Pathology of the GI System

1
Pathology of the GI System

• DMI 56
• Marilyn Rose

2
Imaging Considerations

• The KUB is the starting point as a survey film
  taken without contrast
• The frequency of findings on a KUB is low and
  nonspecific
• It will rule out bowel obstruction and
  perforations
• Also it assesses the placement of various tubes
  and catheters

3
Bowel Gas Patterns
4
Usual Findings On The Abdominal Radiograph

• Gas patterns
• Abdominal organs and soft tissues
• Very few air-fluid levels if normal
• Very little calcification in vessels or soft
  tissues if normal

5
Evaluation of the GI System

• Endoscopy
• Examines the internal surfaces
• Abnormal areas can be biopsied and examined
  histologically
• Radiography
• Contrast is usually administered to enhance
  evaluation
• Very few organs of the abdomen can be fully
  examined without contrast
• Fluoroscopy is used to evaluate organ motility

6
Contrast Agents/Medications

• Barium sulfate
• Air
• Methylcellulose
• Glucagon

7
Other Studies

• CT
• Visualizes small differences in tissue
• Demonstrates organs not apparent on non-contrast
  enhanced radiographs
• Very useful in localization
• Spiral CT visualizes structures often missed on
  conventional CT
• Patients are often given both oral and IV
  contrast agents for ideal enhancement of organs
  and tissues

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CT Abdomen w/Contrast
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Other Studies

• MRI
• Still in the developing stages due limitations
  from scan times and bowel motion
• Sonography
• Very useful in evaluating masses
• Nuclear medicine
• Useful in demonstrating GI bleeding

10
Abdominal US
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Abdominal Tubes And Catheters

• Naso-gastric tubes
• Inserted for feeding and suction purposes
• Single-lumen Levin is the most common
• Dobhoff tube
• Used to deliver a liquid diet directly to the
  duodenum or jejunum
• Miller-Abbott tube
• Designed to remove gas and fluids
• A rubber bag containing mercury is at one end
• Progress of the tube throughout the bowel is
  followed by radographs at regular intervals

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Tubes and Catheters

• Gastrostomy or Enterostomy Tubes/Catheters
• Inserted directly into the organ for feeding
  purposes
• The percutaneous endoscopic gastrostomy (PEG)
  tube is one of the most commonly used

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Abdominal Tubes
Proper Placement
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Bad Placement!!!
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Genetic/Hereditary Diseases

• Atresia
• Hypertrophic Pyloric Stenosis
• Malrotation
• Imperforate anus

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Atresia

• The congenital absence/ closure of a body orifice
• Symptoms excess salivation, choking, gagging,
  dyspnea, and cyanosis apparent shortly after
  birth
• Coinciding with esophogeal Atresia
  tracheoesophageal fistula
• This condition can be confirmed radiographically
  with contrast or by the passing of a radiopaque
  tube into the esophagus
• The prognosis is good if aspiration prevented
  prior to surgery
• Other types of atresia involving the digestive
  system are
• ileal, duodenal, or colonic atresia

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Intestinal atresia is a broad term used to
describe a complete blockage or obstruction
anywhere in the intestine. Stenosis refers to a
partial obstruction that results in a narrowing
of the opening (lumen) of the intestine. Though
these conditions may involve any portion of the
gastrointestinal tract, the small bowel is the
most commonly affected portion
Atresia
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Esophageal atresia
TE Fistula
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Atresia
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Duodenal Atresia / Stenosis

• 80 occur just distal to ampulla of Vater
• Associations 50
• with Down syndrome 30
• other chromosomic anomalies
• annular pancreas 30
• Malrotation 28
• Biliary anomalies
• Cardiac anomalies
• VACTREL

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• double bubble
• no distal gas

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Duodenal stenosis

• Narrowed area in the 2nd portion of the duodenum

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Jejunal atresia/stenosis

• 3-4 dilated loops
• Contrast enema for additional atresias

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Hypertrophic Pyloric Stenosis

• The pyloric canal is narrowed due to hypertrophy
  of the pyloric sphincter
• It is the most common indication for surgery in
  infants, occurring 3 4 times more often in male
  children
• The first sign is projectile vomiting
• An upper GI will reveal delayed gastric emptying
• Surgery to increase the size of the opening of
  the pyloric channel provides a good prognosis

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Hypertrophic Pyloric Stenosis
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Imperforate Anus

• No anal opening to the exterior
• Usually corrected surgically shortly after birth

27
Inflammatory Diseases

• Esophageal stricture
• Peptic ulcer
• Gastroenteritis
• Chrons Disease
• Appendicitis
• Colitis
• Esophageal varices

