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ROLE OF IMAGING IN ACID PEPTIC DISORDERS

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ROLE OF IMAGING IN DIAGNOSIS OF ACID PEPTIC DISORDERS : 

ROLE OF IMAGING IN DIAGNOSIS OF ACID PEPTIC DISORDERS DR.M.SANTOSH KUMAR 1ST YR PG IN RADIODIAGNOSIS KIMS

ACID PEPTIC DISORDERS : 

ACID PEPTIC DISORDERS Acid peptic disorders include a number of conditions whose pathophysiology is believed to be the result of damage from acid and pepsin activity in the gastric secretions.  APD include : Oesophagitis and Oesophageal Ulcers Gastritis and Gastric Ulcers Duodenitis and Duodenal Ulcers Peptic ulcers are defects in the GI mucosa that extend through the muscularis mucosa.

PREVALENCE OF H PYLORI INFECTION WITH UPPER GI DISEASE : 

PREVALENCE OF H PYLORI INFECTION WITH UPPER GI DISEASE Disease Prevalence(%) Active chronic gastritis 100 Duodenal ulcer 95 Gastric cancer (body or antrum) 80–95 MALT lymphoma 90 Gastric ulcer 60–80 Non ulcer dyspepsia 35–60 Asymptomatic population 20–55

IMAGING MODALTIES : 

IMAGING MODALTIES PLAIN RADIOGRAPH BARIUM STUDIES:BARIUM SWALLOW BARIUM MEAL BARIUM FOLLOWTHROUGH ULTRASONOGRAPHY ENDOSCOPIC ULTRASONGRAPHY COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING RADIONUCLIDE STUDIES PET CT

GASTRO-OESOPHAGEAL REFLUX DISEASE AND PEPTIC OESOPHAGITIS : 

GASTRO-OESOPHAGEAL REFLUX DISEASE AND PEPTIC OESOPHAGITIS Incompetence of the gastro-oesophageal sphincter mechanism, which allows reflux to occur leads to complications of Peptic Ulceration Fibrosis and stricture formation. Barrett's oesophagus. INVESTIGATIONS barium swallow Radionuclide studies Endoscopy 24 hr ph study

A Scintigraphic study demonstrating grossgastro-oesophageal reflux. : 

A Scintigraphic study demonstrating grossgastro-oesophageal reflux.

Sliding hiatal hernia that demonstrates gross spontaneous gastro-oesophageal reflux : 

Sliding hiatal hernia that demonstrates gross spontaneous gastro-oesophageal reflux

Mild reflux esophagitis : 

Mild reflux esophagitis Thick nodular folds in distal esophagus

Moderate reflux esophagitis : 

Moderate reflux esophagitis Linear erosions and punctate superficial erosions present within a mildly nodular mucosal background. The esophagus is shortened, and a small hiatal hernia is present.

Severe reflux esophagitis : 

Severe reflux esophagitis Transverse folds due to chronic scarring A large, flat ulcer in the distal esophagus and a long linear ulcer with a surrounding halo edema.

Focal stricture d/t Chronic reflux esophagitis : 

Focal stricture d/t Chronic reflux esophagitis Stricture immediately above GE junction.Smooth,tapered margins

Barrett esophagus : 

Barrett esophagus Reticular pattern of esophageal mucosa Metaplasia of squamous epithelium with gastric-type adenomatous mucosa. 2 cm or more of columnar epithelium is required before the term Barrett's oesophagus is applied. 40-fold increased risk of developing a AdenoCa.

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Barrett esophagus stricture in mid esophagus near squamo adenomatous transition zone

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Polypoid esophageal adenocarcinoma Adenocarcinomas nearly always arise within Barrett esophagus and are therefore usually located in the distal esophagus.

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Nodular lesion in Barrets esophagus Endoscopy Endoscopic USG

STOMACH : 

STOMACH Histologically the stomach is composed of mucosa, submucosa, muscularis propria and serosa. Gastric mucosa is characterized by two features, the areae gastricae and the gastric rugae.The areae gastricae pattern is a fine reticular network. Barium examination remains the basic technique for radiological investigation of the stomach . (A) Double-contrast (B) Single-contrast CT is superior to barium studies for evaluation of the gastric wall and extraluminal disease.

Reticular pattern of normal areae gastricae : 

Reticular pattern of normal areae gastricae

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Abnormalities of the areae gastricae PUD : Enlarged forming a coarser pattern Gastric tumours: Focal distortion or absence of the areae gastricae pattern Diffuse atrophic gastritis: the normal areae gastricae pattern is absent.

