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IMAGING OF THE ABDOMEN & THE GIT YEAR 4, MBBS Dr Azlin bt Sa’at @ Yusof Kulliyah of Medicine IIUM.
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CONTENTS  Imaging modalities: Plain XR Contrast studies Ultrasound Computed Tomography Magnetic Resonance Imaging Angiogram and interventional Others: ERCP,  PTC, intra-op & T-tube cholangiogram,  Radionuclide imaging – IDA, Meckel’s and GIT bleed.  Quiz and summary.
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PLAIN ABD XRAY
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Radiographic anatomy know where solid organs lie: intraperitoneal retroperitoneal – kidneys, adrenals, pancreas, psoas, IVC, Ao, lymph node. pro-peritoneal fat GIT 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)
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* 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. PLAIN ABD XRAY (2)
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(3) Various conditions * 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’ PLAIN ABD XRAY (3)
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PLAIN ABD XRAY (4) * 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.
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SUPINE ERECT Small bowel obstruction PLAIN ABD XRAY
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Large bowel obstruction Small + large bowel Toxic dilatation due to ulcerative colitis PLAIN ABD XRAY
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VOLVULUS
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Various conditions * Extra-luminal gas: Free intraperitoneal gas: causes – post-laparotomy (up to 7 days) perforated peptic ulcer IBD / infarction ERECT FILM! – air under diaphragm or lateral decubitus supine – gas outlining the falciform lig. gas on both sides of the bowel (Rigler’s sign) PLAIN ABD XRAY (5)
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PLAIN CXR Air under hemidiaphragm
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Free intraperitoneal air PLAIN ABD XRAY
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* Extra-luminal gas (cont.) - Intramural gas pattern: spherical – pneumatosis coli linear – infarction neonatal period – NEC PLAIN ABD XRAY (6) NEC PNEUMATOSIS COLI
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* Extra-luminal gas (cont.) - Gas elsewhere: * biliary system – following sphincterotomy / fistula (stone) / duodenal ulceration. * GB * kidneys *abscess *subphrenic PLAIN ABD XRAY (7) Kidneys Biliary tree Galbladder
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Subphrenic ???? PLAIN ABD XRAY
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*Ascites *Calcifications - phleboliths - vascular solid organs: liver, spleen, pancreas, adrenals, kidneys. tumours: fibroids, ovarian masses. soft tissue faecoliths. PLAIN ABD XRAY (8)
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Pancreatic Gallstones Appendicolith Uterine fibroid
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* Abdominal / pelvic masses PLAIN ABD XRAY
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CONTRAST STUDIES (1) General * Contrast material: - BARIUM vs GASTROGRAFFIN vs LOCM * Single contrast vs Double contrast Good opacification and coating BUT peritoneal leak  peritonitis Safe if ?peritoneal leak BUT hypertonic, lung irritant if aspirated and less opaque Safe if aspirated or leak BUT expensive and poor opacification and coating Oesophagus, small bowel and TRO Hirschprungs and obstruction only. (no need bowel prep) Ideal for stomach, and colon. Excellent mucosal detail.
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Basic terms: wall of the bowel -> not seen. mucosal folds: contracted -> folded distended -> valv conniventes / haustra abnormal -> ? smoothing / ? Irregular filling defect: Intra-luminal Intra-mural Extra-luminal CONTRAST STUDIES (1)
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Tapering ends vs. overhanging edges (shouldering) - Ulceration: - Stricture: persistent narrowing In profile En face CONTRAST STUDIES (2)
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Description: site of the abnormality what is its shape? how long? is there a soft tissue mass? CONTRAST STUDIES (3)
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(2) Barium swallow Barium swallow vs OGDS Method: - CONTROL FILM !!!! swallow while flouro, oblique position, films taken in full, collapsed +/- air-filled state. Normal: full  smooth outline collapsed  3-4 long straight parallel lines indentation  left: aorta and left bronchus  anterior: (L) atrium and ventricle peristalsis  smooth  elderly: pronounced and prolonged (3o contractions) CONTRAST STUDIES (4)
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Full Collapsed 3o contractions CONTRAST STUDIES (5) – Barium Swallow
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* Pathology: - Carcinoma (a) (b) CONTRAST STUDIES (6) – Barium Swallow
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Benign peptic stricture Achalasia Candidiasis CONTRAST STUDIES (7) – Barium Swallow
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Oesophageal web CONTRAST STUDIES (8) – Barium Swallow Leiomyoma Varices Ca bronchus
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(3) Barium meal * Method: - swallow barium then gas-producing agent, iv smooth muscle relaxant. various positions. Normal: - lesser curvature -> smooth, - greater curvature -> irregular, rugae duodenal cap -> triangular. CONTRAST STUDIES (9) – Barium Meal
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OGDS vs barium meal Pathology: - Hiatus hernia (b) Rolling CONTRAST STUDIES (10) – Barium Meal (a) Sliding
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- Linnitus plastica: adenoca, lymphoma, breast mets, battery acid ingestion, TB, Crohn’s and eusinophilic gastroenteritis. CONTRAST STUDIES (11) – Barium Meal
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Ulcers Benign Malignant Duodenal ulcer CONTRAST STUDIES (12) – Barium Meal
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Erosive gastritis CONTRAST STUDIES (13) – Barium Meal Polyps
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Carcinoma CONTRAST STUDIES (14) – Barium Meal
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Normal barium follow-through and SBE: continuous column < 2.5cm diam. transverse folds appear as filling defect 2-3mm width. If filled  transverse lines If collapsed  feathery folds are most in the jejunum, least in the ileum. CONTRAST STUDIES (15) – Barium follow-thru’ & Small bowel enema (4) Barium follow through and small bowel enema * Differences in method: - Barium follow through vs. SBE / enteroclysis - time-consuming procedure (2-3 hrs) require nasoduodenal intubation shorter time - excellent mucosal detail - view terminal ileum!
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Normal barium follow through SBE / Enteroclysis CONTRAST STUDIES (16) – Barium follow-thru’ & Small bowel enema
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Malabsorption SMALL BOWEL LYMPHOMA CONTRAST STUDIES (17) – Barium follow-thru’ & Small bowel enema
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Malrotation Crohn’s CONTRAST STUDIES (18) – Barium follow-thru’
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Lymphoma Worm infestation CONTRAST STUDIES (19) – Barium follow-thru’
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Barium enema barium enema vs. colonoscopy (vs. CT colonoscopy) Method: - Bowel prep! Control film! Double contrast: Rectal tube, infuse barium, drain, pump air. Normal: - Length variable +/- redundant loops. calibre decreases from caecum to sigmoid colon. ileocaecal valve may cause filling defect. haustra may be absent in descending and sigmoid regions. CONTRAST STUDIES (20) - Barium Enema
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Normal barium enema CONTRAST STUDIES (21) - Barium Enema
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Diverticulosis CONTRAST STUDIES (22) - Barium Enema
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Polyposis coli CONTRAST STUDIES (23) - Barium Enema
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Carcinoma ‘Apple core’ appearance CONTRAST STUDIES (24) - Barium Enema
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TUBERCULOSIS INVOLVING BOWEL
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Strictures: # ca, diverticular ds, Crohn’s, ischaemic colitis, TB, lymphogranuloma venereum, amoebiasis, radiation. ‘THUMBPRINTING’ (amoebiasis) Diverticular disease CONTRAST STUDIES (25) - Barium Enema
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Crohn’s dz: # most freq inv lower ileum and colon # early: - loss of haustration, narrowing and shallow ulceration. # ulcer + mucosal oedema  ‘cobblestone’ # later: deeper ulcer  ‘rose-thorn’ or fissures. # cx: - intra or extra-mural abscesses. fistulae. strictures: smooth and tapered ends. when caecum inv  markedly contracted. CONTRAST STUDIES (26)
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Ulcerative colitis: - similar to Crohn’s dz BUT (see below) CONTRAST STUDIES (27)
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CROHN’S DS (aphtous) Deep ulcer with tracking in the submucosa Shallow ulcers Skip lesions CONTRAST STUDIES (28)
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ULCERATIVE COLITIS Loss of haustra CROHN’S Recto-vaginal fistula CONTRAST STUDIES (29)
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Hirschsprung’s ds Intussusception CONTRAST STUDIES (30)
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ULTRASOUND General considerations preparation normal anatomy: solid organs + biliary tree + vessels + lymph nodes. echogenicity: pancreas, liver, spleen, kidney. hyper hypo appearances of various tissues: fat = hyper; fluid = hypo with posterior acoustic enhancement; calculi/ bone = hyper with post ac shadowing; gas = shadowing.
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NORMAL: Liver Pancreas Spleen Kidney
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Gallbladder Aorta & IVC Lymph nodes NORMAL:
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Oesophagus Stomach Small bowel Gas in bowel NORMAL:
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Cirrhosis PATHOLOGY: Abscesses Metastases Lymphoma
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Cyst PATHOLOGY: Ascites PV thrombosis Cholecystitis with calculi
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COMPUTED TOMOGRAPHY & MAGNETIC RESONANCE IMAGING (1) General considerations Differences between CT and MRI. Windowing in CT, and sequences in MRI. Various densities in CT and intensities in MRI. CT MRI T2W T1W
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COMPUTED TOMOGRAPHY & MAGNETIC RESONANCE IMAGING (2) Pathology Hepatic cysts CT MRI T1W T2W
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NECT Contrasted CT T2W MRI COMPUTED TOMOGRAPHY & MAGNETIC RESONANCE IMAGING (3) Haemangioma Pancreatic Ca 6 months later Post-op 3 months later
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ANGIOGRAPHY & INTERVENTIONAL RADIOLOGY (1) Types: Flush aortogram Inferior vena cavogram / SVCgram Selective: (according to vessels) hepatic artery, renal, spleen, pancreas, coeliac axis, SMA, IMA, uterine artery. may include intervention:  chemoembolization, coil/glue embolization, stenting. Indications: tumour / haemangioma, bleeding, pre-op … etc
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ANGIOGRAPHY & INTERVENTIONAL RADIOLOGY (2) Late phase MULTIFOCAL HEPATOMA ANGIOMA Post-embolisation Arterial phase
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OTHER IMAGING METHODS (1) (1) Endoscopic retrograde cholangio-pancreatogram Stone Stone (2) Percutaneous transhepatic cholangiogram
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OTHER IMAGING METHODS (2) (3) T-tube cholangiogram (4) Radionuclide imaging (I) GIT bleed (II) IDA scan
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MECKEL’S DIVERTICULUM
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THE END !