RD GI formatted

Question 1

AUGUST 20111. Cancer felt on PR, MRI shows that the muscularis is intact with periaortic nodes. (exact recall) [also recalled as: Rectal cancer. Eccentric mass on MRI. Muscular layer intact. No perirectal LN. Para-aortic lymphadenopathy. No mets. Radiological staging:)

a. Stage I
b. Stage II
c. Stage IIIB
d. Stage IIIC
e. Stage IV

Answer 1

e. Stage IV

Radiology Jan 2010 (McMahon)“For rectal cancer, paraaortic nodes are nonregional, and spread to these nodes constitutes M1 (stage IV) disease (24).
Inguinal nodes also represent a nonregional site of nodal metastasis in these patients. This is associated with a very poor prognosis and is generally indicative of diffuse disease.”RG 2006

Question 2

2. 70yo man with previous Dukes C CRC (rectal carcinoma). Presents with presacral soft tissue mass on CT done 2 years after surgery, because of rising CEA. (No previous available to compare). Most appropriate imaging?
   a. PET-FDG
   b. MRI
   c. Surgical biopsy
   d. Percutaneous biopsy (CT-guided)
   e. Re-image with CT in 3 months

Answer 2

a. PET-FDG T if PET-CT
b. MRI T see below

Answer remains controversial (see below) – either A (PET, though needs PET-CT) or B.
If pure PET without CT correlate, then B MRI is best option. CEA = raised in 60-90% of CRC; also can be raised in breast, lung, gastric, pancreatic, bladder, medullary thyroid, etc. malignancies; also can be raised in smokers, PUD, IBD, pancreatitis, cirrhosis, biliary obstruction, etc.Radiology 2004 (Recurrence in patients with rectal carcinoma)
The diagnosis of pelvic recurrence and the differentiation of tumor recurrence and changes associated with previous surgery and/or radiation therapy in the pelvic region constitute a diagnostic challenge for CT, MR imaging, and PET (20–25). Most patients undergoing abdominoperineal resection develop a fibrotic mass in the presacral operative bed. Radiation therapy causes an inflammatory reaction in the pelvic tissues and induces thickening of the perirectal fascia; these changes may appear on CT images for many years and be indistinguishable from tumor recurrence (21).

PET/CT allowed us to differentiate a benign lesion from a tumorous presacral abnormality with a sensitivity of 100% and a specificity of 96%. PET/CT images also provided data that pertained to the involvement of pelvic structures; this information was clinically relevant in selecting an appropriate treatment approach.

AJR March 2010 vol. 194 no. 3 766-771FDG PET/CT has higher sensitivity than MDCT in the identification of sites of recurrent and metastatic disease in patients with colorectal cancer and an elevated CEA level. The two techniques appear to have similar specificity.

Detection of recurrent rectal cancer with CT, MRI and PET/CT – European Radiology 2007, Volume 17, Number 8, Pages 2044-2054
To date, CT is the preferred method for diagnosing local recurrence of CRC. MRI was the superior imaging method with a sensitivity of 91%, a specificity of 100%, and an overall accuracy of 95%. CT reached a sensitivity of 82%, a specificity of 50%, and an accuracy of 68%.MRI is one of the leading imaging modalities for detecting pelvic recurrence of CRC [40–43], in our opinion currently the best, due to its excellent soft-tissue resolution, providing detailed anatomic information. … the positive (PPV) and negative (NPV) predictive values were 87%, 86%, 48% and 98%, respectively.PET is an accurate modality for detecting pelvic recurrence in rectal cancer patients [45], and may have advantages over CT and MRI in differentiating scar from viable tumor. The sensitivity, specificity, overall accuracy, PPV, and NPV were 84%, 88%, 87%, 76% and 92%, respectively. In the study, PET/CT allowed to differentiate benign lesions from presacral recurrences with a sensitivity of 100% and a specificity of 96%.

Question 3

3. Young women (32 years). Barium swallow. Sliding hiatus hernia and stricture to 5mm over 2cm (LAS – narrowing at T6 level), nodular mucosal pattern. Most likely diagnosis:
   a. Barrett oesophagus
   b. Eosinophilic oesophagitis

Answer 3

a. Barrett oesophagus
A = Barrett oesophagus = T (Gore p55)
• Classic = mid-oesophageal stricture or ulcer or reticular pattern assoc/ w/ sliding hiatus hernia
• Innumerable tiny, barium-filled grooves or crevices adjacent to distal side of stricture

B = Eosinophilic oesophagitis = F (Gore p83)
• Segmental strictures in oesophagus
• Ringed oesophagus
• Diffuse oesophageal narrowing
• Abnormal motility with ↑ non-peristaltic contractions
• Primer – proximal or mid oesophagus

Question 4

4. 35 year old Asian (Chinese) woman with enlarged hypodense mesenteric lymph nodes on CT, thickening of the terminal ileum and caecum (LAS – hyperdense ascites). Most likely:
   a. TB
   b. Amoebiasis
   c. Crohn disease
   d. Lymphoma

Answer 4

a. TB

Question 5

5. Male patient post alcohol binge with blood-stained vomiting. Contrast leakage just above GOJ on barium swallow. Most likely complication of the examination:
   a. Mediastinal abscess
   b. Fibrosing mediastinitis
   c. Fistula
   d. Aspiration pneumonia
   e. Septicemia

Answer 5

b. Fibrosing mediastinitis a small theoretical risk, see below
5. Male patient post alcohol binge with blood-stained vomiting. Contrast leakage just above GOJ on barium swallow. Most likely complication of the examination:
a. Mediastinal abscess certainly a possibility, however wouldn’t be specifically caused by “the examination”
b. Fibrosing mediastinitis a small theoretical risk, see below
c. Fistula
d. Aspiration pneumonia
e. Septicemia

Barium:- granulomatous reaction- mediastinitis- mediastinal fibrosis- in lung : internet -> normally doesn’t not cause aspiration pneumonitis. However stays forever in lung Gastrograffin- aspiration pneumonitis- fatal respiratory failure
Omnipaque- water soluble- safer
A water-soluble contrast agent is generally used as the contrast medium of choice for the initial radiographic evaluation of patients with possible upper gastrointestinal perforation. Water-soluble contrast agents are recommended because they have no known deleterious effects on the neck, mediastinum, pleural cavity, or peritoneal cavities and are absorbed rapidly from these extraluminal spaces if a leak is present. Most authors therefore believe that the radiographic examination should be repeated immediately with barium if no leak is seen with a water-soluble contrast agent in patients with a possible esophageal perforation.Water-soluble contrast agents such as Gastroview are generally administered as the initial contrast medium for the detection of esophageal perforation because of a small theoretic risk that extravasated barium in the mediastinum may cause a granulomatous reaction with mediastinitis or mediastinal fibrosis, as previously shown in studies on laboratory cats.Because water-soluble contrast agents are hyperosmolar and can draw fluid into the lungs causing pulmonary edema if aspirated into the tracheobronchial tree [2–4], some investigators even recommend that barium be used as the initial contrast medium to rule out anastomotic leaks after esophagogastrectomy.

Question 6

6. Young woman with diarrhea for 3 months. Small bowel follow through. Jejunum dilated with crowded thin folds. Most likely diagnosis:
   a. Scleroderma
   b. Sprue (Coeliac)
   c. Crohn

Answer 6

a. Scleroderma

6. Young woman with diarrhea for 3 months. Small bowel follow through. Jejunum dilated with crowded thin folds. Most likely diagnosis:
   a. Scleroderma
   b. Sprue (Coeliac)
   c. Crohn

A = Scleroderma = T (Gore & Levine p304, Mayo ebook p226)
• Dilatation of duodenum & jejunum (Type I folds = thin, straight folds with dilated lumen)
• Prolonged SB transit time
• Hidebound bowel = bunching & crowding of SB folds with ↑ no. of folds (virtually pathognomonic of scleroderma)
• Pseudodiverticula/sacculationso Gore/Levine & Dahnert = mesenteric sideo Mayo GI = antimesenterico StatDx & Eisenberg = not specified which side!o Top 3 = antimesenteric

B = Coeliac = F (Gore p306)
• Classified as type I folds, but…
• Decreased number of folds in proximal jejunum, with jejunisation of ileum
• Finely reticular mucosal surface
• Look for cavitary nodes & lymphoma (T-cell)

C = Crohn = F (see above)

DDx for Type 1 folds = dilated lumen with thin (<3mm) straight folds “SOS”
• Sprue (coeliac disease)
• Obstruction (mechanical)
• Scleroderma
• Paralytic ileus
• Other – medications (morphine, atropine), vagotomy

Question 7

7. Man with small bowel follow through, thickening of terminal ileum, fistula

Answer 7

Crohn’s

Question 8

Woman with previous gastric surgery presents with vomiting. Tubular stomach with central narrowing. Stapples extending from LUQ to epigastrium. Most likely cause:

a. slipped band
b. sleeve gastrectomy
c. partial gastrectomy with anastomotic strictures
d. Bilroth 2 with afferent loop syndrome

Answer 8

b. Sleep gastrectomy

A = F = stomach distal to band should be normal

B = T = tubular stomach could be sleeve gastrectomy = narrow tube of residual stomach, the appearance of which has been likened to a “half-moon” or “banana” with a thin string-like lumen (Abdominal Imaging, 2011) – however if laparoscopic, no staples

C = unlikely

D = unlikely

Question 9

Patient transferred from elsewhere following unsuccessful resuscitation. Had massive duodenal bleed. All tubes have been removed. 2 ribbon shaped densities in RUQ. Most likely explanation is:

a. embolisation material
b. T-tub
c. Gossypiboma / textiloma
d. penrose drain

Answer 9

A = F
B = F
C = ?T = Gossypiboma or textiloma is the technical term for surgical complications resulting from foreign materials, such as a surgical sponge, accidentally left inside a patient's body *LW: favoured answer (AJL agrees, the stem says all drains are removed which presumably includes penrose drains)
D = ?T – can be tubular or ribbon-like (can’t find an x-ray of these though!)

Question 10

APRIL 201110. 42 female with known Peutz-Jegher syndrome presents with 3 weeks of nausea and vomiting. CT abdomen shows SBO secondary to intussusception. Which of the following statements is MOST correct?

a. SBO is most commonly caused by intussusception
b. Polyps are benign
c. Carcinoid is the most common cause of distal SBO
d. The most common site of lymphoma in the GIT is in the proximal jejunum
e. Peutz-Jegher is a benign polyposis

Answer 10

• *LJS edit: I would choose b as the most correct - the polyps are benign (hamartomas) but there is a 40% lifetime risk of malignancy, so it is not a benign condition**
• LW: agrees.

*AJL I disagree (on the answer not the underlying principle). The peutz jegher polyps are benign/hamartomatous (therefore a benign polyposis) however it is a stretch to say polyps are benign because some polyps are adenomatous (unrelated to PJ, just related to being a person). I think the problem is mostly question interpretation due to it being a recall.

Previous answer:
e. Peutz-Jegher is a benign polyposis T/F – benign hamartomatous polyps with smooth muscle core predominantly in SB, BUT increased risk of carcinoma in general (2-10% get GIT carcinoma, highest risk is breast Ca)

1. 42 female with known Peutz-Jegher syndrome presents with 3 weeks of nausea and vomiting. CT abdomen shows SBO secondary to intussusception. Which of the following statements is MOST correct?
   a. SBO is most commonly caused by intussusception F Postoperative adhesions cause the majority of small bowel obstructions.
   b. Polyps are benign T/F, but are premalignant. A polyp refers to a protuberance into the lumen from the normally flat mucosa. All adenomas are dysplastic.
   c. Carcinoid is the most common cause of distal SBO F – can cause SBO, but not most common cause.
   d. The most common site of lymphoma in the GIT is in the proximal jejunum F – stomach is most common site: stomach (55-60%) > small intestine (25-30%, esp. ileum) > proximal colon (10-15%) > distal colon (10%)&raquo_space; appendix & oesophagus (rarely involved)
   e. Peutz-Jegher is a benign polyposis T/F – benign hamartomatous polyps with smooth muscle core predominantly in SB, BUT increased risk of carcinoma in general (2-10% get GIT carcinoma, highest risk is breast Ca)

Peutz-Jegher syndrome (UTD)
• Gastrointestinal hamartomatous polyps are present in most patients with PJS. These polyps contain a proliferation of smooth muscle extending into the lamina propria in an arborization-like fashion; the overlying epithelium is normal.
• Up to 69 percent of patients experience an intussusception during their lifetime, most often in the small intestine
• The PJS is associated with an increased risk of gastrointestinal and nongastrointestinal malignancies

Question 11

11. Which best describes grade 5 perianal fistula?
    f. Intersphincteric fistula with abscess
    g. Linear Intersphincteric fistula
    h. Translevator
    i. Transphincter with abscess
    j. Transphincter without abscess

Answer 11

c. Translevator = grade 5.

Which best describes grade 5 perianal fissures?

a. Intersphincteric fistula with abscess = grade 2
b. Linear Intersphincteric fistula = grade 1
c. Translevator = grade 5
d. Transphincter with abscess = grade 4
e. Transphincter without abscess grade 3

Question 12

12. Rectal cancer, transmural thickening, ipsilateral peri rectal nodes, no mets, what stage.
    a. 1
    b. 2a
    c. 3b
    d. 3c
    e. 4

Answer 12

c. 3b True answer is stage 3a (if T2) or stage 3b (if T3)

Stage groupings
stage 0: Tis N0 M0

stage I: T1-2, N0 M0

stage IIa: T3, N0, M0
stage IIb: T4a, N0, M0IIc: T4b, N0, M0

stage IIIa: T1-2, N1, M0
Stage IIIb: T3-4, N1, M0
Stage IIIc: T3-4b, N2, M0

stage IV: any T, any N, M1

Question 13

13. Anal cancer, 2-5cm in size, unilateral internal iliac nodes, no distal mets, what stage.
    a. 1
    b. 2
    c. 3a
    d. 3b
    e. 4

Answer 13

**LJS - 3A

Primary tumour (T)TX: primary tumour cannot be assessedT0: no evidence of primary tumour

Tis: carcinoma in situ (Bowen disease, high-grade squamous intraepithelial lesion [HSIL], anal intraepithelial neoplasia II-III (AIN II-III)

T1: tumour 2 cm or less in greatest dimension

T2: tumour >2 cm but <5 cm in greatest dimension

T3: tumour >5 cm in greatest dimension

T4: tumour of any size invades adjacent organ(s), e.g. vagina, urethra, bladder (note that direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4)

Regional lymph nodes (N)
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in regional lymph nodes
N1a: metastases in inguinal, mesorectal, and/or internal iliac lymph nodes
N1b: metastases in external iliac lymph nodes
N1c: metastases in external iliac and in inguinal, mesorectal, and/or internal iliac lymph nodes

Distant metastasis (M)
Mx: distant metastasis cannot be assessed
M0: no distant metastasis
M1: distant metastasis

STAGE
1 - T1
2 - T2-3 
3a - T1-3 N1      - T4 N0
3b - T4 N1     - N2,3 
4 - m

Question 14

14. Barium follow through, extrinsic filling defect at D2, likely to represent?
    f. Pancreas divisium
    g. Annular pancreas
    h. Pancreatitis
    i. Ectopic pancreas

Answer 14

b. Annular pancreas – dorsal & ventral pancreatic tissues encircle & narrow the periampullary duodenum. If obstructed get double bubble sign. (Gore p693 / Mayo GI)Annular pancreas develops due to failure of ventral bud to rotate with duodenum, causing encasement of duodenum.

5. Barium follow through, extrinsic filling defect at D2, likely to represent?
   a. Pancreas divisium - usually no mass effect on duodenum
   b. Annular pancreas – dorsal & ventral pancreatic tissues encircle & narrow the periampullary duodenum. If obstructed get double bubble sign. (Gore p693 / Mayo GI)
   c. Pancreatitis – enlarged pancreatic head can widen the duodenal sweep (Gore p263)
   d. Ectopic pancreas – intramural or extramucosal broad-based, smooth lesion with central niche/umbilication

Question 15

15. Pregnancy and appendicitis (which is false?)
    a. Risk of perforation of appendix is equal in pregnant and non pregnant patients
    b. Decreased ultrasound sensitivity for appendicitis late in pregnancy (or “difficult to see in 3rd trimester because displacement)
    c. Most common need for emergency surgery besides obstetric cause
    d. US first line of imaging
    e. Higher rate of preterm labour & other complications

Answer 15

a. Risk of perforation of appendix is equal in pregnant and non pregnant patients F (High-Risk Pregnancy, James) An infected appendix appears more likely to rupture during pregnancy, esp. in 3rd trimester, possibly because of delay in diagnosis & intervention.6.

Pregnancy and appendicitis (which is false?)

a. Risk of perforation of appendix is equal in pregnant and non pregnant patients F (High-Risk Pregnancy, James) An infected appendix appears more likely to rupture during pregnancy, esp. in 3rd trimester, possibly because of delay in diagnosis & intervention.
b. Decreased ultrasound sensitivity for appendicitis late in pregnancy (or “difficult to see in 3rd trimester because displacement) T – UTD: the gravid uterus can interfere with performance of this technique, particularly in the third trimester, leading to a high negative laparotomy rate when ultrasound results are inconclusive [20,21]. There are no large series in pregnant women. In one small series, the appendix could not be visualized with ultrasound in 22 of 23 pregnant patients with suspected appendicitis
c. Most common need for emergency surgery besides obstetric cause T = Acute appendicitis is the most common general surgical problem encountered during pregnancy (UTD). Appendicitis is the most common cause of abdominal pain that requires emergency surgical treatment during pregnancy (Radiology 2006). Occurs at same frequency as in non-pregnant women.
d. US first line of imaging T
e. Higher rate of preterm labour & other complications T = Maternal morbidity following appendectomy is low except in patients in whom the appendix has perforated. In contrast, pregnancy related complications are frequent, particularly when surgery was performed in the first or second trimester. No pregnancy complications were observed in women who underwent appendectomy in the third trimester. (UTD).

Question 16

16. 75 year-old female with a Zenker diverticulum. What is the most common presentation:
    a. Halitosis
    b. Cachexia
    c. Dysphagia
    d. Chest infection
    e. Regurgitation of undigested foods.

Answer 16

c. Dysphagia T Present in 80-90% of patients (see article below).
All of these symptoms can/do occur.Diseases of the Esophagus (2008) 21, 1–8. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management.Although several symptoms may be present, 80–90% of patients complain of dysphagia. Regurgitation of undigested foods, halitosis, and hoarseness can also occur. Cervical borborygmi is almost pathognomonic of ZD. As the pouch enlarges, symptoms become more severe with resultant weight loss and malnutrition. As many as 30–40% of patients describe chronic cough and repeated episodes of aspiration, some with aspiration pneumonia. Symptoms may be present for weeks to several years.

Emedicine (Medscape):
The combination of the following symptoms is nearly pathognomonic for Zenker diverticulum:
• Dysphagia
• Regurgitation of undigested food hours after eating
• Sensation of food sticking in the throat
• Special maneuvers to dislodge food
• Coughing after eating
• Aspiration of organic material
• Unexplained weight loss
• Fetor ex ore
• Borborygmi in the neck
Symptoms may last from months to years.The most common life-threatening complication is aspiration. Other complications include massive bleeding from the mucosa or from fistulization into a major vessel, esophageal obstruction, and fistulization into the trachea. Squamous cell carcinoma (SCC) within Zenker diverticulum is extremely rare, occurring in 0.3% of Zenker diverticula worldwide.

Question 17

AUGUST 201017. 25yo Singaporian immigrant. RLQ pain. Fever. CT shows multiple 1cm areas of fat density with surrounding inflammatory change posterior to ascending colon. Most likely diagnosis:

i) Diverticulitis
ii) Pseudomonas colitis
iii) Crohns
iv) Epiploic appendagitis
v) Appendicitis

Answer 17

iv) Epiploic appendagitis – T - Usually left-sided, can be right-sided. At CT, a 1–4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation is considered to be diagnostic of epiploic appendagitis (RG 2000). However seems to be usually a single epiploic appendage affected (StatDx) & usually anterior to colon.or
i) Diverticulitis – T – Uncommon on the right, but higher incidence of right diverticulitis in Asians (AJR July 1998). Common conventional CT findings of acute diverticulitis are hazy infiltration of pericolic fat, focal thickening of the colonic wall, and diverticula (AJR 2000). Dahnert states usually solitary diverticulum.Group consensus was epiploic appendagitis, although tough one.

