surgical pathology & x-rays

7/28/2019 Surgical Pathology & X-Rays

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GIT 3 1

SURGICAL X-RAY & PATHOLOGY

DR. Sherif Abou Bakr


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Normal gas patterns in

plain X-ray abdomen

Index


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Normal plain X-ray film of

the abdomen, demonstrating

soft tissue densities

Normal plain X-ray film of

the abdomen demonstrating

the bowel gas pattern

Index


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Air is seen in non-

dilated loops of smalland large bowel.

Small loops are

centrally located, and

colon is distributed

peripherally like a

picture frame.

Normal Bowel

Gas Pattern:

Index


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This is a normal plain

X-ray abdomen in the

supine position

In supine X-rays

of the abdomen

we look for:

Pattern of gasto identify the

distended loop

Supine AbdomenIndex


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Stomach: Always

Small Bowel: Two

or three loops of

non-distendedbowelNormal diameter = 2.5 cm

Large Bowel: In

rectum or sigmoid

almost always

Gas in

stomach

Gas in a few

loops of

small bowel

Gas in

rectum or

sigmoid

Normal Gas Pattern

This pat ient is mi ld ly distended but st i l l wi th in n orm al

Index


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Erect Abdomen

A few air in

small bowel

Always

air/fluid level

in stomach

In erect X-rays

of the abdomen

we look for:Free air

Air-fluid levels

Index


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Small bowel loops aredistributed centrally in

the abdomen and

have mucosal folds

that cross the entirelumen of the bowel.

These folds are called

valvulae conniventes

orplica circularis and

are visible in gas-filled

loops

Plain X-ray supine : Small intestinal obstruction

Abnormal gas pattern Index


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Abnormal gas patterns

in plain X-ray abdomen

Index


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Plain X-ray abdomen(erect position)

Duodenal atresia

Index


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Plain X-ray abdomen

(erect position)

Duodenal atresia

Index


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Free air under

diaphragm

Perforated

viscera

Both sides of the bowel

wall are outlined by thearrows in the supine film Index


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Plain abdominal

radiograph:

Inverted U-shaped,

gaseous, dilated small

bowel loops can be

observed above oneanother (arrows) in the

middle of the abdomen.

The double arrow points

to an air-fluid level in the

intestines

Small intestinal illius

Absent intestinal sounds

Index


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Multiple loops of minimally dilated

small bowel. Minimal colonic gas

Supine Erect

Air fluid levels at different levels within

the same loop of intestine on the

upright film.

Postoperat ive adyn amic i leusThis is a postoperative patient

with absent intest inal soun ds Index


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Plain X-ray abdomen (erectposition)

Multiple fluid levels

Index


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Plain X-ray abdomen (erectposition)


Index


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Generalized Adynamic Ileus

Gas in dilated small bowel and large bowel to rectum

Long air-fluid levels

Index


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Mechanical Small bowl

obstruction (supine position)

Dilated small bowel

Frequent audible intestinal sounds

(Fighting loops)

Little gas in colon, especially

rectumKey: disproportionate dilatation of SB

Index


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Plain X-ray- Small bowel obstruction secondary to adhesions

Supine

The supine view of the abdomen

demonstrate dilated small bowel without

any air in the colon

Erect

Erect Film shows a large amount of fluid

within the small bowel. There are multiple

small pockets of air arranged in a line noted in theleft lower quadrant (residual colonic gas)Index


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Mechanical

large bowel

obstruction

Dilated colon to point of obstruction

Little or no air in rectum/sigmoid (according to the site of obstruction)

Little or no gas in small bowel, if Ileocecal valve remains competent

Index


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Sigmoid carcinoma causing colon obstruction

SupineErect

Multiple dilated loops of bowel with scattered air fluid levels on the upright film. The caliber

and location of the bowel loops suggest that the air is within the colon. There is some small

intestinal gas noted in the right mid abdomen, but the preponderance of air is in the colon. There is little rectal gas presentIndex


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Barium enema of

the same patientshows an abrupt

obstruction at the

level of thesigmoid colon

Index


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Large bowl obstruction

(supine position)

