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The Alimentary Canal consists of?
- Alimentary canal
- - Oral cavity
- - Pharynx
- - Esophagus
- - Stomach Parts of upper GI ↑
- - Small intestine Parts of lower GI ↓
- - Large intestine
- - Anus
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The Accessory Organs consist of?
- Salivary Glands (Digestive Organ System)
- Pancreas (Organ of the Digestive & Endocrine Systems)
- - Liver (Biliary Tract Organs) ↓
- - Gallbladder
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- Liver: large/triangular two-lobed organ located in the right upper quadrant just inferior to the right hemidiaphragm
- - Extends to just below the body of the 10th rib
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Gallbladder: small pear-shaped sac nested centrally in the posterior/inferior region of the right lobe of the liver
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Right & Left lobes of the Liver are separated by?
falciform ligament
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R lobe has 2 minor lobes on the posterior aspect:
- ?
- ?
Quadrate lobe
Caudate lobe – inferior vena cava (IVC) passes over the surface of this lobe
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The main digestive function of the liver is to produce?
- Bile
- - critical for fat digestion & absorption of fats & fat-soluble vitamins in the small intestine
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Other functions of the Liver aside from producing Bile are?
- - Excretion of bilirubin, cholesterol, hormones, & drugs
- - Metabolism of fats, proteins, & carbohydrates
- - Enzyme activation
- - Storage of glycogen, vitamins, & minerals
- - Synthesis of plasma proteins, such as albumin, & clotting factors
- - Blood detoxification & purification
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The 3 parts of the Gallbladder are?
Fundus – broad, distal end
Body – main, middle section
- Neck – narrow, proximal end that contains the cystic duct
- - Has a spiral valve (folds) that prevent distention or collapse of the cystic duct
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The 3 functions of the Gallbladder are?
- 1.Store bile:
- - Bile not needed for digestion is stored in the GB
- 2.Concentrate bile:
- - Stored bile is concentrated as a result of hydrolysis (removal of water). Too much concentration can result in gallstones (choleliths).
- 3.Contraction to release bile:
- - When fatty food enters the duodenum, the duodenal mucosa secretes the hormone cholecystokinin (CCK), which stimulates the gallbladder to contract & release bile.
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Bile produced in the liver cells travels through small ducts into the ___ & ___ hepatic ducts that exit the liver. These ducts join to form the ___ ___ ___.
- Right, Left
- Common Hepatic Duct
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The common hepatic duct unites with the ___ ___ from the gallbladder to form the ___ ___ ___.
- Bile enters the gallbladder through the cystic duct for storage or continues down into the common bile duct
Cystic Duct, Common Bile Duct
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Bile & Enzyme Pathway
The common bile duct is joined by the ___ ___ at the hepatopancreatic ampulla (___ ___ ___).
*Bile & pancreatic enzymes enter into the duodenum through the hepatopancreatic sphincter (sphincter of Oddi) at the duodenal papilla
*In about 40% of patients, the common bile duct & pancreatic duct pass into the duodenum separately
- Pancreatic Duct,
- Ampulla of Vader
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Pancreas
Located in the ___ ___ of the abdomen between the curve (“C-loop”) of the duodenum & the spleen
- The 3 parts are the ___, ___, & ___?
- Upper Left,
- Head, Body, Tail
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Pancreas
Main digestive function is the production of pancreatic enzymes:
_____ - (breaks down carbohydrates)
_____ - (breaks down fats)
_____ - (breaks down proteins)
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Erect abdomen showing liver shadow
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T-tube cholangiogram showing hepatic ducts, common bile ducts, part of pancreatic duct, & spillage of contrast into duodenum
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Oral cholecystogram showing cystic duct (A), neck (B), body (C), & fundus (D) – this exam is no longer done to evaluate the GB
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GB sonogram – most common method to evaluate the GB
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The 4 organs of the Upper GI System are?
- - Oral cavity (mouth)
- - Pharynx
- - Esophagus
- - Stomach
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The ___ ___ is where food & liquids enter our mouth
___: hard & soft palates
- Uvula – accessory organ of speech, produces some saliva, helps prevent food & liquid from entering the nose
____: tongue - taste buds, assists in chewing, & elevates backward to assist swallowing
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Accessory Organs of Oral Cavity
____ – cooperates with tongue for chewing (mastication)
Food mixes with saliva – start of mechanical digestion
Salivary glands:
____ - largest; located just below & anterior to the ears
_______ - located just below the angles of the mandible
______ - located just below the tongue
- Saliva is mostly water & some salts
- Contains salivary amylase (breaks down starches) to begin chemical digestion
- Teeth,
- Parotids,
- Submandibulars,
- Sublinguals
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The 3 main parts of the Pharynx are?
