Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

FUNDAMENTALS OF BODY CT > Gastrointestinal Tract > Flashcards

Gastrointestinal Tract Flashcards

1
Q

Neoplasic wall thickening characteristics

A
  • 1-2 cm thickness.
  • Asymmetric.
  • Nodular.
  • Lobulated.
  • Spiculated contour.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Benign wall thickening characteristics

A
  • > 3 mm (does not exceed 10 mm).
  • Homogeneous attenuation.
  • Circumferential.
  • Symetric.
  • Segmental.
  • Double halo and target sign.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Indications for CT enterography

A
  • Crohn disease.
  • Inflammatory bowel disease.
  • Intermitent small-bowel obstruction.
  • Obscure GI bleeding.
  • Small bowel tumor suspicion.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

CT enteroclysis use

A

To determine in patients with small bowel obstruction the level and cause of obstruction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Esophageal carcinoma

A
  • 90% are squamous cell carcinoma.
  • 10% are adenocarcinomas arising in Barret esophagus in the distal esophagus.
  • CT findings: Irregular thickening >3 mm, intraluminal polypoid mass, eccentric narrowing of the lumen, proximal dilation, invasion: trachea and bronchi, aorta, etc. metastases to lymphnodes and liver.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Esophageal Mesenchymal Tumors

A
  • Leiomyoma
  • GIST
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Esophagus leiomyoma

A
  • The most common benign tumor of the esophagus.
  • CT: Smooth, well-defined, 2-8 cm, homogeneous, soft-tissue attenuation, esophageal wall eccentrically thickened and lumen is deformed.
  • Multiple 4% of cases.
  • The only tumors (rarely GIST) that have calcifications.
  • May have malignant potential.
  • GIST is more heterogeneous and avid for PET CT FDG.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Esophagitis

A
  • Causes: RGE, corrosive ingestion, long-term intubation, radiation, infection (candida, herpes, CMV, mycobacterium TBC).
  • CT findings: Long segment of circumferential symmetric wall thickening >5 mm, target sign and strictures.
  • Complications: Deep ulcers, perforation, mediastinitis, abscess.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Esophageal injury and perforation

A
  • Causes: Iatrogenic, traumatic, neoplasm, inflammation.
  • CT findings: Wall thickening, intramural hematoma, mediastinal inflammation, periesophageal fluid/contrast/air, pleural effusion.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Boerhaave syndrome

A

Spontaneous rupture of the esophagus associated with violent vomiting.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Hiatus hernia

A
  • 95% are sliding hiatus hernia.
  • Identified by recognition of gastric folds appearing above the esophageal hiatus
  • Edges of esophageal hiatus separated >15 mm.
  • Paraesophageal hernia: Fundus of stomach is above the hiatus adjacent to the distal esophagus.
  • Variant: Coexistence of a sliding hiatal hernia and paraesophageal intrathoracic fundus.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Gastric volvulus generalities

A
  • Abnormal gastric rotation associated with strangulation and obstruction.
  • Organoaxial rotation: Stomach rotates arround it’s long axis.
  • Mesenteroaxial rotation: Stomach rotates arround it’s short axis.
  • Complete gastric obstruction >180° rotation.
  • Emergency surgical repair is needed.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Thickened Gastric Wall

A
  • With good technique, which includes agressive distention, >5 mm.
  • Causes: Carcinoma, lymphoma, gastric inflammation (Crohn or peptic disease), peri gastric inflammation (pancreatitis) and radiation.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Gastritis

A
  • Erosive gastritis: NSAIDS, OH, aspirin, radiation and ischemia.
  • Non-erosive gastritis: HP infection.
  • CT findings: Thickened gastric folds.
  • Erosive gastritis: Mucosa enhances during arterial phase, causing a three-layer wall.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Emphysematous gastritis

A
  • Rare life-threatening condition characterized by air within the thickened gastric wall.
  • Invasion of gas producing bacteria: E. coli or S. aureus.
  • Asociated with caustic ingestion or alcohol abuse.
  • Gas may extend to the portal venous system.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Gastric Carcinoma

A
  • 95% Adenocarcinoma
  • RF: 50-70 years old, chronic atrophic gastritis, pernicious anemia, familial adenomatous polyposis and menetrier disease.
  • Primary tumor: Focal, nodular, irregular thickening of the gastric wall or polypoid intraluminal mass
  • Linitis plastica: Irregular wall thickening + narrowing of the lumen.
  • Wall > 2 cm = invasion of tumor to the perigastric fat
  • Lymphnodes are considered involved > 6 mm (celiac axis and in the gastro-hepatic ligament).
  • Metastases: liver, lungs, adrenal glands, kidneys, bones and brain.
  • Peritoneal carcinomatosis may occur.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Gastric carcinoma recurrence locations (3)

