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Surgical Pathology & X-rays

for

Medical Students
2007

GIT-1
Salivary Glands Esophagus Stomach & Duodenum

Index
Salivary Glands

Thyroglossal cyst
Branchial remnants Pharyngeal pouch Esophagus

Gastric & duodenal ulcers Acute gastritis & acute peptic ulcers Chronic gastric ulcer Complications of peptic ulcers Hour-glass stomach Congenital pyloric stenosis Adult pyloric stenosis

Congenital esophageal atreasia


Esophageal varices Esophageal diverticulum Barretts esophagus Cancer esophagus Cardiac achalasia Stomach & Duodenum Normal appearance Hiatus hernia Congenital diaphragmatic hernia
2

Cancer stomach
Pseudo-pancreatic cyst Volvulous of stomach Duodenal atresia

Jejunal atresia
Duodenal ulcers Duodenal diverticulum
GIT1

To return to this index from any slide, click on INDEX

The following slides includes clinical pictures, gross pathology pictures and X-rays in a systemic approach to important surgical problems. you may be asked about : Diagnosis or differential diagnosis Pathological types (if any) Common clinical presentations

Common complications
Specific investigations Main line of treatment

The answers are expected to be short & precise

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Salivary Glands

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Salivary Glands

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Swellings of Salivary Glands


Inflammatory
Viral: Acute: Mumps
Chronic: ?HIV
Mumps

Neoplasms
Adenoma Carcinoma
Nonepithelial

Bacterial:
Chronic bacterial sialadenitis (usually submandibular complicating chronic obstruction Acute ascending sialadenitis (usually parotid in dehydrated postoperative patients with poor mouth hygiene)
6 Specific

Bilateral parotid swelling with HIV

Infections:

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Sialolithiasis - (Salivary stones)


Incidence

80%
10%
7%

Submandibular
Because secretions are viscid rich in mucous & the gland
lies below the opening of its duct

Parotid

Sublingual

Minor glands

Majority are radio-opaque

Majority are radiolucent


Large submandibular GIT1 stone
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Plain X-ray showing submandibular stone


This is the occlusal view of the mandible that best demonstrates the stone

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Stone submandibular gland

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Sialography: Stone submandibular gland

10

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Submandibular Sialogram
Showing a stone in the submandibular duct
The stone is NOT radiolucent, but it looks so because this is a subtracted image

The classic presentation of a submandibular stone is pain and swelling prior to or during meal This requires almost complete obstruction of the submandibular duct If partial obstruction occurs swelling may be mild with chronic painful enlargement of the gland If diagnostic doubt then stone can be demonstrated by sialogram
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1- Stone in the Rt submandibular duct


(anterior 2/3 of the duct is anterior to the lingual n.)

2- Surgical removal
(Linear incision along the duct -notice the stay suture)

12

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?
Ranula Stone submandibular duct
13 GIT1 INDEX

Ranula
A large mucous retention cyst (mucocele) secondary to obstruction of a minor salivary gland or the sublingual gland.
They represent a unilocular cyst in the sublingual space

14

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Salivary Tumours
Adenomas Carcinomas
Nodularity & regional lymphatic metastasis is highly suspicious of malignancy
Parotid pleomorphic adenoma
Nonepithelial tumours

Usual locations of benign parotid tumours


15

What are the other clinical signs that suggest malignancy?

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Salivary Tumours
Nearly all salivary tumours are slowly growing (even malignant tumour) Is pain a reliable indication of malignancy? Pain is not a reliable indication of malignancy except after invasion of sensory nerves Benign tumours may present with aching pain due to capsular distension and outflow obstruction of saliva The only reliable clinical indication of malignancy are: Facial nerve palsy in parotid tumours Indurations or ulceration of overlying skin or mucosa Regional lymphatic metastasis
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Invastigations of Salivary Tumours


CT & MRI : Confirm that the mass is arising from the salivary gland Demonstrate the tumour borders (well
circumscribed in benign & diffuse invasive in malignant)
Rt.

