Gastrointestinal Radiology

colonic CMV

"Cowdry type A intranuclear bodies" = _______

Non-functional tumor - usually large and metastatic at time of diagnosis

"Large with calcification" pancreatic tumor

Cricopharyngeus

"True upper esophageal sphincter" = _________

Colonic adenocarcinoma - 2nd cause of cancer death

"apple core" lesion of the colon

- Squamous cell - Mid esophagus

"black guy who drinks and smokes" gets esophageal cancer: - subtype? - location?

Candida

"bull's eye" in liver infection

carolis

"central dot sign" in liver

sigmoid volvulus

"coffee bean sign" or "inverted 3 sign"

oriental cholangitis - aka recurrent pyogenic cholangitis

"dilated bile ducts full of pigmented stones"

pyogenic abscess

"double target" sign in liver

Amoebic Abscess

"extra hepatic extension" liver infection

enteromoeba histolytica

"flask shaped uclers" on endoscopy

UC

"lead pipe" appearance due to loss of haustral folds = _________

Chronic aspirin therapy

"multiple gastric ulcers"

Cholangiocarcinoma - pancreatic head mass can also cause this

"painless jaundice" in an elderly man, think _____ (2)

hemangioma

"peripheral nodular discontinuous enhancement" in liver lesion

Duct of Luschka (accessory cystic duct)

"persistent bile leak after cholecystectomy," think ______

Graft vs Host Disease (GVHD) - bowel is featureless, atrophic, and fold thickening

"ribbon bowel"

intrapancreatic accessory spleen -typical scenario: post-traumatic splenosis ("history of trauma") - Heat Treated RBC scan or Sulfur Colloid scan to prove

"ringed stripped pancreatic mass on the arterial phase" = _______ -- typical scenario -- what tests can be used to prove the diagnosis

whipples - diffuse micronodules in jejunum

"sand like nodules" refers to?

Mesenteric Lymphoma - usually non-hodgkin type

"sandwich sign" = ________ - lobulated confluent soft tissue mass encasing the mesenteric vessels

autoimmune pancreatitis - associated with IgG4

"sausage shaped pancreas," capsule like delayed rim enhancement around glad (like a scar)= ______

pseudomyxoma peritonei

"scalloped appearance of the liver" =

chronic rejection

"shrinking pancreatic transplant" means what

Carcinoid

"starburst" appearance of mesenteric mass with desmoplastic stranding = _______

oriental cholangitis

"straight rigid intrahepatic ducts"

schistomiasis

"tortoise shell" appearance of liver

hydatid disease

"water lilly", "sand storm" appearance of mass in liver

- Adenocarcinoma - Distal esophagus

"white guy who is stressed and has chronic reflux" gets esophageal cancer: - subtype? - location?

diverticulosis

(Diverticulosis/diverticulitis) bleeds more

direct

(Indirect/direct) inguinal hernia defect in hesselback triangle

indirect

(Indirect/direct) inguinal hernia lateral to inferior epigastric artery

direct

(Indirect/direct) inguinal hernia medial to inferior epigastric artery

indirect

(Indirect/direct) inguinal hernia: covered by internal spermatic fascia

indirect

(Indirect/direct) inguinal hernia: failure of processus vaginalis to close

PSC

(PBC/PSC) associated with inflammatory bowel disease (UC and crohns)

primary hemochromatosis - Pancreas = Primary

(Primary vs secondary) hemochromatosis: -- liver + pancreas involved

venous thrombosis is more common

(arterial/venous) thrombosis is much more common in the pancreas transplant

- sigmoid: RUQ - cecal: LUQ

(sigmoid/cecal) volvulus points to (RUQ/LUQ)

Serous Cystic Mucinous Cystic IPMN - side branch - main branch Solid Pseudopapillary

***** Summary of Pancreatic Cystic Lesions *****

chart from CTC

****** High yield esophagus *******

***

**Mesenteric involvement may be especially apprent after treatment where the misty mesentery is limited to the portion of the mesentery that contained the treated lymph nodes

***

**Read imaging patterns of acute UC

***

**Used to be thoght that mucoceles of appendix were main cause of pseudomyxoma periotonei but now that has been corrected

- Treat with Whipple - better prognosis than pancreatic adenocarcinoma

- treatment of periampullary tumor? - prognosis compared to pancreatic adenocarcinoma?

- red and white pulp - tiger striped appearance during arterial phase imaging - lymphoma and primary angiosarcoma in spleen are not benign

- types of pulp in the spleen (2) - appearance on arterial phase - most things in the spleen are benign except? (2)

Vascular Complications: - pseudoaneurysm of splenic artery and GDA - splenic vein/portal vein thrombosis Non-vascular complications: - abscess/infection

- what are some vascular complications after pancreatitis? (2) - non-vascular complications? (1)

Side Branch IPMN Main Branch IPMN - Main branch has higher percentage of malignancy compared to side branch

- what are the types of IPMN? - which one is the bad one?

- the only thing that matters is integrity of the pancreatic duct - if the duct is injured, go to OR

- what is the only thing that matters with regard to pancreatic duct trauma? - when does someone have to go to OR w/ pancreatic trauma

- Early symptoms in 2 weeks - get obstruction from post-op edema or the wrap is too tight (will get dilated esophagus)

- when do you see early symptoms of fundoplication surgery? - what is the main problem?

Crohn's disease. Scleroderma.

2 conditions that can cause eccentric sacculations of the small bowel?

Double aortic arch. Aberrant left subclavian artery.

2 most common vascular rings to effect to the esophagus?

Sliding hiatal hernia (GE j moves). Paraesophageal hernia (GE j stable, cardia moves).

2 types of hiatal hernias?

- Ductal Adenocarcinoma: hypovascular - Neuroendocrine/Islet Cell: hypervascular

2 types of pancreatic cancer

shwachman-diamond syndrome - 1st is CF

2nd most common cause of pancreatic insufficiency in kids

- gastrojejunal - choeldochojejunal/ hepaticojejunal - pancreaticojujunal

3 anastomoses after whipple procedure

Diverticulitis. Crohn's disease. Malignancy.

3 causes of intramural tracking?

- delayed gastric emptying (most common) - pancreatic fistula - amylase thru surgical drain (second most common) - wound infection

3 complications after whipple procedure - which ones are the most common

Transmesenteric. Paroduodenal. Foramen of Winslow

3 internal hernias causing SBO?

Nasopharynx- Base of skull to soft palate. Oropharynx- Behind moth from uvula to hyoid bone. Hypopharynx- Hyoid to cricopharngeus muscle (Lower end of cricoid).

3 parts of pharynx?

CBD always drains to major papilla where it meets the duct of Wirsung. Main pancreatic duct always drains pancreatic tail. Duct of Santorini always drains to minor papillae.

3 points of anatomy that are always constant regarding pancreatic duct.

- "coned cecum" involves the TI - Fleischner sign - Stierlin sign

3 signs of colonic TB

Adenocarcinoma. Squamous cell carcinoma. Cloacogenic carcinoma (women, worse prognosis).

3 types of anal canal malignant neoplasms?

4 presentations. Miliary masses. Multiple small to moderate sized masses. One large mass. Splenomegaly without discreate mass.

4 Presentations of secondary splenic lymphoma? (Much more common)

McKittrick-Wheelock syndrome

80 yo lady w/ diarrhea, hyponatremia, hypokalemia. Dx?

Landzert.

A left paraduodenal hernia extends through the fossa of?

Waldeyer.

A right paraduodenal hernia etends through the fossa of?

muscular ring Above the vestibule

A-ring

Muscular/contractile ring at the tubulovestibular junction.

A-ring?

- looks like PSC - "papillary stenosis" - ducts are >2cm - Cryptosporidium

AIDS cholangiopathy

AIDS-related non-hodgkin lymphoma - mass like wall thickening and aneurysmal dilatation of small bowel - may see oral contrast within the affected bowel - mesenteric lymph node involvement common

AIDS, Dx?

CMV esophagitis - giant superficial ulcer

AIDS, Dx?

kaposi sarcoma - thoracoabdominal lymphadenopathy with hypervascular (hyperattenuating) appearance

AIDS, Dx?

prior MAI infection - often affects liver and spleen - hypodense acute phase, hyperdense (hyperechoic) calcified granulomas after recovery - if large hypodense foci, consider AIDS-related NHL

AIDS, Dx?

hepatic fibrosis

AR form of polycystic kidney disease will have hepatic (cysts/fibrosis)

Posterior to esophogus. Smooth indentation.

Aberrant R subclavian?

Accessory (supernumerary) splenic tissue at hilum not post-traumatic (splenosis).

Accessory spleen versus splenosis?

- use sulfur colloid scan - heat damaged RBC scan

Accessory spleen: - how to detect or differentiate from pathologic lymph node

Severe colonic wall thickening with undulation of enhancing inner mucosa, signifies colonic edema....suggestive but not specific for c diff

Accordian sign?

Variant of pancreatic adenoCa, rare, aggressive, seen in elderly males, increased lipase Lipase hypersecretion syndrome - subcutaneous fat necrosis, bone infarcts (pain), eosinophilia

Acinar cell carcinoma

Large amount of lipase. Triad of lipase hypersecretion syndrome- Subcutaneous fat necrosis. Bone infarcts causing polyarthralgias. Eosinophilia.

Acinar cell carcinoma cells produce what?

Rare aggressive variant of pancreatic adenocarcinoma seen in elderly males.

Acinar cell carcinoma?

Triad of hepatomegaly. Ascites. Abdominal pain.

Acute Budd Chiari presents how?

Gallbl wall thickening on T2 (in determinant) + other signs; wall sloughing, peri. fluid, enhancement Interupted rim sign- lack of enhancement dt necrosis/gangrenous

Acute Chole

Torsion

Acute abdominal pain with wandering spleen?

High mortality rate due to generalized bile peritonitis

Acute gb perf?

hepatosplenomegaly and GB wall thickening may be marked. periportal edema.

Acute hepatitis

Lymphangiomas - rare , usually subcapsular Hamartomas- rare, hypodense, isodense and heterogenous enhancement +/- hemosiderin

Additional benign splenic lesions - lymphangiomas - hamartomas

OCP, steroid use, tend to bleed, rare malig transformation Pseudo/capsule, lack of bile ducts and kupffer Drop out on OOP, early enhancement and washout inn delayed and no enhancement on heppatocyte

Adenoma

Steroid use or glycogen storage dis

Adenoma in males?

Little T2 mural hyperintesity or contrast enhancement. May see T2 bright cystic - string of beads- in wall

Adenomyomatosis

Waterhouse Frederickson syndrome. vasculitis - especially if patient with lupus. May precipitate acute adrenal insufficiency - medical emergency - treated with supplemental adrenal corticosteroids. May be 2/2 infection.

Adrenal hemorrhage - spontaneous

Immunocompromised

Almost all pateints with splenic fungal abscesses are ______?

Decreased attenuation

Amyloid in liver?

Small intestine, with valvulae thickening and mucosal granularity.

Amyloidosis most commonly affects what part of the GI tract?

Extremely aggressive. Enlarged heterogeneous mass which may completely replace spleen. Variable heterogeneous enhancement.

Angiosarcoma of spleen.

Duodenal obstruction. Increased susceptibility to pancreaatitis.

Annular pancreas complications?

CT Severity Index. 0 Points for A. 4 Points for E. Add points for necrosis- 0-0; 2; Less than 30 percent. 4- 30-50%. 6-More than 50%.

Another grading system for pancreatitis?

Oriental cholangiohepatitis.

Another name for recurrent pyogenic cholangitis?

Nonpropulsive contractions leading to a corkscrew esophogus and shish kebab esophogus.

Appearance of diffuse esophageal spasm?

Thickening of distal esophageal folds.

Appearance of reflux esophagitis?

Many (>6) small cysts smaller than 2 cm that may have a solid appearance on CT due to apposition of cyst walls. MRI is good to show cystic nature of the lesion.

Appearance of serous cystadenoma of the pancreas?

Nutmeg liver (can be seen in patients with passive venous congestion of liver and early stages of Budd-Chiari syndrome).

Appearance of the liver with enhancing lobules of hepatocytes and areas of edema that do not enhance?

Controversial whether associated with esophagitis.

Association of feline esophogus?

Other cancers such as endometrial, gastric, small bowel, liver, and biliary malignancies

Associations of HNPCC

It's just called a lower esophageal ring

Assymptomatic narrowing of the B ring?

Hereditary Hemorrhagic Telangectasia (aka Osler-Weber-Rendu)

Autosomal dominant disorder with multiple AVMs in liver and lungs ---> cirrhosis and massively dilated hepatic artery

mucosal ring Below the vestibule - thin constriction at the EG junction

B ring

Mucosal ring, ridge of tissue at the squamosal-columnar junction of the distal esophagus.

B-ring?

Due to villous atrophy and hypersecretion of intraluminal fluid, there are flocculations of barium because it cant adhere to bowel wall.

Barium in celiac disease?

Esophageal stricture, abnormally high in location compared to a peptic stricture.

Barret esophogus is also associated with what?

Metaplastic replacement of squamous epithelium with columnar above normal Z-line secondary to longstanding reflux.

Barrett esophagus?

Leiomyoma. Fibrovascular polyp. Squamous papilloma.

Benign esophageal neoplasms?

Hyperplastic polyp (sessile, less than 1cm). Adenomatous polyps (>1cm). Leiomyoma.

Benign gastric neoplasms?

GIST. Leiomyoma. Lipoma. Hemangioma. Others.

Benign mesenchymal tumors include what?

Adenomas. Leimyomas. Lipoma. Peutz-Jeghers syndrome. Cowden disease. Familial polyposis.

Benign small bowel neoplasms?

Lymphangioma. Hemangioma.

Benign splenic neoplasms (2)?

Hemangioma and lymphangioma (hypodense to splenic tissue, may calcify). Hamartoma (isodense to splenic tissue).

Benign splenic tumors and CT characteristics?

Cross sectional over ERCP

Best imaging for PSC?

Pancreatic parenchymal pahse (late arterial)- 40 seconds after injection. Best to detect small areas of non enhancement suggesting necrosis

Best time to image for acute pancreatitis? Why?

Post con T1 where involved potion of spleen is hypoenhnacing.

Best visualization of splenic lymphoma?

- asplenia - reversed aorta/IVC - two fissures in left lung - cardiac anomalies

Bilateral "right sidedness" - 4 features

Does NOT communicate

Biliary cystadenoma relationship to biliary system?

Inicidental small cystic hepatic lesions that doesn't communicate with biliary tree, failure of normal bile duct formation

Biliary hamartomas?

I: partial gastrectomy with gastroduodenoscopy. II: partial gastrectomy with gastrojejunoscopy.

Billroth I versus Billroth II?

From benign to indolent to aggressive

Biologic behavior of IPMN?

Osteomas. Cortical hyperostosis.

Bony abnormalities in patients with adenomatous polyposis syndrome?

Cervical esophogus

Bony esophageal foreign bodies usually where?

Erlenmeyer Flask of distal femurs. AVN of femoral heads. H shaped vertebral bodies from endplate AVN.

Bony findings in Gauchers?

MAI infection - diffuse small bowel thickening - ascites

CD4 count < 50 Dx?

disseminated infection (likely MAI) - often affects liver and spleen - hypodense acute phase, hyperdense (hyperechoic) calcified granulomas after recovery - if large hypodense foci, consider AIDS-related NHL

CD4 count < 50 Dx?

MAI: Nodular thickened nodular jéjunum + diarrhea + LN Acid Fast bacilli Microabscess in liver and spleen pseudo whipple Lungs : pos gallium Other infections in bowel : CMV and cryptosporidium

CD4<50 Dx?

Fatty atrophy or replacement of pancreas with innumerable cysts.

CF effects on pancreas?

Large flat ovoid ulcer

CMV/HIV esophogitis?

Subcutaneous Calcinosis. Raynaud's phenomenon. Esophageal dysfunction. Sclerodactyly. Telangiectasia.

CREST?

Dilated fluid filled bowels with intra luminal flocculations of enteric contrast. Contrast insinuated between the small bowel folds and centrally within the bowel, with a peripheral layer of low attenuation secretions. May also get engorged mesenteric vessels.

CT of celiac?

U shaped distribution of the bowel loop with radially oriented vessles. If there is volvulus you may see the whirl sign of twisting of mesenteric vessels.

CT of closed loop obstruction?

Isoattenuating to muscle but if large may have central necrosis. Strands of tissue radiating to adjacent mesenteric fat, similar to mesenteric carcinoid and sclerosing mesenteritis

CT of desmoid?

Intra-lesional fatty component

CT of fibrovascular polyp?

Higher attenuation ascities (5-20). If advanced you get scalloping of the hepatic margin.

CT of pseudomyxoma peritonei?

Hepatic Adenoma - benign, uncommon neoplasm seen in young women with high estrogen environment, including steatosis and oral contraceptive use. Anabolic steroids, diabetes, and glycogen storage disease are other causes - features often seen include hypervascularity, fat, hemorrhage, and encapsulation - will not take up gadoxetate (eovist) - usually cold on TcSC

CTCE, T2FS, TI in/out, Eovist Dx?

Mucinous colorectal tumors or ovarian serous tumors.

Calcified mets in liver?

Yes, in the acute form of Hep B

Can HCC occur in the acute setting of hepatitis? if so, which type of hepatitis?

NO

Can you vomit after a fundoplication?

Polycystic kidneys

Caroli disease may be associated with what?

Directly to IVC...this is why its spared inearly cirrhosis- gets compensatory hypertrophy. Same thing happens in Budd Chiari when hepatic veins are congested.

Caudate lobe drainage?

Inflammatory lymphocytic infiltrate. Associated with Sjogren and elevated IgG-4 levels

Cause and association of autoimmune pancreatitis?

Chronic gb inflammation- a very rare tumor. Chronic cholecystitis and gallstones are typically present.

Cause of GB carcinoma?

Frequent blood transfusions or defective erythrocytosis.

Cause of Hemosiderosis?

Incomplete rotation of the ventral pancreatic bud

Cause of annular pancreas?

Ingestion of eggs of echinococus granulosus- endemic to mediterranean basin associated with sheep raising.

Cause of hepatic echinococcosis?

Metabolic.

Cause of micronodular cirrhosis?

Failure of fusion of the ventral and dorsal pancreatic buds.

Cause of pancreas divisum?

Congenitial- failure of mesenteric fusion and resultant mesenteric defect. Usually on left. Abnormal rotation of intestine.

Cause of paraduodenal hernias?

Chronic cholecystitis

Cause of porcelain gb?

Mucin producing adenoma or adenocarcinoma of the appendix. May also be due to ovary or colon (Controversial)

Cause of pseudomyxoma peritoneii?

Parasite- Clonorchis sinenis

Cause of recurrent pyogenic cholangitis?

Endoscopy. Seizures. Coughing. Asthma. Childbirth. Severe straining. Blunt trauma.

Causes of Booerrhaave's syndrome?

Acute arterial thrombus, chronic arterial stenosis, low flow states, and venous thrombosis

Causes of colonic ischemia?

Low flow states (shock, major surgery, cardiac abnormality). Atherosclerosis (chronic). Embolism (acute). Venous occlusion (mesenteric venous occlusive disease).

Causes of ischemic bowel?

Heterotopic gastric mucosa. Benign lymphoid hyperplasia. Brunner's gland hyperplasia (large nodules).

Causes of nodular filling defects in duodenal bulb and proximal duodenum?

Infarcted bowel. Ulcers. Acute bowel dilation. Endoscopy. Necrotizing enterocolitis.

Causes of portal venous gas?

Portal hypertension. IVC obstruction. Severe abdominal adhesions.

Causes of rectal varices (not internal hemorrhoids)?

Ulcerative colitis. Crohn disease. Infectious colitis (especially in AIDS). Ischemia. Pseudomembranous colitis.

Causes of toxic megacolon?

Long smooth and narrow. 1-3 months after insult. Longer than peptic strictures

Caustic and NG tube stricture?

- Appendicitis / appendiceal abscess - Cecal / appendiceal carcinoma - Mucocele of the appendix = Lymphoma = Adnexal mass

Cecal mass

- Malabsorption of iron - Skin: dermatitis herpetiformis; lung: idiopathic pulmonary hemosiderosis - increased risk of lymphoma - biopsy is gold standard diagnosis - "fold reversal" - cavitary lymph nodes (low density)

Celiac Sprue: - causes malabsorption of what - what associated skin and lung problem - increased risk of what cancer - gold standard diagnosis - buzzword appearance - type of lymph nodes

Autoimmune proximal eneteritis caused by T cell mediated immune response triggered by antigens in ingested gluten

Celiac disease?

Small branches of the portal vein and hepatic artery bridging the dilated bile ducts. (Refers to contrast enhanced CT)

Central dot sign?

Thrombosed central vein

Central hyperdense dot in cross section in epiploic appendigitis?

South American Trypanosoma cruzi destroys myenteric plexus of esophagus and colon. Causes myocarditis and cardiac aneurysms.

Chagas disease?

Wheel within a wheel or bull's eye. Concentric hyperechoic and hypoechoic rings surrounding the abscess

Characteristic appearance of splenic abscess on ultrasound?

Arterial enhancement. Wash out on portal venous phase. Slight T2 hyper.

Characteristic imaging feature of HCC?

Apthous ulcers (Discrete ulcers surrounded by mounds of edema) which may become confluent.

Chron esophogitis?

Aw stones/small smooth, gradual, slow enhancement of wall (ca- thick nodular) tunica muscularis is hypo T1, Hyper T2, does not enhance

Chronic Chole

Lead pipe colon, fat in walls.

Chronic appearance of UC?

Cholecystoenteric fistula

Chronic gallbladder perf?

Non inherited disorder (the only one of the polyp syndromes that isnt' AD). Hamartomatous polyps throughout the GI tract.

Chronkhite Canada syndrome?

T1- Bright, T2/STIR- dark, No fat sat and No enhancement. Assoc w fibrosis, atrophy of ant r lobe and medial l lobe

Cirrhosis- regenerative/dysplastic nodules

you know it's the CBD when you see the dot of the R hepatic artery

Classic US Anatomy 2

Fat in the falciform ligament/ligamentum teres (remnant of umbilical vein)

Classic US Anatomy 4

Fish mouth papilla pouring out mucin.

