GI and Biliary

EXAM 7/30

Liver (3-4 pounds)

What is the largest solid organ in the body?

RUQ

Where is the liver located in the abdomen?

Over 100 different functions

- Synthesis of substances concerned with blood clotting

- Storage of vitamins

- Detoxification & excretion of substances

- Production of bile (1 qrt a day)

- Metabolism of substances delivered via portal circulation

How many functions does the liver have?

about 1 quart

How much bile is produced by the liver each day?

Emulsifying fat (contains cholesterol)

What is biles function?

Majors: Right (larger & lateral) & Left (smaller & medial)

Minor (both associated with the right lobe): Quadrate (inferior) & Caudate (superior)

What are the loves of the liver? Major & Minor?

Falciform ligament

What separates the major lobes of the liver?

ducts that drain bile into the duodenum

What is the biliary tree?

Triggered by cholecystokinin (CCK) by the presence of fatty food

What triggers the release of bile?

In the lobules of the liver

Where is bile formed?

Right and Left Hepatic duct --> Common hepatic duct --> Common bile duct --> Pancreatic duct (or Duct of Wirsung) --> hepatopancreatic ampulla (or Ampulla of Vater) --> Hepatopancreatic sphincter (or Sphincter of Oddi) -->

Duodenum

Or

Right and Left Hepatic duct --> Common Hepatic duct --> Cystic Duct --> Gallbladder

Explain the biliary tree to the duodenum and to the gallbladder.

Hepatopancreatic Ampulla

Part of the biliary tree where the common bile duct & the Pancreatic duct merge

What is the alternate name for the Ampulla of Vater? What does connect?

Hepatopancreatic Sphincter

What is the alternate name for the Sphincter of Oddi|?

Duct of Wirsung

What is the alternate name for the pancreatic duct?

Cystic duct

(connects off of the common hepatic duct)

What is the name of the duct that takes bile to the gallbladder?

Pear-shaped sac found under the surface of the liver

Describe the shape of the gallbladder.

Store of bile

Concentrate bile,

Contraction when triggered

What are the three sole functions of the gallbladder?

Ultrasound

What is the primary modality of imaging the Gallbladder?

Hydrolysis (removal of water)

How dos the Gallbladder concentrate bile?

Cholelithiasis

What is the condition of having gallstones?

Choleliths - too much water removal forms stones

What is the medical term for gallstones?

Sphincter of Oddi

What is a common site of choleliths?

Immediate Cholangiogram

Surgical Cholangiogram

What are the alternate names for an OR Cholangiogram?

Immediately following a cholecystectomy

In the OR after Surgery

When and Where is an OR Cholangiogram performed?

laparoscopic cholecystectomy

- less hospital times and cost

- Less invasive (outpatient)

- endoscope is inserted through umbilicus

- GB removed & cystic duct cauterized

- Cholangiogram can be performed

How are cholecystectomies usually performed? What are the advantages of this method?

T-tube cholangiography

What is the alternate name for Post-Operative Cholangiography?

Done in radiology dept (IR) by a radiologist

Performed about 24 hours post cholecystectomy

Where & when is T-tube cholangiography performed?

- T-tube catheter is inserted into the common bile duct and extends to outside of the body

- T tube clamped

- scout films

- injection of contrast

- can show residual choleliths undetected during surgery

- May remove stones through a basket catheter passed over a guide wire

Explain T Tube Cholangiography.

Both

Is a T Tube cholangiography diagnostic or therapeutic?

can mimic stones

What do air bubbles mimic in cholangiography?

Percutaneous Transhepatic Cholangiography or PTC

What is a PTHC?

- Direct puncture of biliary ducts using a 22g chiba needle

- done in IR

- needle passes through the skin through the liver

- PT and PTT need to be checked for blood clotting

- can be diagnostic or therapeutic

- most invasive

Explain a PTHC.

1) Liver Hemorrhage

2) Pneumothorax

3) Escape of bile

Risks of PTHC

Endoscopic Retrograde Cholangiopancreatography

ERCP

- Gastroenterologist uses Fiber optic endoscope (duodenoscope)

- Can be dones in OR GI suite, or in fluoro

- Catheter through sphincter of oddi to common bile duct & main pancreatic duct

- diagnostic or therapeutic

Explain an ERCP

Gastroenterologist - using a fiber optic endoscope (duodenoscope)

Who performs ERCP?