MRI
Rt. parotid tumour extending into the superficial & deep lobes

Sq. cell ca

CT
Well circumscribed Lt. parotid tumour of the superficial lobe

Show anatomical relations to plan for surgery


17

Pleomorphic adenoma
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Invastigations of Salivary Tumours


Fine needle aspiration (FNA) For histopathological diagnosis Open surgical biopsy is absolutely contraindicated in tumours of major salivary glands Why?

Pleomorphic adenomas are poorly encapsulated and are very tens. Open biopsy will seed the surrounding tissues with tumour cells causing multiple local recurrences over many years
Open biopsy is done if the tumour is clearly infiltrating or invading the skin
18 GIT1 INDEX

Thyroglossal cyst

Branchial remnants
Pharyngeal pouch

19

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Thyroglossal cyst & fistula

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Thyroglossal cysts
Embryology

The thyroglossal tract arises form foramen caecum at junction of anterior 2/3 and posterior 1/3 of the tongue. Any part of the tract can persist causing a sinus, fistulae or cyst. Most fistulae are acquired following rupture or incision of infected thyroglossal cyst

The classical site for a thyroglossal cyst

21

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This is a CT scan at the level of C4 vertebrae. Try to identify the following structures:

Sternomastoid muscle External jugular vein

Air in laryngeal vestibule


Internal jugular vein Internal carotid artery

C4
External carotid artery Hyoid bone

What is this structure? Thyroglossal cyst


22 GIT1 INDEX

Clinical features of Thyroglossal cysts


Usually found in subhyoid portion of tract 75% present as midline swellings Remainder can be found as far lateral as lateral tip of hyoid bone The cyst elevates on protrusion of the tongue Can present as an infected cyst due lymphoid tissue in the cyst wall
If infected, aspirate cyst rather than incise prevents formation of thyroglossal fistula

Treatment Sistrunk Operation


Transverse skin crease incision Platysma flaps raised. Cyst dissected Middle 1/3 of hyoid and any suprahyoid tract extending into the tongue dissected

23

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Thyroglossal fistula
The classical site for a thyroglossal fistula

Fistulography: note the position of the fistula


anterior to the trachea (black air)
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Branchial remnants
Branchial fistulae and cysts usually arise from second branchial sinus Arise on anterior border of sternomastoid Often bilateral and extend deep into neck Internal opening occasionally found in tonsillar fossa Treatment is by surgical excision
Notice the opening lateral to the mid line
25 INDEX

Branchial cyst

Branchial GIT1 fistula

Pharyngeal pouch
Is posteromedial pulsion diverticulum through Killian's dehiscence Occurs between thyropharyngeus and cricopharyngeus muscles. Both form the inferior constrictor of the pharynx Male : female ratio is 5:1 Usually only seen in the elderly
Aetiology is unknown but upper oesophageal sphincter dysfunction may be important

26

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Pharyngeal pouch
Clinical features
Commonest symptoms are: dysphagia, regurgitation and cough Recurrent aspiration can result in pulmonary complications A carcinoma can develop within the pouch Clinical signs are often absent, however, a cervical lump may be present that gurgles on palpation
27

Barium swallow show residual pool of contrast within the pouch


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Esophagus
Normal anatomy

Cervical

Thoracic

Abdominal

28

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Normal barium swallow

The esophagus have a smooth outline. No persistently narrowed areas are seen. Peristalsis can be observed on screening the patient. The whole examination can be recorded on video if necessary (video-swallow
examination).
29

Lateral view: The course and diameter of the esophagus are normal, the longitudinal mucosal folds are regular
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NORMAL ANATOMY of OesophagusDouble contrast study


The mucosal surface of the esophagus is smooth and featureless on double contrast examination. When the esophagus is distended the mucosal folds disappear. When the esophagus is partially collapsed, then straight parallel longitudinal folds are easily seen. The Z-line demarcates the squamocolumnar junction separating esophageal mucosa from gastric folds. A number of mediastinal structures cause extrinsic impressions upon the adjacent esophagus in the normal individual.
In the elderly individual, osteophytes projecting from the anterior surface of the thoracic vertebrae, a tortuous aorta or an enlarged left atrium may also cause impressions upon the 30 esophagus.

