Chapter 29 - Stomach and Duodenum (CHERI NOTES) Flashcards
(148 cards)
1
Q
__ technique entail using small amounts of barium to coat the mucosa without distending the bowel to demonstrate abnormalities such as varices. (p.752)
A
MUCOSAL RELIEF VIEWS
2
Q
____ technique;using high-density barium suspensions
to coat the mucosa and ingestible effervescent granules
to distend the stomach and duodenum. (p.752)
A
DOUBLE-CONTRAST TECHNIQUE
- this is optimal for the demonstration
of subtle features of the mucosal
surface
3
Q
____ infection has been identified as the major cause
of chronic gastritis; duodenitis; benign gastric and
duodenal ulcers; gastric adenoCA and MALT lymphoma.
(p.753)
A
H.pylori infection
- a gram-negative spiral bacillus that colonizes
the stomachs in as many as 80% of individuals
in some populations.
4
Q
H.pylori infection will only infect ____ epithelium
and is usually localized to the gastric ___
living on the surface epithelial cells
beneath the mucous coat. (p.753)
A
GASTRIC-LIKE epithelium;
gastric ANTRUM
- it survives in gastric acid by using a powerful urease enzyme to break down urea into ammonia and bicarbonate; creating a more alkaline environment for itself.
5
Q
TRUE OR FALSE.
The prevalence of H.pylori infection increases with
age (>50% of Americans older than 60 years) and is high
in lower socioeconomic populations and in
developing countries. (p.753)
A
TRUE
6
Q
TRUE OR FALSE.
Double-contrast technique
demonstrates enlarged areae gastricae in 50% of
patients with H.pylori infection.
A
TRUE
7
Q
_____ is the third most common GI malignancy;
folliwing colon and pancreatic CA. (p.753)
A
GASTRIC CARCINOMA
- most 95% are ADENOCARCINOMAS; the
remainder are diffuse anaplastic (signet-ring)
carcinoma; squamous cell carcinoma; or
rare cell types. - incidence of gastric CA is as much as five
times higher in Japan; Finland; Chile and Iceland
than in the United States. - mortality is high with a 5-year survival rate
of 10% to 20%
8
Q
4 predisposing factors of Gastric CA. (p.753)
A
- smoking
- pernicious anemia
- atrophic gastritis
- Gastrojejunostomy
- H.pylori infection increases the risk of gastric CA sixfold and is the cause of approximately half of gastric adenoCA cases. - peak age is from 50 to 70 years; with males predominating 2:1.
9
Q
4 common morphologic growth
growth patterns of Gastric CA. (p.754)
A
- POLYPOID masses
- ULCERATIVE masses
- INFILTRATING
tumors;
FOCAL PLAQUE-like
lesions with central
ulcer or diffusely
infiltrating (15%);
DIFFUSELY INFILTRATING
(15%) with poorly
differentiated
carcinomatous cells
producing bizarre
thickened folds and
thickened rigid stomach
wall; the so-called
scirrhous carcinomas
10
Q
The terms “____” and “____” may be applied
to describe the resulting stiff narrowed
stomach.
A
LINITIS PLASTICA;
WATER-BOTTLE
STOMACH
11
Q
The GASTRIC CA tumor spreads by \_\_\_\_\_\_ through the gastric wall to involve the perigastric fat and adjacent organs; or it may seed the peritoneal cavity. (p.754)
A
DIRECT INVASION
lymphatic spread is to the regional
lymph nodes including perigastric
nodes along the lesser curvature;
celiac axis; and hepatoduodenal
12
Q
Lymphatic spread of Gastric CA is to the
regional lymph nodes including perigastric
nodes along the _____. (p.754)
A
- LESSER CURVATURE
- CELIAC AXIS
- HEPATODUODENAL
- RETROPANCREATIC
- MESENTERIC
- PARAAORTIC NODES
13
Q
Hematogenous metastases involve the
___; ____; ____and rarely ____ and ___.
(p.754)
A
- ADRENAL GLANDS
- OVARIES
- LIVER;
rarely BONE and LUNG
14
Q
Intraperitoneal seeding of Gastric CA
presents as _____ or ____ tumors. (p.754)
A
CARCINOMATOSIS;
KRUKENBERG OVARIAN
TUMORS
- PET-CT is most effective in the
demonstration of metastatic
lymph nodes and distant spread
of tumor
15
Q
Early gastric cancers appear on barium
studies as ___; ____ and ___. (p.754)
A
- Gastric polyps with risk of malignancy
increased for lesions larger than 1 cm - Superficial plaque-like lesions or nodular
mucosa - Shallow irregular ulcers with nodular
adjacent mucosa
- these lesions are most sensitively detected
on double-contrast studies.
16
Q
CT and MR findings of gastric CA;
give 8. (p.754)
A
1. Focal;often irregular; wall thickening (>1 cm) 2. Diffuse wall thickening due to tumor infiltration (LINITIS PLASTICA) (contrast enhancement is common) 3. Intraluminal soft tissue mass 4. Bulky mass with ulceration 5. rare; large; exophytic tumor resembling leiomyosarcoma 6. extenstion of tumor into perigastric fat 7. regional lympadenopathy 8. metastases in the liver; adrenal and peritoneal cavity
17
Q
TRUE OR FALSE.
