1. Digestive system Diagnostic imaging department of xuzhou medical college Yunjie Qi

2. Diseases of oesophagus

3. oesophageal varices

4. Pathology o esophageal varices result from dilatation of submucosal veins in the esophagus acting as collateral venous drainage in the presence of obstruction elsewhere. Usually this is caused by cirrhosis of the liver so that portal blood flow is rerouted via the esophagus to the superior vena cava.

5. oesophageal varices oesophageal varices are a common and dangerous complication of alcoholic cirrhosis, and bleeding from the varices is a medical emergency

6. oesophageal varices x-ray barium swallow: revealing the mucosae of middle and lower oesophagus erect: used for middle and late stage of oesophageal varices supine/prone ： beneficial for early stage of oesophageal varices

7. esophageal varices appearances of x-ray Thickening, circuitous and disturbance of mucosa longitudinal serpiginous filling defects Dividing line of normal and abnormal esophagus is not clear

8. esophageal varices early stage ： mucosae of distal esophagus are thickening, circuitous the wall is like saw-tooth contraction and relaxation is normal, barium is swallowed smoothly

10. esophageal varices middle stage （ typical ） ：  mucosae of middle and distal esophagus are thickening, circuitous  filling defect is like earthworm  contraction and relaxation is not enough good, barium is swallowed slowly

12. esophageal varices Late stage (serious)  involving the whole esophagus  mucosae is displaced of filling defects which sizes are different  wriggling is weak, barium is swallowed slowly

14. Oesophageal varices CT at mid-chest level demonstrates multiple tubular and rounded contrast enhanced structures surrounding the oesophagus and representing perioesophageal varices (large arrows). Enhancement of the thickened oesophageal wall (small arrow) is due to enlarged submucosal contrast enhanced varices.

15. carcinoma of oesophagus

16. Clinical manifestations 1.carcinoma of esophagus is a malignant tumor arising from the oesophagus, most in over 40 years old. 2.the squamous cell type predominates in the upper and middle third of the oesophagus; adenocarcinoma represents over 60% of all carcinormas of the lower third. 3.swallow difficultly step by step

17. carcinoma of oesophagus Early oesophageal carcinoma 1.limited to the mucosa or submucosa without lymphatic involvement. Their prognosis is much better than that of more developed carcinomas. 2.appear as a plaque-like lesion along one wall of the oesophagus which is frequently ulcerated, or an area of granular, flat mucosa with irregular wall.

18. carcinoma of oesophagus Middle and late oesophageal carcinoma carcinoma invades muscles of oesophagus; 1.mucosa ： destruction, discontinue or disappear 2.relaxation is limited, wriggling is weakening or disappeared. 3.lumens: stenosis, enlargement. 4.dividing line of normal and abnormal esophagus is clear.

23. carcinoma of oesophagus Complications  perforation of oesophagus and cavity formation  lymphatic involvement

24. Posterior mediastinum Perforation of the esophagus

25. tracheo-esophageal fistula

26. carcinoma of oesophagus CT  assess the extension and resectabilitary of the lesion as well as detect lymph node and distant metastasis.

27. The wall of cardia is thickened

28. Upper segment of esophagus

29. lower segment of esophagus

30. Gastric diseases

31. gastric peptic ulcer Pathology gastric ulcers thought to result from weakened mucosal resistance in patients who have a normal or even decreased acid secretion. Patients with peptic ulcer disease usually present with epigastric pain. complications: perforation, obstruction and bleeding

32. gastric peptic ulcer appearances of x-ray  direct appearance: niche  niche may be linear, rectangular or serpiginous  niche may vary in size from very small lesions to entities several centimeters in diameter.  large ulcers are more likely to cause complications such as bleeding and perforation.  most gastric ulcers are located on the lesser curvature or in the antrum of the stomach

33. converging of mucous folds radiating from periphery to centre

35. gastric peptic ulcer direct appearance: niche acute period:  Hampton ’ s line  Hampton ’ s line: result from the edema of mucosa around the entrance of the niche  width: 1~2mm, smooth, transparent line

37. gastric peptic ulcer direct appearance: niche acute period: collar sign, narrow neck sign  collar sign : result from the edema of mucosa around the entrance of the niche; width: 5~10mm  narrow neck sign: the entrance of niche is narrow.

38. collar sign narrow neck sign edema of mucosa

39. gastric peptic ulcer direct appearance: niche chronic period: converging of mucous folds mucosa round the niche is continuous and reaches directly to the margin of it.