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Normal endoscopic picture of the esophagus

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Congenital Esophageal Atreasia

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Congenital esophageal atreasia


The most common type of trachioesophageal fistula is a blind end upper esophagus and a lower remnant connected to the trachea

33

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Oesophageal atresia (diagnosis)

If suspected, a small nasogastric tube will arrest at the blind pouch & will not reach the stomach

34

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Atresia of the esophagus

Examination with contrast material: The white arrows point to the blind end of the esophagus filled with contrast material. The middle lobe of the right lung is partially atelectatic because of aspiration. Presence of a lower fistula is suggested by theGIT1 35 presence of gas in the distended stomach INDEX

Oesophageal atresia

36

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Esophageal varices

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Esophageal varices

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With portal hypertension, collateral vessels develop between portal and systemic veins: Around the lower end of the esophagus & fundus of stomach
(esophageal & fundal varices) [splenic vein short gastric veins coronary
vein esophageal veins azygos system]

Around the rectum (Hemorrhoids) [superior hemorrhoidal middle &


inferior hemorrhoidal]

Around the umbilicus (Caput medusa) [paraumbilical veins epigastric


veins]
Around the liver & diaphragm & retroperitoneal veins. The normal portal pressure is less than 200 mm saline Collateral circulation does not effectively decompress the portal system

The four major manifestations of portal hypertension are:


Esophageal varices, ascites, hypersplenism and encephalopathy.
39 GIT1 INDEX

Factors implicated in the formation of ascites:

Increased portal venous pressure

Reduced serum osmotic pressure due to hypoalbuminemia


Sodium & water retention (inc. adrenal cortical hormones & dec. anti-diuretic hormone)

Hypersplenism
Sequestration and destruction of any or all of the cellular elements of the blood
WBC > 4000 /ml Platelets > 100,000 /ml
Are spontaneous ecchymosis and purpra common presentations of portal hypertension alone? NO

Encephalopathy is related to high blood ammonia level It can result from natural or surgically created porto-systemic shunts in patients with marked hepatocellular dysfunction
40 GIT1 INDEX

Esophageal varices

Upper GI endoscopy
41

Autopsy

Barium swallow

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Barium swallow

Oesophageal varices Numerous rounded and elongated smoothcontoured filling defects are present in the inferior two thirds of the esophagus.
The contour of the esophagus is irregular and speculated.

42

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Barium swallow: Oesophageal varices

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Management of acutely bleeding varices

In patients with hepatocellular dysfunction, bleeding should be rapidly controlled to avoid: The effect of shock on hepatic function. The toxic effect of digested blood absorption.

Main lines of treatment: Heamodynamic stabilization with blood transfusion Reduce the portal blood pressure:
Vasopressine causes constriction of the splanchnic arteria circulation reducing the portal blood pressure 40% Propranolol

Sengstaken balloon temponade Injection sclerothrapy


44

Sengstaken Blakemore tube


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Temponade & gastric wash

INDEX

Injection sclerotherapy of esophageal varices

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Follow-up barium swallow

Note the staplers in the lower end of oesophagus (a treatment modality for esophageal varices)

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Esophageal diverticulum

47

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Barium swallow

Esophageal diverticulum

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Barium swallow - Lateral view

Esophageal diverticulum

Two sharp-contoured filling excesses can be seen on the ventral contour of the esophagus below the tracheal bifurcation
(arrows)

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Barretts esophagus

50

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Gastro-esophageal reflux disease [GERD] is a common disorder


Gastro-esophageal reflux are prevented by: Lower esophageal sphincter Normal hiatus of the diaphragm Management of GERD Bed tilte H2 blockers

GERD may or may not be accompanied with sliding esophageal hernia


Clinical features: Retrosternal burning pain (heart burn) provoked by fatty food Fatty dyspepsia is more common in GERD than gallstone disease
Objective diagnosis: esophageal manometry with 24h pH recording

Proton pump inhibitors


Surgery (failed medical or complications)

Complications of GERD Stricture Shortening

51

Columnar metaplasia [Barretts]

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Barretts esophagus
Endoscope view

Bands of metaplastic epithelium extend proximally

Normal lower esophagus

Barretts esophagus

Columnar metaplasia in the lining mucosa of the lower esophagus in response to 52 chronic gastro-esophageal reflux.

