Imaging

By: Mohamed Mourad University of Alexandria Assistant lecturer of general surgery

GI Surgery Unit Faculty of Medicine University of Alexandria

Different imaging modalities

Imaging

X-ray
Plain

Ultrasound
With contrast
Barium swallow, meal, followthrough, enema ERCP, PTC, OCG

CT

MRI eg MRCP

Chest

Abdomen

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Plain chest x-ray

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Plain X-ray Chest postero-anterior view

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Ideal chest x-ray PA view

Trachea mid way between the 2 clavicles 1/3 of the heart lies in the Rt side of the midline Visible upper diaphragmatic surface from one costophrenic angle to the other

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Normal plain chest x-ray PA veiw

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Plain chest x-ray PA veiw

Free Air under diaphragm Diaphrag matic hernia

Cardiothoracic disorders

Foreign body

Hydro thorax

Pneumothrax

Fractu re ribs

Lung abces s

Radioopaqu e shado w
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Plain standing x ray PA view showing Free air under diaphragm

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Plain standing x ray PA view showing Free air under diaphragm

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Air under diaphragm

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Plain x ray PA & lateral view showing Foreign body in thoracic esophagus

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Congenital diaphragmatic hernia

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Plain abdomen x-ray

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Plain X-ray abdomen supine

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Plain X-ray abdomen standing

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Plain X-ray abdomen

Radio-opaque shadow Distended bowel loops Air fluid level Foreign body Gas in the biliary system or GB

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Plain x ray abdomen and pelvis PA view showing Radio-opaque shadow

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DD radio-opaque shadow of Rt. hypochondrium

Gall bladder stones Renal stones (Dx Lat X-ray & US) Porcelain gall bladder Calcified LN Fracture tr. Process of vertebra FB Fecolith Calcified hydatid cyst
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DD: renal & gall bladder stones

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Radio-opaque shadow of the abdomen x ray

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Chronic panreatitis

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Erect Plain x-ray abdomen &pelvis PA view showing Distended bowel loops

Distended Jejunal loops

Central Valvae conniventes

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Plain x-ray abdomen &pelvis PA view showing Distended bowel loops

Distended Ileal loops

Central featureless

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Plain x-ray abdomen &pelvis PA view showing Distended bowel loops

Distended Colon

peripheral Colonic hausteration

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Plain x-ray abdomen & pelvis showing distended colonic loops

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Post operative adynamic ileus

Supine Erect

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Plain x-ray abdomen and pelvis showing pneumatic tire appearance

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Plain x-ray abdomen and pelvis showing pneumatic tire appearance

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Plain x ray abdomen & pelvis showing double bubble sign

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Plain x-ray abdomen and pelvis Foreign body

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Plain x ray abdomen showing aeroblia

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Invertogram

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Oral Cholecystography

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Steps of oral cholecystography (OCG)

Control X-ray Ingestion of telepaque Another X-ray 12hrs latter Intake of fatty meal Another X-ray 2hrs latter

Remember that 85% of gallstones are radiolucent

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Oral cholecystography (OCG)

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Oral cholecystography (OCG)

Site--- (bt. 12th rib & LV1) Size--- (Contraction with fatty meal) Shape Filling defect Function (concentration & contarction)

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Gall stones in OCG

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Non visualized gall bladder in OCG

Absent gall bladder Stone in cystic duct Non functioning gall bladder

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Barium swallow

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Barium swallow

Technique Normal indentation

Aortic arch Lt main bronchus

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Pathologies by barium swallow

Achalasia of the cardia

Corrosive stricture
Corkscrew oesophagus Carcinoma of oesophagus Oesophageal varices Oesophageal diverticulae

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Achalasia of the cardia

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Barium swallow showing smooth narrowing of distal end of the oesophagus with proximal dilatation

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Barium swallow showing smooth long narrowing of middle 1/3 oesophagus

Corrosive stricture

Single or multiple Long segment Smooth tapering Usually in children Starts at aortic arch level

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Corrosive stricture

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Barium swallow showing Corkscrow oesophagus

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Irregular filling defect mostly Cancer oesophagus

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Oesophageal malignancy

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Oesophageal malignancy

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DD between achalasia and malignancy

The cardia is normally below the diaphragm

In X-ray 1, the oesophagus is interrupted above the diaphragm In X-ray 2, the cardia below the diaphragm is closed with bird beak-like shape

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serpiginous filling defects in the oesophagus Oesophageal varices

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Barium swallow with outpouch of the barium--Oesophageal diverticula

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Epiphrenic and Zenkers diverticulum

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Oesophageal web

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Barium meal

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Barium meal

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Barium meal

Single contrast

Double contrast

Large volume low density Distension of stomach by volume

Small volume high density+ effervescent Distension of stomach by buscopan

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Barium meal (Single & Double)

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Barium meal

1, 2, 3, 4,

Gastric antrum pyloric canal duodenal cap duodenal loop

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Pathological findings in barium meal

Hiatal hernia Chronic benign gastric ulcer Chronic duodenal ulcer Gastric malignancy Gastric outlet obstruction

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Hiatal hernia

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Barium meal in trendlenberg position showing Sliding hiatal hernia

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Barium meal in trendlenberg position showing Sliding hiatal hernia

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Barium meal in trendlenberg position showing Sliding hiatal hernia

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Barium meal in trendlenberg position showing paraoesophageal hiatal hernia

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Barium meal showing paraoesophageal hiatal hernia

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Barretts oesophagus

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Benign gastric ulcer

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Benign gastric ulcer

On lesser curvature Convergence of mucosal folds Out pouch

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Barium meal showing ulcer nich at the middle of lesser curvature with mucosal convergence Benign gastric ulcer

