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Bachtiar Murtala

Dept.of Radiology
Medical Faculty Hasanuddin University
General Objective

To provide basic understanding


about the role of radiological
imaging in diagnosing
gastroenterohepatologic diseases
Specific objectives
Imaging modalities and
techniques/examination
procedures
Radiological appearances of
some GIT and hepatobiliary
diseases
Organs scope
Plain Abdomen
Esophagus-rectum

Liver

Biliary tract

Pancreas
Imaging modalities
Plain abdominal radiography

Conventional radiography with contrast


media
Imaging (US, CT-Scan, MRI, Nuclear
medicine)
Plain abdominal radiography
Commonly used in emergency cases such as ; ileus
(dynamic or adynamic), peritonitis, free-air/fluid,
blunt or penetrating trauma,etc
Usually needed 3 standard positions :
1. Erect
2. Supine
3. LLD ( left lateral decubitus)
4. Cross table ( optional )
Large bowel obstruction
Less commonly than small bowel obstruction
Three main causes : - colon carcinoma
- Volvulus
- Diverticulitis
Small bowel obstruction
Radiological signs
Bowel distended filled by gas++
Lack gas in the distal part
Air fluid level (step ladder appearance)
Valvula conniventes appears as herring bone
(herring bone appearance)
invaginasi
Peritonitis
Bowel wall thickening
Properitoneal fat line disappear/
obliterate
Paralytic ileus sign
Adynamic or paralytic ileus
Bowel distended until distal part
Air fluid levels (+) , longer
Herringbone appearance(-)
Radiography with contrast
Barium Sulphate (BaSO4)
suspension
Iodine
Esophagus :
It should be visualized with contrast media
(Barium Sulfat) Esophagography
Indications :
- Dysphagia
- Dyspepsia
- Haematemesis/melena
- Congenital anomalies ?

Technique of Examination :
The patient is asked to swallow a thick Barium
Sulphate (1:1) or Iodine ( for baby) and followed by
fluoroscopy & taking radiography
B. Abnormalities :
Congenital malformation
- Esophageal atresia
- Short esophagus with a thoracic stomach
(Brachy-esophagus)
- Duplication
Traumatic Disorders rupture
Abnormalities in density foreign bodies
Abnormalities in Size (length & diameter)
Abnormalities in architecture
Radiography positions : - AP
- Right Anterior Oblique
projection (RAO)
- Left Anterior Oblique
projection (LAO)
- Spot Film (optional)

Radiological Signs :
A. Normal Indentations : - Knob aorta
- Left main bronchus
- Left atrium
- Hiatus hernia
Esophageal atresia
Esophageal varices
Caused by portal hypertension,
commonly seen in cirrhosis
hepatis
cobble stone appearance
Esophageal stricture

Narrowing and irregularity due


to corrosive materials
(corrosive stricture)
ACHALASIA
Aganglionic of the distal part of
esophagus
Distal smooth narrowing with
dilatation of the proximal segmen---
mouse tail app.
MOUSE TAIL APPEARANCE
Esophageal hernia

Sliding /axial
Paraesophageal hernia
GASTRODUODENOGRAPHY
(= Maag Duodenum/MD Foto)
Is a radiographic evaluation of the stomach &
duodenum by introducing contrast media inside
[Barium sulfat (+) & air/gas (-)
Indication : - Dyspepsia
- Epigastric pain
- Vomiting
- Haematemesis/melaena
Procedure Of Examination
1. Preparation : fasting 4-6 hours
2. The patient swallows contrast Barium Sulfat
(& air) followed by fluoroscopy and taking
radiography in various position
3. Usually in Supine, Prone, Prone oblique,
Erect. Spot-Film Compression
(recommended)
Radiographic Abnormalities of Gastroduodenal
Disease.
It can be classified as changes in :
Position
Size (redundancy, enrlargement/widening,
narrowing/shrinkage)
Contour
Rugae abnormalities
Filling defect
Function
Fig. 28-14.Left lateral
erect film of the
stomach
Pyloric stenosis
= Infantile Hypertrophic Pyloric Stenosis
DIVERTICLE
- Protrution of mucosa and submucosal outward
- Additional shadow
Gastritis
Mucosal atrophy
Mucosal hypertrophy-
hypersecretion
three level density
Peptic ulcer
Mostly seen in pyloric antrum and duodenal bulbus

Primary Signs :
- En face (frontal view)barium spot with halo (active ulcer) and star
sign ( inactive)
- En profile (lateral view)additional shadow , globular shape (active
ulcer), conus (inactive)
Secondary signs
Contralateral/opposite spastic
insicura
Hypersecretion
Bulb deformity
DUODENUM
Congenital :
Stenosis post bulbar
duodenal atresia
Two bubbles app.
SMALL INTESTINE (JEJENUM & ILEUM)
Normal size: - 20 feets (length)
- 2,5 cm (jejenum); 1,75 cm (ileum)
in diameter
Indications:
Anemia (unclear origin)
Persistent diarrhoe
Abdominal pain
Palpable mass
Excessive protein loss
Malabsorbtion
Contraindication:
Obstruction signs
Perforation
Paralytic ileus
Peritonitis

