Git Rad Anatomy

RADIOGRAPHIC ANATOMY OF THE ABDOMEN AND
PELVIS
prepared by Ali.B (MRT, MSC) 03/14/2022 1

Learning Objectives
 Revise gross anatomy of the GIT
 List the imaging techniques of the GIT
 Identify anatomical structures seen on plain abdominal radiograph
 Identify the following structures on barium examination:
– The esophagus
– The stomach
– The small intestine
– The large intestine

Introduction
 Gross Anatomy
 Imaging Techniques of the Abdomen & pelvis
 Normal Radiographic Anatomy of the Abdomen & pelvis
 Identifying Some Abnormal Radiographs

Gross Anatomy
 Abdomen, in anatomy, the cavity of the body between the chest and the
pelvis in humans and all other vertebrates.
 The largest cavity of the body, bounded
 Anteriorly – by anterior abdominal wall muscles
 Posteriorly - by the vertebral column and posterior abdominal wall muscles
 Laterally - by lower ribs and parts of muscles of abdominal wall
 Superiorly - by the diaphragm
 Inferiorly - by pelvic cavity

 The anterior abdominal wall comprises a number of layers. From superficial
to deep these are:
 the skin and superficial fascia layers
 subcutaneous fat
 muscles and their aponeuroses
 extra peritoneal fat, and
 the peritoneum itself.

 Bony support of the abdomen is minimal, consisting only of lumbar vertebrae
and portions of the pelvis (the ilium and the pubis).
 Muscles: Five pairs of muscles form anterior wall:
 Rectus abdominis
 External oblique
 Internal oblique
 Transversus abdominis
 pyramidalis

Five pairs of muscles form the posterior wall:
 Quadratus lumborum
 Psoas major
 Psoas minor
 Iliacus
 Diaphragm

 Aponeurosis-a broad flat tendons formed by fibres of the abdominal muscles
 Linea alba-formed at the mid line by intertwining of the aponeurosis of the
abdominal muscles
 Fibrous structure that extends from the xiphoid process to the pubic
symphysis.

Reading assignment
 Explain the origins and insertions of the abdominal wall muscles

Anterior abdominal muscles

Posterior abdominal muscles

 Diaphragm
 Psoas major muscles

 The right hemidiaphragm is slightly higher than the left
 The liver is located immediately inferior to the diaphragm on the right
 The stomach bubble can be seen below the left hemidiaphragm
 If you look closely you can see lung markings below the diaphragm on both
sides
 Medially the hemidiaphragms form an angle with the heart - the
cardiophrenic angles (asterisks)

What to look for ?
 Are they raised, tented or flattened?
 Are the costophrenic angles sharp?
 Is there any free intra-abdominal air? (better to be judged if erect or
decubitus)

 Psoas muscle-located on either side of the lumbar vertebrae.
 lateral borders of these two muscles should be faintly visible on a diagnostic
abdominal radiograph when correct exposure factors are used

Psoas major muscle

 Arises from the transverse process of the lumbar vertebrae and combines the
iliacus muscle to attach to the lesser trochanter of the femur.
 On plain abdomen lateral edge of the psoas muscle appears as a near straight
line.
 The iliacus muscle is not visible as it lie over the iliac bones

Contents of the abdominal cavity
 The abdominal cavity contains major organs of the digestive, urinary, and
reproductive systems.
 Major organs of the abdomen include the stomach, liver, small intestine and
large intestine, gallbladder, pancreas, spleen, kidneys, adrenal glands, and
urinary bladder.

 In a female, the abdomen holds the uterus and ovaries.
 In a male, it holds the prostate gland.
 A two-layered membrane, the peritoneum, surrounds the abdominal organs

Abdomen Vs Pelvis
 The abdominal cavity is above the imaginary plane at the level of the iliac
crest and houses:-
 Stomach
 Small Intestine
 Most of the large intestine
 Liver ,GB ,Pancreas and Spleen
 Kidneys and ureters

 Pelvic Cavity, the lower portion of the abdominal cavity is located below this
plane. Contains:-
 Sigmoid colon
 Rectum
 Urinary bladder
 Some of the reproductive organs

Methods of Describing Location of
Structures
 Two methods are commonly used:
 Nine-Region Method
 Quadrant method

