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Diagnostic Radiology > GI / Fluoro > Flashcards

GI / Fluoro Flashcards

(62 cards)

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1
Q

Modality to assess dysphagia or chest pain related to esophageal motility

A

Single-contrast esophagram and manometry

Can do transit and emptying studies: Standing films taken after ingestion of 200 mL barium at 1, 2, and 5 minutes

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2
Q

Modality to assess dyspepsia, early satiety, and/chest pain

A

Upper GI series with esophageal evaluation +/- EGD and or CT

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3
Q

Modality to assess depth of esophageal tumor invasion

A

Endoscopic US

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4
Q

Hiatal hernias

A

Type 1: spasm of longitudinal esophageal muscle causing foreshortening and gastric cardia pulled into thorax; laxity of phrenoesophageal ligament
Type 2: “true paraesophageal,” rarest, GEJ still in abdomen
Type 3: “mixed,” majority of paraesophageal hernias
Type 4: type 3 is joined by herniation of another abd organ, needs surgical correction due to risk of gastric volvulus

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5
Q

Esophagus blood supply

A

Arterial supply
Bronchial and esophageal branches of aorta in thorax
Left gastric (via celiac) and inferior phrenic arteries in abdomen
Cervical esophagus supplied by inferior thyroidal artery

Venous drainage through azygous system (systemic) (along with intercostal and bronchial veins) in thorax, left gastric vein (to portal venous system) in abdomen, and inferior thyroidal vein for cervical esophagus

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6
Q

How to assess esophageal perforation

A

Esophagram: Videofluoroscopic and rapid sequence filming

Nonionic water-soluble contrast media (e.g., Omnipaque) initially, followed with barium if no leak or fistula seen

Barium (or CT) may detect small leak not visible initially

Hydropneumothorax, pneumoperitoneum, V-shaped radiolucency seen through heart

Needs CT & esophagraphy to fully assess

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7
Q

Etiologies of esophageal perforation

A

Iatrogenic 2/2 dilation, endoscopy, RF ablation for AFib, sclerosis of varices

Traumas, foreign bodies, caustic esophagitis, Boerhaave syndrome, status asthmatics, seizures, childbirth, neoplasia/biopsy

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8
Q

Radiographic findings of esophageal carcinoma

A

Infiltrating lesion (most common): Irregular narrowing, luminal constriction (stricture) with nodular or ulcerated mucosa

Polypoid lesion: Lobulated, fungating intraluminal mass

Ulcerative lesion: Well-defined meniscoid ulcers with radiolucent rim of tumor surrounding ulcer in profile view

Varicoid lesion: Thickened, tortuous, serpiginous longitudinal folds due to submucosal spread of tumor, mimicking varices

Asymmetric contour with abrupt proximal borders of narrowed distal segment (“rat-tail” appearance)

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9
Q

CT staging of esophageal carcinoma

A

Stages I and II: Localized wall thickening or small luminal tumor, without mediastinal invasion

Stage III: Tumor extends beyond esophagus into mediastinal tissues
Tracheobronchial invasion: Posterior wall indentation/bowing and tracheobronchial displacement/compression; ± collapse of lobes
Aortic invasion: Uncommon finding (2% of cases)
Pericardial invasion: Based on obliteration of fat plane or mass effect
Mediastinal adenopathy: Discrete or confluent with primary tumor

Stage IV: Extends into mediastinum and distant sites
Liver, lungs, pleura, adrenals, kidneys, and nodes
Subdiaphragmatic adenopathy seen in > 2/3 of distal cancers

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10
Q

Thickened gastric folds

A 
Common:
Gastritis
Gastric ulcer
Portal hypertension, varices
Gastric carcinoma
Pancreatitis, acute; pancreatic pseudocyst
Portal hypertensive gastropathy

Less Common:
Gastric metastases and lymphoma
Ménétrier disease
Zollinger-Ellison syndrome
Caustic gastroduodenal injury
Crohn disease

Rare but Important:
Tuberculosis
Radiation gastritis
Amyloidosis
Eosinophilic gastritis 
Chemotherapy-induced gastritis
Sarcoidosis
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11
Q

Gastric mass

A 
Common:
Gastric carcinoma
Hyperplastic polyps
Artifacts (air/gas bubbles, apposed walls of stomach)
Adenomatous polyp
Intramural  benign gastric tumors
Bezoar (mimic)
Perigastric mass (mimic): Splenomegaly, renal cell carcinoma, hepatocellular carcinoma, splenosis
Gastric varices

