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gi pathology Flashcards

1
Q

Imaging for GI pathology

A

Alimentary Canal
Barium swallow/meal
Abdominal X-ray
Barium Follow-Through
Barium Enema
Cross Sectional Imaging
Ultrasound

Accessory Organs
Dental X-ray
Sialogram
Cross Sectional Imaging
Ultrasound
Fluoroscopic and operative procedures.

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2
Q

Key Acronyms

A

AXR – Abdominal X-ray
Ba – Barium
GORD – Gastro Oesophageal Reflux Disease (GERD in USA)
SBO – Small Bowel Obstruction
LBO – Large Bowel Obstruction
OGD – Oesophageal Dilatation
PR – Per Rectum (i.e., PR Bleed)
RUQ/LUQ – Right and Left upper Quadrant
RIF/LIF – Right and Left Iliac Fossa

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3
Q

Referral for AXR (Not Exhaustive List)

A

Symptoms

Acute abdomen (Pain, nausea and vomiting)
Bowels not opened for significant time (multiple days or weeks)
Unable to pass flatus (gas)
Distension

Suspected Pathologies

Diverticulitis
Bowel Obstruction
Perforation
Incarcerated/strangulated hernia
Toxic Megacolon
Trauma
Foreign Body

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4
Q

Inappropriate AXR requests

A

Constipation – (unless paediatric- specialist referral)
?Appendicitis – U/S or CT more sensitive
?Cholecystitis – U/S more sensitive
?Pancreatitis – U/S, CT or ERCPs more sensitive

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5
Q

Specialist AXR Imaging
Colonic transit studies

A

Also known as “shape studies”
Used for both paediatrics and adults to measure bowel transit time
Capsules containing radio-opaque shapes are swallowed over the course of several days and AXR is taken to assess speed at which they pass through GI system

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6
Q

Contrast Follow-Through

A

Can take place either following a Barium meal study or as a standalone examination
Ba or water soluble contrast is swallowed and a plain film AXR is requested at a specified time(s) in the future
The image is taken and the time since ingested is labelled on the image
Can be used to support diagnosis and certain contrasts act as a laxative agent and so can be therapeutic

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7
Q

Referral for Ba Swallow

A

Symptoms
Dyspepsia (Upper abdominal discomfort/”indigestion”)
Dysphagia – Difficulty Swallowing
Feeling of lump in throat

Suspected Pathologies
Achalasia
GORD
Hiatus Hernia

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8
Q

Contraindications for Ba Swallow

A

Perforation
Post-Surgical setting
High risk of aspiration

Can you think of any alterations to this examination that might impact on these contraindications?
Use a water-soluble contrast agent.

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9
Q

Image Interpretation
A systematic approach to imaging

A

Reviewing AXRs can be tricky:
Organs
Bone
Air
Muscle
Soft tissues
Foreign bodies?

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10
Q

AXR - A Systematic Approach

A

Systematic review:
Air
Bowel
Calcifications
Disability
Bones and solid organs
Everything else
Foreign bodies
Rest of the image

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11
Q

A - Air

A

Air should only feature within the lumen of the bowel.
Pneumoperitoneum is more sensitive on an erect chest x-ray.
Scarcely appears on Abdomen X-rays.. Unless obvious.

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12
Q

A - Air

A

Air should only feature within the lumen of the bowel.
Pneumoperitoneum is more sensitive on an erect chest x-ray.
Scarcely appears on Abdomen X-rays.. Unless obvious.

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13
Q

Air Signs

A

Notice the resemblance between the two?
Football sign- occurs in the case of massive pneumoperitoneum
Abdomen is outlined by perforated gas from a visceral perforation.
More common in paeds.
Can be found secondary to obstruction.

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14
Q

Air Signs

A

Notice the resemblance between the two?
Football sign- occurs in the case of massive pneumoperitoneum
Abdomen is outlined by perforated gas from a visceral perforation.
More common in paeds.
Can be found secondary to obstruction.

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15
Q

Air Signs

A

Rigler’s sign or ‘double wall’ sign
Occurs when gas is present of both sides of the bowel wall.
i.e. when there is gas in the bowel lumen and in the peritoneal cavity.

