curs digestiv bft
TRANSCRIPT
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Radiodiagnosticul aparatului digestiv
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Examenul radiologic constituie una dintre cele mai valoroase metode de examen al tubului digestiv si a devenit indispensabil pentru diagnosticul pozitiv si orientarea tratamentului in afectiunile acestuia. El poate evidentia atat modificari functionale, cat si morfologice, precizand sediul si natura leziunii si permitand urmarirea evolutiei in timp a procesului patologic.
Tehnici de examinare:• Radioscopia abdominala “pe gol”;
• Radioscopia cu suspensie baritata administrata peroral;
• Irigoscopia si irigografia;
• Examenul cu dublu contrast;
• Tomografia computerizata;
• Rezonanta magnetica nucleara.
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Radiologia clinica a esofagului
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Explorari imagistice:
Radiografie toracica F +P: - corpi straini radioopaci, spatiul prevertebral, linii mediastinale,nivel hidro-aeric mediastinal;
Examinarea cu substanta de contrast: - suspensie de sulfat de Bariu: contrast simplu, dublu contrast; - evaluare functionala si anatomica; - fluoroscopie + filme tintite; - inregistrare “cine”/video; OAD, OAS, F, P; - contrast hidrosolubil: perforatie, fistula, post-operator;Examinarea computer-tomografica: - stadierea cancerului esofagian + extensia regionala; - recurenta tumorala dupa esofagectomie;Eco-endoscopia esofagiana;Examinarea prin rezonanta magnetica;
Semiologia modificarilor morfologice esofagiene - rigiditatea parietala; - stenoza (ingustarea) lumenului esofagian; - imaginea lacunara; - imaginea de aditie;
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ESOFAG BARITAT:ASPECTE NORMALE
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Corpi straini esofagieni - radioopaci/radiotransparenti;Radioopaci: rdgf. simple;Radiotransparenti: examinare cu contrast; - sediu (stramtori fiziologice); - modificari functionale esofagiene;Complicatii: perforatia esofagului: - bule aerice de-a lungul peretelui posterior al esofagului cervical - emfizem subcutanat;
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ESOFAG:CORPI STRAINI OPACI
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ESOFAG:CORPI STRAINI. A)capac sticla B)carne
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Tulburari functionale esofagiene:Etiologie:Primitive: - achalazia cardiei, spasmul difuz esofagian, chalazia;Secundare: - esofagita peptica/caustica; - afectare neurologica; - bolile tesutului conjunctiv; - boli metabolice, infectioase; - cancerul esofagian (obstructie, invazie nervoasa);
Diskinezii esofagiene extra-sfincterieneUnde peristaltice secundare: - propagare ascendenta din 1/3 inferioara a esofagului;Spasm difuz esofagian:Clinic: dureri “anginoase” + disfagie intemitenta;Examen baritat: - contractii non-propulsive: “segmentarea” lumenului; - esofag “in tirbuson”;
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DISKINEZIE ESOFAGIANA: pseudodiverticuli Barsony
Inel SCHATSKI
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Achalazia - absenta/relaxare insuficienta SEI; - lipsa concordantei peristaltica esofagiana/relaxare SEI.
Radiografia toracica F + P: - largirea opacitatii mediastinale (partea dreapta); - nivel hidroaeric mediastinal;
Examenul baritat esofagian: - ingustare axiala a esofagului abdominal; - dilatare esofag supraiacent: megaesofag fusiform, megadolicoesofag; - micsorarea camerei cu aer a stomacului; - intirziere in pasajul esofagului abdominal efilat; - modificarea peristaltismului esofagian;
Complicatii: candidoza esofagiana, cancer esofagian;
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ESOFAG:TULBURARI FUNCTIONALE. ESOFAG:TULBURARI FUNCTIONALE. Achalazia cardieiAchalazia cardiei
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Diverticuli esofagieniMecanism: - pulsiune = hernierea mucoasei+submucoasei printre fibrele muscularei - tractiune = toate straturile peretelui esofagian
Diverticulul ZenckerTip: diverticul de pulsiune;Sediu: jonctiunea faringo-esofagiana;Morfologie: - imagine de aditie, contur net, posterior esofagului cervical; - impingere + lateralizare esofag cervical; - dimensiuni mari: staza in diverticul.