The Nine Regions Of Abdomino-Pelvic Cavity
 The abdominopelvic cavity is divided into nine regions through the use of two
horizontal and two vertical planes.
 The two horizontal planes are the transpyloric plane and the transtubercular
plane.
 The two vertical planes are the right and left lateral planes(mid clavicular
planes)

1. The subcostal plane is a horizontal plane which passes anteriorly through
the lowest points of the costal margins.
2. The transtubercular plane is a horizontal plane which passes through the
illiac tubercles of the innominate bones.
3. The midclavicular planes are the vertical planes which bisect the clavicles

 The 3 regions above the subcostal plane are
1. the right hypochondriac region.
2. the epigastric region.
3. the left hypochondriac region.
 The 3 regions b/n the subcostal and transtubericular planes are:
4. The right lumbar region
5. The umbilical region
6. The left lumbar region

 The 3 regions below the transtubericular plane are:
7. the right iliac region(right inguinal region)
8. the hypogastric region
9. the left iliac region (left inguinal region)

 However, in general, locating most structures and organs within the four-
quadrant system is sufficient for radiographic purposes
 This is because of variables that affect specific locations of organs, such as
body habitus, body position and age.

For any body habitus whether hypersthenic or asthenic, abdominal viscera
occupy a lower position:
 in inspiration compared with expiration;
 in the erect position compared with the recumbent position;
 with age and the associated loss of muscle tone

Quadrants Of The Abdomino-Pelvic Cavity
 The intersection of the median sagittal plane with the horizontal plane which
passes through the umbilicus divides the cavity into four quadrants:
 Right upper quadrant
 Left upper quadrant
 Left lower quadrant
 Right lower quadrant

 RUQ  LUQ
 Liver  Spleen
 GB  Stomach
 Hepatic flexure  Splenic flexure
 Duodenum  Tail of the pancreas
 Head of the pancreas  Lt kidney
 Rt kidney  Lt supra renal gland
 Rt suprarenal gland

 RLQ  LLQ
 Ascending colon  Descending colon
 Appendix  Sigmoid colon
 Cecum  2/3 of jejunum
 2/3 of ileum
 Ileo-cecal valve

Imaging Techniques
 Plain abdominal X ray

 Barium study
 CT scan & MRI
 Ultrasound
 Endoscopy

 Plain Abdomen –Acute abdomen and initial assessment prior to barium study
 Barium Studies-examinations using a suspension of barium sulfate to coat or
fill the lumen demonstrate the anatomy and details of the bowel wall.
 CT & MRI- crossectional anatomy and the surrounding structures
- further Investigation and staging of pathologies
 Endoscopy-detailed wall structure and is used particularly in the assessment
of tumors.

 CT, US, and MRI provide comprehensive evaluation of the abdomen including
 the peritoneal cavity
 retroperitoneal compartments
 abdominal and pelvic organs
 blood vessels, and lymph nodes.

Plain Abdominal Radiograph
 Patient Preparations
 Exposure techniques
 Radiation protection
 Radiographic projections

Picture Criteria for optimal abdominal radiograph:
 Whole of abdomen from upper abdomen to symphysis pubis.
 Lateral abdominal wall
 Outlines of the Psoas muscle, lower border of liver and the kidneys.
 Ribs and spinous processes of the lumbar vertebra
 Bowel gas pattern with minimal unsharpness.

 Common Abdomen Films
 Antero-posterior – supine (KUB)
 Antero-posterior –erect
 Lateral decubitus

 The 5 basic radiographic densities :
1. Black: gas
2. White: calcified structures
3. Grey: soft tissues
4. Darker grey: fat
5. Intense white: metallic objects

 Radiographic examination of the abdomen and pelvic cavity is performed for
a variety of reasons, including:
 obstruction of the bowel
 perforation
 renal pathology
 acute abdomen (with no clear clinical diagnosis)

 foreign body localization
 toxic megacolon
 aortic aneurysm
 prior to the introduction of a contrast medium
 Detection of calcifications or abnormal gas collections

 KUB
 Assess adequacy of bowel preparation
 To look for radiopaque GB stones and renal stones
 Abnormal calcifications and gases
 Check exposure factors, patient positioning
 No preparation is needed for acute abdomen

 The abdominal radiograph, or abdominal plain film, is a composite of the
image cast by
 the lower thoracic vertebrae
 lower ribs
 lumbar vertebrae
 sacrum
 coccyx

 the upper parts of the innominate bones
 soft tissues of the abdominal wall
 and major viscera of the abdomen and pelvis.

