8 Gastrointestinal Tract HHoldorf Outline Bowel Wall Gastro esophageal Junction Acute Appendicitis Hypertrophic Pyloric Stenosis Laboratory values Diverticulitis Bowel Obstruction Duodenal Atresia ID: 909169
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Slide1
Abdominal Sonography ILecture 8 Gastrointestinal Tract
HHoldorf
Slide2Slide3OutlineBowel WallGastro esophageal JunctionAcute AppendicitisHypertrophic Pyloric StenosisLaboratory valuesDiverticulitisBowel ObstructionDuodenal AtresiaIntussusception
Slide4Bowel WallThe normal intestinal wall is between 3 and 5 mm thick, depending on distention of the bowel. Five sonographic interfaces can be seen when imaging the intestinal wall.Intestinal pathology creates a sonographic pattern known as the TARGET or PSEUDOKIDNEY sign. This appears as a hypoechoic external rim corresponding to thickened intestinal wall and a hyperechoic center relating to a residual gut lumen or mucosal ulceration. .
Be able to identify an image of the pseudokidney sign
Slide5Slide6Normal Bowel wall
Slide7The wall is divided into four layers as follows:Mucosa : The innermost layer of the digestive tract Submucosa Muscularis externa Serosa/mesentery The outer layer of the gut is formed by fat and another layer of epithelial cells called mesothelium.
Slide8Causes of Wall Thickening of the Small BowelWall edema Malignancy Postoperative Lymphoma Cirrhosis/ascites Peritoneal carcinomatosis
Hypoproteinemia
Slide9Causes of Wall Thickening of the Small BowelInflammatory bowel disease Crohn’s disease Acute ileitis Extraintestinal inflammatory conditions
Pancreatitis
Endometriosis
Homework: Define Crohn’s Disease
Slide10Causes of Wall Thickening of the Small BowelMesenteric ischemia/infarction Thrombosis of mesenteric veins Thrombosis of mesenteric arteries Small bowel disease/malabsorption
Celiac disease
Whipple’s disease : Define Whipple’s Disease for homework
Benign
intestinal tumors
adenoma
,
lipoma
Slide11Benign Gastric Wall Thickening. The wall of the gastric antrum (arrow) as seen in short axis view is diffusely and symmetrically thickened by adjacent acute pancreatitis
Slide12Pseudokidney sign
Slide13Gastro esophageal junctionThe segment of esophagus between the diaphragm and the stomach is called the gastroesophageal junction. On a longitudinal midline view of the epigastrum, this is seen as a target sign posterior to the left lobe of the liver.Be able to recognize an image of the Gastroesophageal Junction (GE junction)
Slide14Slide15Gastroesophageal Junction (GE junction)
Slide16Acute AppendicitisAcute appendicitis is the most common cause of an acutely painful abdomen. Patients present with Peri-umbilical pain shifting to RLQ Leukocytosis (increased WBC count) Nausea, vomiting, and low-grade fever Rebound tenderness
Slide17McBurney’s pointThe right lower quadrant location of the most tender area in the early stages of appendicitis.
Slide18Appendicitis is caused by the obstruction of the appendiceal lumen by a fecalith or hyperplasia of the submucosa. Mucosal secretions increase the intraluminal pressure and compromise venous and lymphatic drainage. Bacterial infection leads to gangrene and perforation. Perforation leads to peritonitis.
Slide19Graded –compression ultrasound is utilized to displace bowel gas and decrease the distance between the transducer and the appendix.Sonographic criteria for diagnosing an inflammatory appendix includesNon-compressible appendix> 6 mm diameterAppendicolith (fecalith)NOTE: Do not be afraid to push the gas away.In female patients of child-bearing age, right lower quadrant pain may be due to pathology of the appendix or gynecologic structures.
Slide20Color flow hyperemia can be observed with an inflamed appendix.Be able to identify several images/examples of acute appendicitis.
Slide21Slide22Normal Appendix
Slide23Abnormal Appendix: Thickened appendix secondary to Crohns’s disease.
Slide24Hypertrophic Pyloric StenosisHypertrophic pyloric stenosis (HPS or sometimes referred to as IHPS) has a 4 to 1 male to female ratio. Characterized by hypertrophy of the circular muscle resulting in elongation of the pylorus and constriction of the canal.
Slide25Slide26The neonatal (3-6 weeks of age) patient presents with Projective vomiting Palpable olive-shaped abdominal massUltrasound is the method of choice for diagnosing HPS. The diagnostic criteria includes Pyloric muscle thickness >3mm Pyloric channel length >12 mm Pyloric cross section >15 mmWith hypertrophic pyloric stenosis, there is an increase in the pyloric diameter and length.
Slide27Identify images of a hypertrophic pyloric stenosis with muscle thickness measured, channel length measured, and cross section measured.
Slide28IHPS
Slide29IHPS : Radiology string sign
Slide30IHPS
Slide31Laboratory valuesCarcinoembryoinic antigen (CEA)Increased levels are found in patients with colon carcinoma. Although it is not specific for colon cancer, it is also associated with cirrhosis, ulcerative colitis, and other cancers.
Slide32DiverticulitisDiverticulitis is the inflammation of diverticulum (Colonic outpouchings). Diverticulum commonly involve the sigmoid colon.Symptoms of diverticulitis include Fever Leukocytosis Left lower quadrant pain
Slide33Slide34Sonographic findings include: Thickening of the bowel wall (> 4mm) Abscess formation Inflamed diverticula (round echogenic structuresBe able to identify an image of diverticulitis
Slide35Diverticulitis of the Sigmoid colon
Slide36Bowel ObstructionMechanical small-bowel obstruction (SBO) can be caused by Intraluminal (food bolus) Bowel wall lesion (tumor, Crohn disease) Extrinsic (adhesions, hernia)-most commonProlonged bowel obstruction can result in
Bowel ischemia
Bowel necrosis
Septicemia
Perforation
Peritonitis
Slide37Slide38Symptoms include Abdominal distention Paint Vomiting Hypotension (caused by fluid depletion) LeukocytosisUltrasound is used to demonstrate loops of distended bowel, level of obstruction, and peristalsisIdentify images of Bowel obstruction in the small bowel and the large colon.
Slide39Bowel Obstruction
Slide40Duodenal AtresiaDuodenal atresia presents in newborns with the onset of vomiting within hours of birth. Once delivered, epigastric fullness form dilatation of the stomach and proximal duodenum is noted. Duodenal atresia may be discovered during a prenatal ultrasound. The ultrasound evaluation will demonstrate: Polyhydramnios
Fluid-filled stomach
Fluid-filled proximal duodenum
This is referred to as the double bubble sign
Identify an image of the double bubble sign
Slide41Slide42Slide43Duodenal Atresia
Slide44IntussusceptionIntussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen (telescoping), causing a bowel obstruction. This is the most common cause of obstruction in infants and typically occurs less than one year of age.
Slide45Slide46Classic symptoms of Intussusception include Vomiting Abdominal pain Rectal bleedingAlthough difficult to detect, a physical finding of a sausage-shaped mass in the right hypochondrium is a classic sign of an Intussusception.Sonographically, Intussusception usually presents as an oval, pseudokidney-appearing mass. On a transverse view, concentric rings of folded bowel are typically seen.Identify images of Intussusception on transverse views.
Slide47Intussusception: Target Sign
Slide48This one has a Think TankNext weekThink Tank Time!!!!!