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Gastric rugae are smooth folds that tend to parallel the long axis of the stomach and are about 3–5 mm thick on barium studies. These comprise mucosa and a portion of submucosa. Abnormal rugal folds become thicker and may be nodular and may efface the rugae. Infiltrative disease like scirrhous carcinoma Radiating folds converging to a central point are typically associated with healing gastric ulcers.

APD of STOMACH : 

APD of STOMACH Gastritis Gastric Erosions Gastric ulcers MC Cause : H.Pylori Other : NSAIDS,Alcohol, Steroid, hereditary factors, emotional stress and smoking.

Gastric Erosions : 

Gastric Erosions Gastric erosions or aphthous ulcers are shallow ulcerations that do not penetrate the muscularis mucosa. They usually appear as small, shallow collections of barium 1–2 mm in diameter surrounded by a radiolucent rim of oedema

Gastritis : 

Gastritis Diffuse erosive gastritis with thick nodular folds.

Gastric Ulcer : 

Gastric Ulcer Gastric ulcer : penetrate the stomach wall through the mucosa into the submucosa and frequently the muscularis propria. 95% are benign MC in the distal stomach and along the lesser curvature. More common on the posterior wall of the stomach than the anterior wall. LC in the fundus.

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Based on the radiographic features of an ulcer.Classified as Benign Indeterminate Malignant

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GASTRIC ULCERS Findings Benign Malignant Site Antrum Fundus Lesser curvature Greater curvature Hampton's line Present Absent Folds Smooth, even Irregular, nodular Associated mass Absent Present Carman meniscus Absent Present Ulcer shape Round, oval linear Irregular Healing Heals completly Rarely heals

Benign Ulcer : 

Benign Ulcer Posterior wall ulcer. Thin regular radiating folds converging to the ulcer Anterior wall ulcer. Unfilled ulcer crater with Ring shadow.

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Benign giant gastric ulcer >3cm. They are commonly associated with perforations.

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Hampton's line Ulcer collar

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Hampton's line : thin line of lucency at the base of the ulcer Ulcer collar : thick smooth rim of lucency at the base of the ulcer. These represent preserved gastric mucosa . This sign is not common, but is diagnostic of a benign ulcer.

MALIGNANT ULCER : 

MALIGNANT ULCER The term ‘malignant ulcer’ is used to indicate an ulcer within a gastric mass, usually a carcinoma Radiologic features of malignant Ulcers: tissue surrounding the ulcer is nodular. abrupt transition between the surrounding tissue and the normal gastric wall. crater does not project beyond the gastric wall. radiating folds stop at the edge of the surrounding tissue and do not reach the crater. crater is often wider than it is deep.

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Malignant ulcer (Gastric AdenoCa) Several abnormal folds seen adjacent to the ulcer crater. They are clubbed,fused,tapered and interuppted.

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Gastric adenocarcinoma: Carman meniscus sign.The ulcer appears as a crescent on the lesser curvature, with nodular tumor surrounding the periphery of the ulcer. This sign is pathognomonic of carcinoma.

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Gastric lymphoma (multiple submucosal masses) Multiple smooth-surfaced filling defects along the greater curvature of fundus. The stomach is the most common extranodal site for non-Hodgkin lymphoma.

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FDG PET/CT. first normal uptake of FDG by the stomach and second increased uptake in gastric lymphoma.

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Major complications of gastric ulcers include Bleeding : MC Perforation Obstruction Penetration.

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Perforated gastric ulcer

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CT :helpful for determining the extraluminal extent of disease with a known or suspected penetrating ulcer. This is helpful for preoperative planning and for assessment of possible percutaneous drainage.

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Scarred antrum with constriction at site of previous ulcer causing narrowing and deformity.

