Radiology (dra Bandong GI Radiology 19 July 08 From doc Bandong’s own words:  Ultrasound of the whole abdomen, there

is perforation, put in NPO for patients who have no history of cholecystectomy. Because we want the gallbladder to be distended in order to evaluate it.  The patient will not eat or have his breakfast, the gallbladder will be contracted because of the bile because you’re bile contains those that will breakdown the fat. Patient should be NPO atleast 4-6 hours.  Normal gallbladder: less than 5 cm in diameter o More than 5: hydrops  Normal wall of gallbladder: around 3 mm o Thickened wall with adjacent fluid in the GI wall: cholecystitis  Ultrasound: stones will appear as white  X-ray: stones will also appear as white  Common radiographic finding for cholecystolithiasis is: inter-luminal stones, wall would be thickened  Stones in common bile duct of gallbladder: choledocholithiasis (please check kung tama, di ko masyado maintindihan)  Stones in gallbladder: cholecystolithiasis  Stone in common bile duct: check intra-hepatic ducts, particularly in region of area of the pancreatic duct  Liver is mainly supplied by portal vein.  Mass in liver: check portal vein if there is possibility of metastasis or a visual ____(may dumaldal, dko narinig na haha) in CBD that would cause portal vein thrombosis  Portal vein size: 1.2  CBD size: 0.7 cm  In patients with previous cholecystectomy, size of CBD would be 1 cm.  In liver cirrhosis, the left lobe of the liver is enlarged, right lobe would be smaller and the margin of the conture of the liver would be nodular, epigenicity of the liver parenchyma is coarsened (jassie on tape: coarse? Coarse?) hahahaha .  Liver cirrhosis: Common feature: small liver with nodular and coarsened pattern with ascites  Importance for requesting for MRI: o In patients who has acute renal failure, we cannot give contrast materials because the minimum contrast material to be given on CT scan would be 16 ml, on MRI it’s I think 5-10 cc.  Structure: barum enema or UGI series, but rule out lower obstruction so barium enema first then UGI series  Most common reason why (peste! Peste! Kahit sa tape di sya maintindihan peste! Haha) emergency request for UTZ for cholecystitis: because GB may be distended more than 8-10 cm, surgical er may be needed. Also to rule out stones in kidney or GB. And to rule out if there is abdominal pain (WTF?!)  What are the common sonographic finding of acute cholecystitis: thickened wall, possibly a stone, and ____shadowing  Acute pancreatitis: echomogenous (echomogenous?! Wala na cranky na ko haha) enlarged pancreatitis or possibility of pseudo-cyst, does not have severe abdominal pain Chronic pancreatitis and pancreatic CA have both calcification on the pancreas. So rule out pancreatic CA first. But in some cases, there are different types of (tpos nawala na lang sya hahahaha) Normal GB wall: less than 3mm Status post cholecystectomy Liver CA: rule out if there is PV thrombosis, the normal size of the spleen is 11x5 cm. more than that: Ddx: lymphoma or leukemia Calcification in the liver and spleen: first impression would be kidney (sobrang di cguro eto yung snabi nya) if patient is Filipino

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**natapos din! Churi churi I tried my best, but I guess my best was not good enough. Haha. Natorture yung tenga ko dun a. happy aral! Panimula palang yan kala nyo haha! –isayANATOMY ESOPHAGUS  muscular tube between 6th vertebral body (cricopharyngeus) and 10th - 12th thoracic vertebra (just below the diaphragm).  It measures 25-30cms in adults.  Esophagus is divided into 3 parts: i) cervical (5cm) - lies behind the trachea , ii) thoracic (20cms) - extends from the thoracic inlet into the posterior mediatinum; and iii) abdominal (1-3cms) starts where esophagus passes through the diaphramatic hernia. 3 esophageal constrictions  Uppermost - caused by cricopharyngeal muscle  Middle - where esophagus is crossed by aortic arch at tracheal bifurcation  Lowermost - caused by gastroesophageal sphincter at the esophageal hiatus of the diaphragm STOMACH


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 Duodenum -- approximately 25 cm long; proximal   Ileum -- approximately 300 cm long; joins the cecum
at the ileocecal valve PLAIN FILM end of small intestine; joined to stomach by the pyloric sphincter. Jejunum -- approximately 200 cm long.

