Radsci 350 Gi System Sections 1 & 2

Front 1

Hiatal Hernia

Back 1

Herniation of the stomach through a weakened cardiac sphincter into the left hemi-diaphragm. There is also a weakening in the esophageal hiatus.

Front 2

Types of Hiatal Hernia

Back 2

- Direct or sliding
- Paraesophageal or rolling
- Intrathoracic Stomach

Front 3

Direct/Sliding Hiatal Hernia

Back 3

There is a pulling of the cardiac sphincter above the diaphragm and the stomach comes through. Ie. both the stomach and the cardiac sphincter come through the esophageal hiatus. Seen when patients do the valsalva maneuver.

Front 4

Paresophageal Hiatal Hernia

Back 4

The cardiac sphincter stays in place but some of the stomach comes through it and the esophageal hiatus. This causes pressure on the distal esophagus and there is a higher chance of necrosis of tissue and bowel due to the fact that it does not slide back into place as the direct/sliding does.

Front 5

Intrathracic Stomach

Back 5

The whole stomach moves up above the diaphragm into the thoracic cavity.

Front 6

Diagnosing Hiatal Hernia

Back 6

Hiatal Hernias are diagnosed through a UGI. Patients are put in the trendelenberg position and asked to do the valsalva maneuver.

Front 7

Treatment of Hiatal Hernia

Back 7

Often treatment is not needed beyond conservative treatment such as dietary restrictions to decrease weight, no carbonation, and no lifting. However, surgery may be required in extreme cases. In these instances, they will do a fundoplication where they tighten the hiatus and the stomach is secured below the diaphragm.

Front 8

Complications of Hiatal Hernias

Back 8

- Schatzki's Ring - A complication of a sliding hiatal hernia, this is a fibrous tissue that tightens around the esophagus.
- Pressure on esophagus - can be caused by all three types of hernias.
- Bowel necrosis - seen in paraesophageal and intrathoracic stomach
- Respiratory and cardiac problems - seen mostly with intrathoracic due to the pressure in the thoracic cavity.

Front 9

Radiographic Demonstration of Hiatal Hernias

Back 9

- A large hiatal hernia may appear on a plain chest radiograph as a soft tissue mass in the posterior mediastinum containing a prominent air-fluid level.
- Otherwise these are identified via barium studies and position of the stomach in comparison to the esophagus and diaphragm.

Front 10

Esophageal Varices

Back 10

Varicose veins (dilated, tortuous veins) of the distal esophagus caused by venous hypertension and portal vein thrombosis. Ie. Caused by liver issues such as sclerosing and/or cirrhosis that cause a pooling of blood due to damage of valves in the veins.

Front 11

Diagnosing Esophageal Varices

Back 11

- Hemorrhage is usually the first sign because veins get too dilated and "pop".
- Appears as lucent, tortuous wave-like filling defects or striations on contrast studies.
- Endoscopy is helpful in diagnosis.

Front 12

Treatment of Esophageal Varices

Back 12

- Vasopressors to constrict veins
- Surgical intervention - bypass surgery.

Front 13

Radiographic Appearance of Esophageal Varices

Back 13

Will look like a wavy border which is a thickening of the folds and will look like round or oval filling defects resembling the beads of a rosary. Is best demonstrated in a double-contrast barium swallow study where upright and recumbant images are taken.

Front 14

Complications of Esophageal Varices

Back 14

- Bleeding and ulceration
- They are an ominous sign in people with cirrhosis because 90% of people with liver disease die within 2 years of diagnosis of esophageal varices.

Front 15

Esophageal Diverticuli

Back 15

An outpouching of one or more layers of the esophageal wall.

Front 16

Types of Esophageal Diverticuli

Back 16

- Pulsion
- Traction
Subsets:
- Zenker's
- Epiphrenic

Front 17

Pulsion Diverticuli

Back 17

Outpouching of one layer - the mucosa - through muscle. This is also called a "false" diverticula.
- Only happens during peristalsis.

Front 18

Traction Diverticuli

Back 18

When all three layers of the esophageal wall pouch out through the muscular layer. Also called a "true" diverticula.
- These diverticula are most often caused by inflammatory processes that cause scar tissue.

Front 19

Zenker's Diverticula

Back 19

These are diverticuli found in the upper area of the esophagus near the pharyngo-esophageal sphincter (ie. proximally)
- Can cause bad breath
- Can cause motor function disturbances and develop in response to the pull of fibrous adhesions after infection of the mediastinal lymph nodes.
- Can lead to aspiration pneumonia due to inability to get rid of food contents.