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Gastrocolic fistula due to a benign gastric ulcer. A large fistulous communication between the greater curvature of the stomach and the left transverse colon

Slide 41: 

Marginal ulcer in the efferent limb, adjacent to the gastrojejunal anastomosis, BillrothII gastroenterostomy.???? Incomplete vagotomy Retained gastric antrum ZES Hypercalcemia Smoking Ulcerogenic drug abuse

Slide 42: 

Thickened Folds D/D Benign Gastritis (Helicobacter pylori) Peptic ulcer disease Zollinger-Ellison syndrome Menetrier disease Varices Malignant Lymphoma Carcinoma Metastases

Slide 43: 

Ulcerative Lesions D/D Nonneoplastic Superficial gastric erosions Peptic or medication-induced ulcers Tumors Adenocarcinoma Gastrointestinal stromal tumor Lymphoma Metastases

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Gastric Narrowings D/D Benign Peptic scarring Corrosive ingestion Granulomatous disease (Crohndisease, sarcoidosis,tuberculosis, syphilis,eosinophilic gastroenteritis) Malignant Scirrhous adenocarcinoma Metastases Lymphoma

APD of DUODENUM : 

APD of DUODENUM Duodenitis Duodenal Ulcers Radiological Investigations Barium studies: Hypotonic duodenography Water-soluble contrast studies Ultrasound and CT are used to evaluate secondary involvement of the duodenum by malignant disease CT in assessing the extent of duodenal neoplasms

DUODENITIS : 

DUODENITIS Multiple thick and nodular folds in the 1st and 2nd parts of duodenum. MC cause is PUD d/t H.Pylori

Duodenal Ulcers : 

Duodenal Ulcers More common than gastric ulcers M>F MC cause : H.Pylori infection Other: stress, smoking, alcohol, caffeine, steroids MC site: anterior surface of duodenum within the bulb. Rarely malignant. Multiple duodenal ulcers in 10% to 15% The presence of multiple postbulbar ulcers suggest Zollinger-Ellison syndrome.

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A persistent, round ulcer crater in the duodenal bulb. Folds radiate up to the crater.

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Postbulbar duodenal ulcer

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Thickened Folds D/D Benign Peptic disease Zollinger-Ellison syndrome Brunner gland hyperplasia Pancreatitis Crohn disease Adult celiac disease Whipple disease Hematoma Cystic fibrosis Malignant Lymphoma

Slide 51: 

Duodenal Narrowing D/D Benign Peptic ulcer disease Pancreatitis Crohn disease Hematoma Superior mesenteric artery syndrome Annular pancreas Malignant Adenocarcinoma Lymphoma Malignant gastrointestinal stromal tumor Metastases

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The principal complications of duodenal ulceration are Perforation : MC Bleeding Stenosis and Penetration of adjacent organs.

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Perforated duodenal bulb ulcer with extravasation of oral contrast material into the peritoneal space

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The duodenal bulb is deformed and resembles a cloverleaf. This is the classic appearance of duodenal bulb scarring from a peptic ulcer

Zollinger-Ellison syndrome : 

Zollinger-Ellison syndrome This syndrome is caused by Gastrinoma (nonbeta islet cell tumours) Gastrin Hypersecretion of HCL Multiple ulcers(intractable) and thickend gastric folds 75 % of the tumours are in pancreas 15 % in the duodenum. 10 % extraintestinal 50%------are malignant and metastatise to liver and regional lymph nodes 25% -----Assosiated with MEN 1 syndrome

Slide 57: 

Imaging of choice in ZES is somatostatin-receptor scintigraphy (SRS). USG, MRI, and CT scans are all limited by low sensitivity; small primary lesions can be easily missed by these imaging tests

ZES : 

ZES The gastric wall and rugal folds are markedly thickened. A benign ulcer along the lesser curvature.ZES

Slide 60: 

CECT Abdomen shows multiple mets in liver in a case of ZES

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ZES : octreotide anterior scintigram shows abnormal uptake in the head of the pancreas.

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MRI :lesion in head pancreas gastrinoma

SUMMARY : 

SUMMARY PLAIN RADIOGRAPH: Role in diagnosing early perforation of peptic ulcers. BARIUM STUDIES: In differentiating benign ulcer from malignant ulcer. In diagnosing stricture and stenosis like complications of PUD. MRI, CT ,USG:useful in assessing for the complications of peptic ulcer disease: abscess, fistula, and pancreatitis. No primary role in the diagnosis of peptic ulcers.

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FDG PET/CT :Role in diagnosing neoplasms Currently used for staging and restaging of gastric malignancies as well as following response to therapy. SOMATOSTATIN RECEPTOR SCINTIGRAPHY Combined with ENDOSCOPIC USG Highly sensitive and specific in localisation of primary tumors and mets in ZES. ENDOSCOPIC USG is an accurate procedure for T and N staging of tumours of the oesophagus and gastro-oesophageal junction.

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THANK YOU

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