1) 25yo Singaporian immigrant. RLQ pain. Fever. CT shows multiple 1cm areas of fat density with surrounding inflammatory change posterior to ascending colon. Most likely diagnosis (SK / group consensus):
i) Diverticulitis – T – Uncommon on the right, but higher incidence of right diverticulitis in Asians (AJR July 1998). Common conventional CT findings of acute diverticulitis are hazy infiltration of pericolic fat, focal thickening of the colonic wall, and diverticula (AJR 2000). Dahnert states usually solitary diverticulum.
ii) Pseudomonas colitis - Relative paucity of pericolonic inflammation + marked colonic wall thickening differentiates PMC from other colitides (StatDx)
iii) Crohns Unlikely.
iv) Epiploic appendagitis – T - Usually left-sided, can be right-sided. At CT, a 1–4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation is considered to be diagnostic of epiploic appendagitis (RG 2000). However seems to be usually a single epiploic appendage affected (StatDx) & usually anterior to colon.
v) Appendicitis Possible

Question 18

18. 15yo Female. RLQ pain. Enlarged mesenteric nodes on US. Appendix not visualised. Most likely:
    i) Typhlitis
    ii) Crohn’s
    iii) Mesenteric adenitis
    iv) Diverticulitis
    v) Appendicitis

Answer 18

iii) Mesenteric adenitis

2) 15yo Female. RLQ pain. Enlarged mesenteric nodes on US. Appendix not visualised. Most likely:
i) Typhlitis
ii) Crohn’s
iii) Mesenteric adenitis
iv) Diverticulitis
v) Appendicitis

Quotes (various sources)
• Mesenteric adenitis is most common < 15 years old (StatDx Paeds) or < 25 years old (StatDx Abdo)
• Appendicitis is frequently associated with lymphadenopathy, most commonly in the mesentery of the right lower quadrant (RG 2005)
• The presence of enlarged lymph nodes in the mesentery of the right lower quadrant with a normal-appearing appendix may reflect mesenteric adenitis in the correct clinical setting (RG 2005)
• Dahnert – enlarged nodes in appendicitis immediately anterior to right psoas muscle, less numerous & smaller (but must visualize normal appendix to exclude!)

Question 19

19. 30yr old female has barium swallow. Shows 6cm long symmetrical narrowing of the distal oesophagus with 1cm of distal dilatation at level of the vestibule. Likely cause:
    i) Achalasia
    ii) Barrett’s
    iii) Ca
    iv) Scleroderma
    v) Cricopharyngeal spasm

Answer 19

ii) Barrett’s – T/F Stricture classically mid oesophagus above the Barrett metaplasia assoc/ w/ sliding hiatus hernia (Mayo/Gore). However a more distal stricture can occur with short-segment Barrett oesophagus or in peptic stricture without Barrett (Gore p55).
3) 30yr old female has barium swallow. Shows 6cm long symmetrical narrowing of the distal oesophagus with 1cm of distal dilatation at level of the vestibule. Likely cause: (SK)
i) Achalasia – F 2cm smooth stricture in region of GOJ that transiently relaxes (Mayo Clinic GI)
ii) Barrett’s – T/F Stricture classically mid oesophagus above the Barrett metaplasia assoc/ w/ sliding hiatus hernia (Mayo/Gore). However a more distal stricture can occur with short-segment Barrett oesophagus or in peptic stricture without Barrett (Gore p55).
iii) Ca F – irregular luminal contour with abrupt, shouldered margins
iv) Scleroderma – F/T – dilated oesophagus and patulous GOJ. However could have this finding later in disease course due to superimposed GORD/Barrett with fusiform stricture formation. Age of onset of scleroderma typically 30-50 years however.
v) Cricopharyngeal spasm – F – higher

• Distal oesophagus – fusiform dilatation just above GOJ (oesophageal vestibule)
o Upper part defined by a transiently contractile ring (the A ring)
• Inferior oesophageal sphincter, caused by muscular thickening
• Transient, changes in shape & disappears at fluoroscopy
• Prominent in patients with hiatus hernia, GORD and some motility disorders
o Lower part defined by another transiently contractile ring (the B ring, transverse mucosal fold or lower oesophageal ring)
• Usually located below the diaphragm (esp. in young people) & not identified radiologically unless hiatus hernia present
• Mucosal ring
• Thin, fixed, does not change appearance
• Marks location of GOJ
• Called Schatzki ring when prominent & symptomatic (dysphagia) – B-ring with < 13mm of luminal narrowing; usually a hiatus hernia is present belowo Mucosal junction b/w oesophagus & stomach occasionally seen as a fine line (the ‘Z’ line)

Question 20

20. 40yo bowel wall thickening of terminal ileum with adjacent calcified mass in the mesentery. Best option:
    i) Crohn’s
    ii) Carcinoid
    iii) Lymphoma

Answer 20

ii) Carcinoid T With mesenteric infiltration get calcification within mesenteric mass in up to 70% (StatDx). Spiculated mass in mesentery with calcification, a/w wall thickening of an adjacent bowel loop. Distal 50cm of ileum is most common site of SB involvement (Gore p333)

4) 40yo bowel wall thickening of terminal ileum with adjacent calcified mass in the mesentery. Best option:
i) Crohn’s F
ii) Carcinoid T With mesenteric infiltration get calcification within mesenteric mass in up to 70% (StatDx). Spiculated mass in mesentery with calcification, a/w wall thickening of an adjacent bowel loop. Distal 50cm of ileum is most common site of SB involvement (Gore p333).
iii) Lymphoma T/F Calcification of nodes can occur, usually after treatment (StatDx)

Question 21

21. 30yo female with diarrhoea. 6cm segment of jejunum demonstrating wall thickening with enteric fistula. Likely:
    i) Crohn’s
    ii) Carcinoid
    iii) Lymphomai
    v) Coeliac

Answer 21

i) Crohn’s T sinus tracts & fistulas are common & characteristic of CD at advanced stages (Gore/Primer). CD is 3rd most common cause of fistula (after iatrogenic & diverticular disease) (Dahnert).

5) 30yo female with diarrhoea. 6cm segment of jejunum demonstrating wall thickening with enteric fistula. Likely:
i) Crohn’s T sinus tracts & fistulas are common & characteristic of CD at advanced stages (Gore/Primer). CD is 3rd most common cause of fistula (after iatrogenic & diverticular disease) (Dahnert).
ii) Carcinoid F
iii) Lymphoma F rarely fistula (StatDx)
iv) Coeliac F

Question 22

22. Middle aged woman fistula between sigmoid and vagina. Exam neglected to specify whether wanted most likely or least likely, so went with most likely:
    i) Rectovesical fistulas more common in females
    ii) Most common cause diverticulitis
    iii) Fistula tract readily visible on CT
    iv) Fistula readily visible on sigmoidoscopy

Answer 22

ii) Most common cause diverticulitis T major cause of colovaginal fistula is sigmoid diverticulitis

6) Middle aged woman fistula between sigmoid and vagina. Exam neglected to specify whether wanted most likely or least likely, so went with most likely:
i) Rectovesical fistulas more common in females F because vagina/cervix/uterus in the way; UTD: “colovesical fistulas secondary to diverticulitis has a distinct (2 to 3:1) male predominance”
ii) Most common cause diverticulitis T major cause of colovaginal fistula is sigmoid diverticulitis
iii) Fistula tract readily visible on CT F UTD “the diagnosis is usually made by the combination of local colonic thickening adjacent to an area of thickened bladder, associated diverticula, and oral contrast material or air in the bladder (prior to instrumentation of the urinary tract)”
iv) Fistula readily visible on sigmoidoscopy F The direct yield (eg, visualization of the fistula) from both BE and endoscopy tends to be low (20 to 26 percent and 0 to 3 percent, respectively)

Question 23

MARCH 201050 yo woman. previous gastric surgery. Present with vomiting. Oral contrast study shows intact gastric fungus and body. Absent antrum and pylorus. Stomach empty into loop of small bowel which courses to RUQ.

a. fundoplication unwrapped?
b. bilroth 2 with afferent loop syndrome
c. partial gastrectomy with stenosis at surgical site
d. sleeve gastrectomy with stenosis

Answer 23

GL : I think probably B: Afferent loop syndrome - an intermittent partial or complete mechanical obstruction of the afferent limb of a gastrojejunostomy.
Occurs in
- partial gastrectomy : Billroth II gastrojejunostomy
- gastric bypass :Roux-en-Y
gastric bypass- pancreaticoduodenectomy

A fundoplication unwrapped = F
B bilroth 2 with afferent loop syndrome = possibly T, although if high-grade obstruction in afferent loop syndrome the afferent loop fails to fill

C = partial gastrectomy with stenosis at surgical site = possibly T, if Bilroth 2 with stenosis of efferent limb & preferential filling of afferent limb
D sleeve gastrectomy with stenosis = F

Afferent loop syndrome (ALS) is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. Creation of an anastomosis between the stomach and jejunum leaves a segment of small bowel, most commonly consisting of duodenum and proximal jejunum, lying upstream from the gastrojejunostomy. This limb of intestine conducts bile, pancreatic juices, and other proximal intestinal secretions toward the gastrojejunostomy and is thus termed the afferent loop.
ALS manifests in acute and chronic forms.
Acute ALS represents complete obstruction of the afferent loop and is a true surgical emergency. It must be diagnosed and corrected expeditiously. Chronic ALS is associated with partial obstruction. It is not a surgical emergency but does require corrective surgery.
Projectile bilious vomiting is a classic manifestation of ALS with partial obstruction.

Question 24

35 yo women. Barium swallow: posterior indentation at C6.

a. zenker
b. eosinophilic oesophagitis
c. cricopharyngeous spasm

Answer 24

StatDx = cricopharyngeal achalasia
• Prominent cricopharyngeus muscle at pharyngoesophageal junction with retention of barium in pharynx on lateral view
• Pharyngoesophageal junction: C5-6 level

Question 25

pneumatosis intestinal. Not in : 
a. APC
b. COPD
C. CF
D. Steroids

Answer 25

A = F (?? Referring to genetic mutation causing FAP)
B = T
C = T
D = T

Question 26

40 yo. Cystitis 2 weeks ago. No other hx. CT circumferential and continuous thickening of ascending and transverse colon. Small amount of ascites. 
A. Crohn's
B. diverticulitis
c. epiploic appendigitis
d. UC
e. pseudomembranous colitis
f.  typhilitis

Answer 26

E = T (?) = 10% of cases of PMC confined to proximal colon; would be in keeping with recent antibiotic usage (2 days to 2 weeks post Abs)

A = F Crohn’s unlikely with no other history. Onset of CD usually 15-25 years (StatDx). Location: Anywhere along gastrointestinal (GI) tract, from mouth to anus - Most common: Terminal ileum (TI) and proximal colon. Cystitis could have been from a colovesical fistula.

B (diverticulitis) = F

C = F epiploic appendagitis doesn’t cause wall thickening

D (UC) = F = unusual without rectosigmoid involvement

E = T (?) = 10% of cases of PMC confined to proximal colon; would be in keeping with recent antibiotic usage (2 days to 2 weeks post Abs)

F (typhillitis) = need neutropenia. Caecum and ascending colon wall thickening – less common but possible in transverse – apparently more common in children. Cystitis from underlying immunosuppression or antibiotic suppression.PMC (StatDx)

Question 27

27. 20 y.o. Female with RLQ pain and imaging showing a dilated sac extending from ceacum containing a rounded density. Most Likely?
    a. Typhlitis
    b. Appendicitis
    c. Crohns
    d. UC
    e. Diverticulitis

Answer 27

b. Appendicitis T

Question 28

28. A young girl presents with abdominal pain. Which of the following regarding omental infarction is false?
    a. The pathology is usually found on the right.
    b. Complications usually include abscess formation and adhesions.
    c. The lesion is usually located near the transverse and ascending colon.
    d. Omental infarction is a benign and self-limiting disease and usually resolves with conservative measures.
    e. US features include a hyperechoic lesion

Answer 28

b. Complications usually include abscess formation and adhesions. F these complications can occur (StatDx), but they’re not ‘usual’

57. A young girl presents with abdominal pain. Which of the following regarding omental infarction is false?
    a. The pathology is usually found on the right. T 90% right-sided
    b. Complications usually include abscess formation and adhesions. F these complications can occur (StatDx), but they’re not ‘usual’
    c. The lesion is usually located near the transverse and ascending colon. T right colon
    d. Omental infarction is a benign and self-limiting disease and usually resolves with conservative measures. T (StatDx)
    e. US features include a hyperechoic lesion T Hyperechoic, nonmobile, noncompressible fixed mass + tenderness to probe pressure (StatDx)

Question 29

29. Adult female with diarrhoea. Small bowel series shows dilated featureless jejunum and increased number of folds in ileum. Most correct answer?
    a. coeliac disease
    b. scleroderma
    c. Crohn disease
    d. ulcerative colitis
    e. SLE

Answer 29

a. coeliac disease T – decreased folds in jejunum with jejunalisation of the ileum (type I folds); on CT low-density mesenteric nodes

35. Adult female with diarrhoea. Small bowel series shows dilated featureless jejunum and increased number of folds in ileum. Most correct answer?
    a. coeliac disease T – decreased folds in jejunum with jejunalisation of the ileum (type I folds); on CT low-density mesenteric nodes
    b. scleroderma F – hidebound bowel (bunching of folds)
    c. Crohn disease F
    d. ulcerative colitis F
    e. SLE F – thickened straight folds (haemorrhage/oedema – type II folds) due to small-vessel vasculitis

Question 30

Rectal cancer on MRI. Circumferential rectal wall thickening. No LN. No met. Staging
a. 1
b 2
c 3a
d 3b
e 4

Answer 30

stage 1
STAGING
stage 1 - T1-2 No

Stage 2

• 2a - T3No
• 2b - T4aNo
• 2c - T4b No

Stage 3
3A - T1-2N1
3B - T3-4 N1
3C - T any N2

stage 4 - M1

Stage Summary 
1 = local disease confined to wall
2 = local disease outside wall
3 = nodal disease
4 = distant mets

Question 31

AUGUST 200931. Which is NOT associated with a recognised increase in incidence of carcinoma of the GIT?

a. Pernicious anemia
b. Cathartic colon
c. Partial gastrectomy
d. Coeliac disease
e. Acantosis nigricans

Answer 31

b. Cathartic colon F - pseudostrictures (smoothly tapered areas of narrowing due to sustained tonus of circular muscles).
1. Which is NOT associated with a recognised increase in incidence of carcinoma of the GIT?
a. Pernicious anemia T chronic atrophic gastritis → increased risk of gastric cancer (risk factor of 2).
b. Cathartic colon F - pseudostrictures (smoothly tapered areas of narrowing due to sustained tonus of circular muscles).
c. Partial gastrectomy T - increased risk of gastric cancer, Bilroth II > Bilroth
d. Coeliac disease T - intestinal T-cell lymphoma, SB adenocarcinoma, oesophageal SCC, colorectal carcinoma
e. Acantosis nigricans T mostly benign, but is seen in a/w malignancy (esp. gastric).UTD – Acanthosis nigricans:Acanthosis (acantho meaning thorn) nigricans (black) is a reactive skin pattern seen in association with insulin resistance (obesity), cancer, and other systemic disorders.While the majority of cases of acanthosis nigricans are benign and associated with obesity, the disease can herald the onset of malignancy as well as a variety of conditions related to insulin resistance. Acanthosis nigricans has been reported in association with a number of cancers, particular gastrointestinal malignancies (eg, gastric, hepatocellular) and lung cancer. The suspicion for malignancy increases in patients with extensive or rapidly progressive lesions, when there is mucous membrane involvement, or when there is prominent sole and palm disease.Acanthosis nigricans has been reported in association with malignancy. Gastric cancers are the most common cause of malignant acanthosis nigricans; other cancers that have been reported in association with this disorder include hepatocellular carcinoma and adenocarcinomas of the lung, ovary, endometrium, kidneys, pancreas, bladder, breast, and other sites [2,21-26]. In one study of 227 patients with internal malignancy-associated acanthosis nigricans, gastric adenocarcinoma was the underlying malignancy in 55 percent [27]. Most commonly, the skin manifestations accompany the malignancy, but they can precede or follow the diagnosis of cancer.

Question 32

32. Which of the following statements regarding US findings of an inflamed appendix is most correct?
    a. Appendix measures 6mm in diameter
    b. Circumferential thickening of the caecum
    c. Reduced echogenicity in the surrounding fat
    d. Adjacent fluid collection is present
    e. Increased surrounding vascularity (Doppler sonography)

Answer 32

d. Adjacent fluid collection is present ?T secondary sign

2. Which of the following statements regarding US findings of an inflamed appendix is most correct?
   a. Appendix measures 6mm in diameter ?F traditionally upper limit of normal 6mm, but StatDx recommend using > 7mm
   b. Circumferential thickening of the caecum F circumferential/focal caecal apical thickening seen in 80%, but non-specific
   c. Reduced echogenicity in the surrounding fat F increased.
   d. Adjacent fluid collection is present ?T secondary sign
   e. Increased surrounding vascularity (Doppler sonography) F increased flow within the wall of the appendix

Question 33

33. Regarding the bowel, which is TRUE?
    a. Hirschsprungs disease is associated with trisomy 21
    b. Changes of cathartic colon primarily involves the descending and sigmoid colon
    c. Tubular adenomatous polyps have a greater malignant potential than villous adenomas
    d. Turners have increased incidence of colonic adenocarcinoma
    e. Meckel’s divertulum typically open into the mesenteric side of small bowel

Answer 33

a. Hirschsprungs disease is associated with trisomy 21 T 10-15% of patients with HD have T21

3. Regarding the bowel, which is TRUE?
   a. Hirschsprungs disease is associated with trisomy 21 T 10-15% of patients with HD have T21

b. Changes of cathartic colon primarily involves the descending and sigmoid colon F Loss of transverse folds and haustral outpouchings on barium enema, history of chronic laxative use; Colon, especially right side (but may involve entire colon & TI)
c. Tubular adenomatous polyps have a greater malignant potential than villous adenomas F villous were considered worse, now Robbins says just depends on size (but villous usually larger).
d. Turners have increased incidence of colonic adenocarcinoma F main tumour risk is gonadoblastoma if Y chromosome present; site-specific risks were increased for meningioma, childhood brain tumors, bladder, and uterine cancer (but not breast cancer) – uncertain significance (small studies)
e. Meckel’s divertulum typically open into the mesenteric side of small bowel F antimesenteric.

Question 34

34. Which of the following statements regarding traumatic bowel perforation is FALSE?
    a. Free fluid between bowel loops is a strong indicator
    b. Localized bowel wall thickening is a feature
    c. Intense contrast enhancement of the bowel wall is a feature
    d. Pneumoperiteoneum is seen in nearly all cases imaged with CT
    e. The proximal jejunum and duodenum are the commonest area affected

Answer 34

d. Pneumoperitoneum is seen in nearly all cases imaged with CT F approx 20%4.

