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216 Cards in this Set
- Front
- Back
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Esophagus - smooth linear thickened folds
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Reflux esophagitis
Esophageal varices |
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Esophagram language
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Mucosa
- nodularity Ulcers - flat - deep - linear - halo of edema Folds - thickened - nodular - transverse (scarring) Associated findings - lack of distensibility - buckling (due to scarring) |
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Barrett esophagus
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Adenomatous metaplasia
10% risk of malignant transformation |
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Esophagitis
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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 |
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Esophageal anatomy
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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 |
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Esophageal stricture
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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 |
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Short segment esophageal stricture
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Chronic reflux esophagitis
Caustic ingestion related stricture Barrett esophagitis (upper to mid esophagus as gastric mucosa is resistant to strictutre) Pill esophagitis |
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Long segment espohageal stricture
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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 |
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Diffuse esophageal spasm
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"rosary bead" or "corkscrew" appearance
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Dilated esophagus with distal beaking
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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 |
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Submucosal esophageal mass
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GIST (MC, more than 50% of B9 esophageal tumors)
Neuroma Fibroma Lipoma Hemangioma Duplication cyst |
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Lobulated distal esophageal filling defect
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Adenomatous polyp
- arising in Barrett's Papilloma Inflammatory esophogastric polyp - enlarged gastric folds that projects into the stomach |
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Pedunculated endoluminal esophageal mass
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Fibrovascular polyp
Carcinosarcoma (spindle cell sarcoma) Adenomatous polyp Food bolus - tx effervescent crystals or muscle relaxants |
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Bulky polypoid esophageal mass
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Adenocarcinoma
Spindle cell carcinoma (carcinosarcoma) Lymphoma |
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Mets to the esophagus
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Usually direct extension from metastatic mediastinal lymph nodes
Gastric Lung Breast |
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Shallow indentations along the esophageal wall
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Ectopic gastric mucosa
- shallow shelf like indentations - usually cervical esophagus Blistering skin diseases Caustic ingestion |
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Lateral pharyngeal pouches
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Small symmetric lateral outpouching in the hypopharynx through thyrohyoid membrane
May be increased in glassblowers, windplayers, elderly |
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Zenker diverticulum
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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 |
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Killian-Jamieson diverticulum
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Diverticulum from anterolateral cervical esophagus
Caudad to cricopharyngeus at level of cricoid cartilage May be bilateral |
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Traction vs. pulsion esophageal diverticulum
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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 |
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Intramural esophageal pseudodiverticulosis
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Multiple tiny outpouchings along esophagus due to dilated submucosal glands
May be 2/2 chronic reflux esophagitis - often a/w stricture |
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Esophageal contractions
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Primary = initiated by swallow
Secondary = initiated by distension or bolus Tertiary = non-propulsive - increase with age Ddx: - vigorous achalasia - esophageal spasm |
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Esophageal spasm
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"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 |
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Schatzki ring
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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 |
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Esophageal web
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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 |
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Esophageal hernias
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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 |
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Esophageal perforation
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Iatrogenic
Boerhaeve's Trauma Esophageal CA |
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Diffuse thickened gastric folds
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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 |
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Multiple small ulcerations/erosions with peripheral edema, along rugae, within the gastric mucosa on UGI
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Acute erosive gastritis:
Meds (ASA, NSAIDS) - EtOH - chemo - H. pylori IBD with aphthous ulcers - Chrohn Infectious gastritis - viral - fungal |
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UGI: single small central ulceration with surrounding edema
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Ectopic pancreas
GIST Mets |
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Benign gastric ulcer
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- 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 |
