Dysphagia Marking Scheme

8/22/2019 Dysphagia Marking Scheme

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ESSAY QUESTION

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

1. Definition 1mrk2. 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

Radiological Investigations/Findings 10mrks

1. Plain chest radiograph PA and lateral2. Plain x-ray of the cervical spine3. Barium Swallow4. CT5. MRI6. Radio nuclide studies


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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 - 1mrk2. Causes 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 infestationPortal pyaemia

Pyogenic and amoebic abscess

Hydatid disease, actinomycosis

Hepatitis, infections mononucleosis

AIDS


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NeoplasmAdenoma

Hepatoma, fibrolamellar carcinoma

Cholangiocarcinoma

Metastases

Radiological Investigations and Findings 10mrks

1. Plain Abdominal X-ray2. Ultrasound3. Angiography4. Radionuclide scanning5. CT6. MRIPlain Abdominal X-ray

1. Right lobea. Elevated right hemidiaphragmb. Depressed hepatic flexure and duodenumc. Depressed right kidney (occasionally it remains high)d. Bulging of the right properitoneal fat linee. Occasionally, splaying of the lower right ribs

2. Left lobea. Gastric fundus displaced downwards and laterallyb. Intra-abdominal oesophagus elongatedc. Extrinsic pressure on lesser curvature of stomachd. 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 ofthe 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. With the aid of an illustrated diagram, describe the radiological anatomy of the stomach

b. Describe the technique of barium meal study


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MARKING SCHEME

1. Well labelled diagram 5mrksDescription 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 thelesser curve that separates the body and antrum. Other parts are the fundus and greater

curvature.

2b. Technique of Barium meal 10mrks

Methods

1. Double contrast2. Single contrast

Indications

1. Dyspepsia2. Weight loss3. Upper abdominal mass4. Gastrointestinal haemorrhage( or unexplained iron-deficiency anaemia)5. Partial obstruction6. Assessment of site of perforation

Contraindication

Complete large bowel obstruction

Contrast Medium

1. Barium sulphate2. Carbex granules or double contrast technique

Patient preparation

1. Nil orally for 6 h prior to the examination2.

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 usedPreliminary film

Plain abdominal x-ray

Technique (double contrast method)


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1. A gas producing agent is swallowed2. 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 theR A O position.

FILMS

1. Spot films of the stomach (lying)a. RAO to demonstrate the antrum and greater curvatureb. Supine to demonstrate the antrum and bodyc. LAO to demonstrate the lesser curvature on en faced. 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. Proneb. AROc. Supined. LAO

4. Additional views of the fundus in an erect position5. Spot films of the oesophagusModification 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 daysafter the examination and may be difficult to flush away

2. The patient should be advised to drink adequate volumes of water to avoid barium impactionComplications

1. Leakage of barium from an unsuspected perforation2. Conversion of a partial large bowel obstruction into a complete obstruction by the impaction of

barium

3. Barium appendicitis if barium impacts on the appendix4. Sides effects of the pharmacological agents used.

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Dysphagia Marking Scheme