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Abdomen & GI systemFINAL

RT 91- Pathology

Spring 2011

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Regions & Quadrants of Abdomen

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Contents of Abdominal Cavity

1. Digestive system– Stomach and Intestines

2. Hepatobiliary System– Liver, gallbladder, & pancreas

3. Urinary system– Kidneys, ureters and bladder

4. Circulatory system– spleen

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Gastrointestinal System

1. Alimentary tract- serves to digest & absorb food– Consists of

• Mouth• Pharynx• Esophagus• Stomach• SM & LG bowel• Rectum

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Small Bowel1. 21 FT long

2. Duodenum1. Duodenal c-loop

ends at ligament of Treitz

3. Jejunum1. Connects to ileum

4. Ileum1. Terminates at

ileocecal junction

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Large Intestine

1. 6 FT long– Extends from

ileocecal junction– Ascending colon

(hepatic flexure)– Transverse colon

(splenic flexure) – Descending colon– Sigmoid– Rectum– Anus

Hepatic flexure

Splenic flexure

Sigmoid

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Congenital and Hereditary Anomalies

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Esophageal Atresia

1. Looping of the feeding tube

2. Atypically short esophagus & terminates in blind pouch

2. Air in stomach

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Esophageal Atresia

1. Congenital anomaly

2. Esophagus fails to _______________ past some point

3. Symptoms come soon after birth– Salivation, gagging,

choking, dyspnea, cyanosis

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Tracheoesophageal Fistula

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Tracheoesophageal Fistula

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Duodenal Atresia

On x-ray a “double-bubble” sign is demonstrated gas in stomach is one bubble

Gas in proximal duodenum is the second bubble

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Duodenal Atresia

1. Congenital anomaly

2. ________________ of duodenum does not exist

3. Resulting in a complete _________________

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Colonic Atresia

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Colonic Atresia

1. Congenital failure of development of the ________________

2. Frequent complication includes fistula formation to the genitourinary system

3. Must be repaired surgically

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Hypertrophic Pyloric Stenosis

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Hypertrophic Pyloric Stenosis

Pyloric canal leading out of the stomach is greatly narrowed

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Hypertrophic Pyloric Stenosis

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Hypertrophic Pyloric Stenosis

1. Congenital anomaly of the stomach

2. Pyloric canal leading out of the stomach is greatly narrowed because of hypertrophy of the pyloric sphincter

3. Most common indication for surgery in infants

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Malrotation

Small bowel on

right and colon

on left

Cecum is not

located in the

RLQ

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Malrotation1. Intestines are not in

their normal position

2. Usually asymptomatic

3. Can lead to bowel volvulus or incarceration of bowel1. Surgery is required

with a resection of bowel involved

Cecum on left

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Hirschsprung's Disease

1. ______________

2. Dilated ______ colon with massive amounts of feces

3. Narrowed segment just below the

dilatation

Feces

Narrowing

Dilated Sigmoid

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Hirschsprung’s DiseaseAKA Congenital Megacolon

1. Absence of neurons in the bowel wall

2. This absence prevents normal relaxation of the colon & subsequent peristalsis

3. Results in gross dilatation

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Meckel’s Diverticulum

Difficult to diagnose with x-ray

Nuclear Medicine is better

Sac-like anomaly within ileocecal valve

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Meckel’s Diverticulum

1. Congenital ________________ of the distal ileum

2. Is remnant of a duct connecting the SB to the umbilicus in the fetus

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Celiac Sprue

X-rays show segmentation of the barium column, flocculation (resembling tufts of cotton) & edematous mucosal changes

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Celiac Sprue1. Hereditary disorder with increased sensitivity to gluten

2. Interferes with normal _____________ and _____________ of food

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Inflammatory Disease

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Esophageal Strictures

X-rays show peristalsis is transitory

Contour appears ragged

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Esophageal Strictures

1. Caused by ingestion of caustic materials1. Household cleaners2. Detergents3. Sulfuric acid4. Sodium hydroxide

2. ____ the esophagus causing edema, swelling, & possible perforation

3. Requires repeated _______________

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GERD1. Incompetent ______

sphincter allowing backward flow of gastric acid and food into esophagus

2. ________________

3. ________may not be evident with barium swallow but strictures & ulcers may be present

