GIT 4 Flashcards

Question

What is this? 2 types imaging features

Answer 1

* Diffuse Dysmotility * * Characterised by intermittent chest pain, dysphagia and forceful contractions. * Diagnosis is diffuse oesohpageal spasm with manometry * TYPES * Primary neurogenic abnormality (vagus) * Secondary reflux oesophagitis * IMAGING FEATURES * Nutcracker corkscrew esophagus * non-specific oesophageal dysmotility disorders

Answer 2

* Esophagitis may present with erosiions, ulcersr and strictures and rarely with perforations and fistulas. * TYPES * infectious * chemical * Iatrogenic * Other * Types in more detail: * Infectious * Herpes * Candidiasis * CMV * Chemical * Reflux oesophagitis * corrosive (lye) * Iatrogenic * radiotherapy * extended use of NG tubes * Drugs * Tetracycline * NSAIDS * Potassium * Iron * Other * HIVE * Scleroderma * Crohn's Disease * Dermatological manifestations * pemphigoid * dermatomyositis bullosa * IMAGING FEATURES * Thickening and nodularity of oesophageal folds * Irregularity of mucosa, granularity, ulcerations * Retraction, smooth tapered luminal narrowing stricture just above the GOJ **HIV Esophagitis.** Large ulcers (red, black and white arrows) are seen in these two views of the distal esophagus from an esophagram in a patient with odynophagia and a CD4 count of 30. Biopsies of the ulcers were negative for CMV. For more information, click on the link if you see this icon ![]()

Answer 3

* **peritoneal mesothelioma** is very similar to peritoneal carcinomatosis, but usually no primary neoplasm is known * **peritoneal sarcomatosis**: if the primary tumour is of mesenchymal origin (i.e. sarcoma) * most commonly metastases from a gastrointestinal sarcoma 1 * **peritoneal lymphomatosis** * most commonly metastases from a primary (e.g. non-Hodgkin lymphoma) elsewhere 1 * **peritonitis/sepsis** * smooth thickening and enhancement of the peritoneum, with stranding of the omentum and mesentery may be seen in intra-abdominal sepsis * benign calcifications tend to be sheetlike, and nodal calcifications in these patients less common 2 * a history of peritoneal dialysis or recent abdominal sepsis is usually easily obtained * **peritoneal tuberculosis (image)**

Answer 4

* Benign ulcers decrease 50%in size within 3 weeks and show complete healing withing 6 weeks with successful medical treatment. * Benign ulcers may heal with local scarring.

Answer 5

* Mesenteric Fibromatosis AKA Desmoid Tumour * Uncommon benign tumour that is locally aggressive, infiltrates adjacent bowel wall and recurs following resection. * associations * FAP * adenomatous polyposis coli (APC) germline mutation. * asbestosis * Imaging * low attenuation on CT * High sig on T2 MRI * Case 1 courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 14806 * Large left-sided abdominal mass with soft-tissue attenuation. * Mesenteric desmoid tumours are bland fibrous tumours that have an association with familial adenomatous polyposis. In this case, there was no such association with confirmation of histology at percutaneous ultrasound-guided biopsy. * Case 2 courtesy of Dr James Sheldon, Radiopaedia.org, rID: 41007 * Abdominal mass measures 17 x 8 x 16 cm with regions of cystic degeneration/necrosis within the right side of the mass - the largest low density region measures 4.5 x 5.2 cm. The mass displaces the bowel to the periphery. Sections show a core paucicellular fibrous tissue composed of bundles of collagen interspersed with bland stellate fibroblasts and a few small vessels. In immunostains, there is strong nuclear staining for beta-catenin. DIAGNOSIS: Fibrous tissue suggestive of a desmoid tumour.

Answer 6

* Tumour * infection * Meatbolic * Trauma * Vascular * Tumour * leukemia * lymphoma * infection * Infectious mononucleosis * histoplasmosis * HIV * Meatbolic * Gaucher disease * Amyloid * Hemochromatosis * Trauma * Vascular * Portal hypertension * Hematologic disorders * anemia * sickle cell * thalassemia * myelofibrosis * myelosclerosis

Answer 7

* AKA American Typanosomiasis * Caused by Trypanosoma cruzi which multiply in the reticuloendothelial system (RES), muscle, and glia cells. When these cells rupture and organisms are destroyed a neurotoxin is released that destroys ganglion cells in the myenteric plexus * Mortality 5% secondary to myocarditis and encephalitis

Answer 8

* Inection * MAI * Yersinia * Sprue/cavitary LN sundrome * Mets * Necrotizing mesenteritis * Whipple Disease

Answer 9

* Toxic megacolon (TMC) * Severe dilation of the trasnverse colon * when inflammation spreased from the mucosa through other layers of the colon * aperistaltic * can perfoated * 30% mortality * UC is the most common cause * CD, Peudomembranous colitis, Ischemic colitis, infectious colitis (CMV, Amebiasis) * Imaging features: * \>6cm * ahaustral irregular colonic contour * may show intraluminal soft tissue masses (pseudopolyps) * BE is contraindicated. proceed to proctoscopy, gravity maneuvers for plain x-ray assessment. * diameter of transverse colon should reduce as successful treatment proceeds. * https://radiopaedia.org/cases/toxic-megacolon-3

