Shanon Patel BDS, MSc., MClinDent, MFDS RCS (Eng), MRD RCS (Edin)

• Specialist in Endodontics,
• Dental Institute, King? College London, London, UK

A detailed evaluation of the anterior chamber can be performed on stable patients using a slit lamp examination erectile dysfunction treatment pumps buy viagra capsules paypal. Patients with suspected posttraumatic glaucoma or retro-orbital hematoma should undergo tonometry to measure the intraocular pressure erectile dysfunction treatment portland oregon proven 100mg viagra capsules, but this test should never be done if there is a possibility of a ruptured globe erectile dysfunction kegel proven 100 mg viagra capsules. Parotid duct laceration can be demonstrated by probing the duct or by performing a sialogram doctor for erectile dysfunction in hyderabad cheap viagra capsules line. Examination of the ear the ear is inspected for the presence of lacerations or hematoma impotence of organic organ best order viagra capsules. The tympanic membrane is examined for perforations or accumulation of blood in the middle ear that is seen as hemotympanum erectile dysfunction meds at gnc viagra capsules 100 mg low cost. Facial Injury 31 General Management Airway management is of prime importance when facial injuries threaten the ability to ventilate the patient. Suction of secretions and manual removal of foreign bodies may establish airway patency, but often endotracheal intubation is indicated. Nasotracheal intubation should not be attempted with nasal, basilar skull, or Le Fort fractures or in apneic patients. Patients with massive facial injuries present a special problem, and the management of the airway in these cases is controversial. Consequently, some advocate the use of awake orotracheal intubation in these cases. This is a difficult and often unsuccessful task in an agitated, possibly hypoxic patient with severe bleeding in the oropharynx. Others have demonstrated the safety and efficacy of using rapid sequence intubation with paralytic drugs in this setting. The decision on the method of intubation should be based on the experience of the physician and the facilities of the emergency room. In selected cases in no need of immediate airway establishment, awake fiberoptic intubation by an experienced anesthesiologist or otolaryngologist is an excellent alternative. In all cases a physician should be immediately available to perform a cricothyroidotomy, if conventional intubation fails. Massive facial injuries that distort anatomic landmarks and produce severe bleeding may make orotracheal intubation impossible. Prolonged attempts at intubation are detrimental to the patient, and early use of cricothyroidotomy is essential and often life-saving. Facial injuries that do not threaten the airway can safely be deferred to the secondary survey and definitive care phases of trauma management. Active bleeding can usually be controlled by direct pressure or packing of wounds. However, prolonged bleeding from facial or scalp wounds can result in hemorrhagic shock and should not be ignored. Treatment of facial fractures can be deferred until the patient is hemodynamically stable. Once the possibility of a ruptured globe has been established, the eye should be protected by use of a Fox shield or similar device to prevent further pressure on the globe. Retro-orbital accumulation of blood or air with deteriorating vision or massive elevation of intraocular pressure requires decompression by lateral canthotomy or creation of a communication from the retro-orbital space in to the maxillary sinus. Penetrating trauma of the ear is relatively uncommon and is managed by minimal debridement, irrigation, and primary closure. Blunt trauma is more common and often results in perichondrial hematoma formation. Because ear cartilage is dependent on its skin covering for blood supply, an interposed hematoma can result in ischemic necrosis of the cartilage. Consequently, the ear must be examined for this condition, and a hematoma should be aspirated. A pressure dressing is applied to prevent reaccumulation of the hematoma or abscess formation. Avulsed cartilage from the ear or nose should be preserved in saline, as it is difficult to recreate the shape of these organs with other tissues. Most facial fractures can be repaired electively with operative fixation and bone grafting if necessary. Antibiotics are unnecessary for most facial lacerations, although open fractures require prophylactic coverage. Severe oromaxillofacial trauma can produce delayed airway occlusion from swelling or bleeding. These patients should be intubated early or observed carefully in a monitored environment. Attempts to perform endotracheal intubation in the presence of extensive facial trauma, without being prepared to perform a cricothyroidotomy, if intubation fails. Blind clamping of bleeding sites is rarely successful and it can injure nerves and other structures that run in proximity to vessels. Injury to the cranial nerves is difficult to detect in severely injured patients, especially if they are comatose, intoxicated, or otherwise unable to cooperate with physical examination. Other causes are scraping by branches or twigs, broken glass, industrial injuries involving power grinders and saws, or welding without adequate eye protection. Clinically, the patient presents with a history of sudden onset of pain in the affected eye and the sensation of having a foreign body in the eye, with increased tearing and resultant blurred vision. If the patient is capable of sitting, ideally the examination should be with a slit lamp. The patient will experience complete relief of the pain after instillation of anesthetic drops on to the affected cornea. The use of eye patches is controversial but generally considered unnecessary for small abrasions. Ocular Foreign Bodies There are certain situations that merit special caution in dealing with apparent corneal abrasions. Patients who present with symptoms of corneal abrasion after high-speed grinding or hammering on metal should be suspected of having a perforated globe. Small fragments of metal can enter the eye at high speed, leaving only minimal evidence of their entry in to the globe. A metal foreign body that impacts the cornea at lower speed may become embedded in the cornea and produce a rust ring that can impair vision if it occurs in the visual axis. A retained wood foreign body is also important to detect, as fungal enophthalmitis can result. With the patient lying supine, the blood is less visible than in an upright position, when it forms a clearly visible layer of blood in the dependent portion of