Less Common:
Gastric metastases and lymphoma
Mesenchymal tumors (e.g., GIST,  lipoma, neural tumor)
Gardner syndrome
Hamartomatous polyposis syndromes
Ectopic pancreatic tissue
Hematoma
Duplication cyst
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12
Q

Target/bull’s eye lesion in stomach

A

Common:
Gastric metastases
Gastric lymphoma
Kaposi sarcoma

Less Common:
Gastric carcinoma
Ectopic pancreatic tissue
Carcinoid
Gastric stromal tumor
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13
Q

Gastric dilation / outlet obstruction

A 
Common:
Gastric or duodenal ulcer
Gastric carcinoma
Gastroparesis
Postoperative state
Gastric volvulus
Hypertrophic pyloric stenosis
Gastric ileus

Less Common:
Pancreatitis, acute
Pancreatitis, chronic
Metastases and lymphoma
Duodenal mass or stricture: Carcinoma, metastases, annular pancreas 
Gastric polyps
SMA syndrome

Rare but Important:
Infiltrating lesions: Crohn disease, sarcoidosis, tuberculosis,etc.

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14
Q

Linitis plastica

A

Common:
Gastric carcinoma
Metastases and lymphoma

Less Common:
Caustic gastroduodenal injury
Peritoneal metastases
Gastritis
Opportunistic infection
Rare but Important:
Crohn disease
Following gastric freezing
Syphilis
Radiation-induced gastritis
Infiltrative granulomatous diseases: Tuberculosis, sarcoidosis, amyloidosis
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15
Q

Contraindications for barium enema

A

Toxic megacolon, fulminent colitis, suspected colonic perforation

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16
Q

Contrast for suspected GI/GU perforation

A

gastrografin or cystogratin

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17
Q

Contrast for suspect aspiration

A

omnipaque due to severe pneumonitis with high-osmolity material like gastrografin

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18
Q

Which hepatic segment is spared in early cirrhosis and why?

A

Caudate - drains directly into IVC, often associated with compensatory hypertrophy

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19
Q

Appearance of hepatic steatosis on CT and MRI

A

NC CT: >=10 HU hypoattenuation relative to spleen
CE CT: less reliable: >=25 HU hypo attenuation relative to spleen in portal venous phase
GRE MRI: enhancement in-phase with signal loss out of phase

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20
Q

Appearance of focal septic steatosis

A

No mass effect (common in gallbladder fossa, subcapsular, periportal)
US: hyperechoic lesion
CT: hypoattenuating
MRI: drop signal in out of phase

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21
Q

Radiation esophageal stricture

A

Long, smooth, narrow that usually spare the GE junction

Requires >50 Gy

Acute radiation esophagitis occurs 1-4 wks post-exposure
Strictures develop 4-8 months post-exposure

