X-RAYSX-RAYS
By
Prof Dr IBRAHIM DAWOUD
Prof of Surgery
Mansoura University
PREFACE TO THE PREFACE TO THE SECOND EDITIONSECOND EDITION
This type of work has been prepared to meet the compelling needs of the under and postgraduate medical students.
To promote its accessibility this work is presented in 2 CDs, each one contains 6 chapters.
The 1st one includes (Barium Series in GIT–Portal Venography – Plain X-ray Abdomen and Biliary).
The 2nd one includes ( Vascular Surgery – Chest – Urology – Varieties and Orthopedic).
In fact no effort has been spared in trying to eliminate the difficulties encountered by medical students during their studies and training surgery.
Waiting hardly for your comments you can contact me at: E-mail [email protected] Tel 0123471715 -- 0502252882 Clinic:
المنصورة – ميدان الطميهى – عمارة الوقاف - الدور الثانى
How to read
Plain X-ray
Plain x-ray (describe the region).
View (PA, lat, oblique).
Position (erect, supine).
Quality.
Exposure.
Chest: Centralization, Bony frame work. Costophrenic angle, Soft tissue shadow.
Abdomen: well prepared or not, radio-opaque shadow, gas shadow.
Bone: Fracture, tumor, inflammation.
Soft tissue mammogram.
How to read X-RAY with dye
G.I.T. Upper GIT: Barium Swallow. Stomach: Barium meal, or Gastrographin meal. Duodenum: Hypotonic duodenography. Small intestine: Barium Follow through. Large intestine: Barium Enema. Sinus: Sinogram. Fistula: Fistulography.
How to read X-RAY with dye
Portal tract Percutaneous trans-splenic portography. Percutaneous transhepatic portography. Transfemoral splenic artery angiography. Transfemoral SMA angiography. Transfemoral IMA angiography. CT. US.
How to read
X-RAY with dye
Biliary Plain X-ray Rt hypochondrium. Oral cholecystography. I.V. Cholangiography. PTC (Percutaneous Transhepatic Cholangiography) ERCP. MRCP. T-Tube Cholangiography. Fistula: Fistulography.
How to read
X-RAY with dye
Urology UTP (Urinary Tract Plain). IVU (Intravenous Urography). MRU. Urethrography. Ascending Cystography. CT scan. US. Fistula: Fistulography.
How to read
X-RAY with dye
Vascular Plain X-Ray. Venography (Phlebography) Arteriography. DVI ( Digital Venous Image). DSA ( Digital Subtraction Angiography). CT scan. Duplex US. MRA.
Barium Swallow showing the esophagus in serial films.
It revealed mild dilatation of the esophagus
with multiple persistent filling defects in the lower third of the esophagus and/or longitudinal furrows.
Diagnosis most probably
Esophageal Varices.
BARIUM SWALOW
How to read
Etiology of esophageal varices. Anatomy of esophageal varices. Complications. What are the other Porto systemic collaterals?
- Hepatopetal collaterals - Hepatofugal collaterals Why EV is considered the most serious problem in
Porto systemic collaterals. Management:
(1) Clinical picture.
(2) Other investigations should be done.
(3) Treatment: - silent varices.
- Bleeding varices ---- Acute attack.
---- In between attacks.
Questions
The left gastric, short gastric, and terminal branches of the splenic vein provide the main venous drainage.
They are arranged into 4 layers with a series of perforating veins.
In Portal Hypertension they are all dilated with reversed or bidirectional blood flow.
Dilated intraepithelial and sub epithelial V may lead to varices on varices----» “Cherry red spot” or “Red wale”.
Grades of varices.
Anatomy of E.V.
SM
MP
Esophagus
XX
◄◄◄◄◄ Bl flow
Mliver
►►►►►--------------------------------------◄◄◄----------------
Esophagus
Bl flowBl flow
liver
----------------------------
Intraepith veinsSubepith veins
Varices on varices
VARICES
VARICES
M
It is present in the lower end of the chest, the bleeding is severe and may be fatal due to.
1- Negative intrathoracic pressure.
2- Shearing movement of the diaphragm.
3- Increased acidity and reflux.
4- Present in inaccessible area.
5- Chronic liver CF with coagulation defect. The amount and time of bleeding are not expected. The blood is digested by Hcl of the stomach, and
fermented by E coli with liberation of huge amount of ammonia liver – more liver failure
Brain -- Ammoniacal encephalopathy.
Why EV is considered the most serious problem
How to read Barium swallow It revealed that the barium-filled diverticulum
extends below the level of the cricopharyngeus posterior to the proximal cervical esophagus.
A large diverticulum may protrude to the left or compress the cervical esophagus.
Diagnosis most probably
Zenker's diverticulum
(posterior hypopharyngeal diverticulum)
Zenker's diverticulum (posterior hypopharyngeal diverticulum) is an acquired mucosal herniation through an area of anatomic weakness in the region of the cricopharyngeus muscle (Killian's dehiscence).
This area of anatomic weakness has been variably described as between the thyropharyngeus and cricopharyngeus muscles or between the oblique and
horizontal fibers of the cricopharyngeus. Patients complain of coughing following swallowing,
food regurgitation, or halitosis. Many patients with have an associated hiatal hernia and/or gastroesophageal reflux.
Rarely, these diverticula are complicated by ulceration or malignancy.
During swallowing, a Zenker's diverticulum appears as a posterior bulging of the distal pharyngeal wall above an anteriorly protruding cricopharyngeus.
At rest, the barium-filled diverticulum extends below the level of the cricopharyngeus posterior to the proximal cervical esophagus.
A large diverticulum may protrude to the left or compress the cervical esophagus.
Treatment: ?
How to read
Barium swallow showing dilatation of the esophageal body.
With short segment stricture. A “bird-beak” like tapering of the esophagus at the GE
junction. OR A Sigmoid “ Mega esophagus” Absence of air-bubble in the fundus of the stomach. Diagnosis most probably Achalasia of the esophagus.
Questions
Describe the pathology.Describe the pathology. -Absence of peristaltic contractions within the
esophageal body & incomplete relaxation of the HPZ.
-The cause of neuropathy and the site of the primary lesion still unknown.
- It is due to damage to the parasympath. Innervations of the esophagus. Also impairment of the non-adrenergic non-cholinergic N.F. of the LES.
-Anatomical lesions in the brain stem “ reduction in No and abnormalities of the cells of the DMN of the vagus”.
- Also in Auerbach´s intramural plexus.
- Complications: *Inhalation pneumonia *Toxic RH. A.
