2-Investigations of the G.I. diseases.ppt

GIT LECTURE 2

1. DR JABBAR JASIM

2. Diagnostic Procedures in GI Diagnostic Procedures in GI
DiseasesDiseases
The gastrointestinal system
includes the GI tract and its
associated glands
1.Esophagus
2. Stomach
3. Small intestine
4.Colon
5.Liver & Biliary tree
6. Pancreas

3. Diagnostic Procedures in GI Diagnostic Procedures in GI
DiseasesDiseases

The diagnostic tests can be divided into several
categories:
1.Structural tests
2.Functional tests
3.Tests for Helicobacter pylori
4.Special blood tests
5.Special stool tests

4. Diagnostic Procedures in GI Diagnostic Procedures in GI
DiseasesDiseases
Structural Tests
1.Radiography
2.Ultrasonography
3.Nuclear Isotope Scanning
4.Magnetic Resonance Imaging
5.Gastrointestinal Endoscopy
6.Endoscopic Ultrasonography

5. Plain X RayPlain X Ray::

Show gas within bowel for diagnosis of
Intestinal obstruction if there are dialated loops
or fluid levels in the erect position.

Soft tissue of the liver, spleen& kidneys &
calcifications in these organs, pancrease , blood
vessels, LNs , calculi.

Chest XR in erect position show air under
diaphragm in perforated viscus

Abdominal radiographs are not useful in Abdominal radiographs are not useful in
GIT bleeding GIT bleeding

6. Normal Plain
Abdominal
Radiograph

7. Normal Plain
Abdominal
Radiograph
showing the
identification
of transverse
colon

8. Air under the
diaphragm
(perforated DU)

9. Small Intestinal
obstruction
(multiple fluid levels)

10. Hiatus hernia
(fluid levels behind
the heart)

11. Calcification of the
pancreas
(chronic pancreatitis)

12. Toxic megacolon

13. Contrast studiesContrast studies

Barium & double-cnotrast barium using air with
barium, will show filling defects, strictures, erosions &
ulcers & even motlity disorders if under fluroscopy.

14. 
Indications:Indications:
•DysphagiaDysphagia
•Heart burn Heart burn
•Chest pain Chest pain
•Possible motility disorders Possible motility disorders

Major uses:Major uses:
•Strictures Strictures
•Hiatus hernia Hiatus hernia
•GERDGERD
•Motility disorders e.g. Motility disorders e.g.
achalasia achalasia

Limitations:Limitations:
•Risk of aspiration Risk of aspiration
•Poor mucosal detailPoor mucosal detail
•Unable to biopsyUnable to biopsy

16. Esophageal varices
as seen by barium
swallow

17. Esophageal
carcinoma

18. Epiphrenic
diverticulum as
shown by
barium swallow

19. 
Indications:Indications:
•Dyspepsia Dyspepsia
•Epigastric pain Epigastric pain
•Anemia Anemia
•Vomiting Vomiting
•Possible perforation Possible perforation

Major uses:Major uses:
•GU, DU. GU, DU.
•Gastric cancerGastric cancer
•Outlet obstruction Outlet obstruction
•Gastric emptying disordersGastric emptying disorders

Limitations:Limitations:
•Low sensitivity for early cancer Low sensitivity for early cancer
•Unable to biopsy or assess H pyloriUnable to biopsy or assess H pylori

20. Duodenal
bulb
Descending
duodenum
Ascending
duodenum

21. Gastric ulcer

22. Gastric ulcer

24. Duodenal ulcer

25. 
IndicationsIndications::
•Diarrhea & abdominal Diarrhea & abdominal
pain of small bowel pain of small bowel
origin origin
•Possible obstruction by Possible obstruction by
strictures etcstrictures etc. .

Major uses:Major uses:
•Malabsorption Malabsorption
•CrohnCrohn’’s diseases disease

Limitations:Limitations:
•Time consuming Time consuming
•Radiation exposureRadiation exposure. .

27. Chronic intestinal
psuedoobstruction

28. Intestinal
Tuberculosis
At diagnosis
Intestinal
Tuberculosis
(after 5 months of
therapy)

29. Early
stenosing
Crohn’s
disease

30. Crohn’s
disease

31. 
Indications:Indications:
•Altered bowel habitAltered bowel habit
•Rectal bleeding Rectal bleeding
•Anemia Anemia

Major uses:Major uses:
•Neoplasia Neoplasia
•Diverticulosis Diverticulosis
•Strictures Strictures
•MegacolonMegacolon

Limitations:Limitations:
•Difficult in frail elderly or Difficult in frail elderly or
incontinent patients incontinent patients
•Sigmoidoscopy is also Sigmoidoscopy is also
necessary necessary
•Possibly misses polyps < 1 cmPossibly misses polyps < 1 cm
•Less useful in Infl B.D.Less useful in Infl B.D.

