Abdomen & GI system
FINAL
RT 91- Pathology
Spring 2010
1

Regions & Quadrants of Abdomen
2

Contents of Abdominal Cavity
1. Digestive system
– Stomach and Intestines
2. Hepatobiliary System
– Liver, gallbladder, & pancreas
3. Urinary system
– Kidneys, ureters and bladder
4. Circulatory system
– spleen
3

Gastrointestinal
System
1. Alimentary tractserves to digest & absorb food
– Consists of
• Mouth
• Pharynx
• Esophagus
• Stomach
• SM & LG bowel
• Rectum
4

1. 21 FT long
Small Bowel
2. Duodenum
1. Duodenal c-loop ends at ligament of
Treitz
3. Jejunum
1. Connects to ileum
4. Ileum
1. Terminates at ileocecal junction 5

Large Intestine
Hepatic flexure
1. 6 FT long
– Extends from ileocecal junction
– Ascending colon
(hepatic flexure)
– Transverse colon
(splenic flexure)
– Descending colon
– Sigmoid
– Rectum
– Anus
Splenic flexure
Sigmoid
6

Congenital and Hereditary
Anomalies
7

Esophageal Atresia
1.
Looping of the feeding tube
2. Atypically short esophagus & terminates in blind pouch
2. Air in stomach
8

Esophageal Atresia
1. Congenital anomaly
2. Esophagus fails to
_______________ past some point
3. Symptoms come soon after birth
– Salivation, gagging, choking, dyspnea, cyanosis
9

Tracheoesophageal Fistula
10

Tracheoesophageal Fistula
11

Duodenal
Atresia
On xray a “double-bubble” sign is demonstrated gas in stomach is one bubble
Gas in proximal duodenum is the second bubble
12

Duodenal Atresia
1. Congenital anomaly
2. ________________ of duodenum does not exist
3. Resulting in a complete
_________________
13

Colonic
Atresia
14

Colonic Atresia
1. Congenital failure of development of the
________________
2. Frequent complication includes fistula formation to the genitourinary system
3. Must be repaired surgically
15

Hypertrophic Pyloric Stenosis
16

Pyloric canal leading out of the stomach is greatly narrowed
Hypertrophic
Pyloric Stenosis
17

Hypertrophic Pyloric Stenosis
18

Hypertrophic Pyloric Stenosis
1. Congenital anomaly of the stomach
2. Pyloric canal leading out of the stomach is greatly narrowed because of hypertrophy of the pyloric sphincter
3. Most common indication for surgery in infants
19

Malrotation
Small bowel on right and colon on left
Cecum is not located in the
RLQ
20

1. Intestines are not in their normal position
2. Usually asymptomatic
3. Can lead to bowel volvulus or incarceration of bowel
1. Surgery is required with a resection of bowel involved
Malrotation
Cecum on left
21

Hirschsprung's
Disease
Feces
Narrowing
1. ______________
2. Dilated ______ colon with massive amounts of feces
Dilated
Sigmoid
3. Narrowed segment just below the dilatation
22

Hirschsprung’s Disease
AKA Congenital Megacolon
1. Absence of neurons in the bowel wall
2. This absence prevents normal relaxation of the colon & subsequent peristalsis
3. Results in gross dilatation
23

Meckel’s
Diverticulum
Difficult to diagnose with xray
Nuclear Medicine is better
Sac-like anomaly within ileocecal valve 24

1. Congenital
________________ of the distal ileum
2. Is remnant of a duct connecting the SB to the umbilicus in the fetus
Meckel’s
Diverticulum
25

Celiac
Sprue
X-rays show segmentation of the barium column, flocculation (resembling tufts of cotton) & edematous mucosal changes
26

1. Hereditary disorder with increased sensitivity to gluten
2. Interferes with normal
_____________ and
_____________ of food
Celiac Sprue
27

Inflammatory Disease
28

Esophageal Strictures
X-rays show peristalsis is transitory
Contour appears ragged
29

1. Caused by ingestion of caustic materials
1. Household cleaners
2. Detergents
3. Sulfuric acid
4. Sodium hydroxide
2. ____ the esophagus causing edema, swelling, & possible perforation
3. Requires repeated
_______________
Esophageal
Strictures
30

1. Incompetent ______ sphincter allowing backward flow of gastric acid and food into esophagus
2. ________________
3. ________may not be evident with barium swallow but strictures & ulcers may be present
GERD
31

