GASTROINTESTINAL IMAGING

dr. Christina Andica

DEPARTMENT OF RADIOLOGY
FACULTY OF MEDICINE, UNIVERSITY OF PADJADJARAN /
HASAN SADIKIN HOSPITAL
BANDUNG
Anatomy
 - Plain photo
Without
- 3 way abdomen
Contrast
series
GI
Imaging - Esophagograhy
-Maag-
Duodenography
With Contrast
- Barium Follow
Through
- Colon in Loop
First thing to do
Establish the name, sex, age and clinical
diagnosis of the patient
Establish the projection of the film
See the marker : Right / Left
Diseases You Should Know
Mechanical Ileus
Localized / Generalized Ileus
Peritonitis
Ulcerative Colitis
Diverculitis
Colonic Carcinoma
Abdominal Images
What to Examine

Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
 Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen
Large vs. Small Bowel
Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall
Small Bowel
Central
Valvulae extend across
lumen
Maximum diameter of 2"
3 Way Abdomen Series

Supine
Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine
Supine

Looking for
Scout film for gas
pattern
Calcifications
Soft tissue
masses
Substitute none
Prone
Looking for
Gas in rectum/sigmoid
Gas in ascending and
descending colon
Substitute lateral
rectum
Erect

Looking for
Free air
Air-fluid levels
Substitute left lateral
decubitus
Erect Chest
Looking for
Free air
Pneumonia at bases
Pleural effusions
Substitute supine
chest
Abnormal Gas Patterns

Localized ileus
Generalized ileus
Mechanical SBO
Mechanical LBO
Important Points
Look for air in the rectum/sigmoid first
Identify the most dilated loops-are they large bowel or
small bowel?
Sentinel loops are 1-2 dilated loops of small bowel
Generalized adynamic ileus almost always occurs in
immediate post-op patients
Always correlate the clinical findings with imaging
findings
Localized Ileus
One or two persistently dilated loops of
large or small bowel
Gas in rectum or sigmoid
Supine Prone

Sentinel Loops
Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis

Ulcer
Ureteral calculus
Generalized Ileus

Gas in dilated small bowel and large

bowel to rectum
Long air-fluid levels
Only post-op patients have generalized
ileus
Supine Erect

Generalized Adynamic Ileus

Mechanical SBO
Dilated small bowel
Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB
Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

*Cause may be visible on plain film

SBO
Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus -get F/O
Mechanical LBO
Dilated colon to point of obstruction
Little or no air in rectum/sigmoid
Little or no gas in small bowel, if
Ileocecal valve remains competent
Incompetent ileocecal valve
Large bowel decompresses into small
bowel
May look like SBO
Get BE or follow-up
Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception
 Supine Prone

Carcinoma of Sigmoid LBO Decompressed into

SB
Distinction between SBO and LBO

Small bowel Large bowel

Haustra Absent Present
Valvula conniventes Present in Absent
jejenum
Number of loops Few
Many
Distribution of loops Peripheral
Central
Radius of curvature of loop Large
Small
Diameter of loop 50 mm+
30-50 mm
Solid faeces May be present
absent

Greinger,Allison. Diagnostic Radiology

PERITONITIS
Radiological findings :

Generalized ileus
Ascites
Pneumoperitoneum
No pre-peritoneal fat
COLON IN LOOP
Indikasi :
Kelainan motilitas
Kelainan pada mukosa (ulkus), divertikel, inflamasi)
Keganasan
Degeneratif
Kelainan kongenital
Kelainan obstruktif
Kontraindikasi
Perforasi dari saluran cerna, ulkus yang mengalami
perforasi
Alergi bahan kontras media
Obstruksi total dari saluran cerna
 SINGLE
CONTRAST STUDY
DOUBLE CONTRAST
STUDY
Ulcerative Colitis
Ulcerative Colitis
Chrons Diseases
Crohn's disease is a disorder of unknown
aetiology that is characterised pathologically by
involvement of all bowel wall layers in a chronic
inflammatory process with non-caseating
granulomas. The granulomatous inflammation
most frequently affects the terminal ileum but it
may affect any part of the gastrointestinal tract
and frequently affected areas are in discontinuity.
There is a tendency to form fistulae.
Chrons Diseases
skip lesions - discontinuous sites of pathology along
the gastrointestinal tract
cobblestone ulceration; a result of apthous
ulceration progressing to oedema and nodular
thickening
lead pipe thickening - thickened, stiff bowel
narrowed lumen
strictures
'rose-thorn' narrow-mouthed ulcers which lead to
fistulae
Skip lessions
This lower abdominal X-ray shows narrowing (stenosis) of the end of the small
intestine (ileum)with loss of mucosal pattern and bowel wall thickening. Crohn's
disease typically affects the small intestine. A solution containing a dye (barium), was
swallowed by the patient. When it passed into the small intestines, this X-ray was
taken (lower GI series).
Colonic
Diverticulitis
Radiographic findings : Colonic Diverticulosis
1. Multiple round or oval
outpouchings of
barium projecting
beyond the lumen on
profile view (white
arrow), barium
collection (white
arrowhead) or ring-like
lesion (black
arrowhead) on en-face
view
Radiographic findings : Colonic Diverticulosis
COLONIC CARCINOMA
 Identify the Types of
Abnormal Gas Patterns
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back
What abnormality is represented here?

Focal Ileus

Generalized Ileus

SBO

LBO

Go Back
Correct
There are multiple air-
containing and dilated loops
of small bowel with little or no
gas in the colon. The findings
are those of a mechanical
small bowel obstruction. The
patient had undergone prior
surgery and the cause of this
obstruction was adhesions
form the prior surgery.

Go Back Go ahead
Correct
There is a dilated colon to
the splenic flexure/ Little
or no gas is seen in the
rectum or in the small
bowel. The findings are
those of a mechanical
large bowel obstruction.
The cause was an annular
constricting carcinoma at
the splenic flexure.

Go Back Go ahead
Correct
There are several air-containing
and slightly dilated loops of
small bowel in the LLQ. These
were persistent. The findings
are those of a localized ileus
(sentinel loops) and their
location would suggest
diverticulitis. The patient had
appendicitis. The sentinel loops
do not always correspond to the
area of inflammation.

Go Back Go ahead
Correct
All of the bowel is dilated.
There is air in the rectum. The
patient was post-op
abdominal surgery and the
bowel sounds were absent.
This is a generalized adynamic
ileus as is seen sometimes
after abdominal surgery.

Go Back Go ahead
Wrong
Look Again

Click on the Go Back

button and look again

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Congratulations, You Graduate

You
know
your
bowel gas