What are the complications of Barretts esophagus? Increased risk of adenocarcinoma 25times GIT1
INDEX

53 INDEX

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Gastroesophageal reflux with longitudinal ulcers arising from the GE junction


54 GIT1 INDEX

Cancer esophagus

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Neoplasms of the oesophagus


Sarcoma

Benign Tumours (RARE)

Malignant Tumours

Malignant Melanoma

CARCINOMA Squamous Cell CA usually Upper 2/3 Adenocarcinoma usually Lower 1/3
Oat cell CA

CA OE has poor prognosis because symptoms occur late


Clinical Features of CA OE

1. Dysphagia
2. Weight loss 3. Recurrent laryngeal n. palsy 4. Cervical Lymphadenopathy
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ADVANCED DESEASE
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Lower 1/3 of the esophagus C. Oat cell carcinoma ( occasionally)


57

Upper 2/3 of the esophagus


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Remember the pathological types of 58 cancer oesophagus.

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Midesophagus Squamous Cell Carcinoma Squamous cell carcinoma arises most commonly in the upper and middle esophagus

59

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Pre-cancerous conditions:
Smoking & alcohol Food contamination of fungi

Diet deficiency in beta carotin, vitamin E & selinium

Clinical features:
Dysphagia is a sign of advanced disease Early symptoms are nonspecific During endoscopy, biopsy any lesion even if small (small cancers are curable)
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Investigations for suspected CA esophagus


Upper GI endoscopy
with biopsy of any suspected lesion

Ba swallow

61

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Endoscopy of the esophagus

Early adenocarcinoma complicating Barretts esophagus

Advanced squamous cell CA of the oesophagus


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Barium swallow Irregularity looks like an apple core lesion in the esophagus. This is typical in carcinoma of the esophagus

63

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Barium swallow

CA esophagus lateral view

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Barium swallow CA oesophagus

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CA Oesophagus

Irregular stricture with shouldered margins


Presenting symptom: Dysphagia

66

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Barium swallow CA oesophagus

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barium swallow demonstrates the typical apple core lesion seen with distal esophageal adenocarcinoma associated with chronic reflux disease.
Also seen is a typical sliding hiatal hernia with the gastric folds fixed above the diaphragm.

68

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Barium swallow
This is not CA esophagus. The esophagus is displaced by CA lung. Note the smooth lining of the displaced segment

69

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Corrosive stricture of the esophagus

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Ba swallow Corrosive stricture


AP view:

Narrowing with smooth outlines at the level of the middle third of the esophagus with a dilatation observed above it.
Distally the lumen of the esophagus is of about the normal diameter.

71

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Carcinoma of the esophagus has a poor survival rate because of late discovery after spread
Spread

Local spread Through the wall into adj. structures


Satellite nodules in the proximal esophagus (submucosal lymphatics)
72

Lymphatic spread Spread to the

Systemic spread

Liver

celiac LNs is a
bad prognostic sign and regarded as distant metastasis (M) in the TNM classification

Lungs
Brain bone

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Carcinoma of the esophagus

73 INDEX

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Postoperative barium swallow demonstrating the gastric conduit in the cervical position with the silver clips marking the anastomosis

74

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Achalasia of the cardiac sphincter

75

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Ba swallow

Autopsy

Achalasia Inability to relax lower esophageal sphincter leads to massive esophageal dilation and produces the characteristic "birds beak" deformity in barium swallow
76 GIT1 INDEX

Barium swallow examination: achalasia Early stage

The esophagus has smooth contour and is narrowed conically at the esophagocardial junction (arrow), above this the distal part of the esophagus is dilated
77 GIT1 INDEX

Late stage:
The esophagus is extremely dilated above the severely narrowed cardia (arrow), with a slightly tortuous course and inhomogenous contrast material filling pattern because of the residual food inside

78

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Achalasia (of the cardiac


sphincter)

Note the huge dilatation of the oesophagus

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Achalasia with bird's beak deformity of the distal esophagus

80

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Lateral view of barium swallow in a patient with achalasia. Note grossly dilated esophagus with abrupt tapering to bird beak-like shape of lower esophageal sphincter

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Achalasia
The oesophagus hugely dilated and tortuous.

