ESOPHAGEAL MOTILITY
peristaltic waves mediated by vagal nuc in medulla
myenteric plexus of auerbach propagates p stim by vagus
tertiary or segmental contractions, nonpropulsive, N?
>200mmHg abn press

ABN STRIATED MUSCLE & UPPER ESOPH SPHINCTER
GERD is the most common cause of dismotility

1. Cricopharyngeal Achalasia - no relaxation of esoph sphinc
sm impression can be asym, seen at C5-6 level
more severe results in spillage into larnyx
see enlarged piriform sinuses, barium retains in vallecula
cricopharyngeal myotomy can reduce Sx

Zenker's Diverticulum - mucosa thru Killian's dehiscence
below inf pharyngeal constrictors & over Cricopharyngeus
Tx w cricopharyngomyotomy or diverticulectomy

2. Total Laryngectomy - Pseudodefect
s/p laryngectomy, all landmarks absent
appears similar to post cricopharyngeal impression
shape changes w swallowing
recurrent tumor will be a fixed defect

3. S/P Radiation Therapy - causes paresis and dec sensation
also hypopharyngeal retention, all result in aspiration

4. Primary Muscle Disorders - failure to initiate peristalsis
Myasthenia Gravis - no trasmission from motor end-plate
initial swallow N, then fatigues quickly
resolves w neostigmine
Myotonic dystrophy - auto dom, muscle can't relax p cont
poor cricopharyngeus resting tone, high aspiration
Polymyositis & Dermatomyositis - inflam deg Dz of st musc
weak and discoordinate musc, dysphagia, regurg & asp
AML - loss of motor neuron fxn

5. Primary Neural Disorders - cause motor discoordination
peripheral or central cranial nerve
Vagotomy - high unilat p tumor resec, discoord upper
MS, Huntingtons, Diphtheria, Tetanus
ABN SMOOTH MUSC & INNERVATION OF LOWER ESOPH

1. Scleroderma - atony II' to atrophy of sm musc in 80% of pt
may be asym, upper 1/3 continues to work
patulous lower, reflux and stricture in 40%
NO response to methylcholine test (R/O Achalasia)
other con tissue diseases also cause this
SLE, RA, Poly & Dermatomyositis
all assoc w Reynaud's, a vasospastic neurogenic abn

2. Myenteric Plexus Destruction - simulates achalasia
II' to inflam like chaga's dz, or metastatic malig invasion

3. Esophagitis - corrosive agents, reflux, infec, radiation
failed I' peristalsis to stomach, III' waves beyond
complete aperistalsis if severe

4. Alchoholic & Diabetic Neuropathies
selective deterioration of esoph motility, esp distal
diabetics have diffuse dec amplitude of contraction

5. Presbyesophagus - inability to initiate or sustain I' peri
Anti-cholinergic agents - Atropine & probanthine
simulate scleroderma w aperistalsis & dilation
Myxedema and amyloid similar

FAILED RELAXATION OF LES
1. Achalasia - obs of dist esoph w prox dilation, 20-40 y/o
Failed sphincter relaxation, barium retained >2.5 sec
No gang cells in auerbachs plexus, no cholinergic cont
mecholyl causes a denervation hypersensitivity resp
hypercontraction & vomiting results
Interupted peristaltic reflex arc, no lower sphinc relax
high vagus interuption, or auerbachs disruption
may see vigorus tertiary cont, hyperactive achalasia
Regurg & aspiration can occur, chronic scarring etc
CXR shows dil w retained food, can compress trachea
sm or absent gastric air bubble
Barium exam must be done in recumbent position
DDx between malig & benign
Benign - <40 y/o, sx <6 mo, N mucosa, smooth taper
Malig - irreg in barium stream, thick st at fundus
5-10% develop sq cell due to irritation
Amyl Nitrate cannot relax sphincter
Sedlitz test - carbonation in esoph cannot open
Tx - balloon dil, perf may not be evident immediatly

2. Chagas' Disease - dest of myenteric plexus by neurotoxin
Typanosoma Cruzi - protazoan from armadillo
assoc w megacolon as well

3. Neuropathy
central or peripheral can result in achalasia
Bilat vagaotomy - sx in 7-14 days, clears in 2 mo
Diabetes and congenital or acquired innervation degen

4. Malignant Lesions - mets to midbrain or vagus nerves
I' or met lesions of dist esoph or gastric cardia
removal often results in restoration of fxn

5. Esophagitis - post reflux stricture
assoc w hiatal hernia

TERTIARY CONTRACTIONS
can be superimposed on N esophageal motility w/o sequela

1. Presbyesophagus - #1, interupted reflex arc II' to age
usually asym, if assoc w dec lower relax dil can occur

2. Diffuse Esophageal Spasm - classic triad, rarely all 3
bad discoord cont, chest pain & inc intralum pressure
peristalsis N initially, but breaks up at arch level
"Corkscrew", or rosary bead app to esoph, pseudodiverticuli
"Nutcracker Esophagus" - Norm peristaltic wave seen, not distortion
NO abn seen on esophagram, manomatry shows P >200mmHg
Tx - procardia & nitro questionable, longitudinal myotomy curative

3. Esophagitis - continues exitation of sensory receptors
reflux, candida, amyloidosis, postirradiation

4. Nutcracker esophagus - a manometric Dx
N I' peristalsis, high amplitude dist cont

5. Neuromuscular - DM, AML, MS, myxedema, myotonic dys, etc

EXTRINSIC IMPRESSIONS ON THE CERVICAL ESOPH
1. Cricopharyngeus Muscle - post C5-6, sim total laryngectomy

2. Pharyngeal Venous Plexus - ant at C6, lax mucosal folds
may vary from swallow to swallow, N in up to 90%

3. Esophageal Web - usually ant & thin, may be mult & rounded
never post

4. Anterior Marginal Osteophyte - smooth reg post indentions
usually asym, may cause dysphagia or irritation

5. Thyroid Enlargement - usually displaces trachea as well
watch for parathyroid enlargment as well, esp w Ca+ sx

6. Ectopic Gastric Mucosa - seen in 4%, congenital & asym
columnar epi in upper esoph, squa epi distal

7. Malignancy - extrinsic mass or lymph node enlargement

EXTRINSIC IMPRESSIONS ON THE THORACIC ESOPH
note whether pushed or pulled by shape of lumen

1. Normal Structures - aorta, L bronchus, L inf pulm vein

2. Vascular Abnormalities
Right side aortic arch - #1, no L aortic knob on CXR
impression caused by R subclav passing post obl
subclav can have 2 other routes w no impression
Cervical aortic arch - supraclavicular, post to esoph
Double aortic arch - S shape indention, or ring arch
Coarctation of the aorta - fig 3 sign on CXR
sx in late childhood, notched ribs due to collat flow
Aortic anuerysm - sickle like displacement of esoph ant
Aberrant R subclavian - arise dist to L subclav, post
Abberant L Pulm art - arise from R pulm, Ant to esoph
Anomalous pulm venous return - type III passes to diaph
indents ant & inf to L atrium indention
Persistent Truncus art - dil bronchial vessels, post

3. Cardiac Enlargement
Left Atrium - ant impression, may shift esoph to R
L ventricle - inf to enlarged L atrium
pericardial tumors, eff or cysts

4. Intrathoracic Masses - mediast, lung, trachea etc

5. Thoracic Osteophytes - more common in cerv, assoc w DISH

6. Paraesophageal Hernia - usually displaces post and R

7. Appical Plueropulmonary Fibrosis - retract toward lesion
assoc w inflam dz like TB etc

ESOPHAGEAL ULCERATION
1. Reflux Esophagitis - #1, acid & pepsin or alk bile & panc
failed LES, 26% of hiatal hernias, prolonged NG
Chalasia - LES fails to remain closed, common in infants
late preg hormones cause generalized SM relaxation
S/P Heller procedure for achalasia - severed obl musc
Tc99 DTPA given orally can be used for reflux study
Baruim is insensitive to early esophagitis - use scope
double contrast can detect ulcers, fine lines & dots
single contrast see granular & serrated mucosa
mult fine trans folds are early sign - feline esoph
longitudinal folds thicker than 3mm
lg trans folds - scarring
Centinal Fold - lg long stom fold extending into esoph
Penetrating ulcers - can form in up to 15%, perf prob

2. Barrett's Esophagus - most in white males, inc w age
Z line jxn to squa epi moved caudally by columnar epithelium
represents B ring, Schatski's ring if <13mm
Hiatal Hernias assoc but not always
UGI - reticular mucosal pattern similar to "aeria gastrica" type pattern
Ulcer formation freq, gastric like w freq stricture
may be tapered only, retic pattern at edges suggestive
Inc Ulceration & stricture = inc odds of Barret's
Pertechnatate - taken up in gastric mucosa, diagnostic
Usually never returns to normal even after Tx

Adenocarcinoma - 10%, like squa cell but spreads dist
30% of esoph Ca, all arise II' to Barretts
Polypoid & ulcerative, assoc w stenosis, stage sim to SCC

3. Candida Esophagitis - most compromised, 75% of aides pts
Abx esp Tetracylcine can allow overgrowth
Thrush - oral involvement only
Adenophaygia - pain w swallowing, intense & local, MI
Pseudomembranous plaques - upper 1/2 may be spared
nodular cobblestone pattern w lg discrete ulcers
shaggy marginal contour due to sloughed mucosa
AIDS - may present w single lg ulcer, resembles ca
Amphotericin B - Tx
4. Herpetic Esophagitis - can be identical to candida
discrete ulcers w less shaggy mucosa, self limiting

5. Cytomegalovirus Esophagitis - dist ulceration, fundus poss

6. TB Esophagitis - II' to terminal Dz in the lungs
fistulas common, miliary nodules, midesophageal

7. Crohn's Esophagitis - go to "ulcerative lesions of the colon"
Aphthous ulcers - earliest sign, punctate, slit or ring
radiolucent halo, linear or serpiginous later
fistulas & perforation, diffuse cobblestone rare
rarest site in GI tract

8. Eosinophilic Esophagitis - fine superficial ulcerations
Dr Hinder assoc w dysphagia in young men

9. Carcinoma of the Esophagus - 95% squamous
Meniscoid ulceration - bulging mass around a crater
Met nodes may ulcerate into esoph

10. Corrosive Esophagitis - inflam changes, mostly dist 2/3
Alkali #1, penetrates deep layers, liquefying nec
Acid less severe, coags outer layers, protective
Scarring & narrowing

11. Radiation Injury - >4500 rads, diffuse inflam, stricture
2000 rads in combo w adriamycin or actinomycin D
resembles candida which is much more common

12. Pill Ulcers - tetracycline, KCL, Fe+, vit C, etc
transition between sm & striated musc @ aorta #1

14. Intramural Esophageal Pseudodiverticulosis - sim ulcers
dilated esophageal glands - Innumerable outpuchings
appear as fine detached granules surrounding esoph

15. Glycogen Acanthosis - 2-3mm mucosal plaques over N esoph mucosa
squamous cells w inc intracellular gllycogen, NO mallig potential
seen in 15% of UGI & 100% post mortem

Alcohol, Syphillis, Histo, and Behcet's syn also

ESOPHAGEAL NARROWING
CONGENITAL CONDITIONS
1. Esophageal Web - thin mem w N mucosa, #1 at 2cm from pharn
arises ant, never post, can be circumfrential
rare dist webs assoc w reflux
may see a jet of barium dist, sim a long stricture

2. Schatzki Ring - lower esoph ring 2-3cm above diaph
jxn between gastric & esoph mucosa
if ring >12-13mm sx unlikely

3. Tracheobronchial Rest - cartilage ring, seq from trach
always dist, present in childhood w vomiting, asp, etc

4. Congenital Stricture - incomplete occlusion, sm w prox dil


NEOPLASTIC LESIONS - see section on filling defects
fixed stricure, overhanging bulging edges, ulceration
Esophogoscopy & Bx needed for Dx

1. Squamous Cell Ca - most common mallig of esoph, 70%

2. Adenocarcinoma - usually follows barretts's
10% of stomach ca spreads to esoph, check cardia closely

3. Mets - esp local ext & Nodes, usually a short seg
any presentation possible, myenteric dest - achalasia
Lymphoma - 10% involve esoph, nodular
Mesothelioma & Breast - long segmental stenosis

4. Benign Tumors - Leiomyomas #1, eccentrically narrow

NONNEOPLASTIC CAUSES OF ESOPH NARROWING
Tapered margins & smooth mucosal surface
R/O diffuse spasm first

1. Reflux - intense spasm & inflam
II' strictures asym, Funnel shaped
Barrett's - marked by cyclic ulceration and healing

2. Corrosives - inflam, stricture as early as 2 wks
Acid causes coagulative necrosis
antrum of stomach #1 site of stricture P acid ingestion

3. Iatrogenesis - post surg changes or post intubation
NG tube allows inc reflux, stricture in 2 wks

4. Infectious - stricture as part of healing inflam
Candida - can have abrupt narrowing
Herpes, Eosinophilic, Behcet's, Crohn's

5. Radiation Injury - relativly radiation resistant
>4000 rads, edema causes mucosal & muscle thickening
Post radiation ca - most pt's don't live long enough

6. Epidermolysis Bullosa - subepi blisters in mucosa
stricture w healing, abrupt transition & webs common
Cicatrizing permenant strictures can form

7. Bullous Pemphigoid - mucosa of mouth & conjuctiva I', scarring
mucosal edema & spasm, bullae erupt leaving ulcers

8. Chronic Graft-vs-Host Dz - II' to donor lymphocytes
allogenic bone trans, resembles bullous dz

9. Sclerotherapy - may resemble ca w overhanging edges
penetrating ulcers common

10. Intramural Esophageal Pseudodiverticulosis
90% assoc w sm stricture, 2/3 in upper, usually <10 tics

ESOPHAGEAL FILLING DEFECTS

MALIGNANT LESIONS
1. Squamous Cell Ca - #1 Esophageal Tumor
50% in mid, 30% dist, 20% prox
infiltrating ca can burrow under mucosa, narrow lumen
Risk Factors - alcohol, tobacco, reflux, hot tea & lye
Tylosis - hyperkeratosis of hands & soles of feet
Previous stricture, Achalasia & Plummer-Vinson syn (web)
Freq assoc w head & neck Squamous cell, always check
Progessive dysphagia #1 sx, Pain assoc w local spread
Wt loss, Hoarseness from rec laryn Nerve involvement
Chronic blood loss
Findings - flat fixed plaque #1, can be fungating polyp
progress to irreg narrowing, wide retrotrach stripe
abrupt transition, overhanging margins, dest of folds
cerv mass causes ant disp of trachea
fist & sinuses common, use CT, thick wall irreg lumen
Stage 1 - T1, stage 2 - T3N0, stage 3 - T3N1, Stage 4 - M1 T1 - submucosal, T2 - muscular layer, T3 - adventitia
T4 - extention to contiguous organs
Prognosis - 90% 5yr for muscosa only, rarely found early
10% cured by rad therapy, palliative dilation also

2. Adenocarcinoma - usually follows barretts's
10% of stomach ca spreads to esoph, check cardia closely

3. Mets - gastric extention common, Lymphoma usually II'

4. Leiomyosarcoma - rare, usually bulky & ulcerated
also called spindle cell squamous ca - spindles mix w sq
may create a cupola