32. Scattered
diverticulosis
of the left
colon

33. Double
contrast
barium
enema
(normal)

34. Barium enema showing familial adenomatosis coli
Arrow point to cancer arise in this setting

35. Pancolonic
diverticulosis

36. Chronic
Ulcerative Colitis

38. 
Major uses:Major uses:
•Abdominal massesAbdominal masses
•Organomegaly Organomegaly
•Ascites Ascites
•Biliary tract dilatation Biliary tract dilatation
•Gallstones Gallstones
•Guided needle aspiration & biopsy of Guided needle aspiration & biopsy of
lesions lesions

Limitations:Limitations:
•Low sensitivity for small lesionsLow sensitivity for small lesions
•Little functional information Little functional information
•Operator dependant Operator dependant
•Gas & obesity may obscure view Gas & obesity may obscure view

39. 
Major uses:Major uses:
•Assessment of pancreatic Assessment of pancreatic
disease disease
•Hepatic tumor depositsHepatic tumor deposits
•Tumor staging Tumor staging
•Assessment of vascularity Assessment of vascularity
of lesions. of lesions.

Limitations:Limitations:
•Expensive Expensive
•High radiation dose High radiation dose
•May understage some May understage some
tumors like esophago-tumors like esophago-
gastricgastric

40. 
Major uses:Major uses:
•Hepatic tumor staging Hepatic tumor staging
•MRCPMRCP
•Pelvic/perianal CrohnPelvic/perianal Crohn’’s s
fistulaefistulae

Limitations:Limitations:
•Role in GIT disease not Role in GIT disease not
fully established fully established
•Limited availability Limited availability
•Time consuming Time consuming
•““ClaustrophobicClaustrophobic”” for some. for some.
•Contraindicated in Contraindicated in
presence of metallic presence of metallic
prosthesis, cardiac prosthesis, cardiac
pacemaker. pacemaker.

41. Tests of structure: Tests of structure:
ENDOSCOPYENDOSCOPY

Endoscpy:
1.UGI,
2.LGI,
3.Enteroscopy,
4.ERCP,
5.EUS ,
6.Double balloon endoscopy,
7.capsule video endoscopy.

Increasingly used for abd diseases, noninvasive & offer
detailed images of abd contents.

42. Examples of therapeutic techniques in endoscopyExamples of therapeutic techniques in endoscopy..

43. Gastrointestinal EndoscopyGastrointestinal Endoscopy
Types of Gastrointestinal Endoscopy
1.Esophagogastroduodenoscopy (Upper GI Endoscopy)
2.Small Bowel Enteroscopy (Jejunoscopy)
3.Colonoscopy (Lower GI Endoscopy)
4.Sigmoidoscopy
5.Endoscopic Retrograde Cholangiopancreatogram (ERCP)

46. Video endoscopy
unit

47. Gastrointestinal EndoscopyGastrointestinal Endoscopy

Direct method to examine and biopsy
the mucosal lining of the
gastrointestinal tract

Various accessories are available to
take biopsies and provide therapy

48. Upper Gastrointestinal EndoscopyUpper Gastrointestinal Endoscopy
Diagnostic Indications
1.Heartburn
2.Dysphagia or odynophagia
Hematemesis or melena
3.Dyspepsia or upper abdominal
pain
4.Unexplained weight loss or
anemia
5.Evaluation of abnormal Barium
meal X-ray
6.Suspected malabsorption
Therapeutic Indications
1.Control of bleeding
2.Dilation of stricture
3.Removal of foreign bodies
4. Removal of polyps
5.Tumor ablation

49. Upper Gastrointestinal EndoscopyUpper Gastrointestinal Endoscopy
Contraindications to Upper GI Endoscopy
1.Uncooperative patient
2.Hemodynamically unstable patient:
a)Recnet AMI,
b)Unstable angina or
c)arrhythmia,
d)Severe resp dis.
3.Suspected perforation
4.Severe RA of the cervical spine
5.Severe shock.
6.Atlanto axial sublaxation.

These may be relative in experienced hands.