A
  1. Local: focal wall thickening at the anastomosis or remaining stomach.
  2. Nodal: Course of hepatic artery or para-aortic region.
  3. Peritoneal: Douglas pouch, parietal peritoneal surfaces or on the surface of the bowel.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Gastric Lymphoma

A
  • Stomach is the most common location of primary GI lymphoma.
  • 90-95% Non-Hodgkin lymphoma of B-cell origin.
  • May cause: polypoid mass, diffuse wall infiltration with featureless walls or markedly thickened walls with nodular thickened folds.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Gastric Lymphoma vs Carcinoma

A
  • Favors lymphoma: >30 mm wall thickness, involvement of more than one region of the GI tract, transpyloric spread of tumor (30% of cases), and more widespread adenopathy above and below the renal hilium, no lumen narrowing.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Gastrointestinal Stromal Tumors

A
  • Most arise from the muscularis propia of the GI tract.
  • > 40 years old
  • Clinic: GI bleeding from mucosal ulceration.
  • Other: Omentum, mesentery and retroperitoneum.
  • 10-30% are malignant. Higher risk of malignany if >5 cm or if outside the stomach.
  • 50% have ulceration of the luminal surface.
  • Cystic degeneration, hemorrage and necrosis are common.
  • Contrast enhancement is seen on the viable tumor, mostly on the periphery.
  • Metastases: Liver and peritoneal cavity.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

GIST vs True Leiomyomas and Leiomyosarcomas

A

GIST have a tyrosine kinase growth factor called protein KIT (CD 117), which is tested by immunohistochemical stain.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Normal luminal diameter and wall thickness of the small bowell

A

<2,5 cm and <3 mm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Causes of bowel “target appearance” of mural enhancement

A

Benign process: Crohn disease, infection, angioedema, hemorrage or radiation enteritis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Small bowel mild wall thickening

A
  • 3-4 mm
  • Causes: hypoalbuminemia, infectious enteritis, mild crohn disease.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Small bowel moderate wall thickening

A
  • 5-9 mm
  • Causes: Ischemia caused by mesenteric vein thrombosis, intramural hemorrage, vasculitis, radiation, moderate crohn disease.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Small bowel severe wall thickening

A
  • > 10 mm
  • Causes: Lymphoma, neoplasms, vasculitis and intramural hemorrage
  • > 20 mm is almost always neoplasm.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Small bowel Neoplasms types (6)

A
  • Lymphomas.
  • Carcinoid.
  • Adenocarcinoma.
  • GIST.
  • Metastases.
  • Multiple small-bowel polyps.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Small bowel Lymphoma

A
  • Single or multiple, focal or diffuse nodular wall thickening (usually simetric), large (9 cm), soft-tissue mass.
  • 50% associated with retroperitoneal adenopathy.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Carcinoid (neuroendocrine)

A
  • 50% appendix, 20% small bowel.
  • Second most common small bowel malignancy.
  • All tumors can metastasize, considered malignant.
  • CT: Brightly enhancing mass, agressive if >2 cm, necrosis, ulceration.
  • Tumor invasion of the bowel wall induces a dramatic fibrosing reaction in the mesentery
  • Carcinoid syndrome: Cutaneous flush and diarrhea by release of vascoactive amines by the tumor. Only occurs with hepatic metastases.
  • Metastases are hypervascular.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Adenocarcinoma of the small bowel

A
  • Rare lesion, 50% in duodenum, spacially near the ampulla.
  • Morphologies (3):
    1. Constricting anular mass with abrupt irregular margins and over-hanging edges.
    2. Distinct polypoid nodule
    3. Ulcerative mass.
  • CT: Only mild enhancement
  • May generate: partial or complete bowel obstruction.
31
Q

GIST (small bowel)

A
  • Malignant GIST are more common in the distal small bowel.
  • Small GIST are homogeneous, large GIST are heterogeneous, necrotic and often ulcerated.
32
Q

Metastases to the small bowel

A
  • Serosal implants with peritoneal carcinomatosis or hematoneous spread of tumor as intramural masses.
  • Primary tumors: Melanoma, breast, lung, renal cell carcinoma.
33
Q