the anterior chamber. Complications from hyphema include hemosiderin staining of the inner surface of the cornea with resulting loss of vision, as well as posttraumatic glaucoma due to fibrotic occlusion of the canals of Schlemm. Treatment is conservative and consists of bed rest with head elevated, sedation, and monitoring of intraocular pressure. Surgery is required occasionally for evacuation of blood or to decompress the anterior chamber. This rust ring is in the visual axis and will seriously impair vision if not removed. C Ruptured Globe Rupture of the globe usually occurs after penetrating injury but can be caused by blunt trauma as well. Penetration of the sclera results in herniation of orbital contents through the wound and exposure of the choroid membrane, visible as a dark layer of tissue in the wound. In either case, distortion of the globe results in loss of functional vision at the time of injury although light perception may be preserved. The latter is performed by instilling fluorescein dye in to the conjunctiva and observing the dye clearing from the cornea or sclera in the area of rupture because of the flow of aqueous humor from the anterior chamber. Although intraocular pressure is reduced in the presence of a ruptured globe, tonometry or any other maneuver that increases pressure on the globe is contraindicated. The conjunctiva is very distensible and often becomes edematous after trauma, resulting in bulging chemosis which frequently limits complete examination. Because of its common association with rupture of the globe, bulging chemosis itself should be considered a sign of possible ruptured globe. The ruptured globe is commonly enucleated if sight cannot be restored to avoid development of a sympathetic ophthalmoplegia in the normal eye. Retrobulbar Hematoma Trauma to the globe can result in bleeding from retroorbital vessels including the ophthalmic artery and vein. In addition, fractures of the orbit that communicate with paranasal sinuses can result in the accumulation of air in the retro-orbital space. If air or blood accumulates under sufficient pressure, ischemic necrosis of the optic nerve can occur. Clinical evidence of this condition includes proptosis, impaired extraocular movements, and progressive loss of vision. Treatment of a symptomatic retrobulbar hematoma is by lateral canthotomy or by surgically perforating the floor of the orbit to allow decompression of the retrobulbar space. In a lateral canthotomy, the lateral canthal ligaments are grasped with a forceps and crushed. Iris scissors are then used to divide the ligament, allowing the globe to protrude forward. Allowing the eye to protrude further decreases the retrobulbar pressure on the optic nerve. C 36 Facial Injury manner, normal vision can be restored once the globe is repositioned and the canthal ligament is repaired. Patients experience diplopia after repair of a lateral canthotomy but the brain gradually adapts and restores normal binocular vision over a period of months. Alternatively, a forceps can be introduced beneath the globe and the floor of the orbit fractured to allow drainage of the retro-orbital space in to the maxillary sinus. The lacrimal system ensures that a constant flow of tears stream across the surface of the eye, maintaining lubrication to facilitate ocular motion, preventing desiccation, and clearing debris, including potential infectious agents. Lacerations involving the lacrimal apparatus, lid margins, and lacrimal duct must all be sought out and referred to an ophthalmologist for repair. Lacerations of the lid margins are reapproximated exactly under microscopic vision to avoid a step-off that can result in constant dripping of tears on to the face. Injury to the lacrimal duct at the medial canthus of the eye is important to detect and repair as scarring and stenosis of the duct can result in a similar problem. Delayed repair of a stenotic lacrimal duct is very difficult and yields suboptimal results in most cases. The globe itself is usually spared when large objects strike the face because of protection afforded by the malar prominence, nose, and superior orbital ridge. However, smaller objects can strike the globe directly, resulting in a massive rise in intraocular pressure. Downward gaze reveals entrapment of the extraocular muscles of the right eye, resulting in a subtle divergent gaze. A common complication of this injury is that the inferior rectus muscle becomes entrapped in the fracture fragments, resulting in restricted upward gaze and diplopia when the patient attempts to look upward. Consequently, it is essential that physical examination should verify that extraocular movements are intact. The characteristic finding is opacification of the maxillary sinus caused by herniation of periorbital fat and blood in to the sinus. Fractures are distributed almost equally between the condyles, angle, and body of the mandible. Maximal incisor opening (normally 5 cm) is reduced, and the patient will note malocclusion of the teeth if the fracture fragments are displaced. At times bony crepitus can be elicited by examination or with voluntary movement of the mandible. Inspection of the mouth often reveals that the fracture is open, with gingival lacerations overlying the fracture site. Airway obstruction can occur in unconscious patients with bilateral mandibular rami fractures, as the tongue is unsupported and falls back in to the posterior pharynx. Trauma to the temporomandibular joint is common and may result in dislocation of the joint or chronic pain with chewing. Plain films are usually adequate to reveal a mandibular fracture, particularly if it is displaced. However, a Panorex view of the jaw is more accurate and should be used if available. Treatment is operative, with wiring or plating of the fracture fragments in to anatomic position. Open fractures of the mandible should be treated with antibiotics that are active against mouth flora. Zygoma Fractures the zygoma provides the bony support to the cheek and thus is commonly implicated in blunt trauma to the face. In the acute phase, however, swelling may mask this finding, so careful palpation of the facial bones to detect pain, a bony step-off, and crepitus of the zygoma should be routine. Injury to the infraorbital nerve may occur and results in anesthesia of the upper lip. Impingement of the zygoma on to the coronoid process of the mandible may result in limited excursion of the mandible and trismus. The submentovertex view (or "bucket handle" view) clearly demonstrates fractures of the zygoma and should be ordered if this fracture is suspected clinically.

