ABDOMEN / GIT 2014 -2015

Dra. Espina [RADIOLOGY]

ABDOMEN VIEWS FOR THE ABDOMEN

Why do clinicians request for imaging of the abdomen or the entire When the patient is in a supine position, the cassette is at the back
GIT? and the x-ray beam is in front of him. So, you will be able to see air
 Primarily, when during physical examination, they can within the bowels.
palpate a mass or the patient can palpate a mass on
himself.
 Patient complains of tenderness.
 If, clinically, clinicians are suspecting obstruction.
 If the patient is a trauma patient and they are looking for
possible ischemia.

When patient is subjected in an upright view, you will be able to

see air-fluid levels. Commonly, you can see air-fluid level in the
This is a normal x-ray of an abdomen. Again, try to look/check all gastric bubble. That’s the normal. Or utmost, you can see 3 air-fluid
the images included in the four corners of the film. levels in the duodenum or jejunum. More than 3 air-fluid levels are
already indicative of an intestinal obstruction.
I. Area of the right and left hemidiaphragm
 Delineates thorax from the abdomen
II. Area of the liver
 Liver is just below the right hemidiaphragm
III. Area of the gallbladder
 Gallbladder is just inferior the liver
IV. Area of the stomach
 With gastric bubble or magenblase
V. Area of the spleen
VI. Area of the pancreas
 In the upper abdomen, midportion
VII. Area of the kidneys
VIII. Bowels
 Lucencies represent air
IX. Psoas muscle
 Should be clearly defined because if not, it may indicate
something is obscuring the psoas line. Commonly, it is fluid
(ascites) that obscure the psoas shadow. It could also be a  In comparing the supine and upright view, you can
mass. see air-fluid levels in an upright view which is not
X. Flank stripe appreciated in a supine view. That’s why if you are
 Line at the lateral border of the abdomen entertaining obstruction, make sure to request a
 In cases of massive ascites, those flank stripes are effaced. supine and an upright view and not just a plain
XI. In the pelvic cavity, primarily, it is the urinary bladder that occupies abdominal film in a supine position.
that space.

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Supplemental views:
 If patient is unable to stand, or nonambulatory, you can
request for a decubitus view. In that case, you can still be
able to see air-fluid level if you are still entertaining an
obstruction.
 Fluid will layer in the dependent portion

 Chest x-ray
 Why is a CXR included?
 The beam is nearer the area of the  Contrast goes through the gastroesophageal
diaphragm. In cases of minimal junction to the esophagus. Dapat wala kayong
pneumoperitoneum or air within the makikitang reflux or no barium going back the
peritoneum, if the patient is standing, the air esophagus. It should be in the stomach already
will go upwards. Since the diaphragm is the because gastroesophageal junction closes. Yan ung
delineation of the thorax and abdomen, in cases of GERD. What you see there is the lumen of
hanggang dun lang sa ilalim ng diaphragm the esophagus.
magle-layer o magpupunta ung air. That’s
why you have to take a CXR. The beam of the
x-ray is nearer the focus of the diaphragm.
 You may also see that in a plain upright
abdominal film but may missed minimal
pneumoperitoneum dahil nacocover siya ng
ibang organs.

 Barium enema is for the colon. You will see the entire
colon. The tube is inserted in the rectum, and then the
barium will be pushed inside. It will run from the sigmoid,
to the descending colon, to the transverse, up to the
cecum.
OTHER IMAGING MODALITIES FOR THE GIT  Two indications to know if you are already done
with the study:
Upper gastrointestinal series (UGIS)  You will see the appendix.
 Includes imaging from the mouth up to the small intestines.  If there is no appendix, you must have a
Patient is asked to ingest a contrast medium called barium. reflux into the small intestine.
Barium, when subjected to x-ray, puti ang itsura niya. So,
that will cover the lumen of the GIT.

 This is part of the UGIS, which we call the barium swallow

or esophagogram. Esophagogram is for the esophagus.
 So, dapat dyan may good flow at hindi bumabalik.
And you see the lining is very smooth. You don’t see
any narrowing. If you see a narrowing, you check it
again because the esophagus, normally, has a
peristalsis. Pwedeng one time, Makita mo siyang
narrow because it is undergoing peristalsis, but of
course, it will not be continuous. Dapat un bubuka
siya eventually if it is normal.

