test 4- powerpoint Flashcards
TWO CATEGORIES OF SONOGRAPHIC
EXAMINATION
- TRANSABDOMINAL
- ENDOLUMINAL
GASTROINTESTINAL TRACT from start to finish
NASOPHARNYX
PHARNYX
ESOPHAGUS
STOMACH
SMALL INTESTINE (DUODENUM, JEJUNUM, ILEUM)
APPENDIX
COLON
RECTUM
ANUS
how does food enter the stomach after leaving the esophagus
gastroesophageal junction at the level of the diaphragm
what are the three parts of the stomach
fundus
body
antrum
what are the 3 muscles of the stomach
longitudinal muscle
circular muscle layer
oblique muscle layer
how does food leave the stomach
pylorus and pyloric sphincter
what does food enter after the stomache
duodenum
different sphincters from top to bottom
esophageal - upper and lower
pyloric
oddi
ileocecal
anal- internal and external
Barium is an oral liquid which is ______________________
highly radio-opaque
Barium exams may be either single (barium alone) or
double contrast which is _______________________
barium and air.
In the latter air is
introduced after the barium. This provides a double
contrast between the radio-lucent air and the radio-
opaque barium which is left coating the mucosa.
Ultrasounds is required to be performed before or after any
endoscopic procedure (which
fills bowel with air) and/or
Barium procedure (air and
contrast are used) or our study
will be about worthless
before
the diff between normal and abnormal endoscopic study
before/after polyp endoscopic removal
Five layers can be distinguished with transabdominal sonography
from inside to outside
- Superficial mucosa (echogenic)
- Deep mucosa with muscularis mucosa (hypoechoic)
- Submucosal (echogenic)
- Muscularis propria (hypoechoic)
- Subserosal fat (echogenic)
- Beyond this is the mesothelium
which covers loops but is not
seen as a layer with
ultrasound.
the stomach is ___________ to the tail of the pancreas
anterior
________________ Can be evaluated with endosonography or
through left lobe of liver on transabdominal
sonography
ESOPHAGOGASTRIC JUNCTION
ESOPHAGOGASTRIC JUNCTION is seen _______________ to aorta
anterior
sonography can visualize what ESOPHAGOGASTRIC JUNCTION issues
- hiatal hernia
- esophageal varices
- tumors
which quadrant is the stomach located in
LUQ
stomach fundus is _____________ to the spleen
medial
Stomach fundus is ________________ to the
left kidney
anterior
Undistended, stomach wall should measure no more than
_________
5 mm
distended, stomach wall should measure no more than
_________
3mm
Body and antrum of the stomach lie _______ or ____________ to the left lobe of the liver,
posterior or
inferior
Body and antrum of the stomach lie _____________ to the
pancreas
anterior
Body and antrum of the stomach lie ___________ to the gallbladder
medial
stomach
Patient may be given 40 - 50 oz
(5 cups) water that has been set out
overnight (aerated)
Right lateral decubitus - antrum
Left lateral decubitus - fundus
May demonstrate major wall thickening > 4 mm
Usually suggested by a focal or generalized
edema of the wall
May result in ascites, or localized abscess, or
pancreatitis
May cause gastric outlet obstruction as lumen
will narrow with inflammation and delay stomach
emptying
Gastric/Peptic ulcers
STOMACH
Fluid and Debris in stomach in patient who is
truly NPO may indicate a _________________________
gastric outlet obstruction
gastric outlet obstruction is usually caused by ________________-
ulcers
STOMACH
Solid mass adherent to gastric wall
Variable echogenicity
Inhomogeneous, may be sharply delineated or
not
POLYPS
STOMACH
Third most common GI malignancy (follows
colon and pancreatic)
May be fungating, ulcerated, diffuse, polypoid,
or superficial
Classified according to extension
CARCINOMA
WHAT IS THE ARROW POINTING AT
FOCAL WALL THICKENING WHICH TURNED OUT TO
BE ADENOCARCINOMA
Third most common GI malignancy (follows
colon and pancreatic)
STOMACH CARCINOMA
Most common tumor of stomach
Smooth muscle tumor
Usually asymptomatic
Hypoechoic mass continuous with muscular
layer of stomach
May hemorrhage and undergo cystic
degeneration
STOMACH LEIOMYOMA
Most common tumor of stomach
STOMACH LEIOMYOMA
Target lesion with variable pattern
By transabdominal imaging, thickened
hypoechoic gastric wall and marked rugal
thickening
stomach LEIOMYOSARCOMA
Occurs in infants with 95% of cases occurring
between 3-12 weeks with the peak occurrence at
4 weeks of age
HYPERTROPHIC PYLORIC STENOSIS
More common in males (4 to 1)
Hypertrophic enlargement of the pyloric muscle
(channel between the stomach and the
duodenum)
HYPERTROPHIC PYLORIC STENOSIS
More common in males (4 to 1)
Infants present with PROJECTILE vomiting without
bile, dehydration, lethargy and failure to thrive
are clinical symptoms
HYPERTROPHIC PYLORIC STENOSIS
More common in males (4 to 1)
PYLORIC STENOSIS
SCANNING TECHNIQUE FOR PYLORIC
STENOSIS
Scanned in both supine baby may be rolled into
right decubitus if needed.
