Image Critique & Evaluation

GASTROINTESTINAL TRACT (GIT)

PATTERNS

DR YAHUZA MANSUR ADAMU

DEPARTMENT OF RADIOLOGY
BAYERO UNIVERSITY KANO
2024
 INTRODUCTION

• GIT pattern evaluation

starts with Plain film of
the Abdomen
• As with all other
systems of the body,
systematic approach is
helpful.
• A good knowledge of
radiographic anatomy is
also important.
 REVIEW OF PLAIN FILM ANATOMY OF THE ABDOMEN

• To help describe the location of symptoms such as

pain or pressure, or to locate structures within the
abdomen either the four quadrants, or nine quadrants
model of the abdomen is used.
• The four quadrant model is used most commonly in
referring to the location of abdominal structures
because each quadrant contains relatively distinct
structures.
• The nine quadrant model is more detailed, for
example in describing pain, such as epigastric vs.
umbilical or inguinal.
• THE 4-QUADRANT • THE 9-QUADRANT
MODEL MODEL
 PLAIN ABDOMENAL RADIOGRAPH
THE 4-QUADRANT MODEL
• The four quadrant model is imagined as two
perpendicular lines passing through the abdomen at the
umbilicus at right angles to each other.
– The horizontal line is at the level of the umbilicus, which is
about the level of L3 and L4 (3rd and 4th lumbar vertebrae).
– The vertical plane corresponds with the midsagittal plane,
which passes through the umbilicus and the symphysis pubis.
• The four resulting quadrants are the
– right upper quadrant (RUQ),
– left upper quadrant (LUQ),
– right lower quadrant (RLQ), and
– left lower quadrant (LLQ).
 THE 4-
QUADRANT
MODEL
 THE 4-QUADRANT MODEL:
CONTENT
• Right upper quadrant:
– Liver, Duodenum, Pylorus, Right kidney, Hepatic flexure,
Portions of ascending and part of the transverse colon.
• The right lower quadrant:
– Appendix, Caecum, Ascending colon, Bladder, Right ovary,
Uterus if enlarged, Right spermatic cord, and Right ureter.
• The left upper quadrant:
– Tip of the medial liver lobe, Spleen, Stomach, Left kidney,
Pancreas, Splenic flexure, and Parts of transverse and
descending colons.
• Left lower quadrant :
– Sigmoid colon, Descending colon, Bladder, and Uterus if
enlarged, Left spermatic cord, and Left ureter.
REVIEW OF PLAIN FILM ANATOMY OF THE
ABDOMEN
• Note the ff:
– The abdomen extend from the diaphragm to the
pelvis
– The gas shadows seen on abdominal films are due
to intraluminal air in the stomach or colon.
– The small bowel hardly contains air on normal
abdominal film
– The presence of air-fluid levels:
• normally seen in the stomach, duodenum and colon;
• unusually in the small bowel.
 above

REVIEW OF CROSS SECTIONAL ANATOMY OF

THE ABDOMEN

• Note the normal

positions of ff organs:
– Intraperitoneal organs
• Right subcostal region:
Liver, gall bladder
• Left subcostal region:
Spleen
IDENTIFY
THE
STRUCTURES
1-9
 REVIEW OF CROSS SECTIONAL ANATOMY OF
THE ABDOMEN
• Note the normal
positions of ff organs:
– Retroperitoneal organs
• Kidneys and perirenal
fascia, adrenal glands,
lymph nodes, pancreas,
aorta, inferior vena cava,
psoas muscles
The Retroperitoneal structures
IMAGE CRITIQUE OF ABDOMINAL
RADIOGRAPH
 Indications for AP Abdomen Radiograph

• Plain-film abdomen radiographs are usually performed

as a
– survey or scout for imaging procedures, without oral
contrast agent.
• The abdomen is also imaged because of
– pain,
– distension, and
– various other conditions.
• Severe abdominal pain and suspicion of bowel
obstruction or perforation
– the frequency of findings on the supine view alone is
considered low and nonspecific; however, in cases of
obstruction it is proven valuable.
• SUPINE • ERECT
 Indications for AP Abdomen Radiograph

• Abdomen radiographs are commonly used to

assess
– placement of various tubes and catheters.
• The assessment of the size of viscera such as
• the liver, kidneys, or spleen
• The assessment of
– vascular calcifications, and penetrating trauma and
bone fractures, these can be ascertained in some
cases from the plain abdomen and pelvis radiograph.
Replaced by ultrasound and CT!
 Image critique
AP Abdominal Radiograph

• The AP abdomen should include from just

above the diaphragm down to the ischial
tuberosities.
• Completely demonstrating the obturator
foramen ensures that the distal field of view
is inclusive of the lower abdominopelvic
region.
• For males over the age of 50 including all of
the prostate gland is also recommended.
 Image critique
AP Abdominal Radiograph

• Also, the lateral body wall should be included on

the radiograph,
• The hands, metallic objects, and clothing that can
cause artifacts should be removed.
• Feeding tube, electrocardiogram lead wires and the
like should be straightened and pulled out of the
field of view.
• In other words, there should be minimal
obstruction of image display by needed patient
monitoring devices left in the field of view.
 Image critique
AP Upright Abdomen

