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216 Cards in this Set

  • Front
  • Back
Esophagus - smooth linear thickened folds
Reflux esophagitis
Esophageal varices
Esophagram language
Mucosa
- nodularity

Ulcers
- flat
- deep
- linear
- halo of edema

Folds
- thickened
- nodular
- transverse (scarring)

Associated findings
- lack of distensibility
- buckling (due to scarring)
Barrett esophagus
Adenomatous metaplasia

10% risk of malignant transformation
Esophagitis
Reflux
- usually lower esophagus, HH, lower esphageal stricture
- nodular/granular mucosa
- linear uclerations
- thickened folds

Pill
- tetracycline
- quinidine
- KCl
- single or multiple focal shallow uclerations
- +/- fold thickening

Inflammatory
- Chron disease
- aphthous ulcers or deep ulcers
- focal
- +/- fistula or stricture

Infectious
- CMV
- large, flat ulceration
- HIV
- large, flat ulceration
- Candida
- diffuse plaques
- shaggy mucosa
- nodular/granular mucosa
- thickened folds
- Herpes
- discrete small ulcerations on an otherwise normal mucosal background
- +/- plaquelike filling defects
- ddx candida, varicella
Glycogenic acanthosis
- numerous nodules and plaques, less well defines than Candidiasis
- cellular hyperplasia and increased cellular glycogen
-

Caustic

Radiation
Esophageal anatomy
Upper, middle and lower 1/3rds

Striated voluntary skeletal muscle transitioning to smooth muscle from cephalad to caudad

Inner circular, outer longitudinal muscles

A ring:
- intermittently imaged ring demarcating cephalad extent of LES

B ring:
- transverse mucosal fold demarcating EG junction, and often squamous columnar junction, distal to A ring

Z line:
- junction between squamous and columnar epithelium

4 areas of normal narrowing:
- cricopharyngeus
- aortic arch
- left mainstem bronchus
- diaphragmatic hiatus
Esophageal stricture
Chronic reflux esophagitis
- smooth tapering distal stricture
- a/w HH
- esophageal shortening
- tx ballon or bougie dilitation _. surgery if ineffective

Caustic ingestion stricture
- smooth tapering stricture
- us. longer length than chronic reflux
- 1-4% risk of esophageal CA
Short segment esophageal stricture
Chronic reflux esophagitis
Caustic ingestion related stricture
Barrett esophagitis (upper to mid esophagus as gastric mucosa is resistant to strictutre)
Pill esophagitis
Long segment espohageal stricture
Caustic ingestion related stricture
Chronic reflux
Prolonged intubation
Radiation
- esophagitis 1-4 weeks post XRT
- stricture 4-8 months post XRT
Cutaneous bullous disease
- Epidermolysis bullosa
- Pemphigus
Diffuse esophageal spasm
"rosary bead" or "corkscrew" appearance
Dilated esophagus with distal beaking
Primary achalasia
- aperistalsis of distal 2/3 of esophagus smooth muscle
- transient emptying of contrast column when pressure exceeds LES
- c/b squamous CA, candidiasis
- dx manometry
- tx Heller myotomy

Scleroderma

Reflux induced stricture

Chagas disease

esophageal CA
- pseudoachalasia
- no intermittent relaxation or emptying on dynamic images
Submucosal esophageal mass
GIST (MC, more than 50% of B9 esophageal tumors)
Neuroma
Fibroma
Lipoma
Hemangioma
Duplication cyst
Lobulated distal esophageal filling defect
Adenomatous polyp
- arising in Barrett's

Papilloma

Inflammatory esophogastric polyp
- enlarged gastric folds that projects into the stomach
Pedunculated endoluminal esophageal mass
Fibrovascular polyp

Carcinosarcoma (spindle cell sarcoma)

Adenomatous polyp

Food bolus
- tx effervescent crystals or muscle relaxants
Bulky polypoid esophageal mass
Adenocarcinoma

Spindle cell carcinoma (carcinosarcoma)

Lymphoma
Mets to the esophagus
Usually direct extension from metastatic mediastinal lymph nodes

Gastric
Lung
Breast
Shallow indentations along the esophageal wall
Ectopic gastric mucosa
- shallow shelf like indentations
- usually cervical esophagus

Blistering skin diseases

Caustic ingestion
Lateral pharyngeal pouches
Small symmetric lateral outpouching in the hypopharynx through thyrohyoid membrane

May be increased in glassblowers, windplayers, elderly
Zenker diverticulum
Diverticulum from POSTERIOR cervical esophagus

Cephalad to cricopharyngeus

Due to increased pressure 2/2 poor relaxation of cricopharyngeus

TX
- cricopharyngeus myotomy
- diverticulopexy/ectomy

DDx:
Pseudodiverticulum due to contrast between pharyngeal contraction and cricopharyngeus
Killian-Jamieson diverticulum
Diverticulum from anterolateral cervical esophagus

Caudad to cricopharyngeus at level of cricoid cartilage

May be bilateral
Traction vs. pulsion esophageal diverticulum
Traction diverticulum of esophagus
- 2/2 infection (i.e. TB)
- mid esophagus
- "triangular" shape
- rare

Pulsion diverticulum of esophagus
- MC
- round outpounching
- 2/2 motility disorders
- does not empty with peristalsis
Intramural esophageal pseudodiverticulosis
Multiple tiny outpouchings along esophagus due to dilated submucosal glands

May be 2/2 chronic reflux esophagitis
- often a/w stricture
Esophageal contractions
Primary = initiated by swallow

Secondary = initiated by distension or bolus

Tertiary = non-propulsive
- increase with age

Ddx:
- vigorous achalasia
- esophageal spasm
Esophageal spasm
"corkscrew" appearance
- p/w chest pain in "nutcracker esophagus"
- 30% of swallows associated with non-propulsive contractions

DDx:
Vigorous achalasia (will eventually have clearing "stripping wave")
Tertiary contractions
Schatzki ring
Thin, shelf-like ring near the GE junction
- thinner vs. B ring
- thinner, more regular and well-defined than stricture
- dilitation if p/w dysphagia

Dysphagia

Idiopathic
Esophageal web
Thin shelf like eccentric filling defect. Fixed on dynamic imaging

Usually anteriorly in upper 1/3 of esophagus

A/W Plummer-Vinson syndrome (iron deficiency anemia)

