Diagnostic Procedures in GIT Diagnostic Procedures in GIT Diseases: Diseases:
May 07, 2015
Diagnostic Procedures in GIT Diseases: Diagnostic Procedures in GIT Diseases:
Introduction:Introduction:
• Major cause of morbidity & mortality.• 10% of GP consultations are for indigestion.• ¼ of GP consultations for diarrhea.• Infective diarrhea is a major cause of ill heath & death in developing countries.• GIT is one of the most common sites for cancer.• Major advances had occurred in the field of GE;• PUD proved to be an infective condition due to HP & Nobel prize had been
given recently to its discoverer, Marshal.• Molecular events in the CRC development had been discovered & from this
effort became successful in its prevention by NSAIDs.• GIT endoscopy made diagnosis of GIT diseases very easy.• Therapeutic endoscopy made it possible to replace surgery for many GIT
conditions as GI bleeding, bilairy stone removal & stenting, palliative cancer stenting, polyp removal, PEG & endoscopic mucosal resection.
History:History:
• Dysphagia: difficult swallowing• Odynophagia: painful swallowing.• Aphagia: can not swallow.• Heart burn.• Non cardiac chest pain.• Regurgitation.• Aerophagia: eructation.• Hematemesis.• Melena.• Hematochesia: fresh bleeding per rectum.• Dyspepsia: abnormal digestion.• Anorexia.• Flatulence.• Alteration in bowel habits.• Bleeding per rectum.• Abd pain.
Physical exams:Physical exams:
Diagnostic Procedures in GI Diseases
• The gastrointestinal system includes the GI tract and its associated glands
• Esophagus• Stomach• Small intestine• Colon• Liver & Biliary tree• Pancreas
Diagnostic Procedures in GI Diseases
• The diagnostic tests can be divided into several categories:
• Structural tests• Functional tests• Tests for Helicobacter pylori• Special blood tests• Special stool tests
Diagnostic Procedures in GI Diseases
Structural Tests
Diagnostic Procedures in GI Diseases
Structural Tests
• Radiography• Ultrasonography• Nuclear Isotope Scanning • Magnetic Resonance Imaging• Gastrointestinal Endoscopy• Endoscopic Ultrasonography
Plain X Ray:
• Show gas within bowel for diagnosis of Int obst 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.
Contrast studies:
• Barium & double-cnotrast barium using air with barium, will show filling defects, strictures, erosions & ulcers & even motlity disorders if under fluroscopy.
Tests of structure: Imaging• Contrast studies: uses & limitations.
Indications Major uses LimitationsBa swallow:
Dysphagia,rfelux,chest pain,motility disorder
Stricture, HH,GERD,Achalasia.
Aspiration risk
Poor mucosal detail
No biopsy
Ba meal:
Dyspepsia,epigastric pain,vomiting,anemia,perforation.
DU,GU,Gastric Ca,GOO,
Gastric emptying disorder.
Low sensitivity for early cancer.
No biopsy
No HP assessment.
Ba follow through:
Diarrhea,abd pain, Obst by stricture
Malabsorption.
Chrons.
Time consuming.
Radiation exposure.
Ba enema
Abn bowel habit,Rectal bleeding,anemia,abd pain
Ca, diverticuli,stricture,megacolon.
Difficult in elderly.
incontinance.,
No biopsy.
Tests of structure: Imaging• U/S,CT,MRI:Increasingly used for abd diseases,
noninvasive & offer detailed images of abd contents.
Indications Major uses LimitationsUS: Masses,abscess,organs,ascites,bil
iary dilation,gall stones,guided needle aspiration & biopsy.
Low sensitive for small ls.
Little functional info.
Operator dependent.
Gass & obesity interfer with it.
CT: Pancreatic dis,liver tumor deposits, tumor staging, vascular lesions.
Expensive,high radiation, may underestimate stage of cancers as esophagus.
MRI: Tumor stage,MRCP,pelvic/perineal, chrons fistula.
Time consuming.
Clusterphobia,role not fully established,limited availability.
