Gastrointestinal Radiology:

Lower GI Study

Mashuri

Department of Radiology, Ulin Hospital

Faculty of Medicine Lambung Mangkurat University
South Borneo
2.5cm
 Gastrointestinal radiology

• Abdominal plain films (KUB)

• Barium studies (BFT/CIL)

• Ultrasound (US)

• Computed Tomography (CT Scan)

• Magnetic Resonance Imaging (MRI)

• Angiography and Interventional Radiology

• Nuclear medicine
Ileus: abnormal gas pattern

• Functional Ileus

• Localized ileus

• Generalized ileus (Paralytic)

• Mechanical Obstruction

• Small bowel obstruction (SBO)

• Large bowel obstruction (LBO)

Functional Ileus:
Localized Ileus
 Pathophysiology: localized ileus

• Inflammation of an adjacent visceral organ

• Focal irritation
• Aperistaltic
• 2 or 3 persistently distended loops of small /
large bowel
 Causes of Localised Ileus
Site Cause

Right upper quadrant Cholecystitis

Left upper quadrant Pancreatitis

Right lower quadrant Appendicitis

Left lower quadrant Diverticulitis

Mid-abdomen Ulcer or kidney/ureteric calculi

 Localized Ileus

• One or two persistently

distended loops of large or
small bowel (usually
smallbowel)
• Gas in rectum or sigmoid
A sentinel loop is a short segment of adynamic ileus close to an
intra-abdominal inflammatory process.
Functional Ileus:
Generalized Ileus
Pathophysiology: generalized ileus

• Entire bowel aperistaltic/hypoperistaltic

• Distended small bowel and large bowel to
rectum (with LBO no gas in
rectum/sigmoid)
• Long air-fluid levels

Cause Remarks

*Postoperative Usually abdominal surgery

Electrolyte imbalance Diabetic ketoacidosis

* almost always
 Radiology finding: BNO 3 posisi

The large and

small bowel are
extensively airfilled
but not dilated.

The large and

small bowel "look
the same".
 Erect

Generalized Ileus

Supine
Mechanical Obstruction:
SBO
Pathophysiology
• A lesion, inside/outsideobstructs the lumen
• SBO can be divided in 2 type:
– Open loop (Simple obstruction)
– Closed loop obstruction
• Dilated small bowel

• Fighting loops (visible loops, lying

transversely, with air-fluid levels at
different levels)

• Little gas in colon, especially rectum

• Dilated small bowel

• Fighting loops (visible loops, lying

transversely, with air-fluid levels at
different levels)

• Little gas in colon, especially rectum

Causes of SBO

Adhesions
Hernia*
Malignancy
Gallstone ileus*
Intussesception
Inflammatory bowel disease

* May be visible on AXR

AXR: Erect AXR: Supine

Air fluid levels

AXR: Left Lateral Decubitus
Large Bowel Obstruction (LBO)
Pathophysiology
• Colon dilates from point of obstruction backwards

• Little/no air fluid levels (colon reabsorbs water)

• Little or no air in rectum/sigmoid

Causes of LBO

Tumour
Volvulus
Hernia
Diverticulitis
Intussusception
Radiology finding: BNO 3 posisi
A volvulus always extends away from the area of twist.Sigmoid
volvulus can only move upwards and usually
goes to the right upper quadrant. Caecal volvulus
can go almost anywhere.
Inflammatory Bowel Disease
Inflammatory Bowel Disease
• Inflammatory bowel disease (IBD) is an
idiopathic disease, probably involving an
immune reaction of the body to its own
intestinal tract.
• The 2 major types of IBD are Crohn disease
(CD) and ulcerative colitis (UC)
Crohn Disease
CHRON’S DISEASE

• Crohn disease = regional enteritis

• Idiopathic inflammatory bowel disease 
• Terminal ileum and ileocaecal valve and
caecum on are most often affected.
• Skip lesions are pathognomic
• Extraintestinal disease is common.
Radiology
BNO
BFT
USG
CT
MR
 BNO

• on X-ray- plain radiograph of abdomen is

usually helpful in cases of obstruction
secondary to chron’s or extraintestinal
manifestations
Barium small bowel follow-through (BFT)

• Mucosal ulcers
– Aphtous ulcers initially 
– Deeper transmural ulcers typically either longitudinal or circumferential
in orientation
– when severe leads to cobblestone appearance
– may lead to sinus tracts and fistulae

