ACCESORY

ORGANS OF THE
DIGESTIVE
SYSTEM

KRISTINE KATE S. PAMITTAN, RRT

 The Digestive System – consist of the
Alimentary tract and the accessory
glands that help in the digestive process
•Abdominopelvic cavity – contains 2 parts:
1.Abdominal cavity - Large superior portion
- It extends from the diaphragm to the superior aspect of the bony pelvis
- It contains the stomach, small and large intestines, liver, gallbladder, spleen, pancreas and
kidneys

•1. Pelvic cavity – lower smaller portion

• - Lies within the margin of the bony pelvis and contains the rectum
and sigmoid of the large intestines , the urinary bladder and the
reproductive organ
Peritoneum – double walled seromembranous sac that encloses the
abdominopelvic cavity
 Parietal peritoneum – the outer portion that is close incontact with the
abdominal wall and most of the undersurface of the liver
 Visceral peritoneum – positioned over or around the contained organs and
forms folds called mesentery and omenta which serves as support of the
viscera in position
 Peritoneal cavity – the space between the two layers which contains serous
fluids
 Retroperitoneum – the area behind the peritoneum where organs like
the
kidneys and pancreas lie
 LIVER AND THE BILIARY SYSTEM

LIVER – the largest gland in the body

-Irregularly wedge shaped gland

- Situated with its base on the right and its apex directed anterior and to the left.
- The deepest point is the inferior portion just above the right kidney
- Its diaphragmatic surface is convex and conforms to the
undersurface
of the

diaphragm
- The visceral surface is is concave and molded over the viscera on which it rests
- It occupies almost all of the righ hypochondrium and the large part of the epigastrium
- The right portion extend inferiorly into the right lateral region as far as the 4th lumbar
vertebrae while the left part extends to the left hypochondrium
Structures of the liver:

 Falciform ligament - the division of the right and left lobe of the liver

 Right lobe – the larger division of the liver

o Caudate lobe - posterior surface
o Quadrate lobe – inferior surface

 Left lobe – the smaller division

 Porta hepatis / hilum of the liver – situated transversely between the two minor lobes
located in the right lobe

 Portal vein / hepatic artery – convey blood to the liver where they enter the porta
hepatis and branch out to the liver substances
 o Portal vein – ends in the sinusoids
o Hepatic artery – ends in the capillaries

 Portal system – contains the portal vein as its main trunk

o Consist of veins arising from the walls of the stomach from the greater part of the
intestinal tract and the gallbladder and from the pancreas to the spleen
o The blood circulating from these organs is carried to the liver for
modification before being returned to the blood
 Hepatic veins – convey blood from the liver sinusoids to the inferior vena cava
 Bile – produced for the emulsification and assimilation of fats
o Secreted at a rate of 1-3 pints (1/2 to 1 ½ L) day
o The channel for elimination for the waste products of the RBC destruction
o A secretion as it is important for the abovementioned functioorming n
for the
digestive process
o Composition is:
 Bile salts
 Bile pigments (mostly bilirubin from the breakdown of hemoglobin)
 Cholesterol
 Phospholipids
 Electrolytes
 Biliary System
- Consist of the liver and the bile ducts including the gallbladder
- Beginning within the lobules as bile capillaries, the ducts unite to form larger and
larger
passages as they converge finally for the two main ducts

 Hepatic ducts – left and right

- They emerge from the porta hepatis and join to form the common bile ducts

 Cystic duct – coming from the gallbladder

- Together with the hepatic duct, are each about 1 ½ inches (3.8 cm) in length

 Common bile duct – the main duct that is formed when hepatic ducts unite
- Passes inferior for a distance of approximately 3 inches / 7.6 cm
- Join the pancreatic duct and together they enter into a chamber called the hepatopancreatic
ampulla (ampulla of Vater)
 Ampulla of Vater – opens into the descending portion of the duodenum

 Choledochal sphincter – controls the distal end of the CBD as it enters the duodenum

