Abdominal

Question 1

Peritoneal calcifications

Answer 1

• cystadenocarcinoma of the ovary: fine sand-like calcification
• pseudomyxoma peritonei: often ring or arc-like calcifications, most numerous in the pelvis
• undifferentiated abdominal malignancies: dystrophic calcification within the tumour masses
• tuberculous peritonitis (tuberculosis) - pneumocystis carinii infection
• hyperparathyroidism
• in newborns: meconium peritonitis
• secondary to continuous ambulatory peritoneal dialysis (CAPD)
• post-operative heterotopic ossification

Question 2

Gardner syndrome

Answer 2

Gardner syndrome is one of the polyposis syndromes. It is characterised by: familial adenopolyposis multiple osteomas: especially of the mandible, skull, and long bones epidermal cysts fibromatoses desmoid tumours of mesentery and anterior abdominal wall Other abnormalities include: supernumerary teeth and odontomas 4 duodenal tumours / ampullary carcinoma 2,3 papillary thyroid carcinoma

Question 3

Epiploic appendagitis

Answer 3

self-limiting ischaemic/inflammatory process involving appendix epiploica of the colon and may either be primary or secondary to adjacent pathology.

Question 4

Bouveret syndrome

Answer 4

Bouveret syndrome refers to a gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum. Thus, it can be considered a very proximal form of gallstone ileus.

Question 5

Gamna–Gandy bodies

Answer 5

Gamna–Gandy bodies are splenic microhemorrhages, which appear hypointense on GRE. It’s a secondary manifestations of cirrhosis.

Question 6

Multiple biliary hamartomas (von Meyenburg complexes)

Answer 6

Multiple biliary hamartomas (MBHs) are a rare cause of multiple benign hepatic lesions. The condition is also known as von Meyenburg complexes, multiple bile duct hamartomas or biliary microhamartomas. Multiple biliary hamartomas are asymptomatic and usually found incidentally, when it is important to differentiate them from other causes of multiple liver lesions, particularly metastases.

Question 7

Choledochal cyst classification

Answer 7

• I - fusiform CBD dialation
• II - extrahepatric saccular dilation
• III - intraduodenal bile duct dilation
• IV - multiple dilations (a: intra- and extrahepatric; b: extrahepatic only)
• V - intrahepatic dilations = Caroli disease

when combination of small bile ducts dilatation and congenital hepatic fibrosis = Caroli syndrome

increased cholangiocarcinoma risk

Question 8

emphysematous cholecystitis

Answer 8

• acute cholecystitis complication in elderly diabetic
• caused gas-forming bacteria
• gas in the lumen or the wall of the gallbladder

Question 9

Gangrenous cholecystitis

Answer 9

Gangrenous cholecystitis is the most common complication of acute cholecystitis: wall ischaemia and necrosis.

• intraluminal membranes
• asymmetrical wall thickness
• with possible wall disruption and/or ulceration
• variable absence of the sonographic Murphy’s sign attributed to ischaemic denervation of the gallbladder

Question 10

Answer 10

Porcelain gallbladder

Question 11

Charcot’s triad

Answer 11

• fever
• abdominal pain
• jaundice

in ascending cholangitis

Question 12

Answer 12

Primary sclerosing cholangitis (PSC)

• beaded, irregular bilde ducts appearence
• PSC is an idiopathic condition with inflammation and destruction of the bile ducts.
• results in multiple strictures, liver damage, and eventually cirrhosis.
• assosciated with ulcerative colitis.

Question 13

primary biliiary cirrhosis

Answer 13

inflammation and destruction of smaller bile ducts than in PSC.

middle-aged women, presents with pruritus, may lead to cirrhosis.

Question 14

AIDS cholangitis

Answer 14

Like PSC, however papillaryy stenosis is present

Question 15

Biliary cystadenoma

Answer 15

Biliary cystadenoma benign cystic neoplasms of the liver in middle-aged. Either unilocular or multilocular. Only rarely are they found in the extrahepatic biliary tree and gallbladder.

Question 16

CT arterial phase

Answer 16

Extensive intrahepatic biliary dilatation caused by an expansile CBD heterogeneously enhancing lesion which is invading the liver.