• Thickened folds due to oedema

• Pseudodiverticula formation: due to contraction at the site of

ulcer with ballooning of the opposite site

• String sign: tubular narrowing due to spasm or stricture

depending on chronicity partial obstruction
Apthous ulcers
First sign of chron’s disease on barium (BFT)
Cobblestone
appearance: due to deep
fissuring ulcers around
inflammed mucosa
Fissuring ulceration in Crohn's
disease - graphically called
`raspberry thorn' ulcers.
String sign:
spasm/fibrosis of bowel
wall
ILEOILEAL FISTULA:
long standing chron’s
Ultrasound

• Limited role, it has been evaluated as an

initial screening tool
• Ultrasound in the assessment of
extraintestinal manifestations.
US image - stricture in a patient with
active Crohn's disease
CT findings

• Fat halo sign=submucosal fat

deposition
• Comb sign=engorgement of the vasa
recta
Fat halo sign in chron’s disease
Transverse CT scan shows the central fatty
submucosal layer of low attenuation (*)
surrounded by higher-attenuation inner (long
arrow) and outer(short arrow) layers grossly
corresponding to the mucosa and muscularis
propria and serosa of the descending colon,
respectively.
Comb sign: hypervascular appearance of the mesentery in active Crohn's
disease. Fibrofatty proliferation and perivascular inflammatory infiltration outline
the distended intestinal arcades. This forms linear densities on the mesenteric
side of the affected segments of small bowel, which give the appearance of the
teeth of a comb.
Ulcerative colitis

• Nonspecific inflammatory bowel disease of

unknown etiology that effects the mucosa
of the colon and rectum
 Ulcerative colitis
• Causes superficial ulceration of colon and rectum.

• It starts from rectum and retrogradely involves whole colon continuously.

• In total colitis- back wash ileitis.

• More common in DR2 related genes.

• More female predilection, age group 30-40 yrs.

• Clinical symtoms- diarrhoea, tenesmus, bleeding per rectum, passage of

mucus, crampy abdominal pain.
 Pathogenesis

• MILD DISEASE: fine granularity

• MODERATE: marked erythema, coarse granularity, contact bleeding and

no ulceration.

• SEVERE: spontaneous bleeding,edematous and ulcerated

• Long standing cases epithelial regeneration- pseudopolyps, pre
cancerous condition
• Eventually shortening and narrowing of colon

• FULMINANT DISEASE: toxic colitis/megacolon

 Radiology

• BNO
• CIL
• CT
• MRI
Acute UC – descending
colon has irregular outline.
No fecal residue in colon
S/O total colitis
Colon in Loop

• Mucosal inflammation-granular appearance to the

surface of the bowel.
• Mucosal ulcers are undermined -button-shaped ulcers
• Islands of mucosa remain giving it a pseudo-polyp
 appearance
• In chronic cases the bowel becomes featureless with
loss of normal haustral markings, luminal narrowing
and bowel shortening- lead pipe sign
ulcerative colitis

normal superficial extensive inflammatory

mucosa ulcerations ulcerations pseudopolyps
granular mucosa
FINE MUCOSAL
GRANULARITY- FIRST
SIGN
NARROWING OF LUMEN
COLLAR
BUTTON
ULCERS
LEAD PIPE COLON
Back wash ileitis :
patulous IC valve and
dilated granular terminal
ileum
 CT findings

• Inflammatory pseudopolyps 

• Inflamed and thickened bowel - target appearance, due concentric

rings of varying attenuation- mural stratification

• In chronic cases, submucosal fat deposition is seen particularly in the

rectum fat halo sign

• Extramural deposition of fat, leads to thickening of the perirectal fat, 

widening of the presacral space 

• Marked muscularis mucosa hypertrophy-lead pipe sign.

