HomeStretch CRACK vol 1. GI

Question 1

Esophageal anatomy

A ring and B ring and Z line

bonus - what esophagitis shows concentric rings?

Answer 1

A: muscular ring above the vestibule

B: mucosal ring Below the vestibule; thin constriction at the GE junction - ShatzB ring

Z line: squamoclumnar junction

Question 2

High stricture + hiatal hernia = ?

What’s the buzzword for this entity?

Answer 2

Barrett

buzzword = reticular mucosal pattern

Question 3

candidiasis appearence on barium swallow

What else looks like that exactly?

Answer 3

discrete plaque-like lesions, nodularity, fold thickening and shaggy appearence

Glycogenic ancothosis looks exactly the same in an asymptomatic elderly patient.

Question 4

Herpes, CMV and HSV esophageal barium

Answer 4

Herpers has a halo - small and multiple ulcers with halo

CMV = HIV = large, flat ovoid ulcer

Question 5

Esophageal diverticulum

Answer 5

• Zenker - (posterosuperior - above cricopharyngeus) pulsion divirticulum posteriorly via site of weakness called Killian dehisence in the hypopharynx
• Killian-Jamieson - anterolateral and more inferior (below cricopharygneus), this one is in the cervical esophagus; least common
  
  • Pulsion diverticulum are Pseudodiverticuli (i.e. don’t have all three layers of esophagus and therefore won’t empty).
• Traction diverticulum - mid esophagus, triangular in shape, TB, will empty since it is a true diverticulum

Question 6

Carny’s Triad

Answer 6

Carney’s Eat Garbage

• Chondroma (pulmonary)
• Extra adrenal pheo
• GIST

Question 7

Hidebound bowel or stack of coins

Answer 7

Scleroderma

Question 8

Fold reversal

Answer 8

CeliaC

Question 9

clover leaf sign

Answer 9

healed peptic ulcer

Question 10

Ribbon bowel

Answer 10

GVHD

Question 11

Lane Hamilton Syndrome

Answer 11

Idiopathic pulmonary Hemosiderosis, which is associated with celec sprue

Question 12

Rigler’s Triad

Answer 12

pneuobilia, obstruction and ectopic location of glasstone

Note that rigler’s sign (pneumoperitoneum) is not included here

Question 13

Spigelian Hernia

Answer 13

Lateral ventral hernia

Hernia along the Semilunar line (S for S)

Question 14

Grynfelt-Lesshaft Hernia

Petit Hernia

Littre Hernia

Amyand Hernia

Richter Hernia

Answer 14

• Grynfelt-Lesshaft Hernia = super lumbar hernia (more common)
• Petit Hernia = inferior lumbat hernia
• Littre Hernia = hernia with meckel diverticulum in it!
• Amyand Hernia = hernia with Appendinx in it!
• Richter Hernia = contains only one wall of bowel and does not obstruct but can strangulate. . .

Question 15

Howship-Romberg Sign

Answer 15

Obturator hernia causing characteristic paresthesia along inner though down to knee

Question 16

Femoral v Direct Inguinal v Indirect Inguinal Hernias

(also obturator)

Answer 16

• Femoral: seen in old ladies, infeior to the inferior epigastric and medial to common femoral vein, below the pubic tubercle; compression of the femoral vein can cause distal collateral venous engorgement; obstruction is common
  
  • obturator will have bowel herniating between obturator and pectineus muscle).
• Direct = medial and anterior to inferior epigastric - goes through Hesselbach’s triangle, not covered by spermatic
• Indirect goes Into the Inguinal canal/lateral to the inferior epigastric artery and into a patent processus vaginalis.

Question 17

Most common types of internal hernias

Answer 17

Paraduodenal hernia in the left occurs through a defect via the fossa of Lanzert (L for L) this one is more common

right sided - goes through fossa of waldeyer

Question 18

What do you think of when you have an enlarged lymph node in the setting of ulcerative colitis

Answer 18

cancer/metastatses

Question 19

Behcet’s

Answer 19

ulcers of penis and mouth

can hit GI and look like crohn’s

cause of pulmonary artery aneursyms

Question 20

What syndromes are associated with rectal cavernous hemangiomas?

Answer 20

Klippel-Trenaunay-Weber and Blue Rubber Bleb syndrome

Question 21

McKittrick-Wheelock Syndrome

Answer 21

Villous andeoma in the rectum with mucous diarrhea (usually in an old lady causing electrolyte imbalances/dehydration).

