The document describes an endoscopic retrograde cholangiogram (ERC) image from a 24-year-old female with jaundice. The ERC shows obstruction and dilation of the intrahepatic and extrahepatic biliary tree down to the cystic duct junction, where there is thinning of contrast and an apparent filling defect in the cystic duct. The findings are consistent with Mirizzi syndrome, which is partial or complete obstruction of the common hepatic duct caused by a stone lodged in the distal cystic duct.
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Diverticulitis: Popular Misconceptions and New ManagementPatricia Raymond
Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Diverticulitis: Popular Misconceptions and New ManagementPatricia Raymond
Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
A brief introduction to the IBD and its classification. Mainly dealing here with the Imaging techniques used in the diagnosis of the IBD.
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
Identifying and Treating Abdominal Lump in Children By Dr. Vivek Rege
This is part of the HELP Talk series at HELP,Health Education Library for People, the worlds largest free patient education library www.healthlibrary.com.
For info log on to www.healthlibrary.com.
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
Research, Development, Test, and Evaluation: A Defensible Process for Federal...Duane Blackburn
Through this "ready reference", MITRE aims to remediate the strain on RDT&E PMs and make it more likely that work necessary to support your agency's mission can continue to be funded. MITRE developed this model after reflecting upon the successes and failures of RDT&E programs from a variety of federal sectors over the past fifteen years.
A brief introduction to the IBD and its classification. Mainly dealing here with the Imaging techniques used in the diagnosis of the IBD.
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.
The stomach J-shaped. It has two surfaces (the anterior & posterior), two curvatures (the greater & lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
Blood supply
The left gastric artery
Right gastric artery
Right gastro-epiploic artery
Left gastro-epiploic artery
Short gastric arteries
Stomach cancer begins when cancer cells form in the inner lining of your stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
It could be:
malignant or benign
primary or secondary
Identifying and Treating Abdominal Lump in Children By Dr. Vivek Rege
This is part of the HELP Talk series at HELP,Health Education Library for People, the worlds largest free patient education library www.healthlibrary.com.
For info log on to www.healthlibrary.com.
Barrett's esophagus is a condition in which the tissue lining the esophagus—the muscular tube that connects the mouth to the stomach—is replaced by tissue that is similar to the lining of the intestine. This process is called intestinal metaplasia.
No signs or symptoms are associated with Barrett's esophagus, but it is commonly found in people with gastroesophageal reflux disease (GERD). A small number of people with Barrett's esophagus develop a rare but often deadly type of cancer of the esophagus.
Barrett's esophagus affects about 1 percent1 of adults in the United States. The average age at diagnosis is 50, but determining when the problem started is usually difficult. Men develop Barrett's esophagus twice as often as women, and Caucasian men are affected more frequently than men of other races. Barrett's esophagus is uncommon in children.
The EsophagusThe esophagus carries food and liquids from the mouth to the stomach. The stomach slowly pumps the food and liquids into the intestine, which then absorbs needed nutrients. This process is automatic and people are usually not aware of it. People sometimes feel their esophagus when they swallow something too large, try to eat too quickly, or drink very hot or cold liquids.
Digestive tract.
The muscular layers of the esophagus are normally pinched together at both the upper and lower ends by muscles called sphincters. When a person swallows, the sphincters relax to allow food or drink to pass from the mouth into the stomach. The muscles then close rapidly to prevent the food or drink from leaking out of the stomach back into the esophagus and mouth.
NIDDK
Research, Development, Test, and Evaluation: A Defensible Process for Federal...Duane Blackburn
Through this "ready reference", MITRE aims to remediate the strain on RDT&E PMs and make it more likely that work necessary to support your agency's mission can continue to be funded. MITRE developed this model after reflecting upon the successes and failures of RDT&E programs from a variety of federal sectors over the past fifteen years.
PAETEC’s innovative equipment and software Financing Solutions are designed to help your
organization keep up – or get ahead – while staying on budget, all with one simple monthly invoice.
2007 Event at Minneapolis Hilton - Big Ink worked with members of the Hartford planning team and their design firm and created coordinating graphics for the event
Change management presentation (persembahan pengurusan perubahan) by eruan & inna (student of University Technology of Malaysia) - Master Degree of Management and Administration for Education
Building research student communities: is there a role for library and learni...Jo Webb
Slides from a symposium exploring the role and experiences of librarians and learning developers in building communities of practice for researchers.Uses two case studies from De Montfort University (Leicester, UK) onexperiences of building a virtual CoP (wiki-based) and a face-to-face writing group.
