Radio Logical Anatomy of Esophagus, Stomach, Small by Talat 11-9

8/3/2019 Radio Logical Anatomy of Esophagus, Stomach, Small by Talat 11-9

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Radiological Anatomy ofEsophagus, Stomach, Small

Intestine and Large Intestine

Talat H. Sharif MD


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Objective

To identify the structures of the GI

tract on X-Rays, Barium Study, CT

Scan and UltrasoundTo be able to understand therelationship of various parts of the

intestinal tract and the structuresaround them.


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Digestive Tract

BEGINS AT THE LIPS

ENDS AT THE ANUS

MAJOR DIVISIONS

MOUTHOROPHARYNX

ESOPHAGUS

STOMACH

DUODENUM

JEJUNUM

ILEUM

COLON

RECTUM

ANUS


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Methods of Examination

Fluoroscopic-radiographic examinationwith barium sulfate is the standardexamination

Single contrast or double contrastDouble contrast provides improvedvisualization of mucosal folds

Water-soluble contrast is used whenperforation is suspected


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Methods of Examination

CT and Ultrasound can detect masses butbasically used for staging of cancer

Non-radiological methods

Fibero-optic endoscopy is a the methodto visualize the mucosa of the stomachand duodenum. In some parts of the worldendoscopy has replaced radiologicmethod as the primary examination


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Oropharynx

PHARYNX DIVIDED INTO 3 SEGMENTS

Nasopharynx

Oropharynx

mechanical breakdown offood through the chewing, chemicalbreakdown through salivary amylase,speech and swallowing occur here.

Hypopharynx


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Pharynx

Three pharyngeal recesses: Food bolusescan lodge in these recesses.

The vallecula is the space or depressionbetween the base of the tongue and theepiglottis.

The two pyriform sinuses are located in the

pharynx, beside the larynx. They are formedby the shape of muscle attachments to thepharyngeal walls.


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Oropharynx


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http://www.emedicine.com/med/images/Large/1611Esophageal_Stricture.jpg


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Esophagus


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What to ExamineMotility disorderAbnormal dilatation / narrowingDiverticulumInflammationUlcerationFilling defect

Mucosal nodularity / plaque


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Esophagus

The adult human esophagus is an 18- to25-cm long muscular tube

Esophagus develops from foregut and byweek 10 is lined by ciliated epithelial cells.

Esophageal peristalsis appears in the firsttrimester,gastro-esophageal reflux can bedocumented in the second trimester

Proximal 1/3-striated muscle

Distal 2/3- smooth muscle


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Esophagus (Course)

Esophagus connect pharynx with the stomach. Begins inthe neck at the lower border of the cricoid cartilage,opposite the C5 and C6 vertebra

Descends in front of the vertebral column, through thesuperior and posterior mediastinum

Passes through the diaphragm and enters the abdomenand ends at the cardiac orifice of the stomach, oppositethe T11 vertebra

General direction of the esophagus is vertical, but itpresents two slight curves in its course

Just before it perforates diaphragm it presents a distinctdilatation


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Esophagogram

Esophagogramshowing thecourse of the

esophagus


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Different parts of Esophagus

Topographically, esophagus has threedistinct regions: cervical, thoracic, andabdominal. The cervical part is 4 to 5cmlong & extends from pharyngoesophagealjunction to the suprasternal notch.

In cervical part, the esophagus is borderedanteriorly by the trachea, posteriorly by thevertebral column, and laterally by thecarotid sheaths and the thyroid gland.


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Thoracic esophagus extends from thesuprasternal notch to the diaphragmatichiatus, passes posterior to the trachea and

its bifurcation, and the left main stembronchus. The esophagus lies posteriorand to the right of the aortic arch at the T4

vertebral level. From the level of T8 untilthe diaphragmatic hiatus the esophaguslies anteriorly to the aorta.


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Abdominal esophagus extends from thediaphragmatic hiatus to the orifice of thecardia of the stomach.

The abdominal esophagus lies in theesophageal groove on the posteriorsurface of the left lobe of the liver.

Measures about 1.25 cm in length

Is somewhat conical in appearance as itenters in the orifice of the stomach


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Esophagogram

Study of esophagus by orally takingbarium sulphate is called anEsophagogram

Patient is asked to drink a thick mixture ofBarium.

