GI differential Diagnoses

GI differential Diagnoses

ESOPHAGUS

Diverticular disease: pharyngocele, Zenker, Killian Jamieson, traction, pulsion, pseudodiverticula, epiphrenic
Luminal narrowing: webs, Plummer-Vinson, vascular ring, Schatzki ring, strictures (reflux, meds, skin lesions, tumor, mets, radiation, eosinophilic gastroenteritis, Crohn’s, lye, Barrett’s, infection, NGT, achalasia, scleroderma, Chagas), extrinsic compression (aorta, left bronchus, left atrium, mediastinal tumor)
High stricture: Barrett’s, radiation, caustic ingestion, CA, mets, meds, skin dz, Crohn’s
Low stricture: peptic stricture, lower esophageal ring, Barrett’s
Nodules/plaques: diffuse - reflux, Candida, glycogenic acanthosis; localized – Candida, superficial spreading CA, Barrett’s

Ulcers: distal – reflux, Crohn’s; small, mid – herpes, medications (tetracycline, doxycycline, KCl, iron, quinidine, NSAIDs, vit C, Fosamax), Crohn’s; giant – CMV, HIV

Megaesophagus: achalasia, scleroderma, distal narrowing from tumor or stricture, Chagas

Contrast extravasation: esophagitis, tumor, vomiting (MW tear, Boerhaave), TE fistula, foregut duplication cyst with communication to esophagus, iatrogenic, trauma

Solitary filling defects: intraluminal – food impaction, foreign body, fibrovascular polyp, spindle cell tumor, leiomyosarcoma, adenocarcinoma; tumor – leiomyoma, fibrovascular polyp, duplication cyst, papilloma, fibroma, hemangioma, SCC, adenocarcinoma, spindle cell tumor, lymphoma, mets (breast, lung, KS, melanoma, RCC); varices – uphill (portal HTN), downhill (SVC obstruction); extrinsic – lymph nodes, engorged vessels, aneurysms, cysts

Thickened folds: esophagitis, lymphoma, varicoid carcinoma, varices
Air-fluid level: hiatal hernia, esophageal diverticulum, CA, achalasia, scleroderma
Feline esophagus: reflux, motor disorders
Corkscrew esophagus: diffuse esophageal spasm, presbyesophagus

STOMACH
Gastritis: H pylori, erosive gastritis (corrosives, alcohol, stress, NSAIDS), granulomatous (Crohn’s, sarcoid, TB, histo, syphilis), eosinophilic, hypertrophic (Menetrier’s, ZE syndrome), recurrent gastric ulcer (ZE syndrome, PUD, drugs), radiation, emphysematous
Target lesions: gastritis (aphthoid type) – erosive (NSAID, alcohol), Crohn’s, infection (Candida, herpes, CMV); submucosal mets (large ulcer) – melanoma, KS > breast, lung, lymphoma; solitary giant bullseye (very large ulcer) – leiomyoma, sarcoma, CA, solitary met, ectopic pancreas, benign ulcer

Filling defect: bezoar, adenocarcinoma, lymphoma, leiomyosarcoma, mets, KS, endometriosis, carcinoid, leiomyoma, lipoma, polyps (hyperplastic #1), varices, ectopic pancreas, extrinsic compression from spleen/pancreas/liver
Giant rugal folds: lymphoma, Menetrier’s, ZE syndrome, gastritis, eosinophilic gastroenteritis, radiation, infection, Crohn’s, mets, varices (mimic)

Linitis plastica: scirrhous CA (#1), lymphoma, mets (esp breast), pancreatic CA (direct invasion), radiation, Crohn’s, eosinophilic gastroenteritis, corrosive ingestion, TB, sarcoid, syphilis

Antral lesions: adenocarcinoma, lymphoma, mets, Crohn’s, PUD, TB, sarcoid, HPS, pylorospasm, antral web, ectopic pancreas, erosive gastritis, caustics

