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ABDOMINAL RADIOLOGY

Dr. Seamus Looby & Dr. Brian A. Hogan Specialist Registrars in Radiology, Department of Radiology, Beaumont Hospital

Imaging Techniques

Plain Film of the Abdomen (PFA)

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Basic Anatomy

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Interpretation of the PFA

PFA findings in specific disease processes

Calcification seen on the PFA

Erect chest radiograph (CXR)

Contrast studies

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Barium Swallow

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Barium Meal

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Small Bowel Follow Through (SBFT)

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Barium Enema

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IVP

Barium study findings in specific disease processes

Ultrasound

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Positron Emission Tomography (PET)

IMAGING TECHNIQUES

Radiology is often used in the investigation of gastro-intestinal (GI) and urological disease processes. Despite its often pivotal role in the management of patients, radiology should never replace thorough clinical history taking and clinical examination. Likewise radiographic images should only be interpreted with knowledge of the clinical setting.

The plain film of the abdomen (PFA) and the erect chest radiograph (CXR) are the most common radiographs that the house physician will be expected to interpret on the ward when dealing with an abdominal problem. Other imaging techniques such as GI contrast studies, ultrasound, CT, magnetic resonance imaging (MRI), ERCP, positron emission tomography (PET) and CT/PET are used in specific problem solving situations.

PLAIN FILM OF THE ABDOMEN

The PFA and the erect CXR are the standard radiographs used in the investigation of the acute abdomen. The KUB (Kidney, Ureters, Bladder) is an alternate name for the same radiograph used when investigating urological problems. The radiograph should include the dome of the diaphragm down to the hernial orifices. While the role of the plain abdominal radiograph has somewhat diminished due to the emergence of other imaging techniques, it still plays a valuable role in the initial investigation of the acute abdomen.

The PFA is also valuable in identifying abdominal calcification. A plain film is often performed prior to contrast studies and is referred to as the ‘control’ film. The image formed in the PFA relies on the same basic radiographic principles as described in the thoracic and musculoskeletal radiology sections.

The standard PFA is taken with the patient supine. Occasionally further abdominal views such as a left lateral decubitus or erect radiograph may be obtained to show free intra- abdominal air or fluid levels. These films require close interpretation and should only be sought in conjunction with a radiologist.

PLAIN FILM OF THE ABDOMEN (PFA) – BASIC ANATOMY

PLAIN FILM OF THE ABDOMEN (PFA) – BASIC ANATOMY Figure 1 Normal abdominal anatomy 1 Gas

Figure 1 Normal abdominal anatomy

1 Gas in caecum

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Liver

2 Gas in descending colon

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Transverse process of L1

3 Gas in stomach

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Right psoas muscle

4 Gastric rugal folds

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Left psoas muscle

5 Twelfth rib

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Head of femur

6 Right kidney

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Pubic symphysis

7 L2 vertebra

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Right sacro-iliac joint

INTERPRETATION OF THE PFA

There are some basic rules regarding interpretation of the plain abdominal film.

Name

It is always important to ensure that the correct radiograph for the correct patient is being

viewed.

Sex Some pathological processes may be commoner in either one of the sexes. Obviously the genitourinary tracts also differ.

Age Old or young? Different pathological processes may vary between those of different ages.

Date of investigation Many radiographs may be present in the patients ‘X-ray bag’ and it is important that the appropriate radiograph is being viewed. Previous radiographs are helpful for comparison.

Marker The right or left side should be labeled on the plain abdominal film.

Position

A supine AP (anteroposterior) abdominal film is usually obtained. However, in cases of

suspected bowel obstruction an erect abdominal film can be helpful as it demonstrates

fluid levels. Occasionally decubitus views (left side down) may be performed to show intraperitoneal free air.

Having completed these steps, it is now possible to systematically interpret the abdominal film.

Hollow viscera Fluid-filled bowel is not visible on the supine film. The bowel may be outlined by intra- luminal gas. Gas outlining rugal folds in the epigastrium will help identify the stomach (Fig.1&2). In the supine position gas will rise anteriorly to outline the body and antrum; fluid will pool posteriorly in the fundus beneath the left hemidiaphragm giving the ‘gastric pseudotumour’ – not to be mistaken for a true mass (Fig.2).

The small bowel loops are located at the centre of the abdomen and should not exceed 2.5cm-3cm in calibre. Often very little of the small bowel is seen and it only becomes evident when abnormal. As it distends valvulae conniventes may be seen.

In contrast, the large bowel loops form a characteristic configuration around the

periphery of the abdomen. The length of the colon varies between individuals and varying amounts of gas and faeces are encountered. The circular mucosal folds surrounding the large bowel, known as haustra, are incomplete and characteristic

sacculations. The normal diameter of the large bowel loops varies from <9cm for the caecum to <5cm for the rest of the large bowel. The appendix is rarely seen, but occasionally an appendicolith (calcified faecal material) may be seen predisposing the patient to appendicitis.

Helpful findings used to distinguish small bowel and large bowel are listed in Table 1. below.

Table 1. The distinction between small bowel and large bowel dilatation

 

Small bowel

Large bowel

Haustra Valvulae conniventes Number of loops Distribution of loops Radius of curvature of loop Diameter of loop Solid faeces

Absent Present in jejunum Many Central Small 30-50 mm Absent

Present Absent Few Peripheral Large 50 mm+ May be present

Grainger & Allison’s Diagnostic Radiology

Soft tissues The solid organs are also visualized on the plain film to varying degrees (Fig.1&2). The liver, kidneys and spleen are commonly seen and should be scrutinized for size, contour or abnormal calcifications. The pancreas is not seen unless it is calcified (Fig.17). The ureters pass near the tips of the transverse processes of the vertebrae and descend over the sacroiliac joints. These areas should be examined for calcified densities which may represent calculi. The diaphragm and the psoas muscles should also be seen and assessed for symmetry.

