Digest IV
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Transcript of Digest IV
![Page 1: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/1.jpg)
Dr. Alexandra PLATON Dr. Corina URSULESCU
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Explorari imagistice:
Radiografie toracică F +P: - indicatii: corpi straini radioopaci, spatiul prevertebral, linii mediastinale, nivel hidro-aeric mediastinal;
Examinarea cu substanţă de contrast: - indicatii: evaluare functionala si anatomica (lumen, perete); - suspensie de sulfat de Bariu: contrast simplu, dublu contrast; - fluoroscopie + filme tintite; - inregistrare “cine”/video; incidente OAD, OAS, F, P; - contrast hidrosolubil: perforatie, fistula, post-operator precoce;
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ESOFAG BARITAT: ASPECTE NORMALE-pliuri de mucoasa
-calibru-peristaltism
Strat subtire Dublu contrast
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Examinarea computer-tomografica: - stadierea cancerului esofagian (extensie locala, regionala, metastaze); - recurenta tumorala dupa esofagectomie;
Eco-endoscopia esofagiana:- examinarea straturilor peretelui esofagian (extensia
intraparietala a tumorii), adenopatii periesofagiene;
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EXAMEN COMPUTER-TOMOGRAFIC: ASPECT EXAMEN COMPUTER-TOMOGRAFIC: ASPECT NORMAL AL ESOFAGULUI TORACICNORMAL AL ESOFAGULUI TORACIC
(perete < 5 mm, net delimitat)(perete < 5 mm, net delimitat)
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Semeiologia modificarilor morfologice esofagieneSemeiologia modificarilor morfologice esofagiene
rigiditatearigiditatea parietala; modificari de calibru:
- stenozastenoza (ingustarea) lumenului esofagian;- dilatareadilatarea lumenului esofagian;
imaginea lacunaralacunara (corp strain intraluminal, tumora benigna sau maligna mucoasa sau extramucoasa, compresiune extrinseca); imaginea de aditieaditie (nisa, diverticul);
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lacunalacuna imagine de aditieimagine de aditie
stenozastenoza dilatatiedilatatie
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Corpi straini esofagieni
- radioopaci/radiotransparenti;
Radioopaci: radiografii simple: forma, contur, localizare, semne de perforatie;
Radiotransparenti: examen esofagian cu contrast; - sediu (strimtori fiziologice); - modificari functionale esofagiene;
Complicatii: perforatia esofagului: - bule aerice de-a lungul peretelui posterior al esofagului cervical - emfizem subcutanat - mediastinita;
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ESOFAG:CORPI STRAINI OPACI
Corp strain esofagian (cui indoit); urmarirea progresiei prin tubul digestiv
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ESOFAG:CORPI STRAINI.A)capac sticla; B) radiotransparent: carne
AA BB
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Inel esofagian (Schatzki) - pliu transversal de mucoasa, deasupra jonctiunii eso-gastrice;
Examinare cu sulfat de Bariu: - evidentiere in timpul distensiei esofagului;
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Tulburari functionale esofagiene:
Etiologie:
Primitive: - achalazia cardiei, spasmul difuz esofagian, chalazia;
Secundare: - esofagita peptica/caustica; - afectare neurologica; - bolile tesutului conjunctiv; - boli metabolice, infectioase; - cancerul esofagian (obstructie, invazie nervoasa);
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Chalazia - reflux gastro-esofagian +/- hernie hiatala;
Diskinezii esofagiene extra-sfincteriene
Unde peristaltice secundare: - propagare ascendenta din 1/3 inferioara a esofagului;
Spasm difuz esofagian:Clinic: dureri “anginoase” + disfagie intemitenta;Examen baritat: - contractii non-propulsive: “segmentarea” lumenului; - esofag “in tirbuson”;
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DISKINEZIE ESOFAGIANA: DISKINEZIE ESOFAGIANA:
pseudodiverticuli Barsonypseudodiverticuli Barsony
Inel SCHATSKI
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Achalazia - absenta/relaxare insuficienta SEI; - lipsa concordantei peristaltica esofagiana/relaxare SEI;
Radiografia toracica F + P: - largirea opacitatii mediastinale (partea dreapta); - nivel hidroaeric mediastinal;
Examenul baritat esofagian: - ingustare axiala a esofagului abdominal; - dilatare esofag supraiacent: megaesofag fusiform, megadolicoesofag; - micsorarea camerei cu aer a stomacului; - intirziere in pasajul esofagului abdominal efilat; - modificarea peristaltismului esofagian;
Complicatii: candidoza esofagiana, cancer esofagian;
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ESOFAG:TULBURARI FUNCTIONALE. ESOFAG:TULBURARI FUNCTIONALE. Achalazia cardiei:Achalazia cardiei:
Dilatarea si alungirea esofagului, staza, diverticuli de pulsiune Dilatarea si alungirea esofagului, staza, diverticuli de pulsiune prin modificarea presiunii intraluminaleprin modificarea presiunii intraluminale
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ACALAZIA CARDIEI : DILATARE PRIN CATETER CU BALONACALAZIA CARDIEI : DILATARE PRIN CATETER CU BALON
ACALAZIA DILATARE POST-DILATARE
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Diverticuli esofagieniDiverticuli esofagieni
Mecanism: - pulsiune = hernierea mucoasei + submucoasei printre fibrele
muscularei - tractiune = toate straturile peretelui esofagian
Diverticulul ZenckerTip: diverticul de pulsiune;Sediu: jonctiunea faringo-esofagiana;Morfologie: - imagine de aditie, contur net, posterior esofagului cervical; - impingere + lateralizare esofag cervical; - colet mai ingust decit sacul herniar; - dimensiuni mari; staza in diverticul;
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Diverticulii esofagului toracic mijlociuMecanism: tractiune (fibroza in jurul adenopatiilor tuberculoase)Morfologie: imagine de aditie; forma conica, in deget de manusa; colet larg; fara staza;
Diverticuli epifreniciMecanism: pulsiune;Sediu: deasupra SEI, proiectie pe partea dreapta a conturuluiesofagian;Morfologie: imagine de aditie, contur net;
Complicatii: - inflamatie; - fistulizare;
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DIVERTICULI ESOFAGIENIDIVERTICULI ESOFAGIENI
Diverticul de pulsiuneDiverticul de pulsiune
Diverticul de Diverticul de tractiunetractiune
Diverticuli medioesofagieni: Diverticuli medioesofagieni: fistula eso-bronsicafistula eso-bronsica
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Stenoze esofagiene benigne
Etiologie: - post ingestie de substante caustice; - peptice (reflux gastro-esofagian);
