RADIO

250: ICC in Radiology and Nuclear Medicine

LEC 08: GASTROINTESTINAL RADIOLOGY
Exam 01| Ppt of Dr Edilberto Fragante, Discussed by Dr. Benedicto| October 24, 2013

OUTLINE
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.

Introduction
Plain Abdominal X-ray: Gas Pattern
Plain Films: Extraluminal air
Plain Films: Calcifications and Foreign Bodies
Plain Films: Soft Tissue Masses/ Densities/ Fluid Accumulations
Contrast Studies
Cholangiogram, T-tube, PTC, ERCP
CT Scan
Nodal Staging

I. BACKGROUND
A. X-ray
X-ray densities
o BLACK radiolucent (AIR)
o GRAY between air and soft tissue (e.g. FAT, psoas shadow)
o WHITE radioopaque (BONE and metals, foreign bodies

Table 1. KUB vs. Plain abdominal film
KUB
Abdominal Film
Pelvis seen completely
Diaphragm seen completely
Bowel preparation needed
No bowel preparation
Position: supine
Position: supine and upright

II. PLAIN ABDOMINAL X-RAY: GAS PATTERN
What to look for in abdominal X-ray
o Gas pattern
o Extraluminal air
o Soft tissue masses/densities/fluid collection
o Calcifications
o Foreign bodies

A. Normal Gas pattern























Figure 1.Normal Bowel Gas Pattern. Supine radiograph shows the
normal distribution of gas in the stomach (large arrow) and
duodenum (small arrow). The normal mottled pattern of stool is
seen in the distribution of the right colon (arrowhead). A few gas
collections within the small bowel (curved arrow) are seen in the
pelvis.

Table 2. Large Bowel vs. Small Bowel on Plain Abdominal X-ray
Small bowel
Large Bowel
Centrally located
Peripherally located
Valvulae conniventes (aka
Haustral markings do not
circlar valves, valves of
extend from wall to wall; they
kerckring, plicae circularis)
are markings on each of the
extend across lumen
outer third of the colons
lumen

Sean, Pat

Figure 2. large bowel haustra (left) and small bowel valvulae (right)

Table2. Bowel gas Pattern

Stomach
Small Bowel
Large bowel
Bowel gas
Always
2-3 loops of non-
Almost always
pattern
with gas
distended bowel
with gas in
(swallowed

rectum and
air vs.
Normal diameter is
sigmoid
bacterial)
<2.5-3 cm

(diameter of 1 coin)




















Figure 3. Comparison of Bowel Gas Pattern

B. Air-fluid level (AFL)

Table 3. Air fluid level

stomach
Small bowel
Large bowel
Air fluid
Always (except in
2-3 levels
None usually
level
supine film)
possible

















Figure 4. Comparison of Air Fluid Levels

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Table 4. Differential vs. Non-differential AFL
Differential
Non-differential
Air and fluid are not aligned
Air and fluid are aligned
Usually seen in bowel
Usually seen in ileus or
obstruction
paralytic ileus














Figure 5. Differential (L) and Non-differential (R) Air Fluid Levels

C. Normal Gas pattern
Supine
o Look for type of gas pattern (whether non-obstructive vs.
obstructive) o Used in scout films (Upper GI series, barium
enema) for calcifications and soft tissue masses)
Upright
o Look for free air and air fluid levels
o Substitute: left lateral decubitus view for patients who cannot
stand upright
Chest upright
o Because some abdominal complaints are just referred from a
chest (lungs or heart) problem
o Look for
Free air (pneumoperitoneum)
Pneumonia at bases (because it mimics GI pain)
Pleural effusions
o Supine chest (used for bed-ridden patients)
Prone or lateral rectum (useful if suspecting obstruction)
o Gas in rectum/sigmoid
o Gas in ascending/descending colon
o Substitute: lateral rectum

Figure 6. Abdomen supine (Upper left), Abdomen upright (upper

right), Chest upright (lower left), Abdomen prone (lower right)

Sean, Pat

D. Abnormal gas pattern

Ileus occurs from hypomotility of the gastrointestinal tract in the
absence of mechanical obstruction
Localized Ileus
o One or two persistently visible dilated loops of large or small
bowel
o Happens when bowels react and dilate due to inflammation
(called Sentinel Loops)
o Could be due to different etiology depending on the location
o Cholecystitis (upper right quadrant), Diverticulitis (lower left
quadrant), Appendicitis (lower right quadrant)
Generalized Ileus
o Gas in dilated small bowel and large bowel to rectum o Long
air-fluid levels
o Common in the postoperative state (after abdominal surgery)
and should resolve within 2-3 days
o If ileus persists for more than 3 days following surgery, it is now
called adynamic or paralytic ileus



