GERD
32

1. Erosion of the mucous membrane of the esophagus, stomach & duodenum
2. Primarily affects
PT’s over 40 years
3. Diagnosis is made mostly with endoscopy
Peptic Ulcer
33

Peptic Ulcer
34

Barrett’s Esophagus
Peptic ulcer of the esophagus often with a stricture
Fibrotic healing of the ulceration
35

Barrett’s Esophagus
36

Radiographically looks like
“cobblestone”
The ______________________ sign is demonstrated where the
TI is so diseased and stenotic
Crohn’s Disease
37

Regional Enteritis
(Crohn’s Disease)
1. Chronic inflammatory disease of no cause
2. Typically occurs in lower ileum but can be seen throughout bowel
String sign
38

Appendicitis
CT is the gold standard
Shows an appendiceal abscess
As a round or oval soft tissue
Density that may contain gas
Appendix is dilated
39

Fecolith within Appendix
Common cause of
Appendicitis
40

1. Inflammation of the appendix resulting from an __________
1. Caused by a fecolith or neoplasm (rarely)
2. Most common abdominal surgery in the US
3. Sonography & CT used in diagnosis
Appendicitis
41

Ulcerative Colitis
BE demonstrates an irregular outline of the colon
_______ _________ appearance
42

1. Inflammatory lesion of the colon mucosa
1. Causes abscess leading to epithelial necrosis & ulceration
Ulcerative Colitis
2. It is idiopathic, thought to be an autoimmune disease
43

Esophageal Varices
On x-ray looks like wormlike defects within the column of
BA
44

Esophageal Varices
Varicose veins that are abnormally lengthened, dilated& superficial
Can be fatal
Occurs from conditions such as cirrhosis that bypass the normal venous drainage mechanism
45

Gastritis
Evidenced by gas bubbles (produced by bacteria) in the stomach
Wall
46

Endoscopy for Gastritis
47

1. Inflammation of the
_______ of the stomach
2. Results from various irritants: alcohol, corrosive agents, & infection
3. Most commonly demonstrated with
___________________
Gastritis
48

Degenerative Diseases
49

Inguinal Herniation
50

1. Protrusion of a loop of bowel through a small opening, usually in the abdominal wall.
2. Can cause obstruction
3. Can be surgically repaired, sometimes needing resection
Inguinal
Herniation
51

Hiatal Hernia
52

1. Weakness of esophageal hiatus that permits some portions of the stomach to herniate into the thoracic cavity
2. Chronic herniation can be associated w/
______
Hiatal Hernia
53

1. A type of hiatal hernia
2. Occurs when a portion of the stomach and the gastroesophageal junction are both above the diaphragm (99%)
1.
This ring is visible radiographically with this condition
2.
May be related to reflux
Schatzki’s Ring
54

Bowel Obstructions
55

Mechanical
Bowel
Obstruction
Large dilated colon
Little small bowel gas
56

1. Occurs from a blockage of the bowel lumen
2. Bowel sounds are
_______________ & high pitched
3. Vomiting _________
Mechanical Bowel
Obstruction
57

Gallstone Ileus
X-ray show air-fluid levels or air in biliary tree
Gallstone may also be visible in the TI where it causes the obstruction 58

1. A type of mechanical obstruction
2. Gallstone can erode
& create a fistula in the SB
3. Obstruction occurs when stone reaches ileocecal valve
Gallstone Ileus
59

Paralytic Ileus
Gas distributed throughout both LG &
SB
Normal bowel sounds are absent
60

Paralytic Ileus
1. Results from failure of peristalsis
2. Absent bowel sounds
61

Volvulus
X-ray shows collection of air conforming to the shape of affected bowel
62

1. Twisting of bowel loop
1. Usually at the sigmoid or ileocecal junction
2. Identifiable with x-ray
3. Usually happens in elderly
Volvulus
63

Intussusception
X-ray looks like a coiled spring
Air fluid levels LG bubble within mid abdomen
64

1. Is a kind of mechanical obstruction
2. Segment of bowel telescopes into distal segment and is driven further into distal bowel by peristalsis
Intussusception
65

Neurogenic Diseases
66

Achalasia
X-ray shows dilated esophagus with little or no peristalsis
67

Failure of the esophageal sphincter to relax causing dysphasia
Distal esophagus open intermittently
Achalasia
68

Diverticular Diseases
69

Esophageal Diverticula
• Occurs when mucosal outpouchings penetrate through the muscular layer of the esophagus
70