Spindle Cell Carcinoma - Carcinosarcoma, mixed tumor
Epithelial cells & Spindles, often lg & polypoid

5. Melanoma - I' from basal cell layer, polypoid filling def

6. Lymphoma - I' rare, usually II', nodular defect
often ulcerates, may elongate & resem varices
7. Kaposi's Sarcoma - systemic multifocal RES tumor

8. Verrucous Carcinoma - occurs in stratified sqau epi
Exophytic, papillary, or warty tumor, rarely mets

9. Villous Adenoma - intermed malig, frondlike interstices


BENIGN ESOPHAGEAL TUMORS
<1% are benign, move freely during swallowing

1. Leiomyoma - Prolif of Smooth musc sim to uterine, #1 Benign
No malig transformation, No ulceration or bleeding
Other GI sites have higher malig trans & ulceration
Obtuse margins, amorphous calc diagnostic but rare
Lobulated & elongated, mid-dist #1, huge at GE jxn
Does not interfer w swallowing or motility initially

2. Fibrovascular Polyp - adipose, stroma & fiber in mucosa
Forms at mucosa just dist to cricopharyngeus
traction at site initiates & elongates w swallowing
can get lg w/o sx, dysphagia & pain
Lg sausage shaped, slightly lobulated filling defect

3. Inflammatory Esophagogastric Polyp - result of reflux
hyperplasia of dist mucosa, usually pushed into stomach

4. Papilloma - Epithelial prolif of unknown etiology, small
can infil submucosal & thicken folds, sim varices
Can also be mult & sim squa cell ca

5. Granular Cell Tumor - rare, often in biliary or bronchus
sm mural mass, may stimulate dysplasia of epithelium

NON-NEOPLASTIC ESOPHOGEAL FILLING DEFECTS
1. Varices - serpiginous mucosal masses, change w pressure
can mimic neoplasm if thrombosed or single polyp
see section on esoph varices

2. Esophagitis - Infectious or Granulomatous
Lymph node enlargement can create filling defects
Candidiasis & herpes - mult round nod defects possible
assoc ulcers & shaggy margins suggest Dx
Crohn's - cobblestones or filiform polyps, rare
Eosinophilic - may present as mult polyps

3. Duplication Cyst - eccentric defect, muscle & mucosa
less common than in remainder of GI tract

4. Foreign Bodies - bones in cerv esoph #1, check 2 views
poorly chewed meat etc lodges in dist, assoc w stricture

5. Intramural Hematoma - post trauma to wall ie FB, scope etc
anticoag pts, post sclerotherapy
sudden onset dysphagia, hematemesis

6. Hirsute Esophagus - follows reconstruction w skin

7. Prolapsed gastric folds - usually spont reduction


ESOPHAGEAL VARICES
Gastric varices closely assoc
Bleeding in sm varices as often as lg, 10% die immediate
Use very thin barium, image during rest & horizontal
complete filling may compress or obscure, unless thromb
earliest in Rt ant lat, dist 1/3, use LAO
forced or blocked insp will distend varices
Probanthine 30mg will distend - antichol, bad w glacoma

1. Portal Hypertension - collateral flow of portal blood
coronary v to periesoph plexus to axygos to SVC
Hepatic cirrhosis - #1, 90% dead in 2 yrs
Ca of pancreas - obstructs portal or splenic veins
pancreatitis, retroperitoneal inflam or fibrosis
polycythemia - high viscosity
Mets or primary Ca of the liver

2. SVC Obstruction - due to tumor or inflam compression
back flow thru azygos sys to periesoph plexus
Thymoma or retrosternal Goiter
Chronic fibrosing mediastinitis

3. Heart Failure

4. Varicele Mimics - thickened mucosal folds
Lymphoma, most ca fixed, no change or peristalsis

Sclerotherapy is accepted esp if portal shunt not an option

DIFFUSE FINE NODULAR LESIONS OF ESOPHAGUS
seen best on double contrast, exclude artifacts

1. Glycogenic Acanthosis - N variant, 1-4mm linear nodules
multifocal plaques of hyperplastic squamous epi
scope only if appearance atypical

2. Esophagitis - granular in early stages, any cause
Candida & Herpes freq, often longitudinal

3. Esophageal Ca - Superficial spreading type, submucosal only

4. Acanthosis Migricans - premalig hyperkeratosis of skin
Multiple verrucous prolif in esoph

5. Leukoplakia - white patches of hyperplastic epi, mid 1/3

6. Cowden Dz - multiple hamartomas, rare

Hirsute esoph, extopic sebaceous glands, bullous pemphigoid

ESOPHAGEAL DIVERTICULI
1. Zenker's Diverticula - post midline at C5-6, pulsion type
II' to motor discoordination of cricopharyngeus
weak spot between obl & circular fibers
food, mucous & drugs can accumulate, may compress esoph
plain film may show widened retrotrach space w AF level
oral contrast differentiates from abcess

2. Traction Diverticula - II' to healing inflam or surg
Thoracic diverticula - occur ant at level of hilum
II' fibrous adhesions assoc w mediast lymph nodes
LAO demonstrates best, look for calc nodes

3. Lateral Diverticula - seen in cerv esoph of pts w dysphagia
at pharyngoesoph jxn just below trans cricopharyngeus
4. Epiphrenic Diverticula - dist 10cm, considered pulsion type
Duplication with communication may be etiology
assoc w motor abn, inc luminal pres, usually asym
may dilate w food & mucous etc

5. Diverticular Carcinoma - suspect ca if irreg, esp if previously smooth

6. Intramural Esophageal Pseudodiverticulosis - sim tics
represent rows of dilated submucosal glands
flask shaped outpouching parrallel to long axis
similar to Rokitansky-Aschoff sinuses of GB
90% assoc w sm stricture in upper esoph
may be II' to reflux, can be localized w fewer than 10

ESOPHAGEAL RUPTURE
1. Congenital Tracheoesophageal fistula - poor lumen dif
common origin from caudal embryonic pharynx in 1st mo
assoc w Tet, vert & rib anomalies, duod & anal atresia
Type A fistula - both blind pouches, no air in stom, #2
Type B fistulas - 90%, upper esoph ends in blind pouch
lower seg con to trach, air in stom pathognomonic
Type C fistula - H type, often asym, down from trach to esoph
Type D fistula - upper con to trachea, no air in stom
Type E fistula - both connect seperatly

2. Acquired Tracheoesophageal Fistulas
Malignancy - 50%, esp esoph ca, late & terminal complic
Instrumentation - assoc w Ca, surg or caustic stric
Trauma - assoc w severe substernal & back pain
dysphagia & resp distress, plueral eff, hydropneumo
Almost always ruptures to the LEFT
Amylase may be detected in the resulting L pleural eff
Boerhaave's Syn - usually at esophagogast jxn, no pulm
epigastric pain radiating to shoulders
present sweating, tachy, often in shock
pneumomediast, eff in L base
Caustic ingestion
Inflam & granulomatous
TB - eoph last organ effected
usually direct errosion form mediastinal nodes
Syphilis - assoc w syphilitic anuerysm
Histo - assoc w nec nodes
Actinomycosis - by local penetration or hematogenous
Crohn's & Behcet's - rare
Ruptured traction diverticulum
Congenital Esophogeal Rupture - II' to pressure during delivery
usually occurs post-medial & spills to R plueral space
L side protected by aorta

DOUBLE-BARREL ESOPHAGUS
intramural dissecting channel

1. Intramural Hematoma - compresses N lumen, may fill
Use water solubles initially, but barium detects sm tear
Emetogenic Injury - #1, mucosal tears from repeat cont
Mallory-Weiss syn - bleed due to mucosal lac at jxn
10% involve only esoph, men over 50 #1
can occur w defecation, cough or lifting also
Instumentation, bougies, trauma or anticoagulation

2. Intramural Abscess - follows mucosal tear
persistent pain, fever, dysphagia, no CXR findings

3. Intraluminal Diverticulum - pocket open prox closed dist
covered on both sides by mucosa, assoc w chronic inflam
pulsion divertic restrained by muscle layer
downward ballooning of partial esoph web also poss

4. Esophageal Duplication - if communicating w lumen

DIAPHRGMATIC HERNIAS
1. Hiatal Hernia - most common finding on upper GI
most sx & complications due to reflux
volvulus w strangulation can be life threatening
Organoaxial - greater curve rotates above lesser
Mesenteroaxial - rotate on omental conections
Lg hernias lead to resp compromise, CXR may detect
Schatzki ring - transition between esoph & gastric muc
helps define extent, double ring sign

2. Paraesophageal Hernia - stomach herniates ANTERIOR to esoph
thru hiatus or adjacent gap, not assoc w reflux
Varices - develop due to lymph & venous obs
Bleeding much worse than in esophageal hiatal hernia
Usually repaired, serious complication potential
asym unless lg, resp probs, volvulus

3. Foramen of Morgagni Hernia - anteriomedial, greater on RIGHT
Present in adults II' to obesity or trauma
if no bowel, resembles pericardial cyst, pulm hamartoma

4. Foramen of Bochdalek Hernia - postlateral, LEFT due to liver
75% symptomatic, chest & back pain, dyspnea
Congenital hernias usually occur here - no hernia sac
abd organs enter before septum transversum closes
resembles cystic adenomatoid formation in lung
severe hernias may have no gas in chest, thin abd

5. Traumatic Diaphragmatic Hernia - usually direct laceration
Blunt also, 90% occur on L, Sx often develop years after
Seen on plain film, sim paralysis, moves w pt position

6. Intrapericardial Hernia - rare, congenital or post trauma

BENIGN GASTRIC ULCERS
Penetration beyond N lumen key
Submucosa more rapidly destroyed than mucosa, undermines
Hampton Line - thin sharp line at ulcer base
Ulcer Collar - seperates ulcer from lumen
Ulcer Mound - ext mucosal edema, dec distensability
can simulate ca, symetric w ulcer in center though
Crescent sign - edema nearly obliterates neck
Antral Diverticula - simulate crescent sign
Mucosal folds Radiate to edge of ulcer, smooth & narrow
Halo sign - wide lucent band of symetric edema
mucosal folds seen up to edge, pathognomonic benign
hazy indistinct borders rather than sharp transition
Size & location are not helpful, except fundus - malig
benign most common on lesser curve & post wall
Ellipse sign - if parrallel to long axis it's an ulcer
if perpendicular it's nonulcerated deformity
95% heal 1/2 in 3wks, complete in 6wks w medical manage
stiffened wall, persistent converging folds
Endoscopy not needed unless atypical

1. Peptic Ulcer Dz - #1 by far, dist in young, prox in old
Marginal Ulceration - post-op comlication of PUD surg
in jejunum 2-3cm from anastamosis, 2-4 yrs out

2. Benign Tumors - Leiomyoma etc

3. Inflam & Granulomatous Processes
4. Radiation Injury - >4500 rads, occur from 1mo to 6yrs P
pain is often unrelenting w no relation to meals
Inc incidence of perforation & hemorrhage, rare healing

5. Pseudolymphoma - Gastric lymphoid hyperplasia
nonspecific late rxn to chronic PUD, mimics malig type
regional enlargement of rugal folds

6. Hepatic Arterial Infusion Chemotherapy - toxic to lining
esp if cath moves into L gastric art


SUPERFICIAL GASTRIC EROSIONS
do not penetrate beyond muscularis mucosa
seen on upper GI approx 50% w air contrast

1. Dyspepsia #1 - 20% bleed, barium won't coat, endoscope
Barium shows fleck & halo, edema around erosion
Incomplete erosions appear as flat epithelial defects
assoc w NSAIDs, rarely aligned w rugal folds
greater curve & antrum due to gravity

2. Aphthoid ulcers - small targets
Crohns - earliest asym stage, noncaseating granulomas
Alcohol, candida, syphilis, CMV also

3. Lymphoma - can appear as tiny ulcers in nodular folds
GASTRIC MALIGNANCIES
Represents a necrotic region in mass, abrupt transition
Remains within the expected confines of N gastric lumen
Nodular center w irreg or amputated radiating folds
Carman's Minescus - semicirc collection convex to lumen
Kirklin complex - elev ridge surrounding a carman ulcer

1. Adenocarcinoma - 90%, poor prognosis because sx late
Risk Factors - Same as for Gastritis, 2:1 male
achlohydria, pernicious anemia, polyps
Expansile Type - villous, well-differentiated
Assoc w intestinal metaplasia
Infiltrative Type - Scirrous Carcinoma, poorly diff
Signet ring cells w INTRAcellular mucin, antrum>body
infiltrates into submucosa causing narrowing & rigidity
CT - thick wall w extensive desmoplasia, extention
Mucious Adenocarcinoma - subtype w EXTRAcellular mucin
also poorly diff, freq punctate calc, submucosal infil
Carcinoma in Situ - limited to submucosa, improved prognosis Pain & wt loss, occult bleeding common
30X greater in japan, iceland & chile

2. Lymphoma - 2%, usually NHL met, almost never Hodgkin's
I' when presents in GI or local node w NO dist nodes
Variable grades of tumor do not predict response to Tx
Presents in ileocecal valve in child, intussusception
Stomach #1 in adult
Origin from mucosal lyphoid B-cells in 80%
Polypoid, Nodular or diffuse thickening of folds poss
Minimal desmoplastic Rxn, Freq cental ulceration, mult 25%
Rarely obstructs, more often dilates lumen
Mets often assoc w enlarged spleen & extrinsic comp by node
DDx - Adenoca cannot be excluded, more fibrotic, obstructing

Pseudolymphoma - actually just a low grade infil of lymphoma
Ulcerating mass or thickened folds sim

3. Sarcoma - rare, develop lg ulcers, sim to benign forms
Leiomyosarcomas, lipo & fibrosarcoma, neurogenic sarcoma

4. Mets - hematogenous melanoma #1, Bull's eye lesion
5. Carcinoid - from Kulchitsky cells in crypts of Lieberkuhn
precursor neuralectodermal cells, rare in stomach
assoc w hyperacidity due to histamine prod
slow growing, long survival even w distal mets

NARROWING OF THE STOMACH
Linitis Plastica Pattern - leather bottle stomach

MALIGNANT CAUSES
1. Adenocarcinoma, Infiltrative Type - Scirrhous Carcinoma #1
infiltrates thru submucosa
no peristalsis beyond Ca, pyloris then spreads prox
Nodular thickening, stage w CT

2. Hodgkin's Lymphoma - invasion can cause desmoplastic rxn
Antral, mucosa effaced but intact, peristalsis retained
Assoc w lg nodes, speenomegaly, poss lobulated mass

3. Mets - Pancreas extention #1, nodes or trans colon also
Mucosa often intact initially, spiculated pattern later
Hematogenous spread from breast

BENIGN CAUSES - rare
R/O extrinsic compression narrowing lumen, esp hepatomeg

1. Gastric Ulcer Dz - intense spasm may hide ulcer
High ulcers in older pt may heal w Hourglass deformity

2. Infection - edema & inflam, smooth thickening, antral pred
Syphilis - tertiary, scattered gummatous polyps
TB & granulomatous processes - ulceration & fistula poss
Eosinophilic Gastritis - infil of eosinophils, outlet obs
resolves w steroid Tx, follows allergy to food
Polyarteritis Nodosa related
Phlegmonous Gastritis - bacterial invasion, submuc edema
Strep #1, E. coli, clostridium, proteus also
Purulent emesis pathognomonic, extreme pain, fever
Emphysematous gastritis - air in wall, LETHAL
Stongyloides Stercoralis - invades wall
CMV - AIDES pts can have advanced cases
3. Crohn's Dz - narrow antrum, slow peristalsis, cobblestones
doudenum involved giving a bilroth-I type pattern