Bones The bones should be systematically examined. The lower ribs, the lumbar vertebrae, sacrum, pelvis and the hips should be inspected for evidence of fractures, scoliosis, degenerative disease, Paget’s disease, myeloma and osteoblastic or osteolytic lesions associated with metastatic bone disease (see musculoskeletal tutorial).

Calcifications (Fig.14-20) It is worth looking at the abdominal film for specific areas of calcification in specific organs.

1. Calcification in the right upper quadrant may indicate gallstones.

2. Renal, ureteric and bladder calculi.

3. Vascular calcification (aorta, splenic artery, pelvic phleboliths).

4. Calcification crossing the spine at L1 may indicate chronic pancreatitis.

5. As mentioned, an area of calcification in the right lower quadrant may indicate an

appendicolith (seen in appendicitis in 10%).

6. Calcification in the genitourinary tracts (uterine fibroids, prostate etc.).

Figure 2 Upper abdominal anatomy RK – Right Kidney RP – Right Psoas SP –

Figure 2 Upper abdominal anatomy

RK – Right Kidney RP – Right Psoas SP – Spleen L – Liver

LK – Left Kidney LP – Left Psoas ST – Stomach with rugae (red arrowheads outline the gastric ‘pseudotumour’)

Abnormal intra-abdominal gas While the erect chest radiograph is primarily used to identify free intraperitoneal gas the PFA may also identify free air. Gas outlining both sides of the bowel wall (Rigler sign) and gas trapped under the falciform ligament are the main findings. The lateral decubitus film may replace erect films when looking for free intraperitoneal air or air/fluid levels in the bowel. Retroperitoneal free air may be seen to outline the kidneys. Air in the biliary tree and portal vein can also be seen in some cases in the right upper quadrant. All these findings may be subtle and are best interpreted by a radiologist.

PLAIN FILM FINDINGS IN SPECIFIC DISEASE PROCESSES

Dilatation of bowel Dilatation of the bowel occurs in mechanical intestinal obstruction and adynamic or paralytic ileus. Mechanical bowel obstruction occurs whenever there is an intrinsic or extrinsic blockage of bowel contents. Prompt diagnosis and institution of optimal treatment is paramount to a good outcome. Taking a good clinical history and thorough clinical examination are key. The PFA assists in the diagnosis and helps distinguish small bowel obstruction from large bowel obstruction and adynamic ileus. The radiological differentiation of these different causes depends mainly on the size and distribution of the loops of bowel (Table 1).

Small bowel obstruction The classic symptoms of small bowel obstruction include crampy abdominal pain, bloating, nausea, vomiting and decreased stool output. Examination may reveal distension, abdominal tenderness, peritoneal signs and high-pitched bowel sounds. The commonest causes are adhesions caused by previous abdominal surgery or peritonitis and herniae. Other causes include neoplasms, inflammation secondary to Crohns disease, appendicitis or TB, intussusception, gallstone ileus, intestinal ischaemia and radiation treatment.

ileus, intestinal ischaemia and radiation treatment. Figure 3 Supine PFA. Large quantities of gas within

Figure 3 Supine PFA. Large quantities of gas within distended loops of small bowel identified by its central position, multiple loops and valvulae conniventes.

Gas proximal to the obstruction represents swallowed air and may be relieved by passage of a nasogastric tube. More than two gas-fluid levels in the small bowel on an upright film (Fig.5) is generally considered abnormal. The presence of gas-fluid levels at different heights in the same loop is considered good evidence of a mechanical obstruction, but may occasionally be seen in adynamic ileus.

obstruction, but may occasionally be seen in adynamic ileus. Figure 4 Gas within the lumen of

Figure 4 Gas within the lumen of the bowel outlines the valvulae conniventes (arrows), which completely encircle the bowel.

Figure 5 Erect PFA. Distended small bowel with several air/fluid levels (arrows).

which completely encircle the bowel. Figure 5 Erect PFA. Distended small bowel with several air/fluid levels

Large bowel obstruction The symptoms of large bowel obstruction include abdominal pain, bloating and nausea. Vomiting is not as common as in small bowel obstruction initially, but may become a feature as the obstruction becomes long-standing. Constipation is a commoner feature than in small bowel obstruction. Absolute constipation where no faeces or flatus is passed per rectum is quite specific for large bowel obstruction. Examination may reveal distension, abdominal tenderness, peritoneal signs and high-pitched bowel sounds.

Most small bowel obstructions are caused by adhesions; in colonic obstructions, adhesions are rarely the cause. The commonest causes include primary tumour of the colon and inflammatory strictures from diverticulitis, inflammatory bowel disease, TB, parasitic disease and ischaemia. Other causes include herniae, volvulus, Hirchsprung’s disease, adhesions, extrinsic lesions (neoplasms, abscesses, endometriosis), faecal impaction and Ogilvie’s syndrome (idiopathic megacolon seen in the elderly or in patients with psychiatric disease).

in the elderly or in patients with psychiatric disease). Figure 6 Supine PFA. Gas-filled, distended large

Figure 6 Supine PFA. Gas-filled, distended large bowel seen peripherally ‘framing’ the abdomen (arrows). Competent ileocaecal valve results in no small bowel dilatation.

Figure 7 Erect PFA. Large bowel obstruction with air/fluid levels (arrows).

PFA. Large bowel obstruction with air/fluid levels (arrows). Volvulus Volvulus refers to a ‘closed loop’ bowel

Volvulus Volvulus refers to a ‘closed loop’ bowel obstruction whereby a segment of bowel twists on its own mesentery. Volvulus of the large bowel is the third most common cause of colonic obstruction. Predisposing factors include redundant loops of bowel, elongated mesentery and chronic colonic distension. Sigmoid volvulus accounts for 80% of cases of colonic volvulus and is commoner in men. A long redundant loop of sigmoid colon can undergo a twist on its mesenteric axis and form a closed-loop obstruction. The characteristic plain film findings (Fig.8) are of a massively dilated segment of sigmoid colon, devoid of haustra and in a characteristic coffee bean shape, with both ends in the pelvis and the apex lying under the left hemidiaphragm.

the pelvis and the apex lying under the left hemidiaphragm. Figure 8 Sigmoid volvulus Massively distended

Figure 8 Sigmoid volvulus Massively distended gas- filled loops of sigmoid colon (black arrows). The characteristic coffee bean shape is seen with the apposing walls of the two limbs in contact with each other (white arrows). Contrast from a recent i.v. contrast examination such as an IVP or CT is seen in the urinary tract.

