Accessory methods in GIT investigation

Esophagus, Stomach,
Liver, Gallbladder,
Pancreas,
Spleen

(in Healthy Adults)

GIT: METHODS OF INVESTIGATION OF THE PATIENT

• Laboratory
• Instrumental
GIT: INSTRUMENTAL INVESTIGATION OF THE PATIENT

• Abdominal ultrasonography
• Endoscopic ultrasonography
• Color Doppler
• Capsular video Endoscopy
• X-ray (Flat-plate film of the abdomen)
• Computed Tomography (CT is more valuable than X-ray)
• Magnetic resonance imaging (MRI), angiography, isotope scan,
• PET (Positron Emission Tomography)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Selective enterography etc.
 THE ESOPHAGUS
• pH-metry (5,5-7,0)
• Manometry is used to investigate motility disorders,
used to measure the function of the lower
esophageal sphincter (the valve that prevents
reflux, or backward flow, of gastric acid into the
esophagus) and the muscles of the esophagus.

• This test will tell your doctor if your esophagus is

able to move food to your stomach normally.
Indications:
• Difficulty swallowing
• Pain when swallowing
• Heartburn and/or regurgitation (bringing food back up
after swallowing it)
• Chest pain
 The esophagus (Cont.)
• X-ray examination may show structural and motor functional disorders. In
addition to the standard barium meal, video- and cinefluoroscopy aid in
detecting anatomic conditions (eg, esophageal webs) and in assessing
motor disorders (eg, cricopharyngeal spasm, achalasia).
• Esophagoscopy can be performed diagnostically to evaluate pain or
dysphagia, to identify structural abnormalities or bleeding sites, or to
obtain biopsy specimens.
• Esophageal biopsy may show thinning of the squamous mucosal layer and
basilar cell hyperplasia, and malignant cells, even without evidence of
gross esophagitis or tumor by endoscopy.
 Stomach & duodenum
• Upper gastrointestinal endoscopy (gastroduodenoscopy) is used to
establish the site of upper GI (gastrointestinal) bleeding; to visually define
and biopsy abnormalities seen on upper GI series (gastritis, gastric and
duodenal ulcers, filling defects, mass lesions); to follow up treated gastric
ulcers; and to evaluate stomach and duodenum for infection Helicobacter
pylori.
• Now X-ray examination is a complementary (to endoscopy) method in
assessing motor disorders and evacuation of stomach and duodenum.
• CT (computer tomography) is useful in the diagnosis of a tumor.
 LIVER, GALLBLADDER

The ULTRASOUND examination is used to assess the size, shape, structure of the liver
and the presence of pathological formations.

• In cirrhosis of the liver, focal-diffuse heterogeneity of tissues is determined,

corresponding to the development of connective tissue.
• Ultrasound provides reliable diagnostics of liver abscesses and cysts.
• The distinctive signs of a congestive liver are organ enlargement, enlargement of the
inferior Vena cava and liver veins.
• Ultrasound allows you to suspect both calculous (the presence of concretions in the
lumen of the gallbladder) and non-calculous cholecystitis (thickening and
compaction of the wall of the gallbladder).
• The main indication for the use of ultrasound in the study of the biliary tract is the
differential diagnosis of jaundice.
ULTRASOUND OF THE NORMAL GALLBLADDER

• In longitudinal sections, the gallbladder looks like an echo-negative pear-shaped

structure. The position, size and shape of its very variable, but the width of the normal
gallbladder rarely exceeds 4 cm.
• The gallbladder has a certain mobility. It can have an elongated shape and, when
scanned, can be determined below the level of the anterior superior iliac crest
(especially if the patient is standing). It can be defined to the left of the middle line. If
the gallbladder is not detected in the normal position, examine the entire stomach
from the right side.
• The thickness of the gallbladder wall is measured on transverse sections; in patients
who did not eat, the wall thickness does not exceed 3 mm or less, and with a tight
filling of the gallbladder, the wall thickness is 1 mm.
 ULTRASOUND OF THE NORMAL GALLBLADDER

• Ultrasound of normal gallbladder. • Normal common bile duct.

• Longitudinal ultrasound sum showing the
• Note the thin wall and absence of echoes common blie duct, situated between the
from within the gallbladder. gallbladder arrows,;ying anterior to the portal vein. The
common bile duct measures 4 mm in diameter
GB, Inferior vena cava IVC, portal vein PV. (crosses). D, diaphragm; PV, portal vein; IVC
Inferior vena cava
 ENDOSCOPIC EXAMINATION
(FIBROESOPHAGOGASTRODUODENOSCOPY - FEGDS)

• is currently mandatory in patients with

stomach diseases.
• this technique is on the first place among
additional methods of examination of
patients with esophageal, stomach and
duodenal pathology due to:
✓ The highest information content of
modern endoscopic technology
✓ exceptionally wide diagnostic and
manipulation capabilities
 FEGDS (cont.)
• Modern fibrogastroduodenoscope allows the doctor to examine all parts of the
stomach, the bulb of the 12th intestine, make a targeted biopsy of the mucous
membrane,
• Photograph a certain area of the mucosa,
• Treat the mucosal defect with various medications or special glue,
• Perform electrocoagulation of a bleeding vessel with a laser beam or remove a polyp,
• Extract a foreign body or remove a postoperative suture.