50. Upper Gastrointestinal EndoscopyUpper Gastrointestinal Endoscopy

51. Upper Gastrointestinal EndoscopyUpper Gastrointestinal Endoscopy
Normal
Esophagus
Normal
Stomach
Normal
Duodenum
Duodenal UlcerGastric UlcerEsophagitis

52. Normal
esophagus

53. Esophageal
Diverticulum

54. Malignant
esophageal
lesion

55. Esophageal
varices

56. Barrett’s
Esophagus

57. Achalasia

58. Esophageal Ulcer
HIV patient

61. Normal
Colonscopy

62. Lower Gastrointestinal EndoscopyLower Gastrointestinal Endoscopy
1.Chronic diarrhea
2. Rectal bleeding
3.Iron deficiency anemia
4.Unexplained abdominal
pain
5.Constipation, change in
bowel habits or stool
caliber
6.Unexplained weight loss
7.Evaluation of abnormal
Barium enema x-ray
8.Personal or family history
of colon cancer
9.Personal history of IBD
Diagnostic Indications
Therapeutic Indications
1.Control of bleeding
2.Removal of polyps
3.Tumor ablation
4.Dilation of stricture
5. Colonic decompression
6.Reduction of sigmoid volvulus

63. Lower Gastrointestinal EndoscopyLower Gastrointestinal Endoscopy
Contraindications to Lower GI Endoscopy
1.Uncooperative patient
2.Hemodynamically unstable patient
3. Suspected perforation
4.Suspected colonic obstruction
5.Suspected diverticulitis
6.Soon after a myocardial infarction

64. Lower Gastrointestinal EndoscopyLower Gastrointestinal Endoscopy

65. Lower Gastrointestinal EndoscopyLower Gastrointestinal Endoscopy
Normal Colon Colon Cancer
Colon Polyp and Polypectomy

66. Endoscopic Retrograde CholangiopancreatogramEndoscopic Retrograde Cholangiopancreatogram
Indications
1.Obstructive jaundice (benign
or malignant)
2.Ascending cholangitis
3.Gallstone pancreatitis
4.Unexplained jaundice or
elevated LFT’s
5.Bile duct injury or leak after
cholecystectomy
6.Chronic pancreatitis
7.Pancreatic cancer
8.Suspected Sphincter of Oddi
dysfunction

67. Endoscopic Retrograde CholangiopancreatogramEndoscopic Retrograde Cholangiopancreatogram
Gallstone impacted at ampulla, sphincterotomy being done and stones
removed

68. Endoscopic Retrograde Cholangiopancreatogram
Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct
sign)

69. Endoscopic UltrasoundEndoscopic Ultrasound

The ultrasound probe is placed
at the tip of the endoscope

Allows ultrasonography of
organs from a close distance

Allows close evaluation of the
bowel wall

Can be used to take fine needle
aspiration samples from
adjoining regions/organs

70. Endoscopic Ultrasound
A T3 Rectal Tumor on EUS

71. Capsule EndoscopyCapsule Endoscopy

72. Capsule EndoscopyCapsule Endoscopy

73. Capsule EndoscopyCapsule Endoscopy
1.Capsule endoscopy is intended for visualization of the small
bowel mucosa
2.It may be used as a tool in the detection of abnormalities of
the small bowel in adults and children from 10 years of age
and up
Diagnostic Indications
Contraindications
Capsule endoscopy is contraindicated for use under the following
conditions:
1.In patients with known or suspected gastrointestinal
obstruction, strictures, or fistulas based on the clinical
picture or pre-procedure testing and profile
2.In patients with cardiac pacemakers or other implanted
electromedical devices
3.In patients with swallowing disorders

74. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Functional Tests
1.Tests for motility
2.24 hour pH monitoring
3.Tests for acid output
4.Tests for malabsorption
5.Tests for pancreatic function

75. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
Tests for motility
1.Esophageal Manometry
2.24 Hour pH Monitoring
3.Anorectal Manometry

76. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
Indications for Esophageal Manometry

Oropharyngeal dysphagia with normal structural studies
1.Cricopharyngeal achalasia,
2.Pharyngeo-UES dyscoordination

Esophageal dysphagia with normal structural studies
1.Primary esophageal body dysmotility e.g. Achalasia,
Diffuse esophageal spasm, Nutcracker esophagus,
2.Hypertensive LES,
3.Collagen vascular disease,
4.Amyloidosis,
5.Hypothyroidism, etc.

