QUESTION-1:
42 yo with faint abdominal pain:
Correct Answer: Lymphoma
- Irregularly thickened posterior gastric wall
- Dx-Lymphoma
Differential Diagnosis:
- Carcinoma / lymphoma / metastases
- Benign tumor (leiomyoma, lipoma)
- Benign ulcer
- Gastritis (infectious, Menetrier’s
Pearls:
- Linitis Plastica-usually diffuse wall thickening with narrow lumen.
- Management
- Endoscopy, biopsy
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Correct Answer Explanation
QUESTION-2:
50 yo man with known NF1:
Correct Answer: Gastrointestinal stromal tumor
Differential Diagnosis:
- Leiomyoma (if esophagus) / lipoma / sarcoma
- Exophytic gastric carcinoma
- Lymphoma
- Management
- Excision
- PET to follow response to Gleevac
- Larger size = poorer prognosis
Pearls:
- Well-circumscribed, exophytic mass from submucosal Cajal “peristaltic pacemaker” cells
70% stomach, but can arise anywhere in GI tract
stomach: 70% (most common gastric sarcoma)
Other consideration: Carcinoid; common in the small bowel; usually hyper enhancing
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QUESTION-3:
Severe abdominal pain:
Correct Answer: Gastric volvulus
Differential Diagnosis:
- Organ axial: #1 common, rotation around longitudinal axis of stomach (line connecting pylorus & fundus)
- Mesenteroaxial: Less common & but morbidity, rotation about mesenteric axis (line connecting greater & lesser curvatures)
- Management: Emergent detorsion, gastropexy vs gastrectomy (necrotic) 30% mortality if treatment del
Pearls:
- Large hiatal hernia, stomach wall edema & gas, beaking of stomach
- UGI confirmed malposition of fundus
- Severe epigastric pain, violent retching without emesis
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QUESTION-4:
Which of the following causes the greatest amount of pancreatic secretions?:
Correct Answer: gastrin
- Gastrin: 17 amino acid peptide amide produced in antral cells + G-cells of pancreas effects on pancreas: strong increase in enzyme output. [source: Dahnert 5th p 779]
- secretin: produced in duodenal mucosa; effects on pancreas: weakly stimulates enzyme secretion
- CCK: produced in duodenal + upper intestinal mucosa effects on pancreas: stimulates pancreatic enzyme secretion.
[source: Dahnert 5th p 779]
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QUESTION-5:
History of recurrent right upper quadrant pain:
Correct Answer: Status post ERCP
Differential Diagnosis:
- Enterobiliary instrumentation (ERCP)
- Portal venous gas & bowel obstruction (ischemia)
Management:
Surgical:Remove ectopic gallstone, cholecystectomy, biliary fistula excision if fistula present
Pearls:
- Central hepatic gas (biliary), multiple air-fluid levels, round calcific density in small bowel
- Rigler triad: Biliary gas, ectopic gallstone, bowel obstruction.
- May see Rigler triad on plain radiograph.
