STOMACH IN MY WAY!! Teresa Wells, BHSA, RDMS, RVT, RT Professor of General and Vascular Sonography Lansing Community College
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1 STOMACH IN MY WAY!! Teresa Wells, BHSA, RDMS, RVT, RT Professor of General and Vascular Sonography Lansing Community College
2 Physiology What it does and why Anatomy GEJ Body Antrum Pyloric canal What is abnormal? STOP IGNORING THE STOMACH! img-9gag-fun.9cache.com/photo/65479_700b_v1.jpg
3 IN CONCLUSION: Sonography is sensitive and specific to detect gastric abnormalities. Sonographer s should be familiar with the ability to detect gastric lesions.
4 WHAT DOES THE STOMACH DO, HOW AND WHY? Bulk storage Mechanical breakdown Gastrin = acid Secretin = antacid Cholecystokinin = GB Mixer
5 FUN FACT: ACID
6 SONOGRAPHICALLY, WHAT S NORMAL? Gut signature 1-16 mm
7 GUT SIGNATURE
8 RUGAE
9 FUN FACT:
10 BULK STORAGE
11 GASTRIC EMPTYING Scintigraphy Meal: cooked eggs and toast mixed with radiopharmaceutical 2-4 hours Gastroparesis- delay in emptying
12 SIZE MATTERS
13 BODY HABITUS docstoc.com/docs/ /body-habitus
14 GASTROESOPHAGEAL JUNCTION
15 GASTROESOPHAGEAL JUNCTION
16 IN CONCLUSION: Ultrasound is an effective method in the investigation of GERD in children Easy to perform Highly sensitivity NO radiation
17 No Reflux GASTROESOPHAGEAL JUNCTION
18 Reflux GASTROESOPHAGEAL JUNCTION
19 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Ravi D. Kadasne, Facebook
20 Very common in infants Vomiting Irritability and crying Failure to thrive Refusal to eat Aspiration pneumonia SCANNING FOR GERD 1. MILD: <3 refluxes in 10 min 2. MODERATE: 4-6 refluxes in 10 min 3. SEVERE: >6 refluxes in 10 min
21 ESOPHAGEAL REFLUX Moving Journal of Clinical Imaging Science Vol. 1 Issue 1 Jan-Mar 2011
22 REFLUX COLOR DOPPLER
23 WIDE ESOPHAGUS ultrasoundcases.info
24 THICKENED ESOPHAGEAL WALL ultrasoundcases.info
25 THICKENED ESOPHAGEAL WALL
26 ESOPHAGEAL VARICES ultrasoundcases.info
27 GASTRIC VARICES
28 ESOPHAGEAL CYST
29 PROXIMAL ESOPHAGUS
30 SPINAL MASS
31 ESOPHAGUS CARCINOMA
32 ESOPHAGUS CARCINOMA
33 FUN FACT: WHICH ANIMAL DOES NOT HAVE A STOMACH? A. Puffer fish B. Platypus C: Seahorse
34 ANTRUM
35 ANTRUM L A P
36 ANTRUM
37 WATER PANCREAS A p
38 WATER FILLED STOMACH? P ultrasoundcases.info
39 PANCREATITIS MIMICKING STOMACH P P ultrasoundcases.info
40 PSEUDOCYST VS. STOMACH P P ultrasoundcases.info
41 PANCREATITIS MIMICKING STOMACH L ultrasoundcases.inf
42 PANCREATITIS MIMICKING STOMACH P ultrasoundcases.inf
43 THICKENED ANTRUM WALL ultrasoundcases.inf
44 THICKENED ANTRUM WALL ultrasoundcases.inf
45 THICKENED ANTRUM WALL ultrasoundcases.info
46 THICKENED ANTRUM WALL
47 THICKENED ANTRUM WALL ultrasoundcases.info
48 THICKENED ANTRUM WALL ultrasoundcases.inf
49 THICKENED ANTRUM WALL
50 PARTIAL THICKENED ANTRUM WALL
51 PARTIAL THICKENED ANTRUM WALL
52 ANTRUM MASS (CARCINOMA) ultrasoundcases.inf
53 GASTRIC ULCER ultrasoundcases.inf
54 recessionbitesblog.wordpress.com/tag/haggis/ FUN FACT: HAGGIS Scottish savory pudding Sheep's stomach stuffed with diced sheep's liver, lungs and heart, oatmeal, onion, suet and seasoning Against US law because of sheep lungs
55 PYLORUS SPHINCTER Pyloric Sphincter Pylorus Pyloric Antrum
56 PYLORUS SPHINCTER
57 HYPERTROPHIC PYLORIC STENOSIS 3 per 1,000 infants Males 4:1 White First born Family history Gastric outlet obstruction Thickening of the muscular layer Failure of the canal to relax