DDx:
Prominent anterior venous plexus
Esophageal hernias
Hiatal
- not predictive of reflux, though most pts. with reflux have an HH

Paraesophageal
- Norml location of GE junction
- gastric body slides anteriorly through the hiatus
- c/b strangulation, gastritis, ulcers
- surgical repair
Esophageal perforation
Iatrogenic
Boerhaeve's
Trauma
Esophageal CA
Diffuse thickened gastric folds
Gastritis
- H. pylori (us. antral)
- medication (us. greater curvature)
- alcohol

Zollinger-Ellison syndrome
- with gastric ulcers

Lymphoma

Gastric CA

Metentrier's
- protein losing gastropathy
- usually in the proximal stomach

Crohn disease
- with aphthous ulcers

Varices
- us. cardia and fundus
Multiple small ulcerations/erosions with peripheral edema, along rugae, within the gastric mucosa on UGI
Multiple small ulcerations/erosions with peripheral edema, along rugae, within the gastric mucosa on UGI
Acute erosive gastritis:
Meds (ASA, NSAIDS)
- EtOH
- chemo
- H. pylori

IBD with aphthous ulcers
- Chrohn

Infectious gastritis
- viral
- fungal
UGI: single small central ulceration with surrounding edema
Ectopic pancreas

GIST

Mets
Benign gastric ulcer
- More common in distal half of stomach
- lesser > greater curvature
- greater curvature medication induced ulcer = "sump ulcer" (ASA, steroids)
- >3 cm = "giant ulcer"
Round, oval or linear collection of barium extending into the submucosa beyond the lumen contour

Surrounding mound of submucosal edema

radiating folds that cross the mound w/o nodularity or clubbing

thin "collar" separating ulcer crater from mucosal pit
"Hampton's line" (thin line of peripheral acid resistant mucosa)

Tx:
follow until healed
Zollinger-Ellison
Gastrinoma

Thickened gastric folds

Gastric erosions and ulcers

Dilated duodenum

Thickened proximal small bowel

Tx:
Imaging with pentatreotide or CT
Resection or H2 blockade
Eosinophilic esophagitis
Multiple thin web-like strictures

"ringed" esophagus

May coexist with longer strictures

Can affect any part of GI tract

Dx:
- Gi sx
- bx proof of eosinophilic infiltration
- absence of parasitic infection
- absence of other organ involvement
Gastric polyps
Inflammatory/Hyperplastic polyps
- common
- usually multiple
- no malignant potential
- a/w familial adenomatous polyposis (FAP)

Adenomatous polyp
- small chance of malignant transformation for larger polyps
Familial adenomatous polyposis (FAP)
Numerous GI adenomatous polys
- in the stomach, INFLAMMATORY polyps, us. fundic (fundic gland polyposis syndrome)
- 100% risk of colorectal CA
- colectomy

Turcot syndrome
- AD
- version of FAP
- GI adenomas
+ medulloblastomas and CNS gliomas

Gardner syndrome
- AD
- version of FAP
- GI adenomas
DOPE
+ Desmoid tumors
+ Osteomas
+ Papillary thyroid CA
+ Epidermoid cysts
Gardner syndrome
Variant of FAP
- AD
- gastric hyperplastic polyps
- GI adenomas
- 100% chance of colorectal CA
DOPE
+ Desmoid tumors
+ Osteomas
+ Papillary thyroid CA
+ Epidermoid cysts
Hamartomatous polyp syndromes
Peutz-Jeghers
- AD
- Mucocutaneous pigmentation
- polyps from stomach to rectum (sparing oral cavity and esophagus)
- majority of polyps are in SB
- gastric and SB polyps are hamartomatous
- colonic polyps are adenomatous!
- 2-3% chance of alimentary tract malignancy

A/W:
- increased risk of stomach, duodenum, colon CA (40% chance by age 40)
- increased risk of pancreatic, breast and genital CA
C/B:
- intussussception
- anemia
- SBO

Multiple hamartoma syndrome (MHS)
- AD
- Facial papules, oral papillomas, keratosis
- rectosigmoid polyps
- Breast: Fibrocystic (50%), ductal-type cancer (30%)
- Thyroid (65%): Adenomas, goiter, follicular cancer
- Clinically: Bird-like face, high arched palate

Juvenile Polyposis
- 25% AD, 75% sporadic
- rectosigmoid polyps
- classified into 3 subtypes
- Isolated juvenile polyps of childhood
- Juvenile polyposis of gastrointestinal tract
- Juvenile polyps of infancy

Cronkite-Canada
- sporadic
- Inflammatory polyps with ectodermal defects (skin, hair, nails)

Cowden disease
- AD
- mucocutaneous lesions
- thyroid abnormalities
- breast abnormalities
- older patients
- 100% have gastric and colonic polyps
- 50% have SB polyps
Hereditary non-polyposis colon CA syndrome (Lynch)
HNPCC = Lynch syndrome
- AD
- microsatellite instability
- colon CA risk
- Endometrial CA
- Breast CA
- Gastric CA
- Liver CA
- Biliary CA
- Brain CA
- Ovarian CA
- Ureteral CA
- Renal CA
Smooth submucosal gastric mass
GIST
Lipoma
Fibroma
Carcinoid
Neuroma
Malignant gastric ulcer
Thickened, "clubbed", fused folds radiating to ulcer crater

Interrupted radiation of folds

Bx of suspicious lesions
Gastric adenoCA
3rd most common GI maligancy after colorectal and pancreatic

A/W:
pernicious anemia
atrophic gastritis
subtotal gastrectomy (2-6 fold risk increase)
adenomatous polyp
Kruckenberg tumor
Intraperitoneal spread of gastric CA to ovary
Single ulcerated gastric mass
Gastric CA
Lymphoma
GIST
Mets
Ectopic pancreas
GE junction mass
Gastric CA
Lymphoma
Pseudotumor
- Fundoplication
Smooth gastric luminal narrowing
Scarring due to chronic gastritis

Granulomatous dz
- TB
- sarcoid

Inflammation
- Crohn disease ("ram's horn" deformity)
- eosinophilic gastritis

Scirrhous gastric CA
Marginal ulcer
A marginal or stomal ulcer is a perianastomotic ulcer developing after a gastroenterostomy.

