Imaging of the abdomen & the gastrointestinal

IMAGING OF THEIMAGING OF THE
ABDOMEN & THE GITABDOMEN & THE GIT
YEAR 4, MBBSYEAR 4, MBBS
Dr Azlin bt Sa’at @ YusofDr Azlin bt Sa’at @ Yusof
Kulliyah of MedicineKulliyah of Medicine
IIUM.IIUM.

CONTENTSCONTENTS
 Imaging modalities:Imaging modalities:
 Plain XRPlain XR
 Contrast studiesContrast studies
 UltrasoundUltrasound
 Computed TomographyComputed Tomography
 Magnetic Resonance ImagingMagnetic Resonance Imaging
 Angiogram and interventionalAngiogram and interventional
 Others: ERCP,Others: ERCP,
 PTC, intra-op & T-tube cholangiogram,PTC, intra-op & T-tube cholangiogram,
 Radionuclide imaging – IDA, Meckel’sRadionuclide imaging – IDA, Meckel’s
and GIT bleed.and GIT bleed.
 Quiz and summaryQuiz and summary..

(1) Radiographic anatomy(1) Radiographic anatomy
- know where solid organs lie:
* intraperitoneal
* retroperitoneal – kidneys, adrenals, pancreas, psoas, IVC,
Ao, lymph node.
* pro-peritoneal fat
* GIT
(2) Interpretation(2) Interpretation
- quality
- views: supine, erect, decubitus (usu lt side down)
- bowel gas pattern:
* normal gas : stomach and colon
* normal air-fluid level : stomach and proximal
duodenum
* stomach – rugae; jejunum – feathery;
small bowel – valvulae conniventes;
colon – haustrations.
PLAIN ABD XRAY (1)PLAIN ABD XRAY (1)

* Dilated? - jejunum > 3.5 cm
- mid small bowel > 3 cm
- ileum > 2.5 cm
- tranverse colon > 5.5 cm
- caecum > 8 cm
- Psoas outline: symmetrical and slightly concave lateral
borders.
- Renal outline : 10-12cm / 3.5 vertebral height.
- Bladder outline.
- Liver and splenic outline.
- Intraperitoneal fluid / collections.
- Calculi / calcifications : GB, kidneys, pancreas, lymph
nodes, vacsular, phleboliths,
tumoral.
- Soft tissue masses.
- Extra-luminal gasses.

(3) Various conditions(3) Various conditions
* Bowel obstruction:* Bowel obstruction:
 Mechanical obstruction of the small bowel:
- small bowel dilatation with normal / reduced calibre of
colon.
 Large bowel obstruction:
- dilatation of large bowel +/- small bowel dilatation.
 Paralytic ileus:
- large + small bowel dilatation +/- gas in sigmoid to rectum.
 Local peritonitis:
- dilatation of loops adjacent to inflammatory process 
‘sentinel loops’

* Bowel obstruction (cont.):* Bowel obstruction (cont.):
 Gasteroenteritis:
- normal / excess fluid levels / ~ paralytic ileus / ~small
bowel obstruction.
 Small bowel infarction:
- obs of small or large bowel
 Closed loop obstruction:
- caecal/sigmoid volvulus – filled with air + char shape.
obstructed hernias – fluid-filled, usu not visible.
 Toxic dilatation of the colon:
- maximal dilatation usu at transverse colon,
lost/abnormal haustra +/- polypoid shadows.

SUPINE ERECT
Small bowel obstructionSmall bowel obstruction
PLAIN ABD XRAYPLAIN ABD XRAY

Large bowelLarge bowel
obstructionobstruction
Small + large bowelSmall + large bowel
Toxic dilatation dueToxic dilatation due
to ulcerative colitisto ulcerative colitis

(3) Various conditions(3) Various conditions
* Extra-luminal gas:* Extra-luminal gas:
- Free intraperitoneal gas:- Free intraperitoneal gas:
* causes – post-laparotomy (up to 7 days)* causes – post-laparotomy (up to 7 days)
- perforated peptic ulcer- perforated peptic ulcer
- IBD / infarction- IBD / infarction
** ERECT FILM!ERECT FILM! – air under diaphragm or lateral decubitus– air under diaphragm or lateral decubitus
* supine – gas outlining the falciform lig.* supine – gas outlining the falciform lig.
- gas on both sides of the bowel (Rigler’s sign)- gas on both sides of the bowel (Rigler’s sign)

PLAIN CXRPLAIN CXR
Air under hemidiaphragm

Free intraperitoneal air

* Extra-luminal gas (cont.)* Extra-luminal gas (cont.)
- Intramural gas pattern:- Intramural gas pattern:
* spherical – pneumatosis coli* spherical – pneumatosis coli
* linear – infarction* linear – infarction
* neonatal period – NEC* neonatal period – NEC
NEC PNEUMATOSIS COLI

* Extra-luminal gas (cont.)* Extra-luminal gas (cont.)
- Gas elsewhere:- Gas elsewhere:
* biliary system – following sphincterotomy / fistula (stone) /* biliary system – following sphincterotomy / fistula (stone) /
duodenal ulceration.duodenal ulceration.
* GB * kidneys* GB * kidneys *abscess*abscess *subphrenic*subphrenic
KidneysBiliary tree
Galbladder

Subphrenic
????

*Ascites*Ascites *Calcifications*Calcifications
- phleboliths - vascular
- solid organs: liver, spleen,
pancreas, adrenals, kidneys.
- tumours: fibroids, ovarian masses.
- soft tissue
- faecoliths.

Pancreatic
Gallstones
Appendicolith
Uterine fibroid

* Abdominal / pelvic masses* Abdominal / pelvic masses

CONTRAST STUDIESCONTRAST STUDIES
(1) General(1) General
* Contrast material:* Contrast material:
- BARIUM vs GASTROGRAFFIN vs LOCM- BARIUM vs GASTROGRAFFIN vs LOCM
* Single contrast vs Double contrast* Single contrast vs Double contrast
Good opacificationGood opacification
and coating BUTand coating BUT
peritoneal leakperitoneal leak 
peritonitisperitonitis
Safe if ?peritonealSafe if ?peritoneal
leak BUT hypertonic,leak BUT hypertonic,
lung irritant iflung irritant if
aspirated and lessaspirated and less
opaqueopaque
Safe if aspirated orSafe if aspirated or
leak BUT expensiveleak BUT expensive
and poorand poor
opacification andopacification and
coatingcoating
Oesophagus, small bowelOesophagus, small bowel
and TRO Hirschprungs andand TRO Hirschprungs and
obstruction only. (no needobstruction only. (no need
bowel prep)bowel prep)
Ideal for stomach, andIdeal for stomach, and
colon. Excellent mucosalcolon. Excellent mucosal
detail.detail.

* Basic terms:* Basic terms:
- wall of the bowel -> not seen.- wall of the bowel -> not seen.
- mucosal folds: contracted -> folded- mucosal folds: contracted -> folded
distended -> valv conniventes / haustradistended -> valv conniventes / haustra
abnormal -> ? smoothing / ? Irregularabnormal -> ? smoothing / ? Irregular
- filling defect:- filling defect:
Intra-luminal Intra-mural Extra-luminal
CONTRAST STUDIES (1)CONTRAST STUDIES (1)

Tapering ends vs. overhangingTapering ends vs. overhanging
edges (shouldering)edges (shouldering)
- Ulceration:- Ulceration:
- Stricture: persistent narrowing- Stricture: persistent narrowing
In profileIn profile En faceEn face

Description:Description:
- site of the abnormality- site of the abnormality
- what is its shape?- what is its shape?
- how long?- how long?
- is there a soft tissue mass?- is there a soft tissue mass?

(2) Barium swallow(2) Barium swallow
* Barium swallow vs OGDS* Barium swallow vs OGDS
* Method:* Method: - CONTROL FILM !!!!- CONTROL FILM !!!!
- swallow while flouro,- swallow while flouro,
- oblique position,- oblique position,
- films taken in full, collapsed +/- air-filled state.- films taken in full, collapsed +/- air-filled state.
* Normal:* Normal: fullfull  smooth outlinesmooth outline
collapsedcollapsed  3-4 long straight parallel lines3-4 long straight parallel lines
indentationindentation  left: aorta and left bronchusleft: aorta and left bronchus
 anterior: (L) atrium and ventricleanterior: (L) atrium and ventricle
peristalsisperistalsis  smoothsmooth
 elderly: pronounced andelderly: pronounced and
prolonged (3o contractions)prolonged (3o contractions)

Full Collapsed 3o
contractions
CONTRAST STUDIES (5) – Barium SwallowCONTRAST STUDIES (5) – Barium Swallow

** Pathology:Pathology: - Carcinoma- Carcinoma
(a) (b)

Benign peptic strictureBenign peptic stricture AchalasiaAchalasia
CandidiasisCandidiasis

Oesophageal webOesophageal web
LeiomyomaLeiomyoma
VaricesVarices
Ca bronchusCa bronchus