Double pylorus: lesser curve antral ulcer, Crohn’s, lymphoma

Gastroenteric fistula: PUD, Crohn’s, CA, iatrogenic, surgery
Free air: surgery and laparoscopy, perforated ulcer, perforated distal bowel (IBD, diverticulitis, tumor)

UGI surgery: plication defect, marginal ulcer, bezoar, chronic gastritis, leak, obstruction, intussusception (jejunogastric), gastric CA, afferent loop syndrome, malabsorption

DUODENUM
Filling defects: benign (often 1st portion, asx) – adenoma, leiomyoma, lipoma, villous adenoma, ectopic pancreas; malignant (often distal to 1st portion, sx) – adenocarcinoma at or distal to papilla, leiomyosarcoma, lymphoma, mets (melanoma, breast, KS, carcinoid); bulb – ectopic gastric mucosa, prolapsed antral mucosa, Brunner gland hyperplasia, varices, duodenitis, Crohn’s, lymphoma, sprue, CF, polyposis, benign tumors; distal – benign lymphoid hyperplasia, ectopic pancreas, annular pancreas, ampulla of Vater, tumor, edema with impacted or passed gallstone, choledochocele; soft and changing – choledochocele, lipoma, duplication cyst

Target lesion: leiomyoma, leiomyosarcoma, met (melanoma, KS, breast, lung, lymphoma), ulcer, ZE syndrome

Luminal outpouchings: ulcer, diverticulum, choledochoduodenal or cholecystoduodenal fistula
Reverse figure 3 sign: pancreatitis, pancreatic CA
Notched duodenum: annular pancreas, post-bulbar ulcer, Crohn’s, post-op, pancreatitis, pancreatic CA

Postbulbar narrowing: adenocarcinoma, lymphoma, mets, postbulbar ulcer, duodenitis, Crohn’s, pancreatitis (extrinsic), pancreatic CA, annular pancreas, intramural diverticulum, duodenal duplication cyst, duodenal hematoma, aortic aneurysm, SMA syndrome (seen in scleroderma, lymphoma)

Papillary enlargement: >15mm; normal variant, choledochocele, papillary edema (pancreatitis, acute duodenal ulcer, impacted stone), ampullary CA

JEJUNUM AND ILEUM

Adynamic ileus: postoperative (#1); inflammatory (often sentinel loop) – pancreatitis, appendicitis, cholecystitis, diverticulitis, peritonitis; metabolic – low K+, Ca++, Mg++; medication – morphine

Mechanical SBO: adhesion, hernia, tumor, gallstone, inflammation with strictures
alabsorpmtion patterns: dilatation, dilution, delay; predominantly thick/irregular folds – Whipple’s, MAI, Strongyloides (proximal), amyloid, Giardia (jejunum), GVH, Cryptosporidium (jejunum), lymphoma, lymphangiectasia, mastocytosis, eosinophilic gastroenteritis; predominantly dilated loops and normal folds – sprue (#1), obstruction, ileus, scleroderma, medication

Thick folds without malabsorption pattern: criteria – folds >3mm, uniformly thickened if diffuse, nodular thickening (pinkyprinting) if focal with stack of coins appearance; submucosal edema – ischemia, infection, radiation, hypoproteinemia, GVH; submucosal tumor – lymphoma, leukemia, submucosal hemorrhage – Henoch-Schonlein purpura, hemophilia, anticoagulation

Tubular bowel: Cryptosporidium, sprue (proximal), lymphoma, GVH, radiation, ischemia, Strongyloides (proximal)

Nodules: mastocytosis, nodular lymphoid hyperplasia, lymphoma, mets, polyps, Crohn’s, eosinophilic gastroenteritis, TB, infection, amyloid, lymphangiectasia, Whipple’s, Waldenstrom’s macroglobulinemia

Diffuse tiny nodules: lymphoid hyperplasia (#1), hypogammaglobulinemia, Giardia, Whipple’s, Waldenstrom’s

