Book Reading

Recognizing Extraluminal Gas in the Abdomen

&
Recognizing Gastrointestinal, Hepatic, and Urinary
Tract Abnormalities
Oleh : Cardio Miftahul Firdaus
Pembimbing : dr. Nurwanto Sp.Rad
SMF Ilmu Radiologi RS Muhammadiyah Lamongan
FK Universitas Muhammadiyah Malang
2021
Extraluminal Gas in the Abdomen
 SIGNS OF FREE
INTRAPERITONEAL AIR
There are three major signs of free intraperitoneal air, which they are most
commonly seen:
■ Air beneath the diaphragm
■ Visualization of both sides of the bowel wall
■ Visualization of the falciform ligament
The most common causes of free air are perforated peptic ulcer, trauma
(whether accidental or iatrogenic), perforated diverticulitis, perforated
appendicitis, and perforation of a carcinoma, usually of the colon
 AIR BENEATH THE
DIAPHRAGM
Air will rise to the highest part of the abdomen.
In the upright position, free air will usually reveal itself under the
diaphragm
 Free air beneath the diaphragm.
There are thin crescents of air beneath both
the right (solid white arrow) and left (dotted
white arrow) hemidiaphragms representing
free intraperitoneal air.
 Although free air is best demonstrated on computed tomography (CT) scans of the
abdomen because of its greater sensitivity in detecting very small amounts of free air

Free air seen on CT scan of the

abdomen. Axial CT scan of the upper
abdomen performed with the patient
supine shows free air anteriorly (white
arrows).
Free intraperitoneal air will normally
rise to the highest point of the abdomen.
If the patient is unable to stand or sit upright, then a view of the abdomen with the
patient lying on the left side taken with a horizontal x-ray beam may show free air
rising above the right edge of the liver
 Left lateral decubitus view showing free air.
Close-up of the right upper quadrant in a patient lying on the left side in the left lateral
decubitus position shows a crescent of air (dotted white arrows) above the outer edge of
the liver (black arrow), beneath the right hemidiaphragm (solid white arrow).
VISUALIZATION OF BOTH
SIDES OF THE BOWEL
WALL
In the normal abdominal radiograph, visualize only the
air inside the lumen of the bowel, not the wall of the bowel itself.
The ability to see both sides of the bowel wall is a sign of free intraperitoneal air
called Rigler sign

Rigler sign.
When air fills the peritoneal cavity, both sides of the
bowel wall will be outlined by air (white arrows)
making the wall of the bowel visible as a discrete line.
This is known as Rigler sign and indicates the
presence of a pneumoperitoneum.
This patient had a perforated gastric ulcer
 VISUALIZATION OF
THE FALCIFORM
LIGAMENT
The falciform ligament courses over the free edge of the
liver anteriorly just to the right of the upper lumbar spine.
 Falciform ligament sign.
Free intraperitoneal air may surround the
normally invisible falciform ligament on the
anterior edge of the liver causing that thin,
soft tissue structure to become visible (solid
white arrows) just to the right of the upper
lumbar spine.
SIGNS OF EXTRAPERITONEAL
AIR (RETROPERITONEAL AIR)
The key signs of extraperitoneal (retroperitoneal) air are a streaky,
linear appearance or a mottled, blotchy appearance outlining
extraperitoneal structures and its relatively fixed position, moving very
little or not at all with changes in patient positioning.
 Extraperitoneal air seen on
CT.
Air is seen in the
retroperitoneum (solid black
arrow) on this axial CT scan of
the upper abdomen. Air outlines
the inferior vena cava (solid
white arrow) and the aorta
(dotted white arrow).
SIGNS OF AIR IN THE BOWEL
WALL
Air in the bowel wall is called pneumatosis intestinalis
 Pneumatosis seen in profile.
Close-up of the right lower quadrant in an
infant demonstrates a thin curvilinear lucency
that parallels the lumen of the adjacent bowel
(white arrows), an appearance characteristic of
gas in the bowel wall seen in profile. In infants
the most common cause for this finding is
necrotizing enterocolitis
 CAUSES AND SIGNIFICANCE
OF AIR IN THE BOWEL WALL
A more common which can occur in the following:
- Chronic obstructive pulmonary disease
- Diseases in which there is necrosis of the bowel wall such as:
Necrotizing enterocolitis in infants and Ischemic bowel disease in
adults
- Obstructing lesions of the bowel that raise intraluminal pressure, such as:
Hirschsprung disease in children and Obstructing carcinomas in
adults
 SIGNS OF AIR IN THE BILIARY SYSTEM
Signs of air in the biliary system include tubelike, branching lucencies in the right upper quadrant overlying the liver,
which are central in location and few in number, and gas in the lumen of the gallbladder.
 Air in the biliary tree. Frontal view of the upper abdomen from an upper gastrointestinal
series demonstrates several air-containing tubular structures over the central portion of the
liver consistent with air in the biliary system (white circle). There is also barium in the
gallbladder (white arrow). This patient had a history of a prior sphincterotomy for gallstones
so that reflux of air and barium into the biliary system would be expected.
Causes of pneumobilia include incompetence of the sphincter of Oddi,
prior sphincterotomy,, and gallstone ileus.
The triad of findings in gallstone ileus are air in the biliary system,
small bowel obstruction, and visualization of the gallstone itself.

