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M-2 Lecture Dr. F. Neuffer 2014

GASTROINTESTINAL IMAGING. M-2 Lecture Dr. F. Neuffer 2014. GI TRACT. Anatomy imaging Pathology Patients. OBJECTIVES:. Vascular supply and effect on pathology location. Age and site considerations in four major disease groups.

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M-2 Lecture Dr. F. Neuffer 2014

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  1. GASTROINTESTINAL IMAGING M-2 Lecture Dr. F. Neuffer 2014

  2. GI TRACT • Anatomy • imaging • Pathology • Patients

  3. OBJECTIVES: • Vascular supply and effect on pathology location. • Age and site considerations in four major disease groups. • Familiarity with imaging findings in Neoplastic, Inflammatory, Vascular and Traumatic diseases relative to the GI Tract. • Modality choices based on pathology considerations.

  4. UPPER GI – ORAL BARIUM CONTRAST STOMACH WITHOUT CONTRAST COLON BARIUM ENEMA - RECTAL BARIUM CONTRAST

  5. AIR UNDER THE DIAPHRAGM NORMAL GAS PATTERN Perforation of GI tract leads to pneumoperitoneum—peritonitis..bleeding Air collecting under the diaphragm on upright x-ray.

  6. ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. UPRIGHT DECUBITUS Left lateral decubitus (left side dependent) shows air along liver margin. This is the preferred x-ray if the patient cannot stand. Air visible under diaphragm

  7. RADIOLOGY DIAGRAM Pathology image X-ray image

  8. BARIUM FILLED ESOPHAGUS AORTIC IMPRESSION

  9. Pediatric patient Coin often is at site of Aortic impression.

  10. ASPIRATION NORMAL SWALLOW ASPIRATION Risk with patients with altered neurological status -post CVA -intoxicated Contrast tracks anteriorly into trachea with aspiration.

  11. ZENKER’S DIVERTICULUM source for aspiration Disordered contraction of cricopharyngeus with swallowing leads to diverticulum formation– elderly patients

  12. NORMAL ESOPHAGUS HIATAL HERNIA *Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus. DIAPHRAGM DIAPHRAGM This allows reflux of gastric contents into esophagus.

  13. ESOPHAGEAL CANCER Distal malignancy may be adenocarcinoma due to Barrett’s esophagus, a dysplastic change caused by chronic reflux of gastric contents.

  14. ESOPHAGEAL CANCER Typical squamous cell carcinoma Poor prognosis from local extension into critical mediastinal structures. (esophagus lacks a serosa) .

  15. TRACHEO-ESOPHAGEAL FISTULA / ATRESIA

  16. Diffuse • Esophageal spasm • sometimes referred to as: • PRESBYESOPHAGUS • Elderly patient • Disordered contraction • Chest pain • Cardiac mimic

  17. CANDIDA ESOPHAGITIS Extensive nodular filling defects in the esophagus in an immunocompromised patient are typical for Candida esophagitis.

  18. ACHALASIA Distended esophagus with distal stricture.-Chronic process Little symptoms. Halitosis • Failure of distal sphincter to relax – • Nerve damage to sphincter leads to obstruction. Stricture due to CANCER / REFLUX has to be considered first. Barium filled esophagus

  19. LOOK ALIKES • Scleroderma-smooth muscle • -- Skin findings • Chagas Disease -Trypanosome infection • --Central America

  20. ESOPHAGEAL VARICES Linear tubular filling defects represent distended veins from shunting due to cirrhosis and portal hypertension.

  21. MALLORY-WEISS TEAR Esophagus shows a linear tear of the distal esophageal mucosa due to vomiting. Barium is seen tracking into the wall. Full thickness tear or rupture (Boerhaave’s syndrome) can lead to mediastinitis and death.

  22. Boerhaave’s Syndrome Post emesis –Perforation esophagus into mediastinum— Edema, Effusion and Pneumomediastinum

  23. ESOPHAGEAL DISEASE • HIATAL HERNIA / ESOPHAGEAL CANCER • CANDIDA / SPASM / VARICES • MALLORY WEISS TEAR / BOERHAAVE’S SYNDROME • ACHALASIA / SCLERODERMA / CHAGAS • TE FISTULA / ZENKERS DIVERTICULUM SIGNS / SYMPTOMS • CHEST PAIN • DIFFICULTY SWALLOWING • HOARSENESS

  24. FUNDUS NORMAL GASTRIC ANATOMY DUODENUM BODY ANTRUM JEJUNUM C-LOOP Single AP radiograph showing filling of distal esophagus, stomach and proximal small bowel without mass, obstruction or filling defect.