82

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Please compare and contrast between cardiac achalasis & CA lower end esophgus

83

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Barium swallow: CA oesophagus v/s Achalasia


The cardia is normally below the diaphragm

In X-ray 1, the oesophagus is interrupted above the diaphragm

In X-ray 2, the cardia below the diaphragm is closed with bird beak-like shape
84

This is CA lower end esophagus

Achalasia of cardia

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Treatment options for cardiac achalasia Pneumatic dilation performed endoscopically

Lower esophageal sphincter myotomy incises enough muscle to relieve symptoms but not enough to result in gastroesophageal reflux
85 GIT1 INDEX

Stomach & Duodenum

86

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Normal anatomy

& corresponding endoscopic picture

87

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Normal lower oesophagus & stomach


This is the normal appearance of the lower oesophagus & stomach, which has been opened along the greater curvature.

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Normal upper GI barium study:


The stomach is of normal size and shape, its mucosal folds are regular. The fornix is filled with contrast material because of the supine position. The duodenum is normal. Jejunal loops filled with contrast material are visible 89 behind the stomach

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Hiatus Hernia

90

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Siding hiatus hernia The esophagogastric junction and the fundus of the stomach (arrow) are situated high in the thorax, above the diaphragm

91

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Siding hiatus hernia

92

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Siding hiatus hernia (retrosternal)

93

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Paraesophageal hiatus hernia


A small segment of the stomach fundus protrudes into the thorax on the left side of the normal esophagus (arrow). The herniated stomach displases the esophagus to the right.
Note that the angle between the esophagus & stomach is preserved (Red arrow)
94 GIT1 INDEX

Congenital diaphragmatic hernia


Congenital parasternal hernia (Morgagni)

Congenital hiatal hernia


95

Congenital diaphragmatic hernia persistent pleuroperitoneal canal (Bochdalek) GIT1 90% are on the leftside
INDEX

Postmortum specimen Diaphragmatic hernia

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Gastric & duodenal ulcers

97

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Gastric Ulcer

98

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Mechanism of acid production in the gastric parietal cell

99

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Acute gastritis with diffuse heamorrhage

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Acute Peptic Ulcers


Etiology: Disruption of gastric mucosal barrier appears as multiple erosions. 50% of patients give history of NSAID/aspirin intake. Acute peptic ulcers cause short attacks of dyspepsia & classically present with hemorrhage.
Pathology: Frequently multiple. Stomach - They can occur in any part. Duodenum - Almost always confined to first part. Shallow punched out and seldom invade musclecoats unlikely to leave healing scars.

Acute duodenal ulcer in anterior wall occasionally perforates. These acute lesions can progress to chronic ulcers.
101 GIT1 INDEX

Chronic Gastric Ulcer

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Chronic gastric ulcer

The ulcer is deep, with sharp proximal edge & a sloping distal edge
The arrow points to an eroded gastric artery which has caused fatal hemorrhage

What are the complications of chronic gastric ulcer?


103 GIT1 INDEX

Benign gastric ulcer of the stomach antrum

1) 2) 3)

It is relatively small (1cm) The mucosa surrounding the ulcer base is not infiltrated by a tumour The radiating rugal folds extend nearly all the way to the margins of the base

Longitudinal section of the benign ulcer and adjacent gastric wall. The normal anatomic layers are discrete and undisturbed

Definitive diagnosis of chronic gastric ulcer depends on endoscopy & biopsy with histological examination
104 GIT1 When do you suspect that a gastric ulcer is malignant? INDEX

Malignant gastric ulcer


Top view, the ulcer is very suspicious Longitudinal section: The pylorus is to the left. Edges are everted. Several prominent nodes of the lesser omentum contained metastatic cancer.

