Kuliah Blok GI Tract_Ro Abd_September 2010

7/27/2019 Kuliah Blok GI Tract_Ro Abd_September 2010

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GI Tract

Dr.Yanto Budiman. Sp.Rad, M.Kes

Bagian Radiologi FK/RS. Atma Jaya


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MODALITIES FOR GI TRACT IMAGING

Plain abdominal film

Intraluminal contrast studies

Ultrasound

CT scan

MRI

ERCP


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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


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The supine abdominal film

The erect chest film

The horizontal-ray abdominal film:- Left lateral decubitus

- Cross Table


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Supine positionAsses:

- 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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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


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Gas in

stomach

Gas in a few

loops of

small bowel

Gas in

rectum or

sigmoid

Normal Gas Pattern

Gas in large

bowel


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Large vs. Small Bowel

Large Bowel

Peripheral

Haustral markings don't extend

from wall to wall

Small Bowel

Central

Valvulae extend across lumen



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Small bowel obstruction


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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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Normal Fluid Level

Stomach

Always (except supine film) Small Bowel

Two or three levels possible

Large Bowel

None normally


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Erect Abdomen (normal)

Always

air/fluid level

in stomach

A fewair/fluid

levels in

small bowel



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Air fluid levels (step ladder sign)


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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



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-Supine - Erect - LLD

Pneumoperitonium


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Intraluminal Contrast Examinations

CONTRAST MEDIA

Positive : Barium and iodine containing water soluble contrastmedium (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


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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


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Upper GI Series


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Small Bowel Follow- Through Examination


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Barium EnemaStudy (Double

Contrast Study) ofLarge Intestine

Descending Colon

Transverse Colon

AscendingColon

Hepatic

Flexure ofColon

Splenic Flexure ofColon

Sigmoid Colon

Rectum


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Fistulogram


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Abdominal Ultrasound

APPROACHES Superficial

Endoscopic: Assisting probes are used in upper GI, pancreaticobiliary, 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 veryuseful tool in assessment of trauma patients

Emerging role of endoscopic ultrasound in biliary and pancreatic pathologies

Guiding procedures

Dopplerstudies for evaluation of vascular structures


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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


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Abdominal CT

INDICATIONS Assessment ofacute abdomen and to rule out conditions such

as acute appendicitis, acute pancreatitis, small bowel obstruction, colitis.

Trauma

CT angiograms for suspected vascular leaks, aneurysm, bowelinfarctions

CT enterography is being used for inflammatory bowel diseases (Crohns disease).

Virtual CT colonoscopy: Not yet a very widely used tool

ADVANTAGES

Excellent cross-sectional imaging modality that provides functional information as well


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Abdominal CT

LIMITATIONS

Availability

Radiation exposure

Expensive


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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


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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.


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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.


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GI Tract

Oesophagus Stomach

Duodenum

Small Bowel

Large Bowel


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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 signorrat tail


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Oesophagus

Hiatus Hernia The stomach has herniate

d through the oesophageal

hiatus (above diaphragma)

Most hernias (80%) are sliding in nature and hernia

te directly while 20% are

paraoesophageal and are

pushed up alongside the

oesophagus


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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


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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. Multiple3. 4% of benign ulcers greater in diameter than 4 cm

4. Ulcer niche/fleck/spot


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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.

Stomach (Benign Ulcer)


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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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Roentgen signs of a malignant ulcer:

1. Location: upper part of the greater curvature

2. Ulcer edges irregular3. Doesnt protrude beyond the line of the lumen

4. Ulcer within a polypoid mass

5. Shallow ulcer surrounded by thick rigid fold

Stomach (Malignant Ulcer)


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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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Gastric carcinoma as a large

Irregular filling-defect (arrow

heads) in the stomach. An area ofulceration has filled with

barium (arrow). The normal

mucosal and rugal fold pattern is

destroyed.


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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.


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Atresia Duodeni

Supine posisition : two bubble app. Erect posisiton : Two air fuid level


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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:

- Cobblestoneappearance, discontinuous &

asymmetrical along the bowel circumference

- Pseudodiverticulae (ballooning of the contralateralwall)

* Complicated:

Strictures, fistulation, abscess formation, tumour


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

Crohn disease


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Crohn disease

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, three-

dimensional projection of the same patient showing the vascular engorgement

(arrows) of an involved ileal loop (comb sign).

A. B.


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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 disorders:

- Colorectal tumours

- Diverticular disease- Colitis

- Miscellaneous conditions (appendicitis,

volvulus)

LARGE BOWEL


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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


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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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Annular type:

- Mucoid adenocarcinoma, scirrhousfibrocarcinoma

- Sites: sigmoid, descending colon, flexures

- Complication: fistula, obstruction

Radiological appearances:

- Filling defect

- Obstruction

Colorectal cancer


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Colorectal cancer


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Colorectal cancer


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Colorectal cancer


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Diverticular disease

Protrusions of the mucosa & submucosa through

a defect in the wall of the bowel.

30% over the age of 60 years & 60% overthe 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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Complication:

- diverticulitis results in pericolic abscess

& localised peritonitis

(Barium enema is contraindicated, water-soluble contrast is preferred)




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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%)


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a.

b.c.

Crohn Disease

a. demonstrating the barium sign of cobble-stone

appearance

b. aphthus ulcer

c. Strictura in CD affecting ascending colon,


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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.


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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 contraindicatedif 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


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Ischaemic colitis

Primary site: splenic flexure.

Radiological appearances:

- ulceration

- splenic flexure thumb-printing

I h i liti


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Ischaemic colitis

Classical splenic flexure thumb-

printing

Thumbprinting pattern involving the proximal

portion of a redundant transverse colon and

hepatic flexure

Volvulus


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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

Appendicitis


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R Signs of acute appendicitis:-Appendix calculus (0.5-6cm)

- Localised paralytic ileus in RLQ

- Sentinel loop-dilated atonic ileum containinga 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

A di iti


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- Scoliosis concave to the right

- Dilated caecum

- Right lower quadrant (RLQ) mass identing

the caecum on its medial border (abscessformation)

- RLQ haze due to fluid & oedema

- Gas in the appendix-rare, unreliable.

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Appendicitis

A di iti


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Ultrasound signs of acute appendicitis :

- Blind-ending tubular structure at the point oftenderness:

- Non-compressible- Diameter 6 mm

- No peristalsis

- Appendicolith casting acoustic shadow

- Surroundingfluid/abscess

Appendicitis

USG APPENDICITIS


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USG APPENDICITIS


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Acute appendicitis


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Acute appendicitis

Acute appendicitis with appendicolith. Abscess formation & appendicolith.


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THANK YOU

Kuliah Blok GI Tract_Ro Abd_September 2010

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