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RADIO 250: ICC in Radiology and Nuclear Medicine

LEC 08: ABDOMINAL RADIOLOGY


Exam 01| Dr. Edilberto Fragante| August 30, 2013
OUTLINE
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.

Introduction
Plain Abdominal X-ray: Gas Pattern
Plain Films: Extraluminal air
Plain Films: Calcifications and Foreign Bodies
Plain Films: Soft Tissue Masses/ Densities/ Fluid
Accumulations
Contrast Studies
Cholangiogram, T-tube, PTC, ERCP
CT Scan
Nodal Staging

I. INTRODUCTION
XRAY DENSITIES
BLACK radiolucent (AIR)
GRAY between air and soft tissue (e.g. FAT, psoas shadow)
WHITE radioopaque (BONE and metals, foreign bodies
PLAIN ABDOMEN VS KUB FILM
Plain Abdomen
Diaphragm seen completely
Bowel preparation not needed
Position: upright and supine

KUB
Pelvis seen completely
Bowel preparation needed
Position: supine

Figure 2. Large Bowel haustrae (L) and small bowel valvulae (R)
Table 2. Bowel Gas Pattern
Bowel Gas
Stomach
Pattern
Appears due to
Always
swallowed air and
with gas
bacterial
production

Small Bowel

Large Bowel

2-3 loops of nondistended bowel

Almost always
filled with gas
in rectum and
sigmoid

Normal diameter
is <2.5 3 cm
(diameter of P1
coin)

II. PLAIN ABDOMINAL X-RAY: GAS PATTERN


A. Normal Gas Pattern

Figure 3. Comparison of Bowel Gas Pattern

Figure 1.Normal Bowel Gas Pattern. Supine radiograph shows the


normal distribution of gas in the stomach (large arrow) and duodenum
(small arrow). The normal mottled pattern of stool is seen in the
distribution of the right colon (arrowhead). A few gas collections
within the small bowel (curved arrow) are seen in the pelvis.

B. Air Fluid Levels


Table 3. Air Fluid Levels
Air Fluid
Stomach
Small Bowel
Levels
Air Fluid
Always (except in
2-3 levels
Levels
supine film)
possible

Large
Bowel
None
usually

Table 1. Large Bowel vs. Small Bowel on Plain Abdominal X-ray


Small Bowel
Large Bowel
Centrally located
Peripherally located
Valvulae conniventes (other
Haustral markings do not extend
names: circular valves, valves of
from wall to wall
Kerkring, plicae circularis) extend
across lumen

Figure 4. Comparison of Air Fluid Levels

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Table 4. Types of Air Fluid Levels


Differential
Air and Fluid are not aligned
Usually seen in bowel
obstructions

right), Chest upright (lower left), Abdomen prone (lower right)


Non-Differential
Air and fluid are aligned
Seen in ileus or paralytic ileus

D. Abnormal Gas Pattern


Functional Ileus
Ileus occurs from hypomotility of the gastrointestinal tract in the
absence of mechanical obstruction
Localized Ileus
o One or two persistently visible dilated loops of large or small bowel
o Happens when bowels react and dilate due to inflammation (called
Sentinel Loops)
o Could be due to different etiology depending on the location
o Cholecystitis (upper right quadrant), Diverticulitis (lower left
quadrant), Appendicitis (lower right quadrant)
Generalized Ileus
o Gas in dilated small bowel and large bowel to rectum
o Long air-fluid levels
o Common in the postoperative state (after abdominal surgery) and
should resolve within 2-3 days
o If ileus persists for more than 3 days following surgery, it is now called
Adynamic or paralytic ileus

Figure 5. Differential (L) and Non-differential (R) Air Fluid Levels


C. Complete Abdominal Series
Supine
o Look for type of gas pattern (whether non-obstructive vs. obstructive)
o Used in scout films (Upper GI series, barium enema) for
calcifications and soft tissue masses)
Upright
o Look for free air and air fluid levels
o Substitute: left lateral decubitus view for patients who cannot
stand upright
Chest Upright
o Because some abdominal complaints are just referred from a
chest (lungs or heart) problem
o Look for
Free air (pneumoperitoneum)
Pneumonia at bases (because it mimics GI pain)
Pleural effusions
Substitute: Supine chest (used for bed-ridden patients)
Prone (useful if suspecting obstruction)
o Look for
Gas in rectum/sigmoid
Gas in ascending/descending colon
o Substitute: lateral rectum

Figure 7. Localized ileus (top; circle: dilated bowel loop), postop adynamic
ileus (bottom; circle: non-differential air fluid level)
Mechanical Obstruction
Causes
o Tumor, volvulus, hernia, diverticulitis, intusussception
Mechanical Small Bowel Obstruction
o After 3-5 hours, gas/fluid accumulates
o Dilated small bowel with differential air-fluid level and absent
or minimal gas in the large bowel
o Early SBO may resemble localized ileus, thus, follow up is
needed
o In early SBO, some gas may be seen in the large bowel

Figure 6. Abdomen supine (Upper left), Abdomen upright (upper

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Figure 11. Dilated large bowel loops due to obstruction/mass (circle)

Figure 8. Dilated small bowel due to SBO; valvulae conniventes


could be appreciated (circle)

Table 5. Summary Table (Remember me!)