Caustice:Examinare cu contrast (hidrosolubil primele zile, baritat > 3 sapt.): - sediu: oriunde, mai frecvent la nivelul strimtorilor fiziologice;Clasic: - stenoza în axul esofagului (centrata), traiect lung, contururi nete,trecere lenta spre esofagul normal; - dilatatie supraiacenta, cu staza baritata;
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STENOZE ESOFAGIENE POSTCAUSTICE:STENOZE ESOFAGIENE POSTCAUSTICE:axiale, lungi, trecere lenta spre esofagul supraiacentaxiale, lungi, trecere lenta spre esofagul supraiacent
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Variante: - stenoze multiple: etajate sau in diferite portiuni esofagiene; - inelare/tubulare; - contururi neregulat dintate;
Tratament: •dilatatie endoscopica, •dilatatie endoluminala cu cateter cu balonas, •chirurgical;
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ESOFAGITA POST-CAUSTICA : DILATARE CU CATETERESOFAGITA POST-CAUSTICA : DILATARE CU CATETERCU BALON tip GRUNTZIGCU BALON tip GRUNTZIG
PRE- DILATATIE CONTROL
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ESOFAGITA CAUSTICA :ESOFAGITA CAUSTICA :FISTULA ESO-BRONSICAFISTULA ESO-BRONSICA
DILATATIE CU TUB RIGID :DILATATIE CU TUB RIGID :PERFORATIA ESOFAGULUIPERFORATIA ESOFAGULUI
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Stenoze peptice
Sediu: - 1/3 inferioara a esofagului; - asociere cu ulcerul peptic; - stenoza centrata în axul esofagului, trecere lenta spre esofagul normal;
Ulcerul peptic: - imagine de aditie, dimensiuni mici, situata pe portiunea stenozata;
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STENOZA PEPTICASTENOZA PEPTICA ULCER PEPTICULCER PEPTIC
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Varice esofagieneEtiologieEtiologie: Hipertensiunea Portala (HTP)
Examinare cu suspensie viscoasa de sulfat de Bariu; - sediu: 1/2 inferioara a esofagului; - imagini lacunare in banda, sinuoase; - imagini lacunare cu caracter “vermiform” - modificare la manevra Valsalva;
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VARICE ESOFAGIENE: examen in strat subtire VARICE ESOFAGIENE: examen in strat subtire
VALSALVAVALSALVA Suplete parietalaSuplete parietala
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Tumori benigne
Leiomiomul-cea mai frecventa tumora benigna esofagiana-sediu: 1/3 inferioara, 1/3 mijlocie;Examen baritat: - defect de umplere, margini nete; - amprenta + ingustare lumen - pliuri de mucoasa intacte;
Examen CT, endoscopie;
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TUMORA BENIGNA:TUMORA BENIGNA:
LEIOMIOMLEIOMIOM
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Tumori maligne esofagiene
- carcinom epidermoid; - adenocarcinom (metaplazie gastrica);
Infiltrant:
- stenoza excentrica fata de axul esofagului; - jonctiune asimetrica cu esofagul supraiacent; - absenta distensiei la trecerea bolului opac; - dilatatie supraiacenta a esofagului;
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Vegetant: - lacuna/defect de umplere; - stenoza neregulata, excentrica a lumenului; - ulceratii in lacuna; - obliterare completa a lumenului;
Ulcerant:Nisa maligna: - nisa plata, incastrata; - nu proemina/foarte putin din contur; - burelet periulceros, umeri simetrici;
Forme mixte: evolutie spre stenoza, obstructie;
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CANCER ESOFAGIANCANCER ESOFAGIAN
INFILTRANT VEGETANTINFILTRANT VEGETANT
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ULCERANTULCERANT
CANCER ESOFAGIANCANCER ESOFAGIAN
FARINGO-FARINGO-ESOFAGIANESOFAGIAN
ESO-CARDIO-ESO-CARDIO-TUBEROZITARTUBEROZITAR
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Bilantul operabilitatii
Extensie loco-regionala si la distanta:
Endoscopie + biopsie; Examen baritat eso-gastro-duodenal: lungimea leziunii;Examen computer-tomografic (mediastin si abdomen superior): - invazia traheo-bronhica; invazia aortei; - extensie ganglionara mediastinala; - extensie metastatica: plamin, ficat; - control post-terapeutic;Eco-endoscopie esofagiana;Imagistica prin rezonanta magnetica;
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Esofagul operat
Metode de imagistica:• radiografia simpla toracica si abdominala;radiografia simpla toracica si abdominala;• examinarea cu contrast: hidrosolubil (precoce); sulfat de Bariu (tardiv);examinarea cu contrast: hidrosolubil (precoce); sulfat de Bariu (tardiv);• examinare computer-tomografica;examinare computer-tomografica;
Tehnici chirurgicale: - chirurgia RGE si a herniei hiatale; - esofagectomii intinse:• inferioare, cu anastomoza eso-gastrica mediastinala;• superioare, cu anastomoza eso-gastrica cervicala;• totale, cu anastomoza faringo-gastrica; esofagectomie cu anastomoza eso-colica;Perioada post-operatorie precoce;Perioada post-operatorie intermediara;Perioada post-operatorie tardiva;
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Esofagoplastie cu stomac Esofagoplastie cu stomac netunelizat: radiografie toracica – netunelizat: radiografie toracica –
aspect normal in perioada aspect normal in perioada postoperatorie precocepostoperatorie precoce
Esofagoplastie cu ileocolon – control cu Gastrografin in perioada postoperatorie precoce
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CONTROLUL BARITAT AL ESOFAGULUI OPERATCONTROLUL BARITAT AL ESOFAGULUI OPERATEsofagoplastie presternalaEsofagoplastie presternala Esofagoplastie cu tub gastricEsofagoplastie cu tub gastric
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Interventii chirurgicale limitate: - rezectia diverticulilor; - miotomii esofagiene; - ablatia tumorilor extramucoase;
Tehnici interventionale: - dilatare, cu sonda cu balonas, a leziunilor stenozante (stenozebenigne, achalazia cardiei); - “stent” esofagian pentru tumorile maligne;
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Explorari imagistice stomac
Examen cu substanta de contrast: - pregatirea pacientului; - suspensie de sulfat de Bariu: contrast simplu, dublu contrast; - examinare fluoroscopica + compresiune dozata + rdgf. tintite; - contrast iodat hidrosolubil: perforatii, peritonita, postoperator precoce;
Ecografia transparietala: ingrosarea peretelui gastric, structurile din jur;Eco-endoscopia: evidentierea straturilor parietale, adenopatii regionale;Examinarea computer-tomografica: stadializarea tumorilor;Metode izotopice: hemoragii;
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STOMAC NORMAL: TEHNICA EXAMINARII RXSTOMAC NORMAL: TEHNICA EXAMINARII RX
Strat subtire: evidentierea pliurilor
de mucoasa
Repletie: evaluarea calibrului si
peristaltismului
Trendelenburg: reflux gastro-esofagian
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STOMAC:A)EXAMEN IN STRAT SUBTIRE;STOMAC:A)EXAMEN IN STRAT SUBTIRE;
B)DUBLU CONTRAST.B)DUBLU CONTRAST.
