git3 - small, large surgical pathology

7/29/2019 GIT3 - Small, Large Surgical Pathology

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Surgical Pathology & X-rays for

Medical Students2008

GIT-3Small intestine

Colon

Rectum & anal canal


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GIT 32

Abnormal gas patterns

in plain X-ray abdomen


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GIT 33

The intestinal tract of normal adults generally contains less than 200 cc of gas

Five gases make up greater than 99% of gas passed per rectum.These are N2 , O2 , CO2 , H2 , and CH4

There are three sources of intestinal gas

Air swallowing Bacterial production Diffusion from the blood

depends upon theposition of thepatient and the levelof anxiety of thepatient

Bedridden patients,for example, may be

unable to eructate swallowed air, thus allowing it to pass

distally into the GIT

Bacterial metabolism is thesource of hydrogen andmethane production

Certain foodstuffs, (e.g.beans)

deliver nonabsorbablecarbohydrates to the colonwhere bacterial metabolismproduces both hydrogen andmethane.


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GIT 34

Normal plain X-ray film of the abdomen, demonstrating

soft tissue densities

Normal plain X-ray film of the abdomen demonstrating

the bowel gas pattern


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GIT 35

The radiographic evaluation of intestinal gas should include the following points:

what segment ofbowel containsthe gas

Dimension of theair-filled gut

Most distal pointthe gas has

passed in theintestine

Identify gutmucosa outlinedby the gas


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GIT 36

In the supine position:Gas normally accumulates in the anteriorly placed segments of intestine:

the distal stomach, transverse colon, and sigmoid colon.

Gas within the remainder of the colon, particularly the rectum, is not uncommon

The gas-filled gut that in the most superior portion of the abdomen on the supine film is usually the stomach

The transverse colon lies immediately inferior

Ascending and descending portions of the colon occupy the right and left lateral most portions of the abdominal cavity

Air in the sigmoid colon tends to occupy a lower mid-line position, but because of variations in the length of the sigmoid mesocolon may extend into the upper mid-abdomen as well

Rectal air occupies a mid-line pelvic position

Small intestinal gas tends to accumulate in the mid-abdomen, framed by the colon


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GIT 37

Stomach : AlwaysSmall Bowel : Twoor three loops of non-distended

bowelNormal diameter = 2.5 cm = 1US quarter

Large Bowel : Inrectum or sigmoid

almost always

Gas instomach

Gas in a fewloops ofsmall bowel

Gas inrectum or

sigmoid

Normal Gas Pattern


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GIT 38

Erect Abdomen

A few air in

small bowel

Alwaysair/fluid level

in stomach


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GIT 39

The position of the bowel is helpful. Small bowel is central while colon isperipheral (frame)

The gas may outline the colonic haustra or intestinal plicae circulares.

Haustra tend to be two to three millimeters wide, and occur at centimeter intervals.

Plicae circulares are approximately one millimeter wide and occur at millimeter intervals.

Extension of either of these soft tissue lines across the entire width of the lumen is

not the only helpful point of distinction. The width of the lines, spacing, and locationof the bowel loop are felt to be more helpful

Occasionally the distinction between colon and small bowel cannot bedetermined and a contrast study is necessary

The distinction between colon and small bowel


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GIT 310

Air is seen in non-dilated loops of smalland large bowel.

Small loops arecentrally located, andcolon is distributedperipherally like apicture frame.

Normal BowelGas Pattern :


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GIT 311

Small bowel loops aredistributed centrally inthe abdomen andhave mucosal foldsthat cross the entirelumen of the bowel .These folds are calledvalvulae conniventes or plica circularis andare visible in gas-filled loops

Plain X-ray supine : Small intestinal obstruction


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GIT 312

The colon gas patternis usually distributed likea picture frame aroundthe periphery of theabdomen.

