INVESTIGATIONS OF GASTRO-INTESTINAL TRACT

1. INVESTIGATIONS OF GASTRO-INTESTINAL TRACT Dr. B. RAMDAS RAI PROF & UNIT CHIEF III YMCH

2. Plain X-Ray Abdomen • Indications :- Intestinal obstruction Perforation Chronic pancreatitis etc.

3. Triad of small bowel obstruction in plain x-ray 1) Dilated small bowel loops > 3 cm 2) Multiple air fluid levels in erect x-ray abdomen 3) Paucity of air in the colon • Perforation – in cases of perforation there will be gas under diaphragm. It is due to significant amount of gas released during bowel perforation

5. Plain X-Ray abdomen showing gas under diaphragm in case of intestinal perforation

6. Ultrasound • Ultrasound contains waves with a frequency of more than 20,000 cycles/second. • The transducer or the probe works as a both transmitter of sound waves & receiver of echoes. • Its used in all abdominal & pelvic conditions.

7. ADVANTAGES :- • No radiation • Non invasive • Effective with efficiency • Painless • Low cost • Available even as portable machines

8. DISADVANTAGES:- • Interpretation can be inadequate • Bowel shadow may prevent proper visualisation • In obese patients image will be inadequate 4 Interpretation is based on echogenicity either hyperechogenicor hypoechogenic

9. Computerised Tomography (CT Scan) • Both plain & contrast CTs are done whenever required • Contrast agents are:- Ionic:- water soluble iodide dyes like sodium diatrizoate Non ionic :- safer but expensive like iohexol , lopamiro In abdominal CT contrast agents can be given orally to delineate bowel properly

10. Indications :- • Neoplasms:- To see the exact location , size, vascularity , extent , lymph node status , metastases & operability • Inflammatory conditions :- like psoas abscess , pseudocystof pancreas , pancreatitis etc.

11. ADVANTAGES:- • More accurate , sensitive & specific • Small lesions are also detected • CT guided biopsies of the mass or lesion & • CT guided FNAC s of lymph nodes can be done

12. DISADVANTAGES:- • Artefacts can be present • Cost factor & availability MRI & PET scan are also being being used .

13. Upper GI Scopy Indications :- Diagnostic – • To identify the lesion & take biopsy in carcinoma oesophagus, carcinoma stomach etc. • For diagnosing other conditions like gastric ulcers , duodenal ulcers , diverticulum , hiatus hernia , oesophageal varices , strictures etc.

14. Therapeutic :- • To remove foreign body • To dilate stricture • To place endostents for inoperable carcinoma oesophagus • To inject sclerosants or banding for varices

15. 2 types of oesophagoscopy:- • Rigid oesophagoscope :- It is done under general anaesthesia . Scope is passed behind the epiglottis & cricoid through the cricopharyngeal opening . This is the most difficult part in oesophagoscopy. After that negotiating through the oesophagus is easier. The lesion is identified & biopsy is taken if required. Complications are perforation & bleeding

16. Fibreoptic flexible oesophagoscope:- It can be done under local anaesthesia. Reflux & hiatus are well identified. Stomach also can be visualized. Easy to pass & perforation is unlikely. But tissue taken for biopsy is smaller & removal of foreign body is also difficult.

17. Endoscopic Ultrasound • It is useful method of finding & assessing involvement or pathology of different layers of oesophagusespescially in carcinoma oesophagus. • It shows all layers clearly & distinctly & so invasion can be better made out & operability can be decided.

18. Contrast study • Types:- • Barium swallow using barium sulphate which is a thick paste. • Using water soluble contrast like‘ Gastrografin’

19. Barium Swallow • Indications :- Dysphagia Pharyngeal pouch Gastro-oesophageal reflux disease

20. Important findings :- • Achalasia cardia- Bird beak appearance • Diffuse oesophageal spasm- Corckscrew appearance • GORD- Shows reflux in trendelenberg position • Carcinoma oesophagus- Rat tail appearance • External compression – Indentation of barium column by superior or posterior mediastinal mass, enlarged left atria as in mitral stenosis.

21. Barium meal in achalasia cardia showing bird beak experience

22. Ca Oesophagus showing rat tail appearance

23. Water soluble contrast radiograph • In suspected oesophageal perforation • Leaking oesophageal anastomosis

24. Barium meal study • Indications • Gastric ulcer- shows a niche which is the ulcer crater , a notch which is due to spasm of circular muscle on the greater curvature. • Chronic duodenal ulcer- shows absence of deformed duodenal cap ( due to spasm of first part of duodenum,bariumwill not stay & so cap will not be formed )

25. 3) Gastric outlet obstruction- the cause may be chronic duodenal ulcer with pyloric stenosis or carcinoma pylorus. Features are- • Enormous dilatation of stomach • Greater curvature below the level of iliac crest • Absence of duodenal cap • No filling of dye in second part of duodenum. • Mottled appearance of stomach because of retained food particles.