Answer 10

* Detection: * detection rate of ulcers by double contrast barium is 60-80% * Imaging features: * ulcer crater seen en face. * distinct collection of barium that persists on different views. * The collection is most often round but can be linear * ulcer crater seen in profile: * Barium collection extends outside the projected margin of the gastric or duodenal wall. * Double contrast studies: * The crater has a white center with a surrounding black 'collar' * Great curvature ulcers are commonly because of malignancy or NSAIDS. * Multiple ulcers are usually due to NSAIDS

Answer 11

The Carman meniscus sign describes the lenticular shape of barium in cases of large and flat gastric ulcers, in which the inner margin is convex toward the lumen. It usually indicates a malignant ulcerated neoplasm; in cases of benign gastric ulcers, the inner margin is usually concave toward the lumen 1. Carman meniscus sign is seen after compression of a gastric tumour that surrounds the lesser curvature thus apposing both surfaces of the surrounding tumour and entrapping contrast between these margins causing a semilunar configuration 2,3. The following must be present in order to visualise the sign 3: flat infiltrating ulcerative lesion with heaped-up margins. saddle region of the stomach i.e. lesser curvature of body or antrum examination should be single-contrast or biphasic study (sign may be visible in double contrast study but may be not recognised). compression must be applied to the stomach.

Answer 12

* Inflammatory disease of unknown causes characterised by focal or diffuse eosinophilic infiltration of the GIT * an allergic or immunologic disorder is suspected because 50% of patients have another allergic disease * asthma * allergic rhinitis * hay fever * Only 300 cases have been reported to date * Rx is with Steroids Clinical Findings * abdo pain * diarrhea * eosinophilia Imaging features * stomach * tapered antral stensosis (common) * Pyloric stenosis (common) * Gastric fold thickening * SB * fold thickening (Common) * Dilatation * Luminal narrowing

Answer 13

Left lumbar hernia, with omental fat protruding as content is noted. Defect measuring 25 mm in diameter. There is also protrusion of omental fat through a defect in the left posterior rectus sheath, consistent with an incidental hernia here. A few non-enhancing simple cortical cysts are seen at both kidneys with maximum diameter of 25 mm. Degenerative changes as osteophytosis are seen at the lumbar spine. Case Discussion Left lumbar hernia (Petit hernia). Additional incidental left posterior rectus sheath hernia

Answer 14

* incidence: 0.2%-2% * most common complications are related to ischemia * intraoperative hypotension * hemorrhage * vasculopathy * emboli * clotting abnormalities * GI Hemorrhage 50% * cholecystitis 20% * emphysematous * acalculous * calculous * Pancreatitis 10% * Perforated peptic ulcer 10% * Mesenteric ischemia 5% * Perforated diverticular disease 5%

Answer 15

Gossypiboma ## Footnote A gossypiboma, also called textiloma or cottonoid, refers to a foreign object, such as a mass of cotton matrix or a sponge, that is left behind in a body cavity during surgery. It is an uncommon surgical complication. The manifestations and complications of gossypibomas are so variable that diagnosis may be difficult and patient morbidity is significant.

Answer 16

* **Indirect inguinal hernia** * defect lateral to the inferior epigastric vessels, * peritoneal sac protrudes through the internal inguinal ring * caused by persistence of processes vaginalis * Indirect inguinal hernias (alternative plural: herniae), a type of groin herniation, are the most common type of abdominal hernia. * Epidemiology * 5 times more common than a direct inguinal hernia, and is * 7 times more frequent in males, due to the persistence of the processus vaginalis during testicular descent. * In children, the vast majority of inguinal hernias are indirect. * Pathology * Indirect inguinal hernias arise lateral and superior to the course of the inferior epigastric vessels, lateral to Hesselbach's triangle, and then protrude through the deep or internal inguinal ring into the inguinal canal. An indirect hernia enters the inguinal canal at the deep ring, lateral to the inferior epigastric vessels. It passes inferomedially to emerge via the superficial ring and, if large enough, extend into the scrotum.

Answer 17

* Sliding type (axial Type) * 95% * GOJ is above the diaphragm * reflux is more likely with larger hernias * "mixed" variant when hernia and esophagus are not in straight axis * IMAGING FEATURES * Gastric folds above diaphragm * Concentric indentation (B-line) above diaphragm * Schatzki ring above diaphragm * ASSOCIATIONS * Oesophagitis 25% * Duodenal ulcers 20% * Paraesophageal hernia 5% * GOJ is in its normal position (ie below diaphragm) * Part of the fund is herniated above the diaphragm through esophageal hiatus and lies to the side of the oesophagus. * Refux is not necessarily associated. * More prone to mechanical complications. * Prophylactc surgery is a consideration * Usually nonreducible.

