Digestive System

PharynxSwallowing function evaluation

Indications
! Cough induced by eating or drinking, dysphagia, varying degrees of
aspiration
! Nasopharyngeal reflux
! Sensation of food sticking, lump or tightness in the pharynx
! Change in swallowing or the inability to handle secretions
secondary to neurological disorders (head trauma, stroke, etc.)
or myopathies.
! Up to 50% of patients in nursing homes have feeding or
swallowing disorders.
Methods of examination
Video recording of swallowing during fluoroscopicimaging. .
This method utilizes high density barium in varying degrees
of thickness, sometimes mixed with foods of varying consistency.
 Pharyngeal Abnormalities
Pharyngeal Abnormalities

Zenkers diverticula
Congenital Pharyngeal Webs
External Impingement by
osteophytes, enlarged lymph
nodes, tumors or enlarged
thyroids
Traumaswallowed sharp
foreign bodies (chicken or
fish bones), penetrating
trauma, caustic agents (lye),
iatrogenic injuries.
Inflammation
 Pharyngeal Abnormalities
Zenkers diverticula
Congenital Pharyngeal Webs
External Impingement by
osteophytes, enlarged lymph
nodes, tumors or enlarged
thyroids
Traumaswallowed sharp
foreign bodies (chicken or
fish bones), penetrating
trauma, caustic agents (lye),
iatrogenic injuries.
Inflammation
 Pharyngeal Abnormalities

Benign Tumors
Malignant TumorsSquamous cell carcinoma most
common; may develop at the base of the tongue,
epiglottis, pyriform sinuses, valleculae, and the palatine
tonsils. CT is helpful, not only in identifying the
tumor but also in detecting invasion of adjacent
structures. Synchronous esophageal carcinoma may
coexist in 5% of patients with head and neck cancer.

 Esophageal Evaluation
Indicationsheartburn;
difficult or painful
swallowing; sensation of
food sticking
Methods of examinationat
fluoroscopy, the esophagus
is usually imaged by
double contrast techniques
(barium and effervescent
granules); water soluble
contrast when perforation
suspected; CT has value in
CA of the esophagus.
 Normal
Normal Air-contrast
Air-contrast Esophagram
Esophagram
 Esophageal Diseases
Inflammation

Gastroesophageal Reflux
Disease (GERD)hiatal
hernia; esophagitis; columnar
lined esophagus (Barretts
esophagus)--occurs in 10-
20% of patients with GERD
and have inc. incidence
(15%) of adenocarcinoma.
 Esophageal Diseases

Gastroesophageal Reflux
Disease (GERD)hiatal
hernia; esophagitis; columnar
lined esophagus (Barretts
esophagus)--occurs in 10-20%
of patients with GERD and
have inc. incidence (15%) of
adenocarcinoma.

 The Stomach and Duodenum-

Hiatal Hernia

in sliding type GE junction

is displaced cephalad
in paraesophageal type, the
stomach is along side of a
normally positioned
esophagus
mixed type is combination
of the above
with GE reflux, esophagitis,
ulcerations and strictures can
occur
 Esophageal Diseases
Inflammation cont.

Extrinsic Agents
caustic (acid or alkaline) ingestion may cause strictures with
and inc. incidence of carcinoma after 3 to 4 decades.
Radiation therapy can cause esophagitis
a variety of oral medications (antibiotics, such as tetracycline
or doxycycline, potassium chloride, quinidine, vitamin C
tablets, and oral ferrous sulfate) can cause mucosal irritation
and ulceration usually because not enough oral fluids are
taken with medication.

 Esophageal Diseases
Inflammation cont.