58 IHPS DIAGNOSIS Muscle width >3mm Canal length >12mm No fluid passing
59 IHPS pedsurg.ucsf.edu
60 HOW TO SCAN FOR IHPS 1. Supine or RPO 2. Longitudinal pyloric canal 3. Water feeding 4. Watch what happens!
61 A. B. WHICH IS HPS?
62 GASTRIC OUTLET OBSTRUCTION
63 GASTRIC OUTLET OBSTRUCTION
64 DILATED STOMACH
65 DILATED STOMACH
66 FUN FACT: Joey Chestnut World record: 69 Hot Dogs and Buns 10 minutes
67 UNUSUAL INCIDENTALS S ultrasoundcases.inf
68 UNUSUAL INCIDENTALS
69 BEZOAR harrypotter.wikia.com/wiki/bezoar "A bezoar is a stone taken from the stomach of a goat and it will save you from most poisons." Snape lecturing in Harry Potter's first year Potion class
70 BEZOAR
71
72 RAPUNZEL SYNDROME
73 RAPUNZEL SYNDROME
74 PICA
75 FOREIGN BODY
76 FOREIGN BODIES
77 BODYPACKS
78 ASCARIS
79 APPENDIX Cecum Small bowel Iliac vessels Psoas muscle Appendix
80 CECUM, TERMINAL ILIUM AND THE APPENDIX
81 MCBURNEY S POINT One-third the distance from the anterior superior iliac spine to the umbilicus
82 SYSTEMATIC SCANNING TECHNIQUE Step #1 Step #2 Step #3 Step #4 Step #5 Step #6 General survey Cecal tip Iliac vessels Muscle Retro-cecal Where does it hurt Scan slowly and patiently with graded compression
83 Lawn-mower Screen for obvious findings STEP #1 GENERAL SURVEY
84 STEP #2 CECAL TIP Identify the Cecum in transverse Bumpy, gas and stool filled bowel
85 Cecum STEP #2 CECAL TIP Bumpy vs. smooth bowel Ilium
86 Identify the Cecal tip Look for appendix inferior/medial STEP #2 CECAL TIP Cecum
87 Scan Parallel and transverse with vessels Look for appendix draping across vessels STEP #3 ILIAC VESSELS
88 STEP #3 ILIAC VESSELS
89 Scan deep to identify the iliacus muscle Identify the appendix laying anterior STEP #4 PSOAS MUSCLE
90 Decrease MHz Scan deep STEP #5 RETRO-CECAL
91 Rotate patient LPO Apply compression on patient s back STEP #5 RETRO-CECAL
92 RUQ?? STEP #6 WHERE DOES IT HURT
93 Greater than 6-7mm is abnormal Always measure AP (not width) MEASUREMENT * 12mm + 8mm
94 ACUTE APPENDICITIS SONOGRAPHIC APPEARANCE
95 SECONDARY FINDING Free fluid Increased vascularity
96 SECONDARY FINDINGS Appendicolith Abscess Edema of surrounding fat
97 ALWAYS IMAGE THE TIP
98 OTHER FINDINGS Mesenteric adenitis Colitis/Crohn s Intussusception
99 TAKE AWAYS: Look at the stomach! Recognize normal Identify abnormal 6 steps to the appendix
100 THANK YOU
101 REFERENCES Carvalho, Santos, Meirelles, Bersot & Niterói - Rio de Janeiro, RJ/BR Transabdominal ultrasound in the detection ofgastroesophageal reflux disease in children: review of 500 cases /ecr2012/C-1857 Chauhan, N. S., & Sood, D. (2011). Case report: Colonic bezoar due to Box Myrtle seeds: A very rare occurrence. The Indian Journal of Radiology & Imaging, 21(1), doi: / Costa Dias, S., Swinson, S., Torrão, H., Gonçalves, L., Kurochka, S., Vaz, C. P., & Mendes, V. (2012). Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights into Imaging, 3(3), doi: /s x Curry, R. A., & Tempkin, B. B. (2011). Sonography: Introduction to normal structure and function (3nd ed.). St. Louis, MO: Saunders.Transabdominal Sonography in Assessment of the Bowel in Adults AJR:192, Dehdashti, H., Dehdashtian, M., Rahim, F., & Payvasteh, M. (2011). Sonographic Measurement of Abdominal Esophageal Length as a Diagnostic Tool in Gastroesophageal Reflux Disease in Infants. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association, 17(1), doi: / Gilja, O. H., Lunding, J., Hausken, T., & Gregersen, H. (2006). Gastric accommodation assessed by ultrasonography. World Journal of Gastroenterology : WJG, 12(18), doi: /wjg.v12.i Hagen-Ansert, S. L. (2006). Textbook of diagnostic ultrasonography. St. Louis, Mo: Mosby Elsevier. Herliczek TW, Raghavan D, McCarten K, Wallach M. Sonographic Upper Gastrointestinal Series in the Vomiting Infant: How We Do It. J Clin Imaging Sci 2011;1:19
102 REFERENCES Kawamura, D. M., & Lunsford, B. M. (2012). Diagnostic Medical Sonography: Abdomen and superficial structures. (3rd ed.) Philadelphia, PA: Wolters Kluwer. Kim, J. S., & Nam, C. W. (2013). A Case of Rapunzel Syndrome. Pediatric Gastroenterology, Hepatology & Nutrition, 16(2), doi: /pghn Likes, M., & Johnston, T. (2012). Gastric pseudoaneurysm in the setting of Loey s Dietz Syndrome. Images in Paediatric Cardiology, 14(3), Miller & Phil., (2011) Gastric Emptying Scintigraphy. Radiology Rounds 9(2). Russo, T., Costa, C., Crujo, C., & Lopes, A. I. (2012). Protein-losing gastropathy associated with cytomegalovirus infection in a child. BMJ Case Reports, 2012, bcr doi: /bcr Weeks, D., MD Transient pancreatitis and small bowel obstruction by trichobezoar Applied Radiology. February 07, Wong, M., Shum, S., Chau, W., & Cheng, C. (2010). Carcinoma of stomach detected by routine transabdominal ultrasound. Biomedical Imaging and Intervention Journal, 6(4), e39. doi: /biij.6.4.e39 Van de Putte P. and. Perlas A. June 3, Ultrasound assessment of gastric content and volume. British Journal of Anaesthesia /bja/aeu151
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