Mucinous adenoCAs frequently
contain stippled calcifications.
(p.754)
A
TRUE
18
Q
____ account for 2% of gastric neoplasms.
p.754
A
LYMPHOMA
19
Q
The ____ is the most common site of
involvement of primary GI lymphoma;
accounting for approximately 50% of
cases. (p.754)
A
STOMACH
- most (80%) gastric lymphoma is Non-Hodgkin; B-cell type. -chronic infection of the gastric epithelium with H.pylori is associated with the risk of developing MALT gastric lymphomas; which are more indolent and have a better prognosis than B-cell lymphomas.
20
Q
TRUE OR FALSE.
Gastric Lymphomas has a better prognosis
than carcinoma with a 5-year survival
rate of 62% to 90%. (p.754)
A
TRUE
- because lymphoma remains confined
to the bowel wall for long periods of time.
21
Q
4 morphologic patterns of gastric
lymphoma. (p.755)
A
- POLYPOID SOLITARY MASS
- ULCERATIVE MASS
- MULTIPLE SUBMUCOSAL
NODULES - DIFFUSE INFILTRATION
22
Q
DIAGNOSIS?
UGI FINDINGS OF:
1. Polypoid lesions
2. irregular ulcers with nodular thickened
folds
3. bulky tumors with large cavities
4. multiple submucosal nodules that
commonly ulcerate and create a target or
“bull’s eye” appearance
5. diffuse but pliable wall and fold thickening
6. rarely; linitis plastica appearance of diffuse;
stiff narrowing. (p.755)
A
GASTRIC LYMPHOMA
23
Q
___ is the primary imaging modality used to
stage lymphoma. (p.755)
A
CT
24
Q
5 CT findings that are helpful in differentiating
gastric lymphoma from carcinoma include
_____. (p.755)
A
- More marked thickening of the wall
(may exceed 3 cm) - Involvement of additional areas of
the GI tract (transpyloric spread of
lymphoma to the duodenum in 30% - Absence of invasion of perigastric fat
- Absence of luminal narrowing and
obstruction despite extensive involvement - More widespread and bulkier adenopathy.
25
____ are the most common mesenchymal
| tumors to arise from the GI tract. (p.755)
GI STROMAL TUMORS (GISTs)
26
Most; but not all; tumors previously
classified as leiomyomas; leiomyosarcomas;
and leiomyoblastomas are now classified
as ___. (p.755-756)
GISTs
```
- approximately 60% to 70% of GISTs
arise in the stomach; and 10% to 30%
of these are malignant
- true leiomyomas and leiomyosarcomas
are very rare in the stomach
- long-term silent growth to a large size
is characteristic
- the overlying mucosa is commonly
ulcerated
```
27
TRUE OR FALSE.
Dystrophic calcifications are relatively
common in both benign and malignant tumors
(GISTs) and helps differentiate these lesions
from other gastric tumors.
TRUE
```
- on UGI series; GISTs appear as
submucosal nodules and masses
- ulceration causes a bull's eye-
appearance and may be responsible
for significant bleeding
```
28
CT is useful in characterizing GISTs because
| they are predominantly ____. (p.756)
EXTRALUMINAL
```
- Benign tumors are smaller
(4 to 5 cm; average size); are
homogenous in density; and
show uniform diffuse enhance-
ment.
- Malignant tumors tend to be
larger (>10 cm) with central zones
of low density caused by
hemorrhage and necrosis and show
irregular patterns of enhancement.
```
29
____ cancer metastases cause linitis
| plastica. (p.756)
BREAST CANCER metastases
30
TRUE OR FALSE.
GASTRIC METASTASES may present as
submucosal nodules or ulcerated masses.
Most are hematogenous metastases. (p.756)
TRUE
- rich blood supply results in common
involvement of the stomach and small
bowel
31
3 common primary tumors with gastric
| metastasis. (p.756)
1. MELANOMA
2. BREAST CA
3. LUNG CA
32
TRUE OR FALSE.
KAPOSI SARCOMA; when disseminated in
patients with AIDS involves the GI tract in
50% of patients. (p.756)
TRUE
```
- double-contrast study demonstrate
flat masses with or without ulceration;
polypoid masses; irregularly thickened
folds; multiple submucosal masses and
linitis plastica.
- CT demonstrates enhancing adenopathy
in the porta hepatis; mesentery and
retroperitoneum
- bleeding is a common symptom and
may require embolization
```
33
___ tumors are adenomatous polypoid
masses that produce multiple frond-like
projections.
- most are solitary and of 3 to 9 cm in size;
although giant tumors may be as large as
15 cm.
VILLOUS TUMORS
```
- malignant potential is high
and varies with size of the
lesion (50% for 2 to 4 cm
lesions;80% for lesions
>4 cm). (p.756)
```
34
DIAGNOSIS?