Infectious
Esophagitis
immunosuppression
and general debilitation
are generally the
background for:
herpes simplex
Cytomegalovirus
Candida infection
 Esophageal Disease
Motility Disorders

Presbyesophagus
Diffuse Esophageal
Spasm, the
Nutcracker
Esophagus, and the
Hypertonic Lower
Esophageal Sphincter

 Esophageal Disease
Motility Disorders

Achalasiaa
hypertonic lower
esophageal sphincter;
fluid-filled, dilated
esophagus with
birds beak
appearance distally.
Chagas Disease
picture like that of
achalasia
Barium swallow examination: Early stage: The esophagus has
smooth contour and is narrowed conically at the esophago-
cardial junction (arrow), above this the distal part of the
esophagus is dilated. (=> picture)
Late stage: The esophagus is extremely
dilated above the severely narrowed cardia
(arrow), with a slightly tortuous course and
inhomogenous contrast material filling
pattern because of the residual food inside.
 Esophageal Disease
Motility Disorders

Sclerodermaloss of muscle
function in the lower two
thirds of the thoracic
esophagus seen after
ingestion of barium during
fluoroscopy
Miscellaneousrheumatoid
arthritis (RA), systemic lupus
erythematosus SLE and
alcoholism may have
esophageal dysmotility

 Esophageal Disease
Motility Disorders

Esophageal
Diverticulafrequently
occur in the middle and
lower third
Traction typemid-
esophagus
Pulsion typedistal
esophagus
 Esophageal Disease
Varices

produced by either liver

disease with portal
hypertension or thrombosis
of the splenic-portal trunk
occur in the distal
esophagus and bulge into
the esophageal lumen on
esophagram
CT can also detect
esophageal or gastric varices
endoscopy most sensitive
method
 Esophageal Disease
Varices
produced by either liver
disease with portal
hypertension or thrombosis
of the splenic-portal trunk
occur in the distal esophagus
and bulge into the esophageal
lumen on esophagram
causing multiple small defects
due to the varicies.
CT can also detect
esophageal or gastric varices
endoscopy most sensitive
method

 Esophageal Disease
Foreign bodies (FB)

if radiopaque,
detectable with plain
films
need barium for non-
opaque FBs
in adults, oversized
piece of meat is most
common FB.
1.
 Esophageal Disease
Neoplasms

Benign
Leiomyomas
duplication cysts and
lipomas
epithelial polyps are
rare
1.
 Esophageal Disease
Malignant Neoplasms

Primaryasymptomatic
until large enough to
interfere with food
transport
Squamous-cellmost
common
Adenocarcinomadevelops
in the setting of dysplastic
mucosa ass. with Barretts
esophagus

 Esophageal Disease
Malignant Neoplasms

Primary
asymptomatic until
large enough to
interfere with food
transport
Squamous-cellmost
common
Adenocarcinoma
develops in the setting
of dysplastic mucosa
ass. with Barretts
esophagus
 Esophageal Disease
Malignant Neoplasms

Lymphomas rare
Spindle-cell tumor
(carcinosarcoma or
pseudosarcoma)
Leiomyosarcoma

 Esophageal Disease
Malignant Neoplasms

Lymphomas rare
Spindle-cell tumor
(carcinosarcoma or
pseudosarcoma)
Leiomyosarcoma

 Esophageal Disease
Malignant Neoplasms
CT useful in staging
preoperatively90%
accuracy in detecting
mediastinal metastases;
MRI has similar accuracy;
CT and MRI also useful
in detecting liver metastases

aorta
 Esophageal Disease
Malignant Neoplasms
Metastaticlung,
breast, and renal CA as
well as melanoma and
Kaposis sarcoma (in
AIDS patients) can
involve or spread to
esophagus
 Esophageal Disease
Malignant Neoplasms
Metastaticlung,
breast, and renal CA as
well as melanoma and
Kaposis sarcoma (in
AIDS patients) can
involve or spread to
esophagus
 Esophageal Disease
Trauma
may rupture with major
trauma
esophagus
rupture more often occurs
secondary to severe vomiting
(Boerhaaves syndrome);
tends to occur in the left side
of the lower esophagus and
may extend into the left
pleural space; fluoroscopy
with a small amount of
water-soluble contrast will
show extravasation in area of
rupture
stomac
 Esophageal Disease
Trauma
instrumentation may cause perforation
particularly after dilatation for treatment of
stricture or achalasia
leaks can occur post-operatively following
gastroesophageal anastomoses