A spot image with the patient in the upright position shows a giant hiatal hernia impotence your 20s discount viagra capsules 100 mg with mastercard. Note how pooling of barium in the fundus of the stomach (large black arrows) causes it to flop inferiorly beneath the gas-filled body impotence help buy viagra capsules 100 mg cheap, erroneously suggesting an upside-down intrathoracic stomach erectile dysfunction tools purchase cheapest viagra capsules and viagra capsules. Also note a small amount of barium cascading from the fundus through the diaphragm (small black arrows) in to the intra-abdominal portion of the stomach medication that causes erectile dysfunction purchase online viagra capsules. Another spot image with the patient in the prone erectile dysfunction treatment methods viagra capsules 100 mg mastercard, right anterior oblique position shows that the gastric body has passed below the diaphragm with the herniated gastric fundus (black arrows) now located above the body online erectile dysfunction drugs reviews order viagra capsules cheap. The body and antrum of the stomach have herniated through the esophageal hiatus of the diaphragm in to the lower chest, while the fundus and gastroesophageal junction are below the diaphragm. Note how the gastric body and antrum are narrowed (arrows) where they traverse the diaphragm. Affected individuals are often asymptomatic, but they may occasionally develop life-threatening complications due to obstruction, strangulation, or infarction of the hernia. Many patients with gastric volvulus are asymptomatic, but some may develop gastric outlet obstruction or incarceration and strangulation of the intrathoracic stomach, resulting in gastric necrosis and perforation. Considering that gastric volvulus occurs in the elderly, however, surgery probably should not be performed on asymptomatic patients with this condition (depending on their age), as the risks of surgery may outweigh the risk of developing serious complications. Less frequently, increased pressure in the splenic vein in patients with splenic vein obstruction also leads to reversal of flow through the short gastric Gastric volvulus (upside-down intrathoracic stomach) Gastric volvulus is an uncommon condition caused by a diaphragmatic defect that enables all or part of the stomach to herniate in to the thorax with an upside-down configuration (hence the term upside-down intrathoracic stomach). The entire stomach (arrows) is located above the diaphragm in the right lower chest and has flipped upside-down, so that the greater curvature is located above the lesser curvature, also known as an organoaxial gastric volvulus. Multiple smooth, round submucosal masses (arrows) are seen in the gastric fundus, resembling the appearance of a bunch of grapes. A large, lobulated submucosal mass (arrows) is seen on the medial wall of the gastric fundus. In the latter patients, however, venous blood from the dilated fundal plexus is diverted to the portal venous system via the coronary vein without producing esophageal varices. As a result, patients with combined esophageal and gastric varices almost always have portal hypertension, whereas patients with isolated gastric varices may have splenic vein obstruction as the cause of their varices. When major bleeding occurs in patients with gastric varices caused by splenic vein obstruction, these individuals can be treated by simple splenectomy. Portal hypertensive gastropathy may be manifested on barium studies by thickened, undulating folds in the gastric fundus due to a combination of mucosal hyperemia and dilated submucosal vessels. Gastric diverticulum A gastric diverticulum is usually discovered as an incidental finding on barium studies. The diverticulum almost always arises from the posterior wall of the gastric fundus, so it is best visualized in profile on lateral views of the stomach, appearing as a relatively large, rounded outpouching with a 92 Chapter 4: Stomach. The diverticulum (arrows) is seen arising from a discrete neck on the posterior wall of the gastric fundus. The web is characterized by a sharply defined band-like defect (white arrows) at right angles to the gastric wall that markedly narrows the lumen. There is marked elongation and narrowing of the pyloric canal, which bulges in to the duodenum, producing a discrete indentation (black arrows) on the base of the duodenal bulb. Antral webs and diaphragms Antral webs and diaphragms are membranous septa in the distal gastric antrum that are oriented perpendicular to the long axis of the stomach. While some investigators believe that antral webs and diaphragms are congenital abnormalities, these patients may be asymptomatic until adulthood. Antral webs and diaphragms typically appear on barium studies as sharply defined band-like defects occurring at right angles to the gastric wall. In patients with marked luminal narrowing, a web can occasionally be mistaken for the pylorus, and the antrum distal to the web for the duodenal bulb. This condition may represent a milder form of the same abnormality found in infants and children. Most patients with the adult form of hypertrophic pyloric stenosis are asymptomatic, but some may develop nausea and vomiting due to gastric outlet obstruction. About 50% of patients have associated gastric ulcers, most likely developing as a result of delayed gastric emptying with hypergastrinemia and subsequent hyperacidity. In contrast, the distal end of the hypertrophic pyloric muscle may bulge in to the duodenum, producing a concave indentation on the base of the duodenal bulb. Narrowing and obstruction of the lumen may be caused by acute inflammation, edema, and spasm or by chronic fibrosis and scarring. An upright spot image shows a dilated, fluid-filled stomach with pooling of barium and debris near the greater curvature because of the effect of gravity. A repeat spot image after the table was tilted to its horizontal setting with the patient in a right side down lateral position enables barium to reach the site of obstruction because of the effect of gravity. Note marked narrowing of the proximal descending duodenum (arrow) by an advanced pancreatic cancer invading the duodenum. Gastric outlet obstruction may be manifested on barium studies by retained food and debris in a variably dilated stomach with delayed emptying of barium in to the duodenum. In patients with chronic gastric outlet obstruction, the stomach may become massively distended, extending inferiorly in to the lower abdomen or even the pelvis. The purpose of the barium study is not only to confirm the presence of gastric outlet obstruction and determine its severity, but also to elucidate the underlying cause. A persistent barium collection in the antrum, pylorus, or duodenal bulb should suggest peptic ulcer disease, whereas a discrete mass or irregular narrowing of the gastric antrum or duodenum should suggest malignant tumor. Paradoxically, retained food in the stomach may prevent antegrade passage of barium (especially low-density barium) to the site of obstruction in the distal antrum, pylorus, or duodenum, limiting the value of the barium study. Even in patients with relatively high-grade gastric outlet obstruction, however, this problem can often be circumvented by having the patient ingest high-density (250% w/v) barium in the upright position and turning him or her 90 degrees to the right as the fluoroscopy table is lowered to a recumbent position in order to utilize the effect of gravity and manipulate the high-density barium to the site of obstruction and elucidate its cause. Gastroparesis may also occur as an idiopathic condition, primarily in young women. Treatment includes hyperkinetic agents such as metaclopramide to increase gastric peristalsis and, if possible, correction of the underlying cause. Hyperirritable stomach Patients with nausea and vomiting are often referred for barium studies to determine if their symptoms are caused by mechanical obstruction. Paradoxically, regurgitation of ingested barium may cause the radiologist to abort the procedure because of inadequate residual barium in the stomach for diagnostic purposes. However, a subset of patients with nausea and vomiting may have a so-called hyperirritable stomach characterized on barium studies by a constellation of findings, including rapid emesis of much of the ingested barium, a collapsed stomach with little or no retained debris or fluid, and normal emptying of residual barium in to nondilated duodenum and proximal small bowel. Also note a stricture (white arrow) at the gastrojejunal anastomosis that further predisposed this patient to the development of a gastric bezoar. A spot image after rapid emesis of most of the ingested barium shows a collapsed stomach with little or no retained debris or fluid and emptying of a