GI Section

The following are True/False answers:

1.

1 F

2  T

3  T

4  T

5  F

PSEUDOMEMBRANOUS COLITIS
=CLOSTRIDIUM DIFFICILE DISEASE (more appropriate name because pseudomembranes are uncommon)
Cause: overgrowth of Gram-positive Clostridium difficile in response to a decrease in normal intestinal flora
Etiologic agent: cytotoxin produced by C. difficile
Predisposed:
(a) complication of antibiotic therapy with tetracycline, penicillin, ampicillin, clindamycin, lincomycin, amoxicillin, chloramphenicol, cephalosporins
(b) complication of some chemotherapeutic agents: methotrexate, fluorouracil
(c) following surgery / renal transplantation / irradiation; intestinal vascular insufficiency
(d) shock, uremia
(e) proximal to large bowel obstruction
(f) debilitating diseases: lymphosarcoma, leukemia
(g) immunosuppressive therapy with actinomycin D

Histo: pseudomembranes (exudate composed of leukocytes, fibrin, mucin, sloughed necrotic epithelium held in columns by strands of mucus) on a partially denuded colonic edematous mucosa (mucosa generally intact); reactive edema in lamina propria, submucosa, and eventually subserosa
profuse watery diarrhea, abdominal cramps, tenderness
fever, fecal blood, leukocytosis.  less common: chronic diarrhea, toxic megacolon, hyperpyrexia, leukemoid reaction, hypoalbuminemia with anasarca, confluent small yellow plaques (= pseudomembranes) adherent to mucosal surface seen on endoscopy (50%)
Location: rectum (95%); confined to right + transverse colon (5-27%)
Plain film: adynamic ileus pattern = moderate gaseous distension of small bowel + colon
"transverse banding" = marked thickening + distortion of haustral folds
"thumbprinting" most prominent in transverse colon
diffusely shaggy + irregular surface (confluent pseudomembranes)
Barium Enema (CONTRAINDICATED in severe cases):
"accordion-like" haustral thickening = contrast material trapped between distorted thickened closely spaced transverse edematous folds (simulating intramural tracts) pseudoulcerations = barium filling clefts between pseudomembranes irregular ragged polypoid contour of colonic wall
discrete multiple plaque like lesions of 2-4 mm in size (DDx: polyposis, nodular form of lymphoma)
N.B.: Risk of colonic perforation!
CT (85% sensitive, 48% specific):
colonic wall thickening of 4-22 mm (61-88%)
smooth circumferential thickening (44%)
accordion sign (51-70%) = alternating bands of edematous haustral folds separated by intraluminal contrast material
nodular thickening (17%)
homogeneous enhancement due to hyperemia
pericolonic stranding (42%)
ascites (15-25%)
NO colonic abnormality (12-39%)

Dx:(1)Stool assay for Clostridium difficile cytotoxin (detects toxin B): cumbersome to perform
(2)Enzyme immunoassay test (up to 33% false-negative results): detects toxin A + B
(3)Stool culture (95% sensitive): not available for 2 days
(4)Pseudomembranes on proctosigmoidoscopy
Cx: peritonitis
Prognosis:15% mortality; most patients recover within 2 weeks
Rx: discontinuation of suspected antibiotic + administration of vancomycin / metronidazole with attention to fluid and electrolyte balance

2.

Answers:

1. T

2. F

3. T

4. T

5. T

DDX for smooth esophageal narrowing includes: congenital stenosis, web, surgical repair of esophageal atresia, caustic burns, gastric acid-reflux, intubation- reflux, compromise of circulation, XRT of mediastinum, post infection - rare. Lower esophageal narrowing includes: scleroderma, achalasia, diffuse spasm, esophagitis

Classic findings of Barrett's include: high esophageal stricture/ulcer, HH, GER. Strictures are at proximal zone of columnar metaplasia. Can also have strictures in distal esophagus.--peptic stricture. Reticular mucosal pattern is also a finding..

DDX for high esophageal strictures include caustic ingestion, mediastinal XRT, primary or mets, rarely esophageal. involvement by dermatologic disorders such as epidermolysis bullosa dystrophica and benign mucous membrane pemphigoid.

3.

1  T

2  T

3  F

Adult Form Of Hypertrophic Pyloric Stenosis
(secondary to mild infantile form)
acute obstructive symptoms uncommon
nausea, intermittent vomiting
postprandial distress, heartburn
Associated with:
(1) peptic ulcer disease (in 50-74%) (prolonged gastrin production secondary to stasis of food)
(2)chronic gastritis (54%)
persistent elongation (2-4 cm) + concentric narrowing of pyloric channel
parallel + preserved mucosal folds
antispasmodics show no effect on narrowing
proximal benign ulcer (74%), usually near incisura

4.

1  F

2  T

3  F

4  F

EPIDERMOID CYST OF SPLEEN
= EPITHELIAL CYST = PRIMARY CYST OF SPLEEN
Cause: infolding of peritoneal mesothelium / collection of peritoneal mesothelial cells trapped within splenic sulci
Histo:(1) mesothelial lining (2) squamous epithelial lining = epidermoid cyst = squamous metaplasia from embryonic inclusions within preexisting mesothelial
surface epithelium
Age:2nd-3rd decade (average age of 18 years)
May be associated with: polycystic kidney disease
(a) unilocular + solitary (80%)
(b) multiple + multilocular (20%)
average size of 10 cm
peripheral septations / cyst wall trabeculations (in 86%)
curvilinear calcification in wall (9-25%)
may contain cholesterol crystals, fat, blood
Cx: trauma, rupture, infection

5.

1  ?T

2  ?T

3  T

4  T

5  F

Internal Hernia
Incidence:5% of all hernias, responsible for <1% of mechanical small bowel obstruction
Classification of hernias:
(a) retroperitoneal: usually congenital containing a hernial sac
1.paraduodenal (ligament of Treitz)
2.foramen of Winslow
3.intersigmoid
4.pericecal / ileocolic
5.supravesical
(b) anteperitoneal:
small group of hernias without a peritoneal sac
1.transmesenteric (transverse / sigmoid mesocolon)
2.transomental
3.pelvic (including broad ligament)
A. PARADUODENAL HERNIA (53%)
(a) through fossa of Landzert on left side (3/4)
lateral to 4th portion of duodenum and behind descending + transverse mesocolon
(b) through fossa of Waldeyer on right side (1/4)
caudal to SMA and inferior to 3rd portion of duodenum
B. LESSER SAC HERNIA (<10%)
through foramen of Winslow in retrogastric location
Invaginated gut: ileum > jejunum, cecum, appendix, ascending colon, Meckel diverticulum, gallbladder, greater omentum
C. HERNIA THROUGH BROAD LIGAMENT (very rare)
after laceration / fenestration from surgery or during pregnancy

6.

1  T

2  T

3  T

4  T

1. Adenomatous Polyposis Syndrome

Peutz-Jeghers Syndrome

- according to Buck's AFIP notes, the polyps rarely occur outside the GI tract.

Cowden’s Syndrome (Multiple Hamartoma Syndrome)

Cronkhite-Canada Syndrome

Juvenile Polyposis

Ruvalcaba-Myhere-Smith Syndrome

7.

1

2

Celiac Disease
=NONTROPICAL SPRUE = GLUTEN-SENSITIVE ENTEROPATHY
=characterized by malabsorption resulting from atrophy of small intestinal villi
Irritating agent: gliadin polypeptides in wheat, rye, barley, oats
May be hereditary: detected in 15% of 1st-degree relatives
Countries: North America, Europe, Australia, India, Pakistan, Middle East, Cuba
Age: childhood by age 2 years; 30-40 years with M<F; 40-60 years with M>F
Rx: gluten-free diet: corn, rice, tapioca, soya, millet, vitamin supplements

CT:
small bowel dilatation + increased fluid content ± mucosal fold thickening
mild to moderate lymphadenopathy in mesentery / retroperitoneum (up to 12%)

8.

1  T

2  F

3 

4  T

5  T

9.

Answers:

1. F

2. T

3. F

4. F

10.

Answer:

1. false

2. true

3. true

4. true

Adenomas are almost always in women. 90% present with mass effect, pain, or hemorrhage. Type V is associated with metabolic disease such as type 1 glycogen storage disease ( von Gierke), DM.

MRI appearance is heterogeneous if there is hemorrhage. Areas of increased T1 signal have fat, methemoglobin hemorrhage. Also increased signal on T2.

Low signal intensity of adenoma on T1 is secondary to necrosis.

11.

Answer:

5. false

6. false

7. false

8. false,   true for Sx pt

8a. false

Meckels is a remnant of the vitelline duct. Antimesenteric ileal border w/in 100cm of the ileocecal valve. 15% contain ectopic gastric mucosa

Meckels contains all layers of the bowel; therefore it's a true diverticulum. Symptomatic Meckels occurs more in males than females, BUT asymptomatic Meckel's are in both sexes equally.

Meckel's diverticulum is formed from incomplete invagination of the vitelline duct. Incidence in autopsies is up to 3%. ??? prob doesn't invaginate over time.

Malformation is 3-5X more common in men

12.

Answer:

9. true

10. false

11. true

12. true

13. false,   common ( occasional presentation with ulcer in ileal segment-- ?bleeding) prob--false

Ileal dysgenesis is found in adults and is segmental dilatation affecting the distal ileum. Probably developmental in origin, a supposition supported by the presence of ectopic gastric mucosa or other aberrant mucosal linings. There is focal atonicity. Obstructive symptoms. On Barium, see dilated focal segment of ileum and occasionally an ulcer.

Segmental dilatation in kids which is a different disease is thought to be secondary to a neuromuscular disorder.

13.

Answer:

14. True

15. False

16. True

17. False

In an immunocompetent patient, the most common causes of cholangitis are stricture from prior surgery (36%), calculi (30%), sclerosing cholangitis, and an obstructed drainage catheter.

A secondary cholangitis resembling primary sclerosing cholangitis is an uncommon but well-recognized component of AIDS. The condition is thought to be secondary to opportunistic infection by Cryptosporidium, cytomegalovirus, or both. In addition to biliary tract signs and symptoms, patients with AIDS-related cholangitis may suffer abdominal pain and diarrhea from cryptosporidial enteritis.

14.

Answer:

18. false

Duodenal atresia is most commonly associated with Down Syndrome.

15.

Answer:

22. False

23. True

24. ?? false- commonly?-- only 15%

25. True

26. True

27. false????( true diverticula?)

28. false

29. false

In sclerosing cholangitis, chronic obliterative fibrotic inflammation involves the intra- and extrahepatic bile ducts. It appears on cholangiography as multiple strictures in the intra- and extrahepatic biliary tree with pruning of the normal branching pattern, nodular duct walls, and diverticula.

Sclerosing cholangitis can occur either as a primary form (either idiopathic or associated with inflammatory bowel disease or retroperitoneal fibrosis) or may be secondary to cholangitis, surgery, or stone disease. 15% of patients with primary sclerosing cholangitis develop sclerosing cholangiocarcinoma. 70% of patients with primary sclerosing cholangitis have ulcerative colitis. A small percentage of patients with sclerosing cholangitis have an associated fibrosing syndrome involving the retrobulbar area (orbital pseudotumor), salivary gland, thyroid gland, retroperitoneum (retroperitoneal fibrosis), and blood vessels. Associated with sicca complex, Riedel's struma( a chronic proliferating inflammatory fibrosing, process, usually involving both lobes of the Thyroid), retroperitoneal fibrosis, mediastinal fibrosis, but none has been reported consistently.

A greater # of pt are dx earlier asymptomatic secondary to incidentally noted elevated serum alk-phos. Elevation of bilirubin and AST aren't as marked or as consistent as alk-phos. Natural history is variable but usually progressively downhill. No known therapy has been proven effective short of liver transplantation.

Diverticular outpouchings vary in size. Are a characteristic feature of PSC. Appear to develop as herniations adjacent to strictures , whereas others arise as mucosa extensions into a thickened duct wall.

16.

Answer:

30. False

31. True

32. False

33. True

34. True

Carcinoma of the gallbladder has been reported anecdotally in adenomyosis but risk of neoplasm is usually not sufficient to indicate prophylactic surgery.

Hyperplastic cholecystoses are benign non neoplastic noninflammatory gallbladder abnormalities which include adenomyomatosis, cholesterolosis, cholesterol polyps.

17.

Answer:

35. True

36. True

37. True

38. False

39. True? is a risk factor for ca., but not necessarily the precursor-- false??

According to Harrison’s, patients with primary sclerosing cholangitis can have signs suggesting acute cholangitis. 70% of patients with primary sclerosing cholangitis can have ulcerative colitis and primary sclerosing cholangitis can precede ulcerative colitis. Primary sclerosing cholangitis usually involves both the intra- and extrahepatic ducts and gives a beaded appearance with strictures. 15% of patients with primary sclerosing cholangitis will get cholangiocarcinoma.

Risk factors for cholangiocarcinoma include PSC, choledochal cyst, familial polyposis, congenital hepatic fibrosis, oriental cholangitis, history of thorotrast exposure.

18.

Answer:

40. False

41. True

42. False

43. True

44. True

Secondary sclerosing cholangitis is associated with inflammatory bowel disease (ulcerative colitis in 66-75%, occasionally with Crohns disease). However, the term primary is used because there is no convincing evidence that primary sclerosing cholangitis is caused by or is secondary to inflammatory bowel disease.

19.

Answer:

45. False true?-- neonatal hepatitis is a cause.

46. True

47. false

48. True

Causes of enlarged gallbladder:

Hydrops of the gallbladder is defined as massive distention of the gallbladder without evidence of a congenital malformation, stone, or inflammatory etiology. Most cases are idiopathic.

The following are all causes of GB hydrops:

- Kawasaki’s - Sjogren’s - Systemic sclerosis

- nephrotic syndrome - leukemia - familial Mediterranean fever

- TPN - scarlet fever - leptospirosis

- ascariasis - typhoid - staph/strep

In Rumack, hydropic gallbladder may be due to Kawasaki's, pseudomonas, klebsiella, group B strep, neonatal hepatitis, necrotizing enterocolitis, CF with inspissated bile.  Can also occur in children on TPN. Transient gallbladder distension can occur in infants or premies and is secondary to transient bile plugging.

20.

Answer:

49. True

50. True

51. False

52. True

Pneumatosis Intestinalis Cystoides represents cystic or arcuate collections of gas located in the subserosa or submucosa - usually in the jejunum. 15% is primary and 85% is secondary

21.

Answer:

53. True

54. True

55. True

56. False

57. True

58. False

59. True

Toxic megacolon is defined as acute transmural fulminant colitis with neurogenic loss of motor tone and rapid colonic dilation (>5.5 cm in transverse colon). Ulcerative colitis is the most common cause. BE is contraindicated. The mortality is 20%. Possible causes:

- UC - Crohn’s

- Ischemic colitis - Amebic colitis

- salmonellosis (typhoid fever) - cholera

- shigellosis (bacillary dysentery) - Strongyloides

- Campylobacter - Behcet’s

- pseudomembranous colitis (rarely)

 typhoid fever.

22.

Answer:

60. True (if toxic megacolon is present)

61. True

62. False

63. False true

64. False

Other contraindications to BE:

1) immediately following a biopsy with a rigid sigmoidoscope (wait 5 days)

Use single contrast BE for:

1) Hirschsprung’s

2) Acute diverticulitis

3) High grade colonic obstruction

4) colonic fistula

5) ischemic colitis

23.

Answer:

65. True

66. True

67. false

68. false

69. True

The appendix is seen in 10-15% of normals. A normal appendix is small, narrow( < 6mm), blind ending structure with extremely thin wall.

An appendicolith can be an incidental finding and without associated clinical findings, are not indicative of appendicitis. However, of all appendicitis 30% have appendicoliths. US accuracy of dx acute appendicitis is greater than 90%. Sensitivity is 80 - 89%.

Sonographic findings of acute appendicitis include:

noncompressible RLQ tubular structure

target appearance of appendix

appendix diameter > 6mm

lumen distended with anechoic/ hyperechoic material

appendicolith

circumferential loss of submucosal layer of appendicitis

loculated pericecal fluid

prominent pericecal fat.

24.

Answer:

74. True

75. True

76. True

77. True

78. True

Prolonged use of stimulant-irritant cathartics (> 15 years) results in neuromuscular incoordination from clinically increased muscular activity and tonus. This is exclusively a radiographic diagnosis. Involvement is often proximal to distal, with the first changes in the cecum and ileocecal valve. The former often appears conical, while the latter is flattened and gaping. There is general loss of haustration which may extend to the distal colon:

Additional agents which might cause it: phenophthalein, aloin

25.

Answer:

79. True

80. True

81. True

82. True

Kulchitsky cells are argentaffin cells which give rise to carcinoids. Myenteric plexus aka Auerbach's is between the two layers of muscularis. Meissner's is a submucosal plexus. Lymphoid tissue is distributed throughout the GI tract.

26.

Answer:

82. False

83. False

84. False

Rectum, ascending and desc colon are retroperitoneal. Sigmoid and transverse mesocolon are intraperitoneal.   The first part of the duodenum is covered by peritoneum. The remainder of the duodenum is retroperitoneal.

27.

Answer:

85. False

86. False

87. False

88. False

89. False

Mallory-Weiss tears are due to sudden increase in intraesophageal pressure from violent projection of gastric contents against a fixed lower esophagus. This results in linear tears at/above/below the gastroesophageal junction (below in 76%). Mallory-Weiss tears are the most common cause of esophagus non-variceal bleeding and account for 5-10% of all acute upper GI bleeds. Most heal spontaneously but some require vasopressin, embolization, or surgery. The tear usually involves the mucosa and submucosa and is self-limited. It is more common in males, usually 30-60 years-old. The tears usually follow binge drinking. The best form of diagnosis is endoscopy, although angiography (left gastric artery injection) can be used. On barium studies the tears appear as linear shallow ulcers (single 77%, multiple 23%) at the gastroesophageal junction. The differential diagnosis is linear ulcers from gastroesophageal reflux. The history is helpful in the differential diagnosis.

28.

Answer:

90. True

91. True

92. False

93. False

94. False

A filiform polyp is a nonspecific histological polyp seen in inflammatory bowel disease. It characteristically has a branching pattern and looks like strands of mucus. It may be the first sign of inflammatory disease. The polyp itself is not precancerous; however, remember that the risk of colon cancer is increased in inflammatory bowel disease. It can cause intussusception in children; however, the most common cause in kids is idiopathic. Filiform polyp is secondary to residual inflammed and/or hyperplastic or reparative tissue protrudes in to the lumen.

Barium Enema findings: acute ulcerative colitis

mucosal granularity and stippling

collar button ulcers

haustral thickening or loss

inflammatory polyps

contiguous circumferential disease

Barium Enema findings: chronic ulcerative colitis

haustral loss

lumen narrowing

loss of rectal valves

widened presacral space

post inflammatory pseudopolyps

complications of ulcerative colitis

cancer significantly higher than general population

annual incidence 10% after first decade of colitis

risk increased with increased extent of disease

toxic megacolon

1.6-13% of patients can be the initial manifestation

Turcot's

Colonic and CNS tumours

29.

Answer:

95. True

96. True

97. False

98. True

99. True

There are approximately 200 deep mucosal glands aligned in parallel rows in the esophagus. Each gland contains several ducts which merge to form a single main duct that extends 2-5 mm in the wall of the esophagus to open at the mucosal surface. Intramural pseudodiverticulosis is due to dilated excretory ducts. Approximately 34-48% of patients with intramural pseudodiverticulosis have Candida colonization. Some feel that Candida predisposes to intramural pseudodiverticulosis; others feel that inflammation around the ducts can cause plugging leading to intramural pseudodiverticulosis. In fact, 80-90% of patients with intramural pseudodiverticulosis have inflammatory disease in the esophagus histologically. Intramural pseudodiverticulosis is therefore a sequela of chronic esophagitis, especially reflux.

40% of patients with intramural pseudodiverticulosis have strictures which can be benign or malignant. Intramural pseudodiverticulosis usually occurs in the elderly, it is twice as common in males, 20% of patients are diabetic, and 15% are alcoholics. Most patients have intermittent or slowly progressive dysphagia which is dramatically relieved with mechanical dilatation.

On esophagography, there are fleck-shaped collections of barium arranged along the axis of the esophagus. They commonly lack communication with the esophageal lumen and thus are differentiated from shallow ulcers. Occasionally they can form bridging structures in the wall of the esophagus resulting in discrete tracks. If the ducts perforate it can lead to intramural pseudodiverticulosis. One half of patients with intramural pseudodiverticulosis have diffuse disease and 1/2 of patients have segmental disease. Many patients with intramural pseudodiverticulosis have high esophageal strictures (40%?).

30.

Answer:

100. True

101. True

102. false

103. True

Our pathologists use nuclear pleomorphism, number of mitoses, and presence of necrosis to distinguish atypical from typical carcinoid. There is a gradation with a lot of inter- (and probably intra-) observer variation. Radiographically, we cannot make a distinction unless metastases are present, which would be atypical.

31.

Answer:

104. False

105. False

106. True

The rectosigmoid is involved in 95%. The mucosa is hyperemic, but sometimes beneath the ulcers, there is a vasculitis raising the question of whether ulcers are caused by an initial vasculitis-induced ischemic necrosis of the mucosa. The ileum is involved in 10-25% ("backwash ileitis").

32.

Answer:

107. True (non propulsive)

108. True (Barrett’s)

109. True

110. False

111. False

Barrett esophagus is an inflammatory condition in which the pseudostratified squamous epithelium of the esophagus is replaced by columnar (gastric) epithelium. It is thought to result from chronic reflux, which is invariably present, and is usually associated with a sliding hiatal hernia. An esophagram reveals a characteristic, finely reticular mucosal pattern. The ulcerations of Barrett esophagus tend to be deep and penetrating, resembling peptic ulcerations in the stomach. They are usually separated from the hiatal hernia by a variable length of normal-appearing mucosa. Strictures form in a small percentage of patients. Technetium pertechnetate examination usually shows increased activity in the affected segment, as the isotope is actively secreted by the gastric-type mucosa. Approximately 10% of patients with this condition have been reported to develop adenocarcinoma. 25-50% pt with GER have abnormal motility. Inflammatory esophagogastric polyps are seen in GER and frequently straddle a HH.

33.

Answer:

112. False

113. True

114. True

115. False

116. False (greater risk-- they have a 10% risk of developing ca rather than a 10% increased risk above baseline)

Patients with carcinoma of the esophagus usually present with extensive tumor. They remain asymptomatic during much of their development and therefore often present at a stage which is too advanced to permit cure. The incidence of carcinoma is higher among those with esophagitis, untreated achalasia, lye strictures, diverticula, webs, alcohol, cigarette smoking, hot tea, and aflatoxin (Aspergillus molds found in nuts) exposure. The Plummer-Vinson (Paterson-Kelly) syndrome, which consists of dysphagia, iron deficiency anemia, and mucosal lesions of the mouth, pharynx, and esophagus, has also been linked to esophageal carcinoma. When the cancers become overt, almost 50% of these tumors are located in the middle third, 30% in the distal third, and 20% in the upper third. Histologically, about 60-70% are either poorly or well-differentiated squamous cell carcinoma, and 5-10% are adenocarcinoma. The remainder are undifferentiated. 70% of patients are dead within one year of diagnosis, and the five year survival rate is 5-10%. Metastases occur as a relatively late phenomenon. Between 1-15% of pt with head and neck cancer develop an esophageal SCC., so they have a significantly increased risk of developing a separate primary SCC.

34.

Answer:

117. False

118. True

119. False

120. True

121. True (non caseating)

35.

Answer:

122. False

123. False

124. False

125. False

A Shatzki ring is a constant lower esophageal ring which is due to mucosal thickening or may be secondary to scarring from reflux.. It occurs at the level of the B ring.

Muscular rings of the esophagus are transient rings related to contraction.

On a good double contrast exam, the squamocolumnar junction (which is 1-2 cm above the gastric sling fibers) can be seen. It is also called the Z-line

The best technique to detect a muscular ring is a prone single contrast examination.

36.

Answer:

126. True

127. False

128. True

129. True

130. True

        15mm=15% rule

37.

Answer:

131. True

132. True

133. False

134.true

135. True

The small bowel valvulae probably cannot be completely effaced as we count the valvulae/inch when a small bowel enema is done. Jejunum loops can't be effaced but ileum can be.

38.

Answer:

136. True

137. false

138. True

139. True

140. True

Focal nodular hyperplasia is twice as common in females. They can bleed with rupture causing hemoperitoneum. The incidence rises to 14% if the patient is on oral contraceptives. (Is 0-14% common?). Focal nodular hyperplasia is the only tumor that contains Kupffer cells. It is multifocal in 20%. On non-enhanced CT, focal nodular hyperplasia has slightly decreased attenuation - this changes to isodense to hyperdense with contrast injection. Fewer than 1/3 of cases present because of clinical Sx , most are incidentally found.

39.

Answer:

145. False

146. False

147. True

148. False

Esophageal varices arise from the dilated left gastric (coronary) veins and drain into systemic veins of the thorax (hemiazygous, azygous, intercostal). The IMV can shunt blood from the splenic vein to the hemorrhoidal veins in the pelvis.

Collaterals in portal vein hypertension include:

- portal v-> coronary/l gastric, short gastric, vertebral plexus, IVC, hemiazygous

-coronary v->azygous, hemiazygous, vertebral

-IMV->inf and middle hemorrhoidal. v.

40.

Answer:

149. True

150. False

151. True

152. True

153. True

Following discussion is about nontropical sprue. (= celiac disease)

The folds are not thickened in uncomplicated celiac disease. Fold thickening can be seen with malabsorption-related hypoalbuminemia. The Moulage (wax)  pattern is seen in 50% - it is a smooth contour with effaced pattern less folds.

Have stunted villi in celiac disease. The moulage sign represents flocculated barium seen in celiac disease. Luminal fluid excess can be due to hypersecretion and is non-specific for the disease. There is increased separation or apparent abscence of folds in the jejunum. ? Can get increased number of folds in the ileum referred to reversal of folds between the ileum and jejunum. Can get painless transient intussusceptions.

41.

Answer:

141. False

142. False

143. False

144. True

Lymphogranuloma venereum is more common in males. It is commonly symptomatic with rectosigmoid narrowing, deep ulcers, and fistulae. It is caused by Chlamydia trachomatis, which is not a retrovirus. Treatment with tetracycline in the acute phase is successful.

Gonococcal proctitis has a similar radiographic appearance.

The clinical spectrum ranges from the asymptomatic carrier state when a primary painless vesicle forms and resolves . The disease then evolves. to inguinal syndrome from lymphadenopathy bloody diarrhea, rectal pain, tenesmus. If left untreated, deep ulceration, stricturing, rectovaginal fistulas may occur.

42.

Answer:

70. False

71. True

72. False

73. True

Glucagon is naturally made by the alpha cells in the islets of Langerhans. Glucagon increases blood glucose and gastric acid release, increases hepatic ketogenesis, and increases lysis of adipose. It acts by binding to cell membrane receptors; it is a smooth muscle spasmolytic: The gallbladder and papilla of Vater relax with injection of glucagon

0.1 mg - stomach and duodenal hypotonia

0.25 mg - small bowel hypotonia

1.0 mg - colonic hypotonia

Glucagon is contraindicated:

Anticholinergics (Buscopan, Hyoscine butylbromide) are contraindicated in patients with glaucoma. They tend to decrease gastric secretions.

43.

Answer:

154. True

155. probably True

156. True

157. False

158. True

ITP has thickened folds secondary to hemorrhage.

SLE probably has thickened folds secondary to hemorrhage due to vasculitis.

Scleroderma doesn't have thickened folds. Get Hidebound bowel, The valvulae are bunched together because of the fibrosis.

44.

Answer:

159. False

160. True

161. False

162. False

163. False

The differential diagnosis for aphthous ulcers includes:

Aphthous ulcers are shallow ulcers.

45.

Answer:

164. True

165. True

166. False

167. True

168. False

46.

Answer:

169. False

170. False

171. False

172. False

173. True

Lymphoma is first a submucosal process (submucosal nodules). Other presentations include: enlarged folds, polypoid masses, or stricture. The most common presentation is a polypoid mass or an infiltrating stricture indistinguishable from carcinoma. (There is no serosal layer.)

Lymphoma of the esophagus accounts for 1-2% of all cases of lymphoma of the GI tract. (Stomach is the most common site, followed by small bowel.) It is more commonly of the non-Hodgkin’s variety. The typical appearance is distal narrowing due to adjacent spread from the gastric fundus. There can also be direct invasion of the esophagus from mediastinal lymph nodes, or extrinsic compression by mediastinal lymph nodes. Usually NHL and less commonly Hodgkins.

Gastric lymphoma is much more common. Non-Hodgkin lymphoma accounts for the majority of gastric lymphoma and radiographically occurs in four forms: infiltrative, ulcerating, polypoid, and endoexophytic. Hodgkin disease typically produces a desmoplastic reaction, resembling scirrhous carcinoma.

47.

Answer:

174. True

175. True

176. True

177. True

178. True

48.

Answer:

179. True

180. True

181. False

182. False

Neutropenic colitis ("typhlitis") (inflammed cecum) most commonly involves the cecum and terminal ileum. CT findings include: wall thickening (occasionally with low attenuation intramural areas of edema or necrosis), pneumotosis, pericolonic fluid, and thickening of the fascial planes. Untreated can lead to transmural necrosis and perforation.

In pseudomembranous colitis, the inflammation is less pronounced than in typhlitis. Clostridium difficile is seen in pseudomembranous colitis.

49.

Answer:

183. True

184. False

185. False

186. False

Herpes esophagitis is often seen in the immunocompromised patient. CMV and HIV esophagitis are also not uncommon in an immunocompromised patient. All are commonly symptomatic. All most commonly involve the mid-esophagus.

"Candidiasis is by far the most common cause of infectious esophagitis,"

50.

Answer:

187. True

188. False

Glycogenic acanthosis (epithelial hyperplasia) is seen in the mid or distal esophagus. It is a benign disease which is degenerative and age-related. There is increasing frequency with increasing age. In the elderly it is seen in up to 30% of contrast esophagrams.

Acanthosis nigricans is thickening and discoloration of the skin and papillomatosis from idiopathic causes. 60% of cases in adults are associated with gastric adenocarcinoma. It is also associated with lymphoma, Cushing’s syndrome, acromegaly, and Stein-Leventhal syndrome.

51.

Answer:

189. true

190. True

191. prob true-- but can have other etiologies, but is most likely secondary to portal HTN

Gastric varices have been found in all parts of the stomach, although the majority are found in the fundus and proximal body. They cause thickened mucosal folds which vary in size and shape. The presence of gastric varices without esophageal varices usually indicates splenic vein occlusion, which is most commonly caused by pancreatitis or pancreatic carcinoma. CT may be more sensitive than conventional radiologic examination in dx gastric varices because it can delineate not only the luminal varices, but also the deeper intramural and perigastric varices.

When there is splenic vein obstruction, the flow reverses to fill the short gastrics which then drain into the coronary v which drains into the portal v. Splenic v thrombosis may be intrinsic or more commonly extrinsic. Extrinsic compression from chronic pancreatitis, pancreatic pseudocysts, pancreatic. ca., peripancreatic lymphoma, mets, retroperitoneal fibrosis/bleeding. Intrinsic thrombosis may result from polycythemia or myeloproliferative, or idiopathic. In the presence of isolated gastric varices, without esophageal varices, portal HTN is so much more common than splenic v obstruction that most pt with isolated gastric varices are from portal HTN. If necessary, CT or angio can be performed to document the pathophysiology.

"Uphill" varices form when there is increased flow through the coronary veins, usually the result of portal hypertension (most commonly due to alcoholic cirrhosis in the U.S.), with blood flow toward the azygous vein. Therefore, they predominate in the lower half of the esophagus. Normally, the esophageal plexus drains into the coronary v, then to the splenic v. In portal HTN, the esophageal plexus drains into the azygous/hemiazygous and then into the SVC.

"Downhill" varices develop when the superior vena cava is obstructed below the entrance of the azygous vein. The collateral vessels are most developed in the upper half of the esophagus. Mediastinal tumor or inflammatory disease is usually the cause.

52.

Answer:

192 True

193. True

194. True

195. True

Hepatocellular carcinoma can have a variable appearance on ultrasound. Most lesions <5 cm are hypoechoic - larger tumors can be hyperechoic secondary to fibrosis and necrosis. Eighty percent of hepatocellular carcinomas occur in patients with preexisting chronic liver disease such as cirrhosis, hemochromatosis, or alpha-1-antitrypsin deficiency. It occurs in about 10% of patients with chronic active hepatitis, which is most commonly due to hepatitis B. A strong association exists between dietary aflatoxin and hepatocellular carcinoma in southeast Asia and Africa, and it is a well-known complication of Schistosoma japonicum, which is endemic in the Far East. Also the fat within HCC can make the lesion hyperechoic.

53.

Answer:

196. True

197. True

198. False

There is a strong male predominance in post-Billroth carcinoma, perhaps as high as 36:1. Pt who undergo partial gastrectomy are at increased risk for developing gastric ca. Usually BII affected more than BI. The mortality form gastric ca 15yrs or more post gastrectomy is 3-7X greater than general population.

54.

Answer:

199. True

200. True

201. True

202. false

GI duplications are most common in the terminal ileum. Pertechnetate can be useful since some of the duplications contain gastric mucosa.

Enteric duplications are usually on the mesenteric side. The majority of duplication cysts are spherical duplications and have no direct communication with the lumen. They are most frequently in the ileum. The rare tubular duplication lumen may be in communication with the normal bowel at both ends, or at only one end. Occasionally there is no communication. Ectopic gastric mucosal lining can be useful in the dx. 99m-Tc has been reported to have 86% sensitivity.

55.

Answer:

203. true

204. true

205. false

206. false

207. false

60-75% of cases of colonic volvulus involve the sigmoid. In S. America and in Africa volvulus is secondary to dilated and elongated sigmoid from a high fiber diet. In US, usually is in elderly males and residents of nursing homes secondary to chronic constipation and obtundation (bloating) from medication.

Therapy usually consists of emergency sigmoidoscopy and rectal tube placement which is successful in 90%. Recurrence is 50%. Contrast low pressure barium enema may occasionally be required. to demonstrate sigmoid volvulus. F/U barium exam is recommended to evaluate for underlying carcinoma.

Pt present with abdominal pain and distension from obstruction. Obstipation and vomiting are also symptoms. Sx are usually acute but can be chronic.

56.

Answer:

208. false ( more a focal stricture rather than diffuse)

209. true

210. true

DDX for smooth esophageal narrowing includes: congenital stenosis, web, surgical repair of esophageal atresia, caustic burns, gastric acid-reflux, intubation- reflux, compromise of circulation, XRT of mediastinum, post infection - rare. Lower esophageal narrowing includes: scleroderma, achalasia, diffuse spasm, esophagitis

Classic findings of Barrett's include: high esophageal stricture/ulcer, HH, GER. Strictures are at proximal zone of columnar metaplasia. Can also have strictures in distal esophagus.--peptic symptoms. Reticular mucosal pattern is also a finding..

DDX for high esophageal strictures include caustic ingestion, mediastinal XRT, primary or mets, rarely esophageal. involvement by dermatologic disorders such as epidermolysis bullosa dystrophica and benign mucous membrane pemphigoid.

GI Section

Select the single best answer:

57.

Answer: b

58.

Answer: c

CC malignant die from malabsorption.   PJ malignant 2-3%GI, 13% breast

59.

Answer: b

60.

Answer: b

61.

Answer: a

62.

Answer: a

63.

Answer: b

64.

Answer:???

65.

Answer: b. leiomyoma

66.

Answer: c

most likely answer for 40y.o man. Etoh cirrhosis is the most common in this age group. Pancreatic calcification.

Advanced gastric ca are seen on plain films as a soft tissue mass indenting on the gastric shadow. Rarely, mucin-producing scirrhous ca contain gross areas of calcification that have a stippled , punctate appearance. Peak incidence of ca is 50-70 y.o. but 3-5% of pt with ca are younger than 35y.o. Pt are only symptoms when have advanced disease.  25,000 new cases per year.

Gastric mets are found in less than 2% of pt with ca. Mets are most commonly melanoma or breast. Can get spread from colon ca along the gastrocolic ligament; so, findings are along the greater curve. Omental mets may spread superiorly to the stomach via the proximal greater omentum aka the gastrocolic ligament.

Leiomyoma are usually in pt over 50y.o. Can be found in the stomach, antrum, body, or fundus. On plain film, rarely, leiomyomas can contain irregular streaks or clumps of calcifications.. The larger the mass, the more epigastric pain and bleeding. Rarely they grow larger than 5cm. Most often their discovery is incidental. Benign gastric tumors (polyps, leiomyomas) have been present in 5% and up to 25% of autopsies.

Gastric varices can be recognized on plain film as a lobulated mass. Depending on the etiology, pancreatic calcification can be seen. usually secondary to patients with portal hypertension secondary to cirrhosis or liver disease. Cirrhosis is one of the 10 leading causes of death. Frequency is 15 per 100,000. In the US, it is the third leading cause of death for men 34-50 y.o.

67.

Answer: a. dysplastic fingernails

68.

Answer: Crohns,. e

ZE has grossly thickened edematous duodenal and jejunal folds. 75% of ulcers are located in the stomach or duodenal bulb. 25% of ulcers are located in the post bulbar duodenum or jejunum.

Duodenal involvement by Crohns is usually assoc with antral involvement. Findings include aphthous ulcers, one or more larger ulcers, thickened nodular folds, cobblestoned appearance. Can eventually get fibrosis, narrowing, sacculations. Can get fistulization.  Strictures are usually in the post bulbar duodenum.

Celiac sprue secondary to increased immunoglobulin production secondary to gluten ingestion. The villi are absent in sprue. Lamina is thickened. Changes in the duodenum included decreased number of folds, nodular changes rarely.

Duodenal carcinoids can be seen as  polypoid, submucosal masses, or ulcerated lesions.

Giardia is dx with duodenal biopsy or aspirate. Radiographic findings are non specific including irregular fold thickening, hypermotility, luminal narrowing.

69.

Answer: c

95% of bile is resorbed in the ileum. Bile is resorbed by active transport process through the intestinal mucosa in the distal ileum.

70.

Answer: c

Success of initial intubation depends on location--lesions distal to esophagus are more difficult to intubate and get balloon for dilatation to. Proximal esophageal strictures tend to be more difficult to dilate than distal strictures. Once successful intubation and dilatation have been achieved, location does not have a major effect on long term outcome. Malignant strictures are less likely to respond than benign. Patients with anastomotic strictures are reportedly more difficult to intubate. Epidermolysis usually diffusely involves the esophagus. According to S Rubesin, epidermolysis bullosa shouldn't be dilated because there is a high rate of perforation due to the friable mucosa and the diffuse involvement.

71.

Answer: b

Common causes for pneumobilia include post-op, e.g. sphincterotomy or Whipple pancreaticoduodenectomy, biliary enteric fistula, pancreatitis, emphysematous cholecystitis. Most common causes of biliary enteric fistula include gallstone, post-op, uncommon causes include Peptic Ulcer Disease perforation into biliary tract, trauma.

Mesenteric infarction causes portal venous air.

72.

Answer:

a. true

b. true

c. ??true b/c decreased drainage into the hepatic veins --> decreased intrahepatic IVC pressure.

d. true

US chief role in management of cirrhosis is dx of portal HTN. Doppler identifies flow direction.

Stage II cirrhosis on angio is characterized by corkscrew appearance of hepatic artery branches. Portal flow is bidirectional. Stage III has wide spread corkscrewing of arteries and increased arterial flow.

Stage II, wedged hepatic venography, Stage IIA show opacification of portal v for 2-4s but eventual drainage into hepatic v. With Stage IIB, opacification of main or segmental portal v for more than 4s. Normal liver shows drainage into hepatic vein. Wedge hepatic venography gives sinusoidal pressure.

Collateral pathways lead to the IVC. ? increased blood flow to IVC--? increased pressure

73.

Answer: c. trauma

This question has also been asked as "What is the most common cause of fluid collection in the anterior pararenal space in a child who has had blunt trauma?"--answer : pancreatitis

On the other hand, in a child, following blunt trauma, the most common gastrointestinal injury involves the duodenum.

74.

Answer: b

Complications of ERCP.

Pancreatitis 1%

cholangitis 0.8

drug side effects 0.6

pancreatic abscess 0.3

GI injury 0.2

mortality 0.2

75.

Answer: a. hyperplastic

Hyperplastic polyps represent 75-90% of all gastric polyps. They are not premalignant, but they are associated with atrophic gastritis and 8-28% of patients with hyperplastic polyps have synchronous gastric carcinomas. They are usually smooth, sessile, round, and 5-10 mm in size. In addition, they are usually clustered in the fundus and body (i.e., multiple). The differential diagnosis includes leiomyomas, adenomatous polyps, and polyposis syndromes.

Adenomatous polyps (villous, tubular, tubulovillous) account for <20% of all gastric polyps. They are dysplastic lesions which may undergo malignant degeneration. 30-40% of patients with adenomatous polyps have a synchronous gastric carcinoma.

76.

Answer: b. chondroma

They are probably referring to Carney’s syndrome. This condition (24 reported cases, M:F=1:11) includes:

77.

Answer: c. cecum

78.

Answer: e rectum

79.

Answer: b. posterior lower midline pharyngeal diverticulum

Zenker diverticula originate in the midline of the posterior wall of the hypopharynx at an anatomic weak point known as Killian’s dehiscence =posterior hypopharyngeal diverticulum. It is an acquired mucosal herniation. At this location, immediately above the cricopharyngeus, there is a divergence between the fibers of this muscle and the inferior pharyngeal constrictor which is superior to the cricopharyngeus. During swallowing, increased intraluminal pressure forces mucosa to herniate through. The etiology of Zenker diverticula is not firmly established, but premature contraction or motor incoordination of the cricopharyngeus muscle is thought to play a major role. Their development presumably takes time, however, as they have not been reported in children. Carcinoma arises in 0.3% of pt with Zenker's

80.

Answer: c. contraction of the muscularis mucosa

Contraction of the muscularis mucosa gives transient 1-2 mm horizontal folds. This is often associated with reflux. Feline esophagus alone does not indicate esophagitis.

Secondary contractions of the esophagus are due to thoracic esophageal distention.

81.

Answer:

a. True

b. False

c. False

d. False

e. False

Hemangiomas classically are echogenic with posterior acoustic enhancement. They should not have demonstrable flow on Doppler; they are more common on the right; they are well defined. They occasionally can get a prominent central vein. Hemangiomas are hyperechoic mass with discrete margins, with possible acoustic enhancement. Color doppler demonstrates filling vessels in the periphery of the tumor but not significant doppler flow deep within the hemangioma

Answer:  a

Regenerating nodules can occasionally be appreciated on US and are hypoechoic.

Colon carcinomas are usually hypoechoic on US. If the colon ca is mucinous, can get calcifications.

Lymphoma of the bowel is usually hypoechoic. mural thickening. Lymphoma is usually hypo or anechoic but echogenicity is variable.

Breast ca is hypoechoic to the surrounding tissues. Kopans.

adenoma--adrenal- solid mass. can have calcification

hepatic- can be hyper, hypo, iso or mixed echogenicity.

            parathyroid- hypoechoic relative to thyroid

Tumors that calcify include mucinous ca of the colon or pancreas, bronchogenic ca, and breast ca. Mucinous adenocarcinoma of the colon is the most common primary neoplasm associated with calcified liver lesions

83.

Answer: b. pancreatitis

84.

Answer: e. target sign or pseudokidney sign in the right lower quadrant

The sonographic hallmark of acute appendicitis is the recognition of abnormal appendix. The abnormal appendix is noncompressible tubular structure which in the transverse plane has a "target" configuration.

85.

Answer: e. hepatic venoocclusive disease

Many gastrointestinal complications have been reported after transplantation. These include peptic ulcer disease; massive hemorrhage; colon perforation (in association with diverticulitis, CMV infection, or idiopathic); fecal impaction, sometimes leading to obstruction, ileus, or even colonic necrosis; or pancreatitis.

Specifically, for bone marrow transplantation, the following intestinal complications may occur:

Post bone marrow transplant pt are probably neutropenic and thrombocytopenic; therefore , are unlikely to be hypercoagulable and develop Budd Chiari.

86.

Answer: a. is pathognomonic for gastric carcinoma

No sign in gastrointestinal radiology has generated more confusion or disagreement than the meniscus sign of a malignant ulcer, which was originally described by Carman in 1921 and refined by Kirkland in 1934. The Carman-Kirkland meniscus complex is caused by a cancer straddling the lesser curvature of the gastric antrum or body in which the tumor is broad. Manipulation and compression of the lesion at fluoroscopy may result in the demonstration of a discrete ulcer crater that has a meniscoid configuration. The convex inner border of the meniscus may be quite irregular and is almost always directed toward the gastric lumen, whereas the concave outer border of the meniscus, representing the base of the broad, shallow ulcer, tends to be smoother and usually does not project beyond the expected gastric contour. A radiolucent halo may be seen adjacent to the meniscus as a result of apposition of the elevated edges of the tumor on the anterior and posterior walls. Although the Carman-Kirkland meniscus complex is a reliable radiologic sign of malignancy, it can be demonstrated in only a small percentage of all malignant ulcers of the stomach.

87.

Answer: c. lungs

Clinical manifestations of scleroderma include skin fibrosis and Raynaud’s (peripheral vasospasm). These are the most common and earliest manifestations.

The esophagus is eventually involved in approximately 90% (hypomotility in 50%). The smooth muscle in the distal half to two-thirds of the esophagus is replaced by fibrosis, resulting in diminished esophageal motility. Because the lower esophageal sphincter tone is severely decreased, gastroesophageal reflux commonly occurs, often resulting in peptic esophagitis and stricture formation.

Less common abnormalities are: renal failure, synovitis, basilar interstitial lung disease, and cardiac conduction abnormalities.

88.

Answer: b. adenocarcinoma

Cholangiocarcinoma exists in three distinct forms: as an infiltrative, stricturing process; a bulky exophytic tumor; or a polypoid intraluminal mass. On CT, tumor mass at the level of biliary obstruction is seen in approximately 70% of patients. Klatskin tumor refers to a cholangiocarcinoma occurring at the junction of the right and left hepatic ducts. Except for the rare anaplastic neoplasm, almost all cholangiocarcinomas are adenocarcinomas arising from bile duct epithelium

89.

Answer: a

Tumors that calcify include mucinous ca of the colon or pancreas, bronchogenic ca, and breast ca. Mucinous adenocarcinoma of the colon is the most common primary neoplasm associated with calcified liver lesions

90.

Answer: a. left gastric artery

Mallory Weiss tear

91.

Answer: a. cystic duct

92.

Answer: b. the fundus and c. the body of the stomach

93.

Answer: b. blind loop syndrome

94.

Answer: a. sprue

95.

Answer: b. MAI

96.

Answer: b. extrinsic to the circular muscle

97.

Answer: c. mastocytosis

Answer: b. left lateral decubitus

Pneumoperitoneum is best detected with left lateral decubitus (left side down leading to air lateral (actually superior) to the liver or supine cross table lateral (leading to air on the underside of the anterior abdominal wall).

99.

Answer: a. lesser omentum

The lesser sac is also known as the "omental bursa." The lesser omentum slings the lesser curvature of the stomach to the undersurface of the liver. The lesser sac lies behind the lesser omentum, stomach, and more inferiorly, the greater omentum. The lesser sac is anterior to the transverse colon and the transverse mesocolon.

100.

Answer: b. histiocytosis

The different manifestations of histiocytosis:

101.

Answer: c. postbulbar ulcer

In annular pancreas there is stenosis in the periampullary region with extrinsic defect on the medial margin of the 2nd portion of the duodenum.

A duodenal diaphragm (web) occurs in the 2nd portion of the duodenum near the ampulla of Vater. A thin radiolucent line extends across the duodenal lumen. There is proximal duodenal dilatation.

Duodenal diverticulum is an acquired lesion, usually at the medial border of the 2nd portion of the duodenum. (can be in the 3rd or 4th portion, however)

A postbulbar ulcer is usually located on the medial wall of the proximal descending duodenum above the ampulla of Vater. It can be difficult to demonstrate secondary to severe spasm. Edema and spasm often result in a smooth rounded indentation on the lateral wall of the duodenum opposing the ulcer.

102.

Answer: a. esophageal achalasia

Achalasia is due to decreased number of ganglion cells in Auerbach’s plexus. The etiology is unknown. 7% develop esophageal carcinoma. There is esophageal dilatation, stasis of esophageal contents, absence of primary peristalsis, and incomplete or absent lower esophageal sphincter relaxation. The distal esophagus is smooth, tapered, and beak-like. Incomplete emptying of the esophagus occurs, even when the patient is upright. There is slowly progressive dysphagia during the middle decades. Odynophagia and chest pain are uncommon. Most patients are between 20-40 y/o.

103.

Answer: b. most of the gastrin-producing cells are removed

Both the Billroth-I and Billroth-II operations removed the distal 2/3-3/4 of the stomach. Gastrin-producing cells are in the antrum, so all should be removed. Acid-producing (parietal) cells are located in the fundus and body, so only a portion are removed. The goal is to "excise the entire gastrin mechanism as well as a large portion of the parietal cell mass."

104.

Answer: b. secretin

Trypsinogen is secreted by the pancreas.

Secretin is the most potent stimulant for water and bicarbonate secretion.

Enterokinase is secreted by the duodenum and converts trypsinogen into trypsin.

Cholecystokinin is the most potent stimulant for protease secretion by the pancreas.

Gastrin is produced by G cells in the antrum of the stomach - it causes the parietal cells to secrete acid.

105.

Answer: d. hyperplastic polyp (present in at least 40%)

106.

Answer: b

Mastocytosis is characterized by the accumulation of mast cells. These pt have increased local and systemic release of histamine. There is increased output of gastric acid associated with duodenal ulceration and duodenitis. Bone manifestation is secondary to mast cell infiltration leading to fibroblastic activity and granulomatous rx. Can get osteopenia and bone destruction or osteosclerosis which involves mostly the axial skeleton

Multiple osteomas of the mandible, calvarium, or tubular bones can accompany Gardner's. This closely resembles familial polyposis coli. These pt have a 100-200 x increased risk of developing periampullary duodenal ca. Most pt are asymptomatic .

GI Section

The following are matching answers:

107.

1 c

2

3

108.

1 c

2 a

3 b

4 d

109.

Answer:

1. c

2. d ,e

3. b ,e

4. a

5. ??e--2,3,5 are all hamartomatous

(Gardner’s syndrome matched with c because a, b, d, and e don’t match and I guess keratin xanthoma fits with Jim Buck’s comment, "Other subcutaneous -omas also occur." (with FAPS))

1. Adenomatous Polyposis Syndrome

Peutz-Jeghers Syndrome

- according to Buck's AFIP notes, the polyps rarely occur outside the GI tract.

Cowden’s Syndrome (Multiple Hamartoma Syndrome)

Cronkhite-Canada Syndrome

Juvenile Polyposis

Ruvalcaba-Myhere-Smith Syndrome

110.

6. d

7. a

8. a

9.a

10.c

Inspissated meconium may obstruct the colon causing the mucous plug syndrome. Far fewer of these fetuses have CF than with meconium ileus.

Meconium ileus is obstruction and dilation of ileum from impaction of abnormal sticky and thick meconium of fetuses with cystic fibrosis.

Meconium peritonitis can be caused by volvulus, jejunum or ileal atresia or meconium ileus. Secondary to any GI perforation in utero. Results in dystrophic calcification.

Meconium Plug Syndrome is a form of neonatal intestinal obstruction secondary to failure of passage of meconium from the colon. Meconium plug is a result of colonic inertia rather than a cause of intestinal obstruction. Frequently is a presenting symptoms of Hirschsprung disease. It is rarely due to CF. Show signs of obstruction 2-3 day of life.

Small left colon is a functional disorder. Has a definite association with maternal diabetes. Vomiting, abd distension, and failure to pass meconium are symptoms in the neonatal period. Colon is dilated to the splenic flexure. Meconium is frequently within the left colon and distended transverse colon.

Meconium Aspiration is caused by aspiration of meconium stained fluid. happens 10% of deliveries but ,1% incidence of meconium asp. syndrome.

Persistent Fetal Circulation may be due to many reasons e.g. diaphragmatic hernia, meconium aspiration, unknown etiology. When severe, there is significant r-l shunting and hypoxia and acidosis.

111.

Answer:

11. a

12. b

13. c

14. d

15. e

16. f

MAI (MAC) is most likely to cause pseudo-Whipple’s disease which is a disseminated mycobacterial infection with an increased number of mesenteric and retroperitoneal lymph nodes. The lymph nodes are Periodic Schiff stain positive (like Whipple’s disease) but, unlike Whipple’s, the lymph nodes are also acid fast positive. In Whipple’s disease, the macrophages are filled with PAS and glycogen and gram-positive rods are seen - this disease responds to antibiotics.

Strep Bovis bacteremia have a high incidence of colorectal tumors.

112.

Answer:

17. c

18. d

19. e

113.

Answer:

20. c

21. a

22 d

Calcitonin is a biochemical marker for familial medullary carcinoma of the thyroid. MEN 2A consists of pheochromocytoma, medullary thyroid ca, parathyroid hyperplasia. 2B has pheochromocytoma and medullary ca but pt also have dysmorphic features.

Carcinoid tumors excrete multiple monoamines and peptides such as histamine, catecholamines, bradykinins, thachykinins, enkephalins, endorphins, vasopressin, gastrin, adrenocoricotrophin prostaglandins.

Clinical features of VIPoma include diarrhea, hypokalemia, hypochlohydria.

114.

Answer:

23. a

24. a

115.

Answers:

25. b

26. d and f

27. e

28. c

29. a

30. g

The esophagus is involved in 90% of cases of scleroderma. The proximal one third (striated muscle) remains normal, but the distal 2/3 (smooth muscle) is involved. There is a patulous LES with abnormal motility. In the small bowel, there can be atony and subsequent dilation (pseudoobstruction) and possible malabsorption. The small bowel and colon can get sacculations. "Hidebound" describes normal thickness folds with straightened bowel margins.

Crohns disease is characterized by transmural inflammation, fistulae, fissures, and linear ulcers. It is also associated with post-inflammatory polyps, or pseudopolyps.

Zollinger-Ellison syndrome occurs secondary to a gastrinoma which is most often a non-beta islet cell tumor in the pancreas. Most are malignant with metastases to the liver. It presents with severe (multiple and recurrent) peptic ulcer disease. 90% have ulcers and postbulbar ulcers are particularly suspicious. Gastric folds are markedly thickened (especially in the body and the fundus) from the high level of acid secretion. 50% of patients have diarrhea. Hypersecretion of acid leads to a large fluid volume which dilutes barium

Lymphoid hyperplasia is usually found in the ileum (and jejunum). Peyer’s patches are seen in the antimesenteric border and are oriented longitudinally.

Intramural hemorrhage gives the stack of coins appearance secondary to submucosal hemoglobin or edema. Other potential causes of the stack of coins appearance are: trauma, ischemia, XRT, bleeding diathesis, venous obstruction, hypoproteinemia, etc.

116.

Answers:

31. b

32. b

33. a

34. b

35. a and b

Typhlitis represents acute cecal inflammation in immunosuppressed patients (especially AML, ALL, AIDS, renal transplants).

Regional enteritis (Crohns disease) gives fissuring, perirectal and pericolonic abscess, pseudopolyps, etc.

117.

Answer:

36. a

37. c

Impaction of a gallstone in the cystic duct or neck of the gallbladder may cause common hepatic duct stenosis or obstruction. This is known as Mirizzi syndrome. PTC shows stenosis and displacement of the common hepatic duct. Compression usually occurs from the right side of the duct. Gallbladder carcinoma may produce similar defects in the CHD. In most cases of Mirizzi syndrome, there is an anomalous insertion of the cystic duct allowing a parallel arrangement of the cystic duct adjacent to the common hepatic duct.

Hydrops of the gallbladder can be caused by (among others):

118.

Answer:

38. b

39. c

40. a

Twining’s recess is seen in hypertrophic pyloric stenosis. It is associated with Diamond’s sign which is a transient tent-like cleft in the channel.

Valves of Houston are 3 transverse folds in the rectum.

Columns of Morgagni are vertically oriented folds in the anus. Superior to these columns is the pectinate line-- the junction between columnar and squamous mucosa.

119.

Answer:

41. c

42. b

43. a

44. a

45. a

Cystic pancreatic tumors may be classified into two broad categories -- microcystic adenoma (serous) and mucinous cystadenoma (macrocystic). Both are found more commonly in women, but only the microcystic adenomas are associated with von Hippel-Lindau syndrome. The microcystic type is more likely to occur in the head of the pancreas whereas the mucinous type is more commonly found in the body and tail.

The microcystic adenoma has no malignant potential. It is characterized by numerous small cysts, usually under 2 cm, but may have several larger cysts. When the cysts are numerous and very small, the mass may appear echogenic, due to the high number of tissue interfaces. It is usually vascular, and may demonstrate a central stellate scar, with or without calcification.

The mucinous cystadenoma, on the other hand, does possess a malignant potential and may develop into a cystadenocarcinoma. The cysts which characterize this lesion are usually large, and the tumor is typically hypo- or avascular.