Bony Structures
 the two or three lowest thoracic vertebrae, the entire of 11th & 12th ribs,
portion of the next one or two higher ribs.
 all the 5 Lumbar vertebrae and their structure like the body, pedicle,
spinous process, transverse process and the superior and inferior articular
process.
 anterio-posterior projection of the sacrum, the coccyx, the upper parts of
the innominate bones, and part or all of the femoral heads

 Bones can be used as land marks for invisible soft tissue structures
 Transverse process of the lumbar vertebrae act as land marks for the
course of the ureters
 VUJ is located at the level of the ischial spines
 clinically important bone disease may be identified on an abdominal X-ray,
either as a significant unexpected finding or as an unsuspected cause of
abdominal symptoms

 many structures are not clearly defined on a radiograph of the abdomen, and
therefore cannot be fully assessed
 Soft tissue organs visible on abdominal X-rays include the liver, spleen,
kidneys, psoas muscles, bladder (within pelvis), and lung bases (within
thorax).

Lung Bases

 Lung bases on abdominal X-ray
 The lung bases, which pass behind the liver and diaphragm in the posterior
sulcus of the thorax, may be visible on some abdominal X-rays.
 It is worth checking the lung bases as some patients with lung pathology
present with abdominal symptoms.
 If there is consolidation suspected from the abdominal X-ray then a review of
the patient's respiratory system is necessary.

Abdominopelvic viscera
Liver:
 the liver casts a large water-density shadow in the right upper
quadrant .
 The liver’s Posteroinferior border may sometimes be directly
outlined by a fat-density line.
 Fat line represents the extraperitoneal fat layer of the posterior
abdominal wall into which the sharp posteroinferior border of the
liver is embedded.

 The liver lies in the right upper
quadrant (RUQ) and is seen as a
bland area of grey on an abdominal
X-ray.
 The superior edge of the liver
forms the right hemi-diaphragm
contour (arrowhead).
 In this patient the breast shadow
(red line) overlies the liver, and
markings of the right lung are
visible behind the liver.

 Is it enlarged?
 Is it shrunk?
 Is it displaced?
 Are there any signs for a Chilaiditi's syndrome (interposition of the colon
between the right hemidiaphragm and the liver)?
 Are there any calcifications?

Abdominal X-ray showing an enlarged liver (*) displacing the
ascending and transverse colon downward.

 Gallbladder
 The gallbladder is only rarely visible on an abdominal X-ray.
 Its position is very variable.
 Cholelithiasis

Kidneys
 The lower halves of the kidneys are commonly outlined by fat.
 The fat-density line that defines each kidney’s margin represents the
envelope of perirenal fat that surrounds the kidney.
 The hila of the rt and lt kidneys closely approximate or overlap,
respectively, the tip of the right transverse process of the 2nd lumbar
vertebra and the tip of the lt transverse process of the 1st lumbar
vertebra.

Mental reconstruction of the upper halves of the kidneys shows that, with the pt
supine,
 the rt kidney shadow is superimposed upon the 12th rib
 The lt kidney shadow is superimposed upon the 11th and 12th rib.

 Kidneys on abdominal X-ray
 Natural contrast between the kidneys and the low density retroperitoneal fat
that surrounds them means they are often visible on an X-ray of the abdomen.
 They lie at the level of T12-L3 and lateral to the psoas muscles.
 The right kidney is usually slightly lower than the left due to the position of
the liver.

 Look at the kidneys, ureter and
bladder
 Is there position normal?
 Are they enlarged or shrunk?
 Are there any calcifications?
 Is there a variant?

Spleen
 the inferior pole and the lower diaphragmatic surface of the spleen are
indirectly indicated by the extra peritoneal fat layer in many normal
adults.
 the upper visceral surface of the spleen may be indirectly indicated by
gas in the fundus of the stomach.
 the lower visceral surface of the spleen may be indirectly indicated by
gas in the splenic flexure.

