STOMACH IN MY WAY!!michigansonographerssociety.org/.../04/Stomach-in-my-way_wellsMS… · STOMACH...

STOMACH IN MY WAY!! Teresa Wells, BHSA, RDMS, RVT, RT

Professor of General and Vascular Sonography

Lansing Community College

STOP IGNORING THE STOMACH!

• Physiology

• What it does and why

• Anatomy

• GEJ

• Body

• Antrum

• Pyloric canal

• What is abnormal?

img-9gag-fun.9cache.com/photo/65479_700b_v1.jpg

IN CONCLUSION:

Sonography is sensitive and specific to detect gastric abnormalities.

Sonographer’s should be familiar with the ability to detect gastric lesions.

WHAT DOES THE STOMACH DO, HOW AND WHY?

• Bulk storage

• Mechanical breakdown

• Gastrin = acid

• Secretin = antacid

• Cholecystokinin = GB

• Mixer

FUN FACT: ACID

SONOGRAPHICALLY, WHAT’S NORMAL?

• “Gut signature”

• 1-16 mm

GUT SIGNATURE

FUN FACT:

BULK STORAGE

GASTRICEMPTYING

Scintigraphy

• Meal: cooked eggs and toast mixed with radiopharmaceutical

• 2-4 hours

• Gastroparesis- delay in emptying

SIZE MATTERS

BODY HABITUS

docstoc.com/docs/89895225/Body-Habitus

GASTROESOPHAGEALJUNCTION

IN CONCLUSION:

Ultrasound is an effective method in the investigation of GERD in children

Easy to perform

Highly sensitivity

NO radiation

GASTROESOPHAGEAL JUNCTION

No Reflux

GASTROESOPHAGEAL JUNCTION

Reflux

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Ravi D. Kadasne, 2015. Facebook

SCANNING FOR GERD

1. MILD: <3 refluxes in 10 min

2. MODERATE: 4-6 refluxes in 10 min

3. SEVERE: >6 refluxes in 10 min

Very common in infants

• Vomiting

• Irritability and crying

• Failure to thrive

• Refusal to eat

• Aspiration pneumonia

ESOPHAGEAL REFLUX

Journal of Clinical Imaging Science | Vol. 1 | Issue 1 | Jan-Mar 2011

Moving

REFLUX COLOR DOPPLER

WIDE ESOPHAGUS

ultrasoundcases.info

THICKENED ESOPHAGEAL WALL


ESOPHAGEAL VARICES


GASTRIC VARICES

ESOPHAGEAL CYST

PROXIMAL ESOPHAGUS

SPINAL MASS

ESOPHAGUS CARCINOMA

FUN FACT: WHICH ANIMAL DOES NOT

HAVE A STOMACH?

A. Puffer fishB. Platypus

C: Seahorse

ANTRUM

ANTRUM

AL

P

ANTRUM

WATER PANCREAS

p

A

WATER FILLED STOMACH?

P


PANCREATITIS MIMICKING STOMACH


P P

PSEUDOCYST VS. STOMACH

PP



L




P

THICKENED ANTRUM WALL


PARTIAL THICKENED ANTRUM WALL

ANTRUM MASS (CARCINOMA)


GASTRIC ULCER


FUN FACT: HAGGIS

• Scottish savory pudding

• Sheep's stomach stuffed with diced sheep's liver, lungs and heart, oatmeal, onion, suet and seasoning

• Against US law because of sheep lungs

recessionbitesblog.wordpress.com/tag/haggis/

PYLORUS SPHINCTER

Pyloric Antrum

Pyloric Sphincter

Pylorus

PYLORUS SPHINCTER

HYPERTROPHIC PYLORIC STENOSIS

3 per 1,000 infants

Males 4:1

White

First born

Family history

• Gastric outlet obstruction

• Thickening of the muscular layer

• Failure of the canal to relax

IHPS DIAGNOSIS

Muscle width >3mm

Canal length >12mm

No fluid passing

pedsurg.ucsf.edu

IHPS

HOW TO SCAN FOR IHPS

1. Supine or RPO

2. Longitudinal pyloric canal

3. Water feeding

4. Watch what happens!

WHICH IS HPS?

A. B.

GASTRIC OUTLET OBSTRUCTION

DILATED STOMACH

FUN FACT:

Joey Chestnut

World record:

• 69 Hot Dogs and Buns

• 10 minutes

UNUSUAL INCIDENTALS

S


UNUSUAL INCIDENTALS

BEZOAR

"A bezoar is a stone taken from the stomach of a goat and it will save you from most poisons."

—Snape lecturing in Harry Potter's first year Potion class

harrypotter.wikia.com/wiki/Bezoar

BEZOAR

RAPUNZEL SYNDROME

FOREIGN BODY

FOREIGN BODIES

BODYPACKS

ASCARIS

APPENDIX

• Cecum

• Small bowel

• Iliac vessels

• Psoas muscle

• Appendix

CECUM, TERMINAL ILIUMAND THE APPENDIX

MCBURNEY’S POINT

• One-third the distance from the anterior superior iliac spine to the umbilicus

SYSTEMATIC SCANNING TECHNIQUE

Step #1 General surveyStep #2 Cecal tipStep #3 Iliac vesselsStep #4 MuscleStep #5 Retro-cecalStep #6 Where does it hurt