Right portal vein appears severely narrowed, highly suspicious of tumour invasion. (CT portal phase below)

extensive CHOLANGIOCARCINOMA

Question 17

Cholangiocarcinoma

Answer 17

• malignant tumours arising from cholangiocytes in the biliary tree and are the second most common primary hepatic malignancy after hepatocellular carcinoma (HCC).
• presents with painless jaundice
• Risk factors:
  • Caroli disease / choledochal cyst
  • choledocholithiasis more than cholelithiasis
  • primary sclerosing cholangitis (PSC)
  • recurrent pyogenic cholangitis (hepatolithiasis)
  • cirrhosis
  • toxins
  • viral infections
• intrahepatic in 20% of cases, extrahepatic in 80%

Question 18

Cholangiocarcinoma - types

Answer 18

intrahepatic - 20%; extrahepatic - 80%

• Mass-forming
  
  • Intrahepatic, exophytic, nodular (peripheral) tumours are most commonly of the mass-forming type
  • They demonstrate variable amounts of central fibrosis, usually marked.
• Periductal infiltrating
  
  • Most common at the hilum (over 70%), where they are known as Klatskin tumours
  • they can also be seen in combination with mass-forming tumours within the liver.
  • Growth along the walls of the duct may narrow or dilate the duct.
• Intraductal
  
  • Alterations in duct calibre, usually duct ectasia with or without a visible mass.
  • If a mass is visible it may be mural or polypoid in shape.
  • The duct dilatation is thought to be due to abundant mucin production. This entity is thought to be similar to the pancreatic intraductal papillary mucinous neoplasms (IPMN).
• Extrahepatic/large duct
  
  • These tumours are most commonly infiltrating, although both exophytic (mass-forming) and polypoid (intraductal) types are identified. They have similar appearances to their intrahepatic counterparts.

Question 19

Imaging of cholangiocarcinoma

Answer 19

Mass-forming cholangiocarcinomas:

• homogeneously low in attenuation on noncontrast scans
• heterogeneous minor peripheral enhancement with gradual centripetal enhancement.
• capsular retraction may be evident (helpful in distinguishing cholangiocarcinomas from other hepatic tumours.)
• bile ducts distal to the mass are typically dilated.
• unlike HCC, cholangiocarcinoma only rarely forms a tumour thrombus.

Periductal infiltrating:

• intrahepatic tumours appear as regions of duct wall thickening or of the periductal parenchyma, with altered calibre of the involved duct (usually narrowed).
• most common at the hepatic hilum.
• longer than benign strictures (i.e. approximately 20 mm in length)
• contrast enhancement.
• peripheral dilatation of the biliary tree.

Intraductal tumours:

• alterations in duct calibre
• usually duct ectasia with or without a visible mass.
• If a polypoid mass is seen it is hypoattenuating on pre-contrast imaging and demonstrates enhancement.

DWI/ADC: a peripherally hyperintense “target” appearance on DWI favours cholangiocarcinoma over hepatocellular carcinoma

Question 20

gallbladder metastasis

Answer 20

melanoma

Question 21

double duct sign

Answer 21

dialtion of both pancreatic and common bile ducts.

even if no mass still suspicious of adenocarcinoma.

Question 22

Answer 22

small mass is located in the uncinate process of the pancreas with a preserved fat plane around the superior mesenteric artery and veins. Both the biliary tree and pancreatic duct are dilated. A prominent coeliac node is also present. Incidental splenunculi.

Pancreatic ductal adenocarcinoma

Question 23

Hereditary syndromes with increased risk of pancreatic ductal adenocarcinoma

Answer 23

• Hereditary non-polyposis colorectal cancer (HNPCC, Lynch syndrome)
• familial breast cancer
• familial atypical multiple mole melanoma (FAMMM)
• hereditary pancreatitis
• ataxia-telangiectasia
• Peutz-Jeghers syndrome

Question 24

Acinar cell carcinoma

Answer 24

• rare, aggressive cariant of pancreatic adenocarcinoma
• in elderly males
• produces large amounts of lipase, which leads to:
  
  • subcutaneous fat necrosis
  • bone infarcts leading to polyarthralgias
  • eosinophilia

Question 25

Serous cystadenoma

Answer 25

* "grandmother tumor" * \> 6 cyst, \< 2 cm * hypervascular pancreatic tumor (specific) * doesn't cause pancreatic duct dilation or tail atrophy * central stellate calification

Question 26

hypervascular pancreatic tumor

Answer 26

serous cystadenoma (grandmother tumor) or neuroendocrine tumors

Question 27

Answer 27

serous cystadenoma central calcifications

Question 28

most common cystic neoplasm of the pancreas

Answer 28

Mucinous cystic neoplasms of the pancreas

Question 29

Mucinous cystadenomas (MCN) of the pancreas

Answer 29

* "mother tumor" * malignant potential * few (\< 6), large (\> 2 cm) cysts * in the pancreatic body or tail * has a capsule (the other pancreatic tumor woth capsule is SPEN)

Question 30

Answer 30

mucinous cystadenoma (mother tumor)