Which of the following statements regarding traumatic bowel perforation is FALSE? RG 2006/2000

a. Free fluid between bowel loops is a strong indicator T Interloop fluid specifies fluid between the folds of mesentery and bowel. These usually polygonal collections are uncommonly associated with solid organ injury and more likely to be related to bowel or mesenteric injury.
b. Localized bowel wall thickening is a feature T
c. Intense contrast enhancement of the bowel wall is a feature T – increased bowel wall enhancement may represent bowel injury with vascular involvement (can be seen more diffusely as part of the hypoperfusion-shock complex, esp kids)
d. Pneumoperitoneum is seen in nearly all cases imaged with CT F approx 20%
e. The proximal jejunum and duodenum are the commonest area affected T - The common sites of blunt trauma injury in the small bowel are the proximal jejunum, near the ligament of Treitz, and the distal ileum, near the ileocecal valve. In these regions, mobile and fixed portions of the gut are continuous and therefore are susceptible to shearing forceCT findings specific for bowel injury

• Bowel Wall Discontinuity (uncommon sign)
• Extraluminal Contrast Material (uncommon sign)
• Extraluminal air (highly specific; seen in 20% of cases)CT findings less specific to bowel injury
• Intraperitoneal/retroperitoneal fluid (>90% but low specificity)
• Bowel Wall Thickening (seen in 55% SB & 20% LB)
• Abnormal Bowel Wall Enhancement
• Mesenteric foci of fluid, air, or fat stranding may be secondary to bowel injury alone
• Retroperitoneal air is seen with duodenal or ascending/descending colon injury

Question 35

35. Which of the following regarding small bowel barium studies is TRUE?
    a. Multiple jejunal nodules are seen in celiac disease
    b. There is an increase in the number of jejunal folds in celiac disease
    c. Scleroderma is typically associated with thickenend folds
    d. Nodular jejunal folds is seen with Whipple disease
    e. Hematogenous metastases are typically seen on the mesenteric side of the small intestine

Answer 35

d. Nodular jejunal folds is seen with Whipple disease T thickened nodular folds predominantly in distal duodenum & jejunum; fine mucosal nodularity; low attenuation (fatty) nodes; sacroiliits (Gore p313)5.

Which of the following regarding small bowel barium studies is TRUE?

a. Multiple jejunal nodules are seen in celiac disease F may have finely reticular mucosal surface; type I folds (i.e. dilatation of SB but no fold thickening)
b. There is an increase in the number of jejunal folds in celiac disease F decreased folds in proximal jejunum +/- increased, thicker than usual folds in the ileum (jejunisation of the ileum) – type I folds
c. Scleroderma is typically associated with thickenend folds F patchy fibrosis leads to bunching & crowding of small bowel folds (hidebound sign with an increased number of folds; (anti)mesenteric sacculations)
d. Nodular jejunal folds is seen with Whipple disease T thickened nodular folds predominantly in distal duodenum & jejunum; fine mucosal nodularity; low attenuation (fatty) nodes; sacroiliits (Gore p313)

e. Hematogenous metastases are typically seen on the mesenteric side of the small intestine F often submucosal
* *LJS - antimesenteric as this is where vessels are smallest and tumour cells get stuck

Question 36

36. Which of the following regarding GI scleroderma is TRUE?

a. Oesophageal function is relatively preserved in the upper third
b. The most frequent site of GI involvement is the duodenum
c. Oesophageal perforation is common
d. Involvement of the colon is rare
e. GI involvement is unusual in systemic sclerosis

Answer 36

a. Oesophageal function is relatively preserved in the upper third T

6. Which of the following regarding GI scleroderma is TRUE?
   a. Oesophageal function is relatively preserved in the upper third T
   b. The most frequent site of GI involvement is the duodenum F oesophagus
   c. Oesophageal perforation is common F
   d. Involvement of the colon is rare F oesophagus 80%, SB 60%, LB 40%
   e. GI involvement is unusual in systemic sclerosis F

Question 37

37. 70yo man with Hx Dukes B rectal carcinoma treated with surgery and XRT 2y ago. Now has moderately elevated CEA. CT shows thickened pre-sacral soft tissue with no other abnormality. Previous CT scans lost. MOST APPROPRIATE next investigation?
    a. MRI pelvis
    b. Surgical biopsy of presacral soft tissue
    c. CT guided biopsy of presacral soft tissue
    d. FDG-PET scan
    e. Repeat CT and CEA in 3/12

Answer 37

a. MRI pelvis ?T see below
d. FDG-PET scan ?T if PET-CT

7. 70yo man with Hx Dukes B rectal carcinoma treated with surgery and XRT 2y ago. Now has moderately elevated CEA. CT shows thickened pre-sacral soft tissue with no other abnormality. Previous CT scans lost. MOST APPROPRIATE next investigation?

a. MRI pelvis ?T see below
b. Surgical biopsy of presacral soft tissue
c. CT guided biopsy of presacral soft tissue
d. FDG-PET scan ?T if PET-CT
e. Repeat CT and CEA in 3/12

Answer remains controversial (see below) – either A (PET, though needs PET-CT) or B. If pure PET without CT correlate, then B MRI is best option. CEA = raised in 60-90% of CRC; also can be raised in breast, lung, gastric, pancreatic, bladder, medullary thyroid, etc. malignancies; also can be raised in smokers, PUD, IBD, pancreatitis, cirrhosis, biliary obstruction, etc.Radiology 2004 (Recurrence in patients with rectal carcinoma)The diagnosis of pelvic recurrence and the differentiation of tumor recurrence and changes associated with previous surgery and/or radiation therapy in the pelvic region constitute a diagnostic challenge for CT, MR imaging, and PET (20–25). Most patients undergoing abdominoperineal resection develop a fibrotic mass in the presacral operative bed. Radiation therapy causes an inflammatory reaction in the pelvic tissues and induces thickening of the perirectal fascia; these changes may appear on CT images for many years and be indistinguishable from tumor recurrence (21).PET/CT allowed us to differentiate a benign lesion from a tumorous presacral abnormality with a sensitivity of 100% and a specificity of 96%. PET/CT images also provided data that pertained to the involvement of pelvic structures; this information was clinically relevant in selecting an appropriate treatment approach.AJR March 2010 vol. 194 no. 3 766-771FDG PET/CT has higher sensitivity than MDCT in the identification of sites of recurrent and metastatic disease in patients with colorectal cancer and an elevated CEA level. The two techniques appear to have similar specificity.Detection of recurrent rectal cancer with CT, MRI and PET/CT – European Radiology 2007, Volume 17, Number 8, Pages 2044-2054To date, CT is the preferred method for diagnosing local recurrence of CRC. MRI was the superior imaging method with a sensitivity of 91%, a specificity of 100%, and an overall accuracy of 95%. CT reached a sensitivity of 82%, a specificity of 50%, and an accuracy of 68%.MRI is one of the leading imaging modalities for detecting pelvic recurrence of CRC [40–43], in our opinion currently the best, due to its excellent soft-tissue resolution, providing detailed anatomic information. … the positive (PPV) and negative (NPV) predictive values were 87%, 86%, 48% and 98%, respectively.PET is an accurate modality for detecting pelvic recurrence in rectal cancer patients [45], and may have advantages over CT and MRI in differentiating scar from viable tumor. The sensitivity, specificity, overall accuracy, PPV, and NPV were 84%, 88%, 87%, 76% and 92%, respectively. In the study, PET/CT allowed to differentiate benign lesions from presacral recurrences with a sensitivity of 100% and a specificity of 96%.

Question 38

38. MOST CORRECT regarding Crohn’s disease.
    a. Appendix is a common site of limited disease
    b. Adenocarcinoma is a complication
    c. Short segment involvement
    d. Lymphadenopathy is not seen
    e. Luminal narrowing is uncommon with bowel wall thickening

Answer 38

b. Adenocarcinoma is a complication T not as high risk as UC though
a. Appendix is a common site of limited disease F TI (95%), colon (22-55%), rectum (14-50%) [StatDx]

b. Adenocarcinoma is a complication T not as high risk as UC though
c. Short segment involvement F although do have skip lesions
d. Lymphadenopathy is not seen F prominent peri-enteric nodes in active phase
e. Luminal narrowing is uncommon with bowel wall thickening F as a transmural process – string sign in TI

• - Hallmarks of Crohn’s colitis include
o early aphthous ulcers
o later confluent deep ulcerations (distribution of ulcers is random and assymmetrical)
o predominant right colon disease
o discontinuous involve¬ment with intervening regions of normal bowel
o asym¬metric involvement of the bowel wall o stric¬ture
o fistulas
o sinus formation

• Adenocarcinoma
o ileal or colonic esp. in the vicinity of chronic fistulaeo 5-6 X increased risk of colonic carcinoma (not as much as UC)

Question 39

MARCH 2009 39.Commonest location for a GIST tumour?

1. Stomach
2. Small bowel
3. Oesophagus
4. Appendix
5. Large bowel

Answer 39

1.Stomach - T - 60-70% of GIST; Stomach (70%) > small bowel (30%)&raquo_space; colon > peritoneum

Question 40

40. Old man with clinical scenario suggesting mesenteric ischaemia. What is the commonest cause?
41. SMA thrombus
42. SMA embolus
43. SMV thrombus
44. Aortic dissection
45. IMA thrombus

Answer 40

2. SMA embolus - T - >50% (Dahnert)
3. Old man with clinical scenario suggesting mesenteric ischaemia. What is the commonest cause? (JS)

1.SMA thrombus - F - 4-18%
2.SMA embolus - T - >50% (Dahnert)
3.SMV thrombus - F - venous cause in <10%
4.Aortic dissection - F
5.IMA thrombus - F
SK 2011
• SMA embolus is most common cause of acute mesenteric ischemia (40-50% of cases) (StatDx)
• Embolus usually lodges in SMA near origin of middle colic artery
• Chronic mesenteric ischaemia is secondary to mesenteric atherosclerotic disease (UTD)
• Presumably they mean ACUTE mesenteric ischaemia?

Question 41

41. Clinical scenario of diarrhoea, flushing etc. Portal venous CT suggests mesenteric lesion with desmoplastic reaction and liver mets. What is the next most appropriate investigation?
42. MRI
43. MIBG scan
44. Octreotide scan
45. Triple phase CT abdomen
46. USS pelvis

Answer 41

• AJL - Now often imaged with dotatate PET
  3. Octreotide scan - T - see below
  3. Clinical scenario of diarrhoea, flushing etc. Portal venous CT suggests mesenteric lesion with desmoplastic reaction and liver mets. What is the next most appropriate investigation? (JS + GC + TW / SK)
  1. MRI – F? (although the flowchart below says octreotide, chest CT and abdominal MR) – the NCCN guidelines say abdominal CT (multiphase) or MRI (which presumably has been done given the findings), then do octreotide scan “as appropriate”
  2. MIBG scan- F - uptake in 44-63%. This would be true if known diagnosis of metastatic disease – to determine Iodine avidity to determine further therapy.
  3. Octreotide scan - T - see below
  4. Triple phase CT abdomen - F - liver lesions already thought to be mets

Question 42

42. 45 year old recent chemotherapy. Now has pancytopenia. CT shows thick wall caecum, adjacent stranding, mural gas. What is the most likely diagnosis?
43. Psuedomembranous colitis
44. Ulcerative colitis
45. Crohn disease
46. Typhlitis
47. Ischaemic gut

Answer 42

4.Typhlitis - T - infection of the caecum and ascending colon in patients who are neutropenic and immunocompromised by chemotherapy. Concentric, marked thickening of the walls of the colon with prominent pericolonic inflammatory change. Will occasionally have pneumotosis. Can develop colon ischaemia. Can be caused by candida, CMV, Gram - (pseudomonas, klebsiella, E coli, B fragilis or enterobacter). BE risky due to risk of perforation.

Question 43

43. In regard to Carcinoid tumours, which is false:
44. When in the large bowel, are most common in the rectum
45. Sestamibi is the most specific method of imaging
46. When containing gastrin, may lead to Zollinger Ellison Syndrome
47. Are associated with bowel wall kinking

Answer 43

2. Sestamibi is the most specific method of imaging - F - octreotide best NM study, then MIBG (FDG generally no good)
   * AJL - now use dotate PET.
3. When in the large bowel, are most common in the rectum - T - small bowel (42%, esp. distal ileum), rectum (27%) > appendix (24%) > proximal duodenum (< 10%) & stomach (9%) > oesophagus (< 1%) – from RG 2007 (SK)
4. Sestamibi is the most specific method of imaging - F - octreotide best NM study, then MIBG (FDG generally no good)
5. When containing gastrin, may lead to Zollinger Ellison Syndrome - T - Type II gastric carcinoid tumours occur in MEN1 with a gastrinoma and ZE syndrome.
6. Are associated with bowel wall kinking - T - Small intestinal carcinoids may produce a kink or curvature of the intestinal wall that has been called a hairpin turn. The kinking is the result of tumor infiltration and fibrosis. (RG 2007)

Question 44

44. When performing a double contrast barium enema. Which is false?
45. Buscopan is routinely used.
46. Flexures are best imaged with patient erect
47. Reflux of barium into the terminal ileum is a normal finding
48. CT should not be performed for 2 days
49. Contrast should be instilled until the caecum is full before instillation of gas

Answer 44

5.Contrast should be instilled until the caecum is full before instillation of gas - F - Radiology article (2000) “we instill a column of barium into the middle of the transverse colon where it crosses the spine. Once the barium reaches the middle of transverse colon, the enema bag is gently lowered to the floor and rectum is drained by gravity. The goal is to empty the rectal ampulla of barium, so that when air is insufflated, bubbles will not be created in the barium pool. The goal is not to clear the entire rectosigmoid colon.

6. When performing a double contrast barium enema. Which is false? (TW)
7. Buscopan is routinely used - T - used to induce colonic hypotonia (alternative is glucagon, but Buscopan is better).
8. Flexures are best imaged with patient erect - T - the splenic flexure is viewed best with the patient in an erect, or recumbent right RPO position. The hepatic flexure is imaged with the patient in the erect LPO position.
9. Reflux of barium into the terminal ileum is a normal finding - T
10. CT should not be performed for 2 days - T - barium + CT = crap pictures.
11. Contrast should be instilled until the caecum is full before instillation of gas - F -

Radiology article (2000) “we instill a column of barium into the middle of the transverse colon where it crosses the spine. Once the barium reaches the middle of transverse colon, the enema bag is gently lowered to the floor and rectum is drained by gravity. The goal is to empty the rectal ampulla of barium, so that when air is insufflated, bubbles will not be created in the barium pool. The goal is not to clear the entire rectosigmoid colon. Radiology 2000; 215: 642-650 (would have been a useful article 4y ago).

Question 45

45. Which of the following is the most correct regarding PICC line placement?
46. Access via Cephalic vein
47. Tip in the brachiocephalic vein
48. Thrombolysis indicated for blockage
49. Catheter of choice for TPN
50. Puncture site above the elbow

Answer 45

5.Puncture site above the elbow - T - generally at or above elbow crease. Try to prevent movement of catheter and kinking with elbow movement. 7

.Which of the following is the most correct regarding PICC line placement? (GC)
1.Access via Cephalic vein - F - overall, the basilic vein is the optimal site for PICC, followed by the brachial veins and the cephalic vein.

2. Tip in the brachiocephalic vein - F - at the junction of SVC and right atrium.
3. Thrombolysis indicated for blockage - F - removal.
4. Catheter of choice for TPN - F - parenteral nutrition solutions should be infused into a large central vein to reduce the risk of intimal damage from the catheter and infusate. Often a tunneled central venous catheter is used. Although PICC line administered TPN is described. TPN solution ismore viscous and larger lumen required.
5. Puncture site above the elbow - T - generally at or above elbow crease. Try to prevent movement of catheter and kinking with elbow movement.

Question 46

46. Which is the least specific for / least suggestive of bowel perforation?
47. Thumbprinting
48. Intramural gas
49. Gas in the biliary tree
50. Increased distance between bowel loops
51. Portal venous gas

Answer 46

4. Increased distance between bowel loops – F causes include ascites, bowel wall thickening, Crohn disease (SK)
5. Which is the least specific for / least suggestive of bowel perforation? (JS, GC, TW)
6. Thumbprinting - T - colitis (including IBD, ischaemic etc), lymphoma
7. Intramural gas - T - seen with NEC, steroids, colitis
8. Gas in the biliary tree - T - biliary fistula secondary to passage of gallstone or duodenal ulcer
9. Increased distance between bowel loops – F causes include ascites, bowel wall thickening, Crohn disease (SK)
10. Portal venous gas - T - NEC, mesenteric infarct

Question 47

47. Which of the following is the most specific for mesenteric ischaemia?
48. Extensive vascular calcification
49. Pneumatosis
50. Bowel wall thickening
51. Bowel loop separation

Answer 47

2.Pneumatosis - T - “Air in the abnormal bowel wall is highly suggestive of ischaemia” (B&H)

9. Which of the following is the most specific for mesenteric ischaemia? (JS)
10. Extensive vascular calcification - F - atheromatous disease is one of the causes but heaps of people have vascular calcification without developing ischaemia.
11. Pneumatosis - T - “Air in the abnormal bowel wall is highly suggestive of ischaemia” (B&H)
12. Bowel wall thickening - F - is non-specific but is the most frequently observed CT finding in ischaemia and is caused by mural oedema, haemorrhage or superinfection.
13. Bowel loop separation - F - I presume they are referring to ascites which can occur in lots of conditions

Question 48

48. Which of the following is the most correct regarding Crohn’s Disease?
49. Appendiceal tip
50. Short segment
51. Lymphadenopathy uncommon

Answer 48

10. Which of the following is the most correct regarding Crohn’s Disease? (JS/SK)
11. Appendiceal tip - F - generally involves the terminal ileum and then the appendix, so just the tip is unlikely.
12. Short segment - T?? - skip areas of asymmetric bowel wall thickening in 82% (Dahnert). SK – unlikely to be short segment on its own.
13. Lymphadenopathy uncommon - T - mesenteric adenopathy in 18% (Dahnert)

Question 49

49.Ileocecal bowel wall thickening is most likely to represent

1. Carcinoid
2. Adenocarcinoma
3. Crohn’s disease
4. Lymphoma
5. GIST

Answer 49

3.Crohn’s disease - T - terminal ileum (alone / in combination in 95%); colon in 22-55%, esp. on right side.

Question 50

AUGUST 200850.Which is a contraindication to use of hyoscine?

1. Diabetes mellitus
2. Glaucoma
3. Epilepsy
4. Diabetes insipidus

Answer 50

2.Glaucoma - mydriasis and cycloplegia may cause increased intraocular pressure. (MB) Buscopan (used as an antispasmodic for Barium enema & CT colonography). Anticholinergic agent (like atropine). IV buscopan produces a dry mouth and about 10% suffer blurred vision (lasts about 20mins). Tachycardia may result in HTN if the patient is on beta blockers. Acute glaucoma is precipitated only in the rarer closed-angle type of glaucoma. [Large Bowel, CI Bartram]

Question 51

51. Which is false regarding a Ba enema?
52. A CT should not be done for 2 days post procedure
53. The caecum should be filled prior to instillation of gas
54. Buscopan is routinely administered

Answer 51

2.The caecum should be filled prior to instillation of gas F - filling should continue until Ba flows around splenic flexure and into transverse colon - then head up 30 degrees to drain. Spot views of rectosigmoid area should be obtained before the caecum fills. Insufflate gas to see if some more of the distal Ba column can be pushed around the splenic flexure. Filling the proximal colon should not be attempted until transvere colon is about 2/3 full. Levine – barium to mid transverse colon, then drop bag to ground to drain.

13. Which is false regarding a Ba enema?
14. A CT should not be done for 2 days post procedure T - severe artifact from dense Ba.
15. The caecum should be filled prior to instillation of gas F - filling should continue until Ba flows around splenic flexure and into transverse colon - then head up 30 degrees to drain. Spot views of rectosigmoid area should be obtained before the caecum fills. Insufflate gas to see if some more of the distal Ba column can be pushed around the splenic flexure. Filling the proximal colon should not be attempted until transvere colon is about 2/3 full. Levine – barium to mid transverse colon, then drop bag to ground to drain.
16. Buscopan is routinely administered T - Bowel preps induce considerable colonic spasm, particularly in the sigmoid, which will prevent the a column moving proximally. If filling is continued, the rectum will become overdistended and anal incontinence is likely. Buscopan is usually given after rectal drainage before gas insufflation. Couch says it works for ~7 minutes. [Large Bowel, CI Bartram]Levine – used to induce colonic hypotonia & improve distension of the sigmoid colon.

