PANCREAS

Anatomy
- lies transversely in the upper abdomen at the L1-L2 level.
- head and body are retroperitoneal; tail is intraperitoneal lying in the splenorenal ligament.
- Pancreatic size is variable but normal maximum adult AP measurement is 3.5cm. for the
head, body and tail.
Imaging techniques
A. Abdominal film demonstrates pancreatic calcifications.
B. Chest Film- demonstrates pleural effusion, basal atelectasis, elevated diaphragm.
C. Ultrasound- normal pancreas has homogeneous echopattern of slightly higher echogenicity than
the liver.
D. CT scan- more helpful than ultrasound in assessing pancreatic outline and tail, peripancreatic
tissues and blood vessels.
E. ERCP (Endoscopic retrograde cholagiopancreatography)
-endoscopic assessment of upper gastrointestinal tract and ampulla
-contrast assessment of pancreatic and bile ducts.
-most effective method for imaging pancreatic duct.
- therapeutic and diagnostic procedures which may be undertaken at
ERCP
a. sphinoterotomy
b. stone extraction from bile duct and pancreatic ducts
c. biopsy of the gut or ampulla
d. cytology of pancreatic juice and brushings
e. balloon dilatation of benign strictures
f. stent insertion
g. pancreatic cyst drainage
F. Angiography inferior to CT in assessing respectability of malignant tumors
G. MRI pancreas is difficult to adequately image because of respiratory motion and peristalsis.
H. Fine needle biopsy performed under ultrasound , CT or fluoroscopic control
I. CT scan method of choice in imaging the pancreas.
Common pancreatic diseases
A. Acute pancreatitis
Chest film changes left pleural effusion with high amylase
basal atelectasis
elevated diaphragm
pulmonary edema
wide mediastinum (pseudocyst)
Abdominal film changes
- colon cut off sign transverse colon is dilated but cuts off abruptly at the
splenic flexure.
- sentinel loops
-duodenal ileus most specific
- small bowel ileus
- gasless abdomen due to persistent vomiting
- gastrocolic separation
- left renal halo sign
- ascites
- obliterated left psoas outline
- gas bubbles in the pancreas
- fat necrosis mottled shadowing
- bone changes avascular necrosis
- bone infarcts
- lytic lesions
Barium studies widened duodenal or C-loop with compressed medial border
ampullary edema
thickening of gastric and duodenal folds
Ultrasound findings:

normal in 30% of cases

ultrasonic changes may be seen after 12-24 hours
enlarged and hypoechoic pancreas
pancreatic duct dilatation may be present complications:
-phlegmon, hemorrhage, abscess, fluid collection and pseudocyst
CT scan changes:
best imaging technique for demonstrating pancreas and peripancreatic tissues and associated
complications.
pancreatic enlargement (diffuse or local)
decreased attenuation
indistinct outline
phlegmon low density mass
hemorrhage high density areas
fluid collections, pancreatic and peripancreatic
inflammation of peripancreatic tissues
abscess
free intraperitoneal fluid

B. Chronic Pancreatitis
plain film changes pancreatic calcifications predominant features of alcoholic
pancreatitis.
-bone infarcts
Barium studies hypotonic duodenography: reversed 3 or epsilon sign of duodenal loop
- effacement or speculation of duodenal folds.
- ampulla edema
Ultrasound and CT scan enlarged or smaller than normal
- focal and diffuse changes with irregular outline and loss of definition of fascial planes
- pancreatic and common bile duct are frequently dilated
ERCP irregular and dilated main duct
- irregular filling and cytic dilatation of side branches
- narrowing or smooth stricture of common bile duct
C. Pancreatic Tumors
Barium studies and hypotonic duodenography
-widened duodenal loops
- fixation of the loop
- anterior displacement, speculation of medial mucosal fold
- nodular mucosal filling defects
- inverted 3 or Frostberg sign
Ultrasound findings:
- positive findings in 80-90% of cases
o early focal bulge to pancreatic outline
o late irregular lobulated mass of low or mixed echogenicity
- distal chronic pancreatitis
- dilated common bile duct, pancreatic duct, distal to tumor
- signs of spread liver metastasis, portal and peripancreatic nodes, invasion of retroperitoneal
fat, loss of definition of adjacent tissues, occlusion of splenic and portal veins.
CT-SCAN:
- superior to ultrasound in assessing tumor invasion of peripancreatic structures
- preferred technique for assessing operability
UPPER GASTROINTESTINAL TRACT
Methods of examination:
1. Plain film
2. Upper GI series
a. Examination with an opaque contrast medium