  25. GASTRIC ULCER Barium collects in ulcer crater Endoscopic view of ulcer

  26. ULCER CAN PERFORATE INTO PANCREAS AND LEAD TO PANCREATITIS Silva, A. C. et al. Radiographics 2004;24:677-687

  27. GASTRIC CARCINOMA PYLORIC STENOSIS

  28. PYLORIC STENOSIS Narrowed pyloric channel Thickened pylorus ULTRASOUND

  29. GASTROPARESIS DIABETIC NEUROPATHY EFFECT

  30. GASTRIC DISEASE • ULCER • CANCER • PYLORIC STENOSIS • GASTROPARESIS SIGNS / SYMPTOMS • PAIN • ANEMIA • HEMATEMESIS / MELENA • EMESIS • WEIGHT LOSS

  31. NORMAL SMALL BOWEL JEJUNUM Early contrast is predominantly in jejunum and later predominately in ileum. (note difference in mucosal fold pattern) ILEUM COLON

  32. SMALL BOWEL OBSTRUCTION Ng tube ERECT Note dilated small bowel centrally placed with air/fluid levels on upright exam.

  33. POST – OP ADYNAMIC ILEUS COLON LARGE AND SMALL BOWEL SM. BOWEL SUTURES Symmetric dilation of large and small bowel is seen normally as a post operative ileus.

  34. SMALL BOWEL BARIUM STUDY HERNIA CT Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery.

  35. CROHN'S DISEASE normal Narrowed distal ileum due to chronic inflammation is typical for Crohn’s disease.

  36. SMALL BOWEL DISEASE • ULCER • OBSTRUCTION • POST-OPERATIVE ILEUS • CROHN’S DISEASE SIGNS / SYMPTOMS • PAIN • HEMATEMESIS • DISTENTION • DIARRHEA

  37. SPLENIC FLEXURE NORMAL COLON HEPATIC FLEXURE TRANSVERSE COLON DESCENDING COLON ASCENDING COLON Normal air contrast barium enema (double contrast-air and barium per rectum) shows filling of colon with air and barium retrograde to the cecum with reflux into the terminal ileum. TERMINAL ILEUM CECUM

  38. COLON DISEASE • APPENDICITIS / DIVERTICULITIS • POLYP / CANCER • VOLVULUS • GI HEMORRHAGE SIGNS / SYMPTOMS • RIGHT / LEFT LOWER QUADRANT PAIN • FEVER / ELEVATED WBC’s • DISTENSION / OBSTRUCTION • WEIGHT LOSS • HEMOCULT POSITIVE STOOL / ANEMIA • MELENA / HEMATOCHEZIA

  39. ACUTE APPENDICITIS NORMAL DISTENDED APPENDIX WITH LOCAL INFLAMMATION.

  40. ABSCESS Catheter has been placed by radiologist using CT guidance draining abscess collection. DRAINAGE

  41. PEDUNCULATED COLON POLYP (DESCENDING COLON) stalk on polyp--pedunculated

  42. COLON CANCER Barium enema showing apple-core type constricting lesion with proximal dilation of colon—”APPLE - CORE”constricting lesion

  43. SMALL BOWEL vs COLON OBSTRUCTION Ng tube

  44. COLON SIGMOID VOLVULUS Dilated horse-shoe shaped sigmoid colon due to volvulus. “COFFEE BEAN SIGN”

  45. COLON VOLVULUS “BEAK SIGN” Barium fills to point of obstruction -- twist of sigmoid colon

  46. ULCERATIVE COLITIS Normal

  47. PSEUDOPOLYPS with ulcerative colitis

  48. CHROHN’S COLITIS Segmental distribution commonly referred to as “skip lesions”

  49. CROHN’S VS ULCERATIVE COLITIS Skip Fistula Continuous Colon cancer

  50. DIVERTICULOSIS Balloon in rectum to Help control barium. Barium extends from lumen outward into diverticulum.

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