• The AP upright abdominal radiograph is always

performed first in a two (AP erect + AP supine)
or three (AP supine + AP erect or Chest including
the diaphragms) view abdominal series.
• Patient should be placed in the upright position
during transport for a minimum of 5 minutes and
ideally 15 minutes prior to imaging.
• No motion: ribs, diaphragm and gas filled
structures should be sharp; the exposure is made
on expiration.
 Image critique
AP Upright Abdomen
• Diaphragm must be entirely included,
– unless a PA upright chest radiograph is also taken as part of
the abdominal series.
– The lateral margins of the abdomen must be demonstrated
and all lateral soft tissues out to the skin line when
penetrating injury is suspected.
• No rotation evidenced by pelvis and lumbar
vertebrae being symmetrical.
– Specifically, the right and left iliac wings equal in size
and shape, and
– spinous processes in center of vertebrae.
– The obturator foramina symmetrical and opened.
• Radiographic exposure should demonstrate
low contrast that visualizes the liver and
renal margins, psoas muscle outline, lumbar
transverse processes, and lower ribs.
• The exposure should show good contrast
between air, muscle, and fat as these tissues
may show key diagnostic information.
 Image critique
AP Supine Abdomen

• Structures demonstrated variably are the

renal outlines, ureters, psoas muscles, liver,
spleen, diaphragm, peritoneal fat stripes,
bladder, ribs, lumbar vertebrae, and pelvis.
The lateral margins to include the entire
flanks must be demonstrated.
• No motion: ribs, diaphragm and gas filled
structures should be sharp; the exposure is
made on expiration.
 Image critique
AP Supine Abdomen
• Diaphragm must be entirely included if only the
supine view is taken. If an upright or decubitus
film is also taken then the lower pelvis to include
the ischial tuberosities must be seen.
• Most of the upper abdomen to include from T11
down and including the obturator foramina. The
lesser trochanter should also be demonstrated on
the AP trauma screening of the abdomen and
pelvis.
• No rotation: evidenced by pelvis and
lumbar vertebrae being symmetrical.
Specifically, the right and left iliac
wings equal in size and shape, and
spinous processes in center of
vertebrae. The sacrum should be
centered midline to the symphysis
pubis.
• Radiographic exposure should
demonstrate low contrast that visualizes
the liver and renal margins, psoas muscle
outline, lumbar transverse processes, and
lower ribs.
• The exposure should show good contrast
between air, muscle, and fat as these
tissues may hold key diagnostic
information.
 PATTERN RECOGNITION ON
ABDOMINAL RADIOGRAPH
• A systematic approach to AXR interpretation is
essential to avoid missing significant
pathological changes.
• Determine the ownership, adequacy and
technical quality of the film.
– Name and date of birth of the patient and date
radiograph was performed.
– Projection (AP, PA, LATERAL).
– Posture (e.g. supine or erect).
– Adequacy of exposure.
– Look for ‘gases, masses, bones and stones’.
• Gases
– Look for normal or abnormal
intraluminal and extraluminal gas
distribution. (Note: high inter-
observer variability in interpretation
of gas patterns)
– Small bowel
• Intraluminal gas is usually
minimal,
• centrally located within
numerous tight loops of small
diameter (2.5–3.5 cm),
• distinguished by valvulae
conniventes (Stack of coins),
characteristic mucosal folds that
stretch all the way across the
small bowel loops.
Large bowel
• Has a mixture of
gas and faeces
located within
loops of larger
diameter (3–5 cm)
around the
periphery,
• with haustra,
which are
mucosal folds that
stretch only part-
way across the
diameter of the
large bowel loops.
– Abnormal findings include:
• Dilated loops of small or large bowel—
obstruction, ileus or inflammation
• Air–fluid levels on erect AXR—more than
5 fluid levels, greater than 2.5 cm in length
is abnormal and associated with
obstruction, ileus, ischaemia and
gastroenteritis.
• Intramural gas —ischaemic colitis
• Intraperitoneal gas—
– perforated viscus or penetrating abdominal injury.
– Rigler’s sign (double-wall sign) occurs when both sides of
the bowel wall can be visualised and is a good indication
of free intraperitoneal gas.
– However the sensitivity for detecting perforation on AXR
is low and
– is best confirmed as subdiaphragmatic air on erect CXR or
with a CT scan.
• Extraperitoneal gas—within the soft tissues,
retroperitoneal structures or chest in infection or
trauma.
• Masses
– Look for the size and position of the solid organ
shadows of the liver, spleen, kidneys and bladder
– Identify the retroperitoneal shadow of the psoas
muscles.
– Bulging of the lateral margin or obliteration of the
psoas shadow may indicate retroperitoneal pathology.
– Look for the dilated, calcified sac of a ruptured aortic
aneurysm, or
– adjacent bony trauma (e.g. transverse process
fractures).
• Bones
– Look for abnormalities of the visible bones
such as the
• ribs, spine, sacrum and pelvis (e.g. fractures, scoliosis,
degenerative disease, tumours and metastatic deposition).
– These may be incidental or provide
additional information on the cause of the
abdominal pain.
• Stones
– Look for renal, ureteric and bladder
stones/calcification.
– Examine the RUQ and transpyloric
plane at the level of L1 for evidence of
gallstones (15% radio-opaque) or
• pancreatic calcification.
• confirmation with USS or CT is indicated.
• Trace the course of the ureter from the
pelvis of the kidney, along the tips of the
lumbar spine transverse processes, over
the sacroiliac joint, down to the ischial
spine and medially to the bladder;
• 80–90% of renal tract stones are radio-
opaque, but will require non-contrast CT
or USS to confirm their position in the
ureter.
THANK YOU