28
Esophageal Stricture

• Secondary to the ingestion of caustic materials
• Strictures can be differentiated radiographically
  from peristalsis by virtue of remaining unchanged
• Esophageal strictures can be corrected by special
  tubes designed to dilate the area

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Esophageal Strictures

• Differential diagnosis
• Achalasia
• Foreign body in esophagus
• Compressing vascular abnormalities
• Cricipharyngeal achalasia
• Retrophangeal abscess
• Esphagitis

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Esophageal Stricture
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Peptic Ulcer

• An erosion of the mucous membrane of the
  esophagus, stomach or duodenum
• The most likely site is the duodenal bulb and on
  the lesser curvature of the stomach
• Ulcers are thought to be from a variety of
  hereditary and environmental factors
• It is thought that the helicobacter pylori
  bacterial may cause ulcers
• The main symptom is pain radiating to all parts
  of the abdomen

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Peptic Ulcer

• An ulcer will appear on a radiograph as a
  sunburst filling defect
• Medication is often to inhibit acid production
• Most ulcers are benign unless they perforate
• Perforation can lead to a life-threatening
  condition

33
Gastroenteritis

• Inflammation of the mucosal lining of the stomach
  and small bowel
• Often a precursor to ulcer development
• There are a variety of causative factors i.e.,
  aspirin, physical stress, infections
• Most ulcerations from gastroenteritis heal
  quickly once the causative agent is omitted
• Erosive ulcerations are often visualized on a
  radiograph

34
Crohns Disease

• A chronic inflammatory disease of unknown
  etiology
• The causative factors are family history, and
  stress
• It begins as mucosal inflammation with inventual
  thicken of all layers of the bowel wall

35
Crohns Disease

• Fistulas may form to adjacent structures
• Scarring often results in mechanical bowel
  obstructions
• A barium study will reveal areas of stenosis, and
  a cobblestone appearance from criss-crossing
  ulcerations
• Patients often experience severe diarrhea and the
  possible development of carcinomas with a poor
  prognosis
• Treatment involves decreasing inflammation,
  relief of diarrhea, treatment of infection, with
  occasional surgical resection

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Crohns Disease
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Appendicitis

• An inflammation of the vermiform appendix
  resulting from an inflammation or fecalith
• Most common abdominal surgery emergency in the US
• Individuals experience an acute onset of lower
  right quadrant pain with fever
• Surgical removal of the appendix is the most
  common treatment

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Appendicitis
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Ulcerative Colitis

• An inflammatory lesion of the colon mucosa of
  unknown etiology
• Thought to be an autoimmune disease
• Inflammation of the mucosa and submucosa causes
  abcesses to form, often leading to ulceration
• The mucosa is replaced by fibrous tissue giving
  the colon a rough appearance
• Sigmoidoscopy and colonoscopy are the usual means
  of diagnosis
• Treatment involves steroid therapy with
  occasional bowel resection

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Ulcerative Colitis
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Esophageal Varices

• Abnormally lengthened, dilated, and superficial
  veins (Varicose veins)
• Exacerbated by conditions that cause a resistance
  to normal blood flow through the liver
• These conditions cause a bypass of the normal
  venous drainage mechanism
• The blood is directed through the esophageal and
  gastric collateral veins
• The increase in flow through these channels
  result in venous dilation

42
Esophageal Varices

• Best demonstrated in recumbent with thin barium
• Patients with esophageal varices are subject to
  their rupture and hemorrhage which is often fatal
• Ruptured varices account for 1/3 of the deaths
  from cirrhosis
• Treatment may consist of sclerotherapy, ligation,
  or vasopressin infusion, or bypass shunts applied
  via interventional radiology
• The shunts reduce portal hypertension

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Esophageal Varices
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Herniation

• A protusion of a loop of bowel through a small
  opening
• Inguinal canal hernias most commonly happen to
  men
• Reducible hernias can be manipulated back into
  the abdominal cavity
• Incarcerated hernias cannot be reduced
• A hernia that cuts off blood supply is called a
  strangulated hernia

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Inguinal Hernia
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Hiatal Hernia

• A weakness in the esophageal hiatus allowing the
  stomach to protrude into the thoracic cavity
• Occurs in about half the population over 50
• Most hernias are asymptomatic, however some are
  accompanied by reflux
• If all the stomach slides above the diaphragm
  this is known as an intrathoracic stomach results
• This condition is life-threatening and requires
  surgical reduction

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Hiatal Hernia
48
Bowel Obstructions

• Mechanical Bowel Obstructions
• A blockage of the bowel lumen
• Usually requires interventional surgery
• Most are caused by incarcerated hernias
• Other causes
• Gallstones may occlude the ileocecal valve
• Twisting of the bowel upon itself known as
  volvulus
• The bowel telescopes into itself known as
  intussusception
• Adhesions, tumors, Crohns disease, and
  appendicitis