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Ultrasound
 No radiation  Stomach
 Good for solid and cystic structure  Just below the left hemidiaphragm
 Anything that is black pertains to fluid  Aorta
 Gallbladder  Noncontrast-enhanced/plain CT scan (hindi
 It is fluid-filled. That’s why it is black. This is maputi)
what we call anechoic, or no echo.  Intestines
 Liver  Jejunum occupies the LUQ.
 It is a solid organ. That’s why we can see an  Ileum occupies the RLQ.
echogenicity.
 Right kidney MRI
 Adjacent the liver  Almost the same as the CT scan

CT scan ABDOMINAL ABNORMALITIES

 Axial cut (parang hinati ung tao sa loaf of bread)
Ano ba ung pinakacommon?
 If patient presents abdominal enlargement, dalawa lang
iisipin mo. Either may mass or massive ascites. Commonly,
it is massive ascites.

I. Ascites
 Abnormal fluid collection within the peritoneal cavity

 Vertebra
 It is in the posterior portion of the patient.
 Liver
 On the right side
 Stomach
 With air inside (magenblase)
 Aorta
 Normally, it should not be that white. If the
CT scan is contrast-enhanced, meaning nag-
inject ng contrast sa veins, all the vessels will
light up. Nagiging maputi.
 Spleen
 On the left side
 Kidneys
 They are hyperdensed. It means that it is a
contrast-enhanced study.  This is a plain abdominal film of a child. You see that
the air within the bowels is concentrated at the
 Coronal view (parang plain x-ray din siya na nakaharap sa center of the abdomen. Bakit nasa center? Because
inyo ung patient) the bowels are air containing and, if you imagine, you
have lots of fluid surrounding that, lumulutang na
lang sila. So, they are floating at the center. This is
your indication that likely you have a massive ascites.
 You also look at the flank stripes. They are already
effaced because of massive fluid collection.
 In the ultrasound, fluid is black. What you see is fluid
within the peritoneal cavity.
 In the CT scan, you can also see a fluid collection
within the peritoneal cavity.
 In MRI, depending on what sequence, fluid will
present as white.

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II. Pseudomyxoma peritonei IV. Abnormal calcifications
 When the fluid collection is secondary to malignancy, e.g.  You have normal calcifications like the bones.
ovarian cancer  Abdominal aortic calcification
 Fluid collection will not be that white in ultrasound or  Linear or curvilinear calcifications just to the left of
not that hypodensed in CT scan. It will present as the spine.
several septation. It will be lobulated with septation.  In elderly, aorta may be calcified kasi tubular ang
In short, it is a complicated fluid collection. aorta. It gives us curvilinear calcifications.

III. Pneumoperitoneum
 Air collection within the abdominal cavity.
 If you are entertaining pneumoperitoneum, request
for a CXR because you will be able to see the air just  Lymph node calcification
below the diaphragm.  Irregular, ill-defined calcifications
 You will see lucency in the entire abdominal cavity  Scattered
which looks like a football. So, that is what we call
football sign in massive pneumoperitoneum.

 Gallstones
 Calcifications below the liver shadow

 If you ask for a CT scan, since nakahiga ang patient,

air will go up. You have to look at the upper portion.
Air is at the anterior portion of the abdominal cavity.

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 Nephrolithiasis
 You have there cauliflower-like calcification.
 If patient did not undergo intravenous pyelogram or
any procedures for the kidney, yet you see
calcifications, this is a staghorn calculi.
2014 -2015
[RADIOLOGY]
 Calcifications in the pancreas
 Calcifications in the midupper abdomen
 Commonly caused by alcoholic pancreatitis
 Chronic pancreatitis secondary to alcoholism

LIVER

 Urinary bladder calcification  In ultrasound, you see black structure. Those are the hepatic veins.
Veins are filled with fluid (blood) kaya siya itim.
 In contrast-enhanced CT scan, liver is white.
 In MRI, it is the same as CT scan. Take note that the border of the
liver is very smooth. Hindi siya corrugated. Hindi siya wavy. It looks
like a sponge.

Hepatomegaly
 There are several ways to measure the liver.
 By x-ray, ultrasound (mas maganda), or CT scan
 But if you are given an x-ray like this, you will notice
an abnormality. Air in the bowels is displaced
because of very large liver.