4. Sarcoidosis - 10% have stomach involvement, usually antral
may mimic ca, pain, thickened folds, bleeding
extensive adenopathy assoc, must Bx for Dx

5. Corrosive Agents - esp Acids due to coagulative necrosis
acute inflam heals by fibrosis, sim to malig
Antrum of stomach most common site of stricture
Iron Intoxication - usually children, intense corrosive
Hepatic art Chemo - tends to resolve P tx stoped

6. Radiation - >4500 rads, usually not in tx fields
Achlorhydria - reduces parietal cell pop

7. Stenosing Antral Gastritis - inflam efaces folds, sim ca
spasm may be caused by myenteric damage

8. Amyloidosis - protien polysaccaride complex deposites

9. Peudolymphoma - hyperplasia, linitis assoc w lg ulcer

10. Intramural Gastric Hematoma - compresses lumen, FUNDUS
Submucosal mass simulating a mesenchymal tumor

11. Gastric Partitioning - get Hx

12. Perigastric Adhesions - circumfrential antral narrowing
Mucosa remains intact, peristalsis N

THICKENING OF GASTRIC FOLDS
Magenstrasse - folds of lesser curve channel fluid to duo
Lamina propria, muscularis mucosa & portions of submuc
edema or inflam of any layer can effect folds
Antral folds >5mm abnormal, Fundal folds thicker
Areae Gasticae - N anatomic folds most prom in antrum
no known physiologic fxn, prom in inflam & hyperplasia

BENIGN CAUSES
1. PUD - #1, fold size in body & antrum assoc w acid level
Most II' progresion from Gastritis

Zollenger-Ellison Syn - acid prod II' to gastrinoma
Glandular hyperplasia & hyperchlorhydria
Lg amounts of retained gastric fluid, PUD in 75%
Fold thickening extends to duo & sm bowel
Esoph stricture due to GERD also assoc
25% assoc w MEN-I - Panc, Parathyroid, Pituitary

2. Gastritis - Helicobactor plays a role in all
99% of duodenal ulcers, Tx w Abx, Flagyl & bismuth
Acute Gastritis - #1 exogenous cause, resolves change
Etoh, ANSAIDS, bile, ischemia & acidosis predispose
UGI - mild fold thickening, incomplete erosions
Endoscope see much better due to pale appearance
Chronic Gastritis - plasma cell infil into lamina propria
Nodular filling defects from heaped up plasma cells
Heals slowly, may remain for years, Antrum > Body
Hypertrophic Gastritis - hyperplasia II' to chron inflam
assoc w inc secretions, freq ulcers
Prominent areae gastricae, 4-5mm & angular, N 1-2mm oval
Fundal Gastritis - Ab to parital cell & intrinsic factor
often asym, pernicious animia poss, assoc w achlorhydria
Intestinal Metaplasia - mucosa trans to villiform
inc incidence of adenoma's & adenoca
Atrophic Gastritis - chronic progression, loss of folds
tubular narrowing & loss of mucosal glands
Antral Gastritis - localized to antrum w no dou involved
flattening of the prepyloric shoulders, corregated muc
persistent pain unchanged by antacids or eating, Helicobactor freq
3. Hyperplastic Polyps - 90% of gastric polyps, non-malig
Often assoc w adenoca due to common link w Gastritis
Usually Antral, <1.5cm & line up along rugal folds
Tx for Helicobactor often causes complete regression
DDx - Menetrier Dz & Villous Tumor, Dx w Bx
hanging drops can sim ulceration of melenoma etc

4. Menetrier Disease - Idiopathic mucosal hyperplasia, Helico?
Foveolar hyperplasia - abn tight jxn's, protien leaks out
Hypoprotienemia - Edema, ascites, rash & diarrhea
Glandular Hyperplasia - leads to achlorhydria
UGI - Bizarre giant rugal fold thickening, esp at greater C
Sluggish peristalsis, slight premalig potential, Antrum often spared
CT - IV bollus shows epithelial enhancement, mucosa low atten
DDx - protien loss also w atrophic gastritis & gastric Ca

Pediatric Hypertrophic Gastropathy - sim protein loss
Prox stomach only, follows GI or resp viral prodrome

5. Gastric Varices - assoc esoph varices, very pliable
Dil short & L gastric veins empty to coronary v of stom
if portal v patent, less varices
No Esoph varices pathognomonic of Splenic v occ

6. Infectious - hyperemia of stomach II' to bacteria or toxin
Anisakis - viceral larva migrans from raw fish, nematode
acute pain in 4-6 hrs P ingestion, self-limited
Pencil-like filling defects 30mm long
CMV - diffuse gastritis w thick nodular folds
differs from Kaposi's nodules, no diffuse gastritis
Eosinophilic infil
Granulomatous processes - TB, Crohn's, sarcoid, Syphilis
seen before characteristic antral narrowing

7. Corrosive agents - intense mucosal edema & inflam
assoc w ulceration, atony, rigidity
fixed open pyloris, free air in wall is bad
fluids follow magenstrasse & accum in antrum
tetonic contraction prevents further passage

8. Radiation - >4500 rads, not often included w lower abd

9. Pancreatic Dz - greater curvature, often w pseudocyst
direct metastatic ca spread also

NEOPLASTIC CAUSES OF THICKENED FOLDS
1. Lymphoma - fold enlargement often in proximity to mass
assoc ulceration & loss of pliability, Lukemic infil sim
Pseudolymphooma - benign prolif, even histo misleading

2. Adenoca, Mucinous Type - occasionally as lg tortuos folds
preserves realitivly N gastric vol & peristalsis, Bx Dx
Punctate calc may be assoc - Mucinous or colloid ca
Pathognomonic, similar to Psammoma bodies in thyroid

FILLING DEFECTS IN THE STOMACH
Areae Gastrica - N on all air-contrast, usually antral
Glucagon, thick barium give best results
indicates thinner mucus, prone to ulcers possibly
prominence assoc w hypertrophic mucosa, ie inc PUD

1. Polyps - usually asym, may bleed, or prolapse w outlet obs
3 Types, both can be seen w adjacent ca

Hyperplastic Polyps - #1 loc filling defect, 90% of gastric polyps
NOT malig, excess epi regeneration in response to inflam
hyperplastic glands, often cystic, rare mytosis
multiple & randomly scattered, Uniform 1-2cm & smooth
Bx unless multiple and uniform in older pt, 7% assoc w Ca

Adenomatous Polyps - dysplastic glands, Premalig
Lg w irreg lobulated surface, inc size = inc malig
single & antral, sessile or peduculated
Papillary w freq mytosis, inflam changes NOT prom
Tubular Type - smooth but lobulated, antral
Villous Type - Irreg interstices, inc malig trans
most have Ca in situ at time of Dx

Cronkhite-Canada Syn - juvenile type polyps, presents in elderly, F>M
alopecia, onychodystrophy, hyperpigmentation & malabsorbtion
100% have polyps in stomach & colon, >50% in small bowel
hamartomas w no malig potential, protien losing enteropathy

Familial Colon Polyposis - inc stomach polyps as well

Gardner's Syn - stomach polyps in <5%, inc risk of ampullary Ca in 12%
2. Hamartomas - N mucosa arranged differently
Peutz-Jeghers syn - Sm bowel polyps, mucocutatneous pig
No malig potential
Cowden Dz - hamartomas thruout GI, circumoral papillomas
Ruvalcaba-Myhre-Smith syn - thruout GI, macrocephaly
pigmented genital macules, retard, subQ lipomas

3. Gastric Duplication Cyst - Rare, contain all layers
usually Dx at infancy, vommiting, anemia
usually no communication but bleed & perf
Greater curve

4. Adenoca, Expansile Type - arise de novo or from polyp
Anemia & epigastric pain #1, often asym
Assoc w pernicious anemia & atrophic gastritis
Consider malig if sessile & >2cm
Mucinous Adenocarcinoma - assoc w granular calc

5. Lymphoma - multiple ulcerating polypoid tumors typical
Pseudolymphoma - benign prolif which mimics

6. Mets - Melanoma #1, bull's eye app, always w sm bowel also

7. Spindle Cell Tumors - 80% of benign gastric neoplasms
any size, usually asym, ulcerate as enlarge, 5% w calc
intra or exogastric forms, can mimic ext compression
Leiomyoma - matted sm muscle w vasc collagen stroma
Lipomas, Hemangiomas, Fibromas & Neurogenic tumors

Sarcoma - rare in stom, arise intramural, present luminal
bulky w extensive cent necrosis, extensive local spread
diff from leiomyoma by lg exogastric mass
Spread to liver & lung, node involvement rare
Leiomyoblastoma - slow growing, from sm muscle, antral
Kaposi's Sarcoma - coalescing nodules in submucosa
Smooth w no ulceration

8. Carcinoid Tumor - from precursor neuroectodermal cells
sessile polyps or broad based filling defect
local invasion or hepatic mets, slow growing, long surv

9. Plasmacytoma - much more common in sm bowel
in stomach usually assoc w multiple myeloma in pt >50
INFLAMMATORY & EXTRINSIC FILLING DEFECTS
can mimic intramural & luminal masses

1. Ectopic Pancreas - most common in greater curve, <2cm
50% symtomatic w vague pain, nausea

2. Enlarged Gastric Folds - esp menetrier's, crohn's, TB
Gastric Ulcers w assoc edema
Hypertrophied Antral Pyloric fold - extends antrum to duo
assoc w chronic gastritis, fixed unlike antral prolapse

3. Bezoar - mottled appearance, assoc w ulcers
Phytobezoar - veg, esp persimmons which coag in acid
Trichobezoars - hairballs, esp schizo women
FB or gallstone can cause ulceration

4. Hematoma - either intramural or clot sitting in fundus

5. Double Pylorus - gastroduodenal fistula, lesser curve
assoc w PUD, N mucosa between sim a filling defect

6. Eosinophilic Granuloma - not assoc w bone form or allergy
Sessile smooth polyp, pt usually asym
Localized form, almost exclusively in stomach

Eosinophilic Gastroenteritis - diffuse form, infil of all layers poss
Hx of systemic or food allergy, present w pain & diarhea
involves dist stomach & entire sm bowel esp jejunum
marked thickening if muscle involved, ascites if serosa involved
assoc w peripheral eosinophilia (gastric Loffler's syn?)

7. Arterial Impression - Splenic on post med wall

8. Extramedullary Hematopoesis - esp w chronic myelogenous L

9. Amyloidosis - mult sm defects, usually w diffuse GI invol

10. Candidiasis - mult nodules w central ulcers, bull's-eye

MASSES OF THE FUNDUS
above horizontal line from esophagogastric jxn
adjacent to L liver, diaph & spleen

1. Neoplasms - benign can mimic malig
Adenocarcinoma - nodular, ulcerate freq, prox to esoph
may see a deformed gas bubble on upright film
Lymphoma - stom body often assoc as well, rare esoph ext
Leiomyosarcoma - rare, lg w central ulceration
Pancreatic or splenic flexure tumors often extend
Celiac nodes - compress central fundus

2. Normal structures - 70% of impressions benign, transient

3. Non-neoplastic
Esophageal prolapse - erosion & bleeding assoc
Hiatal hernia - redundent tissue when reduced
Varices - diff to distinguish alone, post & postmed wall
cirrhosis, splenomegly, esoph varices assoc
Thick Rugae - make sure well distended
Splenectomy defect - II' to short gastric art ligations
splenules grow later, poss in stomach wall
Subphrenic abcess, Hematoma, unfilled polyp also

MISCELLANEOUS STOMACH PROCESSES
GASTRIC REMENANT COMPLICATIONS
Bilroth I - gastroduodenostomy, Bilroth II - gastrojejunostomy
works due to the removal of most of the gastrin secreting cells

1. Marginal Ulcers - usually develop in jejunum, efferent loop
Assoc w retained antral seg, freq perforation
lg marginal ulcerations seen w Z-E syndrome

2. Bezoar - common in both I & II due to dec pepsin & acid
Stoma size has no bearing, usually up to 4cm
can cause outlet obs or pass to sm bowel, obs ileum
inadequate chewing assoc w poor dentition

3. Gastric Stump Carcinoma - Much more common w Bilroth II
20% develop in 20 yrs, even if done for benign causes
chronic bile & panc reflux prob accounts for this
Barium demonstrates poorly, Always need baseline
Recurrent Ca - usually considered a 2nd I' if >10 yrs
Lymphoma - retains pliability
any ulcer should raise suspicion

4. Hyperplastic Polyps - response to bile & panc reflux
Suture granuloma - round defect at anastamosis
only w non-absorbable suture

5. Jejunogastric Intussusception - rare but lethal
Jejunum enters stomach, eff loop 75% of the time
Chronic form is possible
Glucagon & barium can aide in reduction
Gastrojejunal prolapse more common, obs if large

6. Macrocytic Anemia - any process which removes antrum or ileum
Also caused by bacterial overgrowth in blind loop


GASTRIC OUTLET OBSTRUCTION
1. Peptic Ulcer Disease - 60%, usually in the duo, bileous
pylorus & dist antrum also but rarly body
Spasm, inflam, edema, scar contracture, stom distended
vomiting, delayed 1-2hrs, relieves the constant pain
scarring of bulb w pseudodiverticula indicates benign
N bulb more suspicious of malig
2. Malignant Tumors - annular ca of antrum, 30% of cases
often no pain or pain less than 1 yr, vomiting & wt loss
Scirrhous Carcinoma of pylorus identical to benign stric
invades submucoasal & musc layers, preserves mucosa
early met, duo usually spared & N in appearance

3. Benign Tumors - rare, prolapse of antral polyp
filling defect in bulb, may reduce easily

4. Inflammatory Disorders - infiltration or spasm of antrum
Crohn's Dz of stomach - 2/3 of pts develop this
Granulomatous - rare
Pancreatitis & cholecystitis - inflam spasm of duo
corrosives & amyloid also

5. Antral Mucosal Diaphragm - membranous septa 3cm from pyloris
Congenital - failure of embryonic forgut to canulize
Fibrosis cause also postulated II' to PUD
Asym if opening >1cm, 2mm seen asym until adulthood
may see jet effect, can mimic a 2nd duo bulb

6. Gastric Duplication - may narrow and deform the antrum

7. Annular Pancreas - compresses lat descending duo

8. Gastric Volvulus - rare, assoc w lg hiatal hernia
Organoaxial - rotation around the long axis
Mesenteroaxial - rotates on gastrohepatic omentum
Sx vary from none to surgical emergency
Vasc occ assoc w 30% mortality
Double AF level seen on upright films

9. Hypertrophic Pyloric Stenosis - infantile or delayed adult
adult don't have high grade, 50% assoc w ulcers
retained semisolid food causes secretion of gastrin & acid = PUD
spasm caused by PUD exacerbates
Pyloris elongates to 2-4cm, invaginates into bulb
can sim scirrhous ca or Pylorospasm on UGI
Torus Hyperplasia - focal hypertrophy at lesser curve
greater curve develops serrations
Sonography - muscle layer >3mm anechoic rim
length greater than 17mm
central echogenic center of mucosa & submucosa

