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Bachtiar Murtala

Dept.of Radiology Medical Faculty Hasanuddin University

General Objective
To provide basic understanding about the role of radiological imaging in diagnosing gastroenterohepatologic diseases

Specific objectives
Imaging modalities and

techniques/examination procedures Radiological appearances of some GIT and hepatobiliary diseases

Organs scope

Abdomen Esophagus-rectum Liver Biliary tract Pancreas

In general
Plain abdominal radiography Conventional radiography with contrast

Imaging (US, CT-Scan, MRI, Nuclear


Plain abdominal radiography

Commonly used in emergency cases such as ; ileus

(dynamic or adynamic), peritonitis, free-air/fluid, blunt or penetrating trauma,etc Usually needed 3 standard positions : 1. Erect 2. Supine 3. LLD ( left lateral decubitus) 4. Cross table ( optional )

Large bowel obstruction

Less commonly than small bowel obstruction
Three main causes : - colon carcinoma - Volvulus - Diverticulitis

Colon cancer

Small bowel obstruction

Radiological signs
Bowel distended filled by gas++
Lack gas in the distal part Air fluid level (step ladder appearance) Valvula conniventes appears as herring bone

(herring bone appearance)


Necrotizing enterocolitis ( NEC)

Pneumatosis intestinalis

( Gas within bowel wall )

Bowel wall thickening
Properitoneal fat line disappear/

obliterate Paralytic ileus sign

Adynamic or paralytic ileus

Bowel distended until distal part
Air fluid levels (+) , longer

Herringbone appearance(-)

Radiography with contrast

Barium Sulphate (BaSO4)

suspension Iodine

Salivary glands :
Consist of : - Parotic glands - Submandibular glands Indications : Stones; inflamation; neoplasm Technique : - Plain Foto - Sialography - CT - MRI

Sialography :
Duct orifice. is located & intubated by a blunt needle/abbocath 0,5 1,5 ml contrast medium (water soluble/lipiodol) injected slowly

& then taking a series pictures Give a few drops of lemon juice make an after lemon film 10 later to evaluate the remaining contrast
Abnormalities : Chronic obstructive Sialectasis - stone - strictures Chronic non-obstructive Sialectasis (chronic inflamation)
Tumours (mostly mixed salivary type)

Esophagus :
It should be visualized with contrast media (Barium Sulfat) Esophagography Indications : - Dysphagia - Dyspepsia - Haematemesis/melena - Congenital anomalies ? Technique of Examination : The patient is asked to swallow a thick Barium Sulphate (1:1) or Iodine ( for baby) and followed by fluoroscopy & taking radiography

B. Abnormalities :

Congenital malformation - Esophageal atresia - Short esophagus with a thoracic stomach (Brachy-esophagus) - Duplication Traumatic Disorders rupture Abnormalities in density foreign bodies Abnormalities in Size (length & diameter) Abnormalities in architecture

Radiography positions : - AP - Right Anterior Oblique projection (RAO) - Left Anterior Oblique projection (LAO) - Spot Film (optional) Radiological Signs : A. Normal Indentations : - Knob aorta - Left main bronchus - Left atrium - Hiatus hernia

Esophageal atresia

Esophageal varices
Caused by portal hypertension,

commonly seen in cirrhosis hepatis cobble stone appearance

Esophageal stricture

Narrowing and irregularity due to corrosive materials (corrosive stricture)

Tumours : - Benign

: Filling defect with smooth border Forked stream appearance (Fluoroscopy) - Malignant : Filling defect with irregular border Spasticity

Aganglionic of the distal part of

esophagus Distal smooth narrowing with dilatation of the proximal segmen--mouse tail app.


(= Maag Duodenum/MD Foto) Is a radiographic evaluation of the stomach & duodenum by introducing contrast media inside [Barium sulfat (+) & air/gas (-) Indication : - Dyspepsia - Epigastric pain - Vomiting - Haematemesis/melaena

Procedure Of Examination
1. Preparation : fasting 4-6 hours 2. The patient swallows contrast Barium Sulfat (& air) followed by fluoroscopy and taking radiography in various position 3. Usually in Supine, Prone, Prone oblique, Erect. Spot-Film Compression (recommended)

Normal Anatomic Radiography

Radiographic Abnormalities of Gastroduodenal Disease. It can be classified as changes in :

Position Size (redundancy, enrlargement/widening,

narrowing/shrinkage) Contour Rugae abnormalities Filling defect Function

Fig. 28-14.

Left lateral erect film of the stomach

Pyloric stenosis
= Infantile Hypertrophic Pyloric Stenosis

- Protrution of mucosa and submucosal outward - Additional shadow

Mucosal atrophy
Mucosal hypertrophy-hypersecretion

three level density

Peptic ulcer
Mostly seen in pyloric antrum and duodenal bulbus

Primary Signs :
- En face (frontal view)barium spot with halo (active

ulcer) and star sign ( inactive) - En profile (lateral view)additional shadow , globular shape (active ulcer), conus (inactive)

Secondary signs
Contralateral/opposite spastic insicura Hypersecretion Bulb deformity

BENIGN Filling defect with smooth border


Types : 1. Early gastric cancer Limited in mucosa/submucosa mimicking ulcer 2. Advance gastric cancer Filling defect irregular border - Annular ( infiltrating type ) - Exophytic ( fungating type ) - Linitis plastica ( schirrus type) - Ulcer type, filling defect + ulcer

Congenital :

Stenosis post bulbar duodenal atresia Two bubbles app.