 The Stomach and Duodenum

Indications
peptic ulcer disease may cause epigastric pain,
hematemesis and melena
nausea and vomiting suggest possibility of
obstruction
a palpable mass may involve the stomach

weight loss and anorexia are non-specific but can

occur with gastric cancer

 The Stomach and Duodenum

Methods of Examination
Fluoroscopic-radiographic examination utilizing barium
sulfate suspension alone in infants, children and some adults,
or high density barium along with effervescent powders and
glucagon (air contrast exam or biphasic exam); water
soluble contrast is used when perforation is suspected
CT and ultrasound can demonstrate large gastric
masses

Normal Biphasic Upper GI series

 The Stomach and Duodenum
Disease-Congenital Anomalies
Duplication and Diverticula
(tics)
Gastric tics occur in cardia
Duodenal tics are common in
2nd and 3rd portions
duplications are rare
Congenital Restsaberrant
pancreatic tissue can occur in
the gastric antrum and
proximal duodenum;

 The Stomach and Duodenum

Disease- Peptic Ulcer Disease

Gastritis
Fold Enlargement and
Mucosal Distortion
Erosionsgastric or
duodenal
 The Stomach and Duodenum
Disease- Peptic Ulcer Disease
Ulcers
most common in the
antrum, pyloric canal, and
duodenal bulb
greater curvature ulcers
are often caused by
ingestion of medications
such nonsteroidal anti-
inflammatory drugs

 The Stomach and Duodenum

Disease- Peptic Ulcer Disease
Radiographic Findings cont.
Perforated Ulcersupright films will show free
air
Scarring and obstruction

Hypergastrinism (Zollinger-Ellison
syndrome)multiple ulcers and inc. gastric
secretion secondary to gastrinomas; ulcers may
be in small bowel

 The Stomach and Duodenum

Inflammatory Diseases
Extrinsic Agentsalcohol, anti-inflammatory
drugs, ferrous sulfate tablets
Specific infections
tuberculosis and syphilis
Strongyloidiasis in South America

opportunistic infections with herpes virus

 The Stomach and Duodenum

Inflammatory Diseases
Crohns Disease
Gluten Enteropathy
Miscellaneous Disorders
Menetriers disease
Eosinophilic gastroenteritis
Scleroderma
Cystic fibrosis may cause
inflammatory changes in
stomach and duodenum

 The Stomach and Duodenum

Motility disorders
Nuclear medicine gastric
emptying studies
(radionuclide is mixed with
food).
gastroparesis especially in
diabetics
patients after truncal vagotomy
may combine lack of motility
and diminished gastric acid
secretion
bezoars may form in the
stomach

 The Stomach and Duodenum

Vascular disorders

gastric or duodenal
varicesbest visualized
on CT scans

 The Stomach and Duodenum-

Benign Neoplasms
Adenomatous and
Inflammatory Polyps and
Villous Adenomas
Intramural Tumors (Lipomas,
neurofibromas, and
leiomyomas)
Polyposis syndromes (familial
colonic polyposis, Gardners
syndrome, Peutz-Jeghers
syndrome, Cronkhite-Canada
syndrome)

 The Stomach and Duodenum-

Benign Neoplasms

Adenomatous and
Inflammatory Polyps and
Villous Adenomas
Intramural Tumors (Lipomas,
neurofibromas, and
leiomyomas)
Polyposis syndromes (familial
colonic polyposis, Gardners
syndrome, Peutz-Jeghers
syndrome, Cronkhite-Canada
syndrome)
 The Stomach and Duodenum-
Primary Malignant Neoplasms

Imaging
Barium studies vs.
Endoscopy in Gastric CA
detectionin a recent review
of a large series of gastric
cancers, double contrast UGI
studies detected 99% of cancers
and malignant tumor was
diagnosed or suspected in 96%
of cases, compared to the
reported sensitivity of
endoscopy and biopsy of 94%
to 99%.
 The Stomach and Duodenum-
Primary Malignant Neoplasms

CT is useful in
detecting
lymphadenopathy and
liver metastases but is
not accurate in staging
because it does not
accurately image the
true extent of
pathology
 The Stomach and Duodenum-
Primary Malignant Neoplasms

