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Subject:

Anatomy
Date:
Title:
4.8 Radiology of the Abdomen
Lecturer:
Dr. Nakpil
Sem/ A.Y.:
Transcribers: Arce J., Arquiza A., Arriba H., Avenir M., Azarraga C., Balberia J.
Trans Subject Head: Chong, Cheryl; (uerm2018a.anatomy@gmail.com)
I.
OUTLINE
I.Outline
II. Objectives
III.Radiology of the abdomen
A. Imaging Modalities
B. Stomach and Bowel Patterns
C. Indications for Abdominal Radiographs
D. Pharynx
E. Esophagus
F. Stomach
G. Small Intestines
H. Colon
I.
Accessory Organs
J. Urinary System
IV. Review Questions
V. References
II. OBJECTIVES
At the end of the lecture, the student should be able to:
1.
Identify anatomic structures that may be seen in different
imaging modalities
2.
Recognize typical imaging manifestations of some common
diseases involving the gastrointestinal and urinary tracts
III.

RADIOLOGY OF THE ABDOMEN

A. IMAGING M ODALITIES
The most common modality for studying the abdomen is the plain
abdominal radiograph / flat plate of the abdomen.
Radiographic Densities
1. Air - radiolucent/ black
2. Fat - radiolucent
3. Fluid-containing structures/soft-tissue masses - radioopaque/ white
4. Bone radio-opaque
5. Metalradio-opaque, used when administering contrast

Intravenous: Iodine

Oral: Barium
Abdominal radiograph
o
Used to determine presence or absence of bowel obstruction
Upright Abdominal Film
o
used to look at the presence or absence of obstruction
o
Free air would collect beneath the diaphragm
o
Take a look at air-fluid levels

Expect that air (lucent) is above, the fluid (opaque) is


below
Differential Air-Fluid Levels
o
Seen in the presence of obstruction
o
Normally, air-fluid levels in one loop of bowel would end at the
same level
o
In bowel obstruction, the proximal and distal end would be at
different levels (the other end is lower compared to the other)
1.

UPPER GI SERIES (UGIS)

Series of x-ray images


Used to visualize the lower esophagus to the stomach to the
duodenum.

Visualizes alimentary tract to the ligament of Treitz (at the


duodenojejunal flexure)
Barium is an oral contrast, sometimes rectal, depending on where
you administer it.
Follow fluoroscopically the patients as they ingest the barium
taking note of the peristalsis and motility of the esophagus.

2.

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November 27, 2014


nd

2 /A.Y. 2014-2015

o
To evaluate for swallowing disorder
o
To evaluate for suspected lesions of pharynx and esophagus

Double contrast technique


o
distends the pharynx by asking the patient to phonate/speak
out loud
o
distends the entire length of the esophagus by:

First, giving gas-producing crystals such that the gas


emitted will distend the lumen

Then, letting the patient take in barium to coat the


mucosa.

Single contrast technique/full column there is no introduction


of air, just barium swallow.

Cross sectional imaging techniques


o
CT/MRI

For staging malignancies especially for the esophagus


or pharynx and clarifying findings seen with other studies
such as ultrasound

Complements barium studies because it is able to


demonstrate the walls and extent of the disease if it
extends outside the lumen (in barium studies, one only
sees the barium column within the lumen)
o
CT scan

Poor in evaluating the mucosa

It is unable to differentiate inflammatory and neoplastic


conditions because they look the same.
o
MRI

Preferred modality for evaluating the pharynx

Determines extent of esophageal disease

Gives clear depiction of blood vessels

Can demonstrate varices in portal hypertension

Evaluate mediastinal vascular anatomy

CT can also do the same


Note: MRI/CT scan are not used in esophagus unless looking for
extensions of masses.

Figure 1.Typical abdominal radiograph usually taken in (A) erect and


(B) a supine position in a normal child. Dense areas: spine and pelvis;
Radiolucent areas: stomach, colon, ileum which is located in the pelvic
cavity.

BARIUM SWALLOW/ESOPHAGOGRAM

B. STOMACH AND BOWEL PATTERNS


Important in interpreting radiographs.
Stomach:
o
Anterior: body and antrum (air would collect; air collects in the
NON-DEPENDENT portion)
Colon/Large Intestine
o
seen in the periphery (frames the abdominal radiograph)

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ANATOMY: 4.8 Radiology of the Abdomen


o

Air will appear like a frame; will be framing the rest of the
abdomen.
Small bowel: at the center
C.

INDICATIONS FOR ABDOMINAL RADIOGRAPHS

External impressions caused by adjacent structures:


o
Aortic arch
o
Left main bronchus
o
Left atrium when it enlarges, it pushes the esophagus more
posteriorly

Especially used to rule out the presence of obstruction.