1. Body of stomach 2. Fundus 3. Anterior wall 4. Greater curvature 5. Lesser Curvature 6. Cardia 9. Pyloric sphincter 10. Pyloric antrum 11. Pyloric canal 12. Angular notch 13. Gastric canal 14. Rugal folds Small Intestine  The is a tube measuring about 2.5 cm in diameter.  The complete small intestine is approximately 600 cm (20 feet) long and coiled in loops, which fill most of the abdominal cavity.  It extends from the pyloric sphincter to the ileocecal valve

*Top: Gas in the stomach *Left: Free Gas in the small bowel *Right: gas in the rectum/sigmoid

*Right: Always air-fluid level in the stomach *Left: Few air-fluid levels in the small bowel

Radiology – GI Radiology by Dra Bandong LARGE VS SMALL BOWEL

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LARGE BOWEL o Peripheral o Haustral markings do not extend from wall to wall SMALL BOWEL o Central o Valvula extend across the lumen o Maximum diameter of 2”

Abnormal gas patterns  Functional ileus o Localized (sentinel loops) o Generalized adynamic ileus  Mechanical obstruction o Small bowel obstruction (SBO) o Large bowel obstruction (LBO) Air in Rectum or Sigmoid Localized Ileus Generalize d Ileus SBO Yes Air in Small Bowel 2-3 distended loops Multiple distended loops Multiple dilated loops None – unless ileocecal valve incompetent Air in Large Bowel Air in rectum or sigmoid Yesdistend ed No Yes dilated


Yes No



May resemble early mechanical SBO o Clinical course o Follow up

GENERALIZED ILEUS  Gas in dilated small and large bowel down to the rectum  Long air fluid levels  Only post-op patients have generalized ileus

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o Tumor o Volvulus o Hernia o Diverticulitis o Intussusception Incompetent ileocecal valve o Large bowel decompression into the small bowel o May look like SBO o Follow up study o Barium enema o Air goes to small bowel o Request for barium enema  To rule out obstruction  Barium hardens o If no LBO, do SGIS o Dilated segments

Small bowel obstruction

  

Adhesion, hernias, etc. > 5cm, distended CAUSES o Adhesions o Hernia o Volvulus o Gallstone ileus o Intussusceptions

Gallstone Ileus  Air in biliary tree  Stone in ileocecal valve

Generalized Adynamic Ileus  distended Mechanical LBO  CAUSES

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Sigmoid Volvulus  Distended sigmoid  Cause is generally considered a defect in the cholinergic receptors of Auerbach’s plexus (between the inner circular and the outer longitudinal muscle layers of the muscularis). Characteristically, primary peristaltic stripping waves are absent in either the upper (early) or the whole (late) esophagus. Tertiary waves may be present but in the late stages the esophagus is atonic. The lower esophageal sphincter fails to relax. In the late stages, the distal esophagus tends to make a right angle bend before entering the stomach due to the extreme tortuosity of the esophagus. This is called “bird’s beak” or “rat-tail” sign.


CONTRAST STUDIES 1. Lateral Projection - to rule out pathology in the esophagus 2. AP Projection - hypopharynx ACHALASIA LEFT POSTERIOR OBLIQUE VIEW OF THE GASTRIC ANTRUM

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Allows you to visualize the gastric antrum and the duodenal cap while being able to sweep in double contrast phase


This view is like the compression of the antrum in single contrast. The fundus is in double contrast and the duodenal sweep is sometimes seen to a better advantage C-LOOP/DUODENUM

This view will provide you a double contrast view of the anterior wall of the stomach and sometimes of the posterior portion of the fundus There is a lesion on the posterior wall (Arrow) PRONE VIEW OF THE ENTIRE STOMACH AND DUODENUM


the patient in LPO position will demonstrate the duodenal cap and the rest of the duodenum in double contrast.

