MEDICAL X-RAY PART 1 by odiaworld

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									Surgical Pathology & X-rays
                  for

      Medical Students
                2007

              GIT-1
       Salivary Glands
       Esophagus
       Stomach & Duodenum
                                          Index
Salivary Glands
Thyroglossal cyst                              Gastric & duodenal ulcers
Branchial remnants                             Acute gastritis & acute peptic ulcers
Pharyngeal pouch                               Chronic gastric ulcer
Esophagus                                      Complications of peptic ulcers
Congenital esophageal atreasia                Hour-glass stomach
Esophageal varices                            Congenital pyloric stenosis
Esophageal diverticulum                       Adult pyloric stenosis
Barrett’s esophagus                           Cancer stomach
Cancer esophagus                              Pseudo-pancreatic cyst
Cardiac achalasia                             Volvulous of stomach
Stomach & Duodenum                             Duodenal atresia
Normal appearance                             Jejunal atresia
Hiatus hernia                                 Duodenal ulcers
Congenital diaphragmatic hernia               Duodenal diverticulum

2                                                                                       © GIT1
                 To return to this index from any slide, click on “INDEX”
The following slides includes clinical pictures, gross pathology pictures
and X-rays in a systemic approach to important surgical problems.
you may be asked about :
Diagnosis or differential diagnosis
Pathological types (if any)
Common clinical presentations
Common complications
Specific investigations
Main line of treatment


The answers are expected to be short & precise


3                                                                     © GIT1
                                                                       INDEX
    Salivary Glands




4                     © GIT1
                      INDEX
    Salivary Glands




5                     © GIT1
                      INDEX
                   Swellings of Salivary Glands

  Inflammatory                 Mumps                  Neoplasms
                                                   Adenoma
 Viral: Acute: Mumps
                                                   Carcinoma
              Chronic: ?HIV
                                                   Nonepithelial
 Bacterial:
 Chronic bacterial
 sialadenitis (usually
 submandibular
 complicating chronic
 obstruction                   Bilateral parotid
                              swelling with HIV
 Acute ascending
 sialadenitis (usually
 parotid in dehydrated
 postoperative patients
 with poor mouth
 hygiene)
6 Specific   Infections:                                            © GIT1
                                                                         INDEX
                    Sialolithiasis - (Salivary stones)
                                Incidence
      80%
                                10%             7%

 Submandibular                Parotid        Sublingual      Minor glands


Because secretions
 are viscid rich in
mucous & the gland
lies below the opening
      of its duct

Majority are               Majority
radio-opaque               are
                           radiolucent

 7                                                                  stone
                                                Large submandibular © GIT1
                                                                        INDEX
Plain X-ray showing submandibular stone
This is the occlusal view of the mandible that best demonstrates the stone




8                                                                            © GIT1
                                                                             INDEX
   Stone
submandibular
    gland




9               © GIT1
                INDEX
     Sialography: Stone submandibular gland




10                                            © GIT1
                                              INDEX
Submandibular Sialogram
Showing a stone in the submandibular duct
The stone is NOT radiolucent, but it looks so because this is a subtracted image

                                                       •The classic presentation of a
                                                       submandibular stone is pain
                                                       and swelling prior to or
                                                       during meal
                                                       •This requires almost
                                                       complete obstruction of the
                                                       submandibular duct
                                                       •If partial obstruction occurs
                                                       swelling may be mild with
                                                       chronic painful enlargement
                                                       of the gland
                                                       •If diagnostic doubt then
                                                       stone can be demonstrated
                                                       by sialogram

   11                                                                              © GIT1
                                                                                   INDEX
 1- Stone in the Rt submandibular duct
 (anterior 2/3 of the duct is anterior to the lingual n.)

 2- Surgical removal
 (Linear incision along the duct -notice the stay suture)




     1                                      2



12                                                          © GIT1
                                                            INDEX
              ?
     Ranula   Stone submandibular duct




13                                       © GIT1
                                         INDEX
     Ranula


              A large mucous retention
              cyst (mucocele) secondary to
              obstruction of a minor
              salivary gland or the
              sublingual gland.
              They represent a unilocular
              cyst in the sublingual space



14                                      © GIT1
                                        INDEX
                      Salivary Tumours
                                                         Nonepithelial
      Adenomas                  Carcinomas                 tumours

                                            Nodularity
                                            & regional
                                            lymphatic
                                            metastasis
                                            is highly
                                            suspicious
                                            of
                                            malignancy
Parotid pleomorphic adenoma

                                What are the other
                                 clinical signs that
                               suggest malignancy?
             Usual locations
             of benign
             parotid tumours