Diverticulii esofagului toracic mijlociuMecanism: tractiune (fibroza in jurul adenopatiilor tuberculoase)Morfologie: forma conica, in deget de masnusa;
Diverticuli epifreniciMecanism: pulsiune;Sediu: deasupra SEI, proiectie pe partea dreapta a conturului esofagian;Morfologie: imagine de aditie, contur net;
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DIVERTICULI ESOFAGIENIDIVERTICULI ESOFAGIENI
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Stenoze esofagiene benigne
Etiologie: - post ingestie de substante caustice; - peptice (reflux gastro-esofagian);
Caustice:Examinare cu contrast: - sediu: oriunde, mai frecvent la nivelul strimtorilor fiziologice;Clasic: - stenoza în axul esofagului (centrata), traiect lung, contururi nete, trecere lenta spre esofagul normal; - dilatatie supraiacenta, cu staza baritata;
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STENOZE ESOFAGIENE POSTCAUSTICESTENOZE ESOFAGIENE POSTCAUSTICE
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Tumori maligne esofagiene - carcinom epidermoid; - adenocarcinom (metaplazie gastrica);
Infiltrant: - stenoza excentrica fata de axul esofagului; - jonctiune asimetrica cu esofagul supraiacent; - absenta distensiei la trecerea bolului opac; - dilatatie supraiacenta a esofagului;
Vegetant: - lacuna/defect de umplere; - stenoza lumenului; - ulceratii in lacuna; - obliterare completa a lumenului;
Ulcerant:Nisa maligna: - nisa plata, incastrata; - nu proemina/foarte putin din contur; - burelet periulceros, umeri simetrici;
Forme mixte: evolutie spre stenoza, obstructie;
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CANCER ESOFAGIANCANCER ESOFAGIAN
INFILTRANT VEGETANTINFILTRANT VEGETANT
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ULCERANT FARINGO-ESOFAGIAN ESO-CARDIOTUBEROZITARCANCER ESOFAGIANCANCER ESOFAGIAN
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Radiologia clinica a stomacului
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Explorari imagistice stomac
Examen cu substanta de contrast: - pregatirea pacientului; - suspensie de sulfat de Bariu: contrast simplu, dublu contrast; - examinare fluoroscopica + compresiune dozata + rdgf. tintite; - contrast iodat hidrosolubil: perforatii, peritonita;
Ecografia transparietala;Eco-endoscopia;Examinarea computer-tomografica;Metode izotopice;
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STOMAC NORMAL:TEHNICA EXAMINARII RX
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Anomalii de pozitie stomac
Hernia hiatala: trecere intermitenta/permanenta a unei portiuni din stomac prin orificiul hiatal;Clasificarea Ackerlund: - tip I: brahiesofag + HH; - tip II: paraesofagiana (rostogolire); - tip III: alunecare;
Dg. Radiologic: - Rdgf. simpla: camera cu aer in mediastinul posterior; - Ex. baritat: esofag, pozitia cardiei, tipul de hernie, reductibilitate, reflux gastro-esofagian;
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HERNII HIATALE: A)prin alunecare; B)prin HERNII HIATALE: A)prin alunecare; B)prin rostogolirerostogolire
A B
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HERNII HIATALE PRIN ALUNECARE (TIP III)HERNII HIATALE PRIN ALUNECARE (TIP III)
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HERNII HIATALE: BRAHIESOFAG
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Amprente si deplasari gastrice - hepatomegalie, splenomegalie, mase pancreatice;
Stomac in cascada - compresiune prin colon meteorizat; - marea curbura aliniata diafragmului: punga superioara/inferioara; - profil: “stomac obscen”;
Volvulusul gastric - longitudinal: dupa axul cardio-piloric; - transversal (mezenterico-axial);
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STOMAC:MODIFICARI DE POZITIE/AMPRENTE
SPLINA
Pseudochist pancreatic
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VOLVULUS GASTRIC