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Two main types: 1. Sliding Hiatal Hernia (99%)  EG junction lies above the diaphragm, or  Distal most esophagus measures more than 50% of the diameter of the tubular esophagus=patulous cardia=predisposed to GE reflux, or  Prominent gastric folds extend into distal esophagus from stomach  May be reducible or incarcerated; sliding refers to EG junction, not to reducibility 2. Paraesophageal Hiatal Hernia  Portion of stomach herniates through esophageal hiatus above diaphragm but EG junction continues to be subdiaphragmatic  Usually non-reducible  Not associated with GE reflux GASTRIC GI STROMAL TUMOR

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Most commonly involves terminal ileum Bowel wall becomes markedly thickened and submucosa infiltrated (picket-fence) “Thumb-printing“ may be seen Loops are widely separated and there may be mass effect Another form may have a large ulceration which is confined and produces so called “aneurysmal dilatation” of the bowel ULCER



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• • • •

INDICATIONS FOIR DOUBLE CONTRAST (AIR CONTRAST) BARIUM ENEMA Rectal bleeding : gross or occult Polyps or carcinoma: suspected or known Inflammatory Bowel Disease: suspected or known Patient over 40y/o who can cooperate and turn over without assistance

CONTRAINDICATIONS TO BARIUM ENEMA OF ANY TYPE • Suspected acute perforation • Acute fulminating colitis • Immediately after biopsy Sigmoid Colon

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Most common parasitic infestation in the world Most common in children ages 1 to 10 years Most often found in distal small bowel

Life cycle • Infection is through contaminated soil • Involves GI tract of host twice • First time as egg • Migrates through lungs • Adult travels up trachea


to GI tract for maturation (2 months) Rectosigmoid Colon

X-ray findings • Long, tubular filling defects, especially in distal small bowel • The worm ingests barium and the barium may be seen as a thin line of contrast in the center of the worm • Especially after the remainder of the barium exits the small bowel. See below (streak of barium in LUQ): BARIUM ENEMA

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Splenic Flexure • •

INDIATIONS FOR WATER SOLUBLE CONTRAST ENEMA Suspected perforation or high-risk for intestinal perforation Therapeutic enema for disimpaction (after failure of routine cleansing enemas)

Hepatic Flexure


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5. 6.

7. 8. 9.

(usually requires >1,000 mL of free intraperitoneal gas + intraperitoneal fluid) "Telltale triangle sign" = triangular air pocket between 3 loops of bowel Depiction of diaphragmatic muscle slips = two or three 6-13 cm long and 8-10 mm wide arcuate softtissue bands directed vertically inferiorly + arching parallel to diaphragmatic dome superiorly outline of ligaments of anterior inferior abdominal wall: "Inverted V sign" = outline of both lateral umbilical ligaments (containing inferior epigastric vessels) Outline of medial umbilical ligaments (obliterated umbilical arteries) "Urachus sign" = outline of middle umbilical ligament

…sobrang di ko alam kung san isisngit ang mga ito kaya dito na lang sila…tapos mya ibang pics na di ko nailagay kasi walang labels sa slide…ayun…

RUQ gas 1. Single large area of hyperlucency over the liver 2. Oblique linear area of hyperlucency outlining the posteroinferior margin of liver 3. Doge's cap sign = triangular collection of gas in Morison pouch (posterior hepatorenal space) 4. Outline of falciform ligament = long vertical line to the right of midline extending from ligamentum teres notch to umbilicus; most common structure outlined 5. Lligamentum teres notch = inverted V-shaped area of hyperlucency along undersurface of liver 6. Ligamentum teres sign = air outlining fissure of ligamentum teres hepatis (= posterior free edge of falciform ligament) seen as vertically oriented sharply defined slitlike / oval area of hyperlucency between 10th and 12th rib within 2.5-4.0 cm of right vertebral border 2-7 mm wide and 6-20 mm long 7. "Saddlebag / mustache / cupola sign" = gas trapped below central tendon of diaphragm 8. Parahepatic air = gas bubble lateral to right edge of liver CARCINOMA OF THE ESOPHAGUS Histology • Squamous cell ca (95%) • Adenocarcinoma arising from heterotopic gastric mucosa or columnar-lined epithelium (Barrett’s) • Large, bulky, polypoid intraluminal mass which may be pedunculated - Mucoepidermoid carcinoma • Spread is facilitated by the esophagus’ lack of a serosa Location
Upper 1/3 Middle 1/3 Lower 1/3 20% 50% 30%

FREE INTRAPERITONEAL AIR (PNEUMOPERITONEUM) Etiology 1. Disruption of wall of hollow viscus • Blunt or penetrating trauma, • Iatrogenic perforation • Diseases of GI tract • Perforated gastric / duodenal ulcer, appendix, Diverticulitis, • Necrotizing enterocolitis with perforation, Inflammatory bowel disease 2. Through peritoneal surface • Transperitoneal manipulation, Abdominal needle biopsy / catheter placement Imaging findings 1. Large collection of gas 2. Abdominal distension, no gastric air-fluid level 3. "Football sign" = large pneumoperitoneum outlining entire abdominal cavity 4. "Double wall sign" = "Rigler sign" = air on both sides of bowel as intraluminal gas and free air outside