Small bowel tumors: benign – adenoma (#1), leiomyoma (#2), lipoma, hemangioma, neurogenic tumors, Brunner gland hyperplasia, heterotopic pancreatic tissue; malignant – mets (melanoma, RCC, breast, KS), lymphoma, carcinoid (#1 primary tumor), leiomyosarcoma (large ulcerating), adenocarcinoma; polyposis syndromes

Small bowel stricture: Crohn’s, lymphoma, mets, infection, radiation, ischemia, adenoCA, extrinsic compression, NSAIDs; focal stricture with shouldering – adenoCA (#1), breast mets, TB

Coiled spring: intussusception, intramural hematoma

Large ulcerated mass (endoexoenteric): lymphoma, leiomyosarcoma, mets (melanoma), interloop abscess

Diverticula: small bowel, Meckel’s

Intraluminal filling defects: parasites (Ascaris, tapeworm), bezoar, foreign body, gallstone, lipoma

Enteric fistulas: Crohn’s, diverticulitis, CA, TB, radiation, surgery, iatrogenic

Serosal: carcinoid, serosal mets, diverticulitis, appendicitis, endometriosis

Mesenteric bowel ischemia: occlusive – emboli (afib, LV aneurysm), arterial thrombosis (atherosclerosis), venous thrombosis (portal HTN, pancreatitis, tumor, hypercoagulable state, drugs); nonocclusive – low flow state

Shortened transit time: anxiety, hyperthyroid, medication (reglan), partial SBO

COLON

Crohn’s: fold thickening, wall thickening, nodular pattern (cobblestone), string sign, aphthoid ulcers, filiform polyps, sinus tracts and fistulas, mesenteric fat stranding, creeping fat, lymphadenopathy, separated bowel loop (omega sign), pseudosacculations, strictures, asymmetric, skip lesions

UC: ahaustral, granular mucosa, filiform polyps, starts in rectum, continuous spread, backwash ileitis, crypt abscesses, strictures (worrisome)

Mass lesions: normal lymphofollicular pattern, pneumatosis coli, colitis cystica profunda, amyloid, endometriosis, ischemic colitis, polyps, polyposis syndromes, lipoma, leiomyoma, hemangioma, villous adenoma, adenocarcinoma, mets, lymphoma, hemorrhoids

Polypoid filling defects: polyps - hyperplastic (#1), adenomatous (#2), hamartomatous, post-inflammatory; polyposis – FAP, Peutz-Jeghers, juvenile polyposis, Turcot, Cronkhite-Canada, Cowden; lymphoma; pneumatosis

Carpet lesion: villous adenoma, adenoCA, polyposis, endometriosis, varices

Colonic urticaria: herpes, Yersinia, allergy, Crohn’s, ischemia

Aphthoid ulcers: Crohn’s, amebiasis, Behcet’s, CMV, herpes, TB, Yersinia (TI)

Deep ulcers: UC, Crohn’s, Behcet’s, infectious (amebiasis, TB, Salmonella, Shigella, histo, Candida, herpes, CMV), ischemic colitis, radiation

Bowel wall thickening (thumbprinting): hemorrhage – ischemia, Henoch-Schonlein purpura, hemophilia, anticoagulation; tumor – lymphoma, leukemia; edema – infectious (pseudomembranous colitis, CMV, E Coli, Salmonella, Shigella, amebiasis, typhlitis), IBD

Circumferential (apple core) or asymmetric narrowing: tumor – adenocarcinoma, serosal mets (stomach, ovarian, colon, pancreas); inflammation – diverticulitis, IBD, TB, amebiasis; other – endometriosis, pelvic abscess, epiploic appendagitis; multifocal – lymphoma, serosal mets, TB, amebiasis, Crohn’s, endometriosis

Long segment narrowing: scirrhous adenocarcinoma, lymphoma, UC, Crohn’s, ischemic stricture, radiation

Ahaustral colon: cathartic abuse (usu R colon), UC, Crohn’s, amebiasis, aging (usu L colon), scleroderma, radiation, prior ischemia

