Stomach

Question 1

1- Regarding laparoscopic adjustable gastric banding:

A. On scout films, the band should be parallel to the Gastro Oesophageal Junction (GOJ)

B. When patient ingests contrast, position of band best assessed on lateral decubitus projection

C. Is connected by tubing to a port anterior to the rectus sheath

D. With band slippage, the pouch is narrowed

E. Perforation rates are typically 1-2%

Answer 1

C. Is connected by tubing to a port anterior to the rectus sheath

Band should be perpendicular to GOJ on scout film.

Position is best assessed straight AP or slightly RPO.

Band slipping leads to eccentric pouch dilation.

Perforation typically < 0.5%

Question 2

2- Which of the following favours gastric lymphoma rather than other gastric malignancies?

A. Preservation of the fat plane around the stomach

B. Luminal narrowing

C. Involvement of the proximal half of the stomach

D. Heterogenous gastric wall thickening

E. A single site of disease within the stomach

Answer 2

A. Preservation of the fat plane around the stomach

Preservation of the fat plane around the stomach, diffuse and homogenous wall thickening, multifocal disease within the stomach, nodal disease either side of the mesenteric vessels, nodal disease extending below the level of the renal veins and a propensity for the distal half of the stomach are all features of gastric lymphoma.

Question 3

3- Which of the following is the most correct statement with regards to Gastrointestinal Stromal tumor (GIST) of the stomach?

A. Most patients present below the age of 50

B. GISTS of the stomach have a more aggressive histology when compared with GISTS from other sites

C. Mural calcification is a common feature

D. Larger lesions tend to be more homogenous in enhancement

E. Central fluid attenuation/necrosis is common

Answer 3

E. Central fluid attenuation/necrosis is common

Stomach GISTs tend to present in patients over 50.

CT usually shows a well-defined heterogeneously enhancing, round, exophytic mass, commonly with central necrosis.

Mural calcification is recognised but not common.

Stomach GISTs tend to be less aggressive histologically than GISTs at other sites.

Question 4

1. A 64-year-old man undergoes a barium meal examination for upper abdominal pain. A 10 mm ulcer is demonstrated at the gastric antrum. Which radiological feature would favour a diagnosis of malignant rather than benign gastric ulcer?

A. round ulcer shape

B. ulcer crater confined within the gastric contour

C. gastric folds identified up to the edge of the ulcer crater

D. associated duodenal ulcer disease

E. uniform mucosal collar around a centrally located ulcer

Answer 4

B. ulcer crater confined within the gastric contour

Many distinguishing features of gastric ulceration have been proposed in an attempt to classify gastric ulcers as benign or malignant, but there is significant overlap between the two categories.

One reliable sign of a benign ulcer is the projection of the ulcer outside the gastric contour in profile, due to excavation into the mucosal wall.

In contrast, a malignant ulcer occurring within a tumour mass does not usually extend beyond the confines of the gastric wall.

Other features indicative of benignity include around, centrally located ulcer with a uniform collar of edematous mucosa, gastric folds extending to the edge of the ulcer crater and associated duodenal ulcer disease.

Question 5

2. A 65-year-old woman, with a history of previous partial gastrectomy 10 years earlier, presents with upper abdominal pain and early satiety. She undergoes a double-contrast barium meal, which demonstrates a 4 cm intraluminal, mottled filling defect in the gastric remnant with no fixed attachment to the gastric wall. What is the most likely diagnosis?

A. suture granuloma

B. trichobezoar

C. phytobezoar

D. gastric carcinoma

E. villous adenoma

Answer 5

C. phytobezoar

Bezoars are masses of accumulated ingested material forming in the stomach or intestines.

Phytobezoars are the commonest type, composed of poorly digested fibre and vegetable matter.

They are seen particularly in patients with previous gastric surgery, probably due to diminished gastric emptying.

Patients may be asymptomatic or present with early satiety or symptoms of gastritis, as phytobezoars are irritant.

Occasionally, they may obstruct the stomach with a ball–valve mechanism. They are seen as relatively mobile filling defects, the interstices of which are filled with barium.

Trichobezoars are composed of hair, and are usually larger, and found in younger patients, particularly those with a psychiatric history.

Gastric carcinoma, villous adenoma and suture granuloma are all causes of gastric filling defects but have a constant relationship to the gastric wall.

Question 6

3. A 54-year-old man with known metastatic malignant melanoma presents with epigastric pain and hematemesis. What is the most likely finding in the stomach on double-contrast barium meal?

A. multiple submucosal nodules with central ulceration

B. solitary ulcerated mass in the gastric antrum

C. linitis plastica

D. solitary, well-defined, pedunculated filling defect

E. thickened tortuous gastric folds

Answer 6

A. multiple submucosal nodules with central ulceration

GI tract metastases are seen in 4–8% of patients with malignant melanoma.

The small intestine is most commonly affected, followed by the colon and stomach.

Typical features are of multiple submucosal nodules, with a target appearance due to central ulceration.

This appearance is particularly seen with malignant melanoma metastases but may also be seen with gastric metastases from breast, lung and renal cell carcinoma.

Other common appearances of gastric metastases include linitis plastica in 20%, most typically from breast cancer, and a solitary mass in 50%.