A
B
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STOMAC NORMAL: EXAMEN BARITAT
evaluarea in dublu contrast a antrului si fornixului
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Anomalii de pozitie stomac
Hernia hiatala: trecere intermitenta/permanenta a unei portiuni dinstomac prin orificiul hiatal;Clasificarea Ackerlund: - tip I: brahiesofag + HH; - tip II: paraesofagiana (rostogolire); - tip III: alunecare;
Dg. Radiologic: - Rdgf. simpla: camera cu aer in mediastinul posterior; - Ex. baritat: esofag, pozitia cardiei, tipul de hernie, reductibilitate,reflux gastro-esofagian;
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HERNII HIATALE: A) prin alunecare; B) prin rostogolireHERNII HIATALE: A) prin alunecare; B) prin rostogolire
A B
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HERNII HIATALE PRIN ALUNECARE (TIP III)HERNII HIATALE PRIN ALUNECARE (TIP III)
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HERNII HIATALE:BRAHIESOFAGHERNII HIATALE:BRAHIESOFAG
esofagesofag
diafragmdiafragm
cardiacardia
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Amprente si deplasari gastrice - hepatomegalie, splenomegalie, mase pancreatice;
Stomac in cascada - compresiunea polului superior gastric prin colon meteorizat; - marea curbura aliniata diafragmului: punga superioara/inferioara; - profil: “stomac obscen”;
Volvulusul gastric - longitudinal: dupa axul cardio-piloric; - transversal (mezenterico-axial);
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STOMAC: MODIFICARI DE POZITIE/AMPRENTE
SPLINA
Formatiune expansiva pancreatica
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VOLVULUS GASTRICVOLVULUS GASTRIC
Volvulus de pol superior – stomac in cascada
Volvulus mezenterico-axial
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VOLVULUS GASTRIC
Mica curbura
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Gastrite
Diagnostic: ex. endoscopic +/- examen baritat eso-gastro-duodenal;
Gastrita acuta - etiologie: alcool, salicilati, afectare infectioasa; - aspect radiologic: - pliuri ingrosate (> 5mm, pseudopolipoid), - eroziuni mucoase superficiale, inconjurate de edem (aspect “varioliform), - hipersecretie gastrica;
Gastrita hipertrofica (boala Menetrier) - hipertrofie importanta a pliurilor corpului gastric (> 1cm),apect pseudo-cerebriform, +/- gastro-enteropatie exudativa;
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GASTRITAGASTRITA GASTRITA MENETRIERGASTRITA MENETRIER
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ULCERUL GASTRIC
- Dg. radiologic: examen baritat eso-gastro-duodenal; - semne directe + semne indirecte
Semne directe: nisanisa + edem periulceros + convergenta pliurilor; - sediu: tipic: portiunea verticala a micii curburi; - profil : imagine de aditie; - forma: variata: rotunda, triunghiulara, ascutita; - dimensiuni variate: 5-10 mm – mari (nisa Haudeck); - contur precis, cu/fara colet; - delimitata superior/inferior: dig periulceros; - semnul Hampton: banda transparenta subcavitara; - fata: imagine “in cocarda”;
![Page 57: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/57.jpg)
NISA GASTRICA BENIGNANISA GASTRICA BENIGNA imaginea de profilimaginea de profil
![Page 58: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/58.jpg)
ULCERE GASTRICE:ULCERE GASTRICE:
nisa, convergenta pliurilornisa, convergenta pliurilor
![Page 59: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/59.jpg)
NISA GASTRICA BENIGNANISA GASTRICA BENIGNA imaginea de fata: nisa, edem, convergenta pliurilorimaginea de fata: nisa, edem, convergenta pliurilor
![Page 60: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/60.jpg)
Semne indirecte - triada Barclay: hiperkinezie, hipertonie, hipersecretie; - gastrita hipertrofica de insotire; - semnul “indicatorului”: la nivelul marii curburi gastrice; - rigiditatea micii curburi; - spasm antral, spasm piloric;
Aspecte particulare in functie de localizare - nisa- nisa in lacuna (pe marea curbura); - nisanisa subcardiala # diverticul subcardial; - nisanisa la unghiul micii curburi: fenomene de rigiditate;
Ulcerul canalului piloric - nisanisa + spasm piloric = imagine de “perla pe ata”;
![Page 61: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/61.jpg)
ULCER PE MAREA ULCER PE MAREA CURBURA:CURBURA:nisa in lacuna (edem)nisa in lacuna (edem)
ULCER PILORICULCER PILORIC
![Page 62: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/62.jpg)
EVOLUTIE, COMPLICATII
Favorabila - sub tratament: diminuare, disparitie, cicatrice;
Nefavorabila: - marirea ulcerului: nisa Haudeck; - stenoza gastrica; - penetratie (pancreas, ficat, mezocolon); - perforatie: pneumoperitoneu (rdgf. simpla); ex. contrast hidrosolubil; - hemoragie digestiva superioara;
![Page 63: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/63.jpg)
NISA HAUDECKNISA HAUDECK
STENOZA PILORICA:STENOZA PILORICA:Stomac dilatat, alungit, cu Stomac dilatat, alungit, cu
importanta staza si evacuare importanta staza si evacuare pilorica tardiva, filiformapilorica tardiva, filiforma
![Page 64: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/64.jpg)
Diagnostic diferential: Diagnostic diferential: DIVERTICUL GASTRIC – DIVERTICUL GASTRIC –
fara edem, pliurile de mucoasa fara edem, pliurile de mucoasa patrund in diverticulpatrund in diverticul
![Page 65: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/65.jpg)
Tumori gastrice benigneTumori gastrice benigne
Polipi gastriciPolipi gastrici
2 variante: - hiperplazicihiperplazici – mai frecventi
- lacune < 1 cm, net delimitate
- fara potential de malignizare
- adenomatosiadenomatosi – mai mari
- sesili/pediculati (mai ales in antru)
- potential de malignizare
Leiomiom, neurinom, lipom, fibromLeiomiom, neurinom, lipom, fibrom
-Rare, localizare extramucoasa
-Ex. baritat – imagini lacunare rotunde, net delimitate
- ulceratii (leiomiom)
-Ecografia, CT: extensia masei submucoase
![Page 66: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/66.jpg)
POLIPI GASTRICI
![Page 67: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/67.jpg)
CANCERUL GASTRIC
Debut (“early gastric cancer”)
Invazie limitata la mucoasa si submucoasa, fara afectare ganglionarasau metastaze la distanta. - tip I: proeminent (h > 0,5 cm); - tip II: superficial: - II a: elevat; - II b: plat; - II c: depresionat; - tip III: excavat;
Dg.: endoscopie + ecoendoscopie
![Page 68: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/68.jpg)
CANCER GASTRIC CANCER GASTRIC LA DEBUT TIP IIILA DEBUT TIP III
![Page 69: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/69.jpg)
CANCER GASTRICCANCER GASTRICVEGETANT
INFILTRANT
![Page 70: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/70.jpg)
CANCER GASTRIC AVANSAT