Barium trapped in the clefts between fronds
produces a characteristic soap-bubble
appearance. (p.756)
VILLOUS TUMORS
- the tumors are mobile and deform with
compression
- all should be treated as malignant lesions.
35
___ are lesions that protrude into the lumen
| as sessile or pedunculated masses. (p.756)
POLYPS
```
- Their appearance on double-
contrast UGI series depends
on whether they are on the
dependent nondependent
surface.
```
36
A polyp on the ___ surface appears
as a radiolucent filling defect in the barium
pool. (p.756)
DEPENDENT
37
A polyp on the ____ surface is covered with
| a thin coat of barium. (p.756)
NON-DEPENDENT
38
The ____ sign is produced by the acute angle
of attachment of the polyp to the mucosa.
(p.756)
BOWLER HAT sign
39
The ___ sign consists of two concentric rings
and is produced by visualizing a
pedunculated polyp end-on.
MEXICAN HAT sign
- polyps are commonly
multiple
40
____ polyps account for 80% of gastric
| polyps. (p.756)
HYPERPLASTIC polyps
- most are less than 15 mm in
diameter.
- they are not neoplasms;
but rather hyperplastic
responses to mucosal
injury especially gastritis
- they may be located
anywhere in stomach;
- are frequently multiple;
have no malignant potential;
but are indicative of chronic
gastritis.
41
____ polyps account for 15% of gastric polyps
and are true neoplasms with malignant
potential. (p.757)
ADENOMATOUS polyps
```
- most are solitary;
located in the ANTRUM; and
are larger than 2 cm in diameter
- polyps that are larger than
1 cm; lobulated or pedunculated
should have biopsies taken of them
because of the risk of malignancy
```
42
____ polyps occur in Peutz-Jeghers syndrome.
| They have no malignant potential. (p.757)
HAMARTOMATOUS POLYPS
43
____ are submucosal neoplasms composed
| of mature benign fatty. (p.757)
LIPOMAS
```
- UGI series reveals a smooth
well-defined submucosal
lesion that occasionally
ulcerates.
- CT provides a definitive
diagnosis by the demonstration
of sharply circumscribed wall
mass with uniform fat
attenuation
```
44
ECTOPIC PANCREAS is common intramural
| lesion; usually found in the _____. (p.757)
ANTRUM
- lobules of heterotropic pancreatic tissue;
up to 5 cm in size; are covered by gastric
mucosa.
- most are nipple shaped or cone shaped
with small central orifices
45
The term ____ refers to an intraluminal
gastric mass consisting of accumulated
ingested material. (p.757)
BEZOAR
```
- may be composed of a wide
variety of substances
- stones may be ingested or
form with bezoar
- any ingested foreign body
may produce an intraluminal filling
defect.
```
46
_____ are bezoars are composed of hair.
| p.757
TRICHOBEZOARS
47
_____ are bezoars composed of fruit or
| vegetable products. (p.757)
PHYTOBEZOARS
48
_____ are bezoars consist of tablets and
| semi-solid masses of drugs. (p.757)
PHARMACOBEZOARS
49
TRUE OR FALSE.
EXTRINSIC MASSES on the dependent
surface produce ill-defined radiolucencies.
(p.757)
TRUE
```
-the mucosa may be impressed
upon by an extrinsic mass and be
seen in profile as a white line
- pancreatic; splenic; hepatic and
retroperitoneal masses may impress
upon stomach
- CT is excellent for demonstrating
the nature of an extrinsic mass impression
```
50
Normal gastric folds are thicker and more
undulated in the ___ stomach and along
the ____ curvature. (p.758)
PROXIMAL stomach and along
the GREATER curvature
```
- they have smooth contour
and taper distally
- gastric distention causes the
folds to become thinner;
straighter and less prominent
- normal rugal folds consist of
both mucosa and submucosa
and may become thickened
by disease processes that
infiltrate these layers
```
51
TRUE OR FALSE.
GASTRITIS is much more common than
gastric ulcers. (p.758)
TRUE
52
The hallmarks of gastritis are ______ and
| _______. (p.758)
THICKENED FOLDS and
SUPERFICIAL MUCOSAL
ULCERATIONS (EROSIONS)
- the thickened folds are
usually caused by mucosal
edema and superficial
inflammatory infiltrate
53
____ are defined as defects in the mucosa
that do not penetrate beyond the
muscularis mucosae. (p.758)
EROSIONS
54
___ ulcers (also called ___) are complete
erosions that appear as tiny central flecks
of barium surrounded by a radiolucent halo
of edema. (p.758)
APTHOUS ULCERS
(also called VARIOLIFORM
EROSIONS)
55
____ erosions appear as linear streaks and
| dots of barium. (p.758)
INCOMPLETE EROSIONS
- erosions heal without scarring
- barium precipitates may
mimic erosions; appearing
as distinct punctate barium
spots but without the
distinctive radiolucent halo
of a radiolucent halo of a true
erosion
56
_____ gastritis is the most common form
of gastritis and is the most common cause
of gastric folds. (p.758)
HELICOBACTER PYLORI
GASTRITIS
- almost all patients with
benign gastric and duodenal
ulcers have H.pylori gastritis.
