RADIO Temp 250 [8] LEC 05 GI Radiology

Page 1 / 8Karen, Andrew

TOPIC OUTLINEI. Plain Films

A. Gas PatternB. Extraluminal AirC. Calcification and Foreign BodiesD. Masses/Densities and fluid collections

II. Contrast StudiesA. EsophagusB. StomachC. Small Intestine

III. CholangiogramIV. Barium Enema

We only included the slides that were discussed by Dr. Benedicto. She skipped quite a lot of slides.

I. PLAIN FILMS

What to Examine: Gas pattern Extraluminal air Soft tissue masses/densities & fluid collections (e.g. psoas) Calcifications Foreign bodies

Plain abdominal – start at diaphragmKUB – must include the inferior border

Important feature of abdominal radiographs: presence of gas

A. GAS PATTERN

The abdomen is unique in such as a sense that you can do triple contrast (air, IV contrast, barium contrast)

LARGE VS. SMALL BOWEL

Large bowel Peripheral Haustral marking don’t extend

from wall to wall

Small bowel Central Valvulae extend across the lumen

Location will tell you (large bowel is outer box)

NORMAL BOWEL GAS PATTERN

Air is normal within intestine. Ask the patient to fast and not to talk or cry (baby), so as not to

introduce solids or liquid or gas into the bowel Air produced is from: Swallowed air and bacterial production

Stomach Always with gas

Small bowel 2-3 loops of non-distended bowel

Normal diameter is < 2.5-3.0cm (diameter of 1 peso coin)

Large bowel Almost always with gas in rectum and sigmoid

The bowels should be clean (no fecal material, gas, etc.). Preparation is key! If the bowels were badly prepared, you may mistake opacities or lucencies as tumors.

NORMAL AIR-FLUID LEVELS (AFL)

Stomach Always

(except in supine film)

Small bowel Two to

three levels possible

Large bowel None

normally

From 2016 trans: Differential: obstructive (AFL are not aligned) Non-differential: ileus or paralytic ileus

COMPLETE ABDOMINAL SERIES

If chest has series like AP, and lateral views, abdomen also has. Supine Upright or Left lateral decubitus

o Left lateral decubitus if the patient cannot stand (e.g. trauma, unconscious)

o Why left? Because the liver is in the R (air can be delineated by the liver border if patient is asked to lie on L)

Chest – upright or supine Prone or lateral rectum (useful if suspecting obstruction)

o Why prone or lateral? Because rectum is at posterior (positioning the patient at prone or lateral places the gas to the rectum)

<Dr. Benedicto skipped the specifics of the abdominal series. You may want to check 2016 trans.>

RAD 250: GASTROINTESTINAL RADIOLOGY RAD 250

Page 2 / 8KAREN, ANDREW

ABDOMINAL GAS PATTERNS: ILEUS AND OBSTRUCTION

Ileus is more benign. It means the bowels move slowly versus obstruction wherein nothing passes.

Sentinel loops: loops surrounding areas of pathology. The pathology causes edema of adjacent bowel which causes gas accumulation in the bowel, as seen in the sentinel loops.

The area where dilated loops clump is the area of pathology. Example: if the impression is a gallbladder pathology, expect sentinel loops at that area. Therefore, this technique is confirmatory! Another usual

indication is in cases of appendicitis. But this technique is not anymore used nowadays.

Key features:o 1-2 persistently dilated loopso Gas in rectum or sigmoid

Pitfalls:o May resemble mechanical small bowel obstructiono Clinical courseo Follow-up 6 hours to 8 hours

POSTOPERATIVE: ADYNAMIC ILEUS

You expect dilated loops and air-fluid levels in post-op patients though this may resemble ileus. Therefore, do a sequential study (It is important to know how many hours post-op). You expect gas to decrease thru time.

Left image: dilated loops; Right image: air-fluid level

MECHANICAL OBSTRUCTION: CAUSES

Tumor Volvulus Hernia Diverticulitis Intussusception

Mechanical Small Bowel Obstruction: Key Features and Pitfallso 3-5 hours – gas/fluid accumulateo Dilated small bowel with air-fluid level

o Early SBObstruction may resemble localized ileus and should get follow-up

This is an SBO because of the valvulae conniventes.