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Gastrite
Diagnostic: ex. endoscopic +/- examen baritat eso-gastro-duodenal;
Gastrita acuta - etiologie: alcool, salicilati, afectare infectioasa; - aspect radiologic: pliuri ingrosate (pseudopolipoid), eroziuni mucoase superficiale, inconjurate de edem (aspect “varioliform),hipersecretie gastrica;
Gastrita hipertrofica (boala Menetrier) - hipertrofie importanta a pliurilor corpului gastric (> 1cm),apect pseudo-cerebriform, +/- gastro-enteropatie exudativa;
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GASTRITA GASTRITA MENETRIER
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ULCERUL GASTRIC
- Dg. radiologic: examen baritat eso-gastro-duodenal; - semne directe + semne indirecte
Semne directe: nisanisa + edem periulceros + convergenta pliurilor; - sediu: tipic: portiunea verticala a micii curburi; - profil : imagine de aditie; - forma: variata: rotunda, triunghiulara, ascutita; - dimensiuni: varaite: 5-10 mm - mari(nisa Haudeck); - contur precis, cu/fara colet; - delimitata superior/inferior: dig periulceros; - semnul Hampton: banda transparenta subcavitara; - fata: imagine “in cocarda”;
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NISA GASTRICA BENIGNA imaginea de profil
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ULCERE GASTRICEULCERE GASTRICE
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NISA GASTRICA BENIGNA imaginea de fata
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Semne indirecte - triada Barclay: hiperkinezie, hipertonie, hipersecretie; - gastrita hipertrofica de insotire; - semnul “indicatorului”: la nivelul marii curburi gastrice; - rigiditatea micii curburi; - spasm antral, spasm piloric;
Aspecte particulare in functie de localizare - nisa- nisa in lacuna (pe marea curbura); - nisanisa subcardiala # diverticul subcardial; - nisanisa la unghiul micii curburi: fenomene de rigiditate;
Ulcerul canalului piloric - nisanisa + spasm piloric = imagine de “perla pe ata”;
EVOLUTIE, COMPLICATIIFavorabila: tratament: diminuare, disparitie, cicatrice;Nefavorabila: - marirea ulcerului: nisa Haudeck; - stenoza gastrica; - penetratie (pancreas, ficat, mezocolon); - perforatie: pneumoperitoneu (rdgf. simpla); ex. contrast hidrosolubil; - hemoragie digestiva superioara;
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ULCER PE MAREACURBURA
ULCER PILORIC
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NISA HAUDECKNISA HAUDECK
STENOZASTENOZAPILORICAPILORICA
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CANCER GASTRIC AVANSATVegetant: - masa tumorala exofitica intraluminala + necroza, ulceratie; - defect de umplere/lacuna,defect de umplere/lacuna, delimitare imprecisa, distructia peretelui;
Infiltrant: - ingrosarea peretelui; - rigiditate, absenta peristalticii;rigiditate, absenta peristalticii; - distrugerea mucoasei; - ingustarea lumenului gastric » schir gastric;
Ulcerant: - nisa maligna;- nisa maligna; - profil: “menisc”, contur rectiliniu, in limitele peretelui, dig periulceros cu umerii egali, pliuri infiltrate opite la distanta de nisa;
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CANCER VEGETANT &ULCERAT
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CANCER GASTRIC VEGETANT
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CANCER GASTRIC INFILTRANT
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CANCER GASTRIC ULCERANT
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Ulcerul bulbar duodenal
Nisa + modificarile mucoasei (edem, convergenta pliurilor)
Forme anatomo-radiologice:Edematoasa: - bulb nedeformat; - nisa + edem periulceros = imagine “in cocarda”;Forma edemato-scleroasa: - contur bulbar cu incizuri si ancose; - nisa + edem periulceros + benzi de fibroza in submucoasa;Forma sclero-edematoasa - deformarea bulbului: stenoza, biloculare, dilatatie pre-stenotica;(“diverticul Cole”); - identificare dificila a nisei;
