Vicente Francisco R. Hizon, M.D. Augustina D.

Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
OUTLINE I. II. III. IV. V. VI. VII. VIII. Pharynx Esophagus Abdomen Stomach & Duodenum Small Intestines Large Intestines, including Rectum and Anus Liver, Hepatobiliary Tree & Gall Bladder Pancreas

pharyngogram shown on the left), abnormal luminal contour, or focal increased density; (2) mucosal irregularity owing to ulceration or mucosal elevation (3) asymmetric distensibility caused by infiltrating tumor or extrinsic nodal mass. 4. Computed Tomography Scan (CT-Scan)

• • •

For a more detailed evaluation For less radiation exposure: request for with multislice ||> May allow better visualization and evaluation of osseous structures, soft tissues and vascular networks; Uses contrast agents administered intravenously, takes a longer scanning time, and is more expensive.

Disclaimer: Don’t hate us for this trans. This is our first trans on Imaging Modalities and we tried our best to make this at par with our usual transes. If you find any difficulty appreciating the figures, please see Dr. Hizon;s slides. The file’s uploaded in our Scribd account.

PHARYNX Radiographic Evaluation 1. Plain Radiograph or X-ray • most common imaging modality


Soft tissues of the neck viewed laterally Neck is positioned in hyperextension Usually x-ray comes from the patient’s right side, film is at the left Done to evaluate the thickness and osseous structures of the pharyngeal area; normal pharyngeal airspace: 1-2 cm in thickness ||> This is a lateral view of the neck to image the normal pharynx. The neck should be hyperextended and it is important to instruct the patient not to move. Note the thickness of the soft tissues and check for abnormal indentations Normal: Homogenous image; air column seen anterior vertebra

• •

5. Magnetic Resonance Imaging (MRI) • even better than CT-scan • uses a magnetic beam to visualize tissue • Soft tissue appearance is much better than CT-Scan • Metallic implants/objectscontraindicated

• • •

titanium, friendly

porcelain

MRI

This modality is best for soft tissues and is only reserved for difficult cases. MRI provides much greater contrast between the different soft tissues of the body

Pharyngeal Disorders that need imaging: 1. Diverticula

• •

Can be anterior, lateral or posterior; congenital or acquired “Zenker’s Diverticulum” o Also known Pharyngo-esophageal Diverticulum, o Originates in Laimer’s triangle or Kilian’s dehiscence o It is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the oesophagus) o Take a look at thickness of prevertebral face

2. Fluoroscopy

• • • •

next most common Evaluation of structures in real life time – flexion, extension and in swallowing In swallowing – soft tissue density of prevertebral structures can be seen If there’s a foreign body, this can be used  have patient swallow barium so that the defect can be seen. Divided into the nasopharnyx, oropharynx and hypopharnyx Fluoroscope- consists fluorescent screen of an X-ray source and

• •

Modified barium swallow study - Barium-impregnated liquids and solids are ingested by the patient. A radiologist records and, with a speech pathologist (a.k.a speech therapist), interprets the resulting images to diagnose oral and pharyngeal swallowing dysfunction. This is also used in studying normal swallow function.

3. Double Contrast Pharyngography

• •

Makes use of contrast agent like Barium, in addition to Xray. Allows detection of tumors that are difficult to visualize endoscopically.

2. Retropharyngeal Abscess

• •

• Radiographic signs : (1) intraluminal mass- seen as a filling defect (pointed by arrows in the

Note the marked swelling of the prevertebral space, which indicates mass infection. Lucencies: indicate tissue breakdown compatible with tubular abscesses

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 1 of 13

Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
• •
If with calcifications  may be indicative of chronic tuberculosis. Take note of the thickness w/c is > 2 cm 3. Functional Disorders
A mass posterior to the pharynx; streaks of lucency

to detect

impairment of function.

Only a small amount of contrast or light barium is used because there is always the danger of aspiration and obstruction of the respiratory tree. In cases of aspiration (which can cause pneumonitis), the patient should be immediately hydrated by nebulization and administered with expectorants. This won’t work if thick contrast media is used. Watersoluble media are also not used in this procedure because it may lead to pulmonary edema.

May be caused by spasm due to: A. Neuromuscular Dysfunction • CNS Disease • Muscle Disease • Myasthenia Gravis • Peripheral Nerve Disease B. Abnormalities in the crico-pharnygeal sphincter • Achalasia, Myotonic Dystrophy, Familial Dysautonomia (Riley-Day Syndrome) Malignant Epithelial Neoplasms (Tumors)

1.