Front 20

Epiphrenic Diverticuli

Back 20

Diverticuli that arise in the distal 10cm of the esophagus.
- Associated with incoordination of esophageal peristalsis and sphincter relaxation. This increases the intraluminal pressure in this segment.
- Is a cardiac sphincter issue and can be a problem in people who try to swallow too large of bites of food.

Front 21

Radiographic Demonstration of Esophageal Diverticula

Back 21

Seen on routine esophagram radiographs or fluoroscopy as outpouchings from the esophagus since contrast will fill them and usually remain longer in the outpouching.

Front 22

Treatment of Esophageal Diverticula

Back 22

Do not require treatment unless they start to cause issues with swallowing or infection. Then treatment is:
- Dietary restrictions
- Antibiotics
- Removal or "clipping" it off from the esophagus.

Front 23

Esophageal Fistulas

Back 23

A fistula is an abnormal passage between two normal structures. In the esophagus then it is an abnormal passage off of the esophagus.
- Can be esophageal atresia in infants meaning "no passage" development
- Is characterized by incomplete development of the esophagus
- It is usually associated with fistulous tract with the TRACHEA

Front 24

Diagnosis of Esophageal Fistulas

Back 24

Can see acute respiratory distress, drooling, obstruction when placing NG tube.
- Can be caused by congenital abnormalities or malignancy
- Seen on radiographs as abnormal connections when contrast fills them off the esophagus.

Front 25

Differences in Fistulas/Atresia

Back 25

Esophageal fistulas/atresia are listed as Type I-IV. The type describes the defect as to which parts of the esophagus/trachea are connected or missing.

Front 26

Treatment of Esophageal Fistulas

Back 26

In an infant born with fistulas/atresia, the treatment is immediate surgery in order to save the infant's life as it will affect ability to breathe/eat and can cause aspiration pneumonia.

Front 27

Esophageal Neoplasms

Back 27

Can be benign or malignant.
- Benign - Leiomyoma
- Malignant - Carcinoma

Front 28

Benign Esophageal Neoplasm - Leiomyoma

Back 28

Found in the distal esophagus, this neoplasm will present as a well-delineated, well-circumscribed lesion. It will present as lucency and might be only in the muscle but can grow into the lumen.
- Treatment is surgical resection to relieve pressure on the esophagus.

Front 29

Malignant Esophageal Neoplasm - Carcinoma

Back 29

- Caused by chronic irritation that causes tissues to continually regenerate losing differentiation.
- Chronic use of tobacco and/or alcohol predispose a person to esphageal carcinoma.
- Can be caused by chronic reflux as well.
- Most commonly found in the distal 1/3 of the esophagus.

Front 30

Radiographic Appearance of Esophageal Carcinoma

Back 30

Will show up as a narrowing of the lumen with irregular borders.

Front 31

Symptoms and Complications of Esophageal Carcinoma

Back 31

Symptoms/Complications - Dysphagia is the major symptom but it does not occur right away which is why carcinomas are not diagnosed early very often. Also tend to bleed so can cause a metallic flavor in the mouth or coughing up of blood.

Front 32

Treatment of Esophageal Carcinoma

Back 32

Prognosis is low at a 10% 5-year survival rate. This is because it often invades surrounding tissues such as hiatuses, heart, IVC, DA, etc...This can cause major vessels to hemorrage and make it impossible to resect the whole tumor.
- They will remove the tumor completely if it has not invaded the surrounding tissues (better prognosis) or remove sections if it has invaded and then treat with chemotherapy. Newest treatment is laser therapy.

Front 33

Diagnosis of Esophageal Carcinoma

Back 33

Done through Fluoroscopy, Endoscopy, Laryngoscopy, and CT.
- Appears on contrast studies as flat, plaquelike lesions of the walls to start and progresses to irregular narrowing with ulceration of the walls. Looks jagged and "rat-bite" like. IE. irregular borders like all cancerous lesions.

Front 34

Ulcers

Back 34

Ulcers are a group of inflammatory processes involving the stomach and duodenum. They are caused by the actions of acid secreted by the stomach. Peptic ulcer disease includes gastric and duodenal ulcers.

Front 35

Major Complications of Peptic Ulcer Disease

Back 35

- Hemorrhage
- Perforation
- Gastric Outlet Obstruction due to swelling in the area
- Peptic Ulcer disease is the most common cause of acute upper gastrointestinal bleeding.

Front 36

Common Areas for Peptic Ulcer Disease

Back 36

Ulcers are most commonly found in the distal esophagus near the cardiac sphincter, the greater curvature of the stomach, and the proximal part of the duodenum near the pyloric sphincter.

Front 37

Causes and Treatment of Peptic Ulcers

Back 37

Caused by excess pylori bacteria which cause irritation to gastric and duodenal linings. They are treated with high dose antibiotics to decrease pylori bacteria.