• Modern endoscopes are characterized by a small diameter and great flexibility, which
allows you not to use local anesthetic substances during the procedure.
• Proper endoscope treatment after the study virtually eliminates the possibility of
infection transfer, for example, Helicobacter pylori
• CT with intravenous contrast – the diagnostic value is much
higher than that of ultrasound with small sizes of liver
formations.
• Endoscopic retrograde pancreatocholangiography – in severe
liver dysfunction with a significant increase in bilirubin levels,
when intravenous contrast does not provide sufficient
information, contrast is performed when the contrast agent is
directly injected into the bile ducts through an endoscope
 Endoscopy
• With the special probe, which is entered through endoscope, four or six
small pieces mucous membrane from suspicious places are took.

• Then they are studied under a microscope. The histological description of

preparations is to be done. Histology test is very important for detection
of the Helicobacter pylori infection, tumor, and structural changes of the
mucous membrane.
 Endoscopy

• The flexible sigmoidoscope and colonoscope are used to examine the distal
and entire colon;
• sigmoidoscopy and colonoscopy, or both, are indicated for the diagnosis and
staging of inflammatory bowel disease and for the investigation of colonic
symptoms, particularly bleeding;
• when polyps are found, they can often be removed with a diathermy snare.
• For investigation of the rectum the nonflexible rectoscope is used. Histology
test is very important for detection of the infection, inflammation, tumor,
and structural changes of the mucous membrane.
 ORAL CONTRAST INVESTIGATIONS

Barium sulphate is the best contrast medium for the gastrointestinal

tract.
• its atomic number is high
• it produces excellent opacification
• good coating of the mucosa
• non-absorbable
• non-toxic
• it is completely inert
X-ray with barium meal allows to estimate position, shape, size
of the stomach, relief of a mucous membrane, and a motility,
especially the time of the gastric emptying (1-3 hr).
ORAL CONTRAST INVESTIGATIONS OF OESOPHAGUS

Barium swallow
• It is the contrast study of the swallowing mechanism and passage of
food bolus from mouth up to the fundus of the stomach
Barium examinations of the oesophagus
• Indications:
dysphagia (causes: corrosive strictures, carcinoma and achalasia)
motility disorders of oesophagus
pharingo-oesophageal malignancies
pharyngeal diverticula
webs
 ORAL CONTRAST INVESTIGATIONS

Procedure
• The patient drinks some barium and its passage down the oesophagus
is observed on a television monitor.
• Films are taken with the oesophagus both full of barium to show
the outline, and following the passage of the barium to show mucosal
pattern (films are taken in filling phase and empty phase).
Films are taken in frontal and lateral projections during the process of
swallowing.
ORAL CONTRAST INVESTIGATIONS OF THE STOMACH

Barium examinations of the stomach

• It is a radiological study of the stomach, duodenum and proximal
jejunum. It is done by oral administration of barium.

Indications:
• suspected malignancies of gastroesophageal junction, stomach and
duodenum
• gastric or duodenal obstructive lesions
• gastric or duodenal ulcers
• motility disorders
• congenital anomalies
ORAL CONTRAST INVESTIGATIONS

Procedure
• The patient fasts for at least 6 hours to the
examination.
• Single and double contrast studies are
performed after the patient
swallows around 250 ml of barium suspension.
• Air is used to produce double contrast effect.
• Films are taken in various positions with the
patient both erect and lying flat, so that each
part of the stomach and
duodenum is seen.
 NORMAL BARIUM MEAL

• Single and double contrast studies are done with barium

• In single contrast method bowel is filed only with barium.
• In double contrast, the mucosa is coated with barium and introduction of
gas distends the lumen of the bowel.
Double contrast method demonstrates mucosal irregularities which
are obscured in single contrast.
THE BOWEL

Fecal occult blood testing (FOBT) may point to

intestinal blood loss.