Colonic loops containhaustrations which donot extend all the wayacross the lumen of thebowel


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GIT 313

Large vs. Small Bowel

Large BowelPeripheral

Haustral markings don't

extend from wall to wallSmall Bowel

Central

Valvulae extend acrosslumen

Maximum diameter of 2"


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GIT 314

This is a normal plainX-ray abdomen in thesupine position

In supine X-raysof the abdomenwe look for:

Free airAir-fluid levels


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GIT 315

Abnormal Gas Patterns

Functional Ileus

Localized (Sentinel Loops)Generalized adynamic ileus

Mechanical Obstruction

SBOLBO


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GIT 316

Plain X-ray Abdomen - Postoperative adynamic ileus

Multiple loops of minimally dilated small bowel with air fluid levels at differentlevels within the same loop of intestine on the upright (103-2) film. There is asmall amount of gas in the right colon

Supine Erect


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GIT 317

Plain X-ray abdomen (erect position)

Multiple fluid levels


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GIT 318

Plain X-ray abdomen (erect position)



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GIT 319

Mechanical Small bowlobstruction (supine position)

Dilated small bowelFrequent audible intestinal sounds(Fighting loops)

Little gas in colon, especially rectumKey: disproportionate dilatation of SB


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GIT 320

Plain X-ray- Small bowel obstruction secondary to adhesions

Supine

The supine view of the abdomendemonstrate dilated small bowel without

any air in the colon

Erect

Erect Film shows a large amount of fluidwithin the small bowel. There are multiplesmall pockets of air arranged in a line noted in theleft lower quadrant (residual colonic gas)


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GIT 321

Plain abdominalradiograph: Inverted U-shaped, gaseous, dilated

small bowel loops canbe observed above oneanother (arrows) in themiddle of the abdomen.The double arrow pointsto an air-fluid level in theintestines

Small intestinal illius


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GIT 322

Mechanical SBO

Causes Adhesions

Hernia*

Volvulus

Gallstone ileus*

Intussusception

*Cause may be visible on plain film


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GIT 323

Mechanical LBO

Key Features

Dilated colon to point of obstruction

Little or no air in rectum/sigmoidLittle or no gas in small bowel, if

Ileocecal valve remains competent


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GIT 324

Mechanicallarge bowelobstruction

Dilated colon to point of obstructionLittle or no air in rectum/sigmoid(according to the site of obstruction)Little or no gas in small bowel, if Ileocecal valve remains competent

Tumor (CA colon)Volvulus (Sigmoid)Hernia (strangulated)IntussusceptionDiverticulitis


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GIT 325

Sigmoid carcinoma causing colon obstruction

Supine Erect

Multiple dilated loops of bowel with scattered air fluid levels on the upright film. The caliber and locationof the bowel loops suggest that the air is within the colon. There is some small intestinal gas noted inthe right mid abdomen, but the preponderance of air is in the colon. There is little rectal gas present


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GIT 326

Barium enema of the same patient

shows an abruptobstruction at thelevel of the

sigmoid colon


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GIT 327

Large bowl obstruction

(supine position)


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GIT 328

History : Elderly man with newonset of abdominal painPhysical exam : distended,tympanitic abdomen

Diagnosis: SigmoidVolvulus

In sigmoid volulus, the colon

appears as a dilated,inverted U-shaped loop which extends from the pelvis into the mid-upper abdomen. (coffee bean sign)


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GIT 329

Sigmoid VolvulusMost common colonic volvulus

Water soluble enema confirms

distal obstructionIf discovered early,

colonoscopic decompression isusually effective


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GIT 330

Volvulous of thesigmoid colon


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GIT 331

Volvulous of thesigmoid colon


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GIT 332

Generalizedadynamic ileus

Supine


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GIT 333

Generalized Adynamic Ileus

Gas in dilated small bowel and large bowel to rectumLong air-fluid levelsOnly post-op patients have generalized ileus


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GIT 334

Both mucosaland serosalsurfaces of

bowel wall areoutlined by gasindicating thatthere must befree gas in theperitonealcavity