Transverse plane demonstrates long axis
To localize pylorus, scan transversely, descending
along lesser curvature of stomach, through left
lobe of the liver
Locate antrum of stomach
MEASURING FOR PYLORIC STENOSIS
MEASUREMENTS SHOULD BE MADE FROM THE ANTRUM OF THE
STOMACH TO THE MOST DISTAL PORTION OF THE IDENTIFIABLE
CHANNEL
Scanning the baby in a sagittal plane demonstrates the
pylorus in transverse.
The enlarged muscle will present as a “donut sign” (an
anechoic to hypoechoic muscle mass with a central lumen of
increased echogenicity)
PYLORIC MUSCLE BEING PUSHED
DOWN UNDER STOMACH.
just more images
On the second ultrasound exam the pyloric
muscle thickness was 4mm. This was a
definite abnormal finding consistent with
pyloric stenosis.
On an early study, the pyloric muscle
is somewhat prominent, but the
thickness measurement of 2.8mm is
not diagnostic of pyloric stenosis.
Recommend follow-up in a few days
types of hernias
TYPES OF HERNIAS ARE:
* INGUINAL HERNIA.
* FEMORAL HERNIA.
* UMBILICAL HERNIA.
* INCISIONAL HERNIA.
* EPIGASTRIC HERNIA.
* HIATAL HERNIA.
Spigelian hernias
occur through defects
in this muscle _____________
to the rectus sheath.
lateral
SMALL BOWEL
Jejunum and ileum lie in the central portion of the
abdomen, inferior to the __________ and ________, and superior
to the _____________
liver and stomach
urinary bladder
SMALL BOWEL
May see valvulae ______________ – “keyboard sign” seen in
duodenum & jejunum
conniventes
SMALL BOWEL
where is conniventes taking place at
duodenum and jejunum
SMALL BOWEL
Normal sections of bowel should be smaller than ____________ in
diameter and should demonstrate peristalsis
3 cm
SMALL BOWEL
SMALL BOWEL
SMALL BOWEL
SMALL BOWEL
SMALL BOWEL
Many causes of obstructions, i.e.
adhesions, inflammatory
masses, neoplastic lesions,
volvulus, intussusception
(more often in children),
and luminal obstruction
(impaction)
small bowel
another name for impaction for small bowel
luminal obstruction
SMALL BOWEL
ILEUS aka _______________
acute intestinal pseudo-obstruction
SMALL BOWEL
what pathology
Characterized by failure of the intestine to propel its contents,
owing to diminished motility
Caused by peritonitis, bowel ischemia, myocardial infarction,
surgery, medications, hypokalemia, and infection
Sonographically characterized by small bowel distended with
either air or fluid (if air it will be hard to scan this patient)
Peristalsis is normal to increased
ileus
SMALL BOWEL
Most common nonspecific inflammation of the small
bowel
CROHN’S DISEASE
SMALL BOWEL
Most common nonspecific inflammation of the small
bowel
Cause is unknown
Most often involves the ileum
May affect the colon, jejunum, and stomach
Commonly associated with ulcers, fistulae, and mucosal
nodularity
Sonographic appearance is hypoechoic thickening of the
bowel wall and mesentery—hard like melted plastic
No blind end like the appendix
CROHN’S DISEASE
SMALL BOWEL
what is it?????
