GI imaging related to Endoscopy

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GI imaging related to Endoscopy

• Nicola Bartholomew
• Faculty of Health

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Learning Objectives

• This session will provide you with an
  appreciation of a range of diagnostic imaging
  tests used to evaluate the GI tract

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Symptoms of Bowel Disorders

• General malaise, weight loss, vomiting, anaemia
• Abdominal pain, distension
• Bowel habit altered frequency, constipation,
  diarrhoea, bleeding, mucus
• Anal perineal pruritis, tenesmus, discharge

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Investigations

• Abdominal examination
• Anorectal examination digital exam
• proctoscopy
• Plain films
• U/S
• Endoscopy
• Fluoroscopy
• CT

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Plain Films
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AXR

• Acute abdominal conditions
• Rule out obstruction (small or large bowel)
• Rule out perforation

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Large bowel Obstruction
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Sigmoid Volvulus
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Perforation
Pneumoperitoneum
Free air beneath diaphragm
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Endoscopy

• Visual examination of the interior of a hollow
  organ by the use of a fibre optic endoscope

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Enteroscopy

• Endoscopic examination of the small intestine
• Very long, flexible scopes
• Long procedure

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Capsule Endoscopy

• Tiny capsule contains camera
• Journeys through bowel
• Transmits signals later downloaded as images
• Detects bleeding source
• in 31 76 patients

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snare
Pedunculated polyp
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Fluoroscopic Imaging

• Fluoroscopy is a study of moving structures
• Continuous x-ray beam passed through body
• Transmitted to TV monitor
• Contrast agent required

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The need for Contrast Agents
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Contrast agents

• Barium Sulphate
• Water soluble non-ionic contrast
• Gadolinium for MRI (alter magnetic properties of
  hydrogen nucleii

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Fluoroscopy Unit
Image on monitor
Image intensifier
Table houses X-ray tube
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Oesophagus and Stomach

• Barium swallow oesophagus
• Barium meal - stomach

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Gastric Ca
Oesophageal fistula
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Gastroscopy

• May be undertaken with
• or without sedation
• Air filled stomach
• Demonstrates mucosa
• Option for biopsy

Stomach ulcer
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ERCP

• Endoscopic Retrograde CholedochoPancreatogram
• A method to evaluate the biliary tree and
  pancreatic ducts by endoscopic retrograde
  cannulation of the ampulla of Vater

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Small Bowel

• Continuous with stomach at pyloric sphincter
• Leads into large intestine at ileo-caecal valve
• 5 metres
• Duodenum, jejunum, ileum
• Barium follow through
• Small bowel enema

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Barium follow through

• Diagnosis of Crohns or tumour
• Nil by mouth prior to exam
• Metachlopramide
• Barium suspension swallowed
• Images taken at 20 min intervals

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Small Bowel Enema (Enteroclysis)

• Used in addition to or instead of Follow Through
• Usually ? Crohns, Coeliac disease
• Pain, diarrhoea, malabsorption
• SBE catheter inserted via nose to duodenal /
  jejunal flexure
• Local anaesthetic spay into nose and throat
• Barium methyl cellulose

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SBE
MRI
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Large Bowel Studies
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Sigmoidoscopy
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Sigmoidoscopy

• Performed in OP clinics
• Investigates last 2 ft of large bowel
• Rigid sigmoidoscope 10 inches long
• Flexible sigmoidoscope
• 2 feet long , fibre optics
• more complete examination
• more comfortable
• Biopsy

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Technique

• Low residue diet and laxative enema to clear
  bowel
• Lies on left side , knees drawn up to chest
• Digital exam check for blockage
• Lubricated sigmoidoscope inserted into rectum
• Air introduced via scope to inflate bowel
• Suction removes liquid stool, blood, mucus
• Side effects abdominal cramps, bloating,
  bleeding
• perforation risk 1 in 5000

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Colonoscopy

• Gold standard investigation
• Demonstrates entire large bowel and
  interventional
• (limitations due to user error and pathology)
• Flexible fibre optic tube
• Sedative and analgesia administered
• Reactions to sedative
• Not well tolerated by patient and expensive

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Colon Anatomy
CIRCULAR MUSCLE
MUCOSA
SEROSA
SUBMUCOSA
LONGITUDINAL MUSCLE
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Double Contrast Barium Enema

• Complements endoscopic imaging
• Two contrast media are used barium sulphate
  suspension and air.
• Barium white
• Air - black

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Barium enema bag
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Method

• Patient preparation low residue diet, laxative
• Rectal intubation with balloon catheter
• Anti spasmodic agents
• 400ml barium sulphate solution introduced
• Drained out
• Air introduced to inflate colon
• Images taken under fluoroscopic control

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Images
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Side effects

• Abdominal cramps
• Constipation
• Side effects due to antispasmodics
• blurred vision
• dry mouth
• nausea, vomiting
• Small risk of perforation lt1 in 5,000

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Comparison

• Sigmoidoscopy limited study, good definition of
  sigmoid. Interventional. 95 sensitivity
• Barium Enema complete study, sometimes poor
  definition of sigmoid area. Purely diagnostic.
  90 sensitivity
• Limitations due to pathology user experience

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BaE Benefits Risks

• 94 100 sensitivity for polypsgt1cm
• Cheap and available
• Perforation risk 1 in 1000
• Major haemorrhage 1/3000
• Death 1-3/10,000

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Complicated Diverticular Disease

• Formation of
• Strictures
• Abscesses
• Fistulas

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Pathology

• Diverticular disease
• Inflammatory bowel disease
• Polyps
• Colorectal cancer

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Diverticular Disease
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Colo-vaginal fistula
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Colovesical Fistula
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Inflammatory Bowel Disease
Crohns disease
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Ulcerative colitis
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Colorectal Polyps
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Colorectal Cancer

• Peak incidence between 70 80 years
• 2nd highest cause of cancer death
• Prevalent in highly developed countries
• Diet related
• Most colorectal cancers arise from adenomas
• Appear as polypoid, ulcerating or stenosing
  lesions

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Colorectal Cancer
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National Screening Programme

• 35 000 diagnosed with CRC in UK each year
• 2nd common cause of cancer death in UK
• April 2006
• Men and women 60 - 69 yrs
• Faecal Occult Blood test

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Single Contrast Enema

• Indicated for
• Uncooperative/immobile patients
• Unprepared patients
• Acute obstruction
• Assesses anatomy and excludes gross pathology
• Perforation water soluble enema

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Computed Tomography

• Staging tool for colorectal cancer
• Evaluates extension of tumour through bowel wall
• Metastatic spread
• Developing as a diagnostic tool

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Liver metastasis
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CT pneumocolon
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Virtual Colonoscopy
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Benefits of CT compared with BE

• Minimally invasive
• Lower risk of perforation
• Shorter exam time
• No sedation
• Cheaper
• However less sensitive

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MRI

• Gadolinium enhanced MRI
• Comparable to colonoscopy for diagnosis
• (92 v 98)
• Better specificity than CT
• No radiation dose

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PET Scanning

• Positron Emission Tomography
• Physiological images
• Detects radiation emitted from radioactive
  substance
• Different colours / brightness on image
  represents function
• Detects disease in earliest stages
• Requires normal chemical balance

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Ultrasound

• a method of obtaining images of internal organs
  by sending high-frequency sound waves into the
  body. The reflected soundwaves' echoes are
  recorded and displayed as a real-time, visual
  image.

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Anorectal Ultrasound

• Used for staging of rectal carcinomas and
  post-radiation assessment
• Assesses invasion of cancer through bowel wall
• No radiation dose

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The end