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Investigations in Stomach and Duodenum Dr Bina Ravi MS,MNAMS,FICS LHMC, New Delhi.

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Presentation on theme: "Investigations in Stomach and Duodenum Dr Bina Ravi MS,MNAMS,FICS LHMC, New Delhi."— Presentation transcript:

1 Investigations in Stomach and Duodenum Dr Bina Ravi MS,MNAMS,FICS LHMC, New Delhi

2 Investigations Functional Bacteriological Biochemical Morphological

3 Functional Gastric Secretory test → pH monitoring, BAO, MAO, Plasma gastrin studies Gastric Emptying studies → Ba meal, Bile reflux (HIDA), Gastric barostat, MRI motility

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6 Recurrent Ulcer Stomal ulcer Incomplete vagotomy – Gastric analysis, Sham feeding – Cephalic phase Retained antrum – ZES – BAO + MAO, Secretin, Secretin stimulation Post operative NSAIDs use

7 ZES Duodenal tumors – 50% BAO – > 15 meq / hr N. Fasting Gastrin - < 150 pg/ml Gastrin provocative test – Secretin / Ca IV - > 200 pg/ ml at 15 mts Endoscopy, EUS, CT, Laparoscopy SASI, Octreoscan – Sensitivity / Specificity > 75%

8 Bacteriological H. pylori Invasive →Endo. Bx, histology, culture,80-95% Sensitivity, %Specificity Non invasive →Serologic, urea breath test, fecal H. pylori antigen test H. pylori Negative → screen for Aspirin, NSAIDS levels in blood and urine

9 Morphological Bleeding Acute - DU, GU, Varix, Mallory Weiss, vascular ectasia – Dieulafoys disease Chronic - DU, GU, Tumor- stomach, periampullary

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11 Biochemical Tumor Markers CEA ▲ in 1/3 patients ≈ stage CEA + Ca 19-9 or CA 50 ↑ sensitivity

12 CA Stomach : significance of tumor marker β HCG CA 125 CEA alpha fetoprotein CA 19-9, tissue staining for C - erb B 2

13 CA 125, β HCG Pre-op indicator of  aggression  tumor burden  Prognostic “Botet”

14 Diagnosis Diagnosis Auto-fluorescence Endoscopic Ultrasound Optical Coherence Tomography Virtual Biopsy

15 Endoscopy Size, location, morphology of lesion Mucosal abnormality, bleeding Proximal and distal spread of tumor Distensibility

16 Endoscopy Abnormal motility ► SM infiltration, extramural extension – vagal infiltration Bx –6 – 10 – 90% accuracy Early Ca → 0.1% indigocarmine dye test

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19 EUS EUS Good for T & N Not good for M Radial probes –7.5 or 12MHz better for Biopsy

20 T 1

21 T 2

22 T 3

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26 OCT / Virtual Biopsy Optical coherence tomography Beyond routine endoscopy Differentiates - benign and malignant, mucosal dysplasias

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29 LIFE Light Induced Fluorescence Endoscopy Early detection of dysplasias and superficial malignant lesions, in situ Ca

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34 Contrast Radiography Motility – Ba meal, hypotonic duodenography Structural changes Diagnostic accuracy: –Single – 80% –Double – 90%

35 Computed Tomography Abdomen and chest Lateral extension, Systemic mets- 75% Triphasic spiral CT – T stage, stomach filled with water Tako et al 1998 – Adv gastric Ca – 82% Early Ca – 15%

36 CT – T Staging Gastric distension Does not differentiate T1 and T2 T3 stranding in perigastric fat Does not differentiate transmural and perigastric lymphadenopathy Accuracy 80 – 88% in Advanced disease

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38 CT – N Staging Size – no predictor of involvement > 8mm sensitivity – 48%, specificity 93% Identifies distal nodes (not seen on EUS) No of involved nodes N RLN according to current TNM classification

39 CT – M Staging Liver mets – thin collimation, overlapping slides, dual phase imaging 75 – 80 % mets detected Small volume ascites – EUS and CT

40 Conventional US Good clinical evidence of liver mets When treatment options are limited – before palliation Used in conjunction with or, alternative to MRI – indeterminate lesions on CT

41 MRI T assessment – No evidence that MRI better than CT For identification of indeterminate lesions IV contrast allergy Endoluminal MR – experimental only and no advantage over EUS

42 PET FDG (fluorodeoxyglucose) 18 F Preferrential accumulation of PEG in tumour Sensitivity 60%, specificity 100%, Accuracy 94% Detects 20% missed mets on CT Differentiates: malignancy from inflammation

43 PET+CT Combo

44 PET

45 Laparoscopy Peritoneal Disease M1 – CT, EUS, Small volume ascites Routine use after CT / EUS before radical surgery Additional information than CT Complementary to CT / EUS Accuracy 84%

46 Laparoscopy US Probes III dimension in US – detects unsuspected liver and lymphnode metastases Eliminates need for laparotomy

47 Mechanism of Photo-toxicity Release of singlet oxygen S phase cells more vulnerable than G phase cells

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56 Inside Story – Wonder Pill Pill with a camera – M2 A Pictures taken at 2 frames per second Microchip in camera with 8 hour battery Receiver in the belt Ambulatory endoscopic monitoring

57 Camera Pill

58 Summary H.Pylori – Non invasive, invasive Gastric acid, Gastrin secretory studies Tumor markers – CEA, CA 19-9, EUS – Early T & N stages CT – distant metastasis

59 Summary OCT – virtual biopsy, LIFE – new methods PET – Non-invasive, physiological and biological measurement, better tissue differentiation


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