If obstruction is incomplete/early – see some gas in the colon If complete and prolonged obstruction – no gas in large bowel

Fluid accumulates “string of beads” (see R side of the patient on the image taken upright)

Proximal jejunal obstruction – entirely filled with fluid

GALLSTONE “ILEUS”

Aerobilia It happened so fast haha. Sorry. Wala din yung slide na yun sa copy naming ng ppt.

LARGE BOWEL OBSTRUCTION



B. EXTRALUMINAL AIR

FREE AIR: CAUSES

(not presented or skipped but in the powerpoint)

Rupture of hollow viscuso Perforated ulcero Perforated diverticulitiso Perforated carcinomao Trauma or instrumentation

Post-op: 5-7 days Not usually seen in perforated appendix

PNEUMOPERITONEUM

(Left image: fluid collection at the R side of patient; look at CP angle)

Air beneath the diaphragm Left lateral decubitus view- air outlines liver

Rigler’s Sign Air inside

and outside bowel lumen outlines

See the R side of patient, yung tatlong rows of intestine

(Image below) In pediatric patients, you’ll see the falciform ligament when there is gas in the peritoneum. This is called the football sign.

Left image: There is delineation of the liver border under the diaphragm.Right image: There are “horns” at the side of the bladder.

For pneumoperitoneum: If few air is present ok lang (Im assuming this means no need for Rx)If progressively increasing this is a problem

C. CALCIFICATION AND FOREIGN BODIES

The location of the calcification tells you which organ is involved.Also, TB must always be ruled out if you see calcifications.



Hepatic calcification

Urolothiases are are usually benign unless there are too much.

Mercury Ingestion: There are flecks of irregular calcification. Management is antidote Coin ingestion: management is monitoring for signs of obstruction.

D. MASSES/DENSITIES & FLUID COLLECTIONS

SOFT TISSUE MASSES/DENSITIES

(skipped)

Hepatosplenomegalyo Plain films poor for judging liver size

Tumor or cysto Bowel displacement Paucity of gas “Pad sign” – extrinsic compression of the bowel

Fluid collectionso Abscesses/Hematomaso Ascites/Loculated fluid collections

(Image above: Hepatosplenomegaly)

Pharyngeal space usually 2-3mm in X-ray. If bulging, then it is edematous

II. CONTRAST STUDIES

A. ESOPHAGUS

Esophagogram – study of esophagus using 2 cups of Barium, using fluoroscopy

Upper GI series uses double contrast (air + fluid, ie. Barium with carbonated drinks



Plate #. Shows the normal barium swallow findings

ACHALASIA

Hypertonic distal lower esophageal sphincter (LES) Loss of peristalsis “Bird’s beak” appearance – esophagus tapers at the level below

thoracic inlet Etiology: loss of ganglion cells of esophageal myenteric plexus

(controls esophageal peristalsis

Plate #. Arrows point to the “Bird’s Beak” appearance of LES

ZENKER’S DIVERTICULUM

Also called Pharyngoesophageal diverticulum Excessive pressure within the lower pharynx causing the weakest

portion of the pharynx to balloon out forming a diverticulm Pulsion type due to motility disorder, mechanical obstruction,

chronic wear and tear Causes: Obstruction, bleeding, perforation, infection, CA Notice retention of dye in esophagogram For better visualization, it is important to have a lateral film with

contrast also. Lateral on plate #, also shows the stricture caused by diverticulum

Frontal and Lateral Esophagogram of Zenker’s Diverticulum

HIATAL HERNIAS [READING ASSIGNMENT] An abnormal protrusion of the esophagus and/or stomach through the

esophageal hiatus. These hernias occur at the GEJ.

