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General Objective
To provide basic understanding about the role of radiological imaging in diagnosing gastroenterohepatologic diseases
Specific objectives
Imaging modalities and
Organs scope
Plain
In general
Plain abdominal radiography Conventional radiography with contrast
media
Imaging (US, CT-Scan, MRI, Nuclear
medicine)
(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 )
Colon cancer
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
invaginasi
Peritonitis
Bowel wall thickening
Properitoneal fat line disappear/
Herringbone appearance(-)
suspension Iodine
Salivary glands :
Consist of : - Parotic glands - Submandibular glands Indications : Stones; inflamation; neoplasm Technique : - Plain Foto - Sialography - CT - MRI
Sialography :
Duct orifice. is located & intubated by a blunt needle/abbocath 0,5 1,5 ml contrast medium (water soluble/lipiodol) injected slowly
& then taking a series pictures Give a few drops of lemon juice make an after lemon film 10 later to evaluate the remaining contrast
Abnormalities : Chronic obstructive Sialectasis - stone - strictures Chronic non-obstructive Sialectasis (chronic inflamation)
Tumours (mostly mixed salivary type)
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,
Esophageal stricture
Tumours : - Benign
: Filling defect with smooth border Forked stream appearance (Fluoroscopy) - Malignant : Filling defect with irregular border Spasticity
ACHALASIA
Aganglionic of the distal part of
esophagus Distal smooth narrowing with dilatation of the proximal segmen--mouse tail app.
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)
Fig. 28-14.
Pyloric stenosis
= Infantile Hypertrophic Pyloric Stenosis
DIVERTICLE
- Protrution of mucosa and submucosal outward - Additional shadow
Gastritis
Mucosal atrophy
Mucosal hypertrophy-hypersecretion
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
TUMOR
BENIGN Filling defect with smooth border
Polip
Malignant
Types : 1. Early gastric cancer Limited in mucosa/submucosa mimicking ulcer 2. Advance gastric cancer Filling defect irregular border - Annular ( infiltrating type ) - Exophytic ( fungating type ) - Linitis plastica ( schirrus type) - Ulcer type, filling defect + ulcer
DUODENUM
Congenital :
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:
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
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
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
Tumor
Fungating type : - usually medullary Ca. - Sites: Caecum, Ascending Colon, Rectum - Complication: Bleeding, fistula Polypoid type : - Sites: usually Descending Colon - Complications: Intussusception
Annular type : - Sites: Sigmoid, Descending Colon, flexures - Complication: Fistula, obstruction Pathology : - 50 75% adeno Ca. - 20% fibro Ca. - 10% mucoid adeno Ca. Metastasis : Liver or regional nodes Radiographically : Filling defect with Obstruction signs
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)
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)
- 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
Cholangitis
Cholangiocarcinoma
CIRRHOSIS HEPATIS
- Liver atrophy - Increasing echogenecity, fibrotic. - Irregular of the surface - Portal hypertention - Splenomegaly - Ascites.
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