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Radiography of the GI System Chapter 17. Anatomy Of Digestive System Alimentary Canal Alimentary Canal Mouth Mouth Pharynx Pharynx Esophagus Esophagus.

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Presentation on theme: "Radiography of the GI System Chapter 17. Anatomy Of Digestive System Alimentary Canal Alimentary Canal Mouth Mouth Pharynx Pharynx Esophagus Esophagus."— Presentation transcript:

1 Radiography of the GI System Chapter 17

2 Anatomy Of Digestive System Alimentary Canal Alimentary Canal Mouth Mouth Pharynx Pharynx Esophagus Esophagus Stomach Stomach Small / Large Intestine Small / Large Intestine

3 Anatomy Of Digestive System Accessory glands Accessory glands Liver Liver Gallbladder Gallbladder Salivary glands Salivary glands Pancreas Pancreas

4 Esophagus Long muscular tube carries food and saliva from laryngopharynx to stomach Long muscular tube carries food and saliva from laryngopharynx to stomach Approximately 10 in. long in adult Approximately 10 in. long in adult Lies in midsagittal plane Lies in midsagittal plane

5 Esophagus Originates around C-6 Originates around C-6 In thorax, it is anterior to spine, posterior to trachea and heart In thorax, it is anterior to spine, posterior to trachea and heart Passes through diaphragm through esophageal hiatus Passes through diaphragm through esophageal hiatus

6 Esophagus Inferior to diaphragm curves sharply left Inferior to diaphragm curves sharply left Increases in diameter Increases in diameter Joins stomach at esophagogastric junction Joins stomach at esophagogastric junction At level of xyphoid tip At level of xyphoid tip 4 layers of the esophagus 4 layers of the esophagus Outermost - fibrous Outermost - fibrous Muscular Muscular Submucosal Submucosal Innermost - Mucosal Innermost - Mucosal

7 Stomach Dilated saclike portion of digestive tract Dilated saclike portion of digestive tract Composed of same 4 layers as esophagus Composed of same 4 layers as esophagus Outermost - fibrous Outermost - fibrous Muscular Muscular Submucosal Submucosal Innermost - Mucosal Innermost - Mucosal

8 Stomach (cont’d) Divided into 4 parts Divided into 4 parts Cardia Cardia Fundus Fundus Body Body Pyloric portion Pyloric portion Entrance to stomach is cardiac orifice Entrance to stomach is cardiac orifice Controlled by cardiac sphincter Controlled by cardiac sphincter Exit is the pyloric orifice Exit is the pyloric orifice Controlled by pyloric sphincter Controlled by pyloric sphincter

9 Stomach (cont’d) Body Body Begins at cardiac notch Begins at cardiac notch Contains rugae Contains rugae Terminates at angular notch Terminates at angular notch Pyloric portion Pyloric portion Consists of pyloric antrum and canal Consists of pyloric antrum and canal (antrum: cavity or chamber) (antrum: cavity or chamber)

10 Body Habitus - Effect On Positioning Hypersthenic Hypersthenic Horizontal and superior Horizontal and superior Dependent portion above umbilicus Dependent portion above umbilicus Asthenic Asthenic Vertical and inferior Vertical and inferior Sthenic Sthenic Generally found between xyphoid process and iliac crest Generally found between xyphoid process and iliac crest

11 Functions Of Stomach Breaks down food chemically Breaks down food chemically Broken down material is called? Broken down material is called? chyme chyme A storage area for further digestion A storage area for further digestion

12 Small Intestine Extends from pyloric sphincter to ileocecal valve Extends from pyloric sphincter to ileocecal valve Joins large intestine at right angle Joins large intestine at right angle Digestion and absorption of food occur in small intestine Digestion and absorption of food occur in small intestine Approximately __ feet in length in adult Approximately __ feet in length in adult 22 22

13 Small Intestine Contains same four layers as stomach and esophagus Contains same four layers as stomach and esophagus Mucosa contains projections called villi to facilitate digestion and absorption Mucosa contains projections called villi to facilitate digestion and absorption Divided into 3 parts: Divided into 3 parts: Duodenum Duodenum Jejunum Jejunum Ileum Ileum