what is TI
While blood flow is increased, peristalsis is virtually absent
SMALL BOWEL
Intestinal obstruction due to knotting &
twisting of bowel
VOLVULUS
SMALL BOWEL
two types of volvulus
Closed loop - lumen is
occluded at 2 points along
the length
Dilated bowel
(C or U shaped loop)
SMALL BOWEL
what shape is dilated bowel
c or u shaped loop
SMALL BOWEL
Malrotated bowel can potentially occur at any age but in approximately
75% of cases is within a month of birth, most within the first week, and
90% within 1 year. Suspected when a healthy baby suddenly presents with BILIOUS VOMITING
MIDGUT VOLVULUS
SMALL BOWEL
Sonographic findings may include
* clockwise whirlpool sign
* inverted SMA/SMV relationship
* abnormal bowel
* dilated duodenum proximal to obstruction
* thickened wall of small bowel distal to obstruction
* dilated fluid-filled loops of small bowel
* free intra-abdominal fluid
MIDGUT VOLVULUS
SMALL BOWEL
The telescoping of bowel–Proximal loop of bowel
telescopes into the lumen of the adjacent distal portion
Can lead to bowel obstruction, perforation, peritonitis, and
vascular compromise
Usually occurs in children (between ages 3 mos and 3
years)
Symptoms include intermittent, colicky pain, distension,
and vomiting, possibly an abdominal mass and rectal
bleeding
Usually evaluated with ultrasound and corrected with a
barium enema
INTUSSUSCEPTION
SMALL BOWEL
Sonographic appearance - target pattern (donut sign); can
have a pseudokidney appearance in the long axis
INTUSSUSCEPTION
SMALL BOWEL
more pseudo kidney sign which is ____________________
INTUSSUSCEPTION
SMALL BOWEL
The most common presenting symptom is
painless rectal bleeding, followed by intestinal
obstruction, volvulus and intussusception.
MECKELS DIVERTICULUM
SMALL BOWEL
may present with all the features as acute appendicitis
MECKELS DIVERTICULUM
SMALL BOWEL
a true congenital diverticulum,
is a small bulge in the small intestine present at birth.
It is a remnant of the omphalomesenteric duct
(also called the vitelline duct)
It is the most frequent malformation of the
gastrointestinal tract.
It is present in approximately 2% of the
population, with males more frequently
experiencing symptoms
MECKELS DIVERTICULUM
SMALL BOWEL
It is the most frequent malformation of the
gastrointestinal tract.
MECKELS DIVERTICULUM
SMALL BOWEL
A memory aid is the rule of 2’s:
2% (of the population)
2% are symptomatic
2 feet (from the ileocecal valve)
2 inches (in length)
2 types of common ectopic tissue (gastric and
pancreatic)
Most common age at clinical presentation is 2
Males are 2 times as likely to be affected
MECKELS DIVERTICULUM
SMALL BOWEL
For the case on the right: A
diagnosis of “most likely
appendicitis” was made,
however the lesion was very
close to the midline and this
was conveyed to the surgeon
who rather than making the
usual incision in RLQ went
from midline and found an
infected, dilated Meckels
diverticulum
colon and rectum
▪ Colon usually lies in the periphery of the abdomen
▪ Lateral on right and left and runs transverse
superiorly along the liver margin in the upper
abdomen
▪ No special techniques are available for evaluating
the colon
▪ Usually more air in the colon than in small bowel–
Fluid filled colon is unusual
▪ Wall should measure 4 - 9 mm thick when not
distended and 2 - 4 mm thick when distended
colon wall should measure ________ when distended and ___________ when not distended
2 - 4 mm thick when distended
4 - 9 mm thick when not
distended and
COLON AND RECTUM
- ________________– obstructed loop is likely to be
gas filled (usually better diagnosed
radiographically) - Crohn’s colitis - produces signs identical to
Crohn’s of small bowel - Colonic Impaction- chronic constipation leads
to stool that hardens and cannot move. Can
occur in the elderly and for those on long
term narcotic pain medications.
Obstruction
COLON AND RECTUM
- __________________ - produces signs identical to
Crohn’s of small bowel
Crohn’s colitis
COLON AND RECTUM
- ________________- chronic constipation leads
to stool that hardens and cannot move. Can
occur in the elderly and for those on long
term narcotic pain medications.