- retained gastric antrum
- incomplete vagotomy
- smoking
- ZE
- hypercalcemia
Linitis plastica
Submucosal spread of tumor resulting in gastric narrowing, thickening and rigidity

DDx:
Scirrhous gastric CA
Breast mets
Corrosive ingestions
Lymphoma
Sarcoid
Afferent loop syndrome
Dilitation of the afferent loop (doudenum and jejunum) in Billroth II

-adhesions
- recurrent ulcer
- recurrent tumor

c/b
- stasis
- overgrowth
- B12 deficiency
- perforation
Post Billroth complications
Marginal ulcer

Recurrent gastric CA

Recurrent Ulcer

Duodenal stump dehiscence

Jejunogastric intussussception

Bezoar

Afferemt loop syndrome
Small outpouching along greater curvature near antrum
Gastric ulcer

Partial gastric diverticulum (changes in size and shape)
Gastric pneumatosis
Iatrogenic (gastrostomy)
Emphysematous gastritis
Obstruction
Emesis
Medications (steroids, chemo)
Fundal pseudotumor
Esophagus projecting into gastric fundus at GEJ
Doudenal fold thickening
Duodenitis
- H pylori

Brunner gland hyperplasia
- "cobblestone" appearance

Crohn disease

Infection
- Whipple
- sprue
- giardiasis

Lymphoma
Doudenal ulcers
Crater, pit, linear erosion

Rarely malignant as an isolated finding

May be multiple in ZE

Usually anterior within the bulb

Consider malignancy or ZE when located beyond ampulla of Vater

Can lead to sarring of the bulb ("cloverleaf" deformity, multichannel bulb)

C/B
bleeding
perforation (MC cause of nontraumatic perforated viscus)
obstruction
Focal duodenal thickening
Duodenitis

Pancreatitis

Cholecystitis

Annular pancreas

Adenocarcinoma (duodenum, pancreas)
Multiple duodenal erosions
Duodenitis (h pylori)

Crohn disease

Viral (CMV, herpes)

Medication (ASA, steroids, EtOH)

ZES
Periampullary mass on UGI
Ampullary adenoCA (duodenal, pancreatic, biliary)

Edema in ampulla (stone passage)

Adenomatous polyp
Duodenal mass
Mets (more likely than primary adenoCA)

AdenoCA

Lymphoma

GIST
Reverse 3 or Epsilon sign

Irregular narrowing, loss of mucosal folds in D2, with medial ulceration

Pancreatic CA
Multiple small duodenal filling defects
Ectopic gastric mucosa

Brunner gland hyperplasia

Nodular lymphoid hyperplasia

Polyposis syndrome (FAP (Garders, Cowden), Hamartomatous syndrome (Peutz-Jeger, Juvenile, Cronkite-Canada))
Polygonal nodular pattern in the duodenal bulb
Heterotopic gastric mucosa
- may protect against peptic ulcer disease

Lymphoid hyperplasia
- smaller and more nodular

Brunner gland hyperplasia
Submucosal duodenal mass
Enteric duplication cyst

Ectopic pancreas

Lipoma

GIST
Duodenal diverticulum
Us. arise from 2nd part of duodenum

May be multiple

May be confused with ulcer

Intraluminal diverticulum
- sac like fluid/contrast filled intraluminal mass
Linear compression of 3rd part of duodenum with proximal dilitation
SMA syndrome

Scleroderma

AAA

Pancreatitis

Neoplasm
Thickened pyloric channel, adult
Neoplasm

Adult hypertrophic stenosis

Pyloric torus defect
- triangular collection of contrast in pylorus
Aortoenteric fistula
Prior Aortic graft

Usually in setting of perigraft infect

Loss of fat plane surrounding graft

P/W GIB

CTA or aortography
GIST
cKit positive MC mesenchymal tumor of GI tract

May be benign or malignant
- size is a predictor

stomach > SB > esophagus > colorectal

Mets:
peritoneum
liver

Ca++ in 25%
Central necrosis common
FDG avid
LGIB
Submucosal SB mass or polypoid filling defect
GIST
Hemangioma
Lipoma
Mets
Lymphoma
Inflammatory fibroid polyp
- rare
- aka Vanek tumor, neurinoma, fibroma, infective granuloma, plasma cell granuloma
Inverted diverticulum
Multiple intraluminal SB masses
Polyposis syndrome
- FAP (Gardner, Turcot)
- Hamartomatous (Peutz-Jeghers (pedunculated cauliflower-like polyps), Multiple Hamartoma symdrome, Cowden, Juvenile polyposis, Cronkite-Canada)

Lymphoma

Mets

Hemangiomas/Hemangiomatosis

NF
SB Hemangioma
Usually jejunum

Increased in:
Turner syndrome
Blue nevus
HHT

C/B
LGIB
Intussussception
Obstruction
SB hemangiomatosis
Klippel Trenaunay Weber

Hemangiomatosis

Maffucci
Carcinoid (small bowel)
Derived from neural crest

40% within 2' of TI

30% multiple

Malignant transformation in tumor > 1 cm
- invasion into mesentery may cause desmoplatic reaction

UGI:
- intramural mass
- +/- ulceration
- kinking and tethering of SB loops
- partial obstruction
Enhancing mesenteric mass with mesenteric thickening and retraction
Carcinoid

Retractile mesenteritis

Mets
SB lymphoma
20% of SB malignant tumors

Multiple nodules
Infiltrating
- circumferential thickening
- increased luminal diameter
- +/- ulceration
Polypoid
Endo-exoenteric with excavation

Increased risk:
AIDS
Crohn
SLE
Sprue
Loss of normal fold pattern in SB loop w/o dilitation
Ischemia

Amyloidosis

Lymphoma
SB adenocarcinoma
MC duodenum > jejunum > ileum

Annular constricting mass

Increased risk:
Adult celiac disease
Regional enteritis
Multiple nodular SB filling defects
Mets
- melanoma
- breast
- Kaposi's

Lymphoma

Polyposis syndrome
Cavitating SB mass
GIST

Lymphoma

Mets
- colon CA
Diffuse mesenteric soft tissue masses with serosal implants
Serosal metastases

Primary peritoneal mesothelioma
Well circumscribed cystic lesion in mesentery/SB
Enteric duplication cyst
- may communicate with lume
- may contain any bowel mucosa

Mesenteric cyst
Blind loop obrstruction
Diverticulum
Cystic neoplasm
Ascariasis
Roundworm infection

Tropical climates

Barium seen in adult worms as linear SB filling defects
- +/- fold thickening
- +/- obstruction
Eggs ingested, hatch, larvae penetrate SB wall, travel to lungs intravenously, penetrate alveoli, climb bronchi, swallowed.
Thin SB folds with dilitation
Mechanical obstruction

Ileus
- post surgical
- medications (narcotics)

Scleroderma
- esophagus > duodenum > anorectal > SB > colon
- dilitation
- closely spaced thin folds
- duodenum identical to SMA syndrome
- "hidebound" appearance
- delayed transit time
- antimesenteric sacculations
- pneumatosis cystoides intestinalis

Sprue
- reversal of jejunal and ileal fold patterns
- "jejunization" of ileum, "Ilialization" of jejunum
- hypersecretion
SB obstruction
Adhesions
- post-operative
- post inflammatory

Hernias

Neoplasm

Intussusception

Stricture
- Crohn
- radiation
- ischemic

Volvulus
Thickened, straight SB folds
Segmental thickened straight SB folds:
- Ischemia
- hypoperfusion, arterial or venous obstruction
- healing, stricture or perforation
- normal radiograph or sentinal loop
- Radiation enteritis
- Hemorrhage
- Adjacent inflammation

Diffuse thickened, straight SB folds
- venous congestion
- hypoproteinemia
- cirrhosis
SB nodular thickened folds
Segmental nodular thickened SB folds
- Crohn
- Infection
- Giardiasis (proximal)
- majority asymptomatic
- diarrhea and malabsorption
- TB, Yersinia (distal)
- MAI (immunocompromised)
- Cryptosporidium (immunocompromised)
- Lymphoma
- Mets

Diffuse nodular thickened SB folds
- Whipple's (proximal)
- Lyphangectasia (cogenital or acquired)
- Nodular lymphoid hyperplasia (iGA or IgM deficiency)
- Polyposis syndromes
- Eosiniophilic gastroenteritis
- Amyloidosis
- Mastocytosis (skeletal sclerosis, dense bones, skin lesions)
- Mets
- Lymphoma
Whipple disease
Tropheryma whippelii

Proximal SB segmental and diffuse nodular thickening

Low density LAD

Sacroilitis

Hyperpigmentation
Low density paraaortic LAD
Whipple's

Celiac

Testicular mets

MAI

Lymphoma

Epidermoid carcinoma
Innumerable SB uniform nodules
Lymphoid hyperplasia
- usually distal SB proximal colon
- < 4 mm in size
- IgA or IgM deficiency
- associated parasitic infection
- increased risk ofgastric and colonic CA

Lymphoma

Mets
- hematogenous melanoma

Polyposis
Diffuse segmental featureless SB loops
Ischemia

Infection (enteritis)

Celiac disease

Acute radiation enteritis

GVHD

Amyloidosis
Circumferential thickened small bowel on CT
Ischemia

Crohn

Radiation enteritis

Infection

Lymphoma
Pneumatosis
Ischemia

Benign
- corticosteroids
- scleroderma
- COPD
- pneumatosis cystoides intestinalis
- GVHD
Sprue/Celiac disease
Non-tropical
- gluten sensitivity

Tropical sprue
- unknown cause

Ilealization of jejunum, jejunization of ileum

Hypersecretion with flocculation and segmentation of barium

DDx:
ZE
Caustic ingestion
Crohn

C/B
strictures
ulcers
lymphoma

A/W
Low density LN
Lymphoma
Adenocarcinoma
Dermatitis herpetiformis
IgA deficiency
Intussusception
"Coiled spring"

"Accordion"

Bowel within bowel

DDx:
Transient
Leadpoint
Celiac disease
SB TB
Crohn mimic
- ulcerations
- luminal narrowing
- multiple segmental involvement
- wall thickening
- fistula formation
- mesenteric mass
- cecal spasm
- ileocecal valve incompetence
- mesenteric adenopathy
UC
Idiopathic inflammatory disease

- continuous involvement, distal to proximal, starting at rectum
- multiple ulcerations
- GRANULAR mucosa
- FEATURELESS bowel loops
- LEAD PIPE

Increased risk of colorectal adenoCA (after 10 years of disease)
- smooth or tapered narrowing

A/W:
sacroiliitis
iritis
PSC
cholangioCA
colorect adenoCA
pyoderma gangrenosum
erythema nodosum
-
Toxic megacolon
2/2 severe acute inflammation with adynamic ileus

UC
C Diff (infectious colitis)
Crohn

Findings
- Diffusely distended colon
- Diffuse wall thickening
- Mucosal nodularity (UC, 2/2 pseudopolyps)

C/B:
Perforation

Contraindication to:
Colonoscopy
BE

DDx:
Adynamic ileus
Distal colonic obstruction
Clustered nodular mucosa - colon
Inflammatory polyps
- UC

Adenocarcinoma

Lymphoma

Dysplasia
- UC
Smooth or irregular colonic in the setting of UC
Carcinoma

Benign stricture
Ahaustral shortened colon
UC

Cathartic abuse
Colonic distension, wall thickening, thumbprinting
Pseudomembranous colitis

UC / Crohn

Infectious colitis

Ischemic colitis
Colonic diffuse nodular mucosal elevations +/- umbilication
Prominent lymphoid pattern

Early Crohn disease

Polyposis
Colon - asymmetric aphthous ulcers
Crohn disease

Infectious colitis
- Yersinia
- Amebiasis
Crohn colitis
Segmental skip lesions

- Linear and transverse ulcers
- "collar-button" ulcers
- "thorn-like" ulcers (deep penetrating)
- inflammatory polyps
- strictures
- fistulae
Barium enema - short segment colonic narrowing with fold thickening and loss of haustration
Diverticultitis

Carcinoma

Serosal mets
Diverticulitis
Infection of diverticula

Focal microperforation of veins

Ddx:
carcinoma
crohn

c/b:
peritoneal Abscess
Sepsis
Hepatic abscess
Mesenteric venous thrombosis
Fistulae
Adhesions

Imaging:
- f/u colonoscopy or CT after resolution to r/o carcinoma
Giant sigmoid diverticulum
Giant sigmoid diverticulum

Results from underlying diverticulosis

May have ball valve effect leading to enlargement
Can be confused with abscess, look for thin regular wall.
Radiation colitis
Often in setting of pelvic malignancy