57
```
DIAGNOSIS? ______ GASTRITIS
UGI findings of:
1. thickening (<5 mm) of gastric folds
2. nodular folds;
3. erosions
4. antral narrowing
5. inflammatory polyps
6. enlarged gastric gastricae (p.758)
```
HELICOBACTER PYLORI
| GASTRITIS
58
```
DIAGNOSIS? _____ GASTRITIS
is most often caused by alcohol; aspirin and
other NSAID agents or steroids
Double-contrast UGI findings include:
1. erosions (aphthous ulcers)
2. thickened nodular folds in the antrum
3. limited distensibility of the antrum
4. wall stiffness and limited peristalsis
(p.758)
```
EROSIVE Gastritis
59
```
DIAGNOSIS? _____ GASTRITIS
is a chronic autoimmune disease that
destroys the fundic mucosa but spares the
antral mucosa. (p. 758)
Characteristic UGI findings:
1. decreased of absent folds in the fundus
and body ("BALD FUNDUS")
2. narrowed; tube-shaped stomach
(fundal diameter < 8cm)
3. small (1 to 2mm) or absent areae
gastricae. (p.758)
```
ATROPHIC Gastritis
```
- destruction of parietal cells
results in decreased acid
and intrinsic factor production
that leads to Vit.B12 def.
and pernicious anemia
- antibodies to the parietal
cells and intrinsic factors are
found in peripheral blood
samples.
```
60
_____ gastritis is an acute; often fatal;
| bacterial infection of the stomach. (p.758)
PHLEGMONOUS GASTRITIS
```
- multiple abscesses are formed
in the gastric wall; which is
markedly thickened.
- the rugae are swollen
- barium penetrates into
abscess crypts in the gastric
wall
- peritonitis develops in 70%
of cases
- healing usually results in a
severely contracted stomach
```
61
___ are the most common cause of
| PHLEGMONOUS GASTRITIS. (p.758)
ALPHA-HEMOLYTIC
STREPTOCOCCI
```
- but a variety of other bacteria
have also been identified
- it may arise a complication
of septicemia; gastric surgery or
gastric ulcers
```
62
_____ gastritis is a form of phlegmonous
gastritis caused by gas-producing organisms;
usually Escherichia coli or Clostridium
welchii. (p.758)
EMPHYSEMATOUS
Gastritis
```
- most cases are caused by
caustic ingestion; surgery;
trauma or ischemia
- multiple gas bubbles are
apparent within the wall of
the stomach
```
63
_____ gastroenteritis is a rare disease
characterized by diffuse infiltration of the
wall of the stomach and small bowel by
eosinophils. Any or all layers of the wall
may be involved. (p.758)
EOSINOPHILIC Gastroenteritis
```
- The condition is associated
with a peripheral eosinophilia
as high as 60%.
- initially; the folds are markedly
thickened and nodular; esp. in the
antrum
- when chronic; the antrum is
narrowed with a nodular
"cobblestone" mucosal pattern
- ascites and pleural effusions
may be present
```
64
```
______ also called GIANT HYPERTROPHIC
GASTRITIS; is a rare condition characterized
by excessive mucus production; giant
rugal hypertrophy; hypoproteinemia;
and hypochlorhydria. (p.758)
```
MENETRIER DISEASE
```
- pathologically; patients have
mucosa thickened by hyperplasia
of epithelial cells.
- UGI findings include:
1. markedly enlarged (>10 mm in the
fundus) and tortuous but pliable
folds in the fundus and body; esp.
along the greater curvature; with
sparing of the antrum
2. hypersecretion has diluted the
barium and impaired mucosal coating
```
- CT demonstrates nodular thick folds
with smooth serosal surface and
normal gastric wall thickness between
folds.
65
___ appear as smooth; lobulated filling
| defects resembling thickened folds. (p.758)
VARICES
66
VARICES are most common in which part of
| the stomach? (p.758)
FUNDUS
```
- usually accompanies esophageal
varices
- isolated gastric varices occur with
splenic vein occlusion
- MDCT with contrast enhancement
is an excellent method for confirming
the presence of gastric varices as
demonstrating their cause.
- CT shows well-defined clusters
of rounded and tubular enhancing vessels.
- additional findings of portal hypertension
may be evident
```
67
```
TRUE OR FALSE.
LYMPHOMA and SUPERFICIAL SPREADING
GASTRIC CARCINOMA may produce
distorted rigid gastric folds that are
commonly ulcerated and appear nodular.
(p.758)
```
TRUE
68
The ____ stomach is the most common
| location for neoplasms. (p.758)
DISTAL Stomach
69
____ is defined as a full-thickness defect
in the mucosa. It frequently extends to the
deeper layers of the stomach; including the
submucosa and muscularis propria. (p.759)
ULCER
```
- about 95% of ulcerating gastric
lesions benign
- all gastric ulcers should be
examined endoscopically or be
followed to complete
radiographic healing.