Multiple small-bowel, polyps

A
  • Peutz Jeghers.
  • Other polyposis syndromes.
34
Q

Crohn Disease

A
  • Inflammation of the bowel mucosa, wall, mesentery, with marked submucosal edema.
  • CT findings:
    1. 80% Small bowel, specially the terminal ileum, 30% colon.
    2. Circumferential thickening: Mild > 3 mm, moderate 4-9 cm, Severe >10 cm
    3. Wall thickening may be homogeneous or may have a “target” or “double halo” sign.
    4. Wall thickening with marked wall enhancement.
    5. Comb sign
    6. “Skip areas” of normal bowel between diseased segments.
    7. Misty mesentery.
    8. Fistulas and sinus tracts between the bowel loops.
    9. Extramural abscesses + mesenteric lymph nodes.
35
Q

Celiac Disease

A
  • Autoimmune inflammation of the small bowel, secondary to ingestion of gluten.
  • Dilated and fluid-filled small-bowel loops.
  • Wall thickening, then atrophy and wall thining.
  • Fluid excess in the ascending colon, with increased gas.
  • Jejunization of the ileum
  • Increased vascularity of the mesentery and it’s adenopathies.
36
Q

Mesenteric Ischemia

A
  • Acute or chronic.
  • 60-70% thrombosis, emboli or low-flow states (Ex. ICC).
  • 5-15% trombosis of the SMV.
  • CT findings: circumferential wall thickening, mural hyper-enhancement, mural hypo-enhancement, venous engorgement of the mesentery, visible thrombus in the SMV.
  • Infarction –> Perforation
  • Might generate: Pneumatosis and portal venous gas.
37
Q

Small Bowel Obstruction

A
  • Complete: Dilation of proximal bowel >2,5 cm, distinct transition zone and collapsed distal small bowel.
  • Partial: Small-bowel feces sign.
  • Paralytic Ileus.
  • 50-75% caused by adhesions.
  • Other causes: Tumor, abscess, intussusception, inflammation, endometriosis, complicated hernia (10%).
38
Q

Closed loop obstruction

A
  • The obstructed loop may twist (volvulus).
  • Beak or whirl signs.
  • Dilated bowel loops with stretched and prominent mesenteric vessels.
39
Q

Midgut Volvulus

A
  • Associated with congenital malrotation of the small bowel, abnormal fixation of the mesentery and short mesenteric root.
  • May be intermitent.
  • Causes abdominal pain.
  • CT: Swirling of the mesenteric vessels, reversed position of the mesenteric artery and vein, ectopic location of small bowel loops and ligament of Treitz.
40
Q

Intussusception

A
  • 5% of adult cases of small bowel obstruction.
  • Causes: Lipoma, other benign submucosal tumors, carcinoma, metastatic disease and lymphoma.
  • CT: Bowel inside bowel.
41
Q

Misty mesentery definition and causes

A
  • Vagely defined area of increased attenuation in the mesenteric fat.
  • Causes: Mesenteric edema (hypoproteinemia, HTP, mesenteric vein thrombosis, etc.), hemorrage (trauma, ischemia, blood clotting disorders), inflammation (pancreatitis, inflammatory bowel disease), early stage lymphoma, primary mesenteric neoplasm, or sclerosing mesenteritis.
42
Q

Sclerosing mesenteritis phases (3)

A
  1. Mesenteric lipodystriophy.
  2. Mesenteric panniculitis.
  3. Retractile mesenteritis.
43
Q

Cystic Mesenteric Masses causes (5)

A
  1. Cystic Lymphangiomas.
  2. Enteric duplication cysts.
  3. Enteric cysts.
  4. Cystic mesothelioma.
  5. Cystic teratomas.
44
Q

Mesenteric Neoplasms types (5)

A
  1. Lymphoma.
  2. Metastases.
  3. Desmoid tumor.
  4. GIST.
  5. Sarcomas.
45
Q

Mesenteric Lymphoma Generalities

A
  • The most common malignancy seen in the mesentery.
  • Lymphoma of the small-bowel: Discrete solitary mass, multiple masses or focal nodular or circumferential wall thickening.
  • Enlarged individual or large confluent mesenteric nodes.
46
Q

Mesenteric Metastases Generalities

A
  • Far more common than primary tumors arising in the mesentery.
  • Origin (4).
    1. Direct extension: Carcinoid, small bowel adenocarcinoma.
    2. Lymphatic flow: Lymphoma and leukemia.
    3. Hematogenous spread to bowel wall: Melanoma, breast, lung cancer.
    4. Peritoneal seeding: Ovarian and colon cancer.
47
Q

Desmoid tumor (mesenteric fibromatosis) Generalities

A
  • Arises most commonly in the mesentery of the small bowel.
  • Histogically benign but may invade locally and recur after excision.
  • 75% associated with abdominal surgery.
  • Gardner syndrome produces them in the abdominal wall.
  • CT: Well defined homogeneous solid mass without hemorrhage, necrosis or cystic changes.
48
Q

