DEPARTMENT OF RADIOLOGY FACULTY OF MEDICINE, UNIVERSITY OF PADJADJARAN / HASAN SADIKIN HOSPITAL BANDUNG Anatomy GI Imaging Without Contrast - Plain photo - 3 way abdomen series With Contrast - Esophagograhy -Maag- Duodenography - Barium Follow Through - Colon in Loop First thing to do Establish the name, sex, age and clinical diagnosis of the patient Establish the projection of the film See the marker : Right / Left
Diseases You Should Know Mechanical Ileus Localized / Generalized Ileus Peritonitis Ulcerative Colitis Diverculitis Colonic Carcinoma
Abdominal Images What to Examine Gas pattern Extraluminal air Soft tissue masses Calcifications Erect Abdomen Always air/fluid level in stomach A few air/fluid levels in small bowel Large vs. Small Bowel Large Bowel Peripheral Haustral markings don't extend from wall to wall Small Bowel Central Valvulae extend across lumen Maximum diameter of 2" 3 Way Abdomen Series
Supine Prone or lateral rectum Erect or left decubitus Chest - erect or supine Supine Looking for Scout film for gas pattern Calcifications Soft tissue masses Substitute none Prone Looking for Gas in rectum/sigmoid Gas in ascending and descending colon Substitute lateral rectum Erect Looking for Free air Air-fluid levels Substitute left lateral decubitus Erect Chest Looking for Free air Pneumonia at bases Pleural effusions Substitute supine chest Abnormal Gas Patterns
Localized ileus Generalized ileus Mechanical SBO Mechanical LBO Important Points Look for air in the rectum/sigmoid first Identify the most dilated loops-are they large bowel or small bowel? Sentinel loops are 1-2 dilated loops of small bowel Generalized adynamic ileus almost always occurs in immediate post-op patients Always correlate the clinical findings with imaging findings Localized Ileus
One or two persistently dilated loops of large or small bowel Gas in rectum or sigmoid Sentinel Loops Supine Prone Pancreatitis Ulcer Diverticulitis Cholecystitis Appendicitis Ulcer Ureteral calculus Sentinel Loops Generalized Ileus
Gas in dilated small bowel and large bowel to rectum Long air-fluid levels Only post-op patients have generalized ileus Generalized Adynamic Ileus Supine Erect Mechanical SBO
Dilated small bowel Fighting loops Little gas in colon, especially rectum Key: disproportionate dilatation of SB Mechanical SBO Causes Adhesions Hernia* Volvulus Gallstone ileus* Intussusception *Cause may be visible on plain film SBO Mechanical SBO Pitfalls Early SBO may resemble localized ileus -get F/O Mechanical LBO
Dilated colon to point of obstruction Little or no air in rectum/sigmoid Little or no gas in small bowel, if Ileocecal valve remains competent Incompetent ileocecal valve Large bowel decompresses into small bowel May look like SBO Get BE or follow-up Mechanical LBO Causes Tumor Volvulus Hernia Diverticulitis Intussusception Carcinoma of Sigmoid LBO Decompressed into SB Prone Supine Distinction between SBO and LBO Small bowel Large bowel Haustra Valvula conniventes Number of loops Distribution of loops Radius of curvature of loop Diameter of loop Solid faeces Absent Present in jejenum Many Central Small 30-50 mm absent Present Absent Few Peripheral Large 50 mm+ May be present Greinger,Allison. Diagnostic Radiology
Air in Rectum or sigmoid Air in Small Bowel Air in Large Bowel Localized Ileus Yes 2-3 distended loops Air in rectum or sigmoid Generalized Ileus Yes Multiple distended loops Yes- Distended SBO No Multiple dilated loops No LBO No None-unless ileocecal valve incompetent Yes- Dilated
PERITONITIS Radiological findings :
Generalized ileus Ascites Pneumoperitoneum No pre-peritoneal fat COLON IN LOOP Indikasi : Kelainan motilitas Kelainan pada mukosa (ulkus), divertikel, inflamasi) Keganasan Degeneratif Kelainan kongenital Kelainan obstruktif Kontraindikasi Perforasi dari saluran cerna, ulkus yang mengalami perforasi Alergi bahan kontras media Obstruksi total dari saluran cerna
SINGLE CONTRAST STUDY DOUBLE CONTRAST STUDY Ulcerative Colitis Ulcerative Colitis Chrons Diseases Crohn's disease is a disorder of unknown aetiology that is characterised pathologically by involvement of all bowel wall layers in a chronic inflammatory process with non-caseating granulomas. The granulomatous inflammation most frequently affects the terminal ileum but it may affect any part of the gastrointestinal tract and frequently affected areas are in discontinuity. There is a tendency to form fistulae. Chrons Diseases skip lesions - discontinuous sites of pathology along the gastrointestinal tract cobblestone ulceration; a result of apthous ulceration progressing to oedema and nodular thickening lead pipe thickening - thickened, stiff bowel narrowed lumen strictures 'rose-thorn' narrow-mouthed ulcers which lead to fistulae
Skip lessions This lower abdominal X-ray shows narrowing (stenosis) of the end of the small intestine (ileum)with loss of mucosal pattern and bowel wall thickening. Crohn's disease typically affects the small intestine. A solution containing a dye (barium), was swallowed by the patient. When it passed into the small intestines, this X-ray was taken (lower GI series). Colonic Diverticulitis Radiographic findings : Colonic Diverticulosis 1. Multiple round or oval outpouchings of barium projecting beyond the lumen on profile view (white arrow), barium collection (white arrowhead) or ring-like lesion (black arrowhead) on en-face view Radiographic findings : Colonic Diverticulosis COLONIC CARCINOMA Identify the Types of Abnormal Gas Patterns What abnormality is represented here? Focal Ileus Generalized Ileus SBO LBO Go Back What abnormality is represented here? Focal Ileus Generalized Ileus SBO LBO Go Back What abnormality is represented here? Focal Ileus Generalized Ileus SBO LBO Go Back What abnormality is represented here? Focal Ileus Generalized Ileus SBO LBO Correct Go ahead There are multiple air- containing and dilated loops of small bowel with little or no gas in the colon. The findings are those of a mechanical small bowel obstruction. The patient had undergone prior surgery and the cause of this obstruction was adhesions form the prior surgery. Go Back Correct Go ahead There is a dilated colon to the splenic flexure/ Little or no gas is seen in the rectum or in the small bowel. The findings are those of a mechanical large bowel obstruction. The cause was an annular constricting carcinoma at the splenic flexure. Go Back Correct Go ahead There are several air-containing and slightly dilated loops of small bowel in the LLQ. These were persistent. The findings are those of a localized ileus (sentinel loops) and their location would suggest diverticulitis. The patient had appendicitis. The sentinel loops do not always correspond to the area of inflammation. Go Back Correct Go ahead All of the bowel is dilated. There is air in the rectum. The patient was post-op abdominal surgery and the bowel sounds were absent. This is a generalized adynamic ileus as is seen sometimes after abdominal surgery. Go Back Wrong Look Again Click on the Go Back button and look again Go Back Congratulations, You Graduate You know your bowel gas