Question 7

4. A 66-year-old woman with a known large para-oesophageal hiatus hernia presents with sudden onset of severe epigastric pain and vigorous retching without production of vomitus. Passage of a nasogastric tube is unsuccessful. Plain abdominal radiograph demonstrates a markedly distended stomach in the left upper quadrant extending into the chest. What is the most likely diagnosis?

A. pyloric stenosis

B. ‘cup-and-spill’ stomach

C. acute gastric volvulus

D. acute gastric dilatation

E. paraduodenal hernia

Answer 7

C. acute gastric volvulus

Acute gastric volvulus is abnormal rotation of one part of the stomach around another part, which may be classified as organoaxial, mesenteroaxial or combination type, depending on the axis of rotation.

Predisposing factors include ligamentous laxity, hiatus hernia and diaphragmatic eventration.

The classic presentation is with the Borchardt triad of sudden severe epigastric pain, intractable retching with no vomitus produced, and inability to pass a nasogastric tube into the stomach.

Other plain film findings include unexpected location of the gastric bubble and air–fluid levels in the mediastinum or upper abdomen, but definitive diagnosis is by barium meal.

The condition is a surgical emergency, as it may result in gastric ischaemia or perforation.

Acute gastric dilatation and pyloric stenosis may result in gastric distension on plain film, but would not present with intractable retching or difficulty with nasogastric tube passage.

A ‘cup-and-spill’ stomach is an anatomical variant on barium meal, which may simulate an organoaxial volvulus.

A paraduodenal hernia usually presents acutely as small bowel obstruction.

Question 8

5. A 48-year-old man presents with epigastric pain, weight loss and peripheral oedema. Blood tests demonstrate hypoalbuminaemia. At barium meal the stomach is well distended, but there is poor mucosal coating. Markedly enlarged and tortuous gastric rugae are seen in the fundus and body of the stomach, with sparing of the antrum. What is the most likely diagnosis?

A. lymphoma

B. Ménétrièr’s disease

C. gastric carcinoma

D. Zollinger–Ellison syndrome

E. eosinophilic gastroenteritis

Answer 8

B. Ménétrièr’s disease

Ménétrièr’s disease is characterized by mucosal hypertrophy of the fundus and body of the stomach, with excessive mucus secretion and a protein-losing enteropathy.

There may be associated gastric ulceration.

Barium meal shows impaired mucosal coating due to hypersecretion and marked gastric fold thickening, though the stomach distends normally.

The stomach is the commonest site for gastrointestinal lymphoma, which maybe polypoid, ulcerating or infiltrative.

The infiltrative form may cause pronounced thickening of gastric folds, with preserved stomach distensibility, but hypersecretion isn’t a feature.

Infiltrating gastric carcinoma may also cause thickened gastric folds, but associated desmoplastic reaction results in a rigid, poorly distensible stomach.

Zollinger–Ellison syndrome results in hypersecretion of gastric acid, which impairs mucosal coating of barium, and is associated with ulceration and enlargement of rugal folds, buthypoproteinaemia is not a feature.

Eosinophilic gastroenteritis may cause enlarged gastric folds and be associated with protein-losing enteropathy if the small bowel is involved. However, the antrum is most commonly involved.

Question 9

6. On a barium meal examination, the incisura angularis marks the border between which structures?

A. lesser and greater curvatures of the stomach

B. antrum and pylorus of the stomach

C. fundus and body of the stomach

D. body and antrum of the stomach

E. oesophagus and the stomach

Answer 9

D. body and antrum of the stomach

The stomach is divided into the fundus, body, antrum and pylorus. The fundus is that part of the stomach extending superiorly and to the left of the cardiac orifice. The body extends from the cardiac orifice to the incisura angularis, which is a constant notch at the lower end of the lesser curvature marking the border between the body and the antrum of the stomach. The antrum extends from the incisura angularis to the proximal pylorus.

Question 10

7. A 41-year-old woman with morbid obesity presents with a plateau in weight loss 12 weeks after laparoscopic gastric banding. She undergoes a contrast swallow, which demonstrates concentric dilatation of the neostomach with a widely patent stoma. What is the most appropriate management?

A. no action necessary

B. nutritional advice

C. prompt decompression of the stoma by the radiologist

D. fluoroscopically guided band inflation

E. surgical replacement of the gastric band

Answer 10

B. nutritional advice

Laparoscopic gastric banding involves laparoscopic placement of an inflatable gastric band across the proximal stomach, forming a small fundal neostomach or pouch.

The band is connected to a subcutaneous port that can be accessed percutaneously to allow inflation or deflation of the band and adjustment of stomal width and degree of hold-up.

The commonest postoperative complication is dilatation of the pouch.

Three main types are described.

(1) Acute concentric pouch dilatation is due to band overinflation, and is seen as a prestenotic dilatation proximal to an obstructed stoma. It presents as acute dysphagia and requires prompt decompression of the stoma.

(2) Chronic concentric pouch dilatation with a widely patent stoma is seen in patients who continue to overfill their neostomach after surgery. Nutritional advice is required.

