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Chapter 15 Merrills Digestive System: Salivary Glands, Alimentary Canal, and Biliary System ANATOMY OF THE DIGESTIVE SYSTEM Esophagus, Stomach, Duodenum, Large Intestines, Salivary Glands, Alimentary Canal, and Biliary System...
Chapter 15 Merrills Digestive System: Salivary Glands, Alimentary Canal, and Biliary System ANATOMY OF THE DIGESTIVE SYSTEM Esophagus, Stomach, Duodenum, Large Intestines, Salivary Glands, Alimentary Canal, and Biliary System 2 Digestive System Consist of two parts: Accessory glands Salivary glands Liver Gallbladder Pancreas Spleen Alimentary canal Alimentary canal and accessory organs, with liver lifted to show gallbladder 3 Alimentary Canal A musculomembranou s tube that extends from the mouth to the anus Components Mouth Pharynx Esophagus Stomach Small intestine Large intestine (terminates at Alimentary canal and accessory organs, with liver lifted to show gallbladder anus) 4 Mouth (1 of 6) Also called oral cavity First division of digestive system Enclosed dental arches Receives saliva from salivary glands Divisions Oral vestibule Oral cavity Anterior view: oral cavity 5 Mouth (2 of 6) Oral vestibule Space between teeth and cheeks Oral cavity, or mouth proper Space between dental arches Roof formed by hard and soft palates Floor formed by tongue Communicates with Anterior view: oral cavity pharynx posteriorly via 6 Accessory Organs in Mouth (Oral Cavity) 7 Terms Mastication Deglutition Peristalsis Copyright © 2018, Elsevier Inc. All Rights Reserved. Mouth (3 of 6) Hard palate Most anterior portion of roof Formed by maxillae and palatine bones Soft palate Begins behind last molar Suspended from posterior border of hard palate Highly sensitive to touch Anterior view: oral cavity 8 Mouth (6 of 6) Frenulum of tongue Median vertical band on inferior surface of tongue Extends between undersurface of tongue and sublingual space Restricts posterior movement of anterior part of tongue Teeth Function in mastication Anterior view of undersurface of tongue and floor of mouth (chewing) 9 Salivary Glands (1 of 4) Three pairs Parotid (largest) Submandibular Sublingual (smallest) Produce approximately 1 L of saliva per day Saliva mixes with food during mastication Softens the food Keeps the mouth moist Contributes digestive enzymes. Salivary glands from left lateral aspect 10 Pharynx (1 of 2) Serves as a passage for both food and air Common part of digestive and respiratory systems Musculomembranous tubular structure located in front of the vertebrae and behind the nose, mouth, and larynx Approximately 5 inches (13 cm) in length 11 Pharynx (2 of 2) Extends from inferior body of sphenoid to C6-C7 At level of C6-C7, it becomes continuous with esophagus Subdivided into three portions Nasopharynx Oropharynx Laryngeal pharynx 12 Larynx (1 of 2) The organ of the voice Division of respiratory system Serves as air passageway between pharynx and trachea 1 ½ inches (3.8 cm) in length Movable tubular structure suspended from hyoid bone Extends from superior margin of C4 to inferior margin of C6 Sagittal section of face and neck 13 Larynx (2 of 2) Epiglottis situated above laryngeal entrance/trachea and behind hyoid bone Said to prevent food from passing into the larynx during swallowing Shaped like a leaf The thyroid cartilage forms the laryngeal Sagittal section of face and neck prominence, or 14 Esophagus (1 of 2) Long muscular tube Approximately 24 cm (10 inches) long and 1.9 cm (inch) in diameter Functions to carry food and saliva from laryngopharynx to (A) Anterior view of esophageal divisions. (B) Locations of stomach natural constrictions of the esophagus. (A, Modified from Patton K, Thibodeau G: Anatomy and physiology, ed 8, St. Lies in midsagittal Louis, 2013, Mosby. B, From Drake R, Vogl W, Mitchell AWM: Gray's anatomy for students, ed 2, Philadelphia, 2010, Churchill Livingstone.) plane (MSP) 15 Esophagus (2 of 2) Originates at C6 Passes through diaphragm at T10 Esophageal hiatus Joins stomach at esophagogastric junction at T11 Expanded terminal end = cardiac antrum Lateral view of thorax shows esophagus positioned anterior to vertebral bodies and posterior to trachea and heart. 16 PA Esophagogram (Slight RAO Oblique) Copyright © 2018, Elsevier Inc. All Rights Reserved. 