git1 surgical pathology & x-rays

7/31/2019 GIT1 Surgical Pathology & X-Rays

http://slidepdf.com/reader/full/git1-surgical-pathology-x-rays 1/160

Surgical Pathology & X-rays for

Medical Students2007

GIT-1Salivary Glands

Esophagus

Stomach & Duodenum



© GIT12

Salivary Glands

Thyroglossal cyst

Branchial remnants Pharyngeal pouch

Esophagus

Congenital esophageal atreasia

Esophageal varices

Esophageal diverticulum

Barrett’s esophagus

Cancer esophagus

Cardiac achalasia

Stomach & Duodenum

Normal appearance

Hiatus hernia

Congenital diaphragmatic hernia

Index

Gastric & duodenal ulcers

Acute gastritis & acute peptic ulcers Chronic gastric ulcer

Complications of peptic ulcers

Hour-glass stomach

Congenital pyloric stenosis

Adult pyloric stenosis

Cancer stomach

Pseudo-pancreatic cyst

Volvulous of stomach

Duodenal atresia

Jejunal atresia

Duodenal ulcers

Duodenal diverticulum

To return to this index from any slide, click on “INDEX”



© GIT14

Salivary Glands

INDEX



© GIT15

Salivary Glands

INDEX



© GIT16

Swellings of Salivary Glands

Neoplasms

Adenoma

Carcinoma

Nonepithelial

Inflammatory

Viral: Acute: Mumps

Chronic: ?HIV

Bacterial:

Chronic bacterial sialadenitis (usually submandibular complicating chronic obstruction

Acute ascending

sialadenitis (usually parotid in dehydrated postoperative patients with poor mouth hygiene)

Specific Infections:

Mumps

Bilateral parotid

swelling with HIV

INDEX



© GIT17

Sialolithiasis - (Salivary stones)

Minor glandsSubmandibular

80%

Parotid

10%

Sublingual

7%

Incidence

Majority areradio-opaque

Majorityare

radiolucent

Large submandibular stone

Because secretions

are viscid rich in mucous & the gland

lies below the opening

of its duct

INDEX



© GIT18

Plain X-ray showing submandibular stone

This is the occlusal view of the mandible that best demonstrates the stone

INDEX



© GIT19

Stonesubmandibular

gland

INDEX



© GIT110

Sialography: Stone submandibular gland

INDEX



© GIT111

•The classic presentation of a

submandibular stone is pain

and swelling prior to or

during meal

•This requires almostcomplete obstruction of the

submandibular duct

•If partial obstruction occurs

swelling may be mild with

chronic painful enlargement

of the gland

•If diagnostic doubt then

stone can be demonstrated

by sialogram

Submandibular Sialogram

Showing a stone in the submandibular duct

The stone is NOT radiolucent, but it looks so because this is a subtracted image

INDEX



© GIT112

1 2

1- Stone in the Rt submandibular duct

(anterior 2/3 of the duct is anterior to the lingual n.)

2- Surgical removal

(Linear incision along the duct -notice the stay suture)

INDEX



© GIT113

?

Stone submandibular ductRanula

INDEX



© GIT114

Ranula

A large mucous retention

cyst (mucocele) secondary to

obstruction of a minor

salivary gland or thesublingual gland.

They represent a unilocular

cyst in the sublingual space

INDEX



© GIT115

Salivary Tumours

CarcinomasNonepithelial

tumoursAdenomas

Parotid pleomorphic adenoma

Usual locations

of benign

parotid tumours

Nodularity

& regional

lymphatic

metastasis

is highly

suspicious

of

malignancy

What are the otherclinical signs that

suggest malignancy?

INDEX



© GIT116

Salivary Tumours

Nearly all salivary tumours are slowly growing (even malignant

tumour)

Is pain a reliable indication of malignancy?

