IMAGING OF THE

ABDOMEN & THE GIT

YEAR 4, MBBS

Dr Azlin bt Sa’at @ Yusof

Kulliyah of Medicine
IIUM.
 CONTENTS
 Imaging modalities:
 Plain XR
 Contrast studies
 Ultrasound
 Computed Tomography
 Magnetic Resonance Imaging
 Angiogram and interventional
 Others: ERCP,
 PTC, intra-op & T-tube cholangiogram,
 Radionuclide imaging – IDA, Meckel’s
and GIT bleed.
 Quiz and summary.
PLAIN ABD XRAY
 PLAIN ABD XRAY (1)
(1) Radiographic anatomy
- know where solid organs lie:
* intraperitoneal
* retroperitoneal – kidneys, adrenals, pancreas, psoas, IVC,
Ao, lymph node.
* pro-peritoneal fat
* GIT

(2) Interpretation
- quality
- views: supine, erect, decubitus (usu lt side down)
- bowel gas pattern:
* normal gas : stomach and colon
* normal air-fluid level : stomach and proximal
duodenum
* stomach – rugae; jejunum – feathery;
small bowel – valvulae conniventes;
colon – haustrations.
 PLAIN ABD XRAY (2)
* Dilated? - jejunum > 3.5 cm
- mid small bowel > 3 cm
- ileum > 2.5 cm
- tranverse colon > 5.5 cm
- caecum > 8 cm

- Psoas outline: symmetrical and slightly concave lateral

borders.
- Renal outline : 10-12cm / 3.5 vertebral height.
- Bladder outline.
- Liver and splenic outline.
- Intraperitoneal fluid / collections.
- Calculi / calcifications : GB, kidneys, pancreas, lymph
nodes, vacsular, phleboliths,
tumoral.
- Soft tissue masses.
- Extra-luminal gasses.
 PLAIN ABD XRAY (3)
(3) Various conditions

* Bowel obstruction:

 Mechanical obstruction of the small bowel:

- small bowel dilatation with normal / reduced calibre of
colon.

 Large bowel obstruction:

- dilatation of large bowel +/- small bowel dilatation.

 Paralytic ileus:
- large + small bowel dilatation +/- gas in sigmoid to rectum.

 Local peritonitis:
- dilatation of loops adjacent to inflammatory process 
‘sentinel loops’
 PLAIN ABD XRAY (4)
* Bowel obstruction (cont.):

 Gasteroenteritis:
- normal / excess fluid levels / ~ paralytic ileus / ~small
bowel obstruction.

 Small bowel infarction:

- obs of small or large bowel

 Closed loop obstruction:

- caecal/sigmoid volvulus – filled with air + char shape.
obstructed hernias – fluid-filled, usu not visible.

 Toxic dilatation of the colon:

- maximal dilatation usu at transverse colon,
lost/abnormal haustra +/- polypoid shadows.
 PLAIN ABD XRAY

SUPINE ERECT

Small bowel obstruction

 PLAIN ABD XRAY

Large bowel Toxic dilatation due

obstruction to ulcerative colitis

Small + large bowel

VOLVULUS
 PLAIN ABD XRAY (5)
(3) Various conditions

* Extra-luminal gas:

- Free intraperitoneal gas:

* causes – post-laparotomy (up to 7 days)

- perforated peptic ulcer
- IBD / infarction
* ERECT FILM! – air under diaphragm or lateral decubitus
* supine – gas outlining the falciform lig.
- gas on both sides of the bowel (Rigler’s sign)
 PLAIN CXR

Air under hemidiaphragm

PLAIN ABD XRAY

Free intraperitoneal air

 PLAIN ABD XRAY (6)
* Extra-luminal gas (cont.)
- Intramural gas pattern:
* spherical – pneumatosis coli
* linear – infarction
* neonatal period – NEC

NEC PNEUMATOSIS COLI

 PLAIN ABD XRAY (7)
* Extra-luminal gas (cont.)
- Gas elsewhere:
* biliary system – following sphincterotomy / fistula (stone) /
duodenal ulceration.
* GB * kidneys *abscess *subphrenic

Biliary tree Kidneys

Galbladder
 PLAIN ABD XRAY

Subphrenic
????
 PLAIN ABD XRAY (8)

*Ascites *Calcifications
- phleboliths - vascular
- solid organs: liver, spleen,
pancreas, adrenals, kidneys.
- tumours: fibroids, ovarian masses.
- soft tissue
- faecoliths.
 Pancreatic

