Download investigations of gastro-intestinal tract

INVESTIGATIONS OF
GASTRO-INTESTINAL
TRACT
Dr. B. RAMDAS RAI
PROF & UNIT CHIEF III
YMCH
Plain X-Ray Abdomen
O Indications :-
Intestinal obstruction
Perforation
Chronic pancreatitis etc.
O Triad of small bowel obstruction in plain x-ray
1) Dilated small bowel loops > 3 cm
2) Multiple air fluid levels in erect x-ray abdomen
3) Paucity of air in the colon
O Perforation – in cases of perforation there will be
gas under diaphragm. It is due to significant
amount of gas released during bowel perforation
Plain X-Ray abdomen showing gas under
diaphragm in case of intestinal perforation
Ultrasound
O Ultrasound contains waves with a
frequency of more than 20,000
cycles/second.
O The transducer or the probe works as
a both transmitter of sound waves &
receiver of echoes.
O Its used in all abdominal & pelvic
conditions.
O ADVANTAGES :1.
2.
3.
4.
5.
6.
No radiation
Non invasive
Effective with efficiency
Painless
Low cost
Available even as portable machines
O DISADVANTAGES:-
1. Interpretation can be inadequate
2. Bowel shadow may prevent proper
visualisation
3. In obese patients image will be
inadequate
4 Interpretation is based on echogenicity
either hyperechogenic or hypoechogenic
Computerised Tomography
(CT Scan)
O Both plain & contrast CTs are done whenever
required
O Contrast agents are:Ionic:- water soluble iodide dyes like
sodium diatrizoate
Non ionic :- safer but expensive like
iohexol , lopamiro
In abdominal CT contrast agents can be given
orally to delineate bowel properly
O Indications :1. Neoplasms:- To see the exact location , size,
vascularity , extent , lymph node status ,
metastases & operability
2. Inflammatory conditions :- like psoas abscess ,
pseudocyst of pancreas , pancreatitis etc.
O ADVANTAGES:1. More accurate , sensitive & specific
2. Small lesions are also detected
3. CT guided biopsies of the mass or
lesion &
4. CT guided FNAC s of lymph nodes can
be done
O DISADVANTAGES:1. Artefacts can be present
2. Cost factor & availability
MRI & PET scan are also being being
used .
Upper GI Scopy
Indications :Diagnostic –
1. To identify the lesion & take biopsy
in carcinoma oesophagus ,
carcinoma stomach etc.
2. For diagnosing other conditions like
gastric ulcers , duodenal ulcers ,
diverticulum , hiatus hernia ,
oesophageal varices , strictures etc.
O Therapeutic :1. To remove foreign body
2. To dilate stricture
3. To place endostents for inoperable
carcinoma oesophagus
4. To inject sclerosants or banding for
varices
O 2 types of oesophagoscopy:-
O Rigid oesophagoscope :- It is done under
general anaesthesia . Scope is passed
behind the epiglottis & cricoid through the
cricopharyngeal opening . This is the most
difficult part in oesophagoscopy. After that
negotiating through the oesophagus is
easier. The lesion is identified & biopsy is
taken if required.
Complications are perforation & bleeding
O Fibreoptic flexible oesophagoscope:-
It can be done under local anaesthesia.
Reflux & hiatus are well identified.
Stomach also can be visualized. Easy to
pass & perforation is unlikely.
But tissue taken for biopsy is smaller &
removal of foreign body is also difficult.
Endoscopic Ultrasound
O It is useful method of finding &
assessing involvement or pathology of
different layers of oesophagus
espescially in carcinoma oesophagus.
O It shows all layers clearly & distinctly
& so invasion can be better made out
& operability can be decided.
Contrast study
O Types:1. Barium swallow using barium
sulphate which is a thick paste.
2. Using water soluble contrast like‘
Gastrografin’
Barium Swallow
O Indications :-
Dysphagia
Pharyngeal pouch
Gastro-oesophageal reflux disease
O Important findings :1. Achalasia cardia- Bird beak appearance
2. Diffuse oesophageal spasm- Corckscrew
appearance
3. GORD- Shows reflux in trendelenberg position
4. Carcinoma oesophagus- Rat tail appearance
5. External compression – Indentation of barium
column by superior or posterior mediastinal mass,
enlarged left atria as in mitral stenosis.
Barium meal in achalasia cardia showing
bird beak experience
Ca Oesophagus showing rat
tail appearance
Water soluble contrast
radiograph
O In suspected oesophageal perforation
O Leaking oesophageal anastomosis
Barium meal study
O Indications
1. Gastric ulcer- shows a niche which is
the ulcer crater , a notch which is due
to spasm of circular muscle on the
greater curvature.
2. Chronic duodenal ulcer- shows
absence of deformed duodenal cap (
due to spasm of first part of
duodenum,barium will not stay & so
cap will not be formed )
3) Gastric outlet obstruction- the cause may be
chronic duodenal ulcer with pyloric stenosis or
carcinoma pylorus.
Features are1. Enormous dilatation of stomach
2. Greater curvature below the level of iliac crest
3. Absence of duodenal cap
4. No filling of dye in second part of duodenum.
5. Mottled appearance of stomach because of
retained food particles.