The spleen lies in the left upper quadrant immediately superior to the left
kidney

X-ray of abdomen showing enlarged spleen

 Densities that cannot be explained by anatomical structures are often seen on
abdominal X-rays.
 These may be artifactual, for example due to medical devices, or due to soft
tissue calcification.
 This calcification may not be pathological, but differentiating significant
calcification from that which can be ignored is not always straightforward.
 The clinical features must be considered whenever abnormal calcification is
suspected

 Examples of calcified structures seen on plain abdomen
 Cholelithiasis
 Nephrolithiasis
 Calcified mesenteric LNs
 Costochondral calcifications

 Phleboliths
 Residual contrast
 Calcified vessels
 Calcified adnexal/uterine masses

Bowel Gas Patterns
 Any part of the bowel may be visible if it contains gas/air within the lumen.
 Gas/air is of low density and forms a natural contrast against surrounding
denser soft tissues.
 It is often difficult to differentiate between normal small and large bowel,
but this often becomes easier when the bowel is abnormally distended

Stomach
 The fundus of the stomach frequently indicated in AP erect
abdominal radiographs by the presence of a gas bubble.
 In such instances, the fundus of the stomach is observed to underlie
the left dome of the diaphragm.

 The stomach may be visible if it contains gas/air.
 It is not visible if it is either completely empty, or fluid filled
 The lowest part of the stomach crosses the midline

Small bowel
 individual segments of the small intestine may be identified in an AP-
erect film by either a small gas bubble or an air-fluid line.
 the amount and distribution of gas and the number and length of air-
fluid line in the small bowel are extremely variable.
 Most of the gas in the small bowel represents swallowed air.

Large bowel
 large bowel segments are generally identified easily if filled with gas.
 This is b/c the air-density areas representing the interaluminar gas
outlined by the distinctive sacculated, or hausterated, intraluminar
border of the water-density shadows cast by the walls of the large
bowel

Small Bowel vs Large Bowel
 Small bowel Identified by:

 Central position in the abdomen
 Valvulae conniventes - mucosal folds that cross the full width of the
bowel
 Large bowel normal large bowel may be identified by:
 Peripheral position in the abdomen (the transverse and sigmoid colon
occupy very variable positions)
 Haustral markings
 Contains feaces
prepared by Ali.B (MRT, MSC)

03/14/2022 94
prepared by Ali.B (MRT, MSC)
03/14/2022 95
Bladder and fundus of the uterus
 The bladder in a normal male casts an ovoid water-density shadow in the
suprapubic region of the radiograph.
 The superior border of the bladder in a normal female is outlined by a fat
line and is broadly indented by the fundus of the uterus if the uterus is
anteverted and anteflexed
 The fundus of the uterus may cast an ovoid water-density shadow above the
bladder shadow.

 Bladder abdominal X-ray
 The bladder has variable appearance depending on how full it is.
 It has the same density as other soft tissue structures, due to its water
content.

SBO Vs LBO

Barium Stadius

 The plain film can be very informative in pts with an acute abdomen, but for
most other intestinal disorders some form of contrast examination is
necessary.
 Barium sulphate is the best for the GIT.
 It produces excellent opacification, good coating of the mucosa and
completely inert
 Available in different forms: paste, powder, liquid, tablets

Contraindications
 Cannot be used intravasculary
 Suspected bowel perforation
 Anastomotic leak
 Recent or impeding abdominal surgery
 Gastrografin (hypaque) replaces barium sulphate

Indications
 Filling Defects
 Strictures
 Diverticulum
 Ulceration

Types of barium exams
 Barium swallow
 Barium meal
 Barium follow through
 Barium enema
 Double contrast exam

 Double contrast examination: standard for stomach and colon
 Lumen is distended by introducing air
 Mucosa is coated by barium
 Short acting muscle relaxant may be used

 It is important to understand some basic terms applicable to barium
examinations of the GIT which are often used in rather a loose way:
 The wall of the bowel is never seen as such.
 What is seen is the outline of the lumen and from this one has to draw
conclusions about the state of the wall.