Chemical Esophagitis

C.


• •

Nasopharynx – more common for Filipinos  better diagnosed with CT-Scan or MRI Oropharynx Hypopharynx ESOPHAGUS

• •
2.

Ingestion of corrosive material Perforations indicate spillage

Motility Disorders PRIMARY

A.

B.
C.

Radiographic Evaluation CT-Scan – can be used for a dynamic study MRI

Achalasia: most common esophagogram • Cardiospasm

indication

for

• •

Deficiency of the ganglion cells of Auerbach’s plexus Failure of relaxation of the Lower Esophageal Sphincter (LES) Mecholyl Test Usually 30-50 yrs.

Radiographic Evaluation 1. Contrast Esophagography


• •

Usually done because the esophagus collapses Ask patient to hold the contrast medium in his/her mouth and swallow it slowly Single Contrast - Employs the most usual contrasts Use of Barium (non water-soluble) or other Water-soluble contrasts Double Contrast Other liquid media such as Sprite® or 7-Up® can be added to the contrast medium normally a part of upper GI series look for mucosal irregularities look for abnormal filling defects, areas of narrowing or dilatation seen in segments due to normal persistalsis of the esophagus

• • • • •

B A

A. Take note of the nasograstic tube and the lucent area compatible with achalasia. B. Dilated terminal part of the esophagus. Balloon-like dilatation is always ABNORMAL.

• 1st step: Drink contrast then hold in mouth 2nd step: Swallow then contrast is traced A B C D

• Diffuse Esophageal Spasm • Presbyoesophagus • Chalasia

Idiopathic Pseudo-obstruction esophagus

–constriction

of

SECONDARY • Connective Tissue Disorders (i.e. Scleroderma, SLE, etc.) • Reflux Esophagitis • Metabolic & Endocrine Disorders (i.e. DM, Alcoholism, etc.) • Neuromuscular Disease • Can be secondary to radiographic treatment
A. AP view. B. Lateral view. Look at where the esophagus is resting. The esophagus is not usually seen since it usually collapsed when empty. C. Done under fluoroscopic guidance. Check for filling defects and mucosal irregularities. D. Esophagogram of a normal esophagus as it enters the esophageal hiatus. Observe the smoothness of the mucosal surface.

3.

Congenital Anomalies • esophageal contrast study is usually indicated

*Note: If there’s suspicion of tracheoesophageal reflux -> ALERT RADIOLOGIST due to possibility of aspiration

B. Esophageal Disorders that warrant imaging studies

Atresia and TracheoEsophageal Fistula (TEF): most common cause: Iatrogenic due to chemicals

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Thurs, Feb. 24, 2011

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
Types:

• •

ABDOMEN A: Atresia with Distal TEF B: Atresia without TEF A. Radiographic Evaluation B. Contrast Study (barium enema, upper GI series C. CT-Scan D. MRI E. Ultrasound F. Nuclear (Radioisotope) Scanning Radiographic Evaluation 1. Plain Abdomen X-ray

There is a filling defect in the image (blind pouch) compatible with complete obstruction. In this case, no TEF is observed.

• • •
 

C: TEF without Atresia (H-type) D: Atresia with Proximal E: Atresia with Double TEF Duplication BronchoEsophageal Fistulas TEF

• • •

Patient in supine position. (X-ray beam above, X-ray plate below) Plain abdominal X-ray: upper limit should include the diaphragm; primarily for visualization of Upper GI Tract KUB studies: film should extend down the pubis and cover the whole pelvis What to Examine: o Gas Pattern – look at distribution of bowel gas o Extraluminal Air o Soft Tissue Masses o Calcifications – especially in the area of the gallbladder and the kidneys and urinary tract o Psoas Muscles & Flank stripes o Liver, Spleen & Bladder (esp. visible when distended) o Osseous structures Normal Gas Pattern: o Stomach: Always present (gastric bubble) o Small Bowel: 2 or 3 loops of non-distended bowel; finer lucencies o Rectum or Sigmoid: Almost always present

4. Esophageal Tumors

• • • •

Squamous: most common in the upper 2/3 Gastric: distal 3rd Esophagogram can reveal tumors well, provided that it is not yet fully obstructed If with complete obstruction: length cannot be determined so need to request CT-scan Diagnosed nowadays by Esophagoscopy and Endoscopy • Malignant Neoplasms • Carcinomas (Squamous, Adenocarcinoma, Carcinoid)

A

B

C

A. The image shows complete obstruction. B. Partial obstruction secondary to tumor mass. Take note of the irregularities in the esophageal mucosa suggesting multi-focus type of esophageal cancer. C. This is a classical picture of “shouldering defect” in esophageal carcinoma (Concentric carcinoma): irregular outline of esophagus.

