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Upper GI radiology quizNick Carroll

Questions

Case 1A 65-year-old male was referred with iron-deficiency anaemia and a change in bowel habit. Below are two images from barium enema.1 Image 1a clearly demonstrates an apple-core carcinoma of the rectum, but what is labelled A on image 1b?2 How common is this phenomenon?3 What would you do next?4 What further imaging is required?

Nick Carroll MA MRCP FRCR is a Consultant Radiologist at Addenbrooke’s

Hospital and Papworth Hospital, Cambridge, UK. He qualified from

Cambridge University and King’s College Hospital, UK. He specializes

in gastrointestinal radiology and techniques which combine both

endoscopy and radiology, in particular, endoscopic ultrasound.

Competing interests: none declared.

Figure 1

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Case 2An 18-year-old male presented with increasing abdominal pain and fever. The 2 axial images (Figures 2a + 2b) demonstrate a number of abnormalities.1 What is labelled as A?2 What is labelled B?3 What is labelled C?

Figure 2

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Case 3A 24-year-old female presents with blurred vision, lethargy and occasional confusion. She is given serum insulin 12 μmol/ml and a provisional diagnosis of insulinoma.The CT does not demonstrate any lesion in the pancreatic head (Figure 3a:A). The EUS clearly shows a 1.5 cm diameter mass in the head of the pancreas (Figure 3b:B).1 Is it unusual for CT not to demonstrate an abnormality?2 How sensitive is EUS?3 What could you do next to confirm the EUS findings?4 If surgery is indicated is any other imaging helpful?

Figure 3

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Case 4A 45-year-old female presents with diarrhoea. Below are 3 images from CT examination:

• Figure 4a demonstrates mesenteric mass which contains some calcification

• Figure 4b demonstrates thickening of adjacent small bowel

• Figure 4c demonstrates liver metastases.1 What biochemical tests would you recommend?2 What is the most likely diagnosis?3 Are further imaging tests helpful?4 What medical treatment may alleviate symptoms?

Figure 4

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Case 5A 62-year-old female presents with dyspepsia and weight loss. Endoscopy shows extrinsic compression of the second part of the duodenum, and ulceration. CT is shown below (Figures 5a+b).1 What abnormality is labelled as A?2 Biopsies were taken. What special immunohistochemical stains would you recommend?3 What process is represented by the nodule labelled as B?4 There are no enlarged lymph nodes. Is this unexpected?

Case 61 What sign is demonstrated in the left upper quadrant labelled as A (Figure 6)?2 Can you see an underlying cause?3 What sign is labelled as B?4 What imaging modality would you request next?

Figure 5

Figure 6

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Case 7A 43-year-old male presents with gradual onset of colicky abdom-inal pain and diarrhoea with acute exacerbation.1 What is the feature labelled as A (Figure 7)?2 Is this large or small bowel?3 What other features should you look for?4 Which imaging modality would you recommend next and why?

Case 8A 34-year-old female from Thailand presents with abdominal dis-tension and pain, and night sweats. There is loculated ascites.1 What abnormality is labelled A (Figure 8a)?2 What is labelled as B (Figure 8b)?3 What other features would be helpful in making a diagnosis?4 What would you organize next?

Figure 7

Figure 8

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Answers

Case 11 A is a synchronous polyp in the more proximal colon.2 Synchronous polyps occur in 20–25% of patients with CRC.3 Full evaluation of bowel with colonoscopy or, if unable to pass distal tumour, CT colography.4 CT of the chest, abdomen and pelvis should be undertaken for staging the distal tumour; it may be combined with colography, if necessary.Rectal tumours should be assessed with pelvic MRI including high resolution imaging to evaluate T and N stage and relation-ship to the mesorectal fascia.

Case 2Images 2c and 2d demonstrate advantages of reformatting the multi-detector CT images especially along the axis of tubes such as the portal vein. In this case, an appendicolith is associated with pelvic sepsis, subsequent liver abscess and portal vein thrombosis.

Figure 2

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Case 31 CT is poorly sensitive in the evaluation of the pancreas for endocrine tumours. Better results are obtained with multi-phase and multi-detector imaging.2 Sensitivity of EUS may be as high as 95%.3 EUS findings may be confirmed with angiography and venous sampling (Figure 3c; A, tumour blush).4 Many surgeons use intra-operative ultrasound to confirm lesion location and best surgical approach, and to exclude other lesions elsewhere in the pancreas. Multiple lesions occur in 10% of patients.

Case 41 Urinary 5HIAA levels. Serum serotonin.2 Carcinoid syndrome due to metastatic, malignant ileal carci-noid tumour.3 Radio-labelled octreotide scanning may reveal unexpected metastases and can predict medical treatment response.4 Octreotide. A synthetic somatostatin analogue.

Case 51 A large partially necrotic mass arising from the duodenal wall. This is most likely to be a stromal tumour but the differential diagnosis includes lymphoma, adenocarcinoma of the duode-num, and metastatic disease.2 CD 117 (CKit) and CD 34 amongst others. The former is diag-nostic for a gastrointestinal stromal tumour (GIST).3 Peritoneal spread of tumour. This is relatively common with GIST tumours.4 GIST tumours rarely metastasize to lymph nodes (less than 5%).

Figure 3

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Case 61 Small bowel obstruction.2 There is a gallstone in the bowel in the lower left quadrant (Figure 6b).3 Gas in the biliary system.4 CT to confirm gallstone ileus (Figure 6c).

Case 71 Featureless bowel with poor mucosal detail.2 This is, in fact, distended inflamed small bowel, although the position might suggest descending colon.3 Exclude free gas. This may require an erect chest X-ray. Ex-clude small bowel or large bowel obstruction. Look for associ-ated features (e.g. sacroiliac joints, which are normal here).4 A barium study may give you more information about the extent of mucosal abnormality and functional information (e.g. obstruction). CT allows evaluation of extramural bowel disease, is sensitive for free gas and fluid, and is easier to tolerate in acute presentation of bowel disease.

Figure 6

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Case 81 A is labelling a centrally calcified low-attenuation liver lesion.2 B is labelling thickened peritoneum. Given the history and background, these two features strongly suggest peritoneal tuberculosis.3 Lymph node enlargement (Figure 8c), pleural effusion or lung disease.4 Aspiration of ascites for acid-fast bacilli and culture or omen-tal biopsy.

Figure 7 b Follow-through demonstrates long segment of narrowed,

ulcerated ileum consistent with Crohn’s disease. c CT demonstrates

full- thickness disease with mesenteric inflammation again consistent

with Crohn’s disease.

Figure 8

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