 Usually the most reliable information is obtained when the bowel is fully
distended.
 Mucosal folds are seen when the bowel is in a contracted state so that the
mucosa becomes folded.
 When the bowel is distended these mucosal folds disappear

 The normal mucosal pattern may be altered by smoothing out or by abnormal
irregularity.
 Filling defect is a term used to describe something occupying space with in
the bowel there by preventing the normal filling of the lumen with in the
barium column.

Esophagus
 It is 25-30cm in length the majority of this being in the thorax, with short
cervical and intra-abdominal segments.
 Most of its course is within posterior mediastinum
 Its cervical portion lies to the left of midline
 It enters the thorax in the midline, deviating to the left to lie behind the
trachea and left main bronchus.

 Cervical: continuous with the oropharynx, commences at the lower border of
cricoid cartilage (at level of C5/6)
 Thoracic: from superior thoracic aperture (T1) to the esophageal hiatus (T10)
in the diaphragm which covers the inferior thoracic aperture
 Abdominal: from oesophageal hiatus and is continuous with the cardia of the
stomach at the gastro esophageal junction.

Relations
 posteriorly: vertebral column; descending aorta; thoracic duct (at thoracic
plane); accessory azygous and hemi azygous veins(at T8/9)
 anteriorly: trachea (to T4/5); recurrent laryngeal nerve(in tracheoesophageal
groove); left main bronchus; left atrium
 left lateral: lung, pleura, aorta, left subclavian artery, thoracic duct
 right lateral: lung; pleura; azygos vein

 The esophagus has a number of important relationships in its course through
the thorax.
 The cervical part is related anteriorly to the trachea, with the common
carotid artery and the thyroid gland lying laterally.

 The thoracic part begins in the superior mediastinum and then enters the
posterior mediastinum.
 It passes to the right of the aortic arch and then descends with the aorta on
its left side.
 Its main anterior relationships are the left main bronchus, pericardium and
heart.
 The right aspect of the esophagus is bordered by the pleura and azygos vein.

 The distal esophagus then passes through the diaphragm, surrounded mainly
by fibres of the right crus at the level of T10.
 The short abdominal segment is related anteriorly to the left lobe of the
liver.
 The esophagus inclines forward to pierce the diaphragm to the left of the
midline at the level of tenth thoracic vertebrae.

Esophagus AP & Lateral view

Barium Swallow(Esophagram)
Pathological indications:
 Dysphagia
 Achalasia
 Diverticulum ( Zenker’s diverticulum or Pharyngeal pouch)
 Esophageal varices
 Gastro-esophageal reflux
 Hiatus hernia
 Neoplasms ( benign or malignant)

The Esophagus
 The barium swallow is the contrast examination employed to visualize the
esophagus.
 Plain film does not normally show the esophagus unless it is very dilated.(e.g.
achalasia), but they are of use in demonstrating an opaque foreign body such
as a bone lodged in the esophagus.
 The pt drinks barium and its passage down the esophagus is observed on a
television monitor.

 Films are taken in an oblique position to project the esophagus clear of the
spine with the esophagus both full of barium, to show the outline and empty
to show the mucosal pattern.
 In normal barium swallow, the esophagus when full of barium should have a
smooth outline.
 When empty and contracted, barium normally lie in b/n folds of mucosa
which appears as 3 or 4 long, straight parallel lines.

 Three anatomical and physiological constrictions.
• Constrictions are seen anteriorly and to the left on a barium swallow
1. Aortic arch impression
2. Left main bronchus impression
3. Left atrium impression
• At the level of the atrium there is a long shallow anterior concavity

Stomach
 Dilated portion of the alimentary canal situated in the upper part of abdomen
extending from left hypochondriac region in to the epigastric and umbilical
region (much under the cover of the lower rib)
 Muscular cavity
 Two surfaces: anterio-superior and posterio-inferior

 It has four parts:
 cardia: small area surrounding the cardiac orifice and the GEJ
 Fundus: the rounded portion of the stomach that lies superior and posterior
to the cardia.
 Body: lies distal to the cardia and comprises most of the organ
 It is the most anterior portion of the stomach.
 extends from the fundus to the incisura where it then becomes the antrum.