Pain is not a reliable indication of malignancy except after

invasion of sensory nerves

Benign tumours may present with aching pain due to capsular

distension and outflow obstruction of saliva

The only reliable clinical indication of malignancy are:

Facial nerve palsy in parotid tumours

Indurations or ulceration of overlying skin or mucosa

Regional lymphatic metastasis

INDEX



© GIT117

CT & MRI :

Confirm that the

mass is arising from

the salivary gland

Demonstrate thetumour borders (well

circumscribed in benign & diffuse invasive in

malignant)Show anatomical

relations to plan for

surgery

Invastigations of Salivary Tumours

MRI

Rt. parotid tumour extending into the

superficial & deep

lobes

Sq. cell ca

Rt.

CT

Well

circumscribed Lt.parotid tumour of

the superficial lobe

Pleomorphicadenoma

INDEX



© GIT118

Invastigations of Salivary Tumours

Fine needle aspiration (FNA)

For histopathological diagnosis

Open surgical biopsy is absolutelycontraindicated in tumours of major

salivary glands

Why?

Pleomorphic adenomas are poorly

encapsulated and are very tens. Open

biopsy will seed the surrounding tissues

with tumour cells causing multiple localrecurrences over many years

Open biopsy is done if the tumour is clearly infiltrating or invading the skin

INDEX



© GIT119

Thyroglossal cyst

Branchial remnants

Pharyngeal pouch

INDEX



© GIT120

Thyroglossal cyst & fistula

INDEX



© GIT121

The classical site for a

thyroglossal cyst

Thyroglossal cystsEmbryology

•The thyroglossal tract arises form foramen caecum at

junction of anterior 2/3 and posterior 1/3 of the tongue.

• Any part of the tract can persist causing a sinus, fistulae or

cyst.

•Most fistulae are acquired following rupture or incision of

infected thyroglossal cyst

INDEX



© GIT122

C4

This is a CT scan at the level of C4 vertebrae. Try to identify the following structures :

Sternomastoid muscle

Hyoid bone

Air in laryngeal vestibule

Internal jugular vein

Internal carotid artery

External carotid artery

External jugular vein

What is this structure?

Thyroglossal cyst

INDEX



© GIT123

•Usually found in subhyoid portion of tract

•75% present as midline swellings

•Remainder can be found as far lateral as lateral tip of hyoid bone

•The cyst elevates on protrusion of the tongue

•Can present as an infected cyst due lymphoid tissue in the cyst wall •If infected, aspirate cyst rather than incise prevents formation of thyroglossal fistula

TreatmentSistrunk Operation •Transverse skin crease incision

•Platysma flaps raised.

•Cyst dissected•Middle 1/3 of hyoid and any suprahyoid

tract extending into the tongue dissected

Clinical features of Thyroglossal cysts

INDEX



© GIT124

Fistulography: “note the position of the fistula

anterior to the trachea (black air)”

The classical site for a

thyroglossal fistula

Thyroglossalfistula

INDEX



© GIT125

•Branchial fistulae and cysts

usually arise from second

branchial sinus• Arise on anterior border of

sternomastoid

•Often bilateral and extend

deep into neck•Internal opening

occasionally found in

tonsillar fossa

•Treatment is by surgical

excision

Notice the opening lateral to the mid line

Branchial remnants

Branchialcyst

Branchial

fistulaINDEX



© GIT126

Pharyngeal pouch•Is posteromedial pulsion diverticulum through Killian's

dehiscence

•Occurs between thyropharyngeus and cricopharyngeus muscles. Both form the inferior constrictor of the pharynx

•Male : female ratio is 5:1

•Usually only seen in the elderly

•Aetiology is unknown but upper oesophageal sphincter dysfunction may be important

INDEX



© GIT127

Clinical features•Commonest symptoms are:

dysphagia, regurgitation and

cough

•Recurrent aspiration can resultin pulmonary complications

• A carcinoma can develop

within the pouch

•Clinical signs are often absent,however, a cervical lump may

be present that gurgles on

palpationBarium swallow show residual

pool of contrast within the pouch

Pharyngeal pouch

INDEX



© GIT128

EsophagusNormal

anatomy

Cervical

Thoracic

Abdominal

INDEX



© GIT129

The esophagus have asmooth outline. No

persistently narrowed

areas are seen.

