GIT 2 Flashcards

Question

Parasitic Infectious enteritis 3

Answer 1

* hookworm * Thickened folds * nodulatity * tape worm * filling defect in bowel * Ascaris * Filling defect * intestinal obstruction * Ascaris lumbricoides (roundworm) * Most common helminthic infestation in the world * Usually asymptomatic and most common in children ages 1 to 10 years * Most often found in distal small bowel * Life cycle * Infection is through contaminated soil * Involves GI tract of host twice * First time as egg * Migrates through lungs * Adult travels up trachea * Returns to GI tract for maturation (2 months)

Answer 2

* Yersina enterocolitica * thickened folds * nodularity * terminal ileum * ulcers * TB * Strictures * Obstruction * Terminal ilium * Histosplasmosis * thickened folds * Nodularity * Salmonellosis * Thickened folds * nodularity * Terminal ilium * campylobacter * Thickened folds * Nodularity * loss of haystration * Terminal ilium

Answer 3

* CMV * Thickened folds in Caecum * pancolitis * TB * Thicken folds in caeum * Adenopathy with low central attenuaiton * Terminal ileum * MAI * THickened folds * nodularity * adenopathy * Cryptosporidiosis * Thickened folds * Giardiasis * Thickened folds * largely jejunal * jejunal spasm. Introduction Cryptosporidiosis has been recognised as an opportunistic infection of the bile ducts since 1972 when Kovatch and White described cryptosporidial cholangitis in juvenile rhesus monkeys.' In 1983 the first cases of hepatobiliary cryptosporidiosis in patients with AIDS were reported.23 It was suggested that the gall bladder was the source of the bile duct infections. Soon after this, infection of the biliary tree by cytomegalovirus (CMV) was described, both in association with cryptosporidial infection and on its own.45 Several papers describing the pathological findings in the biliary tract in patients with AIDS have now been published. Most of these include only small numbers of patients and it remains difficult to form an impression of the incidence of clinical disease in the biliary tree and the range of pathological findings.67 Material from the gall bladder and biliary tree is usually difficult to obtain. In the largest published study, reviewed by Cello (1992), out of 40 patients with bile duct disease 18 had a specific histopathological diagnosis.8 The diagnoses were based on biopsy specimens taken from the ampulla of Vater or post mortem findings. The commonest diagnoses made were CMV (eight cases) and cryptosporidium (six cases). Other specific diagnoses included Mycobacterium avium (three cases), Kaposi's sarcoma (one case) and lymphoma (one case). The remaining 22 cases all showed inflammatory changes. Department of Histopathology, St Mary's Hospital Medical School, Imperial College of Science, Technology and Medicine, London W2 IPG R D Goldin Department of Medicine J Hunt Correspondence to: Dr R D Goldin Accepted for publication 20 January 1993 Cytomegalovirus This is one of the commonest organisms in patients with AIDS and frequently affects the liver and biliary tree. It is usually part of a disseminated disease: cholestatic liver function tests have been reported in one third of patients and radiological evidence of sclerosing cholangitis in 3-11%.9 In the case of the biliary tree viral inclusions do not always have the characteristic owl's eye appearance and immunohistochemistry for CMV is extremely useful in doubtful cases. Cryptosporidial infection Cryptosporidial infection is a common cause of diarrhoea in patients with and without AIDS.10 Biliary tract disease, however has only been seen in patients with AIDS." Biliary tract abnormalities have been described in 10% of patients with intestinal cryptosporidiosis."I The organism is a sporozoa and undergoes its complete life cycle within a single host making reinfection a possibility.'2 In the bile ducts and intestines the organism is seen as small, round, basophilic structures on the luminal surface, 2-4 ,um in size. Although they can usually be seen easily in haemotoxylin and eosin stained sections, a Giemsa stain has been recommended. Cryptosporidial infection is associated with little inflammation, although in the bowel it has been claimed that there is an increased number of apoptotic bodies. Surprisingly, "an exuberant inflammatory reaction" has been described in association with biliary tract cryptosporidiosis in one study."3 The electron microscopic appearance of the organism is characteristic but is not necessary for diagnostic purposes. A potentially important preliminary observation is that there is electron microscopic evidence of autonomic nerve damage in the bowel and it has been suggested that this may cause disordered motility.'4 A corresponding abnormality may be found in the biliary tree. Mycobacterium avium intracellulare Mycobacterial infections are also very common in patients with AIDS and have been identified in duodenal or ampullary biopsy specimens in a number of patients with bile duct disease.8 These have usually been caused by M avium intracellulare. As in other parts of the body these are frequently found in large numbers in poorly formed granulomas and are both Ziehl Neelson and periodic acid Schiff positive. Microsporidial infection Microsporidia are diverse phyla. Infection by members of this group is extremely rare in patients who do not have AIDS. Enterocytozoon bienusi has mainly been associated with intestinal infection and diarrhoea'5 but microsporidia have been associated with peritonitis and granulomatous hepatitis.'6 It has also been found associated with sclerosing cholangitis and its importance has probably been underestimated.'7-20 This has been confirmed by a recent study in which the diagnosis was made in eight patients with AIDS who had unexplained cholangitis.2' In all eight patients the organism was detected by staining bile samples, in six it was detected in duodenal biopsy specimens. Diagnosis of infection by these organisms requires active consideration by the