GI differentials and notes
Terms
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- DDx – Gastric Fold Thickening
-
* Inflammation (eosinophilic, post RTx, corrosive, Crohn's)
* Infiltration (including CA)
* Ménétrier’s disease
* Varices (fundus)
Zollinger-Ellison syndrome
Amyloidosis
Lymphoid hyperplasia - DDx - Small bowel filling defect
-
* INFLAMMATION: - Nodular lymphoid hyperplas - Crohn's
* INFILTRATION: - Whipple's - Mastocytosis - Waldenstrom's
* NEOPLASM: - Lymphoma - Polyposis syndromes - DDx - Gastric filling defect (s)
-
* Mets (lung, breast, melanoma, renal)
* Polyps (syndromes)
* Gastroesoph varices
* Pancreatic rest (single, inf antrum) - DDx - Duodenal Filling Defects
-
*Benign mass (usu prox)- Adenoma, leiomyoma
*Malignancy (usu distal)- AdenoCA, mets
*Ectopic gastric mucosa, Prolapsed antral mucosa
*Brunner gland hyperplasia, lymphoid hyperplasia
*Varices
*Ectopic pancreas (usu distal)
*Other: Choledococele, annular panc [distal] - DDx – Coned Cecum
-
*Crohn’s (TI always involved)
*TB (TI usu involved)
*Amebiasis (TI not involved)
*UC (w/ backwash Ileitis)
*Appx, R-sided ticitis
*CA of cecum (and mets) - DDx – Dilated SB with Normal Folds
-
*Sprue
*Scleroderma
*Lactase Deficiency
*Obstruction / Ileus
*Vagotomy
*Meds: MSO4, Atropine, etc.
*Chaga’s disease - DDx – Regular Thickening of SB Folds
-
*Hemorrage (anticoag, hemophilia)
*Edema (low protein, angioneurotic)
*Lymphangiectasia
*Radiation
*Early Crohn's - DDx – Irregular SB Fold Thickening
-
WAG CLEM
*Whipple’s Dz
*Amyloid
*Giardiasis, Graft vs. Host
*Cryptosporidiosis
*Lymphoma
*Eosinophilic gastroenteritis
*MAI - DDx - Mesenteric mass
-
CRADLE
* Carcinoid -“spoke wheel†(DDx: desmoid)
* Retractile Mesenteritis
* Adenocarcinoma
* Desmoid
* LAD (Lymphoma, TB, Yers, Whipple’s, MAI)
* Everyone forgets metastases - DDx – Liver Lesion with Central Scar
-
*FNH - brief enh, scar hiT2, hot SC scan
*Fibrolamellar HCC - scar loT2, calcs
*Adenoma - heterogeneous enh
*Hemangioma - centripetal enh - Causes of HCC
-
WHAT causes HCC?
Wilson’s dz
Hemochromatosis
Alpha-1-antitrypsin
Tyrosinosis
Hepatitis
Cirrhosis
Carcinogens (aflatoxin, sex hormones, thorotrast) - DDx – Multiple Intestinal Polyps
-
*Adenomatous polyps
--FP (MC, screening)
--Gardner's (osteomas)
--Turcot (a/w CNS glioma)
*Hamartomatous Polyps
--Peutz-Jegher’s(usually SB)
--Cowden’s dz
--Juvenile polyposis
--Cronkhite-Canada syndrome
--Bannayan-Riley-Ruvalcaba
*Post-Inflammatory (filiform)
*Pseudopolyps - Staging – Colorectal CA
-
A: Limited to mucosa
B: Muscularis propria
-B1 into muscularis propria
-B2 thru muscularis propria
C: Lymph node mets
-C1 limited to bowel wall
-C2 into adipose tissue
D: Distant Metastases - DDx – Cholangitis
-
* Sclerosing (1° and 2° forms)
- Irreg bile ducts, "tics"
- 1°-idiopath. 10% get CA
- 2°-65% a/w IBD (usu UC)
* Oriental Cholangitis
- Postinf (clonorchis/ascaris)
- Extra & Intra dilat, calculi
* Ascending Cholangitis
- infection of obstructed ducts (E. coli > Klebs > Pseudom) - DDx – Hypervascular Liver Masses (seen in arterial phase)
-
Primary
- HCC (esp. Fibrolamellar)
- Hemangioma
- FNH
- Hepatic adenoma
- Hemangioendothelioma, hemangiopericyt
Metastases
- Neuroendocr: islet, carcinoid
- RCC
- Breast CA
- Thyroid
- Sarcoma
- Melanoma - DDx – Cystic Pancreatic Lesions:
-
Microcystic adenoma (Lil old ladies...)