Answer 18

A helpful mnemonic for remembering the features of a Bochdalek hernia is: 5 Bs Mnemonic B: Bochdalek B: big B: back and lateral, usually on the left side B: baby B: bad (associated with pulmonary hypoplasia) To remember the side in which a Bochdalek hernia more commonly occurs (and to contrast that with Morgagni hernias) Bochdalek has an L for left and Morgagni has an R for right. In the initial chest radiograph, a radiolucent cystic large lesion is present, which occupies most of the left chest. It has a thin wall and an air-fluid level, it displaces the mediastinum, the trachea and the right lung compensates with overdistention.

Answer 19

* Abscess * hematoma * Psedomyxoma peritonei * Pancreatic necrosis

Answer 20

* congenital diaphragmatic hernias * Bockdaleck * left * Posterior * Morgagni * right 90% * anterior * where epigastric artery travels * rare (2% of CDH) * traumatic * left \> right * may be masked by positive pressure ventilation Morgagni hernias (alternative plural: herniae) are one of the congenital diaphragmatic hernias (CDHs) and are characterised by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias tend to be: * anterior * more often right-sided (~90%) * small * rare (~2% of CDH) * at low risk of prolapse Associations of Morgagni Hernias * pentalogy of Cantrell * congenital heart disease * trisomy 21 (Down syndrome) * intestinal malrotation 7

Answer 21

* all patients, except for those with denovo definitely benign gastic ulcers, should proceed to endoscopy with biopsy

Answer 22

* Mucosal structures * web = asymmmetric * Ring = symmetric * may occur anywhere in the oesophagus. * Associations * iron-deficiency anaemia (cervical webs) * Plummer vinson Syndrome (1st picture) * Hypopharyngeal carcinoma

Answer 23

* Malignancy of mesothelial cells linging the peritoneum. * Associated with asbestos exposure * Imaging features * peritoneal soft tissue nodules, mental and mesenteric masses or nodules * ascites * bowel wall thickening * Fixation of SB Malignant peritoneal mesothelioma is an uncommon primary tumour of the peritoneal lining. It shares epidemiological and pathological features with - but is less common than - its pleural counterpart, which is described in detail in the general article on mesothelioma. Other abdominal subtypes (also discussed separately) include: multicystic mesothelioma tunica vaginalis testis mesothelioma Epidemiology Approximately 20-30% of all mesotheliomas arise from the peritoneal serosal lining. As with pleural mesothelioma, there is also a strong association with asbestos exposure (primarily the crocidolite variety), and this occupational hazard probably accounts for disease predominance in middle-aged to older males (most common age group is 50 to 70 years and it may also account for the slightly increased male predilection). Despite this, ~50% of cases have no history of exposure to asbestos, although prior radiation exposure, exposure to thorium, talc, erionite or mica, as well as in patients affected by familial Mediterranean fever and diffuse lymphocytic lymphoma have also been reported. The overall incidence is approximately 1-2 cases per million.

Answer 24

* Aphthous ulcers, usually in antrum and duodenum * Stricture: Pseudo-Billroth 1 appearance on barium studies. * Fistulization

Answer 25

* Mucosal folds * thick irregular do not extend through collar * penetration * ulcers project within 'projected' luminal surface * Carman/meniscus sign * Location * eccentrically in tumour mound * Collar * thick, nodular, irregular * Other * limited peristalsis * limited distensibility * Gastrohepatic LNS * common

Answer 26

Ogilvie Syndrome dilatation of the colon in older adult patients. Often history of laxative abuse, antiparkinson medication or metabolic abnormalities * dilated ahaustral colon * often affects just the proximal colon * no mechanic obstrcution * water soluble contrast enema is diagnostic study of choice Colonic dilation with no clear mechanical cause/transition point. A colonic pseudo-obstruction (also known as Ogilvie syndrome) was considered as a possibility due to the post-operative status and associated electrolyte disturbances. Patient improved one day later only with clinical management. Adynamic ileus, which is usually associated with small bowel dilation, is a differential, although both conditions have a similar clinical management. Toxic megacolon secondary to Clostridioides difficile colitis and ischaemic colitis would present with similar dilation, but associated with bowel wall thickening and associated inflammatory changes such as fat stranding. Right kidney complex cyst was recommended for ultrasound correlation. https://radiopaedia.org/cases/ogilvie-syndrome-2

Answer 27

* NSAIDS * H Pylori * ETOH

Answer 28

Tuberculous Pathology Reactivation of tuberculous collections lying dormant in the peritoneum accounts for the majority of cases. Direct spread may occur from the gastrointestinal tract, and dissemination through lymphatic or haematogenous means have also been described. Direct extension from the female genital tract has been described 11. Tuberculous peritonitis is commonly classified as follows: * wet type * most common (~90%) 1 * dry type * fibrotic-fixed type Of note, there is considerable overlap between the three types. Tuberculosis in different organ systems may mimic alternate pathology so histopathological or laboratory evidence is often required to support suspicions on imaging before commencing treatment.