Front 38

Gastric Ulcers

Back 38

- Appear almost anywhere in the stomach but the most common site is the lesser curvature. Not usually found in the fundus - found here can be a concern for stomach CA.
- People with Type A blood are more prone to Gastric Ulcers.

Front 39

Diagnosis and Radiographic Appearance of Gastric Ulcers

Back 39

- Found using endoscopy and fluoroscopy.
- May be seen after the stomach empties as areas that collected contrast material and as outpouchings during peristalsis. Will look like an excavation in the wall of the stomach.
- May be benign or malignant and the borders will help determine which.

Front 40

Treatment of Gastric Ulcers

Back 40

If benign - conservative treatment of high-dose antibiotics, BRAT or fluid diets. If serious pain, they may do a vagotomy where they cut the nerve to reduce pain.

Front 41

Duodenal Ulcers

Back 41

- Most common form of peptic ulcer
- People with Type O blood are more prone to duodenal ulcers.
- They are found most commonly in the proximal portion of the duodenum.

Front 42

Diagnosis and Radiographic Appearance of Duodenal Ulcers

Back 42

- Pain is the cardinal symptom
- Will appear in fluoroscopy as a collection of edematous barium and mucosal folds projecting from the lumen.
- Appears as unusually fillings or filling defects, decreased lumen size due to constriction, and duodenal bulb deformity.

Front 43

Treatment of Duodenal Ulcers

Back 43

Conservative treatment with diet, medication, and possible vagotomy to relieve pain.

Front 44

Visualizaiton of Complications of Ulcers

Back 44

Perforation is seen as free air under the diaphragm.
Gastric Outlet Obstruction is seen as narrowing of the lumen of the distal stomach or duodenal bulb.

Front 45

Cancer of the Stomach

Back 45

Includes Gastric Carcinoma and Adenocarcinoma.
- Adenocarcinoma is the most significant malignant tumor of the stomach and is usually in the distal stomach.
- Types can be fungating or polypoid (a mass), ulcerating (of the mucosal lining), or superficial.

Front 46

Problems associated with Gastric Adenocarcinoma

Back 46

- Creates problems emptying stomach which causes hemorrhage.
- Can interfere with other vessels such as IVC creating pressure and blood flow problems
- Usually not diagnosed very early which means it does not have a very good prognosis - survival rate is 10%.

Front 47

Predispositions for Gastric Adenocarcinomas

Back 47

Several conditions appear to predisopse a person to stomach cancer:
- People with atrophic gastric mucosa (seen in pernicious anemia)
- People 10-20 yrs after a partial gastrectomy for peptic ulcer disease
- People with achlorhydria (absence of hyrochloric acid in gastric secretions.

Front 48

Radiographic Appearance of Gastric Adenocarcinoma

Back 48

Usually seen as filling defects with jagged borders. However, gastric carcinoma can present with a broad spectrum of appearances depending on the type of tumor and it's profusion into the gastric walls or not.

Front 49

Treatment of Gastric Adenocarcinoma

Back 49

Depends on the extent of the tumor, but is usually radical sub-total gastrectomy. Chemotherapy after operation is effective.

Front 50

Types of Gastric Resection

Back 50

Two types are Billroth I and Billroth II.
- Billroth I - They will remove the mid and distal regions of the stomach and leave the fundus to attach to the duodenum.
- Billroth II - They remove the mid and distal regions of the stomach but will attach the fundus to the jejunum instead of the duodenum.

Front 51

Small Bowel Obstructions

Back 51

Obstruction of the bowel caused by:
- fibrous adhesions from previous surgery (scar tissue)
- Secondary to external hernias
- Fluid in bowel due to inflammatory processes
- Herniation of bowel into the inguinal canal

Front 52

Diagnosis and Radiographic Appearance of Small Bowel Obstruction

Back 52

Diagnosed through abdominal xrays, colon examinations, and CT. Will have you do flats and uprights.
Seen on xray as:
- Stepladder sign - snake like pattern of small bowel stacking on top of itself.
- Gas proximal to small bowel obstruction (ie. Air above, none below) is swallowed air.

Front 53

Treatment of Small Bowel Obstruction

Back 53

Decompression to eliminate air above obstruction. Possibly surgery if obstruction cannot be relieved.

Front 54

Ileus

Back 54

Immobility of the intestines without any obstruction. Ie. no movement of the bowel.

Front 55

Types of Ileus

Back 55

1. Adynamic - caused by anesthesia which relaxes the bowel and bowel doesn't restart peristalsis
2. Localized - caused by trauma or one area that is not working.
3. Colonic - Same as localized by specific to the area of the colon.