*Starvation *Perforation *Diverticulae *Carcinoma
Management
Clinical picture. Other Investigations:
* Chest X-ay. * Endoscopy and biopsy.
* Manometry. * Radionuclide esoph transit study. Treatment:
- Medical– long acting nitrites or Ca channel blockers.
- Frequent dilatation.
- Surgery:
* Heller's esophago-cardiomyotomy.
* Esophagogastrectomy.
Barium swallow shows irregular areas of narrowing and dilatation ----- “Shish kebab” “corkscrew” “rosary bead” esophagus.
The esophageal muscle is hypertrophied, but histologically normal.
Treatment:
- Medical– long acting nitrites or Ca channel blockers.
- Frequent dilatation.
- Long esophageal myotomies.
What are other types of myotomies in GIT?
Diffuse esophageal spasm
Barium swallow shows mild dilatation of the esophagus with irregular stenotic lesion in the lower end of the esophagus “moth eaten appearance”
With shouldering. The stenotic segment is long giving a
“rat-tail” appearance. Diagnosis most probably
Cancer esophagus
Cancer esophagus
Questions
How to DD between Achalasia and Cancer esophagus?. Pathology of Cancer esophagus . What is “ Barrett's esophagus” Diagnosis of cancer esophagus.
Treatment.
ACHALASIA CANCER ESOPHAGUS
Middle aged female Old aged male
Long history of dysphagia Short history
Dysphagia more to fluids Dysphagia more to solids
Dysphagia is intermittent Dysphagia is progressive
No Gas bubble in stomach Presence of Gas bubble
Barium- moderate to huge dilatation, with smooth short segment stricture
Barium- mild dilatation, with irregular long segment stricture, and shouldering
Endoscopy as you enter a cave
difficult to pass the stricture
Pathology: absent or degenerated N plexus
Pathology: Malignant cells
Pathology
N/E: Polypoid (fungating) mass- Stenotic – Ulcerative. M/E: Sq CC- Adenocarcinoma- Sarcoma . TNM:
-Tx: can not be assessed. * Nx: can not be assessed.
-T0: no evidence of 1ry . * No: no nodal involvement.
-Tis: In situ. * N1: Regional LN involved.
-T1: Submucosa.
-T2: Muscularis propria. * Mx: can not be assessed
-T3: Adventitia. * M0: no evidence
-T4: Adjacent structures * M1: Presence of metasta Spread
Barrett's Esophagus
Columnar cell metaplasia >3cm in the distal tub esoph 3 types ( intestinal- junctional- fundic) . It is common in pts with GERD and peptic stricture of
the esophagus. I t is considered as a premalignant. Treatment. Regular follow up by endoscopy and
histopathology. Low grade dysplasia: continue medical ttt and follow
up High grade dysplasia: treated as carcinoma in situ.
Treatment
Cervicalesophagus
Sup mediastinum
Middle and lower third
Cardia
Pharyngolaryngoesophagectomy.
Split sternum esophagectomy
Lewis-tanner operation
Transhiatal esophagectomy
Free jejunal transfer
Three phase esophagectomy
Transhiatal esophagectomy
Esophagogastrectomy
Three phase esophagectomy
Abdominal Gastrectomy
Bypass Kischner gastric bypass
Colon bypass Jejunum bypass
NormalBarium in Trendlenberg position
*Barium meal in Trendlenberg position.
*Displacement of the cardio-esophageal junction above the esophageal hiatus.
*Part oh the stomach is present in the chest.
*Reflux of barium into the esophagus.• Diagnosis:
Type I ( Axial – Sliding ) Hiatal Hernia
With Reflux esophagitis
( GERD)
(Gastroesophageal Reflux Disease)
Questions
Types of H.H. Pathology of Reflux Esophagitis. Complications of GERD. What is “ Barrett's esophagus” Diagnosis. Treatment.
Pathology The normal PH of the lower esophagus is 5 - 6.5. With GERD PH falls below 4 with direct chemical
damage to epithelium. Also pepsin, trypsin, bile salts, and lysolecithin. Inflammatory cells appear in the epithelium. The total epithelial thickness is reduced. Ulceration – which is healed by fibrosis
or -- Columnar cell metaplasia Complications: - Chronic blood loss
- Deep ulceration with periesophagitis
- Formation of stricture and web
- Columnar cell changes
Clinical Picture Symptom Grade Description
Heartburn
None 0 No heart burn
Minimal 1 Occasional episode
Moderate 2 Reason for medical ttt
Severe 3 Interfere with activity
Regurgitation
None 0 No regurgitation
Minimal 1 Occasional episode
Moderate 2 On position or straining
Severe 3 Asp pneum., Noct cough
Dysphagia
None 0 No dysphagia
Minimal 1 Occasional episode
Moderate 2 Require fluid to clear
Severe 3 Require medical ttt
InvestigationsCategory Test Indications
RadiologicalChest X-ray Aspiration pneumonia, perforation
Barium Dysphagia, perforation, motility disorder
Cine radiology Motility disorder, reflux disease
CT Staging of malignant disease
US External Diaphragmatic screening
Endoscopic Staging of malignant disease
Isotope Liquid or solid T³³ for esoph transit and reflux
Endoscopy All esophageal pathology
PhysiologicalManometry Motility disorder and GERD
Bernstein test Esophageal sensitivity to acid
Acid reflux test Reflux disease
24 hr PH monit Reflux disease
TREATMENTUncomplicated Disease Wt reduction and stop smoking and alcohol. Avoid tight closes. Frequent small meals. The last meal is 3 hrs before sleep. Antacids 1 hr after meal and at bed time. The pt is advised to sleep on several pillows with
elevation of foot of the bed.
Indications of Surgery:
- Failure of medical ttt
- Presence of mechanically defective LES
- Development of complications
- Pts with neutral or alkaline reflux
TREATMENT* Nissen Fundoplication: Laparoscopic approach. Transabdominal. Transthoracic.
* Belsey Mark IV Partial Fundoplication:
* Hill Gastropexy
* Angle chick Prosthesis
Complicated Cases
- Acquired short esophagus--- Collis Gastroplasty
- Benign stricture--- Fundic patch
- Barrett esophagus--- follow up
---- as in situ carcinoma
Laparoscopic repair of H.H.
CORROSIVE ESOPHAGEAL STRICTURE
CORROSIVE ESOPHAGEAL STRICTURE
*Barium meal of an infant.
*Dilatation of the stomach.
*Double-track appearance( enfolding of the mucosa into the pyloric canal.
*String sign. (convex narrow elongated pyloric canal.
*Mushroom effect of the pyloric mass indenting the duodenal cap.