Plain X-rayabdomen

Supine

Pneumoperitoneum


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GIT 335

Pneumoperitoneum


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GIT 336

Intestinal obstruction

Dynamic AdynamicPeristalsis is workingagainst mechanical

obstruction Absent peristalsis

Paralytic ileus

Nonpropulsive peristalsis

Mesenteric vascular occlusion

Intraluminal Impacted faeces

Foreign body

Intramural Malignant or inflammatory stricture

Extramural Peritoneal bands

Strangulated hernia

Volvulus,Intussusception


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GIT 337

Dynamic obstruction

Abdominal pain Distension Vomiting Absolute constipation

Symptoms of intestinal obstruction

These symptoms will vary according to the site of obstruction

Clinical types of obstruction Small bowel obstruction Large bowel obstruction

High Low

Distension is early & markedPain is mild

Vomiting & dehydration arelate

Early profusevomiting (Rapiddehydration)

Minimal distension

Minimal fluid levels

in abdominal X-ray

Vomiting is delayedPain is predominant

with central distension

Multiple central fluid

levels in x-ray


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GIT 338

The clinical picture of intestinal obstruction is also influenced by whether the presentation is:

Acute Chronic Acute onchronic

Subacute

Usually insmall bowel

obstructionSudden onset

of severecolicky centralabdominal pain

& distensionEarly vomiting

& constipation

Usually inlarge bowel

obstructionLower

abdominal colic& constipation

Followed bydistension

Short history of distension &

vomiting on topof backgroundof pain &constipation

Incompleteobstruction


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GIT 339

Pathophysiology

Above obstruction Below obstructionObstruction

The bowel has normalperistalsis & absorption untilit becomes empty, then becomes immobile

Proximal peristalsis increases toovercome obstruction (increases intestinal sounds)

If obstruction is not relieved, the

bowel will dilate, peristalsis willdecrease

With more dilatation the bowelbecomes flaccid & paralyzed

Distension is due to :Gas produced by overgrowth of organisms

Fluid of digestive juices which is not absorbed

Dehydration & electrolyte loss are due to:Reduced oral intake

Defective intestinal absorption

Vomiting

Fluid sequestration in bowel lumen


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GIT 340

Examples of dynamic obstruction

Extramural Peritoneal bands

Strangulated hernia

Volvulus,Intussusception


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GIT 341

Peritoneal bands


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GIT 342

Small bowel obstructionsecondary to intraperitonealfibrous band adhesion


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GIT 343

Intestinal Obstruction Small Bowel Infarctionsecondary to intraperitoneal

fibrous band (Late presentation

irreversible intestinal ischemia)

The commonestcause of inrtaperitonealbands is previousinrtaperitonealoperation. e.g. : appendectomy,exploration,..

S ll b l b i


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GIT 344

Central distension of small intestinal loops.

Note the metal clips of a previous operation

Small bowel obstruction

Erect :



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GIT 345

Strangulated hernia

St g l t d f l h i i g


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GIT 346

Strangulated femoral hernia causingintestinal obstruction

1

2

3

4

S ll i i l l i


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GIT 347

Small intestinal strangulation

This loop of intestine was strangulatedwithin a hernia.

How would you know that this loop is viable or not?

Strangulated femoral hernia

Strangulated para-umbilical hernia

S ll i t ti l


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GIT 348

Small intestinal gangrene

This gangrenous loop of small intestine was strangulated within a hernia.

What was the possible clinical presentation of this patient?

What is the next step in management?


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GIT 349

Intussusception


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GIT 350

Small bowlIntussusception

More pictures for intussusception will come later


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GIT 351

Small bowel obstruction

Erect :


Supine :

Central distension of small intestinal loops


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GIT 352

Volvulus

Si id


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GIT 353

Sigmoidvolvulus

Sigmoid volvulus


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GIT 354

Sigmoid volvulus

(late irreversible gangrene)


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GIT 355

Small bowl volvulus


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GIT 356


Intramural Malignant or

inflammatory stricture


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GIT 357

Chronic intestinalobstruction due to CAdescending colon

Ba enema shows the shadow of the mass

Dilated intestinal loops are seen


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GIT 358

Dilated bowelloops proximal tothe obstruction.