VHL (renal & liver cysts)
Mucinous Cystadenoma /CA
Epithelial
Simple cyst
Pseudocyst
Duct Ectasia - DDx – Hypervascular Pancreatic Mass
-
Primary
- Islet cell
- SPEN
- Microcystic adenoma
METS
Adrenal, Thyroid, RCC, melanoma - Crohn's mimics
-
TCbY
Tuberculosis
Campylobacter
Yersinia enterocolitica - UC mimics
-
Amebiasis
Salmonella / Shigella
Ischemia
Pseudomembranous Colitis
Behcet’s -
Esophagus
Diverticular disease: -
pharyngocele
Zenker
Killian Jamieson
pseudodiverticula
epiphrenic -
Esophagus shows
Luminal narrowing
DDx? -
Webs
Plummer-Vinson
Vascular ring - Pulm sling anterior, aberrant R subclav posterior
Schatzki ring
Strictures (long list)
Cancer
Extrinsic compr (Ao, L bronch, L atrium, mediast mass) - Causes of esophageal strictures
-
*Reflux
*Tumor, Mets, Barrett's
*Meds, RTX, NGT, Lye
*Crohn's, Eosinophilic GEitis
*Scleroderma, Achalasia, Chagas -
Esophagus shows
high stricture
DDx? -
Barrett’s
RTX, meds
caustic ingestion
CA, mets
skin dz
Crohn’s -
Esophagus shows
Low stricture
DDx? -
Peptic stricture
Lower esophageal ring
Barrett’s -
Esophagus shows
Nodules/plaques
DDx? -
DIFFUSE - reflux, Candida, glycogenic acanthosis
LOCALIZED – Candida, superficial spreading CA, Barrett’s -
Esophagus shows ulcers
DDx? -
*DISTAL – reflux, Crohn’s
*SMALL, MID – Crohn’s, HSV, meds (tetra/doxycycline, KCl, Fe, quinidine, NSAIDs, vit C, Fosamax)
*GIANT – CMV, HIV -
Esophagus shows megaesophagus
DDx? -
Achalasia
Scleroderma
Chagas
Distal tumor or stricture -
Esophagus shows contrast extravasation
DDx? -
Esophagitis
Tumor
Vomiting (MW tear, Boerhaave)
TE fistula
Foregut dupl cyst w/comm to esophagus
Iatrogenic
Trauma -
Esophagus shows
corkscrew esophagus
DDx -
Diffuse esophageal spasm
Presbyesophagus -
Esophagus shows
Air-fluid level
DDx -
Hiatal hernia
Esophageal diverticulum
CA
Achalasia
Scleroderma -
Esophagus shows
Thickened folds
DDx -
Esophagitis
Lymphoma
Varicoid carcinoma
Varices -
Esophagus shows
Solitary filling defect -
INTRALUMINAL – food, foreign body, fibrovasc polyp, spindle cell tumor, leiomyosarc, adenoCA
TUMOR – leiomyoma, fibrovasc polyp, duplication cyst, papilloma, fibroma, hemangioma, SCC, adenoCA, spindle cell tumor, lymphoma, mets (breast, lung, KS, melanoma, RCC)
VARICES – uphill (portal HTN), downhill (SVC obstruction)
EXTRINSIC – lymph nodes, vessels, aneurysms, cysts -
Gastritis
seen in the stomach.
DDx -
H pylori
Erosive (lye, EtOH, stress, NSAIDS)
Granulomatous (Crohn’s, sarcoid, TB, histo, syphilis)
Eosinophilic
Hypertrophic (Menetrier’s, ZE syndrome)
Gastric ulcer (ZE syndrome, PUD, drugs)
RTX
Emphysematous -
Target lesions
seen in the stomach.