Question 52

52. Which is most correct regarding adenomyomatosis?
53. MRI cannot distinguish between the 3 subtypes
54. The segmental type is characterised by a GB stricture on MRCP
55. It is a premalignant condition
56. Can differentiate from cancer on ultrasound
57. All 3 types have an increased risk of stones

Answer 52

14. Which is most correct regarding adenomyomatosis? (GC)
15. MRI cannot distinguish between the 3 subtypes - F Localised (adenomyoma): focal, freq. semilunar or crescentic solid mass, usu in fundus. Segmental: focal circumferential thickening in the midportion (“waist”) of GB producing an “hourglass” appearance. Diffuse: diffuse mural thickening and luminal narrowing.
16. The segmental type is characterised by a GB stricture on MRCP - ??T - see above.
17. It is a premalignant condition - F - dysplastic changes and even carcinoma may arise from adenomyomatous epithelium, esp. in patients with segmental type, but this seems to be related to the presence of gallstones and chronic inflammation.
18. Can differentiate from cancer on ultrasound - ??F - dysplastic changes and even Ca in situ may arise from the epithelium of adenomyomatous hyperplasia, However, the development of Ca is believed to be related to the presence of stones, chronic inflammation and metaplastic changes rather than the AM itself.SK – StatDx says of “little clinical significance” & to “consider chronic cholecystitis”. While it gives GB carcinoma as a DDx, it seems to indicate you can differentiate the two.
19. All 3 types have an increased risk of stones - T - gallstones in 25-75% (Dahnert doesn’t differentiate the types). RG states 90% have coexistent gallstones. [MRI of GB, RG 2008; Benign tumours/tumourlike conditions of GB, RG 2002]

Question 53

53. 40 yo. male with diarrhoea. Desmoplastic response surrounding a calcified mesenteric mass + heterogeneous liver on CT. Next test is:
54. MIBG
55. Triple phase liver CT
56. MRI
57. Octreotide
58. Angio

Answer 53

4. Octreotide – T - Somatostatin receptor scintigraphy performed with 111In-octreotide is a sensitive method of localizing radiologically occult carcinoid tumors, with a reported sensitivity of 80%–100%.
5. 40 yo. male with diarrhoea. Desmoplastic response surrounding a calcified mesenteric mass + heterogeneous liver on CT. Next test is: (GC)
6. MIBG - uptake in 44-63% (higher frequency in midgut carcinoids + with elevated serotonin levels). Liver lesion = presumed metastasis. See flow chart.
7. Triple phase liver CT 3.MRI 4.Octreotide – T - Somatostatin receptor scintigraphy performed with 111In-octreotide is a sensitive method of localizing radiologically occult carcinoid tumors, with a reported sensitivity of 80%–100%.
8. Angio [Anatomic & Functional Imaging of Metastatic Carcinoids RG 2007]

Question 54

54. Which is not a normal embryological variant?
55. PV aneurysm
56. Fistulation between PV and IVC
57. Portosystemic shunt
58. PV duplication

Answer 54

2. Fistulation between PV and IVC F - this is the aim of TIPS for patients with portal HTN (diversion of blood from portal circulation, through hepatic parenchyma, to the systemic circulation; usually between right hepatic vein and right PV).
3. Which is not a normal embryological variant? (GC) CME99.10
4. PV aneurysm T - incomplete regression of the distal right vitelline vein leading to a diverticulum that would ultimately develop into an aneurysm in the proximal SMV could explain aneurysms in that location. An inherent weakness of the vessel wall is another theory proposed to support a congenital origin. The most common locations are the portal confluence, main PV, and intrahepatic PV branches at bifurcation sites.
5. Fistulation between PV and IVC F - this is the aim of TIPS for patients with portal HTN (diversion of blood from portal circulation, through hepatic parenchyma, to the systemic circulation; usually between right hepatic vein and right PV).
6. Intrahepatic portosystemic shunt T - persistence of an omphalomesenteric venous system with the right horn of the sinus venosus and rupture of a congenital aneurysm of the portal vein into a hepatic vein are congenital conditions that have been proposed to explain intrahepatic portosystemic shunts.
7. PV duplication T - Congenital anomalies of the main PV include prepancreatic portal vein, which is frequently associated with situs inversus and other congenital malformations; double PV; congenital agenesis of the PV; and congenital agenesis of the major branches of the portal vein. [Congenital & Acquired Anomalies of the PV system, RG 2002]

Question 55

55.Cystic mass in pancreas. Which is least true?

1. If centered in the tail and with Ca++ one should consider mucinous adenocarcinoma
2. Side branch dilation with normal main duct, consider IPMT
3. Hx of pancreatitis, consider pseudocyst
4. 4cm cyst within head of pancreas with no Ca++ or enhancement, one can exclude serous cystadenoma/ adenocarcinoma

Answer 55

4.4cm cyst within head of pancreas with no Ca++ or enhancement, one can exclude serous cystadenoma/ adenocarcinoma F - When there is a unilocular cyst with a lobulated contour located in the head of the pancreas, one should consider a unilocular macrocystic serous cystadenoma. The presence of irregular wall thickening in a unilocular cyst is suggestive of a more aggressive biologic nature.

17. Cystic mass in pancreas. Which is least true? (GC) Primer p248
18. If centered in the tail and with Ca++ one should consider mucinous adenocarcinoma T - majority occur in the body/tail. Eggshell/peripheral Ca++ is uncommon but specific for mucinous cystic neoplasms and highly predictive of malignancy.
19. Side branch dilation with normal main duct, consider IPMT T - identification of a septated cyst that communicates with the main pancreatic duct is highly suggestive of a side-branch or mixed IPMN. However, it is important to be aware that lack of communication with the main pancreatic duct at imaging does not exclude an IPMN.
20. Hx of pancreatitis, consider pseudocyst T - a unilocular cyst in a patient with a history of pancreatitis is almost always a pseudocyst. The diagnosis is further supported by imaging findings that include pancreatic inflammation, atrophy or calcification of the pancreatic parenchyma, and dilatation of and calculi in a typically thin-walled pancreatic duct.
21. 4cm cyst within head of pancreas with no Ca++ or enhancement, one can exclude serous cystadenoma/ adenocarcinoma F - When there is a unilocular cyst with a lobulated contour located in the head of the pancreas, one should consider a unilocular macrocystic serous cystadenoma. The presence of irregular wall thickening in a unilocular cyst is suggestive of a more aggressive biologic nature.

Question 56

56. Haemangiomas have a number of atypical features. Which is most unlikely?
57. 1cm subcapsular lesion which rapidly fills and is isodense on PV phase
58. Low signal septa on T2 imaging
59. Peripheral puddling, non-continuous enhancement on arterial imaging
60. 3cm lesion with capsular retraction
61. Homogeneous arterial enhancement

Answer 56

4.3cm lesion with capsular retraction F -

18. Haemangiomas have a number of atypical features. Which is most unlikely? (GC)
19. 1cm subcapsular lesion which rapidly fills and is isodense on PV phase T flash haemangioma
20. Low signal septa on T2 imaging T - may be seen in large heterogeneous lesions. Central scar also possible in large lesions.
21. Peripheral puddling, non-continuous enhancement on arterial imaging T - could be seen in large heterogeneous lesions or lesions with central cystic change. Part of the classic appearance is peripheral nodular discontinuous enhancement progressing centripetally.
22. 3cm lesion with capsular retraction F - 5.Homogeneous arterial enhancement T - seems to occur significantly more in small lesions (42% of those <1cm). =”flash” haemangiomas

Question 57

57. Desmoid tumour, which is true?
58. Occurs in posterior medial femur
59. Periostitis in <5%
60. Commonly presents with pain
61. Can only be diagnosed by biopsy

Answer 57

1.Occurs in posterior medial femur T - along medial ridge of linea aspera at attachment of adductor magnus aponeurosis. Histol: shallow defect with proliferating fibroblasts, multiple small fragments of resorbing bone (microavulsions) at tendinous insertions.

19. Desmoid tumour, which is true? (GC) Below applies to cortical desmoid (peak 14-16 yo).
20. Occurs in posterior medial femur T - along medial ridge of linea aspera at attachment of adductor magnus aponeurosis. Histol: shallow defect with proliferating fibroblasts, multiple small fragments of resorbing bone (microavulsions) at tendinous insertions.
21. Periostitis in <5% F - lamellated periosteal reaction (D); might or might not exhibit periosteal new bone (B&H).
22. Commonly presents with pain F - no localising signs/symptoms (D); may or may not be associated with pain - painful desmoids should become asymptomatic with rest (B&H).
23. Can only be diagnosed by biopsy F - “don’t touch” lesion. But may be confused with malignancy (OSA) or osteomyelitis.

Question 58

58. In which case would you notify the team?
59. Portal venous gas post UVC placement
60. UVC passing caudally at the umbilical level
61. UVC tip at porta hepatis
62. UAC tip at T10
63. A calcified hepatic mass developing since removal of UVC

Answer 58

2. UVC passing caudally at the umbilical level – T - this would imply that the catheter is in the UA. Another possible complication of UVC is the tip of the UVC can coil in the umbilical recess before entering the left portal vein. If after coiling in the umbilical recess, the UVC is advanced farther, it may travel in a retrograde direction in the umbilical vein toward the umbilicus. Rarely, the UVC may reach the IVC but may progress caudally rather than cranially in the IVC.
3. In which case would you notify the team? (GC)
4. Portal venous gas post UVC placement - air embolism at the time of catheterisation is not uncommonly seen on the initial radiograph (due to poor technique). The air is an isolated finding and will be absorbed. Conversely, PV air associated with NEC will typically be accompanied by pneumatosis intestinalis.
5. UVC passing caudally at the umbilical level – T - this would imply that the catheter is in the UA. Another possible complication of UVC is the tip of the UVC can coil in the umbilical recess before entering the left portal vein. If after coiling in the umbilical recess, the UVC is advanced farther, it may travel in a retrograde direction in the umbilical vein toward the umbilicus. Rarely, the UVC may reach the IVC but may progress caudally rather than cranially in the IVC.
6. UVC tip at porta hepatis – Less correct, would still notify team. The preferred location of the tip of the UVC is at the IVC-RA junction. Leaving the catheter in the portal vein or injecting hyperosmolar solutions into the PV contributes to the development of hepatic necrosis or PV thrombosis.
7. UAC tip at T10 - a high location is acceptable. UAC should not be positioned with its tip b/w T10-L3 (should be high T8-10 or low below L3)5.A calcified hepatic mass developing since removal of UVC - If the UVC perforates an intrahepatic vascular wall, a hepatic hematoma may result; these may eventually calcify. Thrombus may also calcify.

Question 59

AUGUST 200759.Risk of GI cancer, which is false:

1. Pernicious anaemia.
2. Cathartic colon.
3. Partial Gastrectomy.
4. Celiac disease.
5. Acanthcosis nigricans.

Answer 59

2.Cathartic colon F Loss of transverse folds and haustral outpouchings on barium enema, history of chronic laxative use; Colon, especially right side (but may involve entire colon & TI)

21.Risk of GI cancer, which is false: (GC)
1.Pernicious anemia T chronic atrophic gastritis → increased risk of gastric cancer (risk factor of
2). 2.Cathartic colon F Loss of transverse folds and haustral outpouchings on barium enema, history of chronic laxative use; Colon, especially right side (but may involve entire colon & TI)
3.Partial gastrectomy T - increased risk of gastric cancer, Bilroth II > Bilroth I. (previous ans F).
4.Celiac T - T-cell lymphoma, SB adenocarcinoma, oesophageal SCC, colorectal carcinoma, HCC
5.Acanthosis nigricans T mostly benign, but is seen in a/w malignancy (esp. gastric).T - divided into 2 categories: benign and malignant. Malignant AN is a paraneoplastic syndrome due to secretion of a substance from a tumour or in response to the tumour, ie. similar to epidermal growth factor.
Gastric adenocarcinoma is by far the most common underlying malignancy (others: lung, uterine). UTD – Acanthosis nigricans:Acanthosis (acantho meaning thorn) nigricans (black) is a reactive skin pattern seen in association with insulin resistance (obesity), cancer, and other systemic disorders.While the majority of cases of acanthosis nigricans are benign and associated with obesity, the disease can herald the onset of malignancy as well as a variety of conditions related to insulin resistance. Acanthosis nigricans has been reported in association with a number of cancers, particular gastrointestinal malignancies (eg, gastric, hepatocellular) and lung cancer. The suspicion for malignancy increases in patients with extensive or rapidly progressive lesions, when there is mucous membrane involvement, or when there is prominent sole and palm disease.Acanthosis nigricans has been reported in association with malignancy. Gastric cancers are the most common cause of malignant acanthosis nigricans; other cancers that have been reported in association with this disorder include hepatocellular carcinoma and adenocarcinomas of the lung, ovary, endometrium, kidneys, pancreas, bladder, breast, and other sites [2,21-26]. In one study of 227 patients with internal malignancy-associated acanthosis nigricans, gastric adenocarcinoma was the underlying malignancy in 55 percent [27]. Most commonly, the skin manifestations accompany the malignancy, but they can precede or follow the diagnosis of cancer.

Question 60

60. Findings on Barium follow through?
61. Whipples associated with nodules.
62. Scleroderma with strictures.
63. Mastocytosis with strictures.

Answer 60

1.Whipples associated with nodules. T – type III folds; rare systemic infection (tropheryma whippelii), mainly affects GIT, CNS and joints. Barium: irregular small bowel thickening, sand-like nodules, wild mucosal pattern, no/minimal dilatation. CT: low attenuation mesenteric lymph nodes, hepatosplenomegaly, ascites.

22. Findings on Barium follow through? (GC)
23. Whipples associated with nodules. T – type III folds; rare systemic infection (tropheryma whippelii), mainly affects GIT, CNS and joints. Barium: irregular small bowel thickening, sand-like nodules, wild mucosal pattern, no/minimal dilatation. CT: low attenuation mesenteric lymph nodes, hepatosplenomegaly, ascites.
24. Scleroderma with strictures F - may see a megaduodenum with an abrupt cutoff at SMA level (due to atrophy of neural cells with hypoperistalsis), ie. not a true stricture. Other small bowel findings include: prolonged transit time, “hidebound” pattern (60%), pseudodiverticula, pneumatosis cystoides intestinalis.
25. Mastocytosis with strictures. F - generalised irregular distorted nodular thickened folds +/- wall thickening (due to infiltration by mast cells, lymphocytes, plasma cells); diffuse pattern of sand-like mucosal nodules; urticaria-like lesions of GIT mucosa. Complications include PUD (increased histamine release leads to increased gastric acid secretion, this could lead to stricture. (Gore p323 = nodular thick SB folds + sclerotic bony lesions)

Question 61

61. Associations, true/false:
62. Strongyloides and duodenal stenosis.
63. Amoebiasis and gastric involvement.
64. Amyloidosis and narrowing and rigidity of the stomach
65. Intramural oesopheageal pseudodiverticulosis and oesophageal carcinoma
66. Gastric dilatation and diabetes mellitus
67. Menetrier’s disease and carcinoma of the stomach

Answer 61

True : 1, 3, 5

23. Associations, true/false: (GC)
24. Strongyloides and duodenal stenosis. T - Paralytic ileus due to massive intestinal infestation, with mild to moderate dilatation of proximal 2/3 of duodenum and jejunum, oedematous mucosal folds. Ulcerations lead to strictures of the 3rd and 4th parts of duodenum (rigid pipestem appearance and irregular narrowing in advanced cases). Filiform larva in contaminated soil penetrates skin/mm, passes from subcutaneous tissues to lung via lymphatics/venous circulation. Ascends airways and gets swallowed, settles in duodenum and matures into worm, lays eggs into GI lumen that are then excreted faecally. (Gore p 188/410)
25. Amoebiasis and gastric involvement. F - invades areas of relative stasis (right colon & caecum 90% > hepatic & splenic flexures > rectosigmoid). Loss of haustral pattern with granular appearance, collarbutton ulcers, cone-shaped caecum, several cm long colonic stenosis (result of healing and fibrosis), amoeboma (hyperplastic granuloma with bacterial invasion of amoebic abscess), thickened fixed open ileocaecal valve. (Gore p410) – can mimic Crohn.
26. Amyloidosis and narrowing and rigidity of the stomach T - GI involvement in primary amyloidosis more common than in secondary. Stomach changes in 37%; may be diffuse infiltrative (similating linitis plastica), localised infiltration (often in antrum), or an amyloidoma (well-defined submucosal mass). Gore p625
27. Intramural oesopheageal pseudodiverticulosis and oesophageal carcinoma F (college answer) - condition of unknown cause; dilated excretory ducts of the deep mucous glands, result from obstruction of the ducts by plugs of viscous mucus and desquamated cells or by extrinsic compression of the ducts by periductal inflammatory infiltrates and fibrotic tissue; assocd with diabetes, alcohol, severe oesophagitis and oesophageal stricture. Up to 90% of pts have assocd stenoses of various origins; mostly in upper oesophagus. There is an increased prevalence of pseudodiverticulosis in pts with oesophageal cancer - suggesting that surveillance is warranted - but a sequential relationship has not been shown as yet. [AJR 1995]
28. Gastric dilatation and diabetes mellitus T - secondary to autonomic neuropathy. 6.Menetrier’s disease and carcinoma of the stomach F (college answer) - Dahnert: development of gastric cancer reported. Path consult: Ca may develop but incidence not higher than in ordinary atrophic gastritis
29. Menetrier’s disease and carcinoma of the stomach: *LW - TRUE: weak leak, with UTD stating Hypertrophic gastropathy (including Ménétrier’s disease) [73] and various immunodeficiency syndromes have been linked with gastric cancer. However, the strength of these associations remains undefined.

Question 62

62.Which is true re: Solitary Rectal ulcer?

1. Associated with rectal carcinoma.
2. Diagnosis excluded if multiple ulcers.
3. Anterior rectal wall prolapse is a feature.
4. Evacuation proctograhy is usually normal.
5. Associated with ulcerative colitis.

Answer 62

3.Anterior rectal wall prolapse is a feature. T - aka mucosal prolapse syndrome: prolapse of anterior rectal wall → mucosal ischaemia due to traumatisation from the anal sphincter during defaecation. Patients typically present with PR bleeding and pain on defaecation.

24.Which is true re: Solitary Rectal ulcer? (GC)
1.Associated with rectal carcinoma. F - but is an important differential.
2.Diagnosis excluded if multiple ulcers. F - may be small or large, single or multiple.
3.Anterior rectal wall prolapse is a feature. T - aka mucosal prolapse syndrome: prolapse of anterior rectal wall → mucosal ischaemia due to traumatisation from the anal sphincter during defaecation. Patients typically present with PR bleeding and pain on defaecation.
4.Evacuation proctography is usually normal. F - there is failure of the anorectal angle to open while straining.
5.Associated with ulcerative colitis. F - not in Dahnert. But there is an article on this in GI Endoscopy 2006 (via MD consult if you guys can access it!)
6.Pathogenesis of solitary rectal ulcers:- prolapsed rectal mucosa is forced downward due to the pressures generated by the rectum during defaecation. The opposing force of the paradoxical contraction of the puborectalis muscle can generate high pressures within the rectum and lead to mucosal ischaemia which can predispose to ulceration. Shear forces occur on the mucosa caused by the puborectalis muscle. On defecation proctography see rectal prolapse as well as incomplete or delayed rectal emptying.
• Rectal ulcer syndrome (StatDx)
• Traumatic or ischemic ulceration of rectal mucosa associated with disordered evacuation
• Diagnosed on barium enema or sigmoidoscopy

Question 63

63. Which is false re: Barrett’s oesophagus?
64. Increased risk of SCC.
65. Classically mid to lower oesophageal stricture on barium.
66. Associated with reticular mucosal pattern on barium swallow.
67. Associated with sliding hiatus hernia.
68. Associated with scleroderma.