(3) Eccentric pouch dilatation occurs due to slippage of the band, and requires complete decompression and surgical replacement of the band. A plateau in weight loss may also be due to loss of effect of band tightening. At fluoroscopy, fluid may be injected to tighten the band to achieve an optimal stomal width of 3–4 cm

Question 11

@# 8. A 69-year-old man undergoes staging of gastric carcinoma diagnosed at upper gastrointestinal endoscopy. CT of the abdomen demonstrates focal gastric wall thickening with extension into the perigastric fat, but no invasion of adjacent structures. Five local lymph nodes measuring 10–12 mm in short axis diameter are identified. There is no distant metastatic disease. What is the TNM staging of the tumour?

A. T2 N0 M0

B. T2 N1 M0

C. T2 N2 M0

D. T3 N1 M0

E. T3 N2 M0

Answer 11

D. T3 N1 M0

T3 tumours penetrate the subserosa but do not invade adjacent structures. On CT, this may be appreciated as blurring of the tumour margin or wide reticular strands radiating from the tumour edge.

Nodal staging depends on the number of regional nodes visible, with nodes larger than 8cm being regarded as pathological.

The presence of 1–6 regional nodes results in a stage of N1, with 7–15 nodes and >15 nodes representing nodal stages of N2 and N3 respectively.

Non-regional nodes such as para-aortic and retropancreatic nodes are considered M1 disease.

Question 12

9. A 65-year-old man presents with early satiety and bloating, and undergoes barium meal. This demonstrates a smoothly marginated, 15 cm mass in the body of the stomach, making an obtuse angle with the gastric wall. CT demonstrates peripheral enhancement of the mass with central areas of low attenuation and extragastric extension into the lesser sac. There is no associated lymphadenopathy. What is the most likely diagnosis?

A. gastrointestinal stromal tumour

B. gastric carcinoma

C. gastric lymphoma

D. adenomatous polyp

E. gastric carcinoid

Answer 12

A. gastrointestinal stromal tumour

Gastrointestinal stromal tumours are the commonest mesenchymal tumours of the gastrointestinal tract. They are characterized by expression of KIT, a tyrosine kinase growth factor receptor, which distinguishes them from leiomyomas and leiomyosarcomas. They occur most commonly in the stomach, and have the classic appearance of a submucosal mass on barium meal, forming an obtuse angle with the gastric wall in profile. Focal areas of ulceration are seen in 60%.

On CT, the tumours measure up to 30 cm and are often predominantly extragastric.

Typical features are of peripheral enhancement, with central low attenuation representing necrosis, haemorrhage and cyst formation.

Lymphadenopathy is not a feature.

Gastric carcinoma and lymphoma rarely demonstrate exophytic growth and commonly have associated lymphadenopathy.

Adenomatous polyps are mucosal lesions.

Gastric carcinoid is usually seen in the antrum and characteristically shows associated ulceration.

Question 13

4.Emphysematous gastritis is most commonly associated with which of the following organisms?

(a) S.pnemoniae

(b) C.difficile

(c) S.milleri

(d) E.coli

(e) S.aureus

Answer 13

(d) E.coli

Clostridium welchii is another common cause of this unusual condition. S.pneumoniae, S. aureus (and E.coli) may cause non-emphysematous gastritis. S.milleri is a cause of liver abscesses and C. difficile colitis

Question 14

14.A patient with a metastasis from a GIST tumour undergoes a contrast-enhanced CT study before and after chemotherapy. On the initial study, the lesion measures 5 cm in diameter and has a density of 100 HU. At follow up, the lesion measures 6 cm and has a density of 80 HU. How should you classify the response to chemotherapy?

(a) Complete response

(b) Partial response

(c) Mixed response

(d) Stable disease

(e) Progressive disease

Answer 14

(b) Partial response

metastatic GIST tumours are treated with monoclonal antibody agents. These typically reduce the blood supply and metabolism of the tumours with little change in tumour size and as such, the RECIST criteria are of little value. The Choi criteria differ from RECIST in that to obtain a PR, one needs a 10% reduction in size or a 15% reduction in density. Progressive disease requires 1 tumour growth a 15% reduction in lesion density, a lesion or a or growing nodule of enhancing tumour within an existing lesion. There is no mixed response category.

Question 15

21.Which of the following is not a recognised cause of gastric fold thickening?

(a) Adult hypertrophic pyloric stenosis

(b) lymphoma

(c) Gastritis

(d) Menetrier’s disease

(e) Zollinger-Ellison syndrome

Answer 15

(a) Adult hypertrophic pyloric stenosis

This has similar appearances to infantile hypertrophic pyloric stenosis but may be associated with ulceration. Differentiation from malignancy in the antrum may also be difficult.

Question 16

32.Where do gastrointestinal stromal tumours (GIST) most commonly arise?

(a) Esophagus

(b) Stomach

(c) Small intestine

(d) Colon

(e) Appendix

Answer 16

(b) Stomach

Approximately 60% arise in the stomach, 30% in the small bowel, 7% in the ano-rectal region and the remainder in the oesophagus and colon .

Question 17

20.Which of the conditions does not predispose patients to gastric volvulus?

(a) Hiatus hernia

(b) Phrenic nerve palsy

(c) Previous sigmoid volvulus

(d) Diaphragmatic eventration

(e) Splenic abnormalities

Answer 17

(c) Previous sigmoid volvulus

Other predisposing factors include gastric distension and traumatic diaphragmatic hernia. It is more commonly seen in the elderly and presents with acute upper Gl obstruction and wrenching without producing vomitus. It is important to assess the patient for signs of ischaemia on cross-sectional imaging as this is a surgical emergency.