Air in Rectum
Air in Small Bowel
or Sigmoid
Localized
Yes
2-3 distended loops
Ileus
Generalized
Yes
Multiple distended
Ileus
loops
SBO
No
Multiple dilated loops
LBO
No
None, unless ileocecal
valve is incompetent

Air in Large
Bowel
Yes
Yes
No
Yes

III. PLAIN FILMS: EXTRALUMINAL AIR


A. Free Air

Figure 9. Presence of gas in the large bowel in early/incomplete SBO


o Complete/prolonged obstruction leads to absence of gas in the
large bowel
o Proximal jejunal obstruction leads to complete filling of fluid
(seen in upright film as step-ladder configuration)

Causes
o Rupture of a hollow viscus
Perforated ulcer
Perforated diverticulitis
Perforated carcinoma
Trauma or instrumentation
o Patients 5-7 days post-op
o Not usually seen in perforated appendix because the appendix
is in the retroperitoneum
Pneumoperitoneum
o Air beneath the diaphragm

Figure 12. Air beneath the hemidiaphragm.


o Could also be appreciated in left lateral decubitus view where
the air goes to the contralateral side and outlines the liver
Figure 10. String of beads (circle) and complete filling of
fluid/differential air fluid level (arrow)
Mechanical Large Bowel Obstruction
o Dilated colon to point of obstruction
o Little or no air in rectum/sigmoid
o Little or no gas in small bowel if ileocecal valve remains
competent
o If incompetent ileocecal valve, LBO might look like SBO since
the large bowel decompresses into the small bowel (thus,
follow up or order barium enema)

Figure 13. Air outlining the liver

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RIGLERS SIGN: air inside and outside bowel lumen outlines walls
(normally, only inside walls of bowels are seen)

Figure 18. Mercury ingestion (L) and Coin ingestion (R)


Figure 14. Notice the air between the walls
FOOTBALL SIGN: falciform ligament sign; abdomen shaped like a
football; falciform ligament resembles the stitches at the middle of
the football

Figure 15. Looks like a football right?


IV. PLAIN FILMS: CALCIFICATIONS & FOREIGN BODIES
Possible Areas of Calcifications:
o Chronic pancreatitis calcifications on mid-abdomen
o Splenic calci
o Hepatic TB stipled calcifications
o Calcified lymph nodes (many in ileocecal region)
o Tabesmesenterica calcifications in the mesentery
o Urolithiases
o Nephrocalcinosis in parenchyma; vs. Nephrolithisis which is
in the collecting system
o Uterine fibroma
o Mercury ingestion flecks of calcification
o Coin ingestion usually in ileocecal valve have to take 2
views (AP lat or AP oblique); removal through bowel excretion

V. PLAIN FILMS: SOFT TISSUE MASSES/ DENSITIES/ FLUID


COLLECTIONS
Soft Tissue Masses
o Hepatosplenomegaly (look for gastric bubble because an
enlarged spleen can displace the stomach)
o Plain films are poor for judging liver size
o Tumor or cyst
Signs of bowel displacement (paucity of gas and pad sign extrinsic compression of bowel)
Fluid collections (ddx for a soft tissue mass)
o Abscesses/hematomas
Ascites/loculated fluid collections (obscured liver edge and
sagging flanks)
o Ovarian new growth - intestines displaced laterally and
superiorly
o Retropharyngeal abscess - normally, 0.5-1 cm from trachea to
vertebra
o Psoas abscess - confirmed by psoas sign and UTZ; obscures psoas
line and bowels
o Periappendiceal abscess with appendicolith

Figure 19. Hepatosplenomegaly (L) and Ascites (R)


VI. CONTRAST STUDIES
Esophagus

Esophagogram 2 cups barium, fluoroscopy


Normal barium swallow
Barium flows in seconds so you have to do it quick
Upper GI series double contrast studies (Barium + sprite so
youhave air/barium contrast)

Figure 16. Chronic pancreatitis (L) and Splenic calcifications (R)

Figure 20. Esophagogram

Figure 17. Hepatic tuberculosis (L) and Calcified lymph nodes (R)

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Figure 21. Normal Barium Swallow