Normal caliber of the gastrointestinal Tract:
o
Small Intestine: 3 cm
o
Colon: 6 cm
o
Cecum: 9cm
Dilatation greater than these diameters is indicative of obstruction

Note: Plain abdominal radiographs are always done before any other
contrast techniques in order to differentiate the contrast material such
as barium from calcification on subsequent radiographs.
D.

PHARYNX

3 regions:
o
Nasopharynx

From skull base to soft palate

Functions mainly for respiration


o
Oropharynx

Soft palate to hyoid bone


o
Laryngopharynx/hypopharynx

Hyoid bone to cricoid catilage (cricopharyngeus


muscle, C5-C6)
Epiglottis cartilaginous area between oropharynx and
hypopharynx
Valecullae two symmetric pouches formed in the recess
between the base of the tongue and epiglottis
Piriform recess deep symmetric lateral recess

Figure 3. Lower esphagus. Z and A (gastroesophageal


junction/GEJ)marks the junction between the esophagus and the
stomach; Z (squamo-columnar junction); A (asymmetrical mucosal
lining); B (tubulovesicular junction); V (vestibule)
F.

STOMACH

Greater omentum - attached to the greater curvature


Lesser omentum attached to the lesser curvature
Presence of incisura angularis at the lesser curvature
Differences between body and antrum of the stomach:
o
Antrum- gastrin producing cells
o
Body- parietal cells which produce HCl, chief cells (secrete
pepsinogen)

Figure 4.Stomach
Figure 2.Parts of the pharynx and structures: NP (nasopharynx), OP
(oropharynx), HP (hypopharynx), V (vallecula), P (piriform fossa), HB
(hyoid bone), white arrow on picture B (epiglottic cartilage)
E.

ESOPHAGUS

From the cricopharyngeus muscle to the gastroesophageal


junction
Structural differences within the esophagus:
o
Upper 1/3 skeletal muscle
o
Middle 1/3 mixed (skeletal and smooth muscle)
o
Lower 1/3 smooth muscle
o
Distal portion is covered with serosa, the rest is covered with
adventitia
o
Mucosa is featureless, unlike in the GIT where it has mucosal
folds

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2.

Pylorospasm VS Congenital Hypertrophic Pyloric Stenosis


Pylorospasm
o
Reactive problem
o
Secondary to insult to gastric mucosa or muscle
contraction from other causes of stress
Congenital Hypertrophic Pyloric Stenosis
o
Develops between 2-10 weeks of age
o
Secondary to the hypertrophy of the pyloric muscle
(3mm)
o
Pyloric canal elongated beyond 14mm
o
Ultrasound is the preferred method of examination for
children to prevent unnecessary radiation dose

Figure 5.The stomach using double contrast imaging technique. Taken


at an oblique position to appreciate entire stomach. Rugae are visible
(seen as folds traversing the length of the stomach)
CLINICAL CORRELATION
1.

Hiatal Hernia
Protrusion of stomach to the mediastinum throuh the esophageal
hiatus (T10)
Usually see in middle-aged patients
Types:
o
Paraesophageal Hernia

Cardia remains intact

The fundal part herniates

No regurgitation of gastric contents

GEJ remains in the level of diaphragm


o
Sliding Hiatal Hernia

Most common

Sliding of the abdominal part of the cardia and


part of the fundus to the hiatus with some
regurgitation of stomach contents

Figure 8. Pyloric Stenosis (Narrowing of the pyloric sphincter)

Figure 9. Mushroom Sign represents hypertrophied pyloric stenosis


shown in a radiograph; Thick arrow pointing upwards- hypertrophied
pyloric sphincter with narrow strip of barium in the lumen (Mushroom
stalk); Pyloric canal is very elongated. Barium is actually lining the
narrow pyloric canal. (White opacity is barium); *only the lumen is seen

Figure 6. Different types of Hiatal Hernia

Figure 7. Hiatal Hernia

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Figure 10. Ultrasound of pylorus showing a donut sign. Left thick arrow
pointing to the right- hypoechoic (dark gray) part represents the
hypertrophic pyloric muscle; right thick arrow pointing upward-- internal
echogenic (light) part represents thickened mucosa of pyloric canal

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G.
1.

3.

SMALL INTESTINE
DUODENUM

Divided into four parts.


st
o
1 part Duodenal bulb/ cap; is the only intraperitoneal part
of the duodenum
nd
o
2 part: Descending

Valvulae conniventes/ plicae circulares start at this


portion. They traverse the entire diameter of the small
intestines

Ampulla of Vater is also located here


rd
o
3 part: Horizontal
th
o
4 part: Ascending portion
Pancreas is cradled at the C-shaped loop of the duodenum
Ends at the duodenojejunal flexure where it is tethered by the
Ligament of Treitz

Figure 11. Duodenum and its four parts: duodenal bulb, descending
part, horizontal part and its ascending part.
2.