17 RAO Esophagram Upper and Mid Esophagus Copyright © 2018, Elsevier Inc. All Rights Reserved. 18 Stomach (1 of 6) Dilated, saclike portion of the digestive tract extending between the esophagus and small intestine Four parts Cardia Fundus Body Pyloric portion (A) Anterior surface of stomach. (B) Interior view. 19 Stomach (2 of 6) Cardia is section surrounding esophageal opening Fundus is superior portion that fills the left hemidiaphragm Filled with air when patient is in the upright position (gas bubble) Body located between fundus and pyloric portion Interior surface contains numerous longitudinal folds called rugae 20 21 Stomach (3 of 6) Last portion is pyloric portion Consists of pyloric antrum and narrowed pyloric canal Lesser curvature = right border Greater curvature = left border The greater curvature is 4 to 5 times longer than the lesser curvature. Cardiac notch = sharp angle at esophagogastric junction 22 23 Stomach (4 of 6) Entrance and exit controlled by sphincters Cardiac orifice = opening between esophagus and stomach Cardiac sphincter controls opening (muscle) Pyloric orifice = opening between stomach and small intestine Controlled by pyloric 24 Stomach Frontal View Copyright © 2018, Elsevier Inc. All Rights Reserved. 25 26 Anatomy of Distal Esophagus and Stomach (Sphincter) Copyright © 2018, Elsevier Inc. All Rights Reserved. 27 Coronal Sectional View of Stomach Copyright © 2018, Elsevier Inc. All Rights Reserved. 28 Barium-Filled Stomach and Duodenum 29 Stomach (5 of 6) Stomach position greatly affected by body habitus Higher and more horizontal in hypersthenic Lower and more midline in asthenic Size, shape, and position of stomach and large intestine for the four different types of body habitus. Note extreme difference between hypersthenic and asthenic types. 30 Stomach (6 of 6) Functions: Storage area for food during part of digestion Secretes acids, enzymes, and other chemicals to chemically break down food Mechanically breaks down food by churning and peristalsis Chyme = chemically and mechanically altered food that leaves stomach 31 Air-Barium Distribution Black = Air White = Barium Copyright © 2018, Elsevier Inc. All Rights Reserved. 32 33 Which was taken PA (prone) and which AP (supine)? A B 34 RAO prone AP supine (air in fundus) (barium in fundus) Copyright © 2018, Elsevier Inc. All Rights Reserved. 35 Small Intestine (1 of 3) Extends from pyloric sphincter to ileocecal valve Average adult length = 22 feet Mucosa called villi – aids in process of digestion and absorption Three portions Duodenum Jejunum Ileum 36 Small Intestine (2 of 3) Duodenum is 8 to 10 inches long and C-shaped Widest portion and shortest portion Fixed in position and located in retroperitoneal space First portion is called duodenal bulb Portion that joins jejunum is a sharp curve called the duodenojejunal flexure 37 4 Parts of Duodenum Copyright © 2018, Elsevier Inc. All Rights Reserved. 38 Duodenum Shortest and widest C-loop “Romance of the abdomen” Retroperitoneal Area of abdominal romance – where the head of the pancreas is enfolded in the arms of the duodenum, and the liver is nestled around. 39 Anatomy Review What is the position—supine or prone? Copyright © 2018, Elsevier Inc. All Rights Reserved. 40 Anatomy Review Esophagus Fundus Rugae Esophagogastric Junction Lesser Curvature D- Angular Notch Greater E-Pyloric Curvature Antrum Body F-Pyloric Sphincter G-Duodenal Bulb H- Descending Portion of Duodenum Copyright © 2018, Elsevier Inc. All Rights Reserved. 41 Small Intestine (3 of 3) Function: Digestion and absorption of food Loops of small intestine lying in central and lower abdominal cavity 42 Summary of Mechanical Digestion Mastication (chewing) Oral cavity Deglutition (swallowing) Pharynx Deglutition Esophagus Deglutition 1-8 seconds Peristalsis (waves of muscular contractions) Stomach 2-6 hours Mixing Peristalsis } Chyme (digestive enzyme) Small intestine Rhythmic segmentation (churning) 3-5 hours Peristalsis Copyright © 2018, Elsevier Inc. All Rights Reserved. 