Pseudosacculations: Crohn’s, scleroderma, ischemia

Obstruction: CA, diverticulitis, volvulus, impaction, hernia

Megacolon: toxic megacolon – pseudomembranous colitis, UC, Crohn’s, amebiasis; acute distension – obstructive CA, ileus, volvulus; chronic – laxative abuse, Ogilvie syndrome, congenital Hirschsprung’s, Chagas, neuromuscular disorders (Parkinson, DM, scleroderma, amyloid), hypothyroid

Adult intussusception: usually ileoileal; tumors – polyps, lipoma, mets, lymphoma, carcinoid; idiopathic, Meckel’s diverticulum, feeding tube; no lead point consider sprue, scleroderma, Whipple’s

Pneumatosis coli: pneumatosis cystoides – COPD, asthma, CF, iatrogenic, CVD, steroids; pneumatosis intestinalis – infarcted bowel, NEC, toxic megacolon, typhlitis

Coned cecum: Crohn’s, lymphoma, mets, TB, amebiasis, typhlitis

Ileocecal deformities: Crohn’s, UC, amebiasis (spares TI), TB, typhlitis, lymphoma, adenocarcinoma, carcinoid, intussusception

Enlarged ileocecal valve: >3cm; lipomatous infiltration (#1), lipoma, Crohn’s, lymphoma, prolapsing ileal neoplasms

Cecal filling defect and nonfilling appendix: carcinoid, appendicitis, appendix stump, mucocele

Fat containing mass adjacent to colon: epiploic appendagitis, omental infarction

Proctitis: Condyloma acuminata, lymphogranuloma venereum, GC, UC, Crohn’s, HIV, herpes

Rectal involvement: serosal mets, TOA, radiation, appendicitis, diverticulitis, endometriosis

Presacral space widening: >2cm; rectal inflammation (colitis, radiation), infection, tumor, pelvic lipomatosis, edema hemorrhage

LIVER

Solid masses: hemangioma, FNH, adenoma, HCC, mets, regenerating nodules, focal fatty deposition, lymphoma

Cystic masses: infectious – pyogenic abscess, amebiasis, Echinococcus; benign – simple cysts, ADPKD, biliary cystadenoma, biloma, intrahepatic GB; malignant – necrotic tumors, cystic mets, cholangioCAcreased density: hemochromatosis, glycogen storage disease, Wilson’s, amiodarone, chemotherapy, thorotrast, anemia, regenerative nodules in cirrhosis (low T2)

Decreased density: fatty liver – obesity, alcohol, DM, steroids, chemotherapy; radiation-induced

Mottled density without focal mass: passive congestion, Budd-Chiari, geographic fatty infiltration, hepatoma, lymphoma

Hypervascular: hemangioma, hemangioendothelioma, cholangioCA, HCC, mets (islet cell, melanoma, carcinoid, RCC, thyroid, breast, sarcoma)

Hyperechoic: round – hemangioma, hyperechoic mets (hypervascular and calcified mets), HCC, fibrolamellar HCC, focal fat, lipoma, AML, Gaucher’s; linear – pneumobilia, PV gas, biliary ascariasis; multiple punctate foci – hepatitis, granulomatous infection, PCP, biliary hamartomas, pneumobilia, PV gas, vascular calcs

Multiple hypoechoic: tumor – mets, lymphoma, HCC; infection – pyogenic, amebic, Echinococcus, Candida, Schistosomiasis; other – regenerative nodules in cirrhosis, sarcoid, extramedullary hematopoiesis, hematomas, hemangiomas

Hepatic hemorrhage: iatrogenic, trauma, adenoma, HCC, pregnancy

Gas in liver: pneumobilia – ERCP, surgery, penetrating ulcer, gallstone ileus, CA, bowel obstruction; PV air – bowel necrosis > IBD, abscess, obstruction, ulcer, NEC, iatrogenic, liver transplant; abscess; emphysematous cholecystitis