Adenocarcinoma of
the stomach
scirrhous carcinomas
(linitis plastica)

The Stomach and Duodenum-

Primary Malignant Neoplasms
Leiomyosarcomabulky
tumors with large
ulcerations
 The Stomach and Duodenum-
Primary Malignant Neoplasms

Lymphomamimics
adenocarcinoma

 stomach

liver
spleen
The Stomach and Duodenum-
Primary Malignant Neoplasms
Carcinoidmay mimic all the
benign and
malignant lesions
 The Stomach and Duodenum-
Primary Malignant Neoplasms
Adenocarcinoma of the
duodenum is rare

 The Stomach and Duodenum-

Metastatic Neoplasms
Melanoma
Lymphoma
Kaposis sarcoma
Breast carcinoma--
mimics linitis plastica

 The Stomach and

Duodenum-
Metastatic Neoplasms
Melanoma
Lymphoma
Kaposis sarcoma
Breast carcinoma-- --
mimics linitis plastica
Stomach and Duodenum- iatrogenic Conditions
Surgery for PUD
! fewest complications following vagotomy and pyloroplasty
! gastric resection and gastroduodenostomy(Bilroth I), and gastric
resection with gastrojejunostomy (Bilroth II) not uncommon
prior to advent of drug therapy
! marginal ulcers can occur in postop patients
 Small Intestine

Indications for evaluationunexplained diarrhea,,

unexplained intestinal bleeding, malabsorption,
- abdominal pain or tenderness, suspected partial SB
- obstruction not clear from plain films
Most common fluoroscopic exam done today because
endoscopy of stomach and colon is usually performed
for evaluation of those structures.
Small Intestine
Methods of Examination
Oral Barium for routine evaluation
patient drinks 480 to 600 ml; ; must be
NPO for at least 8 hours prior to exam
because food interferes with evaluation of
the mucosa
 Small Intestine
Methods of Examination Methods of Examination
Enteroclysis when routine exam negative and high clinical
suspicion-- --barium and methylcellulose pumped into SB via
nasointestinal tube during fluoroscopic observation
- Improved visualization of focal lesions
- partial bowel obstructive such as adhesions processes
- occasionally demonstrate Meckel's diverticula-- --usually
asymptomatic but can bleed or be a site of volvulus or
intussusception
 Computerized Tomography
Crohn's Disease-- --helps to identify abscesses and
fistulas and determine extent of disease
Intestinal Ischemia-- dilated, thick-walled, , fluidfilled loops
of SB
Primary SB malignancies-- --to determine extraluminal
extent of tumor
Small Intestine
Methods of Examination
Nuclear Medicine
Meckel's Diverticulum-- ; gastric mucosa can bleed;
detectable with Technetium scans
GI Bleeding not detectable by endoscopy
 Nuclear Medicine
! Meckel's
Diverticulum-
-can bleed; gastric
mucosa can bleed;
detectable with
Technetium scans
! GI Bleeding not
detectable by endoscopy
! Meckel's Diverticulum-
- ; gastric mucosa can bleed;
detectable with
Technetium scans
! GI Bleeding not
detectable by endoscopy
 Angiography
! GI bleeding must
exceed 2 cc/min in order
to be visualized
! Intestinal Ischemia-- --
patients with post
prandial pain and weight
loss
Submucosal Infiltration
. What can infiltrate.
! Edema
! Inflammatory exudate
! Blood
! Lymph tissue
! Tumor
Two Patternsdepend on amt. of
infiltration
! Small amount = stack-of of-coins
Little separation of the normal folds
! Large amount = picket fence
Greater separation of normal folds
 Hallmark features are
- Dilatation
- Dilution, especially in jejunum
Segmentation
- Masses of barium separated from adjacent clumps
- Not commonly seen with newer barium mixtures
 Scleroderma
- Entire small bowel is usually dilated
- Close approximation of valvulae (hide-bound
appearance)
- Does not have increased secretions as does Sprue
- May be associated with pneumatosis intestinalis
Hallmarks of the disease are
- Nodules
- Markedly thickened bowel wall (picket-fence)
Small bowel may or may not be dilated
Affects jejunum mostly
Amyloid
-Marked thickening of the valvulae (picket-fence)
- No dilatation or dilution
Affects entire small bowel
 Small Intestine
Inflammatory Diseases
Crohn's Disease-- --unknown etiology; usually begins in
ileum but can involve all parts of SB; begins with
aphthous ulcerations, mucosal fold thickening and
distortion; progresses to deep ulcerations, , nodular mucosal
pattern, and eventual stenosis
 Small Intestine
Inflammatory Diseases
Whipple's Disease-- mucosal fold
thickening (picket fence) and
irregular fold distortion with or
without dilatation; jejunum
affected primarily
Ascariasis
Giardia lambliausually
limited to duodenum and
jejunum
Thickening of the folds
Marked spasm and irritability
of the bowel
Increased secretions is
common