2/2 to occlusive arteritis

Acute:
Fold thickening
Thumbprinting
Luminal narrowing

Chronic (2 years post tx)
Gradual luminal narrowing
Stricture
Adhesions
Loss of haustration
Pseudomembranous colitis
C diff

Yellowish plaques covering the mucosa

May be segmental or continuous

Nonspecific acute appearance on CT and BE
- fold thickening
- wall thickening
- thumbprinting
- pericolic edema
- vascular congestion
Amebiasis
Protozoan infection by ingestion
Trophozoites invade bowel

Usually cecum and sigmoid, less common TI

Multifocal confluent ulcerations
Secondary bacterial invasion

Findings:
- granular mucosa
- ulcerations
- non-distensibility
- wall thickening
- hemorrhage
- mass (ameboma)
- may mimic UC

C/B:
- hepatic amebic abscess
- abscess rupture and dissemination
- strictures (long term)
- fistula
- perforation
- peritonitis
Colon cutoff sign
Plain film sign denotes acute pancreatitis

Gaseous distension of the right and proximal transverse colon, narrowing and fold thickening in splenic flexure and left colon due to adjacent pancreatic effusion/inflamation
Colonic pseudodiverticula
Sacculations along the antimesenteric colonic wall

DDx:
Crohn disease
Scleroderma
Mastocytosis
Systemic abnormal proliferation and deposition of mast cells

Skeletal sclerosis

GI:
Infiltration of SB > colon
Hypersecretion
Wall edema

Focal wall thickening
Distortion
Rarely, fine nodular mucosal pattern
Epiploic appendigitis
Ddx:

Mesenteric panniculitis (usually root of mesentery)
Omental infarction (more diffuse, usually right hemiabdomen)
Colonic polyps
Adenomatous
- tubular
- tubulovollous
- villous (caulifower, rasperry, frondlike appearance)
- Malignant potential villous > tubulovillous > tubular
- Malignancy risk also increases with size
- <1 cm = <1%
- 1-2 cm = 10%
- > 2 cm = 40%

Inflammatory
- usually < 1 cm
- no malignant potential

Hamartomatous
- Peutz-Jeghers
- Juvenile polyposis

Postinflammatory
- in setting of healing Crohn disease or UC
- tiny filiform polyps

Pseudopolyp
- stool in a diverticula projecting into lumen
- inverted diverticulum
Submucosal colonic mass
Lipoma
- soft
- deformable

GIST
- rare
- MC in rectum if in colon

Endometriosis

Serosal mets
- tethering
pneumatosis cystoides intestinalis
COPD

Peptic ulcer

Pyloric stenosis

Bypass surgery

Transplant surgery
Primary tumors with local extension to involve colon
Prostate -> anterior rectun

Ovarian -> anywhere

Renal -> ascending or descending

Gastric, pancreatic -> transverse
Colonic lymphoma
3 appearances:

Polypoid mass

Annular constricting lesion

Aneurysmal dilitation with mucosal ulcerations
Colitis cystica profunda
Multiple rounded mucin-filled cysts within the wall of recto-sigmoid

Unknown cause

P/W:
rectal bleeding
pain
rectal prolapse

DDx:
villous adenoma
Appendiceal mucocele
Obstructed mucous-filled appendix

Fluid filled dilated appendix
Filling defect in cecum on BE
May have peripheral Ca++

with or w/o:
Mucinous hyperplasia
Mucinous cystadenoma
Mucinous Cystadenocarcinoma
pneumatosis cystoides coli
Idiopathic gas filled cysts within bowel wall

Unknown cause

A/W
Collagen vascular disease
ischemia
DM
Trauma
Mechanical colonic obstruction
MC underlying colorectal CA

Diverticulitis

Volvulus

Extracolonic neoplasm

fecal impaction

Hernia/adhesion (rare)
Sigmoid volvulus
Older patients

Redundent mesentary

Hx of constipation

Surgery versus decompression via transrectal intubation
Cecal ileus
Abnormally positioned air filled cecum + air filled distal colon

Cecum rotates to nondependent position and gradually distends with gas

High risk for perforation after 2-3 days

Tx:
rectal tubes and cathartics
if failure, then surgical or endoscopic decompression
Rectocele
Bulge of anterior rectal wall into the vagina

Due to pelvic floor weakness

More common in females
- multiple vaginal deliveries
- hysterectomy
Enterocele
Abnormal descent of peritoneal sac containing bowl into the pouch of douglas

Due to pelvic floor weakness

More common in females
- multiple vaginal deliveries
- hysterectomy
Solitary rectal ulcer syndrome
Found in patients with chronic defecation problems
- i.e. transient intussusception
- spastic pelvic floor syndrome

Findings:
- thickened rectal wall
- mucosal granularity
- stricture
- ulceration

DDx:
Rectal CA
Mets
Loss of haustrations, right colonic shortening, inconsistent luminal constrictions
Crohn colitis
UC
Chronic cathatic use
- senna
- castor oil
- cascara
Dysplastic liver nodules
High T1W may indicate fat or copper
Liver - High T2W, low T1W, capsular retraction
Cirrhosis with HCC
Cholangiocarcinoma
Confluent hepatic cirrhosis
- wedge shaped region extending from portahepatis to capsule
- usually anterior right lobe
- no venous invasion
- no growth
Hemochromatosis
Primary
- AR
- liver, pancreas, heart low signal T2W, spleen normal
- cirrhosis
- HCC
- arthropathy
- heart failure
- screen w/ serum ferritin and transferrin

Secondary (hemosiderosis)
- transfusion, diet, increased absorption
- liver, spleen, BM low signal T2W, pancreas nl
Diffuse low attenuation liver with multiple masses
von Gierke glycogen storage disease
- Liver diffusely fatty due to hormones
- increased hepatic adenomas w/ risk for HCC

Fatty liver with mets

Fatty liver with multifocal HCC
Heterogeneous hepatic enhancement with caudate sparing
Budd-Chiari
- primary = membranous hepatic venous obstruction
- a/w HCC
- Israel, South Africa, The Orient
- secondary
- central or sublobular venous occlusion
- central due to hypercoagulable state
- sublobular due to drugs
- "spider web" venogram = sublobular