14 Duodenum inches in length inches in length Widest portion of small intestine Widest portion of small intestine Follows a C-shaped course Follows a C-shaped course Contains 4 regions Contains 4 regions Superior, descending, horizontal, ascending Superior, descending, horizontal, ascending

15 Jejunum And Ileum Jejunum Jejunum Upper remaining 2/5 of small bowel Upper remaining 2/5 of small bowel Ileum Ileum Terminates at ileocecal valve Terminates at ileocecal valve Both are gathered into freely movable loops (gyri) Both are gathered into freely movable loops (gyri) Attached to posterior abdominal wall by mesentary Attached to posterior abdominal wall by mesentary (the double layer of peritoneum) (the double layer of peritoneum)

16 Valvulae conniventes Muscular bands encircling small bowel usually seen to traverse bowel wall at right angles to long axis of the bowel

17 Large Intestine What is the main purpose? What is the main purpose? Reabsorbs fluids and eliminate waste products Reabsorbs fluids and eliminate waste products About _____ feet in length in adult About _____ feet in length in adult 5 Greater in diameter than small intestine Greater in diameter than small intestine Contains same four layers as esophagus, small intestine, and stomach Contains same four layers as esophagus, small intestine, and stomach Which are? Which are?

18 Portions Of Large Intestine Cecum Cecum Ascending Ascending Joins transverse colon at right colic flexure Joins transverse colon at right colic flexure Transverse Transverse Descending Descending Joins transverse colon at left colic flexure Joins transverse colon at left colic flexure Sigmoid Sigmoid Rectum Rectum Anal canal Anal canal

19 Large Intestine The muscular portion contains external bands of muscle known as taeniae coli The muscular portion contains external bands of muscle known as taeniae coli These bands create a series of pouches known as? These bands create a series of pouches known as? haustra haustra

20 Compare Haustra Large bowel Valvulae conniventes Small bowel

21 Variations In Body Habitus Hypersthenic Hypersthenic Colon lies in periphery of abdomen Colon lies in periphery of abdomen May need double films! May need double films! Asthenic Asthenic Intestines are bunched together in lower abdomen Intestines are bunched together in lower abdomen

22 Radiographic Exams

23 Contrast Media Barium sulfate Barium sulfate Water insoluble Water insoluble Iodinated contrast media Iodinated contrast media Water soluble Water soluble Horrible taste Horrible taste Does not adhere to wall of alimentary tract Does not adhere to wall of alimentary tract Indicated in case of perforation Indicated in case of perforation

24 Contrast Media Air Air Considered a negative contrast Considered a negative contrast Generally administered by carbon dioxide crystal ingestion Generally administered by carbon dioxide crystal ingestion Barium and Air are often used as a double contrast agent Barium and Air are often used as a double contrast agent

25 Preparing pt. for GI study Have contrast agents mixed and ready to go Have contrast agents mixed and ready to go Explain exam to pt. Explain exam to pt. Ensure pt. has followed preparation instructions! Ensure pt. has followed preparation instructions!

26 Ensure that footboard is securely on table! Use short exposure times Use high kVp to penetrate barium Take exposures end of full expiration! Preparation cont’d

27 Radiography Of Esophagus Can use double or single contrast Can use double or single contrast Barium should flow to sufficiently coat esophagus Barium should flow to sufficiently coat esophagus Can be done upright or recumbent Can be done upright or recumbent Exam will usually be started with fluoroscopy Exam will usually be started with fluoroscopy

28 AP or PA Projection Pt. supine or prone Pt. supine or prone Center midsagittal plane to cassette Center midsagittal plane to cassette Bottom of cassette should be placed just below tip of xyphoid Bottom of cassette should be placed just below tip of xyphoid Pt. drinks contrast before exposure and continues drinking during exposure Pt. drinks contrast before exposure and continues drinking during exposure Shield! Shield!