Study is done under flouroscopy by aRadiologist

Images are captures on hard copy (film)during swallowing and after to study

motility and to rule abnormality


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Esophagogram

Performed in dysphagia and to ruleout pharyngeal or esophageal

abnormalityIt is a contrast study

AP & Lateral projections are taken

Valsalva maneuver is done andadditional films are taken


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Stages of Esophagogram


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Normal esophageal narrowing

At the site of its

origin

Aortic archLeft mainbronchus

Diaphragm


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Impressions on Esophagus

Aortic arch

Left main

bronchusLeft atrium


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Relationship of thoracic Part ofEsophagus

Anterior Trachea Left main stem bronchus

Pericardium Behind and to the right of aortic archPosterior

Vertebral column Hemiazygous vein Right aortic intercostal arteries Aorta near diaphragm


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Relationship of Thoracic Part ofEsophagus

Right

Right pleura

Azygous veinLeft

Aortic arch

Left subclavian artery Left pleura

Descending aorta


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Relations in thoracic inlet

Anterior

Trachea

Thyroid gland

Posterior Vertebral column

Longus coli muscles

Either side

Common carotid artery

Thyroid gland

CT Scan Showing the esophagus

and its adjoining structures


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Thoracic Esophagus

Relations insuperiormediastinum


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Relations at the level of heart


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Relations of distal part


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Stomach


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Anatomical drawing of stomach


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Anatomical relations of Stomach


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StomachIt is a muscular, elastic, pear-shaped bagMost dilated part of GI tractLies crosswise in the abdominal cavity in the lefthypogastric and epigastric regionsCapable of gross alterations in size and shapeIs about 30 cm long and 15 cm wide at its widestpointHas a capacity of about 1500 cc in adultsMucosa is honeycombed with over 35,000gastric glands and is folded into numerousridges that almost disappear when the stomachis distended with food


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Plain Film of the Abdomen

Things to look for Gas pattern

Extraluminal air

Soft tissue masses

Calcifications

Foreign body


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Normal Gas Pattern on plainfilm

Stomach Always

Small Bowel Two or three loops of non-distended

bowel

Normal diameter = 2.5 cm

Large Bowel In rectum or sigmoid almost always


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Plain film abdomen

Normal Postoperative


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Barium Meal Study

B i M l St d


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Barium Meal Study


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Parts of Stomach

Cardia

Fundus

Body

Antrum

Pylorus

Greater curvatureLesser curvature

Barium Meal Study


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Barium mealstudy of

Stomach andDuodenum

StomachFundus ofStomach

GastroesophagealJunctionBody of

Stomach

Barium Meal Study


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GASTRICFUNDUS

ANTRUM

DUODENALBULB


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Fundus ofStomachshowing

mucosal folds

Pyloric Antrum andDuodenal Bulb

C-Loop ofDuodenum


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Stomach

Cardia is the intersection of the stomachand esophagusA ring of muscle known as the cardiacsphincter is present in this part.Fundus is the most superior part of thestomach and lies above the entrance ofesophagus

On Chest X-ray, air is usually seen in thefundus, producing the gastric bubble


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Chest X-ray (stomach bubble)


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Stomach

Distal stomach consists of the antrum andpylorusAntrum forms the beginning of the distalstomach followed by pylorusPyloric canal is 3 cm in length and leads tothe duodenumPyloric sphincter separates the stomach

from duodenumPyloric sphincter remains closed until thefood here is modified & is suitable to passinto the small intestine

Stomach Relations


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Stomach Relations

Antero superior surface Diaphragm

Left

Spleen

Right

Liver - left and quadrate lobes

Posterior inferior surface

Diaphragm

Left adrenal

Left kidney

Splenic artery Anterior surface of pancreas

Left colon

Transverse mesocolonCT Scan of Abdomen

CT Scan of abdomen


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CT Scan of abdomen(stomach relations)

CT Scan of abdomen


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CT Scan of abdomen(stomach relations)

can o a omen


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can o a omen(stomach relations)


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Small Intestine


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Small Intestine

Small intestine is the longest part(about 7m) of the gastrointestinal tract

Extends from pylorus to ileocecal valve

Is located in the center of the abdomenDiameter is about 2.5 cm and is tubelike structure winds compactly back

and forth within the abdominal cavityThe small intestine is identified byvalvulae circulares / conniventes orcircular folds of mucosa on barium x-

ra stud


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Parts of small Intestine


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Parts of small Intestine


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The small intestine is identified by valvulaecirculares / conniventes or circular folds ofmucosa on barium x-ray study

Parts of Small Intestine


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Parts of Small Intestine

Duodenum

(proximal)

Jejunum (middle)Ileum (distal)


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Small Intestine

Small bowel islocated in the

center ofabdomen


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General relations of Small bowel


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General relations of Small bowel

Anterior

Greater omentum

Abdominal wall

Surrounded by colon

Some small bowel extends topelvis


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Duodenum

Duodenum is the first part of the smallintestine

It has no mesentery

It is about 25 cm long

Duodenum forms a C-loop around thehead of the pancreas

Whole of the duodenum except for thebulb is retroperitoneal


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Duodenal C Loop


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DifferentParts of the Duodenum