Classic appearance of IPMN on endoscopy?

Mass causing a stricture with a shouldered edge and irregular contour.

Classic appearance of advanced esophageal carcinoma?

Enhancing soft tissue mass with radiating linear bands extending into the mesenteric fat. Calcification is common. Bands are due to an intense desmoplastic reaction secondary to serotonin release, not tumor

Classic appearance of carcnoid affecting the mesentery?

Central stellate calcification.

Classic imaging feature of serous cystadenoma of the pancreas?

Postprandial pain relieved by massaging which reduces the hernia.

Clinical complaint of paraduodenal hernia?

Dramatic- Regurgitation of a fleshy mass.

Clinical presentation of fibrovascular polyp?

Obstruction in boththe efferent and afferent segments of a single bowel loop

Closed loop obstruction?

Splenic fleXure (SMA, IMA junction). Rectosigmoid.

Colon watershed regions?

- Infectious colitis - IBD - Colon cancer = Ischemic colitis

Colonic Wall Thickening

Common duct stone/Obstruction

Common cause of Ascending cholangitis?

Hypercoaguable states such as hematologic disorders, pregancy, OCPs, Malignancy, Infection, Trauma

Common causes of Budd Chiari?

Appendicitis. Diverticulitis. Chron disease, Bowel surgery. Usually E Coli

Common causes of Hepatic abscess.

Adhesions. Hernias. Neoplasms. Intussusception. Volvulus. Foreign bodies. Inflammatory process.

Common causes of small bowel obstruction?

There is no septum between CBD and duct of Wirsung allowing reflux between the two systems.

Common channel syndrome (Pancreaticobiliary maljunction)?

Spectrum of choledochal cyst with the common channel being a very mild form of choledococele.

Common channel syndrome may be in what spectrum?

Esophageal candidiasis (shaggy mucosa). Herpes esophagitis (discrete ulcers). Cytomegalovirus esophagitis (larger ulcers). HIV esophagitis (largest ulcers).

Common esophagitides?

Left posterior lateral wall of distal esophagus just proximal to the gastroesophageal junction.

Common location for Booerhave esophagus perforation?

walls of stomach, duodenum, and Meckel diverticulum.

Common sites of ectopic pancreatic tissue?

Complete infarction, possibly due to wandering spleen with torsion.

Complete nonenhancement of spleen?

T cell lymphoma. Exophytic mass, circumferential bowel wall thickening, or enlarged mesenteric lymph nodes.

Complication of celiac disease in small bowel?

Esophageal ca which has a lag time of 20 years. Candidal infection from stasis.

Complications from achalasia?

Cholangitis. Fibrosis. Portal hypertension. Cholangiocarcinoma.

Complications of Caroli's disease (Type V Choledochal Cyst or communicating cavernous ectasia of the bile ducts)?

Gangrenous cholecystitis. Gallbladder perforation. Emphysematous cholecystitis.

Complications of acute cholecystitis?

- CHOLANGIOCARCINOMA - cirrhosis - cholangitis - intraductal stones

Complications of choledochal cysts (4)

Wedge shaped fibrosis seen in cirrhosis, usually in medial segment of L hepatic lobe or anterior segment of R hepatic lobe

Confluent hepatic fibrosis?

Lymphangiectasia.

Congenital condition that may cause diffuse bowel edema?

Epidermoid cysts.

Congenital splenic cysts which contain an epithelial lining?

Glomerulonephritialport Cortical necrosis

Cortical calc

***

Cover gastric carcinoma vs benign gastric ulcer.

Increased risk of thyroid ca (Usually follicular) as well as skin, oral, breast, and uterine.

Cowden syndrome associations?

AD. Multiple hamartomatous syndrome, common in skin and mucous membranes along with GI tract.

Cowden syndrome?

crohns

Crohns vs UC: gallstones

crohns

Crohns vs UC: hepatic abscess

crohns

Crohns vs UC: pancreatitis

UC

Crohns vs UC: primary sclerosing cholangitis

Intrahepatic mass at confluence of central bile ducts with resultant bile duct dilatation and capsular retraction. Tumor fingers may extend into the bile ducts.

Cross sectional imaging of Cholangiocarcinoma?

Cystic intrapancreatic lesion in contiguity with the duct or sidebranch. Any nodular or enhancing component shoud raise concern for malignancy.

Cross sectional of IPMN?

CBD crossing over the main duct to join the duct of Wirsung.

Crossing sign in pancreas divisum?

Hidebound.

Crowding of the valvulae by fibrosis (scleroderma) term?

Antecolic (In front of transverse colon)

Current favored approach for placement of Roux limb?

Neurofibromatosis.

Cutaneous masses and small bowel tumors?

- Pancreatic pseudocyst - Mucinous cystadenoma - Serous cystadenoma = Intraductal papillary mucinous neoplasm = Solid and papillary epithelial neoplasm

Cystic pancreatic mass

Serous cystadenoma Mucinous cystadenoma Solid and papillary epithelial neoplasm (SPEN) Introduction papillary mucinous neoplasm(IPMN) Large pancreatic endocrine neoplasm with cystic change

Cystic pancreatic neoplasms

- NG tube - Radiation - caustic ingestion

DDX for long esophageal stricture (3)

- low protein - venous congestion - cirrhosis

DDX in small bowel: - Diffuse Thick folds (3)

- whipples - lymphoid hyperplasia (uniform small nodules) - lymphoma - mets (varying size nodules) - intestinal lymphangiectasia

DDX in small bowel: - Diffuse Thick folds with Nodularity (5)

- hemorrhage - adjacent inflammation - ischemia - radiation "HAIR"

DDX in small bowel: - Segmental Thick folds (>3mm) (4)

- crohns - lymphoma - infection - mets "can CLIMb up because it's nodular"

DDX in small bowel: - Segmental Thick folds with Nodularity (4)

- mechanical obstruction - paralytic ileus - scleroderma - sprue

DDX in small bowel: - THIN folds with dilatation (4)

- Achalasia - Chaga's disease - Psuedoachalasia - Scleroderma

DDx for big, dilated esophagus

budd chiari PBC PSC

DDx for massive caudate lobe hypertrophy (3)

- ascites - wall thickening (crohns, lymphoma) - adenopathy - mesenteric tumors

DDx: small bowel loop separation WITHOUT tethering (4)

Mesenchymal tumor (GIST, fibroma,lipoma, neurofibroma), carcinoid, ectopic pancreatic rest

Ddx of submucosal gastric mass

Iron overload

Decreased liver signal on in phase imaging?

Stage T0 (T in situ) - has not grown beyond the inner layer (mucosa) of the colon or rectum Stage T1 - grown through the muscularis mucosa into the submucosa Stage T2 - grown into but not through the muscularis propria Stage T3 - invasion of perirectal fat Stage T4 - involving peritoneal reflection or other organ (beyond mesorectal fascia, e.g. pelvic side wall)

Define T stages in rectal cancer

Pseudopolyp: island of normal or edematous mucosa surrounded by ulcerated or denuded mocusa. Cobblestoning: normal mucosa surrounded by linear ulceration (Crohn's disease). Postinflammatory polyp: regenerating normal mucosa.

Define pseudopolyp, cobblestoning, and post-inflammatory polyp?

- Iron Deposition (hemochromatosis, hemosiderosis) - Amiodarone therapy - Glycogen storage disease = Gold therapy = Thorotrast

Dense Liver

small bowel issue in "patients who have recently lost a lot of weight", think of _____

Describe SMA syndrome

Use fat sat T1 after injection of gadolinium contrast agents with biliary excretion such as Eovist. They cause T1 hyperintense biliary fluid but require 20-45 minute delays to get biliary excretion.

Describe contrast enhanced MRCP.

Last branch of right aortic arch that usually passes behind the esophagus to ascend on the left.

Describe course of aberrant left subclavian artery?

Last branch of left aortic arch that usually passes behind the esophagus to ascend on the right.

Describe course of aberrant right subclavian artery?

Left pulmonary artery arises from right pulmonary artery and courses between the trachea and esophagus.

Describe course of pulmonary sling?

Ventral (Wirsung) only drains a portion of the pancreas while the majority of the pancreatic exocrine gland output is drained through the smaller duct of Santorini into the minor papilla

Describe drainage in pancreas divisum?

Susceptible to biliary infection with Cryptosporidium and CMV which presents with RUQ pain, fever, elevated LFTs

Describe patients with AIDS cholangitis?

Occurs when a primary contraction wave pushes barium caudally but at the mid third of the esophagus it breaks with regression of the bolus proximally

Describe proximal escape in esophagography?

Locally aggressive mass composed of proliferating fibrous tissue

Desmoid tumor of mesentery?

Diagnosed by upper GI as a thickening and small outpouching of a gastric fold. Conservative treatment.

Diagnosis of marginal ulcer? Treatment?

Carcinoid. Desmoid. Sclerosing mesenteritis

Diff Dx of sclerosing mesenteric mass?

Adenopathy below renal hila is unusual in gastric carcinoma but common in lympohma.

Diff between gastric carcinoma and lymphoma?

Focal stricture. Muscular esophageal ring above GE junction (A ring). Esophageal cancer. Esophageal web (rarely circumferential, usually in upper esophogus.

Diff for circumferential esophageal constriction?

Iron overload (most common cause). Medications (Amiodarone, gold, methotrexate). Copper overload (Wilsons). Glycogen excess (glycogen storage also leads to multiple adenomas)

Diff for hyperattenuating liver?

Fatty liver. Hepatic amyloid (seen here).

Diff for hypoattenuating liver?

True cyst may have septations. Post traumatic pseudocyst may have peripheral calcifications.

Difference between post traumatic pseudocyst and true cyst in spleen?

Serous Cystadenoma: - old ladies - pancreatic head - multiple small cysts - central calcifications Mucinous Cystic: - women in 50s - pancreatic body/tail - unilocular lager cysts - peripheral calcifications

Difference between serous cystadenoma and mucinous cystic neoplasm: - patient population - pancreas location - cysts - calcifications

Mesenchymal tumors (GIST, fibroma, lipoma, NF) Carcinoid. Ectopic Pancreatic Rest.

Differential for a submucosal gastric mass?

Metastatic tumor (Usually post treatment). Fibrolamellar HCC (10%). HCC (Uncommon). Epithelioid hemangioendothelioma. Intrahepatic cholangiocarcinoma. Confluent hepatic fibrosis.

Differential of capsular retraction?

If contain fat, will drop out because intracellular. If contain hemorrhage- T1 bright. Otherwise it can be hard if they don't have fat or blood

Differentiators of adenomas from more serious hepatic masses?

Severe tertiary contractions following 30% of swallows. Corckscrew appearance at -ray.

Diffuse esophageal spasm characteristics?

Menetrier disease. Intestinal lymphangiectasia. Mastocytosis. Radiation enteritis. Progressive systemic sclerosis. Celiac disease. Graft-versus-host disease. Ischemic enteritis.

Diffuse intestinal disease?

Lack of flow within the hepatic veins, thrombus in hepatic veins/IVC, and formation of collaterals

Direct vascular findings of Budd Chiari?

Lipoma. Crohn's disease. Lymphoma. Prolapsing ileal neoplasms.

Diseases that can enlarged the ileocecal valve?

Cowden disease.

Disorder that causes thyroid and breast abnormalities, hyperkeratosis, and harmartomas of the small bowel?

Yersiniosis: lacks lumen narrowing, lacks deep ulceration, short, self-limited course, heals without scarring.

Distinguishing features between Crohn's disease and Yersiniosis?

No, because the cystic duct is obstructed.

Does emphysematous cholecystitis result in air in the biliary system outside of the gallbladder?

SVC osbtruction. Proximal esophogus. Much less common.

Downhill varices?

- typically in the pancreatic head - "double duct" sign on imaging - SBFT: "wide duodenal sweep or "frostburg's Inverted 3 sign"

Ductal adenocarcinoma: - where in the pancreas - buzzword sign on imaging - buzzwords on a small bowel follow through (2)

- NEVER cancerous - occurs from "increased peptic acid" - usually solitary (think ZE syndrome when not)

Duodenal ulcer trivia: - are they cancerous? - occurs from _______ - usually solitary or not?

fibrolamellar HCC - Younger patients without cirrhosis - large, Slow growing, heterogeneously enhancing, large, spoke-wheel, lobulated mass with T2 hypointense non-enhancing central scar (calcified) - Calcification and necrosis are common (> 50%) - Nodal metastases (> 50%) and "Satellite" nodules are often present - DDx: FNH => T2 hyperintense and delayed enhancing of central scar (fibrosis)

Dx and primary DDx?

focal nodular hyperplaia - Benign tumor of liver caused by hyperplastic response to localized vascular abnormality - 2nd most common benign liver tumor, usually in young women - T2 Bright, homogeneously enhancing mass on arterial phase CT or MR with delayed enhancement of central scar is diagnostic of FNH - Portal venous phase: Hypodense or isodense to normal liver - Delayed: Mass - Isodense to normal liver, Central scar - Hyperdense or hyperintense (due to fibrous tissue) - Gadoxetate-enhanced MR: Most specific test to diagnose FNH with prolonged enhancement of entire FNH (except scar) on delayed scan

Dx and primary DDx?

(sideroblastic) regenerative nodules - GRE and T2 low signal, T1 isointense to liver - Can't differentiate regen from dysplastic from low grade HCC on imaging

Dx?

Appendicitis: periappendiceal inflame fat. CT ddx: TOA, IBD, mesenteric adenitis

Dx?

Autoimmune Pancreatitis - elevated IgG4 - associated with other autoimmune diseases (Sjögren syndrome, IgG4-associated cholangitis, autoimmune thyroiditis, interstitial nephritis, primary biliary cirrhosis, ulcerative colitis, SLE) - sausage shaped gland with capsule like enhancement around pancreas, NO calcs or ductal dilatation (vs chronic pancreatitis) - may present with obstructive jaundice, diabetes, and abdominal pain, but may be painless and present with steatorrhea

Dx?

Barrets Esophagus: squamous to columnar from chronic reflux- high esophagus wo ho intubation, radiation, caustic etc 10% malig degeneration mucosal pseudodivitericulum (as here) FDG avid metaplasia

Dx?

Biliary Leak ( trauma) - left lateral uptake

Dx?

Candida esophagitis - often presents with oral thrush - longitudinally oriented filling defects (plaques) - indistinguishable from herpes

Dx?

Caustic

Dx?

Cecal Volvulus

Dx?

Colonic obstruction w colonic urticaria (submucosal edema) from ischemia - life threatening

Dx?

Coned Cecum: TB, Lymphoma (here), Chrons, Abscess

Dx?

Crohn: Distorrtion and enlargement of the ICvalve DDx: Infection: TB, Yersinia, Amebiasis Mass: Adeno, Lymphoma, Carcinoid Inflammation: Crohn/IBD

Dx?

DIverticulitis! Diverticulosis, mucosa intact- abscess Of course looks like an apple core lesion

Dx?

Duodenal Hematoma Coiled spring appearance from anything that expands the intramural layer Resolves with time, c/b intusseption US cystic, MR and C T fluid attenuation Ddx: intussception

Dx?

Duodenal polyps with Peutz-Jeuger Syndrome: - AD Hamartomatous polyposis syndrome affecting Jejunum and ileum > duodenum > colon > stomach - Risk for cancer (10%) of stomach, duodenum, colon as well as Extra-GI tract cancers: Pancreas, breast, reproductive organs - DDx: familial adenomatous polyposis, Gardner syndrome, Brunner gland hyperplasia, lymphoid hyperplasia, mets/lymphoma, Juvenile Polyposis, Bannayan-Rile-Ruvalcaba, Cowden, and Crohnkite-Canada - complications: Intussusception, SB obstruction, malignant neoplasms in Bowel > breast > pancreas > reproductive tract

Dx?

Ectopic Pancreatic Rest: ddx: gist, leiomyoma, small malig (adeno, lymphoma, mets etc)

Dx?

Ectopic Pancreatic Rest: Bulls Eye Lesion- ulceration central

Dx?

Esophageal Ca Squamous: tobacco and alcohol Adeno: Barretts Imaging indistinguishable- raised plaques early- mass like later

Dx?

Familial adenomatous polyposis syndrome - Autosomal dominant genetic disorder characterized by formation of innumerable colonic adenomatous polyps at young age and increased risk for colonic and extracolonic tumors - Innumerable filling defects or ring shadows ± extraintestinal lesions representing adenomatous (± malignant) polyps in colon > stomach > duodenum > small bowel - Extracolonic malignancies associated with FAP include Duodenal ampullary carcinoma (12% lifetime risk), Thyroid cancer, Childhood hepatoblastoma, Gastric carcinoma, CNS tumors (mostly medulloblastoma) - DDx: Peutz-Jeghers (hamartomatous polyposis), Gardner syndrome, Brunner gland hyperplasia, lymphoid hyperplasia, mets/lymphoma, Juvenile Polyposis, Bannayan-Rile-Ruvalcaba, Cowden, and Crohnkite-Canada

Dx?

Focal Adenomyomatosis

Dx?

Focal Adenomyomatosis T1 post con US: echogenic and cystic Hyperplastic Cholesterolosis - strawberry GB

Dx?

Focal Fatty sparing classic location- medial l hepatic lobe

Dx?

Focal/Groove Pancreatitis T2 fluid, cystic changes, thickening of adjacent duodenum , tapering of duct favor vs neoplasm

Dx?

Free Air Riglers Sign

Dx?

GIST - Submucosal tumor of gastrointestinal (GI) tract derived from mesenchymal interstitial cells of Cajal - well-circumscribed, submucosal mass on arterial phase CECT images; - ulceration and necrosis are common, often exophytic and sometimes hemorrhagic, calcifications in 25% - hypermetabolism on PET predictive of response to imatinib (Gleevec)

Dx?

GIST : smooth, lobulated, mesenchymal tumor - KIT, tyrosine kinase- tested for and inhibitor to treat Ddx: Desmoid: mesenteric fibromatosis, soft tissue sarcoma Also- Mets, inflammatory pseudotumor (younger pep- chronic inflammation), lymphoma

Dx?

GVHD (multisys inflammation - separated ribbon like loops - featureless colon - 100 days after BM transplant - DDx : radiation or infection: CMV or crypto

Dx?

GVHD: - competent T cells into immunocompromised pt - Tx w T cell inhibitors and steroids

Dx?

Gastric Ca w Perf Free air and contrast w stomach mass

Dx?

Gastritis (h.pylori, nsaids) - nodular wall thickening

Dx?

Gen Esophagitis- many causes, lots of overlap: Candida esophagitis -Multiple tiny, round lucencies ± ulcers -Usually in immunocompromised patients Viral esophagitis -Superficial ulcers on normal mucosa -Usually in immunocompromised patients -Radiation esophagitis -Granular mucosa, ↓ distensibility/stricture -History of cancer with mediastinal irradiation Caustic esophagitis -Long ulceration and stricture -Diagnosis: History and endoscopic biopsy Drug-induced esophagitis -Acute onset of odynophagia with ulceration and spasm -Stricture is uncommon -Diagnosis made by imaging and classic history

Dx?

HCC within regenerative nodule - "nodule within a nodule" in liver - will have different signal/density within a portion of the lesion with the HCC appearing as hypoattenuating, hypervascular, restricting, T2 bright, and with possible signal loss on fat suppression and OOP

Dx?

HPV esophagitis - squamous papillomatosis

Dx?

Hepatic Adenoma - benign, uncommon neoplasm seen in young women with high estrogen environment, including steatosis and oral contraceptive use. Anabolic steroids, diabetes, and glycogen storage disease are other causes - features often seen include hypervascularity, fat, hemorrhage, and encapsulation - will not take up gadoxetate (eovist) - usually cold on TcSC

Dx?

Hepatic Lac fu HIDA for leak 1- < 1cm 2- 1-3 cm 3- > 3 cm 4- 25-75% one lobe or 3 segments 5- > 75% one lobe or > 3 segments 6_ hep avulsion

Dx?

Hepatic angiosarcoma - often multiple, tend to bleed - Associated with: Thorotrast, radiation, polyvinyl chloride, anabolic steroids, and NF 1

Dx?

Hepatosteatosis

Dx?

Herpes esophagitis - tiny ulcers surrounded by radiolucent halo of mucosal edema - often indistinguishable from candida

Dx?

IPMN SIDE branch > 3 cm bad, small cystic mass in the head with main duct enlargement MAIN duct > 10 mm --> higher risk for cancer -can look like chronic pancreatitis Malignant features = main duct >10mm, diffuse or multifocal, enhancing nodule or solid hypovascular mass

Dx?

Intusception on BE with a lead Point: BE column doesn't advance Lead point not as common in SB intussceptions

Dx?

Klatskin tumor - type of cholangiocarcinoma that occurs at the bifurcation of the right and left hepatic ducts

Dx?

Leukemia with diffuse splenic lymphomatous involvement - Ddx: Lymphoma, Fungal or mycobacterial infection/microabescesses - less likely mets, sarcoid, hemangiomas, lymphangioma - US: hypoechoic, looks like cysts

Dx?

Linittus Plastica - Will not distend w contrast - Ddx: gastric carcinoma, mets (often breast ca), caustic gastric injury, lymphoma, Chronic gastritis, Crohns, Radiation

Dx?

Lymphoid Follicles - DDx: Peutz-Jeghers (hamartomatous polyposis), Gardner syndrome, Brunner gland hyperplasia, lymphoid hyperplasia, mets/lymphoma, Juvenile Polyposis, Bannayan-Rile-Ruvalcaba, Cowden, and Crohnkite-Canada

Dx?

Lymphoma - narrowing wo obstruction

Dx?

Meckles

Dx?

Melanoma mets - melanoma mets are T1 hyper due to melanin (blood products can also be T1 hyper) - most mets are T1 hypo. T2 hyper

Dx?

Mets- Breast cancer

Dx?