Symposium was led by Katie Fraser (now University of Leicester), and content contributed by Melanie Petch and Jo Webb (both De Montfort University).
Looks at the nature and qualities of information literacy assessment.
Slides for a workshop delivered at LILAC (Librarians' Information Literacy Annual Conference) in Limerick March 29-31 2010. Workshop leaders were scheduled to be Chris Powis (University of Northampton, UK) and Jo Webb (De Montfort University, UK), but session was actually led by Amanda Poulton (Also de Montfort University).
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
LOWER GI HEMORRHAGE- PLAYLIST OF 6 VIDEOS
Dear Viewers,
Greetings from “Surgical Educator”.
I have made a playlist for Lower GI Hemorrhage which consists of six videos on various causes of Lower GI Hemorrhage. They are Introduction, diverticular disease, haemorrhoids, fissure-in-ano, colorectal carcinoma and inflammatory bowel disease. If you watch all these videos together you will become confident to tackle the clinical problem of Lower GI Hemorrhage. You can watch these videos in the following link: https://www.youtube.com/playlist…
Thank you for watching the videos.
Management of Perforated Duodenal Diverticulum: Case Reportasclepiuspdfs
It has been reported that duodenal diverticula are common but perforated duodenal diverticulum is a rare entity. At this time, there is no standardized management for perforated duodenal diverticulum. In these cases, patients usually complain of vague abdominal pain and computed tomography scan is mostly ordered used as an important diagnostic method. Diagnosis and the severity of the disease need to be assessed before any intervention. Essentially, the perforated small bowel is treated with surgical intervention. However, conservative treatment with broad-spectrum antibiotics and strict nil per os has been offered in the past for stable patients. Below, we report one case of perforated duodenal diverticulum that we managed with conservative treatment.
Describes the imaging diagnostic criteria of acute diverticulitis in barium studies , ultrasound , computed tomography and MRI .and the classification and complications of acute diverticulitis
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
1. Section V – Gastrointestinal Radiology
Figure 1
186. You are shown a radiograph (Figure 1) from a small bowel follow-thru in a 32-year-old male with chronic
abdominal pain. Which one of the following is the MOST likely diagnosis?
A. Crohn’s disease
B. Sprue
C. Midgut volvulus
D. Paraduodenal hernia
E. Pseudomyxoma peritonei
Diagnostic In-Training Exam 2002 1
2. Section V – Gastrointestinal Radiology
Question #186
Findings: The radiograph demonstrates encapsulation of jejunal loops in the left mid abdomen.
Rationales:
A. Incorrect. Crohn’s disease involves the small bowel in 75% of patients at the time of presentation. Affected
segments show fold thickening and ulceration. Sinus tracts and fistulae are also noted. Although surrounding
fibrofatty proliferation may produce a mass effect or displace bowel on SBFT, encapsulation of bowel loops is
not noted with Crohn’s disease.
B. Incorrect. Sprue or gluten sensitive enteropathy produces villous atrophy and radiographically shows reversal of
the normal fold pattern with loss of normal jejunal folds and an increased number of folds per inch in the
ilium. Transient intussusceptions, hypomotility and flocculation of barium can also be seen. However, none of
these findings are present on this film.
C. Incorrect. Midgut volvulus is produced by twisting of small bowel loops around the shortened mesenteric
vascular pedicle in patients with congenital small bowel malrotation. A corkscrew deformity of the jejunal loops
is noted on SBFT. Obstruction to venous return produces edema and hence thickened folds in the involved
bowel. Such changes are not noted on this film.
D. Correct. Internal hernias are abnormal protrusions of intraabdominal structures through a normal opening or
through a congenital or acquired defect in fascia or mesentery. Encapsulation of jejunal bowel loops in either
the right or left mid abdomen is characteristic of paraduodenal hernia - the most common type of internal
hernia. The amount of contained small bowel can vary from a few loops to the majority of the small bowel.
Patient typically present with intermittent abdominal pain thought to be secondary to episodes of obstruction.
Left sided paraduodenal hernia is more common than right sided paraduodenal hernia.
E. Incorrect. Pseudomyxoma peritonei results from seeding of the peritoneal cavity by benign or malignant mucin
secreting cells. The cells typically come from a ruptured mucinous cystadenoma or cystadenocarcinoma of the
appendix or ovary. Though bowel can be distorted, obstructed or tethered by tumor or mucin, encapsulation as
noted here is not seen.
Citations:
Maglinte DDT, Bisset III GS, Congenital and Developmental Anomalies of the Small Bowel in Adolescents and Adults pp 247-251
in Clinical Imaging of the Small Intestine 2nd ed, eds Herlinger H, Maglinte DDT, and Birnbaum BA, Springer, New York, 1999.
