Pathology Test 2.pdf

Pathology Test 2 Hiatal Hernia Hiatal hernia is a medical condition where a portion of the stomach protrudes into the thoracic cavity through the esophageal hiatus. There are two main types of hiatal hernias: Sliding Hiatal Hernia: In severe cases, most of the stomach is found within the thoracic...

Pathology Test 2 Hiatal Hernia Hiatal hernia is a medical condition where a portion of the stomach protrudes into the thoracic cavity through the esophageal hiatus. There are two main types of hiatal hernias: Sliding Hiatal Hernia: In severe cases, most of the stomach is found within the thoracic cavity above the diaphragm Causes symptoms like heartburn and difficulty swallowing Rolling (Paraesophageal) Hiatal Hernia: Portion of the stomach rolls up alongside the esophagus, while the gastroesophageal junction remains in place Caused by weakening of a small muscle (esophageal sphincter) located between the terminal esophagus and the diaphragm As a result of aging or other factors, this sphincter may weaken and permit a portion of the stomach to herniate through the esophageal hiatus A sliding hiatal hernia may produce a radiographic sign termed Schatzki’s ring, which is a ringlike constriction at the distal esophagus Radiographic Demonstration of Hiatal Hernia 1. - Barium Swallow (Esophagus & Stomach) Study: Intra-abdominal/Thoracic Pressure: Images can be taken under conditions of increased intra-abdominal or intra-thoracic pressure to visualize herniation of the stomach into the chest. Prone with Bolster: Placing the patient in the prone position with a bolster beneath them may help highlight the hernia. Trendelenburg Position: Tilting the patient head-down can accentuate reflux and herniation. Water Test: Having the patient swallow water while the study is conducted can demonstrate the hernia more clearly. Valsalva Maneuver: Having the patient perform a Valsalva maneuver (straining as if having a bowel movement) can also highlight herniation. Leg Raises: Lifting the patient's legs during the procedure can help show the hernia and reflux more clearly. 2. Chest X-ray: A chest X-ray may be used to visualize the chest and upper abdominal area. - A soft tissue mass in the posterior mediastinum, which could represent herniated stomach. - Air/fluid levels in the chest or upper abdomen, which can be indicative of reflux or herniation. Hiatal Hernia Repair 1. 2. 3. 4. 5. 6. 7. - Patient Preparation: The patient is placed under general anesthesia to ensure they are unconscious and pain-free during the procedure Carbon dioxide gas may be used to inflate the abdominal cavity, creating space for the surgery. Incisions: Several small incisions (usually 3-5) are made in the abdominal wall. These serve as entry points for surgical instruments and a laparoscope, which is a thin, flexible tube with a camera and light at the end. Visualization: The laparoscope is inserted through one of the incisions, allowing the surgeon to see the surgical area on a video monitor. Repositioning the Herniated Stomach: Surgeon repositions the herniated portion of the stomach from the chest cavity back into the abdominal cavity. The hiatus (the opening in the diaphragm through which the esophagus passes) is repaired and tightened to prevent further herniation. Fundoplication: This involves wrapping the top of the stomach (fundus) around the lower esophagus and suturing it in place to prevent acid reflux. Closure: After the repairs are completed, the incisions in the abdominal wall are closed with sutures or surgical staples. Recovery: Minimally invasive, which typically results in less post-operative pain, shorter hospital stays, and quicker recovery times compared to traditional open surgery Peptic Ulcer Disease Peptic ulcer disease (PUD) is a condition characterized by the presence of ulcers in the stomach or the first part of the small intestine (duodenum). 1. Helicobacter pylori (H. pylori) Infection: Bacteria that can infect the lining of the stomach and duodenum. Can lead to inflammation, and over time, it can cause peptic ulcers. Ulcers are typically small and shallow erosions that can perforate or cause hemorrhage. These ulcers are often found in the anterior wall of the stomach or the duodenal bulb (the initial part of the duodenum). 2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Can also be caused by the use of certain medications, such as aspirin a ibuprofen (Motrin) These drugs can irritate the lining of the stomach and duodenum, leading to the development of ulcers Often found in the stomach, particularly in the lesser curvature, but can also occur in the duodenum. Benign vs malignant Peptic Ulcer Disease Treatment 1. 2. 3. - Lifestyle changes Avoiding spicy foods Quitting smoking Reducing alcohol intake Stress reduction Antacids Short term relief by neutralizing stomach acid H.pylori eradication If bacteria is the cause, antibiotics are given Stomach Cancer 1. 2. 3. 4. - Infiltration of Gastric Wall and Wall Thickening: Stomach cancer can invade the stomach wall, leading to thickening of the stomach wall, which may resemble fibrosis Narrowing and Fixation of the Stomach: As stomach cancer progresses, it can narrow and fix the stomach, resulting in symptoms like difficulty swallowing and discomfort. Large Irregular Polypoid Mass: Stomach cancer can present as a sizeable, irregular, polypoid mass within the stomach, indicative of advanced disease. Location of Stomach Cancer: Most stomach cancers occur in the distal stomach (lower part), especially in the antrum and pylorus, while the upper part, the fundus, is less commonly affected. Hypertrophic Pyloric Stenosis- Acquired Acquired conditions develop after birth as a result of various factors, including infections, lifestyle choices, environmental influences, or trauma. 1. Extrinsic Pressure: - Occurs when external factors, such as tumors or structures outside the pylorus, apply pressure and constrict the pyloric opening, hindering the passage of food. 2. Healing Ulcers and Scar Tissue: - Healing of ulcers in the stomach or duodenum can leave behind scar tissue. - The accumulation of scar tissue narrows the pyloric lumen, leading to symptoms like vomiting and abdominal pain. Hypertrophic Pyloric Stenosis- Congenital Congenital conditions are present at birth or develop during fetal development. 