Question 31

Solid pseudopapillary epithelial neoplasm (SPEN)

Answer 31

* SPEN = Frantz tumor = daughter tumor * mostly benign, ~15% can be malignan * well-encapsulated lesion with varying solid and cystic components owing to haemorrhagic degeneration

Question 32

Intraductal papillary mucinous neoplasm (IPMN)

Answer 32

* IPMN * more often in elderly males, but in females as well - grandfather tumor * benign or malignant * main duct location - 60% are malignant * cystic intrapancreatic lesion in contiguity with the main duct or a side branch * if nodular or enhancing component - concern for malignancy * main duct IPMN (with dilatation of the main duct \>5 mm) * either segment of the pancreatic duct (or the entire duct) are dilated and filled with low density (mucin thus water signal) material * branch duct IPMN * single or multiple side branches demonstrating marked dilatation cystic mass-like appearance which often mimics cystic tumours of the pancreas * its appearance has been termed a bunch of grapes due to its appearance * microcystic variety has appearances similar to serous cystadenomas, but again communication with the main pancreatic duct is the key to the correct diagnosis

Question 33

IPMN DDx

Answer 33

DDX: chronic pancreatitis - difficult to distinguish from main duct type on account of dilated duct mucinous cystadenoma/cystadenocarcinoma - should not appear to communicate with the main pancreatic duct serous cystadenoma - should not appear to communicate with the main pancreatic duct, may appear similar to microcystic branch type IPMN, 30-40% have central calcification

Question 34

Fukuoka consensus guidelines, also referred to as the Tanaka criteria

Answer 34

**Investigation** * cyst \<5 mm * asymptomatic - invasive carcinoma is rare, follow-up only * symptomatic - further evaluation or resection * cyst \>5 mm * pancreatic protocol CT or MRI pancreas and MRCP to evaluate **Classification** * branch duct IPMN (BD-IPMN) * cyst \>5 mm communicating with main duct * main duct IPMN (MD-IPMN) * dilatation of the main duct \> 5 mm without other cause for obstruction * 5-9 mm: "worrisome feature" * ≥10 mm: "high-risk stigmata" * mixed-type IPMN: appears like an advanced branch duct IPMN with main pancreatic duct dilatation (\>5 mm) **High-risk stigmata** * enhancing solid component \>5 mm * main pancreatic duct ≥10 mm * obstructive jaundice **Worrisome features** * cyst ≥3 cm * thickened and enhancing cyst wall * enhancing mural nodule \<5 mm * main pancreatic duct 5-9 mm * lymphadenopathy * abrupt change in calibre of the pancreatic duct with distal pancreatic atrophy * cyst growth rate ≥5 mm in two years * elevated Ca19-9

Question 35

Insulinoma

Answer 35

* most common neuroendocrine pancreatic tumor * symptoms (Whipple triad): * hypoglicemia * clinical symptoms of hypoglicemia * alleviation of symptoms after glucose

Question 36

Gastrinoma

Answer 36

* 2nd most common neuroendorine tumor * causes hypersecretion of gastric acid resulting in **Zollinger-Ellison** syndrome * associated with MEN 1 (then multiple and in the duodenum)

Question 37

Answer 37

double bubble sign causes: * duodenal web * duodenal atresia/stenosis * annular pancreas * midgut volvulus * external compression of the duodenum: * choledochal cyst * mesenteric duplication cyst * intramural duodenal haematoma * preduodenal portal vein * retroperitoneal tumour * superior mesenteric artery syndrome

Question 38

Von Hippel-Lindau disease (mnemonic)

Answer 38

H: haemangioblastoma I: increased risk of renal cell cancer P: phaeochromocytoma P: pancreatic lesions (cyst, cystadenoma, cystadenocarcinoma) E: eye dysfunction (retinal haemangioblastoma), endolymphatic sac tumours L: liver, renal and pancreatic cysts

Question 39

Groove pancreatitis

Answer 39

focal pancreatitis between the head of the pancreas, duodenu and common bile duct. DDx - adenocarcinoma

Question 40

Modified CT severity index in acute pancreatitis

Answer 40

**Pancreatic inflammation** 0: normal pancreas 2: intrinsic pancreatic abnormalities with or without inflammatory changes in peripancreatic fat 4: pancreatic or peripancreatic fluid collection or peripancreatic fat necrosis **Pancreatic necrosis** 0: none 2: 30% or less 4: more than 30% **Extrapancreatic complications** 2: one or more of pleural effusion, ascites, vascular complications, parenchymal complications and/or gastrointestinal involvement **Total score** Total points are given out of 10 to determine the grade of pancreatitis and aid treatment: 0-2: mild 4-6: moderate 8-10: severe

Question 41

Answer 41

Diffuse pancreatic parenchymal enlargement predominantly affected the body and tail with decreased attenuation. Indistinct pancreatic margins with surrounding retroperitoneal fat stranding. Thickened oedematous large bowel at the hepatic and splenic flexures. Multiple peripancreatic and periportal lymph nodes. Relative hypoattenuation of the liver to the spleen in keeping with hepatic steatosis.