SMALL INTESTINE (JEJENUM & ILEUM) Normal size: - 20 feets (length) - 2,5 cm (jejenum); 1,75 cm (ileum) in diameter Indications:

Anemia (unclear origin) Persistent diarrhoe Abdominal pain Palpable mass Excessive protein loss Malabsorbtion


Obstruction signs Perforation Paralytic ileus Peritonitis

Technique of Examination

1. Plain abdominal radiography 2. Follow Through Patient is asked to swallow 200-300 cc Barium sulfat (1:2-3 water),followed by taking pictures 30-60 minutes interval until contrast seen in caecum


Crohns Disease = Regional ileitis Adhesion Fistula

COLON Indication : Haematochesia Persistent diarrhea Abdominal mass Obstructive symptoms Congenital abnormalities Contraindication : Ileus (Paralytic) Suspect Bowel Perforation Peritonitis

Technique of Examination :

Barium enema
(colon inloop) Mostly Double-Contrast method Preparation is the most important to remove faecal material from the colon Colon inloop : - Using a thin Barium sulfat (1:3-6) aprox. 2 L - Contrast should fill colon entirely (rectum-caecum) - Picture taken in many positions/ views.

1. Atresia Ani (Imperforate anus) , Foto polos abdomen terbalik (Invertogram) 2. Hirschsprungs disease ( megacolon congenitum )

Atresi ani
Radiographically : Technique of examination for atresia ani: Inverted or Wangesteen position Knee-chest position Aim : to identify the lowest end of air in colorectal

Lower level High level

Dilatation/Distension : - Idiopathic symptomatic megacolon (older age) - Hirschsprungs disease (megacolon

Disease of childhood, mostly males Abscent of ganglion cells in the mesenteric plexus in the narrowing segment (mostly sigmoid colon, 40%) Marked dilatation above the area of aganglionosis. Radiographically : - Plain abdominal films veriable degrees of distension of GIT above the obstruction - Barium enema/colon inloop

- Colon in loop : Narrowing along the site of aganglionosis Dilatation above the narrowing, might be associated with irregularity/sawtoothing/ulcerative Colitis Narrowing of the Colonic Lumen :

Obstruction of colon Obstruction to the flow of Barium can be caused by : Spasm Annular Carcinoma Intusussception Volvulus Diverticulitis


Carcinoma of Colon 3 types : Fungating type Polypoid type Annular type

Fungating type : - usually medullary Ca. - Sites: Caecum, Ascending Colon, Rectum - Complication: Bleeding, fistula Polypoid type : - Sites: usually Descending Colon - Complications: Intussusception

Annular type : - Sites: Sigmoid, Descending Colon, flexures - Complication: Fistula, obstruction Pathology : - 50 75% adeno Ca. - 20% fibro Ca. - 10% mucoid adeno Ca. Metastasis : Liver or regional nodes Radiographically : Filling defect with Obstruction signs

Intussusception = Invagination A proximal segment of bowel (intussusceptum) into lumen of a distal segment (intussuscepiens) Location : Ileoileal > ileocolic > colocolic Radiographic sign : - Coiled spring or cupping sign -proximal bowel dilatation -absence of gas in dist segment

Cupping sign

Coiled spring

US findings : -Target sign, doughnut sign or bulls eye sign (transverse scan ) - pseudokidney sign ( longitudinal scan)

Inflammation :
- Ulcerative colitis - Crohns Disease

Ulcerative Colitis - Loss of haustra - Contracted,shortened & small calibre - Saw-toothing/ulceration - Stringiness/String sign


Acute appendicitis
Acute appendicitis acute appendiceal inflammation due

to luminal obstruction and superimposed infection Most common abdominal surgical emergency. Diagnosis clinical history, physical examination & laboratory studies. Imaging is useful and advisable in patients with atypical symptoms. Mortality rate in developing countries : 1%. () to 5% in small children & elderly. Surgical aim to operate early before complications such as appendiceal rupture & peritonitis developed. Helical CT scan & graded compression US powerful imaging methods in appendicitis




Imaging modalities :

- USG : Ultrasonografi / Ultrasound - CT scan : Computerized Tomography - MRI : Magnetic Resonance Imaging - MRCP : MRI for Cholangiopancreatography. - PTC(D) : Percutaneus Transhepatic Cholangiography ( Drainage ) - T-Tube Cholangiography, Durante operatif , Post operatif - Nuclear Medicine

- Soliter / multiple
- Echogenic/hyperechoic structure dengan acoustic shadowing

Acute Cholecystitis
* Gallbladder wall thickening > 3 mm
* Sludge



- Liver atrophy - Increasing echogenecity, fibrotic. - Irregular of the surface - Portal hypertention - Splenomegaly - Ascites.


USG : Iso hipo or hiperechoic mass Ill-defined TUMOR METASTASIS Noduler bull-eye, usually multiple, Well defined

Liver abscess
Hypoechoic mass Irregular and thicken wall

Liver cyst
Free-echoic mass, well defined, Solitary or multiple

Biliary obstruction
Causes : - Stone - Tumor intra/extraluminer. such as Panreatic cancer,

- Strictur cholangitis, etc

Biliary obstruction due to cancer of caput pancreas