1. 2. - 3. - Gender Predominance: HPS is more common in males, with a male-to-female ratio of around 3:1. Muscular Changes: HPS is characterized by the abnormal enlargement (hypertrophy) and increased cell numbers (hyperplasia) of the circular layer of smooth muscle in the pyloric region of the stomach. Pyloric Lumen Narrowing: The hypertrophied muscle narrows the pyloric opening, obstructing the passage of food from the stomach to the small intestine. This results in a distended stomach and forceful vomiting (acid but no bile) Hypertrophic Pyloric Stenosis- Imaging and Treatment Ultrasound is modality of choice as it is timely If inconclusive, UGI performed Barium Meal Demonstrations: 1. Abnormally Large Dilated Stomach: Can reveal an abnormally large and dilated stomach- may be indicative hypertrophic pyloric stenosis 2. Delayed Passage of Contrast: This delay can occur when there is an obstruction or narrowing in the pathway, such as in hypertrophic pyloric stenosis, where the pyloric canal is constricted. 3. Pyloric Canal Appearance: The pyloric canal may appear as a thin string of barium contrast, measuring only 1-2 cm in length Treatment for Hypertrophic Pyloric Stenosis: Pyloromyotomy, a surgical procedure to release the thickened muscle of the pyloric canal and widen the opening. This surgical intervention allows for the normal passage of food from the stomach to the duodenum. Caterpillar Intestinal Obstruction 1. Mechanical Causes: Result from physical barriers that obstruct the intestinal lumen- tumors, adhesions (bands of scar tissue), volvulus (twisting of the intestines), and inguinal hernias. Tangible Obstructions: Typically tangible and can be visualized or felt Referred to as "simple" and "closed" obstructions. Colon Cancer: Approximately 70% of large bowel obstructions are attributed to colon cancer. 2. Functional (Paralytic or Adynamic Ileus): Causes: Occur when peristalsis (the muscular contractions that move contents through the intestines) is inhibited Toxic: Toxic causes include peritonitis, certain medications, and inflammation that paralyze intestinal motility. Traumatic: Traumatic factors, particularly abdominal surgery, are a common cause of functional obstruction. If the intestines do not regain their normal motility within 72 hours after surgery. Medications like atropine can be used to manage this post-surgical complication. Intestinal Obstruction- Pathogenesis Bowel Distension Due to Swallowed Air: Obstruction can cause a buildup of gas and swallowed air in the affected segment of the intestine As the air accumulates, it results in distension (swelling) of the bowel. More Distension Due to Fluid Accumulation: In response to the initial obstruction and gas accumulation, the body may attempt to secrete fluids into the affected bowel segment This can further exacerbate distension Fluid and Electrolyte Imbalances Due to Suctioning: Medical interventions like suctioning or nasogastric tube insertion may be used to remove gas and fluid from the blocked intestine. This can lead to fluid and electrolyte imbalances as essential fluids are removed. Distension Persists Leading to Complications: If the obstruction persists and is not relieved, it can lead to more severe complications. The ongoing distension can result in reduced blood flow to the affected part of the intestine, leading to ischemia (inadequate blood supply) Ischemia can progress to necrosis (tissue death) and gangrene (gangrenous bowel), which are serious and life-threatening conditions. Mechanical Obstructions 1. Simple Mechanical Obstruction: Characteristics: Develops rapidly. involves a single point of obstruction in the intestine Blood flow to the affected area is usually maintained, which means that there is no interference with the blood supply Gas and fluid can accumulate proximal to the obstruction within a few hours. Treatment: Simple mechanical obstruction often requires early diagnosis and emergency intervention. Treatment may involve surgery or endoscopy. Appearance: Step ladder shape (distended loops) Stacked coins (mucosal folds) 2. Closed Loop Mechanical Obstruction: Characteristics: Involves obstruction at two points in the intestine, creating a loop. Can occur, in cases of volvulus (twisting of the intestines). Blood supply to the affected segment is compromised, leading to increased pressure within the loop. Complications: The compromised blood supply can lead to ischemia (inadequate blood flow) in the looped segment of the intestine. Ischemia can progress to infarction (tissue death), resulting in necrosis. Necrosis can lead to serious complications, including sepsis and peritonitis, and, in some cases, gangrene. Appearance: Inverted U shape Radiographic Appearance Functional Obstruction (adynamic ileus) Functional intestinal obstruction (adynamic ileus) is characterized by reduced or absent peristalsis - Adynamic ileus can affect both the large and small bowel, resulting in a uniformly dilated appearance of the intestines. - Unlike mechanical obstruction, there is no specific, demonstrable point of obstruction or physical blockage in the intestine. - One of the hallmark signs of adynamic ileus is the generalized, uniform distension of the bowel without a clear site of constriction. - Typically resolves on its own without the need for surgical intervention, It may resolve within 36 to 48 hours. Mechanical vs Functional Mechanical Intestinal Obstruction: - Caused by a physical blockage (e.g., tumor, adhesion) - Clear point of obstruction, can be dangerous, with increased fluid accumulation and pressure - May lead to compromised blood supply, necrosis, and severe complications - Treatment often involves surgical intervention to decompress, remove the obstruction, and prevent necrosis or perforation. Functional Intestinal Obstruction (Adynamic Ileus): - Due to a lack of muscle contractions (peristalsis) - Uniform distribution of air - No specific point of obstruction; intestines are diffusely dilated. - Resolves within 36-48 hours - Management focuses on supportive care, including hydration and nutrition. Large bowel obstruction, haustra distended, fewer loops Sigmoid- inverted U Volvulus