Arrow points tothe etiology of obstruction

Ba enema:

The ilio-cecal valve in this patient is incompetent


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GIT 359


Intraluminal Impacted faeces

Foreign body


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GIT 360

Fecal impaction

As a result of chronic constipation,the patient is unable to expel stools, itfurther accumulates into a larger,harder mass that is impossible topass by normal defecation.

Impaction is most common ininactive elderly people

Symptoms include chronic

constipation. There can be fecalincontinence and paradoxical diarrheaas liquid stool passes around theobstruction

Foreign body


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GIT 361

Foreign body

Phyto-bezoar in the jejunum

Peritonitis:


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GIT 362

Peritonitis:

Primary Infection of the peritoneal fluid withoutintra-abdominal disease:Haematogenous spread Lymphatic spread Direct spread: usually associated with CAPD catheters Ascending infection: from the female genital tract

Secondary Inflammation of the peritoneum arisingfrom an intra-abdominal source:Infectious Non-infectious Blood Ischaemia Bile Chemical Foreign body

Perforation

Usually due to spreadinginflammation across thewall of an intra-

abdominal viscus

Localized

Generalized

Patho-physiology of Normally , the greater omentum


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GIT 363

protein-rich fibrinousexudate

Patho-physiology ofperitonitis

Early : hyperemia & fluid transudate

y , gchanges its position with

intestinal peristalsis & abdominal muscles contraction

Peritoneal inflammation willsuppress peristalsis & abdominal

muscles contractions

Clinically : Early: Guarding, reboundtenderness, decreased

or absent intestinalsounds

The greater omentum willadhere to & surround the

inflamed organ preventingfurther spread of inflammation

The exudate willsuppress peristalsis

(paralytic ileus), and limitsspread of infection

Ileus --- fluid accumulates withinthe intestine + intraperitoneal

exudate --- decreased intravascular volume --- hyopvolemia


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GIT 364

The most common cause of generalized peritonitis is

perforation of an intra-abdominal viscus


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GIT 365

Generalizedperitonitis

withfibrinousexudate

Infarction:

Area of ischemic necrosis caused by


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GIT 366

Infarction:Aetiology ofinfarction

Occlusive Arterial :

Embolism Thrombosis Extrinsic compression Venous :

Thrombosis Extrinsic compression

Non-occlusive Shock:

Hypovolaemia Cardiogenic Sepsis

Vasoconstrictor drugs

impaired arterial supply or venous drainage

Arterial mesenteric vascular occlusion

Infarction of small intestine


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GIT 367

Compare the dark red to grey infarcted bowel with the pale pink normal bowel atthe bottom. Some organs such as bowel with anastomosing blood supplies, or liver with a dual blood supply, are hard to infarct.

This bowel was caught in a hernia and the mesenteric blood supply wasconstricted by the small opening to the hernia sac.

What other causes can result in such massive intestinal infarction?

M i l


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GIT 368

Mesenteric vascularocclusion

Irreversible small bowl ischemia

Mesenteric ischaemia


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GIT 369

Mesenteric ischaemia


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GIT 370

Intussusception


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GIT 371

Intussusception (Ileo-ileal)


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GIT 372



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GIT 373

Intussusception (Ileo-ileal) - postmortum

Intussusception


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GIT 374

Intussusception



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GIT 375

Intussusception (Ileo ileal)

What are the early clinical featuresof a child presenting withintussusception?

A child of about 6 months old, developssudden onset of screaming with drawingof the legs. The attacks are recurrent.Vommiting may occure early, stoolsmay be normal first, then the child

passes blood & mucous

Redcurrent jelly stools

Intussusception of ileum into the colon


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GIT 376

The leading proximal, small bowelsegment (intussusceptum) telescopes into the distal, colonsegment (intussuscipens).