*Diagnosis most probably
“Infantile Hypertrophic Pyloric Stenosis”
Questions Pathology (incidence, Etiology. NE, MP, Complications). Clinical picture. D.D.
1- Pylorospasm
2-Gastroenteritis
3- GERD
4- Increased ICT
5-Infection (pneumonia, meningitis) Treatment.
1- Medical
2- Surgical: Ramstedt´s pyloromytomy
Types Hernia through foramen of Bochdalek.
(Persistence of the pleuroperitoneal canal) Hernia through foramen of Morgagni or Magendie.
(Parasternal through a triangular defect lateral to the sternum)
Herniation through the central tendon. Congenital H.H. Congenital short esophagus. Eventration of the diaphragm Traumatic diaph H
*Barium meal and follow-through.
*Showing pylorus, pylorodudenal junction, duodenal cap, and 1st, 2nd,and 3rd parts of the duodenum in serial films.
*Persistent ulcer niche in the 1st part of the duodenum.
*The niche appeared as a barium-filled crater at the upper border of the duodenum.
*Persistent deformity of the duodenal cap.
*in end-on view “Trefoil Deformity”
*Diagnosis most probably
“Chronic Duodenal Ulcer”
Questions How to DD bet Chr gastric ulcers and Chr DU. Pathology of DU. Clinical picture:
(Quality- Radiation- Rhythmicity- Periodicity). Investigations
1- Laboratory.
2- Endoscopy
3- Gastric FT ( FTM – Basal secretion – Maximum sec. )
4- Serum Gastrin Treatment.
1- Medical .
2- Surgical.
3- Treatment of complications.
Gastric Ulcer Duodenal Ulcer Age Older Younger
Sex Equal Male : female 10:1
Bl Gp - ve O
Family H +ve +ve
Constitution Careless Hyperactive
Acidity Normo or Hypo Hyperacididty
Motility Hypomotility Hypermotility
Etiology ▼mucosal resistance
▲parietal cell mass
▲vagal tone
▼regen power of G mucosa
Endocrine dysfunction
Liver cirrhosis
Gastric Ulcer Duodenal Ulcer
Pain Soon after eatingNot on lying down
2 hrs after eating Hunger & night pain
Vomiting Considerable No vomiting
Periodicity Present Well marked
Appetite Afraid to eat Good
Weight Weight loss No loss of weight
Hemorrhage Hematemesis more Melena more
Medical:
1- Diet:
2- Drugs{1} Antacids {2} Anticholenergic drugs
{3} Sucralfate {4} Bismuth compounds
{5} H2 receptor blockers {6} Proton-pump inhibitors
3-Mnagement of Acute exacerbations{1} Hospitalization {2} Ryle tube
{3} Sedation {4} Anticholenergic
{5} H2 receptor blockers {6} Proton-pump inhibitors
Treatment
Surgical:{1} Vagotomy with or without drainage
{2} Subtotal Gastrectomy
Treatment of Complications:{1} Bleeding
{2} Perforation
[a] acute perforation.
[b] subacute perforation
{3} Pyloric obstruction
{4} Recurrent ulceration:
[a] Incomplete vagotomy [b] Z-E syndrome
[c] Retained gastric antrum [d] Hypercalcemia
[e] Inadequate resection
Vagotomy:[a] Trunkal vagotomy------------------- need drainage procedure
[b] Selective vagotomy----------------- need drainage procedure
[c] Super selective----------------------- no
[e] Tailor operation---------------------- no
Drainage:
{1} pyloroplasty
{2} Gastrojejunostomy
{3} Antrectomy [a] Billroth I------------------ Gastro-duodenostomy
[b] Billroth II ---------------- Gastro jejunostomy
Subtotal Gastrectomy: [a] Billroth I-------------- Gastro-duodenostomy
[b] Billroth II ------------ Gastro jejunostomy (side to side)
[c] Polya ---------------- “ “ (end to side )
[d] Hofmeister---------- “ “ (end to side ) with valve
PYLOROPLASTY
Gastrojejunostomy
Gastrojejunostomy
*Barium meal.
*Showing the stomach is mildly dilated with obstruction of its outlet.
*A large ulcer is present in the lesser curve.
*The ulcer lies inside the wall of the stomach.
*Associated with a notch on the greater curvature .
*Diagnosis most probably
“Malignant Gastric Ulcer”
Questions How to DD radiologically bet benign and malignant
gastric ulcers. Pathology. Clinical picture. Investigations. Treatment.
1- Operable.
2- Inoperable
Benign Vs Malignant Ulcer Benign Ulcer Malignant Ulcer
No Single or Multiple Usually single
Site Ulcer-bearing area Outside ulcer-bearing area
Size Less than 1 inch More than 1 Inch
Shape Regular,rounded,oval Irregular
Edge Sharp Everted (Carmen's Meniscus s)
Base Lies outside the wall(Ulcer niche)
Lies inside the wall(Polypoid or ulcerative mass)
Margin Radiating mucosal folds (fibrosis)
Rigidity of the gastric wall around ulcer (infiltration)
Ass ulcer notch G C no
duodenal deformity no
Chr DU
Malignant ulcer
TNM Staging T1- limited to the mucosa and submucosa T2- The muscularis or subserosa. T3- Tumor penetrates the serosa. T4- Contiguous structures.
N0- No metastasis. N1- Perigastric LN ≤ 3cm of the tumor N2- Perigastric LN ≥ 3cm of the tumor including Gastric,
Common hepatic, splenic, and celiac
Mo- No metastasis M1- Distant metastases
*Barium meal.
*Showing the stomach is hugely dilated with obstruction of its outlet.
“soup-plate” - “Tea-pot” - “Hour-glass” stomach
*The stomach is mostly located in the pelvis.
*A fluid level is present.
*Delayed emptying of the stomach.
*Deformity of the duodenum .
*Diagnosis most probably
“Gastric outlet obstruction”
Claw-shape sign.
Spring-coil sign.
Egg-on-cake sign
Egg-on-cake sign
Barium Enema showing the Rectum, sigmoid colon descending colon, and part of the transverse colon.
It revealed abrupt stoppage of dye at the transverse colon with a filling defect
Giving Claw-shape sign.
Spring-coil sign.
Egg-on-cake sign.
Diagnosis most probably
INTUSSUSCEPTION.
BARIUM ENEMA
How to read
Definition.
Invagination of one loop of the gut into the other Pathogenesis
Partial obstruction initiates hyper peristaltic activity of the proximal segment, so that instead of pushing the obstructing agent it pushes the wall of the gut itself invaginating one loop into the other.
Pathology.
3 layers (entering- returning- ensheathing) Types.
