The document describes 3 radiology case studies involving the gastrointestinal system: 1) A case of scleroderma diagnosed based on an x-ray showing dilation of the small bowel with closely spaced folds. 2) A case of appendicitis diagnosed on CT showing an enlarged appendix with periappendiceal inflammation and an appendicolith. 3) A case of a gastric leiomyoma diagnosed on barium study and CT showing a rounded filling defect in the stomach with central ulceration arising from the gastric wall.

1. Section IV – Gastrointestinal Radiology
Figure 1
135. You are shown a radiograph from a small bowel follow-through in a 40-year-old woman with abdominal
distension and chronic diarrhea (Figure 1). Which one of the following is the MOST likely diagnosis?
A. Crohn’s disease
B. Sprue
C. Scleroderma
D. Giardia infection
E. Eosinophilic enteritis
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2. Section IV – Gastrointestinal Radiology
Question #135
Findings: The radiograph demonstrates dilation of the small bowel with closely spaced normal thickness folds.
Rationales:
A) Incorrect. Crohn’s disease involves the small bowel in 75% of patients at the time of presentation. Affected
segments show fold thickening and ulceration. Sinus tracts and fistulae are also noted. Surrounding fibrofatty
proliferation may produce a mass effect or displace adjacent bowel. None of these findings, however, are noted
here.
B) Incorrect. Sprue or gluten sensitive enteropathy produces villous atrophy and radiographically shows reversal
of the normal fold pattern with loss of normal jejunal folds and an increased number of folds per inch in the
ilium. Transient intussusceptions, hypomotility, and flocculation of barium can also be seen. However, none
of these findings are present on this film.
C) Correct. Scleroderma causes smooth muscle atrophy and fibrosis. Radiographically the small bowel appears
dilated with closely spaced but normal caliber valvulae conniventes as shown in this radiograph. Wide mouth
diverticula are frequently noted on the mesenteric side of the bowel, although they are not seen here.
Hypomotility is common and along with the dilation can produce bacterial overgrowth syndrome and the
symptoms noted here. The small bowel is the second most commonly affected portion of the GI tract in
scleroderma.
D) Incorrect. Giardia lamblia is a common intestinal parasite. The radiographic findings in this protozoal infection
are most common in the duodenum and proximal jejunum and consist of thickened folds associated with
bowel irritability, hypermotility, and increased secretion.
E) Incorrect. Eosinophilic enteritis is a benign infiltration of the bowel wall with eosinophils. The etiology is
unclear but the disease responds rapidly to steroids. Radiographically fold thickening that can be nodular is
noted most prominently in the proximal small bowel. Gastric antral involvement is also common.
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3. Section IV – Gastrointestinal Radiology
Figure 2A
136. You are shown three images from a contrast enhanced CT in a 33-year-old man with a 4 day history of
abdominal pain (Figures 2A, 2B and 2C). Which one of the following is the MOST likely diagnosis?
A. Mesenteric adenitis
B. Appendicitis
C. Crohn’s disease
D. Carcinoid
E. Epiploic appendagitis
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4. Section IV – Gastrointestinal Radiology
Figure 2B
Figure 2C
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5. Section IV – Gastrointestinal Radiology
Question #136
Findings: The CT image demonstrates an enlarged and partially air filled appendix with an appendicolith noted at
its juncture with the cecum. There is extensive periappendiceal and pericecal inflammation.
Rationales:
A) Incorrect. Mesenteric adenitis is a benign inflammatory process usually involving the mesenteric lymph nodes
in the right lower quadrant. On CT, it appears as a cluster of enlarged nodes. Occasionally ileal or cecal wall
thickening is noted. The extensive perienteric and periappendiceal inflammation shown here would not be seen.
B) Correct. Appendicitis is usually 2ry to luminal obstruction. In this case, a discreet high-density appendicolith is
noted at the juncture of the cecum and appendix. The appendix is enlarged and there is significant inflammatory
stranding about the appendix with wall thickening noted involving the cecal tip. The findings are characteristic
of appendicitis.
C) Incorrect. Crohn’s disease is an idiopathic inflammatory condition noted predominantly in the small and large
bowel. On CT wall thickening is noted in the involved bowel with fibrofatty proliferation often also seen.
Isolated involvement of the appendix would be extremely unusual.
D) Incorrect. Carcinoid is a slow growing tumor derived from enterochromaffin cells. Approximately 50 % of
carcinoids are found in the appendix. The lesions typically appear as a small mural mass on CT. Nodal metastasis
in the mesentery can show extensive surrounding desmoplasia and retraction. Although appendiceal carcinoid
can present as an appendicitis 2ry to luminal obstruction, this would not be the most likely diagnosis.
E) Incorrect. Epiploic Appendagitis is a rare inflammatory condition resulting from either appendageal torsion
or spontaneous venous thrombosis of the draining vein. CT findings of epiploic appendagitis include a small
paracolic fat lesion with adjacent inflammatory stranding. A central high attenuating dot and or thickening in
the adjacent bowel and peritoneum is also noted.
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6. Section IV – Gastrointestinal Radiology
Figure 3A
Figure 3B
137. You are shown a radiograph of the gastric fundus from a biphasic upper gastrointestinal exam (UGI) (Figure
3A) along with a CT scan (Figure 3B) through the upper abdomen in a 62-year-old man with melena.
Which one of the following is the MOST likely diagnosis?
A. Lymphoma
B. Adenocarcinoma
C. Brunner’s gland hamartoma
D. Carcinoid
E. Leiomyoma
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7. Section IV – Gastrointestinal Radiology
Question #137
Findings: The radiograph from the UGI and CT demonstrates a smooth bordered rounded filling defect in the
gastric fundus with a central ulceration. The lesion appears to arise from the gastric wall with an abrupt margin with
the remainder of the wall.
