstruction is present, it is not mandatory. Some centres prefer the negative contrast provided by the fluid in the bowel lumen. Patients with smallbowel obstruction are also often unable to tolerate oral contrast due to vomiting.

Question 44

A 41-year-old female with a background of arthralgia, chronic abdominal pain, and diarrhoea is investigated via a small bowel series. Findings include a prolonged transit time, and dilated loops of small bowel with normal appearing valvulae and pseudodiverticula. What is the most likely diagnosis?

A. GI scleroderma.

B. Behcet’s disease.

C. Whipple disease.

D. Small bowel lymphoma.

E. Coeliac disease.

Answer 44

A. GI scleroderma.

Deeply penetrating ulcers are seen in Behcet’s disease. Whipple disease is an extremely rare form of intestinal lipodystrophy. Thickening of jejuna folds is seen, but there is little or no small bowel dilatation and small bowel transit time is normal. Pseudodiverticula are not seen in coeliac disease. The valvulae are thickened in lymphoma.

Question 45

A 45-year-old man, with a history of AIDS, has a 3-month history of abdominal pain and weight loss. A CT scan of abdomen is performed which shows ascites with peritoneal thickening, several areas of mural thickening in the small bowel, and multiple low attenuation lymph nodes. Which one of the following infections is most likely?

A. CMV infection.

B. TB.

C. Cryptosporidiosis.

D. Amoebiasis.

E. Campylobacter.

Answer 45

B. TB.

Cryptosporidiosis is the most common cause of enteritis in AIDS patients. It more commonly causes proximal small bowel thickening in the duodenum and jejunum, and CT may show small lymph nodes. CMV infection of the small bowel can show a terminal ileitis indistinguishable from Crohn’s disease. The typical CT findings in amoebiasis are thickening of the right colonic wall and a rounded abscess in the right lobe of liver with a peripheral zone of oedema. TB usually shows ileocaecal involvement, low attenuation mesenteric nodes, and ascites with peritoneal thickening. Mycobacterium avium intracellulare may also occur with low attenuation mesenteric nodes and thickening of small bowel folds.

Question 46

A 44-year-old man presents with a vague history of central abdominal pain and mild weight loss. On further questioning, there are other features in the history suggestive of malabsorption. Amongst other investigations, a CT scan of abdomen is requested. This shows dilated fluid-filled small bowel loops and multiple enlarged mesenteric lymph nodes, encasing the mesenteric vessels. The lymph nodes are of homogeneous soft tissue density. What is the most likely cause of the CT findings?

A. Whipples disease.

B. Coeliac disease complicated by lymphoma.

C. Cavitating mesenteric lymph node syndrome.

D. Abdominal tuberculosis.

E. Castleman disease.

Answer 46

B. Coeliac disease complicated by lymphoma.

Whipples disease, cavitating mesenteric lymph node syndrome, and abdominal TB more typically have mesenteric lymph node enlargement that has central low attenuation, rather than being of homogeneous soft-tissue density. Whipple disease is a systemic bacterial infection caused by Tropheryma whippelii. Lymph nodes affected by Whipple disease typically have a high fat content, causing the low attenuation, usually between 10 and 20 HU. Cavitating mesenteric lymph node syndrome is associated with coeliac disease. The lymph nodes are truly cavitating and usually regress following a gluten-free diet. The lymph nodes in abdominal tuberculosis typically have caseous necrosis and thus central low density on CT. Castleman disease causes benign masses of lymphoid tissue of unknown aetiology. It can cause mesenteric lymphadenopathy, which is homogeneous, but the disease itself is rare and mesenteric involvement is much less common than mediastinal involvement.

Question 47

(MSK) 16. A 35-year-old female with a history of flushing, pruritis, and diarrhoea is referred for a small bowel series. A barium study demonstrates irregular diffuse thickening of small bowel folds. There is also diffuse osteosclerosis. Laboratory tests reveal elevated serum tryptase level. What is the diagnosis?