Answer 29

* Definition * syndrome of overproduction of gastrin * clinical findings * PUD * Diarrhoea * pain * Causes * Gastrinoma 90% * islet cell tumour in pancreas or duodenal wall 90% * 50% of tumours are malignant * 10% of tumours are a/w MEN Type 1 * Antral G-Cell hyperplasia 10% * Imaging features * ulcers * duodenal bulb \> Stomach \> post-bulbar duodenum * Multiple Ulcers * Thickened gastric and duodenal folds * Increased Gastric secreations * Reflux oesophagitis.

Answer 30

Richter hernias, also known as parietal hernias, (alternative plural: herniae) are an abdominal hernia where only a portion of the bowel wall is herniated and comprise 10% of strangulated hernias. These hernias progress more rapidly to gangrene than other strangulated hernias but obstruction is less frequent. Pathology In contrast to most other types of hernia, only the antimesenteric wall of the bowel herniates without compromising the entire lumen. This herniation is usually through a small, firm defect in the abdominal wall. Although any part of the bowel can be affected, the terminal ileum is most frequently involved. Richter hernias can occur at 2: femoral ring (36-88%) inguinal ring (12-36%) abdominal wall incisional hernia (4-25%) rare: umbilical, ventral, Spigelian, supravesical, sacral foramen, triangle of Petit, retrosternal, and diaphragmatic hernias trocar ports for laparoscopic surgery (port site hernia)

Answer 31

* Infection * CMV * Candida * Herpes * Cryptococcus * MAI * Tumour * Kaposi Sarcoma * Lymphoma

Answer 32

massively dilated sigmoid loop (inverted U) projects from the pelvis to upper quadrant proximal colonic dilatation is typical by not always present. typically occurs in older adult constipated patients. extends into upper abdomen liver overlap sign: overlaps lower margin of the liver Apex above T10. northern exposure sign: dilated twisted sigmoid colon projects above the transverse colon apex lies under the left hemidiaphragm inferior convergence into the pelvis Swirling of bowel and vessels, best seen on coronal CT

Answer 33

* Pseudomyxoma peritonei * gelatinous substance accumulates in peritoneal cavity because of widespread mucinous cystadenocarcinoma * appendix * ovary * scalloped indentations of liver * with or without calcificaiton * thickening of peritoneal surfaces * septated 'pseudo' ascites * thin walled cystic masses

Answer 34

* Femoral Hernia * enlargement of the femoral ring * peritoneal sac protrudes medial to the femoral sheath * Occurs more frequently in women

Answer 35

* Thin annular symmetric narrowing at the junction of the oesophagus with the stomach (B ring level). * Present in 10%. * Symptomatic in 30%. * Symptoms of dysphagia and heart burn usually occur if rings cause oesophageal narrowing of \< 12mm. Now considered a conserwence of reflux.

Answer 36

* Mucosal folds * thin * regular * extend up to crater edge * penetration * margin of ulcer crater extends beyond projected luminal surface * Location * centrally within mount of edema * Collar * hampton line 1-2mm lucent line around the ulcer caused by thin mucosa overhanging the crater mouth seen in tangent. It is a reliable sign of a benign ulcer but present in very few patients. * Other * normal peristalissi * Incisura: invagination of opposite wall * Gastrohepatic LNS * occasional

Answer 37

* Phrenic ampulla: * normal expansion of the distal oesophagus. Does not contain gastric mucosa * A-ring * a for Above. aka Wolf ring * indentation at upper boundary of the phrenic ampulla * B-ring * indentation at lower boundary of the phrenic ampullar * normally not seen radiologically unless there is a hiatal herna * Z-line * zig-zag line: squamocolumnar mucosal junction between oesophagus and stomach. Not visible radiologically. * C- ring * Diaphragmatic impression * the esophagus lacks a serosa. * Upper 1/3 has striated muscle * Lower 2/3 has smooth muscle.

Answer 38

Morgagni hernia Morgagni hernias (alternative plural: herniae) are one of the congenital diaphragmatic hernias (CDHs) and are characterised by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias tend to be: anterior more often right-sided (~90%) small rare (~2% of CDH) at low risk of prolapse Clinical presentation Only ~30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia. Epidemiology Associations pentalogy of Cantrell congenital heart disease trisomy 21 (Down syndrome) intestinal malrotation 7 Pathology Morgagni hernias most often contain omental fat, but transverse colon (60%) or stomach (12%) may be included within the hernia. Treatment and prognosis Some sources recommend laparoscopic surgical repair, even in asymptomatic patients, to avoid the risk of strangulation of the hernia contents 6. History and etymology Giovanni Battista Morgagni (1682-1771) was an Italian anatomist and pathologist 8. Differential diagnosis cardiophrenic angle lesions: the main differential diagnosis for Morgagni hernia is a cardiophrenic fat pad. It appears radiolucent compared with other lesions not containing fat focal diaphragmatic eventration diaphragmatic rupture: from trauma, but usually other supportive signs of chest and/or abdominal trauma would be apparent. This is most commonly seen posterior and posterolaterally