DDx -
Gastritis (aphthoid) – erosive (NSAID, EtOH), Crohn’s, infection (Candida, HSV, CMV)
Submucosal mets (large ulcer) – melanoma, KS > breast, lung, lymphoma
Solitary giant bullseye (very large ulcer) – leiomyoma, sarcoma, CA, solitary met, ectopic pancr, benign ulcer -
UGI surgery
seen in the stomach.
DDx -
*plication defect, afferent loop syndrome
*marginal ulcer, leak
*bezoar
*chronic gastritis, *malabsorption
*obstruction, intussusception (jejunogastric)
*gastric CA -
Filling defect
seen in the stomach.
DDx -
*bezoar, adenoCA
*lymphoma, leiomyoma/sarc, mets, KS
*endometriosis, carcinoid, lipoma
*polyps (hyperplastic #1), *varices
*ectopic pancreas, extrinsic compr from spleen/panc/liver -
Free air seen adj to the stomach.
DDx -
* Surgery & laparoscopy
* Perforated ulcer
* Perf distal bowel (IBD, diverticulitis, CA) -
Antral lesions seen in the stomach.
DDx -
AdenoCA, lymphoma, mets
Crohn’s, PUD
TB, sarcoid
HPS, pylorospasm
Antral web
Ectopic pancreas
Erosive gastritis, caustics -
Gastroenteric fistula
DDx -
PUD
Crohn’s
CA
Iatrogenic
Surgery -
Double pylorus seen
DDx -
Lesser curve antral ulcer
Crohn’s
Lymphoma -
Linitis plastica
DDx -
Scirrhous CA (#1)
Lymphoma, mets (esp breast), Pancreatic CA (direct invasion)
RTX, corrosive ingestion
Crohn’s, eosinophilic GEitis
TB, sarcoid
Syphilis -
Giant rugal folds in the stomach.
DDx -
* Lymphoma, mets
* Menetrier’s
* ZE syndrome
* Gastritis, eosinophilic GEitis, Crohn’s
* RTX
* infection
* varices (mimic) -
Filling defect in distal duodenum
DDx -
*benign lymphoid hyperplasia
*ectopic / annular pancreas
*ampulla of Vater
*malignancy
*edema w/impacted or passed gallstone
*choledochocele -
Filling defect in the duodenum which is soft and changing
DDx -
*choledochocele
*lipoma
*duplication cyst -
Duodenal benign tumors
(often 1st portion, asx) -
* Adenoma
* Leiomyoma
* Lipoma
* Villous adenoma
* Ectopic pancreas -
Malignant tumors of duodenum
(distal to 1st portion, sx) -
* AdenoCA at or distal to papilla
* Leiomyosarcoma
* Lymphoma
* Mets (melanoma, breast, KS, carcinoid) -
Target lesion in duodenum
DDx -
* Leiomyoma
* Leiomyosarcoma
* Met (melanoma, KS, breast, lung, lymphoma)
* Ulcer, ZE syndrome -
Luminal outpouchings in the duodenum
DDx -
* Ulcer
* Diverticulum
* Fistula (with GB or bile duct) -
Reverse figure 3 sign of the duodenum
DDx -
pancreatitis
pancreatic CA -
Notched duodenum
DDx -
Annular pancreas
Post-bulbar ulcer
Crohn’s
Post-op
Pancreatitis
Pancreatic CA -
Postbulbar narrowing of the duodenum
DDx -
*AdenoCA, lymphoma, mets
*Ulcer, duodenitis, Crohn’s
*Pancreatitis, pancr CA, annular panc
*Intramural tic, duplication cyst
*Hematoma, aortic aneurysm, SMA syndr -
Enlargement of Ampulla of Vater
(>15mm)
DDx -
Papillary edema (pancreatitis, ulcer, stone)
Ampullary CA
Choledochocele
Normal variant -
Adynamic ileus
DDx -
* Postoperative (#1)
* Inflammatory (often sentinel loop) – pancr, appy, GB, tics, peritonitis
* Metabolic – low K+, Ca++, Mg++
* Medication – morphine - Mechanical SBO causes
-
Adhesions
Hernia
Tumor
Gallstone
Inflammation w/stricture -
SB shows malabsorption with mainly thickened irregular folds
DDx -
* Whipple’s
* MAI, Strongyloides (prox), Giardia (jej), Cryptosp (jej)
* Amyloid
* GVH, lymphoma, mastocytosis
eosinophilic GEitis -
SB shows malabsorption with mainly dilated loops and normal folds
DDx -
* Sprue (#1)
* Obstruction / Ileus
* Scleroderma
* Medication -
SB shows thickened folds without malabsorption pattern
DDx -
Submucosal...