Vegetant: - masa tumorala exofitica intraluminala + necroza, ulceratie; - defect de umplere/lacuna,defect de umplere/lacuna, delimitare imprecisa, distructia peretelui;Infiltrant: - ingrosarea peretelui; - rigiditate, absenta peristalticii;rigiditate, absenta peristalticii; - distrugerea mucoasei; - ingustatarea lumenului gastric » schir gastric;Ulcerant: - nisa maligna;- nisa maligna; - profil: “menisc”, contur rectiliniu, in limitele peretelui, dig periulceros cu umerii egali, pliuri infiltrate oprite la distanta de nisa;
![Page 71: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/71.jpg)
CANCER VEGETANT &CANCER VEGETANT &
ULCERATULCERAT
![Page 72: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/72.jpg)
CANCER GASTRIC VEGETANTCANCER GASTRIC VEGETANT
![Page 73: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/73.jpg)
CANCER CANCER GASTRIC GASTRIC INFILTRANTINFILTRANT
![Page 74: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/74.jpg)
CANCER GASTRIC CANCER GASTRIC ULCERANTULCERANT
![Page 75: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/75.jpg)
CANCER GASTRICCANCER GASTRIC
![Page 76: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/76.jpg)
Limfoame gastrice - non Hodgkin/Hodgkin;Macroscopic: polipoid, ulcerant, infiltrant;
Aspect radiologic:Aspect radiologic: - mucoasa proeminenta + ingrosarea pliurilor; - multiple eroziuni + ulceratii;
Examinare ecografica;Examinare ecografica;
Examinare computer-tomografica;Examinare computer-tomografica;
![Page 77: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/77.jpg)
RADIODIAGNOSTICUL STOMACULUI OPERAT
Interventii conservatoare: - vagotomie: totala (+ piloroplastie); selectiva; - gastroenteroanastomoza: ansa jejunala la marea curbura gastrica;
Rezectii gastrice: - partiale; - subtotale: rezectie 2/3 distala + anastomoza gastro-duodenala, gastro-jejunala; - totale – anastomoza eso-jejunala;
![Page 78: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/78.jpg)
TIPURI PRINCIPALE DE REZECTIE GASTRICA SI TIPURI PRINCIPALE DE REZECTIE GASTRICA SI ENTERO - ANASTOMOZEENTERO - ANASTOMOZE
PEAN-BILROTHPEAN-BILROTHtermino-terminalatermino-terminala
REICHEL-POLYAREICHEL-POLYAtermino-lateralatermino-laterala
ROUX-BROWNROUX-BROWNeso-jejunala “Y”eso-jejunala “Y”
![Page 79: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/79.jpg)
Complicatii precoce - dezunirea suturilor » peritonita: nivel hidroaeric subdiafragmatic(rdgf. abdominala simpla); - ocluzii: rdgf. abdominala simpla; - fistule: examinare cu substanta de contrast hidrosolubila;
Complicatii tardiveSindroame functionale - reflux gastro-esofagian: post gastrectomie polara superioara; - sindrom de ansa aferenta: staza baritata in ansa aferenta; - sindrom de ansa eferenta (dumping syndrome): evacuare precipitatasi distensia accentuata a eferentei;
![Page 80: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/80.jpg)
Sindroame organo-functionale
- gastrita bontului; - stomita, jejunita;
Afectiuni organice
- invaginatia acuta/cronica a ansei aferente/eferente; - prolapsul mucoasei gastrice; - ulcerul peptic: gura de anastomoza, ansa eferenta (primii 5 cm); - cancerul pe bont: recidiva; primitiv
![Page 81: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/81.jpg)
ULCER PEPTIC POST-OPERATORULCER PEPTIC POST-OPERATOR
GEA REICHEL-POLYAGEA REICHEL-POLYAGEA TIP PEAN-BILROTHGEA TIP PEAN-BILROTH
![Page 82: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/82.jpg)
STENOZA GURII DE ANASTOMOZA: A)ulcer; B) cancerSTENOZA GURII DE ANASTOMOZA: A)ulcer; B) cancer
![Page 83: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/83.jpg)
STOMAC OPERAT : COMPLICATIISTOMAC OPERAT : COMPLICATII
Ulcer anastomoticUlcer anastomotic Stenoza gurii de anastomozaStenoza gurii de anastomoza Neoplasm gastricNeoplasm gastric
![Page 84: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/84.jpg)
![Page 85: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/85.jpg)
Explorarea imagistica a duodenului
Examinarea cu substanta de contrast - sulfat de Bariu: contrast simplu/dublu contrast; - probe farmacodinamice: duodenografia hipotona; - contrast hidrosolubil: perforatii;
Ecografia: peritonite localizate secundare perforatiilor acoperite, extensia locala a tumorilor
Eco-endoscopia: modificari parietale
Examinarea computer-tomografica: extensie tumorala
![Page 86: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/86.jpg)
DUODEN:DUODEN:EXAMEN BARITATEXAMEN BARITAT
PlenitudinePlenitudine Strat subtire/relief mucosStrat subtire/relief mucos
BULB DUODENALBULB DUODENAL
CADRU DUODENAL IN DECUBITCADRU DUODENAL IN DECUBIT
![Page 87: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/87.jpg)
Modificarile de pozitie
Duoden inversDuoden invers
Duoden in “M”Duoden in “M”
Compresiuni de vecinatateCompresiuni de vecinatate:: - vezicula biliara; - tumori vateriene; - tumori pancreas cefalic; - tumori renale drepte;
Aderente si tractiuni post-inflamatorii;Aderente si tractiuni post-inflamatorii;
![Page 88: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/88.jpg)
AMPRENTE DE VECINATATE PE DUODENAMPRENTE DE VECINATATE PE DUODEN
COLECISTCOLECIST
ADENOPATII
![Page 89: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/89.jpg)
DUODEN : MODIFICARI DE POZITIEDUODEN : MODIFICARI DE POZITIE
![Page 90: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/90.jpg)
Ulcerul bulbar duodenal
Nisa + modificarile mucoasei (edem, convergenta pliurilor)
Forme anatomo-radiologice:
Edematoasa: - bulb nedeformat; - nisa + edem periulceros = imagine “in cocarda”;
Forma edemato-scleroasa: - contur bulbar cu incizuri si ancose; - nisa + edem periulceros + benzi de fibroza in submucoasa;
![Page 91: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/91.jpg)
Forma sclero-edematoasa - deformarea bulbului: stenoza, biloculare, dilatatie pre-stenotica (“diverticul Cole”); - identificare dificila a nisei;
Fenomene de insotire: - triada Barclay;
![Page 92: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/92.jpg)
ULCER DUODENAL BULBARULCER DUODENAL BULBAR
FORMA EDEMATOASAFORMA EDEMATOASA
FORMA SCLERO-EDEMATOASA SCLERO-CICATRICIAL
![Page 93: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/93.jpg)
ULCER BULBARULCER BULBAR
STENOZANT:STENOZANT:DIVERTICULIDIVERTICULI
SECUNDARISECUNDARI
COLE (1) &COLE (1) &
ACKERLUND(2)ACKERLUND(2)
1122
![Page 94: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/94.jpg)
ULCER BULBAR DUBLU:”KISSING-ULCER”ULCER BULBAR DUBLU:”KISSING-ULCER”
![Page 95: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/95.jpg)
Complicatii: - perforatie: pneumoperitoneu; penetratie - hemoragie digestiva;
Ulcer duodenal post-bulbar - obs. Sdr. Zollinger-Ellison; - sediu: D2 supravaterian; - nisa + spasm de insotire (“perla pe ata”);
![Page 96: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/96.jpg)
ULCER DUODENAL POSTBULBARULCER DUODENAL POSTBULBAR
![Page 97: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/97.jpg)
ULCER BULBAR PERFORAT IN ULCER BULBAR PERFORAT IN
MAREA CAVITATE PERITONEALA: MAREA CAVITATE PERITONEALA: examinare cu GASTROGRAFINexaminare cu GASTROGRAFIN
![Page 98: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/98.jpg)