5 types *ileo-ileal *ileo-caecal
*ileo-colic *ileo-ileo-caecal
*colo-colic
Questions
Clinical types. 1- Infantile type (always acute) 2- Adult type ( acute – chronic) Clinical picture. Other Investigations. DD. Acute entero-colitis - Henoch purpura Rectal prolapse Treatment: Resuscitation Ryle tube Removal of obstruction
Barium Enema showing the Rectum, sigmoid colon, and part of the transverse colon.
It revealed Multiple, smooth, regular, rounded filling defects localized to the rectum and sigmoid colon
Diagnosis most probably
BILHARZIAL POLYPOSIS
BARIUM ENEMA
How to read
Pathology.
1- Etiology: Common in Egypt, caused by S Mansoni.
2- Site: Heaviest affection in the sigmoid and rectum.
3- Pathological types
{a} Submucous type.
{b} Diffuse type.
4- Pathogenesis.
5- Complications:
Hge, anemia, rectal prolapse Clinical Picture. D.D. Investigations. Treatment.
Questions
Barium Enema showing the Rectum, sigmoid colon, descending colon and part of the transverse colon.
It revealed Multiple, smooth, regular, rounded filling defects localized to the rectum and sigmoid colon
Giving ( Honey-comb appearance)
Diagnosis most probably
VILLOUS ADENOMA
BARIUM ENEMA
How to read
Pathology:
Also called PAPILLARY ADENOMA
1- Age: above 45y
2- Site: rectum and sigmoid
3- N/E: sessile bulky soft mass with smooth or velvety surface and numerous frond-like projections.
4- MP: Core of CT covered with a single layer of columnar epithelium.
5- the tumor is a precursor of papilliferous carcinoma
Questions:
Clinical picture Discharge of blood and mucous from the rectum Feeling of incomplete evacuation Mucous diarrhea with K loss and Ms weakness Diagnosis Sigmoidscopy and biopsy Treatment Low anterior resection for tumors > 7 cm Abdominoperineal resection for tumors < 7 cm,
and proved to be malignant. Complete local excision for other sites
Questions:
Barium Enema showing the Rectum, sigmoid colon, descending colon and part of the transverse colon.
It revealed Multiple, smooth, regular, rounded filling defects
With Large irregular mass at the rectosigmoid with
shouldering and moth-eaten appearance
Diagnosis most probably
VILLOUS ADENOMA with Cancer Rectosigmoid
BARIUM ENEMA
How to read
TRUE POLYPS:
(1) Juvenile polyps: It is a hamartomatous polyp It occurs in children, usually single In the rectum, never turn malignant Spontaneous auto amputation
(2) Villous Adenoma:
(3) Adenomatous polyp: The commonest tumor The polyps are pedunculated, firm tumors, with
irregular surface, rarely turn malignant. Bleeding per rectum, anemia, prolapse. Treatment by Endoscopic polypectomy
Types of colonic polyposis
(4) Familial Polyposis: It is a hereditary disease transmitted from both sexes
to both sexes. Large No of polyps in the colon and rectum before
puberty, that turn malignant before 40 y. They may be sessile or pedunculated. Pain, diarrhea, tenesmus, blood and mucous in stool. Treatment by total or subtotal colectomy, or
abdominoperineal for malignant tumors.
(5) Syndromes. Gardner syndrome Cronkhite- Canada syndrome. FALSE POLYPS:
Hyperplastic epithelium ( Bilharzial – Ulcerative colitis – at the edge of TB ulcer, and dysenteric ulcer
Barium Enema showing the Anal canal, Rectum, Sigmoid colon, Descending colon.
Marked dilatation of the colon, with the presence of funnel shaped segment below it, and spastic collapsed segment extending distally to the anorectal region.
Diagnosis: Most probably HIRCHSPRUNG DISEASE
- The dilated segment --- (Megacolon) - The funnel segment ---- ( Transition zone) - The stenosed segment– ( Spastic segment)
How to read
Pathology: Etiology N/E: MP: Complications: Clinical picture: Investigations: ---- Biopsy Treatment:
1. Swenson's
2. Soave's
3. Duhamel´s
4. Lynn´s
Questions
Barium Enema showing the Anal canal, and Rectum.
It revealed abrupt stoppage of dye at the upper end of the rectum with narrowing, with characteristic
“Twisted bird's peak” OR “Ace of Spade” Sign
DIAGNOSIS
Volvulous of the Sigmoid
How to read
Plain X-ray abdomen. It revealed marked dilatation of the sigmoid colon occupying the greater part of the abdomen, and
displacing the diaphragm. Giving the characteristic sign Omega- shape sign
Diagnosis most probably
Volvulous of the Sigmoid
How to read
Etiology: Chr. Constipation Abnormal elongation of pelvic
mesocolon. Hyperperistaltic activity twist Pathology: The upper loop falls in front of the lower loop, and the
twist occurs in Anticlock-wise direction. The veins are compressed congestion. Lib. of huge amount of Co2 & N2 severe distention. Gangrene, perforation, with fatal peritonitis. Clinical picture:
of Acute Intestinal Obstruction
Questions
Investigations: Treatment Resuscitation Ryle Removal of obstruction
{A} Proctoscopic decompression
With the pt in Knee-elbow position
Sigmoidopexy after few days
{B} Immediate laparotomy
(1) Manual Untwist if the loop is viable
( In a CLOCK-WISE direction )
(2) Resection by the Paul Mikulicz method
or Hartmann procedure
Barium enema showing the rectum, sigmoid colon, descending colon, transverse colon, and part of the ascending colon.
It revealed a large irregular filling defect, with destruction of the wall (moth-eaten appearance).
Failure of passage of the dye proximal to the mass
Diagnosis most probably
Cancer Ascending Colon
How to read
Barium enema showing the rectum, sigmoid colon, descending colon, and part of the transverse colon.
It revealed an irregular filling defect, with stricture and shouldering (Apple- core appearance).
Failure of passage of the dye proximal o the mass (in the last film) Diagnosis most probably
Cancer Transverse Colon
How to read
Barium enema showing the rectum, sigmoid colon, descending colon, transverse colon, and descending colon.
It revealed an irregular stricture at the lower end of the descending colon (Moth- eaten appearance).
Diagnosis most probably
Cancer Descending Colon
How to read
Barium enema showing the rectum, sigmoid colon, and part of the descending colon.
It revealed an irregular filling defect, with stricture and shouldering (Apple- core appearance).
