Unit 4 - Lower GI Tract Pathology

What is small bowel obstruction associated with?

Dilated bowel loops proximal to site of obstruction

What are the symptoms for a patient with a SB obstruction?

• Epigastric pain

• Distention

What are the ultrasound findings of a small bowel obstruction?

• Tubular or round echo-free

• 6% fluid-filled

• Compressibility of bowel

What is the differential diagnosis for a SB obstruction?

Appendicitis

What is this image showing?

SB obstruction / dilation

What is this image showing?

SB obstruction / dilation

Fluid filled loops are not ALWAYS associated with obstruction. Could be from:

• Over hydration

• Gastroenteritis

• Paralytic ileus

• Dilated, fluid-filled loops without peristalsis

Sonographer needs to demonstrate …. in relation to fluid-filled loops

Pliability & compressibility of the bowel wall

How is Acute Appendicitis caused?

From obstruction & inflammation leading to ischemia of vermiform appendix

Acute Appendicitis results in: (6)

• Edema

• Compromised vascular supply – necrosis

• Increase in bacteria – infection & inflammation

• Rupture (perforation)

• Abscess

• Peritonitis

During Acute Appendicitis, the lumen becomes obstructed from:

• Fecal material – fecalith

• Appendicolith

• Inflammation

• Mucocele

• Foreign body

• Carcinoma of cecum

• Kinking

What are the symptoms for Acute Appendicitis?

• RLQ pain

• Rebound tenderness over McBurney’s point

• N, V, D

• Anorexia

• Fever

What lab work may demonstrate Acute Appendicitis?

A high WBC = leukocytosis

Acute Appendicitis is more common at _______ _____

Younger ages

What are the differential diagnoses for Acute Appendicitis?

• Acute gastroenteritis

• Mesenteric lymphadenitis in children

• Ruptured ectopic pregnancy

• Mittelschmerz

• Inflammation of Meckel’s diverticulum

• Regional Enteritis

• Right ovarian cyst or torsion

What lab work is done to check for Acute Appendicitis?

• CBC

  • Checking for elevated WBC = leukocytosis

• Pregnancy test (if female in reproductive age)

• Thorough history & examination necessary

What is the gender and age of people that are at a high risk of misdiagnosis of acute appendicitis?

Women in their 20-40s

In what group patients is Acute Appendicitis hard to diagnose?

• Obese

• Older

The appendix is found _______

Retrocecal

What is the normal outside diameter of the appendix?

< or = 6mm

What is the normal wall measurement of the appendix?

< or = 2-3mm

What is the normal length of the appendix?

1-9 inch (average 3 in.)

What should you identify in a normal appendix?

• Blind end of the appendix

• If it is compressible

• Graded compression over McBurney’s point

When looking at the appendix you should image with what transducer(s)?

• Curvilinear

• High frequency linear

This is a transverse view of the appendix, but the location of the transducer is…

Longitudinal to the body

How might you identify an Inflamed Appendix/Appendicitis?

• Target lesion in RLQ

• Thickening of bowel wall

  • From edema

• Noncompressible mass

• Lack of peristalsis

• Appendicolith (calcifications)

• Hyperemic

• May be fluid or abscess collection

• Evaluate quadrants looking for free fluid

What is the abnormal diameter for a appendix?

> 6mm

What is the abnormal wall thickness?

>2mm

What is this image showing?

Fluid within the appendix

What is Mucocele?

(Rare pathology) Gross enlargement of appendix due to accumulation of mucoid substance within lumen

What are the 3 classifications of Mucocele?

• Mucosal Hyperplasia

• Mucinous Cystadenoma

• Mucinous Cystadenocarcinoma

What is Mucosal Hyperplasia?

Over growth

What is Mucinous Cystadenoma?

Cystic benign legion or neoplasm causing an enlargement

What is Mucinous Cystadenocarcinoma?

Malignant tumor in appendix

What are the symptoms for Mucocele?

• RLQ pain

• 25% are asymptomatic

What lab work can be done to check for Mucocele?

• CBC

  • Increased WBC

• Erythrocyte sedimentation rate

• CEA (may be elevated) – cancer marker

What are the ultrasound findings for Mucocele?

• Cystic mass, Well-defined hypoechoic mass with fine internal echoes

• Complex mass with high-level echoes

• Calcification possible

What is the differential diagnosis for mucocele?

Appendicitis

What is this image showing?

Mucocele

Primary adenocarcinomas are ______, but may present as ________ _______ with perforation

RARE, acute appendicitis

Mucocele is a malignant or benign mass?

Benign

What is Meckel’s Diverticulum?

Pouchlike herniation in the distal ileum

What are the symptoms for Meckel’s Diverticulum?

• Obstruction

• Rectal bleeding

• Tenderness

• Diverticular inflammation

• Elevated WBC

What is the differential diagnosis for Meckel’s Diverticulum?

Appendicitis

What is Crohn’s Disease?

Regional Enteritis – regional inflammation

Where does Crohn’s Disease normally affect?

The terminal from the ileum to the cecum

What are the symptoms for Crohn’s Disease?

• Diarrhea

• Fever

• RLQ pain

What are the ultrasound findings for Crohn’s Disease?

• Symmetrically swollen bowel

• Uniformly increased wall thickening

• Rigidity to pressure from transducer

• Absent or sluggish peristalsis

What are the differential diagnoses for Crohn’s disease?

• Appendicitis

• Meckel’s Diverticulum

• Diverticulitis

Is Crohn’s disease a malignant or benign disease?

Benign

Is a Lymphoma tumor benign or malignant?

Malignant

What is Lymphoma?

Multiple nodules/masses, will most likely involve mesenteric vessels

What age does Lymphoma normally occur at?

65 years of age

What is the most common tumor of the GI tract in children? And in what ages?

• Lymphoma

• < 10 years of age

What are the symptoms for Lymphoma?

• Intestinal blood loss

• Weight loss

• Anorexia

• Abdominal pain

• Intestinal obstruction

• Palpable mass

What are the ultrasound findings of Lymphoma?

• Large discrete intraperitoneal mass

• Target pattern

• Lumen may be dilated with fluid

• Frequently involves:

  • Mesenteric vessels & nodes

• Pseudokidney or hydronephrotic pseudokidney

What is this image showing?

A lymphoma

What are the differential diagnoses for a Lyphoma?

• Pseudokidney

• Leiomyosarcoma

What is a Leiomyosarcoma?

Rare, malignant smooth muscle tumor

______ of primary small bowel tumors are _____________

10%, Leiomyosarcoma

Leiomyosarcoma tumors affect what age of people?

50-60s

Leiomyosarcoma are found more commonly in ______ children who are _____ years of age

Male, 8

What are the symptoms for Leiomyosarcoma?

• Abdominal pain

• Palpable mass

What are the ultrasound findings of Leiomyosarcoma?

• Large, solid mass

• Containing necrotic areas anterior to solid viscus

• Color Doppler – demonstrate low-velocity flow in mass

What is the differential diagnosis for Leiomyosarcoma?

Lymphoma