Answer 39

* Abdominal wall metastases * Origin * melanoma * skin tumours * neurofibromatosis * iatorgenic seeding * lymphoma * imaging features * soft tumour mass in subcutaneous fat with or without focal bulging

Answer 40

pts not very sick, mimics diverticulitis splenic flexure to sigmoid rectum involved 15% of the time invariably nonocclusive cause thumb printing - haemorrahge and oedema in the wall rarely pancolonic in distribution conservative rx. heals spontaneously strictures are rare CT: Halo or target sign

Answer 41

* The location of a lesion can be evaluated by observing the angle the lesion forms with the wall * an acute angle * mucosal * polyp * cancer * Obtuse angle * extramucosal * intramural * extramural * The preservation of the mucosal pattern is also a hint to the location of the lesions * disruption of normal pattern: MUCOSAL * Presence of normal Pattern: intramural or extramural location * The distinction of the outline * smooth, distinct: extramucosal * Irregular, fusszy: Mucosal

Answer 42

* Lateral Pharyngeal Pouches * AP oesophagram at level of pharynx demonstrates lateral outpouchings through weakness in thyrohyoid membrane. * Large in glassblowers and wind instrument players. * Zenker Diverticulum * Pulsion diverticulum * originates in the midline of the posterior wall of the hypopharynx at an anatomic weak point known as killian dehiscence * above cricopharyngeus at fiber divergence with inferior pharyngeal constrictor. * During swallowing, increased intraluminal pressure frces mucosa to herniated through the wall. * The cause of Zenker diverticulum is not firmly est. * but premature contraction and/pr motor incoordination of the cricopharyngeus muscle are thought to play a major role. * COMPLICATIONS * Aspiration * ulceration * Carcinoma * Killian-Jamieson DIverticulum * Below criopharungeus * Off midline. Ie is lateral * Lateral to the cervical oesophagus.

Answer 43

* liver lac * splenic lac * renal trauma * bowel hematoma * pancreatic fracture * RARE * GB injury * adreanal hemorrhage

Answer 44

arterial occlusion (thrombotic, embolic, vasculitis) 40% low flow states (reversible, nonocclusive) (50%) venous thrombosis (10%) may occur in either SMA or IMA distribution or both.

Answer 45

* SCC - most common world wide * Adenoca. * usually in the distal oesophagus/GOJ * in the US the incidence is now higher than SCC * Lymphoma * Leiomyosarcoma * Mets ASSOCIATIONS * SCCS ares a/w * H&N cancers * Smoking * ETOH * Achlasia * Lye ingestion * Adenoca's is a/w * barrets * GORD * Obesitiy IMAGING Features of malignant Oesophageal neoplasm * CT * invasion into mediastinum/aorta * Local LN enlargment * Mets: * LIver * lung * LAD * Gastrohepatic ligament * Endoscopic US * Extension through wall * LN Mets * Spectrum of Appearance * infiltrative, shelf like margins * Annular, contricting * Polypoid * ulcerative * varicoid * does not change in configuration during fluoro in contrast to oesopaheal varices * unusual bulky forms * carcinosarcoma, * fibrovascular polyp * Leimyosarcoma * Mets

Answer 46

* Imaging features * FB usually lodges in the coronal orientation * important to exclude an underlying schatzki ring or carcinoma once the FB is removed.

Answer 47

Peritoneal nodularity in patients with an IUD may be seen with Actinomycosis Pelvic actinomycosis infection is a rare but serious infection caused by Actinomyces sp., an opportunistic gram-positive bacteria usually introduced by foreign bodies specially IUCDs, surgery, or trauma. It generally falls under the broader spectrum of pelvic inflammatory disease. Pelvic infection from several Actinomyces sp. can occur, which include: * Actinomyces israelii: by far the most common causative organism 3 * Actinomyces naeslundii * Actinomyces viscosus * Actinomyces eriksonii The organisms are indigenous in the oral cavity, gastrointestinal tract, and genital tract, with opportunistic infection occurring when the mucosal barrier is broken. Associations * placement of intra-uterine contraceptive devices: usually when it has been present for a prolonged period * ~25% of IUCDs eventually get colonised by Actinomycosis sp. * 2-4% of IUCDs that are colonised ultimately develop a serious actinomycotic infection

Answer 48

appendix thickness \>6mm calcified appendicolith fat stranding assymetrical cecal wall thickening only proximal filling and inflammationdistally -\> tip appendicitis LNs in mesoappendix

Answer 49

* 5% of all ulcers * types * carcinoma 90% * lymphoma 5% * Rare malignancies * sarcoma * carcinoid * Mets *

Answer 50

* Echinococcus (ie hydatid - picture) * traumatic cyst * Metastases * Intrasplenic aneurysm

Answer 51

* Collagen vascular disease that involve the smooth muscle of the oesophagus, stomach and small bowel * Imaging features * Lack of primary waves in distal 2/3 * GOJ patulous unless stricture supervenes * Reflux oesophagitis * Strictures occur late in disease * Oesophagus dilates most when stricture sypervenes.