The small intestine (blue arrow) is goinginto the large intestine (green arrow)

Intussusception (Ileo-colic)


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GIT 377

p

Barium enema with rectal instillation under fluoroscopy is the gold standard for both diagnosing and red cing childhood ileo colic or colocolic intussusception


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GIT 378

Barium enema showingintussusception

Passing from the rectum, the barium fillsthe colon untill a mass is noted (the intussusception)

Transverse colon

Barium enema is used for reduction of the intussusception

It is about to be completelyreduced (note the barium is going into the small intestine)

both diagnosing and reducing childhood ileo-colic or colocolic intussusception

Barium enema for diagnosis & reduction of intussusception


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GIT 379

Head of intussusceptionis at hepatic flexure

Free flow of contrast intodistal small bowel indicates

complete reduction

Partial reduction

Barium enema


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GIT 380

Barium enema

Intussusception (Claw sign)


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GIT 381

The rectallyadministeredcontrast materialdraws around thehead of theintussusception(arrow) (Claw sign)

Barium enema


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GIT 382



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GIT 383

Barium enema



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GIT 384

Small IntestineOther pathological conditions


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GIT 385


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GIT 386

Meckels diverticulum

Inflamed

Remember the complicationsof Meckels diverticulum

Infection & obstruction (as theappendix)May contain gastric, colonic or pancreatictissue usually at the diverticulum mouth

Peptic ulceration with severe bleeding

Intussusception

Intestinal obstruction (band between umbalicus & diverticulum)

Meckels diverticulum


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GIT 387

ec e s d ve t cu u


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GIT 388

Meckelsdiverticulum


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GIT 389

Crohns Disease

Regional enteritis


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GIT 390

Deep linear mucosal ulcerations, with edema of the mucosa between the ulcers

Remember that symptoms & signs of acute Crohns resemble acuteappendicitis

Chronic Crohns can cause enteric

strictures & fistulae


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GIT 391

The Appendix

Normal appendix


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GIT 392

Normal appendix (postmortem)

Acute appendicitis with gangrenous tip


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GIT 393

Various positionsof appendix inorder offrequency:

1. Retrocecal 74%

2. Pelvic 21%

3. Paracecal 2%

4. Subcecal 1.5%

5. Preileal 1%

6. Postileal 0.5%

7. Sub-hepatic 8. Lt. iliac fossa in situs invertus

How can differentpositions alter theclassical clinicalpicture?

d


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GIT 394

Acute Appendicitis

Acute Appendicitis


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GIT 395

Acute Appendicitis


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GIT 396

Note flakes of pus

Acute Appendicitis


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GIT 397

Opened to showfecalith inside

Regarding appendicitis


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GIT 398

g g ppa. The risk of developing the illness is greatest inchildhoodb. Mortality increases with age and is greatest in theelderlyc. 20% of appendices are extraperitoneal in a

retrocaecal positiond. Faecoliths are present in 75-80% of resectedspecimense. Appendicitis is a possible diagnosis in the

absence of abdominal tenderness All answers are correct.

Pelvic appendicitic can present with few abdominal symptoms & signs. Rectalexamination is t he key to diagnosis.

A i i i


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GIT 399

Acute peritonitis

The loops of bowelare plasteredtogether withyellowish fibrinousexudate containing alarge number of neutrophils.

When this process heals, what complications may develop?

What are the factorsthat favor thedevelopment of diffuse peritonitis?


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GIT 3100


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GIT 3101

Subphrenic

abscess A pocket of infectionhas developedbeneath thediaphragm elevatingit as seen on thechest x-ray


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GIT 3102

Colon

l d f h l


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GIT 3103

Diverticular disease of the colon

Sigmoid Colon Most Common SiteDiverticula are small (0.5 to 1.0 cm in diameter) outpouchings of the colon that occur inrows at sites of vascular penetration between the single mesenteric taenia and one of


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GIT 3104

rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric taeniae. At the sites of most diverticula, the muscular layer isabsent (see Figure 1). Technically, such lesions are really pseudodiverticula; truediverticula (which are much less common than pseudodiverticula) involve all layers of

the bowel wall. Nevertheless, both pseudodiverticula and true diverticula are generallyreferred to as diverticula

Diverticula are located at sites whereblood vessels enter the colonic wall

The sigmoid colon is the most common siteof diverticula: in 90% of patients withdiverticulosis, the sigmoid colon is involved.If a diverticulum becomes inflamed as aresult of obstruction by feces or hardenedmucus or of mucosal erosion, a localized

perforation (microperforation) may occur --a process known as diverticulitis. Theincidence of diverticulitis is about 10% to25% in patients with colonic diverticula