- barium sulfate agent of choice

- inert and isotonic
b. double contrast method examination with an opaque contrast medium plus gas producing
medications.
Rules to be applied ion the use of Barium Sulfate:
1. Free passage thru the colon must be certain
2. Barium studies in a patient with suspected perforation must be approached with caution. Water
soluble contrast materials are useful on some occasions, but these agents are hypertonic an should
be used with caution elderly and dehydrated patients.
ESOPHAGUS
Plain film detection of opaque foreign bodies
- demonstrates fluid filled esophagus in achalasia
- in suspicious perforation of the esophagus, plain film may reeal air fluid in the mediastinium
or pleura.
- CA of the esophagus may cause widening of the mediastinum
Esophagogram ingestion of barium sulfate suspension
1. double contrast demonstrate wall neoplasm and esophagitis
2. full column
3. mucosal relief esophageal varices
4. fluoroscopic observation and motion recording technique esophageal mobility
Radiologic Anatomy
-30cm. long; upper portion at the level of C6 and gastroesophageal junction at the levl of T11.
- smooth longitudinal folds of the cervical and thoracic esophagus in collapsed state
- Major impressions
a. level of aortic arch
b. left main stem bronchus
c. left ventricle
Congenital Anomalies:
1. esophageal atresia 85% associated with fistula
2. congenital stenosis or webs
3. duplications
Hiatal hernia:
1. Sliding or Axial esophagogastric junction forms the most proximal portion of
herniated stomach.
generally slides but may be fixed
lead marks of esophagogastric junction extending above the esophageal
hiatus
a. lower esophageal mucosal ring
b. notch from the gastric sling fibers
c. proximal level of area gastricae of stomach
- direct causal relationship[ between hiatal hernia and gastroesophageal reflux
2. paraesophageal hernia esophagogastric hunction remains fixed below hiatus a
portion of gastric fundus herniates along side the lower esophagus into the chest.
3. Mixed
Lower esophageal mucosal ring or Schatzkis ring
marks the lower border of the vertibule
appears as thin transverse structure encircling the esopagogastric junction
fixed caliber of the ring
important cause of solid food dysphagia
ring less than 13mm nearly always cause dysphagia
Reflux Esophagitis
o mucosal and contour irregularity
o erosions, ulcerations, wall thickening
o fold thickening
o segmental narrowing stricture formation.

Non-reflux Esophagitis
1. infections C slbicans most common
fine ulcerations and cobblestones pattern
abnormal motility, severe ulcerations
psuedomembrane formation
herpetic, cystomegalovirus
2. AIDS
3. Caustic * esophageal dilatation and atony
Exudative plaques, pseudomembrane formation, erosions and
elcerations, intranural dissection and mediastinitis
4. Radiation motility disturbance occurs within 1-3months following
radiotheraphy
-stricture occurs after 6-8 months
5. medication induced tetracycline, KCL
DIVERTICULAR DISEASE
1. Pulsion diverticulum mucosal herniations thru muscular wall
- related to esophageal motility disorders
- oval or rounded and smooth
a. Zenkers diverticulum along the posterior wall of the upper end of esophagus at its junction
with the pharynx.
b. Epiphrenic lower third of esophagus just above the diaphragm
2. Traction due to extrinsic inflammatory involvement of esophagus
o Mid esophageal
3. Intramural pseudodiverticulosis multiple small outpounchings in the wall
ESOPHAGEAL VARICES
- changeable fold thickening or serpingenous and polypoid defects in the lower esophagus
- best shown by mucosal relief technique
CARCINOMA OF THE ESOPHAGUS
A. polypoid fillinf defect in the barium filled lumen
-edges of the lesion are sharply demarcated producing sharp angle or overhanging
edges.
- surface of the lesion is irregular or nodular
B. Infiltrating annular constricting filling defect or narrowing the lumen
- stenotic area is irregular and mucosal folds are absent.
STOMACH AND DOUDENUM
Examination Technique using barium sulfate:
Single contrast
a. Compression demonstrate lesions and structural details including
erosions and areae gastrica.
b. Mucosal relief radiographs of the stomach in prone and supine
position with small amount of barium
c. Distention with barium suspension
Double contrast provides greatest mucosal detail
Radiologic Anatomy of the Stomach:
Anatomically divided into 3 (three) parts:
a. Fundus lies above the transverse line drawn thru the esophago-gastric
junction
b. Body lies between the gastric fundus, and line transecting the stomach at
incisura angularis
c. Antrum extends from incisura angularis to pyloric canal

