Bachtiar MurtalaDept.of Radiology Medical Faculty Hasanuddin University

General ObjectiveTo provide basic understanding about the role of radiological imaging in diagnosing gastroenterohepatologic diseases

Specific objectivesImaging modalities and

techniques/examination procedures Radiological appearances of some GIT and hepatobiliary diseases

Organs scope Plain

Abdomen Esophagus-rectum Liver Biliary tract Pancreas

In general Plain abdominal radiography Conventional radiography with contrast

media Imaging (US, CT-Scan, MRI, Nuclear

medicine)

Plain abdominal radiography Commonly used in emergency cases such as ; ileus

(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 )

Large bowel obstruction Less commonly than small bowel obstruction Three main causes : - colon carcinoma - Volvulus - Diverticulitis

Colon cancer

Small bowel obstruction

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

(herring bone appearance)

invaginasi

Necrotizing enterocolitis ( NEC) Pneumatosis intestinalis

( Gas within bowel wall )

PeritonitisBowel wall thickeningProperitoneal fat line disappear/

obliterate Paralytic ileus sign

Adynamic or paralytic ileusBowel distended until distal partAir fluid levels (+) , longer

Herringbone appearance(-)

Radiography with contrast Barium Sulphate (BaSO4)

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 contrastAbnormalities : 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 varicesCaused by portal hypertension,

commonly seen in cirrhosis hepatis cobble stone appearance

Esophageal stricture

Narrowing and irregularity due to corrosive materials (corrosive 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.

MOUSE TAIL APPEARANCE

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 Examination1. 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)

Normal Anatomic Radiography

Radiographic Abnormalities of Gastroduodenal Disease. It can be classified as changes in : Position Size (redundancy, enrlargement/widening,

narrowing/shrinkage) Contour Rugae abnormalities Filling defect Function

Fig. 28-14.

Left lateral erect film of the stomach

Pyloric stenosis= Infantile Hypertrophic Pyloric Stenosis

DIVERTICLE- Protrution of mucosa and submucosal outward - Additional shadow

Gastritis Mucosal atrophy Mucosal hypertrophy-hypersecretion

three level density

Peptic ulcerMostly 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

TUMORBENIGN Filling defect with smooth border

Polip

MalignantTypes : 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 :

Stenosis post bulbar duodenal atresia Two bubbles app.

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:

Obstruction signs Perforation Paralytic ileus Peritonitis Technique of Examination

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

Crohns Disease = Regional ileitis Adhesion Fistula

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.

COLONA.Kongenital1. Atresia Ani (Imperforate anus) , Foto polos abdomen terbalik (Invertogram) 2. Hirschsprungs disease ( megacolon congenitum )

Atresi aniRadiographically : Technique of examination for atresia ani: Inverted or Wangesteen position Knee-chest position Aim : to identify the lowest end of air in colorectal

Lower level High level

Dilatation/Distension : - Idiopathic symptomatic megacolon (older age) - Hirschsprungs disease (megacolon

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

Carcinoma of Colon 3 types : Fungating type Polypoid type Annular type

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)

HEPATOBILIER & PANCREAS Imaging modalities :

- 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.

HEPATOCELLULAR CARCINOMA/HCC HEPATOMA

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 obstructionCauses : - Stone - Tumor intra/extraluminer. such as Panreatic cancer,cholangiocarcinoma

- Strictur cholangitis, etc

Biliary obstruction due to cancer of caput pancreas