ESSAY QUESTION 1. Discuss the radiological management of a fifty year old woman with dysphagia? MARKING SCHEME 1.

Definition 1mrk 2. Causes 4mrks i. Mechanical causes (Intrinsic) Stricture Schatzis ring Oesophageal web Oesophageal carcinoma ii. Motility disorders Diffuse Oesophageal spasm Achalasia iii. Generalised muscular disorders Muscular dystrophy Myasthenia gravis iv. Generalised neurolic disorders Parkinsonism Multiple sclerosis Cerebro vascular disease v. Connective tissue disorders Scleroderma

Mechanical (Extrinsic Causes) Mediastinal neoplasm and/or lymphadenopathy Mediastinal benign masses such as duplication cyst/ bronchogenic cyst Vascular abnormalities such as aberrant right subclavian artery Large anterior cervical spine ostegophytes 10mrks

Radiological Investigations/Findings 1. 2. 3. 4. 5. 6. Plain chest radiograph PA and lateral Plain x-ray of the cervical spine Barium Swallow CT MRI Radio nuclide studies

Finding will depend on the cause. State the findings as seen on each imaging modality

3.

A patient presents with hepatomegaly. Discuss the differential diagnosis.

MARKING SCHEME 1. Definition 2. Causes 1mrk 9mrks

Vascular
Congestive heart failure Congestive pericarditis Budd-chiari syndrome

Cirrhosis
Hypertrophic nodular Congenital cystic disease with hepatic fibrosis

Infiltrative
Fatty infiltration Reticulosis Storage disease (histiocytosis, amyloid)

Biliary
Obstructive jaundice

Blood disorders
Myelofibrosis Thalassaemia Sickle cell disease

Infection and infestation

Portal pyaemia Pyogenic and amoebic abscess Hydatid disease, actinomycosis Hepatitis, infections mononucleosis AIDS

Neoplasm
Adenoma Hepatoma, fibrolamellar carcinoma Cholangiocarcinoma Metastases

Radiological Investigations and Findings

1. 2. 3. 4. 5. 6. Plain Abdominal X-ray Ultrasound Angiography Radionuclide scanning CT MRI

10mrks

Plain Abdominal X-ray 1. Right lobe a. Elevated right hemidiaphragm b. Depressed hepatic flexure and duodenum c. Depressed right kidney (occasionally it remains high) d. Bulging of the right properitoneal fat line e. Occasionally, splaying of the lower right ribs 2. Left lobe a. Gastric fundus displaced downwards and laterally b. Intra-abdominal oesophagus elongated c. Extrinsic pressure on lesser curvature of stomach d. Sometimes, posterior stomach displacement on lateral film. 3. Localized masses are detectable on plain abdominal x-ray if they lie adjacent to or deform one of the visible borders such as the diaphragm. Other Imaging Modalities such as US, Radionuclide scanning, CT, MRI, angiography will readily reveal enlargement of one or both lobes and may characterize the pathology in some. US is the most cost effective investigation for subphrenic, hepatic and subhepatic abscesses as well as cystic lesions in the liver e.g. hydatid cyst. CT is useful in identification and staging of hepatic neoplasms 2. a. b. With the aid of an illustrated diagram, describe the radiological anatomy of the stomach Describe the technique of barium meal study

MARKING SCHEME 1. Well labelled diagram 5mrks Description 5mrks The stomach communicates with the oesophagus by the cardia at the gastro oesophageal junction and with the duodenal cap by the pyloric canal. The incisura anglularis is a notch on the lesser curve that separates the body and antrum. Other parts are the fundus and greater curvature. 2b. Technique of Barium meal 10mrks

Methods
1. Double contrast 2. Single contrast

Indications
1. 2. 3. 4. 5. 6. Dyspepsia Weight loss Upper abdominal mass Gastrointestinal haemorrhage( or unexplained iron-deficiency anaemia) Partial obstruction Assessment of site of perforation

Contraindication
Complete large bowel obstruction

Contrast Medium
1. Barium sulphate 2. Carbex granules or double contrast technique

Patient preparation
1. Nil orally for 6 h prior to the examination 2. The patient is advised not to smoke on the day of the examination as it increases gastric moility 3. It should be ensured that there are no contraindications to the pharmacological agents used

Preliminary film
Plain abdominal x-ray

Technique (double contrast method)

1. A gas producing agent is swallowed 2. The patient then drinks the barium while lying on the left side. 3. The patient then supine and slightly on the right side to bring the barium up against the gastri oesophageal junction. 4. The patient is asked to roll on the right side then quickly over in a complete cycle to finish in the R A O position.

FILMS
1. Spot films of the stomach (lying) a. RAO to demonstrate the antrum and greater curvature b. Supine to demonstrate the antrum and body c. LAO to demonstrate the lesser curvature on en face d. Left lateral tilted head up 45o to demonstrate the fundus 2. Spot films of the duodenal loop (lying) a. Prone with a compression pad to prevent barium from flooding into the duodenum. 3. Spot films of the duodenal cap (lying) a. Prone b. ARO c. Supine d. LAO 4. Additional views of the fundus in an erect position 5. Spot films of the oesophagus

Modification of technique for young children

The main indication will be to identify a cause for vomiting. Single contrast technique is used.

After care
1. The patient should be warned for a few days that his bowel motions will be white for a days after the examination and may be difficult to flush away 2. The patient should be advised to drink adequate volumes of water to avoid barium impaction

Complications
1. Leakage of barium from an unsuspected perforation 2. Conversion of a partial large bowel obstruction into a complete obstruction by the impaction of barium 3. Barium appendicitis if barium impacts on the appendix 4. Sides effects of the pharmacological agents used.