Question 18

31.Which of the following is not a recognised complication of partial gastrectomy?

(a) Bezoar

(b) Gastric carcinoma

(c) Fistula formation

(d) Gastric lymphoma

(e) Marginal ulceration

Answer 18

(d) Gastric lymphoma

Partial gastrectomy was previously a common operation for the treatment of peptic ulcer disease, often in association with a vagotomy.

Question 19

43.A 56-year-old has undergone previous surgery is referred to nuclear medicine for a gastric emptying study. The patient ingests radio-labelled fruit juice, bread and scrambled egg. The gastric emptying curves demonstrate the liquid phase to have a T1/2 of 10 minutes and the solid phase to have a T1/2 of 20 minutes. How would you interpret these findings?

(a) Normal gastric emptying

(b) Dumping syndrome

(c) Gastric stasis

(d) Previous vagotomy

(e) Gastric outlet obstruction

Answer 19

(b) Dumping syndrome

The T1/2 for both of these phases is abnormally low indicating rapid transit of liquid and solid components; dumping syndrome may be seen following gastric surgery. Normal rates of emptying are T1/2<30 minutes for liquids, and 30-120 minutes for solid food. Vagotomy leads to rapid gastric emptying and delayed solid emptying. Gastric stasis will result in delayed transit of solid and liquid components.

Question 20

53.A 46-year-old man presents vomiting, epigastric pain, ankle swelling, poor appetite, and weight loss. OGD shows marked enlargement of the proximal rugal folds and ulceration. A subsequent barium examination shows dilution of barium in the stomach and thickening of folds the small intestine. What is the most likely diagnosis?

(a) Carney syndrome

(b) Helicobacter pylori infection

(c) Ménétrier’s disease

(d) Pernicious anemia

(e) VIPoma

Answer 20

(c) Ménétrier’s disease

Ménétrier’s disease (giant hypertrophic gastritis) results in marked thickening of the gastric mucosal folds, typically in the proximal half of the stomach. The gastric mucosa secretes copious mucus (dilution of barium), which results in a protein-losing enteropathy (leading to SB fold thickening). It is ass achlorhydria which can lead to ulceration

Question 21

55.Which of the following conditions is not associated Helicobacter pylori colonisation?

(a) Oesophageal cancer

(b) Gastric ulcer

(c) Gastric carcinoma

(d) MALT Lymphoma

(e) Duodenal ulcer

Answer 21

(a) Oesophageal cancer

Esophageal carcinoma rates have been increasing as H. pylori colonisation rates have fallen. A protective effect against some conditions has been postulated but this is highly controversial.

Question 22

73.A patient undergoing an endoscopic US examination is found to have a lesion within the muscularis propria layer of the stomach wall. What is the most likely diagnosis?

(a) Adenocarcinoma

(b) Lipoma

(c) Gastro-intestinal stromal tumour

(d) Peritoneal metastasis

(e) Varices

Answer 22

(c) Gastro-intestinal stromal tumour

GIST, leiomyoma and leiomyosarcoma arise in this level. Adenocarcinoma arises within the mucosa. Lipoma within the submucosa. Metastases are seen at the serosal surface. Varices may be in the submucosa or extrinsic to the stomach.

Question 23

26. A 50-year-old male is admitted with epigastric pain, diarrhoea and vomiting. Ascites is present clinically. Serum albumin is low and the patient is anaemic. Colonoscopy is normal but the patient is intolerant of upper gastro-intestinal endoscopy. Barium meal reveals a normal antrum but elsewhere there are diffusely thickened and enlarged gastric folds despite good gastric distension. Which one of the following is the most likely diagnosis?

a. Gastric lymphoma

b. Menetrier’s disease

c. Gastric adenocarcinoma

d. Acute gastritis

e. Linitis plastic

Answer 23

26. b. Menetrier’s disease

Menetrier’s disease is a condition characterized by gastric mucosal hypertrophy and protein-losing enteropathy. It is often associated with anaemia. The changes are most marked along the greater curve and the antrum is spared in approximately 50% of cases. Gastric lymphoma typically involves the antrum. With gastric adenocarcinoma and linitis plastica, stomach distension is not typically preserved.

Question 24

QUESTION 4
A 72-year-old man presents to his GP with increasing dyspepsia and weight loss. He has not experienced any other GI symptoms and physical examination is unremarkable. A barium meal is performed with the administration of intravenous Buscopan. The oesophagus is normal in appearance but a ‘bull’s eye’ lesion is noted in the gastric mucosa. Which one of the following is not a recognized cause of this appearance?

A Gastric carcinoma

B Gastrointestinal stromal tumour (GIST)

C Magenstrasse

D Melanoma metastases

E Neurofibromatosis

Answer 24

C Magenstrasse

Magenstrasse refers to the normal longitudinal mucosal folds seen adjacent to the lesser curve of the stomach during a barium meal. The ‘bull’s eye’ appearance seen during a barium meal is due to a central ulcer in an elevated area of submucosa. A GIST may well have this appearance and neurofibromatosis an cause single or multiple target lesions. Melanoma is the commonest cause of submucosal gastric metastases.