43 Three Primary Functions of Digestive System 1. Ingestion and/or Oral cavity digestion Pharynx Esophagus 2. Absorption Stomach Small intestine 3. Elimination Small intestine (and stomach) Large intestine 44 Large Intestine (1 of 5) Begins at junction of small intestine and ends at anus Forms an arch around the loops of small intestine Four main parts Cecum Colon Rectum Anal canal 45 Large Intestine (2 of 5) Approximately 5 feet long Haustra = series of pouches along large intestine Taeniae coli = muscular bands that form haustra Cecum is pouchlike portion below the junction of the ileum and colon The ileocecal valve is just below the junction of the ascending colon and the cecum. 46 Large Intestine (4 of 5) Colon has four portions Ascending Transverse Descending Sigmoid Right colic flexure = sharp angle at ascending and transverse Left colic flexure = sharp angle at junction of transverse and descending Sigmoid portion forms S- shaped loop and ends at rectum at level of third sacral segment Rectum extends from sigmoid 47 Large Intestine (5 of 5) Function: Reabsorption of fluids Elimination of waste products 48 Air-Barium Distribution in Large Intestine 49 Anatomy Review AP barium enema 50 Anatomy Review LAO barium enema Notice Left Colic Flexure “open” 51 52 53 Liver and Gallbladder 54 Liver and Gallbladder Anterior View Posterior/Inferior View 55 Liver and Biliary System Liver is largest gland in the body Falciform ligament divides liver into two major lobes Right lobe Left lobe Two minor lobes evident on visceral surface Caudate lobe Quadrate lobe 56 Liver (2 of 2) Primary function from imaging standpoint is production of bile Bile is collected by ducts and carried to gallbladder for storage or passes into duodenum 57 Gallbladder 58 Bile Route Right and left hepatic ducts ▼ Common hepatic duct ▼ Common bile duct ▼ Pancreatic duct ▼ Duodenum 59 Functions of Gallbladder Storage of bile Concentration of bile Hydrolysis- the chemical breakdown of a compound due to reaction with water (H2O added to bile) Choleliths (gallstones) – solid material (bile, cholesterol) Contraction when stimulated Cholecystokinin (CCK) (hormone stimulates gallbladder to release bile into Duodenum through contraction) Induces satiety 60 Anatomy Review 61 Gallbladder Cystic Duct Neck Body Fundus Copyright © 2018, Elsevier Inc. All Rights Reserved. Operative Cholangiogram Anatomy Review of Biliary Ducts 62 Right Hepatic Left Hepatic Duct Duct Common Cystic Hepatic Duct Duct Body Copyright © 2018, Elsevier Inc. All Rights Reserved. (Gallbladder) Anatomic Relationships 63 When imaging - PA to reduce OID Supine for gallbladder drainage Extends from the duodenum to the spleen Pancreas Consists of a head, neck, body, and tail It’s an exocrine and an endocrine gland Insulin and glucagon are produced in Islets of Langerhans Metabolizes glucose 64 Spleen Is not part of the digestive system Part of the lymphatic system Ductless organ Produces lymphocytes Stores red blood cells removes dead or dying red blood cells Below left hemidiaphragm Behind Stomach 65 Review Question (1 of 9) What is the first division of the digestive system? A. Mouth B. Stomach C. Small intestine D. Salivary glands 66 Review Question (2 of 9) Which salivary gland is the largest? A. Parotid B. Sublingual C. Submandibular 67 Review Question (3 of 9) Which salivary glands are the smallest? A. Parotid B. Sublingual C. Submandibular 68 Review Question (4 of 9) In which body habitus type is the stomach almost horizontal and high in the abdomen? A. Sthenic B. Asthenic C. Hyposthenic D. Hypersthenic 69 Review Question (5 of 9) The most superior portion of the stomach is the: A. Fundus B. Body C. Pylorus D. Cardiac antrum 70 Review Question (6 of 9) The distal esophagus empties its contents into which of the following? A. Duodenum B. Pyloric canal C. Duodenal bulb D. Cardiac antrum 71 Review Question (7 of 9) Which opening is at the distal end of the small intestine? A. Anus B. Cardiac orifice C. Pyloric orifice D. Ileocecal orifice 72 Review Question (8 of 9) In which abdominal region does the large intestine originate? A. Left iliac B. Right iliac C. Left lumbar D. Right lumbar 73 Review Question (9 of 9) Which structure is located between the ascending colon and the transverse colon? A. Sigmoid B. Left colic flexure C. Right colic flexure D. Descending colon 74 Copyright © 2018, Elsevier Inc. All Rights Reserved. Radiographic Procedures Contrast Media and Technical Considerations 75 Technical Considerations Gastrointestinal (GI) transit Examination procedure