 15                                                            © GIT1
                                                                INDEX
                  Salivary Tumours
Nearly all salivary tumours are slowly growing (even malignant
tumour)
Is pain a reliable indication of malignancy?
Pain is not a reliable indication of malignancy except after
invasion of sensory nerves
Benign tumours may present with aching pain due to capsular
distension and outflow obstruction of saliva
The only reliable clinical indication of malignancy are:
Facial nerve palsy in parotid tumours
Indurations or ulceration of overlying skin or mucosa
Regional lymphatic metastasis
16                                                              © GIT1
                                                                INDEX
      Invastigations of Salivary Tumours
CT & MRI :                Rt.       MRI
                                    Rt. parotid tumour
                                    extending into the
Confirm that the                   superficial & deep
mass is arising from                lobes
the salivary gland                  Sq. cell ca
Demonstrate the
tumour borders (well
circumscribed in benign             CT
& diffuse invasive in               Well
malignant)                          circumscribed Lt.
                                    parotid tumour of
Show anatomical                    the superficial lobe
relations to plan for               Pleomorphic
surgery                             adenoma
 17                                               © GIT1
                                                       INDEX
Invastigations of Salivary Tumours
Fine needle aspiration (FNA)
For histopathological diagnosis

Open surgical biopsy is absolutely
contraindicated in tumours of major
salivary glands
Why?
Pleomorphic adenomas are poorly
encapsulated and are very tens. Open
biopsy will seed the surrounding tissues
with tumour cells causing multiple local
recurrences over many years
Open biopsy is done if the tumour is
clearly infiltrating or invading the skin
  18                                        © GIT1
                                            INDEX
     Thyroglossal cyst
     Branchial remnants
     Pharyngeal pouch




19                         © GIT1
                           INDEX
     Thyroglossal cyst & fistula




20                                 © GIT1
                                   INDEX
                  Thyroglossal cysts
Embryology

•The thyroglossal tract arises form foramen caecum at
junction of anterior 2/3 and posterior 1/3 of the tongue.
•Any part of the tract can persist causing a sinus, fistulae or
cyst.
•Most fistulae are acquired following rupture or incision of      The classical
infected thyroglossal cyst
                                                                    site for a
                                                                  thyroglossal
                                                                       cyst




   21                                                                    © GIT1
                                                                          INDEX
This is a CT scan at the level of C4 vertebrae. Try to identify the following structures:


Sternomastoid muscle

External jugular vein

Air in laryngeal vestibule

Internal jugular vein

Internal carotid artery
                                                                  C4
External carotid artery

Hyoid bone

What is this structure?

   Thyroglossal cyst
    22                                                                                      © GIT1
                                                                                            INDEX
Clinical features of Thyroglossal cysts
•Usually found in subhyoid portion of tract
•75% present as midline swellings
•Remainder can be found as far lateral as lateral tip of hyoid bone
•The cyst elevates on protrusion of the tongue
•Can present as an infected cyst due lymphoid tissue in the cyst wall
•If infected, aspirate cyst rather than incise prevents formation of thyroglossal fistula



Treatment
Sistrunk Operation
•Transverse skin crease incision
•Platysma flaps raised.
•Cyst dissected
•Middle 1/3 of hyoid and any suprahyoid
tract extending into the tongue dissected


   23                                                                                       © GIT1
                                                                                            INDEX
      Thyroglossal
         fistula

The classical site for a
 thyroglossal fistula




                           Fistulography: “note the position of the fistula
                                  anterior to the trachea (black air)”
 24                                                                      © GIT1
                                                                         INDEX
  Branchial remnants
•Branchial fistulae and cysts
usually arise from second
branchial sinus
•Arise on anterior border of
sternomastoid
                                  Branchial
•Often bilateral and extend
                                    cyst
deep into neck
•Internal opening
occasionally found in
tonsillar fossa
•Treatment is by surgical
excision
 Notice the opening lateral
      to the mid line
                                              Branchial
  25                                               © GIT1
                          INDEX                fistula
Pharyngeal pouch
•Is posteromedial pulsion diverticulum through Killian's
dehiscence
•Occurs between thyropharyngeus and cricopharyngeus
muscles. Both form the inferior constrictor of the pharynx
•Male : female ratio is 5:1
•Usually only seen in the elderly
•Aetiology is unknown but upper oesophageal sphincter dysfunction may be important




   26                                                                      © GIT1
                                                                            INDEX
Pharyngeal pouch

Clinical features
•Commonest symptoms are:
dysphagia, regurgitation and
cough
•Recurrent aspiration can result
in pulmonary complications
•A carcinoma can develop
within the pouch
•Clinical signs are often absent,
however, a cervical lump may
be present that gurgles on
                                    Barium swallow show residual
palpation                           pool of contrast within the pouch
 27                                                            © GIT1
                                                                INDEX
               Esophagus
      Normal
     anatomy


                           Cervical




                           Thoracic




                           Abdominal


28                                     © GIT1
                                       INDEX
 Normal barium swallow




