GI Tract

Dr.Yanto Budiman. Sp.Rad, M.Kes Bagian Radiologi FK/RS. Atma Jaya

MODALITIES FOR GI TRACT IMAGING

Plain abdominal film Intraluminal contrast studies Ultrasound CT scan MRI ERCP

Plain Abdominal Film

Often the first preliminary test

INDICATIONS Bowel obstruction Viscus perforation Foreign body ingestion ADVANTAGES Easy availability Low cost
LIMITATIONS Screening modality; usually need another imaging test to confirm d iagnosis Lack of anatomic detail

Plain Abdominal Film

The supine abdominal film The erect chest film The horizontal-ray abdominal film: - Left lateral decubitus - Cross Table

Plain Abdominal Film

Supine position
Asses: - The preperitoneal fat line - The psoas outlines - Distribution of gas - The calibre of bowel : N: Calibre of small bowel is 2.5 cm & colon is 5 cm. - The thickened of bowel wall - Displacement of bowel by soft-tissue masses. - Calculus
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Supine

Plain Abdominal Film

NORMAL GAS PATTERN Stomach
Always

Small Bowel
Two or three loops of non-distended bowel Normal diameter = 2.5 cm

Large Bowel
In rectum or sigmoid almost always Normal diameter = 5 cm

Gas in stomach

Gas in a few loops of small bowel

Gas in large bowel

Gas in rectum or sigmoid

Normal Gas Pattern

Plain Abdominal Film

Large vs. Small Bowel Large Bowel
Peripheral Haustral markings don't extend from wall to wall

Small Bowel
Central Valvulae extend across lumen

 Small bowel obstruction

Plain Abdominal Film

The erect chest film

Erect To asses: - free gas beneath the diaphragm (pneumo-peritonium) - air fluid levels - chest abnormality e.g effusion pleura

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Plain Abdominal Film

Normal Fluid Level Stomach Always (except supine film) Small Bowel Two or three levels possible Large Bowel None normally

Plain Abdominal Film

Always air/fluid level in stomach A few air/fluid levels in small bowel

Erect Abdomen (normal)

Air fluid levels (step ladder sign)

Plain Abdominal Film

The horizontal-ray abdominal film Erect & left lateral decubitus. The patients should be in position for 10 min before the film is taken. To asses : fluid levels & free gas

-Supine

- Erect

- LLD

Pneumoperitonium

Intraluminal Contrast Examinations

CONTRAST MEDIA Positive : Barium and iodine containing water soluble contrast medium (iodograffin). Negative : air and CO2 Barium Swallow INDICATION Esophageal pathologies Single- or Double-Contrast Upper GI Series / Barium meal INDICATIONS Imaging of pharynx, esophagus, stomach, and duodenum

Intraluminal Contrast Examinations

Small Bowel Follow-Through Examination and Enteroclysis INDICATIONS Imaging of small intestinal and ileocecal pathologies Single- or Double-Contrast Enemas INDICATIONS Imaging of the large intestine Fistulograms and Sinograms INDICATIONS for assessment of fistulae and sinus tracts

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Barium Esophagogram

Upper GI Series

Small Bowel Follow- Through Examination

Transverse Colon Hepatic Flexure of Colon

Barium Enema Study (Double Contrast Study) of Large Intestine

Splenic Flexure of Colon Ascending Colon Descending Colon

Sigmoid Colon

Rectum

 Fistulogram

Abdominal Ultrasound
APPROACHES Superficial Endoscopic: Assisting probes are used in upper GI, pancreaticobilia ry, and colorectal pathologies for staging malignancies INDICATIONS Gallbladder and hepatic pathology Delineation and differentiation of intra-abdominal cystic structures Trauma; FAST (focused abdominal sonography in trauma) is a very useful tool in assessment of trauma patients Emerging role of endoscopic ultrasound in biliary and pancreatic pa thologies Guiding procedures Doppler studies for evaluation of vascular structures