Colonic Impaction
Third leading cause of death
from cancer (after lung and breast)
colorectal cancer
Carcinoma - Third leading cause of death
from cancer (after lung and breast)
50% arise in rectum and rectosigmoid colon
25% in sigmoid
25% in rest of colon
Large colon cancer appears as a non-specific
hypoechoic target lesion
Smaller lesions are much more difficult to
identify
Must use a high-frequency transrectal probe;
US good for staging
colorectal cancer
COLON
Mucosal herniations through muscular layer of
bowel wall
Become more prevalent with increasing age
May lead to infection and inflammation
Complications - abscess, fistula, bowel perforation
Most occur in sigmoid colon
Not typically seen by ultrasound
DIVERTICULITIS/DIVERTICULOSIS
COLON
- THE YOUNG ARE USUALLY AFFECTED AND SYMPTOMS USUALLY
DEVELOP OVER TIME, RATHER THAN SUDDENLY. - IS AN INFLAMMATORY BOWEL DISEASE (IBD) THAT CAUSES
LONG-LASTING INFLAMMATION. - ULCERATIVE COLITIS CAUSES ULCERS AND BLEEDING WITH
INFLAMMATION—THIS CAN BE DEBILITATING AND SOMETIMES CAN
LEAD TO LIFE-THREATENING INFECTIONS OR COMPLICATIONS
INCLUDING COLON CANCER - MODERATE AND SEVERE COLITIS IS DEFINED WHENEVER THE
MAXIMUM COLONIC WALL THICKNESS (MEASURED IN ANY OF THE
COLONIC SEGMENTS EXAMINED) WAS MORE THAN 6 OR 8 MM
COLITIS AND ULCERATIVE COLITIS
full name for appendix
VERMIFORM APPENDIX
Locate the cecum and terminal ileum
Must use a graded pressure on the transducer to
displace the gas-filled bowel (primarily the cecum)
Usually can identify inflamed, distended
appendices
Should measure no more than 6 mm in diameter
Hypoechoic part of the wall should measure no
more than 2 mm thick
about appendix
what should normal appendix measure
no more than 6mm in diameter
hypoechoic part of wall no more than 2mm thick
origin at cecum that meets appendix is called
(McBurney’s Point)
appendix is where in relation to the iliacus m.
anterior
appendix is where is relation to iliacs
▪ Iliac artery and vein medially
▪ May be draped over iliac
vessels
▪ May be posterior to terminal
ilium or cecum
▪ Check pelvis near right adnexa
▪ Partially compressible
APPENDIX
APPENDIX
APPENDICITIS
Almost always associated with obstruction of the
appendiceal lumen
May occur in any age group, most often affecting young
adults
Clinical signs: general periumbilical pain, leukocytosis,
fever, and sometimes nausea, pain will eventually localize to
the RLQ with point tenderness and rebound tenderness
When vomiting occurs, it nearly always follows the onset of
pain. Vomiting that precedes pain is suggestive of intestinal
obstruction.
if vomiting occurs before pain then is is indicative of __________________
intestinal obstruction
if vomiting occurs after pain then it is indicative of _________________
appendicitis
APPENDICITIS
Chief complication is abscess formation and
generalized peritonitis
A ruptured appendix may be much more
difficult to visualize
Diameter > 6 mm with mucous in lumen and
associated focal pain over the appendix is
sufficient to establish diagnosis of unruptured
appendicitis
May contain a stone - called “appendicolith”
appendix may contain a stone which is called _____________
appendicolith
Acute appendicitis. Non-compressible,
inflamed appendix (arrowheads) lies next to
the normal compressable ileum. The lumen is
dilated and the diameter is 11 by 13 mm. Note
the fluid-debris level within the lumen.
Acute appendicitis. The inflamed appendix shows
local disturbance of the layer structure of the wall
indicating local transmural progression of the
infection. The surrounding inflamed fat will probably
effectively wall-off the imminent perforation.
White arrows: Ulcerations—possible rupture
Open arrow: Appendicolith
Black arrows: Bright (inflamed) fat
COMPLICATIONS OF APPENDICITIS
Patients, who delay in seeking medical treatment may
later present with:
* An abscess (pus-containing appendiceal mass) or
* inflammatory phlegmon where the appendix has
ruptured and the patient’s own defense
mechanisms attempt to use fat and omentum to
circumscribe the infection and contain it
* Chronic Appendicitis an ongoing battle with
appendicitis recurrence.
Patients are diagnosed as ‘appendiceal phlegmon’
and are usually managed conservatively because the
surgeon knows that appendectomy in such cases is
technically difficult or even impossible since normal
tissues are involved in containing the infection.
Distension of the appendix by mucous
Uncommon lesion
More common in women; mean age is 55 years
Clinically presents with RLQ pain. May be
asymptomatic
Can rupture causing massive accumulation of
gelatinous ascites
Sonographically - appears as a purely cystic or
complex mass up to 7 cm in diameter;
demonstrates posterior enhancement
MUCOCELE
Distension of the appendix by mucous
MUCOCELE
Sonographically - appears as a purely cystic or
complex mass up to 7 cm in diameter;
demonstrates posterior enhancement
MUCOCELE
MUCOCELE