 Small Intestine
Motility Disorders
Scleroderma --dilated SB; ;
mucosal sacculations
 Small Intestine
Vascular Diseases

Intestinal Ischemia
mild dilatation or normal on barium studies
mesenteric artery stenosis on angiogram

 Small Intestine
Foreign Bodies

Bezoars, drugs, enteroliths, gallstones,

miscellaneous (bones, sharp objects)
 Small Intestine
Malabsorption

Nontropical Sprue--
2ndary to gluten
hypersensitivity
 Small Intestine
Malabsorption

Spruethe hallmark
features are: dilatation
and dilution, especially
in jejunum with
stacked coin
appearance.
 Sprue the hallmark
features are: dilatation
and dilution, especially
in jejunum with
stacked coin
appearance.
 Small Intestine
Benign Neoplasms
Solitary
Leiomyomas
Carcinoid tumors
Adenomatous polyps
Multiple
Lipomatosis
Peutz-Jeghers
syndrome
Cronkhite-Canada
syndrome
Malignant Neoplasms
! Primary
! Adenocarcinomas
! Leiomyosarcomas
! Lymphoma
 Small Intestine
Malignant Neoplasms
Metastatic--Breast, lung,
kidney, melanoma,
carcinoid and Kaposi's
sarcoma
Enterography: Polypoid filling defect in the terminal ileum (arrows).
Filling defect caused by fibrosis is visible at the lover contour of the
tumor.
CT examination: Contrast enhanced axial scans: An intraluminal,
bulging soft tissue mass is visible in the ventral wall of the
ascending colon (upper pictures-arrows). Distally the lumen is
narrowed, the circular thickening of the mucosal wall is irregular,
the adjacent fat is infiltrated (lower pictures - arrows).
3. Picture: Larger ulcers (arrows) involve deeper layers of the
bowel wall.
Double-contrast barium examination: 1. Picture:
'Cobble-stoning' caused by swelling of longitudinal
and transversal mucosal folds is visible. (=> picture)
 Small Intestine
Hernias
Inguinal
Paraduodenal
 Colon and Appendix

Indications (colon CA and inflammatory bowel

disease are the major reasons for studying)
subacute or chronic diarrhea, change in caliber of stool,
constipation, and weight loss suggest colon disease but most
often no organic disease is found
severe anemia seen with right colon neoplasms
abdominal distension suggests obstruction
left-lower-quadrant mass suggests diverticulitis or tubo-
ovarian mass
right-lower-quadrant mass suggests appendiceal or tubo-
ovarian mass

 Colon and Appendix

Radiologic Techniques
clean colon is of vital importance therefore require
colon prep with large volumes of oral liquids, laxatives
and enemas
Air or Double Contrast (Barium and air)--preferred
technique particularly for evaluation of blood in the stool
or suspected polyps; not feasible in all patients particularly
frail elderly individuals; detects 94% of colo-rectal CA
Single Contrast (Barium only)good method for
evaluation of non-specific complaints; preferred for
elderly debilitated patients; detects 89% of colon CA