Gallstone ileus.
The three key findings of gallstone ileus are
present on this study.
Axial CT scan of the upper abdomen shows
air in the lumen of the gallbladder (black
arrow) and dilated small bowel (white
arrow) consistent with a mechanical small
bowel obstruction
Recognizing Gastrointestinal,
Hepatic, and Urinary Tract
Abnormalities
 Computed tomography (CT), ultrasound (US), and magnetic
resonance imaging (MRI) have essentially replaced conventional
radiography and, in some instances, barium studies for the
evaluation of the gastrointestinal (GI) tract
 ESOPHAGUS
Single- and/or double-contrast examinations of the
esophagus are performed with the patient drinking liquid
barium, either by itself (single contrast) or accompanied by
a gasproducing agent that provides the “air” in a double-
contrast examination.
Fluoroscopic observation of the esophagus can also
reveal abnormalities in esophageal motility

Tertiary waves.
This is a severe example of disordered and
nonpropulsive waves of contraction in the
esophagus called tertiary waves (white arrows).
 Diverticula of the GI tract are usually produced when the mucosal
and submucosal layers herniate through a defect in the muscular layer
of the bowel wall.
 Esophageal diverticula
occur in the neck (Zenker), around the carina
(traction), and just above the diaphragm
(epiphrenic)