Nasopharynx – passageway for air only
Oropharynx – passageway for air & food/liquid (but not at the same time!)
Laryngopharynx – passageway for air & food/liquid (but not at the same time!)
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Swallowing
_____ - the 2 lower parts of the pharynx (oropharynx & laryngopharynx) involved:
- Food & liquid enters oral cavity
- Tongue pushes food/liquid back while soft palate covers the nasopharynx
•Prevents food/liquid from going up into nasal cavities
- Epiglottis is depressed to cover the larynx & tracheal opening; vocal cords also contract to close off epiglottis
•Prevents aspiration into the trachea & lungs
Deglutition
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Sialogram showing normal submandibular duct
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CT showing parotid glands
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Esophagus Anatomy
Muscular tube that extends from laryngopharynx to stomach
- About 25 cm (10”) in length & 2 cm (3/4”) in diameter
- Located posterior to the trachea & larynx; anterior to cervical & thoracic vertebrae
- Begins at level of C5/C6 (upper margin of thyroid cartilage); enters stomach at level of T11
- No digestion takes place in esophagus; collapsible tube that uses peristalsis (waves of muscular contraction) to push food into the stomach
Esophagus Anatomy
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Esophagus Pathway
As the esophagus descends through the mediastinum, it is in contact with the aorta & bronchi:
First indentation: ____ ____
Second indentation: ___ ___ ___
- aortic arch,
- left primary bronchus
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Esophagus Pathway
Esophagus passes through the diaphragm & into the abdomen slightly to the left, just behind the IVC & in front of the aorta
- Abdominal part of esophagus that connects to the stomach is called the ___ ___
cardiac antrum
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Connection to Stomach
___ (_) ___ – opening between esophagus & stomach
Also called the cardiac orifice because it is near the part of the diaphragm on which the heart rests
___ ___ – between esophagus & stomach
Acts as a one-way valve to prevent stomach contents from backing up into esophagus
When this sphincter does not close properly, gastric contents will splash up into the esophagus, causing reflux (“heartburn”)
___ ___ – superior to cardiac orifice (EG junction)
Esophagogastric (EG) junction,
Cardiac sphincter,
Cardiac notch
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Esophagogram showing aortic arch indentation (A) & L main bronchus (B) indentation
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_____ Anatomy
Muscular sac between the esophagus & small intestine located in the mid to upper left upper quadrant of the abdomen
- Expands & contracts – serves as a reservoir for food/liquid
- The holding capacity of the stomach allows us to forgo eating constantly for energy
- Mechanical & chemical digestion takes place in the stomach
Stomach
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The 3 main parts of the Stomach are ___, ____,& ____?
Fundus, Body, Pylorus
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Parts of the Stomach
____ - ballooned-shaped upper portion superior & lateral to the cardiac orifice (EG junction) that connects to the esophagus
In the erect position, the ___ is filled with air (“gastric bubble”)
Fundus
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Parts of the Stomach
___ - large, curved middle section
Has constricted ring-like area called the angular notch where it enters into the pylorus
Body
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Parts of the Stomach
___ - end portion that connects to the duodenum of the small intestine; opening to small intestine is called the pyloric orifice
___ ___ – slight dilation just past the angular notch
___ ___ – narrowed part that connects to the duodenum
- Between the pyloric canal & the duodenum is the pyloric sphincter, which prevents backflow of intestinal contents into the stomach
- Pylorus,
- Pyloric antrum,
- Pyloric canal
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Curvatures & Parts of Stomach
____ ____:
Along medial border
Concave in shape
Between cardiac & pyloric orifices
Lesser curvature
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Curvatures & Parts of Stomach
___ ___:
Along lateral border
Convex in shape – up to 4x’s longer than lesser curvature
Between cardiac notch & pylorus
Greater curvature
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Curvatures & Parts of Stomach
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Mucosal Folds
Folds of mucosa called ____.
- Flatten out when food arrives
- Allows stomach to expand
- Assists with mechanical digestion
Gastric canal – formed by rugae along the ___ ____.
- Shape provides a path for fluids to go directly from the body of the stomach to the pylorus
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Duodenum Anatomy
First part of small intestine; 20-24 cm (8”-10”) long
- Rests against head of the ____
- Shaped like the letter “C”
___ ___ (__)* – short part just past pylorus
*Common site for ulcer disease
___ ___ – contains duodenal papilla (opening for common bile & pancreatic ducts)
___ ___ – curves back
___ ___ – fixed bend where duodenum connects to the jejunum Fixed in place by the ligament of Treitz
- pancreas,
- Duodenal bulb (cap),
- Descending portion,
- Horizontal portion,
- Duodenojejunal flexure
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Radiographic Anatomy – Stomach & Duodenum
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Air-Barium Distribution
Supine: barium in fundus; air in body & pylorus
Prone: air in fundus; barium in body & pylorus
Erect: air in fundus; barium in lower body & pylorus
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Prone – air in fundus; barium in body & pylorus
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Erect – air in fundus; barium in lower body & pylorus
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Supine – barium in fundus; air in body & pylorus