JEJUNUM

The proximal 2/5 of the small intestine

It occupies the left upper quadrant of the abdomen

Entirely intraperitoneal

Feathery mucosal pattern

Wider lumen, thicker wall

Prominent valvulae conniventes

Mesentery contains less fat

It has arterial branches with fewer arcades and longer vasa


recta

ILEUM

Distal 3/5 of the small intestine


Entirely intraperitoneal
Has more arcades but has relatively featureless mucosal folds
Thinner, less frequent mucosal folds
Narrower lumen, thinner wall
Contains more lymphoid follicles in the submucosa (Peyers
patches)
Enteroclysis the distilling contrast material directly inside the
Small Intestine (SI), through a tube.
o
You place the catheter beyond the level duodenojejunal
flexure/ligament of Treitz and you pump in the fluid and let the
entire thing fill the small intestine (Nakpil, 2014)
o
Used to evaluate the SI but maintaining equal luminal
distension

Figure 13.Normal enteroclysis. The enteroclysis catheter (curved


arrow) has been passed through the C-loop of the duodenum to the
location of the ligament of Treitz (arrowhead). This technique provides
uniform distension of the jejunum (J) and ileum (I).
o

It is unlike the Upper GI Series (UGIS)wherein the patient will


just drink the contrast material. UGIS will depend on the
normal peristalsis of the organ and require the need to wait

Figure 12. Jejunum and Ileum.


Jejunum: feathery appearance due to the increased presence of plicae
circulares, wider lumen, longer vasa recta
Ileum: narrower lumen, widely spaced plicae

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mesentery) where ileal diverticulum would arise


If inflamed, mimic acute appendicitis
Meckels diverticulum would sometimes contain gastric mucosa
or pancreatic mucosa
Can occur in patients as young as 7 yrs old
CT scan, ultrasound would look like an appendicitis
syndrome of twos
o
occurs in approximately 2% of the population
o
about 2 inches (5cm) long
o
located about 2 feet from the ileocecal junction
o
often contains at least 2 types of mucosa

Ileum
Figure 14 & 15.Normal small bowel follow-through. (A) Prone
abdominal radiograph. The small bowel is demonstrated on an UGIS by
having the patient ingest additional barium and by taking additional
radiographs to document its passage through the small bowel into the
colon. (B) Spot compression view of the terminal ileum. The spot
compression provides separation of bowel loops in the RLQ to optimally
demonstrate the terminal ileum (TI)

Ileocecal junction where the small intestines end.


Ileocecal Valve
o
sphincter that controls the passage of ileal contents into the
cecum
o
The valve is actually two internal mucosal folds that cover a
thickened smooth muscle sphincter.
o
at around 1-2cm expect to see the appendix
Cecum (not a part of small intestine) is a pouch that is connected
to the ascending colon and the ileum; it extends below the
ileocecal junction, although not suspended by a mesentery
Appendix (not a part of small intestine) also originates on the
same area as that of the ileocecal valve; suspended by mesentery
called the mesoappendix

Meckels Diverticulum

Figure 17. Meckels Diverticulum

CLINICAL CORRELATION
1.

Ulcer
Ulcers are GI lesions that extend through the muscularis mucosae
and are remitting, relapsing lesions. (Erosions affect only the
superficial epithelium.)

Acute lesions are small and shallow

Chronic ulcers may erode into the muscularis externa or perforate


the serosa

May occur in the stomach, but most occur in the first part of the
duodenum (Netters Clinical Anatomy)
The mucosa, submucosa, and some muscularis externa have already
been eaten by the ulcer. There appears to be an outpouching but what
you can see is the crater on the wall. (Nakpil, 2014)

Figure 18. Technicium-99m pertechnetate isotope scan showing


Meckels diverticulum (arrowhead).

Figure 16. Perforated gastric ulcer with wall adherent to pancreas.


(Right) Barium contrast image of perforated ulcer that appear as an
outpouching.

Figure 19. Malrotation. The jejunum is on the right side. There should
be a C-loop formed by the duodenum with the duodenojejunal flexure
prominent. But in this image, the flexure is not distinguishable. Fundus
(F), body of stomach (B), antrum (A), duodenal bulb (DB), jejunum (J).

2.

3.

Malrotation
Duodenum normally sweeps across midline and end on the left
side of the vertebrae, level of the ligament of Treitz where it will
become the jejunum
Malrotation occurs when the duodenum fails to cross the midline,
occupying the right lower quadrant (RLQ) and pushing the cecum
to the right upper quadrant (RUQ).

