MEDICINE

GIT RADIOLOGY AND IMAGING
Lecturer: Dr. Renato M. Carlos| Date: 09-25-09 Transcriber(s): Kat S.

OUTLINE
I. II. Introduction Imaging Modalities A. Plain Abdominal Radiograph B. Contrast examinations 1. Barium swallow / esophagogram 2. UGIS 3. SBS 4. Barium enema C. Ultrasound D. CT Scan E. MRI F. ERCP T tube Cholangiogram IOC Interventional radiology A. Angiogram and embolization B. Abscess drainage C. CT guide biopsy

Air fluid levels – step ladder sign - Distended jejunum appears as stack of coins, mucosal folds are more adherent to each other -ileum when distended mucosal folds are effaced -Obstruction is more distal somewhere in the ileum

III.

INTRODUCTION DENSITIES AIR FAT WATER
TISSUES

SOFT

BONE

Pneumoperitoneum – in ruptured viscous. Air escapes into the peritoneal cavity, Double wall sign – translucent inner wall (mucosa) and outer wall (serosa). Boarder of the liver and diaphragm is also seen, as air insinuates in between. Rigler’s sign – upright position,air goes up, inner and outer wall of the stomach is seen. B. CONTRAST EXAMINATIONS 1. Barrium swallow / esophagogram Barium sulfate- contrast medium used, an inert substance, radioopaque Indications: - esophageal motility disorders - atresia and tracheoesophageal fistula - duplication - esophageal diverticula - foreign bodies - esophageal perforation - hiatal hernia - esophagitis - rings, webs and strictures - esophageal varices - esophageal tumors Achalasia – severe narrowing in the gastroesophageal junction, proximal is dilated and distal is constricted -in advance cases esophagus may appear sigmoid - terminal part shows a beak-like narrowing representing an nonrelaxing LES.

2 Basic: 1. Black – radiolucent (air and fat) 2. White – radioopaque (include bones, metals and contrast medium) Intermediate density – gray color – water and soft tissues or organ structures. Intestines- contain air. IMAGING MODALITIES

Take note of the pattern of calcifications. If its toothlike – think of teratoma or cyst; vascular calcification – hemangiomas that appears as ring-like Indications: 1. Abdominal pain 2. Abdominal distention – obstruction, ileus, atresia 3. Vomiting 4. Diarrhea 5. Trauma – intraabdominal bleeding and ruptured viscous → pneumoperitoneum Things to look at 1. Intestinal Gas Pattern 2. Osseous Structures 3. Abnormal Calcifications 4. Abnormal Soft Tissue Densities 5. Renal Shadow 6. Psoas Shadow Calcifications and psoas shadow - psoas muscles bounded by fat thus appears translucent and is enlarged in the presence of tumors and abscesses. Kidneys lie along the lumbar area and is also bounded by fat - renal shadow

A. -

PLAIN ABDOMINAL RADIOGRAPH Used to show calculi, calcifications, stones, tumors

Enlarging mass in the lower neck. 2.

Diverticulosis - outpouching

a.

b.

a. Duodenal atresia – double bubble sign, shows an enlarged stomach and proximal duodenal distention, absence of distal gas (colonic gas) b. Jejunal atresia – triple bubble sign. absence of distal gas Page 1 of 4 (colonic gas)

Upper GI series - px on NPO, ingest barrium and effervescent tablet Indications ◦ Hematemesis ◦ Melena ◦ Hernia ◦ subacute or chronic nausea and vomiting ◦ palpable mass in the upper abdomen