Peristalsis can be

observed on screening

the patient.The whole examination

can be recorded on video

if necessary (video-swallow

examination).

Normal barium swallow

Lateral view: The course and diameter of the esophagus

are normal, the longitudinal mucosal folds are regular

INDEX



© GIT130

NORMAL ANATOMY of Oesophagus-Double contrast study

•The mucosal surface of the esophagus is smooth

and featureless on double contrast examination.•When the esophagus is distended the mucosal

folds disappear.

•When the esophagus is partially collapsed , then

straight parallel longitudinal folds are easily seen.

•The Z-line demarcates the squamocolumnar

junction separating esophageal mucosa from

gastric folds.

• A number of mediastinal structures cause

extrinsic impressions upon the adjacentesophagus in the normal individual.•In the elderly individual, osteophytes projecting from the

anterior surface of the thoracic vertebrae, a tortuous aorta or

an enlarged left atrium may also cause impressions upon

the esophagus.INDEX



© GIT131

Normal endoscopic pictureof the esophagus

INDEX



© GIT132

Congenital EsophagealAtreasia

INDEX



© GIT133

Congenital esophageal atreasia

The most common

type of trachio-

esophageal fistula

is a blind end

upper esophagus

and a lower remnant connected

to the trachea

INDEX



© GIT134

Oesophageal atresia (diagnosis)

If suspected, a small

nasogastric tube willarrest at the blind pouch &

will not reach the stomach

INDEX



© GIT135

Examination with contrast material: The white arrows point to the blind end of the

esophagus filled with contrast material. The middle lobe of the right lung is partially

atelectatic because of aspiration. Presence of a lower fistula is suggested by the

presence of gas in the distended stomach

Atresia of the esophagus

INDEX



© GIT136

Oesophageal atresia

INDEX



© GIT137

Esophageal varices

INDEX



© GIT138

Esophageal varices

INDEX

With t l h t i ll t l l d l b t



© GIT139

With portal hypertension, collateral vessels develop between

portal and systemic veins:

Around the lower end of the esophagus & fundus of stomach

(esophageal & fundal varices) [ splenic vein – short gastric veins – coronary vein – esophageal veins – azygos system ]

Around the rectum (Hemorrhoids) [ superior hemorrhoidal – middle &

inferior hemorrhoidal ]

Around the umbilicus (Caput medusa) [ paraumbilical veins – epigastric veins ]

Around the liver & diaphragm & retroperitoneal veins.

The normal portal pressure is less than 200 mm saline

Collateral circulation does not effectively decompress the portal system

The four major manifestations of portal hypertension are:

Esophageal varices, ascites, hypersplenism and encephalopathy.

INDEX



© GIT140

Factors implicated in the formation of ascites :

Increased portal venous pressure

Reduced serum osmotic pressure due to hypoalbuminemia

Sodium & water retention (inc. adrenal cortical hormones & dec. anti-diuretic hormone)

Encephalopathy is related to high blood ammonia level

It can result from natural or surgically created porto-systemic shunts in

patients with marked hepatocellular dysfunction

Hypersplenism

Sequestration and destruction of any or all of the cellular elements of the blood

WBC > 4000 /ml

Platelets > 100,000 /ml

Are spontaneous ecchymosis and purpra common presentations of portal hypertension alone? NO

INDEX



© GIT141 Barium swallow

Esophageal varices

“Autopsy”

Upper GI endoscopy

INDEX



© GIT142

Oesophageal varices

Barium swallow

Numerous rounded and

elongated smooth-

contoured filling defects

are present in the inferior two thirds of the

esophagus.