Contrast media Preparation of examination room Exposure time Radiation protection 76 Gastrointestinal Transit Peristalsis = contraction waves by which the digestive tube propels contents toward the rectum Three to four waves per minute occur in the filled stomach Average emptying time for stomach is 2 to 3 hours Average transit time to ileocecal valve is 2 to 3 hours 77 Examination Procedure The radiographer responsibilities include: Preparing the room, equipment, and contrast media prior to the patient's arrival. Assisting the patient for the procedure with: artifact removal Gowning explanation of procedure. Obtaining and recording a thorough history. Obtaining a scout image of the anatomy of interest. Communicating with and assisting the patient before and after contrast administration. Assisting the fluoroscopist during the procedure, as needed. Post-exam radiographic images 78 Contrast Media Radiographic demonstration of the alimentary canal requires use of contrast media Singe contrast and double contrast studies Barium sulfate is most common contrast for the alimentary canal Water-soluble iodinated contrast media may also be used 79 Barium Sulfate Positive or radiopaque Chalk-like substance Absorbs more x-rays BaSO4 Copyright © 2018, Elsevier Inc. All Rights Reserved. 80 Colloidal Suspension Never dissolves in water Rate of separation varies by brand Contraindications: perforated viscus (loss of gastrointestinal wall integrity) or presurgical procedure Copyright © 2018, Elsevier Inc. All Rights Reserved. 81 Barium Thick Barium Thin Barium 3:1 or 4:1 ratio of 1:1 ratio of BaSO4 BaSO4 to water to water Copyright © 2018, Elsevier Inc. All Rights Reserved. 82 Water-Soluble Iodinated Contrast Media Indications Perforated viscus Presurgical procedure Contraindications Hypersensitivity to iodine 83 Contrast Media Orally administered iodinated medium differs from barium sulfate in the following ways: It outlines the esophagus, but it does not adhere to the mucosa as well as a barium sulfate suspension does 84 Contrast Media Iodinated solutions move through the GI tract quicker than barium sulfate Clears the stomach in 1 to 2 hours Iodinated solutions do not adhere as well to esophageal mucosa as does barium sulfate Iodinated solutions provide satisfactory examinations of the stomach, duodenum, and large intestine 85 Contrast Media Water-soluble media Easily removed by aspiration before or during surgery Readily absorbed by the body and excreted by kidneys in cases of perforation Ideal when perforated ulcers are considered Disadvantage – bitter taste 86 Preparation of Examination Room (1 of 2) Room should be completely prepared before patient enters Adjust equipment controls to correct settings Have footboard and shoulder supports ready Check for proper operation of the imaging and recording devices Prepare type and amount of contrast Make appropriate image markers available 87 Preparation of Examination Room (2 of 2) Before beginning examination, the radiographer should Describe the contrast media and administration (i.e., taste, enema tip insertion) Use layman's terms (drinking, texture as thick and taste as bitter) Inform the patient that the room will be darkened during the procedure Introduce the patient and fluoroscopist to each other 88 Exposure Time Challenge of GI radiography is to eliminate motion Based on each region Peristalsis greatest in stomach and duodenum Slows in distal part of GI tract Peristalsis affected by body habitus, pathology, use of narcotic pain medicine, body position, and respiration 89 Radiation Protection Close collimation and use of optimum technique factors protect patient from unnecessary radiation exposure Gonadal shield should be used according to state regulations or to reduce patient anxiety 90 Modified Barium Swallow Videofluoroscopic procedure performed in conjunction with a speech therapist Known as: Swallowing Dysfunction Study Videofluoroscopic swallow study (VFSS) 91 Deglutition The act of swallowing is performed by the rapid and highly coordinated action of many muscles Imaging and recording must occur at 30 frames per second (fps) Fluoroscopic examination may be performed in the department using stationary equipment or in a room equipped with a mobile C-arm A specialized patient chair is