Technique of Examination
1. Plain abdominal radiography
2. Follow Through
Patient is asked to swallow 200-300 cc Barium
sulfat (1:2-3 water),followed by taking pictures
30-60 minutes interval until contrast seen in
caecum
Abnormalities
Crohns Disease = Regional
ileitis
Adhesion
Fistula
COLON
Indication : Haematochesia
Persistent diarrhea
Abdominal mass
Obstructive symptoms
Congenital abnormalities

Contraindication : Ileus (Paralytic)


Suspect Bowel Perforation
Peritonitis
Technique of Examination :
Barium enema
(colon inloop)
Mostly Double-Contrast method
Preparation is the most important to remove
faecal material from the colon
Colon inloop : - Using a thin Barium sulfat
(1:3-6) aprox. 2 L
- Contrast should fill colon entirely
(rectum-caecum)
- Picture taken in many positions/
views.
COLON
A.Kongenital
1. Atresia Ani (Imperforate anus) , Foto polos
abdomen terbalik (Invertogram)

2. Hirschsprungs disease ( megacolon


congenitum )
Atresi ani
Radiographically :
Technique of examination for atresia ani:
Inverted or Wangesteen position
Knee-chest position
Aim : to identify the lowest end of air in colorectal
Lower level

High level
Dilatation/Distension :
- Idiopathic symptomatic megacolon (older age)
- Hirschsprungs disease (megacolon congenital)
Disease of childhood, mostly males
Abscent of ganglion cells in the mesenteric

plexus in the narrowing segment (mostly


sigmoid colon, 40%)
Marked dilatation above the area of aganglionosis.

Radiographically :
- Plain abdominal films veriable degrees of
distension of GIT above the obstruction
- Barium enema/colon inloop
- Colon in loop :
Narrowing along the site of aganglionosis
Dilatation above the narrowing, might be
associated
with irregularity/sawtoothing/ulcerative
Colitis
Narrowing of the Colonic Lumen :
Obstruction of colon
Obstruction to the flow of Barium can be caused by :
Spasm

Annular Carcinoma

Intusussception

Volvulus

Diverticulitis
Intussusception = Invagination
A proximal segment of bowel (intussusceptum)
into lumen of a distal segment (intussuscepiens)
Location : Ileoileal > ileocolic > colocolic
Radiographic sign :
- Coiled spring or cupping sign
-proximal bowel dilatation
-absence of gas in dist segment
Cupping sign

Coiled spring
US findings :
-Target sign, doughnut sign or bulls eye
sign (transverse scan )
- pseudokidney sign ( longitudinal scan)
Necrotizing enterocolitis ( NEC)
Pneumatosis intestinalis
( Gas within bowel wall )
Inflammation :
- Ulcerative colitis
- Crohns Disease
Ulcerative Colitis
- Loss of haustra
- Contracted,shortened & small calibre
- Saw-toothing/ulceration
- Stringiness/String sign
Diverticle
Acute appendicitis
Acute appendicitis acute appendiceal inflammation due
to luminal obstruction and superimposed infection
Most common abdominal surgical emergency.
Diagnosis clinical history, physical examination &
laboratory studies.
Imaging is useful and advisable in patients with atypical
symptoms.
Mortality rate in developing countries : 1%.
() to 5% in small children & elderly.
Surgical aim to operate early before complications such as
appendiceal rupture & peritonitis developed.
Helical CT scan & graded compression US powerful
imaging methods in appendicitis
IMAGING IN APPENDICITIS
ABDOMINAL PLAIN FILMS

APPENDICOGRAPHY

ULTRASOUND

CT SCAN

MRI (MAGNETIC RESONANCE IMAGING)


HEPATOBILIER & PANCREAS
Imaging modalities :
- USG : Ultrasonografi / Ultrasound
- CT scan : Computerized Tomography
- MRI : Magnetic Resonance Imaging
- MRCP : MRI for Cholangiopancreatography.
- PTC(D) : Percutaneus Transhepatic
Cholangiography ( Drainage )
- T-Tube Cholangiography, Durante operatif ,
Post operatif
- Nuclear Medicine
Gallstones/cholelithiasis
- Soliter / multiple
- Echogenic/hyperechoic structure dengan
acoustic shadowing
Acute Cholecystitis

* Gallbladder wall thickening > 3 mm


* Sludge
CIRRHOSIS HEPATIS
- Liver atrophy
- Increasing echogenecity, fibrotic.
- Irregular of the surface
- Portal hypertention
- Splenomegaly
- Ascites.
HEPATOCELLULAR CARCINOMA/HCC HEPATOMA
USG : Iso hipo or hiperechoic mass
Ill-defined

TUMOR METASTASIS
Noduler bull-eye, usually multiple,
Well defined
Liver abscess
Hypoechoic mass
Irregular and thicken wall

Liver cyst
Free-echoic mass, well defined,
Solitary or multiple
Biliary obstruction
Causes :
- Stone
- Tumor intra/extraluminer.
such as Panreatic cancer,
cholangiocarcinoma
- Strictur cholangitis, etc
Biliary obstruction due to cancer of caput pancreas
Acute pancreatitis