 Pylorus: the funnel shaped area located inferiorly to the body and in the
curve of the stomach
 The pyloric antrum narrows into the pyloric canal as it joins the duodenum of
the small intestine at the pyloric orifice.
 The pylorus or pyloric canal represents the outlet of the stomach into the
duodenum
 It lies to the right of the midline at a variable level depending on gastric
filling and position of the subject.

 Has two curvatures:
Lesser curvature
 forms the rt boarder of the stomach and extends from the cardiac
orifice to the pylorus (forms posterior wall of upper stomach)

The greater curvature-
 lies lower anteriorly to the left
 Much longer than the lesser curvature
 Extends from the left of the cardiac orifice over the dome of the
fundus and sweeps around and to the right to the inferior part of the
pylorus

 Two openings
Cardiac orifice
it is the region of GEJ that prevent reflux of stomach content in to the
esophagus
Pyloric orifice
at the level of gastro-duodenal junction formed by circular muscle of the
stomach

 Has two notches
Angular notch (Incisura angularis)
 located on the lesser curvature where the stomach curves to the right
side of the abdomen.
 It marks the transition between the body of the stomach and the pyloric
antrum.

Cardiac notch (Incisura Cardiaca):
located on the superior aspect of the stomach between the cardiac antrum
of the esophagus and the greater curvature

 The anatomical relations of the stomach
 anteriorly, the left lobe of the liver above and the abdominal wall inferiorly.
 Posterior to the stomach is a blind ended peritoneal recess called the lesser
sac which lies between it and its posterior relations.
 inferiorly the body and tail of pancreas overlaid by the transverse mesocolon.

 When the stomach is empty, its mucosal lining falls in to longitudinal ridges
and folds called rugea

 Anteriorly it is related to left lobe of the liver
 Posteriorly related to the left hemidiaphrgm, spleen, left kidney and the
pancreas

Barium Meal (upper GI series)
 The barium meal is the standard contrast examination to examine the distal
esophagus, stomach and duodenum.
 For this the pt drinks about 2oo ml of barium.
 Each part of the stomach and duodenum is shown distended by barium and
also distended with air but coated with barium to show the mucosal pattern.

Imaging Through Barium Meal
 To provide better mucosal detail, the stomach is distended by giving a gas

producing agent and an IV injection of a short-acting smooth muscle relaxant.
 In normal barium meal, each part of the stomach and duodenum should be
checked to ensure that no abnormal narrowing is present.
 A transit contraction wave must not be confused with a constant pathological
narrowing.

 The outline of the lesser curvature of the stomach is smooth with no filling
defects or projections visible but the greater curve is nearly always irregular
due to prominent mucosal folds.
 In the stomach the mucosa is thrown up into a number of smooth folds and
barium collects in the troughs b/n the folds.
 There should be no effacement of the folds or rounded collection of barium.

 Prone

 Supine

 RAO

 Gastric mucosa is characterized by two features:
 the areae gastricae which form the mucosal surface pattern
 the gastric rugae, which form the gross or macromucosal pattern

Normal gastric rugea
Stomach on barium meal, in supine position. The stomach mucosa is

coated with barium and distended with air. The posteriorly-lying fundus
contains dense barium. The first part of the duodenum is distended with air,
while the descending second part contains barium .
Abnormal rugal patterns

Small Bowel
 The small intestine is the longest part (about 7m) of the gastrointestinal tract
 Extends from pylorus to ileocecal valve
 Fairly narrow about 2.5 cm tube like structure winds compactly back and
forth within the abdominal cavity
 The small intestine is identified by valvulae circulares or circular folds of
mucosa on barium x-ray study.

 Subdivisions of the Small Intestine
 Duodenum
 Jejunum
 Ileum

Duodenum
 shortest ,widest and least mobile part of small intestine

 C-shaped tube of ≈ 25cm long which curves around the head of the pancreas
 situated in the epigastria and umbilical regions
 It extends from pylorus to duodeno-jejunal junction at lig. treiz
 Is studied as a continuation of barium meal

 Described as having first, second, third and fourth parts
First part (superior part)
 5 cm long
 Contains the duodenal cap or bulb (conical shape) and passes superiorly,
posteriorly and to the right before turning down to become the second part
 at the level of first LV
 duodenal cap: resembles pylorus which has same rugal pattern

Second part (descending part)
 8 cm long
 Runs inferiorly over hilum of right kidney and to the right of second and third
vertebrae
 The second (descending) portion passes down anterior to the right kidney and
posterior to the transverse colon.