Hepatic venous congestion - cardiogenic

PV occlusion
Hyperattenuating liver
Hemochromatosis

Amiodarone

glycogen storage disease

Gold therapy

thorium dioxide therapy
Hepatic radiation injury
12 Gy acutely, 40 Gy cumulative

Sharply demarcated hypodense region

Low T1W, high T2W

Becomes fatty infiltrated with age
Rim enhancing cystic liver lesion
Abscess
- diverticulosis, surgery, cholecystitis, appendicitis, acending infection, hematogenous spread
- e coli adults
- staph aureus children

Cystic HCC

Cystic mets

Biliary cystadenoma
Amebic hepatic abscess
Fluid density with hypodense ring

Entamoeba histolytica

Cecal and bowel infection with trophozoites

Hematogenous to liver

Anchovy paste internal contents
Hepatic echinococcal disease
Echinococcus granulosus or multilocularis

- dogs and sheep for e. granulosus
- Daughter cysts within a larger cyst
- Multiple cysts with septations or somewhat ill-defined margins
- peripheral ca++
- anaphylaxis
- percutaneous tx

Ddx:
Pyogenic abscess
Biliary cystadenoma
Solid cystic mass in liver
Infected cyst
Cystic HCC
Hemorrhagic cyst
Cystic mets
von Myerberg complexes
Subcentimeter hypodensities in the liver.

+/- peripheral enhancement

Dilated biliary radicals in fibrous stroma in the liver.
Peribiliary cysts
Multiple tiny cysts of differing sizes lining the intrahepatic biliary system, or occuring as clusters or discreet cysts

Usually asymptomatic w/o intrahepatic biliary dilitation

A/W:
Cirrhosis
PHTN
OLT
cholangitis
ADPKD
Hepatic candidiasis
Often culture negative

Immuncompromised host

CT:
- multiple small hypoattenuating masses
- +/- calcifications
- periportal delayed enhancement

US:
- "Bulls-eye" pattern (central hyper, outer hypo)
- "Wheel within a wheel" central hypo, inner hyper, outer hypo
- uniformly hypo liver 2/2 fibrosis
- echogenic liver 2/2 scar formation
Giant hepatic hemangioma
> 4 cm (some say > 10cm)

Central fibrosis may prohibit uniform enhancement

A/W:
Mass effect
Kasabach-Merritt
Thrombosis
Rupture
Atypical hemangioma
5% of population has incidental hemangiomas

15% of hemangiomas are atypical
- "flash filling" early arterial enhancement with washout
- central centrifugal filling

33% atypical on US
- inhomogeneous echogenicity
- iso or hypoechoic mass with hyperechoic rim
- hypoechoic in the setting of fatty liver
FNH
2nd most common hepatic tumor after hemangioma

Comprising hepatocytes, Kupffer cells, bile ducts

Incidental mass in 30-40 yo female MC

Multiple in 20%
- a/w with vascular malformations, liver hemangiomas in 25%


Isodense to liver on precontrast
"Lightbulb enhancement"
Central scar
Stellate fibrous septae
May have large peripheral draining veins
Delayed normalization with surrounding parenchyma
Displacement of vascular structures without invasion

US:
- usually isoechoic
- increased internal vascularity

MR:
- isointense to surrounding liver on T1W and T2W, though often atypical appearance
- central scar typically low T1W, high T2W

Nucs:
2/3 of FNH will be + on sulfur colloid (greater than or equal activity compared to BG liver)
Fibrolamellar CA
Malignant hepatic neoplasm

Similar appearance to FNH
- less homogeneous enhancement
- large mass, central scar, Ca++
- angioinvasion
- lymphadenopathy

Outcomes similar to HCC
Hepatic adenoma
Benign primary liver tumor composed of cords of hepatocytes

Young women

A/W OCP

Multipe in 30%:
- OCP
- glycogen storage disease (von Gierke) (with risk of malignant degeneration)
- anabolic steroids
- familial DM

May be large at presentation with propensity for hemorrhage

CT:
Encapsulated mass
Heterogeneous mosaic enhancement
Capsular enhancement

MR:
Internal heterogeneous T1W may be 2/2 fat or hemorrhage

No real imaging differentiation from HCC

Tx:
Stop OCP and reimage
Surgical removal
Biliary cystadenoma/cystadenocarcinoma
Comprised of biliary duct precursors lined by columnar epithelium

Premalignant lesion

MC middle aged white women

No reliable differentiation from cystadenocarcinoma

CT:
- resembles benign complicated cyst
- large encapsulated cystic mass
- internal enhancing septae (not peripherally arranged as in hydatid disease)
- Ca++ (favors cystadenocarcinoma)

Tx:
surgical removal
Hepatic angiomyolipoma
Rare benign lesion containing fat, vessels and smooth muscle.

FAT MAY BE <5% OF MASS

Found in 5% of patients with tuberous sclerosis

Do not tend to bleed

Solitary or multiple

CT:
- 1-20 cm
- well circumscribed fat-containing lesions

US:
- hyperechoic component = fat (may be <5% of mass)
Fat containing liver mass
Angiomyolipoma

Lipoma

Adenoma

HCC (40% contain fat)

Dysplastic nodule

Liposarcoma (metastatic)
Cirrhosis - dysplastic nodule, regenerating nodule
Regenerative nodule:
- healing liver in a cirrhotic BG
- usually <2 cm
- hyperdense to BG on NECT
- not seen on CECT or T1W
- isointense on T1W and T2W

Dysplastic nodule:
- has some amount of atypia
- can harbor, lead to HCC
- may be high T1W (2/2 internal fat or Cu++)
- usually > 2 cm
- DARK ON T2W
- Isointense on T2W and CE
- doesn't enhance
HCC
Risks:
EtOH
HBV/HCV
Aflatoxin
NASH
Hemochromatosis
von Gierke
Thorotrast

May be:
focal
multifocal
diffuse

Typical appearance
- early arterial enhancement and washout
- capsule
- internal fat
- mosaic appearance (multicompartmentalization)
- Ca++ in 10%

May have fibrous capsule
- delayed enhancement
- ddx adenoma

May contain fat
- ddx adenoma

Atypical appearance is common
- look for secondary signs
- vascular invasion
- cirrhosis
- THAD
- cystic (mimics abscess)
Cholangiocarcinoma
Arising from biliary epithelium

Risk factors:
PSC
Choledochal cyst
Familial polyposis
Congenital hepatic fibrosis
Opisthorchis sinensis
Thorotrast

Intraductal variant
- presents as polypoid intraluminal filling defect
- secretes mucin similar to IPMN in pancreas
- better prognosis
Hepatic lymphoma
Usually secondary, primary extremely rare

