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TOPIC OUTLINE

I.

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

Large bowel
Almost always with gas in rectum and sigmoid

Plain Films
A. Gas Pattern
B. Extraluminal Air
C. Calcification and Foreign Bodies
D. Masses/Densities and fluid collections

II.

Contrast Studies
A. Esophagus
B. Stomach
C. Small Intestine

III. Cholangiogram
IV. 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 diaphragm
KUB must include the inferior border
Important feature of abdominal radiographs: presence of gas

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
bowe
l
Two to
three levels
possible
Large
bowe
l

None
normally

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
from wall to wall

dont

extend

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

Karen, Andrew

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.>

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RAD 250: GASTROINTESTINAL RADIOLOGY

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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.

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


MECHANICAL OBSTRUCTION: CAUSES

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 loops
o Gas in rectum or sigmoid

Pitfalls:
o May resemble mechanical small bowel obstruction
o Clinical course
o 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.

KAREN, ANDREW

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception

o
o
o

Mechanical Small Bowel Obstruction: Key


Features and Pitfalls
3-5 hours gas/fluid accumulate
Dilated small bowel with air-fluid level
Early SBObstruction may resemble localized ileus and
should get follow-up

This is an SBO because of the valvulae conniventes.

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RAD 250: GASTROINTESTINAL RADIOLOGY

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B. EXTRALUMINAL AIR
FREE AIR: CAUSES
(not presented or skipped but in the powerpoint)

If obstruction is incomplete/early see some gas in the


colon
If complete and prolonged obstruction no gas in large
bowel

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

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

Rupture of hollow viscus


o Perforated ulcer
o Perforated diverticulitis
o Perforated carcinoma
o Trauma or instrumentation
Post-op: 5-7 days
Not usually seen in perforated appendix

Air beneath the diaphragm


Left lateral decubitus view- air outlines liver
Riglers Sign
Air inside
and outside
bowel
lumen
outlines
See the R
side of
patient,
yung
tatlong
rows of
intestine

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

LARGE BOWEL OBSTRUCTION

(Image below) In pediatric patients, youll see the falciform


ligament when there is gas in the peritoneum. This is called the
football sign.

KAREN, ANDREW

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RAD 250: GASTROINTESTINAL RADIOLOGY

RAD 250

Also, TB must always be ruled out if you see calcifications.


Hepatic calcification

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

Urolothiases are are usually benign unless there are too much.

The location of the calcification tells you which organ is


involved.

KAREN, ANDREW

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RAD 250: GASTROINTESTINAL RADIOLOGY

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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)

Hepatosplenomegaly
o Plain films poor for judging liver size
Tumor or cyst
o Bowel displacement

Paucity of gas

Pad sign extrinsic compression of the bowel


Fluid collections
o Abscesses/Hematomas
o Ascites/Loculated fluid collections

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

LES segment
phrenic ampulla

(Image above: Hepatosplenomegaly)

Plate #. Shows the normal barium swallow findings


ACHALASIA

KAREN, ANDREW

Hypertonic distal lower esophageal sphincter (LES)


Loss of peristalsis

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RAD 250: GASTROINTESTINAL RADIOLOGY

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Birds 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 Birds Beak appearance
of LES

ZENKERS 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

Red arrows: Schatzkis


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

FOREIGN BODY
Frontal and Lateral Esophagogram of Zenkers Diverticulum

Barium or barium-soaked cotton delineates level of radioopaque FB

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)

Red arrow: Shape of the superior edge of balut delineated


SMALL ESOPHAGEAL ULCERS

1.

SLIDING / AXIAL
The
gastroesophageal junction (GEJ) or B-line herniates
>2cm above the diagphragm
Associated with GERD
Comprises 99% of all hiatal hernias

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

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

KAREN, ANDREW

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RAD 250: GASTROINTESTINAL RADIOLOGY

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CAUSTIC ESOPHAGEAL STRICTURE

long segment involved


by 2-4 weeks get healing with fibrosis

progressi
ve

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

Upper GI Series. D1: duodenal bulb, D2: descending aorta


D3: transwerse colon; D4: descending colon
GASTRIC ULCER

ulcer crater project outside wall


sign of undermining - Hamptons line, smooth rim or collar of
edema

B. STOMACH
CHEMICAL GASTRITIS

KAREN, ANDREW

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RAD 250: GASTROINTESTINAL RADIOLOGY

RAD 250

strong alkali & acids affect both esophagus & stomach


alkalis cause coagulation necrosis
3-10 weeks cicatrization atonic stomach, small capacity
(+) pyloric spasm will spare duodenum

ASCARIASIS

Seen on contrast film


Alive: takes in contrast, radioopaque
Dead: cannot take in contrast, radiolucent

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

FOREIGN BODY

Contrast will delineate foreign bodies

Green line: Division of jejunum and ileum


DUODENAL ULCER

radiating
folds
DUODENAL DIVERTICULA

KAREN, ANDREW

1 mucosa prolapse thru muscularis (2nd & 3rd portions)


2 inflammation (1st portion)
Causes: obstruction ,bleeding, perforation, infection.

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RAD 250: GASTROINTESTINAL RADIOLOGY

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III. CHOLANGIOGRAM
T-TUBE, PTC, ERCP:
BILIARY TREE
ECTOPIC GALLBLADDER

Red arrows: Gallbladder.


gallbladder above liver

Right

plate

shows

GALLSTONES

BOCKDALEK HERNIA

Congenital diaphragmatic hernia at the left side

Gallstones with radioopaque borders


T-TUBE CHOLANGIOGRAM
Bockdalek Hernia. Back Door at the LEFT

KAREN, ANDREW

Left by surgeons in order to visualize stones after a month


Establishes patency of biliary tree

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RAD 250: GASTROINTESTINAL RADIOLOGY

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IV. BARIUM ENEMA


4

positions:

CHOLEDOCHOLITHIASES

Note the presence of lucencies with well-defined borders


inside the biliary tree

Position 1, Right Lateral Decubitus

BILIARY ASCARIASIS

Position 2, Left Lateral Decubitus

Lucent ascaris with opaque body walls

Position 3, Anteroposterior

KAREN, ANDREW

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RAD 250: GASTROINTESTINAL RADIOLOGY

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HIRSCHPRUNGS DISEASE

Absence of myenteric ganglia at distal colon commonly


rectosigmoid
Look for transitional zone

Position 4, Post-evac
Red arrow: Transitional zone. Fuzzy bowel since it is
feces-filled.
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

END OF TRANSCRIPTION
Andrew: Hello blockmates! Libre ko kayo after ng
Radio exam!
Intussuscipiens: white, with barium enema

KAREN, ANDREW

Karen: Yeay! Super long trans! Hahaha. But mostly


photos. Last week of Radio na! More block food outing
please!

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