Bowel

Question 1

What is the DDx for a Gasless Abdomen?

Answer 1

Gasless Abdomen DDx

Adults:

1. High obstruction
2. Ascites (Cirrhosis, Malignant; Hypoalbuminaemia; Peritonitis)
3. Pancreatitis - acute
4. Fluid-filled bowel - total active colitis; closed loop obstruction
5. Large abdominal mass

Child:

1. High Obstruction
2. Vomiting
3. Fluid-filled loops

Question 1

DDx of Dysphagia in Adults

Answer 1

DDx for Dysphagia in Adults

Intrinsic:

1. Reflux strictiure
2. Tumours - carcinoma; lymphoma; leiomyoma
3. Iatrogenic strictures - corrosives, radiotherapy
4. Plummer-Vinson web (previous case; from C4 to T1; iron def. anaemia; post gastrectomy; is premalignant)
5. Schatzki ring - acute obstruction occurs if diameter < 6mm.
6. Candida
7. Skin disorders - Epidermolysis bullosa; pemphigus

Extrinsic:

1. Tumours - LNs, mediastinal masses
2. Vascular - aberrant Rt Sub. art (cases below - not oblique filling defect and post indentation on AP and lat film); aortic aneurysm
3. Pharyngeal pouch - air fluid level in neck
4. Goitre
5. Paravertebral abscess / haematoma

Neuromuscular:

1. Achalasia
2. Scleroderma
3. Chagas

Question 2

DDx for Smooth Oesophageal Strictures

Answer 2

DDx includes:

Inflammatory:

1. Peptic / Reflux oesophagitis
2. Corrosives - long, symmetrical, takes years
3. Iatrogenic - prolonged NG

Neoplastic:

1. Leiomyoma - eccentric, polypoid mass
2. Mediastinal mass - Ca bronchus; LNs
3. Squamous Ca of Oesophagus

Others:

1. Achalsia
2. Scleroderma
3. Epidermolysis Bullosa (prev.image)
4. Pemphigus (image below)
   5.

Question 3

DDx or Stomach filling defects.

Answer 3

Primary Malignant Neoplasms:

• Carcinoma - usually 1 - 4 cm (any polyp >2cm should be considered malignant). Risk factors include:
  
  • Asbestosis
  • Peutz - Jeghers
  • Adenomatous polyps
• Lymphoma: usually non-Hodgkin’s; extension across the pylorus is suggestive of lymphoma.

Polyps:

• Hyperplastic (see previous image): commonest gastric polyp. Usually multiple and small. Associated with chronic gastritis.
• Adenomatous: usually solitary; 1-4 cm. Increased risk of malignant transformation. Associated with pernicious anaemia.
• Hamartomatous: multiple, small, rare in Antrim. Associated with Peutz-Jeghers syndrome, familiar polyposis coli and Gardener’s syndrome.

Submucosal:

• Leiomyoma - associated with central ulceration and patients can present with massive haematemesis.
• Lipoma: can change shape with patient position and may be relatively mobile on palpation.
• Metastasis: frequently ulcerate forming the “bull’s-eyes” / target lesion. These are usually due to melanoma, but also bronchus, breast and Kaposi’s.

Extrinsic Indentation:

• Pancreatic tumour / pseudocyst
• Hepatomegaly / splenomegaly
• Retroperitoneal tumours

Others:

• Lymphoid hyperplasia (see case below); associated with Helicobacter pylori gastritis
• Pancreatic rest: usually on the inferior wall of the Antrim and create a “bull’s-eye” or target lesion.
• Bezoar

Question 4

“Bull’s Eye” / Target lesion DDx

Answer 4

• Submucosal metastasis:
  
  • melanoma
  • Lymphoma
  • Carcinoma - breast, bronchus, pancreas
  • Carcinoid
• Leiomyoma
• Pancreatic “rest”
• Neurofibroma: may be multiple.