29 RAO or LAO Positions Pt should be rotated degrees Pt should be rotated degrees Center about 2 inches lateral to MSP Center about 2 inches lateral to MSP Bottom of cassette below xyphoid Bottom of cassette below xyphoid

30 RAO or LAO Positions Pt must drink before and during exposure Use shielding!

31 Lateral Projection Place pt in lateral position Place pt in lateral position Center midcoronal plane to cassette Center midcoronal plane to cassette Bottom of cassette below xyphoid process Bottom of cassette below xyphoid process Pt must drink continuously before and during exposure Pt must drink continuously before and during exposure Use shielding! Use shielding!

32 Structures Shown/Film Evaluation Entire barium filled esophagus from lower neck to stomach Entire barium filled esophagus from lower neck to stomach Barium should be sufficiently penetrated Barium should be sufficiently penetrated Surrounding structures should be visible, not overpenetrated Surrounding structures should be visible, not overpenetrated No rotation on AP, PA, or lateral projections No rotation on AP, PA, or lateral projections Esophagus should be displayed between heart and spine on oblique projections Esophagus should be displayed between heart and spine on oblique projections

33 What is the Valsalva Maneuver? Useful in demonstrating esophageal varices Useful in demonstrating esophageal varices Have pt. first deeply inspire Have pt. first deeply inspire Swallow contrast Swallow contrast Bear down Bear down Recumbent position Recumbent position

34 Esophageal varices Extremely dilated sub- mucosal veins in the lower esophagus Most often a consequence of portal hypertension, commonly due to cirrhosis Pts with esophageal varices have a strong tendency to develop bleeding

35 Radiography Of The Stomach Upper GI Series Generally consists of fluoroscopy and serial radiographs Generally consists of fluoroscopy and serial radiographs Single or double contrast Single or double contrast Pt. should follow a low residue diet for 2 days prior to exam Pt. should follow a low residue diet for 2 days prior to exam Pt. must be NPO after midnight Pt. must be NPO after midnight AP scout generally obtained prior to exam AP scout generally obtained prior to exam

36 UGI Positioning - AP Projection Position Position Supine Supine CR CR MSP at L1-L2 MSP at L1-L2 Between MSP and left side if using small film Between MSP and left side if using small film At MSP if using 14 X 17 At MSP if using 14 X 17 Structures Structures Barium filled fundic portion Barium filled fundic portion Hiatal hernias, if present Hiatal hernias, if present

37 Single v. Double Contrast Single Contrast Single Contrast Shows size, shape, and position of stomach Shows size, shape, and position of stomach Examines changing contour of stomach during peristalsis Examines changing contour of stomach during peristalsis Observe filling and emptying of duodenal bulb Observe filling and emptying of duodenal bulb

38 Double Contrast Mucosal lining is well visualized Mucosal lining is well visualized Small lesions are less easily obscured Small lesions are less easily obscured

39 Compare Single and Double Contrast

40 Which is taken AP and which is taken PA?

41 UGI Study - PA Projection Prone Position Prone Position Center at MSP if using 14 X 17 Center at MSP if using 14 X 17 CR CR Perpendicular to plane of film at level of L1- L2 Perpendicular to plane of film at level of L1- L2

42 UGI study - PA Projection Structures shown? Size, shape, and relative position of stomach Evaluation: All pertinent anatomy No rotation Exposure sufficient to penetrate barium Surrounding structures visible

43 UGI Positioning - PA Oblique Projection Position Position Recumbent Recumbent Body rotated degrees Body rotated degrees Hypersthenic patients require more rotation Hypersthenic patients require more rotation CR CR Perpendicular to L1-L2 Perpendicular to L1-L2 Between vertebral column and elevated lateral border of the abdomen Between vertebral column and elevated lateral border of the abdomen

44 UGI Positioning - PA Oblique Projection Structures Structures Entire duodenal loop Entire duodenal loop Best image of pyloric canal and duodenal bulb Best image of pyloric canal and duodenal bulb Evaluation Evaluation All pertinent anatomy All pertinent anatomy No superimposition of pylorus and duodenal bulb No superimposition of pylorus and duodenal bulb Duodenal bulb and loop in profile Duodenal bulb and loop in profile