The contour of the

esophagus is irregular andspeculated.

INDEX



© GIT143

Barium swallow:Oesophageal varices

INDEX

Management of acutely bleeding varices



© GIT144

Sengstaken –Blakemore tube

g y g

In patients with hepatocellular

dysfunction, bleeding should be rapidly

controlled to avoid:

•The effect of shock on hepatic function.

•The toxic effect of digested blood

absorption.

Temponade & gastric wash

Main lines of treatment:

Heamodynamic stabilization with

blood transfusion

Reduce the portal blood pressure:

•Vasopressine causes constriction of the

splanchnic arteria circulation reducing the portal blood pressure 40%

•Propranolol

Sengstaken balloon temponade

Injection sclerothrapy INDEX



© GIT145

Injection sclerotherapy of esophageal varices

INDEX



© GIT146

Follow-up barium swallow

Note the staplersin the lower end

of oesophagus

(a treatment modality for esophageal varices)

INDEX



© GIT147


INDEX

B i ll



© GIT148

Barium swallow


INDEX



© GIT149

Barium swallow - Lateral view


Two sharp-contoured filling

excesses can be seen on the

ventral contour of the esophagus

below the tracheal bifurcation(arrows)

INDEX



© GIT150


INDEX

Gastro-esophageal reflux disease [GERD] is a common disorder



© GIT151

Gastro esophageal reflux disease [GERD] is a common disorder

Gastro-esophageal reflux are prevented by:

•Lower esophageal sphincter

•Normal hiatus of the diaphragm

GERD may or may not be accompanied with sliding esophageal hernia

Clinical features:

Retrosternal burning pain(heart burn) provoked by fatty

food

Fatty dyspepsia is more common in GERD than

gallstone disease

Objective diagnosis: esophageal manometry

with 24h pH recording

Management of GERD

•Bed tilte

•H2 blockers

•Proton pump inhibitors

•Surgery (failed medical or complications)

Complications of GERD

Stricture

Shortening

Columnar metaplasia [Barrett’s] INDEX




© GIT152

Barrett s esophagus

Normal lower esophagus Barrett’s esophagus

Columnar metaplasia in the lining mucosa

of the lower esophagus in response to

chronic gastro-esophageal reflux.

What are the complications of Barrett’s esophagus?

Increased risk of

adenocarcinoma 25 times

Bands of metaplastic

epithelium extend proximally

Endoscope view

INDEX



© GIT153

INDEX



© GIT154

Gastroesophageal reflux with longitudinal ulcers

arising from the GE junction

INDEX



© GIT155

Cancer esophagus

INDEX

N l f h h



© GIT156

Neoplasms of the oesophagus

Benign Tumours

(RARE)

Malignant TumoursSarcoma

Malignant Melanoma

CARCINOMA

Squamous Cell CA

usually Upper 2/3 Adenocarcinoma

usually Lower 1/3

Oat cell CA

Clinical Features of CA OE

1. Dysphagia

2. Weight loss

3. Recurrent laryngeal n. palsy

4. Cervical Lymphadenopathy

ADVANCEDDESEASE

CA OE has poor prognosis because symptoms occur late

INDEX



© GIT157

Upper 2/3 of the esophagusLower 1/3 of the esophagus

C. Oat cell carcinoma ( occasionally)

INDEX



© GIT158

Remember the pathological types of

cancer oesophagus. INDEX



© GIT159

Midesophagus SquamousCell Carcinoma

Squamous cell carcinomaarises most commonly

in the upper and middle

esophagus

INDEX

Pre-cancerous conditions:



© GIT160

Pre-cancerous conditions:

•Smoking & alcohol

•Food contamination of fungi•Diet deficiency in beta carotin,

vitamin E & selinium

Clinical features:Dysphagia is a sign of advanced

disease

Early symptoms are nonspecific

During endoscopy, biopsy any lesion even if small (small

cancers are curable)

INDEX

Investigations for suspected CA esophagus



© GIT161

Investigations for suspected CA esophagus

Upper GI endoscopy

with biopsy of any suspected lesion

Ba swallow

INDEX

Endoscopy of the esophagus



© GIT162

Advancedsquamous cell CAof the oesophagus

Endoscopy of the esophagus

EarlyadenocarcinomacomplicatingBarrett’s

esophagus

INDEX

Barium swallow



© GIT163

Irregularity looks like

an apple core lesion

in the esophagus.