The esophagus have a
smooth outline. No
persistently narrowed
areas are seen.
Peristalsis can be
observed on screening
the patient.
The whole examination
can be recorded on video
if necessary (video-swallow
                              Lateral view: The course and diameter of the esophagus
examination).
                              are normal, the longitudinal mucosal folds are regular
   29                                                                        © GIT1
                                                                              INDEX
NORMAL ANATOMY of Oesophagus-
Double contrast study
•The mucosal surface of the esophagus is smooth
and featureless on double contrast examination.
•When the esophagus is distended the mucosal
folds disappear.
•When the esophagus is partially collapsed, then
straight parallel longitudinal folds are easily seen.
•The Z-line demarcates the squamocolumnar
junction separating esophageal mucosa from
gastric folds.
•A number of mediastinal structures cause
extrinsic impressions upon the adjacent
esophagus in the normal individual.
•In the elderly individual, osteophytes projecting from the
anterior surface of the thoracic vertebrae, a tortuous aorta or
an enlarged left atrium may also cause impressions upon
     esophagus.
the 30                                                            © GIT1
                                                                  INDEX
Normal endoscopic picture
of the esophagus




31                          © GIT1
                            INDEX
     Congenital Esophageal
           Atreasia




32                           © GIT1
                             INDEX
 Congenital esophageal atreasia

             The most common
             type of trachio-
             esophageal fistula
             is a blind end
             upper esophagus
             and a lower
             remnant connected
             to the trachea




33                                © GIT1
                                  INDEX
Oesophageal atresia (diagnosis)

If suspected, a small
nasogastric tube will
arrest at the blind pouch &
will not reach the stomach




  34                              © GIT1
                                  INDEX
 Atresia of the esophagus




Examination with contrast material: The white arrows point to the blind end of the
esophagus filled with contrast material. The middle lobe of the right lung is partially
atelectatic because of aspiration. Presence of a lower fistula is suggested by theGIT1
   35                                                                             ©
presence of gas in the distended stomach                                           INDEX
     Oesophageal atresia




36                         © GIT1
                           INDEX
     Esophageal varices




37                        © GIT1
                          INDEX
Esophageal varices




38                   © GIT1
                     INDEX
With portal hypertension, collateral vessels develop between
portal and systemic veins:
Around the lower end of the esophagus & fundus of stomach
(esophageal & fundal varices) [splenic vein – short gastric veins – coronary
vein – esophageal veins – azygos system]

Around the rectum (Hemorrhoids) [superior hemorrhoidal – middle &
inferior hemorrhoidal]

Around the umbilicus (Caput medusa) [paraumbilical veins – epigastric
veins]

Around the liver & diaphragm & retroperitoneal veins.

                The normal portal pressure is less than 200 mm saline
         Collateral circulation does not effectively decompress the portal system

The four major manifestations of portal hypertension are:
Esophageal varices, ascites, hypersplenism and encephalopathy.
 39                                                                             © GIT1
                                                                                    INDEX
Factors implicated in the formation of ascites:
Increased portal venous pressure

Reduced serum osmotic pressure due to hypoalbuminemia
Sodium & water retention (inc. adrenal cortical hormones & dec. anti-diuretic hormone)

Hypersplenism
Sequestration and destruction of any or all of the cellular elements of the blood
WBC > 4000 /ml
Platelets > 100,000 /ml
Are spontaneous ecchymosis and purpra common presentations of portal hypertension alone? NO


Encephalopathy is related to high blood ammonia level
It can result from natural or surgically created porto-systemic shunts in
patients with marked hepatocellular dysfunction

  40                                                                                          © GIT1
                                                                                              INDEX
Esophageal varices




                             Upper GI endoscopy

 41                                               © GIT1
      “Autopsy”      Barium swallow
                                                  INDEX
Barium swallow
      Oesophageal varices


Numerous rounded and
elongated smooth-
contoured filling defects
are present in the inferior
two thirds of the
esophagus.
The contour of the
esophagus is irregular and
speculated.


 42                           © GIT1
                              INDEX
Barium swallow:
Oesophageal varices




  43                  © GIT1
                      INDEX
Management of acutely bleeding varices

In patients with hepatocellular
dysfunction, bleeding should be rapidly
controlled to avoid:
•The effect of shock on hepatic function.
•The toxic effect of digested blood
absorption.