Ileal diverticulum/ Meckels diverticulum


Remnant of the proximal part of the embryonic omphalo-enteric
duct (yolk stalk; 30-60 cm from the ileocecal junction.
Finger-like pouch, blind ending, but located in the ileum (3-6 cm
long)
It is always located at the anti-mesenteric border (away from the

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1.

2.

Colon is first filled with barium and then the barium is


drained out, leaving only a thin layer of barium on the
wall of the colon.
The colon is then filled with air.
a. Provides a detailed view of the inner surface of the
colon, making it easier to see narrowed areas
(strictures), diverticula, or inflammation.
Air-fluid level may be better appreciated.

Figure 20. Child with intestinal malrotation indicated by the low position
of the duodenojejunal junction (arrowhead) overlying the spine rather
than the normal position to the left of the spine at the level of the
duodenal bulb.
4.

Small bowel obstruction


Seen in upright/erect abdominal radiograph due to small pockets of
air becoming trapped against the superior wall of the bowel in the
valvulae conniventes.
The linear arrangement of air bubbles on the image (string of
pearls) is considered diagnostic of small bowel obstruction.

Figure 22. Single Contrast Barium Enema

Figure23. Double Contrast Barium Enema


2. Computed Tomography Scan (CT Scan)

Used not to evaluate the mucosa but to evaluate the extent of the
lesion
Figure 21. String of pearls sign in an abdominal x-ray.
H.

COLON

Table 1. Retroperitoneal and intraperitoneal structures


Retroperitoneal
Intraperitoneal

Ascending colon

Sigmoid colon

Descending colon

Appendix

Cecum

Transverse colon
Imaging methods to evaluate the large intestines
1.

Barium enema
An X-ray examination of the large intestine (colon and rectum).
To make the intestine visible on X-ray,
o
Colon is filled with a contrast material which contains
barium through a tube inserted into the anus.
o
The barium in the contrast material then blocks X-rays,
causing the colon to show up clearly on the X-ray.
Two types of barium enema examination
o
Single contrast

The colon is filled with barium, which outlines the


intestine and reveals large abnormalities.
o
Double contrast

Also known as air-contrast study

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3. CT (virtual) Colonography

Also a CT scan, a machine can take a look inside the lumen of the
colon. Image is reformatted by software.

Appears like a usual colonoscopy although a colonoscopy would


have the advantage of taking a specimen for biopsy, its
disadvantage however is that it cannot reach the ileocecal part
due to the length of the GIT
4. Transrectal ultrasound

Primarily used to detect prostate cancer in men.


5. Colonoscopy

Is a test that allows doctors look at the inner lining of a


patients large intestine.

Helps find ulcers, colon polyps, tumors, and areas of inflammation


or bleeding.

Tissue samples can be collected (biopsy) and abnormal growths


can be taken out. Colonoscopy can also be used as a screening
test to check for cancer or precancerous growths in the colon or
rectum (polyps).
CLINICAL CORRELATION

1.

Diverticulosis
Very common in elderly patients but they are usually benign/not
neoplastic findings
Usually occurs in the sigmoid and descending colon

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Appear as outpouchings on the colonic wall


Also known as false diverticula because they lack the muscularis
layer (3 layers are the mucosal layer, muscularis and the outer
serosa)
Pouches may not cause any symptoms, or they may bleed or
become painful, inflamed, or infected. Infection and rupture will
lead to diverticulitis.

Figure 27. Coffee Bean Sign


Figure 24. Relation of diverticula to blood vessels and taeniae

2.

Colonic Carcinoma
The most common type of gastrointestinal cancer. It is a
multifactorial disease process, with etiology encompassing genetic
factors, environmental exposures (including diet), and inflammatory
conditions of the digestive tract.
At the level of hepatic flexure, the colonic wall has started to
disappear and thelumen is very narrow. The mass is located on the
areas where there is no barium.
Common in the retrosigmoid region
Apple core sign in radiograph

Figure 25. Double contrast of a colon with diverticulosis


1.

Sigmoid Volvulus

The twisting or malrotation of the sigmoid colon causing


obstruction.

Dilated loop of sigmoid colon has a coffee bean shapeand the


wall between the two volvulated loops of sigmoid (black
arrow) points toward the RUQ.

In the birds beak sign, a larger proximal dilatation and a


smaller distal dilatation are shown (white arrows)

Figure 28. Apple Core sign in descending colon

Figure 29. Apple core sign in transverse colon


Figure 26. Sigmoid volvulus

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3.