This is typical in

carcinoma of the

esophagus

Barium swallow

INDEX

Barium swallow



© GIT164

Barium swallow

CA esophagus – lateral view

INDEX

Barium swallow



© GIT165

Barium swallow

CA oesophagus

INDEX

CA Oesophagus



© GIT166

Presenting symptom: Dysphagia

CA Oesophagus

Irregular stricture with shouldered margins

INDEX

Barium swallow



© GIT167

Barium swallow

CA oesophagus

INDEX



© GIT168

barium swallow

demonstrates the typical

apple core lesion seen

with distal esophagealadenocarcinoma

associated with chronic

reflux disease.

Also seen is a typicalsliding hiatal hernia with

the gastric folds fixed

above the diaphragm.

INDEX

Barium swallow



© GIT169

Barium swallow

This is not CA esophagus.

The esophagus is displacedby CA lung.

Note the smooth lining of the

displaced segment

INDEX



© GIT170

Corrosive stricture

of the esophagus

INDEX

Ba swallow -



© GIT171

Ba swallow -Corrosive stricture

AP view:

Narrowing with smooth

outlines at the level of the

middle third of the

esophagus with a dilatation

observed above it.

Distally the lumen of the

esophagus is of about the

normal diameter.

INDEX

Carcinoma of the esophagus has a poor survival rate



© GIT172

Carcinoma of the esophagus has a poor survival rate

because of late discovery after spread

Spread

Local spread

•Through the

wall into adj.

structures

•Satellite

nodules in the

proximal

esophagus(submucosal lymphatics)

Lymphatic spread

Spread to the

celiac LNs is a

bad prognostic signand regarded as

distant metastasis

(M) in the TNM

classification

Systemic spread

•Liver

•Lungs•Brain

•bone

INDEX

Carcinoma



© GIT173

of theesophagus

INDEX



© GIT174

Postoperative barium

swallow demonstrating thegastric conduit in the

cervical position with the

silver clips marking the

anastomosis

INDEX



© GIT175

Achalasia of the cardiac sphincter

INDEX



© GIT176

Achalasia Inability to relax lower esophageal sphincter leads to massive

esophageal dilation and produces the characteristic "birds beak"

deformity in barium swallow

Ba swallow Autopsy

INDEX

Barium swallow examination: achalasia Early stage



© GIT177

The esophagus

has smoothcontour and is

narrowed

conically at the

esophago-cardial junction

(arrow), above

this the distal

part of theesophagus is

dilated

Barium swallow examination: achalasia Early stage

INDEX

L t t



© GIT178

Late stage:

The esophagus is

extremely dilated abovethe severely narrowed

cardia (arrow), with a

slightly tortuous course

and inhomogenous

contrast material filling

pattern because of the

residual food inside

INDEX

h l i (



© GIT179

Achalasia (of the cardiac

sphincter)

Note the huge dilatationof the oesophagus

INDEX



© GIT180

Achalasia with bird's beak deformity of the distal esophagus

INDEX



© GIT181

Lateral view ofbarium swallow

in a patient with

achalasia.

Note grossly

dilated esophaguswith abrupt

tapering to “bird

beak-like” shape

of lower

esophagealsphincter

INDEX

A h l i



© GIT182

Achalasia

The oesophagushugely dilated and

tortuous.