Esophageal diverticula.
Just above the diaphragm in the distal
esophagus (epiphrenic diverticulum)
(black arrow)
 Hiatal Hernia
Most hiatal hernias are asymptomatic, but there is an
association between the presence of some hiatal hernias
and clinically significant gastroesophageal reflux
 Hiatal hernia.
There is a bulbous collection of contrast (solid
white arrow) representing the stomach
herniated above the diaphragm (dashed white
arrow). There are gastric folds present in the
hernia, identifying it as part of the stomach. The
narrowing seen above the hernia (dotted white
arrow) is the esophagogastric junction.
 Gastric Ulcers
In adults, infection with Helicobacter pylori accounts for
almost three out of four cases of gastric ulcer disease
Most ulcers occur on the lesser curvature or posterior wall in
the region of the body or antrum. About 95% of all gastric
ulcers are benign. The other 5% will represent ulcerations
in gastric malignancies
 Carcinomas of the stomach.
There is a large, polypoid filling defect in
the antrum of the stomach that displaces
the barium around it (solid black arrow).
Contained within the mass and seen en
face is an irregularly shaped collection of
barium that represents an ulceration in the
mass (dotted black arrow).
This was an adenocarcinoma of the
stomach
 DUODENAL ULCER
They are overwhelmingly caused by H. pylori infection
(85% to 95%).
The radiologic findings of duodenal ulcers include a
persistent collection of contrast, more often seen en face
with surrounding spasm and edema. Healing of duodenal
ulcers produces scarring and deformity of the bulb
 Acute duodenal ulcer
Contained within the duodenal bulb on
its anterior wall is a collection of
barium (black arrow), shown to be
persistent on a number of other images,
surrounded by a zone of edema (white
arrow) that displaces the barium from
around the ulcer.
 Perforated duodenal ulcer.
Axial computed tomography scan of
the upper abdomen done with oral
and intravenous contrast shows a
tract of extraluminal oral contrast
from the duodenum (solid white
arrow) into the peritoneal cavity
(dotted white arrow).
The patient had a perforated
duodenal ulcer repaired at surgery.
SMALL AND LARGE BOWEL
Key abnormal findings of bowel disease on CT are
thickening of the bowel wall, submucosal edema,
hemorrhage, hazy infiltration of fat, and extraluminal air
or contrast
 SMALL BOWEL – Crohn Disease
Crohn disease is a chronic, relapsing, granulomatous inflammation of
the small bowel and colon, usually involving the terminal ileum, resulting
in ulceration, obstruction, and fistula formation.
 Crohn disease
A close-up image of the right lower
quadrant from a small bowel follow-
through study in another patient
shows multiple streaks of barium
(solid and dotted white arrows),
representing multiple enteric
fistulae originating from an
abnormal loop of small bowel
(dashed white arrow) and
connecting with each other and the
large bowel.
 LARGE BOWEL –
Diverticulosis
Colonic diverticulosis increases in incidence with increasing
age, most often involves the sigmoid colon, and is almost
always asymptomatic, although it can lead to diverticulitis
or massive GI bleeding.
 Diverticulosis.
In this computed tomography scan of the
pelvis, diverticula contain air and appear
as small, usually round outpouchings,
especially in the region of the sigmoid
colon (white oval).
LARGE BOWEL – Diverticulitis
CT is the study of choice for imaging diverticulitis, and the
findings include pericolonic inflammation, thickening of
the adjacent colonic wall (>4 mm), abscess formation,
and/or confined perforation of the colon.
 Diverticulitis, computed tomography
(CT).
Infiltration of the pericolonic fat is
demonstrated by a hazy increase in
attenuation (white arrow) of the normal fat.

Focal infiltration of fat is a common

characteristic of inflammatory disease
 Colonic Carcinoma
Colon cancer is the most common cancer of the GI tract. Most
occur in the rectosigmoid region and take years to develop.
The imaging findings of colonic carcinoma are a persistent,
large, polypoid or annular constricting filling defect of the colon,
which may have frank or microperforation, or large bowel
obstruction and metastases especially to the liver and the lungs.
Annular constricting carcinoma of the
rectum.
There is a characteristic applecore lesion
of the rectum caused by circumferential
growth of a colonic carcinoma.

The margins of the lesion (black arrows)

demonstrate what is called an
overhanging edge.
The “core” of the “apple” (white
arrow) is composed of tumor tissue—all
of the normal colonic mucosa has been
replaced.
 Colitis
Colitis is inflammation of the large bowel.
There are causes of colitis including infectious, ulcerative and
granulomatous, ischemic, radiation-induced.
Colitis of any etiology can cause thickening of the bowel wall,
narrowing of the lumen, and infiltration of the surrounding fat.

Colitis.
The colon demonstrates
thumbprinting (white arrows) and a
pattern that is called the
accordion sign.
 Appendicitis
Appendicitis is also diagnosed using ultrasound.
CT is the study of choice in diagnosing appendicitis. Findings
include a dilated appendix (>6 mm), which does not fill with oral
contrast, periappendiceal inflammation, increased enhancement of
the wall of the appendix with intravenous (IV) contrast, and
sometimes identification of an appendicolith (fecalith)
 Appendicitis, computed
tomography
There is infiltration of the
periappendiceal fat in the right
lower quadrant manifest by the
increased attenuation in the
mesenteric fat (white arrow).
 PANCREATIC
Pancreatitis  The two most common causes of pancreatitis are
alcoholism and gallstones.
CT findings include enlargement of the pancreas, peripancreatic
stranding, pancreatic necrosis, and pseudocyst formation.
 Acute pancreatitis
The body of the pancreas is enlarged (black arrow). There is infiltration of the
peripancreatic fat (white arrows)
HEPATOBILIARY
ABNORMALITIES
 Cirrhosis
Cirrhosis is a chronic, irreversible disease of the liver, which
features destruction of normal liver cells and diffuse fibrosis.
Complications of cirrhosis include portal hypertension, ascites,
renal dysfunction, hepatocellular carcinoma, hepatic failure,
and death.
In its later stages, cirrhosis produces a small liver with a lobulated
contour, inhomogeneous appearance of the parenchyma, prominent
left and caudate lobes, splenomegaly, varices, and ascites.
Portal hypertension may develop, which can lead to dilated vessels around the
stomach, splenic hilum, and esophagus, representing varices