Inflammatory pseudopolyps
MRI

• Wall Thickening- median wall thickeness of colon

ranges from 4.7 to 9.8 mm, more severe the
disease more thicken the wall

• Increased Enhancement- enhancement of the

mucosa with no or less enhancement of the
submucosa

• Loss of haustral markings

Mri image reveals
thickening of colon with loss
of haustral markings
 Summary

Pathology Crohn Ulserative

Distribution Skip lesion Continous
Rectal involvement About 20% Always
Depth of wall involved Transmural Mainly mucosal
Granuloma Characteristic Absent
Complications
Stricture Common and often multiple Unusual
Fistulae Common Very rare
Anal/perianal lesion Common Uncommon
Toxic megacolon Unusual Relatively common
Malignant transformation Lower risk High risk
Colorectal Cancer
Locations
• Rectum 35%
• Sigmoid 25%
• Desc colon 10%.,
• Asc colon 10%
• Transverse colon 10%
• Caecum 10%
Symptoms

• Abdominal pain — 44 percent

• Change in bowel habit — 43 percent
• Hematochezia or melena — 40 percent
• Weakness — 20 percent
• Anemia without other gastrointestinal
symptoms — 11 percent
• Weight loss — 6 percent
 Radiology: Colon in loop
(Barium Enema)

• Polypoid lesions
• Annular lesions (<5cm)
• Flat lesions
Polypoid lession
 Annular type

From: http://www.kgan.minami.fukuoka.jp
 Annular type: apple core
"apple-core" lesion

Annular carcinoma of the sigmoid colon. The lumen of the sigmoid is narrowed
severely by the circumferential mass with mucosal destruction and the overhanging
edges or shouldering at the tumor margins.
Annular type
 Flat lesion/Plaquelike

Flat carcinoma of the

sigmoid colon
- a unilateral broad-
based contour defect.

From: http://www.kgan.minami.fukuoka.jp
 US
• The primary role of ultrasound (US) in patients with colonic cancer is the
detection of hepatic metastases.
• US has a detection rate of 70-90% for hepatic metastases.
 CT Scan

Indications for CT scan

• CT scan is used for staging colonic carcinoma prior to surgery, for

assessing and staging recurrent disease, and for detecting the presence
of distant metastases.
• Preoperative CT scan is indicated if distant metastases or local invasion of
adjacent organs or abdominal wall are suggested clinically.
• In older patients who may be unable to undergo colonoscopy or barium
enema, modified CT scan may be performed for primary detection of
colorectal tumors.

Colonic tumors may be diagnosed on CT scan as an incidental finding.

 CT Scan
CT Findings

• A localized tumor may be seen on CT scan as an intraluminal or intramural

mass of soft tissue density adjacent to the gas-filled or contrast-filled bowel
lumen
• More advanced tumors are associated with thickening of the bowel wall (>6
mm) and infiltration of the pericolic fat (local perforation)
• Annular carcinomas are detected by a thickening of the bowel wall and
narrowing of the lumen. This thickening is concentric if the scanning plane
is at right angles to the long axis of the bowel (obstruction)
• Extracolonic tumor spread is indicated by a loss of tissue fat planes
between the colon and surrounding structures (peritoneal spread)
• Intussuseption (in polypoid lesion), rare
• Tumors less than 2 cm in diameter cannot be detected reliably by the
standard CT scan technique.
 CT Scan
CT Findings

Preoperative CT – colon wall

thickening and infiltration of
the pericolic fat
 CT Scan
CT Findings

Numerous metastases.
The tumor cells were arranged
in nodules and occupied
approximately 90% of the
hepatic parenchyma.
Contrast-enhanced CT showing liver metastases.
Several low-density metastases involve both lobes of
the liver.
 CT Scan

Stage Description
T1 Intraluminal polypoid mass; no thickening of bowel wall
T2 Thickened colonic wall >6 mm; no periodic extension
T3a Thickened colonic wall plus invasion of adjacent muscle or organs
T3b Thickened colonic wall plus invasion of pelvic side wall or abdominal wall
T4 Distant metastases, usually liver, lung or adrenal
modified from Thoeni
N staging
Nodes greater than 10 mm in diameter are considered abnormal.
M Staging
Hepatic metastases are the most common site of distant spread.
Other common sites include the lungs, adrenals, peritoneum, and omentum.
CT Scan Staging System
For Colonic Cancer
 MRI
• MRI provides greater contrast between soft tissues than CT
scan.
• Colonic tumors have low signal intensity (similar to adjacent
skeletal muscle) on T1-weighted sequences, which facilitates
their differentiation from high-signal perirectal fat.
• T2-weighted images are used to detect pelvic sidewall
invasion.
• MRI and CT scan have a similar overall accuracy
(approximately 60%) in the detection of enlarged lymph nodes
(N staging) and liver metastases (M staging).
• MRI has a higher sensitivity (91%) than CT scan (82%) in
detecting local recurrence and a higher specificity (100%) than
CT scan (69%).
Thank You