Barium enema Page 2 of 4 .5 cm . more adherent unlike the haustra of the colon. more prominent in the jejunum than in ileum -transit time of the medium is within 2-3 hrs Lymphoma -segmentation and distortion of the mucosal folds. spleen. infection or ischemia C. Take note of the mucosal patterns of the small intestine. barium is injected and pushed with air. constipation e. Also diagnosed with CT scan String sign -hypertrophic pyloric stenosis . hematochezia b.Gall bladder. Tumors cause narrowing of the lumen Diverticulosis – multiple diverticles or outpouchings taking up the medium. catheter inserted into the anus. 3.Enlarging pancreatic mass Haustral patterns is 23cm apart Appendix is 2-3 haustras apart beyond the ileocecal valve that is like a lip. - Used to study the colon Px on NPO. .Fluids such as Bile appears dark. produce narrowing of the lumen . intraabdominal and retroperitoneal masses ◦ Small amount of fluid collections in the peritoneal space are also easily assessed.Adenocarcinoma Colitis -thumbprinting -inflammation.pear shaped. This shows the distribution of the small bowel. kidneys and fluid-filled structures such as the gallbladder and urinary bladder ◦ Ability to characterize lesions as solid. – not anymore used for its diagnosis Colon cancer -apple core deformity -tumors are usually circumferential. Inflammatory. wall measures 8mm. laxative given to cleanse to bowel. rectal bleeding c. it has to be big for it to be seen in UGIS. Small Bowel Series (SBS) Indications a. neoplastic or infectious diseases which result in mucosal changes or obstruction of the small bowels. Indications a. while calcifications or stones appears white (hyperechoic) 4.narrowing of the lumen of the pylorus (but is now directly dx by the use of UTS) Peptic Ulcer -seen outpouching or mound which corresponds to the edematous base around the ulceration.(Symptoms related to peptic ulcer disease or lesions involving the stomach and duodenum) Double contrast exam – barium is radio opaque and effervescent is translucent. Take note of the differences of the valvulated patterns.Any enlargement of the structures suspect tumor. change in stool caliber d. Causes severe bleeding. if there’s thickening – cholecystitis . about >2.when ruptured produces intramural abscess or localized peritonitis. characteristic finding of malabsorption syndrome ULTRASOUND Indications ◦ Evaluation of solid organs such as the liver. severe anemia (Symptoms related to Colon Cancer or Inflammatory Bowel Disease) - Widening of C loop on SBS -doudenal loop in relation with the pancreas . can become infecteddiverticulitis. weight loss f. pancreas. cystic or complex ◦ Of value in evaluating nonpalpable.

draping . Due to calcifiactions/stones. and mucosal brushings can be done IOC may be used to visualize nonpalpable stones during surgery T-tube cholangiogram is used to detect retained stones after surgery Normal T-tube Normal ERCP CBD stone FAST (Focused Abdominal Sonography for Trauma) Objective: Detection of free fluid (leaky fluid / minimal fluid) secondary to injury of the abdominal organs h HEPATORENAL SPLENORENAL MRCP advantages over ERCP (a) is noninvasive (b) is cheaper (c) uses no radiation (d) requires no anesthesia (e) is less operator dependent (f) allows better visualization of ducts proximal to an obstruction (g) when combined with conventional T1.Patient positioning. can able to detect polypoid lesion and tumor E. biopsy. tumor chemoembolization. fascial planes and potential spaces b.able to show the mucosal linings. inflammatory or neoplastic duct anomalies Page 3 of 4 . therapy may be initiated without waiting for the incision to heal 2.Diagnostic sampling for Laboratory Analysis . and can demonstrate calcifications within masses IV. ERCP(Endoscopic Retrograde Cholangiopancreatography) Cholangiography – used to study biliary tree Indications/Method of Examination ◦ can be used to evaluate the biliary tree to detect common bile duct stones. removal of fluid for palliative or therapeutic purposes C. Surgical Biopsy 1. CT-Guided Biopsy Indications . A powerful imaging technique for evaluating the abdominal walls. CT SCAN Indications a. bleeding control.and T2-weighted sequences. inside is multiple small echogenic foci. IOC Oral Cholecystogram – showing multiple gall stones D. Visceral Angiogram and embolization Indications . May be used to evaluate the entire abdomen for masses and their extension into adjacent structures. stone extraction. all organ systems. exudates from transudates. while MRI takes about 30-45min -In Sigmoid Ca – advantage of CT over barium enema is that your able to identify if there’s serosal involvement or any involvement outside the colon which is important in staging. risks of surgery and general anesthesia are avoided F.presurgical evaluation of lesions . minimal trauma.it takes about 10 sec to scan the entire abdomen. sterilization. intraperitoneal and retroperitoneal spaces. pre-operative devascularization… Technique: . sphincterotomy.Therapeutic management.g. into Femoral Artery - Given contrast medium to enhanced structuresvessels appear white. fat appear dark. Percutaneous Abscess/Fluid Drainage Indications .Tissue diagnosis of disease . MRI Advantages over CT: can evaluate pancreas.Embolization: Endovascular treatment of specific diseases. Multi-detectional CT scan – able to attain different planes or sections -virtual colonography . management planning is immediate.Aspiration for microbiologic/cytologic studies Advantages vs. No use of X-ray Normal hepatic Angiogram Hepatoma on angiogram B. e.evaluation and treatment of vascular diseases . INTERVENTIONAL RADIOLOGY A. c. Guidewire.Introduction of Needle. Advantage over MRI: -Used in general abdominal cases -Can detect calcifications. decreasing the risk of tumor dissemination 3. Catheter. MRI does not . adrenals and chemical structures. to normal as well as neoplastic tissue. Can also differentiate between solid and cystic masses.Gall bladder: bile is dark. sound waves can’t penetrate through it and produces distal acoustic shadowing – Cholelithiasis Acute cholecystitis with lithiasis thickened gall bladder wall with pericholecystic fluid Acoustic shadowing impacted stone at the gall bladder neck ◦ ◦ ◦ During ERCP. allows detection of extraductal disease.