Abdominal Ultrasound
ADVANTAGES Inexpensive, noninvasive, no contrast LIMITATIONS Operator dependent Inferior for assessment of bowel pathology due to artifact from air Lack of mucosal detail

Abdominal CT
INDICATIONS Assessment of acute abdomen and to rule out conditions such as acute appendicitis, acute pancreatitis, small bowel obstructio n, colitis. Trauma CT angiograms for suspected vascular leaks, aneurysm, bowel infarctions CT enterography is being used for inflammatory bowel disease s (Crohns disease). Virtual CT colonoscopy: Not yet a very widely used tool

ADVANTAGES Excellent cross-sectional imaging modality that provides functio nal information as well

Abdominal CT
LIMITATIONS Availability Radiation exposure Expensive

MRI
ADVANTAGES Superior soft tissue detail Excellent cross-sectional imaging tool for evaluation and staging of malignancies, especially rectal and esophage al, inflammatory and obstructive pathologies DISADVANTAGES Higher cost Contraindicated in patients with metallic hardware Long imaging time/ Claustrophobia

ERCP
Endoscopic, Retrograde Cholangio Pancreatography

Involves introduction of an endoscope into the duodenum followed by cannulation of the biliary tree. It is often performed along with papillotomy, which serves as a therapeutic intervention for biliary calculi and drainage procedures of obstructed bile ducts.

ERCP
INDICATIONS in jaundice of unclear origin and suspected pancreatic e.g chronic pancreatitis and pseudocysts. Primary approach for drainage and stenting of benign and malignant biliary obstruction, the main advantage being that the liver need not be punctured. If the papilla cannot be cannulated or the obstruction cannot be passe d with a guidewire, a percutaneous transhepatic approach may be trie d. However, in difficult and postoperative cases, noninvasive methods such as magnetic resonance cholangiopancreatography (MRCP) are i ncreasingly being used for evaluation.

GI Tract
Oesophagus Stomach Duodenum Small Bowel Large Bowel

Oesophagus

Achalasia
Motilitas disorder Neuronal degeneration within the Auerbachs plexus in the region of the gastro-oesophageal junction The characteristic barium swallow findings are of a dilated oesophag us with a smoothly tapered,conical narrowing of the distal oesophagus beak sign or rat tail

Oesophagus

Hiatus Hernia
The stomach has herniate d through the oesophageal hiatus (above diaphragma) Most hernias (80%) are sli ding in nature and hernia te directly while 20% are paraoesophageal and are pushed up alongside the oesophagus

Oesophagus

Oesophageal carcinoma
Dysphagia ,age > 40,.Weight lo ss and anorexia Irregular circumferential lesion with mucosal destruction, oesop hageal narrowing with shoulderi ng and abrupt transition to adja cent normal tissue

Stomach

Gastric ulcer

Discontinuity in the mucous membrane of the stomach with inflammatoory base.

Roentgen signs of a benign ulcer: 1. Location: lesser curvature & adjacent part of the posterior wall 2. Multiple 3. 4% of benign ulcers greater in diameter than 4 cm 4. Ulcer niche/fleck/spot

Stomach (Benign Ulcer)

5. Cartwheel configuration = folds radiate from the ulcer like the spokes on a wheel 6. An incicura on the greater curvature opposite a gastric ulcer. 7. The ulcer protrudes beyond the line of the lumen.