The adenocarcinoma is infiltrating between the


layers
105 GIT1 INDEX

Chronic gastric ulcer The edges of the ulcer are heaped up due to epithelial regeneration. The ulcer base is smooth and contains only granulation tissue
If the ulcer was discovered on endoscopy, multiple biopsies should be taken to exclude malignancy even if the ulcer looks benign
106 GIT1 INDEX

Chronic gastric ulcer

107

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Barium meal

Benign gastric ulcer on the lesser curvature of the stomach

108

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Large ulcer is filled with barium on the lesser curvature of the stomach with star-shaped mucosal folds converging towards the lesion

109

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Barium study

Gastric ulcer

110

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Upper GI barium study: It shows a large gastric ulcer along the lesser curvature of the stomach. Surgery was performed and the ulcer was benign
111 GIT1 INDEX

Barium meal
gastric ulcer There is a large ulcer crater on the greater curvature aspect of the distal stomach (arrow). There are multiple folds radiating to the edge of the ulcer crater. All the folds taper gradually to the edge of the crater.
112 GIT1 INDEX

Barium meal
Pre-pyloric gastric ulcer
Carmens meniscus sign

113

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Chronic Gastric Ulcer


This gastric ulcer has been present for some time as judged by the amount of puckering of the surrounding mucosa and by the depth of the ulcer. The gastric mucosa around shows gastritis. Frequently, vessels in the base of the ulcers will ulcerate and the patient will bleed profusely, if not fatally Does infection have a role in the development of peptic ulcer? GIT1
INDEX

114

Helicobacter pylori
It is important in the etiology of : Chronic gastritis Peptic ulcer Gastric cancer Helicobacter pylori Eradication therapy
is a main treatment in peptic ulcer

Hydrolyze urea

Amonia (strong alkali)

Antral G cells

Metronidazole Amoxycillin
Bismuth

Gastrin

115

A proton pump inhibitor is usually added

Gastric acid hypersecretion


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Helicobacter gastritis Helicobacter organisms may be tested for urease activity. Staining of the gastric biopsy shows the characteristic curved rods embedded in the mucin layer of the stomach

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Complications of peptic ulcers


Bleeding
Patient presented with hematemesis, shock followed by melina Endoscopy showed acute gastric bleeding

Perforation
Patient presented with acute abdominal pain

Penetration
Posterior wall ulcer penetrates to pancreas (back pain)

Plain X-ray chest & abdomen showed air under the diaphragm

117

Malignant Gastric Ulcer

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"Hourglass" contraction of the stomach


Due to chronic peptic ulceration there is fibrosis and contracture of the stomach leading to an hourglass shape
118 Results in altered stomach mobility with delayed gastric emptying GIT1 INDEX

Upper GI endoscopy for diagnosis of peptic ulcer

119

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Congenital pyloric stenosis

120

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Stomach antrum & pyloric canal

Abnormal

Normal
Antrum

Pyloric canal

121

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Hypertophic pyloric stenosis. Note the prominent hypertrophied circular pyloric muscle
with elongation and narrowing of the pylorus It is a cause for "projectile" vomiting in infants about 3 to 6 weeks of age. Males are affected more than females(4:1)
122

It should be differentiated from other causes of vomiting in infancy

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Symptoms include non-bilious vomiting often starting as simple regurgitation progressing to projectile vomiting after most feedings.Vometing contains milk but no bile
Less frequent findings are constipation, progressive weight loss, dehydration, hypochloremic alkalosis.

Symptoms occur most commonly during the second to sixth weeks with peak age at presentation being 3rd -4th weeks. HPS rarely presents after 3 months of age.

Physical examination may reveal visible gastric peristaltic waves and a palpable pyloric mass (olive).

123

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If the clinical and physical findings are suggestive of HPS then an ultrasound exam is the first study of choice.
D.D. of Hypertophic pyloric stenosis of infancy

Gastro-esophageal reflux

U.S. Findings: There is thickening and elongation of the


pyloric muscle. diagnostic for HPS

Raised intracranial pressure


Duodenal atresia
124 Intestinal obstruction

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Gasrtographin meal

Congenital pyloric stenosis

125

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(Adult) Pyloric Stenosis


Gastric outlet obstruction

126

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Barium meal

Pyloric stenosis

127

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Barium meal

Pyloric stenosis

128

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Ba meal pyloric stenosis


24 hours after drinking contrast material most of it is still visible in the stomach with residual food above it. The stomach is dilated, its lower pole hangs below the iliac crest. Only minimal contrast material filling is observed in the small intestines
129 GIT1 INDEX

Barium meal

Pyloric stenosis

130

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Cancer Stomach

131

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A large tumor of the stomach seen as a filling defect in the body and antrum of the stomach causing irregular contours on both the lesser and the greater curve.
132 GIT1 INDEX

Gastric Carcinoma

How would you suspect that a patient is having cancer stomach?