Radiologist in IR

Who performs PTHC?

Radiologists in IR

Who performs T Tube Cholangiography?

- no ionizing radiation

- detection of small stones

- no contrast

- less pt prep

4 Reasons why Ultrasound is preferred

Oral cavity (mouth) --> Pharynx -> Esophagus -->Stomach--> Small Intestines --> Large Intestines --> Anus

List the parts of the alimentary canal.

Salivary glands

Pancreas

Liver

Gallbladder

List the accessory organs of the digestive system.

- Intake & digestion of food, water, vitamins, and minerals

- Absorbs food, water, vitamins, and mineral into the blood & lymphatic capillaries

- Eliminate any unused material

Functions of the Digestive System

- Modified Barium Swallow

- Esophagogram

- Upper GI series (UGI)

What are some common radiographic procedures of the upper digestive system?

Oral cavity (mouth)

Where does the alimentary canal begin?

Upper/lower teeth, hard & soft palates, tongue, uvula

What forms the oral cavity?

Salivary glands

- secrete saliva = water, salts, and enzymes

What are the accessory glands of the mouth and what is their function?

Parotid - near the ear

Submandibular (submaxillary) - below maxilla

Sublingual - below the tongue

List the pairs of Salivary glands

act of swallowing the bolus

What is deglutition?

teeth and tongue cooperate in chewing motions to mx with saliva - initiate the mechanical part of digestion

What is mastication?

Nasopharynx

Oropharynx

Laryngopharynx

What are the three parts of the pharynx?

oropharynx

Which part of the pharynx is epiglottis attached to?

depresses over the laryngeal opening - respiration is inhibited

What does the epiglottis do during swallowing?

about 10 inches and 3/4 inches in diameter

How long is the esophagus?

Begins posterior to the level of the lower border of the cricoid cartilage of the larynx (C5-C6)

Terminates at the connection to the stomach around T11

At what level does the esophagus start and end?

T10

At what level does the esophagus pass through the diaphragm?

True

T/F: The esophagus is posterior to the trachea.

Esophagus

IVC

Aorta

Three diaphragmatic opening

Cardiac antrum

What is the abdominal segments of the esophagus called?

Esophagogastric junction, Gastroesophageal junction or cardiac orifice

What is the opening between the esophagus and stomach called?

wavelike series of involuntary muscular contractions propelling solids and semisolid materials through the alimentary canal

Define peristalsis

stomach

What is the most dilated portion of the alimentary canal?

serves as reservoir for swallowed food and fluid - can expand

What is the function of the stomach?

longitudinal folds in the internal lining of the stomach

- assist with mechanical digestion of food within the stomach

What are rugae?

formed by rugae along the lesser curvature that funnels fluid directly from the body of the stomach to the pylorus

What is the gastric canal?

fundus

What is the most posterior aspect of the stomach?

Pylorus

What is the most posterior portion of the stomach?

- fundus (highest portion) filled with air

- pylorus filled with barium

If a patient is prone describe where the barium and air would be within the stomach.

- fundus is the filled with barium

- pylorus if filled with air

If a patient is supine describe where the barium and air would be within the stomach.

- air in the fundus and barium in the pyloric portion (air/barium line is straight)

If a patient is erect describe where the barium and air would be within the stomach.

duodenum

What is the first part of the small intestine?

head of pancreas sits in the C loop of duodenum

What is the romance of the abdomen?

T

T/F: Duodenum is a retroperitoneal part of the small intestine.

Shortest, widest, and most fixed portion of the small bowel.

Describe the duodenum.

Superior (first)

Descending (second)

Horizontal (third)

Ascending (fourth)

Duodenojejunal flexure

List the parts of the duodenum

4-8 seconds - solids

1 second - liquids

How long does it take for solids and liquids to pass from mouth to stomach?

semifluid mass in the stomach

What is chyme?

2-6 hours

- protein/fat move slower than carbs

- movement by mixing and peristalsis

About how long does chyme remain in the stomach?

3-5 hours

Rhythmic segmentation (churning) and peristalsis

How long for the small intestine?