Delayed retention of contrast: cholangioCA, hemangioma, fibrous tumor, scar (FNH, adenoma, fibrolamellar HCC, hemangioma)

BILIARY SYSTEM

Extrahepatic biliary dilatation: intrapancreatic (#1) – pancreatic CA, calculus, chronic pancreatitis; suprapancreatic – cholangioCA, metastatic lymph nodes; portal – cholangioCA, GB CA, surgical strictures, hepatoma; choledochal cyst


Types of obstruction: tumor – abrupt termination of duct, mass adjacent to duct; pancreatitis -–smooth, long tapering; lithiasis-related – calculus visible, meniscus sign, intrahepatic dilatation; cholangitis – sclerosing, AIDS, oriental; Caroli’s; biliary cystadenoma

Double duct sign: dilated BD and PD; pancreatitis, pancreatic CA, stone impacted in ampulla, cholangioCA, duodenal or ampullary CA

Filling defects in bile duct: stone, blood clot, parasite, sludge, tumor

Hemobilia: iatrogenic, tumor, trauma, infection

Strictures on ERCP: hilum – cholangioCA, porta hepatis nodes, GB CA; 1cm from ampulla – pancreatic CA, cholangioCA, mets; long segment – chronic pancreatitis, lymphoma; CHD at cystic duct region – Mirizzi’s, GB CA, cholangioCA; multiple intrahepatic – sclerosing cholangitis, HIV, ischemic, primary biliary cirrhosis, liver mets (rare); multiple intrahepatic and extrahepatic -–sclerosing cholangitis, HIV, ischemia

Irregular wall and filling defects: cholangitis – HIV, oriental, ascending

Pancreatic duct: stricture – pancreatic CA, chronic pancreatitis; cystic dilatation and side branches – chronic pancreatitis, IPMT; variants - annular pancreas, pancreas divisum

Cholecystectomy leaks: cystic duct remnant, duct of Luschka

GB wall thickening: >3mm; diffuse – nonfasting GB, acute cholecystitis, chronic cholecystitis, portal HTN, hypoalbuminemia, hepatitis, AIDS (cryptosporidium, CMV, MAI), ascites; focal – GB CA, mets (melanoma), cholesterol polyps, adenomyomatosis, tumefactive sludge, AIDS

GB wall hyperechoic foci: calculus, polyp, cholesterol, emphysematous cholecystitis, porcelain GB

Dense gallbladder: vicarious excretion of contrast, calculi, milk of calcium, oral cholecystogram, hemorrhage

Biliary enteric fistula: cholecystitis (gallstone ileus), PUD, tumor, trauma, surgery, Crohn’s

PANCREAS

Focal pancreatic signal abnormality: tumor, focal pancreatitis, adenopathy

Pancreatitis: causes - biliary stones, alcohol, drugs, hyperlipidemia, infection, trauma; complications – fluid collection, pseudocyst, abscess, necrosis, splenic artery pseudoaneurysm, splenic vein thrombosis

Cystic lesions: tumor – microcystic adenoma, mucinous cystadenoma, IPMT, solid/cystic and papillary epithelial neoplasm, cystic islet cell tumor; cyst – simple, pseudocyst, ADPKD, VHL, duct ectasia; abscess

Hyperechoic pancreas: CF, pancreatic lipomatosis

Hypervascular: islet cell tumor, hypervascular mets

Hypovascular: adenocarcinoma, focal chronic pancreatitis

SPLEEN

Anatomic variations: accessory spleen, lobulations, wandering spleen, polyspenia, asplenia, splenosis (s/p trauma)

Focal splenic lesions: tumor – mets (lymphoma, melanoma), hemangioma, lymphangioma, hamartoma; infection (often calcified) – abscess, Candida, TB, MAI, Schistosomiasis, PCP; other – infarct, septic emboli, hematoma, cyst (simple, hydatid) pancreatic pseudocyst, fatty nodules in Gaucher’s

Microabscess pattern: Candida, MAI, TB, PCP, bacterial, fungal, Gaucher’s, sarcoid, KS, lymphoma, mets