Volvulus - Volvulus is the complete twisting of a loop of bowel around its mesenteric base, potentially compromising its blood supply Sigmoid Volvulus: - Sigmoid colon twisting on itself, forming an inverted "U" shape - Becomes distended and loses its normal haustral markings, giving it a sausage or balloon-like appearance - Creates a closed loop in the intestine, potentially compromising blood supply Cecal Volvulus: - Involves the cecum, which is the beginning of the large intestine, twisting around its mesentery. - Cecum becomes distended and shifts up and to the left within the abdomen. - The distended cecum can appear as a kidney-shaped mass on imaging. Cecum- kidney Small vs Large Bowel Small Bowel: Location: Distended loops are typically seen in the central abdomen. Appearance: On imaging, the small bowel may resemble stacked coins. Characteristic Sign: The "step ladder sign" may be observed in the small bowel, which is a pattern of parallel lines or markings on the radiograph. Large Bowel: Location: Distended loops of the large bowel are often found in the periphery of the abdomen. Appearance: The haustra (sacculations) of the large bowel are distended, giving it a segmented appearance. Comparison: There are typically fewer loops of the large bowel visible on imaging compared to the small bowel. Pneumoperitoneum Pneumoperitoneum is the presence of air or gas in the peritoneal cavity, which surrounds the abdominal organs - Cause: most common cause being a perforation of an abdominal viscus, such as an ulcer, benign ulcers, tumors, or traumatic injuries. - Induced during laparoscopic surgery for improved visibility and access to abdominal organs. - Diagnosis: involves radiographic imaging, such as an upright chest radiograph, can reveal the presence of air or gas in the abdominal cavity Lower GI Procedures- Barium Enema 1. 2. 3. - Double Contrast Barium Enema: This procedure uses thick barium contrast followed by the introduction of air into the colon It provides detailed visualization of the colon's mucosal patterns, making it suitable for detecting subtle abnormalities. Single Contrast Barium Enema: This version uses only thin barium contrast without introducing air. Broader evaluation of gross pathologies and may be preferred for certain patient populations, such as children or debilitated individuals. Defecogram (Evacuative Proctography): Focuses on assessing rectal and anal function during defecation. It aids in the diagnosis of conditions related to defecation dysfunction. Barium Enema Procedure Patient Preparation: Low residue diet for 2-3 days. Clear fluid diet on the day before the exam. Laxative and colonic lavage if necessary. Barium Temperature: Room temperature is recommended by most experts for patient comfort. Contrast: Single contrast (SC) uses barium at 15-25% weight/volume (W/V). Double contrast (DC) uses barium at 75-95% W/V. Equipment: Necessary equipment includes gloves, clamp, lubricant, footstep, and an IV pole (positioned 18-24 inches above the rectum). Provide the patient with a gown and slippers for comfort. Explain the procedure to the patient to enhance cooperation. Run barium through the enema tip before insertion. Ensure proper positioning in the Sim's position (left lateral with the right knee flexed) to relax abdominal muscles and reduce pressure on the anal sphincter. Maintain patient privacy and comfort by covering them entirely. Enema tube insertion is done in two steps: first towards the umbilicus by 2.5 to 4 cm, then superiorly and slightly anteriorly by 3-4 cm. Wear disposable gloves and apply lubricant to the enema tip. Avoid excessive patient exposure while exposing the anus. Provide breathing instructions and insert the enema tip on expiration. Advance the tip gently without forcing it to avoid possible perforation. Maintain the bag height 18-24 inches above the rectum. Barium Enema Barium Enema Barium Enema Virtual Colonoscopy Virtual Colonoscopy, also known as CT Colonography, is a non-invasive procedure used to examine the colon. - Method: The procedure consists of performing an abdominal CT scan after insufflating carbon dioxide (CO2) into the colon to distend it, allowing for better visualization. - Advanced Imaging: Virtual Colonoscopy employs advanced imaging techniques and virtual reality software to reconstruct three-dimensional images of the colon. - Alternative to Optical Colonoscopy: It offers an alternative to traditional optical colonoscopy, which is invasive and involves the insertion of a colonoscope through the rectum. - Diagnostic Utility: Virtual Colonoscopy is effective in detecting colorectal polyps, tumors, and other abnormalities within the colon. - Non-Invasive: It provides detailed images of the colon's interior without the need for a traditional scope insertion, making it a less invasive option for colorectal screening. Colostomy Barium Enema Purpose: - To assess the colostomy and the connected portion of the colon. - To check for any potential issues, such as blockages, leaks, or other abnormalities. Procedure: - The patient's stoma and colostomy bag may be removed temporarily. - A catheter is inserted into the stoma. - Barium contrast material is introduced through the catheter and into the colon. X-ray imaging or fluoroscopy is used to monitor the flow of the contrast material through the colostomy and colon. - The procedure helps in visualizing the anatomy and functionality of the colostomy and identifying any potential problems. Colostomy Barium Enema Purpose: - To assess the colostomy and the connected portion of the colon. - To check for any potential issues, such as blockages, leaks, or other abnormalities. Procedure: - The patient's stoma and colostomy bag may be removed temporarily. - A catheter is inserted into the stoma. - Barium contrast material is introduced through the catheter and into the colon. X-ray imaging or fluoroscopy is used to monitor the flow of the contrast material through the colostomy and colon. - The procedure helps in visualizing the anatomy and functionality of the colostomy and identifying any potential problems. Crohn’s Disease: IBD Crohn's Disease, also known as Regional Enteritis, is a chronic inflammatory disorder that primarily affects the gastrointestinal (GI) tract. Cause: The exact cause is unknown, may involve a combination of genetic, environmental, and immunological factors. Stress may also play a role in exacerbating symptoms. Age: Young adults, although it can occur at any age. Location: Can occur in any part of the GI tract, from the mouth to the anus. Involves the terminal ileum, which is the end portion of the small intestine. Pathology: Transmural inflammation, meaning it can affect the entire bowel wall. Complications, include the formation of fistulae (abnormal connections or passageways between different parts of the GI tract or between the GI tract and other organs) Symptoms: Includes abdominal pain, diarrhea, and weight loss Can cause flare-ups and periods of remission. Treatment: Medication, dietary changes, and, in some cases, surgery. Crohn’s Disease: IBD Crohn's Disease, also known as Regional Enteritis, is a chronic inflammatory disorder that primarily affects the gastrointestinal (GI) tract. Cause: The exact cause is unknown, may involve a combination of genetic, environmental, and immunological factors. Stress may also play a role in exacerbating symptoms. Age: Young adults, although it can occur at any age. Location: Can occur in any part of the GI tract, from the mouth to the anus. Involves the terminal ileum, which is the end portion of the small intestine. Pathology: Transmural inflammation, meaning it can affect the entire bowel wall. Complications, include the formation of fistulae (abnormal connections or passageways between different parts of the GI tract or between the GI tract and other organs) Symptoms: Includes abdominal pain, diarrhea, and weight loss Can cause flare-ups and periods of remission. Treatment: Medication, dietary changes, and, in some cases, surgery. Radiographic Appearance: Skip Lesions String Sign (Narrowing) Cobblestone Appearance Fistula Formation Crohn’s Disease: IBD Skip lesions Cobblestone Skip-lesions String Ulcerative Colitis: IBD Cause: The exact cause is unknown, but it is believed to have a genetic and autoimmune component. Stress may exacerbate symptoms but is not a direct cause. Prevalence: It is about five times more common than Crohn's Disease. Age: It primarily affects young adults but can occur at any age. Symptoms: Common symptoms include bloody diarrhea, abdominal pain, weight loss, and fever. Location: Arises in the left colon and is often continuous with the rectum. I t primarily affects the recto-sigmoid area of the colon. Pathology: Superficial ulcerations of the colon mucosa and submucosa. Unlike Crohn's Disease, which is transmural (affecting the entire bowel wall), it primarily affects the mucosal and submucosal layers and does not involve the deeper layers of the bowel wall. Clinical Course: The disease may have periods of remission and progression, where symptoms improve and worsen over time 1. Mucosa - thickened, deep ulcerations, loss of mucosal pattern – fibrosis - pipestem sign (narrowing) 2. Loss of haustral markings 3. Toxic megacolon –dilation ... possible perforation (emergency colectomy) Ulcerative Colitis: IBD IBD Locations Crohn's Disease: - Characterized by skip segments, meaning it can affect one part of the digestive tract while leaving others unaffected. - Commonly involves the terminal ileum, cecum, ascending colon, and small bowel, spares the rectum. - Treatment options include medications, surgery, and in some cases, fecal transplant. - Involves the mucosa and submucosa, affecting multiple layers of the bowel wall. - Disease involvement is often not continuous but has gaps in affected areas. Ulcerative Colitis: - Involves continuous segments of the large bowel, particularly the rectum. - Approximately 95% of cases have rectal involvement. - Characterized by inflammation of the mucosa and submucosa, primarily affecting the top layers of the bowel wall. - Treatment may involve dietary changes, including a low-bulk diet. - Surgery is sometimes necessary to manage the condition, often involving the removal of the affected colon. Malabsorption Syndrome: IBD Malabsorption Syndrome: Intestinal mucosa is unable to adequately absorb nutrients from the digestive tract, leading to deficiencies in various vitamins, minerals, and other essential nutrients. Potential causes: 1. Following Gastric Surgery: Can alter the digestive processes, including reducing the production of intrinsic factor, a protein needed for the absorption of vitamin B12 (leading to vitamin B12 deficiency) 2. Pancreatic Disorders: Conditions that affect the pancreas, such as chronic pancreatitis or pancreatic enzyme deficiencies, can impair the digestion of fats, proteins, and carbohydrates, leading to malabsorption 3. Hepato-biliary Disease: Diseases of the liver and biliary system can interfere with the production and release of bile, which is essential for the absorption of fats and fat-soluble vitamins. 4. Small Bowel Diseases: Conditions like Crohn's disease and infections that affect the small intestine can damage the intestinal lining, reducing the absorption of nutrients. 5. Hereditary Disorders: Some hereditary conditions, like celiac disease (gluten intolerance), can lead to damage to the intestinal lining and malabsorption of nutrients. Treatment - dietary modifications, nutritional supplementation, medications, probioitcs, or fecal transplant Malabsorption Syndrome: IBD Radiographic Appearance Small bowel dilation, or irregular distorted folds Diverticular Disease: IBD Diverticular Disease: presence of small pouches or pockets called diverticula in the wall of the colon, typically in the lower part of the large intestine (colon). Age: Rare in individuals below the age of 35. However, its incidence increases with age, and it is more commonly seen in older adults. Stress and Lifestyle Factors: Stress and alterations in bowel habits, such as bouts of constipation and diarrhea, can contribute to the development or exacerbation of diverticular disease. Signs and Symptoms: Majority may not experience any symptoms. Can include: Flatulence (excessive gas) Intermittent diarrhea Constipation Discomfort or tenderness in the lower left quadrant (LLQ) of the abdomen, which may be palpable. Treatment: Initial treatment- managing symptoms with medications. Surgery is