Transcript Materials covered in lecture

GASTROINTESTINAL
IMAGING
M-2 Lecture
Dr. F. Neuffer
2014
GI
TRACT
 Anatomy
 imaging
 Pathology
 Patients
OBJECTIVES:
 Vascular supply and effect on pathology location.
 Age and site considerations in four major disease groups.
 Familiarity with imaging findings in Neoplastic, Inflammatory,
Vascular and Traumatic diseases relative to the GI Tract.
 Modality choices based on pathology considerations.
UPPER GI – ORAL BARIUM CONTRAST
STOMACH
WITHOUT CONTRAST
COLON
BARIUM ENEMA - RECTAL BARIUM CONTRAST
NORMAL GAS PATTERN
AIR UNDER THE
DIAPHRAGM
Perforation of GI tract leads to pneumoperitoneum—peritonitis..bleeding
Air collecting under the diaphragm on upright x-ray.
UPRIGHT
ERECT AND DECUBITUS
ABDOMEN FILMS SHOW FREE
AIR UNDER THE DIAPHRAGM.
DECUBITUS
Air visible under diaphragm
Left lateral decubitus (left side
dependent) shows air along liver
margin. This is the preferred x-ray if the
patient cannot stand.
RADIOLOGY DIAGRAM
Pathology
image
X-ray
image
BARIUM FILLED ESOPHAGUS
AORTIC IMPRESSION
Pediatric patient
Coin often is at site of
Aortic impression.
ASPIRATION
NORMAL
SWALLOW
ASPIRATION
Risk with patients
with altered
neurological status
-post CVA
-intoxicated
Contrast tracks anteriorly into
trachea with aspiration.
ZENKER’S DIVERTICULUM
source for aspiration
Disordered contraction
of cricopharyngeus with
swallowing leads to diverticulum
formation– elderly patients
NORMAL
ESOPHAGUS
HIATAL HERNIA
*Note distended
distal esophagus
with herniation of
gastric fundus into
chest through
esophageal hiatus.
DIAPHRAGM
DIAPHRAGM
This allows reflux of gastric
contents into esophagus.
ESOPHAGEAL CANCER
Distal malignancy may be adenocarcinoma due to Barrett’s esophagus, a dysplastic
change caused by chronic reflux of gastric contents.
ESOPHAGEAL
CANCER
Typical squamous cell carcinoma
Poor prognosis from local
extension into critical mediastinal
structures.
(esophagus lacks a serosa)
.
TRACHEO-ESOPHAGEAL FISTULA / ATRESIA
Diffuse
Esophageal spasm
sometimes referred to as:
PRESBYESOPHAGUS
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Elderly patient
Disordered contraction
Chest pain
Cardiac mimic
CANDIDA
ESOPHAGITIS
Extensive nodular filling
defects in the esophagus
in an immunocompromised
patient are typical for
Candida esophagitis.
ACHALASIA
Distended esophagus with distal
stricture.-Chronic process
Little symptoms. Halitosis
Failure of distal sphincter to relax –
Nerve damage to sphincter
leads to obstruction.
Stricture due to CANCER / REFLUX has
to be considered first.
Barium filled esophagus
LOOK ALIKES
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Scleroderma-smooth muscle
-- Skin findings
Chagas Disease -Trypanosome infection
--Central America
ESOPHAGEAL
VARICES
Linear tubular filling defects represent
distended veins from shunting due to
cirrhosis and portal hypertension.
MALLORY-WEISS
TEAR
Esophagus shows a linear tear of the distal
esophageal mucosa due to vomiting. Barium is
seen tracking into the wall.
Full thickness tear or rupture (Boerhaave’s
syndrome) can lead to mediastinitis
and death.
Boerhaave’s
Syndrome
Post emesis –
Perforation esophagus
into mediastinum—
Edema, Effusion and
Pneumomediastinum
ESOPHAGEAL DISEASE
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HIATAL HERNIA / ESOPHAGEAL CANCER
CANDIDA / SPASM / VARICES
MALLORY WEISS TEAR / BOERHAAVE’S SYNDROME
ACHALASIA / SCLERODERMA / CHAGAS
TE FISTULA / ZENKERS DIVERTICULUM
SIGNS / SYMPTOMS
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CHEST PAIN
 DIFFICULTY SWALLOWING
 HOARSENESS
FUNDUS
NORMAL
GASTRIC
ANATOMY
DUODENUM
BODY
ANTRUM
JEJUNUM
C-LOOP
Single AP radiograph
showing filling of distal
esophagus, stomach
and proximal small
bowel without mass,
obstruction or filling
defect.
GASTRIC
ULCER
Barium collects
in ulcer crater
Endoscopic
view of ulcer
ULCER CAN PERFORATE INTO PANCREAS
AND LEAD TO PANCREATITIS
Silva, A. C. et al. Radiographics 2004;24:677-687
GASTRIC CARCINOMA
PYLORIC STENOSIS
PYLORIC STENOSIS
ULTRASOUND
GASTROPARESIS
DIABETIC NEUROPATHY EFFECT
GASTRIC DISEASE
 ULCER
 CANCER
 PYLORIC STENOSIS
 GASTROPARESIS
SIGNS / SYMPTOMS
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PAIN
ANEMIA
HEMATEMESIS / MELENA
EMESIS
WEIGHT LOSS
NORMAL
SMALL BOWEL
JEJUNUM
Early contrast is
predominantly in
jejunum and later
predominately in
ileum.