small amount of barium in to non-dilated duodenum and proximal small bowel. This patient had a hyperirritable stomach with marked nausea and vomiting secondary to treatment with oxycodone for back pain. Gastric bezoars Gastric bezoars are defined as conglomerate masses of food or foreign matter in the stomach. Affected individuals may present with nausea, vomiting, bloating, and early satiety, sometimes necessitating endoscopic dissolution of the bezoar. Gastric bezoars have classically been described in people who ingest unripe persimmons or other fruit or vegetable matter that is not adequately broken down in the stomach (also known as phytobezoars). Patients who have undergone Roux-en-Y gastric bypass are also at increased risk for developing bezoars in the gastric pouch because of surgical bypass of the gastric antrum and body (the functional equivalent of severe gastroparesis) (see later section, Laparoscopic Roux-en-Y gastric bypass). It should also be recognized that patients with gastric bezoars may have acute clinical symptoms of relatively short duration and that bezoars sometimes can heal rapidly on conservative treatment without need for endoscopic intervention. Affected individuals usually present with acute gastric outlet obstruction manifested by sudden onset of severe nausea and vomiting. In the presence of a leak, water-soluble contrast material is an innocuous agent that causes no damage in the peritoneal cavity, and, unlike barium, is quickly resorbed after the study is completed. On the other hand, water-soluble contrast agents are less radiopaque than barium, so subtle leaks are less likely to be detected. If no definite leak is found, the study immediately is repeated with high-density barium to rule out subtle leaks that could be missed with water-soluble contrast agents. A large, expansile mass (arrows) is seen in the duodenal bulb and adjacent descending duodenum associated with the classic coiledspring appearance of a gastroduodenal intussusception. Postoperative stomach Partial gastrectomy the most common indications for partial gastrectomy are distal gastric carcinomas and refractory or complicated gastric ulcers. The initial spot image after administration of a water-soluble contrast agent shows a questionable tiny leak (small arrow) abutting the esophagojejunal anastomosis (large arrow). A repeat spot image after administration of high-density barium unequivocally shows two small leaks (arrows) from both sides of the esophagojejunal anastomosis. This case illustrates the importance of repeating the examination with high-density barium when no definite leak is seen with a water-soluble contrast agent. A water-soluble contrast study shows breakdown of the gastrojejunal anastomosis (black arrow) with extravasation of contrast material in to multiple extraluminal collections and tracks (white arrows) in the left subphrenic space. A Billroth I procedure entails a distal gastrectomy with an end-to-end antroduodenostomy. Scarring at the gastrojejunal anastomosis may also cause obstruction of the afferent loop, resulting in an afferent loop syndrome. Anastomotic strictures also predispose patients to the development of bezoars in the gastric remnant, though bezoars can develop even in the absence of strictures because of surgical resection of the gastric antrum and body (the functional equivalent of gastroparesis) (see earlier section, Gastric bezoars). A short segment of smooth, symmetric narrowing (arrow) is seen at the gastrojejunal anastomosis due to a benign anastomotic stricture. Although the anastomosis is widely patent, this patient had intractable nausea and vomiting because of the effect of gravity and resulting functional obstruction. In such cases, surgical repositioning of the anastomosis may be required to facilitate gastric emptying. Anastomotic ulcers (also known as marginal ulcers) typically develop on the jejunal side of the gastrojejunal anastomosis. Total gastrectomy and esophagojejunostomy Total gastrectomy and esophagojejunostomy is most commonly indicated for surgical treatment of advanced or proximal gastric carcinomas. There are three forms of surgery: a simple loop esophagojejunostomy, a Roux-en-Y esophagojejunostomy, and a Roux-en-Y esophagojejunostomy with creation of a jejunal pouch. Because of massive bile reflux in to the esophagus, this procedure is rarely performed. With a Roux-en-Y esophagojejunostomy, the jejunum is transected just distal to the esophagojejunal anastomosis, creating a short, blind-ending jejunal stump, with anastomosis of the Roux limb to the diverted duodenum and jejunum 40 cm or more distal to the esophagojejunostomy to prevent or minimize bile reflux in to the esophagus. The latter procedure may also entail creation of a jejunal pouch (also known as a Hunt-Lawrence pouch) as a reservoir distal to the esophagojejunostomy. Anastomotic leaks occur in about 10% of patients after esophagojejunostomy and Roux-en-Y reconstruction. There is a long segment of narrowing with thickened, spiculated folds in the Roux limb abutting the esophagojejunal anastomosis (arrow) due to submucosal edema and hemorrhage from acute postoperative jejunal ischemia. In such cases, postoperative contrast studies may reveal thickened folds, thumbprinting, or tubular narrowing of the Roux limb. Narrowing at the esophagojejunal anastomosis may develop as a late complication due to a benign postoperative stricture, alkaline reflux esophagitis, or recurrent tumor. A short segment of smooth, slightly asymmetric narrowing (arrow) is seen at the esophagojejunal anastomosis due to a benign anastomotic stricture. A long segment of narrowing is seen involving the distal esophagus (short arrows) and both loops of jejunum (long arrows) abutting the esophagojejunal anastomosis due to recurrent tumor encasing these structures. When recurrent tumor is suspected on barium studies, endoscopy and biopsy should be performed for a definitive diagnosis. This patient had severe nausea and vomiting because of partial gastric outlet obstruction due to relatively tight narrowing of the banded segment (arrow) at the outlet of the gastric pouch. When the patient is recumbent, barium may flow uphill in to the gastric fundus, mimicking breakdown of the gastric staple line, so assessment of staple line integrity should initially be performed with the patient upright. The two most common complications are narrowing of the banded segment and disruption of the staple line. Patients with a narrowed banded segment typically present with obstructive symptoms; barium studies may show variable narrowing of the banded segment with dilatation of the pouch and delayed emptying of barium in to the remaining stomach. In contrast, patients with staple line dehiscence typically present with recurrent weight gain; barium studies may show barium passing from the pouch in to the remaining stomach via a gastrogastric fistula where the staple line is disrupted. A watersoluble contrast study shows a long, narrowed gastric tube (after resection of the greater curvature) with focal extravasation of contrast material from the staple line on the proximal greater curvature (small arrow) in to a confined extraluminal collection (large arrow) in the left subphrenic space. A watersoluble contrast study shows disruption of the gastrojejunal anastomosis with focal extravasation of contrast material in to multiple confined collections and tracks (arrows) in this region. Unlike other forms of restrictive surgery, sleeve gastrectomy is irreversible and is associated with a high frequency of leaks. Such leaks are typically visualized on water-soluble contrast studies as focal areas of extravasation from the staple line along the greater curvature in to one or more extraluminal collections in the left subphrenic space. Laparoscopic Roux-en-Y gastric bypass Laparoscopic Roux-en-Y gastric bypass has become an increasingly popular form of bariatric surgery because of its ability to produce sustained weight loss by restricting food intake. This procedure currently accounts for more than 90% of all bariatric surgery performed in the United States. A laparoscopic approach is favored over an open laparotomy because of a lower postoperative morbidity and shorter recovery period. Roux-en-Y gastric bypass is performed by transecting and stapling a segment of the proximal stomach to create a small gastric pouch abutting the gastroesophageal junction. The pouch is anastomosed side-to-side to a loop of proximal jejunum (also known as the Roux limb), which is then transected adjacent to the anastomosis, creating a short, blindending jejunal stump. A side-to-side jejunojejunostomy is also created between the distal end of the Roux limb and the diverted duodenum and jejunum (also known as the afferent limb or pancreaticobiliary limb).