Cirrhosis with portal hypertension,

computed tomography.
Portal hypertension can lead to dilated
vessels around the stomach, splenic
hilum (white arrows), and esophagus,
representing varices. Splenomegaly
may develop (S).
There is characteristic enlargement of
the caudate lobe (C) relative to the right
lobe of the liver (black arrow),
especially in alcoholic cirrhosis
 Hepatocellular Carcinoma (Hepatoma)
Hepatocellular carcinoma is the most common primary hepatic malignancy. On CT, most HCCs are low density (hypodense) or the same density as normal liver (isodense) without contrast; then they enhance on the arterial phase with IV contrast (hyperdense) and return to hypodense
or isodense on the venous phase.
 Diffuse hepatocellular carcinoma of
the liver, computed tomography.
The arterial phase demonstrates patchy
enhancement (black arrow), indicating
the probability of tumor necrosis in the
low-attenuation areas. There is ascites
present (A). The overall volume of the
liver is decreased and the contour is
lobulated from underlying cirrhosis.
 Cavernous Hemangioma
Cavernous hemangiomas are the most common primary liver tumor and second in frequency to metastases for localized liver masses. MRI is frequently the preferred modality in the evaluation of hemangiomas, because it is more sensitive than a nuclear medicine–tagged red blood cell scan and more specific than a multiphase CT scan.
 Cavernous hemangioma of the liver, magnetic resonance imaging.
A, This image (an axial T1-weighted image) demonstrates a well-circumscribed, slightly lobular
dark mass in the right hepatic lobe (white arrow in all images).
B, Subsequent images following the administration of intravenous contrast (gadolinium) show
peripheral-to-central enhancement, until the entire mass homogeneously enhances on a delayed 10-
minute image.
C, The combination of this enhancement pattern and the signal characteristics of the lesion allows an
unequivocal diagnosis of hemangioma.
RENAL
 Renal cell carcinoma (hypernephroma)
Renal cell carcinoma is the most common primary renal malignancy and
shows a propensity for extension into the renal vein and for metastasizing to
lung and bone. On CT, it is usually a solid mass that enhances with IV contrast
but remains less dense than the normal kidney. On ultrasound, smaller renal
cell carcinomas are usually hyperechoic.
 Renal cell carcinomas, computed tomography and ultrasonography.
A, There is a low-density mass involving the anterior portion of the left kidney (white arrow). The tumor is
seen to extend directly into the left renal vein (black arrow), a feature of renal cell carcinomas.
B, Sagittal ultrasound on another patient with renal cell carcinoma shows an echogenic mass (M) occupying
the midportion of the kidney (dotted white arrows).
PELVIC
 URINARY BLADDER
Bladder Tumor
Most malignant bladder tumors are transitional cell tumors.
Transitional tumors may occur simultaneously anywhere along the
uroepithelium from the bladder to the ureter to the kidney.
The primary tumor appears as focal thickening of the bladder wall
and/or produces a filling defect in the contrast-filled bladder.
 Transitional cell carcinoma of the bladder,
computed tomography urogram.
There is a filling defect in the left lateral wall
of the contrast-filled bladder (solid white
arrow), representing a tumor.
The defect at the base of the bladder (black
arrow) is caused by the prostate gland.
The calyceal collecting systems (dotted white
arrows) are normal.
TERIMA KASIH