 Uterine calcified fibroid

 If the patient is female
 Uterus may be calcified
 Calcified myoma

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Hepatitis
 Commonly, when you do ultrasound of hepatitis, it is
normal. But when you do have findings by ultrasound, the
liver is darker and you see echoes. May mapuputing area.
Those are the ducts. Ducts are not to be seen in a normal
ultrasound.
Cirrhosis
 You have a very coarsened liver parenchyma. The border is
already nodular, wavy, shrunken, and you see surrounding
black structures (black in ultrasound is fluid). Adjacent to
the liver is ascites which is a component of liver cirrhosis.
 Cirrhosis by plain CT scan shows the wavy, nodular border
of the liver. Adjacent the liver is the fluid collection
(ascites).
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Hemochromatosis
 This is a plain CT scan. If it is contrast-enhanced, aorta and
kidney should be white. But how come the liver is so white?
It is because of hemochromatosis. Don’t be mistaken that if
the liver is white, it is a contrast-enhanced study. This
means that the liver is more hyperdense.
Portal vein gas
 This is a CT scan image. You see branching lucencies. It is
black in CT scan. It is air. Para siyang tree in a bud. It is
because of air in the portal vein and its branches. The portal
vein gas, if it is within the portal vein, usually the air reaches
the peripheral 2 cm of the liver.
Metastasis
 You have a primary malignancy somewhere else. Liver is
one of the most common organs for metastasis.
 You have there hypoechoic nodules and masses in the liver.
 If you do a CT scan, you see multiple hypoechoic nodules
and masses.
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 If you do MRI, again, multiple hypodense structures within Hepatic cyst

the liver. Pag masyado ng marami like that, that’s  Cyst is fluid-filled. Commonly, it is a simple cyst. Ultrasound
metastasis. will present as black.

Hepatocellular carcinoma
 If the malignancy is primarily in the liver, you see
heterogenous masses within the liver.
 If you are dealing with mass anywhere else in the body, you
should request for contrast-enhanced CT scan because
malignancies are always vascular. There is something
supplying that mass, kaya siya lumalaki, and it is a vessel.
 For you to be able to know if that’s really a malignancy, you
request for contrast-enhanced and you will see the mass
enhances. Pagnag-enhance, ibig sabihin pumuputi. This
means that this is vascular. More often than not, it is
malignant.

 If you do a CT scan, it will present as hypodense. So, mas

maitim ng konti.
 If you do MRI, depending on what sequence, fluid will
present as white.

Hemangioma
 Hemangioma is benign. It is a vascular malformation. It can
be seen anywhere in the body, commonly seen in the liver.
And if it is seen in the liver, it will present as hyperechoic.
Meaning maputi. Usually, it is well defined.
 If you really want to know if it was hemangioma, you may
ask for a triple phase CT scan. Triple phase means you get
arterial scan, then a follow up venous phase, and then a
delayed phase. Because hemangioma involves arteries and  Note that in a cyst, margins are vey well-defined. So, it is
veins. So, if you do a triple contrast study, you will see that benign. If the border is irregular, ill-defined, or thickened, it
the contrast will have peripheral delayed enhancement. is malignant.

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Abscess
 “nana”
 It is common in liver.
 Actually, it is difficult to differentiate it from hepatocellular
carcinoma. So, ano lang ang magdifferentiate? Dyan na ang
papasok ang clinical eye. Patient is having high fever for one
week. More favoured ang abscess rather than
hepatocellular carcinoma. Patient is a teenager. Less likely
na hepatocellular carcinoma. You have to correlate it
clinically.
 If you do contrast-enhanced CT scan, you see that the
periphery is white while the center is hypodense. Bakit
periphery lang ang pumuti? Remember that in abscess, ang
vascularized lang ay ang paligid lang niya, sa capsule. And
then the inside of that is already “nana.” So, pus / necrotic
materials inside. Wala siyang vessels kaya it will not light up.

Trauma
 Spleen and liver are usually involved.
 Look for signs of trauma. Liver has lacerations. You also
have hematoma.

Echinococcal cyst BILIARY TREE

 This is pathognomonic of Echinococcus. You have there a
cystic lesion. But you have curvilinear echoes inside. What is
Echinococcus? Echinococcus is a parasite. It is a tapeworm.
Yung curvilinear echoes ay ung parasite, ung cocoon niya. It
looks like a rose.

 This is a magnetic resonance cholangiopancreatography (MRCP).