This ulcer cannot be differentiated from the cytomegalovirus ulcer illustrated in garlic pills erectile dysfunction discount viagra capsules 100mg otc. Double contrast esophagograms typically reveal one or more large erectile dysfunction self treatment order viagra capsules 100 mg with amex, ovoid or diamond-shaped ulcers surrounded by a thin radiolucent rim of edema erectile dysfunction medication list cheap 100mg viagra capsules free shipping, often associated with small satellite ulcers erectile dysfunction doctors albany ny purchase viagra capsules 100mg with visa. Other inflammatory conditions Eosinophilic esophagitis Eosinophilic esophagitis (EoE) is an inflammatory condition of unknown etiology characterized by intraepithelial eosinophilia in the esophagus vascular erectile dysfunction treatment buy viagra capsules 100 mg cheap. During the past decade jack3d impotence 100mg viagra capsules, EoE has been diagnosed with greater frequency because of an increasing prevalence or an increasing awareness of the disease, or perhaps a combination of both. In adults, EoE tends to affect young men who present with long-standing dysphagia and occasional food impactions. These patients often, but not always, have an atopic history, asthma, or peripheral eosinophilia. The diagnosis is confirmed on endoscopic biopsy specimens showing more than 20 eosinophils per high-power field. There is a long, smooth stricture (arrows) with tapered proximal and distal margins in the midesophagus. A mild stricture is seen in the distal esophagus with multiple distinctive ring-like indentations (arrows) in the region of the stricture. Patients with EoE may develop upper, mid-, or distal esophageal strictures, typically seen on esophagography as long segments of symmetric narrowing with a smooth contour and tapered margins. Other patients with EoE may have a variable number of distinctive ring-like indentations (typically in the region of a stricture), producing a ringed esophagus. Affected individuals typically ingest the medication with little or no water immediately before going to bed. The pills or capsules tend to lodge in the upper or midesophagus where it is compressed by the adjacent aortic arch or left main bronchus. Prolonged contact of the esophageal mucosa with the pills presumably causes a focal contact esophagitis. Affected individuals may present with severe odynophagia, but there is usually marked clinical improvement after withdrawal of the causative agent. The radiographic findings in drug-induced esophagitis depend on the nature of the offending medication. Tetracycline and doxycycline are associated with the development of small, discrete ulcers in the upper or midesophagus indistinguishable from those in herpes esophagitis. In contrast, other offending medications may cause more severe esophagitis, leading to the development of large ulcers. Acute radiation esophagitis usually occurs 2 to 4 weeks after the initiation of radiation therapy. This condition may be manifested by ulceration or by a granular appearance of the mucosa and 50 Chapter 3: Esophagus. There is marked loss of caliber of the entire thoracic esophagus without a discrete stricture. In a young man with allergies, asthma, or both, a small-caliber esophagus is virtually pathognomonic of eosinophilic esophagitis. Caustic esophagitis Ingestion of lye or other caustic agents can lead to a severe form of injury characterized by marked esophagitis and stricture formation. When esophagography is performed immediately after a patient ingests a caustic agent, watersoluble contrast media should be used because of the risk of esophageal perforation. Such studies may reveal marked edema, spasm, and ulceration of the affected esophagus, and in some cases, esophageal disruption. A smooth, tapered area of concentric narrowing (arrows) is seen in the midesophagus due to mediastinal irradiation. A long segment of marked narrowing is seen in the thoracic esophagus due to severe scarring from previous caustic ingestion. This degree and severity of esophageal narrowing is characteristic of a chronic lye stricture. Other esophagitides Alkaline reflux esophagitis is caused by reflux of bile or pancreatic secretions in to the esophagus after partial or total gastrectomy. Nasogastric intubation is an uncommon cause of esophagitis and formation of relatively long strictures in the distal esophagus. Such strictures may progress rapidly in length and severity on follow-up barium studies. This patient has a nasogastric intubation stricture manifested by a long segment of marked narrowing (black arrows) in the distal esophagus. An unsuccessful attempt to dilate the stricture was complicated by an esophagopleural fistula (small white arrow) with water-soluble contrast material entering an extraluminal collection (large white arrows) in the left pleural space. Benign tumors Squamous papilloma Squamous papillomas are uncommon benign tumors in the esophagus. This patient has a small, slightly lobulated papilloma (arrow) in the midesophagus. Candida esophagitis could produce similar findings, but this was an elderly patient who had no esophageal symptoms and was not immunocompromised. Papillomas usually appear on double contrast esophagography as small, sessile polyps with a smooth or slightly lobulated contour. Other patients can have innumerable papillomas in the esophagus, a rare entity known as esophageal papillomatosis. Glycogenic acanthosis Glycogenic acanthosis is a benign condition in which there is accumulation of cytoplasmic glycogen in the squamous epithelial cells lining the esophagus, causing focal, plaquelike thickening of the mucosa. Glycogenic acanthosis may be manifested on double contrast studies by multiple small, rounded nodules or plaques in the mid- or, less commonly, distal esophagus. However, the plaques of candidiasis tend to be linear, and this infection typically occurs in immunocompromised patients with odynophagia, whereas the nodules of glycogenic acanthosis tend to have a more rounded appearance, and this condition usually occurs in older individuals who are not immunocompromised and have no esophageal symptoms. Thus, it is usually possible to differentiate glycogenic acanthosis from Candida esophagitis based on the clinical and radiographic findings. When esophageal leiomyomas grow exophytically in to the mediastinum, they can sometimes be recognized on chest radiographs by the presence of a mass in the right superior mediastinum, rarely containing dense calcification. Leiomyomas are usually manifested on barium studies by a smooth submucosal mass, etched in white, that forms right angles or slightly obtuse angles with the adjacent esophageal wall when viewed in profile. Fibrovascular polyp Fibrovascular polyps are rare benign mesenchymal tumors characterized by a pedunculated intraluminal mass that can grow to enormous sizes in the esophagus. These lesions consist histologically of varying amounts of fibrovascular and adipose tissue covered by normal squamous epithelium. This lesion has a smooth surface etched in white (arrows) and the slightly obtuse margins characteristic of a submucosal mass viewed in profile. There is a smooth, sausage-shaped