Scalloped contour: infarcts, septic emboli, hematoma, metastatic implants, pseudocyst

Splenic cyst: primary – congenital, true; secondary – calcified, false, prior infarct, trauma, infection, echinococcus, pancreatic pseudocyst

Splenic calcifications: TB, histo, PCP, phleboliths, hemangioma

Splenomegaly: tumor – lymphoma, leukemia; infection – infectious mono, histo, sarcoid; metabolic – Gaucher’s, amyloid, hemochromatosis; trauma; vascular – portal HTN, hematologic disorders

PERITONEAL CAVITY

Peritoneal mets: ovarian, stomach, colon, pancreas

Pseudomyxoma peritonei: mucinous cystadenoCA from ovary or appendix, mucocele

Peritoneal fluid collections: ascites, urinoma, biloma, seroma, lymphocele, pseudocyst, CSFoma; complex – abscess, hematoma, pseudomyxoma peritonei, pancreatic necrosis

Intraperitoneal calcifications: arterial calcs, appendicolith, mesenteric node, gallstone, pancreatic calcs, porcelain GB, renal/ureteral stone, nephrocalcinosis, old hematoma, abscess, fibroid, fetal skeletal part, phlebolith, teratoma, echinococcal cyst, mucinous tumor

MISC

General GI DDx: Crohn’s, lymphoma, TB (infection), mets, CA, radiation, ischemia
Mucosal: acute angle, absence of normal mucosal pattern, irregular fuzzy margin

Submucosal: obtuse angle, presence of normal mucosal pattern, smooth distinct margin

Extrinsic: spiculation, tethering

AIDS: infection – CMV, Candida, herpes, Cryptosporidium, MAI; tumor – KS, lymphoma; esophagus – ulcers (Candida, CMV, herpes, HIV), sinus tracts (TB, Actinomycosis); proximal small bowel – ulcers (cryptosporidium), nodules (KS, lymphoma, MAI); distal small bowel – enteritis (TB, MAI, CMV); colon – colitis (CMV, pseudomembranous), typhlitis; rectum – herpes, lymphoma; biliary – strictures (CMV, Cryptosporidium); liver and spleen – KS, lymphoma, Candida, TB, MAI, PCP

Abdominal trauma: liver laceration (#1), splenic lac, renal trauma, bowel hematoma, pancreatic fx, GB injury, adrenal hemorrhage

Abdominal complications after cardiac surgery: GI hemorrhage, cholecystitis, pancreatitis, perforated peptic ulcer, mesenteric ischemia, perforated diverticulitis

Low density lymph nodes: TB, MAI, lymphoma, testicular tumor, mucinous adenoCA, Whipple’s

Cystic abdominal mass: abscess, loculated ascites, panc pseudocyst, ovarian cyst or tumor, lymphocele, cystic lymphangioma, enteric duplication cyst, cystic teratoma

Mesenteric mass: lymphoma, mets, carcinoid, mesenteric fibromatosis, mesothelioma

Large LUQ mass: stomach (leiomyosarcoma), pancreas (pseudocyst, nonfunctioning islet cell tumor, mucinous tumor), adrenal (carcinoma), spleen (lymphoma), kidney (RCC, lymphoma)

RLQ inflammation: appendicitis, Crohn’s, cecal diverticulitis, perforated cecal CA, mesenteric adenitis, PID

Volvulus: gastric (organoaxial, mesenteroaxial), midgut, colon (sigmoid, cecal)

Hernia: paraesophageal, paraduodenal, inguinal, umbilical, Spigelian, lumbar, Richter’s, incisional

Abdominal wall: mets (melanoma, NF, iatrogenic seeding), rectus sheath hematoma (trauma, anticoagulation)

Ascites: cirrhosis, mets, CA, hypoalbuminemia, CHF, pancreatitis

Gasless abdomen: obstruction with fluid-filled bowel, severe vomiting, high obstruction, achalasia, impaired swallowing, continuous NG suction