26. 4.Carcinoma stomach- irregular filling defect 5.Pseudocyst of pancreas- widened vertebrogastricangle 6. In chronic duodenal ileus- shows dilatation of stomach, 1st & 2nd part of duodenum, proximal portion of 3rd part of duodenum 7. Others – gastric volvulus , duodenal diverticula, trichobezar, gastric fistulas, diaphragmatic hernias when stomach is the content

27. 8.Carcinoma head of pancreas- ‘ pad sign ‘ Periampullary carcinoma- ‘ reverse 3 sign ‘ 9.Hiatus hernia

28. Complication :- It may precipitate intestinal obstruction.

29. Barium Enema • It is the contrast x-ray done to visualize large bowel • Therapeutic barium enema is done in intussusception

30. Indications & findings 1) Carcinoma colon- irregular filling defect 2) Ileocaecal tuberculosis- pulled up caecum , obtuse ileocaecal angle , incompetent ileocaecal valve 3) Ulcerative colitis- loss of haustrations, lead pipe appearance 4) Colonic polyps- smooth , regular filling defect 5) Congenital mega colon – narrow zone , zone of cone , dilated proximal segment

31. 6) Diaphragmatic hernia- colonic shadow in the left thoracic cavity 7) Gastro-oesophageal fistula- leak into the stomach from colon. Contraindications:- acute colonic conditions

32. Sigmoidoscopy • It is used to visualise rectum & sigmoid colon, take biopsies from suspected lesions & do therapeutic procedures like polypectomy , control of bleeding etc. • 2 types- Rigid- 25 cm long with illumination Flexible- 60 cm long

33. Colonoscopy • It is 160 cm long, flexible • It is passed upto the caecum Indications :- • Bleeding per rectum • To take biopsies from different parts of the bowel • To identify synchronus growths, ulcerative collitis

34. Contd- 4.To remove polyps, 5. When barium enema shows irregularity 6. For therapy- colonoscopicpolypectomy, dilatation of stricture colon etc. Contraindication :- Acute ulcerative colitis

35. Complications :- • Perforation of the bowel , splenic flexure is the commonest site • Trauma • Sepsis • Haemorrhage

36. DIFFERENTIAL DIAGNOSIS AND EVALUATION OF DYSPHAGIA

37. Dysphagia is difficulty in swallowing • Odynophagia is painful swallowing

38. Dysphagia can be – 1) Acute due to foreign body impaction or acute infection 2) Chronic due to causes like stricture or carcinoma • Dysphagia can be oropharyngeal or oesophageal depending on the cause • Dysphagia can be progressive or intermittent

39. Causes of dysphagia:- Common Causes 1. Gastro-oesophageal reflux disease(GERD/Hiatus Hernia) 2. Carcinoma Oesophagus- here dysphagia is of short duration and progressive. 2/3rd of the lumen should be blocked by tumor to develop dysphagia.

40. 3. Foreign Body in Oesophagus- it may be coin, bone piece, denture etc. It causes acute dysphagia 4. Carcinoma of pharynx or posterior 1/3rd of tongue 5. Corrosive Strictures- It is usually alkali stricture. 6. OesophagealCandidial Infection- It is due to immunosuppression In association with HIV infection, steroid therapy, cancer therapy etc

41. 7. Plummer- Vinson Syndrome 8. Mediastinal swellings like primary tumors, nodal mass either lymphoma or secondaries or tuberculosis.

42. RARE CAUSE 1.Diffuse oesophageal spasm- They are inco-ordinated contractions of oesophagus causing chest pain or dyshagia. It is common in distal 2/3rd of oesophagus. Hypertrophy of circular muscle fibres with very high persistent pressure of 400-500 mm of mercury is specific. Treatment is calcium channel blockers, vasodilators, endoscopic dilatation and extended oesophageal surgical myotomyupto the aortic arch.

43. 2. Oesophageal diverticula, Chagasdisease 3. Dysphagia lusoria- It is a congenital vascular anomaly of aortic route 4. Thyroid swelling- It is uncommon to develop dysphagia in a thyroid swelling. Large malignant thyroid or anaplastic thyroid can cause dysphagia with dyspnea or strider. 5. Boerhaave’s Syndrome- It is vertical full thickness tear of lower oesophagus due to vomiting with closed glottis. It is often life threatening and emergency

44. 6. Neurological causes like stroke, bulbar palsy, motor neuron disease, Parkinson’s disease etc. 7. Congenital anomalies of oesophagus 8. Drug induced dysphagia- Drugs like KCL, quinine, NSAID can cause dysphagia. 9. Mediastinal fibrosis

45. EVALUATION OF A PATIENT WITH DYSPHAGIA 1. Proper history 2. Haematocrit 3. Chest X-Ray- To see for any mediastinal mass lesion, foreign body. 4. Oesophagoscopy- Once lesion is detected, it is treated accordingly. Biopsies from lesions, endotherapy and other procedures like foreign body removal, strictured dilatation, sclerotherapy can be carried out

46. 5. Barium Swallow may show irregular filling defect or extrinsic compression 6. CT Chest- It helps to identify the anatomical location of the cause. Extent, spread , nodal status , size & operability of tumour can also be well assessed

47. 7. Oesphagealmanometry in achalasia cardia / GERD 8. Endosonography is very useful in many conditions causing dysphagia. It can assess site , layers of oesophagus, nodes , spread etc. 9. USG abdomen to see for metastases in the liver , ascites etc.

48. Treatment for dysphagia:- • Treatment depends on cause. • Heller’s myotomyfor achalasia cardia • Oesphageal resection for carcinoma. • Dilatation for strictures • Foreign body removal etc.

49. THANK YOU