Rationales:
A) Incorrect. The stomach is the most common site of lymphomatous involvement in the GI tract, but gastric
lymphoma makes up only 3% of all gastric malignancy. Radiographically lymphoma can appear as an
infiltrative, ulcerative, or nodular mass that often mimics the appearance of adenocarcinoma. The antrum and
body are most commonly involved. The smoothly and very discreetly marginated mass seen on the radiograph
and CT in this case would be unusual for lymphoma.
B) Incorrect. Adenocarcinoma is the most common gastric malignancy making up 95% of cancers. They can
present as an infiltrative, either polypoid or ulcerative mass. A linitis plastica appearance is also noted. It would
be unusual however for an adenocarcinoma to present as the rounded submucosal process shown in this case.
C) Incorrect. Brunner’s glands occur in the duodenum and secrete alkaline mucus. Hyperplastic changes of the
glands may produce a small mass like lesion. These glands do not occur in the gastric fundus nor do Brunner’s
gland hamartomas become this large
D) Incorrect. Less than 5% of gastrointestinal carcinoid tumors are located in the stomach. Radiographically they
appear as small (1-4 cm) submucosal masses. Central ulceration may occur.
E) Correct. Leiomyomas make up 90% of mesenchymal gastric tumors. They typically appear as a submucosal
mass with smooth and sharply circumscribed margins. The majority has an endogastric growth pattern with
about 20% showing an exogastric or endo-exogastric configuration. Although lesions are usually less than 3 cm,
lesions as large as 25 cm have been reported. Central ulceration is not uncommon, being noted in 50-70% of
leiomyomas greater than 2 cm in size.
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8. Section IV – Gastrointestinal Radiology
Figure 4
138. You are shown a single image from an abdominal CT in a 67-year-old woman with abdominal pain
(Figure 4). Which one of the following is the MOST likely diagnosis?
A. Gastroduodenal artery pseudoaneurysm
B. Pseudocyst
C. Pancreatic adenocarcinoma
D. Superior mesenteric vein thrombosis
E. Peripancreatic adenopathy
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9. Section IV – Gastrointestinal Radiology
Question #138
Findings: The image demonstrates thrombosis of the superior mesenteric vein.
Rationales:
A) Incorrect. The gastroduodenal artery is located on the ventral surface of the head of the pancreas. GDA
pseudoaneurysm can occur as sequelae of pancreatitis and present as an enhancing mass in the head of the
pancreas. Although the appearance would be possible with a thrombosed pseudoaneurysm, its location would
not be consistent with the GDA.
B) Incorrect. Pancreatic pseudocysts form as a sequelae of pancreatitis. They are usually located in or adjacent to
the pancreas although less commonly they can be seen in locations that are more distant.
C) Incorrect. Pancreatic adenocarcinoma is the most common pancreatic malignancy and typically presents as an
ill-defined hypo enhancing pancreatic mass.
D) Correct. The superior mesenteric vein is located adjacent and medial to the pancreatic head, usually to the
right, and slightly anterior to the superior mesenteric artery. Thrombosis of the SMV is associated with a variety
of factors including infection, hypercoagulable states, and recent surgery. Hyper enhancment of the vein wall,
while not uncommon, or residual flow about the thrombus is noted.
E) Incorrect. Low-density adenopathy can be seen in a variety of diseases including mycobacterial infection,
Whipple’s disease, and testicular neoplasms. This location and appearance however would be unusual and
would not explain the appearance of the SMV.
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10. Section IV – Gastrointestinal Radiology
Figure 5A
139. You are shown two images from a CT scan in a 30-year-old woman being worked up for a liver mass.
Figure 5A was obtained during the portal venous phase. Figure 5B is a 4 minute delayed image. Which one of
the following is the MOST likely diagnosis?
A. Hypervascular metastasis
B. Hepatic hemangioma
C. Hepatic adenoma
D. Fibronodular hyperplasia
E. Fibrolamellar carcinoma
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11. Section IV – Gastrointestinal Radiology
Figure 5B
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12. Section IV – Gastrointestinal Radiology
Question #139
Findings: The images show a large well-circumscribed lesion in the right lobe of the liver that demonstrates
nodular peripheral discontinuous enhancement that is equal to that of the vessels. The delayed image shows gradual
peripheral fill-in.
Rationales:
A) Incorrect. Although most metastases are hypovascular relative to normal liver, several are hypervascular
particularly in the early arterial phase. These include renal cell cancer, islet cell tumors, carcinoid as well as
occasionally sarcomas, melanoma, adrenal tumors and breast cancer. Most become iso or hypo attenuating on
more delayed scanning. None would demonstrate the discontinuous nodular peripheral enhancement shown
here with persistent fill-in over time.
B) Correct. Hemangioma is the most common benign hepatic tumor. On enhanced CT or MRI, they typically
show a discontinuous nodular peripheral enhancement that is equal to that of the vessels and gradually fills in
over time as shown here.
C) Incorrect. Hepatic adenomas are benign tumors that occur most commonly in women. They are associated
with oral contraceptive use. They typically show early homogenous enhancement with rapid fading to
isoattenuation.
D) Incorrect. FNH is the second most common benign hepatic tumor and is more common in women.
Radiographically it appears as a well-circumscribed lesion with homogenous early enhancement. Delayed
images typically show fading to isoattenuation with normal liver. A central scar is frequently present.
E) Incorrect. Fibrolamellar carcinoma is a subtype of hepatocellular carcinoma occurring most commonly in
younger patients. It has a better prognosis than HCC and is not associated with underlying cirrhosis. On CT,
it typically appears as a large lesion with heterogeneous enhancement and often a central calcified scar.
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