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16
Q

GI Pathologies

A

In this following section we shall discuss pathologies relating to the alimentary canal. This shall include the following details:
Aetiology of the pathology
Symptoms
Imaging Strategy
Radiographic Appearances
Treatments
Potential Complications
It is important to consider all aspects so that we can empathise with our patient and consider the overall pathway that they might follow.

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17
Q

Achalasia: Overview

A

Achalasia is a physiological pathology of the oesophagus
Caused by absent or disorganised oesophageal peristalsis and impaired relaxation of lower oesophageal sphincter.
Symptoms include:
Dysphagia
chest discomfort
regurgitation of food

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18
Q

Achalasia: Overview

A

Achalasia is a physiological pathology of the oesophagus
Caused by absent or disorganised oesophageal peristalsis and impaired relaxation of lower oesophageal sphincter.
Symptoms include:
Dysphagia
chest discomfort
regurgitation of food

19
Q

Achalasia: Radiographic Appearances

A

Some Achalasia appearances on Ba Swallow examinations include:
Dilated sections of oesophagus
Tapering of the inferior oesophagus “Bird Beak Sign”
Pooling of stasis of the Barium within the oesophagus

20
Q

Achalasia: Treatment and Complications

A

No curative treatments, symptomatic treatments include:
Prescribing muscle relaxants
OGD
Botox Injection
Laparoscopic surgery –”Heller’s Myotomy” procedure

21
Q

Hiatus Hernia: Overview

A

Hiatus Hernia is the herniation of abdominal anatomy through the diaphragm into thoracic cavity
More common in female and older individuals
Often asymptomatic and found incidentally
(Radiographic Appearances combined with next pathology…)

22
Q

Hiatus Hernia: Overview

A

Hiatus Hernia is the herniation of abdominal anatomy through the diaphragm into thoracic cavity
More common in female and older individuals
Often asymptomatic and found incidentally
(Radiographic Appearances combined with next pathology…)

23
Q

Hiatus Hernia: Treatment and Complications

A

If asymptomatic then usually no treatment
Surgical management if severe and causing symptoms (such as epigastric pain and nausea/vomiting)
Complications include:
Gastric Volvulus
Tension Gastrothorax
Cameron Lesions (Erosions at the hernia site)

24
Q

Gastro-Oesophageal Reflux Disease

A

GORD is a very common pathology, estimated to effect 13.98% of people worldwide (Nirwan et al., 2020).
Pathophysiology is influenced by a variety of factors including laxity/compliance of the gastro-oesophageal sphincter, pressure across this sphincter and diet.
Treatment can be via medicine to neutralise or reduce the quantity of stomach acid, or in severe cases there is a surgical approach called a “fundoplication”. (NHS, 2020)
Complications include oesophagitis, ulceration, haemorrhage and aspiration pneumonia.

25
Q

Gastro-Oesophageal Reflux Disease

A

GORD is a very common pathology, estimated to effect 13.98% of people worldwide (Nirwan et al., 2020).
Pathophysiology is influenced by a variety of factors including laxity/compliance of the gastro-oesophageal sphincter, pressure across this sphincter and diet.
Treatment can be via medicine to neutralise or reduce the quantity of stomach acid, or in severe cases there is a surgical approach called a “fundoplication”. (NHS, 2020)
Complications include oesophagitis, ulceration, haemorrhage and aspiration pneumonia.

26
Q

Gastric (peptic) Ulcer - Overview

A

Gastric ulcers are ulcerations of the stomach for which there are a number of risk factors:
H.Pylori Infection
Taking regular NSAIDs
Smoking

Symptoms include:
Abdominal pain
Vomiting
Loss of Appetite
Weight Loss

27
Q

Gastric (peptic) Ulcer - Imaging

A

Radiographic imaging is not routinely used to diagnose gastric ulcers. It can be visible on Ba meals.
It is important to be aware of this pathology however, as it’s complications include:
Perforation
Upper GI bleeding
Haematemisis
Which may trigger an imaging request.

28
Q

Gastric (peptic) Ulcer - Imaging

A

Radiographic imaging is not routinely used to diagnose gastric ulcers. It can be visible on Ba meals.
It is important to be aware of this pathology however, as it’s complications include:
Perforation
Upper GI bleeding
Haematemisis
Which may trigger an imaging request.