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Zollinger-Ellison
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Gastrinoma
Thickened gastric folds Gastric erosions and ulcers Dilated duodenum Thickened proximal small bowel Tx: Imaging with pentatreotide or CT Resection or H2 blockade |
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Eosinophilic esophagitis
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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 |
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Gastric polyps
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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 |
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Familial adenomatous polyposis (FAP)
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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 |
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Gardner syndrome
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Variant of FAP
- AD - gastric hyperplastic polyps - GI adenomas - 100% chance of colorectal CA DOPE + Desmoid tumors + Osteomas + Papillary thyroid CA + Epidermoid cysts |
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Hamartomatous polyp syndromes
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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 |
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Hereditary non-polyposis colon CA syndrome (Lynch)
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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 |
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Smooth submucosal gastric mass
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GIST
Lipoma Fibroma Carcinoid Neuroma |
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Malignant gastric ulcer
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Thickened, "clubbed", fused folds radiating to ulcer crater
Interrupted radiation of folds Bx of suspicious lesions |
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Gastric adenoCA
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3rd most common GI maligancy after colorectal and pancreatic
A/W: pernicious anemia atrophic gastritis subtotal gastrectomy (2-6 fold risk increase) adenomatous polyp |
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Kruckenberg tumor
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Intraperitoneal spread of gastric CA to ovary
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Single ulcerated gastric mass
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Gastric CA
Lymphoma GIST Mets Ectopic pancreas |
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GE junction mass
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Gastric CA
Lymphoma Pseudotumor - Fundoplication |
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Smooth gastric luminal narrowing
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Scarring due to chronic gastritis
Granulomatous dz - TB - sarcoid Inflammation - Crohn disease ("ram's horn" deformity) - eosinophilic gastritis Scirrhous gastric CA |
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Marginal ulcer
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A marginal or stomal ulcer is a perianastomotic ulcer developing after a gastroenterostomy.
- retained gastric antrum - incomplete vagotomy - smoking - ZE - hypercalcemia |
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Linitis plastica
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Submucosal spread of tumor resulting in gastric narrowing, thickening and rigidity
DDx: Scirrhous gastric CA Breast mets Corrosive ingestions Lymphoma Sarcoid |
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Afferent loop syndrome
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Dilitation of the afferent loop (doudenum and jejunum) in Billroth II
-adhesions - recurrent ulcer - recurrent tumor c/b - stasis - overgrowth - B12 deficiency - perforation |
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Post Billroth complications
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Marginal ulcer
Recurrent gastric CA Recurrent Ulcer Duodenal stump dehiscence Jejunogastric intussussception Bezoar Afferemt loop syndrome |
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Small outpouching along greater curvature near antrum
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Gastric ulcer
Partial gastric diverticulum (changes in size and shape) |
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Gastric pneumatosis
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Iatrogenic (gastrostomy)
Emphysematous gastritis Obstruction Emesis Medications (steroids, chemo) |
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Fundal pseudotumor
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Esophagus projecting into gastric fundus at GEJ
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Doudenal fold thickening
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Duodenitis
- H pylori Brunner gland hyperplasia - "cobblestone" appearance Crohn disease Infection - Whipple - sprue - giardiasis Lymphoma |
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Doudenal ulcers
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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 |
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Focal duodenal thickening
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Duodenitis
Pancreatitis Cholecystitis Annular pancreas Adenocarcinoma (duodenum, pancreas) |
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Multiple duodenal erosions
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Duodenitis (h pylori)
Crohn disease Viral (CMV, herpes) Medication (ASA, steroids, EtOH) ZES |
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Periampullary mass on UGI
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Ampullary adenoCA (duodenal, pancreatic, biliary)
Edema in ampulla (stone passage) Adenomatous polyp |
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Duodenal mass
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Mets (more likely than primary adenoCA)
AdenoCA Lymphoma GIST |
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Reverse 3 or Epsilon sign
Irregular narrowing, loss of mucosal folds in D2, with medial ulceration Pancreatic CA |
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Multiple small duodenal filling defects
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Ectopic gastric mucosa
Brunner gland hyperplasia Nodular lymphoid hyperplasia Polyposis syndrome (FAP (Garders, Cowden), Hamartomatous syndrome (Peutz-Jeger, Juvenile, Cronkite-Canada)) |
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Polygonal nodular pattern in the duodenal bulb
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Heterotopic gastric mucosa
- may protect against peptic ulcer disease Lymphoid hyperplasia - smaller and more nodular Brunner gland hyperplasia |