Answer 63

1.Increased risk of SCC. F - increased risk of adenocarcinoma (30-40 times greater with more than 2cm of Barretts) – Robbins (10% lifetime risk – Mayo)

25.Which is false re: Barrett’s oesophagus? (JS)
1.Increased risk of SCC. F - increased risk of adenocarcinoma (30-40 times greater with more than 2cm of Barretts) – Robbins (10% lifetime risk – Mayo)
2.Classically mid to lower oesophageal stricture on barium. T - middle (40%) to lower oesophagus (60%) (Dahnert) – i.e. higher than in straight-out GORD
3.Associated with reticular mucosal pattern on barium swallow. - T - reticular mucosal pattern in the distal oesophagus is the most sensitive finding (Primer)
4.Associated with sliding hiatus hernia. - T - hiatus hernia in 75-94% (Dahnert)
5.Associated with scleroderma. - T - Scleroderma causes a patulous LOS which predisposes to reflux and then Barretts
• Mid-esophageal stricture with hiatal hernia and reflux is essentially pathognomonic (StatDx/Federle)

Question 64

64. Budd Chiari, which is not a risk factor?
65. SLE.
66. OCP.
67. Bone marrow transplant.
68. IVC web.
69. Chronic pancreatitis.

Answer 64

5.Chronic pnacreatitis F

26. Budd Chiari, which is not a risk factor? (GC)
27. SLE. T
28. OCP. T - thrombosis; hypercoagulable state.
29. Bone marrow transplant. T - thrombosis; vessel wall injury due to immunosuppression.
30. IVC web. T - non-thrombotic cause.
31. Chronic pnacreatitis F

Causes: idiopathic (2/3). Thrombosis - hypercoagulable state (5P’s: PCV, pill, pregnancy, increased plts, PNH), or injury to vessel wall (XRT, chemo/IS in BMT patients, Jamaican bush tea) Non-thrombotic - tumour extension into IVC (RCC, HCC), IVC diaphragm (congenital, acquired), right atrial tumour, constrictive pericarditis, RHF. [Dahnert, p694]

Question 65

65. The following statements are true in relation to hepatic adenomas?
66. Uptake is seen on sulphur colloid scans in the majority.
67. Uptake of SPIO is a recognized feature.
68. 50% have fat on CT.
69. 60% have calcification on CT.
70. Majority associated with OCP use.

Answer 65

5.Majority associated with OCP use. T - 2.5x risk after 5-year use, 25x risk >9-year use. Other risk factors include type I glycogen storage disease and use of anabolic steroids.

27. The following statements are true in relation to hepatic adenomas? (GC)
28. Uptake is seen on sulphur colloid scans in the majority. F - Kupffer cells are often found in adenomas but in reduced numbers and with little or no function. Focal photopenic lesion seen on Tc-99m sulphur colloid scans; 23% may show uptake equal to or slightly less than liver. Also, usually no increased activity on HIDA scan (cf. FNH); and no gallium uptake.
29. Uptake of SPIO is a recognized feature. F - usually don’t show uptake of superparamagnetic iron oxide particles, resulting in decreased SI on T2WI. Also, usually no substantial uptake of Gd-BOPTA (Multihance), lesions appear hypointense on delayed imaging.
30. 50% have fat on CT. F - mass of decreased density due to fat and areas of necrosis in 30-40%.
31. 60% have calcification on CT. F - rarely calcified (10%). Calcifications usually seen within cystic portions that represent areas of necrosis or old haemorrhage.
32. Majority associated with OCP use. T - 2.5x risk after 5-year use, 25x risk >9-year use. Other risk factors include type I glycogen storage disease and use of anabolic steroids.

Question 66

66.Liver MRI, which most likely to show loss of signal in out-of-phase imaging?

1. Adenoma.
2. FNH.
3. HCC.
4. Mets.
5. Pseudotumour.

Answer 66

1. Adenoma. T - adenoma cells are larger than normal hepatocytes and contain large amounts of glycogen and lipid. Intra- and extracellular lipid uncommonly manifests as macroscopic fat deposits within the tumour (7%). In contrast, 35-77% of adenomas demonstrate steatosis at chemical shift imaging.
2. FNH F - presence of fat is extremely rare; usually patchy in distribution; intratumoural steatosis may or may not be assocd with diffuse hepatic steatosis.
3. HCC. F - larger tumours have patchy fatty metamorphosis, seen as macroscopic fat on CT. Fatty change can be seen in up to 35% of small HCCs, seen as a signal drop on chemical shift imaging.
4. Mets. F - in general, liver mets do not contain fat. Exceptional examples include VIPoma.
5. Pseudotumour. F - majority occur in Asians, children/young adults, right lobe; may contain calcification, larger lesions may have central necrosis. Variable MR appearance, usually T1 hypointense / T2 hyperintense cf. skeletal muscle, and heterogeneously enhance. Cause is unknown, some believe it is a low-grade fibrosarcoma with inflammatory (lymphomatous) cells; usually contains both T and B-cells (cf. clonal population in lymphoma). Quasineoplastic lesion consisting of inflammatory cells and myofibroblastic spindle cells; IPT most commonly involves lung and orbit, but can occur anywhere.[Fat-containing lesions of Liver RG 2005; Inflammatory pseudotumour RG 2003]

Question 67

67. LIVER Associations:
68. Peliosis hepatis is associated with HIV and AIDS.
69. HCC is associated with OCP.
70. Selective hypertrophy of segments 3 & 4 occur in Budd-Chiari.
71. Adenomatous hyperplastic nodules typically enhance during arterial phase following IV contrast.

Answer 67

1. Peliosis hepatis is associated with HIV and AIDS. T - peliosis hepatis is a rare benign disorder characterised by multiple blood-filled cysts. Steroids, OCP, tamoxifen, oestrogens, Ig therapy, and azthioprine are usually assocd with PH. It has also been reported in pts with haem/onc disorders (Hodgkin’s, MM), transplantation, chronic infection (esp. pulmonary TB and HIV). Rochilimaea henselae or Bartonella henselae are bacterial agents causative for peliosis in immunodeficient patients that can be treated with antibiotics. [Pseudotumoural appearance of PH, AJR 2005]
2. LIVER Associations: (GC)
3. Peliosis hepatis is associated with HIV and AIDS. T - peliosis hepatis is a rare benign disorder characterised by multiple blood-filled cysts. Steroids, OCP, tamoxifen, oestrogens, Ig therapy, and azthioprine are usually assocd with PH. It has also been reported in pts with haem/onc disorders (Hodgkin’s, MM), transplantation, chronic infection (esp. pulmonary TB and HIV). Rochilimaea henselae or Bartonella henselae are bacterial agents causative for peliosis in immunodeficient patients that can be treated with antibiotics. [Pseudotumoural appearance of PH, AJR 2005]
4. HCC is associated with OCP - Less correct T - several studies have demonstrated that prolonged use (esp. >8yrs) and higher synthetic oestrogen content increases the relative risk of adenoma and HCC. The effect of adenoma formation may be reversible with discontinuation, but HCC still can occur after resolution of the adenoma. The absolute risk of HCC is small, but the RR of 2.6 in case-control studies could have implications in societies where OCP use is prevalent and other RFs are uncommon, esp. because the risk of HCC does not decrease for at least 10yrs after prolonged OCP use. [HCC diagnosis & treatment, BI Carr 2005]
5. Selective hypertrophy of segments 3 & 4 occur in Budd-Chiari. F - caudate hypertrophy.
6. Adenomatous hyperplastic nodules typically enhance during arterial phase following IV contrast. F - ie. a low-grade dysplastic nodule (high-grade being an atypical adenomatous hyperplasia). Regenerative nodules: low T2, variable T1, no enhancement on arterial phase imaging. HCC: high T2, variable T1, intense arterial enhancement. The SI and enhancement characteristics of dysplastic nodules are not yet well established; but I assume they would not “typically” enhance (unless they are large-? or contain a focus of HCC). [Benign vs Malig Hepatic Nodules RG 2002]

Question 68

68.In Caroli’s disease, which are false (multiple answers):

1. There is an association with renal medullary cystic disease.
2. There is an increased risk of HCC.
3. Associated with ARPKD.
4. Tc-99m HIDA scan is typically normal
5. There is a marked predisposition to biliary calculous disease

Answer 68

False 2 and 4

30. In Caroli’s disease, which are false: (GC)
31. There is an association with renal medullary cystic disease. T – associated with MSK (considered a form of medullary cystic disease) & ARPKD
32. There is a markedly increased risk of HCC. F (SK)- increased risk for cholangiocarcinoma (7%, Dahnert ). 100x’s greater than normal population.
33. Associated with ARPKD. T - patients with ARPKD also have congenital hepatic fibrosis. This is due to ductal plate malformation (double-layered sleeve of hepatocyte precursor cells that forms around the portal veins, remodels abnormally resulting in increased no. of bile ducts with abn branching and variable dilatation). Part of DPM also consists of fibrosis of the portal tracts. It is hypothesized that CHF and Caroli’s represent a spectrum of portal tract malformations (CHF = small duct involvement with portal fibrosis; Caroli’s = large duct ectasia without fibrosis).
34. Tc-99m HIDA scan is typically normal F Unusual pattern of retained activity throughout liver (StatDx)
35. There is a marked predisposition to biliary calculous disease T - Cx include bile stasis with recurrent cholangitis, predominantly bilirubin calculi, and liver abscess.

Question 69

69. The following are true regarding MRCP?
70. Highly specific for pancreatic divisum.
71. Detects 60% of stones.
72. Is accurate in the diagnosis of early pancreatitis.
73. Is best performed using a gradient echo T1 weighted sequence.
74. Is unlikely to be successful if the serum bilirubin is 5 times normal

Answer 69

1. Highly specific in the diagnosis of pancreatic divisum. T - has been shown to be highly sensitive and specific for pancreas divisum. Non-communication of the dorsal and central ducts, independent drainage sites and a dominant dorsal pancreatic duct can be seen using MRCP. Depiction can be improved using dynamic MRCP after secretin stimulation. [Singapore Med J 2008]
2. The following are true regarding MRCP? (GC)
3. Highly specific in the diagnosis of pancreatic divisum. T - has been shown to be highly sensitive and specific for pancreas divisum. Non-communication of the dorsal and central ducts, independent drainage sites and a dominant dorsal pancreatic duct can be seen using MRCP. Depiction can be improved using dynamic MRCP after secretin stimulation. [Singapore Med J 2008]
4. Detects 60% of stones F - MRCP is well suited to the diagnosis of choledocholithiasis because CBD stones appear as low-signal intensity foci within the high-SI bile. Stones as small as 2 mm can be detected. Sensitivity 81-100%; specificity 85-100%; PPV 82-100%; NPV 94-100%. In view of the high NPV of MRCP, the primary utility in the setting of choledocholithiasis may lie not in the detection of CBD stones but in their exclusion.
5. Is accurate in the diagnosis of early pancreatitis. F - In the severe forms of the disease, imaging is performed to assess the perfusion of the pancreatic parenchyma, the extent of necrosis, and the presence and extent of fluid collections. CECT is currently considered the standard reference for evaluating these parameters; it also presents a more manageable environment for severely ill patients. However, contrast-enhanced MRI/MRCP can also accomplish these goals and have recently been suggested as an alternative to CECT for the initial staging of acute pancreatitis.
6. Is best performed using a gradient echo T1 weighted sequence. F - Fast GRE T1-weighted sequence is used as the 3-plane localiser. Imaging the pancreatic duct is dependent on heavily T2WI that selectively displays static or slow-moving fluid-filled structures. Two different and complementary approaches are generally used for MRCP: a thick-slab, single-shot TSE T2-weighted sequence and a multisection thin-slab, single-shot TSE T2-weighted sequence.
7. Is unlikely to be successful if the serum bilirubin is 5 times normal. F - potentially an issue with CT cholangiography.

Question 70

70. CT findings in Cancer of the head of pancreas, which is most correct:
71. Enhancement of lesion is during arterial phase is typical.
72. There is typically preservation of parenchyma in body and tail of pancreas.
73. Accuracy of CT with regard to predicting that a tumor is resectable approaches 100%.
74. Accuracy with regard to predicting that a tumor is non-resectable is about 90-100% in most series.
75. Obstruction of both the CBD and main pancreatic duct is specific for malignancy in the pancreatic head

Answer 70

4. Accuracy with regard to predicting that a tumor is non-resectable is about 90-100% in most recent series. T - non-resectable if local extension or invasion of contiguous organs, vascular encasement or obstruction, liver mets. High probability of unresectability if circumferential contiguity of tumour to vessel is >50% (84% sensitive, 98% specific).
5. Obstruction of both the CBD and main pancreatic duct is specific for malignancy in the pancreatic head. F -“double duct sign” is a reliable indicator of an obstructing lesion, although it is not specific for pancreatic adenocarcinoma.
6. CT findings in Cancer of the head of pancreas, which is most correct: (GC) CME02.47
7. Enhancement of lesion during arterial phase is typical. F - hypovascular lesion, with maximal attenuation difference between tumour & pancreas best seen during parenchymal (late arterial) phase. PV phase is ideal for detection of liver mets. About 10% of pancreatic adenoCa are isoattenuating relative to the background parenchyma.
8. There is typically preservation of parenchyma in body and tail of pancreas. F - atrophy of body and tail is an indirect sign (20%).
9. Accuracy of CT with regard to predicting that a tumor is resectable approaches 100%. F - pancreatic adenoCa infiltrates lymphatic vessels early, and local infiltrative disease can manifest as subtle infiltration of peripancreatic tissue. This local invasion can cause underestimation of the true extent and stage of the tumor and is a cause of aborted surgical resection if not identified preoperatively.
10. Accuracy with regard to predicting that a tumor is non-resectable is about 90-100% in most recent series. T - non-resectable if local extension or invasion of contiguous organs, vascular encasement or obstruction, liver mets. High probability of unresectability if circumferential contiguity of tumour to vessel is >50% (84% sensitive, 98% specific).
11. Obstruction of both the CBD and main pancreatic duct is specific for malignancy in the pancreatic head. F -“double duct sign” is a reliable indicator of an obstructing lesion, although it is not specific for pancreatic adenocarcinoma.

TNM staging:
T1 <2cm;
T2 >2cm - both confined to pancreas
T3 extends beyond pancreas but doesn’t involve vessels
T4 involves either coeliac axis or SMA N1 involves regional nodes
M1 distant mets
Stage I (T1 or T2) and stage II (T1-2N1, T3N0-1) are resectable.
Stage III (T4) and stage IV (M1) are unresectable.

Question 71

71. The following statements related to endocrine tumors of the pancreas are true?
72. Gastrinomas are malignant in 10% of cases.
73. About 60% of insulinomas are benign.
74. About 40% of insulinomas are extra-pancreatic.
75. About 70% of insulinomas are < 15mm in diameter.

Answer 71

4.About 70% of insulinomas are < 15mm in diameter. T - avg tumour size 1-2cm.

33. The following statements related to endocrine tumors of the pancreas are true? (GC)
34. Gastrinomas are malignant in 10% of cases. F - 60% are malignant; with mets to liver, spleen, lymph nodes and bone.
35. About 60% of insulinomas are benign. F - 90% are benign (10% associated with MEN 1, 10% are multiple, 10% have islet cell hyperplasia, 10% are malignant).
36. About 40% of insulinomas are extra-pancreatic. F - <1%
37. About 70% of insulinomas are < 15mm in diameter. T - avg tumour size 1-2cm.

Question 72

72. Which is true re intussusception
73. Plain films rarely abnormal
74. Viral gastroenteritis is a recognized aetiological factor
75. Small bowel obstruction is a contraindication to radiological reduction
76. Onset >12hours is a contraindication to radiological reduction
77. Idiopathic in almost half of cases

Answer 72

2.Viral gastroeneteritis is a recognized etiological factor - T - increasing body of evidence suggests that viral triggers may play a role in some cases (ie, seasonal variation of intussusception; has been associated with some forms of rotavirus vaccine; approx 30% of pts experience viral illness before onset)

34. Which is true re intussusception (TW)
35. Plain film is rarely abnormal - F - plain radiographs are less sensitive and less specific than US. A variety of findings can be seen: signs of intestinal obstruction, target sign, soft tissue density projecting into gas of the large bowel (crescent sign).
36. Viral gastroeneteritis is a recognized etiological factor - T - increasing body of evidence suggests that viral triggers may play a role in some cases (ie, seasonal variation of intussusception; has been associated with some forms of rotavirus vaccine; approx 30% of pts experience viral illness before onset)
37. Small bowel obstruction is a contraindication to radiological reduction - F - it causes bowel obstruction.
38. Onset >12 hours is a contraindication to radiological reduction - <1% mortality if performed <24 hrs. Longer duration increases rate of failed reduction and perforation.
39. Idiopathic in almost half of cases – in children approximately 75% of cases are considered idiopathic as there is no clear disease trigger or pathological lead point. Most common cause of intestinal obstruction in infants between 3 and 36 months of age. It is less common before 3/12 and older than 6y. Presence of air in the cecum or terminal ileum cna help exclude intussusception in pts with a low clinical suspicion of the disease. Pneumatic reduction - perforation risk <1% (perf usually in distal side of intussusception, often transverse colon). Other risk factors of perf = <6mo, long duration of symptoms (>/= 3d), evidence of SBO. Success rate 80-95% of pts with ileocolic intussusception. Recurrence 10%. UTD

Question 73

73. Liver

1. Peliosis hepatis is associated with HIV AIDS

Answer 73

yes

Question 74

74. Aassociations:
75. Strongyloides and duodenal stenosis
76. Moraxella catarrhalis is the same as H influenza
77. Chlonorchis sinensis and filling defects on cholangiogram

Answer 74

1 and 3 true

1. Strongyloides and duodenal stenosis. T - Paralytic ileus due to massive intestinal infestation, with mild to moderate dilatation of proximal 2/3 of duodenum and jejunum, oedematous mucosal folds. Ulcerations lead to strictures of the 3rd and 4th parts of duodenum (rigid pipestem appearance and irregular narrowing in advanced cases).
2. Moraxella catarrhalis is the same as H. influenza F - HI: small gram negative coccobacillus; encapsulated and non-encapsulated strains; most common cause of acute exacerbation of COPD. MC: gram negative diplococcus; second most common cause of acute exacn COPD. Along with Strep. pneumoniae, these are the most common causes of otitis media in kids.
3. Chlonorchis sinensis and filling defects on cholangiogram. T - intrahepatic calculi.

Question 75

76. CME US paediatric liver

1. echogenic mass with cysts and calcification is compatible with hepatoblastoma

Answer 75

yesT - typically hypervascular on Doppler, heterogeneous echogenicity from hemorrhage / necrosis. Calcifications in up to half. Lesions are most commonly well defined and have a tendence to displace rather than ivnade adjacent structures. Well-defined, solid, echogenic lesions, which may have a spoked-wheel appearance (Radiographics 2005; Donnelly) Hepatoblastoma is the most common primary liver tumor of childhood (43% of total liver masses). Primarily in children <3yo. Predisposing conditions - Beckwith-Wiedemann, hemihypertrophy, familial polyposis coli, Gardner syndrome, Wilms tumor, biliary atresia. 90% have elevated AFP.

Question 76

77. CME MRCP

1. is highly specific for panc divisum

Answer 76

yes

Question 77

78. Risk of GI carcinoma, false
79. pernicious anemia
80. cathartic colon
81. partial gastrectomy
82. coeliac
83. acanthosis nigrans

Answer 77

2.Cathartic colon F - pseudostrictures (smoothly tapered areas of narrowing due to sustained tonus of circular muscles).