Ulcer duodenal post-bulbar - obs. Sdr. Zollinger-Ellison; - sediu: D2 supravaterian; - nisa + spasm de insotire (“perla pe ata”);
Complicatii: - perforatie: pneumoperitoneu; penetratie - hemoragie digestiva;
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ULCER DUODENAL BULBARULCER DUODENAL BULBAR
FORMA EDEMATOASAFORMA EDEMATOASA
FORMA SCLERO-EDEMATOASA SCLERO-CICATRICIAL
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ULCERBULBARSTENOZANT:DIVERTICULISECUNDARICOLE (1)&ACKERLUND(2)
1122
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ULCER BULBAR DUBLU:”KISSING-ULCER BULBAR DUBLU:”KISSING-ULCER”ULCER”
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ULCER DUODENAL POSTBULBARULCER DUODENAL POSTBULBAR
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Boala CrohnAfectare granulomatoasa, idiopatica, evolutie cronica, adult tinar;Sediu: predilect ileon terminal;Dg. Imagistic: explorare cu substanta de contrast + imagistica sectionala (ecografie, CT);
Evolutie:Debut: - edemul mucoasei: aspect fin granular; - ingrosarea pliurilor: pliuri neregulate, fuziforme, nodulare; - hipertrofia foliculilor limfatici/placi Peyer: lacune juxtapuse, contururi poligonale, “nodul de alarma”; - ulceratii: initial “aftoide”: eroziunea mucoasei de acoperire a foliculilor limfatici hipertrofiati: nisa in lacuna (fata), imagine de aditie (profil); - aspect ulcero-nodular: “pavaj cu dale” (“cobblestone”);
Scleroza si stenoza: - semnul corzii “string sign”: ingustare tubulara a lumenului; - stenoze scurte, etajate, “in clepsidra”; - dilatare in amonte a anselor; - cecul nu se opacefiaza: semnul “saltului”; - ingrosare si retractie mezenterica a anselor + hipertrofia ggl. limfatici; - fistule (intre anse, intre ansa patologica si vezica);
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BOALA CROHN ST I
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BOALA CROHN:FAZA ULCERATIVA (ST.II)
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Rectocolita ulcero-hemoragicaAfectiune inflamatorie cronica, cu etiologie necunoscuta si evolutie in pusee;
Dg. Imagistic:• Radiografia abdominala simpla:Radiografia abdominala simpla: - prezenta megacolonului toxic (c.ind. pentru clisma baritata);• Clisma baritata:Clisma baritata: - prezenta, extinderea bolii +/- complicatii; - modificari functionale: hipertonie, hiperkinezie, modificarea haustrelor; - modificarea mucoasei: aspect granular, edemul mucoasei; - ulceratii: pete opace (fata); imagini de aditie (profil); - profil: spiculi, forma de “T”, “buton de camasa”, contur dublu al colonului; - modificari de tip polipoid: imagini pseudo-lacunare (regenerarea mucoasei);Cronicizare: - disparitia reliefului mucoasei, scurtarea segmentelor colice, deschiderea unghiurilor colice, lipsa haustratiilor; - stenoze tubulare (microcolon);Complicatii: - megacolon toxic; - perforatii (in peritoneu sau organele vecine); - stricturi; - potential de malignizare;
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RECTOCOLITAULCERO-HEMORAGICAST I:”HARTA GEOGRAFICA”
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RECTOCOLITA ULCERO-HEMORAGICAST II:ULCERATII & PSEUDOPOLIPI
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RECTOCOLITA ULCERO-HEMORAGICA: PSEUDOPOLIPI & ULCERATII
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RECTOCOLITAULCERO-HEMORAGICA:ST III:FORMASTENOTICA=>MICROCOLON
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Diverticulii colonuluiSediu: oricare segment, predilect sigmoid
Diverticuli simpli: - clisma baritata: imagini de aditie multiple, dimensiuni variate; - atasate prin pedicul lumenului colic; - asociere cu spasm colic la acelasi nivel;