also used to facilitate consistent, safe, and comfortable upright position during imaging Barium sulfate is the standard contrast agent used for VFSS 92 Team Members Speech therapist Radiologic technologist Radiologist 93 Duties of team members Rad tech: prepares room, patient Speech therapist: prepares contrast media (thin and thick) semi solid barium (pudding), barium on a solid (cracker) and barium mixed into a carbonated beverage Administers the contrast medium in various consistencies , quantities, and using different mechanisms such as a spoon, cup or straw Radiologist: may operate fluoro, comments on findings in real time, dictates results of exam for patients medical record. 94 Lateral Modified barium swallow study (MBSS) (1 of 8) Lateral often the only projection obtained during a modified barium swallow study (MBSS). AP may be added based upon information obtained during fluoroscopy of the patient in the lateral position. 95 Lateral Modified barium swallow study (MBSS) (2 of 8) Patient position Seated (or standing) in a true lateral position Depress the shoulders MCP perpendicular to IR Part position Head into a lateral position IR/Collimation Radiation field to the level of the EAM to the jugular notch; include all anterior oropharyngeal structures and the cervical vertebrae posteriorly Central Ray (CR) Perpendicular to the IR 96 Lateral Modified barium swallow study (MBSS) (3 of 8) Structures Shown Contrast- filled mouth Pharynx Cervical esophagus 97 Lateral Modified barium swallow study (MBSS) (4 of 8) Evaluation criteria All soft tissue pharyngolaryngeal structures Area from nasopharynx to the uppermost part of the lungs in preliminary studies No superimposition of the trachea by the shoulders Closely superimposed mandibular shadows 98 AP Modified barium swallow study (MBSS) (5 of 8) Patient position Upright standing or seated Part position MSP to the midline of the vertical grid Shoulders in the same horizontal plane Center the IR at the level of or just below the laryngeal prominence 99 AP Modified barium swallow study (MBSS) (6 of 8) Central Ray (CR) Perpendicular to the laryngeal prominence IR/Collimation Adjust the radiation field to the level of the EAM to the jugular notch and 1 inch (2.5 cm) beyond the skin edges on the sides 100 AP Modified barium swallow study (MBSS) (7 of 8) Structures shown Contrast-filled mouth Pharynx Cervical esophagus Unilateral abnormalities (if present) 101 AP Modified barium swallow study (MBSS) (8 of 8) Evaluation Criteria All soft tissue pharyngolaryngeal structures Area from nasopharynx to the uppermost part of the lungs No rotation 102 Radiographic Procedures Pharynx and Larynx RAO: Projection Commonly Taken During Esophagram/ Esophagography Copyright © 2018, Elsevier Inc. All Rights Reserved. 104 Clinical Indications for Esophagogram Anatomic anomalies Carcinoma of Esophageal reflux esophagus Esophageal varices(enlarged veins) Foreign body obstruction Impaired swallowing mechanism/ difficulty swallowing (dysphagia) 105 What Are the Major Causes of Esophageal Varices? Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarring cuts down on blood flowing through the liver. As a result, more blood flows through the veins of the esophagus. 106 What Is Barrett’s Esophagus as Demonstrated Here? Damage to esophagus due to excess reflux – causes inflammation and redness. Copyright © 2018, Elsevier Inc. All Rights Reserved. 107 Diagnosis of Esophageal Reflux 1. Breathing exercises (two types) 2. The water test 3. Compression paddle technique 4. The toe-touch test Copyright © 2018, Elsevier Inc. All Rights Reserved. 108 1. Breathing Exercises Valsalva maneuver Patient takes in deep breath and holds in breath while bearing down as if trying to move the bowels. Mueller maneuver Patient exhales, then tries to inhale against closed glottis. Copyright © 2018, Elsevier Inc. All Rights Reserved. 