Main lines of treatment:
Heamodynamic stabilization with
blood transfusion
Reduce the portal blood pressure:
•Vasopressine causes constriction of the
splanchnic arteria circulation reducing the
portal blood pressure 40%
•Propranolol
Sengstaken balloon temponade
                                              Sengstaken –Blakemore tube
   44                                                                     © GIT1
Injection sclerothrapy                        Temponade & gastric wash   INDEX
     Injection sclerotherapy of esophageal varices




45                                                   © GIT1
                                                     INDEX
Follow-up
barium swallow
Note the staplers
in the lower end
of oesophagus
(a treatment
modality for
esophageal
varices)




 46                 © GIT1
                    INDEX
     Esophageal diverticulum




47                             © GIT1
                               INDEX
     Barium swallow

     Esophageal diverticulum




48                             © GIT1
                               INDEX
Barium swallow - Lateral view

Esophageal diverticulum

Two sharp-contoured filling
excesses can be seen on the
ventral contour of the esophagus
below the tracheal bifurcation
(arrows)




49                                 © GIT1
                                   INDEX
     Barrett’s esophagus




50                         © GIT1
                           INDEX
Gastro-esophageal reflux disease [GERD] is a common disorder
Gastro-esophageal reflux are prevented by:     Management of GERD

•Lower esophageal sphincter                    •Bed tilte

•Normal hiatus of the diaphragm                •H2 blockers

  GERD may or may not be accompanied           •Proton pump inhibitors
     with sliding esophageal hernia            •Surgery (failed medical or complications)
Clinical features:
Retrosternal burning pain
(heart burn) provoked by fatty
food
    Fatty dyspepsia is more
    common in GERD than
       gallstone disease
Objective diagnosis: esophageal manometry
           with 24h pH recording
                                                  Complications of GERD
                                             Stricture
                                             Shortening
    51                                                                               © GIT1
                                             Columnar metaplasia [Barrett’s]               INDEX
  Barrett’s esophagus
                                                  Endoscope view




                                                      Bands of metaplastic
                                                  epithelium extend proximally
Normal lower esophagus      Barrett’s esophagus   What are the complications
                                                   of Barrett’s esophagus?
Columnar metaplasia in the lining mucosa
of the lower esophagus in response to
                                                       Increased risk of
chronic gastro-esophageal reflux.
    52                                            adenocarcinoma 25©timesGIT1
                                                                         INDEX
53           © GIT1
     INDEX
     Gastroesophageal reflux with longitudinal ulcers
              arising from the GE junction
54                                                 © GIT1
                                                    INDEX
     Cancer esophagus




55                      © GIT1
                        INDEX
            Neoplasms of the oesophagus
                                                                    Sarcoma
Benign Tumours                    Malignant Tumours
                                                               Malignant Melanoma
    (RARE)

                              CARCINOMA


         Squamous Cell CA                 Adenocarcinoma             Oat cell CA

          usually Upper 2/3                usually Lower 1/3




CA OE has poor prognosis because symptoms occur late
Clinical Features of CA OE
1. Dysphagia
                                               ADVANCED
2. Weight loss
3. Recurrent laryngeal n. palsy
                                                DESEASE
 56                                                                     © GIT1
4. Cervical Lymphadenopathy                                              INDEX
Lower 1/3 of the esophagus              Upper 2/3 of the esophagus

C. Oat cell carcinoma ( occasionally)
   57                                                                © GIT1
                                                                     INDEX
Remember the pathological types of
cancer oesophagus.
 58                                  © GIT1
                                          INDEX
Midesophagus Squamous
Cell Carcinoma
Squamous cell carcinoma
arises most commonly
in the upper and middle
esophagus




59                        © GIT1
                          INDEX
Pre-cancerous conditions:
•Smoking & alcohol
•Food contamination of fungi
•Diet deficiency in beta carotin,
vitamin E & selinium

Clinical features:
Dysphagia is a sign of advanced
disease
Early symptoms are nonspecific
During endoscopy, biopsy any
lesion even if small (small
cancers are curable)
60                                  © GIT1
                                    INDEX
     Investigations for suspected CA esophagus
     Upper GI endoscopy               Ba swallow
with biopsy of any suspected lesion




61                                                 © GIT1
                                                   INDEX
     Endoscopy of the esophagus


                         Early
                         adenocarcinoma
                         complicating
                         Barrett’s
                         esophagus




                         Advanced
                         squamous cell CA
                         of the oesophagus

62                                    © GIT1
                                      INDEX
  Barium swallow
Irregularity looks like
an apple core lesion
in the esophagus.
This is typical in
carcinoma of the
esophagus




  63                      © GIT1
                          INDEX
Barium swallow
CA esophagus – lateral view




  64                          © GIT1
                              INDEX
Barium swallow
CA oesophagus




 65              © GIT1
                 INDEX
 CA Oesophagus




   Irregular stricture with
    shouldered margins

Presenting symptom: Dysphagia




  66                            © GIT1
                                INDEX
Barium swallow
CA oesophagus




 67              © GIT1
                 INDEX
barium swallow
demonstrates the typical
apple core lesion seen
with distal esophageal
adenocarcinoma
associated with chronic
reflux disease.
Also seen is a typical
sliding hiatal hernia with
the gastric folds fixed
above the diaphragm.