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GERD

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Peptic Ulcer1. Erosion of the

mucous membrane of the esophagus, stomach & duodenum

2. Primarily affects PT’s over 40 years

3. Diagnosis is made mostly with endoscopy

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Peptic Ulcer

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Barrett’s EsophagusPeptic ulcer of the esophagus often with a stricture

Fibrotic healing of the ulceration

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Barrett’s Esophagus

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Crohn’s Disease

Radiographically looks like “cobblestone”

The ______________________ sign is demonstrated where the TI is so diseased and stenotic

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Regional Enteritis (Crohn’s Disease)1. Chronic

inflammatory disease of no cause

2. Typically occurs in lower ileum but can be seen throughout bowel

String sign

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Appendicitis

CT is the gold standard

Shows an appendiceal abscessAs a round or oval soft tissueDensity that may contain gas

Appendix is dilated

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Fecolith within Appendix

Common cause ofAppendicitis

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Appendicitis1. Inflammation of the

appendix resulting from an __________ 1. Caused by a fecolith

or neoplasm (rarely)

2. Most common abdominal surgery in the US

3. Sonography & CT used in diagnosis

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Ulcerative Colitis

BE demonstrates an

irregular outline of the

colon

_______ _________ appearance

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Ulcerative Colitis1. Inflammatory lesion of the colon mucosa1. Causes abscess

leading to epithelial necrosis & ulceration

2. It is idiopathic, thought to be an autoimmune disease

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Esophageal VaricesOn x-ray looks like wormlike defects within the column of BA

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Esophageal Varices

Varicose veins that are abnormally lengthened, dilated& superficial

Can be fatal

Occurs from conditions such

as cirrhosis that bypass the

normal venous drainage

mechanism

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Gastritis

Evidenced by gas

bubbles (produced by

bacteria) in the stomach

Wall

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Endoscopy for Gastritis

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Gastritis1. Inflammation of the_______ of the stomach

2. Results from variousirritants: alcohol,corrosive agents, &infection

3. Most commonlydemonstrated with___________________

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Degenerative Diseases

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Inguinal Herniation

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Inguinal Herniation

1. Protrusion of a loop of bowel through a small opening, usually in the abdominal wall.

2. Can cause obstruction

3. Can be surgically repaired, sometimes needing resection

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Hiatal Hernia

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Hiatal Hernia1. Weakness of

esophageal hiatus that permits some portions of the stomach to herniate into the thoracic cavity

2. Chronic herniation can be associated w/ ______

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Schatzki’s Ring1. A type of hiatal hernia

2. Occurs when a portion of the stomach and the gastroesophageal junction are both above the diaphragm (99%)

1. This ring is visible radiographically with this condition

2. May be related to reflux

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Bowel Obstructions

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Mechanical Bowel Obstruction

Large dilated colon

Little small bowel gas

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Mechanical Bowel Obstruction

1. Occurs from a blockage of the bowel lumen

2. Bowel sounds are _______________ & high pitched

3. Vomiting _________

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Gallstone Ileus

X-ray show air-fluid levels or air in biliary tree

Gallstone may also be visible in the TI where it causes the obstruction

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Gallstone Ileus1. A type of mechanical obstruction

2. Gallstone can erode & create a fistula in the SB

3. Obstruction occurs when stone reaches ileocecal valve

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Paralytic Ileus

Gas distributed

throughout both LG &

SB

Normal bowel sounds

are absent

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Paralytic Ileus

1. Results from failure of peristalsis

2. Absent bowel sounds

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Volvulus

X-ray shows collection of air conforming to the shape of affected bowel

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Volvulus1.Twisting of bowel loop1. Usually at the

sigmoid or ileocecal junction

2. Identifiable with x-ray

3.Usually happens in elderly

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Intussusception

X-ray looks like a coiled springAir fluid levels LG bubble within mid abdomen

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Intussusception1. Is a kind of

mechanical obstruction

2. Segment of bowel telescopes into distal segment and is driven further into distal bowel by peristalsis

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Neurogenic Diseases

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Achalasia

X-ray shows dilated esophagus with little or no peristalsis

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AchalasiaFailure of the

esophageal sphincter to

relax causing dysphasia

Distal esophagus open

intermittently

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Diverticular Diseases

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Esophageal Diverticula

• Occurs when mucosal outpouchings penetrate through the muscular layer of the esophagus