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22
Q

Caustic/NG tube esophageal stricture

A

Long, smooth, and narrow developing 1-3 months after exposure

Increased cancer risk with caustic stricture with up to 20 yr lag time

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23
Q

Feline esophagus

A

Nml variant with multiple transverse esophageal folds

Debated association with esophagitis risk

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24
Q

Submucosal gastric mass

A 
Mesenchymal tumors
GIST
fibroma
lipoma
neurofibroma
ectopic pancreatic rest
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25
Imaging appearance of gastric GIST
Submucosal arising from interstitial cells of Cajal Smooth endoluminal surface, often exophytic +/- central necrosis and calcification Benign if <2 cm vs large or elsewhere in GI tract
26
Complications of Roux-en-Y gastric bypass?
``` Post-operative leak ~10 d post-op Gastrogastro fistula SBO often a/w anastomotic edema/hematoma Internal hernia, MC transmesocolic > Peterson's space Stomal stenosis Marginal ulcer ```
27
SBO on plain radiographic and false positives
Multiple air-fluid levels at different heights with lack of colonic air False negative: supine imaging False positives: ileum with colectomy and ileum with ascites (compresses ascending, descending, and rectum)
28
Approach to CT for SBO
1. Distention >3cm with transition point? Small bowel feces sign? 2. Simple or closed-loop 3. Signs of ischemia from mild to severe: engorged mesenteric vessels -> ascites around bowel -> wall thickening -> pneumatosis intestinalis
29
Paraduodenal hernia
Congenital anomalies, due to embryologic failure of mesenteric fusion and resultant mesenteric defect MC on left through Landzert's fossa behind the ascending duodenum, a/w SB loops between the pancreas and stomach
30
Foramen of Winslow hernia
Dilated SB loops in upper abdomen with mesentery btwn IVC and main PV
31
Rigler's triad
pneumobilia (from cholecystoduodenal fistula), | small bowel obstruction, and ectopic gallstone within the small bowel
32
Fluid in peritoneal cavity on CT
Serous: HU -10 to 15 Hematogenous: HU >30, ~45 Exudative: In-between Pseudomyxoma peritonei: septations, mottled densities, calcification, scalloping and mass effect on liver
33
Cystic abd/pelvic massess
``` Abscess - locations, air Located ascites - displaced organs Pancreatic pseudocyst Ovarian/cystic tumor Lymphocele - often after surgery Cystic lymphangioma Enteric duplication cysts - often mesenteric border Cystic teratoma Peritoneal inclusion cyst Spinal meningeal cyst ```
34
Aneurysm cutoffs
Abd Ao: >3 cm | Iliac arteries: >1.5 cm
35
Retroperitoneal fibrosis on CT
Two-thirds of cases are idiopathic. Known causes include drugs (ergot alkaloids), neoplasms (lymphoma, metastases, sarcoma), retroperitoneal hemorrhages (leaking AAA), and infections (tuberculosis, fungus). Increased density around RP and organs, sparing posterior and Ao wall
36
Internal iliac branches
``` Anterior division: Superior/inferior vesical Obturator Middle rectal Internal pudendal Inferior gluteal ``` Posterior division: Iliolumbar Lateral sacral Superior gluteal
37
Cystitis cystica and cystitis glandularis
inflammatory disorders that result from chronic irritation of the bladder wall caused by recurrent bacterial cystitis or bladder stones. CT shows multiple hypervascular enhancing polypoid masses of variable size
38
Bladder Schistosomiasis on CT
Eggs laid in the bladder wall produce nodular wall thickening in the acute phase and result in a fibrotic contracted bladder with wall and distal ureteral calcification in the chronic phase
39
Leiomyoma or lipoleiomyoma vs leiomyosarcoma on CT
Malignant: rapid growth, post-menopause, irregular low-attenuation areas of hemorrhage and necrosis Benign: overlaps, can be calcified, cystic, homo or heterogeneous
40
Ddx for complex adnexal mass
``` Tubo-ovarian abscess Ectopic pregnancy Ruptured hemorrhagic ovarian cyst Peritoneal inclusion cyst Adnexal torsion ```
41
Cystic lesions of prostate
``` Prostatic abscess Prostatic utricle cyst or mullein duct cysts - congenital, often midline/upper BPH - often lateral Prostatic retention cysts - lateral Cystadenoma - rare benign tumor Cystic carcinoma - very rare ```
42
BPH on CT
>25-30cc and lobular, calcifications, elevated bladder base +/- bladder thickening and trabeculation if chronic outflow obstruction ***Indistinguishable from prostate CA
43
Testicular cancer characteristics
55% seminomas - very curable with orchiectomy and radiotherapy, RP node dissection often not necessary 45% nonseminomas - radiation resistant, orchiectomy often with RP node dissection, mediastinal/lung spread often not present without para-aortic node involvement except with choriocarcinoma
44
Splenic regeneration/splenosis
Absence of Howell-Jolly bodies on peripheral smear s/p splenectomy
45
Cystic mass in spleen, DDX
80% post-traumatic change 20% congenital epidermoid or mesothelial cysts Rarely - echinococcal or pancreatic pseudocyst
46
Splenic micro abscesses ddx
often fungal > P. jiroveci, CMV, TB, sarcoidosis, lymphoma, Kaposi sarcoma
47