Caecal volvulus is far less common and tends to occur moreso in women and younger patients. The distended caecum tends to be displaced upward and to the left (Fig.9). The ascending colon and caecum may have a long mesentery predisposing it to volvulus with the caecum twisting on its long axis. Colonic ileus, distal obstruction, pregnancy and chronic faecal retention have been implicated as precipitating causes.

retention have been implicated as precipitating causes. Figure 10 A magnified image of the same patient

Figure 10 A magnified image of the same patient as above with caecal volvulus. The gas filled appendix (arrow) is seen in the left upper quadrant.

Figure 9 Supine PFA shows the massively dilated caecum in the left upper quadrant. The asterix marks the normal position of the caecum. Dilated loops of small bowel are also seen (arrows).

upper quadrant. The asterix marks the normal position of the caecum. Dilated loops of small bowel

Adynamic or paralytic ileus Adynamic ileus is a disorder of intestinal motor activity. The clinical appearance ranges from minimal symptoms to generalized abdominal distension. Complete absence of bowel sounds over a three-minute period indicates adynamic ileus (complete absence of peristalsis in a paralyzed bowel). It occurs to some extent in almost every patient who undergoes abdominal surgery. It is postulated that drying of the bowel, excessive handling or change in temperature during surgery may be responsible. Other causes include peritonitis, medications e.g. morphine, barbiturates and L-dopa, electrolyte imbalance e.g. hypokalemia, hypomagnesemia and hypocalcemia, endocrine disorders e.g. hypothyroidism, abdominal trauma and gram negative septicaemia.

Thumbprinting of the colon Thumbprinting of the colon (Fig.11&12) is a plain film finding indicative of colitis. The characteristic finding is of sharply defined thumbprint like indentations along the wall of the colon. Thumbprinting is due to oedematous haustral folds which are thickened and outlined by the gas in the distended lumen. Ulcerative colitis is by far the commonest cause. Other causes include Crohns disease, ischaemic colitis, pseudomembranous colitis and other infectious colitides.

pseudomembranous colitis and other infectious colitides. Figure 11 Supine PFA showing thumbprinting (arrows) in a

Figure 11 Supine PFA showing thumbprinting (arrows) in a patient with an acute exacerbation of ulcerative colitis.

Toxic megacolon Toxic megacolon is characterized by extreme dilatation of a portion of colon or entire colon combined with systemic toxicity. The commonest cause is ulcerative colitis. Other causes include Crohns disease, pseudomembranous colitis, ischaemic colitis and infectious colitis. The patient is usually very ill with abdominal pain and tenderness, tachycardia, fever and leucocytosis. The prominent dilatation (>6cm) is seen in the transverse colon. Thumbprinting, dissection of gas into the bowel wall and free intraperitoneal air may also be seen.

bowel wall and free intraperitoneal air may also be seen. Figure 12 Toxic megacolon with thumbprinting

Figure 12 Toxic megacolon with thumbprinting (arrow) in a patient with an acute exacerbation of ulcerative colitis

Figure 13 Ischaemic colitis with dilatation of the transverse colon and gas in the wall of the descending colon (arrows) indicative of bowel infarction.

descending colon (arrows) indicative of bowel infarction. CALCIFICATIONS SEEN ON THE PFA The PFA is also

CALCIFICATIONS SEEN ON THE PFA

The PFA is also helpful in identifying intra-abdominal calcification which appears as an opacity on the film. The position, size, contour and density can help in identifying the source of the calcification and suggest whether it is likely to be a significant finding. Calcification can occur in virtually any organ including the kidneys and urinary tract, the liver, gallbladder, spleen, pancreas and both the male and female genital tracts. The calcification may be due to calculi (gallstones, urinary tract), infection (TB, histoplasmosis, schistosomiasis), benign tumours (fibroids, leiomyomas), malignant tumours (mucinous carcinoma of stomach or colon), haematoma, metabolic disorders or may be vascular in nature (arterial, phleboliths). There are many other miscellaneous causes of abdominal calcification.

Figure 14 Right-sided staghorn calculus . Approximately 80% of renal calculi are opaque. Urinary stasis

Figure 14 Right-sided staghorn calculus. Approximately 80% of renal

calculi are opaque. Urinary stasis and infection are important predisposing factors. Patients may complain of renal colic and

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Figure 15 Calcified gallstone in the right upper quadrant. Approximately 20% of gallstones are radiopaque. They may be single or multiple, smooth or faceted and may be laminated. Ultrasound, MRCP and ERCP are better investigations for visualising gallstones and the biliary system.

may be laminated. Ultrasound, MRCP and ERCP are better investigations for visualising gallstones and the biliary
Figure 16 A view of the right upper quadrant shows both renal calculi (arrows) and

Figure 16 A view of the right upper quadrant shows both renal calculi (arrows) and a laminated gallstones (arrowheads).

calculi (arrows) and a laminated gallstones (arrowheads). Figure 17 Calcification occurs in 20% to 40% of

Figure 17 Calcification occurs in 20% to 40% of patients with chronic alcoholic pancreatitis. 90% of patients with pancreatic calcification have high alcohol intake.

Figure 18 Abdominal Aortic Aneurysm Atherosclerosis in elderly patients often causes arterial calcification. The walls

Figure 18 Abdominal Aortic Aneurysm Atherosclerosis in elderly patients often causes arterial calcification. The walls of aneurysms also often calcify as seen here (arrowheads).