Mucinous Cystadenoma - middle-aged women (always) - premalignant - macrocystic lesion in body/tail of pancreas (usually unilocular , thick septations>2cm) - Peripheral calcifications - resect

Dx?

Pancreatic Lac fu ERCP Staging A- fluid, <50% B- >50% body tail C0 > 50 % head

Dx?

Pancreatic ductal adenocarcinoma - hypoenhancing lesion - Trousseau syndrome: migratory thrombophlebitis - smoking is risk factor - double duct sign - if SMA or celiac involvement >180 deg--> nonresectable - elevated CA 19-9 - Peutz-Jeghers, HNPCC, BRCA, ataxia-telangiectasia - widened duodenal sweep, inverted 3 sign - fibrotic inflammatory pseudotumor from CP can look similar

Dx?

Peritoneal Malignant Mesothelioma ddx: primary peritoneal cacinomatosis- serous papillary or peritoneal carcinomatosis Much more extensive than infection

Dx?

Portal Venous Gas; Pneumotosis and PVG from gas producing bacteria wi necrotic bowel

Dx?

Primary Sclerosing cholangitis -inflammation of BOTH intra and extrahepatic ducts which are saccular and small <5mm -"central regenerative hypertrophy" -assoc with UC -increased risk of cholangiocarcinoma, cirrhosis Rx: transplant really the only type of cirrhosis that has dilated intrahepatic bile ducts

Dx?

SMA syndrome - obstruction of 3rd portion of duodenum by SMA

Dx?

Scleroderma

Dx?

Scleroderma -third portion of duodenum often dilates

Dx?

Scleroderma; dilated, high bound jejunum w sacculations a/w pneumoperitoneum, intuseption

Dx?

Sclerosing Cholangitis Aw UC and CBD involvement PBC- aw women and only intrahepatic involvement Acute pyogenic cholangitis- aw obstruction Oriental/Recurrent Pyogenic

Dx?

Sclerosing Mesenteritis - vague clinical s/s - older pt - calcs denser than carcinoid/desmoid

Dx?

Secondary Hemochromatosis - Iron overload disorder in which there is structural and functional impairment of involved organs due to increased iron intake, transfusions, etc. affecting Affects RES: Liver, spleen, nodes - Liver, spleen, and nodes are hyperdense on NECT and markedly hypointense on T2WI or in-phase GRE MR

Dx?

Serous Cystadenoma -old women - grandma -benign but sometimes removed due to associated symptoms -microcystic lesion in head of pancreas (sponge) -central scar and central calcifications -does not communicate with duct vHL

Dx?

Simple Cyst Epidermoid looks the same- less Ca2 Echinococcus or abscess more complex

Dx?

Solid and Pseudopapillary tumor of the pancreas (SPEN) - low grade malignancy seen in young women -Well-defined, heterogeneous, large mass (usually in pancreatic tail with a thick, enhancing capsule, Most often solid, but can have variable internal cystic components and intratumoral hemorrhage -Capsule enhances on CECT and T1 C+ MR and appears as rim of low T2 signal intensity

Dx?

Spigelian Hernia- Lateral to the rectus abdominus

Dx?

Todani classification Type 1: fusiform CBD dilation, most common -shown here 2- CBD saccular diverticulum 3- choledochocele at ampulla 4- CBD dilation with extra or intrahepatic dilation 5- intra only/carolis surgical resection - Associated with gallbladder ca and cholangiocarcinoma

Dx?

Toxic Megacolon from UC with pseudopolyposis from edema. UC most common cause of megacolon BE absolute contra

Dx?

Whipple: - Multisystem disease caused by Tropheryma whippelii bacillus - Results in periodic-acid-Schiff positive glycoprotein-laden macrophages infiltrating tissues

Dx?

Wilsons - Autosomal recessive disorder in which copper (Cu) accumulates pathologically in liver and other organs - nonspecific imaging findings (copper has no effect on MR) with imaging directed at identification of nodules and HCC - can cause hyperattenuation on NECT

Dx?

XGC- xanthogranulomatous cholecystitis - rare inflammatory macrophage and lipid

Dx?

Zenckers Diverticulum: Pulsion, posterior Killian Jameison is smaller lateral pulsion below cricopharyngeus

Dx?

annular pancreas - failure of ventral bud to rotate with the duodenum - results in encasement of the duodenum

Dx?

biliary hamartoma or "von Meyenburg complex" - Asymptomatic benign malformations of biliary tract of no clinical concern - hepatic cysts are usually larger in size and less numerous - Multiple, near water density/intensity liver lesions < 15 mm in diameter - Varied enhancement based on cystic and solid components - No communication with biliary tree - US: Small and well-circumscribed lesions, often have echogenic walls with small fluid content (more echogenicity and fewer cystic lesions than anticipated based on CT or MR)

Dx?

celiac sprue - "fold reversal": jejunum like ileum and ileum like jejunum

Dx?

hepatoma= HCC Cirrhotic liver Case from above

Dx?

leiomyomatosis peritoneal disseminata

Dx?

omental infarct - fatty mass with hyperattenuating ring within omentum (often abutting colon) - main DDx: acute epiploic appendagitis - same appearance + central dot sign (thrombosed vein)

Dx?

pancreatic divisum - the main portion of the pancreas is drained by the minor papilla

Dx?

pancreatic laceration

Dx?

small bowel adenocarcinoma - most commonly in duodenum and jejunum - celiac, crohn, and polyposis syndromes have increased risk - focal circumferential wall thickening ± enlarged mesenteric nodes; perivascular invasion ± metastases: Liver, peritoneal surfaces, ovaries - Often presents with intussusception

Dx?

wandering spleen - lax mesentery - associated with bowel malrotation - can cause torsion, infarct - chronic partial torsion --> splenomegaly, gastric varices

Dx?

Cholangiocarcinoma -delayed enhancement -dilated peripheral ducts -capsular retraction -encases NOT invades the veins - seen in older men - risk factors: PSC, cholangitis, clonorchis senesis, HIV, HEP B/C, ETOH and thortrast

Dx? - 4 imaging features - who and risk fators

Esophageal candidiasis - Risk Factors: immunocomprised or motility disorders - Barium: shaggy esophagus with plaque-like lesions - Mimic: glycogen acanthosis

Dx? - Risk factors - barium study - main mimic?

Hepatic adenoma - solitary lesion in a female on OCPs - multiple: glycogen storage disease or liver adenomatosis - most commonly in right hepatic lobe - regress after OCPs stopped - Tx: ---smaller than 5cm watch ---bigger than 5cm, resect

Dx? - classic patient scenario - association when multiple - most common location - treatment

Hemangioma: - favors women (get bigger in pregnancy) - US Findings: hyperechoic with enhanced through transmission and NO doppler flow inside the lesion - CT: "peripheral nodular discontinuous enhancement" - Bx: need to do core biopsy, not FNA - Atypical ones have reverse halo sign

Dx? - favor women or men - US findings - CT buzzword - how to biopsy the lesion

Caroli's Disease: - AR - central dot sign - assoc with polycystic kidneys and medullary sponge kidney - risk of cholangiocarcinoma, cirrhosis, cholangitis, and intraductal stones

Dx? - inheritance - associations - buzzword - complications

Whipple's disease of small bowel - Pathogen: Tropheryma Wipplei - Buzzword: "sand like nodules" - marked swelling of duodenal and jejunal folds - low density (near fat) lymph nodes

Dx? - pathogen - buzzword - fluoro appearance - type of lymph nodes

Sarcoidosis - usually splenomegaly, but can have 1-2 cm hypodense nodules - can rupture - gastric antrum is most common site of sarcoid in GI tract

Dx? - sign of spleen - complication - most common site in GI tract

Eosinophilic esophagitis - Hx: young man with long history of dysphagia (and atopia) - concentric rings on upper GI - "Ringed esophagus" - Tx: steroids

Dx? - typical history? - what does it look like on barium study - buzzword - treatment?

Scleroderma: Esophagus: LES is incompetent --> chronic reflux Lung: NSIP lung changes (ground glass with sub-pleural sparing) Small Bowel: "hide bound" with closely spaced valvulae conniventes

Dx? - underlying esophageal problem? - associated lung problem? - associated small bowel problem?

Achalasia: - absent primary peristalsis of the distal 2/3 of esophagus - lower esophageal sphincter wont relax Barium: dilated esophagus with a "Bird's Beak" Increased risk of Candida and Squamous Cell CA

Dx? - underlying problems (2) - barium study - increased risk for what? (2)

Barretts esophagus - Upper GI: mid/high esophageal stricture with an associated hiatal hernia - "Reticular mucosal pattern" - precursor to adenocarcinoma

Dx? - what does it look like on upper GI? - buzzword?

Osler Weber Rendu (HHT) -autosomal dominant -multiple AVMs liver, lungs--> brain abscess (via shunt) -leads to cirrhosis - shown here with dilated hepatic artery, innumerable small tangles of telangiectatic vessels, and larger vascular masses or pools

Dx? -inheritance pattern -finding

Carcinoid - Well-differentiated neuroendocrine tumor usually originating in digestive tract - "starburst" mesenteric mass with desmoplastic stranding and calcification - tethering of small bowel and encasement/narrowing of vessels can be seen - location = jejunoileal > colorectal > appendiceal > gastric - carcinoid syndrome (flushing, diarrhea, asthma, pain, right heart failure) when mets to liver - MIBG and Octreotide can help

Dx? When does the associated syndrome occur? What other scans could help?

- in the back (posterior) --- "Z" is in the back of the alphabet - Occur at killian dehiscence or triangle (the site of weakness)

Dx? where do they occur (front/lateral/back)? what is the site of weakness called?

Esophageal web - a ring caused by a thin mucosal membrane - most commonly in the cervical esophagus

Dx? where are they most commonly located?

Macronodular liver contour resulting from multiple hepatic metastases, which may mimic cirrhosis.

Dx? No history of hepatitis or ethanol

MRCP doesn't allow for concurrent intervention. Doesn't actively distend biliary ductal system. Worse spatial resolution.

ERCP over MRCP advantages?

Central portal triad and periopheral venous drainage to hepatic veins

Each hepatic segment contains its own:

Apthous ulcers due to lymphoid hyperplasia and lymphedema.

Eariliest histologic changes of Chron?

Expansion of periportal space (hilar fat) from atrophy of the medial L hepatic lobe. (arrow on IVC expanded)

Earliest sign of cirrhoiss?

Very very rare but would be a cystic lesion with internal undulating membrane and daughter cysts.

Echinococcal cyst in spleen?

AFP (75%)

Elevated lab value in HCC?

Hepatic parenchyma surrounding the gallbladder is replaced with periportal fat

Empty gallbladder fossa sign?

Thickened folds in stomach and small bowel in a patient with allergy hx.

Eosinophilic gastritis?

epiploic appendagitis

Epiploic appendagitis vs omental infarct: occurs on the left

omental infarct - larger mass with more oval shape than epiploic appendagitis "ROI" - right omental infarct

Epiploic appendagitis/omental infact: occurs on the right

Rare vascular malignancy causing multiple spherical subcapsular masses that can become confluent. They may have a halo or target appearance

Epithelioid hemangioendothelioma?

- Reflux esophagitis - Drug-induced stricture - Esophageal carcinoma = Iatrogenic (nasogastric tube) = Caustic ingestion = Radiation changes

Esophageal Stricture

Benign mucosal lesion with malignant potential, usually arising in a Barret's esophogus. Usually 1.5 cm or greater and resected.

Esophageal adenoma?

Gastric pull-through (esophagogastrectomy). Colonic interposition.

Esophageal bypass surgical techniques?

- irregular contour - abrupt (shouldered) edges Subtypes: - Squamous cell (mid) - Adenocarcinoma (distal)

Esophageal cancer: - buzzwords for barium study (2) - subtypes?

Spectrum from scattered plaque like lesions in mild disease to very shaggy esophogus in severe cases.

Esophageal candidiasis?

- Achalasia - Scleroderma - Esophageal / gastric carcinoma = Esophagitis with stricture = Post Sx changes (vagotomy)

Esophageal dilation

- Proximal esophageal pulsion diverticulum (Zenker, Killian-Jamison) - Distal esophageal pulsion diverticulum (epiphrenic) - Mid-esophageal traction diverticulum = Intramural pseudodiverticulosis

Esophageal diverticulum

Indistinguishable from primary esophageal cancer

Esophageal lymphoma?

- Reflux esophagitis - Candida esophagitis - Superficial spreading carcinoma = Drug induced esophagitis

Esophageal pseudodiverticuli

- Varices - Reflux esophagitis - Varicoid esophageal carcinoma = Lymphoma

Esophageal submucosal masses / thickened folds

- Reflux esophagitis - Viral esophagitis (CMV, HIV, HSV) - Drug induced esophagitis = Caustic ingestion = Esophageal carcinoma

Esophageal ulcers

Thin anterior infolding/indentation of the upper esophogus- usually assymptomatic but can cause dysphagia. Controversial association with anemia (Plummer Vinson) and Carcinoma.

Esophageal web?

80%

Esophogus involved in what percentage of patients with scleroderma?

Sacroilitis, Iritis, Ereythema nodusum, pyoderma gangrenosum

Extra-abdominal manifestations of UC?

Hepatitis. Sclerosing cholangitis. Cholangiocarcinoma. Sacroilitis. Ankylosing spondylitis.

Extracolonic sequelae of ulcerative colitis?

Familial adenomatous polyposis. AD. Innumerable premalignant adenomatous polyps in colon and small bowel.

FAP?

Mesenteric fibromatosis.

FAPS (Gardner's type) effect on the mesentery?

Hypo/Hyper. Variable on diffusion. Central scar Norml hepatocytes w disfunctional bile ducts

FNH

US: spoke wheel on US doppler CT: homogeneous on arterial phase MRI: - Stealth lesion: isointense on T1 and T2 - central scar will have delayed enhancement

FNH appearance: - US - CT - MRI

No

FNH assoc. with OCPs?

Abscess (forms earlier after pancreatitis, days to weeks, high HU 20-50, may contain air).

Factors that distinguish a pancreatic abscess from pseudocyst?

- Fat: drops out on out of phase - Iron: drops out on In phase

Fat vs iron liver: - drop out on out of phase - drop out on in phase

CT: noncontrast study - 40 HU, contrasted study - <100 HU and less than 25 HU than spleen US: brighter than the right kidney MRI: drop out on the out of phase images

Fatty liver on: - CT - US - MRI

diabetes. obesity. elderly. Cystic fibrosis.

Fatty replacement of the pancreas is common in?

Weight loss. Anorexia. Alopecia. Multiple intestinal hamartomas.

Features of Cronkhite-Canada syndrome?

Normal variant. Scleroderma. GER.

Feline esophagus differential?

Normal variant characterized by multiple transverse esophageal folds.

Feline esophogus?

placenta (umbilicus) --> umbilical vein --> L portal vein --> Ductus venosus --> middle/left hepatic vein --> IVC - some flow also goes to the liver (Right sided pathway) and to the IVC via R hepatic vein

Fetal circulation anatomy

Cause esophageal shorteneing, leading to a hiatal hernia

Fibrosis from a peptic stricture can do what?

May clinically present with SBO. Assymetric bowel fibrosis from ulcerations in the mesenteric side of the bowel producing pseudosacculations on the antimesenteric side. Fibrosis can lead to the string sign- a segmental stricture.

Fibrostenotic type of Chron?

Pedunculated mass composed of mesenchymal elements with a significant fatty component.

Fibrovascular polyp?

Reversal of jejunal and ileal fold patterns. Normally jejunal has more folds, but it loses them and the ilum gains them to compensate. Note that they get lots of SB SB Intussusceptions.

Fluoro Imaging of celiac disease?

Thickened nodular folds in the affected regions with luminal narrowing, mucosal ulceration, and separation of bowel loops. Cobblestone appearance as a result of crisscrossing deep ulcerations.

Fluoro findings for Chron disease?

Erosion.

Focal loss of superficial epithelium?

Disorganized liver tissue with no malignant potential

Focal nodular hyperplasia?

Barium. water-soluble contrast should be avoided for it can cause pulmonary edema.

For an esophagram, if aspiration or a tracheo-esophageal fistula is suspected what contrast should be used?

Water-soluble contrast.

For an esophagram, if esophageal rupture is suspected what contrast should be used?

Serosa. Muscularis (thin longitudinal and thick circumferential smooth muscle). Submucosa. Mucosa.

Four layers of small intestine?

Nasopharyngeal reflux. Laryngeal penetration. Tracheal aspiration. Cricopharyngeal achalasia. Cricopharyngeal hypertrophy.

Functional abnormalities of the pharynx in barium swallows?

Variant of FAP. Involves stomach. Most polyps are hyperplastic, but elsewhere in GI tract they are adenomatous.

Fundic gland polyposis syndrome?

Microabscesses, multiple small low densities.

Fungal infections of the spleen, most common finding?

- bone marrow transplant patients - "ribbon bowel" - bowel is featureless, atrophic, and fold thickening

GVHD: - type of patients - buzzword - appearance on imaging

Loss of wall planes, irregular thickening and enhancement - often manifests w invasion into the liver T1 hypo- T2 hyper Malig polypoid lesion w early, persistent enhancement (benign washout)

Gallbladder Ca

- associated with gallstones - 80% have direct invasion of liver and nodes at diagnosis

Gallbladder Cancer

Air in biliary system. Radiopaque stone. Bowel obstruction. All 3 present probably only 30% of the time.

Gallstone ileus triad?

T2 and MRCP - low signal High central protein may give them T1 hyperintensity but in general cholesterol stones T1 hypo and pigmented T1 hyper

Gallstones

Multiple tiny foci of hemosiderin deposition resulting from portal htn. Low signal on all sequences. GRE dark.

Gamna Gandy bodies?

FAP with desmoid tumors, osteomas, papillary thyroid cancer, epidermoid cysts (DOPE Gardner)

Gardner syndrome?

Intestinal adenomatous polyps with osteomas of the skull or long bones. Epidermoid cysts. Fibromatosis.

Gardner syndrome?

Distal stomach. Assoc with small bowel disease. Earliest pathologic change is formation of apthous ulcers

Gastric Chron?

- Hypertrophic gastritis - Gastric carcinoma - Lymphoma = Mets = Menetrier disease

Gastric Fold Thickening

- PUD - Gastric carcinoma - Lymphoma = Mets = Zollinger-Ellison syndrome

Gastric Ulcer

Either a mass or a gastric ulcer

Gastric adenocarcinoma can present how?

Small gastric pouch created with a volume of 15-30 cc by excluding the distal stomach from path of food.

Gastric pouch in Roux en Y?

- 5% chance of cancer - occurs from "altered mucosal resistance"

Gastric ulcer trivia: - chance of being cancer (%)? - occurs from ________

Major cause of Zollinger-Ellison syndrome. MEN-1 syndrome. 60% Malignant. Ectopic locations outside pancreas.

Gastrinoma facts?

MEN 1

Gastrinoma is associated with what syndrome?

Describes location of gastrinoma. Junction of the cystic duct and CBD, duodenum inferiorly, and neck and body of pancreas medially

Gastrinoma triangle?

Communication between gastric pouch and excluded stomach, can be an early or late complication. May cause recurrent weight gain or inadequate weight loss

Gastrogastric fistula s/p RYGB

Females more common.

Gender for hemangiomas?

Males

Gender in PSC?

Nonenhancing central region from cystic degeneration

Giant hemangioma imaging?

Secrete glucagon. Produce Diabetes Mellitus. 80% Malignant.

Glucagonoma facts?

1- Superficial less than 1 cm. 2- Between 1 and 3. 3- Greater than 3 cm. 4- Greater than 10 cm or destruciton or devascularization of one lobe. 5- Destruction or devascularization of both lobes.

Grades 1-5 liver injury?

1- Less than one cm subcapsular hematoma or laceratation or parenchymal hematoma. 2- Between 1 and 3 cm. 3- Larger than 3 cm. 4A- Active extrav or other vascular injury or shattered spleen. 4B Active intraperitoneal bleeding.

Grades of splenic injury?

Balthazar. A-Normal. B-Focal or diffuse enlargement. C- Mild peripancreatic stranding. D- Single fluid collection. E-Two or more fluid collections

Grading system for acute pancreatitis?

Multiple punctate calcifications. Histoplasmosis. Tuberculosis. Sarcoidosis.

Granulomatous disease of the spleen, major finding and common causes?

Drape like mesentery in the anterior abdomen connecting stomach to anterior aspect of the transverse colon

Greater omentum?

T1-Iso to hypo T2- Iso to mild hyper Early enhancement and washout on delayed and mild enhancement of fibrous capsule on hepatocyte

HCC

100-300 days - image in 3-4.5 months

HCC doubling time:

- occurs in cirrhosis or chronic liver disease - doubles in about 300 days - AFP is elevated - can explode and cause spontaneous hepatic bleeds

HCC: - what conditions does it typically occur in - doubling time - tumor marker - complication of HCC

Prior pnuemocystis jiroveci infection - numerous tiny calcifications in the spleen

HIV positive Dx?

MAI infection - low attenuation lymphadenopathy - retroperitoneal and mesenteric nodes

HIV positive with fever, diarrhea and weight loss for 3 weeks Dx?

Benign- Usually associated with Peutz Jehers, Juvenile polyposis, Cronkhite-Canada syndromes

Hamatromatous polyp?

Doesn't happen. They involute if they are present in cirrhosis.

Hemangiomas in cirrhosis?

T2 bright , may enhance peripherally or homogenously. Uncommon to see the pattern you see in hepatic hemangiomas

Hemangiomas on MRI in spleen?

Primary/Hereditary/AR: Hemochromatosis is increase iron within hepatocytes. Secondary: Iron increase in RES is hemosiderosis.

Hemochromatosis vs Hemosiderosis (aka secondary hemochromatosis)?

Hemochromatosis/hepatocytes. In hemosiderosis the RES (Bone marrow, spleen, Kupfer cells in liver) has a high capacity for iron storage.

Hemosiderosis or Hemochromatosis leads to cirrhosis?