ULCER PERFORAT: PNEUMOPERITONEUULCER PERFORAT: PNEUMOPERITONEU
semiluna aerica subdiafragmatica bilateralsemiluna aerica subdiafragmatica bilateral
![Page 99: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/99.jpg)
STENOZA PILORICASTENOZA PILORICA
ULCEROASA,ULCEROASA,
DECOMPENSATADECOMPENSATA
![Page 100: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/100.jpg)
Diverticulii duodenaliMecanism: pulsiuneSediu: frecvent D2, in interiorul potcoavei duodenale;Morfologie: imagine de aditie, contur net, prelungire de pliuri in interior;
![Page 101: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/101.jpg)
DIVERTICULI DUODENALIDIVERTICULI DUODENALI
![Page 102: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/102.jpg)
Stenoze duodenale - medio-bulbara: dupa ulcer bulbar duodenal; - D2: T cap de pancreas: cadru largit, pliuri sterse, stenoza, cauciuc “pe janta” ampulom vaterian tumori duodenale - D3: pensa mezenterica;
![Page 103: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/103.jpg)
Stenoza portiunii descendente Stenoza portiunii descendente a duodenului in formatiuni a duodenului in formatiuni
expansive pancreaticeexpansive pancreatice
LARGIREA CADRULUILARGIREA CADRULUIDUODENAL IN CANCERDUODENAL IN CANCERPANCREATIC CEFALICPANCREATIC CEFALIC
![Page 104: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/104.jpg)
PENSA AORTO-MEZENTERICAPENSA AORTO-MEZENTERICA
![Page 105: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/105.jpg)
Tumori duodenaleTumori duodenale
-rare;
-polipi: imagini lacunare bine delimitate, dimensiuni mici;
-schwanom, leiomiom: stergerea pliurilor, ulceratii;
-adenocarcinom: stenoza neregulata, excentrica
-limfom: stergerea pliurilor, stenoza
![Page 106: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/106.jpg)
POLIPI DUODENALIPOLIPI DUODENALI
![Page 107: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/107.jpg)
Schwanom duodenal: stergerea pliurilor, ulceratieSchwanom duodenal: stergerea pliurilor, ulceratie
![Page 108: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/108.jpg)
![Page 109: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/109.jpg)
EXPLORAREA IMAGISTICA A INTESTINULUI SUBTIRE
Radiografia abdominala simpla: distensia anselor, nivele hidro-aerice
Tranzitul baritat: 600-900 ml suspensie baritata, urmarire in fluoroscopie, rdgf. tintite, compresiune dozata, contrast simplu/dublu contrast;-pozitia anselor, pliuri, calibru;
Enteroclisma: tub nazo-gastric pina la unghiul Treitz, contrast simplu,dublu contrast, fluoroscopie + rdgf. tintite;»modificatori de comportament:• acceleratori ai tranzitului: lichide reci, neostigmina, metoclopramida;• inhibitori ai tranzitului: Buscopan, morfina, codeina, atropina;-pozitia anselor, aspectul mucoasei, calibru;
Opacefiere retrograda (dupa clisma baritata): examinarea ultimelor anse ileale;
![Page 110: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/110.jpg)
OCLUZIE INTESTINALA INALTA :NIVELE HIDROAERICEOCLUZIE INTESTINALA INALTA :NIVELE HIDROAERICE
““POTCOAVA”POTCOAVA”
““Trepte de scara”Trepte de scara”
![Page 111: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/111.jpg)
EXAMEN BARITAT INTESTINAL:EXAMEN BARITAT INTESTINAL:A) Tranzit baritat; B) pe sonda:”enteroclisis”A) Tranzit baritat; B) pe sonda:”enteroclisis”
AA
BB
![Page 112: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/112.jpg)
EXAMEN BARITAT JEJUNAL:ASPECT NORMALEXAMEN BARITAT JEJUNAL:ASPECT NORMAL
![Page 113: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/113.jpg)
Examinare computer-tomografica - umplerea anselor cu contrast diluat hidrosolubil; - nivelul obstructiei sau perforatiei, ingrosarea peretilor, abcese intre anse;
Explorare izotopica:• Tc99 + hematii: diagnosticul hemoragiei intestinale;• Indium111 + leucocite: diagnosticul leziunilor inflamatorii;
Biopsia leziunilor IS: ghidaj ecografic/computer-tomografic;
![Page 114: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/114.jpg)
Semeiologia radiologica a ISSemne functionale: - hiper/hipotonia; - tonus alternant; - hiper/hipokinezia; - aeroenteria; - imagini hidro-aerice;Semne organice: - alterarea reliefului mucoasei: relief “de baraj”, edematos; - rigiditatea segmentara: - stenoza; - lacuna; - imagini de aditie;
![Page 115: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/115.jpg)
DISKINEZIEDISKINEZIE
INTESTINALAINTESTINALA
HIPERTONAHIPERTONA
![Page 116: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/116.jpg)
Boala CrohnAfectare granulomatoasa, idiopatica, evolutie cronica, adult tinar;Sediu: predilect ileon terminal;Dg. Imagistic: explorare cu substanta de contrast + imagisticasectionala (ecografie, CT);
Evolutie:Debut: - edemul mucoasei: aspect fin granular; - ingrosarea pliurilor: pliuri neregulate, fuziforme, nodulare; - hipertrofia foliculilor limfatici/placi Peyer: lacune juxtapuse,contururi poligonale, “nodul de alarma”;
![Page 117: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/117.jpg)
- ulceratii: initial “aftoide”: eroziunea mucoasei de acoperire a foliculilor limfatici hipertrofiati: nisa in lacuna (fata), imagine de aditie (profil); - aspect ulcero-nodular: “pavaj cu dale” (“cobblestone”);
Scleroza si stenoza: - semnul corzii “string sign”: ingustare tubulara a lumenului; - stenoze scurte, etajate, “in clepsidra”; - dilatare in amonte a anselor; - cecul nu se opacefiaza: semnul “saltului”; - ingrosare si retractie mezenterica a anselor + hipertrofia ggl.limfatici; - fistule (intre anse, intre ansa patologica si vezica);
![Page 118: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/118.jpg)
BOALA CROHN ST IBOALA CROHN ST I
![Page 119: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/119.jpg)
BOALA CROHN: FAZA ULCERATIVA (ST.II)BOALA CROHN: FAZA ULCERATIVA (ST.II)
![Page 120: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/120.jpg)
BOALA CROHN: FAZA BOALA CROHN: FAZA ULCERATIVA SI STENOZANTA ULCERATIVA SI STENOZANTA
(ST.III)(ST.III)
![Page 121: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/121.jpg)
Caracteristici fundamentale:Caracteristici fundamentale: - gradare in severitatea leziunilor, cu aparitie pe sarite: “skip lesions”; - tendinta la aparitie pe marginea mezenterica a intestinului;
Imagistica sectionala• Ecografia: - ingrosarea peretelui intestinal; prezenta abceselor;• Computer-tomografia: - ingrosarea peretelui + ingustarea lumenului; - hipertrofia grasimii mezenterice peri-ileale; - adenopatii mezenterice; - abcese interanse si extraintestinale;
![Page 122: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/122.jpg)
Tuberculoza ileo-cecala
Afectiune inflamatorie specifica, localizare predilecta pe ultimaansa ileala si portiunea proximala a colonului;Cale de diseminare: hematogena, alimentara;Dg. Imagistic: enteroclisma, tranzit baritat;Debut:Debut: - ansa ileala dilatata, hipotona; edem al mucoasei: pliuri ingrosate,neregulate; - hipertrofia foliculilor limfatici: imagini lacunare multiple, nodulde alarma;Perioada de stare:Perioada de stare: - ulceratii prin necroza de cazeificare a foliculilor;