Ovarian cyst ddx
Follicles - low attenuation, <3cm, thin wall Corpus luteum - variable but intense enhancement Functional cyst - >3cm but thin wall (<3mm) Hemorrhagic cyst - similar but complex internal fluid Benign cystic teratoma Cystadenoma - thin wall/septations, NO solid component or ascites Paraovarian cyst - in broad ligament, benign Endometriosis - variable appearance and often complex, MR shows T2 shadow where signal is lost T1->T2 Peritoneal inclusion cyst - inflammation of peritoneum causing entrapment of ovary, multi-lobulated fluid extension of peritoneal recess Hydrosalpinx Tubo-ovarian abscess Adnexal torsion - Fallopian tube wall >3mm, associated with ovarian mass, uterine deviation to side of torsion Ovarian carcinoma - ascites, thickened bowel, obstruction, clumping, mental cake
48
Adrenal mass ddx
Myolipoma - removal if >7cm due to hemorrhage risk Cyst - <20 HU Pseudocyst - s/p hemorrhage, separations, calcification, higher density Hem orrhage - ~45 HU with fat stranding Adrenal adenoma - often <20 if not 10 HU Adrenocortical carcinoma - >5-6cm, necrosis, 50% hormonal Pheochromocytoma - liver attenuation, cystic, necrosis, calcification Mets - heterogenous, enhancement, hemorrhage, >43 HU Lymphoma
49
Adrenal calcifications ddx
``` Previous hemorrhage Histoplasmosis TB Addison dx Wolman dx ```
50
Calculations to determine adrenal adenoma?
Lipid-rich - 70%, -2 to 10 HU Lipid-poor - 30%, 20 to 25 HU Relative % washout (RPW) = (E-D/E)x100 >40% = benign Absolute % washout (APW) - (E-D/E-U)x100 >60% = benign
51
Endometrial CA on CT
Best assessed on MR isoattenuation, heterogeneous enhancement Spread to myometrium -> regional LN -> parametrium
52
Signs of pneumoperitoneum and false positive
Rigler's sign or double wall sign Triangle sign (btwn loops of SB) Cupola sign Football sign and falciform ligament sign False positive = chilaiditi syndrome
53
Appearance of RCC on CT
Variable but often solid, 20-70 HU Clear cell (70%) - heterogeneous (solid, cystic, hemorrhagic, necrotic), enhances in corticomedullary phase with slow washout; better prognosis with multilobular cystic RCC Papillary (chromophil, 10-15%) - a/w ESRD, hypovascular with less enhancement, more homogeneous Chromophobe (5%) - homogeneous, enhances, some have spoke-wheel appearance like oncocytoma, others have fat Should comment on presence of tumor thrombus, adrenal involvement, LN >2cm malignant, 1-2cm indeterminate
54
Oncocytoma on CT
Indistinguishable from RCC, homogenous with low attenuation central stellate scar
55
Angiomyolipoma on CT
MC benign renal tumor Often either sporadic solitary in midget female or multifocal in tuberous sclerosis Well-defined, fat-containing (< -10 HU) with soft tissue that enhances Risk of hemorrhagic conversion if >4 cm ***No calcification
56
TCC on CT
Similar attenuation to renal parenchyma but poor enhancement
57
Phases of CE-CT liver
Non Con -> arterial (hepatoma, FNH, carcinoid) -> portal -> equilibrium (lesions disappear) -> delayed (hemangioma, cholangioCA, fibrotic)
58
Hepatic statuses on CT
Decreased attenuation relative to spleen >10 HU NonCon >25 HU CE Can be focal, diffuse, or multifocal
59
Ddx of hyperlattenuation of liver (75-140 HU)
``` Iodine depostion 2/2 amiodarone Gold salts Hemochromatosis Wilson's dx Glycogen strorage dx Thorium contrast ```
60
Nodular liver ddx
cirrhosis - irregular modularity, often heterogenous with patchy fat infiltration, prominent fissures, portal HTN, portages hepatis LN >1 cm EtOH cirrhosis - right atrophy with left/caudate hypertrophy Regenerative nodules - <1cm, iso/hypodense and appear larger on portal phase, no enhancement or persistent hyperattuation if sideritic nodules Dysplatic nodules - often no visualized HCC: isodense with rapid enhancement and washout Cholangiocarcinoma: delayed enhancement, capsular retraction Mets - particularly breast, CRC, SCLC, melanoma, carcinoid
61
Budd-Chiari on CT
Obstruction of outflow 2/2 web, compression, or thrombosis; a/w pregnancy, OCP, polycythemia vera, chemotherapy Acute - hepatomegaly w/ nml morphology, IVC/hepatic veins narrowed, early central enhancement/washout relative to periphery Chronic - caudate hypertrophy, liver atrophy with regenerative nodules that remain enhanced in portal phase unlike HCC, dilated azygous vein, intrahepatic collaterals
62
Steps of Barium swallow
Patient ingests effervescent crystals (If hypo pharyngeal symptoms, obtain AP/Lat swallow w/ thick barium) LPO of upper then lower Eo RPO of upper than low Eo Turn pt prone and turn table horizontal (If h/o fundoplication, turn to side, then supine, then right side and take spot film of GE junction) Turn into swimmer's position (RAO), drink thin barium and follow proximal end into stomach Then drink like a vacuum to fill Eo and take flour of upper and lower esophagus Have patient drink water Turn pt supine, check that Eo cleared of barium, and do provocative manuveurs for reflux (Valsalva, cough, leg raise) Return pt upright, if evidence of stricture of pills catching, have pt swallow barium tablet

Diagnostic Radiology (2 decks)

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