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Digestion
___ ___?
- Mastication (mechanical digestion)
- Salivary amylase (chemical digestion)
___ & ___?
- Swallowing (peristalsis) – no digestion
Liquids pass in about 1 second; food in about 4-8 seconds
____?
- Mixing (mechanical & chemical digestion) & peristalsis
Chyme – stomach contents mixed with gastric juice & moved toward pyloric valve
Gastric juice:
Mucus (protects stomach lining)
Pepsin (enzyme that breaks down proteins)
Hydrochloric acid (destroys pathogens)
Gastric emptying takes about 2-6 hours
___ ___?
- Mixing & peristalsis (mechanical & chemical digestion)
- Oral cavity,
- Pharynx & esophagus,
- Stomach,
- Small intestine
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Radiographic Anatomy of Stomach by Body Type
Hypersthenic: high & transverse
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Radiographic Anatomy of Stomach by Body Type
Sthenic: Typical J-shape
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Radiographic Anatomy of Stomach by Body Type
Hyposthenic/asthenic: low & J-shape
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Contrast Media
Radiographic procedures of the biliary system & GI tract are usually done with contrast media
_____ (+): barium sulfate & iodinated contrast media
•Absorbs x-ray photons to a degree – structures show up light on image
_____ (-): air & carbon dioxide (CO2) crystals •Allows x-ray photons to pass – structures show up dark on image
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___ ___ ___ - are those given by way of the intestines or GI tract. Barium sulfate is the most common enteral contrast media used for radiographic & CT exams. Iodinated contrast media can also be given via the enteral route (i.e., orally or rectally).
Enteral contrast media
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___ ___ ___ - are those given by injection. Iodinated media are the most common types of contrast given parenterally for radiographic & CT exams. In MRI, gadolinium is a paramagnetic agent given parenterally. In nuclear medicine, radioisotopes are administered via this route.
Parenteral contrast media
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_____ is a soft, alkaline metallic element with an atomic number of 56. Barium sulfate is a compound (salt) made of barium, sulphur, & oxygen (BaSO4)
Barium
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“____” (low density) barium usually contains 1 part barium sulfate to 1 part water (liquid form)
“____” (high density) barium usually contains 3-4 parts barium to 1 part water (liquid or paste form)
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Double or Single contrast?
Single
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Double or Single Contrast?
Double Contrast
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____ is a nonmetallic element with an atomic number of 53. Water-soluble iodinated contrast media such as MD-Gastroview® are a mixture of water & 37% organically bound iodine.
Iodine
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Why water-soluble iodinated contrast media?
Because barium is contraindicated if there is any chance that it might escape into the peritoneal cavity, such as in the case of a suspected perforation, or as a pre or post-operative test. Barium is a suspension & not water-soluble!
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The 3 types of Upper GI Procedures are?
Esophagograms
Video swallow
Upper GI series
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Is another name for a Barium Swallow?
Esophagogram
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For which procedure are these the main clinical indications:
Anatomic anomalies – caused by diseases or a congenital condition
Carcinoma – adenocarcinoma is the most common type
Dysphagia – difficulty swallowing
Esophageal varices – distended veins in distal esophagus causing narrowing
Foreign bodies – food or other swallowed objects
Gastroesophageal reflux disease (GERD) – esophageal reflux (heartburn) resulting in esophagitis
Esophagogram/Barium Swallow
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RAO Esophagogram
- Patient prone or erect with body rotated 35°-45° RAO
- Right arm down by side; left arm up to hold cup & straw
- Left knee flexed
- Top of IR 2” above shoulder (at level of mouth)
- CR to IR at level of T5/T6 – enters midway between spine & left scapula
- Expose while patient is taking large sips (mouthful after mouthful)
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RAO Esophagogram
- - Entire esophagus demonstrated down to EG junction
- - Esophagus midway between spine and heart
- - Optimal exposure factors
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Lateral Esophagogram
- Patient in a lateral recumbent or erect with
- Arms up by head with cup between flexed elbows
- Knees flexed to maintain lateral position
- Top of IR 2” above shoulder (at level of mouth)
- CR to IR at level of T5/T6 – enters midcoronal plane of patient
- Expose while patient is taking large sips (mouthful after mouthful)
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Lateral Esophagogram
- - Entire esophagus demonstrated down to EG junction
- - Esophagus midway between spine and heart
- - Arms not superimposing esophagus
- - True lateral position
- - Optimal exposure factors
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Main clinical indications:
Dysphagia
•Coughing and/or choking while eating or drinking
•Wet-sounding voice or changes in breathing when eating or drinking
•Known or suspected aspiration pneumonia
•Masses on the tongue, pharynx or larynx
•Muscle weakness, or myopathy involving the pharynx (common in stroke patients)
•Neurologic disorders likely to affect swallowing.