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GIT 3105

Colonic diverticula are outpouchings of the mucosal layer of the large bowel through thesubmucosa and circular muscle layer of the bowel. Colonic diverticula are virtuallyrestricted to the sigmoid colon only; the rectum is spared as its complete longitudinalmuscle coat protects against their development. Diverticula stimulate marked hypertrophyof the circular muscle layer of the muscle coat. They tend to arise at weak points whereblood vessels penetrate the submucosa

Which of the following statements regarding colonic diverticula are true? (Tick all

those that apply)a)They are true diverticula which contain all the layers of the colonic wall.b)The sigmoid and rectum are the commonest site, as faeces are most solid here andrequire higher pressure to propelc)Their presence stimulates hypertrophy of the circular muscle layer of the large bowel.d)They tend to arise at weak point where blood vessels penetrate the submucosa of thelarge bowel.


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GIT 3106

Profuse Bleeding in Complicated Diverticulitis Usually Ceases SpontaneouslyIn complicated diverticulitis, the disease process has progressed to obstruction,abscess or fistula formation, or free perforation. Complicated diverticulitis may beparticularly challenging to manage,[1] especially because patients may have no knownhistory of diverticular disease.[2] Gastrointestinal bleeding is a complication of diverticular disease in 30% to 50% of cases; in fact, diverticula are the most commoncolonic cause of lower GI bleeding. Approximately 50% of diverticular bleedingoriginates in the right colon, despite the low incidence of diverticula in this segment of the colon. Patients tend to be elderly[1] and to have cardiovascular disease andhypertension. Although patients may lose 1 to 2 units of blood, the bleeding usuallyceases spontaneously, and expeditious operative treatment generally is not necessary.

Barium enema- double contrast


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GIT 3107

Diverticular disease of colon

Barium enema



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GIT 3108



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GIT 3109

Barium enema - Diverticular disease of colon

Ba. Enema-Diverticulitis


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GIT 3110

Diverticulitis

An area of eccentricnarrowing ispresent in thesigmoid colon

(arrows). Withinthis areadiverticula areseen

Barium enema

Di ti l di f l l t t


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GIT 3111

Diverticular disease of colon late stage

Theradiographtaken severaldays after theexamination,remains of contrastmaterial in thediverticula

demonstrateextendeddiverticulosisinvolving theentire colon

78 year old man is complainingof blood in the feces.


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GIT 3112

This is the air-contrast barium

enema showing the sigmoid &descending colon

Does the X ray explain the clinical presentation? Explain.

What is the next step?

The film demonstrates several smallprojections extending out of thecolon. The appearance is typical of diverticulosis

SelectiveAngiography-


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GIT 3113

g g p yActive bleedingfrom right-sidedcolonicdiverticulum

This early film

shows a focus of extravasation(arrow) arisingfrom a division of the right colicbranch of thesuperior mesenteric artery

The later filmd t t


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GIT 3114

demonstratespersistent

extravasation inthis area withfilling of anadjacentdiverticular-likestructure

Adenomatous polyp (colon)


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GIT 3115

A polyp is any outgrowth of a mucosalsurface (as compared to a papilloma,

which is an outgrowth from squamous or transitional epithelium).

Polyps are particularly common in thecolon. This one is on a long stalk(pedunculated).

Polyps of the colon sometimes becomemalignant so that microscopicexamination is important.

The term adenoma is also used since

they are tumors of glandular origin.

How might a patient know that he had a polyp? (What is the possible clinicalpresentation?)

Inflamatory

Polyps of large intestine


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GIT 3116

Inflamatory

Metaplastic

Hamartomatous

Neoplastic AdenomaTubular adenoma

Villous adenoma

Adenocarcinoma

Solitary adenomas are usually found during investigations of colonicbleeding

Villous adenomas usually cause diarrhea, mucous discharge & occasionallyhypokalemia

The risk of malignant transformation in an adenomatous polyp is related to

its size .