Gallstones Uterine fibroid

Appendicolith
 PLAIN ABD XRAY

* Abdominal / pelvic masses

 CONTRAST STUDIES
(1) General

* Contrast material:

- BARIUM vs GASTROGRAFFIN vs LOCM

Good opacification Safe if ?peritoneal Safe if aspirated or
and coating BUT leak BUT hypertonic, leak BUT expensive
peritoneal leak  lung irritant if and poor
peritonitis aspirated and less opacification and
opaque coating

* Single contrast vs Double contrast

Oesophagus, small bowel Ideal for stomach, and
and TRO Hirschprungs and colon. Excellent mucosal
obstruction only. (no need detail.
bowel prep)
 CONTRAST STUDIES (1)
* Basic terms:
- wall of the bowel -> not seen.
- mucosal folds: contracted -> folded
distended -> valv conniventes / haustra
abnormal -> ? smoothing / ? Irregular
- filling defect:

Intra-luminal Intra-mural Extra-luminal

 CONTRAST STUDIES (2)
- Stricture: persistent narrowing

Tapering ends vs. overhanging

edges (shouldering)

- Ulceration:

In profile En face
 CONTRAST STUDIES (3)

Description:
- site of the abnormality
- what is its shape?
- how long?
- is there a soft tissue mass?
 CONTRAST STUDIES (4)
(2) Barium swallow

* Barium swallow vs OGDS

* Method: - CONTROL FILM !!!!

- swallow while flouro,
- oblique position,
- films taken in full, collapsed +/- air-filled state.

* Normal: full  smooth outline

collapsed  3-4 long straight parallel lines
indentation  left: aorta and left bronchus
 anterior: (L) atrium and ventricle
peristalsis  smooth
 elderly: pronounced and
prolonged (3o contractions)
CONTRAST STUDIES (5) – Barium Swallow

Full Collapsed 3o contractions

CONTRAST STUDIES (6) – Barium Swallow
* Pathology: - Carcinoma

(a) (b)
CONTRAST STUDIES (7) – Barium Swallow

Benign peptic stricture Achalasia

Candidiasis
 CONTRAST STUDIES (8) – Barium Swallow

Ca bronchus
Leiomyoma

Oesophageal web Varices

 CONTRAST STUDIES (9) – Barium Meal
(3) Barium meal
* Method: - swallow barium then gas-producing agent,
- iv smooth muscle relaxant.
- various positions.

* Normal: - lesser curvature -> smooth,

- greater curvature -> irregular,
- rugae
- duodenal cap -> triangular.
CONTRAST STUDIES (10) – Barium Meal

* OGDS vs barium meal

* Pathology: - Hiatus hernia

(a) Sliding (b) Rolling

 CONTRAST STUDIES (11) – Barium Meal
- Linnitus plastica:
adenoca, lymphoma, breast mets, battery acid ingestion, TB, Crohn’s and
eusinophilic gastroenteritis.
CONTRAST STUDIES (12) – Barium Meal
Ulcers Duodenal ulcer

Benign

Malignant
CONTRAST STUDIES (13) – Barium Meal

Erosive gastritis Polyps

CONTRAST STUDIES (14) – Barium Meal
Carcinoma
 CONTRAST STUDIES (15)
– Barium follow-thru’ & Small bowel enema
(4) Barium follow through and small bowel enema

* Differences in method:
- Barium follow through vs. SBE / enteroclysis
- time-consuming - require nasoduodenal intubation
procedure (2-3 hrs) - shorter time
- excellent mucosal detail
- view terminal ileum!

* Normal barium follow-through and SBE:

- continuous column < 2.5cm diam.
- transverse folds appear as filling defect 2-3mm width.
If filled  transverse lines
If collapsed  feathery
- folds are most in the jejunum, least in the ileum.
 CONTRAST STUDIES (16)
– Barium follow-thru’ & Small bowel enema

Normal barium follow through

SBE / Enteroclysis
 CONTRAST STUDIES (17)
– Barium follow-thru’ & Small bowel enema

SMALL BOWEL
Malabsorption LYMPHOMA
 CONTRAST STUDIES (18)
– Barium follow-thru’

Crohn’s

Malrotation
 CONTRAST STUDIES (19)
– Barium follow-thru’

Lymphoma Worm infestation

CONTRAST STUDIES (20) - Barium Enema
(5) Barium enema
* barium enema vs. colonoscopy (vs. CT colonoscopy)

* Method: - Bowel prep!