Duodenum is divided into four partsThe first part Measures 5 cm From pylorus to gall bladder neck

is encased in the hepato-duodenal ligamentThe second part (Descending part)- Its 8-10 cm long

From neck of Gall bladder to L3

This part is retroperitoneal It has ampulla, where the openings of pancreatic duct

and common bile duct are seen


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Duodenal Bulb


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Different Parts of the Duodenum

The third part (Transverse)

Extends from L3 across left and upwards

About 10 cm in length

The fourth part

Continues as jejunum at L2

Held in place by the ligament of Treitz

This ligament connects the duodenum to theright crus of the diaphragm


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3rd Part of the Duodenum


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DUODENALULCER

Relationships of 1st part of


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Relationships of 1st part of

Duodenum

Above and anterior

Quadrate lobe of liver

Gall bladder

Behind

Gastrodudenal artery

Bile duct and portal vein

Head and neck of

pancreas

d


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2nd part of the Duodenum

Relationships of 2nd part of


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Relationships of 2nd part of

Duodenum

Anterior Liver Transverse colon JejunumPosterior Right kidney Right renal vein IVC PsoasMedial Head of pancreas

Bile duct Pancreatic ductLateral Right colic flexure

Relationships of 3rd part of


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Relationships of 3rd part of

Duodenum

Anterior SMA

SMV

Posterior

Right ureter Psoas

IVC

Abdominal

aortaUpper

Pancreas

Lower

Jejunum

CT S d f d d


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CT Scan- 2nd part of duodenum


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Relationships of 4th part of


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Relationships of 4th part of

Duodenum

Right Aorta

Left

Left Ureter Left kidney

Above

Body of pancreas

Anterior

Transverse colon

Mesocolon


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Jejunum

J j


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Jejunum

Middle part of small intestine is the Jejunum

It is 8 feet long and 4 cm in diameter

Stays mostly in umbilical regionSurface area increased by plica circulares(circular folds) carrying villi: cells of villi carrymicrovilli

Jejunum and Ileum are attached to posteriorabdominal wall by mesentery

B i St d


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Barium Study

CT S f th bd


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CT Scan of the abdomen


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Ileum

Ileum


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Ileum

Distal part of the small intestine

It is 3.5 m long

Located mostly in hypogastric region

Ileum joins the large intestine (cecum) atthe ileo-cecal junction in the right lowerabdominal cavity

Jejunum and Ileum are attached toposterior abdominal wall by mesentery

B i St d


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Barium Study


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Barium Study (ileocecal


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y (junction)



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Large Intestine

Large Intestine


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g

Large intestine / Colon is about 1.5 mlong

Extends from the ileocecal valve to anus Direction

Cecum starts in right lower flank andextend upward (ascending colon)Lie across the abdominal cavity

(transverse colon) beneath thestomach



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Large Intestine


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g

Then extend downward(descending colon) on the left sideof the abdominal cavity

make a sharp turn in the left lowerportion (sigmoid) to merge with therectum

Caliber decreases from cecum torectum which is a dilatation abovethe anal canal

Large intestine occupy the superior

and lateral edge of the abdomen

Different parts of Colon


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p

Ascending colon

Transverse colon

Descending colonSigmoid

Rectum

Anus

Barium EnemaTransverse Colon


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Barium EnemaStudy (DoubleContrast Study) ofLarge Intestine

Descending Colon

Ascending

Colon

HepaticFlexure ofColon

Splenic Flexure

of Colon

SigmoidColon

Rectum

Large Intestine


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Large Intestine

Large intestine has three longitudinalmuscle bands (taenia coli) with bulges inthe wall (haustra) between them

On X-ray, the colon is identified by thesacculations called haustra scattered allalong the colon

Colon has fat filled tags called appendices

epiploicae on its surfaceThese haustra and epiploicae separate thelarge from the small intestine



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Ascending Colon


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Ascending Colon is thefirst part of the colon

Extends from appendixup to a flexure at the liver

It lies on the right side ofthe abdomen

It is 15 cm long

Its direction as it leaves

the cecum is upwardIt is intraperitoneal

Ascending Colon


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Only the transverse and part of theascending colon are considered to beintra-peritoneal organs

CecumMeasures about 6 cm by 7.5 cmIt is the first part of the ascending

colonIleum enters it at its medial surfaceAppendix is attached to the cecum

at its posterior and medial aspect



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Transverse Colon (Barium Enema)


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This part of the colon isintraperitoneal

It begins at the hepaticflexure and ends at the

splenic flexureTransverse colon is thelongest part of the colon

It is about 50 cm long

It may dip down to thepelvis. Its position isvariable



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Descending Colon


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Descending Colon

Begins at the Splenic flexure anddescends downward to left groin

About 25 cm longLocated on the left side of the abdomenand lies along the left paracolic gutter

