GASTROINTESTINAL RADIOLOGY

Topics to be covered

1. Liver Lesions Haemangioma and HCC

2. CT Colonography
3. Small bowel - CT, MRI or fluoroscopy? 4. Rectal tumor MRI staging

5. Anal fistula MRI imaging

Liver Haemangioma (US)

Atypical

Liver Haemangioma CT A) Pre-contrast

B) Arterial phase

C) Portal venous phase

D) Delayed phase

CT we will not do delayed phase unless haemangioma suspected. Please specify ? haemangioma on request form.

Haemangioma Summary
Common- often incidental US Echogenic -no halo. No colour flow.
Aytpical hypo-echoic in fatty liver - mixed echotexture CT C- low density C+ peripheral vessels (uneven) C+ PV /delay progressive fill-in Small haemangioma fill in immediately and cannot be distinguished from metastates. MRI features similar to CT post Gadolinium

CT -HCC pre contrast

Arterial enhancement (central and early)

Washout on portal venous indicates fast flow

HCC Summary
US - usually heterogeneous Usually HepB +ve with
raised alpha FP CT C- low density C+A central early contrast (high flow rate) C+PV washout cf with liver may have a capsule

MR intracellular fat on T1 out of phase

- similar perfusion characteristics to CT

MRI IMAGES of LIVER

Look at CSF first to tell if T1 or T2 T1-in/out. T1 are grey. Fluid is dark. Black outline

T2-incl HASTE. More definition. Fluid is bright. Gadolinium always with T1

Fatty liver with sparing

Same pt - out of phase T1 MRI

Same patient - CT non-contrast

CT COLONOGRAPHY
Dissection Strip, anus to caecum

Endoluminal (for fun only)

Orientation Overview

800/40 window Axial to loops

Advantages / disadvantages
Sensitivity and specificity is of the order of 90 %

for 10 mm polyps. Easy, quick and well tolerated. Beats barium enema hands down. Safer than optical colonoscopy Approx. half the price of optical colonoscopy No intervention possible as in optical Cy At present for Ba enema indications, but is likely to be used for screening in future. Radiology manpower training required. Radiation dose equivalent to Ba Enema

Incidence of Colonic Perforation at CT Colonography: Review of Existing Data and Implications for Screening Asymptomatic Adult
Source: International Working Group on Virtual Colonoscopy Total VC studies considered Symptomatic Perforation Rates for VC* Total Perforation Rates for VC Perforation Rates for Conventional Colonoscopy 21,923 0.005% 0.009% 0.1-0.2%

Pickhardt 2007

CTC vs Optical Colonoscopy

Consider Is intervention likely to be needed? (cf MRCP vs ERCP)

CTC for average risk and Fam Hx pts. > 50 yrs (radiation) Contraindicated if inflammatory bowel or on steroids
(risk of perforation as inflation is done blind as opposed to Ba enema).

Optical Colonoscopy if biopsy or polypectomy prob

needed All polyposis syndromes High risk Inflammatory Bowel Disease

Overview of CT colonography?
Process CLEANSE DISTEND COMPUTE
Currently
-Tagging -Air -Workstation

Future
-Subtraction -CO2 -new programs

VIEW
REPORT

-Time
-Issues

- CAD

Prep and tagging

Slide courtesy Dr Helen Moore

Longer tube and patient can apply air themselves

Slide courtesy Dr Helen Moore

Lateral topogram

Philips workstation layout

Incomplete air column -Excess fluid

Supine

Prone

Diverticular disease

4 mm Polyp

Ileo-caecal valve

Arrow points To caecum

Residual tagging

Caecal pole

Dirty Caecumnot fully open on supine or prone views

54 yr Recomm optical colonoscopy

The dirty caecum

Complex Folds at flexures

Radiation
Barium enema 6 8 mSv CTC estimate of 7.6 mSv with low mAs.
Increased noise, but high resolution improves definition of small polyps Thin slice, limit tube current Background radiation is 2.4 MSv/year
The worldwide average background dose for a human being is about 2.4 millisievert (mSv) per year.[1] This exposure is mostly from cosmic radiation and natural isotopes in the Earth. This is far greater than human-caused background radiation exposure, which in the year 2000 amounted to an average of about 0.01 mSv per year from historical nuclear weapons testing, nuclear power accidents and nuclear industry operation combined,[2] and is greater than the average exposure from medical tests, which ranges from 0.04 to 1 mSv per year. Source Wikipedia.

Small Bowel Imaging

< 35 yrs MRI for radiation reasons However if pre-surgical workupfluoroscopy CT Enteroclysis only difference from CT is
negative contrast in bowel. No advantage to do if recent normal CT. MR Small bowel breath-hold sequences, dynamic change between sequences. Good soft tissue differentiation. +/- Gadolinium

Normal Fluoroscopic Enteroclysis

Jejunal intubation Low density barium Pumped in to distend Intubation 10 min Study 20 min

Terminal ileum

Skip lesions - Proximal

Follow-through time-consuming flocculation Strictures may be hidden Is superseded by other tests

Enteroclysis- same patient

Intra-luminal mass

CT Enteroclysis

Histo- GIST

Tumor shows up against negative contrast in bowel. Positive contrast could hide it

CT ENTEROCLYSIS
Volumen oral contrast for 45 min pre scan IV Maxolon IV contrast on table

CT to include anal canal and with sagittal.

CT ENTEROCLYSIS
Jejunum often thick-walled
Can evaluate bowel wall due to negative contrast in lumen and IV contrast in wall. Evaluates stomach well also Plus standard CT Reserved for older patients due to radiation dose

MRI Small Bowel

Oral Volumen 30 45 min prior (or Ioscan) +/- IM Buscopan for peristaltic movement Good for Crohns patients with multiple studies
and large radiation dose over time.

Coronal TRUFI Coronal TRUFI fat saturation Coronal HASTE Axial HASTE Coronal T1

MRI ENTEROCLYSIS TRUFI

Normal- HASTE sequence

Terminal ileum

Cutaneous fistula
Post Gadolinium T1 fat sat

Caecum / TI

Crohns disease

Normal

FAT SATURATION

Sag, axial and coronal

Normal anal canal - sagittal

Puborectalis

Internal sphincter
Subcutaneous External sphincter

Normal anal canal - axial at PR

mucosa

Internal sphincter Fat in intersphincteric space

Pubo-rectalis = upper external sphincter

Normal anal canal - coronal

Puborectalis Internal Sphincter

External Sphincter

Post Gad fat saturation T1 Drain in situ

ANTERIOR

POSTERIOR

UC - mucinous tumour

UC - mucinous tumour

Anal canal tumour