Radiologic types • Polypoid/fungating form (most common) o Sessile, polyp o Apple-core lesion • Ulcerating form o Large ulcer within mass • Infiltrating form o Gradual narrowing resembling benign stricture

Radiology – GI Radiology by Dra Bandong • Squamous cell carcinomas of the distal esophagus almost never invade the stomach whereas adenocarcinomas arising from a Barrett’s does • • •

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Metastases • To lymphatics-especially supraclavicular nodes • Hematogenous: lung, liver, adrenal ESOPHAGEAL VARICES

Scalloped esophageal luminal masses Right/ left-sided soft-tissue masses paraesophageal varices Marked enhancement following dynamic CT


Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygos system 1. Uphill varices • Collateral blood flow from portal vein via azygos vein into SVC (usually lower esophagus drains via left gastric vein into portal vein) • Most common cause is portal hypertension secondary to cirrhosis • Varices in lower half of esophagus to the level of the carina (azygous vein) • More common than downhill varices • Causes: o Intrahepatic obstruction from cirrhosis o Splenic vein thrombosis (usually gastric varices only) o Obstruction of hepatic veins o Portal vein thrombosis o IVC obstruction below hepatic veins o Marked splenomegaly / splenic hemangiomatosis (rare) 2. Downhill varices • Collateral blood flow from SVC via azygos vein into IVC / portal venous system (upper esophagus usually drains via azygos vein into SVC) • Varices in upper 1/3 of esophagus • Usually extend down to the level of the carina (azygous vein) • Less common than uphill varices • Causes: o Obstruction of superior vena cava distal to entry of azygos vein due to o Lung cancer (most common) o Lymphoma o Retrosternal goiter o Thymoma • • • • • • • PLAIN FILM Lobulated masses in posterior mediastinum (visible in a small percentage of patients with varices) Silhouetting of descending aorta Abnormal convex contour of azygoesophageal recess UPPER GI SERIES Thickened and interrupted mucosal folds (earliest sign) Tortuous radiolucencies of variable size and location "Worm-eaten" smooth lobulated filling defects CT SCAN esophageal wall and

GASTRIC ULCER Location • Lesser curvature aspect of body and antrum usually for benign ulcers • Benign ulcers also occur on posterior wall; not usually anterior wall • May be found in proximal half of stomach in geriatric patient • Almost all lesser curvature gastric ulcers <1cm are benign • Greater curvature benign ulcers are associated with considerable mass effect which erroneously leads to conclusion of malignancy X-Ray Signs of a benign gastric ulcer • Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach in profile (penetration) • Hampton’s line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa • Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall • Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer • Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an air-contrast study • Thickened folds radiating directly to the base of the ulcer en face X-ray signs of malignant ulcers • Ulcer projects within the anticipated wall of the stomach • Ulcer is eccentrically located within the ulcer mound • Irregularly shaped ulcer crater • Nodular ulcer mound • Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater • Rigidity, lack of distensibility and lack of changeability • Associated large mass • Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall=Kirklin meniscus complex CARCINOMA OF THE STOMACH Histology • Adenocarcinoma (95%) • Rarely, squamous cell Morphology • Polypoid/fungating carcinoma • Ulcerating/penetrating carcinoma (70%) • Infiltrating/scirrhous type=linitis plastica • Superficial spreading type-confined mucosa/submucosa-NOT linitis plastica


Thickened contour



Radiology – GI Radiology by Dra Bandong Metastases • Along peritoneal ligaments o Gastrocolic ligament to transverse colon o Gastrohepatic and hepatoduodenal to liver • To lymph nodes o Locally o Lymphangitic to lungs • Hematogenous o Liver (most common)/adrenals/ovaries/bones Complications Hemorrhage melena>hematemesis Perforation anterior>posterior / Obstruction 5% Penetration <5% off perforation

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15% <10% walled-


Peritoneal seeding Rectal wall=Blumer shelf Left supraclavicular node=Virchow’s node