• Sarcomas (Leiomyosarcoma, Fibrosarcoma, etc.) • Metastasis • Benign Neoplasms • Mucosal (Papilloma or Adenoma) • Submucosal (Neurofibroma, Leiomyoma, Hemangioma, Lipoma, Fibroma, Myeloblastoma, etc.) • Non-neoplastic Polyps Varices Cysts Focal Infection • Hematoma • Hamartoma • Chemical Esophagitis • Foreign Body • Normal Fluid Levels: Stomach: Always present (except in supine film) Small Bowel: Possibly present in 2 or 3 levels (few) Large Bowel: None normally  because water is absorbed

• • •

• • • • 5.

Foreign body - Ingested coin

• Small vs. Large Bowel

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
• Small Bowel o Central o Valvulae conniventes (mucosal foldings of the small intestines) extend across lumen o Has a maximum diameter of 2 in. (dilated if > 2) • Large Bowel o

o

Peripheral Haustral markings (sacculations in the wall of the large intestines) don’t extend from wall-to-wall
Supine Prone

Complete Abdomen: Obstruction Series (Abdominal X-ray positions)

No air-fluid levelling; Presence of gas in the rectum; Diameter is about 2 inches

Supine – this is done first for economic reasons: radiologist recommends whether to proceed with the obstruction series or not Prone

□ Generalized Adynamic Ileus  Gas in dilated small bowel and large bowel to rectum  Long air-fluid levels  Only post-op patients have Generalized Ileus  Can be caused by surgery or medications that affect GI motility

□ Look for:
 Gas in Rectum/Sigmoid  Gas in Ascending and Descending Colon

□ Alternative: Lateral Rectum if patient cannot lie
prone

Erect

□ Look for: 

Free Air/bowel gas  Air under the diaphragm (pneumoperitoneum)

Supine

Erect


leveling

Air-fluid
No presence of differential air-fluid level (2 air-fluid interfaces in 1 bowel);

□ Alternative: Left Lateral Decubitus – if unable to
sit up or stand up • Chest-Erect

• Mechanical Obstruction □ Small Bowel Obstruction (SBO)  Dilated small bowel

□ Look for:
 Changes in the pleural cavity  Blunting of the costophrenic sulci  Free Air  Pneumonia at bases  Pleural effusions

   
blunting of the

Fighting loops: dilating loops are very prominent; walls are thickened  Little gas in colon, esp. rectum Differential obstruction air-fluid levels: may indicate

□ Alternative: Chest-Supine if unable to sit/stand
*Collateral Findings: costophrenic sulci etc. basal pneumonitis,

Key: Disproportionate dilatation of the small bowel Causes:  Adhesions  Hernia*

• •

Causes of Abnormal Gas Patterns Functional Ileus (medical) □ Localized (Sentinel Loops)  One or two persistently dilated loops of large or small bowels

Volvulus** Gallstone

Ileus* obstruction of the ileus by a gallstone from the biliary tree  Intussusception**
**may be visible on plain film **Medical emergencies; Most common emergency procedures

 

There should always be gas in rectum or sigmoid  no gas = obstruction  Seen in Gastroenteritis Pitfall: mechanical SBO may resemble early

No gas in the rectum Thickening of bowel walls In upright –there is air fluid levelling in areas proximal

Pitfall: Early SBO may resemble localized Ileus (get follow up abdominal x-ray after 24 hours to see if it progresses)

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
□ Large Bowel Obstruction (LBO)

• • •

A radiologic emergency
week (if 1 week: proceed with caution!)