```
70
DIAGNOSIS?
Double-contrast UGI series findings:
1. BARIUM-FILLED CRATER on the dependent wall
2. RING SHADOW due to barium coating the edge
of the crater on the nondependent wall
3. DOUBLE RING SHADOW if the base of the ulcer
is broader than the neck
4. CRESCENTIC OR SEMILUNAR LINE when the ulcer
is seen on tangent oblique view.
ULCER
- some ulcers may be linear or rod shaped.
- ulcers are multiple in about 20% of patients.
71
Benign gastric ulcers are caused by
| ___ (70%) and by ___ (30%). (p.759)
70%: H.pylori infection
30%: Non-steroidal
Anti-inflammatory medications
72
DUODENAL ULCERS:
- are usually associated with ____
production of acid.
GASTRIC ULCERS:
- occur with ______ acid levels.
(p. 759)
DUODENAL ULCERS:
- are usually associated with
INCREASED production of acid.
GASTRIC ULCERS:
- occur with NORMAL or even
DECREASED acid levels.
However; hydrochloric acid must be
present for peptic ulceration to occur.
73
3 major complications of PEPTIC ULCER
| DISEASE. (p.759)
1. Bleeding
2. Obstruction
3. Perforation
- bleeding occurs in 15% to 20%
of patients and is manifest by
melena; hematemesis or hematochezia
74
What is the hallmark of BENIGN ULCERS
and the basis for most radiographic signs of
benignancy? (p.759)
MUCOSA THAT IS INTACT TO THE
VERY EDGE OF AN UNDERMINING
ULCER CRATER.
- about 2/3s of all gastric ulcers
evaluated on double-contrast
barium studies can unequivocally
diagnosed as benign.
75
TRUE OR FALSE.
Demonstration of complete and sustained
healing is reliable radiographic evidence of
benign gastric ulcer. (p.759)
TRUE
76
7 signs of benignancy in ulcers? (p.759)
```
1. a SMOOTH ULCER mound with
tapering edges
2. an EDEMATOUS ULCER COLLAR with
overhanging mucosal edge
3. an ULCER PROJECTING BEYOND the
expected lumen
4. RADIATING FOLDS extending into the
crater
5. DEPTH of ulcer greater than width.
6. Sharply marginated CONTOUR
7. HAMPTON LINE (a thin; sharp; lucent
line that traverses the orifice of the ulcer.)
```
77
HAMPTON LINE is best demonstrated
on spot films obtained with compression;
is caused by _____. (p.759)
OVERHANGING GASTRIC
| MUCOSA IN AN UNDERMINED ULCER
78
TRUE OR FALSE.
The size; depth; and location of the ulcer
and the contour of the ulcer base are of
NO DIAGNOSTIC VALUE in differentiating
benign from malignant ulcers. (p.759)
TRUE
79
5 Differential diagnoses for BENIGN ULCER.
| p.759
1. H.pylori peptic disease
2. Gastritis
3. Hyperparathyroidism
4. Radiotherapy
5. Zollinger-Ellison syndrome
80
TRUE OR FALSE.
Evidence of irregular tumor or mass or
infiltration of the surrounding mucosa is
evidence of malignancy. (p.760)
TRUE
81
5 sign of malignancy in ULCER (p.760)
```
1. an ulcer within the lumen of
the stomach
2. an ulcer eccentrically located
within the tumor mound
3. SHALLOW ULCER with a WIDTH
GREATER than its depth
4. Nodular; rolled; irregular or
shouldered edges
5. CARMEN MENISCUS SIGN
```
82
Radiographic sign which is described as
a large flat-based ulcer with heaped-up
edges that fold inward to trap a lens-shaped
barium collection that is convex toward the
lumen. (p.760)
CARMEN MENISCUS SIGN
- the differential diagnosis of
malignant ulcer includes
gastric adenoCA; lymphoma;
leiomyoma and leiomyosarcoma
83
3 imaging findings of EQUIVOCAL
| ULCERS:
```
1. Coarse area gastricae abutting
the ulcer
2. Nodular ulcer collar
3. Mild irregular folds extending
to the ulcer edge
```
- CT is useful in demonstrating
the extent of the tumor mass
and the degree of involvement
of the gastric wall.
84
```
In the DUODENAL BULB; 90% of tumors
are benign.
In the 2nd and 3rd portions of the duodenum;
tumors are 50% benign and 50% malignant.
In the 4th portion of the duodenum;
most tumors are ____. (p.760)
```
MALIGNANT
- small benign tumors of the
duodenum usually present as
smooth polypoid filling defects
85
4 signs of DUODENAL malignancy. (p.760)
1. Central Necrosis
2.Ulceration or Excavation
3. Exophytic or Intramural mass
4. Evidence of tumor beyond the
duodenum
86
```
TRUE OR FALSE.
DUODENAL ADENOCA; although being the
most frequent malignant tumor of the
duodenum; is a rare lesion (1.5% of GI
neoplasms).
```
TRUE
87
TRUE OR FALSE.