 68                          © GIT1
                             INDEX
 Barium swallow
This is not CA esophagus.
The esophagus is displaced
by CA lung.
Note the smooth lining of the
displaced segment




 69                             © GIT1
                                INDEX
     Corrosive stricture
      of the esophagus




70                         © GIT1
                           INDEX
 Ba swallow -
 Corrosive stricture

AP view:

Narrowing with smooth
outlines at the level of the
middle third of the
esophagus with a dilatation
observed above it.
Distally the lumen of the
esophagus is of about the
normal diameter.



71                             © GIT1
                               INDEX
Carcinoma of the esophagus has a poor survival rate
        because of late discovery after spread
                       Spread

 Local spread    Lymphatic spread      Systemic spread
•Through the       Spread to the       •Liver
wall into adj.    celiac LNs is a
structures       bad prognostic sign
                                       •Lungs
•Satellite         and regarded as     •Brain
nodules in the    distant metastasis
                                       •bone
proximal            (M) in the TNM
esophagus            classification
(submucosal
lymphatics)

72                                                    © GIT1
                                                      INDEX
Carcinoma
  of the
esophagus




 73                 © GIT1
            INDEX
Postoperative barium
swallow demonstrating the
gastric conduit in the
cervical position with the
silver clips marking the
anastomosis




  74                         © GIT1
                             INDEX
     Achalasia of the cardiac sphincter




75                                        © GIT1
                                          INDEX
Ba swallow                                                       Autopsy




  Achalasia
  Inability to relax lower esophageal sphincter leads to massive
  esophageal dilation and produces the characteristic "birds beak"
  deformity in barium swallow

 76                                                                  © GIT1
                                                                     INDEX
Barium swallow examination: achalasia Early stage

The esophagus
has smooth
contour and is
narrowed
conically at the
esophago-
cardial junction
(arrow), above
this the distal
part of the
esophagus is
dilated
77                                                  © GIT1
                                                    INDEX
Late stage:
The esophagus is
extremely dilated above
the severely narrowed
cardia (arrow), with a
slightly tortuous course
and inhomogenous
contrast material filling
pattern because of the
residual food inside



78                          © GIT1
                            INDEX
Achalasia (of the cardiac
        sphincter)
Note the huge dilatation
of the oesophagus




79                          © GIT1
                            INDEX
Achalasia with bird's beak deformity of the distal esophagus




80                                                      © GIT1
                                                         INDEX
     Lateral view of
     barium swallow
     in a patient with
     achalasia.
      Note grossly
     dilated esophagus
     with abrupt
     tapering to “bird
     beak-like” shape
     of lower
     esophageal
     sphincter


81                 © GIT1
                   INDEX
      Achalasia

The oesophagus
hugely dilated and
tortuous.




82                   © GIT1
                     INDEX
Please compare and contrast between cardiac achalasis & CA lower end esophgus




 83                                                                    © GIT1
                                                                       INDEX
Barium swallow: CA oesophagus v/s Achalasia
The cardia is normally
below the diaphragm                             1               2

In X-ray 1, the
oesophagus is
interrupted
above the
diaphragm
In X-ray 2, the
cardia below
the diaphragm
is closed with
“bird beak-like”         This is CA lower end       Achalasia of
shape                         esophagus               cardia


   84                                                      © GIT1
                                                            INDEX
Treatment options for cardiac achalasia

                                          Pneumatic dilation
                                          performed
                                          endoscopically




                                      Lower esophageal
                                      sphincter myotomy
                                      incises enough muscle to
                                      relieve symptoms but not
                                      enough to result in
                                      gastroesophageal reflux

 85                                                     © GIT1
                                                        INDEX
     Stomach & Duodenum




86                        © GIT1
                          INDEX
Normal anatomy
& corresponding endoscopic picture




  87                                 © GIT1
                                     INDEX
          Normal lower
      oesophagus & stomach
     This is the normal appearance of the
     lower oesophagus & stomach, which
     has been opened along the greater
     curvature.




88                                   © GIT1
                                      INDEX
Normal upper GI
barium study:
The stomach is of
normal size and
shape, its mucosal
folds are regular.
The fornix is filled
with contrast
material because of
the supine position.
The duodenum is
normal.
Jejunal loops filled
with contrast
material are visible
behind the stomach
   89                   © GIT1
                        INDEX
     Hiatus Hernia




90                   © GIT1
                     INDEX
Siding hiatus hernia

 The esophago-
 gastric junction
 and the fundus of
 the stomach
 (arrow) are
 situated high in
 the thorax, above
 the diaphragm




 91                    © GIT1
                       INDEX
Siding hiatus
   hernia




92              © GIT1
Siding hiatus hernia
    (retrosternal)




 93                    © GIT1
                       INDEX
 Paraesophageal hiatus hernia

A small segment of
the stomach fundus
protrudes into the
thorax on the left
side of the normal
esophagus (arrow).
The herniated
stomach displases
the esophagus to the
right.
Note that the angle between
the esophagus & stomach is
preserved (Red arrow)