(3) Barium meal(3) Barium meal
* Method:* Method: - swallow barium then gas-producing- swallow barium then gas-producing agent,agent,
- iv smooth muscle relaxant.- iv smooth muscle relaxant.
- various positions.- various positions.
* Normal: -* Normal: - lesser curvature -> smooth,lesser curvature -> smooth,
- greater curvature -> irregular,- greater curvature -> irregular,
- rugae- rugae
- duodenal cap -> triangular.- duodenal cap -> triangular.
CONTRAST STUDIES (9) – Barium MealCONTRAST STUDIES (9) – Barium Meal

* OGDS vs barium meal* OGDS vs barium meal
** Pathology:Pathology: - Hiatus hernia- Hiatus hernia
(b) Rolling
(a) Sliding

- Linnitus plastica:- Linnitus plastica:
adenoca, lymphoma, breast mets, battery acid ingestion, TB, Crohn’s andadenoca, lymphoma, breast mets, battery acid ingestion, TB, Crohn’s and
eusinophilic gastroenteritis.eusinophilic gastroenteritis.

UlcersUlcers
Benign
Malignant
Duodenal ulcer

Erosive gastritisErosive gastritis
PolypsPolyps

CarcinomaCarcinoma

(4) Barium follow through and small bowel enema(4) Barium follow through and small bowel enema
* Differences in method:* Differences in method:
- Barium follow through vs. SBE / enteroclysis- Barium follow through vs. SBE / enteroclysis
- view terminal ileum!- view terminal ileum!
* Normal barium follow-through and SBE:* Normal barium follow-through and SBE:
- continuous column < 2.5cm diam.- continuous column < 2.5cm diam.
- transverse folds appear as filling defect 2-3mm width.- transverse folds appear as filling defect 2-3mm width.
If filledIf filled  transverse linestransverse lines
If collapsedIf collapsed  featheryfeathery
- folds are most in the jejunum, least in the ileum.- folds are most in the jejunum, least in the ileum.
– Barium follow-thru’ & Small bowel enema– Barium follow-thru’ & Small bowel enema
- time-consuming- time-consuming
procedure (2-3 hrs)procedure (2-3 hrs)
- require nasoduodenal intubationrequire nasoduodenal intubation
- shorter timeshorter time
- excellent mucosal detailexcellent mucosal detail

Normal barium follow through
SBE / Enteroclysis

MalabsorptionMalabsorption
SMALL BOWEL
LYMPHOMA

MalrotationMalrotation
Crohn’sCrohn’s
– Barium follow-thru’– Barium follow-thru’

LymphomaLymphoma Worm infestationWorm infestation
– Barium follow-thru’– Barium follow-thru’

(5) Barium enema(5) Barium enema
* barium enema vs. colonoscopy (vs. CT colonoscopy)* barium enema vs. colonoscopy (vs. CT colonoscopy)
** Method:Method: - Bowel prep!- Bowel prep!
- Control film!- Control film!
- Double contrast: Rectal tube, infuse barium,- Double contrast: Rectal tube, infuse barium,
drain, pump air.drain, pump air.
* Normal:* Normal: - Length variable +/- redundant loops.- Length variable +/- redundant loops.
- calibre decreases from caecum to sigmoid colon.- calibre decreases from caecum to sigmoid colon.
- ileocaecal valve may cause filling defect.- ileocaecal valve may cause filling defect.
- haustra may be absent in descending and- haustra may be absent in descending and
sigmoid regions.sigmoid regions.
CONTRAST STUDIES (20) - Barium EnemaCONTRAST STUDIES (20) - Barium Enema

Normal barium enema

Diverticulosis

Polyposis coliPolyposis coli

CarcinomaCarcinoma
‘Apple core’
appearance

Strictures:Strictures: # ca, diverticular ds, Crohn’s, ischaemic colitis, TB,# ca, diverticular ds, Crohn’s, ischaemic colitis, TB,
lymphogranuloma venereum, amoebiasis, radiation.lymphogranuloma venereum, amoebiasis, radiation.
‘THUMBPRINTING’
(amoebiasis)
Diverticular disease

Crohn’s dz:Crohn’s dz:
# most freq inv lower ileum and colon# most freq inv lower ileum and colon
# early: - loss of haustration, narrowing and shallow# early: - loss of haustration, narrowing and shallow
ulceration.ulceration.
# ulcer + mucosal oedema# ulcer + mucosal oedema  ‘cobblestone’‘cobblestone’
# later: deeper ulcer# later: deeper ulcer  ‘rose-thorn’ or fissures.‘rose-thorn’ or fissures.
# cx: - intra or extra-mural abscesses.# cx: - intra or extra-mural abscesses.
- fistulae.- fistulae.
- strictures: smooth and tapered ends.- strictures: smooth and tapered ends.
- when caecum inv- when caecum inv  markedly contracted.markedly contracted.

Ulcerative colitis:Ulcerative colitis:
- similar to Crohn’s dz BUT (see below)- similar to Crohn’s dz BUT (see below)

CROHN’S DSCROHN’S DS
Shallow ulcers
(aphtous)
Deep ulcer with tracking in
the submucosa
Skip lesions

ULCERATIVE COLITIS
CROHN’S
Recto-vaginal fistula

Intussusception
Hirschsprung’s ds

ULTRASOUNDULTRASOUND
(1) General considerations(1) General considerations
- preparation- preparation
- normal anatomy: solid organs + biliary tree + vessels +- normal anatomy: solid organs + biliary tree + vessels +
lymph nodes.lymph nodes.
- echogenicity: pancreas, liver, spleen, kidney.- echogenicity: pancreas, liver, spleen, kidney.
hyper hypohyper hypo
- appearances of various tissues:- appearances of various tissues:
fat = hyper;fat = hyper;
fluid = hypo with posterior acoustic enhancement;fluid = hypo with posterior acoustic enhancement;
calculi/ bone = hyper with post ac shadowing;calculi/ bone = hyper with post ac shadowing;
gas = shadowing.gas = shadowing.

NORMAL:NORMAL:
Liver
Pancreas
Spleen
Kidney

Gallbladder
Aorta
&
IVC
Lymph nodes
NORMAL:NORMAL:

Oesophagus
Stomach
Small bowel
Gas in bowel
NORMAL:NORMAL:

Cirrhosis
PATHOLOGY:PATHOLOGY:
Abscesses
Metastases
Lymphoma

Cyst
PATHOLOGY:PATHOLOGY:
Ascites
PV thrombosis
Cholecystitis
with calculi

COMPUTED TOMOGRAPHY &COMPUTED TOMOGRAPHY &
MAGNETIC RESONANCE IMAGING (1)MAGNETIC RESONANCE IMAGING (1)
(1) General considerations(1) General considerations
** Differences between CT and MRI.Differences between CT and MRI.
* Windowing in CT, and sequences in MRI.* Windowing in CT, and sequences in MRI.
* Various densities in CT and intensities in MRI.* Various densities in CT and intensities in MRI.
CTCT MRIMRI
T2WT2W T1WT1W

PathologyPathology
Hepatic cystsHepatic cysts
CTCT
MRIMRI
T1WT1W
T2WT2W

HaemangiomaHaemangioma
NECTNECT Contrasted CTContrasted CT T2W MRIT2W MRI
Pancreatic CaPancreatic Ca
6 months later6 months laterPost-opPost-op 3 months later3 months later

ANGIOGRAPHY &ANGIOGRAPHY &
INTERVENTIONAL RADIOLOGY (1)INTERVENTIONAL RADIOLOGY (1)
(1)(1) Types:Types:
- Flush aortogram- Flush aortogram
- Inferior vena cavogram / SVCgram- Inferior vena cavogram / SVCgram
- Selective: (according to vessels) hepatic artery, renal, spleen,- Selective: (according to vessels) hepatic artery, renal, spleen,
pancreas, coeliac axis, SMA, IMA, uterine artery.pancreas, coeliac axis, SMA, IMA, uterine artery.
- may include intervention:- may include intervention:
 chemoembolization, coil/glue embolization,chemoembolization, coil/glue embolization,
stenting.stenting.
(2)(2) Indications:Indications:
- tumour / haemangioma, bleeding- tumour / haemangioma, bleeding,, pre-op … etcpre-op … etc

ANGIOGRAPHY &ANGIOGRAPHY &
INTERVENTIONAL RADIOLOGY (2)INTERVENTIONAL RADIOLOGY (2)
Late phaseLate phase
MULTIFOCAL HEPATOMAMULTIFOCAL HEPATOMA
ANGIOMAANGIOMA
Post-embolisationPost-embolisationArterial phaseArterial phase

OTHER IMAGING METHODS (1)OTHER IMAGING METHODS (1)
(1) Endoscopic retrograde cholangio-pancreatogram(1) Endoscopic retrograde cholangio-pancreatogram
(2) Percutaneous transhepatic cholangiogram(2) Percutaneous transhepatic cholangiogram
StoneStone
StoneStone

OTHER IMAGING METHODS (2)OTHER IMAGING METHODS (2)
(3) T-tube cholangiogram(3) T-tube cholangiogram (4) Radionuclide imaging(4) Radionuclide imaging
(I) GIT bleed(I) GIT bleed
(II) IDA scan(II) IDA scan

Imaging of the abdomen & the gastrointestinal

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