Achalasia
o Greek term that means does not relax
o Hypertonic lower esophageal sphincter
o No peristalsis below level of thoracic inlet
o Causes halitosis
o NO AUERBACHS PLEXUS OR MEISSNERS PLEXUS (same
pathology as Hirschsprungs disease
o Birds beak because of constriction or narrowing below
level of thoracic inlet; you see a large esophagus which tapers
at the end which looks like a birds beak
o ETIOLOGY: loss of ganglion cells of esophageal myenteric
plexus (which controls esophageal peristalsis)

Figure 24. Foreign body (L) and Small esophageal ulcers (R)
Caustic Esophageal Stricture
o Long segment involved
o By 2-4 weeks, heals with fibrosis progressive luminal
narrowing
Apple-Core Deformity
o Pathognomonic of GI malignancy
o Lumen narrows because of the obstruction brought about by the
mass
o Mass common in lower 2/3 of the esophagus
Esophageal Carcinoma
o Asymptomatic until causes obstruction
o Irregular/nodular
o Eccentric narrowing
o Shelf-like margins
o Most common area of malignancy: LOWER SEGMENT OF
ESOPHAGUS

Figure 22. Achalasia


Zenkers Diverticulum
o Pharyngoesophageal diverticulum
o When there is excessive pressure within the lower pharynx (such
as in swallowing), the weakest portion of the pharyngeal wall
balloons out, forming a diverticulum which may reach several
centimeters in diameter
o Pulsion type secondary to motility disorder, mechanical
obstruction and chronic wear-and-tear
o Causes: obstruction, bleeding, perforation, infection, CA

Figure 25. Caustic esophageal stricture (top) and Esophageal


carcinoma (bottom)
Stomach

Figure 23. Zenkers Diverticulum


Foreign body (i.e. balot)
o Barium swallow or barium-soaked cotton delineates level of
radio-opaque foreign body
o Obstruction of the upper neck dilated upper segment of the
esophagus
Small Esophageal Ulcers (Candidiasis, Herpes, CMV)
o Plaque-like vertically oriented lesions
o Diffuse/long segment of filling defects
o Ragged appearance
o Poor peristalsis
o Looks like ampalaya
Figure 26. Upper GI series. D1 (duodenal bulb), D2 (descending colon),
D3 (transverse colon), D4 (ascending colon)
Gastric Ulcer
o Ulcer crater projects outside the gastric wall
o Sign of undermining: Hamptons line, smooth rim or collar of
edema

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o Rarely seen via UGIS since we use EGD more often


Chemical Gastritis
o Liquid sosa
o Stomach becomes non-distendible
o Strong alkali and acids affect both esophagus and stomach
o Alkali coagulation necrosis
o 3-10 weeks cicatrization (aka scar formation) atonic stomach,
small capacity
o (+) Pyloric spasm spares duodenum

Figure 27. Gastric ulcer (L) and Chemical gastritis (R)


Linitis Plastica
o Stomach CA tumoral infiltration covering the wall (muscularis
propria) of the stomach
o Thickening and stiffening
Gastric Antrum CA
o Apple-core deformity sign at the antrum

Figure 28. Linitis Plastica

Figure 31. Ascariasis in small intestine. Ascaris is alive because it


ingested the contrast.
Foreign body (e.g. santol seeds)
o Contrast film will outline the foreign bodies
Duodenal diverticula
nd
rd
o 1 mucosa prolapsed throughmuscularis (2 & 3 portions)
o 2 inflammation (1st portion-true)
o Causes: obstruction, bleeding, perforation, infection

Figure 32. Foreign body (santol seeds) (L) and Duodenal diverticula (R)
Bockdalek hernia (back door at the left)
o Opening exists in the diaphragm, allowing intra-abdominal organs
(i.e. stomach & intestines) to protrude into the thoracic cavity
o Absent hemidiaphragm so the gastric contents protrudes unto
the thoracic cavity
o Upon auscultation: you hear bowel sounds at the thoracic cavity
and none at the abdomen
X. CHOLANGIOGRAM, T-TUBE, PTC, ERCP
Esophagus

Figure 29. Gastric Antrum CA


Small Intestines

Parts: D1-duodenal bulb, D2-descending, D3-transverse,D4-ascending


Wall thickness: ~1.0-2.0 mm
Jejunal luminal diameter: 3.5 cm
Ileal luminal diameter: 3 cm
Jejunal folds do not disappear with distention (vs. ileal folds that will
disappear with distention)

Ectopic gallbladder
Gallstones (calcifications)
T-tube cholangiogram
o Left by surgeons (for around 1 month) in the patients so theycan
visualize retained stones later on
o Establishes patency/intact biliary tree
o Causes: obstruction, bleeding, perforation, infection
Choledocholithiasis
o Note the presence of lucencies with well-defined borders inside
the biliary tree