Retroperitoneal and connected to theposterior abdominal wall from the splenicflexure to the pelvic part



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Relationships of the HepaticFl


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Flexure

Above and anterior Liver

Behind

Kidney

Medially

Gall bladder fundus

Duodenum

Splenic flexure

CT Scan of the mid abdomen


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CT Scan of the mid abdomen

Relationships of the Splenic

Fl


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Flexure

Splenic flexture is attached todiaphragm by phrenico-colic ligament

Related to

Spleen

Tail of PancreasLeft Kidney

Splenic flexture


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Splenic flexture

Sigmoid Colon
http://www.emedicine.com/radio/images/Large/9226922606.jpg


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Sigmoid Colon

Descending colon becomessigmoid at the level of pelvic inlet

It is about 40 cm longSigmoid makes a sharp turn in

the lower portion to merge with

rectum

Blood Supply of the Colon


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Blood Supply of the Colon

Arterial blood supply to the cecum is from theileocecal branch of the superior mesentericartery

Arterial supply to the ascending colon comesfrom the ileocolic and the right colic branches ofthe superior mesenteric artery

Transverse colon is supplied by the middle colic

artery, a branch of the superior mesentericartery

Descending colon derives its blood supply fromthe left colic branch of the inferior mesenteric

arter

Relationships of Sigmoid Colon


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Relationships of Sigmoid Colon

LateralExternal iliac veinOvary

PosteriorInternal iliac vein

UreterPiriformesSacral plexus

InferiorBladder in male

Uterus and bladder in female Above

Small bowel

Barium Enema w/ air


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Sigmoid colon



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C Sca o t e abdo e



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C Sca o t e abdo e



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RectumC i f i id S l h i


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Continues from sigmoid at S3, along the anteriorsurface of sacrum, passes through the pelvicdiaphragm and continue with anal canal

Length is 12 cm

Upper part 4cm in diameter

Lower part more dilated and called rectalampulla

Anorectal junction

2-3 cm below the tip of coccyx

Peritoneum from front reflects to form

rectovescical pouch anteriorly

recto uterine pouch posteriorly (female)

CT Scan of the pelvis


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Anterior relations of rectum


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MaleBladderSeminal

vescicle

Rectovesicalpouch

Small bowelSigmoid

UretersProstate

FemaleUterusCervixRectouterine

pouchSmall bowelSigmoid

- UretersVagina

Posterior relations of rectum


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Posterior relations are similar in maleand female

Sacrum

Sacral plexus and vessels

Lateral

Pararectal fossa

Piriformes

Levator ani

Coccyges


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CT Scan of the lower abdomen


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Rectum, bladder and seminal vesicles


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Single-contrast barium enema study shows burnt-out

ulcerative colitis.


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Mesentery

Peritoneum, Mesentery and

Omentum


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Omentum

Parietal peritoneum lines the abdominal wallVisceral peritoneum lines the organsBetween the two lies the peritoneal cavityReflections of the parietal peritoneum between

organs are called ligaments Ligaments that connect the stomach to other

organs are called omentaMesentery connects the bowel to the posterior

abdominal wallAll of these contain fat, blood vessels,lymphatics and nerves

Greater Omentum


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Greater Omentum

Extends inferiorly from the greatercurvature of the stomach and foldsover to insert into the transverse

colonOn CT Scan, it is the fatty areabehind the anterior abdominal wall

Lesser OmentumExtends between the lesser

curvature of the stomach and the

liver


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Small Bowel Mesentery


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Fan shaped Connects jejunum and ileum to the

posterior abdominal wall

Root is at duodenojejunal junction It contains SMA and branches

On CT, it is seen to contain fat and

blood vessels

Mesentery


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Radiological Differences Between

Small and Large Intestines


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Small and Large Intestines

Small Intestines

Located in the center ofthe abdomen

Has valvulae conniventes

Smaller in caliber andlonger

Large Intestines

Located at the periphery

Has haustrations

Larger in caliber andshorter

Difference Between Small and

Large Intestines


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Large Intestines


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Appendix

Appendix


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Appendix, is a blind pouch projecting fromthe postero-medial wall of cecum on theright side of the lower abdominal cavity

Small, worm-shaped blind tube, about 2-20 cm in length

Mostly seen 2 cm below Ileo cecal valve

Retrocecal position is most commonlyseen although retrocolic or Pelvic positionsare also seen.



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Where to look for normal appendix


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THANK YOU

Radio Logical Anatomy of Esophagus, Stomach, Small by Talat 11-9

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Transcript of Radio Logical Anatomy of Esophagus, Stomach, Small by Talat 11-9