d. Rugae Longitudinal folds parallel to long axis of the stomach

e. Area gastricae small tufts of gastric mucosa 1-3 mm in size.
Anatomy of the duodenum:
C-shaped curve extending from the pyloric canal to the junction of the duodenum and jejunum at
the junction of the ligament of Treitz
Four segments:
a. Duodenal bulb usually devoid of mucosal folds
b. Descending limb - contains major and minor papillae
c. Transverse limb extends across superior mesenteric artery
d. Limb ascending to ligament of Trietz
Congenital and Developmental anomalies
1. Gastric diverticulum located near esopgahogastric junction
2. Antral web diaphragm composed of mucosal and submucosal tissues
-constrict on proximal to pyloric canal
3. hypertrophic pyloric stenosis elongated, narrow pyloric canal surrounded by muscle mass
impinging on the base of the distal gastric antrum and duodenal bulb.
4. Duodenal diverticulum common at the medial aspect of 2rnd portion im proximity to the
papiulla of Vater.
Gastric Ulcer
Radiographic findings:
- Ulcer crater or niche
o En face of objection extending from the lumen
o Anterior wall ulcers seen as complete or incomplete ring shadows
Differentiation of benign versus malignant ulcers
BENIGN
1. Project beyond the lumen into the wall of
the stomach
2. more likely to the deep
3. surrounding mucosal surface as smooth
4. edematous mound surrounding benign
ulcer (is symmetrical and smooth in outline
5. folds entering the margin of the ulcer are
smooth and distinct from each other

MALIGNANT
1. rest upon a mass that extend into the lumen
of the stomach
2. shallow
3. surrounding mucosal surface has nodular or
irregular component
4. infiltrating tumor surrounding malignant
ulcer is usually asymmetrical and mass like
5. folds emerging towards the ulcer may be
irregular, nodular and variable in thickness
and merge as they reach the margin of the
ulcer.

Duodenal ulcers
Duodenal deformity indirect sign of duodenal ulcer
Cloverleaf deformity pseudodiverticula produced by scarring
Giant duodenal ulcer size exceed 2cm and approaches size of duodenal
bulb.
Carcinoma of the Stomach :
A. Fungating or polypoid
- Filling defect produced by the mass which project into the gastric lumen
- Surface of defect is irregular or nodular
- Superficial deep ulcers may be present
- Junction of filling defect with gastric wall is distinct and forms overhanging
edges
B. Infiltrating
a. Scirrhous Ca infiltrates gastric wall
-thickened and rigid wall with no peristalsis
- mucosal folds are obliterated
- leather bottle stomach or linitis plastica

Benign lesions which cause antral narrowing, wall thickening and decreased
peristalsis
1.
2.
3.
4.
5.

Crohns disease
Tuberculosis
Ingestion of corrosive materials
Irradiation
Sarcoidosis
b. Ulcerating Ca necrosis lead to deep u;lceration with ulcer cavity as
dominant feature
-meniscus tyepe of ulcer ulcer forms within the mass that projects into
the lumen seen in fungating Ca with necrosis
c. Mixed type
SMALL INTESTINES