histopathologist and electron microscopy is useful, although light microscopy is often diagnostic.22 691 on February 8, 2022 by guest. Protected by copyright. http://jcp.bmj.com/ J Clin Pathol: first published as 10.1136/jcp.46.8.691 on 1 August 1993. Downloaded from Goldin, Hunt Lymphomas Lymphoma in patients with AIDS often affects extranodal sites.2' Primary lymphomas of the gall bladder,'24 common bile duct,'25 and head of pancreas26 have been recognised, although this is much less common in disseminated disease. All these reported tumours have been high grade B cell lymphomas ranging from Burkitt-like to immunoblastic tumours. Disease in the gall bladder has so far been asymptomatic; tumours of the bile ducts and the head of the pancreas have presented early with asymptomatic jaundice.'6 Kaposi's sarcoma As is the case in the liver, disease of the gall bladder and biliary tree is seen at necropsy as part of widespread disease, although it rarely presents as a clinical problem.28 29 Kaposi's sarcoma involving the common bile duct, however, has been associated with cholangitis and jaundice.'7 This may also follow on from extensive disease of the hepatic hilum with compression of the main bile ducts.'0 Clinical and radiological findings Gastrointestinal symptoms are common in AIDS,"3 and patients may present with dysphagia, diarrhoea, or abdominal pain. In patients with right upper quadrant pain the clinician should suspect bilary disease." '34 In one study of 64 patients with AIDS and abdominal pain the site was the right upper quadrant in 27, and of these 17 had biliary disease.35 The pain may have been due to acalculous cholecystitis, in which CMV, cryptosporidium, and campylobacter have been implicated,4 or AIDS related sclerosing cholangitis. In the latter serum alkaline phosphatase is often several times above normal, suggesting cholestasis." In a third of cases, however, the serum liver function tests are normal35 and jaundice is rarely seen.33 36 The imaging features of AIDS related cholangitis are dilatation and irregularity of either the intrahepatic or extrahepatic ducts. An ultrasound scan may show intrahepatic and extrahepatic bile duct dilatation or irregularity of both the diameter of the intrahepatic ducts and the common bile duct wall, or periductular hyperechoic regions in the liver."3 33 37 Thickening of the gall bladder wall, due to acalculous cholecystitis, can be detected38 and the pancreatic duct may also be dilated. The sensitivity of ultrasound scanning varies from 100%37 to 70%,36 while the specificity approaches 85%.36 Computed tomography has not been extensively assessed but may be better than ultrasound scanning for detection of intrahepatic disease." Endoscopic retrograde cholangiopancreatography (ERCP) is the optimal diagnostic technique.13 323435 At ERCP four abnormal cholangiographic patterns are discernible.'6 The commonest is sclerosing cholangitis with ampullary stenosis in which both irregularity of the intrahepatic ducts and dilatation of the common bile duct down to the level of the ampulla are evident, with delay in drainage of contrast. Alternatively, isolated ampullary stenosis may be seen when the common bile duct is dilated but the intrahepatic ducts are not stenosed. Similarly, intrahepatic sclerosing cholangitis or extrahepatic biliary strictures may each appear in isolation. In many cases subtle changes occur in the wall of the common bile duct which looks beaded and irregular.39 More than half the patients studied have evidence of ampullary stenosis.33 3 Biopsy specimens of both the ampulla and bile duct can be taken at ERCP and sphincterotomy performed if indicated.3 Because of the design of the biopsy forceps, ampullary cannulation has been difficult and biliary biopsy tends only to be performed after removal of the sphincter. Duodenal and ampullary biopsy specimens were used as surrogates for biliary epithelium and biliary brush cytology specimens taken. Unfortunately, cytology has not proved diagnostic.35 Recently Teflon coated, swivel-tipped, rat toothed biopsy forceps have been marketed (Olympus FB-39Q or FB-40Q). These can be passed down the duodenoscope into the biliary tree through an intact ampulla. They are radio-opaque and incorporate a contrast injection channel and allow targeted biopsy specimens to be taken. The increased use of these forceps will advance the description of biliary pathology. Biopsy specimens from the ampulla and juxta-ampullary bile duct after sphincterotomy have shown CMV and cryptosporidium infection in 11%-25% and 25-35% of cases.'5'6 But these agents are also seen, albeit less frequently, in those without ampullary stenosis. 13 Microsporidial infection17 18 and Candida Sp40 have also been found in the biliary epithelium of these patients, but in 50% of patients a cause for the stenosis is not established. M avium intracellulare has been found in duodenal biopsy specimens. The prognosis of AIDS related sclerosing cholangitis is poor. In the largest series 40% of the patients died within nine months, although biliary disease did not appear to be the cause.'6 There have been two recent studies on related sclerosing cholangitis.'0 41 In the first of these, out of the 20 cases examined, 13 had cryptosporidiosis and six had active CMV infections. Compared with controls the overall survival was no worse (median 7-5 months). Surprisingly, increased age seemed to be protective in AIDS related sclerosing cholangitis. The overall findings in the second study were similar. There was a single case of microsporidial infection. The importance of actively considering the diagnosis of microsporidial infection in patients with AIDS and unexplained sclerosing cholangitis has been borne out in another recent paper.2' In eight patients with AIDS and unexplained cholangitis this diagnosis was made after thorough examination of the biliary tree. [https://jcp.bmj.com/content/jclinpath/46/8/691.full.pdf](https://jcp.bmj.com/content/jclinpath/46/8/691.full.pdf)

