AKALAZYA AKALAZYA Özefagus Motilite Bozukluğudur Özefagus Motilite Bozukluğudur Rare, chronic disorder 1 in 100,000 Affects all ages and both genders Triad: Disfaji-regurjitasyon-kilo kaybı
Achalasia Etiology and Pathophysiology Primer Akalazya Primer Akalazya Sekonder Akalazya Sekonder Akalazya Malignite Malignite Chagas Hastalığı Chagas Hastalığı Diyabet Diyabet
Achalasia Etiology and Pathophysiology Peristalsis of lower two thirds of esophagus absent Peristalsis of lower two thirds of esophagus absent –Impairment of neurons that innervate esophagus –Unopposed contraction of LES LES pressure ↑ LES pressure ↑ Incomplete relaxation of LES Incomplete relaxation of LES Obstruction occurs at/near diaphragm Obstruction occurs at/near diaphragm
Achalasia Etiology and Pathophysiology Gıdalar ve sıvı özefagusta birikir. Gıdalar ve sıvı özefagusta birikir. Özefagus genişler Özefagus genişler
Achalasia Fig. 42-9
Achalasia Clinical Manifestations Symptoms Symptoms –Dysphagia Most common symptom Most common symptom Intermitant Intermitant Paradoxal dysphagia(katı geçer Sıvı geçmez) Paradoxal dysphagia(katı geçer Sıvı geçmez) –Substernal chest pain During/after a meal During/after a meal
Achalasia Clinical Manifestations –Inability to belch –GERD –Regurgitation –Weight loss
Achalasia Clinical Manifestations Gece regurjitasyon Gece regurjitasyon Aspirasyon Aspirasyon Pnömoni Pnömoni Bronşit Bronşit Akciğer abse Akciğer abse
Achalasia Diagnostic Studies Radiologic studies Radiologic studies Manometric studies of lower esophagus Manometric studies of lower esophagus Endoscopy Endoscopy
Achalasia Diagnostic Studies Gögüs grafisi: Gögüs grafisi: Mediastinal genişleme Post. Medias. Hava sıvı seviyesi Post. Medias. Hava sıvı seviyesi Aspirasyon olursa Aspirasyon olursa Pnömoni Pnömoni Bronşit Bronşit Bronşektazi Bronşektazi
Achalasia Komplikasyonlar: Respiratuar sistem en sık Respiratuar sistem en sık Pnömoni Pnömoni Atelektazi, bronşit, abse Atelektazi, bronşit, abse Bronşektazi Bronşektazi Hemoptizi Hemoptizi Etrafa bası Etrafa bası Premalign lezyon(%1-10) Premalign lezyon(%1-10)
Achalasia Treatment Cause unknown Cause unknown Paliative treatment Paliative treatment Goals Goals –Relieve symptoms –Improve esophageal emptying –Prevent development of megaesophagus
Achalasia Treatment Drug therapy Drug therapy –Smooth muscle relaxants –Uzun etkili nitratlar –Ca channel blockers –Nitrogliserin –Botulinum toxin injection 1 to 2 years relief 1 to 2 years relief Symptomatic relief Symptomatic relief –Semisoft diet –Eating slowly –Drinking with meals
Achalasia Treatment Endoscopic pneumatic dilation Endoscopic pneumatic dilation –Outpatient procedure –LES disrupted using balloons of progressively larger diameters –Repeat dilations are often required
Pneumatic dilatation to Treat Achalasia Fig
Achalasia CERRAHİ ENDİKASYON CERRAHİ ENDİKASYON Ciddi özefajit Ciddi özefajit İnfant İnfant Çok ilerlemiş, çok dilate, tortios Çok ilerlemiş, çok dilate, tortios Hasta cerrahi istiyorsa Hasta cerrahi istiyorsa Takibi zor olgularda Takibi zor olgularda
Achalasia Surgical therapy Surgical therapy –Heller myotomy –Zaaijer myotomi –Özefagokardiyal myotomi Done laparoscopically Done laparoscopically LES surgically disrupted LES surgically disrupted Often has antireflux surgery at same time Often has antireflux surgery at same time 1 to 2 weeks for recovery 1 to 2 weeks for recovery Evre 4 olgularda özefajektomi Evre 4 olgularda özefajektomi
Diffüz Özefagus Spazmı Ciddi disfaji, göğüs ağrısı. Ciddi disfaji, göğüs ağrısı. Anjinayı taklit edebilir. Anjinayı taklit edebilir. Stress ile artar. Stress ile artar. Birlikte psikosomatik ağrılar sıktır. Birlikte psikosomatik ağrılar sıktır.