45 UGI Positioning - AP Oblique Projection Position Position Supine Supine Right side elevated degrees Right side elevated degrees Average about 45 degrees Average about 45 degrees CR CR Between vertebral column and left lateral border at L1-L2 Between vertebral column and left lateral border at L1-L2 Structures Structures Fundic portion of stomach filled with barium Fundic portion of stomach filled with barium Evaluation Evaluation All pertinent anatomy All pertinent anatomy No superimposition of pylorus and duodenal bulb No superimposition of pylorus and duodenal bulb Barium filled fundus Barium filled fundus

46 Lateral Projection Position Position Lateral recumbent - right side Lateral recumbent - right side CR CR Level of L1-L2 Level of L1-L2 Between midcoronal and anterior of abdomen Between midcoronal and anterior of abdomen

47 Lateral Projection Structures Structures Pyloric canal and duodenal bulb in hypersthenic patients Pyloric canal and duodenal bulb in hypersthenic patients Evaluation Evaluation No rotation No rotation All pertinent anatomy All pertinent anatomy

48 Small Bowel Follow Through Preparation Preparation Low residue diet for 2 days prior when possible Low residue diet for 2 days prior when possible NPO after midnight before exam NPO after midnight before exam Examination Procedure Examination Procedure Scout film obtained Scout film obtained Patient drinks barium Patient drinks barium Images obtained in prone or supine position Images obtained in prone or supine position Images begin 15 minutes after barium ingested Images begin 15 minutes after barium ingested Barium usually reaches ileocecal valve in about 2 -3 hours Barium usually reaches ileocecal valve in about 2 -3 hours

49 Radiography Of Small Intestine Contrast administration 3 Ways Contrast administration 3 Ways Orally Orally Retrograde Retrograde Reflux filling via barium enema Reflux filling via barium enema Direct injection of contrast through NG tube Direct injection of contrast through NG tube Enteroclysis ( Radiocontrast is infused through tube inserted through nose to duodenum, and images are taken in real time as contrast moves through) Enteroclysis ( Radiocontrast is infused through tube inserted through nose to duodenum, and images are taken in real time as contrast moves through)

50 Small Bowel - AP/PA Projection Patient supine or prone Patient supine or prone CR centered to level of L2 for early films CR centered to level of L2 for early films Iliac crest for later films Iliac crest for later films Continue taking radiographs until barium reaches terminal ileum Continue taking radiographs until barium reaches terminal ileum Fluoroscopic spot films may be taken of terminal ileum Fluoroscopic spot films may be taken of terminal ileum

51 Immediate 15 minutes Small Intestine Follow Through

52 30 minutes 1 hour

53 T.I. Demonstrates Ileocecal Valve

54 Radiography Of Colon

55 Preparation of Colon Pt must take laxative on day prior to exam Pt must take laxative on day prior to exam Pt may have clear liquid day prior to exam Pt may have clear liquid day prior to exam NPO after midnight NPO after midnight Cleansing enemas may also be indicated Cleansing enemas may also be indicated

56 Pt. Preparation Explain exam fully to pt. Explain exam fully to pt. Use care when inserting enema tip! Use care when inserting enema tip! Retention-type balloon tips should only be inflated under fluoroscopic control Retention-type balloon tips should only be inflated under fluoroscopic control Barium should only be administered under fluoroscopic control by radiologist Barium should only be administered under fluoroscopic control by radiologist

57 Single or double contrast Single demonstrates anatomy and tonus (contraction) of colon, along with most abnormalities Single demonstrates anatomy and tonus (contraction) of colon, along with most abnormalities Feces

58 Double Contrast Double allows visualization of lumen along with any polyps or lesions Double allows visualization of lumen along with any polyps or lesions

59 AP Projection - Barium Enema Supine Supine MSP centered to cassette MSP centered to cassette CR at iliac crest CR at iliac crest Entire colon must be included Entire colon must be included Two cassettes are sometimes necessary Two cassettes are sometimes necessary