GASTRIC DILATATION WITHOUT OUTLET OBS
vommiting of food eaten more than 6hrs earlier
food present during UGI, poor peristalsis

1. Acute Gastric Dilation - can occur in minutes to hours
vomiting, dehydratin, periph vasc collapse
Post-op #1, less w NG suction, etc
Inflammatory peritoneal proc via reflex motor neuro path
Immobilazation or pain due to difficulty belching
Pain seldom severe until cyanosis occuring

2. Chronic Gastric Dilation - 30% of diabetics
Poor control = autonomic neuropathy, ketoacidosis worse
Vagotomy w/o emptying procedure has sim app, CNS also
Scleroderma - rare, diffuse hypotonia can develop
polymyositis, dermatomyositis, myotonic musc dystrophy also
Electrolyte & acid-base imbalances alter musc tone
Lead poisoning, hyperventilation also

WIDENING OF THE RETROGASTRIC SPACE
lesser sac lies between stom & vert body
Pancreatic neck 1-1.5cm thick, aortic nodes & aorta
No set width, impression on stom must be demonstrated

1. Benign Causes - Obesity #1, retroperitoneal fat
Post-op adhesions or disruption of N ligaments
Ascites & gross hepatomegaly

2. Pancreatic Masses - Pancreatitis, Pseudocyst, cystademoma
Head lesions compress post inf antrum
Body & tail lesions compress body & fundus of stom
Panc ca fixates wall, ulcerates

3. Other Retroperitoneal Masses - Sarcoma, renal & adrenal ca
Lymphoma & nodes, TB, cysts, abcess
Hematoma or aortic aneurysm
Leiomyomsarcomas - Lg exogastric component


GAS IN THE WALL OF THE STOMACH
Sx of other underlying disorder
mottled shadow of bubbles fixed in wall
Not diagnostic, represents breach of epi

1. Emphysematous Gastritis - severe phlegmonous gastritis
Strep, clostridia, anerobics
Severe pain, hematemesis, rapid progression to death
Mucosa seperates early, cicatricial stenosis results
Rupture & gastric sinus tracts also

2. Severe necrotizing Gastroenteritits - assoc w PUD

3. Corrosives - penetration of mucosa

4. Ischemia - esp assoc w overdistention

5. Trauma - II' to endoscopy, gas pattern linear not mottled

6. Rupture of Pulm Bullus into esoph mucosa
consider if pt is not sick

INVOLVEMENT OF THE ANTRUM & DUO BULB
1. Malignant Lesions - ext to bulb pathognomonic of lymphoma
Adenoca causes outlet obs before bulb involved in 95%
Adenoca still more likely, 50X greater occurance

2. PUD - thickening & ulceration freq in both, fibrosis also

3. Crohn's Dz - blends antrum, pylorus & bulb into a funnel
Pseudo-bilroth I pattern, remains distensable
mucosa can become shaggy & nodular

4. TB - dou involved in 10% of gastric cases, 50% w pylorus
Stomach TB rare even w intestinal or pulm involvement

5. Strongyloidiasis - nodular intramural def, ulcer, strictur

6. Eosinophilic Gastroenteritis - contiguous fold thickening
Assoc w peripheral eosinophilia & food allergy.

ULCERATION OF THE DUODENUM
1. PUD - only 5% in postbulbar region, 7:1 male
Postbulbar more likely to bleed (66%), rarely perforate
Medial wall prox to ampulla of vater #1 (ant wall for bulbar ulcers)
freq incisura on opposite wall, "kissing ulcer"
may cause obs, pancreatitis, bleeding, pain
Shallow flattened niche in med aspect, lat rare
Incisura produced by lat spasm, can persist to fibrosis
Ring Stricture - chronic & progressive, indicative PUD
assoc w severe Sx
Can penetrate to pancreas, pancreatitis, ext compression

2. Zollinger-Ellison Syn - Gastrinoma, most in panc, 2/3 mult 10% in duo
25% of ulcers occur postbulbar, always consider w ulcers dist to ampulla
assoc w fold thickening thruout, hypersecretion
Ulcers fail to respond to traditional therapy
one develops while a 2nd heals, recur P surg resec

3. Malignant Tumors - #1 cause of non-PUD ulcers
Adenocarcinoma #1 in duo, Lymphoma & Sarc can also ulcer
Spread from panc, colon, R kid, GB
Melanoma - hematogenous mets, massive hemorrhage

4. Benign Tumors - lieomyomas can ulcerate

5. Granulomatous Dz - Crohn's assoc w other GI involvement
TB - assoc w severe spasm & mucosal edema

6. Aorticoduodenal Fistula - assoc w aneurysm & post reconst

7. Pseudoulceration - ectopic pancreas can retain barium
Sm diverticula - maliable, no fold thickening

THICKENING OF DUODENAL FOLDS - >5mm
Can create a "Psuedokidney" sign on US

INFLAMMATORY DISORDERS
edema of mucosa or submucosa layers thickens folds

1. PUD - #1, Mucosal edema causes compresable folds
Hyperplasia of Brunner's glands, fixed nodular folds

2. Zollinger-Ellison Syn - assoc w thick gastric rugae
ulcerations distal, 3rd & 4th duo & prox jej

3. Duodinitis - may be more freq cause of pain than ulcers
Hyperactive peristalsis, nodular thickened folds
no assoc ulceration, inc incidence w renal Dz

4. Pancreatitis & Cholecystitis - spasm can prevent filling
Periampullary & prox 2nd duo, elev amylase, ext comp

5. Infectious - TB would also have assoc pyloric & antral Dz
Whipple's Dz - mostly jej (see pg74), infil w PAS pos macrophages
II' to bacteria, all sys involved, arthritis freq
thick pliable folds, NO dilation, NO ulceration
Giardiasis & Strongyloidis - hypersecretion & motility
AIDS - allows mult bugs to induce inflam

6. Uremia - chronic dialysis assoc w nausea & vomiting
Bulb & 2nd portion get irreg stiffened folds
Inc PUD but thick folds not related to hyperacidity

7. Crohn's - may be isolated to duo

8. Sprue - thick folds, marked dilation

9. Cystic Fibrosis - low panc bicarb allows acid damage
fold thickened esp in bulb & 2nd portion
NEOPLASTIC CASUSES OF DUO FOLD THICKENING
Lymphatic Blockage - II' to nodal mets or local extention
Lymphoma & Kaposi's sarcoma also


VASCULAR CAUSES OF DUO FOLD THICKENING
1. Duodenal Varices - obs of portal or splenic, 4 forms
1) flow in sup pancreaticoduodenal vein compresses bulb
2) Sm varices prod diffuse polypoid mucosal pattern
3) Lg submucosal vein cause serpig filling defects
4) Isolated dou varix on med descending side, rare
Always assoc w Esoph varices

2. Mesenteric Arterial Collaterals - celiac or sup mesen obs
Pancreaticoduodenaal arcade lies adj to dec duo
Gastoduodenal also at variable distances
can prod lg defects & widen sweep
Aberent R Hepatic from sup mesen - defect on sup bulb
Chronic congestion leads to edema of wall, dyspepsia

3. Hematoma - folds in a "stacked coin" config, anticoag etc

WIDENING OF THE DUODENAL SWEEP
common N variant esp in fat pt w high trans stomach

1. Acute Pancreatitis - usually II' to Etoh, pain always
panc head may be 3X N size, smooth mass on inner sweep
Paresis & edema of folds & papilla of vater
Displaces greater curve as well, gastric atony & dil
Elev hemidiaph, L eff, sentinel loop, colon cut-off
CT to R/O phleg, pseudocyst etc
Ultrasound - hypoechoic

2. Chronic Pancreatitis - 50% assoc w Etoh, 30% w calc
Malabsorbtion, wt loss, aseptic nec
Fold effacement II' to fibrosis & rigidity of the wall
Spiculated mucosa, enlarged papilla
US - hyperechoic, calc shadows, duct dil II' to fib
3. Psuedocyst - no epi lining of a true cyst
panc fluid exudes into tissue, osmolality pulls in fluid
reactive fibrosis forms wall, those in head widen sweep
70% form in body & tail post to stom
assoc parenchymal calc freq
US - hemorhage into cyst can create complex echos
Infection can occur, rupture into peritoneum poss fatal

4. Pancreatic Head Ca - widening indicates advanced Dz
Antral pad sign - indention on dist greater curve
Double-Contour effect - indention of inner aspect of duo
Inverted 3 sign - comp w fixation of the papilla
more common w inflammation
Spiculation of mucosa - also w inflam but suspicious
Irreg Nodularity more specific to ca
US - demostrates tumors >2cm in head
CT - tumors relatively avasc, less enhance than N gland
most important for staging & Bx guidance
often encase & obs vessels

5. Mets - local ext into panc head from stom, colon, kid
Hematogenous mets to panc head rare
Nodes - pyloric nodes lie inf to bulb & 2nd portion
Pancreatoduodenal nodes between panc & duo

6. Cystadenoma & Cystadenocarcinoma - usually body & Tail
Occur in younger pt than ca, mostly women, asym
High assoc w endocrine abn, thyroid, diabetes, obesity
excision often curative, can grow very lg

7. Aortic Aneurysm or Dilated Lymph Ducts - disp 3rd portion
Choledochal cyst - in child <10 y/o, see below

EXTRINSIC PRESSURE ON THE DUODENUM
all organs of the R upper quad can effect duo

1. CBD - produces linear imp on bulb, R sup
Choldochal Cyst - segmental dil of CBD, 60% pts <10 y/o
triad of jaundice, RuQ mass & pain classic but rare
can widen sweep

2. GB - imp on upper outer margin of bulb & sweep
Hydrops of GB - dist II' to acute or chronic obs
occurs in children
Courvoisier Phenomenon - enlargment w jaundice
usually indicates a malig extrahepatic obs
GB carcinoma - rare, inc in elderly women
freq seen w calc GB wall, can displace & ulcerate duo
Abscess II' to chlecystits can disp or cause dou edema

3. Liver - disp bulb & sweep Leftward, esp caudate
anomalous lobe or nodes in periportal region also

4. R Kidney & Adrenal - imp on post lat sweep
Cysts, renal cell, addisons, etc

5. Pancreas - nodule in lat 2nd portion, ca or annular
post bulbar PUD produces identical app, lat Incisura

6. Colon - mutual indention N in 30%, ant
duodenalcolioc fistulas can develop

7. Vascular - see sec on thickened folds

DUODENAL FILLING DEFECTS
R/O Pseudotumors - GB, ulcer mound, FB, stich abcess, tic
barium in biliary tree suggests gallstone

NONNEOPLASTIC MASSES
N mucosal folds can be redundent, esp at flexure

1. Erosions - sm flecks of barium assoc w PUD or Crohns
improperly mixed barium powder can prod this effect
Nonerosive Duodenitis - #2, velvety thickening of folds
not assoc w PUD or hypersecretion

2. Brunner's Gland Hyperplasia - mult nodular filling defects
mixed serous & mucous acinar lobules, may extend to jej
usually only 1st part of duo in response to PUD

3. Benign Lymphoid Hyperplasia - innuberable tiny nodules
usually not the nodular type, no assoc w lymphoma
assoc w dysgammaglobulinemia in children

4. Heterotopic Gastric Mucosa - elevated lesions 1-6mm
most in immediate post pyloric region

Ectopic Pancreas - discrete defect in prox 2nd, incidental
Pancreatic rests #1 in dist stom along greater curve
central dimple of panc duct often seen

5. Sprue - 1-4mm hexagonal filling defects in bulb
Flattens villi, exposes Brunner's glands
Gluten hypersensitivity

6. Prolapsed Antral Mucosa - lobulated defect at base of bulb
reduction reveals redundant folds

7. Choledochocele - cystic dil of CBD at ampulla
smooth def, projects into lumen on med wall

8. Dulplication Cyst - usually seen early, 10% communicate
fluid filled, seen in concavity of 1st & 2nd portions

9. Vascular Structures - varices, arterial coll
Hematoma - 80% in children & young adults, coiled spring
retroperitoneal 2nd & 3rd portions fixed
crush between vert & abd wall, anticoag, post Bx, etc
BENIGN NEOPLASTIC CAUSES OF DUO FILLING DEFECTS
90% of bulb tumors, 4th portion 90% malig
50% of 2nd & 3rd portion benign, most asym & solitary
may ulcerate & bleed, may obstruct papilla
smooth appearance often does not exclude malig

1. Adenoma - #1, 1cm smooth polyp, often pedunculated
Brunner's Gland Adenoma - local hypertrophy, not neoplasm

Villous Adenoma - more common than tubular in duo
Periampullar #1, usually 2-3cm, Tx w resection
Can grow into ampulla & obs both causing jaundice
Frondlike lobulated defect w fine interces, changeable
Not assoc w mucorea or K+ loss as in colon
more common in duodenum than tubular type

Tubular - more common in jej & ileum, least malig potential

2. Leiomyoma - Submucosal, smooth convex bulge, folds intact
ulceration & bleeding common

3. Lipoma - Submucosal, shape very changeable, pedicle poss

4. Hamartoma - seen in Puetz-Jeghers syn

5. Neurofibromatosis - from subserosal nerve or Auerbach's

6. Cavernous Lymphangioma - irreg dil of lymphatic channels
rare, asym, changeable like lipoma

7. Prolapsed Antral Polyp - pain & anemia freq, adenoma #1

8. Carcinoid or Islet Cell Tumor - same origin & Sx
Submucosal in ant med position prox to ampulla
arise from neuroectodermal precusors, argentaffin cells
Intractable PUD & severe diarrhea, assoc w MEA, freq met
High endocrine activity - Seritonin, insulin, gastrin
MALIGNANT CAUSES OF DUO FILLING DEFECTS
rare, dist to amp, fixed mucosal dest, bleeding, bowel & CBD obs

1. Adenocarcinoma - #1 malignancy in Sm bowel, still uncommon
Expansile Type - Villous, can grow into ampulla & Obs
Infiltrative Type - Circumfrential growth, often narrow
present w obs, poor prognosis

Ampullary Adenocarcinoma - Duo, CBD or Panc origin
Pancreatic Ca has 15X greater occurance
Present Very sm due to obs, may only be vis w endos US
Good Prognosis w Whipple resection
"Silver Stools" - classic clinical sign but rare

2. Leiomyosarcoma - Lobulated, central ulceration, nec center
often have lg extramural component

3. Lymphoma - I' to duo rare, cobblestones

4. Mets - Gastric, Lymphoma, Panc, GB, colon, kidney, nodes
Melanoma - bull's eye

5. Kaposi's Sarcoma - sm plaques or submucosal nodules

DUODENAL NARROWING AND OBSTRUCTION
CONGENITAL
1. Duodenal Atresia - #1, complete obliteration of lumen
80% dist to ampulla, occurs at 6-11wk gest
Double Bubble - dil of prox duo develops in interum
No gas dist to obs, Bilious vomiting at birth
assoc w down's, malrotation, rib & vert malform, etc