Diffüz Özefagus Spazmı DÖS tanısı manometri ile konur. DÖS tanısı manometri ile konur. AÖS normal AÖS normal Yüksek amplitütlü, hipertonik kontraksiyon Yüksek amplitütlü, hipertonik kontraksiyon Radyoloji: Radyoloji: Daralma,segmenter spazm,türbişon görünümü. Daralma,segmenter spazm,türbişon görünümü. Özefagus duvarında düz kas hipertrofisi. Özefagus duvarında düz kas hipertrofisi.
Diffüz Özefagus Spazmı Tedavi: Tedavi: Drug therapy Drug therapy –Uzun etkili nitratlar –Ca channel blockers –Nitrogliserin –Botulinum toxin injection 1 to 2 years relief 1 to 2 years relief Balon dilatation Balon dilatation
Diffüz Özefagus Spazmı Cerrahi Tedavi: Medikal tedavi başarısız ise Epiprenik divertikül oluşmuş ise Cerrahi Teknik; Tercihen laparoskopik Uzun bir özefagomyotomi
Esophageal Diverticula Esophageal Diverticula Saclike outpouchings of one or more layers of esophagus Saclike outpouchings of one or more layers of esophagus
Esophageal Diverticula Esophageal Diverticula Occur in three main areas Occur in three main areas –Zenker’s diverticulum Most common location Most common location –Traction diverticulum Near esophageal midpoint Near esophageal midpoint –Epiphrenic diverticulum Above the LES Above the LES
Sites for Occurrence of Esophageal Diverticula
Esophageal Diverticula Clinical Manifestations Traction diverticulum: May not have signs and symptoms Traction diverticulum: May not have signs and symptoms Symptoms Symptoms –Dysphagia –Regurgitation –Chronic cough –Aspiration –Weight loss
Esophageal Diverticula Surgery Surgery Zenker: Zenker: Krikofaringeal myotomi Krikofaringeal myotomi >2 cm ise Divertikülektomi+Krikofaringeal myotomi >2 cm ise Divertikülektomi+Krikofaringeal myotomi
Hiatal Hernia Herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm Herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm
Hiatal Hernia Two types Two types –1. Sliding Stomach slides into thoracic cavity when supine, goes back into abdominal cavity when standing upright Stomach slides into thoracic cavity when supine, goes back into abdominal cavity when standing upright Most common type Most common type GÖ bileşke diyafragmanın üstüne çıkmıştır. GÖ bileşke diyafragmanın üstüne çıkmıştır.
Hiatal Hernia –2. Paraesophageal or rolling Esophageal junction remains in place, but fundus and greater curvature of stomach roll up through diaphragm Esophageal junction remains in place, but fundus and greater curvature of stomach roll up through diaphragm FOL kusurlu FOL kusurlu Yaşlılarda sık Yaşlılarda sık
Hiatal Hernia Clinical Manifestations May be asymptomatic May be asymptomatic Symptoms include Symptoms include –Heartburn After meal or lying supine After meal or lying supine –Dysphagia
Hiatal Hernia Diagnostic Studies Barium swallow Barium swallow –May show protrusion of gastric mucosa through esophageal hiatus Endoscopy Endoscopy –Visualize lower esophagus –Information on degree of inflammation or other problems
Hiatal Hernia Complications GERD GERD Esophagitis Esophagitis Hemorrhage from erosion Hemorrhage from erosion Stenosis Stenosis Ulcerations of herniated portion Ulcerations of herniated portion
Hiatal Hernia Complications Strangulation of hernia Strangulation of hernia Regurgitation with tracheal aspiration Regurgitation with tracheal aspiration Increased risk of respiratory problems Increased risk of respiratory problems
Hiatal Hernia Surgical Therapy Reduction of herniated stomach into abdomen Reduction of herniated stomach into abdomen Herniotomy Herniotomy –Excision of hernia sac Herniorrhaphy Herniorrhaphy –Closure of hiatal defect
Hiatal Hernia Surgical Therapy Antireflux procedure Antireflux procedure Gastropexy Gastropexy –Attachment of stomach subdiaphragmatically to prevent reherniation
Hiatal Hernia Surgical Therapy Laparoscopically performed Nissen and Toupet techniques are standard antireflux surgeries Laparoscopically performed Nissen and Toupet techniques are standard antireflux surgeries Thoracic or open abdominal approach used in select cases Thoracic or open abdominal approach used in select cases
Nissen Fundoplication Fig. 42-5
GERH Reflü sonucunda distal özefagusta oluşan kimyasal özefajit. Reflü sonucunda distal özefagusta oluşan kimyasal özefajit. GERH 3 neden GERH 3 neden AÖS mekanik bozukluğu AÖS mekanik bozukluğu Yetersiz özefagus temizlenmesi Yetersiz özefagus temizlenmesi İntragastrik basınç artışı İntragastrik basınç artışı
GERH AÖS 3 komponent var AÖS 3 komponent var 1. Total uzunluk 2 cm olmalı 1. Total uzunluk 2 cm olmalı 2. Abdominal uzunluk 1 cm olmalı 2. Abdominal uzunluk 1 cm olmalı 3. İstirahat basıncı >6 mmHg 3. İstirahat basıncı >6 mmHg
GERH Üst GIS grafi Üst GIS grafi Endoskopi Endoskopi Özefagus manometri Özefagus manometri 24 saat özefagus pH testi 24 saat özefagus pH testi
GERH Üst GIS grafi Üst GIS grafi Anatomik yapının belirlenmesinde Anatomik yapının belirlenmesinde Özefagus-kardiya diyafragma ilişkisi Özefagus-kardiya diyafragma ilişkisi Endoskopi Endoskopi Diğer patolojilerin ekarte edilmesinde Diğer patolojilerin ekarte edilmesinde Özefajit tespitinde Özefajit tespitinde Özefagus manometri Özefagus manometri 24 saat özefagus pH testi 24 saat özefagus pH testi
Esophageal Cancer Adenocarcinomas Adenocarcinomas –Arise from glands lining esophagus –Resemble cancers of stomach and small intestine –30% to 70% of esophageal cancers –Incidence in distal esophagus currently ↑ Squamous cell Squamous cell –Incidence currently ↓ in United States
Esophageal Cancer Etiology and Pathophysiology Risk factors Risk factors –Smoking –Excessive alcohol intake –Barrett’s esophagus –Diets low in fruits and vegetables –Plummer Wilson sendromu –Lökoplaki –Mantar toksinleri vb.
