Transcript large - Radiology - University of South Carolina

M-1
RADIOLOGY
OF THE
ABDOMEN
GASTROINTESTINAL TRACT
DR. FRANCIS NEUFFER, MD
UNIVERSITY OF SOUTH CAROLINA
SCHOOL OF MEDICINE
2011
Goals / Objectives
Anatomy
Imaging Choices
Pathology
References
NORMAL
ANATOMY
Esophagus
Stomach
Small bowel
Colon
BASIC DENSITIES VISUALIZED
Bone
Soft Tissue
Fat
Air
X - RAY --- FOUR BASIC DENSITIES
Air
Soft Tissue
Fat
Bone
CT 3D ANGIOGRAM
Celiac artery
Superior mesenteric
artery
HEPATIC ARTERY
SPLENIC ARTERY
CELIAC ARTERY
RIGHT RENAL ARTERY
LEFT RENAL ARTERY
AORTOGRAM
RENAL ARTERY
CELIAC ARTERY AND SUPERIOR
MESENTERIC ARTERY INJECTION
CELIAC ARTERY
SUPERIOR MESENTERIC
ARTERY
LATERAL AORTOGRAM AND CT SHOW ORIGINS
OF
CELIAC ARTERY AND SMA
Celiac
Celiac
SMA
SMA
AP SUPINE ABDOMEN X-RAY
GAS PATTERN
STOMACH
SM. BOWEL
COLON
Normal abdominal gas pattern with air in the stomach and scattered nondistended loops of large bowel and little small bowel gas present.
AP ABDOMEN
NASO-GASTRIC
(NG TUBE)
NASO-GASTRIC
(NG TUBE)
BARIUM IN COLON
STOMACH
UPPER GI
ORAL BARIUM CONTRAST
WITHOUT CONTRAST
COLON
BARIUM ENEMA - RECTAL BARIUM CONTRAST
15
SPOT FILM TAKEN WITH PATIENT IN THE UPRIGHT POSITION
CARDIA
FUNDUS
LESSER
CURVATURE
FUNDUS
RUGAE
UGI
STUDY
GREATER
CURVATURE
DUODENAL BULB
GASTRIC
BODY
ANTRUM
JEJUNUM
FUNDUS
DUODENUM
ANTRUM
C-LOOP
BODY
DUODENAL
JEJUNAL
LIGAMENT
NORMAL
GASTRIC
ANATOMY
Single AP radiograph
showing filling of distal
esophagus, stomach and
proximal small bowel
without mass,
obstruction or filling
defect.
CT COMPARISON
OF THE STOMACH
BARIUM IN
STOMACH
SMALL BOWEL
DUODENAL “C” LOOP
FILM TAKEN IMMEDIATELY AFTER
INGESTION OF BARIUM.
JEJUNUM
JEJUNUM
SMALL BOWEL FOLLOW
THROUGH
(20 minutes later)
ILEUM
Ileocecal valve
Terminal ileum
CECUM
Appendix
TERMINAL ILEUM
APPENDIX EXTENDING FROM CECUM
AIR CONTRAST
BARIUM ENEMA
Terminal
ileum
ESOPHAGEAL DISEASE
ESOPHAGEAL CANCER
HIATAL HERNIA
VARICES
CANDIDA
ESOPHAGEAL TEAR
SIGNS / SYMPTOMS
CHEST PAIN
DIFFICULTY SWALLOWING
HOARSENESS
NORMAL ESOPHAGUS
Aortic
impression
Normal double contrast
esophagram shows coating of
mucosa with barium and air
distention. There are
narrowed areas at the aortic
arch and Diaphragm hiatus.
NORMAL
SWALLOW
ASPIRATION
Contrast tracks anteriorly into
trachea with aspiration.
Aspiration is a problem with patients with CVA
Due to complex neuromuscular requirements of
swallowing.
Also in patients with altered consciousness
Drug overdose/ Alcohol intoxication
ESOPHAGEAL
CANCER
Typical squamous cell carcinoma
Poor prognosis from local
extension into critical mediastinal
structures.
(esophagus lacks a serosa)
NORMAL
ESOPHAGUS
DIAPHRAGM
HIATAL HERNIA
*Note distended
distal esophagus with
herniation of gastric
fundus into chest
through esophageal
hiatus.
DIAPHRAGM
This allows for reflux of gastric
contents into esophagus.
ESOPHAGEAL CANCER
Distal malignancy may be adenocarcinoma due to Barrett’s esophagus - dysplastic change
caused by chronic reflux of gastric contents.
ESOPHAGEAL
VARICES
Linear tubular filling defects represent
distended veins from shunting of blood
from the portal vein to the systemic
circulation due to cirrhosis and portal
hypertension.
CANDIDA
ESOPHAGITIS
Extensive nodular filling defects
in the esophagus in an
immunocompromised patient are
typical for Candida esophagitis.
ESOPHAGEAL
TEAR
Esophagus shows a linear tear of mucosa of
distil esophagus due to vomiting with barium
tracking into the wall.