Appendicitis
Is an inflammation of the appendix, a 3 1/2-inch-long tube of
tissue that extends from the large intestines.
Diameter is > 1 cm (10 mm), it is already considered
appendicitis

Figure 30. Appendicitis, (a) normal appendix (b) inflamed appendix


IX. ABDOMINAL WALL

Figure 31.Muscles of the abdominal wall are as follows: eo = External


oblique; io = internal oblique; tr = transversus abdominis; ra = rectus
abdominis (rectus sheath formation)

ABOVE the arcuate line:


o
Anterior wall of the rectus sheath ABOVE the arcuate line
will be composed of the aponeurosis from external oblique
and anterior lamina of internal oblique
o
Posterior wall, it is composed of transversus abdominis and
posterior lamina of internal oblique
BELOW the arcuate line, all the aponeurosis will go anterior to the
rectus muscle. Posteriorly, transversalis fascia will be left
Importance of the rectus sheath: Hematoma occurred above the
arcuate line stays in that area. However, if it occurs below the
arcuate line, it will penetrate the rectus sheath, this it will be difficult
to control.
Foramen of Winslow- Posterior to the stomach (part of the
LESSER SAC), this serves as a small communication between the
lesser sac and the greater sac.
Hepatorenal fossa or Morisons pouch- Between liver and
kidney that area is where FORAMEN OF WINSLOW meets with
lesser sac
REMEMBER: (R) and (L) Paracolic gutter: Area adjacent to the
ascending and descending colon. Right paracolic gutter
communicates with right subphrenic space while LEFT paracolic
does NOT.

Figure 32.Anatomy of the Peritoneal Cavity.


ABOVE: Diagram of an axial cross section of the abdomen illustrates
the recess of the greater peritoneal cavity and the lesser sac.
BELOW: CT scan with a large amount of Ascites demonstrating the
recesses of the greater peritoneal cavity and the lesser sac. The lesser
sac is bound by the stomach (St) anteriorly, the pancreas (P)
posteriorly, and the gastrosplenic ligament (curved arrow)laterally. The
falciform ligament (arrowhead) separates the right and left
subphrenicspaces. Fluid from the greater peritoneal cavity extends into
the Morison pouch (arrow) between the liver and the right kidney. Fluid
in the gastrohepatic recess (asterisk) separates the stomach from the
liver (L). S=Spleen; GB=Gallbladder, RK=right kidney; IVC=Inferior
vena cava; Ao=Aorta; LK=Left kidney.

Figure 33.S-Stomach, GO = Greater Omentum, Perihepatic space or


anterior subphrenic space (arrow). L = Liver. Greater omentum is
attached from the greater curvature of stomach to transverse colon.

Figure 34.Area of the Lesser sac. LS= Lesser sac. Ghl= Gastrohepatic
ligament.

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ligament (white arrow). Note the small bare area of the spleen (black
arrow) where reflections of the peritoneum from the spleen to the
diaphragm prevent access of intraperitoneal fluid.

I.

ACCESSORY ORGANS
1.

Figure 35.Foramen of Winslow (encircled). L= Liver, S = Stomach


CLINICAL CORRELATION
1.

2.

SPLEEN

Has different enhancements, due to differences in the uptake of


red and white pulp. Either:
o
Hypodense
o
Hyperdense
Normal appearance in ultrasound:
o 12-14 cm for adults
o Appears homogenous
o Has "inverted comma" appearance
o Not usually palpable in adults
Spleen would usually appear homogenous in any imaging
examination
Just a small shadow on the LUQ

Rectus Abdominis Hematoma


Rectus Sheath only found above arcuate line. Below arcuate line,
Rectus Abdominis muscle rests only on transversalis muscle.
Thus, above arcuate line, hematoma is controlled, while below the
arcuate line, it may spread further.
Spigelian Hernia
Occurs in the intersection between linea semilunaris and arcuate
line.
Occur in the lower abdominal wall lateral to the rectus abdominis
and inferior to the umbilicus through a defect in the aponeurosis of
the transversus abdominis and internal oblique muscles
Hernia may contain fat or bowel

RA
A

Figure 37. Normal spleen, CT Scan


CLINICAL CORRELATION
1.

Figure 47. (H) Spigelian Hernia, (RA) rectus abdominis


3.

Ascites
Excess fluid in the peritoneal cavity which can be a result of:
mechanical injury, portal hypertension, widespread metastasis of
cancer cell to abdominal viscera.

Figure 36. Ascites. (A) Longitudinal ultrasound image shows anechoic


ascites (a) surrounding the spleen (S). Fluid outlines the gastrosplenic

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Splenomegaly
Abnormal enlargement of the spleen
Can enlarge up to 10 or more times its normal size
Splenic length greater than 14cm
Inferior tip of spleen is below the inferior pole of kidney
Inferior tip of spleen is below the inferior tip of the liver
If its lower edge can be detected when palpating below the left
costal margin at the end of inspiration, it is enlarged about three
times its normal size.
Possible causes:
o
Portalhypertension
o
AIDS
o
Leukemia
o
Lymphoma
o
Infectious Mononucleosis

Figure 38. Splenomegaly

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2.

