Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
for
Medical Students
2007
GIT-1
Salivary Glands Esophagus Stomach & Duodenum
Index
Salivary Glands
Thyroglossal cyst
Branchial remnants Pharyngeal pouch Esophagus
Gastric & duodenal ulcers Acute gastritis & acute peptic ulcers Chronic gastric ulcer Complications of peptic ulcers Hour-glass stomach Congenital pyloric stenosis Adult pyloric stenosis
Cancer stomach
Pseudo-pancreatic cyst Volvulous of stomach Duodenal atresia
Jejunal atresia
Duodenal ulcers Duodenal diverticulum
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The following slides includes clinical pictures, gross pathology pictures and X-rays in a systemic approach to important surgical problems. you may be asked about : Diagnosis or differential diagnosis Pathological types (if any) Common clinical presentations
Common complications
Specific investigations Main line of treatment
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Salivary Glands
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Salivary Glands
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Neoplasms
Adenoma Carcinoma
Nonepithelial
Bacterial:
Chronic bacterial sialadenitis (usually submandibular complicating chronic obstruction Acute ascending sialadenitis (usually parotid in dehydrated postoperative patients with poor mouth hygiene)
6 Specific
Infections:
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80%
10%
7%
Submandibular
Because secretions are viscid rich in mucous & the gland
lies below the opening of its duct
Parotid
Sublingual
Minor glands
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10
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Submandibular Sialogram
Showing a stone in the submandibular duct
The stone is NOT radiolucent, but it looks so because this is a subtracted image
The classic presentation of a submandibular stone is pain and swelling prior to or during meal This requires almost complete obstruction of the submandibular duct If partial obstruction occurs swelling may be mild with chronic painful enlargement of the gland If diagnostic doubt then stone can be demonstrated by sialogram
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2- Surgical removal
(Linear incision along the duct -notice the stay suture)
12
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?
Ranula Stone submandibular duct
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Ranula
A large mucous retention cyst (mucocele) secondary to obstruction of a minor salivary gland or the sublingual gland.
They represent a unilocular cyst in the sublingual space
14
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Salivary Tumours
Adenomas Carcinomas
Nodularity & regional lymphatic metastasis is highly suspicious of malignancy
Parotid pleomorphic adenoma
Nonepithelial tumours
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Salivary Tumours
Nearly all salivary tumours are slowly growing (even malignant tumour) Is pain a reliable indication of malignancy? Pain is not a reliable indication of malignancy except after invasion of sensory nerves Benign tumours may present with aching pain due to capsular distension and outflow obstruction of saliva The only reliable clinical indication of malignancy are: Facial nerve palsy in parotid tumours Indurations or ulceration of overlying skin or mucosa Regional lymphatic metastasis
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MRI
Rt. parotid tumour extending into the superficial & deep lobes
Sq. cell ca
CT
Well circumscribed Lt. parotid tumour of the superficial lobe
Pleomorphic adenoma
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Pleomorphic adenomas are poorly encapsulated and are very tens. Open biopsy will seed the surrounding tissues with tumour cells causing multiple local recurrences over many years
Open biopsy is done if the tumour is clearly infiltrating or invading the skin
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Thyroglossal cyst
Branchial remnants
Pharyngeal pouch
19
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Thyroglossal cysts
Embryology
The thyroglossal tract arises form foramen caecum at junction of anterior 2/3 and posterior 1/3 of the tongue. Any part of the tract can persist causing a sinus, fistulae or cyst. Most fistulae are acquired following rupture or incision of infected thyroglossal cyst
21
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This is a CT scan at the level of C4 vertebrae. Try to identify the following structures:
C4
External carotid artery Hyoid bone
23
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Thyroglossal fistula
The classical site for a thyroglossal fistula
Branchial remnants
Branchial fistulae and cysts usually arise from second branchial sinus Arise on anterior border of sternomastoid Often bilateral and extend deep into neck Internal opening occasionally found in tonsillar fossa Treatment is by surgical excision
Notice the opening lateral to the mid line
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Branchial cyst
Pharyngeal pouch
Is posteromedial pulsion diverticulum through Killian's dehiscence Occurs between thyropharyngeus and cricopharyngeus muscles. Both form the inferior constrictor of the pharynx Male : female ratio is 5:1 Usually only seen in the elderly
Aetiology is unknown but upper oesophageal sphincter dysfunction may be important
26
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Pharyngeal pouch
Clinical features
Commonest symptoms are: dysphagia, regurgitation and cough Recurrent aspiration can result in pulmonary complications A carcinoma can develop within the pouch Clinical signs are often absent, however, a cervical lump may be present that gurgles on palpation
27
Esophagus
Normal anatomy
Cervical
Thoracic
Abdominal
28
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The esophagus have a smooth outline. No persistently narrowed areas are seen. Peristalsis can be observed on screening the patient. The whole examination can be recorded on video if necessary (video-swallow
examination).