Figure 7. Localized ileus (top; circle: dilated bowel loop), post-op
adynamic ileus (bottom; circle: non-differential air fluid level)

Mechanical Obstruction
Causes
o Tumor, volvulus, hernia, diverticulitis, intusussception
Mechanical Small Bowel Obstruction
o After 3-5 hours, gas/fluid accumulates
o Dilated small bowel with differential air-fluid level and absent
or minimal gas in the large bowel
o Early SBO may resemble localized ileus, thus, follow up is
needed
o In early SBO, some gas may be seen in the large bowel
o Frequency of sound above the range of hearing (>20 Hz to 20
KHz)
o Medical ultrasound uses values within the range of 1 to 20 MHz

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Figure 8. Dilated small bowel due to SBO; valvulae conniventes
could be appreciated (circle

Figure 9. Presence of gas in the large bowel in early/incomplete
SBOComplete/prolonged obstruction leads to absence of gas in the
large bowel

o Proximal jejunal obstruction leads to complete filling of fluid
(seen in upright film as step-ladder configuration)


















Figure 10. String of beads (circle) and complete filling of
fluid/differential air fluid level (arrow)

Mechanical Large Bowel Obstruction
o Dilated colon to point of obstruction o Little or no air in
rectum/sigmoid
o Little or no gas in small bowel if ileocecal valve remains
competent
o If incompetent ileocecal valve, LBO might look like SBO since
the large bowel decompresses into the small bowel (thus,
follow up or order barium enema)

Sean, Pat

Figure 11. Dilated large bowel loops due to obstruction/mass

Table 5. Summary Table (Remember me!)

Air in Rectum
Air in Small Bowel
Air in Large

or Sigmoid
Bowel
Localized
Yes
2-3 distended loops
Yes



Ileus
Generalized
Yes
Multiple distended
Yes


Ileus
loops
SBO
No
Multiple dilated loops
No
LBO
No
None, unless ileocecal
Yes


valve is incompetent

III. PLAIN FILMS: EXTRALUMINAL AIR
A. Free air
Signs
o Air beneath diaphragm
o Both sides of bowel walls
o Falciform ligament sign
o Riglers sign
Causes
o Rupture of a hollow viscus
o Perforated ulcer
o Perforated diverticulitis
o Perforated carcinoma
o Trauma or instrumentation
o Patients 5-7 days post-op (still normal)
Not usually seen in perforated appendix because the appendix is
in the retroperitoneum

1. Pneumoperitoneum
Air beneath diaphragm
Could also be appreciated on left lateral decubitus view: air
outlines liver

















Figure 12. Air beneath the diaphragm (left). Liver outlined at left
lateral decubitus position (right)

RIGLERS SIGN: air insideand outside bowel lumen outlines walls
(normally, only inside walls of bowels are seen)
FOOTBALL SIGN: falciform ligament sign; abdomen shaped like a
football; falciform ligament resembles the stitches at the middle
of the football

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Figure 13. Riglers sign. Note the outline of the outer wall of the
intestine

Figure 14.Football sign

IV. PLAIN FILMS: CALCIFICAITONS AND FOREIGN BODIES
Possible Areas of Calcifications:
o Chronic pancreatitis calcifications on mid-abdomen
o Splenic calci
o Hepatic TB stipled calcifications
o Calcified lymph nodes (many in ileocecal region)
o Tabesmesenterica calcifications in the mesentery o
Urolithiases
o Nephrocalcinosis in parenchyma; vs. Nephrolithisis which is in
the collecting system
o Uterine fibroma
o Mercury ingestion flecks of calcification
o Coin ingestion usually in ileocecal valve have to take 2 views
(AP lat or AP oblique); removal through bowel excretion

Figure 15. Chronic pancreatitis (L) and Splenic calcifications (R)

Figure 16. Hepatic tuberculosis (L) and Calcified lymph nodes (R)

Sean, Pat

Figure 18. Mercury ingestion (L) and Coin ingestion (R)