![Page 123: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/123.jpg)
- ulceratii multiple, in “buton de camasa”; - “string sign”
Evolutie:Evolutie: - reactie de fibroza, cu stenoze, scurtari, retractii si fenomeneobstructive asociate; - retractia marginii externe a cecului “cec amputat”, valvulaileo-cecala beanta;
Forma pseudo-tumorala: asemanatoare cancerului vegetant;
Examinarea CT:Examinarea CT: - ascita, adenopatii, noduli peritoneali, ghidaj pentru punctie-aspiratie cu ac fin;
![Page 124: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/124.jpg)
TUBERCULOZA ILEO-CECALA-DEBUT:TUBERCULOZA ILEO-CECALA-DEBUT:
HIPERTROFIE PLACI PEYER;MICROULCERATIIHIPERTROFIE PLACI PEYER;MICROULCERATII
![Page 125: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/125.jpg)
TUBERCULOZA ENTERO-PERITONEALA:TUBERCULOZA ENTERO-PERITONEALA:
Anse aderente, stenozate, cu retractii; peritonita plastica, adezivaAnse aderente, stenozate, cu retractii; peritonita plastica, adeziva
![Page 126: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/126.jpg)
Diverticuli intestinali - pulsiune/tractiune, marginea mezenterica a IS; - imagini de aditie, in care patrund pliurile mucoasei;
Diverticul MeckelRelicvat embrionar al canalului omfalo-mezenteric;Sediu: - ileon, la o distanta de ~ 50cm de cec;Examen cu contrast:Examen cu contrast: - imagine de aditie, pe marginea antimezenterica a ileonului,perpendiculara pe acesta; - lungime: 1 - 25 cm;Complicatii:Complicatii: - hemoragie (ulcer pe insule de mucoasa gastrica); - infectie, ocluzie;
![Page 127: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/127.jpg)
DIVERTICULDIVERTICUL
MECKELMECKEL
![Page 128: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/128.jpg)
Tumori intestinale
Tipuri anatomo-patologice: carcinoid; adenocarcinom; limfom;
Infiltrante: stenoze neregulate, excentrice, obstructie;Vegetante: stergerea pliurilor, lacuna in lumen;Ulcerante: nisa in lacuna;
![Page 129: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/129.jpg)
Carcinoid ileal:Carcinoid ileal: imagine lacunara la nivelul ultimei anse ileale, dilatarea anselor inimagine lacunara la nivelul ultimei anse ileale, dilatarea anselor in amonteamonte
![Page 130: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/130.jpg)
Parazitoze intestinale - ascarizi: banda transparenta, rectilinie/sinuoasa; - tranzit baritat ascarid; - ocluzie intestinala;
![Page 131: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/131.jpg)
ASCARIZI INASCARIZI IN
JEJUNJEJUN
EVIDENTIATIEVIDENTIATI
PRINPRIN
TRANZITTRANZIT
BARITATBARITAT
![Page 132: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/132.jpg)
TAENIA TAENIA VIZUALIZATA INVIZUALIZATA ININTESTININTESTINPRIN EX BARITATPRIN EX BARITAT
![Page 133: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/133.jpg)
![Page 134: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/134.jpg)
EXPLORAREA IMAGISTICA A COLONULUI
Radiografia abdominala simpla - calcificari, colectii aerice si hidroaerice anormale, pregatireapacientului inaintea clismei baritate;
Clisma baritata - pregatirea pacientului: regim alimentar, laxative, clismeevacuatorii; - contrast simplu, evacuare, dublu contrast; - examinare in fluoroscopie, rdgf. tintite, compresiune dozata;Indicatii: - dublu contrast: suprafata mucoasei (leziuni de dimensiuni mici); - contrast simplu: leziuni polipoide, ulcerative, obstructive, cudimensiuni mari, detectarea fistulelor;
![Page 135: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/135.jpg)
CLISMA BARITATA:EXAMEN IN PLENITUDINECLISMA BARITATA:EXAMEN IN PLENITUDINE
![Page 136: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/136.jpg)
CLISMA BARITATA:CLISMA BARITATA:A) examen post-evacuare=>relief mucos;A) examen post-evacuare=>relief mucos;B) ex. post-insuflatie gazoasa=> dublu contrastB) ex. post-insuflatie gazoasa=> dublu contrast
AA
BB
![Page 137: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/137.jpg)
Examinarea cu substanta de contrast hidrosolubila: - suspiciune de perforatie intestinala, suspiciune de fistula colo-vezicala, explorarea unei fistule externe;
Ecografie trans-rectala: - stadierea tumorilor rectale;
Examinare CT: - perete colic + extensie transparietala; - abcese + mase inflamatorii; - metastaze limfatice, hepatice, peritoneale;
Imagistica prin rezonanta magnetica: - regiunea recto-sigmoidiana;
![Page 138: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/138.jpg)
Anomalii de pozitie ale colonului - congenitale/dobindite;
Situs inversus - inversiune totala a cadrului colic: cec la stinga, sigmoid la dreapta;
Mezenter comun: - anomalie de rotatie; - duoden si unghi Treitz in pozitie normala, jejun in dreaptaabdomenului, ileon si colon anterior si la stinga;
Sindrom Chilaiditi: - interpozitie (fixa/tranzitorie) a colonului intre ficat si diafragm;
![Page 139: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/139.jpg)
ANOMALII DE POZITIE: MEZENTER COMUNANOMALII DE POZITIE: MEZENTER COMUN
ansele intestinale localizate in jumatatea dreapta a abdomenului, valva ileo-cecala la ansele intestinale localizate in jumatatea dreapta a abdomenului, valva ileo-cecala la nivel pelvin, colon ascendent pe linia mediananivel pelvin, colon ascendent pe linia mediana
![Page 140: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/140.jpg)
ANOMALII DE ANOMALII DE LUNGIME:LUNGIME:
MEGA-DOLICO-MEGA-DOLICO-
COLONCOLON
![Page 141: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/141.jpg)
Hernie diafragmatica a colonului: - congenitala (agenezie totala/partiala a diafragmului)/dobindita;Rdgf simpla: imagini hidroaerice in torace;Clisma baritata: evidentierea segmentului herniat;
Cec in pozitie inalta, subhepatica;
Ptoza colica: evidentiata prin clisma baritata;
Deplasarea diferitelor segmente colice prin procese de vecinatate;tumori retroperitoneale, renale, pancreatice, hepatice, splenice; tumori retroperitoneale, renale, pancreatice, hepatice, splenice; abcese (plastron apendicular); abcese (plastron apendicular); splenomegalie, hepatomegaliesplenomegalie, hepatomegalie
![Page 142: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/142.jpg)
ANOMALII CONGENITALE: CEC RECURBATANOMALII CONGENITALE: CEC RECURBAT
![Page 143: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/143.jpg)
Plastron apendicular:Plastron apendicular:
amprenta asupra cecului si ultimei anse ileale
![Page 144: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/144.jpg)
Rectocolita ulcero-hemoragicaAfectiune inflamatorie cronica, cu etiologie necunoscuta si evolutie in pusee;
Dg. Imagistic:• Radiografia abdominala simpla:Radiografia abdominala simpla: - prezenta megacolonului toxic (contraind. pentru clisma baritata);• Clisma baritata:Clisma baritata: - prezenta, extinderea bolii +/- complicatii; - modificari functionale: hipertonie, hiperkinezie, modificareahaustrelor; - modificarea mucoasei: aspect granular, edemul mucoasei; - ulceratii: pete opace (fata); imagini de aditie (profil);