- Control film!
- Double contrast: Rectal tube, infuse barium,
drain, pump air.

* Normal: - Length variable +/- redundant loops.

- calibre decreases from caecum to sigmoid colon.
- ileocaecal valve may cause filling defect.
- haustra may be absent in descending and
sigmoid regions.
CONTRAST STUDIES (21) - Barium Enema

Normal barium enema

CONTRAST STUDIES (22) - Barium Enema

Diverticulosis
CONTRAST STUDIES (23) - Barium Enema

Polyposis coli
CONTRAST STUDIES (24) - Barium Enema
Carcinoma

‘Apple core’
appearance
TUBERCULOSIS
INVOLVING
BOWEL
CONTRAST STUDIES (25) - Barium Enema
Strictures: # ca, diverticular ds, Crohn’s, ischaemic colitis, TB,
lymphogranuloma venereum, amoebiasis, radiation.

‘THUMBPRINTING’
(amoebiasis)

Diverticular disease
 CONTRAST STUDIES (26)
Crohn’s dz:
# most freq inv lower ileum and colon
# early: - loss of haustration, narrowing and shallow
ulceration.
# ulcer + mucosal oedema  ‘cobblestone’
# later: deeper ulcer  ‘rose-thorn’ or fissures.
# cx: - intra or extra-mural abscesses.
- fistulae.
- strictures: smooth and tapered ends.
- when caecum inv  markedly contracted.
 CONTRAST STUDIES (27)
Ulcerative colitis:

- similar to Crohn’s dz BUT (see below)

 CONTRAST STUDIES (28)
CROHN’S DS

Deep ulcer with tracking in

the submucosa

Shallow ulcers
(aphtous)
Skip lesions
 CONTRAST STUDIES (29)

CROHN’S
Recto-vaginal fistula
ULCERATIVE COLITIS
CONTRAST STUDIES (30)

Hirschsprung’s ds

Intussusception
 ULTRASOUND
(1) General considerations
- preparation

- normal anatomy: solid organs + biliary tree + vessels +

lymph nodes.

- echogenicity: pancreas, liver, spleen, kidney.

hyper hypo

- appearances of various tissues:

fat = hyper;
fluid = hypo with posterior acoustic enhancement;
calculi/ bone = hyper with post ac shadowing;
gas = shadowing.
NORMAL:

Pancreas

Liver

Spleen

Kidney
NORMAL:
Gallbladder

Aorta
&
IVC

Lymph nodes
NORMAL:

Oesophagus

Stomach

Small bowel

Gas in bowel
PATHOLOGY:

Cirrhosis

Abscesses

Metastases

Lymphoma
PATHOLOGY:

Cyst

Ascites

PV thrombosis

Cholecystitis
with calculi
 COMPUTED TOMOGRAPHY &
MAGNETIC RESONANCE IMAGING (1)
(1) General considerations
* Differences between CT and MRI.
* Windowing in CT, and sequences in MRI.
* Various densities in CT and intensities in MRI.

CT MRI

T2W T1W
 COMPUTED TOMOGRAPHY &
MAGNETIC RESONANCE IMAGING (2)
Pathology

Hepatic cysts

T1W

CT

MRI
T2W
 COMPUTED TOMOGRAPHY &
MAGNETIC RESONANCE IMAGING (3)
Haemangioma

NECT Contrasted CT T2W MRI

Pancreatic Ca

Post-op 3 months later 6 months later

 ANGIOGRAPHY &
INTERVENTIONAL RADIOLOGY (1)
(1) Types:
- Flush aortogram

- Inferior vena cavogram / SVCgram

- Selective: (according to vessels) hepatic artery, renal, spleen,

pancreas, coeliac axis, SMA, IMA, uterine artery.

- may include intervention:

 chemoembolization, coil/glue embolization,

stenting.
(2) Indications:
- tumour / haemangioma, bleeding, pre-op … etc
 ANGIOGRAPHY &
INTERVENTIONAL RADIOLOGY (2)
MULTIFOCAL HEPATOMA

Arterial phase Late phase Post-embolisation

ANGIOMA
 OTHER IMAGING METHODS (1)
(1) Endoscopic retrograde cholangio-pancreatogram

Stone

(2) Percutaneous transhepatic cholangiogram

Stone
 OTHER IMAGING METHODS (2)

(3) T-tube cholangiogram (4) Radionuclide imaging

(I) GIT bleed

(II) IDA scan
MECKEL’S DIVERTICULUM
THE END !