M-1 RADIOLOGY OF THE ABDOMEN

1. M-1 RADIOLOGY OF THE ABDOMEN GASTROINTESTINAL TRACT DR. FRANCIS NEUFFER, MD UNIVERSITY OF SOUTH CAROLINA SCHOOL OF MEDICINE 2011

2. Goals / Objectives Anatomy Imaging Choices Pathology References

3. NORMAL ANATOMY Esophagus Stomach Small bowel Colon

4. BASIC DENSITIES VISUALIZED Bone Soft Tissue Fat Air

5. X - RAY --- FOUR BASIC DENSITIES • Air • Soft Tissue • Fat • Bone

7. CT 3D ANGIOGRAM Celiac artery Superior mesenteric artery

8. SPLENIC ARTERY AORTOGRAM HEPATIC ARTERY CELIAC ARTERY RIGHT RENAL ARTERY LEFT RENAL ARTERY

9. AORTOGRAM INTERCOSTAL ARTERY SPLENIC ARTERY RENAL ARTERY RENAL ARTERY SUPERIOR MESENTERIC ARTERY

10. CELIAC ARTERY AND SUPERIOR MESENTERIC ARTERY INJECTION CELIAC ARTERY SUPERIOR MESENTERIC ARTERY

11. LATERAL AORTOGRAM AND CT SHOW ORIGINS OF CELIAC ARTERY AND SMA Celiac Celiac SMA SMA

13. AP SUPINE ABDOMEN X-RAY GAS PATTERN STOMACH SM. BOWEL COLON Normal abdominal gas pattern with air in the stomach and scattered non-distended loops of large bowel and little small bowel gas present.

14. AP ABDOMEN NASO-GASTRIC (NG TUBE) NASO-GASTRIC (NG TUBE) BARIUM IN COLON

15. UPPER GI ORAL BARIUM CONTRAST STOMACH WITHOUT CONTRAST COLON BARIUM ENEMA - RECTAL BARIUM CONTRAST 15

16. SPOT FILM TAKEN WITH PATIENT IN THE UPRIGHT POSITION CARDIA FUNDUS LESSER CURVATURE

17. FUNDUS UGI STUDY RUGAE GREATER CURVATURE DUODENAL BULB DUODENAL “C” LOOP GASTRIC BODY ANTRUM JEJUNUM

18. FUNDUS NORMAL GASTRIC ANATOMY DUODENUM DUODENAL JEJUNAL LIGAMENT ANTRUM BODY C-LOOP Single AP radiograph showing filling of distal esophagus, stomach and proximal small bowel without mass, obstruction or filling defect.

19. CT COMPARISON OF THE STOMACH

20. BARIUM IN STOMACH SMALL BOWEL DUODENAL “C” LOOP FILM TAKEN IMMEDIATELY AFTER INGESTION OF BARIUM. JEJUNUM

21. JEJUNUM SMALL BOWEL FOLLOW THROUGH (20 minutes later) ILEUM

22. Ileocecal valve Terminal ileum CECUM Appendix TERMINAL ILEUM

23. APPENDIX EXTENDING FROM CECUM

24. AIR CONTRAST BARIUM ENEMA Terminal ileum

25. ESOPHAGEAL DISEASE ESOPHAGEAL CANCER HIATAL HERNIA VARICES CANDIDA ESOPHAGEAL TEAR SIGNS / SYMPTOMS CHEST PAIN DIFFICULTY SWALLOWING HOARSENESS

26. NORMAL ESOPHAGUS Aortic impression Normal double contrast esophagram shows coating of mucosa with barium and air distention. There are narrowed areas at the aortic arch and Diaphragm hiatus.

27. ASPIRATION NORMAL SWALLOW Contrast tracks anteriorly into trachea with aspiration.

28. Aspiration is a problem with patients with CVA Due to complex neuromuscular requirements of swallowing. Also in patients with altered consciousness Drug overdose/ Alcohol intoxication

29. ESOPHAGEAL CANCER Typical squamous cell carcinoma Poor prognosis from local extension into critical mediastinal structures. (esophagus lacks a serosa)

30. NORMAL ESOPHAGUS HIATAL HERNIA *Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus. DIAPHRAGM DIAPHRAGM This allows for reflux of gastric contents into esophagus.

31. ESOPHAGEAL CANCER Distal malignancy may be adenocarcinoma due to Barrett’s esophagus - dysplastic change caused by chronic reflux of gastric contents.

32. ESOPHAGEAL VARICES Linear tubular filling defects represent distended veins from shunting of blood from the portal vein to the systemic circulation due to cirrhosis and portal hypertension.

33. CANDIDA ESOPHAGITIS Extensive nodular filling defects in the esophagus in an immunocompromised patient are typical for Candida esophagitis.

34. ESOPHAGEAL TEAR Esophagus shows a linear tear of mucosa of distil esophagus due to vomiting with barium tracking into the wall. Full thickness tear or rupture (Boerhaave’s syndrome) can lead to mediastinitis and death.

35. GASTRIC DISEASE ULCER CANCER PYLORIC STENOSIS SIGNS / SYMPTOMS PAIN ANEMIA HEMATEMESIS / MELENA EMESIS WEIGHT LOSS

36. FUNDUS NORMAL GASTRIC ANATOMY DUODENUM ANTRUM BODY JEJUNUM C-LOOP Single AP radiograph showing filling of distal esophagus, stomach and proximal small bowel without mass, obstruction or filling defect.

37. GASTRIC ULCER Barium collects in ulcer crater

38. ENDOSCOPIC IMAGE ulcer RUGAE

39. GASTRIC ANTRECTOMY AND SMALL BOWEL ANASTOMOSIS normal C-LOOP

40. GASTRIC CARCINOMA Narrowed lumen of gastric antrum by adeno carcinoma. Lymph node spread goes to Celiac nodes

41. PYLORIC STENOSIS PYLORIC STENOSIS Normal stomach Oblique view of stomach Air filled fundus Air filled fundus Barium filled antrum Duodenal bulb Duodenal bulb Barium filled antrum Narrowed pyloric channel Pyloric Stenosis is seen in newborns within the first months. There is a 4:1 male ratio and is due to hypertrophied musculature at the pylorus.

42. PYLORIC STENOSIS Thickened pyloric muscular wall Narrowed pyloric channel ULTRASOUNDis used now more for diagnosis

43. SMALL BOWEL DISEASE ULCER OBSTRUCTION POST-OPERATIVE ILEUS CROHN’S DISEASE SIGNS / SYMPTOMS PAIN HEMATEMESIS DISTENTION DIARRHEA

44. DUODENAL ULCER Note barium collection Centrally with surrounding edema.

45. AIR UNDER THE DIAPHRAGM NORMAL GAS PATTERN Perforation of GI tract from ulcer leads to peritonitis and pneumoperitoneum.

46. ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. UPRIGHT DECUBITUS LIVER Left lateral decubitus (left side dependent) shows air along liver margin. This is the preferred x-ray if the patient cannot stand.

47. NORMAL SMALL BOWEL JEJUNUM Early contrast is predominantly in jejunum and later predominately in ileum. (note difference in mucosal fold pattern) ILEUM COLON

48. SMALL BOWEL OBSTRUCTION Ng tube ERECT Note dilated small bowel centrally placed with air/fluid levels on upright exam.

49. PARTIAL SMALL BOWEL OBSTRUCTION DILATED BOWEL * OBSTRUCTION NON DILATED BOWEL Proximal loops are dilated and distal loops are collapsed indicating an obstruction.

50. HERNIA SM. BOWEL BARIUM STUDY Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery.