Lower GI Pathology

Indications of small bowel study

small bowel obstruction
malabsorption syndrom
crohns disease
enteritis

Contraindications of small bowel study

perforation
large bowel obstruction

name all of the studies that could be done on the small bowel

small bowel follow through
small bowel series only
enteroclysis

When is a small bowel follow through finished?

when the barium reaches the iliocecal valve (2-3 hours)

How can a small bowel series increase motility?

lie on right side
glass of ice water
saline instead of water
add Gastrografin
give maxolon/maxeren

How many columns of barium are given in a small bowel series?

one

How is enteroclysis different from a small bowel series or small bowel follow through?

barium is injected into the duodenal/jejunal junction (ligament of trutz)

What is the advantage of enterolysis over other small bowel studies?

no flocculation
no segmentation
visualize defects as injected

What is the disadvantage of entereclysis in comparison to other small bowel studies?

higher dose
more uncomfortable for patient
possible perforation

What radiographs are necessary for small bowel visualization?

AP/PA
can also do oblique or erect as necessary

What is the patient preparations for a small bowel series?

NPO after 12am
no smoking
no gum
food and fluid withheld at least 8 hours prior

What is the patient preparations for a barium enema?

low residual diet for 2-3 days
clear fluid diet the day before
laxatives
colonic lavage if needed

What is the concentration of barium in a single contrast barium enema study?

15-25% w/v

What is the concentration of barium in a double contrast barium enema study?

75-95% w/v

What is the patient's position for inserting an enema tip, and why?

Simm's (left lateral with right knee flexed)
relax ab muscles, decrease anal sphincter pressure

What is the patient's position for removing an enema tip, and why?

left lateral (not simms)
increases pressure on the anal sphincter so the patient has more control of their bowel

What is a single contrast barium enema used for?

children
gross pathology

What is a double contrast barium enema used for?

mucosal pattern
small growths
polyps
diverticula

What are the routine studies for barium enema study?

AP/PA
RAO/LPO
LAO/RPO
L lat
R lat
erect
AP axial

AP/PA large bowel demonstration

all of the large bowel

AP/PA axial large bowel demonstration

30-40* cephalad
retrosigmoid colon

RAO/LPO large bowel demonstration

right colonic/hepatic flexure
ascending colon
sigmoid colon

LAO/RPO large bowel demonstration

left colonic/splenic flexure
descending colon

Where should the central ray be positioned for a large bowel?

at the iliac crests

What is the advantage to virtual CT colonoscopy?

gentle preparation
less discomfort

What is the disadvantage to virtual CT colonoscopy?

Difficult to differentiate pathologies from fecal material

right lateral large bowel demonstration

medial side of ascending colon
lateral side of descending colon
left colonic/splenic flexure

left lateral large bowel demonstration

medial side of descending colon
lateral side of ascending colon
recto-sigmoid colon

Is the air or contrast being visualized when reading a radiograph?

The air

When is a barium enema used therapeutically?

To attempt to reduce intussusception

What is defecography used to study?

functional study of the rectum and anus during evacuation and rest

What are some types of intestinal obstructions?

mechanical simple small bowel
mechanical closed loop small bowel
functional small bowel
large bowel

causes of a mechanical small bowel obstruction?

tumour
adhesions
volvulus
inguinal hernia

causes of a functional small bowel obstruction?

paralytic adynamic ileus
toxic injury
traumatic injury

symptoms of an intestinal obstruction

pain
abdominal tenderness
vomiting
constipation
abdominal distension
decreased bowel sounds

what happens if an obstruction isn't treated?

fluid will accumulate
continued distension
becomes ischemic then necrotic

in what age group do small bowel obstructions normally occur?

older individuals

same symptoms as small bowel obstruction, but more likely in children

appendicitis

define simple mechanical obstruction

one point of obstruction
no blood flow interference
gas and fluid accumulates

radiographic appearance of an incomplete simple mechanical obstruction

stepladder sign
stacked coin

radiographic appearance of a complete simple mechanical obstruction

no gas in the large bowel

define closed loop mechanical obstruction

2 part obstruction
blood supply cut off

complication of closed loop mechanical obstruction

blood supply cut off
infarction - necrotic - gangrene

radiographic appearance of a closed loop mechanical obstruction

inverted u shape

define functional obstruction

peristalsis of the small bowel isn't working properly

radiographic appearance of functional obstruction

distended loops in the central abdomen
gas and fluid levels
gas in the small and large bowel
no specific point of obstruction

main cause of functional obstruction

surgery

radiographic difference between functional and mechanical obstruction

functional-gas in the large bowel
mechanical-no gas in the large bowel

radiographic difference between small and large bowel obstruction

small- distended loops in the central abdomen
large- distended loops in the peripheral abdomen