Esophageal Cancer Etiology and Pathophysiology Risk factors (cont’d) Risk factors (cont’d) –Certain minerals and vitamins –Exposure to lye, asbestos, and metal –History of achalasia
Esophageal Cancer Etiology and Pathophysiology Majority of tumors located in middle and lower portion of esophagus Majority of tumors located in middle and lower portion of esophagus Malignant tumor Malignant tumor –Usually appears as ulcerated lesion –Obstruction in later stages
Esophageal Cancer Clinical Manifestations Symptom onset is late Symptom onset is late Progressive dysphagia is most common( Sıvı geçer katı geçmez) Progressive dysphagia is most common( Sıvı geçer katı geçmez) –Initially with meat, then soft foods and liquids Pain develops late Pain develops late –Substernal, epigastric, or back areas Increases with swallowing Increases with swallowing May radiate May radiate
Esophageal Cancer Clinical Manifestations Weight loss Weight loss Regurgitation of blood-flecked esophageal contents Regurgitation of blood-flecked esophageal contents
Esophageal Cancer Diagnostic Studies Endoscopy with biopsy Endoscopy with biopsy –Necessary for definitive diagnosis Endoscopic ultrasonography (EUS) Endoscopic ultrasonography (EUS) –Important tool to stage Barium swallow with fluoroscopy Barium swallow with fluoroscopy
Esophageal Cancer Diagnostic Studies Computed tomography (CT) Computed tomography (CT) Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) PET PET Bronchoscopic examination Bronchoscopic examination –Detect involvement of lung
Esophageal Cancer Complications Hemorrhage Hemorrhage –If erodes into aorta Esophageal perforation with fistula formation Esophageal perforation with fistula formation Esophageal obstruction Esophageal obstruction Metastasis Metastasis –Liver and lung common
Esophageal Cancer Surgical procedures Surgical procedures –Esophagectomy Removal of part or all of the esophagus Removal of part or all of the esophagus –Esophagogastrostomy Resection of a portion of esophagus and anastomosis of remaining portion to stomach Resection of a portion of esophagus and anastomosis of remaining portion to stomach
Not candidates for surgery Radiation alone Radiation alone Combination chemoradiation Combination chemoradiation
Chemoradiation Additional 69 patients were treated with the same combined therapy and were analyzed. Additional 69 patients were treated with the same combined therapy and were analyzed. Similar results were obtained Similar results were obtained –Median survival : 17.2 months –3-year survival : 30% –5 yr survival :14%
NORMAL ESOPHAGUS Normal double contrast esophagram (barium coating and air distention) Effervescent granules release air with ingestion.
PATHOLOGY/RADIOLOGY CORRELATION X ray image Pathology image
ESOPHAGEAL CANCER Typical squamous cell carcinoma Poor prognosis from local extension into critical mediastinal structures. (esophagus lacks a serosa).
ESOPHAGEAL CANCER Distal malignancy may be adenocarcinoma due to Barrett’s esophagus - dysplastic change caused by chronic reflux of gastric contents.
CT ESOPHAGEAL CANCER CHEST CT PET/CT
ESOPHAGEAL VARICES LINEAR TUBULAR FILLING DEFECTS represent distended veins from shunting due to cirrhosis and portal hypertension
Extensive NODULAR filling defects in the esophagus in an immunocompromised patient are typical for candida esophagitis. Extensive NODULAR filling defects in the esophagus in an immunocompromised patient are typical for candida esophagitis. CANDIDA ESOPHAGITIS
Barium filled esophagus ACHALASIA Distended esophagus with distal stricture due to Achalasia - Failure of lower sphincter to relax – causing obstruction. Etiology is unknown. BIRD BEAK APPEARANCE Stricture due to cancer or reflux caused scarring have to be considered first.
Esophagus shows a linear tear of mucosa of distal esophagus due to vomiting with barium tracking into the wall. Full thickness tear or rupture (Boerhaave’s syndrome) can lead to mediastinitis and death. MALLORY-WEISS TEAR
NORMAL ESOPHAGUS DIAPHRAGM HIATAL HERNIA DIAPHRAGM *Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus.
HIATAL HERNIA L CXR FINDINGS Mass on chest X- ray posterior to heart may be a large hiatal hernia.