INDEX



© GIT183

Please compare and contrast between cardiac achalasis & CA lower end esophgus

INDEX

Barium swallow: CA oesophagus v/s Achalasia



© GIT184

The cardia is normally below the diaphragm

In X-ray 1, theoesophagus is

interrupted

above the

diaphragmIn X-ray 2, the

cardia belowthe diaphragm

is closed with“bird beak-like”

shape

1 2

This is CA lower end

esophagus

Achalasia of

cardia

INDEX

Treatment options for cardiac achalasia



© GIT185

Pneumatic dilation

performed

endoscopically

Lower esophagealsphincter myotomy

incises enough muscle torelieve symptoms but not

enough to result in

gastroesophageal reflux

INDEX



Normal anatomy

& di d i i t



© GIT187

& corresponding endoscopic picture

INDEX

Normal loweroesophagus & stomach



© GIT188

oesophagus & stomach

This is the normal appearance of the lower oesophagus & stomach, which

has been opened along the greater curvature.

INDEX

Normal upper GI



© GIT189

o a uppe Gbarium study:

The stomach is of

normal size andshape, its mucosal

folds are regular.

The fornix is filled

with contrastmaterial because of

the supine position.

The duodenum is

normal.Jejunal loops filled

with contrast

material are visible

behind the stomach INDEX



© GIT190

Hiatus Hernia

INDEX



Siding hiatus



© GIT192

Siding hiatushernia

Siding hiatus hernia( l)



© GIT193

(retrosternal)

INDEX



© GIT196

Postmortumspecimen

Diaphragmatichernia

INDEX



© GIT197

Gastric & duodenal ulcers

INDEX



© GIT198

Gastric Ulcer

INDEX

Mechanism of acid production in

the gastric parietal cell



© GIT199

the gastric parietal cell

INDEX

Acute gastritis



© GIT1100

gwith diffuse

heamorrhage

INDEX

Etiology: Disruption of gastric mucosal

Acute Peptic Ulcers



© GIT1101

Etiology: Disruption of gastric mucosal

barrier appears as multiple erosions.

50% of patients give history of

NSAID/aspirin intake. Acute peptic ulcers cause short attacks of

dyspepsia & classically present with

hemorrhage.

Pathology: Frequently multiple.

Stomach - They can occur in any part.Duodenum - Almost always confined to first

part.

Shallow punched out and seldom invade

musclecoats unlikely to leave healing scars.

Acute duodenal ulcer in anterior wall

occasionally perforates.

These acute lesions can progress to chronic

ulcers.

INDEX

Chronic Gastric Ulcer



© GIT1102

INDEX

Chronic gastric ulcer



© GIT1103

The ulcer is deep, with sharp proximal edge & a sloping distal edge

The arrow points to an eroded gastric artery which has caused fatal hemorrhage

What are the complications of chronic gastric ulcer?

INDEX



© GIT1105

Malignant

gastric ulcer

Top view, the ulcer is

very suspicious

Longitudinal section:

The pylorus is to the left .Edges are everted.

Several prominent

nodes of the lesser

omentum contained

metastatic cancer.

The adenocarcinoma is

infiltrating between the

layers

INDEX

Chronic gastric ulcer



© GIT1106

Chronic gastric ulcer The edges of the ulcer

are heaped up due toepithelial regeneration.

The ulcer base is

smooth

and contains onlygranulation tissue

If the ulcer was discovered

on endoscopy, multiplebiopsies should be taken to

exclude malignancy –even if

the ulcer looks benign

INDEX



© GIT1107

Chronicgastric ulcer

INDEX

Barium meal



© GIT1108

Benign gastric ulcer on the

lesser curvature of the

stomach

INDEX



© GIT1109

Large ulcer is filledwith barium on the

lesser curvature of

the stomach with

star-shaped

mucosal folds

converging towards

the lesion

INDEX

Barium study



© GIT1110

Gastric ulcer

INDEX

Upper GI bariumstudy:



© GIT1111

study:

It shows a largegastric ulcer along

the lesser

curvature of the

stomach.