Diagnosis most probably
Cancer Rectosigmoid Colon
How to read
Pathology(1) Etiology
(2) Incidence------------------------------------>
(3) N/E:
* Polypoidal (Cauliflower) mass
* Stenotic schirrus
* Malignant ulcer
(4) MP
* Adenocarcinoma * Spheroidal CC * Colloid carcinoma
(5) Spread
* Intramural * Direct * Lymphatic
* Blood * Transperit spread * Local implantation
(6) Complications
* Bleeding * Perforation * Fistula
* Intussusception * Acute Int Obst
Questions
Clinical picture Investigations Treatment {A} Without Int Obst Operable1. Caecum Rt hemicolectomy2. Hepatic Flexure Extended Rt hemicolectomy3. Transverse colon Transverse colectomy4. Descending colon Lt hemicolectomy5. Splenic Flexure Extended Lt Hemicolectomy6. Sigmoid colon Pelvic colectomy Inoperable1. Palliative resection2. Palliative Bypass
{B} With Int Obst Resectable(1) One Stage operation * Tumors of the Rt side Rt hemicolectomy * Tumors of the Lt side Lt hemicolectomy, with 1ry
resection anastomosis after on table lavage(2) Two Stages Operations * Tumors on the Rt side Ileotransverse colostomy,
then after 2 weeks Rt hemicolectomy * Lt side Proximal colostomy then 2 w resection Immediate resection with terminal colostomy(3) Three stages operation Unresectable Ileotransverse anastomosis Palliative transverse or pelvic colostomy
Barium enema showing the rectum, sigmoid colon, descending colon, transverse colon, and descending colon.
It revealed an irregular stricture at the rectum (Moth- eaten appearance).
Diagnosis most probably
Cancer Rectum
How to read
Pathology(1) Etiology
(2) Incidence– upper 1/3 (35%) middle 1/3 (30%) lower 1/3 (35%)
(3) N/E:
* Malignant ulcer (commonest)
* Polypoidal (Cauliflower) mass
* Annular (Stenotic) lesion at the rectosigmoid
(4) MP
* Adenocarcinoma * Spheroidal CC * Colloid carcinoma
(5) Spread
* Intramural * Direct * Lymphatic
* Blood * Transperit spread * Local implantation
(6) Complications
* Bleeding * 2ry piles * Fistula
* Acute or chr int obst * Toxemia and cachexia
Questions
(7) Staging
Duke's classification(A) The tumor limited to the rectal wall
(B) Extrarectal tissue but no LN
(C) Regional LN involved {C1} Pararectal LN alone {C2} Central LN
(D) Distant metastases
TNMT0: no tumor Nx: can not be assessed
Tx: can not be assessed No: not involved
Tis: In situ carcinoma N1: involved
T1: Confined to mucosa
T2: Musculosa or serosa
T3: Adjacent structures with no fistula Mx: not assessed
T4: Fistula with any of the above Mo: no known metastases
T5: Direct extension to other M1: Distant metastases
organs or structures
Clinical picture Investigations Treatment
{A} Without Int Obst
Operable
(1) Radical resection with colostomy
[a] Abdomino-perineal [b] Perineo-abdominal
[c] Combined [d] Abdominal
[e] perineal [f] pelvic exentration
(2) Radical resection without colostomy
[a] Sphincter-saving operation
* For tumors 10 cm above the anus
* Excision with 5 cm safety margin with end to end anastomosis either manual or by stapler
[b] Rectum-saving operation1. Early growth situated in the lower 10 cm.
2. Polypoidal or sessile growth, mobile
3. Well differentiated
4. No LN
Local excision Electrocoagulation Endocavitary contact irradiation
Inoperable Palliative resection Radiotherapy Chemotherapy
{B} With Int Obst
Proximal loop colostomy in the transverse colon then treat acc whether operable or inoperable
Barium enema showing sigmoid colon, descending colon, and transverse colon.
It revealed that most of the colon is present in the chest cavity
Diagnosis most probably
Eventration of the Diaphragm
How to read
Barium enema showing the rectum, sigmoid colon, descending colon, transverse colon, and descending colon.
It revealed a narrowed sigmoid colon, with multiple globular shadows in relation to the colon with serrations of the bowel wall
(saw-teeth appearance).
Diagnosis most probably
DIVERTICULOSIS COLI
How to read
Definition Acquired herniations of colonic mucosa (pulsion Diverticulae), through the
circular Ms at the points of Bl V enter.
Pathology1. Incidence
2. Etiology
3. Pathogenesis
Management
1. Diverticulosis Coli
2. Diverticulitis
3. Perforation
4. Fistula
5. Obstruction
6. Bleeding
Questions
Barium enema showing the rectum, sigmoid colon, descending colon, transverse colon, and ascending colon.
It revealed a narrow contracted short colon with loss of haustrations
(pipe- stem appearance).
Diagnosis most probably
ULCERATIVE COLITIS
How to read
DefinitionNon-specific ulceration of mucosa and submuc of rectum and colon.
Etiology*Infection *Autoimmune * Allergic *Genetic *Emotional stress.
Pathology*Starts in the rectum and spreads proximally.
*Abscess in the crypts burst to form small ulcers coalesce to form large ulcer
*The ulcers reflex Ms spasm intramural fibrosis.
*The colon is reduced in length and the m.m. bet ulcers hyperplasic Pseudopolyps.
Complications*Local ( toxic megacolon– hge– stricture– abscess– fistula- carcinoma)
*Systemic ( skin- eye- liver- kidney- Joints- DVT )
Questions
Clinical Picture1. Acute fulminant type
2. Chronic intermittent type
3. Chronic continuous type
Investigations Treatment{1} Medical treatment {2} Surgical treatment Antidiarrheal agent 1. One stage procto-colectomy with Intestinal antiseptic terminal ileostomy Corticosteroids 2. Total procto-colectomy with Supportive therapy ileo-anal pouch Dieting 3. Ileostomy alone in emergency Immunosuppressive 4. Total colectomy with ileo-rectal
anastomosis
Inflammatory Bowel Diseases(1) Regional Enteritis (Crohn´s disease).
(2) Ulcerative colitis.
(3) TB of the intestine ( ulcerative type – hyperplastic TB).
(4) Bilharziasis of the colon.
(5) Ileo-caecal actinomycosis.
Surgical complications of Typhoid Fever:(1) Paralytic ileus.
(2) Intestinal he (at the 3rd week).
(3) Perforation ( at the 3rd week) – ulcers in antimesenteric border- mortality 30% - fistula may develop )
(4) Cholecystitis.
(5) Phelebitis ( esp. lt common iliac V ).
(6) Genito-urinary complications.
(7) Joints : arthritis
(8) Bone : osteomyelitis & typhoid spine.