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Stomach (Benign Ulcer)

Stomach (Benign Ulcer)

8. Edematous ridge leads to the ulcer & surrounds it at its base: - Hamptons line - Ulcer collar - Ulcer mound 9. The association of a gastric ulcer with a duodenal ulcer 10. 80% heal within 4 weeks (rapid healing)

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Stomach (Benign Ulcer)

Stomach (Benign Ulcer)

Stomach (Malignant Ulcer)

Roentgen signs of a malignant ulcer:

1. Location: upper part of the greater curvature 2. Ulcer edges irregular 3. Doesnt protrude beyond the line of the lumen 4. Ulcer within a polypoid mass 5. Shallow ulcer surrounded by thick rigid fold

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Stomach (Malignant Ulcer)

6. The Carman-Kirklin meniscus sign: Large ulcer niche ( 3 to 8 cm) with an elevated rolled margin: - In antrum: crater is crescentic toward lumen of stomach - In body: crater is crescentic & curves away from lumen of stomach

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Stomach (Malignant Ulcer)

Stomach (Malignant Ulcer)

Gastric carcinoma as a large Irregular filling-defect (arrow heads) in the stomach. An area of ulceration has filled with barium (arrow). The normal mucosal and rugal fold pattern is destroyed.

Duodenum

Duodenal Ulcer
On double-contrast barium examination, duodenal ulcer craters are shown as sharply defined, constant collections of barium, sometimes with a surrounding zone of oedema or radiating folds.

Atresia Duodeni

Supine posisition : two bubble app.

Erect posisiton : Two air fuid level

SMALL BOWEL
Crohns disease Idiopathic inflammatory disease. The small-bowel (terminal ileum) is the commonest site affected Western civilisation & young adults etiology remains unknown Characterised by: - Discontinuous transmural ulceration - Fistulation - Spontaneous abscess formation
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Crohns disease
Contrast studies remain the mainstay for diagnosis The radiological changes: * Early: - Mucosal granularity (filling defects) (villous oedema) - Fold thickening - Aphthous ulceration (small, shallow, circular, discret e ulcers surrounded by an oedematous halo)

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Crohns disease
* Advanced: - Cobblestone appearance, discontinuous & asymmetrical along the bowel circumference - Pseudodiverticulae (ballooning of the contralateral wall) * Complicated: Strictures, fistulation, abscess formation, tumour

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 K,,,,,,,,,,,,,,,,,,,,,,,,,

Crohn disease

A.

B. Crohn's disease. (A) Coronal reconstruction image of CT enterography shows thickened distal ileal loops and mural stratification resulting in a target appearance (arrows). Prestenotic dilatation is also seen. (B) A coronal, threedimensional projection of the same patient showing the vascular engorgement (arrows) of an involved ileal loop (comb sign).

Benign tumours and malignant tumours

Benign tumours:
- Adenoma - Leiomyoma (the commonest)

Malignant tumours:
- Lymphoma (the commonest) - Leiomyosarcoma - Carcinoid - Metastases (malignant melanoma & bronchial ca)
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LARGE BOWEL
Large-bowel disorders:
- Colorectal tumours - Diverticular disease - Colitis - Miscellaneous conditions (appendicitis, volvulus)

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Colorectal tumours
Polyps: - A mucosal elevation - Radiographic appearance: * Bowler-hat sign * En face: target sign Colorectal cancer: - The commonest cancers in western Europe & US - Men = women - Tumours tend to be right-sided - May be associated urinary tract & gynaecological malignancy
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POLYPS

Familial Adenomatous Polyposis Syndrome. innumerable small polyps, seen as tiny filling defects (arrow)

Bowler-hat sign

Colorectal cancer

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Colorectal cancer
Fungating type: - Medullary carcinoma - Sites: caecum, ascending colon, rectum - Complication: bleeding, fistula Polypoid type: - Sites: ascending colon usually - Complication: Intussusception

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Colorectal cancer
Annular type: - Mucoid adenocarcinoma, scirrhous fibrocarcinoma - Sites: sigmoid, descending colon, flexures - Complication: fistula, obstruction
Radiological appearances: - Filling defect - Obstruction