Figure 19 PFA in a 39 week pregnant woman with ulcerative colitis. The film was performed to outrule toxic megacolon. Usually radiological procedures are avoided in pregnancy to protect the developing foetus.The foetal head is seen in the mother’s pelvis (arrowheads). The ribs, spine and limbs are also seen.

developing foetus.The foetal head is seen in the mother’s pelvis (arrowheads). The ribs, spine and limbs

Figure 20An IVC filter (arrowhead) is seen in good position below the level of the renal veins. Non-pathological calcifications frequently seen in the pelvis are phleboliths. These are small calcified venous thrombi often seen along the lateral walls of the pelvis. Almost all adults have a few of them.

Figure 21 Magnified view showing phleboliths (arrows) of various sizes.

pelvis. Almost all adults have a few of them. Figure 21 Magnified view showing phleboliths (arrows)
pelvis. Almost all adults have a few of them. Figure 21 Magnified view showing phleboliths (arrows)
Figure 22 Nasogastric (NG) tubes (arrow) are commonly seen on in-patient radiographs. Vascular stents, in

Figure 22 Nasogastric (NG) tubes (arrow) are commonly seen on in-patient radiographs. Vascular stents, in this case a right iliac arterial stent, are also sometimes encountered (arrowhead).

Figure 23 A female patient with bilateral tubal ligation clips (black arrows) and an intrauterine contraceptive device (white arrow).

female patient with bilateral tubal ligation clips (black arrows) and an intrauterine contraceptive device (white arrow).

Figure 24 Cocaine ‘Body Packer’ Calcifications are not the only densities seen on PFA. Swallowed substances such as tablets and in this case smuggled capsules of cocaine may also be seen.

seen on PFA. Swallowed substances such as tablets and in this case smuggled capsules of cocaine

ERECT CHEST RADIOGRAPH (CXR)

An abdominal film is rarely obtained in isolation in the setting of the acute abdomen. The erect chest radiograph may demonstrate free air under the diaphragm indicative of bowel or other organ perforation, as well as reveal chest diseases (pneumonia, pulmonary infarction, myocardial infarction etc.) that may mimic an acute abdomen. Free gas is best demonstrated by examination of the patient in the upright position. Because the gas ascends to the highest point in the peritoneal cavity, it accumulates beneath the domes of the diaphragm (Fig).

it accumulates beneath the domes of the diaphragm (Fig). Figure 25 Erect CXR showing free air

Figure 25 Erect CXR showing free air below both domes of the diaphragm (arrows). The normal gastric bubble is also shown. Free air is normally best seen on the right between the solid liver and the right hemidiaphragm.

It is important to notice that it is an erect CXR and not an abdominal film that is most helpful in showing subdiaphragmatic free air. Pneumoperitoneum associated with significant abdominal pain and tenderness is often caused by perforation of a gas- containing viscus and indicates a surgical emergency. The most frequent cause of pneumoperitoneum with peritonitis is perforation of a peptic ulcer, either gastric or duodenal. Colonic perforation due to obstructing malignancy, toxic megacolon and diverticulitis also may cause pneumoperitoneum.

Pneumoperitoneum rarely occurs due to perforation in appendicitis, a Meckel’s diverticulum and cholecystitis. Other causes include gas-forming bacteria, penetrating injuries, iatrogenic causes (laparotomy, laparoscopy, peritoneal dialysis, perforation during endoscopy), ascent of air through the female genital tract and through a diaphragmatic defect.

the female genital tract and through a diaphragmatic defect. Figure 26 Another erect CXR showing more

Figure 26 Another erect CXR showing more obvious intraperitoneal free air.

Figure 27 Erect CXR showing massive intraperitoneal free air.

erect CXR showing more obvious intraperitoneal free air. Figure 27 Erect CXR showing massive intraperitoneal free

CONTRAST STUDIES

The soft tissue density of the abdominal organs is similar to that of water. Therefore they are usually not visible unless outlined by fat or adjacent gas. Because of this intrinsic lack

of contrast in the abdomen, radio-opaque contrast media are introduced to show up

various organs. Barium studies, intravenous urograms (IVUs) and angiograms are

contrast studies.

Barium is a relatively cheap contrast agent that is used to opacify the gastrointestinal tract during radiological procedures. It is a positive contrast agent as it absorbs x-rays and so

is radiopaque. It may be used on its own in a single contrast study or with gas in a

double contrast study. Gas can be pumped into the bowel or released by gas producing granules to act as a negative contrast agent. It does not absorb x-rays and so is radiolucent. In a double contrast study the barium is used to line the mucosa and gas is

used to fill the lumen thus giving a double contrast effect.

A major complication of barium studies occurs if the barium escapes into the peritoneal

cavity. This may occur in perforation or in leaks following surgical procedures. It will

produce pain and severe hypovolaemic shock. Despite treatment there is a 50% mortality rate and of those who survive 30% will develop adhesions. Water-soluble contrast media may be used safely in situations where perforations or leaks are suspected.

Barium Swallow

A barium swallow is a radiological investigation of the oesophagus whereby the patient

swallows a mouthful of effervescent granules followed by a mouthful of barium contrast.

A

double contrast effect of gas and barium is created within the oesophagus and a series

of

x-ray exposures are obtained as the barium travels from the oropharynx to the

stomach.

Despite the widespread application of upper GI endoscopy barium studies still play a vital role in the investigation of oesophageal pathology. It also has the advantages of being relatively non-invasive, easily tolerated by patients and not requiring sedation. It is performed for the investigation of dysphagia and odynophagia and is invaluable in the diagnosis of oesophageal carcinoma, strictures, diverticulae, ulceration and motility disorders.