Malignant tumors are most common in the
periampullary region and are rare in the
duodenal bulb. (p.760)
TRUE
88
3 morphologic patterns of DUODENAL
| ADENOCarcinoma. (p.760)
1. Polypoid mass
2. Ulcerative mass
3. Annular constricting lesion
```
- metastases to regional lymph
nodes are present in 2/3s of patients
at presentation.
- CT and MR demonstrate an enhancing
soft tissue mass with smooth margins
and frequently a bilobed "dumb-bell"
shape.
- Regional adenopathy; hepatic metastases
and local extent of tumor are demonstrated
for surgical planning.
```
89
Metastases to the duodenum may occur in
| the __ or ___ of the duodenum. (p.760)
WALL or SUBSEROSA
- as the tumor grows; it may extend
into the lumen and present as an
intraluminal mass that may ulcerate
90
The most common primaries (for duodenal
metastases) are ___; ___ and other GI
malignancies. (p.760)
BREAST; LUNG
- the duodenum may be invaded
by tumors of adjacent organs
including the pancreas and kidney.
91
TRUE OR FALSE.
Lymphoma in the duodenum usually
present as nodules with thickened
folds. (p.761)
TRUE
- The nodules associated with
lymphoma are distintly larger
than those seen with benign
lymphoid hyperplasia.
92
This condition account for about half of the
| neoplasms of the duodenum.
DUODENAL ADENOMA
- present as polypoid lesion that
may be pedunculated or sessile
93
____ adenomas have a high incidence of
malignant degeneration and a characteristic
"cauliflower" appearance on
double-contrast UGI series. (p.761)
VILLOUS adenomas
94
GISTs of the duodenum present as
intramural; endoluminal or exophytic mass;
most commonly in the ___ or ___
portion of the duodenum. (p.761)
SECOND or THIRD portion of the
duodenum.
- ulceration is common
- malignant tumors range up to 20 cm
size and are most common in the
more distal duodenum.
95
____ are the second most common
primary malignant tumor of the
duodenum. (p.761)
MALIGNANT GISTs
96
TRUE OR FALSE.
LIPOMA of the duodenum is a soft
tumor that may grow to a large size.
- a definitive diagnosis can be made
by CT or MR demonstration of a
uniform fat density mass
TRUE
97
_____ presents as a small (1 to 3 mm)
polypoid nodules diffusely throughout the
duodenum. (p.761)
LYMPHOID HYPERPLASIA
- the condition is usually benign;
especially in children
- associated with immunodeficiency
states in some adults
98
Gastric mucosa may prolapse through the
pylorus during ____ and cause a lobulated
filling defect at the base of the duodenal
bulb. (p.761)
PERISTALSIS
```
- the diagnosis is suggested by a
characteristic location and a
change in configuration with peristalsis.
- Heterotopic gastric mucosa in
the duodenal bulb is common on
endoscopy (12%) but less frequently
evident radiographically.
```
99
____ glands are located in the submucosa
of the proximal two-thirds of the duodenum
and secrete an alkaline substance that
buffers gastric acid. (p.761)
BRUNNER glands
```
- lesions; usually multiple
and smaller than 5 mm; are
termed HYPERPLASIA
- lesions larger than 5 mm are
termed HAMARTOMAS
- all lesions are benign and
without cellular atypia
```
100
TRUE OR FALSE.
Diffuse nodular gland hyperplasia is a
common cause of multiple filling defects;
often with a cobblestone appearance. (p.761)
TRUE
101
Brunner gland ____ usually presents as
a solitary filling defect and is identical in
appearance to other benign duodenal
nodules. (p.761)
Brunner gland HAMARTOMA
- CT shows well-defined enhancing
nodules.
102
Ectopic pancreas may also occur in the
duodenum; most commonly in the
______ portion. (p.761)
PROXIMAL DESCENDING portion
of the duodenum
- a solitary mass with a central
dimple is most characteristic of
an ectopic pancreas
103
TRUE OR FALSE.
Extrinsic mass impressions on the
duodenum may be made by the gallbladder;
masses in the liver; pancreas; adrenal gland;
kidney or colon; pancreatic fluid collections;
adenopathy or aneurysms. (p.761)
TRUE
104
The valvulae conniventes or Kerckring folds;
of the small bowel begin in the ____ portion
of the duodenum and continue
throughout the remainder of the small
bowel. (p.761)
SECOND portion of the
duodenum
```
- VALVULAE CONNIVENTES are
are permanent circular folds of
mucosa supported by a core of
fibrovascular submucosa.
- normally several millimeters wide
and remain visible even with full
distension of the duodenum.
```
105
Duodenal folds greater than ___ to ___ mm
wide are usually considered thickened.
(p.761)
2 to 3 mm wide
106
TRUE OR FALSE.
Thickened duodenal folds are a nonspecific
radiographic finding that may be found in
normal individuals. The radiographic
diagnosis of a pathologic condition is more
confident when there are additional
findings. (p.761)
TRUE
107
____ refers to inflammation of the
duodenum without discrete ulcer
formation. (p.761)
DUODENITIS
108
The major cause of duodenitis is
| _____ infection. (p.761)
H. pylori infection
- alcohol and antiinflammatory
medications cause a few cases
109
```
DIAGNOSIS?