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 Used for the study of the biliary tree
 Intrahepatic bile ducts within the liver unite to form the common
hepatic duct. Common hepatic duct unites with the cystic duct of
the gallbladder to form the common bile duct. Common bile duct
will unit with the pancreatic duct and enter the second part of the
duodenum. Ano bang nasa loob ng biliary tree? Bile. That’s why it
goes to the duodenum for the emulsification of fats.
 Dapat ang calibre ng biliary tree ay manipis na tube.
Biliary ductal dilatation
 Obstruction in the distal portion will cause dilatation of the
proximal portion. The bile will not be excreted.
 In ultrasound, you will see fluid in the ducts. Katulad ng
sinabi ko kanina, you will not see ducts in a normal liver.
Unless, may hepatitis or biliary ductal dilatation.
 If you request for a CT scan, you will see the dilated ducts
which are fluid-filled.
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 If you request for MRCP, you will see the biliary tree is
tortuous. Busog na busog / dilated. Dapat nga lang tubular
lang siya. You will also see filling defects caused by the
stones in the common bile duct. That causes obstruction
and dilatation of the biliary tree.
Choledochal cyst
 Abnormal dilatation of the biliary tree. There is no proven
cause of dilatation. It is just dilated.
 In Todani classification, the most common is type 1. You
have a fusiform dilatation of the common bile duct (first
picture).
Cholangiocarcinoma
 It is a malignancy involving the biliary tree.
 In MRCP, it is white all over. The proximal biliary duct is
already dilated and tortuous because of obstruction.
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Pneumobilia
 Air within the biliary tree
 In plain abdominal film, there are branching lucencies
overlying the liver shadow.

Gallstone / Cholelithiasis
 You see that the gallbladder has something inside. It is
white.

 In CT scan, you will see lucency within the liver that is not
extending beyond the periphery. Likely, it is air in the biliary
tree and not in the portal vein. If it is in the portal vein, it
reaches up to the periphery of the liver.
Cholecystitis
 Inflammation of the wall. The wall is thickened. Normally, it
should be less than 3 mm.
 The lumen is black.
 There is also fluid outside the gallbladder. We call it
pericholecystic fluid. That is already ascites.

GALLBLADDER

 It is a blind-ending structure filled with fluid.

 In ultrasound (a very good imaging modality for the gallbladder),
the normal gallbladder should be anechoic. There’s nothing inside
except for fluid. So, it will present as black.

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Calculous cholecystitis Acute pancreatitis
 Inflammation of the wall because of obstruction.  Inflammation of the pancreas
 The wall is thickened and gallstone is in the lumen causing  CT scan shows an enlarged pancreas and pseudocyst (fluid
obstruction. or cystic collection adjacent the pancreas).

Malignancy
 Rare
 You will see a solid, irregular, ill-define lesion within the
gallbladder.

Chronic pancreatitis
 Inflammation of the pancreas secondary to alcoholism.
 X-ray will show calcifications in the midupper abdomen.
 CT scan also shows calcification.

PANCREAS

 Head, body and tail

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Carcinoma Trauma
 Solid mass in the pancreatic duct kaya dilated. It’s causing  Contrast-enhanced CT scan shows area with infarction (ung
obstruction. mga hindi pumuti). May lacerations din.
 If not proven benign, always think pancreatic tumors as
malignant kasi mabilis lang ang progress.

Hemangioma
 Well-defined hyperechoic nodule
SPLEEN  Benign
 Request for a triphasic CT scan
 Organ in the left portion
 Ultrasound shows that the spleen is adjacent the left kidney.

Splenomegaly
 Intravenous pyelogram shows compressed pelvic calices in
the left kidney. Compression is caused by an enlarged
spleen.
 If the patient did not undergo intravenous pyelogram, you
will just think of staghorn calculi in the right kidney.

Lymphoma
 Hypoechoic masses within the spleen

PHARYNX AND ESOPHAGUS

 From mouth to the gastroesophageal junction

 Request for barium swallow or esophagogram

Achalasia
 Narrowing of the distal portion of the esophagus and
dilatation of the proximal part.
 Lower esophageal sphincter does not relax

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 Paraesophageal hernia
Presbyesophagus  Gastroesophageal junction is below the
 Seen in the elderly hemidiaphragm or the hiatus.
 Contrast goes to and from the esophagus  Locule of the stomach is already up outside the
 With several unregulated peristalsis abdominal cavity.
 Cause dysphagia

Diverticulum
 Outpouching of the esophagus
 Contrast or food will go to the diverticulum
Esophagitis  Zenker’s diverticulum
 May be secondary to inflammation or caustic substance  Upper portion of esophagus is involved.
ingestion  Epiphrenic diverticulum
 Lumen is narrow because the wall is inflamed.  Distal portion of esophagus is involved.
 Cause dysphagia

Malignancy
Hernia  New growth within the esophagus
 Anything that goes out of the area of the normal structure  Irregular border
 Sliding hiatal hernia  Lumen is narrow.
 Gastroesophageal junction is above the
hemidiaphragm. Napull siya upward.
 Part of the stomach is already up outside the
abdominal cavity.