Malignant ulcer—is a carcinoma which presents with the radiographic appearance of an ulcer niche; these have the radiographic appearance of a benign ulcer but demonstrate microscopic foci of malignancy, usually at the edge of the ulcer Ulcerating malignancy—is a carcinoma having sufficient bulk to present as a mass which also contains a persistent collection representing an ulcer; the mucosa is frequently nodular and the folds do not radiate to the base of the ulcer Linitis plastica (scirrhous carcinoma)—is a diffuse involvement of the wall of the stomach, frequently with flattening of the mucosa, and poor distensibility and contraction of the wall; usually associated with significant fibrosis and muscular hypertrophy; very frequently a signet ring cell type • • DUODENAL ULCER DISEASE 2-3 times more frequent than gastric ulcers 3:1 male:female ratio

DIFFUSE SMALL BOWEL DISEASE Sprue • 3 diseases: Celiac Disease of Children, Nontropical sprue and Tropical Sprue • Celiac disease and Nontropical sprue improve on gluten-free diet • Tropical sprue improves with antibiotics and folic acid X-ray • The hallmark features are: dilatation and dilution, especially in jejunum • Segmentation of the barium column occurs because it moves more slowly through areas of excessive fluid and separates from the rest of the column-not commonly seen with newer barium mixtures • Fragmentation is an exaggerated example of the irregular stippling of residual barium in the proximal bowel (which is normal) • Intussusception is not uncommon but is usually not obstructive; sprue has increased risk of ca and lymphoma • Moulage sign is caused by dilated loop with effaced folds looking like tube into which wax has been poured Scleroderma • Affects esophagus, small bowel and colon, sparing the stomach • Atrophy of the muscular layers and replacement with fibrous tissue • Associated with malabsorption X-ray • Whole small bowel is usually dilated with close approximation of the valvulae (hide-bound appearance) (stack-of-coins) • Does not have increased secretions as does sprue • May be associated with pneumatosis intestinales Whipple’s Disease • Glycoprotein in the lamina propia of the small bowel is Sudan-negative, PAS-positive • Clinically: arthralgia, abdominal pain, diarrhea and weight loss • Treated with long term antibiotics-penicillin • Very rare X-ray • The hallmarks of the disease are nodules and a markedly thickened bowel wall (picket-fence)

Pathophysiology • Excessive acidity in duodenum from • Abnormally high gastric secretion • Inadequate neutralization Location • Bulbar (95%) o Anterior wall– 50% o Posterior wall– 23% o Inferior fornix– 22% o Superior fornix– 5% • Postbulbar (3-5%) o Majority on medial wall just proximal to ampulla o Tendency for hemorrhage in 66% o Male:female ration 7:1 X-ray • Small round, ovoid or linear crater • Kissing ulcers–ulcers opposite from each other on the anterior and posterior walls • Giant duodenal ulcer–>3cm (rare) with higher morbidity and mortality • May be mistaken for the duodenal bulb itself and missed • Clover-leaf deformity–healed central ulcer of the bulb with four-leaf clover-like deformity remaining

Radiology – GI Radiology by Dra Bandong • • Small bowel may or may not be dilated Affects jejunum mostly •

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Amyloidosis • GI involvement is common • Associated with malabsorption X-ray • Marked thickening of the valvulae (picket-fence) • No dilatation or dilution • Affects entire small bowel Hypoproteinemia • Hypoalbuminemia resulting from liver or kidney disease lower than 1.5 grams per cent • Usually asymptomatic from intestinal edema itself X-ray • Changes are present throughout small bowel • Loops are separated due to edema of walls • Folds are quite thick (picket-fence) Giardiasis • Giardia lamblia is a flagellated protozoan, a normal parasite of the small bowel • Clinically: diarrhea and malabsorption • Treated with metronidazole (Flagyl) • Some patients have hypogammaglobulinemia and nodular lymphoid hyperplasia associated with giardiasis X-ray • Usually limited to duodenum and jejunum • Thickening of the folds • Marked spasm and irritability of the bowel • • Increased secretions is common Ischemic Bowel Disease • Thickening of the wall due to edema and hemorrhage • Localized perforations can produce air in the bowel wall or in portal venous system X-ray • Spasm and irritability early is replaced by an atonic bowel later • Lumen is narrowed • Folds are thickened, sometimes producing “thumbprinting” • Healing may result in stricture formation Intramural Bleeding • Suggested if there is duodenal obstruction following trauma • Localized lesions occur with trauma • Diffuse lesions are seen with anticoagulants X-ray • Uniform, regular, thickening of the folds • Separation of the loops • Mass effect • No spasm Radiation Enteritis