Question 25

QUESTION 18
A 68-year-old man presents to his GP with a 1-month history of epigastric pain, vomiting and mild weight loss. Examination is unremarkable and the patient is referred for an upper gastrointestinal endoscopy. This demonstrates mild gastritis with biopsies positive for Helicobacter pylori and he is commenced on eradication therapy. Three months later, the symptoms have persisted and the patient has lost 5 kg in weight. A double contrast barium meal is performed and reveals a shallow ulcer on the lesser curve of the stomach. Which additional finding would make the ulcer more likely to be benign than malignant?

A Hampton’s line is present.

B Nodular mucosal folds stop at the edge of the lesion.

C The ulcer does not extend beyond the gastric wall.

D The ulcer has an irregular margin.

E The ulcer measures 40 mm in size.

Answer 25

A Hampton’s line is present.

Hampton’s line refers to a lucent line crossing the ulcer base: its presence is highly suggestive of a benign ulcer

Question 26

QUESTION 33
A 48-year-old man presents to his GP with epigastric pain, diarrhoea and weight loss over a period of 6 months. Laboratory investigations reveal a reduced serum albumin, and a contrast-enhanced CT of the abdomen demonstrates diffuse thickening of the gastric mucosa. A double contrast barium meal examination is performed and shows markedly thickened mucosal folds in the gastric body with sparing of the gastric antrum. The mucosal folds alter in size and position during the examination. What is the most likely diagnosis?

A Eosinophilic gastritis

B Gastric lymphoma

C Infiltrative gastric adenocarcinoma (Linitis Plastica)

D Menetrier’s disease

E Organoaxial gastric volvulus

Answer 26

D Menetrier’s disease

Menetrier’s disease characteristically produces thickened hyperplastic mucosa (sparing the gastric antrum) but the stomach remains pliable.

Question 27

QUESTION 36
A 49-year-old man develops weight loss, upper abdominal pain and three episodes of vomiting fresh red blood. Subsequent upper gastrointestinal endoscopy reveals a distal gastric adenocarcinoma. The patient undergoes a surgical procedure to resect the tumour, but develops increasing epigastric pain and fever 4 days later. An upper GI contrast study is performed. Which one of the following statements is true regarding this examination?

A A partial distal gastrectomy with gastrojejunostomy (Billroth II procedure) involves an end-to-end anastomosis.

B Control images prior to contrast administration are not indicated in this

C If a water-soluble contrast examination appears normal, barium can be used as it has a higher sensitivity in identifying anastomotic leaks.

D The oesophago-gastric junction is the most common site for perforation and contrast leaks.

E Thickening of the mucosa at the surgical anastomosis with delayed gastric emptying is most likely due to residual gastric tumour.

Answer 27

C If a water-soluble contrast examination appears normal, barium can be used as it has a higher sensitivity in identifying anastomotic leaks.

Anastomotic leakage is one of the most serious complications following gastric surgery and may occur in the acute or chronic phase. In a contrast study, water-soluble contrast should be used initially, but if no leak is detected then barium can be used as it is more sensitive for the detection of subtle postoperative leaks (outweighing the risk of barium spilling into the peritoneal cavity). The most common site for leakage is at surgical anastomoses and suture lines; therefore, control images are invaluable to note the location of these sites and look for extraluminal gas.

Question 28

1. A 63-year-old man is day 7 post-operative following a Billroth II partial gastrectomy for a gastric carcinoma. The initial post-operative phase was uncomplicated, but the patient has begun complaining of increasing abdominal pain. Inflammatory markers have increased with white cell count (WCC), rising from 12 to 42, and CRP increased from 8 to 56. A CT scan carried out with oral and intravenous contrast demonstrates no evidence of contrast leakage into the peritoneum. A skiff of free air is noted in the abdomen. A fluid collection is noted in the right subhepatic space, which extends toward the peripancreatic area. What is the most likely diagnosis?

A. Leakage from the gastroduodenal anastomosis site.

B. Leakage from the duodenal stump.

C. Post-operative pancreatitis.

D. Tumour recurrence.

E. Pseudocyst formation following post-operative pancreatitis.

Answer 28

1. B. Leakage from the duodenal stump.

There is no gastro-duodenal anastomosis in a Billroth II procedure. The amylase is not sufficiently elevated for pancreatitis in most cases and there is no described abnormality in the pancreas. It is too early for pseudocyst formation and tumour recurrence.

Question 29

6. A patient presents to an outpatient barium meal list with a history ofepigastric discomfort and weight loss of 8 kg over 6 months. The bariummeal reveals an ulcer on the greater curve of the stomach, near the pylorus. This ulcer has a surrounding mound. It is demonstrated to project slightly beyond the lumen of the stomach. There is a thin line noted which crossesthe base of the ulcer and a degree of retraction of the greater curve aroundthe ulcer. What type of ulcer is this likely to be?