Full thickness tear or rupture (Boerhaave’s
syndrome) can lead to mediastinitis
and death.
GASTRIC DISEASE
ULCER
CANCER
PYLORIC STENOSIS
SIGNS / SYMPTOMS
PAIN
ANEMIA
HEMATEMESIS / MELENA
EMESIS
WEIGHT LOSS
FUNDUS
NORMAL
GASTRIC
ANATOMY
DUODENUM
ANTRUM
BODY
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 IMAGE
ulcer
RUGAE
GASTRIC ANTRECTOMY
AND
SMALL BOWEL ANASTOMOSIS
C-LOOP
GASTRIC CARCINOMA
Narrowed lumen of
gastric antrum by
adeno carcinoma.
Lymph node spread
goes to
Celiac nodes
PYLORIC STENOSIS
Normal stomach
Oblique view of stomach
Air filled fundus
Air filled fundus
PYLORIC STENOSIS
Barium filled antrum
Duodenal bulb
Duodenal bulb
Barium filled antrum
Narrowed pyloric channel
Pyloric Stenosis is seen in newborns within the first months. There is a 4:1 male
ratio and is due to hypertrophied musculature at the pylorus.
PYLORIC STENOSIS
ULTRASOUND is used now more for diagnosis
SMALL BOWEL DISEASE
ULCER
OBSTRUCTION
POST-OPERATIVE ILEUS
CROHN’S DISEASE
SIGNS / SYMPTOMS
PAIN
HEMATEMESIS
DISTENTION
DIARRHEA
DUODENAL ULCER
Note barium
collection
Centrally with
surrounding
edema.
NORMAL GAS PATTERN
AIR UNDER THE DIAPHRAGM
Perforation of GI tract from ulcer leads to peritonitis and pneumoperitoneum.
UPRIGHT
ERECT AND DECUBITUS
ABDOMEN FILMS SHOW FREE
AIR UNDER THE DIAPHRAGM.
DECUBITUS
LIVER
Left lateral decubitus (left side dependent) shows air along liver margin. This is
the preferred x-ray if the patient cannot stand.
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.
PARTIAL SMALL BOWEL OBSTRUCTION
DILATED
BOWEL
*
OBSTRUCTION
NON DILATED
BOWEL
Proximal loops are dilated and distal loops are
collapsed indicating an obstruction.
HERNIA
SM. BOWEL
BARIUM STUDY
Note hernia in right lower quadrant on both
exams accounting for obstruction. Hernia is
likely cause if there is no history of prior
surgery.
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.
CROHN’S DISEASE
Narrowed
distal ileum
due to
chronic
inflammation
is typical for
Crohn’s
disease.
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
APPENDICOLITH
Occasionally a calculus
(appendicolith) is seen as the
source of appendicitis due to
obstruction of the appendix and
inflammation.
ACUTE
APPENDICITIS
NORMAL
DISTENDED APPENDIX WITH LOCAL
INFLAMATION.
ABSCESS
Catheter has been placed by
radiologist using CT guidance
draining abscess collection.
DRAINAGE
SPLENIC
FLEXURE
NORMAL
COLON
HEPATIC
FLEXURE
DESCENDING COLON
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.
(DESCENDING COLON)
stalk on polyp--pedunculated
PEDUNCULATED
COLON POLYP
COLON POLYP
Polyp on wall without
stalk is coated and
outlined by barium
COLON
OBSTRUCTION
Distension extends to distal
descending colon.
COLON CANCER
Barium enema showing applecore type constricting lesion
with proximal dilation of
colon—”APPLE - CORE”
constricting lesion
MESENTERIC TO HEPATIC PORTAL VEIN
FLOW CAN CARRY METASTASIS TO LIVER
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 and twist of
sigmoid colon
Distended small bowel
Distended large bowel
DIVERTICULOSIS
Barium extends from lumen
outward into diverticulum.
DIVERTICULITIS
Extensive inflammation, wall
thickening and spasm can
simulate carcinoma with
colonoscopy required to confirm.
DIVERTICULITIS
Review
The Match Game
 APPENDICITIS
NEWBORN/PEDS
 ASPIRATION / ESOPHAGEAL CANCER / HIATAL HERNIA
 VARICES / CANDIDA / ESOPHAGEAL TEAR
 COLON CANCER / SIGMOID VOLVULUS
YOUNG ADULT
 CROHN’S DISEASE
 DIVERTICULITIS
 DUODENAL ULCER
ADULT
 GASTRIC CANCER / ULCER / PYLORIC STENOSIS
 SMALL BOWEL OBSTRUCTION
ELDERLY
SUMMARY
PLAIN X-RAY---BOWEL GAS PATTERN
BARIUM---OUTLINES LUMEN
CT---PROBLEM SOLVING
NUCLEAR MED
ULTRA SOUND
SPECIAL SITUATIONS
ANGIOGRAPHY
MR---LITTLE USE