V.
PLAIN FILMS: SOFT TISSUE MASSES/ DENSITIES/ FLUID
COLLECTIONS
Soft Tissue Masses
o Hepatosplenomegaly (look for gastric bubble because an
enlarged spleen can displace the stomach)
o Plain films are poor for judging liver size
o Tumor or cyst
Signs of bowel displacement (paucity of gas and pad sign -
extrinsic compression of bowel)
Fluid collections (ddx for a soft tissue mass)
o Abscesses/hematomas
Ascites/loculated fluid collections (obscured liver edge and
sagging flanks)
o Ovarian new growth - intestines displaced laterally and
superiorly
o Retropharyngeal abscess - normally, 0.5-1 cm from trachea to
vertebra
o Psoas abscess - confirmed by psoas sign and UTZ; obscures
psoas line and bowels
o Periappendiceal abscess with appendicolith

Figure 18. Hepatosplenomegaly (L) and Ascites (R)

VI. CONTRAST STUDIES

A. Esophagus
Esophagogram 2 cups barium, fluoroscopy
Normal barium swallow
Barium flows in seconds so you have to do it quick
Upper GI series double contrast studies (Barium + sprite so you
have air/barium contrast)

Figure19. Esophagogram

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Figure 20. Normal Barium Swallow

1. Achalasia

Greek term that means does not relax o Hypertonic lower
esophageal sphincter o No peristalsis below level of thoracic inlet
o Causes halitosis
NO AUERBACHS PLEXUS OR MEISSNERS PLEXUS (same pathology
as Hirschsprungs disease
Birds beak because of constriction or narrowing below level
of thoracic inlet; you see a large esophagus which tapers at the
end which looks like a birds beak
ETIOLOGY: loss of ganglion cells of esophageal myenteric plexus
(which controls esophageal peristalsis)











Figure 21. Note the narrowing of the esophagus

2. Zenkers diverticulum
Pharyngoesophageal diverticulum
When there is excessive pressure within the lower pharynx (such
as in swallowing), the weakest portion of the pharyngeal wall
balloons out, forming a diverticulum which may reach several
centimeters in diameter
Pulsion type secondary to motility disorder, mechanical
obstruction and chronic wear-and-tear
Causes: obstruction, bleeding, perforation, infection, CA










Figure 22. Zenkers Diverticulum

3. Foreign Bodies
Barium swallow or barium-soaked cotton delineates level of
radio-opaque foreign body
Obstruction of the upper neck dilated upper segment of the
esophagus

4. Small Esophageal Ulcers (Candidiasis, Herpes, CMV)
Plaque-like vertically oriented lesions
Diffuse/long segment of filling defects o Ragged appearance
Poor peristalsis
Looks like ampalaya

Sean, Pat

Figure 23. Foreign body (L) and Small esophageal ulcers (R)

5. Caustic Esophageal Stricture (e.i liquid sosa)
Long segment involved
By 2-4 weeks, heals with fibrosis progressive luminal narrowing

6. Apple-Core Deformity
Pathognomonic of GI malignancy
Lumen narrows because of the obstruction brought about by the
mass
Mass common in lower 2/3 of the esophagus

7. Esophageal carcinoma
Asymptomatic until causes obstruction
Irregular/nodular
Eccentric narrowing o Shelf-like margins
Most common area of malignancy: LOWER SEGMENT OF
ESOPHAGUS

8. Hernia
Axial hiatal hernia
o Part of stomach and cardia pass through hiatus into thorax
Para-esophageal hernia
o Part of stomach herniates thru hiatus but cardia normal
position

9. Others
Esophageal web
o Web 1-2 mm diaphragm
o Common proximal esophagus; idiopathic > 50 years
o Plications of normal squamous mucosa
Schatzkis ring
Ring: short annular narrowing 4-10 mm thick
Mucosal fold at the gastroesophageal junction
Associated hiatus hernia common
























Figure 24. Caustic esophageal stricture (top) and Esophageal
carcinoma (bottom)

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VII. CHOLANGIOGRAM, T-TUBE, PTC, ERCP

A. Esophagus
Ectopic gallbladder
Gallstones (calcifications)
T-tube cholangiogram
o Left by surgeons (for around 1 month) in the patients so
theycan visualize retained stones later on
o Establishes patency/intact biliary tree
o Causes: obstruction, bleeding, perforation, infection
Choledocholithiasis
o Note the presence of lucencies with well-defined borders inside
the biliary tree

Figure 24. (L) Ectopic gallbladder (R) gall stones

Non-specific colitis
o Absence of feces
o Multiple soft loops
o Long segment involvement
o Increased wall thickness
o Wall irregularity saw-tooth appearance
Ileocecal TB
o Conical, retracted cecum
o Deformed ileocecal valve
o Gaping ileocecal valve
o Sterlins sign
Irregular terminal ileum (because ileum opens into a
contracted cecum)
Irritability and rapid emptying of terminal ileum
Stricture and fibrosis

Figure 28. (L) Non-specific colitis (R) Ileocecal |TB

Figure 25. (L) T-Tube cholangiogram. Note the long and large
pancreatic duct of Wirsung seen (R) choledocholithiasis

Ameboma
o Invasion of wall + bacterial infection
o Commonly cecum
o May resemble CA
Periappendiceal abscess

B. Biliary Tree

Figure 26. (L) Biliary Ascariasis (R) Periampullary CA apple core
appearance

C. Large Intestines
Barium enema Put foley catheter (in PGH), inflate, put barium
and pump air (for double contrast)
Divertculosis: outpouchings of mucosa and muscularis mucosae
at sites of blood vessel penetration
Diverticulitis
o RUPTURED diverticulosis
o Deformed sacs
o Presence of abscesses
o Extravasation of contrast

Figure 27. (L) Diverticulosis (R) Diverticulitis

Sean, Pat

Figure 29. (L) Ameboma (R) Periappendiceal abscess. Soft tissue

mass displacing the cecum superiorly.

Intussusception
o Children - common ileocolic 2 inflamed lymphoid tissue
o Adults - look for leading lesion or post-op
o Coil spring appearance
Hirschsprungs disease
o Absence of myenteric ganglia at the distal colon, commonly
rectosigmoid, resulting in reduced bowel peristalsis and
function
o Starts at anus and proceeds proximally
o Affects distal colon, commonly rectosigmoid look for
transitional zone

Figure 30. (L) intussusception (R) Hirschsprungs disease

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Inguinal Hernia
o Small intestine in the inguinal region
Rectal and Sigmoid Polyps
o Higher risk of CA
size > 1 cm
irregular/bizarre contour
sessile/fixation
rapid growth rate
o Polypoid, annular or infiltrating
o Filling defect
o Apple-core deformity

IX. NODAL STAGING

Abnormal LN > 1.0-1.5 cm
Not all enlarged nodes with tumor and normal-sized nodes may
have microscopic tumor
LN may be detected in the mesentery and retroperitoneum
Rectal tumors may metastasize to internal iliac nodes
CT scan has high specificity (96%) for detection of metastatic
lymph nodes, but sensitivity is low

END



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Figure 31.(L) Inguinal hernia (R) Rectal and sigmoid polyps

Familial Polyposis
o Multiple, small polyps (adenomatous)
o Sessile or pedunculated
o High incidence of CA (polyps are premalignant lesions)
Peutz Jeghers Syndrome
o aka Hereditary intestinal polyposis syndrome
o Mucocutaneous lesions
o Multiple (hamartomatous) polyps proliferative mucosa
o Lower incidence of CA (the polyps themselves are benign and
have very low malignant potential)
Colonic CA splenic flexure
NOTE: To differentiate between feces and polyps: Do maneuvers to
move the bowel. Polyps do not change positions while feces do.

VIII. CT SCAN
Planning of surgery and radiotherapy particularly with local
extension of disease
Demonstrate involvement of adjacent organs, such as the
bladder, vagina, and abdominal or pelvic musculature
Provide baseline findings for comparison with post-operative
follow-up
Detection of recurrent disease
Detection of distant metastases
Older patients/patients who are unable to undergo colonoscopy
modified CT is performed for primary detection of colorectal
tumors
Tumors as an incidental finding or diagnosis of colon cancer
suggested in patients undergoing CT for a variety of GI symptoms
Accuracy rates for pre-operative staging: 48-77% (relatively low)
Tumor: luminal narrowing and marked wall thickening
Low spatial and contrast resolution unable to determine exact
depth of tumor invasion in superficial tumors
CT detection of local tumor extension:
o Sensitivity 60%
o Specificity 67-81%
o Inability to detect microscopic extension
Local extension of tumor
o Extracolic mass
o Thickening and nodularity
o Invaded muscle enlarge
o Loss of fat planes between the colon & adjacent organs

Sean, Pat

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