Surgery was

performed and the ulcer was benign

INDEX

Barium meal



© GIT1112

gastric ulcer

There is a largeulcer crater on the

greater curvature

aspect of the distal

stomach (arrow).There are multiple

folds radiating to

the edge of the

ulcer crater. All the

folds taper gradually to the

edge of the crater.

INDEX



© GIT1113

Carmens meniscus sign

Barium meal

Pre-pyloric gastric ulcer

INDEX

This gastric ulcer has

Chronic Gastric Ulcer



© GIT1114

This gastric ulcer has

been present for some

time as judged by the

amount of puckering of the surrounding mucosa

and by the depth of the

ulcer.

The gastric mucosa

around shows gastritis.

Frequently, vessels in the

base of the ulcers will

ulcerate and the patient

will bleed profusely, if notfatally

Does infection have arole in the developmentof peptic ulcer?

INDEX

Helicobacter pylori

It i i t t i th ti l f



© GIT1115

It is important in the etiology of :

•Chronic gastritis

•Peptic ulcer

•Gastric cancer

Helicobacter pylori Hydrolyze urea Amonia (strong alkali)

Antral „G‟ cells

Gastrin

Gastric acid

hypersecretion

Eradication therapy

is a main treatment in peptic ulcer

Metronidazole

Amoxycillin

Bismuth

A proton pump inhibitor is usually

added INDEX



© GIT1116

Helicobacter gastritis Helicobacter organisms may

be tested for urease activity.

Staining of the gastric biopsy

shows

the characteristic curved rods

embedded in the mucin layer

of the stomach

INDEX

Complications of peptic ulcers

Bleeding



© GIT1117 Malignant Gastric Ulcer

Bleeding

•Patient presented with hematemesis,

shock followed by melina

•Endoscopy showed acute gastric

bleeding

Perforation

•Patient presented

with acute

abdominal pain

•Plain X-ray chest

& abdomen

showed air under

the diaphragm

Penetration

Posterior wall ulcer penetrates to

pancreas (back pain)

INDEX



© GIT1118

"Hourglass" contraction of the stomach Due to chronic peptic ulceration there is fibrosis and contracture of

the stomach leading to an hourglass shape

Results in altered stomach mobility with delayed gastric emptyingINDEX

Upper GI endoscopy for diagnosis of peptic ulcer



© GIT1122

Hypertophic pyloric stenosis. Note the prominent hypertrophied circular pyloric muscle

with elongation and narrowing of the pylorus

It is a cause for "projectile" vomiting in infants about 3 to 6 weeks of age. Males are affected

more than females(4:1)

It should be differentiated from other causes of vomiting in infancyINDEX

Symptoms include non-bilious vomiting often starting as simple

regurgitation progressing to projectile vomiting after most



© GIT1123

g g p g g p j g

feedings.Vometing contains milk but no bileLess frequent findings are constipation, progressive weight loss,

dehydration, hypochloremic alkalosis. Symptoms occur most commonly during the second to sixth weeks

with peak age at presentation being 3rd -4th weeks. HPS rarely

presents after 3 months of age.

Physical examination may

reveal visible gastric peristaltic

waves and a palpable pyloric

mass (olive).

INDEX

If the clinical and

physical findings



© GIT1124

U.S. Findings:

There is thickening and elongation of the pyloric muscle. diagnostic for HPS

are suggestive of

HPS then anultrasound exam

is the first study of

choice.

D.D. of Hypertophicpyloric stenosis of

infancy

•Gastro-esophageal reflux

•Raised intracranial pressure

•Duodenal atresia

•Intestinal obstructionINDEX

Gasrtographin meal

C it l l i t i



© GIT1129

24 hours after

drinking contrast

material most of it isstill visible in the

stomach with residual

food above it.

The stomach isdilated, its lower pole

hangs below the iliac

crest.