reserved for complications like perforation, obstruction, or hemorrhage. Dietary modifications- a high-fiber diet recommended to prevent future flare-ups. Foods with seeds, nuts, or popcorn should be avoided. Regular exercise is encouraged to promote gastrointestinal health and reduce the risk of constipation, which can contribute to the condition. Diverticular Disease: IBD Radiographic Appearance Outpouchings of Colon Wall: - Diverticula are small, sac-like protrusions that develop on the colon wall. - They often occur in clusters. Affected Segment Shortened and Lumen Narrowed: - The presence of diverticula can lead to the shortening of the affected segment of the colon and a narrowing of the intestinal lumen, which may impact the flow of stool and waste material. Diverticulitis: - Diverticulitis is a complication of Diverticular Disease and occurs when one or more diverticula become inflamed or infected Meckel's Diverticulum: IBD Meckel's Diverticulum: Congenital abnormality of the small intestine, specifically the ileum, characterized by the presence of a small sac or appendage near the ileum, typically about 2-3 inches in length, resembling a finger of a glove. Develops due to the failure of the vitelline duct to close during embryonic development. Complications: Ulcers: The diverticulum can develop ulcers, which are open sores on its inner lining. Perforation: In some cases, the diverticulum may rupture or perforate, leading to leakage of its contents into the abdominal cavity. Hemorrhage: Ulcers or irritation of the diverticulum's lining can cause bleeding, leading to rectal or intestinal bleeding. Strangulation: In rare instances, the diverticulum can become twisted or strangulated, obstructing the blood supply and causing severe abdominal pain. Meckel's Diverticulum: IBD Radiographic Appearance Intussusception Intussusception: One segment of the bowel telescopes or slides into the segment of bowel just distal to it, similar to how a telescope's sections slide into one another. Characterized by a form of bowel obstruction. Age Group: Intussusception is most commonly observed in infants and children between 3 months and 6 years of age. Location: It can occur in various parts of the gastrointestinal tract, but the most common location is near the ileocecal valve, which is the junction between the small intestine (ileum) and the large intestine (cecum). Can also occur anywhere in the large or small bowel. Pathophysiology: Intussusception typically occurs due to abnormal peristaltic movements in the bowel. Peristalsis forces one segment of the bowel to move into the adjacent healthy segment, causing the telescoping effect. This gradually leads to obstruction and can potentially compromise the blood supply to the affected bowel, resulting in ischemic necrosis. Intussusception is a medical emergency and requires prompt evaluation and treatment. The condition can lead to severe abdominal pain, vomiting, and, if left untreated, can result in tissue damage due to reduced blood supply. Treatment: Often involves medical interventions to reduce the intussusception and restore normal bowel function. In some cases, surgery may be necessary if the condition is severe or recurrent. Intussusception: Radiographic Appearance Sudden Abdominal Pain: Intussusception typically starts suddenly with severe abdominal pain, which can be quite painful and distressing. Blood in Stool: Sometimes, there can be blood in the stool, which might appear red or tarry. Palpable Right-Side Mass: A doctor may be able to feel a lump or mass on the right side of the abdomen, especially in the ileocecal region (where the small and large intestines meet). Polyps Polyps: - Growths that project from the lining of the bowel into the interior of the bowel (lumen). - These growths can have varying characteristics and, in some cases, carry malignant (cancerous) potential. 1. Pedunculated Polyps: - These are polyps that are attached to the bowel wall by a stalk, making them look like they're hanging. - They are commonly found in the ascending and transverse portions of the large bowel and, to a lesser extent, in the recto-sigmoid area. 2. Sessile Polyps: - Sessile polyps do not have a stalk and appear more flat against the bowel wall. - These polyps are more frequently found in the sigmoid and rectum. - Sessile polyps have a greater potential for malignancy compared to pedunculated polyps. Polyps: Radiographic Appearance Rectal Bleeding: Polyps can lead to bleeding from the rectum, which may result in blood in the stool. Diarrhea: Changes in bowel habits, such as increased frequency of loose or watery stools, can occur. Constipation: In some cases, constipation or difficulty passing stool may be a symptom Colon Cancer Dietary Factors: Red meat, especially when consumed in excess, high levels of fat, and sugar have been associated with an increased risk. In contrast, a diet rich in fiber, chicken, fish, fruits, and vegetables is linked to a reduced risk. Smoking: Smoking is another factor that can increase the risk of colorectal cancer. It's essential to quit smoking to reduce this risk and improve overall health. Indications Suggesting Pre-Existing Polyps: Colorectal cancer often develops from pre-existing polyps in the colon. The type of polyp can influence the likelihood of malignancy. Sessile polyps are more likely to be malignant, while pedunculated polyps are usually benign. Common Locations: Colorectal cancer is most frequently found in the recto-sigmoid region, which is the lower part of the colon and the sigmoid colon. The cecum and ascending colon are the next most common sites for the development of this cancer. Prognosis: Regular screenings, such as colonoscopies, are essential for early diagnosis and successful treatment. Detecting and removing pre-cancerous polyps can significantly improve outcomes. Peritonitis Peritonitis Inflammation of the peritoneum, the thin lining of the abdominal cavity. Spread of Infection: Peritonitis can occur when an infection from abdominal organs spreads to the peritoneum. Examples include appendicitis, inflammation of the appendix, and salpingitis, inflammation of the fallopian tubes. Rupture of the GI Tract: If the gastrointestinal tract (GI tract) ruptures, it can release