Dilated colon proximal to point of obstruction  Little or no air in rectum/sigmoid  Little or no gas in small bowel, if…  Ileocecal valve remains competent

• Golden period for correcting volvulus: 72 hours to 1
Be careful during palpation because volvulus may rupture

If incompetent, then small bowel air is seen 
Causes:  Tumor  Volvulus  Hernia  Diverticulitis  Intussusception Pitfalls: Incompetent Ileocecal Valve  Large bowel decompresses into small bowel  May look like SBO

In this case, a Barium enema would both be diagnostic and therapeutic. • In the figures below, take note of the different air-fluid levels

Get Barium Enema or F/O

1st: dilated bowel loop 2nd: differential levelling limited to large gut

||> Intraperitoneal Calcification

Supine

Prone

For Higher Learning: The radiological detection of peritoneal calcification is rare but potentially of major clinical importance because such findings have been associated with □ primary and secondary peritoneal malignancies; □ benign causes:


Air in Large Bowel Air in rectum or sigmoid Yes (Distended) No Yes (Dilated)

Table 1. Air in Rectum or Sigmoid Localized ileus Generalized ileus SBO LBO Yes Yes No No Air in Small Bowel 2-3 distended loops Multiple Distended loops Multiple Dilated loops None (unless ileocecal valve is incompetent)

Sclerosing peritonitis due to peritoneal dialysis Peritoneal tuberculosis Prior meconium peritonitis Hyperparathyroidism Pneumocystis carinii infection Postsurgical heterotopic ossification.

    
||> Intussusception

• An emergency situation

• •

a part of the intestine has invaginated into another section of intestine Intussuscepiens (R) □ The “receiver” □ The part of the bowel into which another part is invaginated in; □ The portion of the bowel containing the intussusceptum Intussusceptum (I) □ The “invaginator” □ The portion of the bowel that has been invaginated within another part

||> Gallstone Ileus • Occurs when the gallstone obstructs the lumen between the Ileum and the Cecum • May cause transient obstruction

R

I

R

I

||> Volvulus • Bean-shaped structure/Inverted U-loop structure in a radiograph is indicative of volvulus
‘Barium enema: incomplete filling of cecum

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
||> Extraluminal Air: Free Intraperitoneal Air
Free Air

Signs of Free Air (Pneumoperitoneum): □ Air beneath diaphragm □ Falciform Ligament Sign □ Air on both sides of bowel wall – Rigler’s Sign

Rigler's sign (also, double wall sign), is seen on an Xray of the abdomen when air is present on both sides of the intestine; a Rigler's sign is present when air is present on the inside (lumenal side) and the outside (peritoneal side).

||> Chilaiditi Syndrome • Normal findings • Loop of large colon insinuates between diaphragm and liver (hepatic flexure) • asymptomatic • Transposition of a loop of large intestine (usu. the Transverse colon) in between the Liver and the Right Diaphragm, causing extreme abdominal pain, volvulus and shortness of breath • Manifests in the abdominal X-ray as Chilaiditi’s Sign – presence of gas in the right Colic angle between the Liver and Right Diaphragm

□ Air

in Lesser Sac (the most anterior part of the peritoneum) – since mataas □ Football Sign and the Falciform ligament sign – seen bulging to the right

The Football Sign appears as a large oval radiolucency reminiscent of an American football seen on supine radiographs of the abdomen. The football sign is most frequently seen in infants with spontaneous or iatrogenic or iatrogenic gastric perforation causing pneumoperitoneum. Falciform ligament sign: seen bulging to the right; linked to the football sign  seen as the football’s seam

Falciform Ligament Sign

• Causes of Free Air: □ Rupture of a hollow viscus (an internal organ; singular form of viscera)  Perforated Ulcer  Perforated Diverticulitis  Perforated Carcinoma  Trauma or Instrumentation □ 5-7 days Post-op □ NOT caused by a perforated Appendix  Because the Appendix is retroperitoneum; and therefore, outside the peritoneum

||> Bochdaleck’s Hernia • One of two forms of a Congenital Diaphragmatic Hernia • Posterior and lateral in location • Heart is displace dot the rught • Bochdalek Foramen is found on the left posterolateral portion of the diaphragm.