A. Benign due to the line noted crossing the base of the ulcer.

B. Benign due to the ulcer projecting beyond the lumen of the stomach.

C. Benign due to the surrounding mound.

D. Malignant due to the finding of scar retraction of the greater curve.

E. Malignant due to being found on the greater curve.

Answer 29

6. A. Benign due to the line noted crossing the base of the ulcer.

This line—Hampton’s line—represents undermining of the mucosa by the more vulnerablesubmucosa. It is not commonly seen, but is taken to be virtually diagnostic of a benign ulcer whenpresent. Projection beyond the lumen and a symmetrical mound are features of a benign ulceralong with smooth radiating mucosal folds. Scar retraction can be seen with benign ulcers. Bothbenign and malignant ulcers are more commonly seen on the lesser curve

Question 30

13. A patient is undergoing a barium meal. What is the best position to place the patient in to see an en face view of the lesser curve?

A. Left lateral.

B. Left anterior oblique (LAO).

C. Supine.

D. Right anterior oblique (RAO).

E. Right lateral.

Answer 30

13. B. LAO.

The right lateral position is not routinely used. The RAO shows the body and antrum of the stomach. Supine positioning shows the greater curve and the antrum of the stomach. Left lateral position shows the fundus of the stomach.

Question 31

A staging CT was performed on a 49-year-old gentleman with a histologically proven adenocarcinoma of the fundus of his stomach. The CT showed invasion of the adjacent contiguous structures but no invasion of adjacent organs, the diaphragm or the abdominal wall. Multiple prominent local nodes were evident and a 1.3-cm (short axis) lymph node was seen in the left para-aortic region. No distant metastases were visible. What is staging?

a T4b N2 MO

b T4a N3 MO

c T3 N3 MO

d T3 N3 M1

e T4a N2 MO

Answer 31

Answer B: T4a N3 MO

Question 32

A patient had recently been diagnosed with gastric carcinoma that had been staged locally as T2 disease. To what extend has the tumour penetrated through the wall?

a Penetrated thorough the serosa

b Invading adjacent organs

c Limited to the submucosa

d Limited to the serosa

e Limited to the mucosa

Answer 32

Answer D: Limited to the serosa

Question 33

An 80-year-old male underwent a barium meal to investigate epigastric pain and early satiety. There was a narrow, tubular stomach with a lack of rugal folds in the proximal stomach and a smooth greater curve. What is diagnosis?

a Zollinger-Ellison syndrome

b Linitis Plastica

C Atrophic gastritis

d Menetrier’s disease

e Corrosive gastritis

Answer 33

Answer C: Atrophic gastritis

The incidence of atrophic gastritis increases with age and symptoms may include epigastric pain and early satiety. Radiological features are a narrow tubular stomach and a reduction in the normal gastric folds.

Question 34

A middle-aged man underwent a barium meal which showed an abnormality of the gastric wall with mural thickening, irregularity, reduced distensibility and absent peristalsis. What is the most likely underlying diagnosis?

a Amyloid

b Pancreatic carcinoma

c Radiation therapy

d Scirrhous cancer

e Syphilis

Answer 34

Answer D: Scirrhous cancer

The listed radiological features are typical of Linitis Plastica (leather bottle stomach) of which scirrhous cancer is the most common cause. Other causes include: other tumours (lymphoma, metastases, pancreatic carcinoma), inflammation (erosive gastritis, radiation therapy), infiltrative disease (sarcoid, amyloid, intramural haematoma) and infection (TB, syphilis).

Question 35

13 An 88-year-old lady presented with a tender distended abdomen. A dilated viscus was visible in the left upper quadrant on plain radiography with a long fluid level. There was leftward and upward displacement with a raised left hemidiaphragm and little gas elsewhere in the abdomen. What is the most likely diagnosis?

a Air swallowing

b Caecal volvulus

c Gastric outlet obstruction

d Gastric volvulus

e Paralytic ileus

Answer 35

13 Answer D: Gastric volvulus

Gastric volvulus, although rare, is more common in the elderly population. It may result from twisting in the longitudinal, transverse or mesenteric axis. The dilated stomach usually contains a long fluid level and is displaced upwards and to the left, causing a raised left hemidiaphragm.

Question 36

15 A gastric ulcer was visible during a barium meal. What feature would favour a benign aetiology over malignancy?

a Irregular contour

b Hampton’s line

c Shallow ulcer

d No protrusion beyond stomach

e Asymmetrical mass

Answer 36

15 Answer B: Hampton’s line

Question 37

16 A patient was diagnosis with Menetrier’s disease on histology. What radiological appearance would support this diagnosis?

a Absence of gastric folds in the proximal stomach

b Thickened folds in the proximal stomach

C Multiple gastric ulcers

d Rigid stomach wall

e Aphthoid ulcers

Answer 37

16 Answer B: Thickened folds in the proximal stomach

This is hypertrophic gastritis and may present with epigastric pain, achlorydia, and protein loss. There are thickened gastric folds mainly in the proximal stomach and greater curve. Unlike in a malignant process the stomach wall does not become rigid, but endoscopy and biopsy are usually necessary for diagnosis.

Question 38

17 A patient underwent a barium meal which demonstrated multiple filling defects. Upper GI endoscopy confirmed multiple gastric polyps, which were biopsied. What is the histology most likely to show?

a Adenomatous polyps

b Hamartomatous polyps

c Hyperplastic polyps

d Leiomyomas

e Metastases

Answer 38

17 Answer C: Hyperplastic polyps

Hyperplastic polyps occur mainly in the body and fundus of the stomach but also randomly throughout the stomach. They measure under 1 cm in size, but rarely be 3-10 cm. This type makes up 80-90% of gastric polyps.