Changes are identical to ischemia since radiation changes are actually secondary to an arteritis with occlusion of small vessels • Localized to area of radiation portal, especially pelvis in female 2° endometrial carcinoma treatment • Previous adhesions from surgery may anchor small bowel in pelvic portal and predispose to XRT changes • Mucosa is most sensitive to radiation X-ray • Localized thickening of the folds 2° edema and hemorrhage • May result in strictures later in course Sigmoid Volvulus • Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract o Most commonly: sigmoid & cecum o Rarely: stomach, small intestine, transverse colon o Results in partial or complete obstruction o May also compromise bowel circulation resulting in ischemia • Sigmoid volvulus most common form of GI tract volvulus • Accounts for up to 8% of all intestinal obstructions • Most common in elderly persons (often neurologically impaired)

Abdominal plain films usually diagnostic 1. Inverted U-shaped appearance of distended sigmoid loop • Largest and most dilated loops of bowel are seen with volvulus 2. Loss of haustra 3. Coffee-bean sign midline crease corresponding to mesenteric root in a greatly distended sigmoid • Sigmoid volvulus – bowel loop points to RUQ • Cecal volvulus – bowel loop points to LUQ • Dilated cecum comes to rest in left upper quadrant 4. Bird’s-beak or bird-of-prey sign seen on barium enema as it encounters the volvulated loop • CT scan useful in assessing mural wall ischemia Air beneath the diaphragm Upright chest radiograph shows a large pneumoperitoneum outlining the spleen and the superior surface of the liver.

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Supine abdominal radiograph shows an collection of air within the subhepatic space.


Coned view of the lower abdomen shows the lateral umbilicus sign (arrow), which is a sign of a large pneumoperitoneum on a plain abdominal radiograph

Diagram of the right upper quadrant shows a triangleshaped collection of air in the Morison’s pouch, as seen on a plain supine abdominal radiograph. This collection is usually bound by the 11th rib, and it may be triangular (doge’s cap), crescent shaped, or semicircular.

Rigler’s Sign

Diagrams of the right upper quadrant show the location of the oblong collection of air in the right subhepatic space seen on a plain supine abdominal radiograph

Right: air on both sides of the bowel wall Left: Normal

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Soft Tissue Masses • Hepatosplenomegaly • Tumor or cyst o Bowel displacement  Paucity of gas  Pad sign – extrinsic compression of bowel Splenomegaly

Mass in Cologastric Space

Pancreatic pseudocyst Myoma Uteri

Renal Cyst

Bowel Outlet Obstruction

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RLQ Abscess

EMERGENCY ULTRASOUND ABNORMAL CALCIFICATIONS Patterns • Rimlike • Linear or track like • Lamellar • Cloudlike Rimlike Calcification - Wall of a hollow viscus • Cysts o Renal cyst • Aneurysms o Aortic aneurysm • Saccular organs o GB Gallstones • Gallstones affect 10-15% of the population and are a major cause of gallbladder (GB) morbidity. Symptomatic gallstones presents with characteristic right upper quadrant discomfort or pain (biliary colic). Most gallstones are mixtures of cholesterol, calcium bilirubinate, and calcium carbonate • Sonographic Diagnosis: o Echogenic foci in GB lumen o Acoustic shadowing o Rolling stone sign – movement of gallstones with GB with position change Lamellar or Laminar – formed in lumen of a hollow viscus • Nephrolithiasis • Cholecystolithiasis • Cystolithiasis GALLBLADDER

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Gallstones (red arrow) within the gallbladder produces a bright surface echo and causes a dark acoustic shadow (S)

With the patient in left lateral decubituis position, the gallstone (red arrow) rolls to the gallbladder fundus. Acute Cholecystitis • Most commonly caused by impaction of a gallstone in the gallbladder (GB) neck obstructing the GB and resulting in inflammation of the GB wall. • Patients present with pain, RUQ tenderness, and leukocytosis • About 70% of patient with acute cholecystitis have diffuse wall thickening • Diffuse and marked wall thickening can also be seen in ascites, pancreatitis, hepatitis, CHF, sepsis, and AIDS Diagnosis for Acute Cholecystitis • Major Criteria o Gallstones o Sonographic Murphy’s sign • Minor Criteria o Wall thickening >3mm o Pericholecystic fluid Normal Study

With the patient supine, the gallbladder (red arrow) is near the neck of the gallbladder.