Esophageal Diverticula (traction)
• Involves all layers of esophagus and results in adjacent scar tissue that pulls esophagus toward area of involvement
71

Zenker’s Diverticulum
72

Zenker’s Diverticulum
1. Involves mucosa only
& results from a
__________ disorder
2. Allows esophagus to
_________ outwardly
3. Found at pharyngealesophageal junction
73

Colonic
Diverticula
Appear as round – oval
Outpouchings of BA projecting beyond bowel lumen
Vary in size 2cm or more
Tend to occur in clusters
74

Colonic
Diverticula
75

1. The presence of diverticula
_________inflammation
2. Diverticula are associated with hypertrophy of the muscular layer of the bowel
3. Most common in
_____________ (95%)
4. Most patients are asymptomatic
Colonic
Diverticula
76

Diverticulitis
1. Inflammation of the diverticulum
2. Exacerbated by feces lodging in the diverticulum
3. Signs and symptoms: fever, LLQ pain, tenderness and increased WBC count
4. BA shows diverticulum
5. Treatment centers on reduction of inflammation and infection
77

Neoplastic Diseases
78

Leimyomas
Appear as intramural defects in the barium outlined esophageal wall
79

Leimyomas of Esophagus
1. __________ tumors
2. Have smooth muscular tumors
3. Exact location can be determined on
CT
80

Gastroesophageal
Adenocarcinomas
Appears as mucosal destruction, ulceration, narrowing and sharp demarcation between normal
Tissue & malignant tumor
81

1. Occur in the lower esophagus around the gastroesophageal junction
Adenocarcinomas
2. Some believe there is a direct link between Barrett’s esophagus & adenocarcinoma
1. 90% have been found to arise from
Barrett’s mucosa
82

Small Bowel Neoplasms
Most common means of identifying is through endoscopy with biopsy
Can be seen on CT & with SBS
83

Small Bowel Neoplasms
1. Most occur in the duodenum & proximal jejunum
2. Some predisposing factors include:
1. Polyposis
2.
Kaposi’s sarcoma
3.
Crohn’s disease
84

BE is exam of choice, showing rounded filling defects
Proctosigmoidoscopy and colonoscopy are critical in evaluation and removal of polyps
Colonic Polyps
85

Colonic Polyps
1. Small masses of tissue arising from the bowel wall to project inward in the lumen
2. More frequently in the left colon
3. Most cancers of the colon & rectum usually arise from previous benign polyps
86

Colon Cancer
1. 2 nd most common cause of cancer mortality
2. Adenocarcinoma is the most common type of colorectal cancer
87

Colon Cancer
88

Colon Cancer
“Apple-Core lesion”
1. Xray shows “napkin ring” or “apple core” lesions
2. Double contrast BE more accurate than single contrast
3. CT colonoscopy also useful
89

CT of Abdomen & GI
1. Clearly demonstrates abdominal organs that are normally not apparent on x-ray w/o contrast
2. Recommended for bowel obstruction diagnosis
3. Virtual colonoscopy can be done to see areas not seen during a regular colonoscopy
90

MRI imaging of Abdomen & GI
1. Still limited due to bowel motion
2. Useful in demonstrating retroperitoneal masses impinging on GI system
3. Can differentiate between pathology & normal tissue
91

US imaging of Abdomen & GI
1. Not useful in imaging of the GI system
2. Extensively used to image the retroperitoneum because of the flexibility of angling the transducer
3. With this modality it is possible to image behind the bowel & assess for abnormalities
92

Nuclear Medicine imaging for
Abdomen & GI
1. Useful is detecting:
1. GI bleeds
2. Gastric emptying time
3. Presence of H. Pylori
4. Infection from gastric ulcers
2. PET has been known to demonstrate
20% of esophageal cancer undetected by
CT
93

Endoscopic Procedures
1.
Fiberoptic tube device to look inside hollow organs or cavities
2.
Upper endoscopy can see esophagus, stomach, duodenum & proximal jejunum
3.
Colonoscopy to the terminal ileum
4.
Small bowel is still out of reach
5.
Capsule endoscopy is a camera pill that is swallowed and takes pictures of the GI tract
1. Drawbacks include inability to biopsy area and locate pathology
2. Insurance reimbursement
6.
Also used for several therapeutic applications
1. Biopsies
2. Stent placement
3. Polyp removal
4. Stone removal
94