A. Mastocytosis.

B. Intestinal lymphangectasia.

C. Amyloidosis.

D. Waldenstrom’s macroglobulinaemia.

E. Whipple’s disease.

Answer 47

16. A. Mastocytosis.

This is a rare disorder characterized by proliferation of mast cells in the skin, bone marrow, liver, spleen, lymph nodes, and small bowel. Histamine released from mast cells is responsible for the associated symptoms of episodic flushing, pruritis, hypotension, and diarrhoea. The serum tryptase level is also elevated in mastocytosis. Whilst the other conditions mentioned could also cause diffuse thickening of small bowel folds, the associated clinical laboratory findings and osteosclerosis are diagnostic of mastocytosis.

Question 48

A 55-year-old woman is admitted to hospital after several episodes of melaena. She has an upper GI endoscopy performed, which is normal. A CT scan of abdomen is requested and this demonstrates a large exophytic mass arising from the jejunum in the left upper quadrant. It is heterogeneous in density, and has some peripheral enhancement and central necrosis. There is no calcification, intestinal obstruction, or evidence of aneurysmal dilatation of the affected segment of jejunum. There is no adjacent lymphadenopathy or ascites. What is the most likely diagnosis?

A. Adenocarcinoma.

B. Lymphoma.

C. Carcinoid tumour.

D. Metastasis.

E. Gastrointestinal stromal tumour (GIST).

Answer 48

E. Gastrointestinal stromal tumour (GIST).

At contrast-enhanced CT, GISTs appear as large exophytic masses with peripheral enhancement. They usually have an attenuation similar to that of muscle, but they may have heterogeneous attenuation, depending on their level of aggressiveness. More aggressive GISTs may also contain a central area of necrosis. Adenocarcinoma of the jejunum is rare, more commonly occurring in the duodenum. They also tend to be stricturing lesions, rather than exophytic masses and may present with obstruction. Carcinoid is also rare in the proximal small bowel, the distal ileum being a more usual location. The primary lesion is often quite small, with the nodal metastatic lesion in the small bowel mesentery being more conspicuous on CT. This is often spiculated (surrounding desmoplastic reaction) and may contain calcification. Lymphoma can have a number of manifestations in the small bowel, from nodular thickening of the mucosal folds to large masses with aneurysmal dilatation of the small bowel in the affected segment. Associated lymphadenopathy is typical.

Question 49

A 45-year-old man has a long history of intermittent diarrhoea, abdominal bloating, and cramps, but has neglected to seek medical advice until now. His GP is worried about undiagnosed Crohn’s disease and sends him for a small bowel series. This shows some dilatation of the proximal small bowel, with segmentation and flocculation of the barium and an increased number of normal thickness folds seen in the ileum. There is no evidence of stricture formation or ulceration. What is the likely diagnosis?

A. Amyloidosis.

B. Chronic ischaemic enteritis.

C. Whipple’s disease.

D. Coeliac disease.

E. Lymphoma.

Answer 49

D. Coeliac disease.

The segmentation and flocculation of barium are findings on a small bowel series that are typical of malabsorption and therefore the most likely diagnosis is coeliac disease. Other findings in coeliac disease include dilatation, a granular appearance to the barium secondary to hypersecretion, jejunization of the ileum, and the ‘moulage’ sign. The latter refers to a smooth, tubular appearance to the jejunum in longstanding coeliac disease, secondary to atrophy and effacement of the jejunal mucosal folds. Lymphoma can be a complication of coeliac disease and generally causes shallow, ulcerated masses or the development of thickened, nodular small bowel folds. Whipple’s disease, amyloidosis, & ch ischaemic enteritis all cause thickening of small bowel folds.

Question 50

A 17-year-old was a rear-seat passenger in a head-on vehicle collision with a combined speed of 120 mph in which the drivers both died at the scene. The patient was wearing a seatbelt and was not ejected from the vehicle. After being cut from the vehicle the patient was airlifted to hospital where a multi-trauma CT was performed. In addition to significant head and chest trauma there was intraperitoneal free fluid and some bubbles of extraluminal intraperitoneal free gas just beyond the ligament of Treitz. There was also duodenal and jejunal wall thickening. What is the most likely diagnosis?

a Jejunal injury with disruption of the bowel wall

b Duodenal injury with disruption of the bowel wall

c Bowel oedema secondary to hypovolaemic shock

d Blunt injury causing contusion of the jejunum and duodenum

e Pancreatic contusion

Answer 50

Answer A: Jejunal injury with disruption of the bowel wall

The most common site of traumatic small bowel injury is the anti-mesenteric border of the proximal jejunum. Blunt abdominal trauma causing hollow viscous injuries occurred in conjunction with multiple trauma in approximately 70% of cases. Bubbles of gas are often seen close to the affected segment; wall disruption will most likely be present if free gas is present.