Transient Pseudomasses
Would sometimes appear in multi-detector/multi-facet CT
examination
Due to differences in the passage of contrast in the white pulp and
red pulp
In more delayed images, the normal homogenous appearance of
the spleen would be demonstrated.

Figure 39. Transient Pseudomasses (S)


2.

medial segments of the left lobe.


Superior and Inferior Parts
o The Right Lobe is divided by the right hepatic vein into anterior
and posterior segments

Anterior Segment:
Segment VIII Superior
Segment V Inferior

PosteriorSegment:
Segment VII Superior
Segment VI Inferior
o
The Left Lobe has medial and lateral segments. It is also
divided into superior and inferior segments by the portal vein.

Lateral Segment:
Segment II Superior
Segment III Inferior

Medial Segment:
Segment IVa Superior
Segment IVb Inferior
Quadrate Lobe: part of right and left lobe
Caudate Lobe: Segment 1 is between the fissure for the
ligamentum venosum, and anteriorly and superiorly the inferior
vena cava. Not included in the right and left lobe.
Hepatic segments are important because it used in describing
lesions for pre-operative planning.

LIVER

PARTS AND SEGMENTS


Functional Anatomy of the Liver

Divide the liver into several planes

IVC is found at the posterior of the liver

IVC tributaries include left, middle and right hepatic veins = form
the longitudinal plane

Transverse plane = crosses left and right portal veins;

Divides liver into superior and inferior portions

Figure 42.CT Scan of the Liver. Superiorly taken at a plane above the
portal vein (LEFT) and inferiorly taken at a plane below the portal vein
(RIGHT).
Imaging Techniques to Evaluate the Biliary Tree
1.

2.

Figure 40. Ultrasound of the liver

Endoscopic retrograde cholangiopancreatography (ERCP)


Placement of a fiberoptic gastroscope
Cannulation of the common bile duct and pancreatic duct at the
level of ampulla of Vater
Retrograde injection of contrast
o Visualization of intrahepatic ducts
o Spilling of contrast around cannulation site into the duodenal
sweep and proximal jejunum
Magnetic Resonance Cholangiopancreatography (MRCP)
special kind of MRI scan enabling the physician to visualize the
bile and pancreatic ducts in a non-invasive way
Provides a similar picture as ERCP without the risks of an invasive
ERCP procedure

Common Bile Duct

On CT Scan: Common bile duct should measure up to 7mm if


greater usually dilated.

With aging the common bile duct usually dilates. If the patient is
around 60 years old or around 70 years old, a CBD measuring of
around 6mm or 7mm still acceptable.

Figure 41.Liver Segments

Middle hepatic vein divides the liver into left lobe and right lobe.
Specifically between the anterior segment of the right lobe and the

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Figure 45. Portal Hypertension


Figure 43.ERCP of the Biliary Tract. The common bile duct A, right
hepatic duct C, and left hepatic duct D. The common hepatic duct E
becomes the common bile duct when the cystic duct B joins it.
CLINICAL CORRELATION
1.

3.

Cirrhosis of Liver
Usually seen in alcoholics or those with chronic hepatitis D & E
Appears nodular with irregular margin
Hepatocyte parenchyma are destroyed and replaced by fibrous
septa: producing regenerative nodules
The nodules impede circulation (primary: portal vein) of blood
through the liverLiver becomes firm; causes portal hypertension
(see below); manifested on the skin as caput medusae
regenerating nodules on cirrhosis needs biopsy
Determines whether it is regenerating or a cause of cancer
On ultrasound, liver looks heterogeneous with coarse parenchyma;
very large compared to the kidneys
Most common cause of portal hypertension

Obstructive jaundice
occurs when the essential flow of bile to the intestine is blocked
and remains in the bloodstream.
might be due to blocked bile ducts caused by gallstones, or
tumours of the bile duct which can block the area where the bile
duct meets the duodenum

Figure 46. MRCP (Magnetic resonance


cholangiopancreatography).The hepatic ducts are dilated and there are
several filling defects which are the stones in the common bile duct
causing obstruction.
GALLBLADDER: CLINICAL CORRELATION
1.

Figure 44. Cirrhosis of the liver


2.

Portal Hypertension
Obstruction of portal vein > pressure rises
Enlarged varicose vein (caput medusae) at sites of anastomoses
between portal systemic veins.
Postacaval anastomoses or portosystemic shunt
Communication between
o Portal Vein and IVC
o Splenic and Left Renal Veins
Divert blood from the portal venous system to the systemic venous
system is just obstruction in the portal vein causing increase in
pressure.