2 American College of Radiology
3. Section V – Gastrointestinal Radiology
Figure 2
187. You are shown a contrast-enhanced CT (Figure 2) in an 84-year-old male with recent weight loss and guaiac
positive stool. Which one of the following is the MOST likely diagnosis?
A. Desmoid tumor
B. Intussusception
C. Internal hernia
D. Lipomatous ileocecal valve
E. Volvulus
Diagnostic In-Training Exam 2002 3
4. Section V – Gastrointestinal Radiology
Question #187
Findings: The CT image demonstrates a long colo-colic intussusception involving the ascending and transverse
colon
Rationales:
A. Incorrect. Desmoid tumors are non metastasizing but locally invasive fibrous tumors. They can occur either in
isolation or more commonly in association with Gardner’s syndrome, particularly following abdominal surgery.
They may present as an abdominal mass or cause bowel obstruction. On CT they appear as a soft tissue mass in
the mesentery either with well circumscribed or infiltrative margins. These findings are not present in this case.
B. Correct. The image demonstrates a long segment colo-colic intussusception. The vast majority of adult colo-
colic intussusceptions have a malignant lead point with adenocarcinoma being the most common histologic
type. The extensive edema seen with the intussusception often makes it difficult to delineate the precise lead
point.
C. Incorrect. Internal hernias are abnormal protrusions of intraabdominal structures through a normal opening
or through a congenital or acquired defect in fascia or mesentery An internal. The most common type is the
paraduodenal hernia shown in the previous question. Although internal hernias can cause distortion of bowel
loops they would not produce the bowel within bowel appearance noted here.
D. Incorrect. Lipomatous ileocecal valve is caused by submucosal infiltration of fat into the lips of the I-C valve. It
is typically seen in older patients and is more common in women. Symptoms are usually absent. Although the
mass can mimic an adenocarcinoma its fatty density on CT and smooth contour usually allow differentiation.
The mass in this case is predominantly soft tissue density and much larger and more extensive and irregular
than a lipomatous I-C valve.
E. Incorrect. A volvulus involving the bowel is produced by twisting of small bowel loops around a point of
fixation. In midgut volvulus associated with malrotation the point of fixation is the shortened mesenteric
vascular pedicle. Volvulus involving fewer bowel loops may also occur around an acquired adhesive band. On
CT a swirling appearance of vessels is seen in conjunction with obstructed small bowel loops. Although arcing
vessels are seen in this case, they are entering the ascending colon rather than twisting around a point of
fixation.
Citations:
Gore RM, Eisenberg RL, Large Bowel Obstruction pp1247-1260 in Textbook of Gastrointestinal Radiology eds Gore RM, Levine
MS, Laufer I, W.B.Saunders, Philadelphia, 1994
4 American College of Radiology
5. Section V – Gastrointestinal Radiology
Figure 3
188. You are shown a radiograph (Figure 3) of the splenic flexure from a double contrast barium enema in a
35-year-old female with diarrhea and abdominal pain. Which one of the following is the MOST likely diagno-
sis?
A. Typhlitis
B. Ulcerative colitis
C. Toxic megacolon
D. Crohn’s disease
E. Pseudomembranous colitis
Diagnostic In-Training Exam 2002 5
6. Section V – Gastrointestinal Radiology
Question #188
Findings: The radiograph demonstrate areas of irregular colonic narrowing and ulceration. More normal caliber
bowel is also noted but demonstrates multiple small aphthous lesions.
Rationales:
A. Incorrect. Typhlitis refers to an acute enterocolitis associated with immunosuppression and neutropenia. The
disease predominantly involves the cecum and right colon and is characterized by marked wall edema and
inflammation. Diagnosis is usually suggested by CT or plain film in conjunction with the clinical setting.
Barium enema or colonoscopy may place the patient at risk of perforation when inflammation is severe. The
appearance of aphthous lesions and irregular areas of colonic narrowing and ulceration in the splenic flexure
would not be typical for typhlitis.
B. Incorrect. Ulcerative colitis is a chronic inflammatory bowel disease, predominantly limited to the mucosa,
with a peak age of onset of 15 to 25 years. The barium enema findings involve the rectum and extend
proximally to a variable extent, often involving the entire colon. Mucosal abnormalities in acute active disease
include granularity, mucosal stippling, collar button ulceration and inflammatory pseudopolyp formation. In
patients with chronic disease, there can be narrowing of the colonic lumen, loss of haustration and shortening
of the colon. The discontinuous irregular involvement noted in this case in addition to the presence of
aphthous lesions are strongly against the diagnosis of UC.