Plain X-ray chest, abdomen & pelvis of an infant, with the patient upside down, and a coin inserted at the anal dimple.
The gas shadow is distal to the level of Ano-coccegeal line (level of pelvic floor Ms- levator ani).
Diagnosis
Low imperforate Anus
How to read
Plain X-ray chest, abdomen & pelvis of an infant, with the patient upside down, and a coin inserted at the anal dimple.
The gas shadow is proximal to the level of Ano-coccegeal line (level of pelvic floor Ms- levator ani).
Diagnosis
High imperforate Anus
How to read
Plain X-ray abdomen & pelvis of an infant, with the patient upside down, and a metal rod is inserted at the anal canal.
The metal rod ends at the level of Ano-coccegeal line and the gas shadow is proximal to the level of Ano-coccegeal line (level of pelvic floor Ms- levator ani).
With no communication between the gas shadow and the metal rod
Diagnosis
High imperforate Anus ( RECTAL ATRESIA)
How to read
Types: Low anomalies High anomalies
1. Covered anus 1. Ano-rectal agenesis
2. Membranous anus 2. Rectal atresia
3. Stenosed anus 3. Cloaca
4. Ectopic anus
Embryology DD of Neonatal Intestinal Obstruction Treatment
Questions
CLOACA
Gastric:Gastric: 1-Pyloric atresia 2. Antral web
DuodenalDuodenal 1- Atresia 2. Malrotation 3- Annular pancreas 4- Anterior portal vein
Small bowelSmall bowel Structural (1) Atresia (2) Internal hernia
(3) Duplication cyst (4) Vitelline duct remnant Mechanical Meconium ileus Acquired (1) Sepsis (2) Necrotizing enterocolitis
ColonicColonic 1- colonic Atresia 2 - Anorectal atresia
3- Hirchsprung disease 4- Meconium blug
Neonatal Intestinal Obstruction
Plain X-ray abdomen & pelvis Postero-anterior view Erect position It revealed multiple air-fluid levels arranged in Step-ladder pattern
Diagnosis most probably
Acute Intestinal Obstruction
How to read
Vulvulae Conneventes
Vulvulae Conneventes
Plain X-ray abdomen & pelvis Postero-anterior view Supine position It revealed dilated intestinal loop
with a characteristic
Vulvulae Conneventes
Diagnosis most probably
Acute Intestinal Obstruction
(Jejunal Obstruction)
How to read
Plain X-ray abdomen & pelvis Postero-anterior view Supine position It revealed dilated intestinal loop with a characterless pattern No Vulvulae Conneventes No Haustrations Diagnosis most probably
Acute Intestinal Obstruction
(Ileal Obstruction)
How to read
Plain X-ray abdomen & pelvis Postero-anterior view Supine position It revealed hugely dilated intestinal loop with a characteristic Haustrations (Sacculations)
Diagnosis most probably
Acute Intestinal Obstruction
(Colonic Obstruction)
How to read
Definition Failure of intestinal contents to progress
Types
Pathology
(1) Proximal segment
* Hyperperistaltic phase * Antiperistaltic phase
* Stage of dilatation
(2) Distal segment Pathophysiology
* Source of fluid * source of air
Questions
Dynamic Adynamic Simple occlusion Pure strangulation
Occlusion with strangulation Paralytic ileus
Clinical picture Investigations Treatment
R R R (Resuscitation) (Ryle tube) (Removal of obstruction)
Mesenteric Vascular Occlusion Etiology * Arterial embolism * Arterial thrombus * Venous thrombus
Investigations* Leucocytosis * ▲serum amylase * distension of small & large int* Paracentesis serosanguinous fluid
Treatment * Viable Gut * Non-viable Gut
Paralytic Ileus Etiology * Reflex symp ↑↑: after op or trauma * Toxic↓↓ in peritonitis
* Anoxic ↓↓: prolonged distension * Biochemical ↓↓: hypokalemia
Clinical picture Investigations• Enema is retained • Air-fluid level
TreatmentTreatment of the primary cause(1) IV fluids(2) Ryle(3) Intestinal stimulants(4) Frequent enemas
Plain X-ray abdomen & pelvis Postero-anterior view Erect position It revealed Air under both copulae of the
diaphragm
for
Differential Diagnosis
How to read
Physiological after abdominal operations or laparoscopy. After utero-tubal insufflations. Penetrating stab wound abdomen Closed abdominal trauma with rupture gut Perforated viscous
{1} Perforated peptic ulcer (gastric- duodenal- Meckel).
{2} Perforated typhoid ulcer.
{3} Perforated diverticulum.
{4} Iatrogenic perforation.
{5} Perforated malignant ulcer Subphrenic abscess with air-forming organisms. Old method (pneumoperitoneum) for treatment of TB.
How to read X-RAY with dye
Portal tract Percutaneous trans-splenic portography. Percutaneous transhepatic portography. Transfemoral splenic artery angiography. Transfemoral SMA angiography. Transfemoral IMA angiography. CT. US.
Percutaneous Trans-splenic Portal Venography. It revealed Splenic sinusoids Splenic vein. Portal vein with its 2ry and 3ry branches Inferior mesenteric vein.
Diagnosis most probably
Portal Hypertension Grade I
How to read
Grades of Portal Hypertension.* Grade O:
Good perfusion, with visualization of the portal vein, and its all branches up to fine arborization, with no collaterals
* Grade I:
Fair perfusion, with visualization of the portal vein up to 3ry branches
* Grade II:
Poor perfusion with visualization of the portal vein up to 2ry branches, with collaterals.
* Grade III:
Poor visualization, only the portal vein, Rt & Lt branches.
* Grade IV:
Non visualization of the portal vein, with hepatofugal circ
Value of portography1. It reveals the site of obstruction in the portal tree.