GIST of the mesentery generalities

A
  • Large >10 cm, with prominent hemorrhage, necrosis and cystic changes.
49
Q

Appendicitis

A
  • Most common cause of acute abdominal pain.
  • CT has 95-98% of sensitivity of its diagnosis.
  • CT findings: > 6 mm of diameter, thickened walls that enhances, periappendiceal inflammatory changes with stranding of the fat, appendicolith or adjacent to a phlegmon or abscess.
  • May occur in the stump of a residual appendix after surgery.
  • Complications: Perforation, phlegmon (>20 HU), abscess (<20 HU), small bowel-obstruction, hepatic abscess and mesenteric vein thrombosis.
  • DD: Crohn disease, cecal diverticulitis, perforated cecal carcinoma, ureteral stone, mesenteric adenitis, hemorrhagic ovarian cyst and pelvic inflammatory disease.
50
Q

Mucocele of the Appendix

A
  • Distended appendix filled with mucus.
  • Causes: Simple chronic obstruction, hyperplasia of mucosa, obstructing benign or malignant neoplasm of the appendix (most common).
  • CT: Well-encapsulated, cystic mass with thin walls, 50% may be calcified.
51
Q

Neoplasms of the Appendix

A
  • 30-50% may present with appendicitis, also with intussusception, GI bleeding or mucocele.
  • Causes:
  • Carcinoid is the most common (80%).
  • Adenocarcinoma.
  • Lymphoma.
52
Q

Anatomic compartments in staging rectal carcinoma (3)

A
  1. The peritoneal cavity above the peritoneal reflections.
  2. The extraperitoneal compartment between the peritoneum and the levator ani muscle.
  3. The perineum identified by the triangular ischiorectal fossa below and lateral to the levator ani.
53
Q

Colorectal carcinoma generalities

A
  • 70% occur in the rectosigmoid region.
  • Spreads by: direct extension, lymphatic drainage, hematogeneous, intraperitoneal seeding.
  • Polyps: <5 mm insignificant, 6-9 mm 1% cancer, 50% are adenomas and precancerous lesions, 10-15 mm 80% adenoma, 1-5% malignant, >20 mm 40% malignant.
  • Cancer appears as larger intraluminal masses with nodular contours and irregular mucosal surfaces or soft tissue mass narrows the lumen.
  • May ulcerate (central low density at the lesion).
  • May be a flat lesion >3mm
  • Apple core lesions
  • Direct invasion, lymph nodes >1 cm, distant metastases to liver 75%, lung 5-50%, adrenal glands 14% and elsewhere.
    -Complications: bowel obstruction, perforation, fistula, ischemic colitis
54
Q

Mucinous Adenocarcinoma special finding to the CT.

A

Calcification in the primary tumor and metastases

55
Q

Colorectal Cancer Recurrence

A
  • 33% of resections have a recurrence
  • 70-80% within the first 2 years.
  • 50% original tumor site.
  • 50% distant sites, specially liver.
  • Multiple sites of recurrence are more common than a solitary site.
56
Q

Colon Lymphoma

A
  • Commonly in association with UC or crohn disease.
  • Also in AIDS or organ transplant.
  • B- Cell lymphoma is the most common.
  • CT findings: Marked thickening of colon wall >40 mm, Multiple intraluminal nodules or focal intramural mass, soft-tissue homogeneous without calcification or necrosis, minimal no no enhancement, regional and diffuse adenopathy often present
  • Colon lumen is commonly dilated or normal, rather than constricted
57
Q

Colon Lipoma

A

Homogeneous fat density (-120 to -80 HU) within a sharply defined tumor

58
Q

Acute Diverticulitis

A
  • > 80% of people >85 years old.
  • Complications: Microperforation can generate diverticulitis and pericolic inflammation, perforation, abscess, fistulas
  • CT: Small rounded collections of air, feces or contrast material outside the lumen of the colon.
  • Acute diverticulitis: usually > 5 cm in lengh, wall thickening, hyperemic contrast enhancement and inflammatory changes into the pericolic fat.
59
Q

Epiploic appendagitis

A
  • Mimics acute diverticulitis or appendicitis.
  • Fat-containing peritoneum-bounded sacs containing fat and blood vessels that extend from the serosa of the colon.
  • 5 mm to 50 mm.
  • Torsion, ischemia, inflammation and severe pain.
  • Self limited
60
Q

Meckel diverticulitis

A
  • Meckel diverticulum is the most common congenital anomaly from the GI tract.
  • Failure of obliteration of the omphalomesenteric duct.
  • Extends from the ileum about 100 cm proximal to the ileocecal valve.
  • CT findings when inflamed: blind-ending pouch with thickened walls, mural enhancement, and inflammation of sorrouding fat.
61
Q