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Submucosal duodenal mass
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Enteric duplication cyst
Ectopic pancreas Lipoma GIST |
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Duodenal diverticulum
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Us. arise from 2nd part of duodenum
May be multiple May be confused with ulcer Intraluminal diverticulum - sac like fluid/contrast filled intraluminal mass |
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Linear compression of 3rd part of duodenum with proximal dilitation
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SMA syndrome
Scleroderma AAA Pancreatitis Neoplasm |
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Thickened pyloric channel, adult
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Neoplasm
Adult hypertrophic stenosis Pyloric torus defect - triangular collection of contrast in pylorus |
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Aortoenteric fistula
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Prior Aortic graft
Usually in setting of perigraft infect Loss of fat plane surrounding graft P/W GIB CTA or aortography |
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GIST
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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 |
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Submucosal SB mass or polypoid filling defect
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GIST
Hemangioma Lipoma Mets Lymphoma Inflammatory fibroid polyp - rare - aka Vanek tumor, neurinoma, fibroma, infective granuloma, plasma cell granuloma Inverted diverticulum |
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Multiple intraluminal SB masses
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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 |
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SB Hemangioma
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Usually jejunum
Increased in: Turner syndrome Blue nevus HHT C/B LGIB Intussussception Obstruction |
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SB hemangiomatosis
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Klippel Trenaunay Weber
Hemangiomatosis Maffucci |
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Carcinoid (small bowel)
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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 |
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Enhancing mesenteric mass with mesenteric thickening and retraction
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Carcinoid
Retractile mesenteritis Mets |
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SB lymphoma
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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 |
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Loss of normal fold pattern in SB loop w/o dilitation
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Ischemia
Amyloidosis Lymphoma |
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SB adenocarcinoma
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MC duodenum > jejunum > ileum
Annular constricting mass Increased risk: Adult celiac disease Regional enteritis |
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Multiple nodular SB filling defects
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Mets
- melanoma - breast - Kaposi's Lymphoma Polyposis syndrome |
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Cavitating SB mass
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GIST
Lymphoma Mets - colon CA |
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Diffuse mesenteric soft tissue masses with serosal implants
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Serosal metastases
Primary peritoneal mesothelioma |
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Well circumscribed cystic lesion in mesentery/SB
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Enteric duplication cyst
- may communicate with lume - may contain any bowel mucosa Mesenteric cyst Blind loop obrstruction Diverticulum Cystic neoplasm |
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Ascariasis
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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. |
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Thin SB folds with dilitation
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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 |
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SB obstruction
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Adhesions
- post-operative - post inflammatory Hernias Neoplasm Intussusception Stricture - Crohn - radiation - ischemic Volvulus |
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Thickened, straight SB folds
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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 |
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SB nodular thickened folds
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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 |
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Whipple disease
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Tropheryma whippelii
Proximal SB segmental and diffuse nodular thickening Low density LAD Sacroilitis Hyperpigmentation |
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Low density paraaortic LAD
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Whipple's
Celiac Testicular mets MAI Lymphoma Epidermoid carcinoma |
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Innumerable SB uniform nodules
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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 |
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Diffuse segmental featureless SB loops
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Ischemia
Infection (enteritis) Celiac disease Acute radiation enteritis GVHD Amyloidosis |
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Circumferential thickened small bowel on CT
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Ischemia
Crohn Radiation enteritis Infection Lymphoma |
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Pneumatosis
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Ischemia
Benign - corticosteroids - scleroderma - COPD - pneumatosis cystoides intestinalis - GVHD |
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Sprue/Celiac disease
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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 |
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Intussusception
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"Coiled spring"
"Accordion" Bowel within bowel DDx: Transient Leadpoint Celiac disease |
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SB TB
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Crohn mimic