Index


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History: Elderly man with

acute onset of abdominalpain

Physical exam: distended,

tympanitic abdomen

Diagnosis: SigmoidVolvulus

In sigmoid volulus, the colon

appears as a dilated,

inverted U-shaped loopwhich extends from the

pelvis into the mid-upper

abdomen. (coffee bean sign)

Index


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Sigmoid Volvulus

Most common colonic volvulus

Water soluble enema confirms

distal obstructionIf discovered early,

colonoscopic decompression is

usually effective

Index


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Volvulous of the

sigmoid colon

Index


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Volvulous of the

sigmoid colon

Index


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Both mucosal

and serosal

surfaces of

bowel wall areoutlined by gas

indicating that

there must be

free gas in the

peritoneal

cavity

Plain X-ray

abdomen

Supine

Pneumoperitoneum

Index


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Pneumoperitoneum

Index


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Intestinal obstruction

Dynamic AdynamicPeristalsis is working

against mechanical

obstruction

Absent peristalsis

Paralytic ileus

Nonpropulsive peristalsis

Mesenteric vascular

occlusion

Intraluminal Impacted faeces

Foreign body

Intramural Malignant or

inflammatory stricture

Extramural Peritoneal bands

Strangulated hernia

Volvulus,

Intussusception

Index


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Examples of dynamic obstruction

Extramural Peritoneal bands

Strangulated hernia

Volvulus,Intussusception

Index


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Peri toneal bands

Index


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Small bowel obstructionsecondary to intraperitoneal

fibrous band adhesion

Index


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GIT 3 35Index


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Intestinal Obstruction

Small Bowel Infarction

secondary to intraperitoneal

fibrous band (Late presentation

irreversible intestinal ischemia)

The commonestcause of

inrtaperitoneal

bands is previous

inrtaperitoneal

operation. e.g. :appendectomy,

exploration,..

Index

S ll b l b t ti


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Central distension ofsmall intestinal loops.

Note the metal clips of

a previous operation

Small bowel obstruction

Erect:


Index


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Strangu lated hern ia

Index

St l t d f l h i i


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Strangulated femoral hernia causing

intestinal obstruction

1

2

3

4

Index

Small intestinal


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Small intestinal

strangulation

This loop of intestine was strangulated

within a hernia.

How would you know that this loop is

viable or not?

Strangulated femoral hernia

Strangulated para-umbilical herniaIndex

ma n es na


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ma n es nagangrene

This gangrenous loop of small intestine was strangulated within a hernia.

What was the possible clinical presentation of this patient?

What is the next step in management?

Index


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In tussuscept ion

Index


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Small bowl

Intussusception

More pictures for intussusception will come later Index


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Small bowel obstruction

Erect:


Supine:

Central distension of small intestinal loops

Index


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Volvulus

Index

Si id


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Sigmoid

volvulus

Index

Sigmoid volvulus


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Sigmoid volvulus

(late irreversible gangrene)

Index


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Small bowl volvulus

Index


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Intramural Malignant or

inflammatory stricture

Index


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Chronic intestinal

obstruction due to CA

descending colon

Ba enema shows the shadow of

the mass

Dilated intestinal loops are seen

Index


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Dilated bowel

loops proximal to

the obstruction.

Arrow points to

the etiology of

obstruction

Ba enema:

The ilio-cecal valve in this

patientis incompetent

Index


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Intraluminal Impacted faeces

Foreign body

Index


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Fecal impaction

As a result of chronic constipation,

the patient is unable to expel stools, it

further accumulates into a larger,

harder mass that is impossible to

pass by normal defecation.

Impaction is most common in

inactive elderly people

Symptoms include chronic

constipation. There can be fecalincontinence and paradoxical diarrhea

as liquid stool passes around the

obstruction

Index

Foreign body


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Foreign body

Phyto-bezoar in the jejunum

Index

Infarction:Area of ischemic necrosis caused by


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Infarction: yimpaired arterial supply or venous drainage

Arterial mesenteric vascular occlusion Index

Infarction of small intestine


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Compare the dark red to grey infarcted bowel with the pale pink normal bowel at

the bottom. Some organs such as bowel with anastomosing blood supplies, or

liver with a dual blood supply, are hard to infarct.

This bowel was caught in a hernia and the mesenteric blood supply was

constricted by the small opening to the hernia sac.