109 2. Water Test Positive if barium regurgitates into esophagus (LPO position, swallow water through straw) 110 3. Compression Paddle Paddle inflated under stomach with patient in prone position Pressure applied to stomach region to create reflux 111 4. Toe-Touch Maneuver Effective for reflux and hiatal hernia 112 Review Question (1 of 2) Peristalsis is affected by: 1) Body habitus 2) Use of narcotic pain medicine 3) Body position A. 1 and 2 only B. 1 and 3 only C. 2 and 3 only D. 1, 2, and 3 113 Review Question (2 of 2) Iodinated contrast agents move through the stomach slower than barium contrast. A. True B. False 114 Projections for Esophagram AP or PA Oblique – esophagus between vertebrae and heart RAO or LPO Lateral - 115 AP or PA Esophagus (1 of 3) Preliminary patient preparation is not required May use single- or double-contrast Single: barium or water-soluble, iodinated Double: barium and carbon dioxide crystals First part of examination is fluoroscopy of swallowing 116 AP or PA for esophagus Pt is either supine or prone Arms above head MSP centered Turn head slightly for ease of drinking barium 117 AP or PA Esophagus (2 of 3) Patient position Supine or prone without rotation Part position Head turned to side to facilitate drinking Central ray (CR) Perpendicular to midpoint of IR at the level of T5-T6 IR/Collimation Radiation field no larger than 12 × 17 inches (30 × 43 cm) 118 AP or PA Esophagus (3 of 3) Structures Shown Esophagus from the lower part of the neck to the stomach Esophagus filled with barium Penetration of barium Evaluation Criteria Esophagus through the superimposed thoracic vertebrae No rotation of the patient AP esophagus, single-contrast study 119 AP/PA Oblique Esophagus (1 of 2) Patient/Part position Recumbent 35- to 40-degree right anterior oblique (RAO) or left posterior oblique (LPO) position Align IR and elevated side of patient approximately 2 inches (5 cm) lateral to MSP Central Ray (CR) Perpendicular to midpoint of IR Enters patient at 2 inches (5 cm) lateral to MSP at level of T5 or T6 120 Oblique projections for esophagus RAO or LPO position Pt is in RAO or LPO with MSP forming a 35 – 40 degree angle from the table RAO – pts side down (right arm) is at side. Side up (left arm) is on pillow by the head LPO – side down (left arm) at side. Side up (right arm ) is on pillow by the head CR – 2 in lateral to MSP on elevated side 121 AP/PA Oblique Esophagus (2 of 2) Structures Shown/Evaluation Criteria Esophagus from lower part of neck to the stomach Esophagus filled with barium Penetration of barium Esophagus between the vertebrae and the heart Contrast-filled esophagus from the lower neck to the esophagogastric junction (A) PA oblique esophagus, RAO position. (B) AP oblique esophagus, LPO position. 122 Lateral Esophagus (1 of 2) Patient/Part position Recumbent Right or left lateral position Patient should face radiographer Arms forward, forearm on the pillow Midcoronal plane (MCP) centered Central Ray (CR) Perpendicular to midpoint of IR Enters patient on MCP at level of T5-T6 IR/Collimation Radiation field no larger than 12 × 17 inches (30 × 43 cm) 123 Lateral Esophagus (2 of 2) Structures Shown/Evaluation Criteria Proximal esophagus without superimposition of the patient's arm Esophagus from the lower part of the neck to its entrance into the stomach Contrast filled esophagus Penetration of barium No rotation Ribs posterior to vertebrae Lateral esophagus, single-contrast study superimposed 124 Barium administration and respiration instructions Feed barium sulfate to pt using spoon, cup or drinking straw, depending on consistency Ask pt to swallow several mouthfuls of barium and to hold a mouthful until immediately before exposure Instruct pt to simply swallow the barium bolus Respiration in inhibited for about 2 seconds after swallowing., pt does not have to hold their breath To show entire esophagus, pt may have to use a straw to drink barium with rapid and continuous swallows 125 Upper GI Procedures Esophagus, Stomach, Small Intestine, and Large Intestine Upper GI Procedures Contrast medium required Increases or decreases tissue density AP abdomen PA upper GI Copyright © 2018, Elsevier Inc. All Rights Reserved. 127 UGI Single-Contrast UGI Double-Contrast UGI Barium sulfate Barium sulfate Carbon dioxide gas or room air Copyright © 2018, Elsevier Inc. All Rights Reserved. 128 Double-Contrast Upper GI Mucosal Folds Demonstrated Copyright © 2018, Elsevier Inc. All Rights Reserved. 129 Upper GI Clinical Indications 1. Peptic ulcer Diverticulum in duodenum 2. Hiatal hernia 3. Diverticula 4. Gastritis 5. Tumor 6. Bezoar 130 Upper GI Clinical Indications Peptic ulcer Copyright © 2018, Elsevier Inc. All Rights Reserved. 