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Colorectal cancer

Colorectal cancer

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Colorectal cancer

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Diverticular disease
Protrusions of the mucosa & submucosa thr ough a defect in the wall of the bowel. 30% over the age of 60 years & 60% over the age of 80 years The sigmoid colon is typically affected. Radiological findings: - Small, flasklike or rounded outpouchings 0.5-2.0 cm, having narrow neck - En face, ring shadows
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Diverticular disease
Complication: - diverticulitis results in pericolic abscess & localised peritonitis (Barium enema is contraindicated, watersoluble contrast is preferred)

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Diverticular disease

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Crohn Disease
Idiopathic characterized by the development of multiple GI tract ulcer s from mouth to anus Common sites : terminal ileum and/or cecum (45%), ileo-c olonic (13%), or colorectal region (30%) Sign on barium meal/ enema :
Segmental intestinal wall thickening with thickened mucosal folds Apthous ulcer; cobble stone app. Multiple skip lesions String sign In the colon, CD mainly aff ects the ascending color with rela

tive sparing of the rectum (50%)

a. b. c.

Crohn Disease a. demonstrating the barium sign of cobble-stone appearance b. aphthus ulcer c. Strictura in CD affecting ascending colon,

Thickened Folds, Irregular: Crohn Disease. Crohn disease of the ileum causes thickened folds (straight arrow) that are irregular and distorted. A more proximal segment of jejunum (open arrow) is effaced and narrowed. The transverse colon (curved arrow) is narrowed and stiffened and has multiple inflammatory polyps producing filling defects. This is skip lesions that are characteristic of Crohn disease.

Colitis
Colitis can subdivided into idiopathic ulcerative, ischaemic and infection aetiologies. The hallmarks of colitis are mucosal inflammati on & ulceration.

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Idiopathic ulcerative colitis

Barium examination is absolutely contraindicated if there is evidence of toxic dilatation. Begins in the rectosigmoid region & eventually involves the entire colon & long stretches of the ileum Plain Radiograph finding Toxic mega colon. Gasless abdomen: due to chronic diarrhea. Absence of fecal materials

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Idiopathic ulcerative colitis

Ba-enema findings:
Collar button ulcer Pipe stem colon: this refers to rigidity and narrowing of the colon due to longitudinal muscle spasm and hypertrophy Back-wash ileitis (ileocaecal valve becomes fixed & incompetent, re sulting in terminal ileal granularity) Stricture Toxic megacolon Pneumatosis coli

Ulcerative colitis

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Ischaemic colitis
Primary site: splenic flexure. Radiological appearances: - ulceration - splenic flexure thumb-printing

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Ischaemic colitis

Classical splenic flexure thumbprinting

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Thumbprinting pattern involving the proximal portion of a redundant transverse colon and hepatic flexure

Volvulus
The colon may twist on its mesentery, resulting in intermi -ttent obstruction. Sigmoid volvulus (60-70%), caecal & transverse volvulus . Radiological examination: - Plain films - Water-soluble contrast enema Radiological findings: - Inverted U without haustra (sigmoid volvulus) - the caecum is often in the left upper quadrant (caecal volvulus)
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volvulus

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Appendicitis
R Signs of acute appendicitis: - Appendix calculus (0.5-6cm) - Localised paralytic ileus in RLQ - Sentinel loop-dilated atonic ileum containing a fluid level - Widening of the preperitoneal fat line - Blurring of the preperitoneal fat line - Blurring of the right psoas outline-unreliable cont
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Appendicitis
- Scoliosis

concave to the right - Dilated caecum - Right lower quadrant (RLQ) mass identing the caecum on its medial border (abscess formation) - RLQ haze due to fluid & oedema - Gas in the appendix-rare, unreliable.

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Appendicitis
Ultrasound signs of acute appendicitis : - Blind-ending tubular structure at the point of
tenderness: - Non-compressible - Diameter 6 mm - No peristalsis - Appendicolith casting acoustic shadow - Surrounding fluid/abscess

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USG APPENDICITIS

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 Acute appendicitis

Acute appendicitis

Acute appendicitis with appendicolith.

Abscess formation & appendicolith.

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