VIQ - GIT Flashcards
@# 12. At endoscopic ultrasound scan for staging of an oesophageal carcinoma, the tumour is seen extending into the hypoechoic fourth layer of the oesophagus but not beyond this. What is the T staging of the tumour?
A. Tis
B. T1
C. T2
D. T3
E. T4
C. T2
Endoscopic ultrasound is the most accurate method for local staging of oesophageal cancer.
At endoscopic ultrasound, the oesophageal wall appears as five distinct alternating hyperechoic and hypoechoic bands that correspond to the histological layers of the oesophagus.
The innermost hyperechoic layer represents the interface between the lumen and the mucosa.
The hypoechoic second layer is a hypoechoic band that represents the muscularis mucosa.
The third layer is a hyperechoic band that represents the submucosa.
The fourth layer is a hypoechoic band that represents the muscularispropria.
The fifth outermost layer is a hyperechoic band that represents the oesophageal adventitia.
The fifth layer in the stomach, duodenum and rectum represents the serosa.
For oesophageal cancer, T1 tumours invade the lamina propria or submucosa.
T2tumours invade the muscularis propria,
T3 tumours invade the adventitia
and T4tumours invade adjacent tissue.
Tis represents carcinoma in situ.
@#e 6. The following statements concerning oesophageal carcinoma are correct: (T/F)
(a) 90% of cases are squamous cell carcinomas.
(b) Most commonly located in the upper third of the oesophagous.
(c) Plummer-Vinson syndrome is a recognised predisposing factor.
(d) It is associated with ulcerative colitis.
(e) Commonest appearance on double contrast barium swallow is of a large ulcer within a bulging mass.
Answers:
(a) Correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Not correct
Explanation:
Oesophageal carcinoma most commonly located in the middle and lower third of the oesophagus. Only 20 occur in the upper one third. Polypoidal or fungating form is the commonest type. Predisposing factors for oesophageal carcinoma include Barrett’s esophagus, alcohol abuse, smoking, coeliac disease & Achalasia.
@#e2 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
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.
@#e2 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
(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.
@#e 32.Where do gastrointestinal stromal tumours (GIST) most commonly arise?
(a) Esophagus
(b) Stomach
(c) Small intestine
(d) Colon
(e) Appendix
(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 .
@#e2 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
D. Metastatic carcinoid tumour
The stellate pattern is characteristic for carcinoid tumor.
@# 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
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.
@#e2 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
(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.
@#e2 (Ped) 48) A 17-year-old girl presents with abdominal pain and rectal bleeding. She undergoes colonoscopy, which demonstrates multiple polypoid lesions in the colon. Which feature would favour a diagnosis of juvenile polyposis rather than familial adenomatous polyposis?
a. a total of 10 polyps in the colon
b. a histological diagnosis of tubulovillous polyps
c. involvement of the rectum
d. mucocutaneous pigmentation
e. a first-degree relative with multiple colonic polyps
a. a total of 10 polyps in the colon
In familial adenomatous polyposis (FAP), multiple (usually around 1000) tubular or tubulovillous adenomatous polyps are seen in the GI tract, predominantly in the colon.
Patients usually become symptomatic in the third to fourth decades and present with abdominal pain, weight loss and diarrhoea.
Juvenile polyposis (JP) is the commonest cause of colonic polyps in children, and usually presents with rectal bleeding. The polyps are hamartomatous and may occur throughout the GI tract. They are less numerous than in FAP, and the condition may be diagnosed with five or more polyps.
Both conditions are autosomal dominant, with 80% penetrance in FAP and variable penetrance in JP.
The rectosigmoid is involved in 80% of cases of JP, whereas the rectum is always involved in FAP. In both conditions, patients are at increased risk of associated adenocarcinoma, seen in 15% of patients by 35 years of age in JP, but in 100% of patients by 20 years after diagnosis in FAP.
Mucocutaneous pigmentation is a feature of Peutz–Jeghers syndrome.
@#e QUESTION 5
A 19-year-old female student presents with acute abdominal pain, elevated CRP and a low-grade temperature. On clinical examination, there is tenderness to light palpation in the right iliac fossa and the patient is febrile. A graded compression ultrasound examination is performed. Which one of the following statements is true?
A A transverse appendiceal diameter of 5 mm is diagnostic of acute appendicitis.
B The finding of a pelvic fluid collection makes a diagnosis of acute appendicitis unlikely.
C The presence of hyperechoic fat in the right iliac fossa makes a diagnosis of acute appendicitis unlikely.
D The sensitivity of graded compression ultrasound in suspected acute appendicitis is 75—90%.
E The specificity of graded compression ultrasound in suspected acute appendicitis is 35—50%.