- multiple small hypodensities
- multiple small hypoechoic lesions
- lymphadenopathy

ddx:
Mets
Candidiasis
Epithelioid hemangioendothelioma
Confluent hypodense masses with peripheral enhancement that typically originate peripherally within the liver and merge confluently

+/- capular retraction
hypovascular

ddx
HCC
mets
Hyperdense material in spleen, liver and abdominal LN
Thorium dioxide (thorotrast)

A/W:
HCC
cholangioCA
angioCA
Cirrhosis
Lung CA
Ca++ liver mets
Mucinous colon
Hypervascular liver mets
Carcinoid

Pheochromocytoma

Islet cell

Thyroid

Renal

Choriocarcinoma

Melanoma

US:
hyperechoic with shadowing
US hepatic mass with hypoechoic halo
Mets

HCC

adenoma
Pseudocirrhosis
Breast CA undergoing chemotherapy

Nodular liver contour
Caudate hypertrophy
Capsular retraction overlying subcapsular mets
Periportal enhancement
Granulomatous disease:

Infection:
- TB
- Schistosomiasis
- Histo, blasto, crypto
- Toxo

Sarcoid

Drugs
- quinidine
- allopurinol

PBC
PSC
Usually in young men with UC

Chronic progression with 12 year median survival

Cholangitis -> periportal hepatitis -> septal fibrosis -> bridging necrosis -> cirrhosis

C/B:
cholangiocarcinoma
- dominant high-grade strictures should be treated with suspicion
Findings. Intra/extrahepatic biliary:
- band strictures
- beaded bile ducts
- intrahepatic biliary pruning
- mural irregularity
- diverticular outpouchings
- long segment strictures may be seen
- 20% will only have intrahepatic findings

DDx:
AIDS cholangiopathy
PBC
Autoimmune cholangitis

A/W:
- antimitochondrial antibodies
- RA
- Sjogren
- Hashimoto's

Findings:
- cirrhosis
- intrahepatic biliary crowding, pruning, tortuosity

Ddx:
PSC
Cirrhosis NOS
AIDS cholangiopathy
AIDS related cholangitis 2/2 CMV or cryptosporidium

Intra/extrahepatic strictures +/- papillary stenosis

May appear identical to PSC

DDx:
- ascending cholangitis
- PSC
Oriental cholangitis aka Recurrent pyogenic cholangitis
Infectious cholangitis (chlonorchis, ascariasis)

Dilated intra/extrahepatic ducts with low density filling defects
Biliary strictures
Localized segmental stricture with upstream dilitation in lateral left or posterior right lobes

US:
- intra/extrahepatic dilitation
- filling defects
- periportal echogenicity
- gallstones
- segmental lobar atrophy
Ascending cholangitis
Biliary infection usually 2/2 stasis

E coli most common pathogen

Increased risk with choledochojujenostomy

- mural irregularity
- strictures

C/B intrahepatic abscesses
- saccular collections in communication with the biliary tree
Choledocholithiasis
CT:
Target sign:
- rim of fluid density surrounding filling defect in CBD

Crescent sign:
- crescent of fluid seen eccentrically in CBD adjacent to filling defect

DDx:
Pseudocalculus
- spasm of the sphincter of Oddi
- no inferior meniscus
- give glucagon or wait
Distal CBD obstruction
Stone

Mass

Papillary stenosis
- inflammation and fibrosis
- may be due to pancreatitis, surgery, choledocholithiasis

Spasm of the sphincter of Oddi

Pancreatitis

Pseudocalculus

AIDS cholangiopathy
Proximal CBD obstruction
Extrinsic compression (LAD MC)

Mass

Mirizzi's

PSC

CholangioCA
Multiple intraductal biliary filling defects
Mucous plugs

Sludgeballs/stones

Caroli's

Recurrent pyogenic cholangitis

Hemorrhage

CholangioCA

Biliary papillomatosis
- rare
- can progress to adenoCA
Caroli's disease
100x Risk of HCC
Hyperenhancing hepatic lesions
HCC

Hypervascular mets

Hemangioma

FNH

Adenoma

Hyperplastic regenerative nodules in the setting of Budd-Chiari (multiple)
Acute pancreatitis causes
Gallstones

EtOH

Drugs
- steroids
- AZT
- diuretics

ERCP

Hyperlipidemia

Hypercalcemia

Trauma

Divisum

Staging system Balthazar
Chronic pancreatitis
EtOH

Hyperlipidemia

Hypercalcemia

Trauma

Familial

Divisum
Autoimmune pancreatitis
Autoimmune pancreatitis

Elevated IgG

Diffuse "sausage" pancreas
Focal inflammation w/ upstream ductal dilitation

Mild clinical course

Tx:
steroids
Gastrinoma
Usually small < 2 cm

May be multiple

Located in gastrinoma triangle
- junction of pancreatic head and body
- ampulla of vater
- cystic duct insertion

75% malignant

- Hypoechoic on US
- Hot on pentatreotide
- liver mets are hyperechoic
Key clinical symptoms somatostatinoma
Diarrhea, steatorrhea, weight loss
Key clinical symptoms VIPoma
WDHA syndrome: watery diarrhea, hypokalemia, achlorhydria
Key clinical symptoms glucagonoma
Necrolytic erythema migrans, diarrhea, diabetes, glossitis
Key clinical symptoms gastrinoma
Abdominal pain, diarrhea, vomiting, hematemesis, melena, weight loss
Key clinical symptoms Insulinoma
Hypoglycemia: sweating, trembling, palpitations, nervousness
MEN type I
PPP (in order of likelihood)

Parathyroid

Pancreatic tumors
- islet cell tumors, multiple
- small, multiple, and biologically less aggressive

Pituitary adenomas

+
Facial angiofibromas
Collagenoma
Adrenal cortical tumor
Lipoma
Foregut carcinoid
MEN type 2a
MPP (in order of likelihood)

Medullary thyroid carcinoma

Pheochromocytoma

Pituitary adenoma
MEN 2b
MP+MMMG

Medullary thyroid carcinoma

Pheochromocytoma

+
- Mucosal neuromas
- marfanoid habitus
- megcolon
- gangliomatosis, intestinal
Non-hyperfunctioning islet cell tumor
Large size