 Hepatopancreatic sphincter (Sphincter of Oddi) – the circular muscle that controls the
ampulla of vater where it remains in a contracted state during interdigestive periods
so that the bile goes to the GB for concentration and temporary storage
 Gallbladder – a thin walled, more or less pear shaped organ that is musculomembranous
sac with a capacity of approximately 2 ounces

- It functions to concentrate bile by absorbing the water contents, temporarily stores

the bile during interdigestive periods and by contracting its musculature to evacuate
the bile during digestion

 Cholecystokinin – a hormone that stimulates the contraction of the GB for the release
of the bile
- The position of the GB varies with each type of body habitus
- It is high and well away from the midline in hypersthenic persons and low and near
the spine in asthenic individuals
 Pancreas - Found posterior to the parietal peritoneum
- Extends across the abdomen from spleen to duodenum
- Produces a wide spectrum of digestive enzymes that break down all categories of food
- Is both an endocrine and exocrine gland
o Exocrine – are arranged into lobules with a highly ramified duct system
 Produces the pancreatic juice which acts on protein fats and carbohydrates
o Endocrine – consist of islets of Langerhans which are randomly distributed throughout the
pancreas which produces hormones
 The islets do not communicate directly into the ducts but release their secretions into
the blood through a rich capillary network
- Hormones produced by the pancreas
o Insulin
o Glucagon

- Enzymes are secreted into the duodenum

- Alkaline fluid introduced with enzymes neutralizes acidic chyme coming from stomach
 Summary of Pathology

1. Abdominal Aortic Aeurysm – localized dilatation of the abdominal aorta

2. Appendicitis – inflammation of the appendix

3. Biliary stenosis – narrowing of the bile ducts

4. Bowel obstruction – blockage of the bowel lumen

5. Cholecystitis – acute or chronic inglammation of the GB

6. Cholecdocholithiasis – calculus in the common bile duct

7. Cholelithiasis – the presence of gallstones

8. Ileus – failure of bowel peristalsis

1. Metastases – transfer of a cancerous lesion from one area to another

2. Pneumoperitoneum – presence of air in the peritoneal cavity

3. Tumor – new tissue growth where the cell proliferation is uncontrolled

4. Ulcerative colitis – recurrent disorder causing inflammatory ulceration in the colon

 ABDOMINAL RADIOGRAPHIC PROCEDURES

PRELIMINARY PROCEDURES AND POSITIONS

- This is usually done without the use of contrast media and its primary function to
detect abnormalities and pathologic conditions that can be seen without CM
- It also acts as a survey or preliminary scout film for special procedures with CM

Patient Preparation

Non Acute conditions

1. Controlled diet

2. Laxative

3. Enemas

Acute conditions (No preparation is done)

Exposure Technique

1. The exposure technique factors should be able to show soft tissue differentiation throughout
the different regions of the abdomen

2. The exposure factors should be adjusted to produce a radiograph with moderate gray tones and
less black and white contrast

3. If the kV is too high the possibility of not demonstrating small semi opaque gallstones increase

4. The following criteria for good quality radiograph for plain abdomen is checked
a. Sharply defined outlines of the psoas muscles
b. Shows lower border of the liver
c. The shadows and the margins of the kidneys are also shown
d. The ribs should also be seen
e. The transverse process of the lumbar vertebrae seen
 Immobilization

- Prevention of movement both voluntary and involuntary

1. To prevent muscle contraction caused by tenseness,

adjust the patient in

a
comfortable position so that he or she can relax

2. Explain the breathing procedure and make sure the patient understand exactly what
happens and what is expected

3. Af needed apply a compression band across the abdomen for immobilization but not
compression

4. Do not start the exposure for 1 to 2 seconds after the suspension of respiration to
allow the patient to come to rest and involuntary movement of the viscera to subside
Radiation Protection
General Rad. Protection techniques must be used. Gonadal shielding is required in the
following situations:

1. If the gonads lie in close proximity (2 inches / 5cm) to the primary x-ray field
despite
proper beam limitation

2. If the clinical objective of the examinations will not be compromised

3. If the patient has a reasonable reproductive potential

 RADIOGRAPHY OF THE ACCESSORY ORGANS OF THE DIGESTIVE SYSTEM

Purpose for Investigation of the Plain Abdomen:

1. for the investigate such on and detection of any condition such as renal stones and tumor
massesthat might cause reffered symptoms

2. examinations for the renal and gallbladder

3. demonstrate the alimentary tract for demonstration of any local lesion

PLAIN ABDOMEN

Considerations:

1. Intestinal tract should be evacuated of gas and fecal materials to obtain an unobstructed image
of the contained viscera

2. Patient should follow strictly instructions before the procedure is done

Sequence of procedures of studying the Accessory organs

1. Abdomen

2. liver and spleen

3. biliary tract

a. gallbladder

b. pancreas

c. biliary tree
Projections:

1. AP supine

2. AP upright

3. PA upright

4. Lateral Projection R/L position

5. AP/PA Projection Left lateral decubitus

6. Lateral Projection dorsal decubitus

Criteria for Quality Abdominal Radiograph

1. Sharply defined outlines of the psoas muscles. Lower border of liver, the kidneys, the ribs, and
transverse process of lumbar vertebrae

2. No blurring of abdominal images

3. Contrast and density well balanced

 Radiography
AP PROJECTION

 Structure shown:
An AP projection of the
abdomen shows the size
and shape of the liver, the
spleen and the kidneys,
and intraabdominal
calcifications or evidence of
tumor masses
PA PROJECTION Upright

When the kidneys are not of primary

interest, the upright PA projection should
be considered. Compared with the AP
projection the PA projection of the
abdomen greatly reduces patient gonadal
dose.
 AP PROJECTION
L lateral decubitus position

Structure shown: left decubitus position is most valuable for demonstrating air or fluid levels when
an upright abdomen projection cannot be obtained
All Radiographic examination of the abdomen requires the patient to suspend respiration at the
end of exhalation to ensure that the organs are not compressed and are on their original position.
This projection is performed if the patient is ill to stand and the air-fluid level is needed to be
demonstrated.
 LATERAL PROJECTION R or L position

Structure shown: demonstrates the prevertebral space

occupied by the abdominal aorta, as well as any
intraabdominal calcifications or tumor masses
 LATERAL PROJECTION R or L dorsal decubitus position

This projection is usually performed in addition to the

AP/PA projection Lateral decubitus to demonstrate
structures on a different angle if the patient is too ill to
stand. The decubitus position is useful in demonstrating
air fluid level in the abdomen.
 BILIARY TRACT
Cholegraphy – general term used to demote specialized Radiologic
examination

of the biliary tract

Cholecystangiography / cholecystocholangiography – examinations with

the use of CM to demonstrate the GB and bile ducts

Cholecystography – examinations with the use of CM to demonstrate the GB

only

Cholangiography – examinations with use of CM to demonstrate the

bile
ducts
 CM Administration
1. oral

2. injection to a vein in single bolus or drip infusion

3. direct injection to the ducts

a. through percutaneous transhepatic puncture
b. during biliary tract surgery
c. indwelling drainage (T-tube)

Methods are according to :

4. route of entry or medium

5. portion of biliary tract examined

Contrast media administered orally
- is absorbed by the intestines, carried to the liver through the portal vein
- from hepatic cells, CM is biochemically changed and excreted with the bile
and conveyed to the gallbladder by system ducts
- the CM carrying bile is stored and concentrated in the gallbladder rendering
it opaque
Purpose of Doing Biliary tract Examination

1. To determine the function of the liver – its ability to remove CM from

the Bloodstream and excrete it with bile

2. To determine the patency and condition of the biliary ducts

3. To determine concentrating and emptying power of the gallbladder
4. To detect presence of calculi, neoplasm, stenosis and indirect lesions
of the head of the

pancreas

5.To detect gallstones which is the greatest

reasonfor biliary tract examination
 ORAL CHOLECYSTOGRAPHY

Patient Instruction

1. The patient should be told of the approximate time required for the examination including
delayed radiographs and colon cleansing

2. Patient should be given clearly printed instructions

a. Preliminary preparations for intestinal tract

b. Preliminary diet

c. Exact time to take oral medium

d. Avoidance of laxatives 24 hours before taking CM

e. NPO after receiving CM

f. Time to report for the examination

 Before
Examinatio
n
1. ask patient about steps done in preparation for the examination

2. ask for any reaction after ingestion of CM

3. appointments for examinations should be as early as possible

Preparation of the Intestinal tract

4. Bowel content maybe light to moderate as to eliminate it easily with cleansing

enema to avoid laxatives

5. If laxatives are needed to be administered should be taken 24 hours before

taking CM to allow the irritation of the bowel to subside and prevent Cm
from being egested with fecal materials
 Preliminary Diet

1. Evening meal should be fat free to prevent possibility of continued emptying of the
gallbladder during the time the liver is excreting opacified bile

2. Noon meal should be rich in simple fats

3. Oral CM administration should be 3 hours after the evening meal

4. NPO after ingestion of CM except small amounts of water

Contrast administration

 The contrast medium available for OCG is normally given to the patient in a single
dose approximately 2 to 3 hours after the evening meal on the night before the
examination.

 The usual single dose of 3 g is administered in the form of four to six

tablets.
Breakfast is usually withheld on the morning of the procedure.

 The absorption time varies from 10 to 12 hours for most present-day oral agents
 RADIOGRAPHY
PA PROJECTION

Structure shown: Entire gallbladder and area of the cystic duct.

Gallbladder with a short scale of contrast and no motion visible on the
gallbladder
 PA OBLIQUE PROJECTION LAO Position

With the patient in the prone position, elevate the right side to the desired
degree of obliquity (15 to 40 degrees)
Structure shown: Opacified gallbladder free from self-superimposition or
foreshortening and from the structures adjacent to the gallbladder
 LATERAL PROJECTION R. Lateral position

The lateral position is required to separate the superimposition of the

gallbladder and the vertebrae in exceptionally thin patients and to place the long
axis of a transversely placed gallbladder parallel with the plane of the IR.
Structure shown: Opacified gallbladder free from self-superimposition or
foreshortening and from the structures adjacent to the gallbladder
 AP PROJECTION R lateral decubitus position

Structure shown: The right lateral decubitus and upright positions are used to
demonstrate stones that are heavier than bile and that are too small to be
visible other than when accumulated in the dependent portion of the gallbladder.
These positions are also used to demonstrate stones that are lighter than bile
and that are visualized only by stratification.
INTRAVENOUS CHOLANGIOGRAPHY
seldom performed because it has relatively higher incidence of reaction to CM
Purpose of the Examination:

1. Examinations of biliary ducts of cholecystectomized patients

2. Examinations of biliary ducts and gallbladder of non-

cholecystectomized
patients

Preliminary cleansing enema

3. laxatives

4. restricted diet

5. enemas
 Contrast
Media used:
 isotonic saline or glucose solution by slow Intravenous infusion

Contraindications:

1. patients with liver disease

2. patients whose biliary tract is not intact

3. obstructive jaundice

4. post – cholecystectomy
 PROCEDURE:
The following steps are observed:

1. Place the patient in the supine position for a preliminary radiograph of

the
abdomen.

2. Place the patient in the RPO position (15 to 40 degrees) for an AP oblique
projection of the biliary ducts

3. Obtain a scout (localization) radiograph and/or tomogram to check for centering

and exposure factors.

4. Advise the patient that a hot flush may occur when the contrast medium
is
injected.

5. Timed from the completion of the injection, duct studies are ordinarily obtained at
10-minute intervals until satisfactory visualization is obtained. Maximum
opacification usually requires 30 to 40 minutes
 PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY

- is another technique employed for preoperative radiologic examination of the

biliary tract. This technique is used for patients with jaundice when the ductal
system has been shown to be dilated by CT or ultrasonography but the cause
of the obstruction is unclear

- Often used to place drainage catheter for treatment of obstructive jaundice

rather than diagnosis.

- Done with fluoroscopic technique by radiologist and the requesting physician.