CT HIATAL HERNIA
SMALL BOWEL OBSTRUCTION ERECT Multiple Dilated Loops of Small Bowel with Air/Fluid Levels Present at Different Heights Ng tube
SMALL BOWEL OBSTRUCTION
String of Pearls Sign UPRIGHT
PARTIAL SMALL BOWEL OBSTRUCTION DILATED BOWEL NON DILATED BOWEL OBSTRUCTION * Proximal loops are dilated and distal loops are collapsed indicating an obstruction. ZONE OF TRANSITION
Proximal loops are dilated and distal loops are collapsed indicating an obstruction. Obstruction most likely due to adhesions in a patient with history of abdominal surgery ZONE OF TRANSISITON CT - SMALL BOWEL OBSTRUCTION PROXIMAL DILATED BOWEL DISTAL NORMAL BOWEL
HERNIA SM. BOWEL BARIUM STUDY CT Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery.
POST – OP ADYNAMIC ILEUS LARGE AND SMALL BOWEL SYMMETRIC dilatation of large and small bowel is seen normally as a post operative ileus. COLON SM. BOWEL
sutures Colon resection POST – OP ADYNAMIC ILEUS
CHROHN’S DISEASE Narrowed distal ileum due to chronic inflammation is typical for Crohn’s disease. normal
APPENDICOLITH Occasionally a calculus (appendicolith) is seen as the source of appendicitis due to obstruction of the appendix and inflammation.
ACUTE APPENDICITIS NORMAL DISTENDED APPENDIX WITH LOCAL INFLAMATION.
DRAINAGE ABSCESS Catheter has been placed by radiologist using CT guidance draining abscess collection
HEPATIC FLEXURE SPLENIC FLEXURE TRANSVERSE COLON CECUM ASCENDING COLON DESENDING COLON TERMINAL ILEUM NORMAL COLON Normal air contrast barium enema (double contrast-air and barium per rectum) shows filling of colon with air and barium retrograde to the cecum with reflux into the terminal illeum
PEDUNCULATED COLON POLYP ( DESCENDING COLON) stalk on polyp--pedunculated
COLON POLYP Polyp on wall, sessile, without stalk is coated and outlined by barium
COLON OBSTRUCTION Distension extends to distal descending colon.
COLON CANCER Barium enema showing an ”APPLE -CORE” constricting lesion with proximal dilatation of colon
COLON SIGMOID VOLVULUS “COFFEE BEAN SIGN” Dilated coffee bean shaped sigmoid colon due to volvulus.
SIGMOID VOLVULUS “BEAK SIGN” Barium fills to point of obstruction and twist of sigmoid colon
Air in bowel wall is due to Necrotizing Enterocolits. #1- an infectious complication of premature infants. Air has tracked into the Portal Vein and is seen in #2. #1#2 NECROTIZING ENTEROCOLITIS
CT - PNEUMATOSIS Air in the bowel wall Small tiny bubbles in the wall bowel loop – Red arrows
DIVERTICULOSIS Barium extends from lumen outward into diverticulum.
Extensive inflammation, wall thickening and spasm can simulate carcinoma with colonoscopy required to confirm. DIVERTICULITIS
Single arrow thickened LB; DBL arrow air in tic
DIVERTICULITIS Black arrow thickened bowel wall, white arrow air in tic
NORMAL SMA ARTERIOGRAM Catheter is placed in superior mesenteric artery showing normal filling of small and large intestinal branches.
ABNORMAL SMA ARTERIOGRAM GI BLEED Subtracted SMA arteriogram shows contrast collecting at site of active bleeding in Rt. lower quadrant.
NUCLEAR MEDICINE Technetium-labeled RBC’S Labeled red blood cells are imaged over 1 hour showing extravasation in Rt. colon steadily increasing indicating active bleeding.
NORMAL GAS PATTERN AIR UNDER THE DIAPHRAGM Perforation of GI tract leads to pneumoperitoneum collecting subdiaphragmaticly on upright x-ray
ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. DECUBITUS UPRIGHT LEFT LATERAL DECUBITUS (left side dependent) shows air along liver margin. This is the preferred x- ray if the patient cannot stand.
Rigler’s Sign – See both sides of the bowel wall. Triangle Sign – Small triangles of air