Hyperenhancement

Ca++

Necrosis
Complex cystic mass in the pancreas
Mucinous cystic

AdenoCA

Cystic islet cell

Cystic mets
Causes of SBO
Adhesions
Malignancy
Crohn
Hernia
Intussusception
Causes of LBO
ColorectalCA
Volvulus
Intussusception
Hernia
Cystic pancreatic masses
Mucinous cystic pancreatic tumor
- middle aged women
- mucinous cystadenoma -> premalignant
- mucinous cystadenocarcinoma -> malignant
- peripheral Ca++
- <6 cysts, > 2 cm each

Cystic/necrotic adenoCA

Serous cystadenoma
- usually benign
- innumerable microcysts with thin septae
- "honeycombed"
- > 6 cysts, < 2 cm each
- central Ca++
- macrosytic variant more like mucinous cystic pancreatic tumor
- resection if symptomatic

IPMN

Solid and papillary epithelial neoplas
- young black women
- tail
- may have Ca++
- 4% mets to liver

Cystic islet cell neoplasm
Solid pancreatic mass
Adenocarcinoma

Islet cell
- hyperenhancing

Mets
- melanoma
- RCC
- colon

Lymphoma

SPEN

Acinar
- mixed attenuation
- older men
- no evascular encasement
- metastatic fat necrosis

Anaplastic
VHL
Renal cysts
- RCC

Pancreatic cysts
- serous cystadenoma
- islet cell tumors


Pheochromocytoma

Hemangioblastomas

Papillary cystadenoma of the epidydimus
Multiple pancreatic cysts
ADPKD

VHL
Multiple punctate pancreatic calcifications
Chronic pancreatitis
- ductal Ca++
- atrophy
- ductal dilitation

Histoplasmosis

Sarcoidosis
Splenic Target lesions
Metastatic disease

Lymphoma

Candia abscesses

TB
Multiple small T2 hyperintense lesions in the spleen
Mets

Lymphoma

Candidiasis

TB
Rim calcified splenic cysts
Hydatid disease

Traumatic cysts (false cysts)

Epidermoid cysts (true cysts)

Aneurysm

Mets
Tiny calcific densities in the spleen
Histoplasmosis

Candidiasis

Sarcoid

PJP

Treated lymphoma

Treated mets
Innumerable hypodensities in spleen and liver
Mets

Lymphoma
- in 1/3 of patients with lymphoma
- splenomegaly not a dependable sign of involvement
- 4 patterns: solitary mass, multiple masses, miliary, splenomegaly

Candidiasis

Sarcoid

TB
Iso- to hypodense solid splenic lesion
Mets

Lymphoma

Hemangioma

Hamartoma
- red pulp
- white pulp
- mixed
- varied appearance
- no encapsulated
- +/- scars, cysts, Ca++
Well-defined heterogeneously enhancing splenic mass
Mets

Lymphoma

Hemangioma

Inflammatory pseudotumor
- occasional central scar

TB

Hemangioma
Multiple small T2 hypointensities in the spleen
Gamna-Gandy bodies
- siderotic nodules

Due to focal hemorrhages

A/W:
- portal hypotension
Heterogeneous hypoechoic mass in spleen
Mets

Lymphoma

Infarct

Abscess
Multiple nodular mesenteric masses
Carcinomatosis

Splenosis
- sulfur colloid scan

Endometriosis

Primary peritoneal Mesothelioma
- asbestos exposure

TB
Multiloculated cystic peritoneal mass
Pseudomyxoma peritonei

Loculated ascites

Cystic primary peritoneal mesothelioma
- not associated with asbestos exposure

Tuberous peritonitis

Lymphatic malformation
Spiculated mesenteric tumor
Carcinoid
- starburst appearance
- 70% a/w ca++
- adjacent bowel wall thickening
- radiating strands

Retractile mesenteritis
- aka sclerosing mesenteritis
- Ca++ common

Desmoid tumor
- Gardener syndrome
- benign but locally aggressive

Mets
Primary soft tissue mesenteric tumors
Desmoid

GIST

Hemangioma

Neurofibroma

Lipoma
3 phase pancreas
Art 20-25
Panc parench 40-45
PV 60-70
Grading acute pancreatitis
Balthasar

A: Nl with lab abnormalities

B: enlarged heterogeneous no peripanc Inflammation

C: peripancreatic inflammation

D: single fluid collection

E: 2 or more fluid collections and/or gas
Islet cell tumor
85% Functioning
Insulinoma
- MC
- 90% benign

Gastrinoma
- 2nd MC
- 75% malignant

15% Non-functioning
- 3rd MC
- 80-90% malignant
Low density mesenteric LN
Treated lymphoma

Necrotic mets

TB/MAI

Histo

Whipple disease

Cavitary mesenteric lymph node syndrome
- occurs in setting of celiac disease
- poor prognosis, increased risk of intestinal hemorrhage and sepsis
Mesenteric cystic mass
Enteric duplication cyst

Abscess

Ovarian cyst

Mesenteric cyst
- rare
- uni- or multilocular
- containing chyle, serous, hemorrhagic fluid
- c/b obstruction, volvulus, infection
- resection

Lymphatic malformation
Richter hernia
Herniation of one wall of a bowel loop
- obstruction rare
- may cause ischemia
External abdominal hernias
Inguinal
- direct
- indirect (MC)

Obturator
- old women
- highest mortality
- between obterator internus and pectineus

Femoral
- medial to femoral vein

Ventral

Lateral ventral

Spigelian
- along linea semilunaris, just lateral to rectus abdominus
- due to increased abdominal pressure
Internal abdominal hernias
Paraduodenal hernia
- 50% of internal hernias
- Left (75%) -> through mesenteric defect in IMA mesentery
- bowel seen lateral to 4th part of duodenum
- Right (25%) -> through mesenteric defect in SMA mesentery
- bowel seen in LUQ, encapsulated in a sac

Foramen of Winslow hernia
- displaces stomach anteriorly and to left
- displaces duodenum to left
Pneumoperitoneum
Post-surgical
- should decrease over 4-5 days

Bowel perforation
- MC duodenal or gastric ulcer

Trauma

Gas containing organisms
Misty mesentery
Edema
- portal HTN
- cardiogenic
- arterial or venous occlusion
- hypoalbuminemai

Inflammation
- diverticulitis
- appendicitis
- pancreatitis
- panniculitis

Neoplasm
- lymphoma