Question 22

retroperitoneal structures

Answer 22

• Duodenum (2nd and 3rd part)
• Pancreas (except tail)
• Colon (ascending and descending)
• Rectum (proximal 1/3)
  
  • distal 1/3 if the rectum is intraperitoneal

Question 23

Mesenteric mass algorithm

Answer 23

1. Cystic versus Solid
2. Single versus multiple
   
   1. If single - does it have fat?
   2. If it doesn’t have fat what do the margins look like?

Question 24

Fissure for the ligamentum venosum

Fissure for the ligamentum teres

Answer 24

• Fissure for the ligamentum venosum: Fibrous remnant of the ductus venosus fetal circululation (closer one to the IVC - relative tot the ligamentum teres). An artery in this fissure is a replaced left hepatic artery.
• Fissure for the ligamentum teres - ligamentum teres (which is found within the falciform ligament) = round ligament of the liver, which is the remnant of the left umbilical vein. . the left hepatic vein also courses here and slits the caunaid system (4a/2 and 4b/3)

Question 25

Cantlie's Line

Answer 25

Liver lobe line. . . divides the liver into functional left and right hepatic lobes (8/4a and 5/4b)

Question 26

Couinaud System Testable Trivia Left hepatic vein / Fissure for Ligamentum Teres (falciform) divides what segments? Middle hepatic vein divides what segments? Right hepatic vein divides what segments? Portal vein devides what? What segment is the caudate lobe? where does it drain?

Answer 26

* Left hepatic vein / Fissure for Ligamentum Teres (falciform) divides 2 from 4a and 3 from 4b) * Middle hepatic vein divides 4a from 8 and 4b from 5 (Cantlie's line) * Right hepatic vein divides 8 from 7 and 5 from 6 * Portal vein divides liver from upper and lower segments * What segment is the caudate lobe = 1 and drains directly into IVC

Question 27

Most common hepatic vascular variant? Most common biliary variant?

Answer 27

* Most common hepatic vascular variant = replaced right hepatic originating from SMA * Most common biliary variant = right posterior segmental into the left hepatic duct

Question 28

Hepatic adenoma subtypes

Answer 28

* Inflammatory = most common; highest bleeding rate * HNF-1 alpha mutated - 2nd most common; multiple masses * Beta-catenin mutated = least common; anabolic steroids and glycogen storage disorders and FAP.

Question 29

Hepatic Angiosarcoma

Answer 29

Most common primary liver sarcoma assocaited with toxic exposures like arsenic, polyvynil chloride and thoratrast Can see in hemochromatosis and NF1 patients usually multifocal and likes to bleed

Question 30

Osler-Weber-Rendu Syndrome

Answer 30

Hereditary Hemorrhagic Telangiectasia AD disorder characterized by muliple AVMs in liver and lungs Leads to cirrhosis and massively dilated hepatic artery lung avms set you up for brain abscesses

Question 31

Fitz-Hugh-Curtis Syndrome

Answer 31

PID complication with enhancement of the anterior liver capsule, perihepatic ascites and peritoneal septations

Question 32

Choledocal cyst classification

Answer 32

* Type 1: Focal dilation of the CBD and most common form * Type 2: rare - diverticulum of bile duct * Type 3: rare - choledococele - focally dilated distal common bile duct protruding into the duodenum * Type 4: both intra and extra * Type 5: intra only = caroli's disease

Question 33

Caroli's disease

Answer 33

Type 5 choledocal cysts (which communicate with ducts!) Central dot sign Associated with polycystic kidney disease, medullary sponge kidney and cholangioCA.

Question 34

Mirizzi syndrome

Answer 34

Cystic duct stone obstructing CBD increased co-incidence of gallbladder CA

Question 35

Peripancreatic fluid collections

Answer 35

* NO necrosis * \< 4 weeks = acute peripancreatic fluid collections * \> 4 weeks = pseudocyst * Necrosis * \< 4 weeks = acute necrotic collection * \> 4 weeks = walled off necrosis

Question 36

Hereditary syndromes with pancreatic CA

Answer 36

HNPCC (Lynch Syndrome), BRCA mutation, Ataxia-telangiectasia, Peutz-Jeger

Question 37

Felty's syndrome

Answer 37

Abnormality of Granulocytes with triad of: Splenomegaly, RA and neuropenia

Question 38

Caplan syndrome

Answer 38

rhematoid pneumoconiosis