* Edema – ischemia, infection, RTx, hypoproteinemia, GVH
* Tumor – lymphoma, leukemia
* Hemorrhage – HSP, hemophilia, anticoag -
"Tubular" appearance of small bowel
DDx -
Cryptosporidium
Sprue (proximal)
Lymphoma
GVH
RTx
Ischemia
Strongyloides (proximal) -
Nodules of small bowel (multiple, but not "tiny" in size)
DDx -
*Mastocytosis, lymphoid hyperplasia
*Lymphoma, mets
*Polyps
*Crohn’s, eosinophilic GEitis
*TB or other infection
*Amyloid, lymphangiectasia
*Whipple’s, Waldenstrom’s -
Diffuse tiny nodules of small bowel
DDx -
Lymphoid hyperplasia (#1)
Hypogammaglobulinemia
Giardia
Whipple’s
Waldenstrom’s -
Shortened transit time seen in small bowel
DDx -
anxiety
hyperthyroid
medication (reglan)
partial SBO -
Small bowel tumors
Benign and maligant types -
BENIGN – adenoma (#1), leiomyoma (#2), lipoma, hemangioma, neurogenic, Brunner glands, heterotopic pancr tissue
MALIGNANT – mets (melanoma, RCC, breast, KS), carcinoid (#1 1ary tumor), lymphoma, leiomyosarc (large ulcerating), adenoCA -
Small bowel stricture:
DDx overall, and for focal stricture with "shouldering" -
* Crohn’s
* Lymphoma, mets, adenoCA
* Infection, RTX
* Ischemia
* Extrinsic compression
* NSAIDs
*** Focal w/shouldering – adenoCA (#1), breast mets, TB -
Coiled spring appearance of small bowel
DDx -
Intussusception
Intramural hematoma -
Large ulcerated mass (endoexoenteric)
DDx -
* Lymphoma
* Leiomyosarcoma
* Mets (melanoma)
* Interloop abscess - Intraluminal filling defects of small bowel
-
* Parasites (Ascaris, tapeworm)
* Bezoar
* Foreign body
* Gallstone
* Lipoma - Causes of enteric fistulas
-
Crohn’s
diverticulitis
CA
TB
radiation
surgery - Serosal lesions of small bowel
-
Carcinoid
Serosal mets
Diverticulitis
Appendicitis
Endometriosis - Causes of mesenteric ischemia
-
*occlusive – emboli (Afib, LV aneur), art thrombosis (athero), venous thrombosis (portal HTN, pancreatitis, tumor, hypercoag state, drugs)
*nonocclusive – low flow state - Features of Crohn's dz in the colon
-
Fold and wall thickening
Nodular pattern (cobblestone)
Aphthoid ulcers
Filiform polyps
Fistulas, strictures, pseudosacc
Mesenteric fat stranding, LAD
String sign, separated loop (omega sign)
Asymmetric, skip lesions -
Polypoid filling defects of the colon
DDx -
*Polyps - hyperplastic (#1), adenomatous (#2), hamartomatous, post-inflamm
*Polyposis – FAP, Peutz-Jeghers, juv polyposis, Turcot, Cronkhite-Canada, Cowden
*lymphoma
*pneumatosis -
Colonic wall thickening (thumbprinting)
DDx -
HEMORRHAGE – ischemia, HSP, hemophilia, anticoag
TUMOR– lymphoma, leukemia
EDEMA– IBD, infection (pseudomembr colitis, CMV, E Coli, Salm/Shigella, amebiasis, typhlitis) -
Long segment narrowing of colon
DDx -
scirrhous adenoCA
lymphoma
IBD
ischemic stricture
radiation - Pseudosacculations of colon
-
Crohn's
scleroderma
ischemia -
Pneumatosis coli
DDx -
Pneumatosis cystoides
- COPD
- asthma
- CF
- CVD
- steroids
Pneumatosis intestinalis
- infarct
- NEC
- toxic megacolon
- typhlitis - Deep ulcers of colon
