GASTROINTESTINAL IMAGING

dr. Christina Andica

DEPARTMENT OF RADIOLOGY
FACULTY OF MEDICINE, UNIVERSITY OF PADJADJARAN /
HASAN SADIKIN HOSPITAL
BANDUNG
Anatomy
GI
Imaging
Without
Contrast
- Plain photo
- 3 way abdomen
series
With Contrast
- Esophagograhy
-Maag-
Duodenography
- 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
Erect Abdomen
Always
air/fluid level
in stomach
A few
air/fluid
levels in
small bowel
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
Sentinel Loops
Supine
Prone
Pancreatitis
Ulcer
Diverticulitis
Cholecystitis
Appendicitis
Ulcer
Ureteral calculus
Sentinel Loops
Generalized Ileus

Gas in dilated small bowel and large
bowel to rectum
Long air-fluid levels
Only post-op patients have generalized
ileus
Generalized Adynamic Ileus
Supine Erect
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
Carcinoma of Sigmoid LBO Decompressed into
SB
Prone
Supine
Distinction between SBO and LBO
Small bowel Large bowel
Haustra
Valvula conniventes
Number of loops
Distribution of loops
Radius of curvature of loop
Diameter of loop
Solid faeces
Absent
Present in
jejenum
Many
Central
Small
30-50 mm
absent
Present
Absent
Few
Peripheral
Large
50 mm+
May be present
Greinger,Allison. Diagnostic Radiology

Air in Rectum
or sigmoid
Air in Small
Bowel
Air in Large
Bowel
Localized
Ileus
Yes
2-3 distended
loops
Air in rectum or
sigmoid
Generalized
Ileus
Yes
Multiple
distended loops
Yes-
Distended
SBO
No
Multiple dilated
loops
No
LBO
No
None-unless
ileocecal valve
incompetent
Yes-
Dilated

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
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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
Correct
Go ahead
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.
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Correct
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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.
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Correct
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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.
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Correct
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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.
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Wrong
Look Again
Click on the Go Back
button and look again
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Congratulations, You Graduate
You
know
your
bowel gas