Only minimalcontrast material

filling is observed in

the small intestines

INDEX

Barium meal



© GIT1132

A large tumor of

the stomachseen as a filling

defect in the

body and antrum

of the stomachcausing irregular

contours on both

the lesser and

the greater curve.

INDEX

Gastric Carcinoma



© GIT1135

Cancer stomachMalignant ulcer

Cancer stomachMalignant infiltration

Cancer stomachCauliflower mass

INDEX

Large ulcerated gastric carcinoma arising in the body of the stomach



© GIT1138

Marked narrowing of almost the

complete stomach, due to diffuse

infiltration of the gastric wall by a

carcinoma (linitis plastica)

Linitis plastica

Diffusely infiltrating carcinoma,

note leather bottle appearance

INDEX

Barium meal - CA stomach: Linitis Plastica



© GIT1139

The distal two thirds of the

stomach is narrowed, rigidperistalsis is absent.

stomach diameter is

decreased. The stomach

lacks the normal rugal

pattern. The mucosal surface is

often smooth but intact, and

ulcers are not a dominant

feature.

"leather bottle" stomach

describes diffuse submucosal

infiltration of the stomach.

INDEX

Early (curable) gastric cancer has no specific features that

Clinical manifestations of gastric carcinoma



© GIT1140

Early (curable) gastric cancer has no specific features that

can differentiate it from benign dyspepsia

Liberal use of gastroscopy in patients over 40 years of age with a new or persistent dyspepsia. With biopsy from any suspicious lesion.

N.B. gastric antisecretory drugs will improve symptoms of gastric cancer

Late symptoms:

•Early satiety

•Bleeding – iron deficieny anemia

•Pyloric obstruction

•Thromboplebitis (Trousseau’s sign) & DVT INDEX

M lti l



© GIT1141

Multiple

polypoid

gastric

masses in

the cardia,

fundus, and

antrum

Metastatic

INDEX

Postoperative stomach



© GIT1142

The afferent jejunal loop

connected to the gastric

stump shows onlyminimal filling, the

majority of the contrast

material flows into the

efferent loop

Postoperative stomach – after Billroth II partial

gastrectomy

INDEX



© GIT1145

The axis of rotation is along the

mesenteric attachment, much the same as is seen with sigmoid colon volvulus

The axis of rotation is the long

axis of the stomach

Organoaxial volvulus Mesenteroaxial volvulus

INDEX

Barium meal



© GIT1148

Duodenal atresia

Dilated stomach (S)

and the part of the

duodenum above the

obstruction (D). Other parts of abdomen do

not contain gas

INDEX

Plain X-ray abdomen



© GIT1150

Plain X-ray of the

abdomen:The arrows point to

the dilated stomach

and that part of the

duodenum which isabove the obstruction.

Other parts of

abdomen do not

contain gas

Double bubble

INDEX

Duodenal atresia



© GIT1151

Gastrographin meal:

The distended

stomach and

duodenum above the

obstruction are visible

after swallowingcontrast material

(arrows).

INDEX

Plain radiograph ofthe abdomen:



© GIT1152

the abdomen:

The arrows point tocharacteristic triplegas bubbles in the

stomach, duodenumand jejunum.

Jejunal atresia

INDEX



© GIT1154

A 35-year-old woman

presents with tarry stools anda hemoglobin level of 7.5 g.

Notice bleeding points

Duodenal ulcer (Endoscopy)

INDEX

Investigations for suspected peptic ulcer

Gastro-duodenoscopy is the most sensitive investigation



© GIT1156

Two well-defined

filling excessesfacing each other

are visible on the

opposite contour

of the duodenal

bulb (arrows)

INDEX

Duodenal ulcer with

trifoliate deformity



A saccular lesion is

filling from the

horizontal part of

the duodenum(arrow).

Course of the

jejunal loops isnormal

duodenum

git1 surgical pathology & x-rays

Documents