- ulcerations - luminal narrowing - multiple segmental involvement - wall thickening - fistula formation - mesenteric mass - cecal spasm - ileocecal valve incompetence - mesenteric adenopathy |
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UC
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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 - |
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Toxic megacolon
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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 |
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Clustered nodular mucosa - colon
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Inflammatory polyps
- UC Adenocarcinoma Lymphoma Dysplasia - UC |
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Smooth or irregular colonic in the setting of UC
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Carcinoma
Benign stricture |
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Ahaustral shortened colon
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UC
Cathartic abuse |
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Colonic distension, wall thickening, thumbprinting
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Pseudomembranous colitis
UC / Crohn Infectious colitis Ischemic colitis |
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Colonic diffuse nodular mucosal elevations +/- umbilication
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Prominent lymphoid pattern
Early Crohn disease Polyposis |
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Colon - asymmetric aphthous ulcers
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Crohn disease
Infectious colitis - Yersinia - Amebiasis |
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Crohn colitis
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Segmental skip lesions
- Linear and transverse ulcers - "collar-button" ulcers - "thorn-like" ulcers (deep penetrating) - inflammatory polyps - strictures - fistulae |
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Barium enema - short segment colonic narrowing with fold thickening and loss of haustration
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Diverticultitis
Carcinoma Serosal mets |
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Diverticulitis
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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 |
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Giant sigmoid diverticulum
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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. |
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Radiation colitis
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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 |
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Pseudomembranous colitis
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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 |
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Amebiasis
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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 |
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Colon cutoff sign
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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 |
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Colonic pseudodiverticula
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Sacculations along the antimesenteric colonic wall
DDx: Crohn disease Scleroderma |
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Mastocytosis
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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 |
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Epiploic appendigitis
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Ddx:
Mesenteric panniculitis (usually root of mesentery) Omental infarction (more diffuse, usually right hemiabdomen) |
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Colonic polyps
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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 |
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Submucosal colonic mass
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Lipoma
- soft - deformable GIST - rare - MC in rectum if in colon Endometriosis Serosal mets - tethering |
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pneumatosis cystoides intestinalis
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COPD
Peptic ulcer Pyloric stenosis Bypass surgery Transplant surgery |
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Primary tumors with local extension to involve colon
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Prostate -> anterior rectun
Ovarian -> anywhere Renal -> ascending or descending Gastric, pancreatic -> transverse |
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Colonic lymphoma
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3 appearances:
Polypoid mass Annular constricting lesion Aneurysmal dilitation with mucosal ulcerations |
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Colitis cystica profunda
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Multiple rounded mucin-filled cysts within the wall of recto-sigmoid
Unknown cause P/W: rectal bleeding pain rectal prolapse DDx: villous adenoma |
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Appendiceal mucocele
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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 |
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pneumatosis cystoides coli
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Idiopathic gas filled cysts within bowel wall
Unknown cause A/W Collagen vascular disease ischemia DM Trauma |
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Mechanical colonic obstruction
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MC underlying colorectal CA
Diverticulitis Volvulus Extracolonic neoplasm fecal impaction Hernia/adhesion (rare) |
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Sigmoid volvulus
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Older patients
Redundent mesentary Hx of constipation Surgery versus decompression via transrectal intubation |
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Cecal ileus
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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 |
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Rectocele
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Bulge of anterior rectal wall into the vagina
Due to pelvic floor weakness More common in females - multiple vaginal deliveries - hysterectomy |
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Enterocele
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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 |
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Solitary rectal ulcer syndrome
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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 |
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Loss of haustrations, right colonic shortening, inconsistent luminal constrictions
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Crohn colitis
UC Chronic cathatic use - senna - castor oil - cascara |
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Dysplastic liver nodules
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High T1W may indicate fat or copper
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Liver - High T2W, low T1W, capsular retraction
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Cirrhosis with HCC
Cholangiocarcinoma Confluent hepatic cirrhosis - wedge shaped region extending from portahepatis to capsule - usually anterior right lobe - no venous invasion - no growth |
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Hemochromatosis
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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 |
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Diffuse low attenuation liver with multiple masses
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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 |
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Heterogeneous hepatic enhancement with caudate sparing
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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 |
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Hyperattenuating liver
|
Hemochromatosis
Amiodarone glycogen storage disease Gold therapy thorium dioxide therapy |
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Hepatic radiation injury
|
12 Gy acutely, 40 Gy cumulative
Sharply demarcated hypodense region Low T1W, high T2W Becomes fatty infiltrated with age |
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Rim enhancing cystic liver lesion
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Abscess
- diverticulosis, surgery, cholecystitis, appendicitis, acending infection, hematogenous spread - e coli adults - staph aureus children Cystic HCC Cystic mets Biliary cystadenoma |
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Amebic hepatic abscess
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Fluid density with hypodense ring
Entamoeba histolytica Cecal and bowel infection with trophozoites Hematogenous to liver Anchovy paste internal contents |
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Hepatic echinococcal disease
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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 |
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Solid cystic mass in liver
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Infected cyst
Cystic HCC Hemorrhagic cyst Cystic mets |
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von Myerberg complexes
|
Subcentimeter hypodensities in the liver.
+/- peripheral enhancement Dilated biliary radicals in fibrous stroma in the liver. |
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Peribiliary cysts
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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 |
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Hepatic candidiasis
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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 |
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Giant hepatic hemangioma
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> 4 cm (some say > 10cm)
Central fibrosis may prohibit uniform enhancement A/W: Mass effect Kasabach-Merritt Thrombosis Rupture |
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Atypical hemangioma
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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 |
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FNH
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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) |
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Fibrolamellar CA
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Malignant hepatic neoplasm
Similar appearance to FNH - less homogeneous enhancement - large mass, central scar, Ca++ - angioinvasion - lymphadenopathy Outcomes similar to HCC |
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Hepatic adenoma
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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 |
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Biliary cystadenoma/cystadenocarcinoma
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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 |
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Hepatic angiomyolipoma
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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) |
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Fat containing liver mass
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Angiomyolipoma
Lipoma Adenoma HCC (40% contain fat) Dysplastic nodule Liposarcoma (metastatic) |
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Cirrhosis - dysplastic nodule, regenerating nodule
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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 |
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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) |
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Cholangiocarcinoma
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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 |
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Hepatic lymphoma
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Usually secondary, primary extremely rare
- multiple small hypodensities - multiple small hypoechoic lesions - lymphadenopathy ddx: Mets Candidiasis |
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Epithelioid hemangioendothelioma
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Confluent hypodense masses with peripheral enhancement that typically originate peripherally within the liver and merge confluently
+/- capular retraction hypovascular ddx HCC mets |
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Hyperdense material in spleen, liver and abdominal LN
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Thorium dioxide (thorotrast)
A/W: HCC cholangioCA angioCA Cirrhosis Lung CA |
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Ca++ liver mets
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Mucinous colon
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Hypervascular liver mets
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Carcinoid
Pheochromocytoma Islet cell Thyroid Renal Choriocarcinoma Melanoma US: hyperechoic with shadowing |
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US hepatic mass with hypoechoic halo
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Mets
HCC adenoma |
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Pseudocirrhosis