2. It reveals the dilated collaterals.
3. It reveals the suitable vein for shunt operation.
4. It reveals direction of blood flow (Hepatopetal – Fugal).
5. We can estimate the portal pressure at the same time.
6. We can estimate the portal flow (Grades).
7. Postoperative for patency of the shunt.
Methods:
Direct
*PT splenic *PT hepatic *Umb v *Operative
*Postop (after portocaval shunt through femo V)
Indirect * Arterial portography *DVI
Indirect Portal Venography. Arterial Portography (Through the splenic artery ) It revealed Splenic sinusoids Splenic vein. Portal vein with its branches up to fine arborization Absence of collaterals. Diagnosis most probably
Normal Portal Venography
How to read
Indirect Portal Venography. Arterial Portography (Through the splenic artery
and SMA) It revealed Splenic sinusoids Splenic vein. Portal vein with its branches up to 3ry branches presence of collaterals. Diagnosis most probably
G I Portal Hypertension
How to read
Indirect Portal Venography. Arterial Portography (Through the splenic artery
and SMA) It revealed Splenic sinusoids Splenic vein. Portal vein with its branches up to 2ry branches presence of collaterals. Diagnosis most probably
G II Portal Hypertension
How to read
Indirect Portal Venography. Arterial Portography (Through the splenic artery
and SMA) It revealed Splenic sinusoids Splenic vein. Portal vein with its Rt & Lt branches presence of many collaterals. Diagnosis most probably
G III Portal Hypertension
How to read
Indirect Portal Venography. Arterial Portography (Through the splenic artery
and SMA) It revealed No vein from the hepatic circulation All the blood is directed away from the liver.
( Hepato-fugal circulation) Diagnosis most probably
G IV Portal Hypertension
How to read
Definition of portal hypertension Etiology Pathology of Portal Hypertension
*Liver *Spleen
*Congestive gastroenteropathy
*Development of Collaterals
*Ascites
Complications of PH. Clinical picture Investigations
Child (Pough) classification
Treatment
Questions
Hepatic Angiography. Through Percutaneous Transfemoral catheter It revealed * Irregular tortuous arteries feeding the tumor (Tumor Blush & Tumor Encasement). * A large No of new vessels around the tumor (neovascularization) ( thread and streaks sign) * Tumor staining in the venous phase Diagnosis most probably
Hepatocellular Carcinoma
How to read
Indirect Portal Venography. Through the splenic artery and SMA It revealed No vein from the hepatic circulation All the blood is directed away from the liver.
( Hepato-fugal circulation) Diagnosis most probably
Obstructed Shunt
How to read
How to read
X-RAY with dye
Biliary Plain X-ray Rt hypochondrium. Oral cholecystography. I.V. Cholangiography. PTC (Percutaneous Transhepatic Cholangiography) ERCP. MRCP. T-Tube Cholangiography. Fistula: Fistulography.
Plain X-ray abdomen ( Rt hypochondrium). The patient is more or less well prepared. It revealed * A radio-opaque shadow (s) in the rt hypochondrium. * A rim of translucency (in the 1st film) (Signet ring). * Dilated ileal loop near to the GB (Sentinel loop). * Colon filled with gas near to GB ( Colon Cut-off sign). * Calcification of the GB wall (6th film) (Porcelain GB) Diagnosis
Radio-opaque Shadow in the Rt hypochondrium for DD most probably
Gall Stone (s) with Chronic calcular cholecystitis
How to read
DD of radio-opaque shadow {1} Gall stone ------- Shape of the stone
------ In lat view in front of the spine
{2} Renal stone ------ Cholecystography or IVU
{3} Calcified LN
{4} Fecolith or FB in the small intestine
{5} Phlebolith
{6} Atherosclerotic renal artery
{7} Hydatid cyst in the liver
{8} Calcified TB kidney or suprarenal gland
{9} Calcified costal cartilage
{10} Fracture transverse process of lumbar vertebra
Questions
Mercedes Benz
Mercedes Benz
Mercedes Benz
Mercedes Benz
Emphysematous GB
Value of plain X-ray in GB diseases{1} It may reveal radio-opaque shadow in 15%
shape of the stone ( faceted – signet-ring)
{2} It may reveal Gas-containing fissures within the stone (Mercedes Benz –sea-gull sign)
{3} Calcification of the wall of the GB (Porcelain GB)
{4} GB may contain bile with high concentration of Ca CO3 (Limey GB)
{5} GB may contain gas (Emphysematous GB)
{6} Dilated ileal loop (sentinel loop)
{7} Colon filled with gas (Colon cut-off sign)
{8} Soft tissue shadow in the Rt hypochondrium (omentum)
{9} Exclude other conditions ( Perforated DU )
Questions
Oral cholecystography It revealed * The dye is well concentrated by the GB. * Normal size and shape of the GB. * No filling defect or effect. * The GB is well contracted after fatty meal. * No other signs of chr inflammation Diagnosis
Normal oral Cholecystography
How to read
Oral cholecystography It revealed * The dye is well concentrated by the GB. * The shape of the GB is distorted.Diagnosis Pharygian Cap
Q: Other anomalies in the Biliary tree
How to read
Oral cholecystography It revealed * Faint concentration of the dye. * Non visualization of the GB (obstructed). * filling effect. * The GB is not contracted after fatty meal. * Other signs of chr inflammation Diagnosis
Chr Calcular Cholecystitis Porcelain GB , Obstructed by a stone in the neck
Q: Causes of non visualized GB
How to read
Oral cholecystography It revealed * Faint concentration of the dye. * filling defect. * The GB is not contracted after fatty meal. * Other signs of chr inflammation Diagnosis
Chr Calcular Cholecystitis ? Cholesterol stone
How to read
Types of Chronic Cholecystitis Types of Gall stones Complications of Gall stones Other investigations Treatment
Questions
Types of Chronic Cholecystitis(1) Chronic calcular cholecystitis.
(2) Chronic non calcular cholecystitis.
(3) Cholecystosis.
Chr inflam. With hyperplasia of all tissue elements
(4) Cholesterosis (Strawberry GB).
Metabolic disturbances deposition of cholesterol crystals in the mucosa red streaked mucosa with cholesterol polyps ( strawberry appearance)
(5) Cholecystitis glandularis proliferans. *Thickening and hyperplasia of all layers (Adenomatosis)
*Mucosal polyps * Diverticular stone abscess & fistula
(6) Biliary Dyskinesia
*Due to spasm in the Oddi sphincter
Questions
Cholecysto-duodenal fistula
Gall bladder----------------
meal and follow through
Gall bladder----------------
meal and follow through
Gall bladder----------------------
PTC
---------------------Gall bladder----------------
cannula--------------
---------------duodenum---------------
Gastrographin meal and follow through shows filling of the Biliary ductal system
via a fistula from the post-bulbar duodenum
to the neck of the small, shrunken gallbladder (Film .2, arrow).
A PTC
(Film .3) also demonstrated
the connection between
the neck of the gallbladder
and the duodenum. No gallstone is seen.
Cholecysto-duodenal fistula
How to read
Types of Cholangiography(1) IV Cholangiography.
(2) Excretion scan (HIDA or PIPIDA).