Figure 28 Figure 31 Figure 29 Figure 30 Figure 28 Normal AP view of the

Figure 28

Figure 28 Figure 31 Figure 29 Figure 30 Figure 28 Normal AP view of the cervical

Figure 31

Figure 28 Figure 31 Figure 29 Figure 30 Figure 28 Normal AP view of the cervical

Figure 29

Figure 28 Figure 31 Figure 29 Figure 30 Figure 28 Normal AP view of the cervical

Figure 30

Figure 28 Normal AP view of the cervical oesophagus from a barium swallow. Figure 29 AP view of the thoracic oesophagus showing the normal impression on the left side of the oesophagus of the aortic arch (white arrow) at the T4 level. The black arrow points to the oesophago-gastric junction. Note the double contrast effect of the barium lining the mucosa with air in the lumen. Figure 30 Oblique view of the thoracic oesophagus showing the normal extrinsic impression of the aortic arch (arrow). Figure 31 Lateral view of the cervical oesophagus showing the normal extrinsic impression of the pharyngeal venous plexus.

Figure 32 Achalasia Achalasia is a disease characterized by incomplete relaxation of the lower oesophageal

Figure 32 Achalasia Achalasia is a disease characterized by incomplete relaxation of the lower oesophageal sphincter due to destruction or absence of ganglion cells in the myenteric or Auerbach’s plexi in the distal oesophagus. This causes progressive dilatation and tortuosity of the oesophagus with incoordination of peristalsis. The main symptoms are dysphagia, chest pain, regurgitation and halitosis. Recurrent episodes of pneumonia due to aspiration may be the presenting feature. The CXR, as well as showing evidence of aspiration pneumonia, may reveal a widened mediastinum, often with an air-fluid level, produced by a dilated residue-filled oesophagus. The characteristic barium swallow findings are of a dilated oesophagus with a smoothly tapered, conical narrowing of the distal oesophagus, the so called beak sign.

Figure 33 Oesophageal carcinoma Irregular circumferential lesion with mucosal destruction, oesophageal narrowing with shouldering and abrupt transition to adjacent normal tissue. Flat plaquelike lesions and less frequently, polypoid masses with ulceration and a fungating appearance are also encountered. Oesophageal carcinoma is a major cause of dysphagia in patients older than 40. There is a close association with drinking and smoking and with head and neck carcinoma. Other associations include achalasia and Plummer-Vinson syndrome.Weight loss and anorexia are common features. It spreads rapidly and often ulcerates. Most are squamous cell carcinomas with adenocarcinoma being associated with Barrett’s oesophagus.

and often ulcerates. Most are squamous cell carcinomas with adenocarcinoma being associated with Barrett’s oesophagus .
Figure 34 Hiatus hernia The stomach has herniated through the oesophageal hiatus (arrow). The proximal

Figure 34 Hiatus hernia The stomach has herniated through the oesophageal hiatus (arrow). The proximal stomach is seen as a barium filled dilatation above the diaphragm in the thorax. Most hernias (80%) are sliding in nature and herniate directly while 20% are paraoesophageal and are pushed up alongside the oesophagus. It is often associated with oesophageal reflux disease.

Figure 35 Erect CXR shows a huge air-filled hiatus hernia with an air fluid level that appears as a retrocardiac mass.

Figure 35 Erect CXR shows a huge air-filled hiatus hernia with an air fluid level that

Barium Meal

A barium meal is a non invasive radiological investigation of the stomach, it has largely

been superceded by OGD. It is a double contrast study. The aim of the study is to distend the stomach and duodenum with gas after coating the mucosa with a thin, even layer of

barium. A series of x-ray exposures are obtained with the patient lying in different positions to coat the gastric and duodenal mucosa with barium and distend them with gas.

Gastric ulcer

A gastric ulcer is part of the spectrum of peptic ulcer disease. It is usually diagnosed by

OGD. However, on a barium meal it has the appearance of a ring shadow of barium surrounded by thickened folds. Irregular folds merging into a mound of polypoid tissue around the crater suggest a malignant ulcer. All gastric ulcers should be biopsied to exclude carcinoma.

Gastric carcinoma There is a spectrum of barium meal appearances for gastric carcinoma. Ulcers vary from shallow erosions in superficial mucosal lesions to huge excavations in fungating polypoid masses. Gastric filling defects and narrowing of the stomach are other common features. Symptoms include dyspepsia, weight loss, vomiting, dysphagia, maelena and symptoms of anaemia.

vomiting , dysphagia , maelena and symptoms of anaemia. Figure 36 Gastric carcinoma as a large

Figure 36 Gastric carcinoma as a large irregular filling defect (arrowheads) in the stomach. An area of ulceration has filled with barium (arrow). The normal mucosal and rugal fold pattern is destroyed. There is a strong association with H.pylori infection.

Figure 38 Duodenal ulcer Peptic ulceration can also affect the proximal duodenum. They cause epigastric

Figure 38 Duodenal ulcer Peptic ulceration can also affect the proximal duodenum. They cause epigastric pain, often relieved by eating, and waterbrash. The chief dangers are gastro-intestinal bleeding and perforation. A barium filled ulcer is seen in the duodenum (arrow).

Figure 37 Linitus plastica The ‘leather bottle’ appearance of linitus plastica can also be seen in gastric carcinoma. It is due to thickening and fixation of the stomach wall, which usually begins near the pylorus and progresses upwards. This is difficult to diagnose on OGD. In a barium meal study the stomach is narrowed and non-distensible on all views. Normal peristalsis is absent. Gastric carcinoma can also cause segmental narrowing.

and non-distensible on all views. Normal peristalsis is absent. Gastric carcinoma can also cause segmental narrowing.

Small Bowel Follow Through (SBFT)

A small bowel follow through examination is an investigation of the small bowel. It is used in the investigation of suspected small bowel disease such as Crohns disease, TB and malignancy. It is indicated in the investigation of abdominal pain, diarrhoea, recurrent upper GI bleeds and iron deficiency anaemia, unexplained weight loss, malabsorption, partial obstruction and radiation change.

Following a bowel preparation (which usually consists of fasting for 8 hours and a laxative), the patient ingests 500-600 mls of a diluted barium mixture and is therefore a single contrast study. A series of x-ray images are obtained every 5-10 minutes until barium reaches the caecum.