T1-hypointense, T2-hyperintense, modularity can mimic cirrhosis

Hepatic Mets

Mimics cirrhosis- fibrosis, regenerativng nodules, regional enhancement (may mimic HCC), clinical picture

Hepatic Necrosis

Benign hepatic neoplasm containing hepatocytes, scattered Kupffer cells and NO bile ducts.

Hepatic adenoma?

Hydatid cyst

Hepatic echinococcus causes what?

Rarely.

Hepatic failure in ADPKD when liver is involved?

If it is more than 25 HU less than the spleen

Hepatic steatosis on enhanced CT?

Historically if it is more than 10 HU less than spleen, now people are even saying 1 HU

Hepatic steatosis on unehnaced CT?

Mets (mc txed breast Ca), fibrolamellar HCC, epithelioid hemangioendothelioma, intrahepatic cholangiocarcinoma, confluent hepatic fibrosis, HCC (uncommon)

Hepatic subcapsular retraction

Discrete small ulcerations scattered randomly throughout the esophogus.

Herpes esophogitis?

Moire spleen.

Heterogeneous spleen in early arterial phase?

- doesn't mean anything if an isolated finding DDx: - postprandial state - advanced pt age - diffuse distal microvascular disease (cirrhosis/chronic hepatitis)

High RI in Liver: - what does it mean - DDx (3)

Carcinoid tumors in the stomach- Will regress after gastrinoma is resected

High gastrin levels may cause what?

Fibrosis in the pancreaticoduodenal groove.

Histopathologic hallmark of groove pancraetitis?

Scirrhous infiltrating mass invading through gb wall into liver. May appear as a polypoid mass. Or mural thickening.

How can GB carcinoma present?

length of narrowed esophagus > 2cm

How can you tell if the wrap has slipped?

Retrocolic- with creation of surgical defect through the transverse mesocolon- higher risk of transmesocolic hernia.

How did Roux limb used to be placed?

Backwash ileitis. (May mimic Chron disease)

How do you get small bowel disease in UC?

Exention into liver. But lymph and hem spread are also common.

How does GB carcinoma spread?

Pruritis

How does PBC present?

No thick enhancing wall.

How is biliary cystadenoma differentiated from hepatic abscess or necrotic mets?

Mitotic rate

How to evaluate for malignancy of GIST on histology?

75

Hyperattenuating liver is higher than what?

Imlammatory polyp. Almost always benign.

Hyperplastic gastric polyp?

- Hemangioma - Focal nodular hyperplasia - Hepatocellular carcinoma (+ fibrolamellar variant) = Hepatic adenoma = Hypervascular mets

Hypervascular Liver Mass

Neuroendocrine tumors (pancreatic NET and carcinoid), renal cell, thyroid, sarcoma and melanoma

Hypervascular hepatic mets

Metastatic pancreatic endocrine neoplasm

Hypervascular liver mass with an associated pancreatic mass?

RCC< Carcinoid, thyroid, chorioca, melanoma, neuroendocrine, sarcomas. variable appearance.

Hypervascular liver mets

Neuroendocrine tumors. RCC. Thyroid. Melanoma. Sarcoma.

Hypervascular mets are what?

Colorectal and pancreatic adenoCa

Hypovascular hepatic mets

Colon, also bladder, prostate, pulmonary Generally hypo/hyper w peripheral ring enhancement on arterial

Hypovascular liver mets

Elderly males, grandfather tumor, greatest age and sex variability, benign to aggressive, main duct type has greatest malignant potential, continuity with duct or side branch, nodular or enhancing component raises concern, resected >3cm, mural nodule or >1 cm pancreatic duct dilitation

IPMN

Main duct or a sidebranch. Main duct is worse.

IPMNs can arise from where? Significance?

Still suspect an isoattenuating pancreatic adeno.

If double duct and no mass?

Other causes- listed in book. Some are mets. duodenal GIST. Lymphoma. Cystic panc tumor. Autoimmune or groove pancreatitis. Neuroendocrine tumor.

If pancreatic mass with no ductal dilatation, consider?

-autoimmune pancreatitis - retroperitoneal fibrosis - sclerosing cholangitis - inflammatory pseudotumor - riedel's thyroiditis

IgG4 associations (5)

3 cm, certainly abnormal if > 4 cm.

Ileocecal valve upper limits of normal size?

Posterior displacement of colon with small bowel anterior to colon. SMA and SMV may be displaced and engorged.

Imaging clues to transmesocolic hernia?

Like PSC with multiple strictures and beaded appearance of bile ducts. Papillary stenosis is a distinguishing feature.

Imaging of AIDS cholangitis.

Featureless distal esophogus with signs of active reflux esophagitis (mucosal granlarity and superficial erosions) more proximally

Imaging of Barret esophgus?

Avid enhancement during arterial phase, with quick washout and late enhancement of scar. Portal vneous phase will only show scar.

Imaging of FNH?

Fibrotic central scar which is hypo on T1 and T2. (Note that FNH scar is T2 hyper with late enhancement).

Imaging of Fibrolamellar HCC?

Nonspecific wall thickening and effacement of the normal small bowel fold pattern. Classic finding is the ribbon bowel.

Imaging of GVHD?

Beaded irregular appearance of the common bile duct and intrahepatic bile ducts

Imaging of PSC?

Large mass with heterogeneous solid and cystic areas. Hemorrhage is typical.

Imaging of SPEN?

Umbilicated submucosal nodule, with the umbilication representing a focus of normal epithelium.

Imaging of a pancreatic rest?

- Low signal on T2, variable on T1 but usually iso. - Enhance same as hepatic parenchyma

Imaging of a regenerative nodule?

Hypervascular on arterial phase- lack portal venous drainage. T2 bright bc hyper vascular unless acute blood)

Imaging of adenomas?

Swirling of mesentery, mushroom shape of mesentery, and/or presence of small bowel loops posterior to the SMA.

Imaging of an internal hernia?

Hyperenhancement and thickening of walls of bile ducts often with a stone present. On U/S maysee debris within biliary system.

Imaging of ascending cholangitis?

Large multiloculated cystic mass with sepatations (differentiator from simple cyst).

Imaging of biliary cystadenoma?

Enlarged hepatic veins and IVC with reflux of IV contrast from the R atrium into the IVC and hepatic veins. Enlarged liver with mottled enhancement. Ascites is usually present.

Imaging of cardiac hepatopathy?

- Variable on T1 and low on T2. High grade may be T2 bright. - They enhance same as hepatic parenchyma unless they are high grade. - T1 high signal with drop out on OOP => fat containing HCC

Imaging of dysplastic nodule?

Assymetric wall thickening and intraluminal membranes

Imaging of gangrenous cholecystitis?

Inflammation around head of pancreas but also duodenal stenosis or cystic change of the duodenal wall. Cystic change best seen on MRI.

Imaging of groove pancreatitis?

Best seen as hypovascular lesions on portal venous phase (in contrast to HCC).

Imaging of hepatic mets.

Bowel between the pectineus and obturator muscles

Imaging of obturator hernia?

Focal or diffuse area of nonenhancing pancreatic parenchyma

Imaging of pancreatic necrosis?

Cluster ofr small bowel loops between the pancreas and stomach.

Imaging of paraduodenal hernia?

Well circumscribed fluid density, no peripheral enhancement. May have peripheral calcifications, but no septations.

Imaging of post traumatic pseudocyst?

Mesenteric masses with striations of soft tissue extending into adjacent fat, calcification may be present.

Imaging of sclerosing mesenteritis?

CT-Iso to hypodense mass that enhances heterogeenously. MRI- T2 Iso to hyper with heterogeenous early enhancement and homogenous delayed enhancement.

Imaging of splenic hamartoma?

Solitary or multiple. Multilocular cystic structure with thin septations. May get septal enhancement.

Imaging of splenic lymphangioma?

Pneumobilia. Lamellated bile duct filling defects. Intrahepatic and extrahepatic bile duct dilatation and strictures.

Imaging triad of recurrent pyogenic cholangitis?

Intermediate T2- 80-100 ms

In MRCP if you want to see biliary ductal system and surrounding tissue?

Hepatocytes (Not Kupffer cells that make up the intrahepatic RES). Pancreas (also T2 dark). Myocardium. Skin. Joints. (Spleen Normal appearance bc RES spared)

In hemochromatosis, where is excess iron stored?

Sometimes can cause splenic rupture.

In hx of pancreatitis, can get intrasplenic pseudocyst, causing what?

Arterial phase- hypoenhancement of mass relative to background pancreas.

In panc adenocarcinoma, what do you see on imaging?

Obstruction at the minor papilla from a Santorinicele. A focal dilatation of the terminal duct of Santorini

In pancreas divisum, what may cause pancreatitis?

Young adults. Asians.

In what patient population does right-sided diverticulitis occur?

Up to 10%

Incidental colonic wall thickening found in what percentage of CT scans?

Achalasia.

Incomplete relaxation of the LES because of neuronal degeneration?

3,4,5, 6 (L to R)

Inferior segments?

Reflux.

Inflammatory polyp associated with what?

Non neoplastic enlarged gastric fold protruding into the lower esophogus. Mucosal in location. Always contiguous with a gastric fold.

Inflammatory polyp?

Radiograph- Air fluid levels, lack of gas in colon

Initial imaging for SBO?

Most common, hypoglycemia, best prognosis, 10% malignant potential

Insulinoma

90% benign. small less than 2 cm. Most difficult to detect on imaging.

Insulinoma facts?

Volvulus.

Internal hernias carry a high risk of what?

Laparoscopic

Internal hernias more common with what approach?

Lined with squamous epithelium. Has a smooth muscle wall.

Internal make up of esophageal duplication cyst?

Chilaiditi sign.

Interposition of the hepatic fleure between the dome of the liver and the right hemidiaphragm?

TI- hypo, T2- hyper, Diffusion restriction, Early enhancment and on delay, no uptake on hepatocyte phase

Intrahepatic Cholangiocarcinoma

- Primary sclerosing cholangitis - Ascending cholangitis - AIDS cholangiopathy = Neoplasm (cholangiocarcinoma, Mets) = Post- transplant arterial ischemia

Intrahepatic biliary ductal strictures

Edematous peripheral liver with sparing of caudate lobe.

Intraprenchymal findings in Budd Chiari?

Can lead to intrasplenic hemorrhage

Intrasplenic pseudocyst?

Invades portal veins, IVC, and bile ducts. Mets usually aren't invasive like this.

Invasive characteristics of HCC?

Decreased signal on all sequences. (Relative to paraspinal muscles as internal control)

Iron overload liver on MRI?

No. Yes.

Is regenerative nodule premalignant? Dysplastic nodule?

Jejunum has larger more feature-full folds and larger villi compared to the ileum.

Jejunum appearance vs ileum?

Anterior protrusion best seen on lateral view. More often bilateral.

KJ diverticulum?

Dilated loops of bowel in the upper abdomen and presence of mesentery between the IVC and the main portal vein.

Key imaging findings for a foramen of winslow hernia?

Area of weakness below attachment of the cricopharyngeus.

Killian Jamison space?

Mirizzi Syndrome cystic duct stone abuts normal size CBD and obstructs BL ducts

Large stone in duct, Dx?

Internal hernia (more common with laparoscopic) or adhesions (Open surgery)

Late presentation of SBO s/p RYGB?

Pancreas divisum

Less common cause of chronic pancreatitis?

Ascending cholangitis

Less common cause of hepatic abscess?

Numerous hypoattenuating 1-3 cm lesions without enhancement.

Less common splenic presentation of sarcoid?

Connects stomach to liver

Lesser omentum?

Limited extension to stomach, duodenum, or CBD (all part of whipple). Limitied venous extension is also resectable.

Limited resection still possible when?

- Gastric carcinoma - Mets - Lymphoma = Crohn disease

Linitis plastica

Liver should be slightly more dense.

Liver to spleen on normal unenhanced CT?

Cervical esophogus

Location for fibrovascular polyp?

Extrinsic or submucosal in the posterior mediastinum. (If submucosal- impossible to diff from leiomyoma on esophagram)

Location of esophageal duplication cyst?

Small bowel or rectum are more likely to be malignant

Locations most common for malignancy of GIST?

CIrrhosis. Cholangiocarcinoma. Recurrent biliary infections.

Long term complications of PSC?

12 - 14 cm

Longitudinal dimension of the spleen should not eceed?

12 - 14 cm.

Longitudinal dimension of the spleen should not exceed?

Means proximal stenosis or distal vascular shunting - less blood in liver (less blood in or more blood out) DDx: - AV or arterioportal fistulas seen in severe cirrhosis -trauma (iatrogenic) -Osler-Weber rendu syndrome

Low RI in Liver: - what does it mean - DDx (3)

VIPoma.

Low attenuation pancreatic mass with dilated loops of bowel?

Usually secondary to systemic disease. Primary involvement of liver is very rare.

Lymphoma of liver

Hereditary nonpolyposis colon cancer syndrome- AD- polyposis syndrome caused by DNA mismatch repair leading to colon cancer from microsattelite instability on a molecular level.

Lynch syndrome?

Parathyroid adenoma. Pituitary adenoma. Pancreatic islet cell tumors.

MEN 1?

T1 hyperintense if acute and hemorrhagic. Chronic will be T1 hypo and T2 hyper.

MR of splenic infarct?

T1 weighted

MRCP

Extraluminal findings. Non invasive. Can see obstructed ducts.

MRCP advantages vs ERCP?

In hemosiderosis, the spleen, liver and bone marrow will be hypointense on all sequences

MRI of hemosiderosis vs hemochromatosis?

Central hyperintensity on T2 with irregular late enhancing wall. May have perilesional enhancement.

MRI of hepatic abscess?

T1 Hypo. Hypovascular. Ill-defined.

MRI of panc adeno?

In and out of phase imaging

MRI sequence for hepatic steatosis?

Hepatitis B or C

Macronodular cirrhosis cause?

Capsular retraction.

Main characteristic suggesting pseudocirrhosis over cirrhosis?

Adnocarcinoma of head of pancreas

Main diff for groove pancreatitis?

Diffuse esophageal spasm presents with chest pain. Presbyesophagus is asymptomatic.

Main differential feature of diffuse esophageal spasms and presbyesophagus?

Duct of Santorini (Superior)- Drains to minor papilla. Duct of Wirsung- Drains to major papilla.

Main pancreatic duct turns to what two ducts which drain what?

Crohn's disease. Tuberculosis. Yersiniosis.

Major inflammatory processes that affect the terminal ileum?

Strictures. Webs. Diverticula (Zenker [pharygoesophageal]). Lateral pharyngeal pouches. Lateral pharyngeal diverticula.

Major structural abnormalities of the pharynx on barium swallow?

Low malignant potential but is resected.

Malignancy of SPEN and treatment?

It is benign but has malignant potential and thus it is resected.

Malignancy of mucinous cystic neoplasm? Treatment?

Increased risk for cholangiocarcinoma

Malignancy risk in recurrent pyogenic cholangitis?

Bulkier and more irregular than the benign variant

Malignant GIST?

Very rare but possible.

Malignant degen of biliary cystadenoma?

SCC. Adenocarcinoma. Lymphoma. Kaposi sarcoma. Spindle-cell carcinoma. Leiomyosarcoma. Metastases.

Malignant esophageal neoplasms?

Gastric adenocarcinoma. Gastric lymphoma. Kaposi sarcoma.

Malignant gastric neoplasms?

Angiosarcoma: - aggressive and has a poor prognosis - heterogeneous, poorly enhancing mass Lymphoma: - most common malignant tumor of the spleen - hypodense, T1 dark, PET hot - Splenomegaly is most common finding Mets: - breast, lung, melanoma - melanoma is the most common met to the spleen

Malignant masses of the spleen (3) - what are they - which one is the most common - general info - imaging appearance

None

Malignant potential of fibrovascular polyp?

Carcinoid tumors. Adenocarcinoma. Lymphoma. Kaposi sarcoma. Leiomyosarcoma. Metastases.

Malignant small bowel neoplasms?

Hemangiosarcoma. Angiosarcoma (thorotrast 1950s). Kaposi sarcoma. Lymphoma (AIDS and non-AIDS). Leukemia.

Malignant splenic neoplasms?

Shouldered margins- suggesting circumferential luminal narrowing

Malignant stricture?

Abnormal skin pigmentation, alopecia, onychodystrophy (Malformation of the nails)

Manifestations of Chronkhite Canada syndrome?

Late arterial (35 seconds after injection or 9-16 seconds after abdominal aortic enhancement)

Many authors think best timing for hypervascular liver lesion is when?

Jejunal mucosa adjacent to gastrojejunal anastamosis is susceptible to gastric secretions, causing marginal ulcers in up to 3% of patients.

Marginal ulcers s/p RYGB?

3 mm and 5 mm.

Maximal size of pancreatic duct in adults and elderly?

GE junction.

Meat impaction usually occurs where in esophogus?

Ulcer at the level of the aortic arch or distal esophogus- areas of narrowing that may predispose to temporary hold ups in passage.

Medication induced esophogitis?

Protein losing enteropathy- diagnosis of exlcusion. Affects proximal stomach- replacement of parietal cells by hyperplastic epithelial cells, leading to achlorhydria. Controversial association with gastric carcinoma

Menetrier disease?

Smooth round submucosal filling defect

Mesenchymal tumor on barium swallow?

- Mets - Carcinoid tumor - Desmoid tumor / Fibrosing meseneteritis = Reactive lymphadenopathy (TB, MAC, Whipple) = Abdominal mesothelioma

Mesenteric Mass

Those with Gardner syndrome

Mesenteric desmoid can be sporadic but more common in what patients?

Diffuse misty mesentery. Variant of sclerosing mesenteritis but inflammation predominates.

Mesenteric panniculitis?

Melanoma

Mets to GB?

Usually direct invastion from gastric lung or breast. Hematogenous spread is very rare.

Mets to esophogus?

Very rare but consider breast, lung, ovarian, and melanoma. Ovarian and melanoma will be cystic. Only will be calcified if mucinous adenocarcinoma.

Mets to spleen?

Menetrier disease (protein-losing enteropathy).

Middle-aged men, enlargement of gastric rugal folds?

stone in cystic duct compresses common hepatic duct type 1- simple obstruction type 2- cholecystocholedochal fistula diagnose stone at cystic duct prior to surgery

Mirizzi syndrome

Paraesophageal

More prone to strangulation: Paraesophageal or Hiatal?

Carcinoid tumor.

Most common appendiceal tumor?

Literature varies between GIST and lymphoma

Most common benign mesenchymal tumor?

Hemangioma

Most common benign splenic lesion?

Main portal vein divides into R and L and then the R branches into A and P

Most common branching of portal veins?

Long term alcohol abuse.

Most common cause of chronic pancreatitis?

Lipomatous infiltration.

Most common cause of enlarged ileocecal valve?

Bowel process with infectious nidus carried to liver.

Most common cause of hepatic abscess?

Hemochromatosis.

Most common cause of iron overload?

GERD. Note, also seen in Zollinger Ellison, Scleroderma.

Most common cause of peptic esophagitis?

Shistosomiasis.

Most common cause of portal hypertension and varices worldwide (parasite)?

Treated breast cancer.

Most common cause of pseudocirrhoiss?

Pancreas divisum

Most common congenital pancreatic anomoly?

Normal CT scan

Most common finding in viral hepatitis?

Klatskin tumor

Most common form of cholangiocarcinoma?

Terminal ileum thickening

Most common imaging finding for Chron disease?

Paraduodenal hernia.

Most common internal hernia?

- Most common: ileum - esophagus is second most common

Most common location for enteric duplication cysts? second most common?

Antrum (most common area for benign ulcers, too). Fundus ulcers, though uncommon, are more likely to be malignant.

Most common location in stomach for a malignant ulcer?

Insulinoma

Most common pancreatic endocrine tumor?

FSE

Most common sequences for MRCP

Ileocecal.

Most common site for intussusception in colon?

Carcinoid

Most common small bowel tumor?

Lymphoma

Most common splenic malignancy?

Benign mesenchymal tumors

Most common submucosal tumors?

Non Hodgkin lymphoma

Most common tumor involving the mesentery?

Transmesenteric. Due to congenital mesenteric defect likely secondary to prenatal intestinal ischemia.

Most common type of hernia in children?

Transmesocolic hernia- defect in transverse mesocolon. Usually s/p RYGB or biliary enteric anastamosis from liver transplant.

Most common type of transmesenteric hernia?

Females- Pouch of Douglas. Males- Retrovesical space.

Most dependent portion of the peritoneum?

Tumoral angiogenesis from hepatic artery.

Most mets are supplied by what arteries?

Are...thus seen in arterial phase.

Most primary hepatic liver masses are/are not hypervascular?

French for casting. Seen on barium study and refers to cast like appearance of featureless jejunum.

Moulage sign?

Single or a few large cysts, less than 6 cysts that are larger than 2 cm. Pancreatic body and tail.

Mucinous Cystadenoma appearance?

Mother tumor, malignant potential, <6 lesions >2 cm, pancreatic body and tail, capsule, may have peripheral calcifications, tx is resection

Mucinous cystadenoma

Capsule

Mucinous cystic neoplasm has a _______?

Usually fungal

Multifocal small splenic abscesses?

Advanced AIDS- Pneumocystic Jiroveci

Multiple calcified splenic lesions in immunocompromised host?

Von Gierke disease

Multiple hepatic adenomas seen when?

- Hepatic cysts - Mets - Multiple abscesses = Cholangiocarcinoma

Multiple hypodense hepatic lesions

- Mets - Lymphoma/ leukemia - Microabscesses = Granulomatous disease (TB, sarcoid) = Multiple splenic infarcts

Multiple splenic masses

Candidiasis, Mets, lymphoma, biliary hamartoma, Caroli disease

Multiple tiny hypo attenuating hepatic lesions ddx

"accordion sign" with C Diff colitis - barium: thumbprinting, ulceration, and irregularity

Name of sign? Significance?

Fleischner sign or inverted umbrella sign - gaping ileocecal valve with narrowed and ulcerated terminal ileum - associated with ileocecal TB - DDx: Crohns

Name of sign? Significance?

Passavant cushion or pad.

Nasopharyngeal reflux is prevented by the soft palate apposing the posterior pharyngeal wall, known as the?