29
Lateral view: The course and diameter of the esophagus are normal, the longitudinal mucosal folds are regular
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If suspected, a small nasogastric tube will arrest at the blind pouch & will not reach the stomach
34
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Examination with contrast material: The white arrows point to the blind end of the esophagus filled with contrast material. The middle lobe of the right lung is partially atelectatic because of aspiration. Presence of a lower fistula is suggested by theGIT1 35 presence of gas in the distended stomach INDEX
Oesophageal atresia
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Esophageal varices
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Esophageal varices
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With portal hypertension, collateral vessels develop between portal and systemic veins: Around the lower end of the esophagus & fundus of stomach
(esophageal & fundal varices) [splenic vein short gastric veins coronary
vein esophageal veins azygos system]
Hypersplenism
Sequestration and destruction of any or all of the cellular elements of the blood
WBC > 4000 /ml Platelets > 100,000 /ml
Are spontaneous ecchymosis and purpra common presentations of portal hypertension alone? NO
Encephalopathy is related to high blood ammonia level It can result from natural or surgically created porto-systemic shunts in patients with marked hepatocellular dysfunction
40 GIT1 INDEX
Esophageal varices
Upper GI endoscopy
41
Autopsy
Barium swallow
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Barium swallow
Oesophageal varices Numerous rounded and elongated smoothcontoured filling defects are present in the inferior two thirds of the esophagus.
The contour of the esophagus is irregular and speculated.
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In patients with hepatocellular dysfunction, bleeding should be rapidly controlled to avoid: The effect of shock on hepatic function. The toxic effect of digested blood absorption.
Main lines of treatment: Heamodynamic stabilization with blood transfusion Reduce the portal blood pressure:
Vasopressine causes constriction of the splanchnic arteria circulation reducing the portal blood pressure 40% Propranolol
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Note the staplers in the lower end of oesophagus (a treatment modality for esophageal varices)
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Esophageal diverticulum
47
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Barium swallow
Esophageal diverticulum
48
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Esophageal diverticulum
Two sharp-contoured filling excesses can be seen on the ventral contour of the esophagus below the tracheal bifurcation
(arrows)
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Barretts esophagus
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Barretts esophagus
Endoscope view
Barretts esophagus
Columnar metaplasia in the lining mucosa of the lower esophagus in response to 52 chronic gastro-esophageal reflux.
What are the complications of Barretts esophagus? Increased risk of adenocarcinoma 25times GIT1
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Cancer esophagus
55
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Malignant Tumours
Malignant Melanoma
CARCINOMA Squamous Cell CA usually Upper 2/3 Adenocarcinoma usually Lower 1/3
Oat cell CA
1. Dysphagia
2. Weight loss 3. Recurrent laryngeal n. palsy 4. Cervical Lymphadenopathy
56
ADVANCED DESEASE
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Midesophagus Squamous Cell Carcinoma Squamous cell carcinoma arises most commonly in the upper and middle esophagus
59
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Pre-cancerous conditions:
Smoking & alcohol Food contamination of fungi
Clinical features:
Dysphagia is a sign of advanced disease Early symptoms are nonspecific During endoscopy, biopsy any lesion even if small (small cancers are curable)
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Ba swallow
61
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Barium swallow Irregularity looks like an apple core lesion in the esophagus. This is typical in carcinoma of the esophagus
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Barium swallow
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CA Oesophagus
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barium swallow demonstrates the typical apple core lesion seen with distal esophageal adenocarcinoma associated with chronic reflux disease.
Also seen is a typical sliding hiatal hernia with the gastric folds fixed above the diaphragm.
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Barium swallow
This is not CA esophagus. The esophagus is displaced by CA lung. Note the smooth lining of the displaced segment
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Narrowing with smooth outlines at the level of the middle third of the esophagus with a dilatation observed above it.
Distally the lumen of the esophagus is of about the normal diameter.
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Carcinoma of the esophagus has a poor survival rate because of late discovery after spread
Spread
Systemic spread
Liver
celiac LNs is a
bad prognostic sign and regarded as distant metastasis (M) in the TNM classification
Lungs
Brain bone
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Postoperative barium swallow demonstrating the gastric conduit in the cervical position with the silver clips marking the anastomosis
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Ba swallow
Autopsy
Achalasia Inability to relax lower esophageal sphincter leads to massive esophageal dilation and produces the characteristic "birds beak" deformity in barium swallow
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The esophagus has smooth contour and is narrowed conically at the esophagocardial junction (arrow), above this the distal part of the esophagus is dilated
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Late stage:
The esophagus is extremely dilated above the severely narrowed cardia (arrow), with a slightly tortuous course and inhomogenous contrast material filling pattern because of the residual food inside
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Lateral view of barium swallow in a patient with achalasia. Note grossly dilated esophagus with abrupt tapering to bird beak-like shape of lower esophageal sphincter
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Achalasia
The oesophagus hugely dilated and tortuous.
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Please compare and contrast between cardiac achalasis & CA lower end esophgus
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In X-ray 2, the cardia below the diaphragm is closed with bird beak-like shape
84
Achalasia of cardia
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Lower esophageal sphincter myotomy incises enough muscle to relieve symptoms but not enough to result in gastroesophageal reflux
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Normal anatomy
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Hiatus Hernia
90
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Siding hiatus hernia The esophagogastric junction and the fundus of the stomach (arrow) are situated high in the thorax, above the diaphragm
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Congenital diaphragmatic hernia persistent pleuroperitoneal canal (Bochdalek) GIT1 90% are on the leftside
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Gastric Ulcer
98
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99
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Acute duodenal ulcer in anterior wall occasionally perforates. These acute lesions can progress to chronic ulcers.
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The ulcer is deep, with sharp proximal edge & a sloping distal edge
The arrow points to an eroded gastric artery which has caused fatal hemorrhage
1) 2) 3)
It is relatively small (1cm) The mucosa surrounding the ulcer base is not infiltrated by a tumour The radiating rugal folds extend nearly all the way to the margins of the base
Longitudinal section of the benign ulcer and adjacent gastric wall. The normal anatomic layers are discrete and undisturbed
Definitive diagnosis of chronic gastric ulcer depends on endoscopy & biopsy with histological examination
104 GIT1 When do you suspect that a gastric ulcer is malignant? INDEX
Chronic gastric ulcer The edges of the ulcer are heaped up due to epithelial regeneration. The ulcer base is smooth and contains only granulation tissue
If the ulcer was discovered on endoscopy, multiple biopsies should be taken to exclude malignancy even if the ulcer looks benign
106 GIT1 INDEX
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Barium meal
108
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Large ulcer is filled with barium on the lesser curvature of the stomach with star-shaped mucosal folds converging towards the lesion
109
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Barium study
Gastric ulcer
110
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Upper GI barium study: It shows a large gastric ulcer along the lesser curvature of the stomach. Surgery was performed and the ulcer was benign
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Barium meal
gastric ulcer There is a large ulcer crater on the greater curvature aspect of the distal stomach (arrow). There are multiple folds radiating to the edge of the ulcer crater. All the folds taper gradually to the edge of the crater.