Congenital abnormality wherein an opening that exists in the infant’s diaphragm allows intra-abdominally located organs (i.e. stomach and intestines) to protrude into the thoracic cavity Has the potential to be life-threatening – can cause deformities in the lungs that can lead to its compression Differential: Morgagni’s Hernia: medial in position

• •

Tel, Ther, Joram, Roland

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)

STOMACH & DUODENUM RADIOLOGIC STUDIES 1. Plain Abdomen X-Ray 4. MRI Small Intestinal Series (will be tackled later)

3. CT-Scan – will not be able to see the small intestine well – due to collapse; useful for locating nodes in malignancies

ACID-RELATED DISORDERS 1. Gastritis ||> Radiologic Findings • Acute □ Mucosal erosions and shallow ulcers that do not penetrate the gastric mucosa • Chronic □ Mucosal thinning and atrophy which is why in image below almost everything is contrast markings

Look for abnormal gas pattern, calcification, outline of liver, psoas shadow 2. Upper GastroIntestinal Series ||> Components:

Esophagogram (refer to previous figures)

• Gastric Series

Gastric irregularities’ mucosal changes

2. Benign Ulcer Disease ||> Radiologic Findings • Hampton’s Line – represents the edge of the overhanging gastric mucosa


Gastric series: Check for the rugal patterns as well as the patency of the GastroDuodenal junction. Normal gastric folds: Parallel to each other; Usually smooth

Ulcer Collar (pointed by arrow in the figure below) • Ulcer Niche (adjacent ) • Edematous gastric folds radiating towards the ulcer

• Duodenal Series
Edematous Gastric Folds

Ulcer Niche

Ulcer Collar

Mucosal bump at the periphery/ ulcer collar; Turn it en passé --<> Hampton’s line

3. Gastric Ulcer

Duodenal series: Loperamide or Buscopan are administered for the relaxation of the Duodenum - look for mucosal irregularities - reading: spastic duodenum – refuses to relax Buscopan – will dilate duodenum

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 7 of 13

Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
Hamptom’s Sign

Irregular mucosa; Cecal shape; Does not expand irregardless of contrast

• Gastric Lymphoma □ The stomach is a very common extranodal site for lymphomas □ Characterized by mucosal elevations and multiple erosions □ Extraluminal: gentler curves as compared to an intraluminal mass: distinct border from mass to mucosa

4. Gastric Diverticulum (may develop from gastric ulcer due to weakening of the walls; not much mucosal changes seen)

OTHER DISEASES 1. Diaphragmatic Hernia GASTRIC CANCER ||> Radiologic Procedures ||> A defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity ||> Treatment is usually surgical (make sure no part of the hernia is strangulated, it might cause Peritonitis)

Contrast studies (UGIS): not used so much nowadays • Endoscopic Ultrasound • CT-Scan (Staging) ||> Radiologic Classification

• •

Type I : Polypoid (> 0.5 cm.)

Type II : Superficial □ IIA : elevated (>0.5 cm) □ IIB : flat □ IIC : depressed (erosions not extending beyond Muscularis Mucosa) • Type III: Excavated (Ulceration)

A

B

C

Diaphragmatic Hernia: Look for the portion of the stomach outside the hiatus

2. Duodenal Ulcer ||> Also known as Peptic Ulcer Disease (PUD) ||> Majority are associated with Helicobacter pylori infections ||> Most Peptic Ulcers arise from the Duodenum (rather than the Stomach) ||> Are generally benign

Stomach (Gastric) Cancer: A. Antral Cancer compressing the pylorus; filling defect B. intraluminal mass; C. Note the irregular borders.

||> Examples • Linitis Plastica (Diffuse Infiltrative Carcinoma) □ A Diffuse infiltrative Carcinoma of the Stomach □ Also known as Brinton’s Disease or Leather Bottle Stomach

Antrum: ulcer NICHE at the proximal part of the duodenum

Leather Bottle Sign

Tel, Ther, Joram, Roland

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

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Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
• • • Also known as Ileocecal Tuberculosis Difficult to differentiate from Crohn’s Disease Can be seen as irregularities in the Terminal Ileum

3. Ileocecal TB with Abscess

Duodenal Ulcer: Note the folds toward the ulcer niche. The walls are edematous.

SMALL INTESTINES RADIOLOGIC STUDIES 1. 2. Plain X-ray Small Intestinal Series 4. Periappendiceal Abscess ||> Usually results from the perforation of an acutely inflamed appendix

||> The Ileum has a feathery appearance as compared to the Jejunum

A

B

SMALL INTESTINAL DISEASES 1. Crohn’s Disease • • • Most common non-specific inflammatory disease of the Small Intestines See thickened folds and mucosal irregularities If chronic – narrowing- string or rat-tail Findings of small fistula Also known as Inflammatory Bowel Disease (IBD) Radiologic Findings: • Thickened intestinal folds • Fistulas, Sinuses, and thickening/retraction of the Mesentery

A periappendiceal abscess in a localized area of displacement of the small intestine

5. Small Intestinal Parasite


• •

• •

String Sign – tubular narrowing of the lumen of the small intestines Transmural type of Inflammation (Inflammation may span the entire thickness of the Intestinal wall): Fine Granular Pattern  Nodular Mucosa (Submucosal Edema)  Ulceronodular Mucosa  Ulcerations
Adult ascaris in the small intestine: Barium-based contrast agents can irritate the worm and promote its migration in other organs like the liver. Sometimes, the patient may even expel vomitus with the worm.