mass (arrows) expanding the lumen of the upper thoracic esophagus. Also note a proximal pseudo-pedicle extending superiorly towards the lower cervical esophagus. Rarely, these patients have a spectacular presentation with regurgitation of a fleshy mass in to the pharynx or mouth or even asphyxia and sudden death if the regurgitated polyp occludes the larynx. A discrete pedicle or pseudo-pedicle may occasionally be seen originating from the upper end of the polyp. As a result, most patients have advanced disease at the time of diagnosis, with overall 5-year survival rates of less than 10%. Early esophageal cancer is defined histologically as cancer limited to the mucosa or submucosa without lymph node metastases. Unlike advanced carcinoma, early esophageal cancer is a readily curable lesion with 5-year survival rates of 90 to 95%. Patients with early adenocarcinomas may also seek medical attention 54 Chapter 3: Esophagus. There is a focal cluster of poorly defined nodules in the midesophagus, producing a confluent area of disease. This appearance should be differentiated from the discrete plaques of Candida esophagitis. These tumors may be manifested on double contrast studies by plaque-like lesions (sometimes containing a flat central ulcer), sessile polyps with a smooth or slightly lobulated contour. Superficial spreading carcinoma is another form of early esophageal cancer characterized on double contrast studies by poorly defined mucosal nodules or plaques that merge with one another, producing a confluent area of disease. Advanced esophageal carcinomas usually appear on barium studies as infiltrating, polypoid, ulcerative, or, less commonly, varicoid lesions. Primary ulcerative carcinomas are usually manifested by a giant, meniscoid ulcer surrounded by a thick, irregular radiolucent rind of tumor. There is a long segment of irregular narrowing in the midesophagus with a nodular, ulcerated contour and relatively abrupt proximal and distal margins (arrows). Multiple large submucosal defects are seen in the distal esophagus due to submucosal spread of tumor. This lesion had a fixed configuration, whereas varices would be expected to change in size and shape at fluoroscopy. A large meniscoid ulcer (white arrows) is seen in the distal esophagus, surrounded by a thick, irregular rind of tumor (black arrows). This appearance should be differentiated from the thin rim of edema associated with giant benign ulcers due to cytomegalovirus and human immunodeficiency virus esophagitis. Also, varices rarely cause dysphagia because they are soft, compressible structures. Squamous cell carcinomas and adenocarcinomas of the esophagus cannot be reliably differentiated on barium studies. Nevertheless, squamous cell carcinomas tend to involve the upper or midesophagus, whereas adenocarcinomas are located predominantly in the distal esophagus. Unlike squamous cell carcinomas, esophageal adenocarcinomas also have a marked tendency to invade the gastric cardia or fundus. A right lateral view of the gastric fundus shows irregular areas of ulceration (white arrows) with obliteration of the cardiac rosette. This patient has a bulky polypoid intraluminal mass expanding the lumen of the midesophagus without causing obstruction. Despite its rarity, this appearance should suggest spindle cell carcinoma, as advanced adenocarcinomas and squamous cell carcinomas typically infiltrate and narrow the lumen, producing very different radiographic findings. Double contrast esophagography has proven to be a valuable technique for diagnosing esophageal carcinoma with a sensitivity of greater than 95% in detecting these lesions in relation to endoscopy. Esophageal lymphoma may be manifested on barium studies by multiple submucosal masses, polypoid lesions, enlarged folds, or strictures. Spindle cell carcinoma is another rare malignant tumor with a biphasic morphology, containing both carcinomatous and sarcomatous cells. Conversely, Schatzki rings can also be missed if the esophagus is overdistended, causing overlap between the lower end of the distal esophagus and upper end of the hiatal hernia, so the ring is not visualized in profile. When carefully performed, biphasic esophagography is a sensitive technique for detecting Schatzki rings, occasionally demonstrating rings that are missed on endoscopy. Lower esophageal rings are almost always located at the gastroesophageal junction. Histologically, the superior surface of the ring is lined by squamous epithelium and the inferior surface by columnar epithelium. Schatzki rings typically appear on esophagography as 1 to 3 mm in length, symmetric, web-like constrictions (usually less than 13 mm in diameter) at the gastroesophageal junction above a hiatal hernia. The more common pulsion diverticula result from esophageal dysmotility with increased intraluminal pressures in the esophagus, whereas traction diverticula are caused by scarring in the soft tissues abutting the esophagus. An upright double contrast view of the distal esophagus shows no evidence of a lower esophageal ring, but this region is not optimally distended. A prone single contrast view from the same study shows an unequivocal Schatzki ring (arrows) above a hiatal hernia. The ring is only visualized when the distal esophagus and hernia are distended beyond the caliber of the ring. A prone single contrast view of the distal esophagus shows a small hiatal hernia without evidence of a lower esophageal ring. However, the region of the gastroesophageal junction is not seen in profile because of overlap between the distal end of the esophagus (large arrows) and the proximal end of the hernia (small arrows). Another view with less distention shows an unequivocal Schatzki ring (arrows) when overlap between the distal esophagus and hiatal hernia has been eliminated. Other patients may develop multiple tiny outpouchings from the esophagus, a condition known as esophageal intramural pseudodiverticulosis. Pulsion diverticula Pulsion diverticula tend to be located in the distal esophagus and are often associated with fluoroscopic or manometric evidence of esophageal dysmotility. The diverticula are usually detected as incidental findings in patients who have no esophageal symptoms. Pulsion diverticula appear on barium studies as multiple rounded outpouchings from the esophageal lumen that have wide necks and do not empty completely when the esophagus collapses. Two pulsion diverticula are seen in the midesophagus as rounded outpouchings (arrows) with wide necks. This patient had associated esophageal dysmotility with multiple weak non-peristaltic contractions. A giant diverticulum (large arrows) is seen arising from the right lateral wall of the distal esophagus near the gastroesophageal junction. There is a second, much smaller epiphrenic diverticulum (small arrow) arising from the left lateral wall of the distal esophagus. Traction diverticula Traction diverticula almost always occur as solitary outpouchings from the midesophagus and are usually caused by scarring from tuberculosis or histoplasmosis involving perihilar or subcarinal lymph nodes. A single diverticulum (arrows) with a flat, tented border is seen arising from the midesophagus.

The severity of ischemia varies from a transient form to transmural necrosis with perforation erectile dysfunction treatment levitra discount viagra capsules 100mg amex. The colon has several collateral arcs (the marginal artery of Drummond and the arc of Riolan) erectile dysfunction sample pills cheap 100 mg viagra capsules fast delivery, so ischemia usually results from low flow states and small vessel disease erectile dysfunction treatment psychological causes buy viagra capsules 100mg on-line, rather than large vessel disease erectile dysfunction review buy viagra capsules 100 mg without a prescription. Colonic dilatation due to adynamic ileus or obstruction may result in ischemia impotence and depression generic viagra capsules 100 mg with visa, from the spectrum of colonic urticaria to transmural necrosis erectile dysfunction specialists order viagra capsules 100 mg otc. Fecal impaction causes rectal mucosal ischemia by dilatation and pressure necrosis, resulting in stercoral ulceration. Ischemia is not uncommon in the cecum, the most distensible portion of colon, in the sigmoid colon, and in the rectum in patients with stercoral ulceration. Transient ischemia of the right colon has been associated with hypotension and various vascular reactions associated with cocaine, penicillin, or oral contraceptive use. This form is usually reversible, healing within syndrome have a positive family history, the majority of PeutzJeghers patients will have only a few, large, pedunculated polyps in the colon, not a carpet of small lesions. Spot radiograph performed during single contrast barium enema reveals smooth-surfaced hemispheric nodules throughout the distal descending and sigmoid colon. Mucosal ischemia alone may be manifested as a colonic urticarial pattern, with relatively flat, polygonal islands separated by thin bariumfilled grooves. If a contrast enema is performed, small or large ulcers of punctate or longitudinal shape may be demonstrated. Chronic radiation colitis is a form of chronic ischemia, owing to progressive obliterative endarteritis. Barium studies are usually performed in the chronic phase, to exclude other causes of bloody discharge, diarrhea, or lower abdominal pain. The mucosal atrophy and wall fibrosis of radiation colitis is manifested as tubular, featureless, narrow colon. This typically occurs in the rectum, because most radiation is performed for prostatic or cervical cancer. Although originally described in urticaria, this radiographic pattern is usually seen in diseases causing mucosal ischemia associated with colonic dilatation due to obstruction or adynamic ileus or in patients with a variety of acute infections. Spot radiograph of the proximal sigmoid colon shows a 4 cm mild narrowing (arrow) with smooth, tapered margins and mildly nodular mucosa. They are often manifested as smooth, undulating, or lobulated folds extending up to 3 cm from the anorectal junction. In other patients, internal hemorrhoids may appear as a group of multiple small, smooth, ovoid, submucusoal-appearing nodules in contiguity with anorectal junction, resembling a "bunch of grapes". Therefore, if nodules at the anorectal junction have an irregular contour or surface, or if lobulated folds extend greater than 3 cm from the anorectal junction, endoscopy with biopsy should be performed to exclude a rectal carcinoma. Other polypoid lesions may be seen at the anorectal junction, such as an inflammatory cloacogenic polyp. Image from overhead radiograph demonstrates a mildly narrow tubular rectosigmoid colon with finely granular mucosa in the rectum. A smoothsurfaced mass is seen on the inferior wall of the sigmoid colon (arrowheads). Colonic wall thickening is due to hyperplasia and fibrosis of the muscularis propria due to infiltrating endometrial tissue. Endometriosis Ectopic endometrial tissue primarily involves the peritoneal surfaces of pelvic organs, in particular the ovaries, fallopian tubes, and rectouterine space (pouch of Douglas). The serosa and subserosal fat of the rectosigmoid junction and sigmoid colon is more frequently involved than that of the terminal ileum. Endometrial tissue may burrow, however, in to the muscularis propria, submucosa, and even mucosa of pelvic bowel loops. As the endometrial tissue passes through the proliferative and secretory phases of the menstrual cycle, bleeding, necrosis, and regeneration of endometrial tissue results in serosal puckering and extensive subserosal fibrosis. The findings are indistinguishable from intraperitoneal metastasis, but the age of the woman and clinical history are guides to the diagnosis. Rarely, deeper bowel wall invasion may result in a smooth, polypoid mass or annular narrowing. Findings at defecography Rectal intussusception Asymmetric or concentric telescoping of a proximal portion of the rectum in to a more distal portion of the rectum is termed intussusception. Invagination of rectal wall in to the anal canal is abnormal, however, leading to sensation of incomplete evacuation, obstructed defecation, and solitary rectal ulcer syndrome. Spot radiograph from double contrast barium enema (not defecogram) shows a 3 cm area of focal mucosal nodularity (arrows) in the mid rectum. There is a 6 cm broadbased protrusion of the anterior wall of the rectum (R), deviating the lower vagina anteriorly (arrow). A small amount of rectal mucosa is invaginating in to the lumen of the distal rectum (arrowhead). This patient complained of incomplete rectal evacuation and inserted a finger in to her vagina to aid rectal clearance. A large rectocele (R) is pushing in to the posterior vaginal wall while the entire bariumcoated lower vagina (arrows) has prolapsed out of the vaginal introitus in to the perineal space. Anal cushion prolapse the anal cushions/hemorrhoidal tissue may be pushed from the anal canal in to the perineum during defecation. Mild eversion of anal tissue is manifested as a rim of lobulated tissue at the anal opening. Greater anal cushion prolapse is manifested as a large lobulated mass extending in to the perineum. As images are not obtained in the frontal view during defecation, the lateral extent of a rectocele or a lateral rectocele may be missed. A large rectocele can bulge deeply in to the posterior vaginal wall and even protrude in to the perineum. Abnormal relaxation of puborectalis muscle or anal sphincter Incomplete relaxation of the puborectalis muscle during defecation has been termed anismus or spastic pelvic floor syndrome. Radiographically, there is incomplete flattening of the puborectalis muscle during defecation (persistence of the anorectal angle) or a radiolucent bar of tissue crossing the distal-most rectum during defecation. Slow, incomplete, or abnormal opening of the anal sphincter is manifest as a narrow opening at the level of the anal sphincter. Enterocele and sigmoidocele the anterior wall of the rectum and posterior wall of the vagina are tethered together by the rectovaginal septum. If the rectovaginal septum is damaged