D The sensitivity of graded compression ultrasound in suspected acute appendicitis is 75—90%.
Graded compression ultrasound of the appendix can avoid unnecessary surgery and ionising radiation particularly relevant for children and women of childbearing age. The finding of a non-compressible appendix with transverse diameter of 6 mm or greater is highly suggestive of acute appendicitis (specificity 86-100%). Other ultrasound findings include hyperechoic fat in the right iliac fossa, peri-appendiceal fluid or a pelvic fluid collection (appendiceal abscess)
@#e QUESTION 6
A 42-year-old man presents to the Emergency Department with a 7-day history of severe bloody diarrhoea and abdominal pain. He has previously been fit and well with no significant medical history. On examination, the patient is dehydrated with generalized abdominal tenderness but no clinical evidence of peritonism. An abdominal radiograph is performed. Which radiographic finding would be most suggestive of a toxic megacolon?
A Caecum measuring 4.5 cm in diameter
B Multiple mucosal islands in a dilated transverse colon
C Pseudodiverticulae in the descending colon
D Thickened haustrae throughout the entire colon
E ‘Thumbprinting’ of the transverse and descending colon
B Multiple mucosal islands in a dilated transverse colon
The presence of severe ulceration leading to mucosal islands is a major sign of toxic megacolon (the other key finding is colonic dilatation > 5 cm).
@#e QUESTION 24
A 23-year-old woman complains of episodes of diarrhoea and rectal bleeding. Her father died of colorectal cancer aged 39. A double contrast barium enema is performed and demonstrates more than one hundred small polyps, measuring up to 5 mm in size, throughout the colon. An upper GI endoscopy demonstrates multiple polypoid lesions in the stomach and duodenum. What is the most likely diagnosis?
A Carcinoid syndrome
B Familial adenomatous polyposis
C Hereditary non-polyposis colorectal cancer
D Juvenile polyposis
E Peutz-Jeghers syndrome
B Familial adenomatous polyposis
Autosomal dominant condition with multiple colonic adenomas and 100%risk of colorectal carcinoma 20 years after diagnosis. Associated with hamartomas in stomach, gastric & duod adenomas & periampullary carcinoma.
@#e2 QUESTION 66
A 79-year-old woman trips and falls whilst stepping off a bus. She suffers a fractured right neck of femur and undergoes a hemiarthroplasty the following day. Her early recovery is complicated by bronchopneumonia which resolves after 5 days of broad-spectrum antibiotics. On her tenth day in hospital she develops abdominal pain and diarrhoea and pseudomembranous colitis is suspected clinically. Which one of the following statements is true regarding pseudomembranous colitis?
A A normal abdominal CT effectively excludes pseudomembranous colitis.
B Ascites is present in up to 40% of patients.
C CT carries a low positive predictive value for pseudomembranous colitis.
D Extensive pericolonic stranding is a typical feature on CT.
E The rectum is not involved in 40—50% of patients.
B Ascites is present in up to 40% of patients.
Ascites can occur with other colitides, but is often seen in pseudomembranous colitis. CT typically demonstrates mucosal enhancement and marked colonic wall thickening but only mild pericolonic stranding, in patients with pseudomembranous colitis. These findings have a high positive predictive value but a normal CT does not exclude pseudomembranous colitis. Rectal sparing occurs in around 10% of patients.
@#e2 QUESTION 77
A 48-year-old man has a strong family history of colorectal cancer. He is found to have a mild microcytic anaemia and a stool sample for faecal occult blood testing is positive. A CT colonography is performed and, on 3D images, a 1-cm focal polypoid mass is seen in the wall of the sigmoid colon. The reporting radiologist is unsure whether this lesion is significant and reviews the 2D supine and prone axial images. Which additional feature would be most consistent with a polyp?
A The lesion contains a locule of gas at its base.
B The lesion has a mean density of -150 HU.
C The lesion is of homogeneous attenuation.
D The lesion lies on the dependent surface of the bowel on prone and supine images.
E There are diverticulae seen in the sigmoid colon.
C The lesion is of homogeneous attenuation.
A polyp will usually demonstrate uniform soft tissue density, similar to the surrounding bowel wall.
@#e2 11. Regarding diverticular disease:
(a) Colonic diverticulosis affects 70-80% by 80 years of age.
(b) Rectosigmoid colon is most commonly affected.
(c) 10-25% of individuals with colonic diverticular disease develop diverticulitis.
(d) Fistula formation occurs in 40-50% of cases complicating acute diverticulitis.
(e) Moderate diverticulitis is present when the bowel wall is thickened >3mm.
Answers:
(a) Correct
(b) Correct
(c) Correct
(d) Not correct
(e) Correct
Explanation:
Fistula formation is seen in 15% of the cases of complicated acute diverticulitis.