LARGE INTESTINES & RECTUM RADIOGRAPHIC EVALUATION 1. Plain Abdominal X-Ray

Crohn’s Disease: Note the thickened mucosal folds

2. Ileocecal Koch’s

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

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2. Barium Enema (Single or Double Contrast)

• •

Also known as Lower Gastrointestinal Series. X-ray pictures are taken while barium sulfate fills the colon via the rectum. Air may be puffed to provide air contrast into the colon to distend it and provide better images (often called a "double-contrast" exam). There is a risk for hypotension associated with valsalva in the elderly undergoing this procedure. 4. Ultrasound 5. Abdominal CT-Scan 6. Rice-Wangensteen Radiograph ||> The Rice-Wangensteen radiographic technique is an inverted lateral radiograph of an infant ||> It is performed when the baby is at least 6 hours old ||> The baby is turned upside down in a lateral position with the hips flexed ||> Mainly used for the assessment of an Imperforate Anus

Double contrast improves visualization of the mucosa ||> If there is a suspected bowel perforation, a water-soluble contrast is used instead of barium.

A and B. Supine image, Arrow points to the insertion of the foley catheter that introduces the contrast until the level of the splenic flexure; C. Lateral Decubitus image. Note the smooth mucosal surface of the colon visualized by Barium Enema.

Wangensteen-Rice radiograph: The infant is held in invert position. Triangular metallic marker identifies the anal dimple. The arrow points to the occlusion on the lateral view. Additional UTZ examination helps to decide the real extent of the rectal atresia. The distal blind pouch plugged with meconium (outlined) disturbs the judgment of the exact level of atresia.

DISEASES OF THE COLON AND RECTUM 1. Congenital Disorders ||> Hirschsprung’s Disease • Also known as Aganglionic Megacolon • Enlargement of the colon secondary to bowel obstruction caused by the persistent contraction of a part of the colon with absent enteric nerves (hence the term ‘aganglionic’) for relaxation

Post evacuation radiography

Redundant rectosigmoid colon

condition where extra loops form, resulting in a longer than normal colon; a mass is felt and then disappears/changes place; presents with constipation

3. Defecography • Also known as Defecating Proctogram

||> Congenital Rectal Atresia ||> Imperforate Anus


An imaging study in which the mechanics of a patient’s defecation are visualized real-time, with the use of a fluoroscope Not done anymore

2. Diverticula

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Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

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Dangerous if spiculed: May rupture

□ Ileocecal Tuberculosis with Abscess: mucosal
irregularities indicate inflammation

3. Inflammatory Diseases ||>Ulcerative Colitis • Radiologic Findings: □ Acute  Fine granulations  Stippled appearance of the mucosa  Failure of the colonic walls to collapse on post-evacuation study □ Chronic  Loss of haustral markings

4. Polyps - there’s a filling defect ||> Morphologic Types • Sessile □ Broad base □ With mound-like protuberances plaques • Pedunculated □ With stalks

Coarse granulations (due to multiple ulcerations which increase in size and number) affecting the entire length of the colon  Accompanied by polypoid changes • Secondary Changes: □ Foreshortening of the Colon □ Lack of haustrations markings and tubular narrowing (Stove-pipe or Garden-hose sign) □ Increase in Presacral space (> 1 cm) □ Fibrosis or strictures may develop □ Increase in presacral space CECAL ABSCESS: ||> Granulomatous Colitis • i.e. Crohn’s Disease

or flattened

5. Malignancies ||> Radiographic Patterns • Annular Constricting

□ Apple-core appearance (mass is black part beside the core)

• Polypoid

||> Infectious Colitis • Examples:

□ Cecal

Abscess:appears almost the same as a malignant mass

• Infiltrating or Stenosing

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 11 of 13

Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

OS Reproduction and Hormonal Regulation OS 215 214 Digestion and Excretion

2

F

Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)
• Manifests with the String Sign

• Ulcerative

Filling defect in the cecum.