Are the main reasons for having this exam?
Video Swallow
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Which exam would be performed based on these main clinical indications?
Ulcers
Gastritis
Hiatal hernia – a portion of the stomach herniates through the diaphragmatic opening
Gastric carcinomas
Pre-op & post-op evaluation for gastric bypass surgery
Upper GI Series
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The routine post-fluoroscopic images if needed for a UGI Series are?
Routine: AP, PA, RAO, LPO, R lateral
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AP UGI
- Patient supine on table
- Arms down by sides
- CR to IR at level of L1 – enters midway between xiphoid tip & lower margin of ribs
- Expose on expiration
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AP UGI
- - Entire stomach & duodenum demonstrated
- - Fundus is barium filled; body & pylorus is air filled (double contrast)
- - Optimal exposure factors
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PA UGI
- Patient prone on table
- Arms up by head
- CR to IR at level of L1 – enters 1”-2” above lower lateral rib margin & 1” to the left of the spine
- Expose on expiration
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PA UGI
- - Entire stomach & duodenum demonstrated
- - Fundus is air filled; body & pylorus barium filled (double contrast)
- - Optimal exposure factors
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LPO UGI
- Patient supine on table
- Rotate body 30°-60° LPO (45° most common)
- Left arm down by side; right arm across chest on left shoulder
- Flex R knee for support
- CR to IR at level of L1 – enters midway between xiphoid tip & lower margin of ribs; center midway between midline of body & L lateral margin of abdomen
- Expose on expiration
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LPO UGI
- - Entire stomach & duodenum demonstrated
- - Fundus filled with barium (double-contrast)
- - Usually demonstrates duodenal bulb filled well with air
- - Optimal exposure factors
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RAO UGI
- Patient prone on table
- Rotate body 40°-70° RAO (45° most common)
- Right arm down by side; left arm up by head
- Flex L knee for support
- CR to IR at level of L1 – enters midway between spine & upside (left) lateral border of abdomen
- Expose on expiration
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RAO UGI
- - Entire stomach & duodenum demonstrated
- - Body & pylorus barium filled (double-contrast)
- - Usually demonstrates duodenal bulb filled well with barium
- - Duodenal bulb and C-loop in profile
- - Optimal exposure factors
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R Lateral UGI
- Patient in a R lateral recumbent position
- Arms up by head Knees flexed to maintain lateral position
- CR to IR at level of L1 – enters lower lateral margin of the ribs, 1”-1.5” anterior to the midcoronal plane
- Expose on expiration
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R Lateral UGI
- - Entire stomach & duodenum demonstrated
- - Pylorus & duodenum barium filled (double-contrast)
- - Pylorus and C-loop visualized
- - Optimal exposure factors
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The 2 types of Biliary Tract Procedures are?
- T-Tube Cholangiogram &
- Endoscopic Retrograde Cholangiographic Pancreatography (ERCP)
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T-Tube Cholangiogram
- Postoperative procedure done after a cholecystectomy
- - Rubber tube in the shape of a “T” left in the common bile duct after the GB is removed
- - Tube allows for drainage of bile & functions as a portal to inject iodinated contrast media to look for stones that were undetected during surgery
- - Stones can also be removed through the T-Tube if necessary
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Patient supine on table
Radiologist injects iodinated contrast media (parenteral) into tube under fluoroscopic guidance
Digital spot images taken in different positions to look for stones or blockage
What procedure is this for?
T-Tube Procedure
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_ _ _ _ -
Using an endoscope to access & visualize the biliary & pancreatic ducts. Performed by a gastroenterologist with fluoroscopic guidance.
- Scope inserted into the mouth, down the esophagus & stomach, & into the duodenum to the duodenal papilla
- Camera within scope used to take images
- Catheter inserted through scope into the duodenal papilla; iodinated contrast media (parenteral) injected & digital spot images taken
Diagnostic: to visualize the common bile duct and/or pancreatic duct
Therapeutic: removal of choleliths & to repair narrowing (stenosis) of the hepatopancreatic sphincter or associated ducts
ERCP
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ERCP showing GB, bile ducts & pancreatic duct
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Common Pathological Conditions
Hiatal hernia
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Common Pathological Conditions
Esophageal carcinoma
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Common Pathological Conditions
Achalasia distal esophagus
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Common Pathological Conditions
Zenker’s diverticulum in esophagus
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Common Pathological Conditions
Duodenal ulcer
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Common Pathological Conditions
Gastric carcinoma
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