- 5% of population (massive body build)

- abdomen broad and deep, diaphragm high, transverse colon high

- GB high and transverse

- stomach is high and almsot transverse (T9-T12)

- center of stomach is about 1 inch distal to xiphoid tip

- duodenal bulb about T11-T12

Describe the abdomen, stomach, and GB in a hypersthenic patient.

- Almost opposite

- More slender, narrower, low diaphragm

- Large intestine very low

- Stomach is J shaped (T11- to iliac crests or L5)

- Duodenal bulb (L3-L4)

- GB - L3-L4

Describe the abdomen, stomach, and GB in a hyposthenic/Asthenic patient.

- Average body build

- Stomach is somewhat J shaped (T10 or T11 down to L2)

- Duodenal bulb - L1, L2

- GB - less transverse

- Splenic flexure quite high

Describe the abdomen, stomach, and GB in a Sthenic patient.

1-2 inches

How far do the parts of the abdomen drop when in the erect position?

False - Barium is a colloidal suspension and never dissolves in water

T/F: Barium dissolves in water.

Perforated hallow viscus

Presurgical Procedure

What are the contraindications of barium?

Perforated hallow viscus or presurgical procedure

What are the clinical indications for water soluble iodinated contrast media?

hypersensitivity to iodine

Contraindications of water soluble iodinated contrast media

T

T/F: Isovue moves through the alimentary canal faster than barium.

- Anatomical anomalies - congenital or disease caused like a stroke

- Esophageal reflux (GERD)

- Barretts Esophagus - mid to distal esophagus erodes away, precursor for cancer

- Esophageal varices - cirrhosis of liver, causes enlargement of veins

- Foreign body obstruction - fish bones

- Dysphagia - Impaired swallowing mechanism

- Carcinoma of esophagus

- Zenker Diverticulum - outpouching of esophageal lining due to weakening

List clinical indications of a Esophagogram

- Breathing Exercises (two types)

o Valsalva Maneuver – deep breathing bear down like moving bowels – forces air against closed glottis

o Mueller Maneuver – exhales then tries to inhale against closed glottis

o Increase of intraabdominal pressure may produce reflux

- Water Test

o Esophagogastric junction regurgitation

o Supine – LPO position – fundus fill with barium – significant barium regurgitates into the esophagus from the stomach

- Compression Technique

o Esophageal reflux – pt prone, compression paddle inflated against stomach region

- Toe-Touch Maneuver

o Investigate cardiac orifice, hiatal hernias, reflux as pt bends over touches toes

What are the 4 techniques in diagnosing esophageal reflux?

- Peptic ulcer - erosions of the stomach or duodenal mucosa

- Hiatal hernia -portion of stomach herniates through diaphragm sliding hernia (Schatzki's ring)

- HPS (hypertrophic pyloric stenosis - most common gastric obstruction in infants

- Diverticula - outward pouching

- Gastritis - inflammation of the lining of the stomach

- Tumor -Gastric adenomas adenomcarcinomas - 95%

- Bezoar - masses that are not digested and built up - hair, fibers, seeds,

- Emesis (hematoemeis)

Clinical indications of an UGI series

- determine pregnancy

- NPO for 8 hours

What is the patient prep for an UGI series?

1) Clinical history - review clinical history with patient and documentation

2) Body habitus - affects positioning

3) Fluoroscopy - identifying positioning landmarks

4) High kVp - 100-125 single or 90-100 for double - short exposure time

What are some imaging considerations for UGI.

90-100 kVp

What kVp would we use for a double contrast UGI?

RAO, Lateral, AP (PA)

Routine projections for an Esophagogram post-fluoro

LAO & Soft tissue lateral

Special projections for an esophagogram post-fluoro

Puts Esophagus between vertebral column and the heart

Why is an RAO esophagogram preferred over an LAO?

35-40 degrees

How much should the patient be obliqued for an RAO esophagogram?

2 inches above the shoulders

What is the IR for an RAO esophagogram?

CR to T5-T6 (2-3 inches inferior to jugular notch or 1 inch inferior to the sternal angle)

What is the CR for an RAO esophagogram?

3 swallows - thick barium bolus or continuous thin barium

How many swallows of barium should be taken before an projection?