Ulcerative colitis generalities

A
  • Inflammation and difuse ulceration of the colon mucosa.
  • Starts at the rectum, extends contiguously proximally to all the colon.
  • Bowel thickess: 7-8 mm.
  • CT findings: Symetrical-circumferential, smooth, wall thickening with lumen narrowingwith target or halo appearance.
  • Edematous strainding and mildy enlarged lymphnodes.
  • May produce Backward ileitis
  • Complications: Colon carcinoma, fibrous strictures, toxic megacolon, massive hemorrhage.
  • Asociations: Sacro-iliitis, cholangitis, uveitis and iritis.
62
Q

Chron colitis generalities

A
  • Transmural inflammation that affects the terminal ileum and proximal colon, and extends distally.
  • Bowel thickness 10-20 mm.
  • Irregular outer wall
  • Active: Target and halo signs.
  • Chronic: Homogeneous enhancement of the colon wall.
  • Lymphnodes up to 1 cm.
  • Fistulas and sinus tracts are frequent.
  • Intrabdominal abcess in 20% of patients.
63
Q

Pseudomembranous colitis Generalities

A
  • Caused by Clostridium difficile.
  • Cytotoxic enterotoxin ulcerates the mucosa and creates pseudomembranes.
  • Pancolitis or segmental colitis with irregular wall thickening (up to 30 mm)
    -Accordion pattern.
64
Q

Typhilitis (Chronic colitis) Generalities

A
  • Infection of the cecum and ascending colon in neutropenic patients.
  • Classic in leukemia + QT.
  • Marked circuferential symmetric wall thickening (10-30 mm), low-attenuation edema and pericecal inflammation and fluid.
65
Q

Ischemic colitis generalities

A
  • Low cardiac output + older patient.
  • Mild to moderate circumferential thickening of the colon wall in a segment of colon corresponding to an anatomic vascular distribution.
  • Commonly affects more: watershed areas at the splenic flexure and rectosigmoid.
  • Target or halo sign.
  • Fat stranding of pericolic fat.
  • Hemorrage and pneumatosis might occur in the bowel wall.
66
Q

Radiation colitis generalities

A
  • Acute phase: Mild wall thickening and pericolic inflammation.
  • Chronic phase: 6-24 months after radioation, mural thickening with prominent stranding in expanded pericolic fat.
67
Q

Infectious colitis CT findings

A
  • Circumferential wall thickening.
  • Homogeneous enhancement of the wall in all the portions of the colon.
  • Inflammatory stranding and edema in pericolic fat.
  • Airfluid in the colon level may be seen.
68
Q

Toxic megacolon CT findings

A
  • Dilatation of colon >5 cm.
  • Thinning of the colon wall.
  • Pneumatosis.
  • Pneumoperitoneum.
69
Q

Pneumatosis intestinalis causes (4)

A
  • Bowel necrosis: bowel ischemia, volvulus, necrotizing enterocolitis, typhlitis or sepsis.
  • Mucosal disruption: Peptic ulcers, endoscopy, enteric tubes, trauma, child abuse, ulcerative colitis or crohn disease.
  • Increased mucosal permeability: AIDS, organ transplantation, QT, steroid therapy, graft-versus-host disease.
  • Pulmonary conditions: COPD, asthma, cystic fibrosis, chest trauma, mechanical ventilation.
  • May be incidental
70
Q

Cystic pneumatosis

A

well-defined bubble or grape like clusters of spherical air collections in the subserosal region of the bowel wall. May produce benign pneumoperitoneum if ruptured.

71
Q

Linear pneumatosis

A

Streaks of gas within and parallel to the bowel wall. May be benign or ischemic.

72
Q

Colonic volvulus

A
  • Twisting or folding of a intraperitoneal segment of the colon.
  • 60-75% sigmoid or 25-40% cecal
  • Can produce the “whirl sign”
  • Axis: Ileocecal valve -> cecal
  • Cecal bascule: cecum folds over on itself (like a toe of a sock).
73
Q

Acute GI bleeding generalities

A
  • Generally evaluated by endoscopy and colonoscopy.
  • If it fails, CT enterography with arterial, portal venous and delayed phase could be helpful.
  • Active bleeding appears as a gradual accumulation of contrast inside the lumen wall.
  • Angiodysplasia is the most common cause of occult GI bleeding.
  • Other causes: Neoplasms, Meckel diverticulum and vascular malformations.

FUNDAMENTALS OF BODY CT (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions