1. 

C

At least some of the small bowel valvulae probably cannot be completely effaced as we count the valvulae/inch when a small bowel enema (enteroclysis) is done. According to Hans Herlinger's book on the small bowel, jejunal loops cannot be effaced but ileum can be.

2.

a.  T

Focal nodular hyperplasia is twice as common in females.

b.  F

Focal nodular hyperplasia does not commonly bleed, but can bleed if it ruptures through the liver capsule causing hemoperitoneum.

c.  T

Focal nodular hyperplasia is the only hepatic tumor that contains Kupffer cells.

d. F

e.  F

...as long as contrast-enhanced CT or MRI is utilized

Focal nodular hyperplasia -- overview

Focal nodular hyperplasia is twice as common in females.  FNH can bleed if it ruptures, causing hemoperitoneum.  The incidence of rupture and bleeding rises to 14% if the patient is on oral contraceptives. Oral contraceptives do not cause FNH, but exert a trophic effect on its growth  Focal nodular hyperplasia is the only tumor that contains Kupffer cells.  It is multifocal in 20% (and thus 80% are solitary).  On non-enhanced CT (NCCT), focal nodular hyperplasia may be isodense to surrounding liver parenchyma or have slightly decreased attenuation  - this changes to isodense to hyperdense with contrast injection (CECT). Lesions are usually well demarcated with MRI. Less than 1/3 of cases present because of clinical symptoms, most are incidentally found.

3. 

D

Lymphogranuloma venereum -- Overview

Lymphogranuloma venereum is more common in males (3-4:1).  It is commonly symptomatic with rectosigmoid narrowing, deep ulcers, and fistulae.  It is caused by the organism Chlamydia trachomatis, which is not a retrovirus.   Treatment with tetracycline in the acute phase is successful before scarring. Gonococcal proctitis has a similar radiographic appearance.

The clinical spectrum ranges from the asymptomatic carrier state when a primary painless vesicle forms and resolves to clinical symptoms that include bloody diarrhea, rectal pain, and tenesmus.  If left untreated, deep ulceration, strictures, and rectovaginal fistulas can form.

4.

a. T

b. F

About 60 % are associated with cholecystoduodenal fistulas.

c. F

Overall incidence of intestinal obstructions from gallstone ileus is from 1-5 %, however, this reportedly increases to 20-25% in the 65-70 year age group.

d. T

e. T

Radiographically, gallstone ileus is characterized by air in the biliary tree, intestinal obstruction and the presence of a radiopaque gallstone surrounded by intestinal gas in an obstructed bowel loop.

Gallstone ileus -- overview

Gallstone ileus occurs in the setting of chronic cholecystitis and refers to erosion of a gallstone into the GI tract with the subsequent development of bowel obstruction. It is more common in women (4-7:1).  About 60 % are associated with cholecystoduodenal fistulas.  Its incidence of intestinal obstructions is from 1-5 %, however, in older individuals this increases (e.g.,  20 to 25 % in the 65 to 70 year age group, respectively).  The most common site of obstruction is the terminal ileum (60-70%) because this is naturally the narrowest portion of the small bowel.  Radiographically, gallstone ileus is characterized by air in the biliary tree, intestinal obstruction and the presence of a radiopaque gallstone surrounded by intestinal gas in an obstructed bowel loop.

5.

B

Focal fatty infiltration has no mass effect and thus vessels are not displaced nor does the liver bulge. There is no contrast enhancement. Most often it occurs as a low attenuation area next to the falciform ligament as seen on CT. Conversely, focal fatty sparing (within a fatty liver) is most commonly seen next to the gallbladder fossa.

6.

a. T

b. F

c. F

d. T

e. T

f. F

Hepatic hemangiomas

Hepatic hemangiomas are the most common benign liver tumor and 2nd most common liver tumor after metastasis.  They are much more common in females.  They can be imaged with nuclear medicine techniques and are best imaged if larger than 2 cm (70-90% are detectable >2 cm). With Tc-99m RBCs they are usually cold (isointense) on the arterial phase and fill-in later with increased activity on 1-2 hour delayed images. As written, the question on SPECT is true. However, if the question were "only seen > 3 cm," the correct response would be false.  Additional (delayed) images on nuclear imaging beyond four hours will decrease the false negative rate. Hepatic hemangiomas are cold on sulfur colloid. Three methods of RBC labeling with Tc-99m exist: in vivo, modified in vivo, and in vitro. In vivo is easiest and fastest but provides the least intense signal/uptake. It is probably "adequate" for this use, however

7.

a. T

Usually the lower esophagus drains via left gastric vein into the portal vein.

b. F

The IMV can shunt blood from the splenic vein to the hemorrhoidal veins in the pelvis. Both the splenic vein and the IMV have their own potential pathways for shunting.

c. T

Esophageal varices arise from the dilated left gastric (coronary) veins and drain into systemic veins of the thorax (hemiazygous, azygous, intercostal).

d. F

Collateral in portal vein hypertension include:

1) Portal vein to coronary (left gastric), short gastric, IVC, hemiazygous;

2) Coronary vein to azygous, hemiazygous, vertebral;

3) IMV to inferior and middle hemorrhoidal veins.

4) Lienorenal.

8.

E

The taenia coli are smooth muscle in an outer longitudinal layer that forms part of the muscularis externa (and are not mesenteric or anti-mesenteric). When contracted continuously, they form the colonic haustrations of the cecum and colon. The serosa of the colon is the attachment site for the appendices epiploicae.

9.

a. F

The spleen may be enlarged but is of low attenuation on NCCT.

b. T

c. F

There is no dilation of the bowel, nor ulcers. Transit time is normal.

d. T

e. F

On CT one sees large bulky 3-4 cm low-density lymph nodes in the mesentery and retroperitoneum (not within the bowel wall or lumen).

Whipple's Disease -- an overview

Whipple's Disease is a chronic multi-systemic disorder which has PAS positive material with foamy macrophages in the submucosa of the jejunum as well as fat deposits that cause lymphatic obstruction.  It is more common in men by 9:1. The spleen may be enlarged but is of low attenuation on NCCT.

Clinically, patients may have a non-deforming arthritis (65-95%) that can precede the disease in a small percentage of patients by up to 10 years.  Skin pigmentation, like that found in Addison's disease, can also be seen.  Also will see malabsorption, steatorrhea and weight loss.

On CT, one sees large bulky 3-4 cm low-density lymph nodes in the mesentery and retroperitoneum (not within the colon).  Moderate thickening of the jejunum and duodenum is found secondary to the submucosal infiltration due to the PAS positive material with foamy macrophages and the lymphatic obstruction.  Can see micronodularity of the small bowel with hypersecretion.  There is no dilation of the bowel or ulcers.  Transit time is normal.  Treatment is with long-term tetracycline.

10.

a.  F

b.  T

c.  F

d.  T

Absolute contraindications to glucagon are:

(1) Patients who have allergy or hypersensitivity to it.

(2) Patients with pheochromocytoma.

(3) Patients with insulinoma (precipitous glucose drop).

Brittle diabetes is a relative contraindication.

Glucagon

Glucagon is naturally made by the alpha cells of the pancreas secondary to low blood glucose levels. Glucagon increases 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 sphincter of Oddi at the papilla (ampulla) of Vater relax with injection of glucagon.

Dose/effects:

0.1 mg - stomach and duodenal hypotonia

0.25 mg - small bowel hypotonia

1.0 mg - colonic hypotonia

Glucagon contraindications

Absolute:

1) Patients who have allergy or hypersensitivity to it

2) Patients with pheochromocytoma

3) Patients with insulinoma (precipitous glucose drop)

Relative:

4) Brittle diabetics

11.

C

All of the other choices, as well as phenophthalein and aloin, can cause cathartic colon. 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.

12.

E

13.

C

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 (such as might occur immediately after the radiology boards). 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. 

14.

a. T

A filiform polyp characteristically has a branching pattern and looks like strands of mucus. It is secondary to residual inflamed and / or hyperplastic or reparative tissue which protrudes into the lumen

b. T

c. F

A filiform polyp is a nonspecific histological polyp seen in inflammatory bowel disease. The polyp itself is not precancerous; however, remember that the risk of colon cancer is increased in inflammatory bowel disease.

d. F

A filiform polyp can cause intussusception in children; however, the most common cause in kids is idiopathic.

e.  F

15. 

C

Intramural pseudodiverticulosis is due to dilated excretory ducts.

Intramural esophageal pseudodiverticulosis

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.

Up to 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.

16.

C

Pathologists use nuclear pleomorphism, number of mitoses, and presence of necrosis to distinguish atypical from typical carcinoid. Radiographically, we cannot make a distinction unless metastases are present, which would be atypical.

17.

a. F

Herpes esophagitis presents with scattered discrete small ulcerations on a background of smooth and normal appearing mucosa.

b. T

The most common complication of HIV-seropositive patients is oral candidiasis. Early candidal esophagitis characteristically shows diffuse (sometimes "shaggy") irregularity of the mucosa. On endoscopy, the characteristic appearance is a multitude of plaque-like lesions. There can be comorbid infection by other agents such as CMV or herpes.

c. F

More advanced oral candidiasis is characterized by a cobblestone appearance with irregular plaques.

d. F

The findings of CMV esophagitis are distinctly different from those in Candida. CMV causes large discrete ulcers with normal intervening mucosa.

e. T

Steroids will exacerbate this condition especially since most patients are immunocompromised. Treat with Mycostatin in most cases.

18.

C

The ileum is involved in 10-25% ("backwash ileitis").

Ulcerative Colitis

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").

more common than Crohn’s

4 times more common in whites

2-4 times increased in Jews

peak ages 15-25 and 55-65

urban > rural

familial pattern

mucosal granularity and stippling

collar button ulcers

haustral thickening or loss

inflammatory polyps

contiguous circumferential disease

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

most common cause of death directly related to ulcerative colitis

liver: hepatitis, sclerosing cholangitis, cholangiocarcinoma, fatty infiltration

musculoskeletal: arthritis, AS, HOA, AVN

mucocutaneous: pyoderma gangrenosum, erythema nodosum

renal: nephrolithiasis, amyloid

hematologic: anemia, arteritis, thrombocytosis

19.

D

Fibroepithelial polyps are found in the ureter. Inflammatory esophagogastric polyps are seen in GERD and frequently straddle a HH. 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 GERD have abnormal motility.  

20.

a. F

Historically, only 10-20% of esophageal carcinoma is adenocarcinoma, but the ratio over the last 5-10 years seems to be changing in favor of adenocarcinoma.

b. T

c. T

Tylosis is characterized by hyperkeratoses on the palms and soles.

d. F

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.

e. T

Between 1-15% of patients with head and neck cancer develop an esophageal squamous cell cancer.

Carcinoma of the Esophagus

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 exposure.  The Plummer-Vinson (?Patterson - Kelly) syndrome, which consists of dysphagia, iron deficiency anemia, and mucosal lesions of the mouth, pharynx, and esophagus, esophageal web, spooning of the nails, achlorhydria (no gastric acid) 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 squamous cell cancer.

21.

C

Cronkhite Canada Syndrome is nonhereditary, characterized by nonneoplastic, nonhereditary inflammatory polyps (as in juvenile polyposis) associated with ectodermal abnormalities. Clinically one sees: Exudative protein-losing enteropathy; diarrhea (disaccharidase deficiency, bacterial overgrowth in small intestine); severe weight loss, anorexia; abdominal pain; nail atrophy; brownish macules of hand and feet; alopecia. 

22.

a. F

b. T

c. F

d. T

e. T

Crohn's Disease

Idiopathic inflammatory disease with granulomatous change

Can effect any part of the GI tract

Peak 15-25 years old

M=F

Familial tendency

Small bowel affected in 80% - Terminal ileum most common location

Small bowel and colon in 50%

Isolated to colon in 15- 20%

Isolated to perianal area in 2-3%

Aphthoid ulcers

Transmural progression

Long linear ulcers on the mesenteric border

Sacculations anti-mesenteric

Inflammatory polyps, pseudopolyps, filiform

Cobblestone pattern

Skip lesions

Distal ileum preferred site

Dismal prognosis

Strictures

Abscess

Fistulas - terminal ilium most common site

Increased incidence of carcinoma (less than ulcerative colitis )

23.

C

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. Regarding the other answers:

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. "A" ring = contracted/hypertrophied muscles in response to an incompetent gastroesophageal sphincter. "B" ring = sling fibers representing U-shaped thickening of inner muscular layers. The best technique to detect a muscular ring is a prone single contrast examination. 

24.

B

Obstruction is not strongly associated with polyps, although occasionally a large one will serve as the lead point for an intussusception. Malignant potential of colonic polyps: Under 5 mm = 0%; 5-9 mm = 1%; 10-20 mm = 10%; greater than 20 mm = 50%

25.

a. F

Adenomas are almost always seen in women. Hepatic adenoma is rare benign neoplasm and is the most common hepatic tumor in young women. Commonly occur secondary to oral contraceptive pills and will not occur in men unless taking anabolic steroids. The risk of developing an adenoma increases with the duration and strength of the oral contraceptive pills. Hepatic adenoma can regress or completely disappear following withdrawal of oral contraceptives or hormonal therapy.

b. T

Adenomas are almost always seen in women. Patients present with mass effect, pain, or hemmorhage.

c. T

In infants and children hepatic adenoma is a vascular tumor and is usually secondary to a metabolic condition called type 1 glycogen storage (von Gierke's) disease. Von Gierke's disease is where glucose is continually stored within hepatocytes.

d. T

MRI appearance is heterogeneous if there is hemorrhage. Areas of increased T1 signal contain either fat, or methemoglobin from hemorrhage. There is also increased signal on T2. Low signal intensity of adenoma when seen on T1 is secondary to necrosis.

e. T

In nuclear medicine, hepatic adenomas are cold (have a low uptake) on Tc-sulfur colloid imaging due to the absence of Kupffer cells. Normally hepatic adenoma consists of atypical hepatocytes containing areas of bile stasis and focal hemorrhage or necrosis. It does not contain bile ducts or Kupffer cells. In distinction, focal nodular hyperplasia has hepatocytes and Kupffer cells.

26.

D

Meckel Diverticulum

Meckels is a remnant of the vitelline duct (omphalomesenteric duct, vitello - intestinal duct).

It occurs on the antimesenteric ileal border within 100 cm of the ileocecal valve.

15% contain ectopic gastric mucosa or pancreatic tissue.

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%.

Hemangioma
Appendicitis
Gastric ectopia
Urinary obstruction
Intussusception
Duplication of bowel
Inflammatory bowel disease

27.

a. T

Ileal dysgenesis is found in adults and is a segmental dilatation affecting the distal ileum.

b. F

Ileal dysgenesis is probably developmental in origin, a supposition supported by the presence of ectopic gastric mucosa or other aberrant mucosal linings in the abnormal segment. Segmental dilatation in kids, which is a different disease, is thought to be secondary to a neuromuscular disorder.

c. T

There is focal atonicity.

d. T

Patients present with obstructive symptoms. On barium exam, there is a dilated focal segment of ileum and occasionally an ulcer.

e. F

Bleeding is not a common presentation.

28.

a. T

b. F

c. T

d. F

AIDS Cholangitis

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.

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.

29.

C

"Hyperplastic cholecystosis" is a spectrum of benign non-neoplastic noninflammatory GB abnormalities which include ademomyomatosis, cholesterolosis and cholesterol polyps. Ademomyomatosis of the gallbladder is an exaggeration of normal infolding of luminal epithelium (creating Rokitansky-Aschoff sinuses, which fill on oral cholecystogram) and is associated with proliferation of smooth muscle, causing marked thickening of the GB wall. It can involve the entire GB, but is more commonly segmental (fundus), and can be confused with cholecystitis or gallbladder carcinoma. Cystic spaces are seen with ring down (comet tail) artifact on ultrasound projecting from nondependent surface of GB wall. 

30.

a. F

Sclerosing cholangitis is NOT characterized by amyloid in a periductal distribution.

b. T

c. T

15 % of patients with primary sclerosing cholangitis develop sclerosing cholangiocarcinoma.

d. T

Sclerosing cholangitis can occur either as a primary form, idiopathic or associated with IBD. 70 % of patients with primary sclerosing cholangitis have ulcerative colitis.

e. T

A small percentage of patients with sclerosing cholangitis have an associated fibrosing syndrome involving the retrobulbar area (orbital pseudotumor), salivary gland, thyroid gland, and blood vessels. Other associations include sicca complex, Riedel's struma, retroperitoneal fibrosis, and mediastinal fibrosis. However none has been reported consistently.

31.

a. T

Diverticular outpouchings vary in size and are a characteristic and pathgnomonic feature of PSC. They appear to develop as herniations adjacent to strictures, whereas others arise as mucosal extensions into a thickened duct wall. Sclerosing cholangitis appears on cholangiography as multiple strictures in the intra- and extrahepatic biliary tree (classic "beaded" appearance) with "pruning" of the normal branching pattern, nodular duct walls ("cobblestone"), and diverticula and pseudodiverticula (pathgnomonic).

b. F

c. F

d. T

e. T

In sclerosing cholangitis, chronic obliterative fibrotic inflammation involves the intra- and extrahepatic bile ducts. The CBD is almost always involved.

32.

a. F

A greater number of patients are diagnosed earlier because of markedly elevated serum alkaline phosphatase. Natural history is variable but usually progressively downhill. No known therapy has been proved effective short of liver transplantation.

b. T

70 % of patients are males and 70 % of these patients are less than 45 years.

c. F

d. T

The stronger association is with UC.

33.

C

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

Benign causes:
    1) gas dissecting from patients with obstructive lung disease
    2) gas entry into the bowel wall from the lumen (ulcer/tear/obstruction) IBD

Malignant causes: (often associated with portal venous gas)
    1) ischemic
    2) inflammatory (ulcer, IBD, collagen vascular disease, Whipple disease)
    3) infection

34.

a. T

b. T

c. T

Inflammatory bowel disease in general is a known cause.

d. F

e. T

Pseudomembranous colitis is a known but rare cause of toxic megacolon.

f. F

35.

B

It is advised to wait 5 days. Also advised to use single contrast barium enema for, 1) Hirschsprung's, 2) Acute diverticulitis, 3) High grade colonic obstruction, 4) colonic fistula, and 5) ischemic colitis.