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G astrointestinal radiology

G astrointestinal radiology. G astrointestinal radiology. The field of gastrointestinal radiology encompasses the study of the : gastrointestinal tract (pharynx, esophagus, stomach, duodenum, small bowel, and colon)

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G astrointestinal radiology

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  1. Gastrointestinal radiology

  2. Gastrointestinal radiology • The field of gastrointestinal radiology encompasses the study of the: • gastrointestinal tract (pharynx, esophagus, stomach, duodenum, small bowel, and colon) • solid abdominal viscera (liver, gallbladder, biliary tract, pancreas and spleen) • peritoneal cavity(mesentery and omentum) • abdominal wall.

  3. Gastrointestinal radiology – the methods • Abdominal plain films (KUB) • (KUB stands for Kidneys, Ureters and Bladder and is a common short term for an abdominal x-ray.) • Barium studies • Ultrasound • Computed Tomography • Nuclear medicine • Magnetic Resonance Imaging • Angiography and Interventional Radiology

  4. Plain Film of the Abdomen

  5. Plain Film of the Abdomen • Often the starting point for the work up of abdominal problems • Upright abdominal x-rays are requested to look for pneumoperitoneum or fluid levels in obstruction or ileus. • Erect and supine films are used to confirm the diagnosis of intestinal obstruction.

  6. Plain Film of the Abdomen Indications for requesting abdominal films Bowel obstruction Free air Abscess Calculi or other abnormal intra-abdominal calcifications Radiopaque foreign bodies

  7. Plain Film of the Abdomen • The normal appearance of gas: • Gas is usually present in stomach • The small bowel may be partially filled with gas • Gas may also be seen throughout the entire colon

  8. Radiolucent fat which surrounds intra-abdominal organs allows for visualization of the soft tissue: Liver - posterior margin visible where outlined by retroperitoneal fat. Spleen - often visible Kidneys - outlines may not be seen in its entirety because of overlying gas and stool Psoas muscles - margins usually visible but may not be seen in its entirety

  9. Plain Film of the Abdomen Small Bowel Distinguishing Features of Small and Large Bowel. Large Bowel

  10. Plain Film of the Abdomen- the „normal” calcifications (with no clinical significance): Vascular-veins of the pelvis (phleboliths) Costal cartilage Mesenteric lymph nodes Injection sites Prostate gland

  11. Plain Film of the Abdomen- the „normal” calcifications (with no clinical significance): vascular-veins of the pelvis (phleboliths)

  12. Plain Film of the Abdomen- the „normal” calcifications (with no clinical significance): costal cartilage

  13. Plain Film of the Abdomen- the „normal” calcifications (with no clinical significance): lymph nodes

  14. Plain Film of the Abdomen- abnormal calcifications "Stones" - renal calculi, cholelithiasis, bladder calculi, appendiciolith Appendicitis fecalith Ureteral calculus Vascular-calcifications, aneurysm Atherosclerosis Abdominal Aortic Aneurysm Pancreatic-chronic pancreatitis Chronic Pancreatitis Leiomyoma (uterine fibroid) Leiomyoma Tumor calcification Other

  15. Plain Film of the Abdomen- abnormal calcifications renal calculi

  16. Plain Film of the Abdomen- abnormal calcifications ureteral calculus

  17. Plain Film of the Abdomen- abnormal calcifications appendicolith

  18. Plain Film of the Abdomen- abnormal calcifications atherosclerosis

  19. Plain Film of the Abdomen- abnormal calcifications chronic pancreatitis

  20. Plain Film of the Abdomen- abnormal calcifications leiomyoma

  21. Bowel obstruction - abnormal gas pattern When the small bowel dilates greater than 3 cm it is abnormal. Mechanical small bowel obstruction – leads to a ladder-like arrangement of dilated small bowel loops, also termed a "stacked coin" appearance. There is very little or absent gas in the colon. supine

  22. Bowel obstruction - abnormal gas pattern Step ladder pattern upright view

  23. Bowel obstruction - abnormal gas pattern step ladder pattern

  24. Bowel obstruction - abnormal gas pattern Mechanical small bowel obstruction X-ray using a horizontal beam technique Supine abdominal x-ray

  25. Bowel obstruction - abnormal gas pattern Mechanical small bowel obstruction – „The string of pearls sign” can be seen on abdominal radiographsobtained with the patient in the upright position or on decubitusabdominal radiographs. Also commonly referred to as the "stringof beads sign", the sign consists of a row or line of severalsmall air bubbles obliquely or horizontally oriented in theabdomen left lateraldecubitus

  26. Bowel obstruction - abnormal gas pattern Mechanical small bowel obstruction – String of pearls sign in a patient with small-bowel obstruction . Left lateral decubitus radiograph of the abdomen demonstrates a row of small air bubbles (arrows). The obliquely oriented row of air bubbles represents small amountsof air trapped between the valvulae conniventes along the superiorwall of predominantly fluid-filled, dilated small-bowel loops. The meniscal effect of the surrounding fluid gives the trappedair an ovoid or rounded appearance. The appearance of the stringof pearls sign depends on the combination of air, fluid-filledbowel loops, and peristaltic hyperactivity. left lateraldecubitus

  27. Bowel obstruction - abnormal gas pattern Mechanical small bowel obstruction – „String of pearls sign” Air trapped at corners of valvulae conniventes (arrows) Almost always seen in obstructed fluid-filled small bowel loops

  28. Bowel obstruction - abnormal gas pattern Mechanical large bowel obstruction – leads to a distended colon but absence of gas in rectum and/or distal colon, +/- small bowel distension. supine upright Dilated colon (with haustra) Air-fluid levels

  29. Free air - abnormal gas pattern Free intraperitoneal air (pneumoperitoneum) - MUST have either an upright or left lateral decubitus view, will see a crescent of air under the diaphragm or outlining the liver. A pneumoperitoneum can be a normal finding in post op patients or patients on peritoneal dialysis; history is important.