Gall Stones
Most commonly seen on plain abdominal radiograph and even on
ultrasound
Concretions in the gallbladder whch may cause biliary colic or
cholecystitis (inflammation of the gall bladder)
Risk factors (FFF):Fat, Female, Forty
Only operated on when it causes pain
Distal end of hepatopancreatic ampulla
Narrowest part of the biliary passages
o Common site for impaction of gallstone
Usually found in the fundus of gallbladder, or obstructing the neck,
or towards the bile duct /cystic duct
On Ultrasound
o Gallbladder is usually filled with anechoic bile
o In the presence of gall stones, you will see intense echoes with
posterior shadowing
On CT Scan
o Gallstones would appear as calcifications
o Thickened gall bladder walls sign of cholecystitis

Figure 47. CT Scan of gallstones

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ANATOMY: 4.8 Radiology of the Abdomen

Figure 48. Ultrasound of Gallstones. The gallstones look like intense


echoes, bright echoes with posterior shadowing.
2.

Choledocholithiasis
Seen as the presence of structures in the region of the common
bile duct
Hepatic ducts dilated beyond the area of the stricture
On MRCP (MR Cholangiopancreatography)
o Seen as filling defects in the common bile duct

Figure 51.Ultrasound of the Pancreas The head, uncinate process, the


body and tail of pancreas, portal vein (PV), and splenic vein (SV). The
pancreatic duct is not usually seen on ultrasound unless it is dilated
CLINICAL CORRELATION
1.

Figure 49. CT Scan of the Gallbladder with Cholelithiasis The area


pointed by the black arrow shows edema and fluid around the
gallbladder.
* Cholelithiasis involves the presence of gallstones
*Choledocholithiasis is the presence of at least one gallstone in the
common bile duct
*Cholecystitis is the inflammation of the gallbladder
3.

PANCREAS

Figure 52. CT of Acute Pancreatitis. It demonstrated enhancement of


only the distal body of the pancreas (p). The pancreatic head and neck
did not enhance and are lost in the fluid (f) extending from the
pancreatic bed.
2.

Unencapsulated
Tongue-shaped
Tail ending in the splenic hilum
Mainly retroperitoneal, except its tail

Pancreatitis
Since the pancreas is unencapsualted, the pancreatic juices would
easily spread to the surrounding tissues.
Would appear normal if imaged early
Seen as fluid collections surrounding the pancreas.

Pancreatic Cancer
Can cause extrahepatic obstruction of the biliary ducts and
jaundice
Can also cause obstruction of the portal vein or the IVC
On UTZ:
o Ill-defined hypoechoic structure
o If an anechoic structure is seen, it could be a dilated pancreatic
duct
Criteria for resectability: If SMA becomes encased by tumor, the
cancer is already non-resectable
o Resectable: Definite fat planes surrounding the Superior
Mesenteric Artery
o Non-Resectable: Tumor is seen surrounding the SMA

Figure 50. Normal CT of the pancreas showing the neck (n), body (b),
and tail (t) of the pancreas.
Figure 53. Pancreatic Carcinoma (black arrow) Resectable. The
superior mesenteric artery and vein (white arrows) are spared of
involvement.
3.

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Pancreatic Tumor (T)


encases and partially narrows the celiac axis (arrowhead) and
partially envelopes the aorta (A). This tumor is non-resectable.

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ANATOMY: 4.8 Radiology of the Abdomen


1.

KIDNEYS

Figure 54. Pancreatic Tumor (T)

J. URINARY SYSTEM
Minor Calyx will join to form Major Calyx
Major Calyx will join to form your renal pelvis Ureter Urinary
Bladder

Figure 56. Ultrasound of Kidney.

Imaging Techniques to evaluate the Urinary System


1.
2.

KUB radiograph - kidney, ureters, bladder scan. Typically a


single x-ray procedure
Intravenous Pyelogram / Intravenous Urogram

Figures 57.CT Scan of kidney. According to Dra. Nakpil, If you are


considering the possibility that your patient has renal stones, the best
image modality is the CT scan (Although the ultrasound can still be
used)
2.

Figure 55. Intravenous Pyelogram / Intravenous Urogram

This procedure is used in order to visualize the entire urinary


system (kidneys, ureters, and the urinary bladder)
Through the injection of a contrast (Intravenously) and then the
kidneys will function to excrete the substances a few minutes after
administration.
Because the substance has already gone through the urinary
system, you will now have access to the urinary system of your
patient and from there can make a diagnosis based on the findings
depicted.

URETERS

There are three constrictions in the ureters where stones would


normally lodge themselves into which would result in the dilation of
its proximal segments
o
UPJ (urinary pelvic junction)

Should appear bright with posterior shadowing

The ureter proximal to this area is very diluted

The proximal area will dilate in order to compensate


for the obstruction
o
UVJ (Ureterovesical junctions)
o
Pelvic brim
3.