131 Hiatal Hernia 132 Duodenal Diverticulum 133 Trichobezoar aka Rapunzel syndrome Caused by trichophagia and trichotillomania (Specific Type of Bezoar) Copyright © 2018, Elsevier Inc. All Rights Reserved. 134 Sliding Hiatal Hernia Sliding hiatal hernias are those in which the esophagus and stomach, referred to as the gastro- esophageal junction, and part of the stomach protrude into the chest. 135 Gastritis Thickening of rugal folds Absence of rugal folds Copyright © 2018, Elsevier Inc. All Rights Reserved. 136 Radiographic Procedures Stomach and Duodenum Stomach: GI Series (1 of 3) Examination often referred to as a gastrointestinal series (GI series) or upper gastrointestinal series (UGI series) Used to evaluate the distal esophagus, the stomach, and some or all the small intestine. May include Scout kidneys, ureters, and bladder (KUB) Fluoroscopic and serial radiographic studies of the esophagus, stomach, and duodenum using ingested contrast (usually barium) When requested, the barium may be imaged as it traverses the small intestines 138 Stomach: GI Series (2 of 3) Patient preparation Requires stomach to be empty Desirable to have colon free of gas and fecal material non–gas-forming laxative may be administered 1 day before the examination Food and water withheld 8 to 9 hours before examination If small intestine examined, food is withheld following evening meal Nicotine and gum are thought to stimulate gastric secretions, so these are often restricted for same time frame 139 Stomach: GI Series (3 of 3) Single- and double-contrast studies Double-contrast includes barium and gas-producing substance (powder, crystals, pills, or carbonated beverage) Biphasic examination = single and double-contrast during the same procedure 140 GI Series Procedure (1 of 2) Guidelines: Usually begin with patient in upright position, if possible Radiologist may examine heart and lungs with fluoroscopy and determine whether stomach is empty Radiologist instructs patient to drink cup of barium Esophagus is examined with first two to three swallows Spot images made as needed Manual manipulation used to coat gastric mucosa (turning patient to side, prone, supine etc) Spot images may be made Patient drinks more barium to fill stomach Spot images taken as needed 141 GI Series Procedure (2 of 2) The GI Examination determines: Size, shape, and position of stomach Examine the changing contour of stomach during Peristalsis Filling and emptying of duodenal bulb Abnormalities in function or contour of anatomy 142 Essential Projections: Stomach and Duodenum PA PA oblique AP oblique Lateral (mediolateral) AP 143 PA Stomach and Duodenum (1 of 4) Patient position Recumbent or upright Part position Align midline of grid to sagittal plane passing halfway between vertebral column and left lateral border of abdomen Center IR 1 to 2 inches (2.5 to 5 cm) above lower rib margin (level of L1-L2) Upright requires IR centered 3 to 6 inches (7.6 to 15 cm) lower than L1 and L2 144 PA Stomach and Duodenum (2 of 4) Central Ray (CR) Perpendicular to center of IR IR/Collimation Radiation field no larger than 10 × 12 inches (24 × 30 cm) – small patients 11 × 14 inches (28 × 35 cm) for larger patients Respiration Exposure made at end of suspended expiration 145 PA Stomach and Duodenum (3 of 4) Structures Shown Barium-filled stomach and duodenal loop Size, shape, and relative position of the filled stomach (upright position) The stomach moves superiorly (prone position) Fundus usually fills in asthenic patients The pyloric canal and the duodenal bulb are well shown (asthenic and Single-contrast PA stomach and hyposthenic patient) duodenum 146 PA Stomach and Duodenum (4 of 4) Evaluation Criteria Entire stomach and duodenal loop Stomach centered at level of pylorus No rotation Penetration of the contrast medium Surrounding anatomy Double-contrast PA stomach and duodenum. 147 Stop here! 148 PA Oblique Stomach and Duodenum (1 of 2) Patient position Recumbent RAO position Part position Midline of IR aligned with sagittal plane passing midway between vertebral column and lateral border of elevated side IR centered to lower rib margin (level of L1-L2) Adjust rotation to 40 to 70 degrees to demonstrate pyloric canal and duodenum 149 PA obl stomach and duodenum 150 151 152