2. Annular Pancreas - at or prox to ampulla, INCOMPLETE obs
Double Bubble but dist gas means no atreasia
May present as adult w inflam of panc etc
Notch defect in Lat duo
Pancreas develops from dorsal & double ventral lobes
Left bud of ventral usually deg, if not this happens
30% assoc w down's, atresia, Malrotation w bands etc

3. Doudenal Diaphragm - webs obs in various degree near amp
2nd or 3rd w prox dil, web may balloon out on exam, "windsock"
35% assoc w malrotation, 50% have additional webs in GI

4. Midgut Volvulus - occurs w inc rotation, 20% assoc w above
Narrow mesenteric attachment to sm bowel
Rotates around sup mesenteric A
Lig of Trietz inf & Rt, Spiral loops on R diagnostic

5. Ladd's Bands - Congenital Peritoneal Bands
Fibrous bands from malrotated Cecum over ant 2nd
Intermittent partial obs, standing relaxes bands

6. Duplication Cyst - rare, may contain mucus or bile
Intramural or extrinsic on mesenteric side, most asym

7. Duodenal Diverticulum - sac w halo due to tic wall, rare

INFLAMMATORY CAUSES OF DOU OBS OR NARROWING
1. Postbulbar Ulcer - usually shallow & flat in med 2nd
assoc w incisura of lat wall, resembles annular panc
Clover-leaf deformity common in duo PUD

2. Crohn's Dz - long stenosis or spiculated ulcers
rarely isolated to duo, funnel stom & duo

3. TB - rare, assoc w other pulm or GI involvement
diffuse ulceration & luminal narrowing sim to Crohn's
abcess & fistula common

4. Sprue - ulcerates w longstanding cases

5. Pancreatitis - inflam thickens dist duo & mesentaric root
Cholecystitis can have similar effect
Psuedocyst in head compresses sweep, no mucosal dest

6. Strongyloidiasis - can also sim Crohn's


MALIGNANT CAUSES OF DUO OBS & NARROWING
1. Pancreatic Ca - 70% in head, narrow 2nd due to invasion
20% in body, 10% in tail, narrow 3rd & 4th
Jaundice #1 presenting Sx, often w dull pain & anorexia
mucosal destruction suggests malig

2. Adenocarcinoma - 90% of I' duo malig, at or dist to amp
annular constricting lesion w overhanging edges

3. Fibro & Leiomyosarcoma - ulcerates, lg extrinsic component

4. Mets - often difficult to diff I' from II' infil
Celiac & Periaortic nodes adj to 3rd, can obs & ulcerate

NONNEOPLASTIC CAUSES OF DUO OBS & NARROWING
1. Hematoma - 80% children & young adults, see sec on fil def

2. Aorticoduodenal Fistula - II' to AAA or dacron repair
pressure nec of 3rd, usually fatal

3. Radiation - 2nd, ulceration or stricture

4. Preduodenal Portal Vein - portal ant to duo, incidental
High assoc w bands, annular panc & malrotation
obs usually II' to assoc probs rather than ant portal v


SUPERIOR MESENTERIC ARTERY SYNDROME
Obs of 3rd (trans) portion w proximal dilation
mesenteric root w sup mesen vessels & nerves ant
aorta & lumbar spine post, create sharp linear obs
Pain, bilious vomitting & relief w flexion common
obs overcome when pt prone, confirms Dx

1. Narrowing of the Aorticomesenteric Angle - some congenital
body casts or fixed hyperextention II' to inj or surg
anorexia w loss of retroperitoneal fat, or AAA

2. Reduced Duodenal Peristalsis - scleroderma, SLE, dermatomy
Aganglionosis - congenital or inflam ie chagas Dz
Vagotomy or adynamic ileus II' to inflam

3. Inflammation - PUD, TB, or abcess from panc, biliary etc
thickens root & duo wall

4. Lumbar lordosis - duo over convex surface

5. Chronic Idiopathic Intestinal Psuedo-Obstruction
may start w duo, progresses to involve entire GI

4. Pancreatitis - focal dil loop

5. Acute Intermittent Porphyria - familial metabolic
Severe colicky pain & obstipation, urine dark w UV expos

6. Ceroidosis - accum of brown lipofucin in musc propria
II' to chronic malabsorbtion & vit E depletion

7. Neotnatal Adynamic Ileus - can primarily effect sm bowel
II' to any usual cause

DILATATION WITH NORMAL FOLDS
N width 3cm, 2-3mm folds at reg intervals, Bx for Dx
SOS - Scleroderma, Obs, Sprue

1. Obstruction or Ileus - #1

2. Scleroderma - Collagen deposits, esp around vasc
Wide-mouth sacculations, "Hidebound", strictures

3. Sprue - or any cause of excess fluid, next section
20% develop lymphoma, 12% get nodes not from lymphoma

4. Neuromuscular Dysfxn - Vagotomy
parasym pathways interupted, inc transit & dil
II' to PUD Tx, look for vagotomy clips
drugs can simulate vagotomy, see above sec


EXCESS FLUID IN LUMEN
can cause dilation, steatorea (bulky fatty stools)
segnemtation, fragmentation, flocculation

1. Sprue - Idiopathic, tropical or Celiac Dz in kids
Villous Atrophy - seen on jejunal Bx
Dilation - most freq finding
Moulage - featurless adynamic loops, mid & dist jej
Barium colum flocculates & segments II' to hypersec
Reversed jejunoileal fold pattern, ileum inc, jej dec
Intussuception common, usually transient & nonobs
Idiopathic & celiac Dz improve w gluten withdrawal
Tropical improves w folic acid or Antibiotic Tx
Reactive lymphadenopathy 12%, regresses w gluten free diet
20% degen to T-cell lymphoma
Hyposplenism & esoph Ca also seen

2. Lymphoma - poss complication of sprue, 9mo prognosis
thickens bowel wall, extraluminal masses

3. Lactase Deficiency - unable to hydrolyze & absorb lactase
Blacks, mexicans & Chinese have 75% prevelance
Cramps & diarrhea 30 min P ingestion
adding 25-100g of lactase to barium results in dilation
4. Connective Tissue Dz - Scleroderma #1, other sx seen 1st
Sm musc atrophy & fibrous dep in mucosal, musc & serosa
Duo prox to mesenteric A most commonly dil but all poss
Hidebound - folds packed together despite dil
Pseudosacculations - Lg broad based pouchs, sim tics
Dermatomyositis has sim presentation

5. Blind Loop - bacterial overgrowth causes inflam
break-down products of bacteria cause osmotic effect

6. Diabetes w Hypokalemia - II' to neuropathy
Diarrhea & malabsorbtion assoc

7. Vascular Insufficiency - dec motility & dec transit = Dil
intramual bleeding & inc luminal fluid common
Vasculitis II' to SLE & Amyloid deposition sim

8. Chronic Idiopathic Intestinal Pseudo-Obstruction
II' to auerbach's disorder poss, chagas Dz simulates

9. Long term Crohn's Dz - Dr Doris's 28cm sm bowel

DILATATION WITH THICKENED MUCOSAL FOLDS
1. Zollinger-Ellison Syn - nonbeta islet cell tumor, gastrinoma
parietal cell stim, rugal thickening, PUD
25% of ulcers occur in dist duo or jej, may be giant
thickening rarely extends to dist jej
50% malig, 10% atypical locations, met to liver & nodes

2. Vascular Insufficiency - venous congestion, emboli esp

3. Inflammatory - Crohn's, TB, radiation
infiltration of mesentary w lymph or venous blockage
Mets work in a similar fashion
Infectious enteritis - esp in immune comp pt
Salmonella, Strongyloides, Candida, CMV, crypto, myco

4. Infiltrative processes - occurs in late stages, rare
Lymphoma primarily submucosal
amyloid -depostited around sm blood vessels
abetalipoproteinemia - fat droplets in mucosal cells

5. Hypoalbuminemia - alb <2.7 g/dl

6. Lymphoma - often causes aneurysmal dilation & fold thicken

SMALL BOWEL DILATION
SMALL BOWEL OBSTRUCTION
60% mortality w no Tx, 5% with
Crampy pain, Bloating, Nausea, Vomiting, dec stool
Tinkles & Rushes or no bowel sounds on exam
distended loops within 3-5hrs, >2 AF levels abnormal
look for valvulae & central position to diff from colon
No gas in colon w complete obs, good DDx from ileus
Barium used for Dx, do BE first to exclude colonic obs
Strangulation - obs blood supply, see obs closed loop
Smooth loop - Edema & hemorrhage can flatten valvulae
Pseudotumor sign - loop may be fluid filled
Gas in bowel wall or portal v, bac can pass w/o rup


EXTRINSIC CAUSES OF OBS
1. Adhesions - surg or peritonitis cause 75%, RLQ usually

2. Hernias - Inguinal, Femoral, Umbilical, Incisional
tapered bowel in inguinal & obterator areas w plain film
Internal hernias - congenital or surg mesenteric
foramen of Winslow also poss but rare

3. Neoplasia or Inflammatory Dz

4. Volvulus - II' to anomalous mesenteric connections

INTRINSIC CAUSES OF OBS
1. Neoplasia - large polypoid tumors

2. FB - Gallstones, enteroliths, Bezoars
Gallstone Ileus assoc w gas in biliary tree in 70%
85% obstruct at the terminal ileum

3. Intussusception - usually children, prox moves into dist
Child - rarely has lead point, peak age 5-9mo, 90%<2yrs
<2yrs assoc w meckel's, >5yrs lymphoma
Lymphoid Hyperplasia also assoc
attempt reduction only if no free air or ascites
Adult - freq lead point, pedunculated polyp, 20% idiopathic
Ileocecal valve 90%, Vasc compromise poss, 1% mort w tx
Abrupt onset pain, "current jelly" stool, palp R side mass
Coiled spring of barium, bi adj mass due to wall edema
Target sign on CT w eccentric widening of middle ring
intususceptum pulls mesenteric fat into intussuscipiens
Retrograde jejunogastric intussection P Billroth II

4. Meconium Ileus - dist sm bowel obs in newborn
assoc w cystic fibrosis or abn intestinal gland sec
colon sm in diameter II' to lack of use

5. Inflam of Bowel Wall - Crohn's, TB, Parasites, Kcl tabs
Radiation, amyloid, amyloid, hematoma

6. Congenital Atresia or Stenosis - Triple bubble sign w jej
lower ileal obs difficult to diff from colon
microcolon as w any congenital obs
Meconium peritonitis is a poss complication II' to rup
curvilinear calc on serosa or bowel wall at birth
Segmental dilation of ileum - N transition dist & prox
poss II' to resolved early obs, seg must be resected
ADYNAMIC ILEUS
marked dec in intensity & freq of bowel sounds
uniform dil of sm & lg bowel, stom as well unlike obs
AF levels often at same height unlike obs

1. Post Surgical - always w abd surg, usually resolves spont

2. Peritonitis - assoc w blurred mucosal pattern & wall edema
ascites, plueral eff, restricted diaph movement
gastroenteritis or enterocolitis can sim peritonitis
Appendical Abcess - can have ileus & true obs

3. Medication - Atropine type effects (muscarinic) freq
opiates, barbituates & sympathomimetis

4. Electrolyte Imbalance - hypokalemia #1, Cl, Ca, Mg also
hypothyroid or hypoparathyroid similar

5. Trauma - assoc w hemorrhage, Fx, shock, hypoxia
also MI or other severe systemic Dz

LOCALIZED ILEUS
1. Inflammation - adj to pancreatitis or cholecystitis
also happens adj to ureter w acute ureteral colic

2. Mesenteric Ischemia - focal or generalized dilation

3. Ogilvie Syndrome - colonic ileus w/o obs, assoc w insult
massive horizontal cecum & R side > L side, perf >12cm
imbalance in sympathetic & parasym innervation
distended w gas, in obs residual stool more prom


ADYNAMIC ILEUS SIMULATING MECHANICAL OBS
1. Chronic Idiopathic Intestinal Pseudo-Obstruction
possibly II' to smooth musc abn or auerbachs defects

2. Pelvic Surgery - focal inflam causes prox dil
hyperactive sounds & vommiting day 5, spont resolution

3. Bladder Distention - resolves w emptying

THICKENING OF SMALL BOWEL FOLDS
REGULAR THICKENING OF SMALL BOWEL FOLDS
any inc in fluid or cells in subucosa or mucosa
reg wide based folds perpendic to lumen w edema & hem
most infiltrative processes cause irreg distorted folds

HEMMORHAGE
sharply delineated margins
uniform thickening in picket fence pattern, esp in jej
mesenteric bleeding can cause extrinsic mass, uncoiled

1. Ischemic Bowel Disease - picket fence pattern, variable
assoc w failure & arteriosclerosis
emboli, trauma or radiation can also cause this

2. Vasculitis - can cause ischemic or hemorrhagic changes
RA, Polyarteritis Nodosa, SLE, Dermatomyositis
Thromboangitis Obliterans - young heavy smokers
Henoch-Schonlein Syn - acute arteritis, assoc w allergic response
strep infect, viral, insect bites, PCN, sulfonamides, etc
purpura, nephritis, abd & joint pain - self limiting

3. Hemophilia - sm bowel more than colon, mesentery freq
severe hepatic Dz, malig, or anticoags similar

4. Idiopathic Thrombocytopenic Purpura - GI, GU & skin bleed
acute - 1-2wks P URI in previous N child, 80% self limit
chronic - young adult female, insidious, autoimmune
II' to platlet antibody

5. Trauma - intramural hematomas common, narrow & obs lumen
EDEMA CAUSING REGULAR THICKENING OF FOLDS

1. Infection - more often irreg folds, see below
very common now due to AIDS

2. Hypoproteinemia - #1, II' to any cause of protien loss

3. Lymphatic Blockage - tumor or lymphangiitis in wall or mes
mesentery fibrosis, inflam bowel Dz also

4. Angioneurotic Edema - auto dom, edema of skin & muc mem
visceral presents as intermittent pain, reverses w no Sx
focal findings, only during an attack
Laryngeal edema most serious presentation

5. Intestinal Lymphangiectasia - gross lymph dilation
mucosal & submucosal foamy macrophage w dense lipid
edema II' to obs & loss of protien thru GI
Not assoc w liver, renal or heart Dz

6. Abetalipoproteinemia - rare, auto rec, fat malabsorbtion
assoc w mental loss, retinitis pigmentosa & acanthosis
foamy epithelial cells w lipids that cannot be transported
IRREGULAR DISTORTED SMALL BOWEL FOLDS

1. Infection - Very common now due to AIDS
TB - sim appearance to Crohn's, localized to ileocecal
Mycobacterium Avium-Intracellulare, Campylobactor

Histoplasmosis - histo laden macrophage in lamina propria
intense villous edema, diffuse sand like filling defects
protien losing eneropathy, lg nodes, focal stenosis

Giardiasis - Protozoan, Sx vary, asym to severe malabsorb
nodular tortuous folds w hypersec, hypermotility
assoc w mult filling defects of lymphoid hyperplasia
dysgammaglobulinemia seen w both
sim to celiac Dz in children, Dou & jej #1
cysts seen in stool or in jej bx, resolves w flagyl
Eosinophils will be seen in periph blood

Strongyloidiasis - can mimic Sprue, Duo & prox jej #1
severe can involve whole GI w spasm & ulcers
toxic dilation & paresis, Dx w worms from duo