133 GIT1 INDEX

Barium meal

CA pylorus

134

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Cancer stomach Malignant ulcer

Cancer stomach
Malignant infiltration

Cancer stomach Cauliflower mass

135

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Large ulcerated gastric carcinoma arising in the body of the stomach

136

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Bameal
Ulcer niche of a malignant gastric ulcer

137

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CA stomach

Linitis plastica

Diffusely infiltrating carcinoma, note leather bottle appearance


138

Marked narrowing of almost the complete stomach, due to diffuse infiltration of the gastric wall by a carcinoma (linitis plastica)

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Barium meal - CA stomach: Linitis Plastica


The distal two thirds of the stomach is narrowed, rigid peristalsis is absent. stomach diameter is decreased. The stomach lacks the normal rugal pattern. The mucosal surface is often smooth but intact, and ulcers are not a dominant feature. "leather bottle" stomach describes diffuse submucosal infiltration of the stomach.
139 GIT1 INDEX

Clinical manifestations of gastric carcinoma


Early (curable) gastric cancer has no specific features that can differentiate it from benign dyspepsia Liberal use of gastroscopy in patients over 40 years of age with a new or persistent dyspepsia. With biopsy from any suspicious lesion. N.B. gastric antisecretory drugs will improve symptoms of gastric cancer Late symptoms: Early satiety

Bleeding iron deficieny anemia


Pyloric obstruction
140 Thromboplebitis (Trousseaus sign) & DVT GIT1 INDEX

Multiple polypoid gastric masses in the cardia, fundus, and antrum

Metastatic

141

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Postoperative stomach after Billroth II partial gastrectomy

The afferent jejunal loop connected to the gastric stump shows only minimal filling, the majority of the contrast material flows into the efferent loop

142

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Pseudo-pancreatic cyst

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Barium meal Pseudo-pancreatic cyst

144

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Volvulous of the Stomach


Organoaxial volvulus Mesenteroaxial volvulus

The axis of rotation is the long axis of the stomach

The axis of rotation is along the mesenteric attachment, much the same as is seen with sigmoid colon volvulus

145

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Barium meal Organo-axial volvulous of the stomach

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Duodenum

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Plain X-ray abdomen


(erect position)

Duodenal atresia Dilated stomach (S) and the part of the duodenum above the obstruction (D). Other parts of abdomen do not contain gas

148

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Plain X-ray abdomen


(erect position)

Duodenal atresia

149

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Duodenal atresia
Plain X-ray of the abdomen: The arrows point to the dilated stomach and that part of the duodenum which is above the obstruction. Other parts of abdomen do not contain gas

Double bubble
150 GIT1 INDEX

Duodenal atresia
Gastrographin meal:
The distended stomach and duodenum above the obstruction are visible after swallowing contrast material
(arrows).

151

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Plain radiograph of the abdomen: The arrows point to characteristic triple gas bubbles in the stomach, duodenum and jejunum.

Jejunal atresia
152 GIT1 INDEX

# Ulcer in the 1st part of duodenum (with clean floor & no everted edge)
153 GIT1 INDEX

Duodenal ulcer (Endoscopy) A 35-year-old woman presents with tarry stools and a hemoglobin level of 7.5 g. Notice bleeding points

Duodenal ulcer (Endoscopy)

154

GIT1 INDEX

Investigations for suspected peptic ulcer


Gastro-duodenoscopy is the most sensitive investigation

Duodenal ulcer

Gastric ulcer
Biopsy

155

GIT1 INDEX

Ba meal 2 duodenal kissing ulcers


Two well-defined filling excesses facing each other are visible on the opposite contour of the duodenal bulb (arrows)

156

GIT1 INDEX

Duodenal ulcer with trifoliate deformity

157

GIT1 INDEX

Duodenal ulcer

Ulcer niche

158

GIT1 INDEX

Barium follow-through

Diverticulum of the duodenum (3rd part)

159

GIT1 INDEX

Barium follow-through

Diverticulum of the duodenum


A saccular lesion is filling from the horizontal part of the duodenum
(arrow).

Course of the jejunal loops is normal


160 GIT1 INDEX