40. converging of mucous folds Radiated mucosae

41. gastric peptic ulcer appearances of x-ray: in direct appearance:  Functional abnormalities: spasm, more secreting, wriggling actively or weakly, tenderness of different degree.  Scar: lesser curvature of the stomach is shortening obstruction of pylorus

42. gastric antrum is narrow obstruction of pylorus

43. gastric carcinoma

44. pathology 1.Gastric carcinoma is a malignant tumor arising from the epithelium of the stomach. 2.Adenocarnoma accounts for 95% of gastric malignancies. majority of gastric carcinomas originate in the prepyloric and pyloric region 3.At the time of clinical diagnosis in patients with complaints the disease is commonly in an advanced stage and metastases in regional lymph nodes or in distant locations are commonly present.

45. gastric carcinoma Causes 1.food preservation by salting which leads a reduction in nitrate derivatives is a important factor. 2.other factors are smoking, alcohol consumption and vitamin deficiencies. 3.patients in pernicious anaemia, atrophic gastritis, or adenomatous polyps.

46. gastric carcinoma double contrast barium study is able to detect more than 95% of gastric carcinomas with a high specificity and should be considered not only as an excellent diagnostic method but also as a primary screening procedure for gastric cancer in persons at risk.

48. mucosae Sub-mucosae protruding type Excavated type superficial elevated type superficial flat type superficial depressed type superficial type Group of early gastric cancer

50. mucosae Sub-mucosae chorion muscle Polypoid/mass ulcerated ulcerating and infiltrating diffuse infiltrating

51. gastric carcinoma B1: polypoid fungating double contrast will reveal an irregular filling defect with a rough lobulated surface and sometimes superficial ulceration.

53. gastric carcinoma B2: ulcerated B2 lesion is visible as a sharply circumscribed ulcer crater,exceeding 3 cm in diameter. Radiating folds converging to the edge of the ulcer are blunted or fused. on double contrast barium study B2 tumors, situated on the anterior or nondependent wall, may produce a double ring image with the outer ring delineating the edge of the tumor and the inner ring indicating the edge of the ulcer.

55. gastric carcinoma B3: ulcerating and infiltrating the B3 tumors are usually large and barium will reveal not only a filling defect but also rigidity of the gastric wall extending beyond the ulcer crater, due to the diffuse tumoural infiltration. compression radiographs reveal an ulceration with irregular borders and a surrounding radiolucent defect. The mass may be more prominent than the ulcer.

57. gastric carcinoma B4: diffuse infiltrating Called scirrhous tumours or linitis plastia, are diffusely infiltrating lesions involving the prepyloric or the whole stomach. They are characterised by a reduction and deformity of gastric lumen associated with a loss of pliability of the walls and a nodular or ulcerated pattern of the mucosa.

59. gastric carcinoma CT : used for staging of gastric carcinoma. 1.Appropriate CT study can be better performed following adequate distension of the stomach with air or water as a contrast medium. 2.Intravenous administration of an spasmolyticum as well as a iodinated contrast approximately 80%. 3.CT is best suited for detecting liver and peritoneal metastases.

63. Benign ulcers A smooth ulcer mound with tapering edges An edematous ulcer collar with overhanging mucosal edges An ulcer projecting beyond the expected lumen Radiating folds extending to the crater Depth of ulcer greater than width An ulcer within the lumen of the stomach Eccentrically located within the tumor mound A shallow ulcer with a width greater than depth Nodular, rolled, irregular, shouldered edges Carmen meniscus sign (describes a large flat- based ulcer with heaped-up edges that fold inward to trap a lens-shaped barium collection that is convex toward the lumen) Malignant ulcers

64. Intestinal diseases

65. Colorectal carcinoma pathology 1.Colorectal carcinoma is a malignant tumor arising from the colorectal epithelium. 2.The large majority of colorectal carcinomas are adenocarcinomas. 3.The most common gross appearance of colon carcinoma is either polypoid or annular. 4.Polypoid carcinomas are preferentially located in the caecum, the ascending colon and the rectum whereas annular and ulcerating lesions are more frequently seen in the tranverse, descending and sigmoid colon.

66. Colorectal carcinoma causes fibre deficiency; increased fat intake; increased consumption of beef;

67. Signs and symptoms - Change in bowel habits –Blood or mucus in stools –Abdominal or rectal pain –Weight loss –Anemia –Obstruction

68. Colorectal carcinoma x-ray appearances  on barium contrast studies, polypoid carcinomas are visible as a lobulated filling defect of variable size with a contour deformity along one margin of the bowel.  annular tumors show deformation of both margins with lumen narrowing.  there is an abrupt transition between the tumor, where the mucosa is no longer visible and the normal aspect of the adjacent mucosa. This leads to a typical appearance of an “ apple core ” or an overhanging edge, called “ the tumor shoulder ”.

74. Colorectal carcinoma CT  CT is able to display colon wall thickening as suggestive for colorectal carcinoma on routine abdominal scans but this method is mainly useful staging of colorectal carcinoma.  recently three-dimensional visualizaion of the colon, also called virtual (imitative) coloscopy, based on spiral CT, has become available.