Yersinia Enterocolitica - G- rod, fever & diarhea in kids
appendicites type presentation in adults, term ileum
Nodules & ulcerations can mimic Crohn's
Follicular Ileitis - sm defects seen for months, healing

Typhoid Fever - Salmonella Typhosa, phag by lymphocytes
multiply in peyers patches forming raised plaques, ulcer
term ileum freq but no skip or fistulas as w crohn's

2. Lymphoma - I' or disseminated, arises in lamina propria
localization to 1 seg of ileum in 75%, CT for Dx
polypoid w ulceration, adj node & mesen often involved
Anuerysmal Dilation - II' to sloughing of cent core
Fistula can form II' to adhesion between loops
CT - shows eccentric nonobstructing mass even when huge
freq long seg of involvement
US - Pseudokidney sign, dil wall w echogenic lumen
Celiac Dz - T-cell Lymphoma most common assoc malig
3. Crohn's Dz - see section on ulcerative lesions of colon
Lymphocytes & plasma cells infil all layers of gut wall
Barium - diffuse granular mucosa 1st, edematous villi, then ulcers
dist ileum #1, skips to other regions, 30% develop obs
"string" sign - irreg thickening & distortion of valvulae
"cobblestones" - ulcers seperate regions of spared N mucosa
Renal - oxalate stones & granulomatous fib of ureters
CT - demonstrates mural, serosal & mesenteric abn
Arthritis - spondyloarthropathy, asym SI involvement #1

4. Whipple's Dz - lamina propria infil w PAS pos macrophagec
G+ rods, Tropheryma Whippelii
Thick pliable folds w NO dilation, NO ulceration, NO flocculation
malabsorbtion, diarrhea, arthritis, fever & nodes assoc
Nodal masses can be large & fatty, usually at mesenteric root
Duo & prox jej #1, spares ileum, often resolves w abx tx
90% assoc w arthritis, 10% as 1st sx,
PAS pos macrophage in skin, CNS & lungs as well
DDx - Intestinal Lymphangiectasia or Amyloid

5. Amyloidosis - 70% of cases involve sm bowel
deposites around sm vessels & in muscle, wall thickens
can progess to a rigid tube, aperistaltic, ulcerate
usually II' to some nec, inflam or malig process

6. Eosinophilic Enteritis - infil of eosinophils, jej #1
assoc w stom infil concominate, reg thickening initialy
diffuse irreg folds, stiffening & mesen nodes later
assoc w specific food allergies, familial atopy
Tx - steroids, Dx 1st though due to poss Giardia

7. Mastocytosis - mast cell prolif in RES of bowel & skin (#1 site)
Histamine release from mast cells - pruritis, asthma etc
Pain & diarrhea, malabsorbtion, utricaria of mucosa
PUD II' to histamine mediated acid secretion
Sclerotic Bones due to prolif of marrow
Degen to Mast Cell Leukemia poss

8. Alpha Chain Dz - defective IgA allows bacterial penetrate
Lamina Propria infil w plasma cells

9. Abetalipoproteinemia - rare auto rec, fat malabsorbtion
Neuro deterioration, retinitis pigmentosa
usually reg thickening, can be nodular & focal

SOLITARY FILLING DEFECTS OF THE SMALL BOWEL
most are neoplasm, usually benign & asym
Pedunculated - defect completely surrounded by contrast
can move up & down the lumen
Sessile - project in lumen lat, fixed, acute edges
Intramural - curved into lumen w obtuse angles, N mucosa
Exophytic - arise from subserosa, bulk in peritoneum
Lobulated masses can project into more than one site

BENIGN NEOPLASMS
1. Leiomyoma - #1, 97% solitary, usually in jej & exophytic
central nec & ulceration common, may intussuscept

2. Adenoma - usually ileum, single well circ polyps
intraluminal & freq cause of intussusception

3. Lipoma - dist ileum & iliocecal valve
Submucosal w prominent intraluminal component, moveable

4. Hemangioma - endothelium lined blood containing spaces
75% multiple, sessile & small, Phleboliths pathog & rare
Osler-Weber-Rendu - telangictasia w nasal & GI hem freq

5. Neurofibroma - rare, subserosa & musc of ileum #1
lobulated mass on antimesenteric border, may ulcerate
multiple w neurofibromatosis

6. Peutz-Jeghers Hamartoma - branching sm musc lined by N epi
solitary or mult usually <5cm, #1 in jej & ileum
multiple pedunculated polyps pathognomonic


MALIGNANT CAUSES OF SOLITARY FILLING DEFECTS
1. Adenocarcinoma - #1, most common at lig of treitz
aggressive & circumfrential w rapid narrowing & obs
rarely broadbased or pedunculated

2. Lymphoma - polypoid, mult ulcerations, displaced adj loops
can be drawn into a pseudopolyp by peristalsis, intuss
mesenteric impressions & diffuse desomoplastic res freq
3. Sarcoma - ileum most common, 2/3 peritoneal w disp loops
leiomyosarcoma lg & bulky, >5cm, freq nec, ulc & hem

4. Mets - most mult, annular or polypoid, always in DDx
mesentery freq involved, desmoplastic rxn also

5. Carcinoid - #1 primary neoplasm of sm bowel, rule of 1/3
1/3 of all carcinoids occur in sm bowel, mostly ileum
1/3 show mets, 1/3 seen w 2nd malig, 1/3 are mult
Carcinoid Syn - flushing, diarrhea, cyanosis
tricuspid & pulmonic valve lesions
Sx II' to seritonin, only systemic w liver mets
Small submucosal lesions initially, grow extaluminally
infil wall & lymphatics, wall thickens, desmoplasia
fixation & angulation of loops
No met if <1cm, 50% met if 1-2cm, 90% met if >2cm


NONNEOPLASTIC SOLITARY FILLING DEFECTS
1. Gallstones - freq cause of ileus, mostly old women
70% have air in the biliary tree, 85% obs at term ileum

2. Inflammatory fibroid Polyp - fibroblasts, vasc tis & eosin
not assoc w eosinophilic enteritis
rare, solitary, usually in 6th or 7th decade, may intuss

3. Duplication Cyst - change in contour, solitary, may communicate
assoc w vert anomalies

4. Heterotropic gastric mucosa

5. Endometriosis

6. Ascaris or Strongyloides

7. Traumatic Neuroma - rare, at site of anastamosis

8. Meckles Diverticulum - oblong filling defect in ileum

9. FB, Blood clot, bezoar, Pills, Varices

MULTIPLE FILLING DEFECTS IN THE BOWEL

POLYPS
1. Peutz-Jeghers Syn - #1, mult GI polyps, esp in sm bowel
assoc w mucocutaneous melanin dep, buccal most common
Hamartomas - arborizing fibromuscular stroma
bleeding, pain, intuss & obs, NOT premalig but 2-3% w ca

2. Gardner's Syn - diffuse colonic polyposis, only 5% in ileum & jej
assoc w osteomas & ST tumors, 12% risk of ampullary Ca
100% prog to colorectal ca, inc sm bowel ca in duo esp
Desmoid Tumors - form esp P surgery

3. Disseminated Gastrointestinal Polyposis - no extra-GI Sx
must have sm bowel & stom involvement, high ca incidence

4. Juvenile Polyposis - hamartomas w no extra-GI manifests
NOT premalig, but pts have a proclivity for bleeding

5. Cronkhite-Canada Syn - juvenile type polyps, presents in elderly, F>M
alopecia, onychodystrophy, hyperpigmentation & malabsorbtion
100% have polyps in stomach & colon, >50% in small bowel
hamartomas w no malig potential, protien losing enteropathy

6. Ruvalcaba-Myhre-Smith Syn - diffuse GI hamartoma's, no malig
assoc w macrocephaly & pigmented genital lesions


OTHER CAUSES OF MULT FILLING DEFECTS
1. Hemangiomas - usually mult but to sm to detect
phleboliths pathog but rare

2. Leiomyomas - rarely mult

3. Lipoma's - rare cases of diffuse bowel & mesen involvment
distinguish from liposarcoma by homogeneity
CT shows mult low attenuation regions in bowel wall

4. Carcinoid - 1/3 multiple, usually too sm for barium

5. Von Recklinghausen's Dz - mult neurofibromas, jejunum #1
eccentric distribution unlike polyposis syndromes, no fold thickening
6. Lymphoma or any Met - mult nodules w cent ulceration

7. Crohn's - pseudopolyps & cobblestones

8. Nodular Lymphoid Hyperplasia - usually sm reg filling def
can sim mult polypoid masses
assoc w dysgammaglobulinemia in children

9. FB & Food - seeds, pits, pills, bezoars, gallstones, clots

10. Parasites - ascaris are tubular, stripe of worm GI tract
travel bowel wall to lung to trach to bowel again

SANDLIKE FILLING DEFECTS
enlargement of villi, usually assoc w fold thickening

1. Lymphangiectasia - Villi dilate w protienacious fluid
Developmental or II' due to obs of lymphatics
Can rupture & spill protien causing osmotic effect
Malabsorbtion & cytopenia assoc

2. Whipple's Dz - lamina propria infil w PAS pos macrophage
Systemic Dz poss induced by bacteria
irreg folds mostly in duo & prox jej seen first
Arthralgia assoc
Mycobacterium Avium Intracellulari - related but dist

3. Waldenstrom's Syn - IgM deposites in lamina propria
Primary Macroglobulinemia, IgM exces
Plasma cell dyscrasia in IgM producing cells
Anemia, Bleeding, Nodes, Hepatosplenomegaly
Sim to Whipple's but no bacterial breakdown products

4. Mastocytosis - mast cells infil lamina propria
assoc w irreg thickened folds

5. Histoplasmosis - rarely disseminated form involves GI
Lamina Propria infil w histo-laden macrophage

6. Yersinia Enterocolitis - irreg thickened folds in dist ileum
Follicular Ileitis - 1-2mm defects for months of healing

Other causes of enlarged villi - Amyloid, sm bowel ischemia
Protein-losing enteropathy, pancreatic glucagonoma
SMALL NODULES 2-5mm

1. Nodular Lymphoid Hyperplasia - jej #1, whole sm bowel poss
assoc w need for IgA immunoglobulin, freq infections
Giardia - found in 90%, Diarrhea, malabsorbtion
Giardia cause irreg fold thickening, N folds if not
Good's Syn - when assoc w thymoma
NORMAL finding in dist ileum of children & young adults

2. Lymphoma - common presentation

3. Crohn's Dz - mucosal granularity is earliest sign
caused by reticular lymphocytic infil widening villi
late stages may show villous enlargement due to adaption
epithelial turnover increases

THICKENED FOLDS W CONCOMITANT STOMACH INVOLVEMENT

1. Lymphoma - irreg lg nodular folds in both
widening & thickening of bowel wall, mesenteric impres

2. Crohn's Dz - dist ileum #1, pseudo-Bilroth-I deformity

3. Eosinophilic Gastroenteritis - coarse nodular folds
stiff & thickend bowel or antrum can sim ca

4. Zollinger-Ellison Syn - extremly prom gastric folds
Hypersecretion floods sm bowel causes chemical enteritis

5. Menetrier's Dz - giant stom folds due to mucosal hypertrophy
Protein losing enteropathy & Hypochlorhydria complete the Triad
Fundus & body of stomach most common, antrum often spared
sharp demarcation between affected & N mucosa
>50% assoc w benign gastric ulcers
massive hypersecretion of mucous, Slight premalignant potential

6. Gastric Varices - assoc w liver Dz & hypoproteinemia

7. Whipple's & Amyloidosis - can also involve stomach

MISCELLANEOUS SMALL BOWEL PROCESSES

SEPARATION OF SM BOWEL LOOPS
thickening of wall or mesentery

1. Crohn's - transmural inflam, mesentary edematous & fatty
Nodes firm & matted, narrow lumen accentuates seperation
TB & CMV have similar appearance esp w AIDES

2. Hemorrhage - into wall or mesentery

3. Node Enlargement - Mets, Lymphoma, Whipple's, Amyloidosis

4. Radiation - causes endarteritis w vascular occlusion & isc

5. Carcinoid - sm sharply defined submucosal lesions
tend to grow extraluminally, infil wall, lymphs & mesen
local release of seritonin causes hypertrophic musc thic
also fibroblast prolif, narrows lumen, kinks bowel
6. Neurofibromatosis - enlarged nerve trunks cause nod defect
Von Recklinghausen's Dz - eccentric polyps, mesen side

7. Ascites - 75% due to cirrhosis, low albumin high portal P
Neoplasm, Peritonitis, lymph blockage
800-1000ml will widen flank stripe, obscure R liver
1st seen along inf tip of R lobe on US

8. Mesothelioma - rare peritoneal tumor, asbestos exp old men
Mult intrinsic & extrinsic nodular masses
Massive ascites, Mets from I' lung Dz common

9. Mesenteric Tumors - rare, most benign lipomas & fibromas
Fibro & leiomyosarcomas arise from vessels
Lymphoid Tumors - benign hyperplasia II'to inflam

10. Mets - intraperitoneal seeding II' to cells in ascitic fl
Adenoca of ovary & stomach #1
Pouch of Douglas in rectosigmoid jxn & Rt lower quad #1

11. Intraperitoneal Abscess - extraluminal gas in bubbles
localized ileus or sentinal loop

12. Retractile Mesenteritis - fibrosis main component
Lipomatosis - related w Fatty infil the main comp
Mesenteric panniculitis - chronic inflam the main comp
all 3 are basicaly the same process w combo of all comp
Sm bowel & sigmoid mesentery #1 sites
Draws bowel into a central kinked mass

13. Retroperitoneal Hernia - herniated segs sep from main
paraduo, paracecal or intersigmoidal #1 locations

14. Graft-vs-Host Dz - complication of allogenic transplant
Necrosis of crypt epithelium, glandular depopulation
mural thickening seperates bowel, severe infection poss
Narrow lumen & loss of folds causes ribbon-like app

SM BOWEL DIVERTICULA & PSEUDODIVERTICULA

1. Duodenal Diverticula - incidental in 1-2%, med by ampulla
often mult, smooth, round & maliable
Duo diverticulitis mimics PUD, Pancreatitis, cholecystitis
Dx of exclusion, can hem, perf, abcess, fistulize
complications w no peritoneal signs or free air
Racemose - bizzare lobulated form

2. Giant Duodenal Ulcer - can be 2-6cm, replace bulb
dist narrowing can prod obs, severe hem, 40% mortality

3. Pseudodiverticula of the Duo - pouchs in sup & inf receses
assoc w PUD, II' to spasm of circ musc opposite ulcer

4. Intraluminal Diverticula - forms from web or diaphragm
origin near ampulla, finger like sac seperated by Halo
assoc w malrotation, annular panc, midgut volvulus
choledochocele, congenital heart Dz, Down's, imp anus

5. Jejunal Diverticula - form at points of vessel entrance
mucosa & submucosa, no musc, atonic, freq mult
Blind Loop Syn - bacterial overgrowth, steatorhea
#1 cause of pneumoperitoneum w/o peritoneal signs