40. Risk of GI carcinoma, which is false: (GC)
41. Pernicious anemia T - increased risk of gastric cancer (risk factor of 2).
42. Cathartic colon F - pseudostrictures (smoothly tapered areas of narrowing due to sustained tonus of circular muscles).
43. Partial gastrectomy T - increased risk of gastric cancer, Bilroth II > Bilroth I. (previously answered F).
44. Celiac T - intestinal T-cell lymphoma.
45. Acanthosis nigricans T - divided into 2 categories: benign and malignant. Malignant AN is a paraneoplastic syndrome due to secretion of a substance from a tumour or in response to the tumour, ie. similar to epidermal growth factor. Gastric adenocarcinoma is by far the most common underlying malignancy (others: lung, uterine). [Dahnert; eMedicine]

Question 78

79. Most common cause of SBO at birth
80. duodenal stenosis
81. malrotation
82. choledochal cyst
83. small bowel atresia
84. meconium ileus

Answer 78

4.small bowel atresia - T - technically includes duodenal atresia

41. Most common cause of SBO at birth: (TW, GC)
42. duodenal stenosis - F - most common cause of high intestinal obstruction in newborns. 30% of duodenal atresia occur in children with down syndrome. 3-5% of DS have DA. (Donnelly)
43. malrotation - F - most cases occur during 1st month of life.
44. choledochal cyst - F
45. small bowel atresia - T - technically includes duodenal atresia
46. meconium ileus - F - assoc with CF. Virtually all infants with MI prove to have CF. Failure to pass meconium within 48h.

Question 79

80. Budd-Chiari, which not a risk factor:
81. Chronic pancreatitis
82. BMT
83. Chemo
84. SLE
85. OCP

Answer 79

1.Chronic pancreatitis F

42. Budd-Chiari, which is not a risk factor: (GC)
43. Chronic pancreatitis F
44. BMT T - thrombosis; vessel wall injury due to immunosuppression/chemo.
45. Chemo T - thrombosis; vessel wall injury
46. SLE. T - 27-42% of SLE pts have antiphospholipid syndrome, characterised by arterial and venoocclusive disease, thrombocytopaenia, and recurrent vascular thromboses & miscarriages. Can present with recurrent strokes, Budd-Chiari, dural venous sinus thrombosis, ischaemic bowel, and recurrent PE.
47. OCP T - thrombosis; hypercoagulable state. Causes: idiopathic (2/3). Thrombosis - hypercoagulable state (5P’s: PCV, pill, pregnancy, increased plts, PNH), or injury to vessel wall (XRT, chemo/IS in BMT patients, Jamaican bush tea) Non-thrombotic - tumour extension into IVC (RCC, HCC), IVC diaphragm (congenital, acquired), right atrial tumour, constrictive pericarditis, RHF. [Dahnert; SLE RG 2004]

Question 80

82. Associations:
83. Strongyloides and duodenal stenosis
84. Moraxella catarrhalis is the same as H influenza

Answer 80

44. Associations: (GC)
45. Strongyloides and duodenal stenosis T - Paralytic ileus due to massive intestinal infestation, with mild to moderate dilatation of proximal 2/3 of duodenum and jejunum, oedematous mucosal folds. Ulcerations lead to strictures of the 3rd and 4th parts of duodenum (rigid pipestem appearance and irregular narrowing in advanced cases).

2.Moraxella catarrhalis is the same as H influenza F - HI: small gram negative coccobacillus; encapsulated and non-encapsulated strains; most common cause of acute exacerbation of COPD. MC: gram negative diplococcus; second most common cause of acute exacn COPD. Along with Strep. pneumoniae, these are the most common causes of otitis media in kids.

Question 81

83. CME Phaeo, false

1. hemihypertrophy is a known association

Answer 81

45.CME Phaeo, false (–) 1.hemihypertrophy is a known association “We speculate that the combination of congenital hemihypertrophy and pheochromocytoma is not coincidental and could be part of the clinical spectrum of the Beckwith-Wiedemann syndrome.” – There are a couple of case reports only, expected answer is most likely false.

Question 82

85. Prune belly, which is false:
86. Abdo wall defect
87. Cryptorchidism
88. Pulmonary hypoplasia
89. Stricture posterior urethra
90. Reflux

Answer 82

4. Stricture posterior urethra F (previously answered T) - Infravesical obstruction or obstruction at the prostatic urethra was originally thought to be due to a type I posterior urethral valve. This theory has been replaced by a new notion that the obstruction may be caused by severe angulation at the prostatic and membranous urethral junction. This may be due to a lack of striated muscle in the membranous urethra or urogenital diaphragm or a ring of obstructive tissue acting as a flap valve due to hypoplasia of the prostate, creating a ballooning of the prostatic urethra. In these patients, studies have also shown that the smooth muscle in the prostate is reduced and the connective tissue content is increased, which may lead to a functional obstruction. Anterior urethral abnormalities range from atresia to megalourethra (fusiform and scaphoid types). The fusiform type is associated with deficient corpora cavernosa and more severe renal defects; scaphoid megalourethra is associated with deficiency of the corpus spongiosum with a normal glans and fossa navicularis. [eMedicine]
5. Reflux T - vesicoureteric reflux in >70%.
6. Prune belly, which is false: (GC)
7. Abdo wall defect T - muscle deficiency due to pressure effects from massive abdo distension.
8. Cryptorchidism T - bilateral; bladder distension interferes with descent of testes. Increased risk of malignant degeneration.
9. Pulmonary hypoplasia T - lungs are affected in 55% of cases. Potter’s sequence occurs in severe urethral obstruction, with 20% death within 1 month and 50% death within 2 yrs due to renal failure +/- pulmonary insufficiency.
10. Stricture posterior urethra F (previously answered T) - Infravesical obstruction or obstruction at the prostatic urethra was originally thought to be due to a type I posterior urethral valve. This theory has been replaced by a new notion that the obstruction may be caused by severe angulation at the prostatic and membranous urethral junction. This may be due to a lack of striated muscle in the membranous urethra or urogenital diaphragm or a ring of obstructive tissue acting as a flap valve due to hypoplasia of the prostate, creating a ballooning of the prostatic urethra. In these patients, studies have also shown that the smooth muscle in the prostate is reduced and the connective tissue content is increased, which may lead to a functional obstruction. Anterior urethral abnormalities range from atresia to megalourethra (fusiform and scaphoid types). The fusiform type is associated with deficient corpora cavernosa and more severe renal defects; scaphoid megalourethra is associated with deficiency of the corpus spongiosum with a normal glans and fossa navicularis. [eMedicine]
11. Reflux T - vesicoureteric reflux in >70%. Congenital non-hereditary multisystem disorder due to primary mesodermal arrest at 6-10wks GA; almost exlcusively in males. Two groups: 1. Severe urethral obstruction (eg. atresia) - assocd with malrotation, skeletal abn, cong heart disease, CCAM; poor prognosis (Potter’s seq). 2. Functional abnormality of bladder emptying - no assocd anomalies but get chronic GU problems. [Dahnert]

Question 83

87. Regarding the bowel, which is not true:
88. Need greater than 1ml/min for diagnosis of bleeding site on angiography
89. Diverticula in the right colon are more likely to bleed then on the left
90. 20% of bleeding is from angiodysplasia
91. Obstruction of a large vessel will result in stricturing
92. CO 2 angiogram better because of decreased viscosity

Answer 83

4.Obstruction of the a large vessel will result in stricturing – if patient doesn’t perforate and has good collaterals it can stricture. More likely to perforate and die with total occlusion of large vessel with acute ischaemia.

49. Regarding the bowel, which is not true: (–)
50. Need greater than 1ml/min for diagnosis of bleeding site on angiography – angio 0.5ml/min B&H. 0.1ml/min for nuclear medicine bleeding study.
51. Diverticula in the right colon are more likely to bleed then on the left -T
52. 20% of bleeding is from angiodysplasia – 20% Robbins. 50% B&H (6% lower GI bleeding, 2%upper GI bleeding (eMed)).
53. Obstruction of the a large vessel will result in stricturing – if patient doesn’t perforate and has good collaterals it can stricture. More likely to perforate and die with total occlusion of large vessel with acute ischaemia.
54. CO 2 angiogram better because of decreased viscosity - T

Colonic Diverticular Haemorrhage not related to diverticulitis 3-47% of diverticulosis 75% located in ASCENDING colon (larger neck and dome of diverticula) 3 x more likely on the right Massive rectal haemorrhage c/o pan Tx is vasopressin 90% success at controlling bleeding, 20% rebleed rate

Question 84

88. Which are not associations?
89. Barrett’s and adenocarcinoma
90. Scleroderma and oesophageal stricture
91. Dermatomyositis and lower 1/3 oeosphageal abnormal contractility
92. Moya moya and scoliosis
93. Trisomy 17 and aqueduct stenosis

Answer 84

3.Dermatomyositis and lower 1/3 oeosphageal abnormal contractility - F - Proximal 1/3 of oesophagus atony and dilation - as it involves the striated muscle of the pharynx and upper oesophagus (RG 2006:26:e22)

50. Which are not associations? (JS)
51. Barrett’s and adenocarcinoma – T - up to 40 times higher risk than the general population (Robbins)
52. Scleroderma and oesophageal stricture – T - develop strictures late, typically fusiform stricture 4-5cm above the GOJ due to reflux oesophagitis (Dahnert)
53. Dermatomyositis and lower 1/3 oeosphageal abnormal contractility - F - Proximal 1/3 of oesophagus atony and dilation - as it involves the striated muscle of the pharynx and upper oesophagus (RG 2006:26:e22)
54. Moya moya and scoliosis – T - NF1 is associated with moya moya (60-70%) and spinal abnormalities such as kyphoscoliosis (50%) according to Dahnert
55. Trisomy 17 and aqueduct stenosis - F - I can only find X-linked hydrocephalus in association with aqueduct stenosis.

Question 85

89. Internal herniation, which is false?
90. Mesentery extending between IVC and the portal vein indicates herniation into the foramen of Winslow
91. Retrocaecal space is the largest pericaecal space
92. Paraduodenal hernia occur especially on the right
93. Herniation into the uterine ligament usually involves the small intestine
94. Something else about paraduodenal hernias

Answer 85

3.Paraduodenal hernia occur especially on the right – Left 75%, Right 25% Paraduodenal hernia, 53% of internal hernias. Congenital defect in descending mesocolon. Frequently asymptomatic. 75% left thru fossa of Landzert – displaces inferior mesenteric vein. 25% Right thru mesentericoparietal fossa of Waldeyer – predisposed in small bowel malrotation.

Question 86

90. Pneumotosis Coli, which is not recognized?
91. Neutropenia with colitis
92. Scleroderma
93. Pseudomyxoma peritonei
94. CF
95. Trauma

Answer 86

3.Pseudomyxoma peritonei is not a recognised cause

Question 87

91. Thickened small bowel folds, which is true?
92. Multiple jejunal nodules are seen in coeliac disease
93. There is an increase in the no. of jejunal folds in coeliac disease
94. Systemic sclerosis is typically associated with thickened folds
95. Nodular jejunal folds are seen in Whipples disease
96. Haematogenous mets are typically seen on the mesenteric border of the small intestine

Answer 87

4.Nodular jejunal folds are seen in Whipples disease T - infection with Tropheryma whippelii; mucosal/submucosal infiltration by PAS+ve macrophages combined with lymphatic obstruction; results in moderate thickening of jej/duo folds, micronodularity (=swollen villi) and wild mucosal pattern. No/minimal SB dilatation, no rigidity of folds, no ulcerations, normal transit time.

53. Thickened small bowel folds, which is true? (GC)
54. Multiple jejunal nodules are seen in coeliac disease F - small bowel dilatation is the hallmark of untreated CD. May see nodular changes in duodenum (“bubbly bulb”) due to peptic duodenitis. In 10% of sprue cases, a mosaic pattern may be present in the small bowel (1-2mm polygonal islands of mucosa surrounded by Ba-filled distinct grooves).
55. There is an increase in the no. of jejunal folds in coeliac disease F - decreased no. of folds in the proximal jejunum (<= 3 folds per inch, due to villous atrophy), increased no. of folds in the distal ileum (>5 per inch). ie. reversal of fold patterns or “jejunization” of ileal loops; this is a specific sign that represents an adaptive response to decreased jejunal mucosal surface. Primer: “the jejunum looks like the ileum, the ileum looks like the jejunum, and the duodenum looks like hell”.
56. Systemic sclerosis is typically associated with thickened folds F - dilated loops with tightly packed, normal-thickness folds (“hidebound/accordion” pattern).
57. Nodular jejunal folds are seen in Whipples disease T - infection with Tropheryma whippelii; mucosal/submucosal infiltration by PAS+ve macrophages combined with lymphatic obstruction; results in moderate thickening of jej/duo folds, micronodularity (=swollen villi) and wild mucosal pattern. No/minimal SB dilatation, no rigidity of folds, no ulcerations, normal transit time.
58. Haematogenous mets are typically seen on the mesenteric border of the small intestine F - haematogenous mets have a predilection for the antimesenteric border; cf. intraperitoneal spread of tumour invovles the mesenteric border.

Question 88

92. Blunt trauma, which is false:
93. Increased duodenum and jejunum
94. Most common cause of pneumoperitoneum
95. Fluid b/n loops highly suggestive
96. Focal thickening
97. Intense enhancement

Answer 88

2.Most common cause of pneumoperitoneum – F - penetrating injury is a more common cause. Sensitivity is 44-55%. Pneumoperitoneum is not diagnostic of perforation - can occur with barotrauma and mechanical ventilation. (RG)

54. Blunt trauma, which is false: (JS)
55. Increased duodenum and jejunum – T - jejunum distal to lig of Treitz > duodenum > ascending colon at ileocaecal valve > descending colon. Related to areas that are relatively fixed.
56. Most common cause of pneumoperitoneum – F - penetrating injury is a more common cause. Sensitivity is 44-55%. Pneumoperitoneum is not diagnostic of perforation - can occur with barotrauma and mechanical ventilation. (RG)
57. Fluid b/n loops highly suggestive - T - free fluid may be related to solid organ injury but fluid between bowel loops is more suggestive of bowel or mesenteric injury. (RG)
58. Focal thickening – T - Seen in 75% of transmural injuries and is more sensitive for bowel wall injury than extravasation or pneumoperitoneum. Greater than 3mm with adequate distention is considered abnormal. (RG)
59. Intense enhancement – T - due to reduced perfusion and interstitial leak of contrast material (RG) / delayed venous transit time (Dahnert) Radiographics 2000;20:1525-1536.

Question 89

93. Which is true re: colonic polypoid lesions:
94. Majority of colonic lipomas occur in the sigmoid colon
95. Colonic lipomas should be considered premalignant
96. Rectal carcinoid <2cms has a low risk of malignancy
97. Colonic adenoma >5mm has a 10% risk of malignancy
98. Hyperplastic polyps are premalignant

Answer 89

3.Rectal carcinoids smaller than 2cms are at low risk of being malignant T - Incidence of mets is related to size: tumours <1cm - 2% metastasize; 1-2cm - 50%; >2cm - 85%. Also depends on location: tumours in rectum metastasize in only 1% (cf. ileum 35%).

55. Which is true re: colonic polypoid lesions: (GC) 1.Majority of colonic lipomas occur in the sigmoid colon F - most commonly in caecum and ascending colon.
56. Colonic lipomas should be regarded as premalignant F - no liposarcomatous degeneration.
57. Rectal carcinoids smaller than 2cms are at low risk of being malignant T - Incidence of mets is related to size: tumours <1cm - 2% metastasize; 1-2cm - 50%; >2cm - 85%. Also depends on location: tumours in rectum metastasize in only 1% (cf. ileum 35%).
58. Colonic adenoma of diameter 5mm has about a 10% chance of being malignant F - incidence of malignancy for polyps: <5mm = 0.5%5-9mm = 1%10-20mm =5-10%>20mm = 10-50% malignant.
59. Hyperplastic polyps are regarded as premalignant F - Non-neoplastic polyps include hyperplastic, hamartomatous and inflammatory. Some hamartomatous polyposis syndromes (Peutz-Jegher, Cowden, Juvenile polyposis) have an increased prevalence of coexisiting adenomas and adenoma-Ca sequence. Neoplastic polyps are tubular, tubulovillous, and villous. Nonepithelial polypoid tumours include carcinoid, leiomyoma, lipoma, haemangioma, lymphangioma, fibroma, neurofibroma.

Question 90

94. Which is true re: solitary rectal ulcer syndrome:
95. Associated with rectal carcinoma
96. Diagnosis excluded if multiple ulcers
97. Anterior rectal wall prolapse is a feature
98. Evacuation proctography is usually normal
99. Associated with ulcerative colitis

Answer 90

3.Anterior rectal wall prolapse is a feature T - aka mucosal prolapse syndrome: prolapse of anterior rectal wall  mucosal ischaemia due to traumatisation from the anal sphincter during defaecation. Patients typically present with PR bleeding and pain on defaecation.

56. Which is true re: solitary rectal ulcer syndrome: (GC)
57. Associated with rectal carcinoma F - but is an important differential.
58. Diagnosis excluded if multiple ulcers F - may be small or large, single or multiple.
59. Anterior rectal wall prolapse is a feature T - aka mucosal prolapse syndrome: prolapse of anterior rectal wall  mucosal ischaemia due to traumatisation from the anal sphincter during defaecation. Patients typically present with PR bleeding and pain on defaecation.
60. Evacuation proctography is usually normal F - there is failure of the anorectal angle to open while straining.
61. Associated with ulcerative colitis F - not in Dahnert. But there is an article on this in GI Endoscopy 2006 (via MD consult if you guys can access it!)

Question 91

95. Which is true re: oesophagus T/F:
96. Obliteration of the fat plane around tumour indicates non resectibility
97. Leiomyoma characteristically in proximal third
98. Leiomyomas typically ulcerate
99. Increased incidence of adenocarcinoma in achalasia
100. Spindle cell tumours characteristically expand the lumen without obstruction

Answer 91

5.Spindle cell tumours characteristically expand the lumen without obstruction – T - usually mid third of oesophagus, cause large bulky smooth intraluminal mass. Although the mass is large and bulky, there is relatively little obstruction to the flow of contrast material (Eisenberg, GI Radiology and also in Mayo Clinic GI review)

57. Which is true re: oesophagus T/F: (JS)
58. Obliteration of the fat plane around tumour indicates non resectibility – F - “Although obliteration of the fat plane is a reliable sign of tumour involvement of adjacent structures, it can also occur in cachectic patients or in patients who have undergone radiation therapy or surgery” RG 2009;29(2):403. Involvement of aorta of greater than 90 degrees of its circumference - resection contraindicated. Important areas to assess are prevertebral fascia, trachea, left mainstem bronchus and aorta to determine resectability. T3 or T4 tumours are often offered preop chemorads so I’m not sure that local invasion indicates non-resectability
59. Leiomyoma characteristically in proximal third – F - occur lower and mid third oesophagus (Dahnert)
60. Leiomyomas typically ulcerate - F - large smooth well-defined intramural mass with eccentric thickening of the wall and deformity of the lumen, may calcify, ulceration is extremely uncommon (Dahnert)
61. Increased incidence of adenocarcinoma in achalasia – F – SCC. Adeno in scleroderma
62. Spindle cell tumours characteristically expand the lumen without obstruction – T - usually mid third of oesophagus, cause large bulky smooth intraluminal mass. Although the mass is large and bulky, there is relatively little obstruction to the flow of contrast material (Eisenberg, GI Radiology and also in Mayo Clinic GI review)

Question 92

96.Which is false re: Barrett’s:

1. Increased risk of SCC
2. Classically mid to lower oesophageal stricture on barium studies
3. Associated with reticular mucosal pattern on barium swallow
4. Associated with sliding hiatus hernia
5. Associated with scleroderma

Answer 92

1.Increased risk of SCC. – F - increased risk of adenocarcinoma (30-40 times greater with more than 2cm of Barretts) - Robbins 58.