An alternative to this investigation is a small bowel enema or enteroclysis. In this investigation, the small bowel is intubated with a nasogastric tube and barium is directly delivered to the small bowel thus allowing for better mucosal definition.

the small bowel thus allowing for better mucosal definition. Figure 39 Normal SBFT showing the stomach

Figure 39 Normal SBFT showing the stomach (1) with normal gatric rugae, the normal fluffy appearance of the jejunum (2) in the left upper quadrant and the more tubular appearing ileum (3) in the right lower quadrant.

Figure 40 It is very important to see the terminal ileum (white arrows) where it

Figure 40 It is very important to see the terminal ileum (white arrows) where it enters the caecum (C) on a SBFT as it is often involved in diseases such as Crohn’s and TB. Note the normal appendix (black arrow).

as Crohn’s and TB. Note the normal appendix (black arrow). Figure 41 Crohn’s disease This chronic

Figure 41 Crohn’s disease This chronic inflammatory disorder may affect any part of the gut, especially the terminal ileum (opposite), colon and the anorectum, with ulcers, fistulae and granulomata. Clinical features include cramping abdominal pain, weight loss, diarrhoea, subacute GI obstruction and fever. Anal and perianal lesions are common. The characteristic barium study findings include strictures, ‘rose thorn ulcers’ (arrows) and ‘cobblestone’ mucosal surfaces. The cobblestone effect can be seen opposite with the dark areas representing islands of normal mucosa and the white linear areas representing barium in linear ulcers.

Figure 42 A SBFT examination in a patient with Crohn’s disease who has had a

Figure 42 A SBFT examination in a patient with Crohn’s disease who has had a right hemicolectomy, therefore the small bowel enters the transverse colon (T). Normal jejunal (J) and ileal (I) bowel folds are seen. The distal ileum is diseased showing the characteristic ‘string sign’ (white arrows) resulting from small bowel narrowing due to marked wall thickening. The separation of this abnormal loop from other parts of the small bowel is indicative of the marked wall thickening

Figure 43 A magnified view of the distal ileum shows the ‘string sign’, ulceration and cobblestone mucosal (arrows) of Crohn’s disease.

view of the distal ileum shows the ‘string sign’, ulceration and cobblestone mucosal (arrows) of Crohn’s

Barium Enema

The double contrast barium enema study is used to investigate the large bowel. It has the advantages of being relatively cheap and uncomplicated but it has the disadvantages of not detecting small polyps. It is still frequently used despite colonoscopy and CT colonoscopy. It is indicated in the investigation of change in bowel habit, iron deficiency anaemia, bleeding per rectum, weight loss, tenesmus and as a screening tool in patients with a history of familial polyposis syndromes. It should not be performed in patients with a suspected colonic perforation, toxic megacolon or severe colitis or following recent colonic biopsy.

The bowel preparation for a barium enema consists of clear fluids only in the preceding 24 hours with morning and evening laxatives. A tube is inserted into the patient’s rectum and 500-700 mls of diluted barium is instilled until the barium reaches the caecum. Air is administered via a pump. A double contrast effect is created with air and barium. The patient moves into different positions and different images are obtained of the large bowel.

and different images are obtained of the large bowel. Figure 44 Normal erect barium enema anatomy

Figure 44 Normal erect barium enema anatomy showing the haustral folds (black arrows). Barium (positive contrast) is seen in the dependent areas, while air (negative contrast) moves superiorly. Incidental note is made of a diverticulum (white arrow).

1

Ascending colon

2

Caecum

3

Descending colon

4

Splenic flexure

5

Rectum

6

Hepatic flexure

8

Sigmoid colon

Figure 45 Diverticular disease A diverticulum is an outpouching of the wall of the gut.

Figure 45 Diverticular disease A diverticulum is an outpouching of the wall of the gut. The term diverticulosis means that diverticula are present, whereas diverticular disease implies they are symptomatic. Diverticulitis refers to inflammation within the diverticulum. Symptoms include altered bowel habit, abdominal pain, nausea and flatulence. In diverticulitis there may be localized or generalized peritonitis and fever. Haemorrhage may occur and is usually sudden and painless. Multiple divertula are shown opposite.

sudden and painless. Multiple divertula are shown opposite. Figure 46 An adenomatous polyp (arrows) may be

Figure 46 An adenomatous polyp (arrows) may be sessile or pedunculated and have a stalk (small arrows) as above. They are premalignant and may be single, multiple or part of a familial polyposis syndrome. Polyps are carcinomatous until proved otherwise and the likelihood of this increases with increasing polyp size.

Figure 47 A double contrast barium enema in a patient with Crohn’s disease showing typical

Figure 47 A double contrast barium enema in a patient with Crohn’s disease showing typical skip lesions (arrows) separated by normal colonic mucosal.

Figure 48 A magnified image showing colonic narrowing caused by an asymmetric stricture. Note the characteristic rose thorn ulcers (arrows).

image showing colonic narrowing caused by an asymmetric stricture . Note the characteristic rose thorn ulcers
Figure 49 Colonic Carcinoma has various appearances including saddle lesions, polyps and annular constricting lesions

Figure 49 Colonic Carcinoma has various appearances including saddle lesions, polyps and annular constricting lesions as above. This is known as an applecore lesion with mucosal shouldering (arrows). They may cause ulceration. Predisposing factors include polyps, ulcerative colitis (and to a lesser extent Crohn’s disease), family history, familial polyposis syndromes and previous cancer. Symptoms include bleeding per rectum, altered bowel habit, tenesmus, weight loss, anaemia, an abdominal mass and pain. Metastatic spread is local, lymphatic, haematogenous (liver, lung, bone) and transcoelomic.