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Barium meal
Pre-pyloric gastric ulcer
Carmens meniscus sign
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114
Helicobacter pylori
It is important in the etiology of : Chronic gastritis Peptic ulcer Gastric cancer Helicobacter pylori Eradication therapy
is a main treatment in peptic ulcer
Hydrolyze urea
Antral G cells
Metronidazole Amoxycillin
Bismuth
Gastrin
115
Helicobacter gastritis Helicobacter organisms may be tested for urease activity. Staining of the gastric biopsy shows the characteristic curved rods embedded in the mucin layer of the stomach
116
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Perforation
Patient presented with acute abdominal pain
Penetration
Posterior wall ulcer penetrates to pancreas (back pain)
Plain X-ray chest & abdomen showed air under the diaphragm
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Abnormal
Normal
Antrum
Pyloric canal
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Hypertophic pyloric stenosis. Note the prominent hypertrophied circular pyloric muscle
with elongation and narrowing of the pylorus It is a cause for "projectile" vomiting in infants about 3 to 6 weeks of age. Males are affected more than females(4:1)
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Symptoms include non-bilious vomiting often starting as simple regurgitation progressing to projectile vomiting after most feedings.Vometing contains milk but no bile
Less frequent findings are constipation, progressive weight loss, dehydration, hypochloremic alkalosis.
Symptoms occur most commonly during the second to sixth weeks with peak age at presentation being 3rd -4th weeks. HPS rarely presents after 3 months of age.
Physical examination may reveal visible gastric peristaltic waves and a palpable pyloric mass (olive).
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If the clinical and physical findings are suggestive of HPS then an ultrasound exam is the first study of choice.
D.D. of Hypertophic pyloric stenosis of infancy
Gastro-esophageal reflux
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Gasrtographin meal
125
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126
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Barium meal
Pyloric stenosis
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Barium meal
Pyloric stenosis
128
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Barium meal
Pyloric stenosis
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Cancer Stomach
131
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A large tumor of the stomach seen as a filling defect in the body and antrum of the stomach causing irregular contours on both the lesser and the greater curve.
132 GIT1 INDEX
Gastric Carcinoma
Barium meal
CA pylorus
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Cancer stomach
Malignant infiltration
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136
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Bameal
Ulcer niche of a malignant gastric ulcer
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CA stomach
Linitis plastica
Marked narrowing of almost the complete stomach, due to diffuse infiltration of the gastric wall by a carcinoma (linitis plastica)
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Metastatic
141
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The afferent jejunal loop connected to the gastric stump shows only minimal filling, the majority of the contrast material flows into the efferent loop
142
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Pseudo-pancreatic cyst
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The axis of rotation is along the mesenteric attachment, much the same as is seen with sigmoid colon volvulus
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Duodenum
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Duodenal atresia Dilated stomach (S) and the part of the duodenum above the obstruction (D). Other parts of abdomen do not contain gas
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Duodenal atresia
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Duodenal atresia
Plain X-ray of the abdomen: The arrows point to the dilated stomach and that part of the duodenum which is above the obstruction. Other parts of abdomen do not contain gas
Double bubble
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Duodenal atresia
Gastrographin meal:
The distended stomach and duodenum above the obstruction are visible after swallowing contrast material
(arrows).
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Plain radiograph of the abdomen: The arrows point to characteristic triple gas bubbles in the stomach, duodenum and jejunum.
Jejunal atresia
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# Ulcer in the 1st part of duodenum (with clean floor & no everted edge)
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Duodenal ulcer (Endoscopy) A 35-year-old woman presents with tarry stools and a hemoglobin level of 7.5 g. Notice bleeding points
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Duodenal ulcer
Gastric ulcer
Biopsy
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Duodenal ulcer
Ulcer niche
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Barium follow-through
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Barium follow-through