4.Carcinoma stomach- irregular filling defect
5.Pseudocyst of pancreas- widened
vertebrogastric angle
6. In chronic duodenal ileus- shows dilatation of
stomach, 1st & 2nd part of duodenum, proximal
portion of 3rd part of duodenum
7. Others – gastric volvulus , duodenal diverticula,
trichobezar, gastric fistulas, diaphragmatic
hernias when stomach is the content
8.Carcinoma head of pancreas- ‘ pad
sign ‘
Periampullary carcinoma- ‘ reverse 3
sign ‘
9.Hiatus hernia
O Complication :- It may precipitate
intestinal obstruction.
Barium Enema
O It is the contrast x-ray done to
visualize large bowel
O Therapeutic barium enema is done in
intussusception
Indications & findings
1) Carcinoma colon- irregular filling defect
2) Ileocaecal tuberculosis- pulled up caecum ,
obtuse ileocaecal angle , incompetent ileocaecal
valve
3) Ulcerative colitis- loss of haustrations, lead
pipe appearance
4) Colonic polyps- smooth , regular filling defect
5) Congenital mega colon – narrow zone , zone of
cone , dilated proximal segment
6) Diaphragmatic hernia- colonic
shadow in the left thoracic cavity
7) Gastro-oesophageal fistula- leak into
the stomach from colon.
Contraindications:- acute colonic
conditions
Sigmoidoscopy
O It is used to visualise rectum &
sigmoid colon, take biopsies from
suspected lesions & do therapeutic
procedures like polypectomy , control
of bleeding etc.
O 2 typesRigid- 25 cm long with illumination
Flexible- 60 cm long
Colonoscopy
O It is 160 cm long, flexible
O It is passed upto the caecum
Indications :1. Bleeding per rectum
2. To take biopsies from different parts
of the bowel
3. To identify synchronus growths,
ulcerative collitis
O Contd-
4. To remove polyps,
5. When barium enema shows irregularity
6. For therapy- colonoscopic polypectomy,
dilatation of stricture colon etc.
Contraindication :- Acute ulcerative colitis
O Complications :1. Perforation of the bowel , splenic
flexure is the commonest site
2. Trauma
3. Sepsis
4. Haemorrhage
DIFFERENTIAL DIAGNOSIS
AND EVALUATION OF
DYSPHAGIA
O Dysphagia is difficulty in swallowing
O Odynophagia is painful swallowing
O Dysphagia can be –
1) Acute due to foreign body impaction or
acute infection
2) Chronic due to causes like stricture or
carcinoma
O Dysphagia can be oropharyngeal or
oesophageal depending on the cause
O Dysphagia can be progressive or intermittent
O Causes of dysphagia:-
Common Causes
1. Gastro-oesophageal reflux
disease(GERD/Hiatus Hernia)
2. Carcinoma Oesophagus- here dysphagia
is of short duration and progressive. 2/3rd
of the lumen should be blocked by tumor
to develop dysphagia.
3. Foreign Body in Oesophagus- it may be coin,
bone piece, denture etc. It causes acute
dysphagia
4. Carcinoma of pharynx or posterior 1/3rd of
tongue
5. Corrosive Strictures- It is usually alkali
stricture.
6. Oesophageal Candidial Infection- It is due to
immunosuppression In association with HIV
infection, steroid therapy, cancer therapy etc
7. Plummer- Vinson Syndrome
8. Mediastinal swellings like primary
tumors, nodal mass either lymphoma or
secondaries or tuberculosis.
O RARE CAUSE
1.Diffuse oesophageal spasm- They are incoordinated contractions of oesophagus
causing chest pain or dyshagia. It is common
in distal 2/3rd of oesophagus. Hypertrophy of
circular muscle fibres with very high
persistent pressure of 400-500 mm of
mercury is specific.
Treatment is calcium channel blockers,
vasodilators, endoscopic dilatation and
extended oesophageal surgical myotomy upto
the aortic arch.
2. Oesophageal diverticula, Chagas
disease
3. Dysphagia lusoria- It is a congenital
vascular anomaly of aortic route
4. Thyroid swelling- It is uncommon to
develop dysphagia in a thyroid swelling.
Large malignant thyroid or anaplastic
thyroid can cause dysphagia with dyspnea
or strider.
5. Boerhaave’s Syndrome- It is vertical full
thickness tear of lower oesophagus due
to vomiting with closed glottis. It is often
life threatening and emergency
6. Neurological causes like stroke,
bulbar palsy, motor neuron disease,
Parkinson’s disease etc.
7. Congenital anomalies of oesophagus
8. Drug induced dysphagia- Drugs like
KCL, quinine, NSAID can cause
dysphagia.
9. Mediastinal fibrosis
EVALUATION OF A PATIENT WITH DYSPHAGIA
1. Proper history
2. Haematocrit
3. Chest X-Ray- To see for any mediastinal
mass lesion, foreign body.
4. Oesophagoscopy- Once lesion is detected,
it is treated accordingly. Biopsies from
lesions, endotherapy and other procedures
like foreign body removal, strictured
dilatation, sclerotherapy can be carried out
5. Barium Swallow may show irregular
filling defect or extrinsic compression
6. CT Chest- It helps to identify the
anatomical location of the cause.
Extent, spread , nodal status , size &
operability of tumour can also be well
assessed
7. Oesphageal manometry in achalasia
cardia / GERD
8. Endosonography is very useful in
many conditions causing dysphagia. It
can assess site , layers of oesophagus,
nodes , spread etc.
9. USG abdomen to see for metastases
in the liver , ascites etc.
O Treatment for dysphagia:-
1. Treatment depends on cause.
2. Heller’s myotomy for achalasia
cardia
3. Oesphageal resection for carcinoma.
4. Dilatation for strictures
5. Foreign body removal etc.
THANK YOU