(note difference in
mucosal fold
pattern)
ILEUM
COLON
SMALL BOWEL OBSTRUCTION
Ng tube
ERECT
Note dilated small bowel centrally placed with
air/fluid levels on upright exam.
POST – OP
COLON
ADYNAMIC ILEUS
LARGE AND SMALL
BOWEL
SM. BOWEL
SUTURES
Symmetric dilation of large
and small bowel is seen
normally as a post operative
ileus.
SMALL BOWEL
BARIUM STUDY
HERNIA
CT
Note hernia in right lower quadrant
on both exams accounting for
obstruction.
Hernia is likely cause if there is no
history of prior surgery.
CROHN'S DISEASE
Narrowed
distal ileum
due to
chronic
inflammation
is typical for
Crohn’s
disease.
SMALL BOWEL DISEASE
 ULCER
 OBSTRUCTION
 POST-OPERATIVE ILEUS
 CROHN’S DISEASE
SIGNS / SYMPTOMS
 PAIN
 HEMATEMESIS
 DISTENTION
 DIARRHEA
SPLENIC
FLEXURE
NORMAL
COLON
HEPATIC
FLEXURE
TERMINAL ILEUM
CECUM
Normal air contrast
barium enema (double
contrast-air and barium
per rectum) shows filling
of colon with air and
barium retrograde to the
cecum with reflux into
the terminal ileum.
COLON DISEASE
 APPENDICITIS / DIVERTICULITIS
 POLYP / CANCER
 VOLVULUS
 GI HEMORRHAGE
SIGNS / SYMPTOMS
 RIGHT / LEFT LOWER QUADRANT PAIN
 FEVER / ELEVATED WBC’s
 DISTENSION / OBSTRUCTION
 WEIGHT LOSS
 HEMOCULT POSITIVE STOOL / ANEMIA
 MELENA / HEMATOCHEZIA
ACUTE
APPENDICITIS
NORMAL
DISTENDED APPENDIX WITH LOCAL
INFLAMMATION.
ABSCESS
Catheter has been placed
by radiologist using CT
guidance draining abscess
collection.
DRAINAGE
(DESCENDING COLON)
stalk on polyp--pedunculated
PEDUNCULATED
COLON POLYP
COLON CANCER
Barium enema showing
apple-core type constricting
lesion with proximal dilation
of colon—”APPLE - CORE”
constricting lesion
SMALL BOWEL
Ng tube
vs
COLON OBSTRUCTION
COLON
SIGMOID VOLVULUS
Dilated horse-shoe
shaped sigmoid colon
due to volvulus.
“COFFEE BEAN SIGN”
COLON
VOLVULUS
“BEAK SIGN”
Barium fills to point of
obstruction -- twist of
sigmoid colon
ULCERATIVE COLITIS
Normal
PSEUDOPOLYPS
with ulcerative colitis
CHROHN’S COLITIS
Segmental distribution
commonly referred to as “skip lesions”
CROHN’S
VS
ULCERATIVE COLITIS
Skip
Continuous
Fistula
Colon cancer
DIVERTICULOSIS
Balloon in rectum to
Help control barium.
Barium extends from lumen
outward into diverticulum.
DIVERTICULITIS
Extensive inflammation, wall
thickening and spasm can
simulate carcinoma.
Colonoscopy required to
confirm.
PSEUDOMEMBRANOUS COLITIS
 ANTIBIOTIC ASSOCIATED
 CLOSTRIDIUM DIFFICILIS
PAIN
DIARRHEA
FEVER
GI HEMORRHAGE
Catheter is placed in superior
mesenteric artery.
NORMAL
BLEEDING
NUCLEAR MEDICINE
Technetium-labeled RBCs
Labeled red blood cells are imaged over 1 hour showing extravasation in
Rt. colon steadily increasing indicating active bleeding.
ISCHEMIC COLITIS
Watershed area-----Splenic flexure
Elderly---Embolic----Fibrillation
Blood in stool----Pain
SMA
IMA
Stomach
MECKEL‘S DIVERTICULUM
Yolk sac remnant at distal
small bowel. Usually
asymtomatic but can bleed.
Technetium 99m labels gastric
Mucosa --Ectopic gastric mucosa
Diverticulum
Bladder
Pediatric patient <2yrs old
SUMMARY
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PLAIN X-RAY---BOWEL GAS PATTERN
BARIUM---OUTLINES LUMEN
CT---PROBLEM SOLVING
NUCLEAR MED
ULTRA SOUND
SPECIAL SITUATIONS
ANGIOGRAPHY
MR---LITTLE USE
RADIOLOGY VACATION SPOT
The end!