Question 39

18 A 50-year-old publican with a history of back pain developed retrosternal pain and melaena. He visited his doctor and, following a negative urea breath test, was referred for a barium meal. This showed linear streaks and dots of barium within the gastric mucosa, preferentially affecting the gastric antrum. What is the most diagnosis?

a Crohn’s disease

b Gastric varices

C Gastric carcinoma

d Emphysematous gastritis

e Erosive gastritis

Answer 39

18 Answer E: Erosive gastritis

Erosive (haemorrhagic) gastritis is associated with peptic disease, infection and Crohn’s disease. Non-steroidal anti-inflammatory drugs are a common underlying cause, which may have been used to treat his back pain. Contrast studies may show complete or incomplete erosions. Complete erosions show a spot of barium surrounded by a radiolucent ring of oedema (target lesion). Incomplete erosions show dots and linear streaks of barium without associated oedema.

Question 40

19 A 30-year-old man with no previous medical or surgical history presented to the Emergency Department with severe epigastric pain. He was retching but was unable to vomit. Plain radiographs demonstrated a large hiatus hernia and grossly distended stomach and an abdominal CT revealed features of a gastric volvulus associated with the hiatus hernia. What feature would suggest an organoaxial volvulus?

a Diaphragmatic rupture

b Evidence of gastric ischaemia

c Gas in the stomach wall

d Greater curvature located cranially

e The fundus positioned caudal to the antrum

Answer 40

19Answer D: Greater curvature located cranially

Question 41

14 A 37-year-old male presented with gastric outlet obstruction. He had a history of epigastric pain related to food and an abdominal CT showed a dilated stomach with irregular inflammatory narrowing in the distal stomach. What is the most likely cause?

a Antral carcinoma

b Crohn’s disease

c Peptic ulcer disease

d Sarcoidosis

e Syphilis

Answer 41

14 Answer C: Peptic ulcer disease

In gastric outlet obstruction caused by inflammatory narrowing 60-65 % is caused by peptic ulcer disease. This is particularly likely in a patient with a history of symptoms probably related to peptic ulcer disease.

Question 42

15 A 55-year-old male presented with severe symptoms of reflux. A barium study showed thickened gastric rugae, duodenal and jejunal folds and multiple peptic ulcers. His serum gastrin level was elevated. What is the most likely diagnosis?

a Barrett’s oesophagus

b Oesophageal Crohn’s disease

c Zollinger-Ellison syndrome

d Pancreatitis

e Helicobacter pylori infection

Answer 42

15 Answer C: Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is secondary to a functional pancreatic islet cell tumour producing gastrin. It causes gastric hypersecretion, which leads to multiple ulcers and a diffuse inflammatory response accounting for the thickened folds.

Question 43

16 A patient presented three months after a gastrojejunostomy with left to right anastomosis with epigastric fullness relieved by bilious vomiting, and B 12 deficiency. CT demonstrated a fluid dense mass adjacent to the head of the pancreas with a further similar mass near the tail of the pancreas. What diagnosis are these findings most suggestive of?

a Anastomotic leak

b Blind loop syndrome

C Incorrect anastomosis

d Anastomotic dehiscence

e Gastric volvulus

Answer 43

16 Answer B: Blind loop syndrome

This occurs following a Billroth II procedure when the afferent loop intermittently partially obstructs and overdistends. Typical features on a contrast examination would be preferential emptying of the stomach into the proximal loop, stasis and regurgitation.

Question 44

17 A 50-year-old landscape gardener presented with abdominal pain and was assessed with a CT scan on which gastric mucosal irregularity was noted. His pain settled with conservative management and he was followed up with a barium meal as an outpatient, which showed multiple target (‘bull’s-eye’) lesions in the stomach.

a Pancreatic `rest’

b Gastric Crohn’s disease

C Gastric carcinoma

d Neurofibroma

e Submucosal metastases

Answer 44

17 Answer E: Submucosal metastases

The commonest cause of bull's-eye' lesions in the stomach is submucosal metastases and of these the commonest primary tumour is malignant melanoma. Other causes of gastric bull’s-eye’ lesions include: leiomyoma, pancreatic rest and neurofibroma.

Question 45

18 A patient was noted to have an abnormal appearance of the stomach wall on abdominal CT. A barium meal was subsequently performed and a diagnosis of ectopic pancreatic tissue (pancreatic rest) was considered. What finding would be most typical of this diagnosis?

a Dots and linear streaks of barium

b Featureless gastric mucosa

c Multiple aphthous ulcers

d Polypoid fundal mass

e Submucosal umbilicated mass

Answer 45

18 Answer E: Submucosal umbilicated mass

Pancreatic rests (ectopic pancreas) typically occur in the greater curvature, pylorus, duodenal bulb or proximal jejunum. They manifest as submucosal nodules between 1 and 5 cm in size. Central umbilication is often present, representing the orifice of the filiform duct.