Answer 52

* direct inguinal hernia * defect medial to the inferior epigastric vessels * the peritoneal sac protrudes through floor of the inguinal canal * caused by weakness in the floor of the inguinal canal

Answer 53

accumulation of mucus within abnormally distened appendix. usually due to tumour (mucinous cystadenoma), or obstructed orifice. imaging features: nonfilling appendix smooth rounded appendicieal mass curvilinear calcificaiton

Answer 54

* granulomatous disease (ie sarcoid) * Lymphoma * mets * Candida * TB * MAI

Answer 55

* Oesophagus * ulcers * candida * CMV * herpes * Sinus tracts * TB * Actinomycosis * Proximal SB * Ulcers: * Cyptococcosis * Nodules * kaposi sarcoma * MAI * Distal SB * Enteritis * TB * MAI * CMV * Colon * colitis * CMV * pseodomembranous colitis * Typhlitis * Biliary * Strictures * CMV * Cryptococcosis

Answer 56

* Esophagus * early: * hypercontractility, distal muscular spasm. Normal caliber * Late * Denervation * megaesophagus * aperistalsis * birds beak appearance at GOJ * mimicks achalasia * Oesophageal complications * ulcers/hemorrhage * perforation into mediastinum * abscess formation * carcinoma 7% * Colon * megacolon (anasphinterneuropathy) * Sigmoid volvulus) 10% * Heart * cardiomyopathy (cardiomegaly) * CNS * encephalitis

Answer 57

* 35% of all cases of colonic volvulus * massively dilated cecum rotates toward midabdomen and points to LUQ, medially placed ICv produces a soft tissue indentation with kidney or coffee bean appearance. * Assicated SB dilatation, decompressed distal colon. * Throught foramen of winslw, lesser sac herna.

Answer 58

Obturator Canal Hernia * Occurs through the obturator foramen * between pectineus and obturator externus * Has the highest mortality rate of all henrias * older women * Obturator hernias (alternative plural: herniae) are characterised by bowel herniating between the obturator and the pectineus muscles. They are a rare type of abdominal hernia and can be a challenge to diagnose clinically. Epidemiology Typically obturator hernias occur in older women 2,3 or patients with chronically raised intra-abdominal pressure (e.g. ascites, COPD, chronic cough) 3. They can occur in pregnancy, due to relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal 3. It has been suggested that there is a female predominance with this type of hernia, and they occur in less than 0.04% of all hernias 6.

Answer 59

sigmoid \> cecum \> trasnverse colon Predisposing factors: redundant loops of bowel, elongated mesentery, chronic colonic distention

Answer 60

* spigelian hernias * occur along the lateral margin of the rectus muscle through the hiatus semilunaris * although these hernias protrude beyond the transverse abdominal and internal oblique muscles, they are contained within the external oblique muscle, thus they may be difficult to detect on physical examination * Groin hernia * Lumbar hernias * occur through either superior (Grynfeltt) or inferior (Petit) lumbar triangle * Richter hernia

Answer 61

1. Ascites 2. urinoma 3. biloma 4. seroma 5. lymphocele (after LN resection) 6. pancreatic pseudocyst 7. cerebrospinal fluid pseudocyst from VP Shunt 8. Duplication cyst 9. Mesenteric cyst 10. Ovarian cyst 11. Lymphangioma

Answer 62

Rectus sheath haematomas, as the term implies, occur when a haematoma forms in the rectus abdominis muscle/rectus sheath. It is most common in its lower segment and is generally self-limiting. Epidemiology Rectus sheath haematomas are more common in women with a 3:1 F:M ratio. Clinical presentation Rectus sheath haematomas most often present as acute onset of abdominal pain with a palpable abdominal mass. Additional findings may include fevers, chills, nausea, vomiting, abdominal tenderness, and abdominal guarding. Depending upon the size and location of the haematoma, patients may also present with signs of hypovolaemic shock or even abdominal compartment syndrome 5. Pathology Aetiology The majority of haematomas result from the rupture of epigastric vessels or by tearing of the fibres of the rectus abdominis muscle. This can be due to 1,4: spontaneously in the context of anticoagulation therapy (most common) direct or indirect trauma coagulopathies e.g. cirrhosis degenerative vascular diseases iatrogenic, e.g. from high femoral arterial puncture Radiographic features Rectus sheath haematomas are classified based upon computed tomography scan findings to guide treatment 6. Ultrasound heterogeneity in rectus abdominis muscle CT haematoma is confined to the abdominal wall. high attenuation on unenhanced images lack of enhancement resolution on follow-up studies helps confirm the diagnosis CT classification type I: small and confined within the rectus muscle; does not cross the midline or dissect fascial planes 6 type II: also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midline 6 type III: large, usually below the arcuate line, and often presents with evidence of haemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space) 6 Left rectus sheath haematoma comprising three loculations with haematocrit effect. There is active extravasation from the left inferior epigastric artery. Prior sternotomy. Markedly enlarged right atrium. Mildly dilated intrahepatic bile ducts. Small right kidney, 7.1 cm in length. Severe lumbar scoliosis convex to the right. Internal fixation (DHS) of left femoral neck. Case Discussion Example of rectus sheath haematoma with haematocrit effect and active contrast media extravasation (i.e. active bleeding) from the inferior epigastric artery. Glick, Y. Rectus sheath haematoma with active extravasation. Case study, Radiopaedia.org. (accessed on 29 Sep 2021) https://radiopaedia.org/cases/55889