its contents, which are often filled with irritating substances such as bile, digestive enzymes, and bacteria, including E. coli. This can lead to peritonitis. A common example is the rupture of the appendix in cases of appendicitis. Penetrating Abdomen Wounds: Peritonitis can also result from penetrating wounds to the abdomen caused by trauma, accidents, or surgical procedures. Peritonitis is a serious medical condition that typically requires prompt medical intervention and treatment with antibiotics. Left untreated, it can lead to severe complications and is considered a medical emergency. Hirschsprung Disease Hirschsprung's Disease (Congenital Megacolon) Characterized by the absence of nerve ganglia in the distal rectum, typically involving the anal sphincter. This leads to a functional obstruction of the bowel, resulting in a set of distinct symptoms Pathogenesis: The aganglionic segment of the bowel remains contracted and lacks peristalsis, which is the coordinated muscular contractions that move contents through the digestive tract. This functional obstruction causes gross dilation of the bowel adjacent to the narrowed segment, leading to the development of a condition known as "megacolon," which refers to the abnormally large or expanded colon. Feces are retained in the dilated portion of the bowel due to the blockage, resulting in symptoms and complications associated with Hirschsprung's Disease. Symptoms: No Bowel Sounds: Newborns typically have no bowel sounds shortly after birth. Failure to Pass Meconium: Meconium, the first stool passed by infants, is not passed as expected. Abdominal Distention: The abdomen becomes swollen or distended due to the bowel obstruction. Poor Weight Gain: Affected infants may have difficulty gaining weight and may experience poor growth. Vomiting: may occur due to the inability of the intestine to properly move stool. In Older Children: Constipation- Older children often experience severe and persistent constipation. Abdominal Distention: Abdominal swelling and discomfort continue to be present. Small Caliber Stool: Stools are typically narrow in diameter. Hirschsprung's Disease requires prompt diagnosis and surgical intervention to address the absence of nerve cells and alleviate the associated symptoms and complications. Hirschsprung Disease Imperforate Imperforate Anus Is a congenital condition characterized by the absence of a normal communication between the rectum and the exterior of the body. Obstruction preventing the passage of stool and gas from the rectum to the outside Pathogenesis: Imperforate anus is often considered an "embryological accident," meaning it occurs during fetal development. The nature and location of the imperforation can vary, ranging from a membrane-like blockage to a complete atresia, where there is no opening for stool or gas to exit from the rectum. Typically diagnosed shortly after birth when it becomes evident that the baby is unable to pass stool. Surgical intervention is almost always required to create an opening (anus) and allow for the normal passage of feces. Biliary Anatomy Biliary Anatomy: The liver, bile production, ducts, and the gallbladder. Bile, produced in the liver at a rate of approximately one quart per day, is a crucial component of the digestive system. It is then transported through various ducts to the gallbladder, where it is stored and concentrated. Bile plays a significant role in the digestion of fats, aiding in the breakdown and absorption of dietary fats. Liver Function: Any impairment or disease affecting the liver can disrupt the production of bile and impact the overall digestive process; Liver diseases, such as cirrhosis, hepatitis, or fatty liver disease, can affect bile production. Bile Duct Obstruction: Blockages or obstructions within the bile ducts can lead to a buildup of bile, causing discomfort and potentially leading to complications like cholecystitis or jaundice. Gallbladder Issues: Conditions such as gallstones or inflammation of the gallbladder (cholecystitis) can cause significant abdominal pain and may require medical intervention. Pancreatic Duct: The pancreatic duct and the bile duct join together before emptying into the duodenum. Conditions affecting the pancreas, like pancreatitis or pancreatic cancer, can affect the proper release of both bile and pancreatic enzymes. Gallbladder Removal: In cases of severe gallbladder disease or gallstones, the gallbladder may be surgically removed. While this can alleviate some issues, it can also result in changes in digestion due to the constant flow of bile into the digestive tract. Gallstones 1. 2. 3. 4. 5. 6. - RUQ Pain: Right upper quadrant (RUQ) abdominal pain is a common and characteristic symptom of gallstones. This pain can range from mild to severe and is often described as a sharp or cramping discomfort. Increase in Pain After Fatty Food/Eating Late: Gallstone pain is typically triggered or exacerbated by the consumption of fatty foods. Eating a heavy or high-fat meal can lead to more pronounced pain. Radiating Pain: The pain associated with gallstones can radiate, or spread, to the right shoulder or even the back. This radiating pain is often referred to as "referred pain." Gallstone Development: Gallstones form when there is an imbalance between cholesterol, bile salts, and lecithin in the gallbladder. This imbalance leads to the precipitation of cholesterol crystals and the formation of gallstones. Radiolucent Stones: Most gallstones are radiolucent, which means they do not appear clearly on conventional X-ray imaging. They are often better visualized with other imaging techniques like ultrasound or CT scans. Initial Exam Is Ultrasound: When gallstones are suspected, the initial diagnostic examination of choice is usually an abdominal ultrasound. Ultrasound is an effective tool for visualizing the gallbladder and detecting the presence of gallstones. Gallbladder and BIliary ducts Cholecystography: It is often used to detect the presence of gallstones or other gallbladder abnormalities. Cholangiogram: This is a radiographic examination of the biliary ducts. It is used to visualize the bile ducts and is often performed to diagnose conditions like blockages or strictures in these