Figure 33. (L) Ectopic gallbladder (R) Gall stones


Figure 30. Duodenal Ulcer
Ascariasis
o Live ascaris will take in contrast, hence, it will be radioopaque (vs. dead ascaris which will not be able to take in
contrast so radiolucent)

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o May resemble CA
Periappendiceal abscess

Figure 34. (L) T-Tube cholangiogram. Note the long and large
pancreatic duct of Wirsung seen (R) Choledocholithiasis
Biliary Tree

Figure 35. (L) Biliary Ascariasis (R) Periampullary CA- apple core
appearance
Large Intestines
Barium enema Put foley catheter (in PGH), inflate, put barium and
pump air (for double contrast)
Divertculosis: outpouchings of mucosa and muscularis mucosae at
sites of blood vessel penetration
Diverticulitis
o RUPTURED diverticulosis
o Deformed sacs
o Presence of abscesses
o Extravasation of contrast

Figure 36. (L) Diverticulosis (R) Diverticulitis


Non-specific colitis
o Absence of feces
o Multiple soft loops
o Long segment involvement
o Increased wall thickness
o Wall irregularity saw-tooth appearance
Ileocecal TB
o Conical, retracted cecum
o Deformed ileocecal valve
o Gaping ileocecal valve
o Sterlins sign
Irregular terminal ileum (because ileum opens into a
contracted cecum)
Irritability and rapid emptying of terminal ileum
Stricture and fibrosis

Figure 37. (L) Non-specific colitis (R) Ileocecal TB


Ameboma
o Invasion of wall + bacterial infection
o Commonly cecum

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Figure 38. (L) Ameboma (R) Periappendiceal abcess. Soft tissue mass
displacing the cecum superiorly
Intussusception
o Children - common ileocolic 2 inflamed lymphoid tissue
o Adults - look for leading lesion or post-op
o Coil spring appearance
Hirschsprungs disease
o Absence of myenteric ganglia at the distal colon, commonly
rectosigmoid, resulting in reduced bowel peristalsis and function
o Starts at anus and proceeds proximally
o Affects distal colon, commonly rectosigmoid look for
transitional zone

Figure 39. (L) Intussusception (R) Hirschsprungs disease


Inguinal Hernia
o Small intestine in the inguinal region
Rectal and Sigmoid Polyps
o Higher risk of CA
size > 1 cm
irregular/bizarre contour
sessile/fixation
rapid growth rate
o Polypoid, annular or infiltrating
o Filling defect
o Apple-core deformity

Figure 40. (L) Inguinal hernia (R) Rectal and sigmoid polyps
Familial Polyposis
o Multiple, small polyps (adenomatous)
o Sessile or pedunculated
o High incidence of CA (polyps are premalignant lesions)
Peutz Jeghers Syndrome
o aka Hereditary intestinal polyposis syndrome
o Mucocutaneous lesions
o Multiple (hamartomatous) polyps proliferative mucosa
o Lower incidence of CA (the polyps themselves are benign and
have very low malignant potential)
Colonic CA splenic flexure
NOTE: To differentiate between feces and polyps: Do maneuvers to
move the bowel. Polyps do not change positions while feces do.

VIII. CT SCAN (not discussed)


Planning of surgery and radiotherapy particularly with local extension
of disease

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Demonstrate involvement of adjacent organs, such as the bladder,


vagina, and abdominal or pelvic musculature
Provide baseline findings for comparison with post-operative follow-up
Detection of recurrent disease
Detection of distant metastases
Older patients/patients who are unable to undergo colonoscopy
modified CT is performed for primary detection of colorectal tumors
Tumors as an incidental finding or diagnosis of colon cancer suggested
in patients undergoing CT for a variety of GI symptoms
Accuracy rates for pre-operative staging: 48-77% (relatively low)
Tumor: luminal narrowing and marked wall thickening
Low spatial and contrast resolution unable to determine exact depth of
tumor invasion in superficial tumors
CT detection of local tumor extension:
o Sensitivity 60%
o Specificity 67-81%
o Inability to detect microscopic extension
Local extension of tumor
o Extracolic mass
o Thickening and nodularity
o Invaded muscle enlarge
o Loss of fat planes between the colon & adjacent organs

VIII.
NODAL STAGING (not discussed)
Abnormal LN > 1.0-1.5 cm
Not all enlarged nodes with tumor and normal-sized nodes may have
microscopic tumor
LN may be detected in the mesentery and retroperitoneum
Rectal tumors may metastasize to internal iliac nodes
CT scan has high specificity (96%) for detection of metastatic lymph
nodes, but sensitivity is low
END OF TRANSCRIPTION

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