-
*UC, Crohn’s
*Behcet’s
*infectious (amebiasis, TB, Salm/Shigella, histo, Candida, herpes, CMV)
*Ischemic colitis
*RTx -
Circumferential (apple core) or asymmetric narrowing of colon
DDx for single and multiple -
Tumor – adenoCA, serosal mets (stom, ova, colon, panc)
Inflamm – diverticulitis, IBD, TB, amebiasis
Other – endometriosis, pelvic abscess, epiploic appendagitis
Multifocal – lymphoma, serosal mets, TB, amebiasis, Crohn’s, endometriosis -
Ahaustral colon
DDx -
Cathartic abuse (usu R colon)
UC, Crohn’s
Amebiasis
Scleroderma
RTx
Prior ischemia -
Aphthoid ulcers of colon
DDx -
Crohn’s
amebiasis
Behcet’s
CMV
herpes
TB
Yersinia (TI) - Characteristics of ulcerative colitis
-
*ahaustral, granular mucosa
*filiform polyps, crypt abscesses
*starts in rectum, continuous spread, backwash ileitis
*strictures (worrisome) -
Presacral space widening:
( >2cm )
DDx -
*rectal inflammation (colitis, RTX)
*infection
*tumor
*pelvic lipomatosis
*edema or hemorrhage - Megacolon DDx
-
*toxic – pseudomemb colitis, IBD, amebiasis
*acute distension – obstructive CA, ileus, volvulus
*chronic – laxative abuse, Ogilvie syn, congenital Hirschsprung’s, Chagas, neuromuscular dz (Parkinson, DM, scleroderma, amyloid), hypothyroid -
Cecal filling defect and nonfilling appendix
DDx -
carcinoid
appendicitis
appendix stump
mucocele - Coned cecum DDx
-
Crohn’s
lymphoma / mets
TB
amebiasis
typhlitis -
Ileocecal deformities
DDx -
IBD
amebiasis (spares TI), TB
typhlitis
lymphoma, adenoCA
carcinoid
intussusception -
Solid mass in liver
DDx -
* Hemangioma, FNH, adenoma
* HCC, mets, lymphoma
* Regenerating nodules
* Focal fat -
Cystic mass in liver
DDx -
* Infectious – pyogenic abscess, amebiasis, Echinococcus
*Benign – simple cysts, ADPKD, biliary cystadenoma, biloma, intrahepatic GB
*Malignant – necrotic tumors, cystic mets, cholangioCA - Increased density of liver
-
*Hemochromatosis, Wilson’s
*Glycogen storage dz
*amiodarone, chemo, thorotrast
*anemia
*regenerative nodules - cirrhosis (low T2) -
Enlarged ileocecal valve
( >3cm )
DDx -
Lipomatous infiltration (#1)
lipoma
Crohn’s
lymphoma
prolapsing ileal neoplasms - Gas in liver:
-
*pneumobilia – ERCP, surgery, penetrating ulcer, gallstone ileus, CA, bowel obstr
*PV GAS– necrosis > IBD, abscess, obstruction, ulcer, iatrogenic, liver transplant
*abscess
*emphysematous cholecystitis - Decreased density of liver
-
fatty liver – obesity, alcohol, DM, steroids, chemotherapy
radiation-induced -
Liver shows mottled density without a focal mass
DDx -
*passive congestion
*Budd-Chiari
*geographic fatty infiltration
*hepatoma
*lymphoma -
Hypervascular liver mass
DDx -
Hemangioma, hemangioendothelioma
CholangioCA
HCC
Mets (melanoma, RCC, sarcoma, islet cell, thyroid, carcinoid, breast, pheo) -
Hyperechoic liver lesion
DDx -
ROUND
-- hemangioma
-- mets (hypervasc & Ca++)
-- HCC, fibrolamellar HCC
-- focal fat, lipoma, AML
LINEAR – pneumobilia, PV gas, biliary ascariasis