  94                            © GIT1
                                INDEX
                 Congenital diaphragmatic hernia
Congenital parasternal hernia
         (Morgagni)




                                            Congenital diaphragmatic
                                                      hernia
       Congenital hiatal hernia
                                            persistent pleuroperitoneal
                                                canal (Bochdalek)
 95                                                                GIT1
                                             90% are on the left©side
                                                                 INDEX
     Postmortum
     specimen
     Diaphragmatic
     hernia




96           © GIT1
              INDEX
     Gastric & duodenal ulcers




97                               © GIT1
                                 INDEX
     Gastric Ulcer




98                   © GIT1
                     INDEX
Mechanism of acid production in
    the gastric parietal cell




99                                © GIT1
                                  INDEX
Acute gastritis
with diffuse
heamorrhage




100               © GIT1
                  INDEX
Acute Peptic Ulcers
Etiology: Disruption of gastric mucosal
barrier appears as multiple erosions.
50% of patients give history of
NSAID/aspirin intake.
Acute peptic ulcers cause short attacks of
dyspepsia & classically present with
hemorrhage.

Pathology: Frequently multiple.
Stomach - They can occur in any part.
Duodenum - Almost always confined to first
part.
Shallow punched out and seldom invade
musclecoats unlikely to leave healing scars.

Acute duodenal ulcer in anterior wall
occasionally perforates.
These acute lesions can progress to chronic
ulcers.
  101                                          © GIT1
                                               INDEX
Chronic Gastric Ulcer




  102                           © GIT1
                        INDEX
Chronic gastric ulcer




The ulcer is deep, with sharp proximal edge & a sloping distal edge
The arrow points to an eroded gastric artery which has caused fatal hemorrhage

        What are the complications of chronic gastric ulcer?
  103                                                                            © GIT1
                                                                                 INDEX
                                             1)   It is relatively small (1cm)
Benign gastric ulcer of the stomach antrum
                                             2)   The mucosa surrounding the ulcer base is not
                                                  infiltrated by a tumour
                                             3)   The radiating rugal folds extend nearly all the way to
                                                  the margins of the base




                                             Longitudinal section of the benign ulcer and adjacent
                                             gastric wall.
                                             The normal anatomic layers are discrete and undisturbed

                                             Definitive diagnosis of chronic gastric ulcer depends on
                                               endoscopy & biopsy with histological examination
   104                                                                                     © GIT1
                                             When do you suspect that a gastric ulcer is malignant?
                                                                                                 INDEX
          Malignant
         gastric ulcer

      Top view, the ulcer is
      very suspicious
      Longitudinal section:
      The pylorus is to the left.
      Edges are everted.
      Several prominent
      nodes of the lesser
      omentum contained
      metastatic cancer.
      The adenocarcinoma is
      infiltrating between the
      layers

105                       © GIT1
                           INDEX
Chronic gastric ulcer
The edges of the ulcer
are heaped up due to
epithelial regeneration.
The ulcer base is
smooth
and contains only
granulation tissue
If the ulcer was discovered
on endoscopy, multiple
biopsies should be taken to
exclude malignancy –even if
the ulcer looks benign
  106                         © GIT1
                              INDEX
        Chronic
      gastric ulcer




107              © GIT1
                  INDEX
Barium meal
Benign gastric ulcer on the
lesser curvature of the
stomach




 108                          © GIT1
                              INDEX
Large ulcer is filled
with barium on the
lesser curvature of
the stomach with
star-shaped
mucosal folds
converging towards
the lesion



109                     © GIT1
                        INDEX
Barium study
Gastric ulcer




 110            © GIT1
                INDEX
Upper GI barium
study:
It shows a large
gastric ulcer along
the lesser
curvature of the
stomach.
Surgery was
performed and the
ulcer was benign

 111                  © GIT1
                      INDEX
  Barium meal

   gastric ulcer

There is a large
ulcer crater on the
greater curvature
aspect of the distal
stomach (arrow).
There are multiple
folds radiating to
the edge of the
ulcer crater. All the
folds taper
gradually to the
edge of the crater.
  112                   © GIT1
                        INDEX
 Barium meal
 Pre-pyloric gastric ulcer

 Carmens meniscus sign




113                          © GIT1
                             INDEX
      Chronic Gastric Ulcer
      This gastric ulcer has
      been present for some
      time as judged by the
      amount of puckering of
      the surrounding mucosa
      and by the depth of the
      ulcer.
      The gastric mucosa
      around shows gastritis.
      Frequently, vessels in the
      base of the ulcers will
      ulcerate and the patient
      will bleed profusely, if not
      fatally

      Does infection have a
      role in the development
114   of peptic ulcer? © GIT1
                            INDEX
            Helicobacter pylori
      It is important in the etiology of :
      •Chronic gastritis
      •Peptic ulcer
      •Gastric cancer