Question 46

19 Following an episode of haematemesis a 48-year-old man visited his doctor. He admitted several months of dyspeptic symptoms, some weight loss and said he had been drinking up to a bottle of spirit daily. He was referred for an endoscopy, which he was not able to tolerate. Consequently, a barium meal was performed which showed a large ulcer within an oedematous mound on the greater curvature. What further feature would suggest a malignant ulcer?

a Carman’s (meniscus) sign

b Central location of ulcer within mound

C Extension of mucosal folds to crater edge

d Hampton’s line

e Thin mucosal folds

Answer 46

19 Answer A: Carman’s (meniscus) sign

Radiological signs of a malignant ulcer include: thick irregular mucosal folds, projection of ulcer within luminal surface, Carman’s (meniscus) sign, eccentric location of ulcer in tumour mound, a thick nodular irregular collar and limited gastric distensibility and peristalsis.

Question 47

18.A 48-year-old woman presents with history of upper abdominal pain, weight loss and bilateral ankle oedema. CT abdomen shows thickened gastric wall with prominent mucosal folds affecting the upper part of the stomach and greater curvature, while the antrum, pylorus and rest of the bowel appear normal.
The most likely diagnosis is?

(a) Crohn’s disease

(b) Gastric carcinoma

(c) Lymphoma

(d) Ménétrier’s disease

(e) Eosinophilic gastritis

Answer 47

(d) Ménétrier’s disease

This is characterised by hypertrophy of gastric folds affecting the greater curvature while usually sparing the antrum, hypoproteinemia (causing ankle oedema) and hypochlorhydria.
Lymphoma involves any part of stomach and antrum. Eosinophilic gastritis often affects the antrum and the proximal small bowel. Crohn’s disease shows multiple aphthous ulcers and commonly affects antrum and pylorus. It usually affects the terminal ileum as well.

Question 48

27. A 65-year-old woman presents with non-specifc abdominal discomfort. Contrast-enhanced abdominal shows a homogenous, extraluminal mass with heterogeneous enhancement and a low attenuation centre arising from the greater curvature of stomach. No lymphadenopathy is seen. A subsequent PET scan shows markedly increased glucose uptake by the lesion. What is the most likely diagnosis?

(a) Carcinoma of the stomach

(b) Gastrointestinal stromal tumour

(c) Lymphoma

(d) Carcinoid

(e) Metastases

Answer 48

27. (b) Gastrointestinal stromal tumour

This is the likely diagnosis given the CT appearances. It presents as predominantly extraluminal masses with heterogeneously enhancing margins and a necrotic centre. Lymph node enlargement is not a feature. Carcinomas show more vigorous local infltration. Metastases from bowel are usually multiple and often present with a history of known primary malignancy. Lymphomas cause circumferential thickening with homogenous enhancement and lymph nodes. Carcinoids are mainly seen around terminal ileum and produce a desmoplastic reaction

Question 49

15. Following statements regarding lymphoma of the gastrointestinal tract are correct: (T/F)

(a) There is an increased risk associated with ulcerative colitis.

(b) The stomach is the most common site of involvement by non-Hodgkin’s lymphoma.

(c) In the colon the rectum is most commonly involved.

(d) Diffuse involvement of the whole stomach is seen in 10-15%.

(e) Presents with thickened valvulae conniventes in the small bowel.

Answer 49

Answers:

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

Explanation:

Lymphoma of the gastrointestinal tract has an increased risk association with Crohn’s disease, coeliac disease, AIDS and SLE. Diffuse involvement of the stomach is seen in 50% of the cases. Caecum is most commonly involved in colon

Question 50

17. Regarding gastrointestinal stromal tumours (GIST): (T/F)

(a) The most significant criteria for predicting malignant potential is tumour size.

(b) It is a cause of haematemesis.

(c) The commonest location is the sigmoid.

(d) There is an association with neurofibromatosis Type 1

(e) Contrast enhancement is invariably uniform.

Answer 50

Answers:

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

Explanation:

Gastrointestinal stromal tumour does not cause hematemesis since they are mostly exophytic.
It is commonly located at stomach. There is heterogenous enhancement with significant hemorrhage and necrosis.

Question 51

15. Following statements regarding lymphoma of the gastrointestinal tract are correct: (T/F)

(a) There is an increased risk associated with ulcerative colitis.

(b) The stomach is the most common site of involvement by non-Hodgkin’s lymphoma.

(c) In the colon the rectum is most commonly involved.

(d) Diffuse involvement of the whole stomach is seen in 10-15%.

(e) Presents with thickened valvulae conniventes in the small bowel.

Answer 51

Answers:

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

Explanation:

Lymphoma of the gastrointestinal tract has an increased risk association with Crohn’s disease, coeliac disease, AIDS and SLE. Diffuse involvement of the stomach is seen in 50% of the cases. Caecum is most commonly involved in colon

Question 52

33. Which of the following are correct regarding mucosal associated lymphoid tissue (MALT) lymphoma of the gastrointestinal tract? (T/F)

(a) Perforation of the stomach is a recognised feature of gastric MALT lymphoma.

(b) MALT lymphoma is widely disseminated at the time of diagnosis is most patients.

(c) The most common site within the stomach is the antrum.

(d) Ulceration is a common feature on barium study.

(e) The normal stomach does not contain lymphoid follicles.

Answer 52

Answers:

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

Explanation:

MALT lymphoma shows very less dissemination and generally has a better prognosis than non-Hodgkin’s lymphoma. The most common pattern on barium study is infiltrative, either focal or diffuse. Ulcerative lesions, especially in stomach are rare.