Answer 4

* Ascariasis/round worm infection * most common parasitic infection world wide * GIT * Jejunum\>ileum, duodenum, stomach * visible on SBFT as longitudinal filling defects * enteric canal of worm is filled with barium * Worms may cluster 'bolus of worms' * can cause SBO * Perforation volvulus * Bilary tract * intermittent biliary obstruction * granulomatous stricture of the bile duct (rare) * Oriental cholangiohepatitis.

Answer 5

* carcinoid tumors arise from enterochromaffin cells * Location * GIT 85% * appendix 50% * SB 33% * 90% distal ileum * 30% SB carcinoids are multiple * 40-80% spread to mesentary * Gastic, colon, rectum 2% * Bronchial Tree 15% * Rare locations * thyroid * Teratomas * ovarian * testicular * Symptoms of GI carcinoids * 70% asymptomatic * 20% obstruction * 15% weight loss * 15% mass * Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 19593

Answer 6

* In patients with carcinoid syndrome, what stage disease/where is their disease? * 90% have liver mets * What symptoms do they have? * recurrent diarrhea 70% * right sided endocardial fibroelastosis * tricuspid insufficiency * pulmonary valve stenosis * The left side of the heart is spared bc/of metabolism by monoamine oxidase inhibitor (MAOi) in the lung * Wheezing bronchospasm * Flushing of face and neck * What substances does the tumour produce? * ACTH * Histamine * bradykinin * Kallikrein * serotonin (excreted as 5-HIAA in urine)

Answer 7

* ischaemia with mesenteric venous compromise * hemorrhage * malignant degeneration * gastric and appendicieal tumours rarely metastazie * SB tumours met commonly

Answer 8

* Mass in SB/filling defect * strong **desmoplastic reaction** causes angulation, kinking of bowel loops (tethered appearance) * mesenteric venous congestion * mesenteric mass on CT with **spoke wheel pattern** is virtually pathognomonic with the only other disease to cause this being retractile mesenteritis (very rare) * **Stipple calcification i**n mesenteric mass * obstruction secondary to desoplastic reaction * VEry vascular tumours * tumour blush at angiography * very hyperintense on T2W imaging * Liver mets (art phase indicated)

Answer 9

* highest to lowest tolerance * duodenum * jejunum * ileum * transverse colon * sigmoid colon * oesophagus * rectum * Radiation entertisis is damage of SB mucosa and wall as a result of therapeutic radiation * Tolerance dose (TD 5/5) is the total dose that produces radiation damage in 5% of pts within 5 years * TD5/5 is 4500cGy in SB and colon * 5000cGy in rectum * Imaging * mural thickening and luminal narrowing usually in pelvic bowel loops

Answer 10

* ace inhibitor related angioedema * acute onset or recurrent acute abdominal pain * segmental area of circumferential bowel wall thicekning * decreased submucosal attenutation * mesenteric edema * ascties * engorgement of the vasa recta * Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 88116 * Case Discussion This patient presented with severe abdominal pain, and had concern of ischemia from the first CT and proceeded to exploratory surgery with negative results. The patient's pain continued for more than a month before repeating the imaging with worsening inflammation, prompting the suggested diagnosis of ACE-inhibitor-related angioedema. After this suggestion, the medication was stopped and the patient's symptoms rapidly improved, with resolution of bowel wall thickening at the final follow-up scan.