C. Incorrect. Toxic megacolon is characterized by an ill, toxic appearing patient with diffuse colonic dilatation.
The colon will also demonstrate loss of haustral folds and an irregular nodular mucosal surface corresponding
to ulcerations and inflammatory pseudopolyps. Barium enema is contraindicated in patients with toxic
megacolon, because of a risk of perforation. Causes include ulcerative colitis as well as infectious colitis.
D. Correct. Crohn’s disease is a chronic inflammatory bowel disease that, like UC has a peak age of onset of 15 to
25 years. Unlike UC however, Crohn’s disease is characterized by transmural inflammation with aphthous
lesions and discontinuous areas of mucosal ulceration and narrowing. Sinus tracts and fistulae are also common
as is small bowel involvement which occurs in 75% of patients at presentation. The appearance in this case
would be typical for colonic involvement with Crohn’s disease.
E. Incorrect. Pseudomembranous colitis is produced secondary to toxin producing Clostridium difficile infection.
The disease usually follows the administration of broad spectrum antibiotics and produces watery diarrhea,
fever, abdominal pain and leukocytosis. Moderate large bowel dilation with thumbprinting is noted on
abdominal plain film exam. On barium enema small irregular plaque like filling defects or small nodules are
noted. In severe cases the luminal margin may appear irregular from poor mucosal coating. These changes are
not noted in this case.
Citations:
Gore RM, Laufer I, Ulcerative and Granulomatous Colitis: Idiopathic Inflammatory Bowel Disease in Textbook of Gastrointestinal
Radiology eds Gore RM, Levine MS, Laufer I, W.B.Saunders, Philadelphia, 1994
6 American College of Radiology
7. Section V – Gastrointestinal Radiology
Figure 4A
Figure 4B
189. You are shown a contrast-enhanced CT (Figure 4A and 4B) of a 25-year-old male with epigastric pain. Which
one of the following is the MOST likely diagnosis?
A. Mucinous ductectatic malignancy
B. Cystic fibrosis
C. von Hipple Lindau disease
D. Tuberous sclerosis
E. Solid and papillary epithelial neoplasm
Diagnostic In-Training Exam 2002 7
8. Section V – Gastrointestinal Radiology
Question #189
Findings: Multiple cysts are identified in the pancreas. A solid enhancing lesion is also noted in the left kidney. In
addition an enhancing mass is noted involving the spinal cord.
Rationales:
A. Incorrect. Mucinous ductectatic tumor is a pancreatic mucinous tumor with an intraductal growth pattern.
Both benign and malignant variants are reported. The median age of patients is in the 7th decade but unlike
the usual mucinous cystic tumor, the lesion is more common in men than women. On CT cystic areas are noted
along with distension of the pancreatic ducts with mucin. The appearance can mimic the changes of chronic
pancreatitis. Duct distension is not noted in this case, nor would this entity explain the spinal and renal
abnormalities noted above.
B. Incorrect. Cystic fibrosis affects multiple epithelial tissues including sweat gland, lung, pancreas, and bowel.
It is inherited as an autosomal recessive trait and occurs in 1 in 3000 Caucasian live births in the US. Pancreatic
secretions in cystic fibrosis patients have increased viscosity and are thought to cause inspissation and resulting
pancreatic atrophy. By 2 years of age more than 80% of patients will have evidence of pancreatic insufficiency.
On CT the pancreas often demonstrates diffuse fatty replacement. Less commonly replacement of the gland by
multiple macroscopic cysts occurs. Although multiple cysts are seen in this patient, cystic fibrosis would not
explain the renal or CNS masses.
C. Correct. von Hippel Lindau disease is characterized by cysts and or neoplasm in multiple organs including
the pancreas, kidney, liver, epididymis and CNS. It is inherited in an autosomal dominant fashion. Onset of
symptoms is typically in the third to fifth decade. Commonly associated lesions include hemangioblastomas
(seen in retina, cerebrum, cerebellum and spinal cord) renal carcinoma and hemangioblastomas, pancreatic cysts
and cystadenomas, and epididymal cysts. The pancreatic cysts, renal carcinoma and spinal hemangioblastoma
seen in this case would be typical for von Hippel Lindau disease.