 Colon and Appendix

Radiologic Techniques
Computerized Tomography
Appendicitisinflammatory changes in fat and enlargement
Diverticulitis--inflammatory changes in fat surrounding
area of involvement (usually in sigmoid colon) and bowel
wall thickening; CT is method of choice since you can
evaluate patient during acute illness (in contradistinction to
BE)
Adenocarcinoma--staging sensitivity, specificity and
accuracy varies from 48% to 100%; mean accuracy in
detecting recurrent tumor is 90%
Lymphoma--staging
 Colon and Appendix
Radiologic Techniques
Ultrasonography
Appendicitisan enlarged non-compressible
appendix in patients with RLQ pain
Intussusceptionin the pediatric population

 Colon and Appendix

Radiologic Techniques
Nuclear Medicine
Immunoscintigraphycolon CA recurrences
GI bleeding study with tagged RBCs

Meckels Diverticulum scanning with

pertechnetateGI bleeding in the pediatric
population

 Colon and Appendix
Congenital Anomalies
Failures of Rotation
with incomplete rotation
mobile cecum can result
in volvulus; when
complete, entire colon in
left abdomen
Barium enema: An approximately 1 cm long segment of the colon is narrow (arrow) in the
recto-sigmoideal region, above which the colon is markedly dilated, the haustration
disappeared completely.
 Colon and Appendix
Inflammatory Diseases
Extrinsic Agents
long standing laxative
abuse
radiation damage to the
rectum and sigmoid
following treatment of
pelvic malignancies
Ulcerative colitis
Crohns Disease
 Colon and Appendix
Inflammatory Diseases
Specific Organismsnumerous causes of colitis--
Tuberculosis, Shistosomiasisis, Amebiasis, Yersinia,
Clostridium perfringens and septicum, Herpes simplex,
Herpes zoster, Campylobacter, venereal-related colitis
2ndary to gonococcus, mycoplasma,
Lymphogranuloma venereum, Clostridium difficile
causes pseudomembranous colitis in patients after
antibiotic therapy

 Colon and Appendix

Diseases
Motility Disorders
Scleroderma--wide mouthed sacculations
Diabetic Diarrhea

Spastic colon--functional

 Colon and Appendix

Vascular Disease
Ischemic Colitis
thumbprint pattern due to intramural hemorrhage
usually reversible

 Colon and Appendix

Diseases
Diverticulosisdiverticulae are most common
in the sigmoid and descending colon
DiverticulitisCT is the technique of choice;
can mimic CA
 Colon and Appendix
Colon Malignancies
Predisposing factorsulcerative colitis, Crohns,
familial polyposis, family history, breast CA,
uterine CA, pelvic irradiation, previous
uterosigmoidostomy, retinitis pigmentosa, 5%
adenomatous polyps (< 5-6mmno risk, 6-
10mm1% risk, 1-2 cm5% risk, >2cm
10% risk, multiple adenomashigh risk).
 Colon and Appendix
Neoplasms
Benign Polyps--both
hyperplastic and
adenomatous
 Colon and Appendix
Neoplasms
Polyposis Syndromes
Familial Polyposis--
hereditary; colon CA precursor
Gardner's syndrome--colon
polyps ass. with soft-tissue
tumors; colon Ca precursor
Turcot syndrome--
combination of intracerebral
tumors and colon polyps
Peutz-Jeghers (hamartomas)
and Cronkhite-Canada
(juvenile polyps) syndromes
both have colon polyps
 Colon and Appendix
Neoplasms
Adenocarcinoma--there is
an adenoma to cancer
sequence that takes several
years to develope; 5-6 mm
no risk, 1-2 cm5% risk,
>2cm10% risk; villous
adenomas40% risk;
multiple adenomasinc. risk
Lymphomacan mimic
adenoCA or be multinodular
and involve entire colon
 Colorectal CA
screening strategies
Screening for colorectal CA is both effective and
cost-effective.
The cost-effectiveness of colorectal CA
screening is likely to be twice as effective as
screening for cervical CA and breast CA.
 Colorectal CA
screening strategies
Although it has been shown to be an effective
screening method, the fecal occult blood test
(FOBT) is the least effective method and must
be performed every 1 to 2 years.
 Colorectal CA
screening strategies
Sigmoidoscopy has been shown to be effective but misses
many polyps and cancers in the remainder of the colon,
therefore colonoscopy is likely better and can be
performed less often (possibly every 10 years) because
of the slow growth of colorectal CA.
But, are there enough qualified endoscopists?
 Colorectal CA
screening strategies
Air-contrast BE is less effective than colonoscopy
but does evaluate the entire colon (every 5 years)
and would likely be needed in order to screen
the entire population.
Virtual colonoscopy is currently being developed
with imaging techniques and may prove to be an
effective method.
 Colorectal CA
screening strategies
The high risk population should be intensively screened.
Because of their 2 to 5 fold higher incidence of colorectal
CA, screening of this population is more effective and
cost-effective than screening the general population.
 Colon and Appendix
Neoplasms
Appendiceal Tumors
Mucocele--caused by low
grade adenoCA; may
calcify
Carcinoid
 Colon and Appendix
Hernias
Inguinal
Morgagni--anterior at cardiophrenic angle;
esophageal hiatus rarely
Spigelian--in fascia of rectus muscle
 Organs of Digestion
Livercongenital
Hemochromatosis
autosomal recessive; defect in iron absorption
causing iron deposition in the liver, pancreas and
skin with classic triad of cirrhosis, diabetes and
bronze pigmentation
Imaginghyperechoic liver on U.S.; increased density of
liver on non-contrast images by CT; hypodensity on
T2-weighted images
 Organs of Digestion
Liverinflammatory
CirrhosisCT and
UShepatomegaly,
heterogenous hepatic
parenchyma, nodularity
of livers surface, ascites,
signs of portal
hypertension including
varices and splenomegaly