Answer 11

* 29 amnio acid peptide produced in alpha cells of the pancreas * Stimulus for release is hynger/hypoglycaemia * Effects * antagonist to insulin -\> increases BSL * relaxation of smooth muscle cells * Relaxation of GB sphincter and sphincter of oddi increasing bile flow. * Useful in Barium enema or when ever smooth smucle spasm is suspected of producing a pseudostenotic lesion. * it can be used in eval of the oesophagus, stomach, duodenum, small intestine, CBD and colon. * Contraindications include * phaeochromocytoma * insulinoma * glaucoma

Answer 12

* replacing DCBE for dectecting and screening of colonic neoplasms * helically acquired axial imagins of the gas distended colon are obtained during breath holding in both prode and supine positions * Images are combined into a detailed model of the colon and viewed on 2D multiplanar recons or primary 3D endoluminal display. * Standard CTColonography does not use IV contrast and uses low does 20% dose of standard CT and 10% less than a DCBE. * Dectection of large polyps \>10mm and polyps 6-9mm is comparable/equal to optical colonoscopy. * Optical colonoscopy is better for polyps \<6mm. * sensitivity 92% \>10mm and per patient specitificy 96% * Requires bowel prep similar to colonoscopy.

Answer 13

* eval of SB and LB in pts with IBD * depicts extraluminal abnormalities * can distinguish active from fibrotic strictures and can delineate fistulas * no ratdiation * long acquisition times * difficult to identify early mucosal lesions. * Imaging findings * Fibrosis * Low t2 sig in a thickened loop * delayed enhancement * acute inflammatory findings * wall thickening * early mucosal enphancement * engorgement of the vasa recta * diffusion restriction in the wall.

Answer 14

* non-neoplastic hyperplastic polyps are the most frequent type of polyp.

Answer 15

* hamartomas * single -\> hamatoma * Multiple * Cronkhite-Canada syndrome * Juvenile polposis * Peutz-Jeghers syndrome * Inflammatory * single * benign lymphoid polyp * fibroid granulation polyp * multiple * juvenile polyp * benign lymphoid polyp * Granulomatous colitis * Unclassified * single * hyperplastic polyp * Multiple * hyperplastic polyposis

Answer 16

Axial T2 HASTE MR ENTEROGRAPHY There are innumerable polyps in the stomach and first part of duodenum of varying size and morphology, most numerous in the distal body and antrum of the stomach where they are confluent and "carpeting" the gastric mucosa. Sparing of the gastric fundus. The gastroduodenal polyps demonstrate moderately hyperintense signal and have a smoothly lobulated, frond-like outline with no obvious extension through the gastric wall **Appearances favour a polyposis syndrome, including Peutz-Jeghers, Cowden, Cronkhite-Canada or juvenile polyposis syndrome. Absence of polyps in the fundus makes familial adenomatous polyposis less likely.** Cronkhite-Canada syndrome is a type of non-neoplastic, non-hereditary hamartomatous polyposis syndrome characterised by rash, alopecia, and watery diarrhoea. Epidemiology There is a recognised male predilection with 3:2 male:female. Patients typically are middle age (50-60 years of age) 1. 75% of the approximate 500 cases in the literature were from Japan 7. Clinical presentation Patients typically present with watery diarrhoea and a protein-losing enteropathy with associated nail atrophy, brownish skin pigmentation, and alopecia 3.

Answer 17

* Epithelial * single * Tubular adenoma * tubulovillous adenomal * villous adenoma * turcot syndrome * Multiple * familial polyposis * Gardener syndrome * Non-epithelial * carcinoid * leiomyoma * lipma * fibroma

Answer 18

* Most common true colonic tumour * found in 10% of pop by the 7th decade * 50% are multiple * Clinical findings * pain haeimorrage * Types * tubular (most common) * tubulovillous * villious (least common) * Location * rectum and sigmoid 60% * Descending colon15% * trans colon 15% * ascending colon 10%

Answer 19

* Benign * \<1cm * Stalk present * smooth * signle * smooth * Malignant * \>2cm * no stalk instead appears sessile * contour is irregular/lobulared * multiple * indented, retracted * histologic differentiation of polyps is invariably difficult radiographically so the majority of lesions require endoscopic sampling.

Answer 20

* polyp \> 1cm * high grade dysplasia * of all the polyps \<1cm, the likely ook that is lesion is an advanced adenoma is 3% * the majority are hyperplastic and the rest are bengn adenomas

Answer 21

* focal proliferation of normal mucosa, therefore not an adenoma * no malignant potential * due to excessive cellular proliferation in Lieberkuhn crypts * 75% of polyps occur distal to the splenic flexure. Mostly in the rectosigmoid area * imaging features * stalked polup * sessile \<5mm

Answer 22

* Postinflammatory polyposis (PIPs, pseudopolyposis, filiform polyps) * benign condition * not a/w cancer * occur most commonly in Crophn disease and UC secondary to regeneration of nonulcerated tissue. * Filiform polyps are thin, short branching structures.