Which is false re: Barrett’s: (JS)

1. Increased risk of SCC. – F - increased risk of adenocarcinoma (30-40 times greater with more than 2cm of Barretts) - Robbins
2. Classically mid to lower oesophageal stricture on barium. T - middle (40%) to lower oesophagus (60%) (Dahnert)
3. Associated with reticular mucosal pattern on barium swallow. - T - reticular mucosal pattern in the distal oesophagus is the most sensitive finding (Primer)
4. Associated with sliding hiatus hernia. - T - hiatus hernia in 75-94% (Dahnert)
5. Associated with scleroderma. - T - Scleroderma causes a patulous LOS which predisposes to reflux and then Barretts

Question 93

97. Which is true re: intussusception:
98. Plain film is rarely abnormal
99. Viral gastroeneteritis is a recognized etiological factor
100. Small bowel obstruction is a contraindication to radiological reduction
101. Onset >12 hours is a contraindication to radiological reduction
102. Idiopathic in almost half of cases

Answer 93

2.Viral gastroeneteritis is a recognized etiological factor - T - most cases in children are thought to be related to lymphoid hypertrophy in the terminal ileum secondary to viral disease (Donnelly)

59. Which is true re: intussusception: (JS)
60. Plain film is rarely abnormal – F - “Radiographs are rarely completely normal” (Donnelly). Findings include paucity of gas in right abdomen, nonvisualisation of caecum, s
61. Viral gastroeneteritis is a recognized etiological factor - T - most cases in children are thought to be related to lymphoid hypertrophy in the terminal ileum secondary to viral disease (Donnelly)
62. Small bowel obstruction is a contraindication to radiological reduction - F - SBO results from intussusception. Contraindications include peritonitis or pneumoperitoneum. Also need adequate fluid resuscitation prior to attempting reduction.
63. Onset >12 hours is a contraindication to radiological reduction - F - Rate of failed reduction is greater if there has been prolonged history (>24h) but this is not a contraindication. <1% mortality if performed <24 hrs.
64. Idiopathic in almost half of cases – F - idiopathic in approximately 90%CME variant

Question 94

98. Which is false in abdomen in patients with AIDS:
99. Small bowel dilatation is a recognized feature of mycobacterium avium infection
100. Toxic megacolon is a recognized feature
101. Perirectal masses are recognized
102. Lack of LN contrast enhancement assoc with Kaposi is typical
103. Reactive hyperplasia is the commonest cause of lymphadenopathy

Answer 94

4. Lack of LN contrast enhancement assoc with Kaposi is typical – F - Typically show strong enhancement due to their high vascularity
5. Which is false in abdomen in patients with AIDS: (JS)
6. Small bowel dilatation is a recognized feature of mycobacterium avium infection – T - Features include mild dilatation of small bowel (jejunum), wall thickening, diffuse irregular mucosal fold thickening, mesenteric lymphadenopathy, hepatosplenomegaly, small echogenic foci in liver and spleen. (Dahnert)
7. Toxic megacolon is a recognized feature – T - Patients with advanced HIV are predisposed to pseudomembranous colitis which is a cause of Toxic megacolon. (Dahnert)
8. Perirectal masses are recognized - T - anorectal conditions are common including perirectal abscess or EBV associated lymphoma
9. Lack of LN contrast enhancement assoc with Kaposi is typical – F - Typically show strong enhancement due to their high vascularity
10. Reactive hyperplasia is the commonest cause of lymphadenopathy – T - most common (according to Dahnert). Other causes are lymphoma, infection (MAC, P carinii)

Question 95

99.Which is not an association:

1. Caroli’s and medullary sponge kidney
2. Neonatal NEC and maternal diabetes
3. Supravalvular aortic stenosis and hypercalcaemia
4. Typhilitis and haematological malignancy
5. Desmoid tumour and familial polposis coli

Answer 95

2.Neonatal NEC and maternal diabetes - F - NEC is seen with prematurity, Hirschsprung disease and bowel obstruction. Maternal diabetes is associated with fetal macrosomia, IUFD, placental insufficiency, polyhydramnios and prematurity.

61. Which is not an association: (JS)
62. Caroli’s and medullary sponge kidney - T - Caroli disease is associated with benign renal tubular ectasia, medullary sponge kidney, infantile polycystic kidney disease, choledochal cyst and congenital hepatic fibrosis. Medullary sponge kidney is associated with Ehlers-Danlos syndrome, parathyroid adenoma and Caroli disease.
63. Neonatal NEC and maternal diabetes - F - NEC is seen with prematurity, Hirschsprung disease and bowel obstruction. Maternal diabetes is associated with fetal macrosomia, IUFD, placental insufficiency, polyhydramnios and prematurity.
64. Supravalvular aortic stenosis and hypercalcaemia – T - supravalvular AS is associated with infantile hypercalcaemia syndrome, Marfans syndrome, Williams syndrome.
65. Typhilitis and haematological malignancy - T - typhilitis is seen in leukaemia, aplastic anaemia, lymphoma, immunosuppressive therapy, neutropenia, MDS and AIDS
66. Desmoid tumour and familial polposis coli – T - Gardners syndrome = colonic polyposis, osteomas and soft-tissue tumours (including desmoid tumours)CME

Question 96

100. Regarding carcinoma of the oesophagus (which is false):
101. CT can reliably distinguish between T2 and T3 lesions
102. Bulging and/ or displacement of the tracheobronchial tree is a strong indicator of invasion
103. Involvement of the celiac nodes indicates M1 disease
104. Endosonography is the most accurate means of pre operative local staging
105. On CT, loss of the fat in the triangle formed by the aorta, oesophagus and vertebral body is a reliable indicator of aortic involvement

Answer 96

1.CT can reliably distinguish between T2 and T3 lesions - F - CT is unable to differentiate between T1, T2 and T3 disease (RG).

‘62.Regarding carcinoma of the oesophagus: (which is false) (JS)

1. CT can reliably distinguish between T2 and T3 lesions - F - CT is unable to differentiate between T1, T2 and T3 disease (RG).
2. Bulging and/ or displacement of the tracheobronchial tree is a strong indicator of invasion - T - CT criteria for local invasion include loss of fat planes between the tumour and adjacent structures in the mediastinum, displacement or indentation of mediastinal structures, aortic invasion is suggested if 90 degrees or more of the aorta is in contact with the tumour or if there is obliteration of the triangular fat space between the oesophagus, aorta and spine adjacent to the primary (RG)
3. Involvement of the celiac nodes indicates M1 disease - T - see below. Note that for a lower oesophageal tumour, a gastric lymph node is N1 disease
4. Endosonography is the most accurate means of pre operative local staging - T - can visualise layers of oesophageal wall to determine depth of tumour invasion (RG)
5. On CT, loss of the fat in the triangle formed by the aorta, oesophagus and vertebral body is a reliable indicator of aortic involvement - T - see above

Staging of oesophageal ca: 
T1 = lamina propria or submucosal invasion,  
T2 = Muscularis propria  
T3 = adventitia  
T4 = adjacent structures 

N0 = no regional nodes 
N1 = regional nodes 

M0 = no distant mets
M1 = depends on location of primary
Proximal oesoph
M1a = cervical LN mets
M1b = all other mets
Mid oesoph
M1b = all distant mets (no M1a category)
Distal oesoph
M1a = coeliac axis LN mets
M1b = all other mets

Question 97

101. CT Colonography, which is true:
102. IV glucagon distends colon
103. Impassable lesion is better evaluated with CT colonography than conventional colonoscopy
104. Water contrast is used in CT colonography

Answer 97

2.Impassable lesion is better evaluated with CT colonography than conventional colonoscopy - T – to exclude synchronous tissue distal to impassable lesion

63. CT Colonography, which is true: (TW)
64. IV glucagon distends colon - F - relaxes smooth muscle to decrease motility. Antispasmodic. Trials have shown glucagon did not significantly improve colonic distention in supine or prone patients.
65. Impassable lesion is better evaluated with CT colonography than conventional colonoscopy - T – to exclude synchronous tissue distal to impassable lesion
66. Water contrast is used in CT colonography

Question 98

102. Regarding the fetal gastrointestinal tract, true/false:
103. Rectal atresia is associated with polyhydramnios
104. Visualised stomach excludes oesohpageal atresia
105. Anorectal atresia

Answer 98

64. Regarding the fetal gastrointestinal tract, true/false: (–)
65. Rectal atresia is associated with polyhydramnios – F - 50% duodenal atresia but rare in ileal, colonic or rectal atresia. *LW, agree that it is false; regarding colonic atresia, and thus hypothesising to rectal atresia pathophysiology - polyhydramnios is rare in colonic atresia (as most fluid resorption happens in small bowel) and, when present, should raise the suspicion that a more proximal obstruction is present.
66. Visualised stomach excludes oesohpageal atresia – F - associated TOF or gastric secretions.
67. Anorectal atresia – F – amniotic volume normal

Question 99

103. Achalasia of the oesophagus, which is false:
104. Dilated vestibule
105. 25% have a dilated oesophagus and colon with chagas
106. Oesophageal perforation common
107. Most oesophageal perforations are iatrogenic

Answer 99

1.Dilated vestibule - F - vestibule is in the region of the LOS which fails to relax in achalasia - beaked tapering at GOJ 65.

Achalasia of the oesophagus, which is false: (–)

1. Dilated vestibule - F - vestibule is in the region of the LOS which fails to relax in achalasia - beaked tapering at GOJ
2. 25% have a dilated oesophagus and colon with Chagas – T -The digestive forms of the disease lead to megaesophagus and/or megacolon in approximately one third of chronic cases, of which 20-50% also present with an associated cardiopathy.
3. Oesophageal perforation common - Pneumatic dilatation for achalasia carries a significant and recognized risk of esophageal perforation (5%). Obtain from patients prior to the dilatation an informed consent emphasizing this risk of perforation. (True if 5% is common)
4. Most oesophageal perforations are iatrogenic T – treatment as above. Achalasia: failure of organised peristalsis and relaxation of the lower oesophageal sphincter.

Question 100

104. Features of scleroderma include:
105. Upper third of oesophagus is preserved
106. Colon involvement rare
107. GIT involvement is rare
108. Oesophageal perforation is common

Answer 100

1.Upper third of oesophagus is preserved T - causes atony and aperistalsis of the lower 2/3 of oesophagus with patulous LOS and GOR 66.

Features of scleroderma include: (JS)

1. Upper third of oesophagus is preserved T - causes atony and aperistalsis of the lower 2/3 of oesophagus with patulous LOS and GOR
2. Colon involvement rare –F - colon is involved in 40-50% with pseudosacculations, eventual loss of haustra, marked dilatation and stercoral ulceration from retained faecal material
3. GIT involvement is rare – F - third most common manifestation (after skin and Raynaud’s), occurs in 40-45%
4. Oesophageal perforation is common - F - not mentioned in Dahnert, Primer or Mayo clinic book

Question 101

105.Which of the following associations are well recognized:

1. Scleroderma and SCC
2. Dermatomyositis and disordered peristalsis of the oesophagus
3. Caroli’s disease and increased risk of HCC
4. Dermoids and FPC
5. Increased age and decreased caliber of the main pancreatic duct

Answer 101

67.Which of the following associations are well recognized: (–)

1. Scleroderma and SCC - F
2. Dermatomyositis and disordered peristalsis of the oesophagus - T (*LW: agree, upper skeletal muscle ospahgus disordered peristalsis).
3. Caroli’s disease and increased risk of HCC - F – increased risk of cholangiocarcinoma
4. Dermoids and FPC: LW - False; presuming they mean familial polyposis colon cancer i.e. Gardner syndrome, which is DESMOIDS and Epidermoid cysts….so sneaky (AJL - Good spot LW)
5. Increased age and decreased caliber of the main pancreatic duct - F – inc age, inc duct size

Question 102

106. Oesophageal stricture:
107. NG tube results in short stricture
108. Pseudodiverticulosis only results in a short segment proximal stricture
109. Endoscope glutaraldehyde results in a long segment stricture
110. Epidermolysis bullosa results in a long segment distal stricture

Answer 102

3.Endoscope glutaraldehyde results in a long segment stricture - T - causes a long stricture with a history of previous endoscopy. Glutaraldehyde is a disinfectant used for sterilising scopes that can cause damage to mucosa if there is inadequate rinsing of equipment post sterilisation. (RG)

68. Oesophageal stricture: (JS, GC, TW)
69. NG tube results in short stricture - F - prevent closure of LOS resulting in reflux and oesophagitis, develop long-segment distal strictures whose length and severity increase rapidly over time (RG)
70. Pseudodiverticulosis only results in a short segment proximal stricture - F - may have a short or long segment stricture in upper or midoesophagus or alternatively may have localised stricture in the distal oesophagus presumably related to reflux oesophagitis. (RG)
71. Endoscope glutaraldehyde results in a long segment stricture - T - causes a long stricture with a history of previous endoscopy. Glutaraldehyde is a disinfectant used for sterilising scopes that can cause damage to mucosa if there is inadequate rinsing of equipment post sterilisation. (RG)
72. Epidermolysis bullosa results in a long segment distal stricture - F - skin diseases are characterised by bullae, ulcers and eventual stricture formation with one or more segments of concentric or asymmetric narrow in the upper or mid oesophagus sometimes with associated webs. (RG)

Question 103

107. With regards to small left colon syndrome, which of the following is false:
108. Bowel dilatation proximal to the splenic flexure
109. Association with maternal diabetes
110. Association with cystic fibrosis
111. Immaturity of the myenteric plexus

Answer 103

3.Association with cystic fibrosis F - NOT related to CF. May see a meconium plug, but this is as a result (and not the cause) of obstruction. ie. meconium plug (SLC) syndrome, cf. meconium ileus in CF babies.

69. With regards to small left colon syndrome, which of the following is false: (GC)
70. Bowel dilatation proximal to the splenic flexure T - colonic calibre becomes abruptly diminuitive distal to splenic flexure.
71. Association with maternal diabetes T - also maternal substance abuse.
72. Association with cystic fibrosis F - NOT related to CF. May see a meconium plug, but this is as a result (and not the cause) of obstruction. ie. meconium plug (SLC) syndrome, cf. meconium ileus in CF babies.
73. Immaturity of the myenteric plexus T - results in a transient functional colonic obstruction.

Question 104

108. The following associations are well recognized:
109. Intramural oesophageal pseudodiverticulosis and oesophageal carcinoma
110. Strongyloidiosis and stenosis of the duodenum

Answer 104

70. The following associations are well recognized: (JS) 1.Intramural oesophageal pseudodiverticulosis and oesophageal carcinoma - F - dilated excretory ducts of deep mucous glands, rare, associated with diabetes, alcohol, severe oesophagitis and oesophageal stricture, causes multiple tiny rounded barium collections in longitudinal rows parallel to long axis of oesophagus that do not appear to communicate with the lumen (Dahnert)
71. Strongyloidiosis and stenosis of the duodenum - T - stricture of the 3rd and 4th part of duodenum (Dahnert)

Question 105

109. In imaging of peritoneum and omentum which of the following is true:
110. Paraduodenal hernia result in herniation of viscera through the foramen of Winslow
111. A Richters hernia typically presents with obstruction on plain film
112. On CT, mesenteric panniculitis is seen to surround vessels rather than displace them
113. Fluid seen over the bare area of the liver is intraperitoneal
114. Segmental omental infarction in the majority of patients shows left sided abdominal changes on CT

Answer 105

3. On CT, mesenteric panniculitis is seen to surround vessels rather than displace them T - (See below)
4. Paraduodenal hernia result in herniation of viscera through the foramen of Winslow F - passes through the fossa of waldeyer. (Left paraduodenal hernia is more common and passes through the fossa of landzert.
5. A Richter’s hernia typically presents with bstruction on a plain film F - entrapment of antimesenteric border of bowel in hernia orifice, usually seen in older women with femoral hernias; partial obstruction with patent bowel lumen; rarely causes SBO. *LW more commonly present with incaration ithout obstruction, as only single wall (antimesenteric wall) extends into hernia, so hence wont presetn as obstuction on AXR.
6. On CT, mesenteric panniculitis is seen to surround vessels rather than displace them T - the mass may envelop the mesenteric vessels, and collateral vessels may develop over time. There may be preservation of fat around the mesenteric vessels (“fat ring sign”); helps distinguish sclerosing mesenteritis from other mesenteric processes such as lymphoma, carcinoid tumor, or carcinomatosis. [RG 2003]
7. Fluid seen over the bare area of the liver is intraperitoneal F - bare area is situated btn reflections of right and left coronary ligts, continuous with the right anterior pararenal space.
8. Segmental omental infarction in the majority of patients shows left sided abdominal changes on CT F - most often right-sided.

Question 106

110. Small bowel dilatation in the absence of small bowel obstruction is seen in:
111. Eosinophilic enteritis
112. Lymphoma
113. Scleroderma
114. Carcinoid
115. Sprue

Answer 106

Lyphoma, scleroderma, sprue

72. Small bowel dilatation in the absence of small bowel obstruction is seen in: (GC)
73. Eosinophilic enteritis. F - causes thickened folds of stomach and small bowel.
74. Lymphoma. T - with normal (due to bowel wall destruction), thickened smooth (lymphatic blockage), or thickened irregular folds.
75. Scleroderma. T - marked dilatation of small bowel + normal fold thickness (smooth m. atrophy), esp. duodenum; hidebound/accordian pattern in 60%.
76. Carcinoid F - causes separation of loops and tethered folds (5HT-induced desmoplastic reaction); could theoretically see dilated loops as a sequelae of mesenteric ischaemia.
77. Sprue. T - due to excessive fluid in the setting of malabsorption.[Dahnert, p776-7]

Question 107

111. The following associations can be made:
112. Giardia with ileal strictures
113. Strongyloidosis and duodenal stenosis
114. Amoeba and apthous ulceration of the colon
115. Yersinia and inflammatory strictures

Answer 107

2 and 3

73. The following associations can be made: (GC)
74. Giardia with ileal strictures. F - overgrowth of commensal parasite. Thickened distorted mucosal folds in duodenum and jejunum (mucosal oedema) with normal ileum; marked spasm, hypersecretion, hyperperistalsis/rapid transit time, segmentation of barium (from motility disturbance and excess intraluminal fluid).
75. Strongyloidosis and duodenal stenosis. T - Paralytic ileus due to massive intestinal infestation, with mild to moderate dilatation of proximal 2/3 of duodenum and jejunum, oedematous mucosal folds. Ulcerations lead to strictures of the 3rd and 4th parts of duodenum (rigid pipestem appearance and irregular narrowing in advanced cases). Filiform larva in contaminated soil penetrates skin/mm, passes from subcutaneous tissues to lung via lymphatics/venous circulation. Ascends airways and gets swallowed, settles in duodenum and matures into worm, lays eggs into GI lumen that are then excreted faecally.

3.Amoeba and apthous ulceration of the colon. T - invades areas of relative stasis (right colon & caecum 90% > hepatic & splenic flexures > rectosigmoid). Loss of haustral pattern with granular appearance, collarbutton ulcers, cone-shaped caecum, several cm long colonic stenosis (result of healing and fibrosis), amoeboma (hyperplastic granuloma with bacterial invasion of amoebic abscess), thickened fixed open ileocaecal valve.
4
.Yersinia and inflammatory strictures. F - gram negative bug; affects terminal ileum - thickened folds and ulceration, lymphoid nodular hyperplasia.

Question 108

112. Bowel Ischaemia:
113. Can be related to superior mesenteric vein thrombosis
114. Is associated with paroxysmal nocturnal haemoglobinuria
115. Vasospasm indicates underlying atherosclerosis and stenosis
116. Occlusion is typically 10cm distal to the SMA origin
117. Plain film changes are only seen after bowel infarction

Answer 108

1 and 2 true

74. Bowel Ischaemia: (GC)
75. Can be related to superior mesenteric vein thrombosis. T - accounts for <10% of all cases of mesenteric ischaemia. Mechanism is a massive influx of fluid into the bowel wall and lumen, resulting in systemic hypovolaemia and hemoconcentration; resulting bowel oedema and decreased outflow secondary to venous thrombosis impede the inflow of arterial blood, which leads to bowel ischaemia. SMV > IMV > portal vein.
76. Is associated with paroxysmal nocturnal haemoglobinuria. T - hypercoagulable state due to destruction of abnormally sensitive RBCs, granulocytes and platelets by activated complement, with complement activation of abn platelets and release of thrombogenic material from lysed RBCs. Results in increased susceptibility to infections, intravascular haemolysis, and venous thrombosis in uncommon sites (cerebral veins, small vessels in kidneys, mesenteric and splenic veins, Budd-Chiari, portal vein).
77. Vasospasm indicates underlying atherosclerosis and stenosis. F - vasospasm occurs in reflex hypotension, digitalis, ergot preps, vasopressin, amphetamines, cocaine. It is the low-flow state that accounts for mesenteric ischaemia in those with preexisting atherosclerosis.
78. Occlusion is typically 10cm distal to the SMA origin. F - thrombosis occurs at origin and site of atherosclerotic narrowing.
79. Plain film changes are only seen after bowel infarction F - AXR has a low sensitivity for detecting mesenteric ischaemia in the early stage, although an abnormal plain film (usually showing ileus) suggests a poor prognosis. Changes include: gasless abdomen (fluid-filled loops from exudation), bowel distension splenic flexure (perfusion territory to SMA), thumbprinting, pseudoobstruction, pneumatosis, portomesenteric gas, ascites.