X-ray with barium meal or barium enema allows to

estimate the position, shape, size of the bowel,
relief of a mucous membrane, and a motility.
 Computed Tomography (CT) Scanning

Uses in the gastrointestinal tract include:

• Staging of tumors for secondary deposits and adjacent infiltration
• Localizing abscess
• As an aid to biopsy and drainage procedures
Magnetic Resonance Imaging

• MRI imaging of the hollow organs of the

gastrointestinal tract is increasingly being used to
evaluate a wide assortment of gastrointestinal tract
disorders.
• As with CT imaging, mild mucosal diseases and small
focal lesions are not well detected with this
technique; however, malignancies can be similarly
evaluated and staged.
 Laparoscopy

(minimally
invasive surgery)

Liver
biopsy
GALLBLADDER AND BILE DUCTS

• Cholecystogram, intravenous
cholangiography and
• T-tube cholangiography
• Endoscopic retrograde
cholangiopancreatography (ERCP)
• Percutaneous transhepatic
cholangiography (PTC)
GIT: THE LABORATORY INVESTIGATION OF THE PATIENT

• Complete Blood Count Test

• Blood sugar tests
• Blood clotting factors
• Electrolytes
• Enzyme & protein blood tests
• Lipid blood tests
• C-reactive protein
• Fecal occult blood test
• Gut flora examination
• Ova and parasites exam
• Tests for Clostridium difficile infection
• Tests for Helicobacter pylori infection
 Diagnosis of H. pylori infection
1.Cytological investigation of smears.
2.Histologic investigation of biopsies.
3.Rapid urease test (CLO-test) may be carried out on gastric antral biopsies to investigate the
possibility of H. pylori infection.
4.Culture of H. pylori infection. Technically difficult and accuracy varies with laboratory, also
expensive.
5.Urea breath test. 13C-labelled urea is ingested. If H. pylori is present, urea is metabolized to
ammonia and carbon-labelled carbon dioxide. The labeled carbon dioxide is then excreted in
breath as labeled carbon dioxide, which is then collected and quantified.
6.Serology test. Detection of antibodies against H.pylori infection. It is not a suitable test to
document efficiency of eradication.
7.Stool antigen test
 PHARMACOLOGICAL TESTS

1. Nitroglycerine reduces a tone of the cardiac

sphincter and improves passableness of the
foot at patients with achalasia and does not
influence patients with organic strictures.
2. Bernstein’s test – for patients with oesophageal
diseases swallowing of a hydrochloric acid is
painful.
 THE STOMACH (1)

Secretion
Parameters Stimulated
Basal Fractional researching of gastric
(submaximal)
Volume of gastric juice, secretion
(mL/hr)
50-100 100-140
The patient swallows a thin probe
Total acidity, titration’s units 40-60 80-100 (diameter of 4-5 mm), and then
gastric juice is sucked away each 15
Unconnected hydrochloric
acid, titration’s units
20-40 65-85 minutes.

Debit (output) total acidity, In total eight portions of gastric juice

mmol/hr
1,5-5,5 8-14 are received.
Debit (output) of unconnected
hydrochloric acid, mmol/hr
1-4 6,2-12
 THE STOMACH (2)

pH-metry
• In the Body of a stomach on an
empty stomach – 1.6 - 2.0;
• after stimulation – 1.2 - 2.0;
• in the pylorus – less then 2,5
Microbiological investigation
The need for microscopy of stool or jejunal aspirate to
identify protozoa such as Giardia is often overlooked.
Laparoscopy has an increasing role in the investigations
of intraabdominal disease.
 INVESTIGATION OF BILE

1) Bile pigments
BLOOD STOOL URINE

Total bilirubin 8.6-20.5

Stercobilinogen (+) Stercobilinogen (+)
mmol/L
Direct (conjugated)
bilirubin 0-2.57 mmol/L
Indirect (unconjugated)
bilirubin 8.6-20.5 mmol/L

17.1 mol/L=1 mg/dl

 The investigation of the bile (duodenal intubation)-1

• The investigation of the contents of the duodenum is carried out in order to

❑ diagnose lesion to the bile ducts and gall bladder
❑ to judge the work of the pancreas.
• The duodenal content is obtained using a probe, which is a tube with a
diameter of 5 mm made of elastic rubber.
• Attached to the end of the probe is an oval metal or plastic olive with holes
communicating with the lumen of the probe. The length of the probe is about
1.5 m. At a distance of 45 cm from the olive there is a mark (distance to the
stomach), then-marks at a distance of 70 and 80 cm.
 The investigation of the bile (duodenal intubation)-2

• The patient swallows the long

tube (3-5 mm) and lies on the
right side.
• At the first the physician gets
from the tube the portion A from
the duodenum. It includes
duodenum juice, bile, and
pancreas juice.

• After stimulation with sulfate magnesium the physician

gets both the portion B from the gallbladder and portion C
from bile tree.
 The investigation of the bile (duodenal intubation)-3

• The investigation is performed on an empty stomach.

• The patient sits with his mouth slightly open; the probe is
inserted so that the olive is at the root of the tongue, and it is
suggested to make a swallowing movement, only slightly
helping the independent movement of the probe.

• All three portions of bile are examined by

✓ Microscopic
✓ Chemical
✓ Bacteriological (sometimes) methods.
NOTE! Microscopic examination of the duodenal contents should be performed immediately after the
allocation of each portion. White blood cells are destroyed in the bile within 5-10 minutes, other cells are
somewhat slower, but still fast.
 Duodenal intubation: NORMAL PARAMETERS

Parameters Portion A Portion B Portion C

Amount 20-35 30-60 30

golden yellow, saturated yellow,
Color light yellow
amber dark olive, brown

Relative density 1.003-1.016 1.016-1.032 1.007-1.011

Transparency transparent transparent transparent

neutral or basic
Reaction pH basic reaction basic reaction
reaction

Hydrochloric acid, the

17.4-52 mmol / l 57.2-184.6 mmol / l 13-57.2 mmol / l
content of bile acids

Cholesterol 1.3-2.8 mmol / l 5.2-15.6 mmol / l 1.1-3.1 mmol / l

 Duodenal intubation: NORMAL PARAMETERS

Biochemical Tests

Parameters Portion A Portion B Portion C

Bilirubin, mmol/L - 256.5-769.7 307.8

Bile acids, g/L - 115 7-14

Lecithin, g/L - 35 1-5.8

Cholesterol, g/L - 4.3 0.8-2.1

Proteins, g/L - 4.5 1.4-2.7

Amylase, g/mL/hr - 1.67-4.45 6-16

Trypsin, mmol/L/min - - 50-500

 Duodenal intubation: NORMAL PARAMETERS

MICROCOPY
Parameters Portion A Portion B Portion C
Epithelium Some Some Some
Leucocytes 2-4 5-10 2-4
Erythrocytes abs abs abs
Atypical cells abs abs abs
Mucus Few Few Few
Crystals Some Some Some
Helminthes abs abs abs
Protozoa abs abs abs
 INVESTIGATIONS

1. Serum proteins (Total protein, Serum albumin, Serum globulin, 1-globulin, 2-
globulin, -globulin, -globulin, Albumin/globulin ratio)
2. Coagulation tests (Activated partial thromboplastin time, Prothrombin index,
Thrombin time, Fibrinogen)
3. Sedimentation tests (Sulema Test, Timol Test, Formol Test)
4. Total cholesterol
5. Minerals (Serum Iron, Transferrin, Serum Cuprous, Caeruloplasmin)
6. Enzymes (Lactate dehydrogenase, Alanine aminotransferase, Aspartate
aminotransferase, Alkaline phosphatase, -glutamyltranspeptidase)
7. Specific tests (The -fetoprotein, viral markers, Autoantibodies)
 STOOL TESTS (1)

MACROSCOPY
Parameters Normal
Amount per day 100-300 g
Consistence Made out (soft)
Shape Cylindrical
Smell Unpleasant
Color Brown
pH Neutral or alkalescent
Slime, blood, pus Abs
The rests of the not digested food The rests of vegetative food
Helminthes Abs
STOOL TESTS (2)
MICROCOPY
Muscular fibres
• With striation Abs
• Without striation some
Connecting fabric Abs or some
Neutral fat Abs or few
Fat acids Abs
Soaps Few
Vegetative cellulose
• Digested -Few
 STOOL TESTS (3)
Parameters
Non digested -Few
Amylum Abs
Iodophil flora Abs
Slime, macrophages, atypical cells, Abs
erythrocytes
Leukocytes, epithelium Some
Crystals Abs
Helminthes Abs
Protozoa Abs
Funguses Abs
 PANCREAS

▪ Serum and Urine amylase

▪ Serum lipase
▪ Blood sugar
▪ Stool tests
▪ Ultrasound scanning
▪ X-ray
▪ Endoscopic retrograde cholangiopancreatography (ERCP)
▪ CT scanning, MRI
▪ Radionuclide scanning (14C)
COMPLETE BLOOD COUNT TEST (CBC)

PARAMETERS Normal
Haematocrit (PCV)
• Male 40-48%
• Female 36-42%
Hemoglobin (HB)
• Male 130-160 g/L
• Female 120-140 g/L
Red blood cells (RBC)
• Male 4.0-5.1x1012/L
• Female 3.7-4.7x1012/L
Color index (CI) 0.86-1.05
Reticulocytes 0.2-1.2%
COMPLETE BLOOD COUNT TEST (CBC)
PARAMETERS Normal
Platelets 180.0-320.0x109/L
White blood cells (WBC)
• Male 4.0-8.8x109/L
• Female 3.2-10.2x109/L
Band neutrophils 1-6%
Segmented neutrophils 45-70%
Eosinophils 1-5%
Basophils 0-1%
Lymphocytes 18-40%
Monocytes 2-9%
Erythrocyte sedimentation rate (ESR)
• Male 1-10 mm/hr
• Female 2-15 mm/hr
THANK YOU
FOR
ATTENTION!