• •

GB demonstrates the gallbladder neck (red arrow) GB wall thickness is measured between the gallbladder lumen and the hepatic parenchyma (red arrowheads) with normal thickness < 3 mm

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The gallbladder (GB) is filled with echogenic sludge and a gallstone (red arrow) is impacted in the gallbladder neck. The gallbladder wall (red arrowheads) is markedly thickened indicative of wall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder. Sonographic Findings: 1. Shotgun sign in intrahepatic biliary ducts (IHBD) become tortuous and their diameter exceeds 2 mm or exceeds 40% of the diameter of the adjacent PV. Color Doppler is used to confirm the absence of blood flow in the enlarged biliary tubes 2. Confluence of enlarged intrahepatic biliary ducts create a stellate appearance of merging tubes 3. CBD is considered diluted in adults if its diameter > 7 mm.

Transverse image reveals dilated bile duct (red arrow) anterior to the portal vein (red arrowhead) resembling a double-barrel shotgun

Dilated IHBD (red arrows) are seen as tortuous tubular structures in the liver. Color Doppler makes differentiation of bile ducts (red arrows) and blood vessels (red arrowheads) easy.

In the transverse image, the common bile duct (red arrowheads) is anterior to the portal vein and the gallbladder (red arrow) is also visualized. Shotgun Sign

Dilated common bile duct (red arrow) measured at 9.7 mm EPIGASTRIC PAIN Pancreatitis • Most commonly caused by alcohol abuse or a gallstone impacted in the distal common bile duct. • Inflammatory changes vary from mild interstitial edema to extensive necrosis with hemorrhage • Patient usually presents with deep epigastric pain that radiates to the back, nausea, vomiting, abdominal tenderness, fever, leukocytosis, and elevated pancreatic enzymes • Pancreatic pseudocysts are sometimes found several weeks after pancreatitis Sonographic Findings: 1. Diffuse enlargement of pancreas with ill-defined margins and hypoechoic parenchyma

Radiology – GI Radiology by Dra Bandong 2. 3. 4. Peripancreatic fat decreased in echogenicity with hypoechoic stranding densities Hemorrhage may cause hyperechoic masses of clot of blood Peripancreatic fluid collections in lesser sac, perirenal areas, and small bowel mesentery

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The pancreas is recognized by identifying its adjacent vasculature:

Huge fluid collection (F) surrounding the pancreas (P) RLQ Pain Appendicitis • The classic presentation is of a 10-30 year old person with right lower quadrant pain, nausea, vomiting, and leukocytosis. The presence of fever is evidence of perforation.

• •

Inferior vena cava (V), abdominal aorta(A), and the superior mesenteric artery (a) The junction of the splenic vein (SV) with the superior mesenteric vein marks the commencement of the portal vein (PV) and is recognized by its teardrop shape The head (H), body (B), and tail (T) of the pancreas course anterior and parallel to the splenic vein (SV)

Transverse image reveals normal appendix (between red arrows and + cursors) and its echogenic submucosa (red arrowhead). The head of the pancreas (H) is enlarged as revealed by the red arrowheads and decreased in echogenicity because of edema. The surrounding structures are superior mesenteric vein (v), superior mesenteric artery (A), and inferior vena cava (IVC). Sonographic Diagnosis: • Visualization of an aperistaltic tubular structure > 6 mm in diameter or visualization of an appendix with a fecolith confirms the diagnosis • Generally, the abnormal appendix is not at all subtle • The wall appears hyperechoic and may be strikingly so with impending perforation • A loculated fluid collection may represent abscess from a perforated appendix or other bowel source such as IBD (ischemic bowel dse) , or GYN source such as TOA (tubo-ovarian abscess)

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Transverse image reveals an 8 mm diameter, noncompressible appendix (between red arrow)

An obstructing appendicolith (red arrow, between + cursors) casts an acoustic shadow (S) and obstructs and dilates the appendix (A) resulting in acute appendicitis.

Image in the long axis of the appendix shows long segment loss of visualization of the submucosa (red arrowhead) and a focal perforation (red arrow).

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