by childbirth, surgery, or other means, the pelvic ileum or sigmoid colon may fall between the vagina and rectum, forming an enterocele or sigmoidocele, respectively. These entities lead to symptoms of a mass or bulge "in" the rectum or a feeling of incomplete evacuation. An enterocele is best demonstrated toward the end of defecation or when the woman increases abdominal pressure. Barium- opacified small bowel protrudes between the vagina and rectum to a varying depth. If barium has not opacified the sigmoid colon and an unexpected soft tissue gap is seen between vagina and rectum, a sigmoidocele should be suspected. This finding is often found in asymptomatic patients or in conjunction with other 188 Chapter 9: Colon reach the sigmoid colon or more barium is instilled in to the rectum via the Miller air tip. The sigmoidocele will then be demonstrated as a loop of sigmoid protruding inferiorly between the vagina and rectum. An enema may be used to demonstrate the residual colonic anatomy, the presence or healing of a leak. An end-to-end anastomosis appears radiographically as a transition zone, often ring-like, with a caliber change between the proximal and distal loops. Without surgical history, the stump of a side to end colorectal anastomosis can be mistaken for a leak. A slight smooth elevation in the immediate postoperative period may be a stitch granuloma or submucosal edema. Any contour irregularity in the remote postoperative period is suspicious for recurrent tumor, focal ischemia, or radiation. A contrast-filled track outside the expected luminal contour or staple lines is consistent with a leak or, if communicating with another organ or skin, a fistula. Gastrointestinal tract tuberculosis: a study of 102 cases including 55 hemicolectomies. Colonic cancer: morphology detected with barium enema examination versus histopathologic stage. A pathological and radiological correlation of the mucosal changes in ulcerative colitis. Correlation of endoscopy and doublecontrast radiography in the early stages of ulcerative and granulomatous colitis. The radiological differentiation between ulcerative and granulomatous colitis by double contrast radiology. Distribution of intraabdominal malignant seeding: dependency on dynamics of flow of ascitic fluid. The term "cystogram" implies evaluation of the bladder alone, without the voiding phase of the examination. Cystography and voiding cystourethrography are performed for the following indications: 1. Evaluation for vesicoureteral reflux in patients with recurrent or chronic urinary tract infections. Evaluation of patients with lower urinary symptoms such as difficulty in initiating voiding, incomplete voiding, incontinence, and post void dribbling. Technique If the patient presents with an indwelling catheter in the bladder (suprapubic or transurethral), that catheter is used to fill the bladder with contrast. If there are two indwelling catheters, one catheter is clamped and the other is used to fill the bladder. If there is no catheter present, a Foley catheter is placed for the study, as described below. Technique for female urethral catheterization Adequate exposure of the urethra is the key to successful catheterization in females. In young, slim women, catheterization is relatively easy but in older women who are overweight or have pelvic floor laxity and prolapse, urethral catheterization can be quite challenging. The reader is referred to an excellent video1 for precise details and illustrations on female urethral catheterization. Prepackaged urethral catheterization kits are readily available and contain all the necessary equipment. A frog leg position (flexion of both knees and then abduction of the thighs as far as feasible for the patient) or lithotomy position facilitates the procedure. The tray is opened and all the equipment is readied; antiseptic solution is poured on the cotton swabs, and the lubricant jelly is squeezed on to the tray and then applied to the catheter tip. The labia minora are separated with the fingers of the non-dominant hand; this hand is now unsterile and is used to maintain urethral exposure. In very overweight women or in those with significant pelvic prolapse, an assistant will facilitate the procedure. The urethral meatus is located between the clitoris and the vaginal introitus, and is cleansed with the antiseptic soaked swabs, followed by advancement of the catheter (with lubricated tip) in to the bladder. Once urine starts to drain through the catheter, it should be advanced a few centimeters further, to ensure complete positioning in the bladder. The balloon of the catheter is inflated with 5 ml of sterile water (supplied in the kit) or room air; although air is not recommended for inflation of the balloon in catheters which are placed for bladder drainage, it allows easier visualization of the balloon in the contrast-filled bladder for radiographic studies. Once the balloon is inflated, the catheter is tugged gently to ensure that it will remain in place for the duration of the study. The vagina may be inadvertently catheterized instead of the urethra, particularly if there is pelvic prolapse. In our experience, questioning the patient is often not helpful as patients are sometimes unable to tell whether the catheter is within the urethra or vagina. Although absence of urine flow through the catheter should be a clue that the catheter is not within the bladder, this too is not helpful if the patient has voided immediately prior to the study. Although the superior aspect of the distended vagina simulates the bladder, the vaginal mucosal folds inferiorly (arrow) are a clue to the malposition of the catheter. Contralateral oblique view shows a small bladder diverticulum (long white arrow) which is not visible on the oblique projection of B. In this circumstance, it is best to leave the vaginal catheter in place to mark the vaginal introitus, and then catheterize the urethra using a new sterile catheter kit. Technique for male urethral catheterization A standard urethral catheterization kit is utilized in men as well, and the sterile technique is similar to that used in women. Extension of the penis by pulling gently on the tip of the penis is important to straighten the urethral curve at the peno scrotal junction, and facilitate passage of the catheter. In uncircumcised males, the prepuce (foreskin) should be retracted prior to the cleansing of the tip of the penis and the urethral meatus with antiseptic soaked gauze. Injection of viscous lidocaine jelly in to the urethra can make the catheter placement more comfortable; the jelly comes preloaded in a blunt-tipped syringe that is injected in to the urethral meatus after sterile preparation of the urethra. The urethral meatus should be firmly occluded (by compressing the glans penis with two fingers) for a minute or two after the lidocaine instillation, so that the jelly can remain in contact with the anterior urethral mucosa.

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