Answer 23

* Polyp * uniform in size * round, stalked sessile * well delineated * preserved colonic haustra * Pseudopolyp * uniform in size * y-shaped, filiform, irregular * fuzzy margins (inflammation) * distorted colonic haustra (inflammation)

Answer 24

1. Familial polyposis 2. Gardner syndrome 3. Peutz-Jeghers syndrome 4. Juvenile polypsosis 5. Cowden disease 6. Turcot syndrome

Answer 25

Familial polyposis. 1:8000

Answer 26

* Screening of family members of familial polyposis patients should start at puberty * malignant degeneration by 40 years old * treatment is propholatictc total proctocolectomy * usually \>100 polyps * Familial adenomatous polyposis syndrome is a common umbrella name under which * gardner and * familial polyposis syndrome

Answer 27

Gardner Syndrome * Polyposis * 100% colon * duodenum 90% * hamartomas of the stomach * soft tissue tumours * inclusion cysts * desmoids * fibrosis * oesteoma in the calvarium, mandible sinuses * entrapment of cranial nerves * malignant transformation in 100% if left untreated * SB and pancreaticoduodenal maligannces * total colectomy recommended. * PATHOLOGY * There is an autosomal dominant inheritance in the FAP gene (chromosome 5q) in a majority of patients but with 20% of cases resulting from new mutations. Extracolonic features often precede the diagnosis of colonic polyps.

Answer 28

* Peutz-Jeghers Syndrome * Pathology Peutz-Jeghers polyps are **non-neoplastic hamartomas due to the proliferation of all three layers of the mucosa,** which have a characteristic feature of a smooth muscle core continuous with muscularis mucosa in a **tree-like branching pattern.** * This distinguishes them from the hamartomatous polyps of Cronkhite-Canada syndrome, juvenile polyposis and Cowden disease 1.

Answer 29

polyps are non-neoplastic hamartomas due to the proliferation of all three layers of the mucosa, which have a characteristic feature of a smooth muscle core continuous with muscularis mucosa in a tree-like branching pattern. This distinguishes them from the hamartomatous polyps of Cronkhite-Canada syndrome, juvenile polyposis and Cowden disease 1.

Answer 30

Patients are at increased risk of: * intussusception * GI tract adenocarcinoma, although the polyps themselves are not premalignant * stomach: 29% lifetime risk 4 * small intestine: 13% lifetime risk 4 * extraintestinal malignancies * adenoma malignum (adenocarcinoma subtype of the cervix) * breast: 45-50% lifetime risk 4, more frequently ductal * pancreas: 11-36% lifetime risk 4 * ovary: 18-21% lifetime risk 4, mainly sex cord tumours * uterus: 9-10% lifetime risk 4 * cervix: 10-23% lifetime risk 4 * testis: 9% lifetime risk 4, large calcifying Sertoli cell tumours * lung: 15-17% lifetime risk 4

Answer 31

Juvenile polyposis * AD * 100% have colon polyps * Presentation in the second decade is most common 2. * Juvenile polyposis syndrome is characterised by the presence of hundreds of hamartomatous polyps containing fluid/mucus. * Both the tumour suppressor gene SMAD4 on chromosome 10q (50% of cases) and BMPR1A gene have been implicated. The genetic basis is not always known 1. * Associations * Other congenital abnormalities are present in 20% of patients 1,2: * intestinal malrotation * Meckel diverticulum * hydrocephalus * congenital heart disease * mesenteric lymphangioma * pulmonary arteriovenous malformation

Answer 32

* Cowden syndrome * Multiple Hamartoma syndrome of the bowel/GIT * Fibrocystic change of the breast * Thyroid changes * mucocutaneous lesions * Increased risk of: * breast ca * Thyroid ca * CNS: dysplastic cerebellar gangliocytoma, occurs when in association with Lhermitte-Duclos disease (LDD) * Syndromic associations Cowden syndrome is part of a group of disease known as PTEN-related diseases, which also includes: Lhermitte-Duclos disease (LDD) Bannayan-Riley-Ruvalcaba syndrome (BRRS) 3 * https://www.ajronline.org/doi/pdf/10.2214/ajr.135.2.385

Answer 33

Turcot syndrome Dr Ammar Haouimi◉ and Assoc Prof Frank Gaillard◉◈ et al. Turcot syndrome is one of the variations in polyposis syndromes. It is characterised by multiple colonic polyps and an increased risk of colon and primary brain cancers. Epidemiology Turcot syndrome is a rare disease. Patients typically present in the second decade 3. Pathology Turcot syndrome is characterised by: intestinal polyposis CNS tumours: most commonly glioblastoma or medulloblastoma Genetics It is thought to carry an autosomal recessive inheritance. Two-thirds of patients have mutations in the APC gene, the same genetic defect as in familial adenomatous polyposis (FAP). These patients have multiple colonic adenomas, and virtually all develop colorectal carcinoma by the age of 40. The common intracranial tumour in this subtype is medulloblastoma. The other third have mutations in the HNPCC genes. Colonic malignancy is not as common in this type but tends to develop at a younger age. Most develop glioblastomas.