Question 51

A 51-year-old male was investigated for vague abdominal symptoms including abdominal pain and weight loss. Physical examination revealed generalised peripheral lymphadenopathy and some areas of hyperpigmentation of the skin. A diagnosis of Whipple disease was suspected and a small bowel contrast study was performed. What features would most support this diagnosis?

a Sand-like nodules (approx 1 mm) in non-dilated small bowel

b Small nodules (>2 mm) in non-dilated small bowel

c Thick folds in non-dilated small bowel

d Normal folds in dilated small bowel

e Thick folds in dilated small bowel

Answer 51

Answer A: Sand-like nodules (approximately 1 mm) in non-dilated small bowel

Whipple disease characteristically causes sand-like nodules in a non-dilated small bowel.

Question 52

A patient underwent a small bowel follow-through study, which you have been asked to review. The luminal diameter was 2 cm and valvulae conniventes and wall both measure 1-mm thick. What is the correct conclusion?

a Crohn’s disease

b Normal study

C Blind loop syndrome

d Small bowel obstruction

e Small bowel lymphoma

Answer 52

b Normal study

Question 53

A young adult male who had recently moved to the UK from India presented with abdominal pain, diarrhoea and weight loss. A CT showed evidence of ileitis. Stool cultures were negative. What feature would favour a diagnosis of tuberculous ileitis rather than Crohn’s disease?

a Aphthous ulcers

b Isolated terminal ileal involvement

c Small rosethorn ulcers

d Thickening of circular small bowel folds

e Ulcers with elevated margins following lymphoid follicles

Answer 53

Answer E: Ulcers with elevated margins following lymphoid follicles

Gastrointestinal tuberculosis most commonly affects the ileocaecal region and may mimic Crohn’s disease. Large shallow, linear, stellate ulcers with margins following the orientation of lymphoid follicles are characteristic.

Question 54

A 26-year-old female presented with a long history of abdominal bloating, pale loose stools and weight loss. She underwent a series of investigations including a small bowel enema and eventually, following jejunal biopsy, was diagnosed with coeliac disease (nontropical sprue). What radiographic features are most likely to have been visible on her small bowel enema?

a Reversal of jejunal and ileal fold patterns

b Stricturing lesions

C Enteroenteric fistulae

d Polypoidal small bowel filling defects

e The moulage sign

Answer 54

Answer A: Reversal of jejunal and ileal fold patterns

Question 55

A 50-year-old woman who had been treated for cervical carcinoma 18 months previously presented with colicky abdominal pain. A CT showed thickening of the ileal wall with luminal narrowing, which was causing partial obstruction. There was also increased attenuation of the associated mesentery. What is the most likely diagnosis?

a Carcinoid

b Crohn’s disease

C Ischaemic bowel

d Lymphoma

e Radiation enteritis

Answer 55

Answer E: Radiation enteritis

Radiological changes appear up to one to two years after radiation. The ileum is the most common part of the bowel affected. There is often increased attenuation of the mesentery.

Question 56

An 80-year-old man was readmitted to the surgical ward one month after an elective abdominal aortic aneurysm repair complaining of nausea and vomiting. A plain abdominal radiograph demonstrated gaseous distension of the stomach and duodenal bulb. Contrast-enhanced CT did not reveal any further abnormality and a barium meal was performed which showed stricturing of the distal duodenum. What is the most likely explanation for these findings?

a Adhesions

b Annular pancreas

c Duodenal haematoma

d Infected Dacron vascular graft

e Paralytic ileus

Answer 56

a Adhesions

Question 57

An adult male presented with weight loss and intermittent abdominal pain. A CT demonstrated a small bowel mass and adjacent soft-tissue mesenteric mass with calcification. An In-111 labelled octreotide study was performed with SPECT images which demonstrated uptake in the small bowel and mesenteric mass and further uptake in the liver and lungs. What is the likely diagnosis?