ducts. Choleography: This is a general term used to describe specialized examinations of the biliary ducts. It can encompass various imaging techniques that focus on the biliary system. Cholecystocholangiogram: This examination involves visualizing both the gallbladder and the biliary ducts. It provides comprehensive information about both the gallbladder and the biliary system. Cholecystopaques (OCG): This term refers to the visualization of the gallbladder using contrast media. It often involves the use of oral contrast agents to enhance the visibility of the gallbladder during imaging. Percutaneous Transhepatic Cholangiography: Percutaneous Transhepatic Cholangiography (PTC): Procedure that involves the direct injection of a contrast agent into the liver under fluoroscopic control Used to visualize the biliary ducts, primarily the intrahepatic and extrahepatic bile ducts Obstructive Jaundice: PTC is commonly used in cases of obstructive jaundice. Occurs when there is a blockage in the bile ducts, preventing the normal flow of bile from the liver to the intestine. This blockage can result from various conditions, such as gallstones, tumors, or strictures. PTC helps identify the location and cause of the obstruction. Stone Extraction & Biliary Drainage (Interventional Procedure): If gallstones are causing a blockage in the bile ducts, PTC can be used to guide the removal of these stones. Biliary drainage- relieve pressure and alleviate symptoms in cases of biliary obstruction. PTC Next Steps: Next steps depend on what we find and the patient's condition: Biopsy: If there are suspicious findings, we might take a small tissue sample to check for cancer or other issues. Drainage: If there's a blockage causing problems like jaundice, we can insert a tube to help bile flow better and relieve symptoms. Stent: Sometimes, we use a tube (stent) to keep bile ducts open if they are narrow. Stone Removal: If there are stones causing issues, we can remove them during or after the PTC. Palliative Care: For patients with serious conditions, we may focus on providing comfort and symptom relief. Laparoscopic Cholecystectomy A Laparoscopic Cholecystectomy is a minimally invasive surgical procedure to remove the gallbladder. Procedure: 1. Small Incisions: Instead of a large incision, the surgeon makes several small cuts in the abdomen. 2. Inserting a Camera: A tiny camera and special surgical instruments are inserted through these small incisions. 3. Visualizing the Gallbladder: The camera allows the surgeon to see inside the abdomen and specifically the gallbladder on a screen. 4. Gallbladder Removal: Using the instruments, the surgeon carefully removes the gallbladder. 5. Closing Incisions: The small incisions are closed with stitches or adhesive strips. 6. Recovery: Recovery is typically quicker and less painful compared to traditional open surgery. Operative Cholangiography Operative Cholangiography: is a procedure performed during gallbladder (GB) surgery to assess several important factors. Purposes: Duct System Patency: It's used to check if the ducts responsible for carrying bile are open and not blocked. This is crucial for proper bile flow and digestion. Detecting Duct Injuries: It helps identify any accidental injuries to the ducts that may have occurred during surgery. These injuries are referred to as iatrogenic and need immediate attention. Finding Residual Stones: The procedure can uncover any remaining gallstones or other obstructions in the ducts that need to be addressed. Evaluating Sphincter Function: It assesses how well the sphincter of Oddi, a muscular valve that controls the release of bile, is functioning. T-tube Cholangiography T-Tube Cholangiography is a medical procedure that involves the use of a T-tube to assess the biliary duct system. 1. Tube Placement: After gallbladder surgery, a T-tube is often inserted into the common bile duct, which is a tube that carries bile from the liver and gallbladder to the small intestine. 2. Dye Injection: Contrast dye is injected through the T-tube into the common bile duct. This dye helps make the bile ducts visible on X-ray images. 3. X-ray Imaging: X-ray images are taken while the contrast dye flows through the bile ducts. These images provide a detailed view of the biliary system. 4. Assessment: The images obtained through T-tube cholangiography are used to assess the patency of the bile ducts, detect any blockages or abnormalities, and ensure that there are no leaks or injuries in the ducts. 5. Monitoring and Treatment: T-tube cholangiography can be used for postoperative monitoring and may guide further treatment if any issues are identified, such as the removal of gallstones or the management of duct obstructions. Endoscopic Retrograde Cholangiopancreatography (ERCP) Purpose: Diagnosis of biliary and pancreatic issues. Therapeutic/interventional procedures, such as stone removal or stent placement. Procedure: A flexible endoscope with a camera is passed through the mouth and into the duodenum. Throat is numbed, and the patient fasts before the exam. The endoscopist finds the ampulla of Vater, the opening where the common bile duct (CBD) and pancreatic duct drain. Cannulation: A tube is inserted into either the CBD or the pancreatic duct. Contrast dye is injected to assess patency and detect stones or tumors. Contraindications: Hypersensitivity to iodinated contrast. Esophageal obstruction, Acute pancreatitis, Pancreatic pseudocyst, Elevated BUN and/or creatinine levels. Preparation: Fasting for at least 8 hours before the procedure. ERCP is a valuable tool for diagnosing and treating biliary and pancreatic conditions, offering both diagnostic and therapeutic benefits. Pancreatitis Pancreatitis is an inflammatory disease of the pancreas characterized by the premature activation of digestive enzymes within the pancreas, leading to the digestion of pancreatic tissue. Causes: Pancreatitis can be caused by various factors, including excessive alcohol consumption, gallstones, hypercalcemia (elevated calcium levels), smoking, a family history of the condition, and substance abuse. Diagnostic Tools: Medical professionals typically use imaging techniques such as ultrasound (US) and computed tomography (CT) scans to diagnose pancreatitis. Jaundice Jaundice, also known as icterus, is a condition characterized by yellowing of the skin and eyes due to an excess of bilirubin in the body. 1. Hemolytic Jaundice: This occurs when there is an increased breakdown of red blood cells, leading to elevated bilirubin levels. 