Answer 34

* being overweight/obese * inactivity * diets high in red meat * diets low in fruits and veg * smoking * heavy alcohol use

Answer 35

* personal hx of CRC or adenomatous polyps * personal hx of chronic IBD * Strong fhx of CRC or polyps * cancer or polyps in a first degree relative \<60yo * or in 2 first degree relative of any age * older age * aftrican american * Ashkenazi Jewish descent

Answer 36

* Rectum 35% * sigmoid 25% * Descening colon10% * ascending colon 10% * trasnsverse colon 10% * cecum 10%

Answer 37

* PAPUS * Plaque-like (cloacogenic tumour at anorectal junction * Annular/applecore (\<5cm long) * Polyp * Ulcerative * Scirrhous (rare: long \>5cm circumferential spread) *

Answer 38

Complications 1. Obstruction 2. intussusception (in polyploid lesions - rare) 3. Local perforation (simulates diverticulitis) 4. Local tumor recurrence 5. Peritoneal spread

Answer 39

* Dukes staging system * Dukes A * limited to bowel wall * 15% * 93% 5ys * Dukes B * extension into serosa or mesenteric fat * 35% * 77% 5ys * Dukes C * LN mets * 35% * 48% 5ys * Dukes D * distant Mets 15% * 7% 5ys

Answer 40

* Tx * no description of the tumors extent is possible * Tis * cancer in the earliest stage. * has not grown beyond the mucosa (inner layer of the bowel) * carcinoma insitu. * T1 * cancer has growth through the mucosa and extends into the submucosa * T2 * Cancer has grown through the submucosa and extends into the muscularis propria * T3 * Cancer has grown thru the muscularis propria into the serosa but not into organs or tissues * T4 * Cancer has grown throught the wall of the bowel into near by tissues or organs

Answer 41

* N0 * no LN involvement * N1 * cancer in 1-3 near by LNs * N2 * Cancer in 4 or more near by LNs * Mx * no description of distant spread is possible bc of incmompleted information * M0 * no distant spread is seen * M1 * distant spread is present.

Answer 42

* MSMS * Mucosa * Submucosa * Muscularis Propria * Serosa

Answer 43

* LN Mets on CT * 50-70% * Liver mets * 60-70% on CECT * 70-80% on MRI

Answer 44

* used to stage and differentiate T2 from T3 disease * T3 disease requires neoadjuvant chemorads before surgery * T2W is the most reliable sequence for local staging * can have desmoplastic reaction with linear T2 hypointensity in T2 disease * T3: * nodular extension of T2 intermediate tumour outside of the Muscularis propria to clam T3 disease * must closely evaluate the external iliac Lns as these denote M1 (distant metastatic disease) in Rectal Ca.

Answer 45

* inflammatory * CD * UC * Behcets * ischaemic * infectious * Iatrogenic * chemo * rads

Answer 46

* Ulceration * granulatiry of mucosa, apththoid * flask like collections of barium. collar button. * edema * displacement of barium: * translucent halo around central ulcer * Spasm * localised persistent contraction * narrowing of bwoel lumen * The whole colon, without skips is affected by an irregular mucosa with loss of normal haustral markings. Case Discussion Continuous lesion without skip,or carpeting of the whole colon is classic for ulcerative colitis. Mucosal inflammation causes a granular appearance to the surface of the bowel. As inflammation increases, the bowel wall and haustra thicken. Mucosal ulcers are undermined (button-shaped ulcers). When most of the mucosa has been lost, islands of mucosa remain giving it a pseudo-polyp appearance. A unique case from Prof. Saeed Rad, Tabriz, Iran.

Answer 47

A Collar button-shaped benign ulcer on the lesser curvature of the stomach (AFIP Neg. #58-5294). B Low-power section through a benign gastric ulcer with a collar button shape showing mucosal undermining and superficial involvement of the muscular wall (AFIP Neg. ,//78-322) Collapse

Answer 48

* Ulcers * deeper linear than in mucosal inflammation * cobblestone appearance * Bowel wall thickening * CT * Wall thickened \>3mm with lumen distended * Halo (in picture): * Fatty (chronic), gray (subacute or chronic), white (acute) with enhancement * **Note the fat halo sign seen in the loop of small bowel anteriorly in both cross-section and longitudinally, representing submucosal fat deposition due to chronic inflammation. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 2610**

Answer 49

* stranding in surrounding fat * inflammatory mass * fistula * creeping fat: * excessive fat deposited around serosal surface (Crohn's disease) * Creeping fat. Coronal SSFSE image demonstrates mesenteric fatty proliferation about the terminal ileum and sigmoid colon (arrows).