URETHRA

(Important Note from Dr. Nakpil) According to the lecture, you should
not be able to see the ureter in its entirety because it should always be
obstructed by peristalsis. Thus, you might see it opening at different
levels each time. However, if you can see the whole length of the ureter
you can suspect an obstruction because it means that has vessel is a
state of dilation.
3.

4.
5.
6.
7.

Retrograde Urethrogram - routine radiologic procedure


(most typically in males) used to image the integrity of the
urethra
Voiding Cystourethrograbm - an x-ray study of the bladder
and urethra that is done while the bladder is emptying
Ultrasound
Computed Tomography (CT) scan
Magnetic Resonance Imaging (MRI)

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Figure 58. Urethra

(Female urethra) Is lined by paraurethral glands


(Male Urethra) Insertion of the catheter through the penile urethra
in order administer the contrast
(Male urethra) Anterior and Posterior
Posterior Urethra has prostratic urethra (parenchyma of the
prostate gland)

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ANATOMY: 4.8 Radiology of the Abdomen

Anterior Urethra has the Membranous urethra (contained in the


urogenital diaphragm)
o
Bulbous urethra
o
Pinoscrotal junction

Note: with obstruction, whatever is proximal to area of obstruction


becomes dilated.

CLINICAL CORRELATION
1.

Horseshoe kidney (Pelvic cake)


This renal condition is the most common renal fusion congenital
anomaly.
Caused by the fusion of the inferior poles of the kidneys across the
midline by a fibrous / parenchymal band.
Thus, the kidney will be malrotated with both renal pelvises
directed more anteriorly and the lower pole calyces directed
medially.
The kidney is in a low position because its ascent in the abdomen
is prevented by the renal tissue encountering the inferior
mesenteric artery in the midline

Figure 62. Cast of the calyces


IV.

GUIDE QUESTIONS

1. An ultrasound image shows a gallbladder with a thick wall,


pericholecystic (around the gallbladder) fluid, and a reflective foci from
within that casts posterior acoustic shadows. The sonographic
impression is:
A. Duplication of the gallbladder
B. Acalculous cholecystitis
C. Acute cholecystitis with stone
D. Cholelithiases
2. A small nodule is noted in the liver on contrast-enhanced CT scan.
You saw that it was located inferior to the right portal vein and is located
between the middle hepatic and right hepatic veins. Which hepatic
segment is most likely involved?
A. II
B. III
C. V
D. VI
Figure 59 & 60. Pelvic cake
2.

Ureteral Duplication (Bifid/ Double Collecting System)


Complete 2 ureters inserting into the urinary bladder
Incomplete- only has 1 ureter inserting into the urinary bladder

3. A contrast radiographic study of the abdomen reveals a feathery


mucosal pattern of a segment of the alimentary tract. Which of the
following structures are most likely responsible for producing this normal
finding?
A. Haustra
B. Plicae circulares
C. Plicae semilunares
D. Rugae
4. A three-week old infant was being evaluated for gastric outlet
obstruction. Ultrasound revealed a hypertrophic pyloric sphincter. This
finding most likely represents thickening of which stomach muscle
layer?
A. Inner circular
B. Innermost oblique
C. Middle circular
D. Outer longitudinal

Figure 61. Bifid/ Double Collecting System


3.

Renal stone formation


3 areas of anatomic narrowing along the ureter: UPJ (UretericPelvic Junction), UVJ (Uretero-Vesical Junction), and Pelvic Ring
(or at level of crossing of Iliac Arteries)
o
Where renal stones can possibly obstruct
This is the most common pathology in the renal system
Can affect both the major and minor calyces of the kidney resulting
to a renal stone formation (Staghorn calculus).
However, in order for it to be considered as a Staghorn Calculus it
should affect at least 2 minor calyces (Thus, calculus meaning a
cast of your collecting system minor calyx, major calyx, renal
pelvis)

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5. A plain abdominal radiograph revealed a staghorn-shaped


radioopacity. Which of the following abdominal organs would most likely
be involved?
A. Gall bladder
B. Kidney
C. Pancreas
D. Urinary bladder
Answer Key: CCBCB
V.

REFERENCES

2017A Transcription.
th
Brant, W., Helms, C. (2012). Fundamentals of Diagnostic Radiology, 4 ed.
Philadelphia: Lippincott Williams and Wilkins.
Gourtsoyianni, H. (ed.) (2002). Radiological Imaging of the Small Intestine.
Germany: Springer-Verlag Berlin Heidelberg.
nd
Hansen, J. (2010). Netters Clinical Anatomy, 2 ed. Philadelphia:
Saunders-Elsevier.

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