Methods of Examination
A. Plain film
B. Barium contrast
1. Conventional small bowel series follow thru examination of small
bowel
- adjunct to UGI study
- radiographs taken at 20-30 minutes interval until terminal ileum is filled
2. Dedicated small bowel meal examines the small bowel without
complete material directly into the small bowel thru a catheter
positioned orally or nasally
- most sensitive radiographic method for detection of early focal small
bowel lesions
- single or double contras
- double contras provides the most detailed examination of mucosal
pattern.
C. CT scan demonstrate anatomic detail of bowel wall surrounding organs
and tissues.
D. Radionuclide Scintigraphy detection of gastric mucosa in Meckels
diverticulum
- Technique of choice in initial investigation of severe acute lower GI
bleeding
Radiologic Anatomy
- Approx. 19-22ft. in length from the duodenojejunal junction to ileocecal valve
- Valvulae conniventes crescentic folds of mucosa and submucosa;
- Circular or spiral bands in distended state
Jejunum : lies at the left upper abdomen
- Folds are more prominent and numerous
- Jejunal folds are not oblioterated with distention
Ileum: lies at the lower right abdomen
- Less numerous folds
- Mild distention may obliterate ileal folds
2-3mm = normal distance between adjacent loopd representing thickness of opposing intestinal walls.
COMMON DISEASE OF THE SMALL BOWEL:
A. Tuberculosis
- Distal small bowel including ileocecal region most common site of involvement
- Ulcerative form multiple transverse ulcers, increased spasm, nodularity, altered motility.
- Hypertrophic form terminal ileum and cecum are narrow, thick and rigid, cecum contracted
into conical shape; ileocecal valve is hypertrophied.
B. Neoplasms
- primary smallors rare
- most common neoplastic involvement metastatic disease

1.
2.
3.
4.
5.
6.

a. Benign Tumors
Adenomatous polyps, leiomyomas most common
adenomas intraluminal filling defects tend to be lobulated or pedunculated.
most frequent in the duodenum
leiomyomas smooth filling defects
lipomas smooth ovoid masses protruding into the bowel lumen which changes in
contour with compression or change in position.
neurofibromas
hemangiomas
hamartomas or polyps seen in peutz-jeghers syndrome
b. Carcinoid tumors
-most common primary small bowel tumor predominantly is
distal ileum
- appendix most common site
- single or multiple submucosal or intramural nodules in distal
ileum
- narrowing, rigidity and separation of bowel loops secondary to
muscular hypertrophy and desmoplastic reaction in the
mesentery.
- speculation of S.B. loops due to extraluminal tumor and serosal
invasion.
c. Malignant neoplasm
1. Adeno CA short annular lesions with abrupt shelf-like
margins
-polypoid and ulcerative
- occurs primarily in duodenum and jejunum
2. lymphoma nodular form are submucosal filling defect
- infiltrative irregular thickening or complete los of
mucosal
folds
- with mesenteric invasion extraluminal mass
displacing bowel loops, distorted bowel folds
3. leiomyosarcomas extrinsic or mural masses with
displacement of
adjacent bowel loops.
d. Metastatic tumors
most common type of neoplastic involvement of S.B.
1. hematogeneous nodular protrusions into the lumen
or intraluminal polypoid mass
2. serosal implants flattened and hazy mucosal folds;
fixation and angulation of bowel loop with luminal
narrowing and obstruction due to desmoplastic
response.
COLON

Methods of Examination :
1.
2.
3.
4.
5.
6.
7.
8.

plain abdominal films ) prmary methods of

barium enema
) evaluation\
CT scan
water soluable contrast
ultrasound
angiography
radionuclide scintigraphy
MRI

Plain film done prior to barium enema

Barium enema :
- requires adequate cleansing of the colon

a. low residue diet

b. laxatives
c. cleansing enema
A. Double Contrast method of choice for demonstrating polyps especially
smaller than 1cm.
- detection of pre-malignant neoplasm and CA at early stage
- depict mucosal abnormalities as superficial erosions
B. Single Contrast- method of choice in emergency situations, aged or
debilitated patients
- Suspicion of large bowel obstruction, acute diverculitis, acute appendicitis
C. Post Evacuation films
Barium enema contraindicated when there is colonic perforation; water soluble contrast agent is used
CT scan evaluation of bowel wall thickness
- method of choice to detection of extraluminal spread of primary colon tumors
- detection and drainage of perirectal, pericolic abscess
Water soluble contrast examination evaluation of possible colonic perforation or anastomotic leak
- therapeutic use of hyperosmilar water soluble contrast enemas for fecal or meconeium
impaction.
Ultrasound limited role; normal bowel is generally not recognized due to intraluminal air or fluid
- detect complications of inflammation or neoplastic abscess or fluid collection.
Angiography to localize and treat site of acute lower GI bleeding
Radionuclide Scintigraphy- to detect presence of acute lower GI bleeding
MRI not used in routine evaluation of the colon except the rectum.
Radiologic Anatomy of the Colon
-

1.5 meters long

extends from ileoocecal valve and cecum to anus
divided into cecum, ascending colon (retroperitoneal), transverse descending
(retroperitoneal), sigmoid, rectum, anus
taeni coli 3 stripe of longitudinal muscle which gives haustrated sacculations.
colon has feature less mucosa in double contrast study
occasional normal features
a. very fine transverse folds called innominate lines or grooves
b. tiny nodules (1-2cm) of uniform size (lymphofollicular pattern) segmentally or
through out the colon.