Vertebral body anomolies

Neurenteric cyst is associated with what?

-insulinoma (MC, B9, small) > gastrinoma (MEN, ca ~50%, zolinger ellison) > non-functional (metastatic, large with calcs) - don't with octreo scan -MEN1, VHL hypervascular MIMIC- Intrapancreatic accessory spleen - follows spleen appearance

Neuroendocrine Pancreatic Tumors

Typhlitis.

Neutropenic colitis (pericecal)?

- Cirrhosis - Treated Mets - Budd-Chiari syndrome = Schistosoma japonicum = Confluent hepatic fibrosis

Nodular Liver Contour

Nodules wo significant fibrosis

Nodular Reenerative Hyperplasia

Neoplasm

Nodular gastric fold thickening?

Enhancing nodule within a dysplastic nodule- Early HCC

Nodule in Nodule appearance?

3rd most common islet cell tumor. Generally malignant. Larger. Necrotic on imaging studies.

Nonfunctioning islet cell tumor facts?

Gallbladder wall thickening or periportal edema

Nonspecific Viral hepatitis findings?

Less than 1.5 cm.

Normal size of duodenal papilla?

Splenic cleft.

Normal splenic finding may mimic a splenic laceration?

Groove Pancreatitis - Form of chronic pancreatitis with soft tissue in pancreaticoduodenal groove - can look like pancreatic cancer - duodenal stenosis, cystic changes common, biliary strictures

Not cancer, Dx?

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Note: Adenomas sometimes have a pseudocapsule which enhances late

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Note: CT and MR Enterography are replacing Fluoro for evaluation of Chron

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Note: Can have congenital budd chiari from a hepatic vein anomoly but its extremely rare.

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Note: Cholangiocarcinoma tends to obstruct bile ducts and cause intrahepatic ductal dilatation, eventually leading to lobar atrophy

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Note: Esophoageal dilatation in scleroderma is apparent before skin changes

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Note: FNH hard to see without contrast.

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Note: Gastric carcinoma may spread locally from the mucosal surface to the serosa in which case 90% of patients will have omental involvement from trans-serosal spread

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Note: Impossible on CT, need angiography to distinguish between splenic AVF and pseudoaneurysm

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Note: Internal hernias are most common cause of SBO after a laparoscopic roux en y

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Note: Liver is second most common solid organ injury due to blunt trauma

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Note: Many authors prefer the describing the primary disease (Thalassemia) with secondary iron overload instead of using secondary hemochromatosis

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Note: Mortality progresses from 0-14 from start to end of Balthazar- A fluid collection is a poor prognostic indicator

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Note: Mortality progresses from 3% to 17% from beginning to end of CT Severity index

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Note: Narrowing of the distal jejunojejunostomy is much more rare and requires surgery

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Note: Other complications of celiac disease: Intussusception, pneumatosis, splenic atrophy, venous embolism, cavitating mesenteric lymph node syndrome- read over these again

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Note: Pancreatic neuroendocrine tumors may be hyperfunctioning or non-hyperfunctioning.

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Note: Paraduodenal was most common type of internal hernia until the rise in RYGB

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Note: Peptic stricture may be focal or may involve a longer sement of esophogus

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Note: Peritoneal fluid is constantly produced, circulated, and finally resorbed around the diaphragm, where it drains into the thoracic duct

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Note: RYGB leads to weight loss from early satiety and malabsorption due to surgical bypass of the proximal jejunum

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Note: Sarcoid in spleen is indistinguishable from lymphoma

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Note: Sometimes biliary cystadeoma comes back after resection

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Note: Systemic fungal infection can seed the liver and spleen due to portal venous drainage of infected bowel

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Note: The pancreatic neuroendocrine tumors often have cystic change and central necrosis

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Note: With a retrocolic roux limb edema at transverse mesocolon defect can also cause an SBO

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Note: You can get an intrapancreatic spleen

HIDA- Positive in FNH due to presence of bile ducts. (FNH pos on 1/3 Sulfur Colloid)

Nuc med scan to diff between hepatic adenoma and FNH?

FNH is hot (has Kupffer cells). Fibrolamellar HCC is cold (No Kupffer cells).

Nuclear scanning distinction of FNH from fibrolamellar HCC?

Sulfur colloid study- Hot 1/3 of time. (image: T1 scar dark and T2 bright - unlike FL-HCC which has a real scar thats dark on both)

Nucs of FNH?

1-8 Clockwise when looking at coronal

Numbering of Couinaud segments?

High amplitude contractions on manometry in conjuction with chest pain. Normal radiography.

Nutcracker esophogus?

- Budd chiari - Hepatic veno-occlussive disease - Right heart failure (hepatic congestion) - Constrictive pericarditis "Hey, BRC is a nut (nutmeg)"

Nutmeg liver DDx (4)

Doesn't spare caudate lobe.

One difference in imaging between VOD and Budd Chiari?

Fibrolamellar doesn't have a capsule. May have a pseudocapsule.

One more difference between fibrolamellar HCC and normal HCC?

Lymphangioma

One more splenic cystic lesion?

Interstitial cells of Cajal

Origination cells for GIST?

Size

Other predictors of GIST malignancy?

Apthous erosions. Cobblestoning. Inflammatory pseudopolyps. Postinflammatory polyps. Skip lesions. Pseudodiverticula.

Other prestenotic changes of Crohn disease?

Lymphoma- Endometrial implants- blood products (T1 bright T2 dark) Function testing- MRC MnDPDP or gad BOPTA Air- T2 signal voids Bile- T1 bright

Other rare GB stuff

PSC, Colon ca, Cholangiocarcinoma

Other risks of UC?

HCC

PBC has increased risk for what cancer

HIV cholangiopathy, except that has papillary stenosis

PSC appears similar to what?

cholangiocarcinoma

PSC has increased risk for which type of cancer

-done for type 1 diabetes -arterial flow from donor SMA, splenic artery -venous drainage from donor portal vein, recipient SMV -exocrine drainage via bowel TRANSPLANT FAILURE 1) acute rejection --> reversed diastolic flow 2) splenic vein thrombosis --> reversed diastolic flow 3) pancreatitis Chronic rejection --> shrinking pancreas can't measure resistive indices b/c no capsule

Pancreas transplant - reason for transplant - blood supply (arterial/venous/exocrine) - failure (acute and chronic)

Microcystic adenoma.

Pancreatic cystic neoplasm associated with von-Hippel Lindau disease?

Insulinomas. Gastrinomas. VIPomas. Somatostatinomas. Glucagonomas.

Pancreatic endocrine neoplasms?

Adenocarcinoma. Cystic pancreatic neoplasms (microcystic adenoma, mucinous cystic neoplasms). Cystic teratomas.

Pancreatic exocrine neoplasms?

Unenhanced. Late arterial. Portal venous.

Pancreatic mass CT protocol?

Necrosis. Hemorrhage. Infection.

Pancreatic phlegmon (massive enlargement of the pancreas by inflammation tissue) complications?

Simple to debris (blood, protein)- so enhancing separations, T2 hyper, T1 hypo or hyper (blood, protein) will change over time (fast) Diff dx: Mucinous cyst

Pancreatic pseudocyst

This is the portion of the jejunum that ends up getting hooked up side to side via jejunujenuostomy

Pancreaticobiliary limb?

Necrotizing pancreatitis. Hemorrhagic pancreatitis. Thrombosis (splenic, portal, mesenteric veins). Pseudoaneurysms. Pseudocysts. Ascites. Abscess.

Pancreatitis complications?

Transverse mesocolon.

Paraduodenal hernia is due to a congenital defect in the?

Trousseau's sign (spontaneous venous thrombosis).

Paraneoplastic condition in pancreatic adenocarcinoma?

Phleboliths.

Pathognomonic finding for cavernous hemangiomas of the colon?

Regenerative nodule- Dysplastic nodule- HCC

Pathway to HCC in cirrhosis?

Age 1: pancreaticoblastoma Age 6: adenocarcinoma Age 15: SPEN

Pediatric Pancreatic Malignancy

May lead to venous compression or thrombosis

Perihilar renal inflammation secondary to pancreatitis?

Carcinoma. Polyps. Leiomyoma. (Familial polyposis syndrome and associated Gardner's syndrome)

Perivaterian neoplasms?

Gynecologic neoplasms along with gastric duodenal and colonic malignancies

Peutz Jeghers Associations?

AD. Multiple hamartomatous pedunculated polyps most commonly in small bowel. May cause intussesception?

Peutz Jeghers?

Portal venous.

Phase to evaluate for splenic trauma?

Asymptomatic, large round air collections in colon wall (iatrogenic mucosal injury).

Pneumatosis cystoides coli?

Infectious colitis. Necrotizing colitis. Bowel infarction. Typhlitis. Toxic megacolon.

Pneumatosis intestinalis causes?

Adenomatous.

Polyps in HNPCC

Osteomas. Glioblastomas. Medulloblastomas. Thyroid carcinoma.

Possible extraintestinal neoplasms of FAPS?

Evolution of a splenic hematoma

Post traumatic pseudocyst in spleen is end result of what?

Rare association with polysplenia syndrome

Preduodenal portal vein?

Jaundice and fevers. Southeast Asia

Presentation of recurrent pyogenic cholangitis?

Fever and malaise

Presentation of splenic inflammatory pseudotumor?

Blunting, flattening, distortion, straightening, and thickening of mucosal folds.

Prestenotic phase of Crohn disease, findings?

- anti-mitochondrial antibodies - middle-aged women - risk of HCC - normal extrahepatic ducts early dz has nml ducts - different from PSC Tx is ursodexycholic acid

Primary Biliary Cirrhosis

Physiologic wave initiated by a swallow

Primary contraction wave?

Deposited in parenchymal cells (incl pancrease, heart, pit, thyroid) from genetic cause.

Primary hemosiderosis

Impaired motility due to replacement of the muscular layers with collagen leading to slow transit and subsequent bacterial overgrowth, dilatation, and pseudoobstruction.

Primary insult to GI tract in scleroderma?

Duodenum and jejunum

Primary sites of involement for celiac diseae?

Very very rare. Solitary hypovascular mass. Can involve beyond the splenic capsule and involve adjacent organs

Primary splenic lymphoma?

Primary, no known source. Secondary, known source (neoplasm, Chagas disease).

Primary versus secondary achalasia?

secondary - Spleen = Secondary

Primary vs secondary hemochromatosis: -- liver + spleen involved

Bad. Except small polypoid lesiosn can undergo curative resection.

Prognosis of GB carcinoma?

Better

Prognosis of calcified mets?

Much better.

Prognosis of fibrolamellar HCC vs other?

Poor.

Prognosis of glucagonoma?

Very good- best of all of the pancreatic endocrine tumors. Only 10% are malignant.

Prognosis of insulinoma?

Muscular atrophy and collagen deposition of distal 2/3 of esophagus resulting in reflux.

Progressive systemic sclerosis' effect on esophagus?

Obstructing ge junction cancer. In normal achalasia there is relaxation of the stricture upon standing, in pseudo this doesn't happen- fixed obstruction doesn't relax with standing.

Pseudoachalasia?

Stricture in the mid/upper esophogus

Pseudodiverticulosis is associated with what?

Multiple tiny outpoachings into the esophageal lumen caused by dilated submucosal glands from chronic esophagitis

Pseudodiverticulosis?

- MAI infection - seen in AIDS patients with CD4<100 - looks just like whipples - Also have splenomegaly and retroperitoneal lymph nodes

Pseudowhipples: - pathogen - in patients with what disease? - fluoro appearance - additional findings within the abdomen

Increased esophageal pressure and comprise nearly all diverticula seen in USA

Pulsion diverticula?

- Choledochal abnormality - Pancreatic pseudocyst - GI duplication cyst / diverticulum = Ovarian cystic lesion = Mesenteric cyst

RUQ cystic mass in a child

50 Gy.

Radiation required to cause a radiation stricture?

Long smooth and narrow like caustic and NG strictures but they spare the GE junction.

Radiation strictures?

Antimesenteric sacculations and a hidebound bowel to due to thin straight bowel fods stacked together

Radiographic findings in scleroderma?

Thickening and nodularity of duodenum and proximal small bowel folds. No hypersecretion like in celiac disease.

Radiography of Whipple disease?

Colitis cystica profunda.

Rare condition with mucinous cysts in colon wall?

venoocclusive disease or hepatic sinusoidal obstruction syndrome - Hepatic venous outflow obstruction due to occlusion of terminal hepatic venules and sinusoids - seen with Hematopoietic cell transplantation (HCT) or less often Graft vs. host disease (GVHD) - Acute onset of painful hepatomegaly, jaundice, ascites within 3 weeks following hematopoietic or stem cell transplantation - nonspecific imaging findings including Hepatosplenomegaly; ascites, Periportal and gallbladder wall edema, Hepatofugal flow on Doppler; ↑ resistive index (> 0.75), Abnormal portal vein waveforms, Small caliber hepatic veins

Recent bone marrow transplant, Dx?

Reflux --> Thick folds and thicker folds More reflux --> Strictures and Barretts More reflux --> Cancer (adeno)

Reflux esophagitis progression to cancer?

Gallstone ilieus- Pneumobilia. Small bowel obstruction. Ectopic gallstone in small bowel.

Rigler's triad?

Immunocompromised (HIV, transplant) motility disorders (achalasia, scleroderma)

Risk factors for candidiasis (2)

Choledocal cysts. PSC. FAP. Clonorchis sisensis infection. Thorium dioxide (Alpha emitter not in use anymore)

Risk factors for development of cholangiocarcinoma?

Alcohol. Smoking. Chronic pancreatitis.

Risk factors for pancreatic adneocarcimona?

Increased risk of cancer up to 20 years after insult.

Risk in caustic stricture?

Hemorrhage

Risk of adenoma?

Especially high morbidity and mortality if its incarcerated.

Risk of obturator hernia?

Transmural ischemia if food bolus is impacted for more than 24 hours. (Treat with removal)

Risk with meat impaction at GE junction?

Increased risk for infection and severe morbidity

Risk with pancreatic necrosis?

Transect jejunum 15-30 cm distal to ligament of Treitz, bringing it up and anastamosing with gastric pouch via a narrow gastrojujenostomy stoma

Roux limb?

- 2% of population - 2 types of mucosa (gastric/pancreatic) - 2 feet from ileocecal valve - 2 inches long - symptoms before 2 yrs old

Rule of 2's for Meckels (5)

Obturator internus hernia

SB dilatationDx?

Usually due to edema or hematoma at the gastrojejunostomy or jejunujenostomy.

SBO s/p RYGB?

Daughter tumor, heterogenous solid and cystic areas, hemorrhagic, capsule, usually resected due to low malignant potential

SPEN

Distal small bowel. Nodular thickened folds on fluoroscopy

Salmonella in small bowel?

Mesenteric lymphoma. Mesenteric fat and vessels are engulfed on two sides by bulky lymphomatous masses.

Sandwich sign?

Focal narrowing of the B (Mucosal) ring of the distal esophogus causing intermittent dysphagia.

Schatski ring?

Pathologic B-ring that can result in dysphagia (inflamed B-ring from reflux).

Schatzki ring?

Rare inherited disorder characterized by diffuse fatty replacement of the pancreas, resultant pancreatic exocrine insufficiency, neutropenia and bone dysplasia.

Schwachman Diamond?

Carcinoid met, desmoid tumor, sclerosing mesenteritis

Sclerosing mesenteric mass

Rare inflammatory condition leading to fatty necrosis and fibrosis of the mesenteric root.

Sclerosing mesenteritis?

Protrusion of bowel through the abdominal wall. Usually inguinal through the groin.

Second most common cause of SBO? (Note that first is adhesions)

Schwachman-Diamond syndrome

Second most common cause of pancreatic atrophy?

Gastrinoma

Second most common pancreatic endocrine tumor?

Physiologic wave initiated by a food bolus.

Secondary contraction wave?

Hypertrophied cricopharyngeus.

Secondary finding of a Zenker diverticulum?

From transfusions etc. Iron deposited in RES (spleen , bone marrow, liver)

Seconday Hemosiderosis

Best seen on T2 and early post con T1 (Will stand out against avidly enhancing spleen)

Seeing sarcoid nodules on MRI?

Grandmother tumor, Hypervascular, >6 lesions <2 cm, benign, classic stellar central calcifications

Serous cystadenoma

- Old ladies - pancreatic head "GRANDMA Serous is the HEAD of the household"

Serous cystadenoma - patient population - where in pancreas

Benign. Grandmother tumor- Elderly women

Serous cystadenoma of the pancreas?

Toxic megacolon

Severe complication of UC?

Angular notch.

Sharp angulation in the lesser curvature that demarcates the junction of the body and antrum?

Autosplenectomy, small, densely calcified splenic remnant.

Sicke cell disease's eventual effect on spleen?

LEFT

Side of paraduodenal hernia?

Rams Horn Crohn pseudo-billroth 1

Sign? Classic Dx? mimic of?

wall echo shadow sign of the gallbladder full of stones - clean shadowing Porcelain GB - variable shadow - risk of CA Emphysematous cholecystitis - dirty shadowing

Sign? DDx?

Engorged mesenteric vessles, ascites surrounding the bowel (increased capillary permeability), Wall thickening, lack of bowel wall enhancement (Vasoconstriction or underperfusion). Pneumatosis.

Signs of ischemia in SBO?

Greater than 10 cm (With central necrosis)

Size of malignant GIST?

Perioral mucocutaneous blue/brown pigmented spots on the lips and gums

Skin manifestations of Peutz Jehers?

Chrons

Skip lesions?

- Small bowel obstruction - Adynamic ileus - Celiac sprue = Scleroderma

Small bowel dilation

Celiac: Jejunum decreased folds, ileum increased folds. Scleroderma: Increased folds throughout. 5 folds per inch is normal.

Small bowel folds in Celiac disease and Scleroderma?

Whipple disease.

Small bowel infection of middle aged men with malabsorption, fever, weight loss, chronic uveitis, endocardiits, arthralgia, lymphadenpathy, and skin pigmentation?

Yersiniosis at terminal ileum.

Small bowel infection that can mimick appendicitis clinically and Crohn disease radiographically?

Supplies jejunum and ileum. Oriented obliquely from the ligament of Treitz in LUQ to ileocecal junction in the RLQ

Small bowel mesentery?

- Crohn disease - Lymphoma - Small bowel hemorrhage = Mets = Amyloidosis = Whipple disease

Small bowel wall thickening

- Pancreatic adenocarcinoma - Islet cell tumor - Solid and papillary epithelial neoplasm = Lymphoma = Mets

Solid Pancreatic Mass

- Hepatic cyst - Solitary mets - Abscess = Peripheral cholangiocarcinoma = Bilary cystadenoma = Hepatic laceration

Solitary hypodense, hypovascular liver mass

Rare. Cause diarrhea.

Somatostatinoma facts?

Varices- But no change on peristalsis.

Sometimes esophageal carcinoma has a varicoid appearance, mimicking what?

Caudate to R lobe size ratio greater than 0.65.

Specific sign in cirrhosis with regard to caudate lobe?

Circular band of muscle encircling the ampulla of Vater

Sphincter of Oddi?

Spigelian: lower quadrant through semilunar line. Richter's: only one wall of bowel involved. Littre's: Meckel's diverticulum hernia.

Spigelian, Richter's, and Littre's hernias?

Well circumscribed area of increased attenuation, doesn't increase on delayed imaging like active bleeding.

Splenic AVM?

Women (medial dysplasia) rupture risk at pregnancy. Men (atherosclerosis).

Splenic artery aneurysm demographics?.

Elevated CA 19-9, CA125, CEA despite being completely benign.

Splenic epithelial cyst may have what?

Tuberous sclerosis

Splenic hamartoma association?

Kasabach Meritt (Aneima, thrombocytopenia, Consumptive coagulopathy). Klippel-Trenaunay-Weber (Cutaneous hemangiomas, varicose veins, extremity hypertrophy). Note that these are usually associated with phleboliths

Splenic hemangiomas associated with what?

Can be subcapsular (Most common) or intraparenchymal (Irregular shape)

Splenic hematomas?

Wedge shaped peripheral nonehnacement. Heterogeneous mass like appearance can also be seen.

Splenic infarct appearance?

Rare focal collection of immune cells and asscoiated inflammatory exudate, of unclear etiology

Splenic inflammatory pseudotumor?

Can only be seen on a contrast study where it appears as a linear or branching area of decreased attenuation.

Splenic laceration?

Splenomegaly is most common. Multiple splenic nodules in 1/3 of Gaucher patients.

Splenic manifestations of Gauchers?

Splenomegaly...often associated with lymphadenopathy or hepatomegaly

Splenic presentation of sarcoidosis?

Injury to intima and media, only contained by adventitia. High chance of rupture without treatment.

Splenic pseudoaneurysm?

- occurs in pancreatitis - causes isolated gastric varices

Splenic vein thrombosis - when can it occur? - what can it cause?

Narrowing of the gastrojejunostomy stoma may occur in 10% of patients leading to dilatation of the pouch and distal esophogus.

Stomal stenosis?

Gaucher's disease. Amyloidosis. Hemochromatosis. Niemann-Pick disease.

Storage disease associated with splenomegaly?

Atresia (jejunum, ileum > duodenum). Jejunoileal stenosis. Enteric duplication cyst. Malrotation. Meckel diverticula. Diverticula. Small bowel obstruction. Small bowel hernias. Adhesions. Adynamic ileus.

Structural abnormalities of the small intestine?

Upper GI with water soluble contrast

Study of choice if post operative leak is suspected?

Pericholecystic abscess

Subacute gb perf?

Rokitansky-Aschoff sinuses of gallbladder

Submucosal glands in esophogus analagous to what?

Segmental continous thickening of affected colon in a vascular distribution with rectal sparing.

Suggestive CT findings of ischemic colitis?

2,4,8,7 (L to R)

Superior segments?

Two prior episodes. Fistula.

Surgical indications for diverticulitis?

Heller myotomy- Incision of the lower esophageal muscle fibers

Surgical treatment of achalasia?

Klippel-Trenaunay-Weber syndrome.

Syndrome of generalized angiomatosis?