Adenomatous polypof the colon


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GIT 3117

of the colon


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GIT 3118

Colon polyp longitudinal section - wall layers are preserved (purly mucosal)


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GIT 3119

Familial adenomatous polyposis

Familial adenomatouspolyposis


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GIT 3120

Multiple adenomatous polyps of the cecum are seen here in a case of familialadenomatous polyposis , a genetic syndrome in which an abnormal genetic mutation leads todevelopment of multiple neoplasms in the colon.

p yp


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GIT 3121

Multiple colonicadenomatous polyps infamilial adenomatous

polyposis

When those patients undergototal colectomy , they will need

regular follow-up. Why?

This is an autosomal dominant

familial disease. Why shouldmembers of affected families beregularly screened starting fromthe age of 10?

Barium enema


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GIT 3122

Familial polyposis of thecolon

Barium enema


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GIT 3123

Familial polyposis of thecolon

Familial adenomatous polyposis


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GIT 3124

Importance of screening program

Large bowl carcinoma occurs 10 20 years after the onset of polyposis

Operative options:

Colectomy with ilio-rectal anastomosis (needsregular follow-up for recurrent polps in the rectalstump. Treated by fulgration

Proctocolectomy with restorative ilio-analanastomosis

Proctocolectomy with iliostomy


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GIT 3125

Cancer colon

cecum What are the possible

clinical presentations?

What are the differentmacroscopic types?

Common macroscopic varieties of colon carcinoma:

1. Annular


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GIT 3126

2. Tubular

3. Ulcer 4. Cauliflower

Possible clinical presentations :

Recent alteration in bowl habbits with constipation needing more laxativesEmergency presentation with intestinal obstruction

Colonic bleeding or progressive anemia

Segmoid carcinoma may cause tenesmus

Palpable mass

Caecal carcinoma may be accidentally discovered during operation for appendicitis or appendicular abscess

Metastasis (usually liver) & ascitis

Cancer cecum


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GIT 3127

Terminal ileum

Remember thedifferent clinicalpresentations of

cancer cecum


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GIT 3128


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GIT 3129 . Everted edge & necrotic floor Malignant ulcer of the colon

Resected segmentof colon from a 70


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GIT 3130

of colon from a 70year old man with

iron deficiencyanemia

What condition

does this patient have? Why is he

anemic?

Colon Carcinoma


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GIT 3131

Causing luminal stenosis


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GIT 3132 Cancer sigmoid colon

Barium enema

CA cecum


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GIT 3133

CA cecum

Barium enema

CA cecum


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GIT 3134

Barium enema

Apple-core type lesion in the sigmoidcolon typical of a carcinoma Air contrast barium film


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GIT 3135

colon , typical of a carcinoma Air contrast barium film

Diverticulosis in the colon, in themiddle of which is found a small apple-core lesion typical of a carcinoma

Barium enema:


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GIT 3136

Barium enema:

A 6 cm long section of the recto-sigmoid regionhas irregular contour,narrowed lumen (1 cm)and filling defect (arrow)

Ba. Enema-Carcinoma ofsigmoid colon


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GIT 3137

sigmoid coloncausing complete

retrogradeobstruction

An irregular massencroaches on thelumen, which ultimatelynarrows to a thindistorted wisp of barium. The massinvolves both thesuperior and inferior margins of the sigmoidcolon, and is thereforecircumferential.

Diverticula are present distal to the obstructing mass. They represent anincidental finding

Barium enema

CA ascending colon


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GIT 3138

g

Barium enema

CA ascending colon


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GIT 3139

g

Barium enema

CA ascending colon


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GIT 3140

g

Barium enema

CA hepatic fle re


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GIT 3141

CA hepatic flexure


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GIT 3142

Barium enema

CA i id l


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GIT 3143

CA sigmoid colon


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GIT 3144

Rectum &

Anal Canal

Thrombosed, infectedpiles


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GIT 3145 What are the complications of piles?

What are the symptoms of piles?