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Leiomyoma Foreign body ingestion
 Border is smooth.  Opacity within the thoracic cage
 Benign  Lodge within the esophagus

Varices
 If patient has portal hypertension secondary to liver
cirrhosis.
 Veins around the esophagus become tortuous.
 Irregularity of esophageal wall
STOMACH AND DUODENUM

 Stomach
 Fundus, body, antrum

 Double contrast UGIS

 Shows barium and air
 Lumen should be smooth. No stenosis or irregularities.
 Rugae – longitudinal folds parallel to long axis of the
stomach
 Areae gastricae – small tufts of gastric mucosa 1-3mm in
size
 Abnormal pag di nakita ang rugae and areae gastricae

Trauma
 Intact esophagus in the upper portion.
 There is spillage of contrast outside the esophagus.
 Likely that the distal esophagus is perforated.

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Hypertrophic pyloric stenosis
 Thickening of the pyloric muscle causing narrowing of the
lumen
 Proximal part of the stomach will dilate.
 String sign and shoulder sign

Polyps
 New growths that are benign
 This will present as filling defects in UGIS.

Ulcer
 Abrasion / ulceration of the mucosa Malignancy
 Small mound in the UGIS  You can see filling defects in UIGS with irregular border.
 Malignancy  In CT scan, there is thickening of the wall of the stomach.
 Irregular border
 Benign
 Smooth border

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Trauma  Duodenum
st
 There is spillage of contrast outside the stomach.  Duodenal bulb (1 part)
 The stomach is perforated. nd
 Descending (2 part)
rd
 Transverse (3 part)
th
 Ascending (4 part)

Chronic ulcer
 There is spillage of contrast outside the stomach in
nontrauma patients.
 The stomach is perforated.
Diverticulum
 Outpouching in the descending segment

Fistula
 Caused by chronic gastric perforation
 From the stomach, you can visualize the colon without
seeing the small intestine.
Duodenal carcinoma
 Irregular narrowing of lumen

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Malignancy in the pancreas Small bowel obstruction
 Cause stenosis or narrowing of the duodenum  Dilated bowels filled with air in supine position
 Multiple air-fluid levels in an upright position

SMALL INTESTINES

 Jejunum
 Occupies LUQ
 Ileum
 Occupies RLQ Crohn’s disease
 Valvulae conniventes  Ulceration of the bowel
 Mucosal folds within the small intestine  Chronic inflammatory changes involving the terminal ileum,
cecum, ascending colon and part of the transverse colon.
 In CT scan, you can see thickened wall.

 Double contrast UGIS

Nonhodgkin’s lymphoma
 Thickening of the wall of the small intestine
 Lumen is narrow.

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Meckel’s diverticulum
 Outpouching
 Rare

Ulcerative colitis
 Inflammation involving the colon
 Lumen is narrow.

Parasitism
 Lumen should be white but there are tubular lucencies
occupying the lumen.
 Ascaris sp.

Malignancy
 New growth from the wall and may go to the lumen
 Filling defect in barium study
 Irregular wall
 Narrowing of the lumen because of an apple core deformity
secondary to colon cancer.

COLON

 Barium enema only or double contrast barium enema for the colon
 Patient is lying on a left decubitus position. Catheter is inserted into
the rectum and barium is injected into the entire colon.
 With haustrations
 Ascending colon, hepatic flexure, transverse colon, splenic flexure,
descending colon, sigmoid colon, rectum
 Visual colonoscopy to see the lumen, haustrations, lumps within
the colon

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 In CT scan, rectum wall is thickened secondary to rectal
carcinoma.

Closed-loop obstruction
 Obstruction secondary to twisting of the colon (volvulus)
 In sigmoid volvulus, it looks like a coffee bean.

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