LIVER, HEPATOBILIARY TREE & GALLBLADDER RADIOGRAPHIC TECHNIQUES 1. Ultrasonography  procedure of choice 2. ERCP (Endoscopic Retrograde Cholangiopancreatography) 3. CT-Scan 4. MRI 5. MRS (Magnetic Resonance Spectroscopy) 6. Nuclear Medicine (Radionuclide Scanning) LIVER 6. Others ||> Redundant RectoSigmoid Colon ||> Radiologic Evaluation: 1. CT-Scan – more expensive&detailed; not used for screening, just for diagnostic purposes 2. MRI 3. Ultrasound Ultrasound with Doppler – flow can be visualized 4. Angiography

Done in the Operating Room usually for checking/screening for Hemangiomas and other tumors • Transfemoral catheter through femoral artery then abdominal aorta then organ of choice ||> Rectal Foreign Body 5. Nuclear (Radioisotope) Scanning

• A

For ‘hotspots’i.e. Ultrasound with Doppler

B C D

You don’t call this the bottle sign. This film shows an actual bottle claimed to be seated upon “accidentally”

||> Large and Small Intestine Fistula - usually iatrogenic

C D

E

||> Cecal Cancer

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 12 of 13

Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

OS Reproduction and Hormonal Regulation OS 215 214 Digestion and Excretion

2

F

Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)

Radiologic Evaluation of the Liver. A. CT-Scan; B. MRI; C. Ultrasound, Normal liver is clear; D. Angiography; and E. Nuclear (Radioisotope) Scanning (Blue Areas = arterial system and red areas = venous system)

||> Diseases of the Liver: 1. Tuberculosis of the Liver
A normal cholecystogram. (left) In the initial phase the contrast medium is seen evenly filling the gal/bladder, the walls of which are smooth. (right) After a fatty meal, the gallbladder has contracted. Now both the fundus and the neck of the gallbladder, as well as the cystic duct is filled with contrast medium and the common bile duct is demonstrated (arrows).

• Gallstones
The Liver is large with calcifications

2. Subcapsular Hematoma

Gallstones are usually moving in contrast to malignant growths.

If dark  mostly fluid; If something becomes bight  malignancy; if a lot of vessels  hemangioma

3. Fatty Liver-

liver brighter than kidneys  cholesterol deposits HEPATOBILIARY TREE ||> Radiologic Evaluation: 1. T-Tube Cholangiography


A sonogram of a fatty liver showing increased echotexture compared with the adjacent kidney (bright liver). The white round structures on the right sonogram correspond to fats.

GALLBLADDER ||> Unseen in normal radiographs; unless it is distended or stonecontaining ||> Radiologic Evaluation: 1. Plain Abdomen X-ray 2. Ultrasound

If it is done poorly  air bubbles will be misinterpreted as gall stones • A fluoroscopic procedure in which contrast medium is injected through a T-tube into the patient’s Biliary tree • The T-tube (a tubular device in the shape of the letter T) is most commonly inserted during a cholecystectomy operation when there is a possibility of having residual gallstones within the Biliary tree

The normal gallbladder (gb) is seen as a cystic structure with echofree contents. The walls of the gallbladder are smooth. Normal liver parenchyma (L) is seen to the left of the gallbladder.

2. ERCP (Endoscopic Retrograde Cholangiopancreatography) - to view pancreatic and biliary tree

3. Oral Cholecystography

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 13 of 13

Vicente Francisco R. Hizon, M.D. Augustina D. Abelardo, MD, FPCR, FPROS, FUSP, FESTRO, FPSO FPSP, MIAC

Patho 1

OS Reproduction and Hormonal Regulation OS 215 214 Digestion and Excretion

2

F

Lec 2A: Pathology ofTract Imaging Gastrointestinal the Female Genital Tract (Vulva and Vagina)

||> Diseases of the Biliary Tree: 1. Biliary Ascariasis

2. Pancreatic Mass

If still alive, a white line is seen inside since the parasite is still swallowing.

2. Retained Biliary Stone/Sludge

PANCREAS RADIOGRAPHIC TECHNIQUES

1. Ultrasonography 2. CT-Scan DISEASES OF THE PANCREAS 1. Pancreatitis ||> Irregularities and swelling in the Pancreas are observed here

Tel, Ther, Joram, Roland

Thurs, Feb. 24, 2011

Page 14 of 13