a Extra adrenal phaeochromocytoma (paraganglioma)

b Carcinoid syndrome

c Widespread carcinoid metastases

d Metastatic gastrointestinal stromal tumour (GIST)

e Lymphoma

Answer 57

Answer C: Widespread carcinoid metastases

In 111-labelled octreotide study is used to assess for somatostatin receptor positive carcinoid disease and if positive may indicate that the patient’s disease is suitable for radiolabelled treatment. Carcinoid syndrome specifically relates to clinical symptoms in the presence of liver or lung metastases but is not a radiological diagnosis. The CT findings are not typical of lymphoma. Paraganglioma is usually assessed with MIBG but does show octreoscan uptake but the radiological findings are not consistent with this diagnosis.

Question 58

25 A previously well 55-year-old male presented with diarrhoea, facial flushing and wheeze. After further investigation he was found to have a carcinoid tumour of the GI tract. What is the most likely site of the primary tumour?

A Oesophagus

b Appendix

C Distal ileum

d Colon

e Rectum

Answer 58

25 Answer B: Appendix

Commonest sites are appendix (>60%) and small bowel 20% (distal 2 feet of ileum). They are rare in the rectum and stomach and virtually never occur in the oesophagus.

Question 59

A patient presented with anaemia and ongoing melaena. Colonoscopy and blood biochemistry results were normal. Red blood cell scintigraphy localised the source of bleeding to the small bowel and an ultrasound of the abdomen showed a well-defined, spherical mass of low reflectivity measuring 5 cm in diameter. What is the most likely diagnosis?

a Carcinoid

b Leiomyoma

c Lymphoma

d Adenocarcinoma

e Tuberculosis

Answer 59

Answer B: Leiomyoma

Leiomyoma are the most common benign small bowel tumours and are responsible for half of cases of small bowel haemorrhage. Their usual presentation is with bleeding from the ulcerated tumour surface in the small bowel. Carcinoma is rare in the small bowel. Carcinoids represent 1.5 % of all GI neoplasms and most commonly occur in the appendix. Ultrasound may show a broad-based intraluminal mass in the early stages. The small bowel is involved in 30% of lymphoma and usually a mass, either circumferential or extending along the bowel, is visible.

Question 60

A 14-year-old boy presented with crampy abdominal pain and a history of darkened stools over the last few weeks. Physical examination was normal other than some vague central abdominal tenderness and pigmentation of the lower lip. An urgent ultrasound showed a probable intussusception. Following reduction a follow-up small bowel study showed multiple broadbased polyps mainly in the jejunum and ileum. What is the most likely diagnosis?

a Familial adenomatous polyposis

b Cowden syndrome

c juvenile polyposis

d Cronkhite-Canada syndrome

e PeutzJeghers syndrome

Answer 60

Answer E: Peutz-Jeghers syndrome

PeutzJeghers is a relatively rare autosomal-dominant condition that is characterised by the presence of gastrointestinal polyps and mucocutaneous pigmentation. The polyps are mainly seen in the small bowel and are classically broad based. In the presence of abdominal pain intussusception occurs in up to 47%.

Question 61

A 34-year-old Indian male was assessed in the Gastroenterology outpatient clinic with a one-year history of weight loss and vague abdominal discomfort. His chest radiograph was of normal appearance and his tuberculin skin test was negative, but he had multiple risk factors for tuberculous disease. Primary intestinal tuberculosis was considered as a possibility and barium studies of the small bowel were arranged which showed disease in the ilea-caecal area. What characteristic would most support tuberculosis as a diagnosis?

a Cobblestoning

b Deep fissures and large shallow linear ulcers with elevated margins

c Longitudinal submucosal ulceration over several centimetres

d Presence of multiple ulcers that resemble `rose thorns’

e Presence of pseudopolyps

Answer 61

Answer B: Deep fissures and large shallow linear ulcers with elevated margins

In primary intestinal tuberculosis the classical presentation is with weight loss and abdominal pain and the tuberculin skin test is negative in most patients. The ulcerative form is the most common manifestation and disease is usually seen in the ileocaecal area. Deep fissures and large shallow linear/stellate ulcers with elevated margins are characteristic.