- Terminal ileum: most common
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QUESTION-6:
Chronic mid abdominal pain:
Correct Answer: Carcinoid
- Calcified, stellate mesenteric mass w/ fat stranding
- Neuroendocrine tumor: increased serotonin flushing, diarrhea, wheezing
- 90% distal ileum region; liver metastases
Management:
- Excision
- 90% 5-yr survival (50% if liver Mets)
Differential Diagnosis:
- Fibrosing mesenteritis (fat halo sign around vessels)
- Desmoid (fibrosis from prior surgery)
- Lymphoma / treated lymphoma
- Metastases (colon,ovary) / small bowel carcinoma
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QUESTION-7:
Intense abdominal pain for the last day:
Correct Answer: Pneumoperitoneum
- Pneumoperitoneum, tics w/ inflammatory change, centrally hypodense rim-enhancing focus
- Management: - Antibiotics - Resection as needed - Follow-up enoscopy
Differential Diagnosis:
- CICI: Cancer Ischemia Colitis IBD
- Bowel wall thickening, fat stranding, enhancement
- Cancer: Focal thickening
- Ischemia: Vascular distribution, vessel filling defect
- Colitis: Entire colon if pancolitis (C. dificile)
- IBD:
- Crohn’s: Skip lesions, ileocolic predilection, fistulas
- Ulcerative colitis: Contiguous extension, anus more proximal
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QUESTION-8:
60 yo with intermittent belly pain; comes and goes over for about 2 weeks:
Correct Answer: Cecal volvulus
- Dilated bowel loops R hemiabdomen, peri-cecal twist point (confirmed at surgery)
- Classically the tip of dilated bowel points to LUQ
- Sigmoid volvulus: Tip usually points to epigastric region
- Management: Detorse endoscopically vs surgically (cecopexy / resect)
Differential Diagnosis:
- Signmoid volvulus (inverted U)
- Obstruction
- Adhesions / neoplasm / intussception - Ileus
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QUESTION-9:
57 presents with abdominal pain, nausea, and vomiting times 2 days:
Correct Answer: Peritoneal carcinomatosis
- Proximal transverse colon (intussusceptum) telescoping into splenic flexure (intussuscipiens = “recipiens”), bowel wall edema, no enteric contrast distal to splenic flexure - Splenic flexure lipoma found to be lead point
- Ileoileal (tumor) : adults
- Ileocolic (idiopathic, Meckel’s) : peds
- Management: ID cause; resect (adult), enematic reduction (ped)
Differential Diagnosis:
- Neoplasm (SB: lymphoma, colon: carcinoma)
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Correct Answer Explanation
QUESTION-10:
60 yo with vague abdominal pain:
Correct Answer: Hepatic steatosis
- Diffusely hypodense liver
- Normal liver at least 10 HU > spleen on non-con study
- Contrast studies less reliable, but liver < 30 to 40 HU than spleen suggestive of hepatic steatosis*
- Management: Treat underlying cause ( fat w/in 2 months of treating)
Differential Diagnosis:
- Anything that causes hepatocytes to fill with / retain fat:
- EtOH, obesity/hyperalimentation most common causes
- Starvation
- Hepatitis/meds (amiodarone, tetracycline)
Diffuse lymphoma (distorts vessels & biliary ducts)
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QUESTION-11:
Incidental lesion seen on ultrasound:
Correct Answer: Hemangioma
- Discontinuous peripheral nodular enhancement w/ delayed fill-in; isodense to hepatic vessels
- #1 common benign tumor of liver (#1 overall = mets)
- Management:
- Excise if size > 5 cm & symptomatic*
- If concern, verify with PET/CT (min uptake) or Tc-99m RBC scan (early phase photopenia)
Differential Diagnosis:
- Hypervascular metastases (RCC, melanoma)
- Cholangiocarcinoma
- Usually NOT isodense to hepatic vessels
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QUESTION-12:
Most likely to involve the proximal small bowel?:
Correct Answer: adenocarcinoma
- Approx 50% of adenocarcinomas of the SB involve the duodenum.
- Dahnert 5th 788 - Crohn’s involves the duodenum in 4-10%.
- Dahnert 5th 809 - Lymphoma involves the duodenum in about 2%.
- Dahnert 5th 842 - Meckel’s diverticula occur in the ileum.
- Dahnert 5th 845
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QUESTION-13:
42 yo man with diffuse abdominal pain:
Correct Answer: Retractile Mesenteritis
- Retractile mesenteritis, also known as sclerosing mesenteritis, systemic nodular panniculitis and liposclerotic mesenteritis, is characterised by nonspecific mesenteric inflammation and fibrosis.
- The prognosis is generally favourable and spontaneous remissions have occasionally been reported. Corticosteroids and immunosuppressive agents including cyclophosphamide or azathioprine may afford symptomatic.
Differential Diagnosis:
- Carcinoid
- Liposarcoma
- Desmoid
- Lymphoma
- Carcinomatosis
Pearls:
- Sclerosing mesenteritis
- Mostly affects men between their 40s and 60s.
- Symptoms including abdominal pain, nausea and vomiting, constipation or diarrhea, weight loss, and fever.
- Cause includes previous abdominal surgery or trauma, autoimmunity, paraneoplastic syndromes, ischemic injury, and infection.
References:
- https://bit.ly/3C78SLq
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