Bachtiar Murtala

Department of Radiology
Medical Faculty Hasanuddin University
General Objective

To discuss about the role of

radiological imaging in diagnosing
gastroenterohepatologic diseases
Specific objectives
Imaging modalities and
techniques/examination
procedures
Radiological appearances of some
GIT and hepatobiliary diseases
Organs scope
 Plain Abdomen
 Esophagus-rectum

 Liver

 Biliary tract

 Pancreas
Imaging modalities
 Plain abdominal radiography

 Conventional radiography with contrast

media
 Imaging (US, CT-Scan, MRI, Nuclear
medicine)
Plain abdominal radiography
 Commonly used in emergency cases such as ; ileus
(dynamic or adynamic), peritonitis, free-air/fluid,
blunt or penetrating trauma,etc
 Usually needed 3 standard positions :
1. Erect
2. Supine
3. LLD ( left lateral decubitus)
4. Cross table ( optional )
Large bowel obstruction
 Less commonly than small bowel obstruction
 Three main causes : - colon carcinoma
- Volvulus
- Diverticulitis
Small bowel obstruction
Radiological signs
 Bowel distended filled by gas++
 Lack gas in the distal part
 Air fluid level (“step ladder appearance”)
 Valvula conniventes appears as herring bone
(“herring bone appearance”)
invaginasi
Peritonitis
Bowel wall thickening
Properitoneal fat line disappear/
obliterate
Paralytic ileus sign
Adynamic or paralytic ileus

Bowel distended until distal part

Air fluid levels (+) , longer
Herringbone appearance(-)
Radiography with contrast
 Barium Sulphate (BaSO4)
suspension
 Iodine
Esophagus :
It should be visualized with contrast media
(Barium Sulfat)  Esophagography
Indications :
- Dysphagia
- Dyspepsia
- Haematemesis/melena
- Congenital anomalies ?

Technique of Examination :
• The patient is asked to swallow a thick Barium
Sulphate (1:1) or Iodine ( for baby) and followed by
fluoroscopy & taking radiography
B. Abnormalities :
Congenital malformation
- Esophageal atresia
- Short esophagus with a thoracic stomach
(Brachy-esophagus)
- Duplication
Traumatic Disorders  rupture
Abnormalities in density  foreign bodies
Abnormalities in Size (length & diameter)
Abnormalities in architecture
• Radiography positions : - AP
- Right Anterior Oblique
projection (RAO)
- Left Anterior Oblique
projection (LAO)
- Spot Film (optional)

Radiological Signs :
A. Normal Indentations : - Knob aorta
- Left main bronchus
- Left atrium
- Hiatus hernia
Esophageal atresia
Esophageal varices
Caused by portal hypertension,
commonly seen in cirrhosis
hepatis
“cobble stone appearance”
Esophageal stricture

Narrowing and irregularity due

to corrosive materials
(corrosive stricture)
ACHALASIA
 Aganglionic of the distal part of
esophagus
 Distal smooth narrowing with
dilatation of the proximal segmen---
“mouse tail app”.
MOUSE TAIL APPEARANCE
Esophageal hernia
Sliding /axial
Paraesophageal hernia
Tumour :
- Benign : • Filling defect with smooth
border
• Forked stream appearance
(Fluoroscopy)

- Malignant : • Filling defect with irregular

border
• Spasticity
Wilhelm Conrad Rontgent 1895
GASTRODUODENOGRAPHY
(= Maag Duodenum/MD Foto)
Is a radiographic evaluation of the stomach &
duodenum by introducing contrast media inside
[Barium sulfat (+) & air/gas (-)
Indication : - Dyspepsia
- Epigastric pain
- Vomiting
- Haematemesis/melaena
Procedure Of Examination
1. Preparation : fasting ± 4-6 hours
2. The patient swallows contrast Barium Sulfat
(& air) followed by fluoroscopy and taking
radiography in various position
3. Usually in Supine, Prone, Prone oblique,
Erect. Spot-Film Compression
(recommended)
Radiographic Abnormalities of Gastroduodenal
Disease.
It can be classified as changes in :
 Position
 Size (redundancy, enrlargement/widening,
narrowing/shrinkage)
 Contour
 Rugae abnormalities
 Filling defect
 Function
Pyloric stenosis
= Infantile Hypertrophic Pyloric Stenosis
Gastritis
 Mucosal atrophy
 Mucosal hypertrophy-hypersecretion
“ three level density”
Peptic ulcer
Mostly seen in pyloric antrum and duodenal bulbus