       Helicobacter pylori        Hydrolyze urea   Amonia (strong alkali)

           Eradication
             therapy                                Antral ‘G’ cells
         is a main treatment in
              peptic ulcer


          Metronidazole
                                                         Gastrin
            Amoxycillin
              Bismuth
                                                      Gastric acid
          A proton pump                              hypersecretion
        inhibitor is usually
115                                                                         © GIT1
               added                                                        INDEX
      Helicobacter gastritis
      Helicobacter organisms may
      be tested for urease activity.
      Staining of the gastric biopsy
      shows
      the characteristic curved rods
      embedded in the mucin layer
      of the stomach




116                                    © GIT1
                                       INDEX
Complications of peptic ulcers
   Bleeding
•Patient presented with hematemesis,
shock followed by melina
•Endoscopy showed acute gastric
bleeding


  Perforation                           Penetration
•Patient presented                     Posterior wall ulcer penetrates to
with acute                             pancreas (back pain)
abdominal pain
•Plain X-ray chest
& abdomen
showed air under
the diaphragm




   117                                 Malignant Gastric Ulcer       © GIT1
                                                                      INDEX
"Hourglass" contraction of the stomach
Due to chronic peptic ulceration there is fibrosis and contracture of
the stomach leading to an hourglass shape
118                                                                     © GIT1
Results in altered stomach mobility with delayed gastric emptying
                                                                        INDEX
      Upper GI endoscopy for diagnosis of peptic ulcer




119                                                      © GIT1
                                                         INDEX
      Congenital pyloric stenosis




120                                 © GIT1
                                    INDEX
Stomach antrum
& pyloric canal        Abnormal



  Normal

                    Antrum




                  Pyloric canal




  121                             © GIT1
                                  INDEX
Hypertophic pyloric stenosis. Note the prominent hypertrophied circular pyloric muscle
with elongation and narrowing of the pylorus
It is a cause for "projectile" vomiting in infants about 3 to 6 weeks of age. Males are affected
more than females(4:1)
 122                                                                                               © GIT1
       It should be differentiated from other causes of vomiting in infancy
                                                                                                   INDEX
Symptoms include non-bilious vomiting often starting as simple
regurgitation progressing to projectile vomiting after most
feedings.Vometing contains milk but no bile
Less frequent findings are constipation, progressive weight loss,
dehydration, hypochloremic alkalosis.
Symptoms occur most commonly during the second to sixth weeks
with peak age at presentation being 3rd -4th weeks. HPS rarely
presents after 3 months of age.

Physical examination may
reveal visible gastric peristaltic
waves and a palpable pyloric
mass (olive).




  123                                                                © GIT1
                                                                     INDEX
If the clinical and
physical findings
are suggestive of
HPS then an
ultrasound exam
is the first study of
choice.


  D.D. of Hypertophic
  pyloric stenosis of
        infancy
                                U.S. Findings:
•Gastro-esophageal reflux       There is thickening and elongation of the
                                pyloric muscle. diagnostic for HPS
•Raised intracranial pressure
•Duodenal atresia
•Intestinal obstruction
   124                                                             © GIT1
                                                                   INDEX
Gasrtographin meal
Congenital pyloric stenosis




  125                         © GIT1
                              INDEX
      (Adult) Pyloric Stenosis
           Gastric outlet obstruction




126                                     © GIT1
                                        INDEX
Barium meal

Pyloric stenosis




 127               © GIT1
                   INDEX
Barium meal

Pyloric
stenosis




 128          © GIT1
               INDEX
Ba meal – pyloric stenosis
24 hours after
drinking contrast
material most of it is
still visible in the
stomach with residual
food above it.
The stomach is
dilated, its lower pole
hangs below the iliac
crest.
 Only minimal
contrast material
filling is observed in
the small intestines
  129                        © GIT1
                             INDEX
Barium meal

Pyloric stenosis




 130               © GIT1
                   INDEX
      Cancer Stomach




131                    © GIT1
                       INDEX
  A large tumor of
  the stomach
  seen as a filling
  defect in the
  body and antrum
  of the stomach
  causing irregular
  contours on both
  the lesser and
  the greater
  curve.

132                   © GIT1
                      INDEX
Gastric Carcinoma




                       How would you
                    suspect that a patient
                      is having cancer
                          stomach?