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Breast CA undergoing chemotherapy
Nodular liver contour Caudate hypertrophy Capsular retraction overlying subcapsular mets |
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Periportal enhancement
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Granulomatous disease:
Infection: - TB - Schistosomiasis - Histo, blasto, crypto - Toxo Sarcoid Drugs - quinidine - allopurinol PBC |
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PSC
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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 |
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PBC
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Autoimmune cholangitis
A/W: - antimitochondrial antibodies - RA - Sjogren - Hashimoto's Findings: - cirrhosis - intrahepatic biliary crowding, pruning, tortuosity Ddx: PSC Cirrhosis NOS |
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AIDS cholangiopathy
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AIDS related cholangitis 2/2 CMV or cryptosporidium
Intra/extrahepatic strictures +/- papillary stenosis May appear identical to PSC DDx: - ascending cholangitis - PSC |
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Oriental cholangitis aka Recurrent pyogenic cholangitis
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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 |
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Ascending cholangitis
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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 |
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Choledocholithiasis
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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 |
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Distal CBD obstruction
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Stone
Mass Papillary stenosis - inflammation and fibrosis - may be due to pancreatitis, surgery, choledocholithiasis Spasm of the sphincter of Oddi Pancreatitis Pseudocalculus AIDS cholangiopathy |
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Proximal CBD obstruction
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Extrinsic compression (LAD MC)
Mass Mirizzi's PSC CholangioCA |
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|
Multiple intraductal biliary filling defects
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Mucous plugs
Sludgeballs/stones Caroli's Recurrent pyogenic cholangitis Hemorrhage CholangioCA Biliary papillomatosis - rare - can progress to adenoCA |
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Caroli's disease
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100x Risk of HCC
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|
|
Hyperenhancing hepatic lesions
|
HCC
Hypervascular mets Hemangioma FNH Adenoma Hyperplastic regenerative nodules in the setting of Budd-Chiari (multiple) |
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Acute pancreatitis causes
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Gallstones
EtOH Drugs - steroids - AZT - diuretics ERCP Hyperlipidemia Hypercalcemia Trauma Divisum Staging system Balthazar |
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Chronic pancreatitis
|
EtOH
Hyperlipidemia Hypercalcemia Trauma Familial Divisum |
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Autoimmune pancreatitis
|
Autoimmune pancreatitis
Elevated IgG Diffuse "sausage" pancreas Focal inflammation w/ upstream ductal dilitation Mild clinical course Tx: steroids |
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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 |
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Key clinical symptoms somatostatinoma
|
Diarrhea, steatorrhea, weight loss
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|
|
Key clinical symptoms VIPoma
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WDHA syndrome: watery diarrhea, hypokalemia, achlorhydria
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|
Key clinical symptoms glucagonoma
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Necrolytic erythema migrans, diarrhea, diabetes, glossitis
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|
Key clinical symptoms gastrinoma
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Abdominal pain, diarrhea, vomiting, hematemesis, melena, weight loss
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Key clinical symptoms Insulinoma
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Hypoglycemia: sweating, trembling, palpitations, nervousness
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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 |
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MEN type 2a
|
MPP (in order of likelihood)
Medullary thyroid carcinoma Pheochromocytoma Pituitary adenoma |
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MEN 2b
|
MP+MMMG
Medullary thyroid carcinoma Pheochromocytoma + - Mucosal neuromas - marfanoid habitus - megcolon - gangliomatosis, intestinal |
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|
Non-hyperfunctioning islet cell tumor
|
Large size
Hyperenhancement Ca++ Necrosis |
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|
Complex cystic mass in the pancreas
|
Mucinous cystic
AdenoCA Cystic islet cell Cystic mets |
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|
Causes of SBO
|
Adhesions
Malignancy Crohn Hernia Intussusception |
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|
Causes of LBO
|
ColorectalCA
Volvulus Intussusception Hernia |
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|
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 |
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|
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 |
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|
VHL
|
Renal cysts
- RCC Pancreatic cysts - serous cystadenoma - islet cell tumors Pheochromocytoma Hemangioblastomas Papillary cystadenoma of the epidydimus |
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|
Multiple pancreatic cysts
|
ADPKD
VHL |
|
|
Multiple punctate pancreatic calcifications
|
Chronic pancreatitis
- ductal Ca++ - atrophy - ductal dilitation Histoplasmosis Sarcoidosis |
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|
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 |
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|
Tiny calcific densities in the spleen
|
Histoplasmosis
Candidiasis Sarcoid PJP Treated lymphoma Treated mets |
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|
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 |
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|
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 |
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|
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 |
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|
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 |