MULT PUNCTATE FOCI – hepatitis, granulomatous inf, PCP, biliary hamartomas, pneumobilia, PV gas, vascular calcs -
Multiple hypoechoic foci in the liver
DDx -
TUMOR– mets, lymphoma, HCC
INFECTION– pyogenic, amebic, Echinococcus, Candida, Schistosomiasis
OTHER– regenerative nodules in cirrhosis, sarcoid, extramedullary hematopoiesis, hematomas, hemangiomas - Delayed retention of contrast in a liver lesion
-
CholangioCA
Hemangioma
Fibrous tumor
Scar (FNH, adenoma, fibrolam HCC, hemangioma) -
Hepatic hemorrhage
DDx -
iatrogenic
trauma
adenoma
HCC
pregnancy -
Extrahepatic biliary dilatation
DDx -
*Intrapancreatic (#1) – pancr CA, calculus, chronic p-itis
*Suprapancreatic – cholangioCA, metastatic LNs
*Portal – cholangioCA, GB CA, surgical strictures, hepatoma
*Choledochal cyst - Types of biliary obstruction
-
*Tumor – abrupt duct termination, mass adj to duct. Bil dil in one lobe of liver - Klatzkin tumor!
*Pancreatitis - smooth, long tapering
*Stone – calculus seen, meniscus, intrahepatic dil
*Cholangitis
*Caroli’s
*Biliary cystadenoma -
Filling defects in bile duct
Possible causes -
stone
blood clot
parasite
sludge
tumor
(on ERCP - air bubble) - Hemobilia DDx
-
iatrogenic
tumor
trauma
infection - Biliary system shows irregular wall and filling defects
-
Cholangitis
- HIV
- oriental
- ascending -
Pancreatic duct disease
-Stricture
-Cystic dil & side branches
-Variants -
* Stricture – pancreatic CA, chronic pancreatitis
* Cystic dil & side branches – chronic pancreatitis, IPMT
* Variants - annular pancr, pancr divisum - Post-cholecystectomy bile leaks are caused by...
-
cystic duct remnant
duct of Luschka -
GB wall thickening
( >3mm)
DDx -
* Diffuse – nonfasting, acute or chronic GBitis, portal HTN, low albumin, hepatitis, AIDS (cryptosp, CMV, MAI), ascites
* Focal – GB CA, mets (melanoma), cholesterol polyp, adenomyomatosis, tumefactive sludge, AIDS - Hyperechoic foci in GB wall
-
Calculus
Polyp
Cholesterol
Emphysematous cholecystitis
Porcelain GB - Dense GB on CT
-
Vicarious excr of contrast
calculi
milk of calcium
oral cholecystogram
hemorrhage -
Biliary enteric fistula is seen.
What are possible causes? -
* Cholecystitis (g-stone ileus)
* PUD
* Tumor
* Trauma / surgery
* Crohn’s - Cystic lesions of the pancreas
-
**Tumor **
microcystic adenoma, mucinous cystadenoma, IPMT, SPEN, islet cell tumor
** Cyst **
simple, pseudocyst, ADPKD, VHL, duct ectasia
** Abscess ** - Obstruction of the colon
-
CA
diverticulitis
volvulus
impaction
hernia - Splenic cyst ddx
-
*primary (congenital, true cyst)
*secondary (Ca++, false)
prior infarct, trauma, infection, echinococcus, pancreatic pseudocyst - Low density lymph nodes in abdomen
-
TB / MAI
lymphoma
testicular tumor
mucinous adenoCA
Whipple’s dz - Multiple liver lesions
-
* abscess
* cystic metastases
* intrahepatic biloma
* Caroli disease
* hepatic cysts
* bile duct hamartoma
* undifferentiated sarcoma
* biliary cystadenoma or cystadenocarcinoma
* cavernous hemangioma
* hydatid cyst
* intrahepatic hematoma