2. Hepatocellular Jaundice: Diseased or damaged liver, such as in cases of cirrhosis or hepatitis, can result in the liver's inability to process and excrete bilirubin effectively. 3. Obstructive Jaundice: Obstruction in the bile ducts, often caused by factors like gallstones or pancreatic cancer, hinders the normal flow of bile and bilirubin from the liver, resulting in jaundice. Cholecystitis and cholelithiasis Cholecystitis and cholelithiasis are two common diseases of the biliary system. Cholelithiasis Refers to the formation of gallstones in the gallbladder or bile ducts. These gallstones are solid particles that can vary in size and composition and may block the normal flow of bile. Gallstones can lead to symptoms such as abdominal pain, especially after eating, and can cause complications like obstruction of the bile duct Cholecystitis Is the inflammation of the gallbladder, often associated with gallstones. When gallstones block the cystic duct, it can lead to the buildup of bile in the gallbladder, causing irritation and inflammation. This condition can result in symptoms such as severe abdominal pain, nausea, and fever. While cholelithiasis and cholecystitis can occur independently, they often coexist. Cholecystitis can be a complication of cholelithiasis when gallstones lead to inflammation in the gallbladder. Cirrhosis of the Liver Cirrhosis of the liver is a serious and progressive condition characterized by the replacement of healthy liver tissue with fibrous scar tissue. Causes: Alcohol Abuse: Chronic excessive alcohol consumption is a leading cause of cirrhosis. It can lead to post-necrotic viral hepatitis, which further damages the liver. Hepato-toxic Drugs and Chemicals: Certain medications and exposure to toxic substances can damage liver cells and contribute to cirrhosis. Diseases of the Bile Ducts: Conditions affecting the bile ducts can obstruct bile flow and lead to cirrhosis. Increased Deposition of Iron Pigment: Conditions like hemochromatosis, where excess iron is deposited in the liver, can lead to cirrhosis. What Happens: In the early stages, the liver may enlarge and show signs of fatty infiltration. At this point, regeneration of liver tissue is still possible. As the disease progresses, fibrous scar tissue gradually replaces healthy liver parenchyma. The liver contracts, leading to a bumpy and nodular surface- This scarring is often permanent and can impair liver function Signs and Symptoms: Early-stage cirrhosis may present with symptoms like fatigue, weakness, nausea, vomiting, unexplained weight loss, and an enlarged liver. In later stages, additional symptoms may develop, including ascites (abdominal fluid accumulation), edema (swelling), dark urine, jaundice (yellowing of the skin and eyes), the appearance of caput medusa (dilated blood vessels around the navel), hepatic encephalopathy (confusion and coma due to liver dysfunction), and, in severe cases, the potential for liver failure and death. Cirrhosis is a serious condition that often requires medical management and lifestyle changes to slow its progression and manage complications. Hepatocellular Carcinoma Hepatocellular carcinoma (HCC) is the most common type of liver cancer, often arising in the context of cirrhosis. Symptoms: Mild upper quadrant (abdominal) pain, unexplained weight loss, hemorrhagic shock (due to bleeding within the tumor), and jaundice (yellowing of the skin and eyes). Diagnosis: HCC is typically diagnosed through imaging techniques like CT and MRI scans. These imaging studies may reveal the presence of a large solitary mass or a number of small lesions in the liver. HCC can distort the liver's normal contour and may invade the hepatic and portal venous systems. The imaging findings may include non-uniform enhancement of the tumor. Treatment: The prognosis for HCC can be quite bleak, particularly when it's diagnosed at an advanced stage. May include surgery, chemotherapy, and sometimes liver transplantation, depending on the extent of the disease. Metastases (spread of cancer to other parts of the body) from HCC often occur late in the disease. HCC can be associated with the risk of fatal bleeding. Pancreatic Cancer Pancreatic cancer- is a type of cancer that originates in the tissues of the pancreas. Most common type begins in the cells that line the ducts responsible for carrying enzymes, known as pancreatic ductal adenocarcinoma. Causes: The exact causes of pancreatic cancer are not entirely clear, but there are some associated risk factors. Increased risk factors for pancreatic cancer include smoking, inherited gene mutations (particularly in families with a history of genetic syndromes or pancreatic cancer), obesity, diabetes, and a history of pancreatitis. Most people diagnosed with pancreatic cancer are over the age of 65. Symptoms: Pancreatic cancer is often not detected early, as it typically doesn't produce noticeable symptoms until it has spread to other organs. Symptoms of pancreatic cancer may include abdominal pain that radiates to the back, loss of appetite, unintended weight loss, jaundice (yellowing of the skin and whites of the eyes), changes in stool and urine color, itchy skin, blood clots, and fatigue. Treatment: The choice of treatment for pancreatic cancer depends on the extent of the disease. Treatment options may include surgery, chemotherapy, radiation therapy, or a combination of these. The prognosis for pancreatic cancer can vary greatly based on the stage of the disease at the time of diagnosis. Pancreatic cancer often has a poor prognosis, and survival rates are relatively low. Median survival for untreated cases is around 3.5 months, but treatment can extend survival to around 8 months, and in some cases, individuals may live for several years. Early detection and treatment can significantly improve the prognosis for pancreatic cancer, which is why it's crucial for individuals at higher risk or experiencing symptoms to seek medical attention promptly.