Question 62

A 33-year-old woman presented with abdominal pain and distension. A plain abdominal radiograph showed small bowel obstruction and a CT was performed which showed a transition point in a segment of small bowel. What feature would suggest that this is jejunal as opposed to an ileal segment?

a Sparse/absent valvulae conniventes

b More frequent arterial arcades

c Thicker valvulae conniventes

d Thinner bowel wall

e Slightly smaller diameter than rest of small bowel

Answer 62

Answer C: Thicker valvulaeconniventes

Question 63

A 31-year-old man was involved in a high-speed road accident and sustained significant chest and head injuries. He was admitted to ITU and a chest radiograph obtained 24 hours later showed pneumoperitoneum. An occult gut injury was suspected. What part of the gut is most likely to have been injured?

a Gastro-oesophageal junction

b Duodenum

C Ileum

d Colon

e Rectum

Answer 63

Answer B: Duodenum

Ninety-five per cent of intestinal trauma occurs in the duodenum and proximal jejunum. The remaining 5 % occurs in the colon. Blunt intestinal trauma at other sites is rare.

Question 64

A 55-year-old male who was previously well, presented with a short history of per rectum bleeding and weight loss. Physical examination was normal and a colonoscopy was not available. A contrast-enhanced CT was performed which showed a submucosal vascular lesion in the ileum with associated moderate volume low-density lymphadenopathy. In addition, in the sigmoid colon, there was an area of irregular but concentric wall thickening consistent with a colonic carcinoma. What is the likely aetiology of each abnormality?

a Colorectal primary carcinoma with small bowel metastases and lymph node involvement

b Carcinoid of the small bowel with large bowel metastases

c Small bowel carcinoma with large bowel metastases

d Concurrent colorectal and small bowel primary carcinoma

e Carcinoid of small bowel with a concurrent colorectal malignancy

Answer 64

Answer E: Carcinoid of small bowel with a concurrent colorectal malignancy

Carcinoid tumours are the most common primary tumour of the small bowel and appendix. One-third of carcinoids are seen in the small bowel and 91 % of these are in the ileum. They are classically submucosal vascular lesions and are associated with low-density lymphadenopathy due to necrosis. Approximately 30% have a second primary malignancy of the gastrointestinal tract.

Question 65

A patient presents for review following a CT of their abdomen and pelvis in another centre. The images have not been transferred but the report describes an enhancing submucosal mass in the ileum with associated changes in the mesentery. The report continues describing a stellate radiating pattern and beading of the mesenteric neurovascular bundles with retraction of the mesentery and thickening of the wall of the subtended loops of bowel. Assuming the report is accurate, what is the most likely diagnosis?

a Lymphoma

b Metastatic gastric carcinoma

c Carcinoid tumour

d Mesenteric panniculitis

e Gardner’s syndrome

Answer 65

Answer C: Carcinoid tumour

This is a description of retractile mesenteritis and is associated with all the listed conditions. However, the enhancing submucosal lesion in the ileum is a classic appearance and site of a carcinoid tumour.

Question 66

A 28-year-old male presented with abdominal pain and diarrhoea. A CT demonstrated an oedematous terminal ileum with large penetrating ulcers. Further clinical examination revealed stomatitis, genital ulcers and iridocyclitis. What is the most likely diagnosis?

a Ulcerative colitis

b Crohn’s disease

c Behcet’s syndrome

d Mirizzi’s syndrome

e Herpes simplex infection

Answer 66

Answer C: Behcet’s syndrome

This is a chronic granulomatous inflammatory disease of unknown aetiology. The natural course is relapsing and there is a triad of aphthous stomatitis, genital ulcers and ocular inflammation. Age of onset is the third decade and it affects twice as many males as females.