 Organs of Digestion
Liverinflammatory
Sclerosing cholangitisprogressive fibrotic
inflammation of the biliary tree leading to biliary
obstruction and cirrhosis. Imaging
cholangiography demonstrates multiple focal
strictures of the bile ducts
 Organs of Digestion
Livertumorous
Cavernous hemangioma
most prevalent non-
malignant tumor
Imaginghyperechoic
lesions with posterior
acoustic enhancement by US;
hyperintense on MRI;
enhances from periphery to
center by CT; increased
uptake on tagged RBCs scan
of liver
 Organs of Digestion
Livertumorous
Metastasescolorectal CA,
stomach, pancreas, breast
and lung most common.
Imagingmost hypodense on
contrast CT; renal and
melanoma may be
hyperintense; MRI equal to
CT in detecting mets but
more expensive and less
effective in detecting disease
elsewhere in the abdomen.
Needle biopsyCT or US
guidance.
 Organs of Digestion
Livertumorous
Hepatocellular CArisk factors are chronic
hepatitis B and C, cirrhosis, glycogen storage
diseases Imaginghypodense enhancing lesion
that often invades vascular structures such as the
portal vein
Needle biopsy with CT or US guidance
 Organs of Digestion
Liverinfectious
Echinococcal cysts or abscesses-
Imaginghypodense on CT or US
 Organs of Digestion
Pancreascongenital
Pancreas divisumlack of fusion of the dorsal and
ventral pancreatic buds resulting in the main pancreatic
drainage occurring through the minor papilla (proximal
to the papilla of Vater) that may be too small to
accommodate the full volume of pancreatic secretions,
resulting in obstruction and pancreatitis
ImagingERCP and MRI
 Organs of Digestion
Pancreastumorous
CA pancreas95% are adenocarcinomas with
dismal prognosis; other tumors include
insulinoma, gastrinoma, macrocystic and
microcystic adenomas Imaging3 or 4
phase CT best showing hypodense mass;
hypoechoic on US
Splenic vein
Longitudinal
image
g
 References
Essential Radiology, Richard Gunderman, Thieme
publishers, 1998.
http://brighamrad.harvard.edu
http://www.indyrad.iupui.edu/rtf/index.html
http://www.rad.uab.edu:591/tf/browse_search.htm
http://www.uhrad.com/Default.htm
http://www.learningradiology.com/medstudents/meds
tudtoc.htm
http://www.vh.org/Providers/Providers.html