Answer 50

* recurrent inflammatory condiof of the bowel caused by altered immunity to intestinal flora * lesions may occur in the enter GIT * most common in the * SB/TI - 80% * Colon - 70% * 25% of patients with colonic disease have pancolitis * Duodenum 25% *

Answer 51

* Initial event * hyperplasia of lymphoid tissue in submucosa * lymphedema * apthoid ulcerations * deeper ucers * fistulas * abscesses * strictures

Answer 52

* fold thickening * nodular pattern * submucosal edema and inflammation * string sign * tubuar narrowing of intestinal lumen (edema, spasm, scarring depending on chronicity) * Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 20855 * Long segment of narrowed terminal ileum in a 'string like' configuration in keeping with a long stricture segment. Termed the string sign of Kantour (gastrointestinal string sign). * Omega sign * asymmetric wall involvement results in contracture and C-shaped loop on SB series * ram horn sign (second image) * loss of antral fornices with progressive narrowing from antrum to pyulous

Answer 53

* Transitional zones are typical, they occure between involved bowel loops and normal bowel * Skip lesions are typical: discontinuous invovlemt of bowel * Lesions appear preferentially at mesenteric side of intestine.

Answer 54

* Gall stones * ossess complications * spondylitis * sacroilitis * Steroid complications * Osteomyelitis * Osteoporosis * AVN * renal stones

Answer 55

* Bowel wall thickening * Normal is \<3mm * mean diameter in CD is10mm * if \>10mm * pseudomem colitis * ischemic * CMV colitis * Halo Sign: * Circumferential submucosal low attenuation surrounded by higher outer attenuation * Inner and out layers surrounding lower attenuation middle layer * target sign * Peribowel inflammation * dirty fat * ground glass * Mesentary * creeping fat * misty mesentery * SB adenopathy * Coming sign.

Answer 56

* Recurrence of disease after surgery * in contrast to UC in which proctocolectomy is curative * Increased incidence of ca. * GIT lumours * lymphoma * Toxic mega colon * fistulas * abscess formation

Answer 57

* unknown cause * clinical findings include diarrhea and rectal bleeding * Disease affects primarily the mucosa (crypt abscesses) and typically starts in the rectum. * **Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that not only predominantly affects the colon, but also has extraintestinal manifestations.** * Epidemiology Typically ulcerative colitis manifests in young adults (15-40 years of age) and is more prevalent in males but the onset of disease after age of 50 is also common 1,3,5 * A combination of environmental and genetic factors are thought to play a role in the pathogenesis, although the condition remains idiopathic. * Ulcerative colitis is less prevalent in smokers than in non-smokers.

Answer 58

* Joints * arthritis * arthralgia * ankspond * liver * sclerosing cholangitis * chronic active hepatitis * cholangiocarcinoma * skin * pyoderma gangrenosum * erythema nodosum * eyes * uveitis * episcleritis

Answer 59

* Lead pipe colon * ahaustral * foreshortened colon * Granular mucosa * shallow confluent ulcerations * polyps * pseudopolyps * filiform polyps * regenerative mucosa * small thin, branching polyps * Spread * rectal disease first which is the worst * continuous spreat from distal to proximal colon * Circumfernetla bowel involvement * Backwash ileitis * only a short segment of TI unlike CD * Gaping ileocecal valve * Atypical imaging features * atypical patter of distribution * sparing. of the rectume 5% as it might be healting * crohn like findings: * discontinuous disease in 5-10% of patients * Mural and extramural findinsg * bowel wall thickening less than CD * distribuaiton from rectum continuously proximal * If pancolitis, TI may be affected for a very short length * Superimposed Ca: * Mass lesion or thick wall stricture * excessive fat surrounding rectosigmoid * creeping fat * Local LN enlargement * common in SB mesentery * infrequently in the retroperitoneum

Answer 60

* Toxic mega colon * ahaustral transverse coclon \>6cm with pseudopolyps on kidney, urethra, bladder * Strictures * obstruction * can be benign or malignant * Malignancy * 5-30 fold increased risk * Annual incidence of 10% after the first decated * multiple in 25% of cases * often flat/scirrhous

Answer 61

* Abnormal connection between the epithelialized surface of the anal canal and the skin * causes * primary * obstruction of anal gland * stasis infection * fistula * secondary * iatrogenic (surgery) * Crohns * infection * malignancy

Answer 62

PARKS CLASSIFICATION 1. Intersphincteric (COMMON) 2. transsphincteric (COMMON) 3. Suprasphincteric 4. Extrasphincteric (UNCOMMON seen inpts with multiple operations)

Answer 63

* Mri is best * describe and classify type of fistula * Distance of mucosal defect to perianal skin * Secondary findings * abscesses * bowel wall abnormalities * reactive nodes