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Dilated Loops of Bowel from Obstruction
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Volvulus and Intussesception
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Intussesseption
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Bowel Obstructions

• Adynamic ileus
• A failure of normal peristalsis
• Often after surgery or due to infection
• Other causes may be bowel ischemia, drug
  reactions, electrolyte imbalance, pancreatitis,
  or severe illness
• Usually lasts no longer than 3 days if treated
  properly
• The absence of peristalsis causes the lumen to
  fill with gas and fluid causing abdominal
  distention
• Treatment includes medical stimulation of the
  bowel to restore peristalsis

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Achalasia

• Failure of the lower esophageal sphincter of the
  distal esophagus to relax, leading to dysphagia
• Radiographs reveal a dilated esophagus
• The distal esophagus will open only
  intermittently, not allowing for food passage
• Treatment may include dilatation of the area

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Dilated Esophagus from Achalasia
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Hirschsprungs Disease

• An absence of neurons in the bowel wall, also
  known as congenital megacolon
• Occurs in about 1 in 5000 births, mostly affects
  males
• The absence of neurons prevents the normal
  relaxation of the bowel and peristalsis,
  resulting in dilatation to the point of narrowing
  and constriction
• This condition is often apparent shortly after
  birth
• Barium enemas demonstrate a transition from the
  narrow distal rectum to a dilated proximal colon

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Complications from Hirschsprungs Disease
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Diverticula

• A pouch or sac that occurs by herniation of a
  mucous membrane through a defect in its muscular
  coat
• These can occur anywhere in the alimentary canal
• These are usually asymptomatic, but if they
  become inflamed, diverticulitis develops
• Extreme cases may require surgical resection

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Esophageal and Colonic Diverticula
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Colonic Diverticula
Normal
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Tumors of the Esophagus

• Tumors of the lower third are most common
• Benign tumors are almost always a leiomyoma, a
  smooth muscle tumor, usually removed surgically
• Cancers of the esophagus constitute about 7 of
  cancers of the GI system
• Overall 5 year survival rate is less than 10
• CT is very helpful to stage the spread of the
  disease
• Predisposing factors are reflux, alcohol, and
  smoking

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Leiomyoma
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Tumors of the Stomach

• Most stomach cancers are malignant
• Only about 10 are benign
• About 95 are adenocarcinomas
• Japan has a rate of stomach cancer that is 5
  times greater than that of the US
• Factors that lead to stomach cancer are being
  male diet high in fish, salty, spicy, cabbage,
  being black, and having type A blood
• 5 year survival rates are less than 20
• Most gastric carcinomas develop in the pyloric
  and antrum regions
• The only successful treatment has been a
  gastrectomy w/a small bowel/esophageal resection

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Stomach-AdenoCa
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Small Bowel Neoplasms

• Very little incidence 2 of all benign and
  malignant neoplasms
• Most small bowel cancers occur in the duodenal
  and proximal jejunal regions
• Surgical resection is the primary means of
  treating small bowel neoplasms

66
Colonic Polyps

• Small masses of tissue arising from the bowel
  wall that project inward
• More frequently noted in the left colon
• Most polyps are benign, but those over 2 cm in
  size have a 50 chance of malignancy
• Proctosigmoidoscopy and colonoscopy are critical
  in evaluation and removal of polyps
• The barium enema w/air is useful in evaluating
  polyps, but polyps can often be mistaken for
  fecal material, or vice-versa
• Patients with a history of polyps are usually
  followed closely

67
Colon Cancer

• One of the most malignancies in the US
• Second most common cause of cancer mortality
• The incidence rises after age 40, doubles with
  each decade, and peaks at age 75
• Americans have a 1 in 20 chance in their lifetime
  of developing colorectal cancer, and a 1 in 40
  chance of dying from it
• People with diets high in sugar and animal fats
  seem predisposed to colon cancer

68
Colon Cancer

• Adenocarcinoma is the most common type
• Most occur in the mid-descending/recto-sigmoid
  region
• These can be diagnosed with a sigmoidoscopy
• Patients usually experience bleeding
• Evaluation usually includes sigmoidoscopy,
  colonoscopy, and the double-contrast BE
• On radiographs the lesion appears as an apple
  core shaped structure

69
Colon Cancer

• Lesions do not metastasize early
• Treatment includes surgical resection, or
  colostomy
• Radiation therapy is usually done before surgery
• Chemotherapy is given when the cancer has
  metastasized

70
Colon CA
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Apple Core Carcinoma
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Mets to liver and Brain from Colon
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Thats all for now
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The End