Scan slowly and patiently with graded compression

STEP #1 GENERAL SURVEY

• Lawn-mower

• Screen for obvious findings

STEP #2 CECAL TIP

• Identify the Cecum in transverse

• Bumpy, gas and stool filled bowel

STEP #2 CECAL TIP

Bumpy vs. smooth bowelCecum

Ilium

STEP #2 CECAL TIP

• Identify the Cecal tip

• Look for appendix inferior/medial

Cecum

STEP #3 ILIAC VESSELS

• Scan Parallel and transverse with vessels

• Look for appendix draping across vessels

STEP #3 ILIAC VESSELS

STEP #4 PSOAS MUSCLE

• Scan deep to identify the iliacus muscle

• Identify the appendix laying anterior

STEP #5 RETRO-CECAL• Decrease MHz

• Scan deep

STEP #5 RETRO-CECAL

• Rotate patient LPO

• Apply compression on patient’s back

STEP #6 WHERE DOES IT HURT

RUQ??

MEASUREMENT

• Greater than 6-7mm is abnormal

• Always measure AP (not width)

+ 8mm* 12mm

ACUTE APPENDICITISSONOGRAPHIC APPEARANCE

SECONDARY FINDING

• Free fluid

• Increased vascularity

SECONDARY FINDINGS

• Appendicolith

• Abscess

• Edema of surrounding fat

ALWAYS IMAGE THE TIP

OTHER FINDINGS

• Mesenteric adenitis

• Colitis/Crohn’s

• Intussusception

TAKE AWAYS:

Look at the stomach!

Recognize normal

Identify abnormal

6 steps to the appendix

THANK YOU

REFERENCES

Carvalho, Santos, Meirelles, Bersot & Niterói - Rio de Janeiro, RJ/BR Transabdominal ultrasound in the detection ofgastroesophageal reflux disease in children: review of 500 cases. 10.1594/ecr2012/C-1857

Chauhan, N. S., & Sood, D. (2011). Case report: Colonic bezoar due to Box Myrtle seeds: A very rare occurrence. The Indian Journal of Radiology & Imaging, 21(1), 21–23. doi:10.4103/0971-3026.76049

Costa Dias, S., Swinson, S., Torrão, H., Gonçalves, L., Kurochka, S., Vaz, C. P., & Mendes, V. (2012). Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights into Imaging, 3(3), 247–250. doi:10.1007/s13244-012-0168-x http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369120/

Curry, R. A., & Tempkin, B. B. (2011). Sonography: Introduction to normal structure and function (3nd ed.). St. Louis, MO: Saunders.Transabdominal Sonography in Assessment of the Bowel in Adults AJR:192,

Dehdashti, H., Dehdashtian, M., Rahim, F., & Payvasteh, M. (2011). Sonographic Measurement of Abdominal Esophageal Length as a Diagnostic Tool in Gastroesophageal Reflux Disease in Infants. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association, 17(1), 53–57. doi:10.4103/1319-3767.74483 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099082/

Gilja, O. H., Lunding, J., Hausken, T., & Gregersen, H. (2006). Gastric accommodation assessed by ultrasonography. World Journal of Gastroenterology : WJG, 12(18), 2825–2829. doi:10.3748/wjg.v12.i18.2825 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087797/

Hagen-Ansert, S. L. (2006). Textbook of diagnostic ultrasonography. St. Louis, Mo: Mosby Elsevier.

Herliczek TW, Raghavan D, McCarten K, Wallach M. Sonographic Upper Gastrointestinal Series in the Vomiting Infant: How We Do It. J Clin Imaging Sci 2011;1:19 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177420/

REFERENCES

Kawamura, D. M., & Lunsford, B. M. (2012). Diagnostic Medical Sonography: Abdomen and superficial structures. (3rd ed.) Philadelphia, PA: Wolters Kluwer.

Kim, J. S., & Nam, C. W. (2013). A Case of Rapunzel Syndrome. Pediatric Gastroenterology, Hepatology & Nutrition, 16(2), 127–130. doi:10.5223/pghn.2013.16.2.127 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760701/

Likes, M., & Johnston, T. (2012). Gastric pseudoaneurysm in the setting of Loey’s Dietz Syndrome. Images in Paediatric Cardiology, 14(3), 1–5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663156/

Miller & Phil., (2011) Gastric Emptying Scintigraphy. Radiology Rounds 9(2). http://www.mghradrounds.org/clientuploads/february_2011/february_2011.pdf

Russo, T., Costa, C., Crujo, C., & Lopes, A. I. (2012). Protein-losing gastropathy associated with cytomegalovirus infection in a child. BMJ Case Reports, 2012, bcr0120125679. doi:10.1136/bcr.01.2012.5679 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448344/

Weeks, D., MD Transient pancreatitis and small bowel obstruction by trichobezoar Applied Radiology. February 07, 2011 http://www.appliedradiology.com/articles/transient-pancreatitis-and-small-bowel-obstruction-by-trichobezoar#sthash.TgNkrh72.dpuf

Wong, M., Shum, S., Chau, W., & Cheng, C. (2010). Carcinoma of stomach detected by routine transabdominal ultrasound. Biomedical Imaging and Intervention Journal, 6(4), e39. doi:10.2349/biij.6.4.e39 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097801/

Van de Putte P. and. Perlas A. June 3, 2014. Ultrasound assessment of gastric content and volume. British Journal of Anaesthesia. 10.1093/bja/aeu151

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