  30. Free air - abnormal gas pattern Air under diaphragm Radiographic signs of free air: 1. Air under diaphragm 2. Rigler’s sign 3. Football sign Air under diaphragm UPRIGHT

  31. Free air - abnormal gas pattern Air under diaphragm Abdominal X-ray using a horizontal beam technique: pneumoperitoneum with free air between the liver and anterior abdominal wall (asterisk) If the patient cannot sit up, order a left lateral decubitus. This will allow air to accumulate over the edge of the liver

  32. Free air - abnormal gas pattern anteroposterior abdominal radiograph Rigler’s sign Extensive free intraperitoneal air is seen, which outlines the outer wall of multiple loops of air-filled bowel. Notice the discernible white stripe (arrows) of bowel wall between the intraluminal air and the free intraperitoneal air. Explanation: Gas normally outlines only the luminal surface of the bowelwall and not the serosal surface, which has a degree of opacitysimilar to that of adjacent peritoneal contents. When at leasta moderate amount of free intraperitoneal air exists, however,this free air is more likely to accumulate between bowel loops,thus permitting visualization of the outer walls of the bowel.This is the classic appearance of the Rigler sign. A variantof the Rigler sign occurs when only the outside of the bowelwall is visible because the lumen is filled with fluid supine

  33. Free air - abnormal gas pattern Abdominal x-ray: 1. Pneumoperitoneum with a large oval lucency overlying the entire abdomen (football sign) 2.Visibility of both sides of the bowel wall (Rigler’s sign, white arrow) 3.Falciform ligament outlined by air on both sides (black arrow) supine view

  34. Bowel obstruction - abnormal gas pattern Adynamic ileus - leads to increased gas throughout the Gl tract, multiple air-fluid levels, and gas in the rectum. There is gas in the small bowel, colon and distal bowel Case of adynamic ileus from pain medications - the bowel is not moving. The pathophysiology is that bowel has lost its motility.

  35. Plain Film of the AbdomenRadiopaque foreign bodies

  36. Barium Studies of the GI Tract

  37. Upper GI and small bowel series = Barium swallow x-ray Small bowel enema = enteroclysis Lower GIseries = Barium enema

  38. Barium Studies of the GI Tract Upper GI

  39. Barium Studies of the GI Tract Upper GI • The passage of the barium through the esophagus, stomach and duodenum is monitored on the fluoroscope. • Additionally, some patients are asked to swallow baking-soda crystals to create gas-this procedure has the modified name of "air-contrast" or "double-contrast upper GI.“

  40. CONTRAINDICATION • Suspected leakage from esophagus into the mediasternum or pleura and peritoneal cavities. • Tracheo-esophageal fistula

  41. The normal anatomy of the esophagus From: http://anatquest.nlm.nih.gov/xml-images/

  42. ESOPHAGEAL CONSTRICTION • Superiorly: level of Cricoid cartilage, juncture with pharynx • Middle: crossed by aorta and left main bronchi • Inferiorly: diaphragmatic sphincter

  43. The normal anatomy of the esophagus

  44. The normal anatomy of the esophagus Trachea Esophagus containing contrast medium Lateral radiograph Esophagus Middle (aortic) esophageal constriction Hilum pulmonis Epiphrenic esophageal dilatation Diaphragma (distal to the plate), Cupula dextra Lower esophageal constriction Diaphragma (close to the plate), Cupula sinistra From Wolf-Heidegger’s Atlas of Human Anatomy, 4th Edition

  45. Esophageal Foreign Body

  46. Esophageal Foreign Body Imaging study: • If the swallowed object may be radiopaque, a single frontal radiograph that includes the neck, chest, and entire abdomen is usually sufficient to locate the object. • 2. If the object is below the diaphragm, further radiographs are generally unnecessary. • 3. If the object is in the esophagus, frontal and lateral chest radiographs are necessary to precisely locate and better identify the object and to be sure that the foreign body is not, in fact, 2 adherent objects.

  47. Esophageal Foreign Body Radiopaque foreign body – acoin, just below the cricopharyngeal muscle Biplane radiographs of the esophagus

  48. Esophageal Foreign Body A pin in the pyriform sinus

  49. Esophageal Foreign Body Imaging study: • 4. Radiolucent objects in the esophagus may be better visualized by repeating the study after having the patient drink a small amount of dilute contrast. This should not be done if endoscopy is planned. • 5. Special care must be taken if the esophagus could possibly be obstructed or perforated. • 6. When a foreign body is strongly suspected on clinical grounds, visualization by endoscopy, which has the added advantage of allowing removal of the object, may be the most efficient method of management.

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