(3) PTC
(4) ERCP
(5) MRCP
(6) Operative :. *Pre-exploratory
*Post exploratory Through choledocoscope
Through T- tube
(7) Postoperative
*2 weeks after exploration CBD through T- tube
*Through a biliary fistula
Questions
T- tube cholangiography It revealed * normal calibre CBD. * normal IH Biliary radicals. * no filling defect or effect in the CBD. * smooth tapered lower end CBD. * The dye is passed to the duodenum Diagnosis Normal T – tube cholangiography Q: Criteria of normal T–tube cholangiography
How to read
Indications of exploration CBD Preoperative Operative Postoperative
Methods of exploration CBD Supra duodenal portion Retro & infraduodenal portion Intra duodenal portion
Questions
T- tube cholangiography It revealed * dilated CBD. * dilated IH Biliary radicals. * filling defect or effect in the CBD. * abrupt stoppage of dye in lower end CBD. * The dye is not passed to the duodenum Diagnosis Residual stone CBD Q: Criteria of missed stone in T–tube cholangiography
How to read
In the immediate postoperative period:
Leave the T- tube for 4-6 weeks * dissolution of the stone. Heparin (25000 u in 250 ml saline/8h for 1 week Chenodeoxycholic acid Monoglyceride mono octanion Methyl tetra butyl ether * Extraction of the stone by Dormia basket. * Fiber optic choledocoscope. * Second operation for sphincteroplasty. * Second operation for Choledochlithotomy
Treatment of Residual stone
After removal of the T- tube * Endoscopic sphincterotomy.
and remove the stone by
Dormia basket or balloon catheter * Second operation for sphincteroplasty. * Second operation for Choledochlithotomy
Associated with high morbidity and mortality
Late (months or years) * Endoscopic sphincterotomy. * Second operation for sphincteroplasty.
* Second operation for Choledochlithotomy
Treatment of Residual stone
Endoscopic Retrograde Cholangio-pancreatography It revealed * dilated CBD. * dilated IH Biliary radicals. * filling defect in the CBD. * abrupt stoppage of dye in lower end CBD. * The dye is not passed to the duodenum Diagnosis Residual stone CBD during extraction by endoscope
How to read
IV Cholangiography It revealed * dilated CBD. * dilated IH Biliary radicals. * filling defect in the CBD. * abrupt stoppage of dye in lower end CBD. * The dye is not passed to the duodenum Diagnosis Primary stones CBD
How to read
Indications of Transduodenal Sphincterotomy
Open the 2nd part of the duodenum longitudinally and pass a grooved probe in the duodenal papilla and divide the papilla and all of the sphincter at 10 O clock
* Stone impacted at the duodenal papilla. * CBD dilated and filled with stones. * Stenosed or fibrosed papilla. * Stones in CBD in pt had undergone
cholecystectomy.
Questions
Indications of Transduodenal Sphincteroplasty
or Choledochoduodenostomy Stones * 1ry stones. * Large stones (>1.5 cm).
* Multiple stones. * Multiple intrahepatic stones
* Recurrent stones * Impacted stones
Strictures * CBD stricture. * Stricture with chr pancreatitis
* Iatrogenic stricture. * Stricture from stone impaction
Severe dilatation CBD > 1inch Biliary Dyskinesia Juxtapapillary Diverticulum
Questions
Intraoperative cholangiography through cystic duct It revealed * normal caliber CBD. * normal IH Biliary radicals. *no filling defect or effect in the CBD. * smooth tapered lower end CBD. * The dye is passed to the duodenum Diagnosis Normal cholangiography
How to read
Fistulogram Cholangiography It revealed * dilated IH Biliary radicals. * dilated CHD. * abrupt stoppage of dye in lower end CHD. CHD stump > 2cm * Failure of passage of the dye to the CBD or to the duodenum
Diagnosis Benign Biliary Stricture with obstruction at the CHD Type I Bismuth classification
How to read
Hepatico-jejunostomyWith entero-anastomosis
IV Cholangiography It revealed * dilated IH Biliary radicals. * dilated CHD. * abrupt stoppage of dye in lower end CHD. CHD stump < 2cm * Failure of passage of the dye to the CBD or to the duodenum
Diagnosis Benign Biliary Stricture with obstruction at the CHD Type II Bismuth classification
How to read
Hepatico-jejunostomyWith entero-anastomosis
MRCP It revealed * dilated IH Biliary radicals. * abrupt stoppage of dye at the confluence of rt and lt HD * Failure of passage of the dye to the CHD or CBD
Diagnosis Benign Biliary Stricture with obstruction at the CHD Type III Bismuth classification
How to read
Type III
End to side Hepatico-jejunostomy with entero anastomosis
End to end Hepatico-jejunostomy with Roux-en Y
T- tube Cholangiography It revealed * dilated IH Biliary radicals. * abrupt stoppage of dye at the lower end of rt and lt HD * Failure of passage of the dye to the CHD or CBD
Diagnosis Malignant Biliary Stricture with obstruction at the CHD Klatskin tumor
How to read
1ST FILM
1ST FILM
1ST FILM
2ND FILM
2ND FILM
2ND FILM
3ND FILM 4TH FILM
3ND FILM
3ND FILM
3ND FILM
4TH FILM
4TH FILM
ERCP
It revealed * 1st film injection of the dye. * 2nd film introduction of the stint. * 3rd film injection of the dye through the stint. * 4th film the cholangiogram after insertion of
the stint
Diagnosis
Malignant Biliary Stricture
with obstruction at the CHD
Klatskin tumor
with stinting of the CBD
How to read
PTC define the extent of ductal involvement. The films show high grade obstruction of the
CHD near the hilus with medial displacement of the duct by adjacent tumor mass.
The intrahepatic ducts are markedly dilated. Diagnosis The findings of a mass partially filling the
gallbladder lumen and extending into the liver with ductal obstruction at level of the porta hepatis and the presence of a gallstone are characteristic of gallbladder carcinoma
How to read
Pathology and staging Diagnosis DD Treatment
Questions
ERCP
It revealed Retrograde filling of the CBD shows the cyst
as an abrupt fusiform cystic dilatation of the CBD. The intrahepatic ducts are normal in caliber. The CBD joins the pancreatic duct near the ampulla; the pancreatic duct is otherwise normal.
Diagnosis
Choledochal cyst
How to read
Anatomy and pathology Type I * Dilatation of extra hepatic BT
1- cystic 2- focal 3- fusiform Type II * Saccular diverticulum
of extra hepatic bile duct Type III * Choledochocele. Type IV
{a} * Dilatation Intra and extra hepatic BT
{b} * Multiple extra hepatic dilatations. Type V * Dilatation confined to the
Intrahepatic BT
Questions
Etiology Clinical Presentation DD Diagnostic studies. Complications. Management
Questions
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