UGI findings of :
1. Thickening (>4 mm) of the proximal
duodenal folds
2. Nodules or nodular folds (enlarged
Brunner glands)
3. Deformity of the duodenal bulb
4. Erosions
```
- CT shows nonspecific wall thickening
DUODENITIS
110
TRUE OR FALSE.
Pancreatitis and Cholecystitis thicken
the duodenal folds by paraduodenal
inflammation. (p.761)
TRUE
```
- both may also cause mass
impressions on the duodenal lumen
- CT or US demonstrates the extent
and nature of the paraduodenal
process.
```
111
```
CROHN DISEASE OF THE DUODENUM
usually involves the ___ and ___ portion
(of the duodenum) and is almost always
associated with contiguous involvement
of the stomach. (p.761)
```
FIRST and SECOND portion of
the duodenum
- duodenal involvement is
manifest by thickened folds;
apthous ulcers; erosions and
single or multiple strictures.
112
GIARDIASIS is caused by an overgrowth
of the parasite Giardia lamblia in the
____ and ___. (p.761)
DUODENUM and JEJUNUM
```
- many patients are
asymptomatic carriers; but
patients with invasion of the gut
wall have abdominal pain;
diarrhea and malabsorption.
```
113
____ is a frequent cause of traveler's
| diarrhea. (p.761)
GIARDIASIS
114
```
DIAGNOSIS?
3 Radiographic findings include:
1. Distorted thickened folds in the duodenum
2. Hypermotility and spasm
3. Increased secretions
```
GIARDIASIS
115
STRONGYLOIDIASIS is caused by infection
| with the nematode; _____. (p.761)
STRONGYLOIDES STERCORALIS
- found in all areas of the world
but most common in the warm;
moist regions of the tropics.
116
TRUE OR FALSE.
Parasite invasion of the intestinal wall
causes vomiting and malasorption.
(p.761-762)
TRUE
117
DIAGNOSIS?
UGI findings of edematous folds; spasm;
dilation of the proximal duodenum and
diffuse mcuosal ulceration. (p.762)
GIARDIASIS
118
TRUE OR FALSE.
LYMPHOMA presents with nodular
thickened duodenal folds. (p.762)
TRUE
119
Intramural hemorrhage is caused by trauma;
anticoagulation and bleeding disorders.
The regular pattern of thickened folds
resembles a _____. (p.762)
STACK OF COINS
120
The fixed retroperitoneal postion of the
____ portion of the duodenum makes it
susceptible to blunt abdominal trauma
and compression against the lumbar spine.
(p.762)
THIRD portion of the duodenum
121
Duodenal ulcers are caused by ____ in 95%
| of cases. (p.762)
H.pylori infection
```
- addition causes include
anti-inflammatory medications;
Crohn disease; Zollinger-Ellison
Syndrome; viral infections or
penetrating pancreatic cancer
```
122
___ ulcers are associated with acid
| hypersecretion. (p.762)
DUODENAL ULCERS
123
Most (95%) of duodenal ulcers are in the
_____; with the ___ wall being most often
involved. (p.762)
DUODENAL BULB; ANTERIOR wall
124
TRUE OR FALSE.
Radiographic diagnosis of a duodenal ulcer
depends upon demonstration of the ulcer
crater or niche. (p.762)
TRUE
-EN FACE: the crater appears as a
persistent collection of barium or
air
- IN PROFILE: ulcers project beyond
the normal lumen
* thickened folds often radiate toward
the ulcer crater; which may be surrounded
by a mound of edema.
*although the shape is usually round or oval;
linear ulcers also occur.
125
duodenal ulcers are smaller than ___ cm im
diameter.
Giant ulcers larger than ___ cm resemble
diverticula or a deformed bulb. (p.762)
smaller than 1 cm;
| larger than 2 cm
126
TRUE OR FALSE.
ULCER CRATERS have no mucosal lining and
therefore no mucosal relief pattern; and do
not contract with peristalsis. (p.762)
TRUE
- endoscopy may be required
to make the differentiation.
127
```
TRUE OR FALSE.
ULCER SCARRING may cause a pattern
of radiating folds with a central
barium collection that is indistinguishable
from an acute ulcer. (p.762)
```
TRUE
- endoscopy may be required
to make the differentiation.
128
Postbulbar ulcers represent about 5% of
the total; but are more commonly
associated with serious ____. (p.762)
UGI Hemorrhage
129
Postbulbar ulcers most commonly involve
the ___ and ___ porions of the duodenum.
(p.762)
SECOND and THIRD portions
of the duodenum
```
- complications of duodenal ulcer
disease include obstruction;
bleeding perforation.
- bleeding from a duodenal ulcer
is most efficiently diagnosed
endoscopically.
```
130
TRUE OR FALSE.