Diverticulita: - saci diverticulari deformati, aspect neregulat si umplereneomogena; - abces pericolic: US/CT; - extravazarea contrastului, traiect paralel cu peretele colic;
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DIVERTICULOZA COLONICADIVERTICULOZA COLONICA
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Tumori benigne colon: polipii
Polip unic/Polipoza multipla (transmitere ereditara dominanta);
Sindroame ce asociaza polipoza intestinala: - Peutz-Jeghers + pigmentarea tegumentelor si mucoaselor; - Gardner + osteoame multiple; - Turcot + tumori SNC; - Cronkite-Canada + anomalii ectodermale;
Diagnostic: clisma baritata (contrast simplu/dublu contrast) + colonoscopie; Caractere radiologice: - sesil (cu baza larga)/pediculat; - defecte de umplere (lacune) rotunde, contur net, inconjurate de un lizereu opac;
Potential de malignitate: - dimensiuni: < 0,5 cm - rar malign; - pedicul bine definit: potential scazut; - conturul de suprafata: reticular, ulceratie - potential crescut de malignitate; - rata cresterii;
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1a
1b
2a
Malignizare redusa
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1c
3d
Malignizare=>50%
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Malignizare foarte frecventa
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POLIP SOLITAR SESIL SIGMOIDIAN
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9 ANI DUPA EXTIRPARE ENDOSCOPICA
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CANCERUL RECTO-COLONIC
Factori favorizanti: - regim alimentar, RCUH, boala Crohn, polipoza familiala, iradierea pelvina;
Histologie: - adenocarcinoame, rar tumori carcinoide, limfoame;
Forme macroscopice: - forme vegetante, ulcerante, infiltrante, mixte;
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MORFOLOGIA CANCERULUI COLO-RECTAL
BORMANN I
BORMANN II
BORMANN III
BORMANN IV
vegetant
Ulcerant pevegetatie
Ulcerant peinfiltratie
Infiltantdifuz=schir
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• RADIOGRAFIA STANDARD=>IN OCLUZIE;
•CLISMA BARITATA CU DUBLU CONTRAST;
•ECOGRAFIA;ENDOSONOGRAFIA;
•CT;COLONOSCOPIA VIRTUALA CT;
• IRM;COLONOSCOPIA VIRTUALA IRMN;
•IMUNOSCINTIGRAFIA;PET.
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SEMIOLOGIA LEZIUNII CANCEROASESEMIOLOGIA LEZIUNII CANCEROASE
- infiltratie: rigiditate parietala + absenta distensiei colice; - lacuna de dimensiuni variate, contur policiclic anfractuos, semiton(forma vegetanta); - nisa maligna (nisa in lacuna); - stenoze de lungime variata, contur neregulat (forma vegetanta) saucaracter regulat (forma infiltranta); - stop complet al progresiei contrastului, precedat de imagine de stenoza; - oprire cu contur neregulat (mularea polului tumoral).
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CANCER VEGETANT/POLIPOID(BORMANN I)
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Vegetant/polipoid:BORMANN I
CANCER COLONIC:TIPURI SEMIOLOGICE
Ulcerant pe vegetant:BORMANN II
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CANCER COLONDESCENDENT:FORMA VEGETANTA(lacuna)
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CANCER ULCERANT:nisa in lacuna
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Ulcerant pe vegetatie: BORMANN II
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Infiltrant difuz =>schir BORMANN IV
“cotor de măr”
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CANCERE AVANSATE LOCO-REGIONAL,TIP MIXT,STENOTIC
RECTALRECTO-SIGMOIDIANRECTO-SIGMOIDIAN
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CANCER CANCER MIXT,MIXT,COLONCOLONTRANSVERTRANSVERSS
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CANCER VEGETANT FUND CECAL;INVAGINATIE
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CANCERE DE CEC VEGETANTE/STENOZANTE
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CANCERSIGMOIDIANAVANSAT:STOP TOTALAL COLOANEIBARITATE