Answer 64

* Bechet disease * HLA B51 associated vasculitis * Intestinal manifestations * ulcers * strictures * fistulas * Extraintestinal manifesations * oral genital skin ulcers * uveitis * aneurysms * arthritis * Behc¸et syndrome is characterized by the histopathologic finding of nonspecific vasculitis in multiple organs. The diagnosis is usually made on the basis of the combination of clinical signs and symptoms. This disease involves the gastrointestinal tract in 10%–50% of patients, and the terminal ileum and cecum are chiefly affected. Barium study is useful in demonstrating the characteristic radiographic features of Behc¸et syndrome involving the gastrointestinal tract. * Behc¸et syndrome is a chronic, recurring, systemic disorder characterized by the histopathologic finding of nonspecific vasculitis in multiple organs. It primarily affects male patients between 11 and 30 years of age. This disease is found worldwide but has been reported to be most commonly seen in the countries of the eastern Mediterranean and the eastern rim of Asia (1,2); clinical features and gastrointestinal manifestations appear to be more common and more severe in Eastern patients than in North American and British patients (1). The prevalence has been reported to be 1 in 10,000 in Eastern countries (2) and 1 in 15,000 in North America (3).

Answer 65

* Occurs mainly in immun ocompromised hosts * imaging features * superficial or deep ulcers * thick wall \>10mm * localised distribution in cecum, TI or Universal colitis * May be indistinguishable from psedomembranous colitis.

Answer 66

* AKA Neutropenic colitis * acutve necrotizing colitis involving the caecum, TI and/or ascending colon in pts with Leukaemia undergoing tx/immunosupression * unknown cause * leukemic bowel infiltration * intramural hemorrhage * bnecrosis * local ishemia * indications for Surgery * failed medical tx * perforation * hx * pericecal abscess and * uncontrolled sepsis * Clinical * RLQ pain * diarrhea * peritonitis * Imaging features * marked thickening of the cecum, tTI and or ascending colon * pericecal fluid and soft tissue stranding more marked than in pseudomembranous colitis * Complicaitons * perforation * pericolonic abscess pneumatosis

Answer 67

* colitis caused by colonic overgrowth of C. difficile * 1-6 weeks after abx * Clincial findings * Diarrhea * fever * pain * leukocytosis * Imaging features * VEry thick haustral folds * thumb printing * ileus * very thick colonic wall * Accordion sign contrast between thickened folds * usually starts in rectum and progresses up * largely left sided disease * may be pancolitic * pericolonic fat changes in 35% * ascities in 35%

Answer 68

* infection iwth Entamoeba histolytica * common in mexico sth americ, Africa, asia * Clinical * diarrhea * fever * may be asymptomatic for long persions * Transmission * person to person * contaminated food/water * imaging features * usually effects the cecum/right colon\> transverse colon\> recto sig. * Coned cecum * stenosis from healing and fibrosis * Ameboma * hyperplastic granuloma (1%) * Pericolic inflammation * fistula formation * intussusception sconday to ameboma in kids * liver abscess * pleuropulmonary abscess * brain abscess * cutaenosu extension (perianal)

Answer 69

* Primary intestinal TB * MAI (AIDS) - mycobacterium avium-intracellulare * M. Bovis (cows milk) * haematogenous spread from pulmonary TB * Caecum \> colon \> jejunum \> Stomach * Imaging features * Stierlin sign * narrowed TI * marked bwoel wall thickening showrt segments * ulcers fissues fistulas strictures * Fleishner sign * marked hypertrophy of the ICv * Depicted * local adenopathy, may show low central density.

Answer 70

* Colitis cystic profunda * beign lookalike disease characterised by submucosal, fluidfilled cysts * commonly in the rectum * cysts up to 3cm. * dx by histo to exclude malignancy (cystic mucinous adenoca.

Answer 71

* Rectal lymphogranuloma venereum * caused by chlamydia tachomatis * sexually transmitted * Usually in MSM group * clincally * bleeding * purulent inflammation of the einguinal LNs occurs * Dx with the Frei intradermal test

Answer 72

* mucosal and submucosal outpouchings through the muscularis * mainly where vessels pierce the muscularis * ie btwn mesenteric and antimesenteric taenia * 95% sigmoid * performation causes diverticulitis * Clinically * pain fever bleeding

Answer 73

* extravasation of barium from tip of diverticulum -\> microperf * free intraperitoneal air -\> rare * intramural or paracolonic abscess * **double tracking (intramural fistula) uncommon** * fistula to bladder/uterus * muscular hypertrophy

Answer 74

* isolated giant sigmoidal diverticulym * rare entity caused by a ball valve mechanism * large balloon-shaped gas-filled instruction in the lower abdomen located centrally in the pelvis * rare * important to differentiate it from a sigmoid or cecal volvulus * Complciations * divertifuotlis * SBO as a result of adhesions * perforation * volvulus of diverticulum

Answer 75

* pts on steroids predisposed to diverticulitis and worse disease * underlying ca may be obscured in pts \> 50 years * endoscopic evaluation is indicated after resolution.