Noncardiac chest pain

77. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
Esophageal Manometry Tracings
Esophageal Manometry

78. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
24 Hour pH Monitoring
1.Patients with non cardiac chest pain
2.Refractory acid reflux symptoms: evaluate treatment efficacy
3.Pre and post-operative evaluation of antireflux surgery
4.Patients with atypical presentations of acid reflux (ENT, pulmonary)
Indications

79. Functional Tests in GI Diseases
24 Hour pH Monitoring

80. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
Anorectal Manometry

Used in the clinical assessment of patients in whom a problem
with defecation is suspected

This technique is helpful in evaluating the anorectal sphincter
mechanism

Contraindicated in the presence of an anal fissure, since the
resting anal pressure is abnormally high

81. Functional Tests in GI Diseases
Anorectal Manometry

82. Tests of structure: Tests of structure:
BiopsyBiopsy

Obtained through endoscpy or
percutanously & sent for histopath exam.


Reasons for biopsy or cytological exams:
1.Brash cytology of suspected
malignant lesions. Histological
assessment of mucosal abns.
2.Diagnosis of infections( candida,
HP, Giardia).
3.Measure enzymes as
disacharidases.
4.Analysis of genetic mutations as
oncogenes , tumor suppressor
genes.

83. Tests of infection: Tests of infection:
Bacterial culturesBacterial cultures
For identifying causes of diarrhea sp
if acute or bloody. Causes of infective
diarrhea:
1.Viruses: Rota, adeno, entero,
requires EM or viral cultures.
2.Bacteria: Campylo jej, EC,
Salmonella, clostridium difficile
( ned toxine isolation).
3.Protozoa: Giardia, ameba,
cryptosporidium & microspore.

84. Functional Tests in GI DiseasesFunctional Tests in GI Diseases
Tests for Malabsorption
1.Serum screening tests for malabsorption
•S. Calcium, Albumin, Iron, Vitamin B
12, Folate, Carotene,
Prothrombin time
2.Quantitative fecal fat determination
•D-xylose absorption test
3.Small bowel biopsy
4.Schilling test for Vitamin B
12
absorption
5.Hydrogen Breath Test for lactose intolerance

85. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Liver Biopsy

Liver biopsy is a diagnostic procedure used to obtain a small
amount of liver tissue which can be examined under a
microscope to help identify the cause or stage of liver disease

The most common way a liver biopsy is obtained is by inserting a
needle into the liver percutaneously

Other ways to biopsy the liver are transjugular, laparoscopic and
surgical

In case of a localized lesion in the liver a US or CT guided biopsy
is performed

86. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases

87. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases

89. 
Stool cultures are essential in the Stool cultures are essential in the
investigation of diarrhea, espicially investigation of diarrhea, espicially
when it is acute or bloody, to identify when it is acute or bloody, to identify
pathogenic organism. pathogenic organism.

Detection of antibodies plays a Detection of antibodies plays a
limited role in the diagnosis of GIT limited role in the diagnosis of GIT
infection caused by organism like H infection caused by organism like H
Pylori, Salmonella species, and E. Pylori, Salmonella species, and E.
histolytica. histolytica.

90. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
Non-invasive
•C13 or C14 Urea Breath Test
•H. pylori IgG titer (serology)
•Stool antigene for H Pylori.
Invasive
•Gastric mucosal biopsy
•Rapid Urease test

91. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
C
13
or C
14
Urea Breath Test

92. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
Mucosal Biopsy

93. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
Rapid Urease Test
•

This test is based on the This test is based on the
urease enzyme present in urease enzyme present in
thethe

H. pyloriH. pylori
Urea is split into NHUrea is split into NH
3 3 and and COCO
22
The change in pH causes The change in pH causes
a color change in the mediuma color change in the medium

94. Diagnostic Procedures in GI DiseasesDiagnostic Procedures in GI Diseases

Blood testsBlood tests
1.1.Liver function tests (LFT’S)Liver function tests (LFT’S)
2.2.Hepatitis serologyHepatitis serology
3.3.S. Amylase & LipaseS. Amylase & Lipase
4.4.Alfa-Feto Protein (AFP)Alfa-Feto Protein (AFP)
5.5.Carcino-Embryonic Antigen Carcino-Embryonic Antigen
(CEA)(CEA)

Stool tests
1.Stool microscopy
2.Stool ova & parasites Stool
culture
3.Stool C. difficile toxin
4.Stool occult blood