Intravenous Urogram (IVU)/ Pyelogram (IVP)

Intravenous Urogram (IVU)/ Pyelogram (IVP) Figure 50 IVPs are indicated in suspected urinary tract pathology. It

Figure 50 IVPs are indicated in suspected urinary tract pathology. It involves the injection of approximately 70mls of iodine based intravenous contrast, which is excreted by the kidneys. Several exposures are taken through the study to assess the urinary tract anatomy. A 20 minute film from an IVU showing normal calyces (C), renal pelvis (P), ureters (U) and bladder (B).

Figure 51 A delayed film from an IVU in a patient with a known bladder tumour. There is a persisting nephrogram (RK), hydronephrosis with a dilated pelvicalyceal system (PC), hydroureter (HU) and a filling defect in the bladder (BT) due to the bladder tumour.

dilated pelvicalyceal system (PC), hydroureter (HU) and a filling defect in the bladder (BT) due to

ULTRASOUND

An abdominal ultrasound is a useful modality in the investigation of the solid abdominal organs. Indications for an abdominal ultrasound include investigation of localized abdominal pain, jaundice, abdominal masses, organomegaly, abnormal liver or renal function, suspected aortic aneurysm and suspected malignancy. It is also useful in investigation the female reproductive system. It offers the advantages of being safe, easy to perform, non invasive and, in most hospitals, it is readily available. It does not involve the use of any radiation and so can be readily used in all patients including children and pregnant women. The only preparation necessary for abdominal ultrasound is fasting for 4 hours so as to distend the gall bladder and make it readily visible.

as to distend the gall bladder and make it readily visible. Figure 52 Ultrasound is the

Figure 52 Ultrasound is the primary investigation for the gall bladder and biliary system. In the normal patient the gall bladder (GB) is uniformly dark and thin walled. If the gall bladder is not seen then the patient has either had a cholecystectomy, is not fasting or the gall bladder is contracted. The adjacent structures such as the liver, spleen, portal vein (PV) and common bile duct (CBD) are also scanned as part of an abdominal ultrasound study. It demonstrates the intra and extrahepatic ducts and can diagnose biliary obstruction. The common bile duct is seen to lie anterior to the portal vein. It is measured at the level of the hepatic artery. A common bile duct diameter of 3-6mm is accepted as normal with 1mm per decade added to patients >60. If there is an obstruction present, the level and the cause of the obstruction can sometimes be identified. The common causes include gallstones in the common bile duct, benign strictures within the common bile duct, pancreatic carcinoma, cholangiosarcoma and lymph nodes in the porta hepatis, which may be inflammatory or malignant.

Figure 53 Ultrasound is 95% specific in the diagnosis of gallstones . The diagnosis is

Figure 53 Ultrasound is 95% specific in the diagnosis of gallstones. The diagnosis is made by demonstrating echogenic or bright foci (black arrows) within the gall bladder (GB), which have posterior shadows (white arrows) and are mobile. Ultrasound is used to diagnose acute cholecystitis. The typical findings are of gallstones or biliary sludge, a thickened gall bladder wall and a sonographic Murphy’s sign i.e. the patient is tender in the right upper quadrant following compression with the ultrasound transducer.

Figure 54 Further ultrasound views of the liver show the IVC entering the heart and the left hepatic vein (LHV) draining from the left lobe of the liver (LLL).

the liver show the IVC entering the heart and the left hepatic vein (LHV) draining from
Figure 55 Ultrasound is often used to assess the kidney. Renal calculi, hydronephrosis, scars, cysts,

Figure 55 Ultrasound is often used to assess the kidney. Renal calculi, hydronephrosis, scars, cysts, abscesses, tumours and perinephric collections can all be seen with ultrasound. Renal size, contour and echogenicity can be recorded. A normal ultrasound of the right kidney (kidney) is shown with a non-dilated pelvicalyceal system (PC).

Figure 56 Moderate hydronephrosis Note the dilated pelvicalyceal system (arrows) when compared to the pelvicalyceal system in Fig.55. The cortex is well maintained.

system in Fig.55. The cortex is well maintained. Figure 57 Gross hydronephrosis in a renal transplant
system in Fig.55. The cortex is well maintained. Figure 57 Gross hydronephrosis in a renal transplant

Figure 57 Gross hydronephrosis in a renal transplant showing dilated calyces (C) and renal pelvis (P). There is marked thinning of the cortex.

COMPUTED TOMOGRAPHY (CT)

A CT abdomen is a three dimensional radiographic view of the abdominal structures. It carries the disadvantage of a high radiation dose. However, it allows for better visualization of the abdominal structures and can help in the diagnosis of malignancy, inflammatory diseases, abscesses, infectious diseases, abdominal aortic aneurysms and many other disease entities. It is often used in the rapid assessment of trauma patients with suspected intra-abdominal injuries. Oral and intravenous contrast is used to improve visualization of the bowel, vascular structures and the abdominal organs. Before a patient receives intravenous contrast, it is important that a history of renal disease and allergies is obtained as the iodine based contrast used in radiology is both nephrotoxic and may cause allergic reactions and even anaphylaxis.

and may cause allergic reactions and even anaphylaxis. Figure 58 Dynamic (with i.v.contrast) axial CT of

Figure 58 Dynamic (with i.v.contrast) axial CT of the upper abdomen showing a left renal tumour (red arrow) and normal anatomy (white arrows – splenic vein, black arrows – left renal vein). Note that the i.v. contrast has caused the vascular structures and abdominal organs to enhance or to become brighter.

AO

Aorta

IVC

Inferior vena cava

GB

Gallbladder

LIV

Liver

LK

Left Kidney

RK

Right Kidney

SB

Small bowel loops

Figure 59 Dynamic axial CT of the mid abdomen showing a left renal artery aneurysm

Figure 59 Dynamic axial CT of the mid abdomen showing a left renal artery aneurysm (black arrows) rupture with haematoma (red arrows) in the retroperitoneum displacing the left kidney anteriorly.