Perforation may be manifest by
pneumoperitoneum or a localized retro-
peritoneal gas collection. (p.762)
TRUE
- Peptic duodenal ulcer is not
a premalignant condition
131
Zollinger-Ellison syndrome is caused by a
| ___. (p.762)
GASTRIN-SECRETING ISLET CELL
TUMOR (GASTRINOMA)
```
- gastrinomas are found in the
pancreas (75%); duodenum
(15%);and extraintestinal sites
(liver; lymph nodes and ovary)
(10%).(p.762)
- the islet cell tumor is malignant
in 60% of cases.
```
132
TRUE OR FALSE.
Gastrinomas also occur as part
of the hereditary syndrome of
multiple endocrine neoplasia;
type I (MEN-1). (p.762)
TRUE
- Continuous gastrin secretion
results in marked hyperacidity
and multiple peptic ulcers in the
duodenum; stomach and jejunum.
133
DIAGNOSIS?
UGI studies show pathognomonic findings
of:
1. Multiple peptic ulcers in the stomach;
duodenal bulb; and most characteristically;
in the postbulbar duodenum
2. Hypersecretion with high-volume gastric
fluid diluting the barium and impairing
mucosal coating
3. Thick edematous folds in the stomach;
duodenum and proximal jejunum. (p.762)
ZOLLINGER-ELLISON SYNDROME
134
_____ pseudotumors are a common cause
of a duodenal filling defect with a central
barium collection; mimicking an ulcerated
lesion. (p.762)
FLEXURAL PSEUDOTUMORS
```
- appearing as rounded; swirled
mucosal folds on the inner aspect
of the flexure at the apex of the bulb;
these tumors are redundant mucosa
and have a variable appearance on
different projections.
```
135
TRUE OR FALSE.
DUODENAL DIVERTICULA are common
(5% of UGI series) and usually incidental
findings. (p.762)
TRUE
- may be multiple and may form
in any portion of the duodenum
136
DUODENAL DIVERTICULA are most
common along the inner aspect of the
______ duodenum. (p.762)
DESCENDING
137
Diverticula are differentiated from ulcers
on a UGI series by the demonstration of
____. (p.762)
```
DEMONSTRATION OF MUCOSAL
FOLDS ENTERING THE NECK OF THE
DIVERTICULUM and
CHANGE IN APPEARANCE WITH
PERISTALSIS
```
138
On plain abdominal radiographs;
duodenal diverticuli may be seen as ___.
(p.762)
ABNORMAL AIR COLLECTIONS
```
- On CT; they may be filled with
fluid and mimic a pancreatic
pseudocyst; or they may contain
air and fluid and mimic a pancreatic
pseudocyst or they may contain
air and fluid and mimic a pancreatic
abscess.
- rare complications include perforation
and hemorrhage.
```
139
TRUE OR FALSE.
Diverticuli adjacent to the ampulla of Vater
may rarely obstruct the common bile duct
or pancreatic duct. (p.762)
TRUE
140
_____ DIVERTICULA are caused by a thin;
incomplete congenital diaphragm that is
stretched by moving intraluminal contents
to form a "wind sock" configuration within
the duodenum. (p.762)
INTRALUMINAL DIVERTICULA
141
___ is the most common congenital anomaly
of the pancreas.
Pancreatic tissue encircles the duodenum
and narrows its lumen. (p.762)
ANNULAR PANCREAS
```
- the abnormality occurs when
the bilobed ventral component
of the pancreas fuses with the
dorsal pancreas on both sides
of the duodenum.
- often present in childhood;
especially in children with
DOWN SYNDROME; about half of
the cases do not present until
adulthood.
```
142
DIAGNOSIS?
UGI series typically demonstrates
eccentric or concentric narrowing of the
descending duodenum. (p.763)
ANNULAR PANCREAS
- is associated with a high
incidence of postbulbar peptic
ulceration in adults.
143
DIAGNOSIS?
CT confirms the diagnosis by demonstration
of pancreatic tissue encircling the
duodenum. (p.763)
ANNULAR PANCREAS
- ERCP demonstrates an annular
pancreatic duct encircling the
duodenum
144
```
TRUE OR FALSE.
DUODENAL ADENOCARCINOMA can present
as a circumferential constricting lesion; with
tumor shoulders giving evidence of mass
effect. (p.763)
```
TRUE
- Ulceration is common
- CT demonstrates the extent
of the lesion
145
TRUE OR FALSE.
PANCREATIC CARCINOMA may also encircle
and obstruct the pancreas.
- Jaundice with dilatation of the bile and
pancreatic ducts are usually present. (p.764)
TRUE
146
____ causes marked wall thickening and
bulky duodenal lymphadenopathy that
may narrow the lumen. (p.764)
LYMPHOMA
147
POSTBULBAR ULCER is commonly associated
with narrowing of the lumen of the ___
and ___ portions of the duodenum. (p.764)
SECOND and THIRD portions
| of the duodenum
148
```
TRUE OR FALSE.
EXTRINSIC COMPRESSION; because of
inflammation or tumor in adjacent organs;
esp. the pancreas; may constrict the
duodenal lumen. (p.764)
```
TRUE