False! - although OCPs may promote their growth

T/F: FNH are related to use of birth control pills.

FALSE!

T/F: FNH is related to OCP use

True

T/F: Patient's with AD polycystic kidney disease will also have cysts in the liver

True

T/F: lower rectal cancer have the highest recurrence rate

Primary Hemachromatosis - AR disorder seen in whites affecting parenchymal cells of liver, pancreas (diabetes), and heart (dilated cardiomyopathy), and skin (bronzing) - Liver that is hyperdense on NECT and markedly hypointense on T2WI or in-phase GRE MR

T1 in phase, Dx?

Hepatic Adenoma - benign, uncommon neoplasm seen in young women with high estrogen environment, including steatosis and oral contraceptive use. Anabolic steroids, diabetes, and glycogen storage disease are other causes - features often seen include hypervascularity, fat, hemorrhage, and encapsulation - will not take up gadoxetate (eovist) - usually cold on TcSC

T1 in, T1 in, T2, CE-MRI, CE-CT Dx?

Primary Hemachromatosis - AR disorder seen in whites affecting parenchymal cells of liver, pancreas (diabetes), and heart (dilated cardiomyopathy), and skin (bronzing) - Liver that is hyperdense on NECT and markedly hypointense on T2WI or in-phase GRE MR

T2, Dx?

Secondary Hemochromatosis - Iron overload disorder in which there is structural and functional impairment of involved organs due to increased iron intake, transfusions, etc. affecting Affects RES: Liver, spleen, nodes - Liver, spleen, and nodes are hyperdense on NECT and markedly hypointense on T2WI or in-phase GRE MR

T2, Dx?

Globus.

Term for sensation of a lump in the throat?

- IBD - Infection (bacterial, TB) - Lymphoma = Ischemia = Mets

Terminal ileal wall thickening

Nonpropulsive contraction that does not result in esophageal clearing. Usually in elderly. Not normal but not necissarily clinically significant.

Tertiary contraction wave?

Nonpropulsive contractions of muscularis propria seen as indentations at the margins of the esophagus which occur locally or over large segments.

Tertiary contraction waves?

Are not

The majority of liver mets are/are not hypervascular?

Carcinoid tumor secreting serotonin.

The substance secreted by this tumor causes an intense desmoplastic response, producing mesentery fibrosis, with tethering and kinging of small bowel?

Inflammatory gastritis

Thickened gastric folds?

Glucagonoma.

Third most common pancreatic endocrine tumor?

A- Muscular. B- Mucosal. C- Diaphrgmatic impressoin.

Three anatomic rings of the distal esophogus?

Most common is surgical defect in mesentery of the transverse colon associated with a retrocolic roux limb. Then Petersons space- between mesentery of the roux limb and the transverse mesocolon. Then the mesenteric dfect created by the jejunojejunostomy.

Three locations for RYGB associated hernias?

Small bowel mesentery. Transverse mesocolon. Sigmoid mesentery.

Three true mesenteries?

Killian's dehisence.

Through what does a Zenker's diverticulum protrude?

4-6 weeks

Timeline for evolution of pseudocyst?

Acute radiation esophogitis 1-4 wks after exposure. Strictures 4-8 months later.

Timeline of radiation induced esophageal injury?

Causes: - UC - C. diff - entamoeba histolytica Buzzword: "loss of haustra" Avoid barium enema because of the risk of rupture

Toxic Megacolon: - causes (3) - buzzword - what imaging study should you avoid

Traction of adjacent structures, typically from tuberculous mediastinal adenopathy. Very rare

Traction diverticula?

Broad category of herniation through defects in any of the three true meseneteries (Small bowel mesentery, transverse mesocolon, sigmoid mesentery)

Transmesenteric hernia?

Mesentery to transverse colon- connect posterior transverse colon to posterior abdominal wall

Transverse mesocolon?

Colectomy

Treatment for FAP?

Partial hepatectomy. Orthotopic liver transplant. Percutaneous ablation. Transcatheter embolization.

Treatment for HCC?

ursodexycholic acid

Treatment for PBC

Emergent cholecystectomy or cholecystostomy

Treatment for gangrenous cholecystitis?

Antibiotics for bacterial overgrowth and prokinetic drugs such as erythromycin or octreotide for bowel motility

Treatment for scleroderma of small bowel?

Endoscopic dilatation.

Treatment for stomal stenosis?

Conservative, resolves as edema and hematoma resolve

Treatment of SBO s/p RYGB?

Cricopharyngeal myotomy and diverticulopexy or diverticulectomy

Treatment of Zenker diverticulum?

Usually resected due to high hemorrhage risk

Treatment of adenoma?

Abx and fluid resuscitation- Endoscopic biliary intervention may be necessary if conservative management fails.

Treatment of ascending cholangitis?

Steroids.

Treatment of autoimmunce pancreatitis?

Emergent cholecystectomy or cholecystostomy. If not a good surgical candidate can be conservative

Treatment of emphysematous cholecystitis?

Anti inflammatories

Treatment of epiploic appendigitis?

Phlebotomy.

Treatment of hemochromatosis?

Iron chelators

Treatment of hemosiderosis?

Surgical and hyperthermic intraperitoneal chemotherapy lavage.

Treatment of pseudomyxoma peritonei?

Perc drainage in addition to abx

Treatment of splenic abscess?

Charcot Triad- Abdominal pain. Fever. Jaundice

Triad of ascending cholangitis?

Requires clinical symptoms of dysphagia.

True Schatski ring?

In addition to polyps also get CNS tumors like gliomas and medulloblastomas

Turcot syndrome?

Medulloblastoma. Glioblastoma multiforme. Family polyposis.

Turcot syndrome?

Diabetes. Progressive systemic sclerosis.

Two common causes of gastroparesis?

Organoaxial. Mesenteroaxial.

Two types of gastric volvulus?

Extrahepatic dilatation of the CBD.

Type I Choledochal cyst?

Extrahepatic saccular dilatation.

Type II Choledochal cyst?

Dilatation of intraduodenal bile duct

Type III Choledochal cyst?

Multiple dilated segments.

Type IV Choledochal cyst?

Carolis disease. Saccular dilatation of the intrahepatic bile ducts- may be segmental or diffuse.

Type V Choledochal cyst?

R sided colitis in immunocompromised patients. Treat with broad spectrum antibiotics and antifungals

Typhlitis?

Diffuse sausage shaped enlargement of the entire pancreas. Can be focal though mimicking a pancreatic mass.

Typical imaging of autoimmune pancreatitis?

Appears cystic but has internal flow

U/S of splenic lymphoma?

Splenic microhemorrhages- Hypointense on GRE (often w Ca2++ - sideroblastic, sarcoid, granumolas in ddx)

US of spleen, Dx?

rectum - with a retrograde progresion

Ulcerative colitis (UC) involves the _______ 95% of the time; - what is the progression of UC

Vascular encasement (SMA). Direct invasion of adjacent organs. Liver metastasis. Adenopathy. Ascites (peritoneal spread).

Unresectable pancreatic cancer factors?

Encasement (>180 circ) of SMA. Mets. Extensive venous invasion.

Unresectable pancreatic tumors?

Varicoid carcinoma of the esophagus.

Unusual variant of esophageal carcinoma that spreads submucosally producing thickened folds?

80

Up to ____ percent of carcinoids spread to the mesentery?

Distal esophogus. Portal HTN.

Uphill varices?

Usually seen as focal circumferential constriction near the GE junction, almost always associated with a hiatal hernia. Usually if symptomatic it won't allow passage of a 12 mm tablet.

Upper GI of Schatski ring?

Malignant gastric ulcer - located within lumen - nodular/irregular edges

Upper GI study: Carmen meniscus sign = ________

Cricopharyngeus muscle. C5-C6. Demarcation between pharynx superiorly and the cervical esophogus.

Upper esophageal sphincter?

Upstream: blood that has NOT yet passed through stenosis Downstream: blood that has passed area of stenosis

Upstream vs downstream in stenosis: definitions

Well circumscribed heterogeneously enhancing mass.

Usual appearance of splenic inflammatory pseudotumor?

Vertebral. Anal atresia. Cardiac. Tracheoesaphageal fistula/esophageal atresia. Renal agenesis/dysplasia. Limb.

VACTERL congenital anomaly mnemonic?

Secrete vasoactive intestinal peptide. WDHA (Watery Diarrhea, Hypokalemia, Achlorhydria). Variable malignancy.

VIPoma facts?

Varices change in size and shape with peristalsis. However, if thrombosed, they may mimic a tumor

Varices vs mass?

Arterial bleeding- Erosion into splenic artery. Pseudoaneurysm- Splenic artery. Venous thrombosis- Splenic vein leading to PVH

Vascular complications of pancreatitis?

Destruction of post sinusoidal venules with patent hepatic veins.

Veno-occlusive disease is what?

Less severe form of achalasia with repetitive nonpropulsive contractions.

Vigorous achalasia?

Mesenteric vein thrombosis

Weird complication of diverticulitis that i hadn't before learned?

Hereditary nonpolyposis syndrome (Lynch syndrome) "They're lynching EVERYONE, EVERYWHERE!!!"

What Polyposis Syndrome: - DNA mismatch repair - cancer everywhere in everything

Turcots Syndrome "Turcots sounds like turban -- worn on the head, so get brain tumors (gliomas and medulloblastomas)

What Polyposis Syndrome: - FAP - Gliomas - Medulloblastomas

gardner syndrome "Desmoids sprouting up everywhere like a Gardener"

What Polyposis Syndrome: - FAP (hyperplastic Stomach, Adenomatous bowl polyps) - desmoid tumors - osteomas - Papillary thyroid carcinoma

50% present as children. 50% present as adults.

What age groups are symptomatic in annulary pancreas?

Specialized mesenteries which attach to the stomach- DO NOT connect to posterior abdominal wall

What are greater and lesser omentums?

Killian-Jamieson diverticula.

What are lateral diverticula of the pharyngoesophageal junction termed?

VIPoma and Somatostatinoma- Poor prognosis

What are other pancreatic endocrine tumors and what is their prognosis?

- squaring of the folds - skip lesions - proud loops - cobblestoning - pseudopolyps - filiform - pseudodiverticula - string sign

What are some buzzwords for crohns disease? (8)

Mucinous cystic neoplasm and SPEN

What are the only pancreatic tumors with a capsule?

Axial torsion. Bascule (folding of cecum on right colon without significant twisting).

What are the two categories of cecal volvulus?

Diffuse bowel wall thickening and ascites are less common.

What are uncommon findings in celiac which is unique?

Surgeon may misidentify common duct as cystic duct- may cause inadvertant common duct ligation

What bad thing can happen with low insertion of the cystic duct?

E coli. CMV. C Difficile

What bugs typically cause pancolitis?

Pancreatitis. Peptic Ulcer Disease. Duodenal Obstruction.

What can annular pancreas in an adult cause?

Secondary candidiasis or aspiration pneumonia.

What can scleroderma of the esophogus lead to?

Breast

What cancer mets are often isoattenuating on the portal venous phase?

Increased intraluminal pressure, leading to gb wall ischemia.

What causes gangrenous cholecystitis?

Transmural inflamation with destruction of ganglion cells (myenteric plexus).

What causes the colonic dilation in toxic megacolon?

Rapid weight loss. Immobilization. Wearing a body cast. Decreased peristalsis. Drugs.

What conditions can lead to superior mesenteric artery syndrome?

Crohn's disease. Certain infections. Radiation therapy. Ischemia.

What conditions may cause focal strictures of the small bowel?

Most types of colitis. Laxative abuse. Scleroderma.

What conditions may result in loss of haustral folds?

Posteriorly.

What direction does a Zenker protrude?

Scleroderma. Crohn's disease. Ischemia.

What disorders cause wide-mouth diverticula (pseudosacculations) in the colon?

Network of blood vessels and lymphatics, sandwiched between the peritoneal layers.

What do the mesenteries consist of?

Gastric acid resulting in Zollinger-Ellison syndrome.

What does gastrinoma secreate and cause?

Lack of peristalsis in distal 2/3 due to smooth muscle atrophy and fibrosis.

What does scleroderma do to the esophogus?

It doesn't cause duct dilatation or tail atrophy.

What does serous cystadeoma not cause, which is unlike pancreatic adeno?

Zigzagging transition zone between squamous epithilium to columnar.

What does the Z-line represent?

Steroids.

What drug is associated with pneumatosis of the bowel?

Obesity. Steroids.

What else can cause fatty atrophy of pancreas?

Chronic esophagitis and scarring- leading to a smoothly tapered stricture above the GE junction.

What happens after chronic reflux?

Bowel can herniate through a mesenteric defect named Landzert's fossa, which is behind the ascending (4th duodenum)

What happens in Left paraduodenal hernia?

Pigment stone formation, biliary stasis, and cholangitis.

What happens in recurrent pyogenic cholangitis?

Evaluate for presence of aortic atheroscloertic diseaes or a L atrial thrombus.

What if arterial thromboembolic disease is suspected?

Look for atherosclerosis of the mesenteric vessels.

What if chronic arterial stenosis is suspected?

Yersinia, Salmonella, TB.

What infectious etiologies typically affect the R colon?

Caroli disease plus hepatic fibrosis

What is Caroli syndrome?

Infection with Tropheryma whippelii, manifesting in GI tract as malabrosption and abdominal pain. May cause arthralgias and skin pigmentation.

What is Whipple disease?

- gastric fundus wrapped around the lower end of the esophagus and stitched in place Indications: - Hiatal Hernia - Reflux

What is a Nissen fundoplication? Indications (2)?

Barium trapped in a pharyngeal contraction wave

What is a pseudo-Zenker diverticulum?

Iron rich regenerative or dysplastic nodule. Hypo on T1 and T2*. Hyper on CT. Rarely if ever malignant

What is a siderotic nodule?

Heterotopic pancreas in the gastric submucosa. Its susceptible to same pancreatic diseases.

What is an ectopic pancreatic rest?

This can happen anywhere below the diaphragm and should always be considered in diff for a cystic structure in patient with hx of pancreatitis.

What is an extrapancreatic pseudocyst?

Hepatic congestion from heart failure, constrictive pericarditis, or R sided valvular disease, ultimately leading to cirrhosis.

What is cardiac hepatopathy?

Choledochal cysts do communicate with the biliary tree

What is different between choledocal cysts and biliary hamartomas?

Focal pancreatitis between head of pancreas, duodenum, and common bile duct.

What is groove pancreatitis?

Excess iron is unable to be stored in the RES, so the spleen and bone marrow aren't affected.

What is hemochromatosis?

Calcifications in the distribution of the pancreatic duct

What is pathognomonic for chronic pancreacitis?

Hyperplastic NOT premalignant polyps

What is present in stomach in FAP?

Inflammation and destruction of smaller bile ducts compared to PSC.

What is primary biliary cirrhosis?

Hemosiderosis leads to it. RES can't handle any more iron. Hepatocytes then store the iron.

What is secondary hemochromatosis and what leads to it?

T2 hyperintense ductules and venules- Delayed enhancement.

What is the central scar really in FNH?

Distal ileum.

What is the most common location of Burkitt's lymphoma in North America?

Hypervascular- Very unique among cystic pancreatic tumors

What is unique about serous cystadenoma of the pancreas?

Heavy T2 weighting

What kind of sequences primarily image the biliary tree?

Hemangioma, peripheral to central enhancement over time.

What liver lesion exhibitis cetripetal opacification?

Fibrolamellar HCC. Hepatoblastoma. Intrahepatic cholangiocarcinoma. Metastases.

What liver malignancies may calcify?

Pancreatic ductal adenocarcinoma

What makes up 80-90% of all pancretic tumors?

Spindle cell tumors (GISTs, leiomyoma, leiomyosarcoma, leiomyoblastoma). Neurofibromas. Lymphomas.

What neoplasms of the stomach grow exophytically?

Most commonly it is transverse colon

What part of bowel can be involved in pancreatitis?

Tropheryma Wipplei

What pathogen causes whipples

10-20%

What percentage of HCCs are hypoenhancing?

75% of PSC patients have UC. Only 4-5% of UC patients have PSC.

What percentage of PSC patients have UC? Vice versa?

Peutz-Jeghers

What polyposis syndrome: - Hamartomas - Mucocutaneous pigmentation - Small and large bowel CA - Pancreatic cancer - GYN cancer

Cowden's syndrome "COWden's gets breast cancer, where milk comes from"

What polyposis syndrome: - hamartomas - BREAST CA - thyroid cancer - Lhermitte-dulcose (posterior fossa, noncancerous brain tumor)

Cronkite-Canada Syndrome

What polyposis syndrome: - hamartomas - stomach, small bowel, colon, ectodermal stuff (skin, hair, nails)

Juvenile Polyposis

What polyposis syndrome: - hamartomas in kids

Rectum- Dual blood suplly, superior rectal artery along with middle/inferior rectal arteries.

What portion of colon is almost never affected by ischemia?

Scleroderma. SLE. Dermatomyositis. Asthma. COPD. CF.

What pulmonary and collagen vascular diseases can cause pneumatosis of the bowel?

Portal vein.

What separates superior segments from inferior segments?

48-72 hours after onset of symptoms.

What timeline is best for eval of panc necrosis?

Mucocele. Mucinous cystadenoma. Myoglobulosis.

What tumors of the appendix can product pseudomyxoma peritonei?

- elevates - moves anteriorly

What two anatomic things happen to the larynx when you swallow?

type 2

What type of choledochal cyst? - diverticulum of CBD

type 1

What type of choledochoal cyst? - Focal dilatation of the CBD

3

What type of choledochoal cyst? choledochocele

4

What type of choledochoal cyst? intra and extrahepatic dilation

Diabetes.

What underlying condition do patients with emphysematous cholecystitis most likely have?

Vitamin B12 from bacterial overgrowth.

What vitamin deficiency may occur with small bowel diverticula?

In suspected enterovesical fistula, urine is collected, spun, and radiographed for dectection of barium.

What's the Bourne test?

Fistula tract connects two mucosal lined structures. Sinus tract ends blindly or in a cavity without normal mucosa.

What's the difference between a fistula and a sinus tract?

Hypervascular so in the late arterial phase.

When are pancreatic neuroendocrine tumors best seen?

Multiple and more commonly located in the duodenum than the pancreas

When associated with MEN-1, describe gastrinomas?

Surgery for consumptive thrombocytopenia (not enough spleen was resected because didn't get splenule). May be mistaken for a lymph node or mass if in an unusual location. Intrapancreatic splenule may be mistaken for a hypervascular pancreatic mass.

When can splenules be clinically significant?

Early due to symptoms of hypoglycemia.

When do insulinomas present?

Within 2 years of gastric bypass.

When do internal hernias usually present?

Only important if the patient is a right hepatic lobe liver doner as they will need to be anastamosed separately in the patient.

When is an aberrant right posterior duct significant?

20-25 seconds

When is arterial phase?

With corticosteroid enemas

When is it possible for rectum to appear normal with involvement of more prox small bowel in UC?

70 seconds

When is portal venous phase of enhancement?

10 days after surgery

When is postoperative leak normally diagnosed?

Desmoid.

When mesenteric fibromatosis occurs in a round shape this is called?

8mmHg

When portal venous pressure exceeds hepatic venous pressure by ___ = portal venous HTN

When larger than 3 cm, mural nodule, or associated dilation of the pancreatic duct to greater than 10 mm

When should an IPMN be resected?

Usually just above GE junction

Where are peptic ulcers?

Distal esophogus, gastric pouch, or blind ending jejunal limb. Rare from the distal jejunojenostomy.

Where do leaks normally arise from?

Posterior abdominal wall.

Where do mesenteries connect?

Mid esophogus above the metaplastic transition. Higher than peptic ulcer because adenamotous tissue is acid resistant.

Where does a barret esophogus stricture usually happen?

Terminal ileum, mimicking chron

Where to yersinia and tb happen in small bowel?

Transverse colon (most non-dependent).

Which colon segment is most commonly involved in toxic megacolon?.

Non-hyperfunctioning. They don't present with the endocrine symptoms so they get bigger.

Which type of pancreatic neuroendocrine tumors are larger at diagnosis?

Describes clinical symptoms of insulinoma. Hypoglycemia, clinical symtoms of hypoglycemia with resolution after admin of glucose

Whipple Triad

Low attenuation lyhmph nodes similar to cavitating mesenteric lymph node syndrome.

Whipple diseae and lymph nodes?

Insulinoma => hypoglycemia, clinical sxs of hypoglycemia, alleviation of sxs with administration of glucose

Whipple triad

Young women

Who gets FNH?

Middle aged women

Who gets PBC?

Kids

Who gets diagnosed with splenic lymphangioma?

Older males. Grandfather tumor. (These tumors have the greatest age and sex variability of all the cystic pancreatic neoplasms)

Who gets intraductal papillary mucinous neoplasm?

Middle aged women- Mother tumor.

Who gets mucinous cystic neoplasm?

Older women- pelvic floor laxity

Who gets obturator hernia?

Young women and children- Daughter tumor.

Who gets solid and papillary epithelial neoplasm (SPEN)?

Immunocompromised patients

Who gets splenic bacterial abscesses?

MIddle aged women

Who typically gets biliary cysteadenoma?

Elderly diabetic.

Who typically gets emphysematous cholecystitis?

Young men who are heavy drinkers

Who usually gets groove pancreatitis?

There is an increased risk of cholangiocarcinoma, may be as high as 25%

Why are choledocal cysts resected?

Hypoalbuminemia and resultant edema.

Why does GB wall get thick in cirrhosis?

Splenectomy increases risk for sepsis dramatically

Why leave spleen in after splenic trauma?

Older- Emboli. Younger- Thrombosis (Patients with hematologic disease)

Why to older and younger patients get splenic infarcts?

AR

Wilson disease genetic pattern?

Hyperattenuating on CT with multiple nodules, eventually leading to hepatomegaly and cirrhosis

Wilson disease in liver?

xanthomalike foam cells- focal or diffuse inflammation- nodular - c/b fistula or abscess, a/w bile excretion from Rokitansky. presents as acute chole. in elderly female

Xanthogranulomatous Cholecystitis

ZE features elevated gastrin and a paradoxical increase in gastric after secretin administration

ZE paradoxical effect?