 The duodenum turns to the left and passes horizontally in front of the spine
as the third (horizontal)
 It ascends in front and to the left of the aorta as the fourth (ascending) part
to end at the duodenojejunal flexure (ligament of Treitz).
 Third part: 8 cm
 Forth part: 4 cm

Studies of Duodenum Through Barium Meal
 The duodenal cap or bulb should be approximately triangular in shape.

 It arises just beyond the short pyloric canal and may be difficult to recognize
if deformed due to chronic ulceration.
 The duodenum forms a loop around the head of the pancreas to reach the
duodeno-jejunal flexure.

Label the anatomical structures indicated by numbers

Jejunum and ileum
 As in duodenum, the pilacae circulares encompass two thirds of the inner

surface of the small bowel
 Jejunum
Attaches anteriorly to the duodenum
 Ileum
Extends from jejunum to large intestine

 Three types of small bowel series
1. Barium follow through
2. Small bowel only series
3. Small bowel enema or double contrast small bowel series

 Radiological difference between jejunum and ileum
 Jejunum is in the upper abdomen, to the left of midline ,whereas ileum is in
the lower abdomen and pelvis
 Jejunum (2.5cm) in diameter is wider than ileum(2cm)
 Pilcae ciruclares are more numerous and deeper set in the jejunum than the
ileum

Barium Follow Through
 The standard contrast examination for the small intestine is the barium small
bowel follow-through
 The patient drinks about 200-300 ml of barium and its passage through the
small intestine is observed by taking films at regular intervals until the barium
reaches the colon.
 this can be a time consuming procedure and usually takes 2-3 hours but
transit time is very variable.

 In normal barium follow through, the normal small intestine occupies the
central and lower abdomen usually framed by the colon
 the terminal portion of the ileum enters the medial aspect of the caecum
through the ileo- caecal valve
 As the terminal ileum may be the first site of disease this region is often
fluoroscoped and observed on a television monitor so that peristalsis can be
seen and films can be taken with the terminal ileum unobscured by the other
loop of small intestine.

What to look for on the image?
 Pattern Analysis
 Location of the abnormality: (duodenum vs. jejunum vs. ileum), focal or
diffused
 Caliber of the lumen: bowel lumen can only be three things… normal,
dilated, or narrowed
 Mucosal contour : The most common contour abnormalities include filling
defects (masses), ulceration, diverticula, and fistulas

 Fold pattern: fold thickening represents bowel wall infiltration, folds thicker
than 3mm. Can be smooth, as in case of hemorrhage and edema or Nodular as
in case of neoplasms and inflammation
 Character and transit time of contrast material should be evaluated

Large Intestine
 The large bowel comprises the colon, rectum and anus.
 The ascending colon, descending colon and rectum are retroperitoneal.
 The transverse and sigmoid colon have a mesentery formed from a double layer
of visceral peritoneum sandwiching connective and adipose tissue with vessels,
nerves and lymphatics.
 The caecum, hepatic and splenic flexures may also have short mesenteries.

Barium Enema
Large intestine
 the standard radiological examination of the large intestine is the barium
enema
 Barium is run into the colon under gravity through a tube inserted into the
rectum.
 There are two types of techniques of Barium enema
 single contrast method and
 double contrast method

 In the single contrast method, the whole colon is distended with barium.
 when a double contrast technique is used only part of the colon is filled with
barium and air is then blown in to push the barium around the colon with the
result that the colon is distended with air and the mucosa coated with
barium.
 Prior bowel preparation by means of aperients or washouts is most important
to rid the colon of faecal material, which might otherwise mask small lesions
and cause confusion by simulating polyps.

Double contrast

References
books
• Butler applied radiological anatomy
• Clark’s radiological positioning & anatomy
websites
• Medscape reference
• Radiology master class
• Learning radiology.com

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RADIOGRAPHIC ANATOMY OF THE ABDOMEN AND

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 Explain the origins and insertions of the abdominal wall muscles

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 Plain abdominal X ray

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