60 PA Projection - Barium Enema Pt. prone Pt. prone MSP centered to film MSP centered to film CR at iliac crest CR at iliac crest Entire colon must be visualized Entire colon must be visualized Barium should be sufficiently penetrated with surrounding structures visible Barium should be sufficiently penetrated with surrounding structures visible

61 PA Axial Projection - BE Pt. prone Pt. prone MSP centered to IR MSP centered to IR CR directed degrees caudal to ASIS CR directed degrees caudal to ASIS Demonstrates rectosigmoid area of colon Demonstrates rectosigmoid area of colon Area must be centered to IR Area must be centered to IR

62 PA Axial Projection - BE

63 AP Oblique Projection - BE Pt. Supine Pt. Supine Body rotated degrees Body rotated degrees CR in. lateral to midline at iliac crest CR in. lateral to midline at iliac crest

64 AP Oblique Projection - BE LPO - Right colic flexure, ascending and sigmoid portions of colon RPO - Left colic flexure, descending colon Must demonstrate entire colon Which oblique is this?

65 PA Oblique Projection (RAO)- Barium Enema Pt. prone Pt. prone Left side elevated degrees Left side elevated degrees CR at iliac crest, 1 -2 inches lateral to midline of body CR at iliac crest, 1 -2 inches lateral to midline of body

66 PA Oblique Projection (RAO)- Barium Enema Best demonstrates hepatic flexure Best demonstrates hepatic flexure Ascending and sigmoid portion Ascending and sigmoid portion Entire colon must be visualized Entire colon must be visualized What projection is this similar to? What projection is this similar to?

67 PA Oblique (LAO) - BE Pt. prone Pt. prone Right side elevated degrees Right side elevated degrees CR to iliac crest, inches lateral to midline CR to iliac crest, inches lateral to midline

68 PA Oblique (LAO) - BE Demonstrates descending portion of colon Demonstrates descending portion of colon Entire colon must be visualized Entire colon must be visualized What flexture doe this best demonstrate? What flexture doe this best demonstrate? (splenic) (splenic) What projection is it comparable to? What projection is it comparable to?

69 Lateral Projection - Barium Enema Lt. or Rt. lateral recumbent position Lt. or Rt. lateral recumbent position Center midcoronal plane to film Center midcoronal plane to film CR enters midcoronal plane at level of ASIS CR enters midcoronal plane at level of ASIS

70 Lateral Projection - Barium Enema Best demonstrates rectum and distal sigmoid portions of colon Rectosigmoid area should be centered, no rotation

71 Lateral Decubitus Positions - BE AP or PA projection AP or PA projection

72 Left Lateral Decubitus Positions - BE Up side is air-filled Up side is air-filled Must include entire colon Must include entire colon Air-filled portion must not be overpenetrated Air-filled portion must not be overpenetrated

73 Upright Position - Barium Enema Demonstrates air-filled flexures and transverse colon Demonstrates air-filled flexures and transverse colon

74 Chassard Lapine’ Demonstrates rectum, rectosigmoid juntion and sigmoid

75 Radiographic exam of defecation process under fluoroscopy Used to evaluate disorders of lower bowel not evident by tests such as colonoscopy or sigmoidoscopy What is a Defecography? (evacuation proctography)

76 Defecation (Having a bowel movement) is a complex action requiring coordination with relaxation and contraction of a large number of muscles Controlled by nervous system, but is also under voluntary control.

77 Defecation cont’d Process is initiated by arrival of stool into rectum This sensation leads to chain of events which ends in evacuation of stool from anus Defecation is voluntarily controlled in healthy, normally functioning people.

78 Defecography is used to Evaluate: Chronic Constipation Rectal prolapse ( walls of rectum protrude through anus and become visible outside body)rectumanus Rectocele (outpouching of rectum) Fecal incontinence Anismus (inappropriate spasm of anal sphincter)

79 Defecography A thickened barium contrast putty is injected into rectum then excreted by patient while radiologist watches and videotapes


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