. Step ladder sign – air fluid levels 5. characteristic finding of malabsorption syndrome 9. Goodluck to all of us. needle is inserted into the biliary system and tube is placed from the hepatic duct to the duodenum . to Angel for the Harrison’s and jollibee breakfast. Colitis -thumbprinting 12. . Jejunal atresia – triple bubble sign.cholecystitis 13.4. mentally.hemangiomas 3. To Alvin for the powerpoint.under UTS and colonoscopy guidance. MRCP advantages over ERCP. Upper GI series: Double contrast exam Pancreatic mass – widening of C loop (duodenal loop) Hypertrophic pyloric stenosis – String sign 8. esp sa exams. Ring-like .used when surgical intervention and ERCP to place a stent to bypass bile obstruction fails. SHOUTOUTS! ^_^ Thanks to Gail for the recording and kay Grace S. Colon cancer (adenoCa) -apple core deformity 11.  And we must not forget to thank God for keeping us alive… continue to pray for our safety in all the calamities that may come. and emotionally ready tayo” (-Carlo Sancha) Hope you enjoyed our early sembreak. sana maging “physically. Achalasia – shows beak-like in barium swalow 7. Lymphoma-segmentation and distortion of the mucosal folds. Rigler’s sign 6. thank you na rin sa effort to send it.. Pneumoperitoneum: Double wall sign. calcifiactions/stones. REFERENCE Lecture ppt and recording Wala masyado sa Harrisons  2.. hehe! KEY POINTS 1– Plain Abdominal Radiograph – shows calcifications. distal acoustic shadowing. if with gall bladder wall thickening .it does not cure the site of obstruction but it only drains the bile that is retained from obstruction 1.allows detection of extraductal disease. FAST – detects free fluid 14.. Stones and tumor 2. Psoas shadow and renal shadow – bounded by fat thus appears translucent 4. T-tube cholangiogram is used to detect retained stones after surgery 15. in small bowel obstruction/ atresia – absence of colonic or distal gas Duodenal atresia – double bubble sign. Patterns of calcification: Toothlike – teratoma or cyst. Cholelithiasis . Diverticulosis – multiple diverticles or outpouchings 10. -done under local anesthesia failure to obtain a diagnostic specimen does not preclude a surgical biopsy PTBD(Percutaneous transhepatic biliary drainage) . Page 4 of 4 ..multiple small echogenic foci.