29
Q

Gastric (peptic) Ulcer – Treatment

A

Gastric Ulcers are treated depending on their severity and causes:
Antibiotics for H.Pylori infections
Proton Pump Inhibitor medication
H2-receptor antagonist medication

30
Q

Small Bowel Obstruction - Overview

A

Mechanical or physiological obstruction of small intestine.
Comprises 80% of all bowel obstructions
Wide variety of risk factors and underlying causes
Symptoms Include:
Abdominal pain
Nausea and vomiting
Distension of abdomen
Unable to pass gas or stool

31
Q

Small Bowel Obstruction – Imaging Presentation

A

AXR poor sensitivity for SBO. (50-60%)
Central dilated loops (>3cm)
Visible valvulae conniventes
Rarer- ‘string of pearls’ sign

32
Q

Small Bowel Obstruction – Treatment and Complications

A

Treatments:
Varies with cause of SBO
Correction of electrolyte balances
Removal of fluid from dilated region via NG/NJ tube
If SBO does not resolve, surgical resection

Risk of perforation if not treated in a timely fashion

33
Q

Lower Bowel Obstructions - Overview

A

A mechanical or physiological obstruction of the large bowel
LBOs comprise 20% of all bowel obstructions
They are often secondary to another pathology such as colon cancer
Symptoms include:
Abdominal pain
Nausea and vomiting
Distension of abdomen
Unable to pass gas or stool
Dehydration

34
Q

Lower Bowel Obstructions - Overview

A

A mechanical or physiological obstruction of the large bowel
LBOs comprise 20% of all bowel obstructions
They are often secondary to another pathology such as colon cancer
Symptoms include:
Abdominal pain
Nausea and vomiting
Distension of abdomen
Unable to pass gas or stool
Dehydration

35
Q

Lower Bowel Obstructions – Imaging Presentation

A

Dilated large bowel loops visible on AXR
For erect imaging air-fluid levels are present

36
Q

Lower Bowel Obstructions – Treatment and Complications

A

Treatment route depends on underlying cause, options include:
Surgical resection
Colonic stent
Treatment of electrolyte imbalance

Risk of perforation if not treated in a timely fashion

37
Q

Pneumoperitoneum - Overview

A

Pneumoperitoneum is the presence of air within the peritoneum. It can be an incidental finding if the patient has had very recent laparoscopic abdominal surgery.
Pneumoperitoneum can also be indicative of a GI perforation, which is a medical emergency.
Symptoms of GI perforation include:
Sepsis
Constipation
Abdominal Bloating
Nausea/Vomiting

38
Q

Pneumoperitoneum - Imaging

A

Both AXR and erect CXRs are frequently used to diagnose pneumoperitoneum.
For CXR, patients should be sat upright for at least 10 minutes prior to imaging.
Following a diagnosis of pneumoperitoneum, patients will often undergo CT imaging to determine the cause and/or plan for surgery

39
Q

Perforation – Treatment and Complications

A

Treatment depends on the cause of the perforation and the condition of the patient.
Sometimes conservative management such as IV antibiotics is sufficient.
Surgical treatment is also commonly utilised.
Bowel perforations can lead to severe illness such as peritonitis and sepsis.

40
Q

Volvulus - Overview

A

Volvulus from the Latin word “to roll” is a twisting of the intestines. There are two main forms of volvulus: sigmoid and caecal, depending on the anatomy that is affected.

Risk factors include:
Chronic constipation
High fibre diet
Congenital disorders
Neurological conditions
Abdominal tumours

Symptoms include:
Constipation
Abdominal Bloating
Nausea/Vomiting
Can be acute or chronic

41
Q

Sigmoid Volvulus – Imaging Presentation

A

On plain film AXR the sigmoid volvulus presents as:
Significantly dilated bowel
“Coffee bean sign”
No visible rectal gas

42
Q

Caecal Volvulus – Imaging Presentation

A

On plain film AXR the caecal volvulus will present with:
Significantly dilated bowel
Sometimes presents as an “embryo” sign. Where the dilated portion of bowel appears similar to the shape of an embryo.

43
Q

Volvulus – Treatment and Complications

A

Treatment depends on the cause and location of the volvulus. Complications include:
Bowel ischaemia (lack of blood supply)
Recurrence

Treatments include:
Sigmoid- repaired via endoscopic depression/ detorsion
Caecal- laparotomy and relocation
Sigmoid/caecal coloplexy (fixation) if recurrent
If ischaemia occurs then surgical resection may occur

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