Question 42

multiple calcified splenic lesions

Answer 42

pneumocystis jiroveci in AIDS

Question 43

Answer 43

H-shaped vertebrae Sharply delimited central endplate depression, classically seen in approximately 10% of patients with **sickle-cell anaemia**, and results from microvascular endplate infarction (figure 1) 3. It may occasionally be seen with other conditions such as **Gaucher disease.**

Question 44

Esophageal rings

Answer 44

A: a few centimetres proximal to the gastro-oesophageal junction, a contraction of oesophageal smooth muscle covered by mucosa B: B ring is a mucosal ring that develops in the distal oesophagus at the gastrooesophageal junction (Z line) C: diaphragmatic impression Schatzki ring: symptomatically narrow oesophageal B-ring occurring in the distal oesophagus and usually associated with a hiatus hernia.

Question 45

Shwachman-Diamond syndrome

Answer 45

shortened extremities cup deformity of ribs Hyperechoic pancreas due to extreme pancreatic lipomatosis, usually with preservation of pancreatic size.

Question 46

Question 47

mesenchymal esophageal masses

Answer 47

* benign * GIST, leiomyoma, hemangioma, others * smooth, round, submucosal

Question 48

esophageal adenoma

Answer 48

* benign, malignant potential * within barrett esophagus * \< 1.5 cm

Question 49

fibrovascular polyp (esophagus)

Answer 49

pedunculated mass with significant fatty component

Question 50

Most common primary retroperitoneal tumor?

Answer 50

**Liposarcoma** * They are usually seen in the extremities (75%), 10-15% liposarcomas arise in the retroperitoneum * most commonly well-differentiated with high fat content * CT findings favouring a liposarcoma over a lipoma include: * inhomogeneous attenuation, with evidence of significant amounts of soft-tissue within the fatty mass * poor definition of adjacent structures * invasion of mediastinal structures * calcification * The higher grade lesions are often devoid of macroscopic fat and have appearances similar to other sarcomas. (Image STIR)

Question 51

Retroperitoneal fibrosis

Answer 51

Retroperitoneal fibrosis (RPF) * typically presents with ureteric obstruction, * Retroperitoneal fibrosis is visible as a soft tissue density mass located around the aorta and iliac arteries. Classically, it develops around the aortic bifurcation and spreads upwards where it can envelop the renal hila. It encases but does not invade or stenose the ureters or vessels. However, ureteric obstruction and venous thromboses can occur. In early or active stages, variable enhancement can be seen with intravenous contrast while no enhancement may be seen in the quiescent disease.

Question 52

Adrenal washout

Answer 52

Absolute = (enhanced-delayed)/(enhanced-unenhanced) adenoma if \>60% Relative = (enhanced - delayed)/enhanced adenoma if \>40%

Question 53

macroscopic fat in adrenal gland

Answer 53

myelolipoma

Question 54

Syndromes associated with pheochromocytoma

Answer 54

von Hippel Lindau MEN 2a and 2b neurofibromatosis type 1 Carney's triad - gastric leiomyosarcoma, pulmonary chondroma, extraadrenal pheo

Question 55

Answer 55

multilocular cystic nephroma herniation into the collecting system specific, but usually doesn't occur and the mass cannot be differentiation from RCC

Question 56

Answer 56

Lobste claw or ball in tree sign of papillary necrosis Causes differential POSTCARD: * pyelonephritis * obstruction * sickle cell disease * tuberculosis * cirrhosis * analgesics (NSAIDs) * renal vein thrombosis * diabetes

Question 57

medullary nephrocalcinosis

Answer 57

* hypercalcemic state (hyperparathyroidism, sarcocidosis) * medullary sponge kidney * renal tubular acidosis (distal, type 1) * furosemide therapy in a child

Question 58

cortical nephrocalcinosis causes

Answer 58

acute cortical necrosis chronic glomerulonephritis chronic transplant rejection hyperoxaluria Alport syndrome

Question 59

most common uretral neoplasm

Answer 59

transitional cell carcinoma

Question 60

fibroepithelial polyp

Answer 60

most common benign tumor of the ureter typically proximally