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Esophageal Diverticula (traction)

• Involves all layers of esophagus and results in adjacent scar tissue that pulls esophagus toward area of involvement

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Zenker’s Diverticulum

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Zenker’s Diverticulum

1. Involves mucosa only & results from a __________ disorder

2. Allows esophagus to _________ outwardly

3. Found at pharyngealesophageal junction

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Colonic Diverticula

Appear as round – oval Outpouchings of BA projectingbeyond bowel lumen

Vary in size 2cm or more

Tend to occur in clusters

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Colonic Diverticula

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Colonic Diverticula

1. The presence of diverticula _________inflammation

2. Diverticula are associated with hypertrophy of the muscular layer of the bowel

3. Most common in _____________ (95%)

4. Most patients are asymptomatic

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Diverticulitis

1. Inflammation of the diverticulum

2. Exacerbated by feces lodging in the diverticulum

3. Signs and symptoms: fever, LLQ pain, tenderness and increased WBC count

4. BA shows diverticulum

5. Treatment centers on reduction of inflammation and infection

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Neoplastic Diseases

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Leimyomas

Appear as intramural defects in the barium outlined esophageal wall

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Leimyomas of Esophagus

1. __________ tumors

2. Have smooth muscular tumors

3. Exact location can be determined on CT

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GastroesophagealAdenocarcinomas

Appears as mucosal destruction,ulceration, narrowing and sharpdemarcation between normal Tissue & malignant tumor

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Adenocarcinomas1. Occur in the lower

esophagus around the gastroesophageal junction

2. Some believe there is a direct link between Barrett’s esophagus & adenocarcinoma1. 90% have been

found to arise from Barrett’s mucosa

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Small Bowel Neoplasms

Most common means of identifying is throughendoscopy with biopsy

Can be seen on CT & with SBS

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Small Bowel Neoplasms

1. Most occur in the duodenum & proximal jejunum

2. Some predisposing factors include:1. Polyposis

2. Kaposi’s sarcoma

3. Crohn’s disease

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Colonic Polyps

BE is exam of choice, showing rounded filling defects

Proctosigmoidoscopy and colonoscopy are critical in evaluation and removal of polyps

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Colonic Polyps1. Small masses of tissue

arising from the bowel wall to project inward in the lumen

2. More frequently in the left colon

3. Most cancers of the colon & rectum usually arise from previous benign polyps

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Colon Cancer1. 2nd most common

cause of cancer mortality

2. Adenocarcinoma is the most common type of colorectal cancer

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Colon Cancer

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Colon Cancer“Apple-Core lesion”

1. X-ray shows “napkin ring” or “apple core” lesions

2. Double contrast BE more accurate than single contrast

3. CT colonoscopy also useful

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CT of Abdomen & GI

1. Clearly demonstrates abdominal organs that are normally not apparent on x-ray w/o contrast

2. Recommended for bowel obstruction diagnosis

3. Virtual colonoscopy can be done to see areas not seen during a regular colonoscopy

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MRI imaging of Abdomen & GI

1. Still limited due to bowel motion

2. Useful in demonstrating retroperitoneal masses impinging on GI system

3. Can differentiate between pathology & normal tissue

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US imaging of Abdomen & GI

1. Not useful in imaging of the GI system

2. Extensively used to image the retroperitoneum because of the flexibility of angling the transducer

3. With this modality it is possible to image behind the bowel & assess for abnormalities

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Nuclear Medicine imaging for Abdomen & GI

1. Useful is detecting:1. GI bleeds

2. Gastric emptying time

3. Presence of H. Pylori

4. Infection from gastric ulcers

2. PET has been known to demonstrate 20% of esophageal cancer undetected by CT

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Endoscopic Procedures1. Fiberoptic tube device to look inside hollow organs or cavities

2. Upper endoscopy can see esophagus, stomach, duodenum & proximal jejunum

3. Colonoscopy to the terminal ileum

4. Small bowel is still out of reach

5. Capsule endoscopy is a camera pill that is swallowed and takes pictures of the GI tract1. Drawbacks include inability to biopsy area and locate pathology2. Insurance reimbursement

6. Also used for several therapeutic applications1. Biopsies2. Stent placement3. Polyp removal4. Stone removal