A-line = ampulla B-line = GEJ (junction between squamous esophageal mucosa and gastric columnar mucosa)

1. SLIDING / AXIAL The gastroesophageal junction (GEJ) or B-line herniates

>2cm above the diagphragm Associated with GERD Comprises 99% of all hiatal hernias

2. PARAESOPHAGEAL / ROLLING Have a normal GEJ but the gastric fundus extends through

the esophageal hiatus into the mediastinum Comprises 1% of all hiatal hernias Life-threatening due to risk of volvulus and incarceration

Red arrows: Schatzki’s ring which represents the GEJ associated with sliding hernias; White arrow: herniated stomach; Green arrow: distorted tertiary waves of contraction

FOREIGN BODY

Barium or barium-soaked cotton delineates level of radio-opaque FB

Red arrow: Shape of the superior edge of balut delineated

SMALL ESOPHAGEAL ULCERS

Candidiasis, Herpes, and CMV can lead to small esophageal ulcers These ulcers appear as grooves and lines on upper GI series Plaque-like vertically oriented lesions Diffuse/long segment filling defects Ragged appearance with poor peristalsis

LES

LES segmentphrenic ampulla



CAUSTIC ESOPHAGEAL STRICTURE

long segment involved by 2-4 weeks get healing with fibrosis progressive luminal narrowing

ESOPHAGEAL CARCINOMA

asymptomatic until causes obstruction irregular /nodular eccentric narrowing shelf-like margins Apple-core deformity: mass surrounds the wall forming a stricture

B. STOMACH

Upper GI Series. D1: duodenal bulb, D2: descending aortaD3: transwerse colon; D4: descending colon

GASTRIC ULCER

ulcer crater project outside wall sign of undermining - Hampton’s line, smooth rim or collar of edema

CHEMICAL GASTRITIS

strong alkali & acids affect both esophagus & stomach alkalis cause coagulation necrosis 3-10 weeks cicatrization atonic stomach, small capacity (+) pyloric spasm will spare duodenum

C. SMALL INTESTINES

Wall thickness: approximately 1.0 – 2.0 mm Jejunum luminal diameter: ≤3.5 cm Ileal luminal diameter: ≤ 3.0 cm Jejunal folds do not disappear with distention while ileal folds will

Green line: Division of jejunum and ileum

DUODENAL ULCER

ASCARIASIS

Seen on contrast film Alive: takes in contrast, radioopaque Dead: cannot take in contrast, radiolucent

fundusbody antrum

pylorusD1D2 D3

D4gclc

jejunum

cardia

ulcer niche

radiating folds



FOREIGN BODY

Contrast will delineate foreign bodies

DUODENAL DIVERTICULA

1° mucosa prolapse thru muscularis (2nd & 3rd portions) 2° inflammation (1st portion) Causes: obstruction ,bleeding, perforation, infection.

BOCKDALEK HERNIA

Congenital diaphragmatic hernia at the left side

Bockdalek Hernia.

“Back Door at the LEFT”

III. CHOLANGIOGRAM T-TUBE, PTC, ERCP:

BILIARY TREE

ECTOPIC GALLBLADDER

Red arrows: Gallbladder. Right plate shows gallbladder above liver

GALLSTONES

Gallstones with radioopaque borders

T-TUBE CHOLANGIOGRAM

Left by surgeons in order to visualize stones after a month Establishes patency of biliary tree

CHOLEDOCHOLITHIASES

Note the presence of lucencies with well-defined borders inside the biliary tree

BILIARY ASCARIASIS

Lucent ascaris with opaque body walls

IV. BARIUM ENEMA

4 positions:



Position 1, Right Lateral Decubitus

Position 2, Left Lateral Decubitus

Position 3, Anteroposterior

Position 4, Post-evac

INTUSSUSCEPTION

Children - common ileo-colic 2 °inflammed lymphoid tissue Adults look for “leading lesion” or post-op “coil spring” appearance Procedure can also be therapeutic, barium enema will push the

intussusceptum (telescoping segment) out

Intussuscipiens: white, with barium enema

HIRSCHPRUNG’S DISEASE

Absence of myenteric ganglia at distal colon commonly rectosigmoid Look for “transitional zone”

Red arrow: Transitional zone. Fuzzy bowel since it is “feces-filled”.

END OF TRANSCRIPTION

Andrew: Hello blockmates! Libre ko kayo after ng Radio exam!

Karen: Yeay! Super long trans! Hahaha. But mostly photos. Last week of Radio na! More block food outing please!

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RADIO Temp 250 [8] LEC 05 GI Radiology