6. Pseudodiverticuli of jej - sacculations in scleroderma
occur w Crohn's & Lymphoma also

7. Meckel's Diverticula - 2% incidence, 80cm from ileocecal v
residual omphalomesenteric duct (vitelline), usually gone at 5-7wks
Opens to antimesenteric side, most asym
30% contain gastric mucosa, colonic & pancreatic also seen
60% of symptomatic children have gastric mucosa
Painless Bleeding #1 Sx, 90% have gastric mucosa
Rule of 2's - Sx before age 2, 2ft from ileocecal valve
2% of population, 2 inches in length
Inflam can mimic appendicites, calc, neoplasm, perf rare
may have stenosed base, or as wide as lumen, triangle

8. Ileal Diverticula - rare, sm & mult, rare complication
ABNORMALITIES OF THE ILEOCECAL VALVE
at first haustral marking, seperates cecum from asc
muscularis primarily ileal, mucosa is colonic
holds until digestion complete, 90% reflux
lips should not exceed 1.5cm thick or 3cm diameter
N stellate appearance en face

BENIGN TUMORS

1. Lipoma - #1, sell circ, rounded, maliable
true capsule present unlike lipomatosis, one lip only

2. Adenoma - polyp or villous adenoma, shaggy irreg borders

3. Carcinoid Tumor - mixed, arise central in valve, ie ileal
edema & plugged lymphatics can cause corragation of cec


MALIGNANT TUMORS

1. Adenocarcinoma - 2% of colon adenoca from valve
lobulation, asym, rigidity, eccentricity
can be smooth at ileocecal valve, sim benign
freq have frondlike shaggy surface, intuss & obs freq

2. Lymphoma - polypoid mass w freq ulceration
minimal desmoplastic rxn, obs late, freq in term ileum
OTHER ABNORMALITIES OF THE ILEOCECAL VALVE

1. Lipomatosis - benign submucosal fatty infil, usually >40yr
intermittent intuss & obs cause diffuse pain
surface lobulated but remains smooth & stellate en face
Prolapse of ileal mucosa rare, asym, only w lipomatosis
vol changes w serial films, barium in ileal lumen

2. Crohn's Dz - panenteric lymphedema w valve enlargement
lipomatous enlargement can also occur
sm sinuses transversing the valve pathognomonic

3. Ulcerative Colitis - backwash ileitis, valve thin, patulos
similar loose valve in cathartic abuse

4. Amebiasis or TB - thickening of valve

5. Intussusception - many loops can pass into cecum
sm central channel seen on sm bowel series, vasc comp

6. Lymphoid Hyperplasia - usually mult papillary lesions
can cause massive valve enlargement
primarily in children II' to inflammation

CECUM ABNOMALITIES

FILLING DEFECTS DUE TO APPENDIX PROCESSES
arises from postmed cecum at jxn of the 3 tenia coli
5-10cm, always on same side between valve & cec apex
75% lie ant to cec

1. Appendicitis - #1, II' to occ from fecolith or inflam
fluid accumulates behind obs, thins, ulcerates
thrombosis & infarction, perf, abcess, peritonitis
unpreped BE demonstrates extrinsic compression
Glucagon may help in filling the appendix, 20% no fill N
Endometriosis, Ovarian Cyst or Tubo-Ovarian Abcess
can mimic appendical abcess
Yersinia Enterocolitis - can mimic Sx & findings
CT for further eval, Neg scan does not exclude
US - 90% specific w graded-compression technique
perforation assoc loss of echogenic mucosa
periappendical fluid collection also
40% assoc w nodes, fecalith can be simulated by air

2. Crohn's Dz - rarely confined to appendix, irreg lumen

3. Inverted Appendiceal Stump - P appendectomy, prom sev wks
sim neoplasm, colonoscopy or resect if no surg hx

4. Mucocele - rare cystic dilation II' to obs, calc wall
4:1 female, middle aged to elderly, 90% benign
Mucus accumulates, usually asym, broad filling defect
CT & US demonstrate a low density mass, internal echoes
curvilinear wall calc strongly suggests the Dx

Pseudomyxoma Peritonei - epi implants in peritoneum, rare
II' to mucocele rupture, massive gelatinous ascites
acute pain at rupture, usually II' to straining

Myxoglobulosis - fish egg like globs of mucous, calc rim
annular calc, not laminated like appendolith

5. Carcinoid - #1 appendiceal neoplasm, 90% in dist ile & cec
arise from argentaffin cells in crypts of lieberkuhn
tends to cause appendicites rather than met
6. Leiomyomas, Neuromas & Lipomas - usually incidental

7. Adenocarcinoma - arises in dist 1/3 of appendix
presents as appendicites, can have massive comp on cec

OTHER CAUSES OF CECAL FILLING DEFECTS
1. Intussusception - Most freq in children, Ileocolic type #1
90% idiopathic in kids, peyers patch hyperplasia, adenovirus assoc
over 5yrs look for etiology, lymphoma #1
Lymphoid Tiss at ileocecal valve makes it sussceptable
Meckle's freq lead point in infant <6mo
Presentation - 85% w pain, 60% w guaic positive stool
24hrs - edema, hem, mild villi sloughing, Currant Jelly stool
48hrs - Ulceration, Muscularis Propria Nec, serosa edematous
BE - Cauliflower mass, if smooth mass seen prob neoplasm
CT - 2 layers of bowel in target, central displaced by mesen
Fluid Reduction - 3ft off table, 3 min, 3 tries, NO BALLOON
Psuedoreduction w patent lumen poss, must be noted, 1% perforate
Air Reduction - Do not exceed 120mmHg, correlate w valsalva
Recurrance - approx 5%, most within 48hrs, higher with cystic fibrosis

2. Mets - Ovary, Colon, Stomach, Pancreas
origin of mesentery near cecum allows stom & panc here

3. Inflammation - granulomatous & infectious processes as w all GI
Ameboma can be particularly prom here

4. Ileocecal Diverticulits - can cause localized mural abcess
50% occur in pts under 30, sim appendicites
appendix may fill on barium, medical not surg Tx poss

5. Cecal Ulcers - rare, healing may leave round filling def
spasm, hypermotility, stricture, resect due to poss perf

6. Adherent Fecalith - cystic fibrosis, can persist for wks, intuss poss

7. Endometriosis - intramural, extramucosal, mucosa intact
no kinking as in sigmoid region

8. Burkitt's Lymphoma - childhood reticuloendothelial tumor
African, mandible & maxilla swelling

9. Cecal Diaphragm - rare, related to colonic atresia
CONED CECUM

1. Amebiasis - once thought to be pathognomonic
Cecum involved in 90%, term ileum N but displaced inf
Valve thickened, rigid, fixed open, colonic skip lesions
Entameba Histolitica in stool poss, resolve quickly w Tx

2. Crohn's Dz - freq assoc w term ileum Dz, rarely isolated
String sign in term ileum

3. TB - characteristic of GI TB, healing fibrosis mostly
most opposite valve, straightening & spasm of valve late
Stierlin's Sign - ileum & cec form straight tube to asc
Mucosa more irreg & coarser than Crohn's
Colon involvement more prominent than ileal
assoc w pulm, cough, fever, nightsweats, anorexia

4. Ulcerative Colitis - tends to be more L colon
Valve fixed open, 10% have backwash ileitis
less narrowing than Crohn's, no valve fistulas

5. Appendicites - Can cause perforated Cecal Divertic

6. Carcinoma of the Cecum - coning II' to nec & perf
can be coned II' to infil, fixed unlike inflam processes

7. Actinomycosis - rare, tends to involve cec & appendix
forms palpable mass & extensive fisutla tracts
Blastomycosis - south american strain, mimics Crohn's

8. Anisakiasis - thickened wall of term ileum to asc colon
ascaris like nematode from raw fish, intermediate larva

9. Typhoid & Yersinia - narrowing & irreg of cec
assoc w more severe term ileum involvement

10. CMV - thickening & spasm of folds in cec or colon, AIDES

11. Typhlitis - necrosis, ulceration, thickening & hem
R colon II' to leukemia, lymphoma, ischemia etc
occurs 1-2wks P chemo initialized, septicemia follows
water soluble contrast only, intramural air poss

ULCERATIVE LESIONS OF THE COLON
10% of UC vs Crohn's cases cannot be distinguished w Bx

1. Ulcerative Colitis - #1 in 20-40 y/o, 2nd peak at 60-70
etiology unknown, hypersensitivity autoimmune poss
freq assoc w con tis Dz, RA, SLE etc
assoc w inc gammaglobulins occ, respond to steroids
II' to ischemia in older, higher colostomy rate
Infection, food allergies & psychosomatic causes poss
Dx made by exclusion of specific other causes of ulcers
plain film to R/O perf or megacolon before barium
BE - loss of haustration & granular mucosa earliest signs
barium tends to underestimate mod or severe Dz
widening of presacral space due to fat prolif
Rectosig area #1 site, origin, scope detects 95%
Rectal Sparing suggests other Dx, never R alone
loss of haustra, polypoid hyperplastic mucosa Foreshortening due to fibrosis & thick muscularis mucos
Crypt Abcesses - puss collction in lamina propria erupts process cannot penetrate thru muscle layers
fine granularity of mucosa 1st sign, edematous wal
Prog to coarse nodular folds, spiked app post evac
remains regionally uniform, no skips
Collar Button Ulcers - may tunnel in submucosa
often confined to mucosa, may network, pseudopolyps
fistulas uncommon, peritonitis more likely
Backwash ileitis 10%, open valve
Lead Pipe - end stage fibrotic narrowing
Filiform Polyps - inflammatory, can be exophytic, sim Ca
No greater risk for Ca than any affected mucosa
CT - shows wall thickening, Thick submucosal fat
Sx - variable w bleeding, diarrhea, prostration
75% later remission, 12% no recurr, 12% no remission
90% segmental usually distal & mild
Toxic Megacolon, perf & diffuse fulm Dz 10%
Spondylitis, iritis, erythema nodosum, liver abn common
whether assoc or II' unknown
Peripheral Arthralgia - often no specific X-ray find
Pericholangitis - con tis inflam of portal V, hep A
fatty infil, chronic hepatitis
Hypercoagulability, venous stasis etc
Colon Ca - HIGH RISK, 10% each 10yrs, young onset worse
usually aggresive Mucious type
infiltrates along mucosa, sim benign stricture
2. Crohn's Dz - Granulomatous Colitis when in colon
Regional Enteritis when in sm bowel, 95% involves term ileum
Mostly adolescent & young adults 20-40yrs, 20% in children
Sx - Diarrhea more intense & earlier than UC, hem rare
RLQ pain freq & severe, extra GI sx sim but less common
Axial Arthritis - 25%, can sim Ank Spondylitis
Sclerotic SI joint & ureteral obs in young pt
BE - Linear ulcers, fisssures, thickened wall, narrow lumen
Aphthoid Ulcers - punctate w halo, earliest sign
asym dist, surrounds N mucosa forming cobblestones
Anal fistulas & Sinuses in 33%, rectal sparing poss
only iatrogenesis & diverticuli cause more fistulas
CT - shows thicker more irreg bowel in Crohn's than UC, <lymphoma
Transmural inflammation & 50% have granulomas, pathog
"Creaping Fat" - massive mesenteric fat prolif, seperates bowel loops
Hydronephrosis - due to ureteric compression, usually on R side
Assoc - Inc risk of Colon Ca but less than UC
Biliary Stones - due to poor bile salt absorbtion, poor enterohepatic circ
Renal Stones - due to exces oxalate absorbtion
50% recurrance at anastomotic sites
20x inc in adenocarcinoma, esp in bypassed loops, 20yr latency
also inc risk of lymphoma in colon & sm bowel
DDx - Tuberculous Colitis, identical presentation & path
TB never causes toxic megacolon, Crohn's may

3. Ischemic Colitis - Abrupt onset of pain & bleeding pathog
pts over 50, usually watersheds of flexure & sig regions
Submucosa most effected w edema & hemorrhage
Mucosa dies off & sloughs rapidly
BE - 90% show thumbprinting & spasm on antimesenteric side
Featureless wall like UC, pseudopolyps
deep ulcers may develop in late stage
Usually follows a short mild course, strictures poss
most return to N without treatment

INFECTIOUS CAUSES OF COLON ULCERATION

1. Tuberculous Colitis - #1 in cec & dist ileum, ext to trans
Simulates Crohn's Dz - may become segmental to sigmoid
originates in submucosal lymphatics, N mucosa overlying
Caseous Nec & ischemia lead to mucosa sloughing
Intense spasm, prog inflam, Fibrosis, thickend wall
Neg TB skin test due to severe illness
Mycobacterium Tuberculis - assoc w pulm Dz
Mycobacterium Bovis - NO pulm Dz, from unpastuerized milk

2. Dysentery - Shigella, colon #1, penetrates mucosa
liberates exo & endotoxin, mucoid & bloody exudate
Necrotic tissue sloughs leaving shaggy ulcers
Short incubation, 1-2d, diarrhea w elec loss
Barium causes severe spasm, sim UC, fistulas poss

3. Salmonella - Dist ile #1, also penetrates
Shorter incubation, 12hrs, sudden fever, vomiting
Usually self limited in simple food poisoning
Typhoid Fever - insidious malaise, headache, pain
Deep ulcerations cause perf & peritonitis
invades lymphs & Peyer's Patches, systemic dissem
prog to massive bleeding, perf, circ failure

4. Gonorrheal Proctitis - Gram stain to DDx from other
most asym, purulent exudate, Sx of ulcerative proctitis
Mucosal edema & ulceration confined to rectum
responsive to Tx, 20% get stricture w no Tx

5. Staph Colitis - II' to broad spectrum oral abx, ie tetracyline
Sx mild or sever, resolves when abx stopped, sim UC

6. Yersinia Colitis - G- bacillus, ileitis & colitis in kids
Involves R colon usually, sim Crohn's or appendicites
Short duration ileitis w fever, diarrhea & RLQ pain

7. Campylobacter F. Colitis - freq cause of infec colitis
inflam of mucosa, bloody exudate, numerous PMN's
Can sim UC or Crohn's, edematous narrowing of term ile
found as actual cause of some nonrecurrent UC Dx
8. Lymphogranuloma Venereum - II' to Chlamydia Trachomatis
obligate intracellular bac, VD exclusively
3:1 male, Rectal stricture pathog, confined to rectum, sim UC
I' in cervix & vagina but 25% have rectal predominance
Bubo formation - inflammed inguinal & pelvic nodes, lymph obs
Bleeding, mucopurulent discharge, fistulas, abcess
Tx - Tetracycline, effective even w extensive pelvic adenopathy

9. Pseudomembranous Colitis - II' to abx, surg, uremia, obs
Clostridium difficile - releases cytotoxin, 15% mortal
Severe diarrhea w or w/o blood, friable edematous mucosa
Raised 1-6mm plaquelike lesions, mucus, fibrin, bac, PMN
BE - diffuse Dz covers entire colon, barium between plaque
haustra edematous, broad transverse bands, shaggy, irreg
Nodular fold thickening, ulceration is not a prominent feature
Barium contraindicated in severe cases, perf
CT - diffuse nodular thickening

10. Fungal Infections - Histo, Mucor, Actino, Candida
invade wall, intense localized inflam, thick irreg folds
Dx usually postmortum

11. Viral Infections
Herpes - VD trans, Sim segmental UC, assoc w skin lesion
rarely causes ulcerations, more often pappillary
CMV - #1 cause of lower GI bleed in renal transplant
Vasculitis cause prom edema, thumbprinting, narrowing
Rotovirus - mild & self limited in kids
Rare prolonged bloody diarrhea, seg spasm, sm ulcers