Question 109

113. Regarding Gastroschisis and Omphalocele: which is false
114. There is a strong association of Beckwith Weidemann syndrome with omphalocele
115. An omphalocele does not contain a covering membrane
116. Gastroschisis is associated with intestinal ischaemia

Answer 109

2.An omphalocele does not contain a covering membrane - F

75. Regarding Gastroschisis and Omphalocele: (–)
76. There is a strong association of Beckwith Weidemann syndrome with omphalocele (10%) - T
77. An omphalocele does not contain a covering membrane - F
78. Gastroschisis is associated with intestinal ischaemia - T

Question 110

114. Regarding oesophageal strictures: which is false
115. Dermatomyositis affects predominantly the lower 1/3
116. Scleroderma causes LOS strictures
117. Reflux causes stricture at squamocolumnar junction

Answer 110

1.Dermatomyositis affects predominantly the lower 1/3 - F - autoimmune, inflammatory myopathy that affects the striated muscle of the proximal third of the oesophagus causing atony and dilatation (Dahnert)

76. Regarding oesophageal strictures, which is false: (JS)
77. Dermatomyositis affects predominantly the lower 1/3 - F - autoimmune, inflammatory myopathy that affects the striated muscle of the proximal third of the oesophagus causing atony and dilatation (Dahnert)
78. Scleroderma causes LOS strictures - T - can cause strictures in late stages - usually 4-5cm above the GOJ (Dahnert). “Have a patulous GOJ, oesophagitis and lower oesophageal stricture” (Mayo clinic)
79. Reflux causes stricture at squamocolumnar junction - T - Classically begins at the GOJ and extends proximally for a variable distance; smooth and tapered margins

Question 111

115. Regarding oesophageal swallows: which one is false?
116. Spasm gives an appearance of multiple tertiary contractions
117. Reflux causes spasm of cricopharyngeus
118. CMV and candida have a similar appearance

Answer 111

3.CMV and candida have a similar appearance - F – CMV typically causes one or more large ovoid ulcers (although it can rarely cause multiple small superficial ulcers, similar to herpes oesophagitis). Candida produces mucosal nodularity with longitudinal plaques and a shaggy contour in severe cases (Dahnert).

77. Regarding oesophageal swallows, which is false: (JS)
78. Spasm gives an appearance of multiple tertiary contractions - T - severe intermittent pain with swallowing with compartmentalisation of the oesophagus by numerous tertiary contractions (Dahnert)
79. Reflux causes spasm of cricopharyngeus – T - this is one of the proposed causes for a Zenker diverticulum - reflux resulting in spasm of cricopharyngeus resulting in increased pressure in hypopharynx and diverticulum formation.
80. CMV and candida have a similar appearance - F – CMV typically causes one or more large ovoid ulcers (although it can rarely cause multiple small superficial ulcers, similar to herpes oesophagitis). Candida produces mucosal nodularity with longitudinal plaques and a shaggy contour in severe cases (Dahnert).

Question 112

117. Risk of Caecal carcinoma
118. 1% synchronous
119. 0.1% synchronous
120. 1% synchronous and metachronous
121. 39% ____ the caecum and ascending colon
122. 10% synchronous

Answer 112

4. 39% ____ the caecum and ascending colon - T - Robbins quotes 39% for cecal / ascending colon carcinoma incidence (path notes 25%).
5. Risk of Caecal carcinoma (TW) - not sure of this question (ie caecal specific Qu).
6. 1% synchronous - F - rate of synchronous CRC is about 5%. Majority occur nearby (same segment or adjacent segment).
7. 0.1% synchronous - F
8. 1% synchronous and metachronous - F - metachronous carcinoma occurred in 2% of total. So Metachronous and synchronous would be about 0.1%.
9. 39% ____ the caecum and ascending colon - T - Robbins quotes 39% for cecal / ascending colon carcinoma incidence (path notes 25%).
10. 10% synchronous - F

Question 113

118. What are risk factors for malignancy in a stomach ulcer
119. pernicious anaemia
120. Crohns disease
121. Coeliac disease
122. H.pylori

Answer 113

Ans: Coeliac disease is false.

80. What are risk factors for malignancy in a stomach ulcer (TW) - (Shit Qu?)
81. pernicious anaemia - T - 2-3x increased risk of gastric cancer. See discussion below
82. Crohns disease - T - Crohns and gastric ca are associated. Disease involves entire GIT and has increased risk of malignancy.
83. Coeliac disease - F. Not gastric ulcer. 3 types of cancer associated with celiac disease: Small bowel lymphoma- “enteropathy-associated T-cell lymphoma” (EATL), other non-Hodgkin’s lymphoma, adenocarcinoma of the small intestine. Increased risk of development of carcinoma of the oesophagus.
84. H.pylori - T - long standing chronic superficial gastritis caused by H. pylori infection, pernicious anemia eventually leads to chronic atrophic gastritis and intestinal metaplasia.

Question 114

125. Oesophagitis, which is false
126. C.M.V. demonstrates fine ulcers in the mid oesophagus.
127. Candida shows nodular folds.
128. Tablets may produce a solitary large flat ulcer.
129. Barretts oesophagus shows a prominent reticular pattern.
130. Varicoid carcinoma may produce tortuous thickened folds.

Answer 114

1.C.M.V. demonstrates fine ulcers in the mid oesophagus. - F - often presents with a large solitary discrete ulcer. Typically occur in HIV patients. May be indistinguishable from herpes oesophagitis or HIV oesophagitis with multiple discrete ulcerations. Giant ulcers are more suggestive of CMV. (Mayo clinic)

87. Oesophagitis, which is false (JS)
88. C.M.V. demonstrates fine ulcers in the mid oesophagus. - F - often presents with a large solitary discrete ulcer. Typically occur in HIV patients. May be indistinguishable from herpes oesophagitis or HIV oesophagitis with multiple discrete ulcerations. Giant ulcers are more suggestive of CMV. (Mayo clinic)
89. Candida shows nodular folds. - T - spectrum of radiographic findings - nodularity, granularity or fold thickening due to mucosal oedema and inflammation, shaggy irregular luminal surface in more severe disease. (Mayo clinic)
90. Tablets may produce a solitary large flat ulcer. - T - typically occur in mid-oesophagus. Localised cluster of tiny ulcers circumferentially or superficial solitary or several discrete ulcers. (Dahnert)
91. Barretts oesophagus shows a prominent reticular pattern. - T - reticular mucosal pattern is the most sensitive finding (Primer)
92. Varicoid carcinoma may produce tortuous thickened folds. - T - superficial spreading carcinoma, demonstrates thickened and nodular folds due to tumour within the submucosa. The tumours are fixed and rigid, unchanged with swallowing unlike varices which change shape with peristalsis. (Dahnert and Mayo clinic)

Question 115

126.With regard to investigation of the small bowel. t/f

1. Whipple’s disease may show fine nodular lesions and a normal calibre bowel.
2. Zollinger-Ellison shows dilated loops with proximal ulcers.
3. Mastocytosis shows sclerotic bone lesions with thickened valvulae conniventes.

Answer 115

all true

88.With regard to investigation of the small bowel, T/F: (GC)

1. Whipple’s disease may show fine nodular lesions and a normal calibre bowel. T - infection with Tropheryma whippelii; mucosal/submucosal infiltration by PAS+ve macrophages combined with lymphatic obstruction; results in moderate thickening of jej/duo folds, micronodularity (=swollen villi) and wild mucosal pattern. No/minimal SB dilatation, no rigidity of folds, no ulcerations, normal transit time.
2. Zollinger-Ellison shows dilated loops with proximal ulcers. T - gastrin hypersecretion due to non-beta islet cell tumour of pancreas; ulcers (bulb, stomach, ligt of Treitz), enlargement of rugal folds, dilatation of duodenum and upper small bowel (fluid overload), thickened folds in duo/jejunum (oedema). Dahnert pnemonic: FUSED - folds (thickened, gastric folds), ulcers (often multiple, postbulbar), secretions increased, edema, diarrhoea.
3. Mastocytosis shows sclerotic bone lesions with thickened valvulae conniventes. T - systemic disease with mast cell proliferation in skin and RES; <6 months old in 50%. Skeletal involvement in 70%: osteoporosis (heparin and Pg release by mast cells activates osteoclasts), scattered well-defined sclerotic foci (histamine release promoting osteoblast activity). SB: generalized irregular distorted nodular thickened folds +/- wall thickening (infiltration of mast cells, lymphocytes, plasma cells), diffuse sandlike mucosal nodules.[Dahnert]

Question 116

127. Peutz Jegher polyps, T/F:
128. Are hamartomas.
129. In the colon are associated with osteomas.
130. Usually are pedunculated.
131. Colonic polyps are more common than small bowel lesions.
132. Predispose to malignancy.

Answer 116

true 1 and 5

89. Peutz Jegher polyps, T/F: (GC)
90. Are hamartomas. T - of the muscularis mucosa, characterised by a smooth muscle core covered by mature glandular epithelium.
91. In the colon are associated with osteomas. F - Gardner’s syndrome = FAP + osteomas.
92. Usually are pedunculated. F - polyps vary in size and may be sessile or pedunculated. Vast majority occur in small bowel, where they are usually broad-based and separated by wide areas of intervening flat mucosa, larger lesions have a multilobulated surface.
93. Colonic polyps are more common than small bowel lesions. F - small bowel >95%, colon and rectum 30%.
94. Predispose to malignancy. T - risk of cancer approaches 40% by 40 yrs of age.[Dahnert; PJS, RG 1997]
    * *LJS - polyps themselves not premalignant but condition predisposes to malignancy

Question 117

128. Other polyp questions.
129. Hyperplastic polyps are associated with colorectal carcinoma
130. Villous adenoma is associated with hyperkalaemia

Answer 117

all false

90. Other polyp questions. (GC)
91. Hyperplastic polyps are associated with colorectal carcinoma F - small <5mm smooth protrusions of the mucosa, often multiple, over half found in rectosigmoid region. Although the vast majority have no malignant potential, it is now being recognized that some “hyperplastic polyps” (the sessile serrated adenomas) located on the right side of the colon, may be precursors of CRC (mismatch repair pathway).
92. Villous adenoma is associated with hyperkalaemia F - the most distal VAs may secrete sufficient amts of mucoid material rich in protein and K+ to produce hypoproteinaemia or hypokalaemia. All are considered potentially malignant and hence excised.[Robbins]

Question 118

129. Ulcerative colitis is associated with, T/F:
130. Fistula.
131. Colorectal carcinoma.
132. Sclerosing cholangitis.
133. Toxic megacolon.
134. Necrotising enterocolitis.

Answer 118

2,3,4 true

91. Ulcerative colitis is associated with, T/F: (GC)
92. Fistula. F - complication of Crohn’s disease (transmural inflammation).
93. Colorectal carcinoma. T - occurs in 3-5%; 20-30 times increased risk (cf. 5-6X in Crohn’s); risk starts 8-10yrs after onset of disease and progresses at 0.5%per year for 10-20yrs and at 0.9% per year thereafter; higher risk with pancolitis and onset in those <15yrs of age. Rectosigmoid > descending, distal transverse colon. Synchronous lesions in 35%.
94. Sclerosing cholangitis. T - 70% of pts with PSC have UC; 4% of UC pts develop PSC.
95. Toxic megacolon. T - +/- perforation in 5-10%; most common cause of death in UC.
96. Necrotising enterocolitis. F - idiopathic enterocolitis most likely related to ischaemia/infection; seen in premature infants around the time of starting oral feeds.

Question 119

130. A positive contrast enema is the next investigation after plain films in, T/F:
131. Small bowel volvulus.
132. Hirschsprung’s disease.
133. Ileal atresia.
134. Meconium ileus.
135. Jejunal atresia.

Answer 119

all true except 1

92. A positive contrast enema is the next investigation after plain films in, T/F: (GC)
93. Small bowel volvulus. F - upper GI study.
94. Hirschsprung’s disease. T - functional obstruction of distal colon due to lack of innervating ganglion cells; rectum always affected, transition zone, aganglionic segment appears normal in size.
95. Ileal atresia. T - microcolon secondary to disuse; dilated loops of more proximal bowel unable to be opacified with contrast due to atresia.
96. Meconium ileus. T - cystic fibrosis - SBO secondary to dessicated meconium in distal ileum. Soap-bubble appearance in RLQ, multiple filling defects in distal ileum/colon.
97. Jejunal atresia. T - BE to exclude large-bowel causes of obstruction, show anatomical size of colon, demonstrate meconium ileus; may see microcolon, or may be normal calibre (due to sufficient intestinal secretions in the remaining small bowel).In an infant with abdominal distension, multiple dilated loops of bowel on AXR, and failure to pass meconium, distal obstruction should be suspected and BE performed.The only upper GI problem that can result in multiple dilated bowel loops is midgut volvulus with diffuse ischaemia. These infants with be intensely ill and will not present with benign abdo distension on examination. In such patients, upper GI needs to be performed.- non-balloon tip catheter, dilute water-soluble contrast (barium can exacerbate evacuation of meconium), slowly via gravity in lateral position first.- if BE demonstrates no abnormalities (rare), contrast should be given from above and position of DJ junction documented to exclude malrotation.

Question 120

131. Concerning Crohn’s colitis, T/F:
132. Involvement of the terminal ileum is necessary to make the diagnosis
133. Toxic megacolon is a recognised complication
134. Rectal involvement is present in up to 50%
135. There is an increased incidence of carcinoma of the colon
136. The presence of pseudopolyps makes the diagnosis questionable

Answer 120

true 2 -4

93. Concerning Crohn’s colitis, T/F: (GC)
94. Involvement of the terminal ileum is necessary to make the diagnosis F - is involved in majority of cases (alone / in combination in 95%), but not a dx requirement.
95. Toxic megacolon is a recognised complication T - but less often than UC.
96. Rectal involvement is present in up to 50% T - 14-50%; deep / collarbutton ulcers, rectal sinus tracts.
97. There is an increased incidence of carcinoma of the colon T - esp. in bypassed loops or in vicinity of chronic fistula. 5-6 times increased risk of CRC (but UC 20-30 times); latency period of 25-30yrs.
98. The presence of pseudopolyps makes the diagnosis questionable F - may be seen in CD (islands of hyperplastic mucosa between denuded mucosa) but also seen in UC. Linear ulcers on mesenteric border are nearly pathognomonic.[Dahnert]

Question 121

132. In achalasia, which are false?
133. Smooth muscle is abnormal
134. The oesophageal vestibule is of normal size
135. There is an association with oesophageal carcinoma
136. Reflux oesophagitis occasionally occurs
137. On barium swallow, there is shouldering of the distal oesophagus

Answer 121

false 2 and 5

94. In achalasia, which are false? (JS)
95. Smooth muscle is abnormal - T - aperistalsis of the distal 2/3 (smooth muscle portion) of the oesophagus with failure of the LOS to relax.
96. The oesophageal vestibule is of normal size - F - vestibule is in the region of the LOS which fails to relax in achalasia - beaked tapering at GOJ
97. There is an association with oesophageal carcinoma - T - risk factor of 1000x (Dahnert) although other sources say only 30 times the risk.
98. Reflux oesophagitis occasionally occurs - T - nocturnal regurgitation and aspiration can occur (Robbins)
99. On barium swallow, there is shouldering of the distal oesophagus - F - radiographic features are absent primary and secondary peristalsis with dilated oesophagus, bird-beak deformity with symmetric tapering of stenotic segment, most marked at the GOJ, periodic relaxation of LOS helps distinguish from pseudoachalasia in carcinoma of the GOJ (fixed obstruction).

Question 122

133. Carcinoid tumours in the bowel, T/F:
134. Are found in 2% of the population at autopsy
135. Most commonly occur in the terminal ileum
136. Carcinoid syndrome occurs in 60% of small bowel carcinoid tumours
137. A desmoplastic reaction is typical
138. There is a definite correlation between size and incidence of metastases

Answer 122

true 2 4 and 5

95. Carcinoid tumours in the bowel, T/F: (GC)
96. Are found in 2% of the population at autopsy F - incidence in autopsy cases = 650 per 100,000 population (0.65%). [eMedicine]
97. Most commonly occur in the terminal ileum T.
98. Carcinoid syndrome occurs in 60% of small bowel carcinoid tumours F - in 7% of small bowel carcinoids. Due to excess serotonin levels when the metabolic pathway to 5-HIAA (in liver) is bypassed (ie. liver mets, primary pulmnary or ovarian carcinoids).
99. A desmoplastic reaction is typical T - due to serotonin-induced mesenteric ischaemia. [RG 2007]
100. There is a definite correlation between size and incidence of metastases T <1cm - 2% metastasize1-2cm - 50%>2cm - 85%. [Dahnert]

Question 123

134. Gastric wall thickening, T/F:
135. Crohn’s disease
136. Menetriers disease
137. Graft versus host disease
138. Eosinophilic gastroenteritis
139. Bloodgood’s disease

Answer 123

only 5 is false

96. Gastric wall thickening, T/F: (GC)
97. Crohn’s disease T - with aphthous ulcers.
98. Menetrier’s disease T - rare, middle-aged men; grossly thickened lobulated folds of the fundus and body (esp. on or near the greater curvature), with relative antral sparing.
99. Graft versus host disease T - lymphocytes from donor BM cause selected epithelial damage of recipient target organs - severe mucosal atrophy occurs in acute GVHD; most commonly involves liver and skin. Small and large bowel may be involved (most commonly distal ileum); variable degrees of concentric wall thickening with a hyperattenuating mucosa; prolonged coating of bowel with oral contrast (incorporated into submucosal layer through mucosal ulcers). Chronic GVHD less often involves the gut (usually salivary gland, mouth, eyes, upper resp tract); fibrosis and atrophy may lead to GI dysmotility (gastroparesis or constipation).
100. Eosinophilic gastroenteritis T - middle-aged women; stomach involvement almost always limited to antrum - mucosal type (enlarged rugae, cobblestone nodules, polyps), muscular type (thickened and rigid wall with narrowed antropyloric region, or bulky intraluminal mass).
101. Bloodgood’s disease F - rare disease characterized by the development of brown or blue cysts in the female breast tissue. aka Cheatle’s disease. (internet search!)

Question 124

135. Carcinoid, T/F:
136. Most lesions of the appendix metastasise.
137. The gastrointestinal tract is the most common site.
138. The duodenum is the most common site in the gastrointestinal tract.
139. Embolisation is useful for liver metastases.

Answer 124

true 2 and 4

97. Carcinoid, T/F: (GC)
98. Most lesions of the appendix metastasise. F - metastasize in 3% (cf. 35% of tumours in ileum).
99. The gastrointestinal tract is the most common site. T - small bowel and appendix account for >95% of all carcinoids.
100. The duodenum is the most common site in the gastrointestinal tract. F - appendix 30-45%, small bowel 25-35% (ileum 91%, jejunum 7%, duodenum 2%).
101. Embolisation is useful for liver metastases. T - No consensus exists regarding the type of embolotherapy that is useful in the treatment of neuroendocrine liver metastasis. Both embolization and chemoembolization have been advocated. The primary objective of embolotherapy in treating neuroendocrine liver metastasis is to reduce tumor bulk, reduce hormone levels, and palliate symptoms. Both embolization and chemoembolization can achieve these objectives.