Answer 63

* Herpes simplex * Candidiasis * CMV/HIV * Mycobacterial * Herpes simplex * Small ulcers \<5mm * normal mucosa between ulcers * More diffuse than reflux ulcers * Candidiasis * plaque-like, reticular * Shaggy margins * Often involve entire oesophagus * CMV/HIV * Typically, elliptical large ulcers, but may be tiny ulcers such as herpes * Etiologic distinction between CMV and HIV ulcers is important because therpies are different * Behcet disease may have a similar appearance * Mycobacterial * ulcers, sinus tracts.

Answer 64

appendicitis occurs 2ndary to obstrcution of the appendiceal lumen or venous obstruction -\> ischaemia -\> bacteria invasion -\> necrosis Common causes of obstruction: appendicoltith, lymphoid hypertrophy, tumour, worms

Answer 65

* Primary Contractions * initiated by swallowing. * distally progressive contraction waves strip the esophagus of its contents. * Propulsive wave. * Secondary contractions * Anty not cleared from the esophagus by a primary wave may be cleared by a locally initially wave. * Propulsive wave * Tertiary Contractions * Nonpropulsive, uncoordinated contractions * these random contractions increase with age and are rarely of clinical significance in absence of symptoms of dysphagia. * Non-propulsive wave. * only peristaltic activity in achalasia. * Peristalsis should always be evaluated fluoroscopically with the patient in a horizontal positive. * In the erect positive the oesophagus empties by gravity.

Answer 66

hampton line 1-2mm lucent line around the ulcer caused by thin mucosa overhanging the crater mouth seen in tangent. It is a reliable sign of a benign ulcer but present in very few patients.

Answer 67

* The GOJ sphincter fails to relax because of degeneration of the **Auerbach plexus.** * The sphincter relaxes only when the hydrostatic pressure of the column of liquid or food exceeds that of the sphincter. * emptying occurs more in the upright than in the horizontal position. * TYPES * Primary (idiopathic) * Secondary * destruction of the myenteric plexus by tumour cells * mets * adenocarcinoma * Infectious * Chagas disease * Clinical Findings * primary occurs predominantly in young patients * onset 20-40 years * dysphagia 100% to both liquids and solids when symptoms begin. * weight loss 90% * Diagnosis * need to exclude malignancy * fundal ca. or lymphoma destroying Auerbach plexus particularly in older adules * Need to exclude oesophageal spasm * Manometry is the most sensitive method to dx elevated lower oesophageal sphincter pressure and incomplete relaxation. * Imaging features * 2 diagnostic criteria must be met * primary and secondary peristalisis absent throughout the oesophagus * Lower esophageal sphincter fails to relax in response to swallowing. * dilated oesophagus typically cuirve to the right and then back to the left when passing through the diaphragm * There may be minimal oesophageal dilation in the early stage of the disease * Beaked tapering of the GOJ * Tertiary waves * Airfluid level in the oesophagus on plain x-ray. * Complications * recurrent aspiration and pneumonia 10% * Increased incidence of oesophageal ca. * Rx * Drugs * nitrates, b-adrenergic agonists, ca-blockers * Balloon dilation * myotomy

Answer 68

* There are three morphologic types of lesions: * Ulcer: abnormal accumulation of contrast media * Polypoid lesions (masses): filling defect * Coexistent pattern: Ulcerated Mass * The above lesions have different appearances depending on whether they are imaging with sing or double-contrast techniques, whether they exist on dependant or non-dependant wall and heather they are imaged in profile or en face.

Answer 69

* Mucosal tear in proximal stomach, across the GOJ or in distal oesophagus. * Usually caused by prolonged vomiting or increased intraluminal pressure. Because the tear is not transmural there is no pneumomediastinum. * Imaging features * Xrays are usually normal * Intravasation rather than extravasation * there may be subtle mucosal irregularity.