NONINFECTIOUS CAUSES OF COLON ULCERATION

1. Radiation Injury - transient proctitis in 50% of pelvic tx
ant rectal wall usually site of max dosage

2. Caustic Colitis - Can follow enema, rare
irritation usually causes expulsion, prox colon more dif

3. Pancreatitris - can cause spiculation of local mucosa
Perf, distention, ulceration poss

4. Malignant Lesions - consider w solitary ulceration
Meniscoid Ulcer - lens shaped w border convex to lumen
Mets - can sim UC or Crohn's esp w leukemia & lymphoma

5. Amyloidosis - can sim UC, Congo red stain for Dx
II' to Con Tis Dz, Lymphoprolif disorders or chron infec

6. Mercury Poisoning - hem & ulceration, assoc renal involv

7. Behcet's Syndrome - Abd pain & diarrhea in 50%, mult colonic ulcers
Primarily Ulcers of buccal & genital mucosa, ocular inflam, skin
Sim Crohn's, central ring lesions, nodules in term ile
Ulcers larger & deeper than Crohn's, freq perf

8. Diverticuli - can sim ulcers, can coexist w UC or Crohn's
spares the rectum due to complete enclosure by longitudinal musc

9. Solitary Rectal Ulcer Syndrome - mainly young people w hem
Ant or Antlat rectum, nodularity preceeds ulcer, stric
within 15cm of verge at edematous valve of Houston

10. Nonspecific Benign ulceration of the Colon - any size
Dx of exclusion preoperatively, can perf, hem or stric
50% in cec & asc, 20% mult, usually antimesenteric

11. Drug Induced Colitis - Chemo, nonsteroidals, antifungals
estrogen, progeterone, vasopressin & ergot also

12. Diversion Colitis - inflam in seg isolated from stream
Sim to UC or Crohn's, granular mucosa in long term

13. Post Rectal Bx - well defined ring shadows

PARASITES OF THE COLON & GI TRACT

1. Amebiasis - Entamoeba Histolitica, cysts in stool
Can present w diffuse colitis like UC
Collar button ulcer, less extensive than UC
Coned Cecum classic, can progress to toxic megacolon
Usually N dist ileum but skip lesions like Crohn's
Tend to settle in stasis regions, asym until wall invade
Cramping, blood, mucus, diarrhea, 90% in cec first
Hepatic Abcess #1 extra-colonic complication
Hemagglutination or ameba precipitin test positive freq
90% have cysts seen in stool
Perf, fistulas & abcess common, rarely effects ileum

2. Giardiasis - Infests duodenum, beaver carrier
Water born, usually self-limit, severe if IgA def
Assoc w Nodular Lymphoid Hyperplasia

3. Chaga's Dz - Trypanosoma Cruzi in Reduviid Bug
Releases neurotoxin which destroys ganglia cells
Megacolon, megaesophagus & mega cardia

4. Ascariasis - Giant pencil sized round worm, 2 times thru
Eggs ingested, hatch & infil mucosa, migrate to lung
reswallowed and turn to adults 2nd time thru
Adult in Sm bowel, eggs incubate in soil, pass to food
Adult worms can migrate to bile ducts
Can cause pneumonia during lung stage

5. Pin Worms - Enterobiasis, usually asym in children
Adult worm in colon, self limiting, Dx w scotch tape

6. Whipworm - Trichuriasis, Embed in superficial mucosa
adults in rectal mucosa, blood suckers, min inflammation
anemia poss w lg worm load
7. Hookworm - Necator & Ancylostoma, pass from soil thru feet
Soil incubation required for larvae, pass thru lungs
Adults in prox sm bowel submucosa, nonspecific inflam

8. Strongyloidiasis - Nematode, can auto infect w/o soil time
Infest Duodenum, can mimic Crohn's, "Pipestem Duodenum"
Hyperinfection in compromised hosts

9. Anisakiasis - Marine roundworm, N host marine mammals
Adult worms in stomach & sm bowel, can become mult
freezing may kill some variaties

10. Tape Worms - Man is N host w pig/cow larvae intermediate
Scolex attaches to Sm Bowel, each seg hermaphroditic
Cysticercosis - reingestion of acutal eggs
larvae encyst in muscle & brain, "rice" calc P dead

Hydatid Cyst - Echinococcus, Tape worm adult in dog host
ingested eggs form encysted larvae esp in liver, 50% calc
Pericyst - Outer cyst wall formed by host
Endocyst - lining produced by larvae, DIC if rupture
Mult "Daughter" cysts, Rim Calc even when viable
Variant from sm forest animals does not induce Pericyst
More common in alveoli, can sim infiltrating malig

11. Schistosomiasis - Blood Flukes, specific snail intermediate
Larvae penetrate skin from water, Adults in Portal Vein
Adults migrate to Colon or bladder depending on species
spines on eggs of the flukes pen wall, not all pass
Some spill back to Portal Sys - Portal HTN
Diffuse Inflammation & edema in colon or bladder
Ova in stool or urine during active phase
Asia & latin america - colon, Africa - Bladder

12. Chlonorchis - Liver Flukes, sim cycle but w fish as well
ingested from fish, Flukes reside in bile ducts
Biliary obs, cholangitis & inc cholangiocarcinoma

13. Dracunculus Medinensis - Guinea Worm, larva enter skin
Adult incysts in LE skin, bursts out in water, Dead female may calc

14. African Tongueworm - Armilifer, N host reptile mucosa
Larvae encyst in pleura & peritoneum
Curvilinear calc seen w dead larvae

NARROWING OF THE COLON
divided into healing UC or malig lesions
Radiographic DDx from malig often impossible
Valves of Houston & Hyster in the rectum
Columns of Morgagni in the anus

1. Ulcerative Colitis - shortening & deperession of flexures
Healing causes re-epithelialzation, lead pipe colon
musc hypertrophy & spasm, fibrosis, 10% stric sig & rec

2. Crohn's Colitis - transmural inflam leads to mult stric
lead pipe colon can also develop, look for ileal Dz

3. Ischemic Colitis - healing can cause stric, sacculations
Flattening & rigidity of antimesenteric border
F/U in 1 wk may show altered app, diff from malig
bleeding may produce filling defect & thumbprinting
Most return to Normal w no sequela

INFECTIOUS CAUSES

1. Amebiasis - segmental spasm, ulcers, granulomas
stric of trans, sig & flexures II' to healing
more pliable & extensive than malig, resolve w Tx

2. Schistosomiasis - reactive fibrosis II' to infestation
stenosing granulomas & pericolonic infil sim Crohn's

3. Dysentery - scarring & fibrosis, rigidity, loss of haustra
exacerbation & remission freq, sim UC

4. TB - distortion, rigidity & narrowing, segmental, sim Cro

5. Gonorrheal Proctitis - usually asym, 20% stric w no Tx

6. Lymphogranuloma Venereum - long narrow rectal stric pathog
Proctitis Obliterans - up to 25cm, mult deep ulcers
fistulas, sinus tracts, prox dilation - CHLAMYDIA

7. Fungal Dz - focal mass & narrowing sim Ca

8. Condyloma Acuminatum - Papova v, I' in genital & perianal
usually sm & superficial, giant condyloma assoc w fags
Active papillary prolif w infil into local tissues
9. Strongyloides - fibrosis, loss of haustra, sim UC


OTHER CAUSES OF NARROWING

1. Pancreatitis - esp dist trans colon & flexure
enzymes follow mesenteric attachments, can sim ca

2. Amyloidosis - esp in rectum & sigmoid, mucosa & musc I'
can also deposit in vessels causeing ischemic colitis

3. Endometriosis - mult lesions, 20% involve colon
80% on inf margin of rectosigmoid, Mucosa "crenulated" or smooth
NO acute angulation, overhangs or ulcerations
fertile female, causes hyperplasia of sm musc & stroma

4. Pelvic Lipomatosis - Inc N pelvic adipose, 99% men
UTI, Constipation, lower back & abd pain, bladder worst
Ureters usually displaced medial, 40% obs in 5yrs
Smooth narrowing & elongation of rectum, lucent pelvis

5. Retractile Mesenteritis - tapered & serrated seg
inflam cells & fibroblasts thicken & retract mesentary
can sim inflam or ca

6. Adhesive Bands - II' to surg, short circumferential areas

7. Typhlitis - II' to child Luekemia, Hematogenous mets etc
exclude perf before enema, tube like R colon, no haustra

8. Psuedolymphoma - irreg narrowing & rigidity, sim ca

9. Surgical Anastamosis Narrowing - sim ca
usually distensible & tapered

10. Radiation - long smooth stric of rec & sig 6-24mo P Tx
Ischem II' to Obliterative arteritis esp w prev vasc Dz
4-6000 rads, mucosal atrophy, fibrosis, wall thickening

11. Cathartic Colon - II' to prolonged stim/irritant cathartic
neuromuscular incoord, sim burned out UC, no ulcer, limp
primarily involves R colon rather than L, rec & sig N
12. Caustic Colitis - II' to detergent enemas
inflam subsides in 1mo, scar begins in pattern sim esoph

13. Solitary Rectal Ulcer Syn or Nonspecific Benign Cec ulcer
both can form stric sim to malig

14. Canon's Point - region of focal narrowing of the transverse colon
due to focal muscle band hypertrophy

DIVERTICULAR DISEASE
herniation of mucosa & submucosa, 50% of people over 60
most seen in L colon but 75% of bleeding from R side
develop between mesenteric & lat teniae, II' to P
occur at intsertion of vasa recta
diet also factor, rare in africa w lg diameter colons
Segmentation & inc P II' narrow lumen main cause of tics
Rectum spared due to complete encirclement by longitudinal musc
Tics in the R colon have wide mouths

1. Diverticulosis - pain related to cause of tics, most asym
painless bleeding common, can develop to 25cm dia
Sawtooth config develops w mult tics, shortens & fixates
Spasm can prevent retrograde flow, lower bag & gluc help

2. Diverticulitis - 20%, micro or macroperf develop, abcess
inflam may localize to wall, or cause segmental narrow
fistulas & extensive abcesses w sm bowel & ureter obsbm
extrav from tic key sign, extrinsic mass imp also poss
caution in acute phase
CT shows thickening of wall & adj fat planes
Can closely sim Ca w chronic fibrosis causeing narrowing
30% recur w dietary & abx alone, 30% require surg

MALIGNANCY OF THE COLON

1. Colorectal Carcinoma - #1 form of primary colon ca, 50-70yrs
2nd most common malig to skin Ca, has been assoc w Strep Bovus
Most arise from previous adenomatous polyps, takes 10yrs
T1 Invasion - lamina propria penetrated to submucosa
T2 - to muscularis, T3 - to subserosa, T4 - thru wall
N1 - 1-3 local nodes, N2 - >3, N3 - vasc nodes
Dukes Staging - A wall, B thru wall, C nodes, D distant
A 80-90% 5yr, C 30% 5yr survival, D Hematogenous #1
20% stage D at presentation, 5% multifocal
50% local recurrance at resection site within 2yrs, esp rectal
L side Sx present earlier than R, anorexia, bleeding
Acanthosis Nigracans - II' to stom, panc, ovary or colon
regress when tumor resected, recur w ca
Neuromyopathy presents sim to acanthosis
30% of colon ca within reach of the educated finger
CEA - CarcinoEmbryonic Antigen often elev, nonspecific
used to follow, elevation leads recurrance by 6mo, 25% no elevation

Exophytic Type - most common in cecum & R colon
Often asym until stage 4, intussusception & anemia

Annular Carcinoma - most common on L colon & rectum
Infil to inner circular ring of musc & follows it
fixed stricture - Usually short seg <5cm, sharp margins
Mucosal detail destroyed, no release w glucagon
present earlier w obstruction

Scirrhous Carcinoma of the Colon - invades along submucosa
"linitus Plastica", intense desmoplastic rxn, dense fibrous infil of wall
involves longer seg, 12cm, lumen narrow to 1-3cm
Mucosa often preserved, no Sx until late, sim burned UC

Mucinous Adenocarcinoma - younger pts, assoc UC, poor prog
>50% of tumor is Extracellular mucin
Very low attenuation, strings of malig cells in mucin

2. Lynch Syndromes - Hereditary Nonpolyposis Colon Ca Syn
5x greater freq than familial polyposis
Chrom 2 abn - defective DNA repair sys
Lynch 1 - no assoc extracolonic malig
Lynch 2 - assoc w extracolonic esp endometrial
Less aggresive - better prognosis stage for stage
3. Mets to Colon - predictable based on anatomic considerations
Direct Extention
Prostate - ext thru Denonvillier's facia to ant rec
sim I' ca, long asymetric annular stric, nodular
Elev serum acid phos means ext beyond capsule
Ovary & Uterus - long desmoplastic stric, angulation
Renal - no desmoplasia
Stom - spread along mesenteric reflections to sup marg
bulky omental mets prod angulation, comp of trans
diff from Crohn's because no retroperitoneal involved
Panc - sim to stom but con via trans mesocolon to inf marg
side opposite of involvement forms pseudosacculation
Intraperitoneal Seeding - Not random, follows flow
50% grow in pouch of Douglas between bladder & ant rec
Blumer's Shelf - a palpable mass from desmoplasia
#2 is the dist sm bowel mesentery in RLQ, indent med cec
Sigmoid mesocolon, ant & R pericolic gutter lat also
Hematogenous Spread
Breast #1 - may present as met to the colon
Thickening & rigidity II' to submucosal infil, sim UC
Lymphangitic Spread - not sig, but key in anastomotic recur

4. Ca Complicating Other Conditions
UC - 6-10X inc, related to length of Dz, not severity
avg onset at 35 instead of 60
Crohn's Colitis - less risk than fulm UC, equal to L UC
bypassed inflammed loops at highest risk
Ureterosigmoidostomy - inc sig adenoca

5. Kaposi's Sarcoma - Progressive RES tumor, skin & viceral
Submucosal nodules can coalesce, circ narrowing, rare in AIDS

6. Carcinoid - usually polypoid, can be infil, sim adenoca

7. Lymphoma - Long seg involvement w no obs, rare
BE - loss of Haustration, Aneurysmal Dilation poss
Rare obs even with lg external mass
DDx - Adenoca cannot be R/O, more fibrotic & will obs
Inc w any cause of immune compromise or weakening
UC & Crohn's Dz also, less than adenoca

BENIGN FILLING DEFECTS OF THE COLON

POLYPS & BENIGN MASSES
polyps #1 cause of filling defects, 12% of population
Sessile, Protuberant, or pedunculated - Remove ALL

1. Adenomatous Polyps - neoplasm, mucus secreting tubules
50% of all polyps, inc R colon incidence over 70y/o
occur in 10% of pts >40yrs
Occur synchronisly in 50%, recur in 40%
adenoca arises from these, 5% eventually transform, size predicts
<1cm 1% ca, 1-2cm 10% ca, >2cm 50% ca
Sessile w irreg lobulated surface or rapid growth suggests ca
malig more likely to bleed
pedicle >2cm = benign, malig sessile cannot be stretched
Tubular Adenoma - 75% <1cm, most pedunculated
glands inside w smooth outer surface
Villous Adenoma - benign, villous fronds, usually sessile
40% transform to ca, 75% >2cm & can be up to 15cm
Mucus secretion can cause elec &