D. Incorrect. Tuberous sclerosis is an autosomal dominant syndrome which has skin, CNS, cardiovascular renal, and
pulmonary manifestations. Renal lesions including intrarenal aneurysms, carcinoma, cysts and angiomyolipomas,
are reported. The latter occur in 40-80% of patients and can cause spontaneous hemorrhage. Diagnosis of AMLs
can be made by showing intratumoral fat on CT or MRI. Although CNS lesions occur, tuberous sclerosis would
not be expected to present the pancreatic or spinal cord findings noted in this case.
E. Incorrect. Solid and papillary epithelial neoplasm is an uncommon pancreatic tumor of young females. More
than 95% of cases are found in adolescent or postadolescent girls and young women. The tumor is generally
a large cystic and solid mass that frequently contains areas of necrosis and hemorrhage with fluid-debris levels.
The sex of the patient and the morphologic appearance of the tumor in the test patient make solid and papillar y
epithelial neoplasm an unlikely diagnosis.
Citations:
Stanley RJ, Semelka RC, Pancreas in Computed Body Tomography with MRI Correlation third ed., eds Lee JKTL, Sagl SS, Stanley
RJ, and Heiken JR, Lippincott-Raven, New York 1998.
8 American College of Radiology
9. Section V – Gastrointestinal Radiology
Figure 5
190. You are shown an image from an endoscopic retrograde cholangiogram (Figure 5) in a 24-year-old female
with painless jaundice. Which one of the following is the MOST likely diagnosis?
A. Adenomyomatosis
B. Mirizzi syndrome
C. Sclerosing cholangitis
D. Caroli’s disease
E. Klatskin tumor
Diagnostic In-Training Exam 2002 9
10. Section V – Gastrointestinal Radiology
Question #190
Findings: The image demonstrates obstruction and dilation of the intra and extrahepatic biliary tree down to a
point just above the juncture with the cystic duct. At this point there is thinning of the contrast column and an
apparent filling defect outlined in the cystic duct. The CBD is normal in size.
Rationales:
A. Incorrect. Adenomyomatosis is characterized by hyperplastic changes in the wall of the gallbladder with
formation of intramural diverticuli or Aschoff-Rokitansky sinuses. This may occur in a diffuse or segmental
fashion. The clinical significance of this finding is uncertain, although it is important to differentiate it from
other causes of gallbladder wall thickening such as carcinoma and cholecystitis. The intramural diverticuli do
not typically involve the distal cystic duct and would not be responsible for the findings shown here.
B. Correct. Mirizzi syndrome is partial or complete obstruction of the common hepatic duct associated with a
stone lodged in the distal cystic duct. It occurs because the distal cystic duct and common hepatic duct are
often bound together in a common sheath. The clinical presentation is often progressive jaundice and
abdominal pain. The findings depicted here are typical for Mirizzi syndrome.
C. Incorrect. Primary sclerosing cholangitis is an idiopathic disorder characterized by inflammation, fibrosis and
strictures involving the intra and extrahepatic biliary tree. Ulcerative colitis is the most frequent associated
condition and is present in 50-75% of cases. Men are affected twice as often as women. Symptoms are usually
insidious in onset and consist of fatigue, right upper quadrant pain, jaundice and pruritus. Multiple short
irregular strictures are seen at cholangiography diffusely distributed throughout the biliary tree. A beaded
appearance of the ducts is often noted with bandlike strictures and small diverticulum like outpouchings
occasionally seen. Such findings are not noted in this case.
D. Incorrect. Caroli’s disease is a congenital disorder characterized by diffuse or segmental dilatation of the
intrahepatic biliary tree. Two types have been characterized, a simple and a periportal fibrosis type. The latter is
more common and is associated with congenital hepatic fibrosis, cirrhosis and portal hypertension. The former
is associated with medullary sponge kidney. Patients usually present in early adulthood with symptoms of
cholangitis (fever, chills, abdominal pain). An increased incidence of malignant transformation is also noted.
The uniform dilation of the biliary tree down to the point of obstruction noted here would not be seen in
Caroli’s disease.
E. Incorrect. Klatskin tumor refers to a cholangiocarcinoma occurring at the confluence of the right and left bile
ducts and common hepatic duct. An increased incidence of cholangiocarcinoma has been noted in patients
with PSC and choledochal cyst as well as patients infested with Clonorchis sinensis or Opisthorchis viverrini.
Patients usually present with painless jaundice. The peak incidence is around 65 years of age. The tumor
typically appears as a short segmental stricture at the bifurcation and would not be consistent with the
appearance shown here.
Citations:
Zeman RK, Cholelithiasis and Cholecystitis in Textbook of Gastrointestinal Radiology eds Gore RM, Levine MS,
Laufer I, W.B.Saunders, Philadelphia, 1994
10 American College of Radiology