Answer 70

mucocele: abdnoraml accumulation of mucus, rupture leads to pseudomyoxoma peritonei cystadenoma cystadenocarcinoma adenocarcinoma carcinoid (usually a small tumour found incidentally at surgery)

Answer 71

Sclerosing peritonitis * uncommon but important complication of chronic ambulatory peritoneal dialysis (CAPD) * incidence increases with the duration of CAPD. * The exact cause is not known. * Clinical onset is heralded by abdominal pain, anorexia, weight loss, and eventually partial or complete SBO. * Loss of ultrafiltration is common, as is flooding dialysis effluent * early dx is essential as cessation of CAPD and tx with total parenteral nutrition, hemodialysis, immunosuppression +/- renal transplant may result in recovery * Imaging features * x-ray * are normal in early disease. * later, curvilinear peritoneal calcification can be seen within the abdomen * may show centrally located, dilated loops of bowel with wall thickening, edema, and thumb printing * CT * peritoneal enhancement * thickening * calcification * loculated intraperitoneal fluid collection * adherent and dilated loops of bowel * **Case 1 courtesy of Dr Vitalii Rogalskyi, Radiopaedia.org, rID: 66354** * **Case 2 courtesy of Dr Vikas Shah, Radiopaedia.org, rID: 7529** * ****Sheet-like calcification across the upper and mid abdomen. Extensive arterial calcification. Multiple surgical clips in left iliac fossa; there was an undisclosed history of a renal transplant. No signs of bowel obstruction. * Case Discussion * Encapsulating peritoneal sclerosis may be a complication of peritoneal dialysis. Chronic inflammation leads to thickening and calcification of the peritoneum, forming a calcified cocoon encasing the bowel and leading to subacute bowel obstruction. There are features here that make it a great exam film: * the cause of renal failure: diabetes leading to extensive arterial calcification * the previous treatment for the renal failure was peritoneal dialysis, leading to the calcification * the most recent treatment is a transplant, evidenced by the surgical clips in the left iliac fossa * Encapsulating peritoneal sclerosis is a rare benign cause of acute or subacute small bowel obstruction. It is characterised by total or partial encasement of the small bowel within a thick fibrocollagenous membrane. * AKA * abdominal cocoon * sclerosing encapsulating peritonitis, * sclerosing peritonitis, * encapsulating peritonitis, * peritonitis chronica fibrosa incapsulata. Epidemiology Encapsulating peritoneal sclerosis can occur at any age, with reports ranging from 2-day neonate to 82 years 5. Clinical presentation The presentation is non-specific and patients may present with vomiting, abdominal pain and/or a subacute bowel obstruction 5. Pathology It can be idiopathic or secondary due to: * continuous ambulatory peritoneal dialysis (prevalence ~0.7%) * tuberculosis * peritoneovenous or ventriculoperitoneal shunts * treatment with practolol * tuberculosis, * sarcoidosis, * familial Mediterranean fever, * gastrointestinal malignancy, ovarian carcinoma 6, * protein S deficiency, * liver transplantation, * fibrogenic foreign material, and * luteinised ovarian thecomasRadiographic features DDx **congenital peritoneal encapsulation,** which is characterised by a thin accessory peritoneal sac surrounding the small bowel.

Answer 72

Paraduodenal hernia (L\>R) SB grouped in sac like configuration (1st picture) Lesser sac hernia (second picture)

Answer 73

Pseudodiverticulosis Neumerous small oesophageal outpouchings reporesetnging dilated glands interior to the muscularis * Usually occur at \>50 years old. * DYsphagia is the presenting symptom. * underlying disease include candidiasis, alcoholism and diabetes. * ASSOCIATED FINDINGS * oesophageal stricture may occur above and/or below * Oesophagitis. * IMAGING FEATURES * Thin flask shaped structes in longitudinal rows parallel to the long axis of the oesophagus * diffuse distribution or localised cluters near peptic strictures. * Much smaller than true diverticulae * When view en face, they can sometimes be mistaken for ulcers. * When viewed in profile they often seem to be floating outside the oesophageal wall with barely perceptible channel to the lumen. * CF: Oesophageal ulcers almost always visibly communicate with the lumen.

Answer 74

* Spontaneous perforation of the oesophagus secondary to a sudden increase in intraluminal oesophageal pressure. Severe epigastric pain. Rx is with immediate thoractomy. Mortality 25%. * Imaging features * pneumomediastinum * pleural effusion (left \> Right) * Mediastinal hematoma * Rupture immediate above diaphragm * usually on the left posterlateral side 90%

Answer 75

1. Leiomyoma (may calcify) 50% 2. Fibrovascular polyp 25% * May be large and mobile attached to upper oesophagus and may contain fat on CT 3. Cysts 10% 4. Papiloma 3% 5. Fibroma 3% 6. Hemangioma 2%

Answer 76

acute inflammation and infarction of epiploic appendages. small adipose structs protruding from the serosal surface of the colon, seen along the free taenia and taenia omentalis betwn cecum and sigmoid colon Imaging features: small oval pericolonic fatty nodule with hyperdence ring and surrounding inflammation LLQ \> RLQ central aear of increased attenuation indicative of a thrombosed vein.