Question 67

A 65-year-old woman was investigated for recurrent diarrhoea. Her husband reported that she also became flushed and slightly short of breath after meals. Carcinoid syndrome was suspected and she was referred for an abdominal CT and small bowel MRI study. What feature is most typical of small bowel carcinoid?

a Duodenal location

b Calcified lymphadenopathy

C Mesenteric mass

d Minimal desmoplastic reaction

e Free fluid

Answer 67

C Mesenteric mass

Question 68

3.A 35-year-old woman with mucocutaneous pigmentation on the hands and feet and in a circumoral distribution presents with cramping abdominal pain. She is found to have iron deficiency anaemia. Plain radiography of the abdomen suggested small bowel obstruction. Contrast-enhanced CT demonstrates jejunal intussusception. The most likely diagnosis is?

(a) Familial adenomatous polyposis

(b) Peutz–Jeghers syndrome

(c) Leiomyoma small bowel

(d) Small bowel carcinoma

(e) Melanoma with bowel metastases.

Answer 68

(b) Peutz–Jeghers syndrome

The syndrome presents with mucocutaneous pigmentation and gastrointestinal polyposis. Small bowel polyps may cause intussusception and anaemia. Other causes can have bowel lesions causing intussusception but do not show mucocutaneous lesions.

Question 69

19.A 45-year-old man presents with acute-onset abdominal pain. Imaging confirms the diagnosis of intussusception. Which of the following is the most likely cause?

(a) Meckel’s diverticulum

(b) Aberrant pancreas

(c) Chronic tuberculosis ulcer

(d) Scleroderma

(e) Idiopathic

Answer 69

(e)Idiopathic

Twenty percent of all adult intussusceptions are idiopathic. The rest of the given causes are rare.

Question 70

20.A 40-year-old patient presents with symptoms of recurrent asthma, heart failure and non-specific abdominal pain after meals and alcohol. CT shows a mass with desmoplastic reaction in the terminal ileum. The liver shows multiple lesions enhancing in the arterial phase. The most likely diagnosis is?

(a) Carcinoid tumour of terminal ileum

(b) Carcinoma of the terminal ileum with liver metastases

(c) Lymphoma

(d) Fibrosing mesenteritis

(e) Carcinoid syndrome

Answer 70

(e) Carcinoid syndrome

Carcinoid tumours most commonly arise from the small bowel or appendix. Liver metastases may result in carcinoid syndrome presenting with symptoms after food and alcohol.

Question 71

60-year-old man presents with abdominal pain. Enteroclysis shows a contrast filling abnormality in the concavity of the second part of the duodenum. Contrast- enhanced CT shows two ‘duodenal lumina’. The medial lumen contains an air-fluid level and causes medial displacement of the pancreatic head. The most likely diagnosis is?

(a) Duodenal duplication cyst

(b) Duodenal diverticulum

(c) Pancreatic pseudocyst

(d) Pancreatic tumour

(e) Necrotic duodenal carcinoma

Answer 71

(b) Duodenal diverticulum

The most frequent location of a duodenal diverticulum is along the medial wall of the second or third part of the duodenum. Most patients are asymptomatic, however some may present with diverticulitis. Barium examination may show the classic ‘windsock’ deformity, with the contras-filled diverticulum seen to project into the true lumen or contrast-filled duodenum projecting medially into the ‘C’ of the duodenum. Duodenal duplication cysts do not communicate with the true lumen of duodenum.

Question 72

10. Features more in keeping with jejunum than ileum include: (T/F)

(a) Thinner walls.

(b) Thicker valvulae conniventes.

(c) More numerous Peyer’s patches.

(d) One or two arterial arcades with long branches.

(e) 2.5cm width diameter.

Answer 72

Answers:

(a) Not correct
(b) Correct
(c) Not correct
(d) Correct
(e) Not correct

Explanation:

Ileum is 2.5 cm in diameter and jejunum is 3-3.5 cm.
Jejunum shows a few Peyer’s patches but they are larger.
Jejunum as thicker walls as compared to ileum.

Question 73

12. Regarding Peutz-Jeghers syndrome: (T/F)

(a) It is inherited in an autosomal recessive manner.

(b) There is an association with intussusception.

(c) Patients are at increased risk of gastrointestinal adenocarcinoma.

(d) Polyps are seen in the stomach.