Front 56

Radiographic Appearance of Ileus

Back 56

Retention of large amounts of gas and fluid in dilated small and large bowel. It will appear uniformly dilated with no haustral markings, smooth borders of intestings, and fluid in the bowel due to inflammatory process. In localized or colonic, it will appear the same but only in the area of ileus.

Front 57

Treatment of Ileus

Back 57

Adynamic ileus caused by surgery usually resolves itself in 36-48 hours. Otherwise, treatment includes insertion of an NG tube to aspirate the stomach, decompress the bowel, and allow the intestine to rest. Also IV injection to correct fluid imbalances.

Front 58

Crohn's Disease

Back 58

An autoimmune disease of the small and large bowel found in young adults. It is an inflammatory, chronic disorder affecting any part of the intestinal tract and layers of the bowel wall.
- Antibodies attack the mucosal linings.

Front 59

Signs and Radiographic Appearance of Crohn's Disease

Back 59

1. Ulceration
2. String Sign - Very skinny areas of bowel that look like a string
3. Fistula formation
4. Cobblestone appearance - Filling defects that look like groups of little lucent pebbles. You will see areas affected then skipped areas. Affected areas are called "skipped lesions".

Front 60

Treatment of Crohn's Disease

Back 60

All are palliative since it is an autoimmune disease.
- Anti-inflammatory drugs
- Restrictive diet
- Surgery

Front 61

Intussusception

Back 61

Telescoping or invagination of part of the bowel into an adjacent distal portion of the bowel. Often found in the ileocecal valve area and there is no known reason. Caused by part of bowel being sucked into the other due to peristalsis.

Front 62

Diagnosis of Intussusception

Back 62

Four effects are usually evident:
1. Severe abdominal pain
2. Forceful, Projectile vomiting
3. Frothy diarrhea
4. Tender and distended abdomen that has rebound tenderness
Seen on xray as the Coiled-spring sign.

Front 63

Radiographic Appearance of Intussusception

Back 63

Coiled Spring Sign - Looks like the water toy that you squeeze and it goes through your hand.

Front 64

Treatment of Intussusception

Back 64

Barium Enema and/or insufflations of air to try and force materials retrograde to "pop" area out. May have to do surgery if this doesn't work.

Front 65

Appendicitis

Back 65

Inflammation of the appendix. The most common cause is a phlebolith that obstructs the appendix causing fecal matter to be caught and become infected. You look for air in the cecum from obstruction. Treatment is surgical removal. The appendix is part of the immune system so they don't "just" remove it anymore unless there is a need.

Front 66

Diverticulosis

Back 66

Out-pouchings or sac-like herniations of the mucous membrane lining due to weakened walls from peristalsis.
- This is NON-inflammed. When it becomes inflamed it is diverticulitis.
- Most frequently found in the sigmoid colon, the incidence increases with age.

Front 67

Diagnosis of Diverticulosis

Back 67

It is asymptomatic and is usually found secondarily on colon exams. No treatment is required but a high-fiber diet will help decrease the chance of developing diverticulosis.

Front 68

Radiographic Appearance of Diverticulosis

Back 68

Appears as smooth, round outpouchings on contast studies. Looks like little white pebbles.

Front 69

Diverticulitis

Back 69

A complication of diverticulosis where the diverticula become inflammed and possibly infected, especially in the sigmoid colon.

Front 70

Diagnosis of Diverticulitis

Back 70

Primarily see hemorrhage and extravasation into the abdominal cavity. Will appear as sawtooth appearance on contrast studies. Looks like jaggedy out-pouchings
- May simulate an annular carcinoma

Front 71

Treatment of Diverticulitis

Back 71

Anti-inflammatories, high dose antibiotics, and surgery if it is severe.

Front 72

Ulcerative Colitis

Back 72

An autoimmune disease of the colon that affects only the mucosa and submucosa of the rectosigmoid area. Seen in young adults, it does no involve the small bowel which is what distinguishes it from Crohn's disease.
- Abscesses develop in the crypts (goblet cells) and antibodies attack there and cause ulcerations and hardening of walls due to scar tissue.

Front 73

Diagnosis of Ulcerative Colitis

Back 73

There is a decrease in peristaltic activity in bowels and an inability to reabsorb water through the colon walls. Blood in stools is bright red (in chrohn's it is dark and tarry).

Front 74

Radiographic Appearance of Ulcerative Colitis

Back 74

- No narrowing of lumen
- films may demonstrate toxic megacolon and loss of haustral marking
- creates a hose-pipe or stove-pipe appearance
- On CT the rectal-cecal area will look like a "target"

Front 75

Treatment of Ulcerative Colitis

Back 75

Concervative to start but usually only treatment is ileostomy.