 133                                 © GIT1
                                      INDEX
Barium meal

CA pylorus




 134          © GIT1
              INDEX
Cancer stomach    Cancer stomach           Cancer stomach
Malignant ulcer   Malignant infiltration   Cauliflower mass




 135                                                   © GIT1
                                                       INDEX
 Large ulcerated gastric carcinoma arising in the body of the stomach




136                                                                     © GIT1
                                                                        INDEX
Ba–meal
Ulcer niche of
a malignant
gastric ulcer




137              © GIT1
                 INDEX
 CA stomach
 Linitis plastica




Diffusely infiltrating carcinoma,   Marked narrowing of almost the
note leather bottle appearance      complete stomach, due to diffuse
                                    infiltration of the gastric wall by a
  138
                                    carcinoma (linitis plastica)            © GIT1
                                                                            INDEX
Barium meal - CA stomach: Linitis Plastica

The distal two thirds of the
stomach is narrowed, rigid
peristalsis is absent.
stomach diameter is
decreased. The stomach
lacks the normal rugal
pattern.
 The mucosal surface is
often smooth but intact, and
ulcers are not a dominant
feature.
"leather bottle" stomach
describes diffuse submucosal
infiltration of the stomach.
  139                                        © GIT1
                                             INDEX
Clinical manifestations of gastric carcinoma
Early (curable) gastric cancer has no specific features that
can differentiate it from benign dyspepsia
Liberal use of gastroscopy in patients over 40 years of age
with a new or persistent dyspepsia. With biopsy from any
suspicious lesion.
N.B. gastric antisecretory drugs will improve symptoms of
gastric cancer
Late symptoms:
•Early satiety
•Bleeding – iron deficieny anemia
•Pyloric obstruction
•Thromboplebitis (Trousseau’s sign) & DVT
 140                                                        © GIT1
                                                               INDEX
   Multiple
  polypoid
   gastric
 masses in
 the cardia,
fundus, and
   antrum

Metastatic




 141           © GIT1
               INDEX
Postoperative stomach –
after Billroth II partial
gastrectomy

The afferent jejunal loop
connected to the gastric
stump shows only
minimal filling, the
majority of the contrast
material flows into the
efferent loop



 142                        © GIT1
                            INDEX
      Pseudo-pancreatic cyst




143                            © GIT1
                               INDEX
Barium meal

 Pseudo-pancreatic
       cyst




 144                 © GIT1
                     INDEX
               Volvulous of the Stomach
      Organoaxial volvulus            Mesenteroaxial volvulus




The axis of rotation is the long   The axis of rotation is along the
axis of the stomach                mesenteric attachment, much
                                   the same as is seen with
                                   sigmoid colon volvulus



145                                                            © GIT1
                                                                INDEX
Barium meal
Organo-axial volvulous of the
stomach




 146                            © GIT1
                                INDEX
      Duodenum




147              © GIT1
                 INDEX
Plain X-ray abdomen
(erect position)

Duodenal atresia

Dilated stomach (S)
and the part of the
duodenum above the
obstruction (D). Other
parts of abdomen do
not contain gas




  148                    © GIT1
                         INDEX
Plain X-ray abdomen
(erect position)

Duodenal atresia




  149                 © GIT1
                      INDEX
Duodenal atresia

Plain X-ray of the
abdomen:
The arrows point to
the dilated stomach
and that part of the
duodenum which is
above the obstruction.
Other parts of
abdomen do not
contain gas


       Double bubble
 150                     © GIT1
                         INDEX
  Duodenal atresia

 Gastrographin meal:
 The distended
 stomach and
 duodenum above the
 obstruction are visible
 after swallowing
 contrast material
 (arrows).




151                        © GIT1
                           INDEX
  Plain radiograph of
  the abdomen:
  The arrows point to
  characteristic triple
  gas bubbles in the
  stomach, duodenum
  and jejunum.

      Jejunal atresia

152                       © GIT1
                          INDEX
# Ulcer in the 1st part of duodenum (with clean floor & no everted edge)

 153                                                              © GIT1
                                                                   INDEX
      Duodenal ulcer (Endoscopy)
      A 35-year-old woman
      presents with tarry stools and
      a hemoglobin level of 7.5 g.
      Notice bleeding points


      Duodenal ulcer (Endoscopy)




154                                    © GIT1
                                       INDEX
Investigations for suspected peptic ulcer

Gastro-duodenoscopy is the most sensitive investigation




          Duodenal ulcer                              Gastric ulcer

                                                          Biopsy


155                                                                   © GIT1
                                                                      INDEX
Ba meal – 2 duodenal kissing ulcers

Two well-defined
filling excesses
facing each other
are visible on the
opposite contour
of the duodenal
bulb (arrows)




 156                                  © GIT1
                                      INDEX
Duodenal ulcer with
trifoliate deformity




 157                   © GIT1
                       INDEX
Duodenal ulcer
Ulcer niche




158              © GIT1
                 INDEX
Barium follow-through

Diverticulum of
the duodenum
(3rd part)




 159                    © GIT1
                        INDEX
Barium follow-through

Diverticulum of the
duodenum

A saccular lesion is
filling from the
horizontal part of
the duodenum
(arrow).

Course of the
jejunal loops is
normal

  160                   © GIT1
                        INDEX

								
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