PROCEDURE:
The following steps are observed:
• Place the patient on the radiographic table in the supine position.
• The patient's right side is surgically prepared and appropriately
draped
• After a local anesthetic is administered, the Chiba needle is
held
parallel to the floor and inserted through the right lateral intercostal
space and advanced toward the liver hilum
• The stylet of the needle is withdrawn, and a syringe filled with
contrast medium is attached to the needle.
• Under fluoroscopic control, the needle is slowly withdrawn until the
contrast medium is seen to fill the biliary ducts.
• After the biliary ducts are filled, the needle is completely withdrawn
and serial or spot AP projections of the biliary area are taken.
This procedure is usually done in the OR to
prevent contamination of the affected area.
The CM is injected through direct puncture into
the liver hilum which is performed by the
physician. The radiographer ensures that spot
film of the structures is being taken after the
administration of CM. the CM that is used
should be water soluble CM because this CM is
easily absorbed by the body meaning it will be
eliminated in the body through urination.
 Postoperative Cholangiography

- Postoperative, delayed, and T-tube cholangiography are radiologic terms applied to

the biliary tract examination that is performed by way of the T -shaped tube left in
the common bile duct for postoperative drainage.

Indication:

1. Demonstrate the caliber and patency of the ducts

2. The status of the sphincter of the hepatopancreatic ampulla

3. Presence of residual or previously undetected stones or other pathologic conditions

 Procedure:

• The drainage tube is clamped the day preceding the examination to let the
tube fill with bile as a preventive measure against air bubbles entering the
ducts, where they would simulate cholesterol stones.
• The preceding meal is withheld.
• When indicated, a cleansing enema is administered about I hour before
the examination. Premedication is not required.
• After a preliminary radiograph of the abdomen has been obtained, the
patient is adjusted in the RPO position (AP oblique projection)
• The contrast medium is injected under fluoroscopic control, and spot and
conventional radiographs are made as indicated.
• The clamp generally is not removed from the T-tube before the
examination is completed.
 According to Bruce Long,
Rollins
and Smith the contrast agent used
is one of the water-soluble organic
contrast media. The density of the
contrast medium used in
postoperative cholangiogram is
recommended to be no more than
25% to 30% because small stones
may be obscured with a higher
concentration.
 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Endoscopy – inspection of any cavity of the body by means of endoscope, an

instrument that allows illumination of the internal lining of an organ

 various fiber optic endoscopes are available to examine the interior lining of the
stomach, duodenum, and the rest of the colon.

 Video endoscope projects the images into the video monitor for multiple
viewing.

 Instrument Duodenoscope is inserted into the duodenum through the mouth,

esophagus and stomach and provide a wide angle side view which is useful for
locating and inserting a catheter or cannula into the small opening of the
hepatopancreatic ampulla or sphincter, leading form the duodenum into the
common bile duct and main hepatic ducts.
 Purposes:
Therapeutic - can be either the removal of choleliths or small lesions of for
repair stenosis (narrowing of blockage of small duct of canal) of the
hepatopancreatic ampulla/sphincter or associated ducts.

Diagnosis– insertion endoscopically of the catheter of injection of the cannula

into the CBD.

Other purposes:

1. investigate the patency of the biliary/pancreatic ducts.

2. reveal any choleliths not previously detected

3. demonstrate small lesions. Strictures, or dilatation within the biliary/pancreatic

ducts.
 Procedure:

1. ERCP is performed by passing a fiberoptic endoscope through the mouth into

the duodenum under fluoroscopic control

2. After the endoscopist locates the hepatopancreatic ampulla ( ampulla of

Yater), a small cannula is passed through the endoscope and directed into the
ampulla

3. Once the cannula is properly placed, the contrast medium is injected into the
common bile duct

4. The patient may then be moved, fluoroscopy performed, and spot radiographs
taken
This procedure is performed in the radiology department with the help of the physicians
from EENT who will perform the procedure. The patient’s throat is sprayed with local
anaesthesia to reduce discomfort during the examination which is why food and drinks
are prohibited 1 hour after the examination because the anaesthesia will cause
temporary paralysis of the organ. The patient is usually sedated during the procedure.
Radiographs must be taken immediately after the introduction of CM because the
injected contrast material should drain from normal ducts within approximately 5
minutes.