Diseases of the Colon

A. Polyps - protrusion into the lumen of the bowel
-when seen on face the Barium forms a right shadow with sharo inner border and
ill-defined outer border
- pedunculated polyps have stalks of variable thickness and length, frequently mobile; when
head and stalk are superimposed on face target or Mexican hat sign
- villous adenomas large sessile polyps with frondike projections
Evaluation of polyps for risk of malignancy
size
contour
stalk
underlying
colon wall
number of polyps

Benign
2cm
smooth
present (pedunculated
long and thin)
smooth

Malignant
2cm (50% malignant)
multilobulated, irregular
absent (sessile, short, thick)

single

multiple

Polyposis Syndrome:

retracted

Familial polyposis innumerable polyps in the colon with extremely high

malignant potential
Gardners Syndrome gliomas of brain or spinal cord and colonic
adenoma
Peutz Jeghers Syndrome hamartoma of colon and more of small bowel
and pigmented mucocutaneous lesions
Canada Cronkhite syndrome hamartoma or inflammatory polyps with no
known malignant potential most common in the colon and stomach

B. Diverticular Disease
- common in the SIGMOID (90%)
- small saccules formed by herniation of the mucosa and muscularis
mucosa thru areas of diminished resistance in the bowel wall
- when seen in profile are smooth round projections from the bowel wall
containing air and or barium; when seen en face, may appear as filling
defects
- DIVERTICULITIS: those cases with extravasation of contrast from
diverticulum microperforation or large abscess cavities)
- Differential diagnosis of diverticulitis
o CA, metastatic disease, Chrons disease, radiation or ischemic
colitis
- Normal mucosa can still be seen in diverticulitis, abnormal mucosa in CA
C. Carcinoma of the Colon
- 60% rectum, 10% sigmoid, 30% rest of the colon
- 3 major types:
1. polypoid intraluminal mass or filling defect attached to the wall by a
broad-based fungating lesion
o mucosal pattern is completely lost at the site of defect
o surface of defect irregular or lobulated
o edges of the lesion form an acute angle with colonic wall
o predominant type in cecum and ascending colon
bleeding often an early symptom
2. annular or infiltrating infiltration of the wall causes narrowing of
bowel lumen
o usually concentric constriction napkin ring CA, apple core or
saddle like
o margins are sharp with overhanging edges
o completely absent mucosal folds
o defect is constant and rigid
o involved colon usually less than 4 cm
o obstruction early symptom
3. scirrhous long area of stenosis with tapered margins and partial
preservation of mucosal pattern
wall is invaded in stenotic or stricture like fashion
may resemble inflammatory disease
D. Amoebiasis
- diffuse or segmental colitis
- acute phase: superficial erosions, deep ulcers
- chronic phase: stricture commonly involving the cecum
- amoeboma or mass lesions: caused by infection and fibrosis, found
primarily in cecum, rectum and flexures
E. Tuberculosis
- hypertrophic or ulcerative type
- ileocecal region involved in 80-90%
- early changes: edema, nodular change and ulcerations
- chronic: contracted and cone-shaped cecum

terminal ileum frequently involved stricture or fixed in open gaping

position
hypertrophic type: intraabdominal abscess and stricture, fistula formation,
small bowel mesentery usually involved

F. Ulcerative colitis
- radiographic findings: fine mucosal granularity with blurring of normal
sharp mucosal outlines
- ulcerations (flask, T or collar button) usually confined to submucosa and
mucosa without intervening area of normal mucosa
- chronic or inactive: coarsely granular mucosa without ulcerations
- led pipe colon foreshortened, narrow and straightened with loss of
haustration
- polypoid changes: pseudopolyps, inflammatory or filiform polyps
- complications: colonic CA, toxic megacolon, strictures
o development of malignancy becomes a significant risk in patients
who have ulcerative colitis for 10 years or more