Esophageal diverticulum caused by failure of the cricopharyngeus muscle to relax, leading to elevated hypopharyngeal pressure

Zenker diverticulum?

phyrigian cap

___ = GB folds on itself

axial (sliding)

____ = hiatal hernia that has GE junction above the diaphragm

paraesophageal (rolling)

____ = hiatal hernia that has GE junction below the diaphragm

chronic dialysis patients

____ patients may get severely thickened duodenal folds which can mimic the appearance of pancreatitis on barium

Budd Chiari Syndrome

_____ = "pregnant woman" (or person in hypercoagulable state) with hepatic vein thrombosis

Portal Hypertensive Colopathy - worse on the right

_____ = edematous bowel (mimics colitis) caused by increased resistance in the liver to the portal circulation which results in colonic venous stasis

traction diverticulum - triangular shape - mid esophagus - empties when esophagus is collapsed - true diverticulum

_____ = esophageal diverticulum occur from scarring (granulomatous disease or TB)

Krukenberg Tumor - stomach and colon cancer most common

_____ = metastatic spread to the ovary - most common causes (2)

Ogilvie Syndrome

_____ = occurs after serious medical conditions and in nursing home patients

Fibrolamellar HCC - "central scar"

_____ = subtype of HCC in younger patients without cirrhosis and normal AFP --- what is the buzzword

Schatzki - "Shatz-B" - Ring

______ = a narrowed (and symptomatic) B ring

Kaposi Sarcoma

______ = biliary duct dilation with hypoechoic periportal infiltration in a patient with AIDS

Passive Congestion: - refluxed contrast into hepatic veins - increased portal venous pulsatility - nutmeg liver

______ = caused by stasis of blood within the liver due to compromise of hepatic drainage --- 3 imaging findings of this condition?

Cystic Fibrosis

______ = condition where ispissated secretions causes obstruction of the proximal pancreatic duct

Hepatic veno-occlusive disease

______ = form of Budd chiari that occurs from occlusion of the small hepatic venules

Toxic megacolon

______ = gaseous dilation of the transverse colon on upright films and right and left colon on supine films

Internal hernia

______ = herniation of viscera, through the peritoneum or mesentery

Cholangiocarcinoma

______ = infiltrative hepatic mass with enhancing soft tissue on delayed phases and "capsular retraction"

esophageal varices

______ = linear (often serpentine), esophageal filling defects causing a scalloped contour

Primary Biliary Cirrhosis (PBC)

______ = middle aged woman with "normal extrahepatic ducts" and "antimitochondrial antibodies"

Papilloma

______ = most common benign mucosal lesion of the esophagus

mucinous cystadenoma

______ = most common mucinous tumor of the appendix

Meckel's diverticulum

______ = persistent piece of the omphalomesenteric duct

Gossypiboma - abscess mimic

______ = retained cotton product or surgical sponge that can elicit an inflammatory response

Gamma Gandy Bodies (Siderotic Nodules) - associated with portal HTN - Gradient is the most sensitive sequence

______ = small foci of hemorrhage in the splenic parenchyma - associated with what condition? - most sensitive sequence for looking at these?

epiphrenic - considered pulsion types

_______ = diverticulum occur above the diaphragm, usually on the right

Choledocal cyst

_______ = imaging of dilated biliary ducts and a history of repeated cholangitis

Linitis plastica

_______ = leather bottle stomach

Chagas Disease

_______ = looks identical to achalasia, found in the jungle, and caused by a parasite that's by transmitted by a fly that paralyzes the esophagus

Splenosis - use sulfur colloid scan (or heat treated RBC) to tell the difference

_______ occurs post trauma where a smashed spleen implants and then recruits blood supply - how to tell that it is spleen and not omental mets or something?

Cricopharyngeus - around C5/C6

________ = border between the pharynx and cervical esophagus

Celiac sprue

________ = small bowel malabsorption of gluten

Pseudoachalasia

_________ = appearance of achalasia, but secondary to a cancer at the GE junction

duct of luschka

accessory cystic duct =

- Splenomegaly - retroperitoneal lymph nodes

additional findings in pseudowhipples (2)

pancreatoduodenectomy and duodenojejunal anastomosis (pylorus spared)

alternative to whipple procedure

lane hamilton syndrome

another name for idiopathic pulmonary hemosiderosis

cecal bascule

anterior folding of the cecum w/o twisting = ________

PBC

antimitochondrial antibodies associated with

NO! - because the organ lacks a capsule

are using resistive indices helpful in pancreatic transplants? why?

- glycogen storage disease (von Gierke) - liver adenomatosis

association with multiple hepatic adenomas (2)

- klippel-trenanay-weber - blue rubber bleb

associations of rectal cavernous hemangioma

- abnormalities of intestinal rotation - sets up spleen for torsion/infarction

associations of wandering spleen (2)

- PCKD - medullary sponge kidney

associations with Caroli's disease (2)

- bacterial overgrowth - malabsorption

associations with jejunal diverticulosis (2)

70 second (portal venous phase) - to be able to tell if the spleen has a laceration

at what timing is a trauma scan CT done?

Primary biliary cirrhosis

autoimmune disease resulting in destruction of small and medium INTRAhepatic bile ducts (not extrahepatic)

Chronic Pancreatitis has both!! - autoimmune has no ductal dilation and no calcifications

autoimmune pancreatitis vs chronic pancreatitis: - which one has ductal dilation - which one has ductal calcifications

Klebsiella

bacterial cause for single hepatic abscess

colonic TB

barium study: "coned shaped cecum" that involves the TI = _______

entamoeba histolytica

barium study: "coned shaped cecum" that spares the TI = ______

- polysplenia - interrupted IVC with azygos continuation - one fissure in right lung - biliary atresia associated with dorsal pancreatic agenesis

bilateral "left sidedness" - 4 features

Zollinger Ellison Syndrome - increased gastric acid output and ulcer formation

buzzword "jejunal ulcer" = _____

"comet tail artifact"

buzzword appearance for adenomyomatosis of GB

colon ovary pancreas "COP caught the calcs"

calcified mets to liver

yes, the well differentiated ones will retain OATP function

can HCC ever look bright on delayed Eovist?

yes - because it comes out with the whipple procedure anyway

can you have surgical resection with pancreatic cancer involvement of GDA?

Chordoma Extra-adrenla pheo GIST "Carney's Eat Garbage" - carnival dudes

carney's triad

Budd Chiari

cause of absent hepatic vein flow

PSC

cause of cirrhosis which results in dilated intrahepatic bile ducts

- Jamaica (alkaloid bush tea) - Radiation - Chemo

causes for hepatic veno-occlusive disease (3)

- right sided CHF - tricuspid regurgitation - cirrhosis w/ vascular AP shunting

causes of PV pulsatility (3)

- thrombosis - tumor invasion - stagnant flow (terrible portal HTN)

causes of absent flow in portal vein (3)

- passive congestion (CHF, portal HTN, splenic vein thrombosis) - lymphoma - leukemia - gauchers

causes of big spleen (4)

- cirrhosis - hepatic venous outflow obstruction

causes of decreased hepatic vein pulsatility (2)

- adjacent inflammatory process (pancreatitis/cholecystitis) - fistula formation with Crohns - Chronic dialysis patients

causes of duodenal inflammatory disease (3)

- tricuspid regurgitation - right sided CHF - increase RA pressure

causes of increased hepatic vein pulsatility (2)

portal HTN

causes of reversed flow in PV (1)

- sickle cell - Post radiation - post thorotrast - malabsorption syndrome (UC > Crohns)

causes of small spleen (4)

celiac sprue

cavitary lymph nodes with low density

Iron --> leads to iron deficiency anemia

celiac sprue causes malabsorption of _______

1- fusiform dilation of the CBD 2- diverticulum 3- choledochocele (at ampulla) 4- BOTH intra and extra hepatic 5- Caroli disease - only intra hepatic

choledocal cyst types (5)

cholesterolosis - not hypertrophied wall and diverticula like in adenomyomatosis

cholesterol and triglyceride deposition in the lamina propria of the GB =

Primary Sclerosing Cholangitis (PSC)

cirrhotic liver pattern is "central regenerative hypertophy" = ______

Salmonella --- "Salmonella, Splenic abscess" -- especially in sickle cell or trauma

classic bug for splenic abscess

"crossing the pylorus" "no obstruction"

classic description of gastric lymphoma

increased risk of pancreatitis

clinical relevance of pancreatic divisum

healed peptic ulcer of the duodenal bulb

clover leaf sign

squamous carcinoma - think HPV

colonic cancer that occasionally arises in the anus

eosinophilic esophagitis

concentric rings on esophagram "ringed esophagus" = ______

- VHL - PKD - CF

conditions associated with simple pancreatic cysts (3)

extrahepatic malignancy advanced cardiac disease advanced pulmonary disease active substance abuse *portal HTN is NOT a true contraindication

contraindications to liver transplant (4) - what is NOT a true contraindication

UC

crohns vs UC: increased risk for cancer

superficial colitis cystica

cystic dilatation of the mucous glands throughout entire colon that are small

...

cystic neuroendocrine

Colonic CMV

deep ulcerations in immunosuppressed patients in colon

1 - initial normal waveform 2 - no diastolic flow 3 - dampening sytolic flow, tardus parvus, RI <0.5 4 - loss of hepatic waveform

describe waveforms for syndrome of impending thrombosis after liver transplant - 4 stages

hyadatid cyst - Well defined hypoattenuating mass on CT with a charactersitic floating membrane or daughter cyst - May have peripheral calcification.

diagnosis?

HCC: - older people with cirrhosis - rarely calcifies and high AFP Fibrolamellar HCC: - young people without cirrhosis - sometimes calcifies with normal AFP

difference between HCC and Fibrolamellar HCC: - age population - cirrhosis - calcifies? - AFP level

Ephiphrenic on right Para-esophageal on left

difference between epiphrenic and paraesophageal hernia?

Extracellular: - stay outside the cell and are blood flow dependent (like CT contrast) - cause T1 shortening Hepatocyte specific: - taken up by normal hepatocytes and excreted into the bile - use when proving an FNH, bile leaks, for picking new lesions after baseline

difference between hepatocyte specific vs extracellular gadolinium agents? uses of both?

Dysplastic nodule is T1 bright while regenerative nodule is T1 dark - both do not enhance

difference between regenerative and dysplastic hepatic nodule

Organoaxial: - greater curvature flips over the lesser curvature - antrum stays in the same place Mesenteroaxial: - twisting over the mesentery - antrum moves up

difference in anatomy between organoaxial and mesenteroaxial gastric volvulus

late findings of chronic pancreatitis

dilatation and beading of the pancreatic duct with calcifications =

moulage sign (seen in celiacs) - looks like a tube with wax poured in it

dilated bowel with effaced folds is what sign?

primary sclerosing cholangitis

dilated intrahepatic bile ducts is very rare in all forms of cirrhosis EXCEPT _______

esophageal pseudodiverticulosis

dilated submucosal glands with multiple small outpouchings = _______

Intestinal lymphangiectasia

dilation of the intestinal and serosal lymphatic channels = _______

primary sclerosing cholangitis (mainly INTRAhepatic ducts)

disease causing progressive inflammation leading to multifocal strictures of intra and extrahepatic bile ducts

NO

do GIST tumors get lymph node enlargement typically?

NO!

do UC patients get large LNs

No! they get "squeezed out" - lesions in a cirrhotic liver should be treated with more suspicion

do cirrhotic livers have normal incidental masses

NO (but esopahgeal webs do increase risk for cancer)

do duodenal webs increase risk for adenocarcinoma

cervical esophagus

do killian jamieson diverticulums occur in the hypopharynx or cervical esophagus

Yes! - because they are pre-malignant

do mucinous cystic neoplasms need to be removed? why?

hypopharynx - above the cricopharyngeus

do zenkers occur in the hypopharynx or cervical esophagus

No - UC is continuous

does UC have skip lesions?

NO (only gastric ulcers) - if you see multiple duodenal ulcers, think Zollinger Ellison syndrome

does aspirin therapy also cause duodenal ulcers

gastric fundus "MEN are superior (on top) so MENetrier's disease involves the TOP (fundus) of the stomach"

does menetrier's disease involve the gastric fundus or antrum?

yes!

does portal hypertensive colopathy get better after hepatic transplant

NO!

does serous cystadenoma of pancreas communicate w/ pancreatic duct

they usually do NOT obstruct, even with massive circumfrential involvement

does small bowel lymphoma commonly cause obstruction?

- main hepatic veins and IVC patent - Portal waveforms will be abnormal (pulsatile)

doppler findings of hepatic veno-occlusive disease

ductal obstruction (T2), cystic changes (necrosis), delayed enhancement of tumor and affected upstream pancreas

ductal adenocarcinoma

- loss of T1 signal (pancreas is normally the brightest T1 structure in the body) - delayed enhancement - dilated side branches

early signs of chronic pancreatitis (3)

pancreatic adenocarcinoma

enlarged gallbladder with painless jaundice, highly suspicious for _______

Lymphoma Normal spleen- hypo to liver on CT, Iso to slightly hyper on US

enlarged spleen, Dx?

- medial to femoral vein - posterior to inguinal ligament - (usually on the right)

femoral hernias are (medial/lateral) to femoral vein and (anterior/posterior) to inguinal ligament

FNH - FL HCC is T2 Dark

fibrolamellar HCC vs FNH: which one is T2 Bright

FNH - fibrolamellar HCC scar does NOT enhance

fibrolamellar HCC vs FNH: both have central scars, but which one has enhancement of the scar?

FL HCC

fibrolamellar HCC vs FNH: calcifies sometimes

FL HCC

fibrolamellar HCC vs FNH: gallium avid

"A" - atrial contraction

first part of triphasic waveform of hepatic veins

Gastric Carcinoma! - outlet obstruction - focal mass - distal stomach - invade beyond serosa

gastric carcinoma vs gastric lymphoma: - more likely to cause outlet obstruction - more likely to be a focal mass - more likely to be in distal stomach - more likely to extend beyond the serosa

mesenteroaxial - stomach twists along short axis - displacement of antrum above the GE junction - can lead to ischemia and obstruction

gastric volvlus in kids

organoaxial - rotation of the stomach along its long axis - antrum rotates anterosuperiorly - fundus rotates posteroinferiorly

gastric volvlus in old laides w/ paraesophageal hernias

portal HTN is most common cause pre - portal vein thrombosis intra - cirrhosis post - right sided heart failure, tricuspid regurgitation, budd-chiari

groups of causes of slow flow in the portal vein (<15cm/s)? - specific causes ?

T1-Hypo, T2- hyper, +C- interuptted peripheral nodular enhancement

hepatic hemangioma

renal melanoma carcinoid choriocarcinoma thyroid islet cell (*hypervascular tumors)

hepatic hyperechoic mets on US (6)

colon lung pancreas

hepatic hypoechoic mets on US

First waveforms are normal D deeper than S: - tricupsid regurgitation (mild to moderate) - B and C on image Fused A, S, and V waveforms with large retrograde D pulse - severe tricuspid regurgitation - D on image

hepatic vein triphasic waveform diagnosis: - D wave is deeper than S

right heart failure - "s" closer to "r" on alphabet, so it is deeper

hepatic vein triphasic waveform diagnosis: - S wave deeper than D

Littre hernia

hernia containing a meckel diverticulum

richter hernia

hernia containing one wall bowel and DO NOT obstruct

Amyand hernia

hernia with appendix in it

barretts

high stricture + associated HH

fatty liver

hot liver on xenon

- asymptomatic (incidental) - big enough, they present as an infant with breathing problems/dysphagia

how can esophageal duplication cysts present? (2)

must biopsy the central scar! - if not, results will show normal hepatocytes

how do you biopsy an FNH

V1 - V2 / V1 - V1 is peak (systolic) - V2 is lower (diastolic)

how do you calculate the resistive index

kids: duodenal obstruction adults: pancreatitis

how does annular pancreas typically present: - in kids? - in adults?

eats up the right sided heart valves (tricuspid and pulmonic valves) causing regurgitation

how does carcinoid affect the heart

- regenerative nodule: T2 dark - HCC: T2 bright regenerative nodule degenerates to HCC

how does regenerative nodule look on T2? HCC?

steroids

how is eosinophilic esophagitis treated?

total mesorectal excision

how is rectal cancer treated?

3-4 weeks

how soon after pancreatitis starts does infection begin to occur?

Budd Chiari - Hepatic venous outflow obstruction - can be thrombotic or non-thrombotic

hypercoagulable, Dx?

menetrier's diease

idiopathic gastropathy w/ rugal thickening

water soluble contrast - safe in the belly

if you are worried about a leak, what do you use for the exam?

-rapid systolic upstroke -0.5 to 0.7 RI -hepatic artery <200 cm/sec

in NORMAL liver transplant US: -describe the systolic upstroke -normal RI -normal hepatic artery velocity?

between the stomach and pancreas, to the left of the liagment of treitz

in left paraduoenal hernia, describe the location of the "sac of bowel"

hepatic artery

in patients with hepatofugal (away from liver) flow in the main portal vein, the shunted blood comes from the _________

Cirrhosis Chronic Liver Disease - Hep B/C - hemochromatosis - alpha 1 antitrypsin

in what settings does HCC typically occur? (2)

celiac sprue regional enteritis

increased risk of small bowel adeno with which two conditions?

bowel wall lymphoma

increased risk of which cancer with celiac sprue

viral hepatitis

infection buzzword: "starry sky" liver

- giardia - strongyloides

infections that like duodenum and proximal small bowel (2)

- TB - Yersinia

infections that like the TI (2)

retroperitoneal bleed

injury to "bare area" of liver results in intra or retro - peritoneal bleed

5 - aka carolis

intrahepatic dilation only

NO! - RI can be low/normal/high in cirrhosis

is RI useful in cirrhosis or predicting how severe it is?

can be primary (MALT) or secondary to systemic lymphoma

is gastric lymphoma primary or secondary

pancreas is a retroperitoneal structure

is the pancrease intraperitoneal or retroperitoneal

splenic vein thrombus - can be from pancreatic cancer or pancreatitis

isolated gastric varices, think about ______________

Chronic Budd Chiari - Caudate hypertrophy and atrophy of peripheral liver with prominent regenerative nodules - can get large caudate collateral vessels - can develop large multiacinar regenerative nodules called focal nodular regenerative hyperplasia which have a halo sign (shown here) or just avid homogenous enhancement persisting into venous phase

jaundice and portal HTN, Dx?

Chronic Budd Chiari - Caudate hypertrophy and atrophy of peripheral liver with prominent regenerative nodules - can get large caudate collateral vessels (shown here) - can develop large multiacinar regenerative nodules called focal nodular regenerative hyperplasia which have a halo sign or just avid homogenous enhancement persisting into venous phase

jaundice and portal HTN, Dx?

shwachman-diamond syndrome

kid w/ diarhrea, short stature (metaphyseal chondroplasia) and eczema

CMV and HIV

large flat esophageal ulcer DDx (2)

BREAST or lung mets

linitis plastica can be mets from which cancers

granulomas and adhesions

long term sequela of barium peritonitis (2)

whipples

low density (near fat) enlarged LNs

hemochromatosis

low signal on in phase and higher signal on out of phase of liver - opposite of fatty liver

Wirsung

major pancreatic duct is called

Hepatic Adenoma - benign, uncommon neoplasm seen in young women with high estrogen environment, including steatosis and oral contraceptive use. Anabolic steroids, diabetes, and glycogen storage disease are other causes - features often seen include hypervascularity, fat, hemorrhage, and encapsulation - will not take up gadoxetate (eovist) - usually cold on TcSC

male w glycogen storage disease Dx?

true diverticulum (congenital)

meckel's diverticulum- true or false diverticulum

Trousseau's syndrome - seen with pancreatic adenocarcinoma

migratory thoombophlebitis also called what? seen with what?

santorini (S - superior, S- smaller aka minor)

minor pancreatic duct =

hemangioma

most common benign liver neoplasm = _______

Hemangioma - contrast uptake and delayed washout

most common benign neoplasm in the spleen - imaging characteristic?

Adenoma

most common benign tumor of the colon and rectum = ________

right posterior segmental branch emptying into the left hepatic duct

most common biliary variant of the liver = ________

EtOH cirrhosis

most common cause of hepatic portal hypertension in the USA

Schistosomiasis

most common cause of hepatic portal hypertension worldwide

posttraumatic "pseduocysts" - no epithelial lining - occur from infarction, infection, hemorrhage, extension from pancreatic pseudocyst

most common cystic lesion in the spleen - occur secondary to what? (4)

stomach

most common extranodal site for Non-Hodgkin lymphoma

posterior fundus of stomach - look for the normal adrenal gland

most common location for a gastric diverticulum

Right hepatic lobe

most common location for hepatic adenoma

retrovesical space - flow of ascites dictates the location of implants

most common location for peritoneal carcinomatosis

closed loop obstruction (often with strangulation)

most common manifestation of internal hernia

GIST

most common mesenchymal tumor of the GI tract

pancreatic lipomatosis - most common cause in kids: CF - most common cause in adults: burger king (cushing, chronic steroid, HLD)

most common pathologic condition involving the pancreas = _______ - causes in kids/adults

slipped nissen - telescoping of GE junction through the wrap

most common reason for recurrent reflux

H. pylori

most common risk factor for gastric carcinoma

gastrinoma - 2nd most common overall

most common type of islet cell tumor associated with MEN syndrome

Insulinoma

most common type of neuroendocrine tumor in pancreas

replaced right hepatic - arising from the SMA

most common vascular variant to liver = _______

ascaris induced pancreatits

most commonly implicated parasite in pancreatitis

short esphagus

most comon reason for slipped nissen

pancreatic ca

most crucial complication of chronic pancreatitis

IPMN - intraductal papillary mucinous neoplasm

mucin producing neoplasm arising from duct epithelium in pancreas

few larger cysts degree of wall thickening, nodularity

mucinous nonneoplastic cysts mucinous ctadenoma mucinous cystadenocarcinoma

McKittrick-Wheelock syndrome

mucous diarrhea --> severe fluid and electrolyte depletion Dx?