Infarction of small intestine

What other causes can result in such massive intestinal infarction?

Index


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Mesenteric vascular

occlusion

Irreversible small bowl ischemia

Index

Mesenteric ischaemia


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Mesenteric ischaemia

Index


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Intussusception

Index


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Intussusception(Ileo-ileal)

Index


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Index


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Intussusception(Ileo-ileal) - postmortum

Index

Intussusception


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Intussusception

Index

Intussusception (Ileo-ileal)


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What are the early clinical features

of a child presenting with

intussusception?

A child of about 6 months old, develops

sudden onset of screaming with drawing

of the legs. The attacks are recurrent.

Vommiting mayoccure early, stools

may be normal first, then the child

passes blood & mucous

Redcurrent jelly stools

Index

Intussusception of ileum into the colon


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The leading proximal, small bowel

segment (intussusceptum)

telescopes into the distal, colon

segment (intussuscipens).

The small intestine (blue arrow) is going

into the large intestine (green arrow)

p

Index

Intussusception (Ileo-colic)


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Intussusception(Ileo colic)

Index

Barium enema with rectal instillation under fluoroscopy is the gold standard for


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Barium enema showing

intussusception

Passing from the rectum, the barium fills

the colon untill a mass is noted (the

intussusception)

Transverse colon

Barium enema is used for

reduction of the intussusception

It is about to be completely

reduced (note the barium is going

into the small intestine)

both diagnosing and reducing childhood ileo-colic or colocolic intussusception

Index

Barium enema for diagnosis & reduction of intussusception


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Head of intussusception

is at hepatic flexure

Free flow of contrast into

distal small bowel indicates

complete reduction

a u e e a o d ag os s & educt o o tussuscept o

Partial reduction

Index

Barium enema


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Barium enema

Intussusception (Claw sign )

Index


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The rectally

administered

contrast material

draws around the

head of theintussusception

(arrow)(Claw sign)

Index

Barium enema


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Barium enema


Index


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Barium enema


Index


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Small IntestineOther pathological conditions

Index


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Meckels diverticulum

Inflamed

Remember the complications

of Meckels diverticulum

Infection & obstruction (as the

appendix)

May contain gastric, colonic or pancreatic

tissue usually at the diverticulum mouth

Peptic ulceration with severe bleeding

Intussusception

Intestinal obstruction (band between umbalicus & diverticulum) Index

Meckels diverticulum


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Meckel s diverticulum

Index


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Meckels

diverticulum

Index


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The Appendix

Index

Normal appendix


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Normal appendix

(postmortem)

Index

Acute appendicitis with gangrenous tip


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Various positions

of appendix in

order of

frequency:1. Retrocecal 74%

2. Pelvic 21%

3. Paracecal 2%

4. Subcecal 1.5%

5. Preileal 1%

6. Postileal 0.5%

7. Sub-hepatic8. Lt. iliac fossa in situs invertus

How can different

positions alter the

classical clinical

picture?Index


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Acute Appendicitis

Index

Acute Appendicitis


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Acute Appendicitis

Index

Acute Appendicitis


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Note flakes of pus

Index

Acute Appendicitis


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Opened to show

fecalith inside

Index


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Subphrenic

abscessA pocket of infection

has developed

beneath the

diaphragm elevating

it as seen on the

chest x-ray

Index


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Crohns Disease

Index

Regional enteritisIndex


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Deep linear mucosal ulcerations, with edema of the mucosa between the ulcers

Remember that symptoms & signs of

acute Crohns resemble acute

appendicitis

Chronic Crohns can cause enteric

strictures & fistulae


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Colon

Index

Normal Barium enema


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The first two films are of an air contrast barium enema. There is both

barium and air within the colon. By changing the position of the patient,

different areas are well outlined with the air. When the patient is lying on his

right side, the air accumulates on the left and vice-versa

The 3rd film is a single contrast barium enema where only barium is instilled

in the colon. The complete colon is well demonstrated. The colonic haustra

are well seen. The terminal ileum and appendix are also filled Index


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Hirschsprungs disease

Index



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Barium enema:

The contrast material

outlines a bowel

segment without

ganglions (arrows),above which

prestenotic dilatation

is visible

Hirschsprung s disease

Index

B i


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Barium enema


Index

B i


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Barium enema


Index


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Diverticular disease of the colon

Index

Barium enema- double contrast


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Diverticular disease of colon

Index

Barium enema


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Diverticular disease of colon

Index


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Barium enema - Diverticular disease of colonIndex

Ba. Enema-

Diverticulitis


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Diverticulitis

An area of

eccentricnarrowing is

present in the

sigmoid colon

(arrows). Withinthis area

diverticula are

seen

Index

Barium enema


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Diverticular disease of colonlate stage

Theradiograph

taken several

days after the

examination,

remains ofcontrast

material in the

diverticula

demonstrateextended

diverticulosis

involving the

entire colon Index

78 year old man is complaining

of blood in the feces.


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GIT 3 100

of blood in the feces.

This is the air-contrast barium

enema showing the sigmoid &descending colon

Does the X ray explain the

clinical presentation? Explain.

What is the next step?

The film demonstrates several small

projections extending out of the

colon. The appearance is typical of

diverticulosis

Index

Selective

Angiography-


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Angiography-

Active bleeding

from right-sided

colonic

diverticulum

This early film

shows a focus ofextravasation

(arrow) arising

from a division of

the right colic

branch of the

superior

mesenteric artery

Index

The later film


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demonstrates

persistent

extravasation inthis area with

filling of an

adjacent

diverticular-like

structure

Index


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Adenomatous polyp (colon)

Index

Ad t l


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Adenomatous polyp

of the colon

Index


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Colon polyp longitudinal section

Wall layers are preserved (purely mucosal)

Index


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Familial adenomatous polyposis

Index

Familial adenomatous

polyposis


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Multiple adenomatous polyps of the cecum are seen here in a case offamilial

adenomatous polyposis, a genetic syndrome in which an abnormal genetic mutation leads to

development of multiple neoplasms in the colon.

polyposis

Index


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Multiple colonic

adenomatous polyps in

familial adenomatous

polyposis

Index

Barium enema


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Familial polyposis of the

colon

Index

Barium enema


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Familial polyposis of the

colon

Index

Cancer cecum


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Terminal ileum

Remember thedifferent clinical

presentations of

cancer cecum

Index


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Cancer colon

cecum What are the possible

clinical presentations?

What are the differentmacroscopic types?

Index


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GIT 3 113Index

Index


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GIT 3 114. Everted edge & necrotic floorMalignant ulcer of the colon

Colon Carcinoma


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Causing luminal stenosis

Index


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GIT 3 116Cancer sigmoid colonIndex

Barium enema

CA


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CA cecum

Index

Barium enema

Apple-core type lesion in the sigmoid

l i l f i Ai b i fil


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colon, typical of a carcinoma Air contrast barium film

Diverticulosis in the colon, in the

middle of which is found a small apple-

core lesion typical of a carcinoma

Index


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Barium enema:

A 6 cm long section ofthe recto-sigmoid region

has irregular contour,

narrowed lumen (1 cm)

and filling defect (arrow)

Index

Barium enema

CA ascending colon


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CA ascending colon

Index

Barium enema

CA ascending colon


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CA ascending colon

Index

Barium enema

CA ascending colon


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CA ascending colon

Barium enema


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CA hepatic flexure

Index


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GIT 3 124Index

Barium enema


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CA sigmoid colon

Index

Ba enema Ulcerative cholitis


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The colon is short, with

smooth haustration and

narrow lumen.

Index


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Rectum &

Anal Canal

Index

Thrombosed infected piles


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Thrombosed, infected piles

Index

Cancer


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Rectum

rectum

Malignant

ulcer

What are the organs that may be involved due to local spread of CA rectum?

Index

Rectal cancer well within the reach of an

examiner's finger


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examiner s finger

Autopsy Picture

Anal canal

Malignantulcer in the

rectum

Index

InvertogramAn invertogram may be used to

investigate the extent of the defect in


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investigate the extent of the defect in

anal or rectal atresia.

The anus is marked with a

radiopaque marker, and the babyinverted.

A lateral radiograph is taken.

The air in the rectum will rise to the

highest point, giving an indication of

the extent of the atresia

Index


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