AO

Aorta

AC

Ascending colon

ES

Erector spinae

LK

Left Kidney

RK

Right Kidney

SMA

Superior mesenteric artery

S

Spinal cord

SMV

Superior mesenteric vein

V

Vertebra

TC

Transverse colon

Figure 60 Axial dynamic CT of a female pelvis showing a left ovarian tumour (white

Figure 60 Axial dynamic CT of a female pelvis showing a left ovarian tumour (white arrow) with areas of calcification within it (black arrows). The tumour was a teratoma and the calcifications were primitive teeth.

BL

Bladder

LIP

Left iliopsoas muscle

RA

Rectus abdominus

RIP

Right iliopsoas muscle

UT

Uterus

REC

Rectum

SAC

Sacrum

MAGNETIC RESONANCE IMAGING (MRI)

MRI is a form of radiology that uses magnetic fields and gradients to provide images of the patient. It gives similar anatomical information as CT (Fig.61), but is better at multiplanar imaging (coronal and sagittal – Fig.62). It does not use X-rays and therefore does not expose the patient to radiation and is therefore relatively safe. As large magnetic fields are use it is very important that electrical and metal objects do not enter the MRI room. A lot of surgical appliances (prostheses, surgical clips, stents etc.) are now MRI compatible, but it is very important to verify this first. Electrical objects such as cardiac pacemakers should never enter the magnetic field.

MRI is invaluable in the characterization of liver, pancreatic and adrenal masses. It also plays a major role in the staging of rectal tumors and the delineation of anorectal fistulas. The biliary system is excellently imaged with MRCP (magnetic resonance cholangio- pancreatography – Fig.63) and MRI is also commonly used in the investigation of the female genito-urinary system (Fig.62).

investigation of the female genito-urinary system (Fig.62). Figure 61 Axial T1 weighted MRI of the abdomen

Figure 61 Axial T1 weighted MRI of the abdomen at the level of the pancreas (white arrows). NB On T1 weighted MRI fat appears bright (high signal) and fluid appears black (low signal).

AO

Aorta

IF

Intraperitoneal fat

L

Liver

SF

Subcutaneous fat

LK

Left Kidney

SMA

Superior mesenteric artery

RK

Right Kidney

SMV

Superior mesenteric vein

Figure 62 Sagittal T2 weighted MRI of the pelvis. NB On T2 weighted MRI fluid

Figure 62 Sagittal T2

weighted MRI of the pelvis.

NB On T2 weighted MRI fluid appears bright (high signal).

U

Uterus

C

Cervix

E

Endometrium

M

Myometrium

B

Bladder

CX

Coccyx

D

L5 intervertebral disc

P

Pubic bone

R

Rectum

S

First sacral vertebra

Figure 63 MRCP is a heavily T2 weighted MRI sequence that demonstrates the fluid-containing bile ducts as high-signal (bright) structures and biliary calculi as low-signal (dark) foci within the ductal system. Stones as small as 2mm can be detected. Multiple calculi in both the extrahepatic bile duct and gallbladder (white arrows). Bright (fluid containing) liver cysts are also noted (red arrows).

extrahepatic bile duct and gallbladder (white arrows). Bright (fluid containing) liver cysts are also noted (red

ENDOSCOPIC RETROGRADE CHOLANGIO- PANCREATOGRAPHY (ERCP)

An ERCP is an investigation generally performed by a gastroenterologist, but utilizes fluoroscopy (continuous x-ray imaging) to help guide the procedure and visualize the biliary system. The patient is fasted for 6 hours, receives sedation and antibiotic cover and then lies in the left lateral position. A side viewing endoscope is used. The endoscope is advanced as far as the ampulla of Vater in the second part of the duodenum. The ampulla is cannulated and 1-2 mls of radiographic contrast is injected to visualize the biliary tract. It gives similar diagnostic information as an MRCP, but has the added advantage of being potentially therapeutic. Biopsies, stone retrieval, biliary stenting and sphincterotomies can all be performed. Complications of the procedure include acute pancreatitis, bacteraemia, septicaemia, aspiration and local damage due to the passage of the endoscope.

and local damage due to the passage of the endoscope. Figure 64 A single image from

Figure 64 A single image from an ERCP showing the endoscope in the duadenum, contrast material in the biliary system (arrowheads) and a gallstone in the common bile duct (arrow).

Figure 65 Another ERCP image showing multiple gallstones in a dilated common bile duct.

showing multiple gallstones in a dilated common bile duct. Figure 66 View of the biliary tree
showing multiple gallstones in a dilated common bile duct. Figure 66 View of the biliary tree

Figure 66 View of the biliary tree post ERCP. Contrast is seen in the ducts and a biliary stent (arrows) has been left in- situ to drain the biliary system. The lower end of the stent is in the duodenum.

POSITRON EMISSION TOMOGRAPHY (PET)

PET imaging has increasingly been used in the evaluation and staging of metastatic disease. It is of particular value in those being considered for surgery and in the assessment of response to chemotherapy. It is also invaluable in the search for disease recurrence and helps differentiate between benign and malignant lumphadenopathy. Currently, glucose is labelled with positron emitting fluorine and is injected intravenously. This isotope, fluorodeoxyglucose (FDG), is taken up with particular avidity by tissues with rapid cell turnover and increased cellular metabolism such as malignant tumours. FDG-PET scanning can be performed along with CT to combine the functional information of PET imaging with the anatomical information obtained with CT imaging.

with the anatomical information obtained with CT imaging. Figure 67 Sagittal fused PET/CT image of the

Figure 67 Sagittal fused PET/CT image of the pelvis in a patient with recurrent rectal carcinoma (arrow). PET/CT combines the anatomical information of CT imaging with the functional information of FDG PET imaging. The hot spot seen on PET imaging is fused with the CT image to give the exact location of the recurrent tumor. This is imortant information for future surgical excision.

ACKNOWLEDGEMENTS

Images courtesy of M.J.Lee, C.Shortt, A.McErlean and K.Abdulla, Department of Radiology, Beaumont Hospital.

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