Tests of structure: endoscopy• Endoscpy: UGI, LGI, Enteroscopy, ERCP,EUS , Double balloon endoscopy, capsule video endoscopy.• Increasingly used for abd diseases, noninvasive & offer detailed images of abd contents.
Diagnostic Procedures in GI Diseases
Functional Tests
Diagnostic Procedures in GI Diseases
Functional Tests
• Tests for motility• 24 hour pH monitoring • Tests for acid output• Tests for malabsorption• Tests for pancreatic function
Gastrointestinal Endoscopy
Gastrointestinal Endoscopy
• Direct method to examine and biopsy the mucosal lining of the gastrointestinal tract
• Various accessories are available to take biopsies and provide therapy
Gastrointestinal Endoscopy
Types of Gastrointestinal Endoscopy
Gastrointestinal Endoscopy
Types of Gastrointestinal Endoscopy
• Esophagogastroduodenoscopy (Upper GI Endoscopy)
• Small Bowel Enteroscopy (Jejunoscopy)
• Colonoscopy (Lower GI Endoscopy)
• Sigmoidoscopy
• Endoscopic Retrograde Cholangiopancreatogram (ERCP)
Upper Gastrointestinal Endoscopy
• Heartburn
• Dysphagia or odynophagia
• Hematemesis or melena
• Dyspepsia or upper abdominal pain
• Unexplained weight loss or anemia
• Evaluation of abnormal Barium meal X-ray
• Suspected malabsorption
• Control of bleeding
• Dilation of stricture
• Removal of foreign bodies
• Removal of polyps
• Tumor ablation
Diagnostic Indications Therapeutic Indications
Upper Gastrointestinal Endoscopy
Contraindications to Upper GI Endoscopy
• Uncooperative patient
• Hemodynamically unstable patient: Recnet AMI, Unstable angina or arrhythmia,Severe resp dis.
• Suspected perforation
• Severe RA of the cervical spine
• Severe shock.• Atlanto axial sublaxation.• These may be relative in experienced hands.
Upper Gastrointestinal Endoscopy
Examples of therapeutic techniques in endoscopy.
Upper Gastrointestinal Endoscopy
Normal Esophagus Normal Stomach Normal Duodenum
Duodenal UlcerGastric UlcerEsophagitis
Lower Gastrointestinal Endoscopy
• Chronic diarrhea• Rectal bleeding• Iron deficiency anemia• Unexplained abdominal pain• Constipation, change in bowel
habits or stool caliber• Unexplained weight loss• Evaluation of abnormal Barium
enema x-ray• Personal or family history of
colon cancer• Personal history of IBD
• Control of bleeding
• Removal of polyps
• Tumor ablation
• Dilation of stricture
• Colonic decompression
• Reduction of sigmoid volvulus
Diagnostic Indications Therapeutic Indications
Lower Gastrointestinal Endoscopy
Contraindications to Lower GI Endoscopy
• Uncooperative patient
• Hemodynamically unstable patient
• Suspected perforation
• Suspected colonic obstruction
• Suspected diverticulitis
• Soon after a myocardial infarction
Lower Gastrointestinal Endoscopy
Lower Gastrointestinal Endoscopy Normal Colon Colon Cancer
Colon Polyp and Polypectomy
Endoscopic Retrograde Cholangiopancreatogram
Indications
Endoscopic Retrograde Cholangiopancreatogram
Indications
• Obstructive jaundice (benign or malignant)
• Ascending cholangitis • Gallstone pancreatitis• Unexplained jaundice or
elevated LFT’s• Bile duct injury or leak after
cholecystectomy• Chronic pancreatitis• Pancreatic cancer• Suspected Sphincter of Oddi
dysfunction
Endoscopic Retrograde Cholangiopancreatogram
Gallstone impacted at ampulla, sphincterotomy being done and stones removed
Endoscopic Retrograde Cholangiopancreatogram
Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct sign)
Endoscopic 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
Endoscopic Ultrasound
A T3 Rectal Tumor on EUS
Diagnostic Procedures in GI Diseases
Capsule Endoscopy
Capsule Endoscopy
Capsule Endoscopy
• Capsule endoscopy is intended for visualization of the small bowel mucosa
• 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
Capsule Endoscopy
• Capsule endoscopy is contraindicated for use under the followingconditions:
– In patients with known or suspected gastrointestinal obstruction, strictures, or fistulas based on the clinical picture or pre-procedure testing and profile
– In patients with cardiac pacemakers or other implanted electromedical devices
– In patients with swallowing disorders
Contraindications
Diagnostic Procedures in GI Diseases
Functional Tests
Diagnostic Procedures in GI Diseases
Functional Tests
• Tests for motility• Tests for pH • Tests for acid output• Tests for malabsorption• Tests for pancreatic function
Functional Tests in GI Diseases
Tests for motility
Functional Tests in GI Diseases
Tests for motility
• Esophageal Manometry
• 24 Hour pH Monitoring
• Anorectal Manometry
Functional Tests in GI Diseases
Indications for Esophageal Manometry
• Oropharyngeal dysphagia with normal structural studies- Cricopharyngeal achalasia, Pharyngeo-UES dyscoordination
• Esophageal dysphagia with normal structural studies - Primary esophageal body dysmotility e.g. Achalasia, Diffuse esophageal spasm, Nutcracker esophagus, Hypertensive LES, Collagen vascular disease, Amyloidosis, Hypothyroidism, etc.
• Noncardiac chest pain
Functional Tests in GI Diseases
Esophageal Manometry Tracings
Esophageal Manometry
Functional Tests in GI Diseases
24 Hour pH Monitoring
Indications
• Patients with non cardiac chest pain
• Refractory acid reflux symptoms: evaluate treatment efficacy
• Pre and post-operative evaluation of antireflux surgery
• Patients with atypical presentations of acid reflux (ENT, pulmonary)
Functional Tests in GI Diseases24 Hour pH Monitoring
Functional 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
Functional Tests in GI Diseases
Anorectal Manometry
Tests of structure: Biopsy• Obtained through endoscpy or percutanously & sent for histopath exam.• Reasons for biopsy or cytological exams:• Brash cytology of suspected malignant lesions.• Histological assessment of mucosal abns.• Diagnosis of infections( candida, HP,Giardia).• Measure enzymes as disacharidases.• Analysis of genetic mutations as oncogenes , tumor suppressor genes.
2.Tests of infection: Bacterial cultures• For identifying causes of diarrhea sp if acute or bloody.• Causes of infective diarrhea:• Viruses: Rota, adeno, entero, requires EM or viral cultures.• Bacteria: Campylo jej, EC,Salmonella,clostridium difficile( ned toxine
isolation).• Protozoa: Giardia,ameba, cryptosporidium & moicrospora.
Functional Tests in GI Diseases
Tests for Malabsorption
Functional Tests in GI Diseases
Tests for Malabsorption• Serum screening tests for malabsorption
S. Calcium, Albumin, Iron, Vitamin B12, Folate, Carotene, Prothrombin time
• Quantitative fecal fat determination• D-xylose absorption test• Small bowel biopsy• Schilling test for Vitamin B12
absorption• Hydrogen Breath Test for lactose intolerance
Diagnostic 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
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
Diagnostic 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
Diagnostic Procedures in GI Diseases
Tests for Helicobacter pyloriC13 or C14 Urea Breath Test
Diagnostic Procedures in GI Diseases
Tests for Helicobacter pyloriMucosal Biopsy
Diagnostic Procedures in GI Diseases
Tests for Helicobacter pylori
Rapid Urease Test
• This test is based on the urease enzyme present in the H. pylori
• Urea is split into NH3 and CO2
• The change in pH causes a color change in the medium
Diagnostic Procedures in GI Diseases
Blood tests
• Liver function tests (LFT’S)
• Hepatitis serology
• S. Amylase & Lipase
• Alfa-Feto Protein (AFP)
• Carcino-Embryonic Antigen (CEA)
Stool tests
• Stool microscopy
• Stool ova & parasites
• Stool culture
• Stool C. difficile toxin
• Stool occult blood
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases
Diagnostic Procedures in GI Diseases