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Hour glass deformity

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Normal duodenal cap and DU

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2 kissing duodenal ulcers

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Trifoliate deformity of DU

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Gastric tumors

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Malignant gastric ulcer

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Malignant gastric ulcer

Any site of stomach mainly antrum and greater curvature Ulcer dose not protrude to the outside Mucosal folds obliterate before the edges of the ulcer

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Lintis platica

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Lintis plastica

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Pyloric filling defect of malignant origin

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Pre-pyloric tumor

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Duodenal diverticulum

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Barium meal showing dilated stomach reaching pelvis with mottled dye without passage of dye to dudenum (Gastric outlet obstruction)

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Barium meal showing Soap dish appearance

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Congenital hypertrophic pyloric stenosis

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GOO by compression from outside

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GOO by pseudopancreatic cyst

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Volvulus of the stomach

Organoaxial volvulus Mesenteroaxial volvulus

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Organo-axial volvulus

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Duodenal atresia

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Barium follow through

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Barium follow through

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Stricture of small intestine

Chrons Lymphoma TB Radiation

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Chrons stricture

Commonly at terminal ileum Multiple, rigid, irregular stricture (string sign of Kantor) Skip lesions Cobble stones Polyps Fistula

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Barium enema

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Barium enema

Single contrast
Filling phase Evacuation phase

Double contrast

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Normal barium enema filling phase

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Pathological findings in barium enema

Colonic cancer Colonic diverticulosis Colonic polyposis Intussusception Hirschsprung disease

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Transverse colon filling defect

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Transverse colon filling defect (colonic malignancy)

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Cancer ascending colon

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Barium enema showing arrest of the dye at the level of rectosegmoid junction due obstruction of the lumen

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Diverticulosis

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Chrons disease

Commonly at terminal ileum Multiple, rigid, irregular Skip lesions Cobble stones Polyps Fistula Loss of hausterations

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Ulcerative colitis

Rectosegmoid Loss of hausteration Polyps No skip lesion Narrow colon (lead pipe)

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Ischemic colitis

segmental narrowing of the entire transverse colon. Within the narrowed segment, there are multiple nodular indentations, many of which have the appearance of thumbprinting

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DD of colonic stricture

Chrons TB Cancer Diverticulitis Ischemic colitis

caecum iliocecal segmoid segmoid splenic flexure

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Hirschsprung disease

Stenotic segment Dilated rectum Transitional zone (funnel) Delayed evacuation

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Rounded filling defect (polyps)

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Rectosegmoid polyps

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Barium enema showing hundreds of filling defects of the entire colon (FAP)

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Intussusception

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Intussusception

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Barium reduction of intussusception

Head of intussusception is at hepatic flexure Partial reduction Free flow of contrast into distal small bowel indicates complete reduction

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Biliary imaging

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Types
Biliary imaging

Ultrasound

Contrast X ray PTC

CT scan

MRCP

ERCP T-tube Cholangiogram

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PTC

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Normal PTC

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CBD stone-PTC

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CBD stone-PTC

One or more intraluminal defects

(round, faceted or lobulated) which

produce varying degrees of biliary obstruction are seen. Occasionally stones are noted as small multiple free-floating defects in a nondilated duct.

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CBD stricture PTC

Transhepatic cholangiogram showing a stricture of the common hepatic duct

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ERCP

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Normal ERCP

Common bile duct Gall bladder

Common hepatic duct

Rt. & Lt. hepatic ducts

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CBD stone-ERCP

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CBD stone-ERCP

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CBD stone-ERCP

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Multiple intrahepatic & extrahepatic stones

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Bile duct carcinoma-ERCP

A short segment constricting lesion with irregular margins was noted at the bifurcation of the common hepatic duct (Klatskin tumour)
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Stents insertion-ERCP

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Cholangiogram

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Normal T-tube cholangiogram

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Normal T-tube cholangiogram

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CBD stone, T-Tube

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CBD stone, T-Tube

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Transcystic IO cholangiogram

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Transcystic IO cholangiogram

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Radiological pattern reflecting the cause of biliary obstruction

Choledocholithiasis (biliary duct stones)

One or more intraluminal defects (round, faceted or lobulated) Occasionally stones are noted as small multiple free-floating defects in a non-dilated duct. Sometimes impacted with crescent sign.
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Radiological pattern reflecting the cause of biliary obstruction

Pancreatic carcinoma

Complete or almost complete obstruction of the mid or distal common duct, usually over a long segment (3-4 cm) of the distal duct

(intrapancreatic portion)

is seen. A "rat-tail" configuration is the typical appearance

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Radiological pattern reflecting the cause of biliary obstruction

Cholangiocarcinoma

The narrowing may occur at any level and typically presents as a segmental stenosis. When the lesion is located at the bifurcation, it is referred to as a Klatskin tumor
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Radiological pattern reflecting the cause of biliary obstruction

Benign stricture

There is a short segmental circumferential stricture in the mid-common duct in a patient with a previous cholecystectomy. Most benign strictures are secondary to ductal injury during cholecystectomy.

(iatrogenic)

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Radiological pattern reflecting the cause of biliary obstruction

Ampullary carcinoma

Focal obstruction of very distal CBD is noted. A smooth constriction or an irregular polypoid mass growing into distal CBD may be seen.

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Radiological pattern reflecting the cause of biliary obstruction

Ascariasis

Worms are seen extending through the common bile duct and major hepatic ducts

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MRCP

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Normal MRCP

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CBD stones-MRCP

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Klatskin tumor-MRCP

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Biliary injury-MRCP

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Liver imaging

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Hydatid liver cyst

Fluid attenuation No peripheral enhancement Daughter cysts Well defined Rounded or oval

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Imaging

Thank You

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