(e) It is associated with pigmented lesions on the fingers

Answer 73

Answers:

(a) Not correct
(b) Correct
(c) Correct
(d) Correct
(e) Correct

Explanation:

It is an autosomal dominant disease showing polyps in stomach, small intestine especially jejunum and may be seen in colon. There is an increased risk of a adenocarcinoma but polyps themselves are hamartomatous

Question 74

13. Regarding Carcinoid tumour: (T/F)

(a) Carcinoid syndrome is the presentation in only 20-30% of cases.

(b) It is rarely multiple.

(c) The commonest location for this tumour is the appendix.

(d) 50% of tumours greater than 2cm in size have metastases.

(e) Angulation of small bowel loops on small bowel follow through is a diagnostic feature.

Answer 74

Answers:

(a) Not correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct

Explanation:

Carcinoid tumour are multiple in 33% of the cases. Carcinoid syndrome is seen in only 7% of the cases and arises due to excess serotonin levels. The 50% of tumours of 1–2 centimetres in size have metastasis, 85% of tumour was greater than 2 cm have metastasis.

Question 75

26. Regarding Small bowel obstruction (SBO) in adults: (T/F)

(a) The small bowel-faeces sign is pathognomonic of SBO.

(b) Gallstone ileus typically causes jejunal obstruction.

(c) Hernias are the most common cause.

(d) Intussusception is associated with an underlying pathology in >75% of cases.

(e) Strangulation is more common in closed loop obstruction.

Answer 75

Answers:

(a) Not correct
(b) Not correct
(c) Not correct
(d) Correct
(e) Correct

Explanation:

Adhesions are the most common cause of small-bowel obstruction in adults followed by hernias and neoplasms.
The small bowel-fecus sign has been described in the context of small-bowel obstruction but has also been also in other metabolic or infectious diseases.
The most common site of stone impaction in gallstone ileus is ileum followed by jejunum and duodenum.

Question 76

27. A small bowel enema reveals smooth thickened folds in a 20cm segment of the small bowel. Differential diagnosis should include: (T/F)

(a) Congestive heart failure.

(b) Radiation enteropathy.

(c) Nephrotic syndrome.

(d) Crohn’s disease.

(e) Lymphoma.

Answer 76

Answers:

(a) Not correct
(b) Correct
(c) Not correct
(d) Correct
(e) Correct

Explanation:

Generalised thickening of small bowel usually occurs in hypoproteinaemia, congestive heart failure and nephrotic syndrome. Long segment thickening may reflect intramural haemorrhage example ischaemia, anticoagulant therapy. Focal thickening of small bowel should include lymphoma, mesenteric metastasis and early Crohn’s disease.

Question 77

29. Which of the following are correct about Carcinoid of the appendix and small bowel: (T/F)

(a) 40-50 arise in the appendix.

(b) The incidence of metastatic disease is directly related to primary tumour size.

(c) Small-bowel carcinoids are multiple in 30-40% of patients.

(d) A spiculated mesenteric mass on CT is incompatible with Carcinoid.

(e) 111-labelled MIBG uptake is specific for carcinoid.

Answer 77

Answers:

(a) Correct
(b) Correct
(c) Correct
(d) Not correct
(e) Not correct

Explanation:

Carcinoid tumours of the gastrointestinal tract are small and often difficult to detect on routine CT scans. On CT, a carcinoid tumour appears stellate, spiculated, mesenteric mass containing calcification in the 70% of the cases. Indium labelled MIBG scan can be used for the detection of several neuroendocrine tumours like pheochromocytoma, neuroblastoma and carcinoid tumours. Octreotide is a somatostatin analogue that can also be useful for diagnosing carcinoid tumours.

Question 78

37. In Whipple’s disease, which of the following are correct? (T/F)

(a) Females are more commonly affected.

(b) Sacroiliitis is a feature.

(c) Ulceration is a common finding on barium studies.

(d) Small bowel dilatation is a typical finding.

(e) Involved lymph nodes are hypodense on CT.

Answer 78

Answers:

(a) Not correct
(b) Correct
(c) Not correct
(d) Not correct
(e) Correct

Explanation:

Males are commonly affected (9:1 = M:F).
There is absence of bowel dilatation, no ulceration and thickening of duodenum and jejunum folds due infiltration by macrophages.