Herpes - Herpes has a Halo

multiple and small ulcers with halo of edema

glycogen acanthosis - mimic of candidiasis

multiple esophageal nodules in asymptomatic old person

E. Coli

multiple hepatic abscesses

tropic pancreatitis

multiple large calculi within a dilated pancreatic duct in a young patient =

serous cystadenoma

multiple small cysts around a calcified central scar in the pancreatic head = ____

littoral cell angioma

multiple small hypoattenating foci on late portal phase and hemosiderin on spleen MRI + clinical hypersplenism

- lymphoma - met (melanoma)

multiple target signs in small bowel (2)

peliosis - usually liver - can explode spontaneously

mutliple blood filled cyst like spaces in a solid organ = ____? - what organ does it typically affect - complication?

diverticulosis with circular muscle hypertrophy. cogwheel narrowing of the sigmoid lumen. hypertrophy of the colonic circular muscle layer and shortening of the longitudinal layer (TAENIA) cause irregular narrowing of the colonic lumen.

myochosis

Rokitansy-Aschoff sinuses

name of the mucosal diverticula that get filled in adenomyomatosis

von-hippel lindau MEN-1

neuroendocrine tumor associations

MRCP or ERCP

next step if suspected pancreatic ductal injury

colonic ileus or Ogalvie syndrome - marked diffuse dilation of the large bowel without a discrete transition point - associated with adynamic ileus and abdominal distention - Descending colon is often less distended than more proximal colon

no obstrucing lesion, Dx?

pancreas > liver > spleen - pancreas and liver are T1 bright - spleen is T2 bright

normal MRI signal characteristics: T1 bright in descending order

like a big watery lymph node - T2 bright - T1 dark - bright on diffusion

normal appearance of spleen: - T1 - T2 - diffusion

flow: towards the liver (antegrade/hepatopedal) velocity: 20-40 cm/s

normal flow and velocity in the portal vein

wandering spleen

normal spleen that wanders off and is in an unexpected location = ______

Mirizzi syndrome

obstruction of common heaptic duct due to impacted cystic duct stone =

A S D

order of letters of triphasic wavform

MIBG Octreotide

other scans to help assist with diagnosis of carcinoid

- donor SMA (supplies head) - donor splenic artery (supplies body/tail)

pancreas transplant gets arterial inflow from which vessels (2)

the bowel - older transplant, via the bladder

pancreas transplant has exocrine drainage via what?

- donor portal vein - receipient SMV

pancreas transplant has venous drainage from what vessels (2)

budd chiari

rapid onset ascites might make you think about _____

Solid Pseudopapillary Tumor of the Pancreas

rare, low grade malignant tumor in young black or asian females in the pancreatic tail

ligamentum venosum (where the replaced right hepatic artery runs)

remnant of ductus venosus

Patients less than 40 yo. Sickle cell trait > disease. Poor prognosis, < 4 months. hypovascular. more often in males (2:1). May extend from the medulla to the cortex and perinephric space in advanced cases.

renal medullary carcinoma

adenomyomatosis

results from hyperplasia of the wall with formation of intramural mucosal diverticula which become filled with cholesterol crystals in the GB =

barretts

retiuclar mucosal pattern in the esophagus =

strangulation - they do NOT obstruct

richter hernias are at increased risk for obstruction or strangulation?

right

right or left sided heterotaxy: apslenia

left

right or left sided heterotaxy: azygous continuation of the IVC

left

right or left sided heterotaxy: biliary atresia

right

right or left sided heterotaxy: cardiac malformations

left

right or left sided heterotaxy: polpysplenia

right

right or left sided heterotaxy: reversed aorta/IVC

- Primary sclerosing cholangitis (most common) - recurrent pyogenic cholangitis - clonorchis sensesis (liver fluke) - HIV - Hep B/C - EtOH - thorotrast

risk factors for cholangiocarcinoma (7) - most common in western countries

Colitis infection: cdiff, also CMV, Salmonella, Campylobacter CDiff- stop other abc- give vanco or metro Ischemia and UC Radiation, lymphoma, typhlitis (TB, Yersenia, Amebosis)

s/p infection, Dx?

Focal Nodular Hyperplasia (FNH)

second most common benign liver neoplasm

Epidermoid cyst ("true" cyst) - grow slowly - can cause symptoms if they are big enough

second most common cystic lesion in the spleen

lipoma

second most common tumor in the colon = _____

kasabach merritt

sequestion of platelets from giant cavernous hemangioma =

cluster of small cysts (T2 hyper) w central low T2 (calcified scar). T1 enhanced septations on delay- fibrous. oligocystic variant- looks like mucinous bengn older

serous cystadenoma

VHL

serous cystadenoma is associated with what disease

candidiasis

shaggy esophagus with discrete plaque-like lesions on barium

crohns disease involvement of the gastric antrum

significance of rams horn deformity?

- GIST - primary adenocarcinoma - lymphoma - ectopic pancreatic rest - met (melanoma)

single target sign in small bowel (5)

carcinoid

small bowel loop separation WITH tethering (1)

Non-hodgkin

small bowel lymphoma is usually hodgkins or non-hodgkins?

cancer - probably mets (i.e. melanoma)

small bowel with nodules of larger or varying sizes (1)

lymphoid hyperplasia

small bowel with uniform (2-4mm) nodules (1)

T2 bright solid, cystic degen/necrosis

solid pseudopapillary tumors

Hepatic adenoma

solitary hepatic lesion seen in a female on OCPs = ______

hepatic adenoma

solitary hepatic lesion seen in a male on anabolic steroids =______

- Meckel's diverticulitis (mimic appendicitis) - GI Bleed (use Tc petechnetate scan) - lead point for intussusception - cause obstruction

some complications of Meckels (4)

Occur in: - trauma - pancreatitis - higher incidence in women of child bearing age who have had two or more pregnancies (more likely to rupture)

splenic artery pseudoaneurysm - in what two main settings can they occur? - in what population are they more common and higher risk

z line - endoscopy only finding

squamocolumnar junction corresponds to which line

Gardner's syndrome

syndrome associated with increased risk of periamupllary carcinoma

- HNPCC - BRCA mutation - ataxia- telangiectasia - peutz-jeghers

syndrome associations with pancreatic adenocarcinoma (4)

esophageal spasm - "nutcracker esophagus" requires manometric findings (>180 mmHg)

tertiary contractions with pain = _______

visceral peritoneum

the liver is covered by _______

low resistance - so blood flow wont stop during diastole

things that need blood all the time have (high/low) resistance waveforms

Hydatid or Echniococcal cysts - caused by Echinococcus granulosus paraside - hydatid cyst: spherical mother cyst that contains smaller daughter cysts - "water lily" sign

third most common cystic lesion in the spleen (most common worldwide) - caused by? - characteristic finding on imaging

Feline esophagus

transient, fine transverse folds which course the esophagus = ______

Bacterial cholangitis - can cause hepatic abscess

triad of "jaundice, fever, and right upper quadrant pain"

- splenomegaly - RA - neutropenia "SANTA wears FELT"

triad of feltys syndrome

CA 19-9

tumor marker for pancreatic adenocarcinoma?

- Risk factor for esophageal and hypophyarngeal carcinoma - Plummer Vinson Syndrome: --- Fe deficiency anemia, dysphagia, thyroid issues, "spoon shaped nails"

two associations of esophageal webs

- acute rejection (#1 cause) - splenic vein thrombosis

two causes for pancreatic graft failure - what is the number one cause?

- barium peritonitis - barium intravasation

two main complications of barium

- EtOH - gallstones

two most common causes of chronic pancreatitis

ligamentum teres (round ligament)

umbilical vein runs in the ______

biliary cystadenoma

uncommon benign cystic neoplasm of the liver in middle aged women that can cause pain or jaundice = ______

mucinous cystic neoplasm "MUCINOUS is the MOTHER"

unilocular cystic lesion in the pancreatic body/tail with peripheral calcifications , with cysts >2cm = ______

Benign gastric ulcer - behind the expected lumen - sharp contour - lesser curvature of stomach

upper GI study: Hampton's Line

esophageal duplication cyst

water density cyst in the posterior mediastinum = ______

low cystic duct insertion

what anatomy increases risk of Mirizzi syndrome?

separation of the loops caused by infiltration of the mesentery, increase in mesenteric fat and enlarged LNs

what are "proud loops"

- delayed enhancement - peripheral biliary dilation - capsular retraction

what are 3 key findings of cholangiocarcinoma

1. defect of transverse mesolcolon 2. mesenteric defect at the enteroenterostomy 3. behind the roux limb mesentery placed in retrocolic or antecolic position***

what are 3 potential sites for internal hernias after roux en y gastric bypass

- vit deficiencies - tropical sprue - terminal leukemia - uremia - thyroid toxicosis - mercury poisoning

what are associations of superficial colitis cystica (6)

- not a true polyp: enlarged papillary fronds filled w/ lipid filled macrophages

what are cholesterol polpys of GB

- uphill varices - bottom half of esophagus

what are esophageal varices caused by portal HTN called? where do they occur?

Cholesterol (75%) - pigmented (25%)

what are most gallstones made of

islands of hyperplastic mucosa

what are pseduopolpys in crohns

- ERCP - Medications (valproic acid) - Trauma (kids) - Pancreatic cancer - Infectious

what are some additional causes of acute pancreatitis (5)

cholecystis AIDS PSC hepatitis Heart Failure Cirrhosis

what are some causes of gallbadder wall thickening (6)

- chronic inflammation - multiple transfusions

what are some causes of secondary hemochromatosis (2)

- fistula formation - abscess - gallstones - fatty liver - sacroiliitis

what are some complications of crohn's disease (5)

- sigmoid - cecal - cecal bascule

what are the 3 types of colonic volvulus

- Insulinoma - Gastrinoma - Non-functional

what are the 3 types of neuroendocrine pancreatic tumors

- IVC - portal vein - CBD - Hepatic artery

what are the 4 connections in liver transplantation

- downhill varices - top half of esophagus

what are the esophageal varices caused by SVC obstruction called? where do they occur?

No necrosis: < 4 weeks: acute peripancreatic fluid collection > 4 weeks - pseudocyst Necrosis: < 4 weeks - acute necrotic collection > 4 weeks - walled off necrosis

what are the fluid collections in pancreatitis called (and timing)

- Fibrosis (decreased T1 and T2) - Fatty replacement (increased T1)

what are the two main changes seen within the pancreas in patients with CF

- gallstones - EtOH

what are the two most common etiologies of acute pancreatitis

- increased risk for diabetes (most of your beta cells are in the tail) - associated with polysplenia

what are the two things you need to know about dorsal pancreatic agenesis

- Carcinoma (95%) - Lymphoma

what are the two types of gastric cancer?

- Celiac - Crohns - AIDS - SLE

what conditions have higher risk for small bowel lymphoma (4)

hot

what do FNH look like on sulfur colloid

tapering of the gastric antrum which causes the stomach to look like a ram's horn

what does "ram's horn deformity" refer to

discontinuous involvement of the bowel

what does "skip lesions" mean

irregular appearance to bowel wall caused by longitudinal and transverse ulcers separated by areas of edema

what does cobblestoning mean in crohn's

tardus - slowed systolic upstroke parvus - decreased systolic velocity

what does tardus parvus mean - each word

atrophy

what happens to spleen in celiacs

ends up in systemic circulation and kills via PE ~ 50% of time

what happens with barium intravasation

Cryptosporidium

what infection classically causes AIDS cholangiopathy

post-inflammatory polpys - long and worm like

what is "filiform" in crohns

early manifestation from obstructive lymphedema - Crohn's buzzword

what is "squaring of the folds" in crohns disease mean

Pulmonary artery aneurysms

what is a "classic" complication of Behcets

Hiatal hernia that is fixed/non-reducible and greater than 5 cm

what is a "short esophagus"

0.5-0.7

what is a normal RI in the liver

can perforate ---> psudomyxoma peritonei

what is a possible complication of mucinous cystadenoma

swollen left supraclavicular node

what is a virchow node

- uncommon complication of post billroth 2 - obstruction of the afferent limb (adhesions, intestinal hernia) --> build up of biliary, pancreatic, and intestinal secretions

what is afferent loop syndrome after billroth 2 surgery

esophageal stricture - seen in 90% of cases

what is an association with pseudodiverticulosis

Ogilvie Syndrome

what is another name for colonic pseudo-obstruction

- serotonin syndrome: flushing and diarrhea - when met to liver

what is carcinoid syndrome? when do you develop carcinoid syndrome?

portal hypertensive gastropathy - thickened gastric wall

what is cause of upper GI bleed in patients with Portal HTN but no varices?

- a bunch of serpiginous vessels in the porta hepatis which may reconstitute the right and left portal veins - caused by portal vein thrombus

what is cavernous transformation of the liver? what causes it?

non-rotated small bowel with normally rotated large bowel

what is classic setting for right sided paraduodenal hernais

problems swallowing secondary to compression from an aberrant right subclavian artery

what is dysphagia lusoria

chronic reflux esophagitis

what is esophageal pseudodiverticulosis caused by? (1)

seen in sigmoid volvulus - all 3 dense lines converge towards site of obstruction

what is frimann dahl's sign

increased risk for gallbladder ca (5x higher risk)

what is importance of Mirizzi syndrome

markedly enlarged pancreas with fatty replacement

what is lipomatous pseudohypertrophy of the pancreas

idiopathic pulmonary hemosiderosis = lane hamilton syndrome

what is lung association with celiac sprue

emergently drained - it can rupture into the pericardium

what is management of amebic abscess in the left lobe? why?

omental surface can get implanted by cancer and become thick - "posterior displacement of the bowel from the anterior abdominal wall"

what is omental seeding/caking

Fe deficiency anemia dysphagia thyroid issues spoon shaped nails

what is plummer vinson syndrome

chronic constipation in a nursing home patient - "sigmOLD volvulus" in an old person

what is predisposing factor for sigmoid volvulus?

- gelatinous ascites - Causes: ruptured mucocele (usually appendix), intraperitoneal spread of a mucinous neoplasm

what is pseudomyxoma peritonei? what causes it?

- direct connection to the IVC through its own hepatic veins - supplied by branches of both the right and left portal veins

what is special about the blood supply of the caudate lobe (segment 1) of the liver (2)

superior - grynfeltt-lesshaft inferior - petit

what is superior lumbar hernia called? inferior?

marked narrowing of the terminal ileum - from a combination of edema, spasm, and fibrosis

what is the "string-sign" in crohns

- scarring from peptic ulcers - granulomatous disease (crohns, sarcoid, TB, syphilis) - scirrhous carcinoma

what is the DDx for ram's horn deformity of the stomach (3)

stenosis (more commonly than thrombosis)

what is the MC cause for parvus tardus waveform in liver transplant

narrowing of the TI

what is the Stierlin sign of TB of bowel

"onion sign" - layering within cystic mass

what is the buzzword finding for mucinous cystadenoma on ultrasound

stage 3 - adventitia Stage 4 - invasion into adjacent structures

what is the difference between stage 3 vs stage 4 esophageal cancer

similar to hemangioma - progressive fill in the solid portions

what is the enhancement pattern of solid pseudopapillary tumor of the pancreas

biopsy

what is the gold standard for diagnosing celiac sprue

SMA and celiac axis involvement - if involved, will make the cancer unresectable

what is the key to staging of pancreatic adenocarcinoma

fistula formation - to anything: other piece of bowel, bladder, uterus, vagina

what is the main long term complication of diverticulitis

pancreatic divisum - the main portion of the pancreas is drained by the minor papilla

what is the most common anatomic variant in the human pancreas? - what is the variant anatomy?

inflammatory psuedocyst - from acute or chronic pancreatitis

what is the most common cystic lesion in the pancreas?

benign stricture - post traumatic from surgery or biliary intervention

what is the most common etiology for jaundice

complete fatty replacement of the pancreas

what is the most common imaging finding in adult CF

stomach

what is the most common location for sarcoid in the GI tract

melanoma

what is the most common met to small bowel

distal appendix - second is terminal ileum

what is the most common primary location for carcinoid

hepatic angiosarcoma

what is the most common primary sarcoma of the liver

histoplasmosis (with multiple round calcifications) - splenic TB can have similar appearance - Brucellosis (solitary large calc)

what is the most common radiologically detected splenic infection - some other infections (2)

spleen

what is the most common solid organ injured in trauma

type 1

what is the most common type of choledochal cyst

paraduodenal hernia - most commonly left

what is the most common type of internal hernia

OATP bile uptake transporter - takes in Eovist - decrease in number with hepatocarcinogenesis

what is the transporter than moves biliary contrast agents into cells

collis gastroplasty - AKA lengthening of a fundoplication

what is the treatment of a short esophagus

AFP will be elevated

what is the tumor marker for HCC

6mm - originally described by ultrasound

what is the typical measurement still used for appendicitis

give IV fluids to reduce risk fo hypovolemic shock

what is treatment for barium peritonitis

splenomegaly

what is typically the only sign of the spleen in sarcoidosis

patients after bone marrow transplant

what kind of patients get GVHD

ilecocecal region

what part of bowel does Behcets MC affect

MAI infection

what pathogen causes pseudowhipples

younger person - associated with "long mesentery

what patient population gets cecal volvulus

increased intraabdominal pressure - ascites, COPD - usually asymptomatic

what predisposes to obturator hernias

Balthazar score - outcome depends on the degree of pancreatic necrosis

what score is used to determine prognosis in pancreatitis? - what main finding do the outcome depend on

<60 degrees

what should doppler angle be

Dermatitis Herpetiformis

what skin problem do celiac sprue patients get

adenocarcinoma - if squamous, think HPV (STD)

what subtype of cancer is rectal cancer typically

hepatic artery - hepatic artery is king in the transplanted liver

what supplies hepatic ducts after liver transplant

NF-1

what systemic disease is the association with GIST

Treated breast cancer mets - can cause contour changes that look like cirrhosis

what treated cancer can cause Pseudo Cirrhosis?

villous adenoma

what type of adenoma carries highest risk for becoming cancer

adenocarcinoma in the gastric remnant

what type of cancer risk exists in patients with old school peptic ulcer surgeries

hamartomas

what types of polpys do they get in juvenile polpys?

IMV and left colic artery

what vessels does left paraduodenal hernia contain

> 1cm - most likely not cholesterol (adenoma/papilloma)

when are GB polpys removed

primary peritoneal mesothelioma - occurs 30-40 years after initial asbestosis exposure

when asbestos involves the peritoneal surface, it is called ____

Stage T3 - they will need chemo/rads prior to surgery

when can rectal cancer not be immediately surgically excised?

when > 5cm - can bleed and rarely turn into cancer

when do you resect hepatic adenomas

2-3cm

when do you treat splenic artery aneurysm

- elderly patients - patients with h. pylori

when does areae gastricae enlarge (2)

first 6 weeks

when does splenic vein thrombosis in pancreatic transplant occur

3-10 days after transplant

when does thrombosis occur in liver transplant

profunda colitis cystica

when the cystic dilation of the mucous glands is large within the pelvic colon and rectum, called ____

Anterior and Lateral

where do Killian-Jamieson diverticula occur (front/side/back)?

cervical esophagus, near cricopharyngeus

where do esophageal webs occur

behind SMA, below the transverse segment of the duodenum at the "fossa of waldeyer"

where do right sided paraduodenal hernias occur

Semilunar line - through the transversus abdominus aponeurosis - close to level of arcuate line

where do spigelian hernias occur

genitals and mouth

where do ulcers of behcets typically occur

- actual buzzword is "Jejunal Ulcer" - duodenal bulb is most common location

where does Zollinger-Ellison favor

Mid esophagus

where does a traction diverticulum occur in the esophagus (superior/mid/distal)

duodenum

where does adenocarcinoma most commonly occur in small bowel

antrum

where does crohns favor in the stomach

antrum

where does h. pylori favor in the stomach

"crosses the pylorus"

where does lymphoma favor in the stomach

- Aortic arch level - distal esophagus

where does medication induced esophagitis usually occur (2)

fundus

where does menetrier's favor in stomach

duodenum and proximal jejunum

where does whipples affect

- the duodenjujunal junction --- aka fossa of landzert

where is exact location of left paraduodenal hernias

- porta hepatis (bare area) - gallbladder fossa

where is the liver not covered by visceral peritoneum (2)

right hepatic lobe (segments 5-8)

which lobe of the liver is commonly transplanted in adults?

D: infection in necrosis

which of the following is the most "salient"? a. hemorrhage in the pancreas b. necrosis in the pancreas c. fluid collection d. infection in necrosis

Billroth 1

which surgery?

Billroth II

which surgery?

peutz-jeghers cowdens cronkite-canada juvenile polpys

which syndromes get hamartomas (4)

gardner turcots

which two syndromes get FAP

Traction - pulsion diverticula will not empty because they contain no muscle in their walls

which type of diverticulum will empty? Traction or Pulsion?

Paraesophageal

which types of HH (axial/paraesophageal) has a higher rate of incarceration?

Pseudowhipples - CD4 < 100

whipples appearance in an AIDS patient

women of child bearing age - NOT associated with prior asbestos exposure

who gets cystic peritoneal mesothelioma

old ladies

who gets femoral and obturator hernias

CF patients - wall thickening of the proximal colon as a complication of enzyme replacement therapy

who gets fibrosing colonospathy? and what is it?

- thorotrast exposure - NF - hemochromatosis - arsenic use - radiation - polyvinyl chloride exposure

who gets hepatic angiosarcomas (6)

AIDS cholangiopathy

who gets papillary stenosis

- women on OCPs - men on anabolic steroids - *AIDS - *renal transplant pts - Hodgkin lymphoma

who gets peliosis (5) (multiple randomly distributed blood-filled cavities throughout the liver. The size of the cavities usually ranges between a few mm to 3 cm in diameter)

- typically done for severe type 1 diabetes - usually with a renal transplant

why is pancreatic transplant typically performed? with what other organ?

eosinophilic esophagitis

young man with long history of dysphagia and atopia