![Page 145: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/145.jpg)
- profil: spiculi, forma de “T”, “buton de camasa”, contur dublual colonului; - modificari de tip polipoid: imagini pseudo-lacunare (regenerareamucoasei);Cronicizare: - disparitia reliefului mucoasei, scurtarea segmentelor colice,deschiderea unghiurilor colice, lipsa haustratiilor; - stenoze tubulare (microcolon);
Complicatii: - megacolon toxic; - perforatii (in peritoneu sau organele vecine); - stricturi; - potential de malignizare;
![Page 146: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/146.jpg)
RECTOCOLITARECTOCOLITA
ULCERO-HEMORAGICA ST I:ULCERO-HEMORAGICA ST I:
edem, stergerea haustatiilor, edem, stergerea haustatiilor, imagini lacunareimagini lacunare
![Page 147: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/147.jpg)
RECTOCOLITA ULCERO-HEMORAGICARECTOCOLITA ULCERO-HEMORAGICA
ST II: ULCERATII & PSEUDOPOLIPIST II: ULCERATII & PSEUDOPOLIPI
![Page 148: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/148.jpg)
RECTOCOLITA ULCERO-HEMORAGICA:RECTOCOLITA ULCERO-HEMORAGICA:
PSEUDOPOLIPI & ULCERATIIPSEUDOPOLIPI & ULCERATII
![Page 149: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/149.jpg)
RECTOCOLITA
ULCERO-HEMORAGICA:
ST III:
FORMA STENOTICA=>
MICROCOLON
![Page 150: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/150.jpg)
Diverticulii colonuluiSediu: sigmoid;Diverticuli simpli: - clisma baritata: imagini de aditie multiple, dimensiuni variate; - atasate prin pedicul lumenului colic; - asociere cu spasm colic la acelasi nivel;
Diverticulita: - saci diverticulari deformati, aspect neregulat si umplereneomogena; - abces pericolic: US/CT; - extravazarea contrastului, traiect paralel cu peretele colic;
![Page 151: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/151.jpg)
DIVERTICULOZA COLONICADIVERTICULOZA COLONICA
![Page 152: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/152.jpg)
Tumori benigne colon: polipii
Polip unic/Polipoza multipla (transmitere ereditara dominanta);
Sindroame ce asociaza polipoza intestinala:Sindroame ce asociaza polipoza intestinala: - Peutz-Jeghers + pigmentarea tegumentelor si mucoaselor; - Gardner + osteoame multiple; - Turcot + tumori SNC; - Cronkite-Canada + anomalii ectodermale;
DiagnosticDiagnostic: clisma baritata (contrast simplu/dublu contrast) +colonoscopie;
![Page 153: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/153.jpg)
Caractere radiologice: - sesil (cu baza larga)/pediculat; - defecte de umplere (lacune) rotunde, contur net, inconjurate deun lizereu opac;
Potential de malignitate: - dimensiuni: < 0,5 cm - rar malign; - pedicul bine definit: potential scazut; - conturul de suprafata: reticular, ulceratie - potential crescut de malignitate; - rata cresterii;
![Page 154: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/154.jpg)
POLIPI PEDICULAŢI
1a
1b
2a
Malignizare redusa
![Page 155: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/155.jpg)
POLIPI SESILI
1c
Malignizare=>50%
![Page 156: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/156.jpg)
POLIPI VILOŞI
Malignizare foarte frecventa
![Page 157: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/157.jpg)
MALIGNIZAREA POLIPULUI
9 ANI DUPA EXTIRPARE ENDOSCOPICA
![Page 158: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/158.jpg)
POLIPOZA COLONICA FAMILIALAPOLIPOZA COLONICA FAMILIALA
![Page 159: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/159.jpg)
POLIPOZA FAMILIALĂ MULTIPLĂa
a, b - aspect radiologic
c, d - aspect colonoscopic
e - specimen de rezecţie
![Page 160: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/160.jpg)
CANCERUL RECTO-COLONIC
Factori favorizanti: - regim alimentar, RCUH, boala Crohn, polipoza familiala, iradierea pelvina;
Histologie: - adenocarcinoame, rar tumori carcinoide, limfoame;
Forme macroscopice: - forme vegetante, ulcerante, infiltrante, mixte;
![Page 161: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/161.jpg)
MORFOLOGIA CANCERULUI COLO-RECTAL
BORMANN I
BORMANN II
BORMANN III
BORMANN IV
vegetant
Ulcerant pevegetatie
Ulcerant peinfiltratie
Infiltantdifuz=schir
![Page 162: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/162.jpg)
DIAGNOSTICUL IMAGISTICDIAGNOSTICUL IMAGISTIC
• RADIOGRAFIA STANDARD=>IN OCLUZIE; RADIOGRAFIA STANDARD=>IN OCLUZIE;
•CLISMA BARITATA CU DUBLU CONTRAST;CLISMA BARITATA CU DUBLU CONTRAST;
•ECOGRAFIA; ENDOSONOGRAFIA;ECOGRAFIA; ENDOSONOGRAFIA;
•CT; COLONOSCOPIA VIRTUALA CT;CT; COLONOSCOPIA VIRTUALA CT;
• IRM;COLONOSCOPIA VIRTUALA IRMN;IRM;COLONOSCOPIA VIRTUALA IRMN;
![Page 163: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/163.jpg)
CLISMA BARITATACLISMA BARITATA
ASPECTE ASPECTE SEMEIOLOGISEMEIOLOGICECE - infiltratie: rigiditate parietala + absenta distensiei colice; - lacuna: dimensiuni variate, contur policiclic anfractuos, semiton(forma vegetanta); - nisa maligna (nisa in lacuna); - stenoze: lungime variata, contur neregulat (forma vegetanta) saucaracter regulat (forma infiltranta); - stop complet al progresiei contrastului, precedat de imagine de stenoza/ oprire cu contur neregulat (mularea polului tumoral);
![Page 164: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/164.jpg)
CANCERCANCER
INCIPIENT (T1)INCIPIENT (T1)
TIP TIP INFILTRATIVINFILTRATIV
(dublu contrast)(dublu contrast)
![Page 165: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/165.jpg)
Vegetant/polipoid:BORMANN I
CANCER COLONIC:TIPURI SEMEIOLOGICE
Ulcerant pe vegetant:BORMANN II
![Page 166: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/166.jpg)
CANCER COLON:SEMEIOLOGIE IMAGISTICA
Tumora vegetanta-ulcerata tip BORMANN II
![Page 167: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/167.jpg)
Ulcerant pe vegetatie: BORMANN II
CANCER COLON DESCENDENT:CANCER COLON DESCENDENT:
FORMA VEGETANTA (lacuna) FORMA VEGETANTA (lacuna)
![Page 168: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/168.jpg)
Infiltrant difuz =>schir
BORMANN IV
“cotor de măr”
CANCER ULCERANT:CANCER ULCERANT:
nisa in lacuna BORMAN IInisa in lacuna BORMAN II
![Page 169: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/169.jpg)
CANCERE AVANSATE LOCO-REGIONAL, STENOTICCANCERE AVANSATE LOCO-REGIONAL, STENOTIC
RECTALRECTALRECTO-SIGMOIDIANRECTO-SIGMOIDIAN
![Page 170: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/170.jpg)
CANCERCANCER
MIXT,MIXT,
COLONCOLON
TRANSVERSTRANSVERS
![Page 171: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/171.jpg)
CANCERE DE CEC VEGETANTE/STENOZANTECANCERE DE CEC VEGETANTE/STENOZANTE
![Page 172: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/172.jpg)
CANCER SIGMOIDIAN: CANCER SIGMOIDIAN: STOP STOP TOTAL TOTAL AL COLOANEI BARITATEAL COLOANEI BARITATE
CANCER VEGETANT CANCER VEGETANT CECAL - INVAGINATIECECAL - INVAGINATIE
![Page 173: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/173.jpg)