define volvulus

complete twisting of a loop of bowel about its mesenteric base of attachment

common sites for volvulus

sigmoid
cecum

radiographic appearance of volvulus

sigmoid: inverted u
cecum: kidney shaped air filled mass

types of inflammatory bowel disease

crohn's disease (regional enteritis)
ulcerative colitis

crohn's disease location

terminal ileum commonly
is regional, so can happen anywhere

crohn's disease symptoms

RLQ pain
blood in stool
possible clubbed nailbeds
transmural

radiographic appearance of crohn's disease

skip lesions
string sign (ulcers or edema)
cobblestones
fistula formation

treatment of crohn's disease

medication (steroids)
diet (less bulk)
surgery if required

ulcerative colitis symptoms

abdominal pain
weight loss
fever
superficial (not transmural)

ulcerative colitis location

rectosigmoid colon
LLQ

radiographic appearance of ulcerative colitis

pipestem sign (fibrosis)
loss of haustra
toxic megacolon
grainy and gritty

ulcerative colitis complications

toxic megacolon
hemorrhage
perforation
obstruction

define malabsorption syndrome

inadequate absorption of nutrients from intestinal mucosa

malabsorption syndrom causes

GI surgery
pancreatic disorder
hepato-biliary disease
small bowel disease
hereditary disorder

malabsorption radiographic appearance

irregular distorted small bowel folds
OR distension with regular folds

define meckels diverticulum

congenital small intestine sac/appendage of fluid in/near ileum

cause of meckels diverticulum

failure of the vitelline duct to close during embryological development

complications of meckels diverticulum

ulcer
perforation
hemorrhage

treatment of meckels diverticulum

surgery if needed

radiographic appearance of meckels diverticulum

finger of a glove near the terminal ileum

define intussusception

segment of the bowel telescope into the segment just distal to it

age group of intussusception

3 months - 6 years

location of intussusception

ileocecal valve (usually)

most common cause of bowel obstruction in young children

intussusception

signs/symptoms of intussusception

abrupt onset of abdominal pain
blood in stool
palpable RLQ

special case of intussusception

adults with tumour, pedunculated polyps, or inflammatory mass
causes nausea and vomiting

radiographic appearance of intussusception

coiled spring
CT: 3 concentric rings
US: doughnut shape

differentiate between diverticulosis and diverticulitis

diverticulosis is mucosa herniating through the muscular layer
diverticulitis is inflamed diverticula

diverticulosis cause

weak muscular wall
low fibre diet
constipation/straining
low exercise

diverticulitis cause

retained fecal material

diverticular disease age

very common over 60

early, middle, and late symptoms of diverticular disease

(early) flatulence
(middle) intermittent diarrhea or constipation
(late) hemorrhoids, LLQ pain

complications of diverticular disease

perforation
abscess
strictures
suppuration

symptoms similar to diverticular disease

hemorrhoids
carcinoma
inflammatory bowel disease

radiographic appearance of diverticular disease

outpouchings of colon wall

treatment of diverticular disease

anti-inflammatory drugs
surgery
diet (no seeds, nuts, popcorn)

types of polyp

pedunculated
sessile
familial

location of polyps

pedunculated- ascending, transverse, rectosigmoid
sessile- sigoid, rectum
familial- throughout colon

symptoms of polyps

rectal bleeding
diarrhea
constipation

causes of peritonitis

1) spread from other abdominal infections
2) rupture of GI tract
3) penetrating abdominal wound

define polyp

growth that projects from the mucosa of the colon into the lumen

symptoms of peritonitis

continuous abdomen pain
tense, rigid abdomen
vomiting
fever

complications of peritonitis

abscesses
adhesions that lead to obstruction
toxic shock

treatment of peritonitis

antibiotics early
surgery late

prognosis of peritonitis

good if localized
poor if generalized

colon cancer locations

colorectal

age of people who get colon cancer

50-70

causes of colon cancer

ulcerative colitis
familial polyps

radiographic appearance of colon cancer

apple core sign
progressive constriction of lumen

preventative measures against colon cancer

less red meat, fat, sugar, smoking
more fibre, chicken, fish, fruits, vegetables

common site of secondary cancer to colon cancer

liver cancer

second most common site for cancer

colon

define hirschsprungs disease

congenital absense of nerve ganglia in the proximal rectum that always involves the anal sphincter

symptoms of hirschprungs disease from birth

no bowel signs
no passage of meconium
abdominal distension

symptoms of hirschprungs disease in an infant

abdominal distension
constipation
small stool

radiographic appearance of hirschprungs disease

huge dilated colon with sudden narrowed segment of colon

treatment of hirschprungs disease

surgically remove narrowed segment (astamosis)

define imperforate anus

congenital absence of normal communication between rectum and exterior of the body

cause of imperforate anus

embryological accident

modality of choice for imperforate anus

ultrasound

radiographic procedure for imperforate anus

1) hold infant upside down for 5 minutes (air to tip of blind pouch)
2) 72" SID, AP, Lat with marker at anal opening
3) measure distance from pouch to opening

complications after surgery for imperforate anus

may have difficulties going to the bathroom