1.Bright red painless bleeding. 2.Mucous discharge

3.Prolapsed piles 4.Pain only with prolapse

Complications of piles :


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GIT 3146

1. Bleeding

2. Strangulation (prolapsed & gripped by theexternal sphincter impairing venous return)

3. Thrombosis of strangulated piles will follow if notreduced within an hour or two

4. Ulceration of the mucous membrane

5. Gangrene if strangulation occludes arterial supply

6. Suppuration if infection is superadded

7. Portal pyaemia

Cancer


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GIT 3147

Rectum

rectumMalignant

ulcer

What are the organs that may be involved due to local spread of CA rectum?

Rectal cancer well within the reach of an examiner's finger


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GIT 3148

Autopsy Picture

Anal canal

Malignantulcer in the

rectum


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GIT 3149

The Colon

Normal Barium enema


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GIT 3150

The first two films are of an air contrast barium enema. There is bothbarium and air within the colon. By changing the position of the patient,

different areas are well outlined with the air. When the patient is lying on hisright side, the air accumulates on the left and vice-versa

The 3 rd film is a single contrast barium enema where only barium is instilledin the colon. The complete colon is well demonstrated. The colonic haustraare well seen. The terminal ileum and appendix are also filled

Hirschsprungs disease


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GIT 3151

Hirschsprung s disease



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GIT 3152

Barium enema:The contrast materialoutlines a bowelsegment without

ganglions (arrows), above whichprestenotic dilatationis visible

Barium enema


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GIT 3153


Barium enema


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GIT 3154


Ba enema Ulcerative cholitis


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GIT 3155

The colon is short, withsmooth haustration andnarrow lumen.

Filling excesses (caused by ulceration) and fillingdefects (caused by mucosal regeneration) give a typicalpicture

Ba. Follow-through-Tuberculous enterocolitis


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GIT 3156

The cecum and ascending

colon are markedly narrowed,nodular, and shortened. Theileocecal valve is gaping, andthe terminal ileum is narrowed

and nodular

Ba. Follow-through-Ischemic colitis


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GIT 3157

segmental narrowing of the entire transversecolon. Within thenarrowed segment, thereare multiple nodular

indentations, many of which have theappearance of thumbprinting

Ba. Follow-through-Advanced Crohn'sdisease of the colon


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GIT 3158

Diffuse narrowing of theascending colon andcecum, associated withextensive deep ulceration

seen in profile. Similar changes are present inthe upper descendingcolon. The terminal ileumis narrowed and has anodular mucosal pattern

Invertogram An invertogram may be used toinvestigate the extent of the defect inanal or rectal atresia


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GIT 3159

anal or rectal atresia.The anus is marked with aradiopaque marker, and the babyinverted. A lateral radiograph is taken.The air in the rectum will rise to thehighest point, giving an indication of

the extent of the atresia


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GIT 3160

Plain X-ray abdomen(erect position)


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GIT 3161

Duodenal atresia

Plain X-ray abdomen(erect position)


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GIT 3162

Duodenal atresia

Ba. Meal follow-through- Smallbowel obstruction by an adhesiveband (Lt. lateral position).


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GIT 3163

The film shows complete interruption of thelumen of the jejunum. Stretched circular mucosal folds without distortion or nodularity extend to the site of the lumeninterruption.

The patient gave a history of abdominal surgery done several years before. Palpationduring fluoroscopy shows fixation of the site of obstruction, usually to the anterior abdominal wall.

The absence of fold distortion or of nodularity is against a malignant cause for

the obstruction. When it is possible toobserve peristaltic activity changing theoutline of the obstructed segment (this bestseen in the single contrast phase), adiagnosis of non-malignant obstruction canbe confidently made even when there is a

history of abdominal surgery for malignancy.

Ba follow-through-Low gradeobstruction by a


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GIT 3164

obstruction by asingle bandadhesion

Dilatation of the proximal jejunum terminating at a

sharply demarcated,short and narrowsegment (arrow); anormal fold pattern in anunderfilled lumen is seenbeyond the narrowedsegment. The patienthad abdominal surgeryseveral years before

Free air underdiaphragm

P f d


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Perforated

viscera

git3 - small, large surgical pathology

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