Complicatii: - sindrom obstructiv; - perforatie (abces pericolic, fistule);Diagnostic diferential:Diagnostic diferential: - spasm local segmentar; - aderente; - stenoze benigne; stenoze post-radice;Extensie loco-regionala: - eco-endoscopia; - examinarea CT si IRMN;Extensie metastatica: - ecografie hepatica; - examinare CT/IRMN abdominala;
![Page 174: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/174.jpg)
T
ENDOSONOGRAFIE RECTALA (6,5 Mhz): tumora
![Page 175: Digest IV](https://reader031.fdocuments.net/reader031/viewer/2022020919/55cf9848550346d03396b394/html5/thumbnails/175.jpg)
TUMORA
Musc.mucosae
submucoasa
mucoasa
IRMN,ANTENA ENDORECTALA:cancer incipient ( pT-1)
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CT:CANCER COLON DREPT-extenzie regionala (T-4)
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COLONOGRAFIE & ENDOSCOPIE VIRTUALA CT
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Radiografia abdominala simpla
Tehnica: - decubit dorsal, raza verticala; - ortostatism, decubit lateral (raza orizontala): abdomen acut(perforatie, ocluzie);
Semeiologie radiologica:Imagini de tonalitate calcara:Imagini de tonalitate calcara: - calcificari condro-costale, suprarenaliene, pancreatice, arteriale(aorta, iliace, splenica), ggl. mezenterici, fibrom uterin, fleboliti; - calculi veziculari, calculi calcificari urinari (coraliform, caliciali, ureter, vezicali), vezica calcificata, prostatice, calculi in Wirsung, chist hidatic calcificat;
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Imagini de tonalitate hidricaImagini de tonalitate hidrica - hepatomegalie, splenomegalie, hipertrofie renala; - tumori: suprarenaliene, retroperitoneale, renale;
Viscere continind lichid:Viscere continind lichid: - glob vezical; - stomac post-prandial; - intestin subtire si colon (v. ocluzii intestinale)
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OCLUZII INTESTINALE
Etiologie: - mecanicamecanica (obturarea lumenului digestiv); - functionala- functionala (disparitia peristaltismului)
Examenul imagistic Examenul imagistic (Rg. abdominala, US, CT)(Rg. abdominala, US, CT) – 5 intrebari5 intrebari:1. Este ocluzieocluzie ? (-> prezenta nivelelor hidro-aerice);2. Este mecanica/functionalamecanica/functionala? (->distensie inaintea obstructiei/
distensia intregului tract digestiv)3.3. SediulSediul obstructiei? (->intestin/colon)4.4. CauzaCauza obstructiei ? (aderente, tumora, invaginatie, volvulus)5. Exista semne de strangulatiestrangulatie? (->ingrosarea peretelui ansei)
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OCLUZIA INTESTINULUI SUBTIRESemne generale: - bula gazoasabula gazoasa; dispozitie: ax oblic intre hipocondrul sting sifosa iliaca dreapta; - arcul gazos- arcul gazos (imagine “in magnet”); - imagine “in retorta”;- imagine “in retorta”; - dispozitie, numardispozitie, numar: unica/multipla, in tot abdomenul; anse jejunale:vertical (“tuburi de orga”); anse ileale: orizontal( “trepte de scara”); - pliuri vizibile (functie de distensia ansei);Etiologie: - strangulatie:- strangulatie: imagini hidro-aerice IS + vacuitate colon; -- obstructiiobstructii: ileus biliar (+aerobilie); - invaginatii- invaginatii: clisma baritata cu reflux ceco-ileal: imagini “in trident”;
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OCLUZIEOCLUZIE
INTESTINALAINTESTINALA
INALTA:INALTA:
ASPECT DEASPECT DE
““MAGNET”MAGNET”
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OCLUZIE INTESTINALA INALTA: NIVELE HIDROAERICEOCLUZIE INTESTINALA INALTA: NIVELE HIDROAERICE
““POTCOAVA”POTCOAVA”
““Trepte de scara”Trepte de scara”
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Ocluziile colonuluiSemne generale: - bula de gaz:- bula de gaz: voluminoasa, inaltime > largime; - arcul gazos- arcul gazos: volum > IS, numar redus/unic; - boseluri:- boseluri: dilatatii haustrale; - distantarea pliurilor: aparitia “pliurilor de flexiune”“pliurilor de flexiune” la cuduraanselor destinse;Etiologie:• Strangulatie:Strangulatie: - volvulusul sigmoidului: arc gazos voluminos, putin lichid, ocupaintreg abdomenul; - volvulusul cecului: dilatarea aerica a cecului, uneori in pozitie para-vertebrala stinga; vidarea fosei iliace drepte;• Obstructie:Obstructie: tumorala;
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VOLVULUS SIGMOIDIAN:VOLVULUS SIGMOIDIAN:
A)BULA DE GAZ SIGMOIDIANA;A)BULA DE GAZ SIGMOIDIANA;
AAB
B) OCLUZIE JOASAB) OCLUZIE JOASADISTENSIE + NIVELE HIDRO-DISTENSIE + NIVELE HIDRO-
AERICE PE COLONAERICE PE COLON
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Ocluzii functionale
Etiologie - patologie urinara (colica, traumatisme renale, retentie acuta de urina); - colica biliara; - pancreatita acuta, apendicita acuta, traumatisme abdominale; - infarctul miocardic;
Semne generale:Semne generale: - absenta/raritatea nivelelor hidro-aerice; - distensie aerica intestinala difuza (gastrica, IS, colon, aer in rect);
Metode de explorareMetode de explorare: Rg abdominala (->distensie); ecografie abdominala (->absenta peristaltismului)
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Perforatiile tubului digestiv
Perforatie in peritoneu liberClasic: semiluna aerica subdiafragmatica, vizibila pe rdgf. abdominala,cu pacientul in ortostatism;Dg. diferentialDg. diferential: sdr. Chilaiditi;
Perforatie cloazonata: - examinare CT: aer extra-digestiv + sediul perforatiei (gastrica,duodenala, sigmoidiana);
Examinare cu contrast: - per os, retrograd; - hidrosolubil; sediul perforatiei;
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Ulcer duodenal perforat: pneumoperitoneupneumoperitoneu
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Hemoragii digestive - Diagnostic ImagisticOrigine: - superioara (eso-gastro-duodenala); - inferioara (IS, colon);
Exteriorizare: hematemeza/melena/rectoragiiHematemeza:1. Fibroscopie: ulcer gastric/duodenal, varice esofagiene;2. Arteriografie: trunchi celiac, artera mezenterica superioara; selectiv:artera gastro-duodenala, artera splenica;3. Embolizare selectiva: microspirale;Varice esofagiene: TIPSS + embolizare;Melena/rectoragii: - coloscopie; - scintigrafie: Tc99; - arteriografie : AMS, AMI; +/- vasopresina;+/- embolizare;
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Infarctul intestinal - Diagnostic imagisticEtiologie: - obstructie brutala (embolie, tromboza, disectie) A. Mez. Sup.;
Diagnostic:Rdgf. abdominala simpla:Rdgf. abdominala simpla: - distensie aerica a IS; pneumatoza parietala;Ecografia (limitata de distensia aerica):Ecografia (limitata de distensia aerica): - Doppler pentru A Mez. Sup;Examinarea CT:Examinarea CT: - modificare parietala, diferenta de captare a contrastului (segmenteischemiate/segmente normale), ocluzia AMS (3D), perforatie,peritonita;ArteriografieArteriografie: selectiva (A.Mez.Sup.)/aortografie; - tratament vasodilatator/tratament fibrinolitic;
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