Primary Signs :
- En face (frontal view)—barium spot with halo
(active ulcer) and star sign ( inactive)
- En profile (lateral view)—additional shadow , globular
shape (active ulcer), conus (inactive)
Secondary signs
 Contralateral/opposite spastic
insicura
 Hypersecretion
 Bulb deformity
DUODENUM
 Congenital :
Stenosis post bulbar 
duodenal atresia
“Two bubbles app”.
Malignant
Types :
1. Early gastric cancer
Limited in mucosa/submucosa mimicking
ulcer

2. Advance gastric cancer

Filling defect – irregular border
- Annular ( infiltrating type )
- Exophytic ( fungating type )
- Linitis plastica ( schirrus type)
- Ulcer type, filling defect + ulcer
SMALL INTESTINE (JEJENUM & ILEUM)
 Normal size: - ± 20 feets (length)
- 2,5 cm (jejenum); 1,75 cm (ileum)
in diameter
 Indications:
Anemia (unclear origin)
Persistent diarrhoe
Abdominal pain
Palpable mass
Excessive protein loss
Malabsorbtion
 Contraindication:
Obstruction signs
Perforation
Paralytic ileus
Peritonitis

 Technique of Examination
1. Plain abdominal radiography
2. Follow Through
Patient is asked to swallow 200-300 cc Barium
sulfat (1:2-3 water),followed by taking pictures
30-60 minutes interval until contrast seen in
caecum
 Abnormalities
Crohn’s Disease = Regional
ileitis
Adhesion
Fistula
COLON
Indication :
• Haematochesia
• Persistent diarrhea
• Abdominal mass
• Obstructive symptoms
• Congenital abnormalities

Contraindication :
• Ileus (Paralytic)
• Suspect Bowel Perforation
• Peritonitis
Technique of Examination : •
Barium enema
(colon inloop)
Preparation is the most important to remove
faecal material from the colon
Colon inloop : - Using a thin Barium sulfat
(1:3-6) aprox. 2 L
- Contrast should fill colon entirely
(rectum-caecum)
- Picture taken in many positions/
views.
COLON
A.Kongenital
1. Atresia Ani (Imperforate anus) , Foto polos
abdomen terbalik (Invertogram)

2. Hirschsprung’s disease ( megacolon

congenitum )
 Atresi ani
Radiographically :
Technique of examination for atresia ani:
• Inverted or Wangesteen position
• Knee-chest position
Aim : to identify the lowest end of air in colorectal
Lower level

High level
Hirschsprung’s disease (megacolon
congenital)
 Disease of childhood, mostly males
 Abscent of ganglion cells in the mesenteric
plexus in the narrowing segment (mostly
sigmoid colon, ± 40%)
 Marked dilatation above the area of aganglionosis.
Barium Enema :
• Narrowing along the site of aganglionosis
• Dilatation above the narrowing, might be associated
with irregularity/sawtoothing/ulcerative Colitis
Intussusception = Invagination
A proximal segment of bowel (intussusceptum)
into lumen of a distal segment (intussuscepiens)
Location : Ileoileal > ileocolic > colocolic
Radiographic sign :
- “Coiled spring “ or “cupping sign”
-proximal bowel dilatation
-absence of gas in distal segment
Cupping sign

Coiled spring
US findings :
-Target sign, doughnut sign or bull’s eye
sign (transverse scan )
- pseudokidney sign ( longitudinal scan)
Necrotizing enterocolitis ( NEC)
 Pneumatosis intestinalis
( Gas within bowel wall )
Inflammation :
- Ulcerative colitis
- Crohn’s Disease
• Ulcerative Colitis
- Loss of haustra
- Contracted,shortened & small calibre
- Saw-toothing/ulceration
- “Stringiness/String sign”
Tumor

Carcinoma of Colon
3 types : • Fungating type
• Polypoid type
• Annular type
 Acute appendicitis
 Acute appendicitis – acute appendiceal inflammation due
to luminal obstruction and superimposed infection
 Most common abdominal surgical emergency.
 Diagnosis – clinical history, physical examination &
laboratory studies.
 Imaging is useful and advisable in patients with atypical
symptoms.
 Mortality rate in developing countries : ± 1%.
 (↑) to 5% in small children & elderly.
 Surgical aim – to operate early before complications such as
appendiceal rupture & peritonitis developed.
 Helical CT scan & graded compression US – powerful
imaging methods in appendicitis
IMAGING IN APPENDICITIS
 ABDOMINAL PLAIN FILMS

 APPENDICOGRAPHY

 ULTRASOUND

 CT SCAN

 MRI (MAGNETIC RESONANCE IMAGING)

HEPATOBILIER & PANCREAS
 Imaging modalities :
- USG : Ultrasonografi / Ultrasound
- CT scan : Computerized Tomography
- MRI : Magnetic Resonance Imaging
- MRCP : MRI for Cholangiopancreatography.
- PTC(D) : Percutaneus Transhepatic
Cholangiography ( Drainage )
- T-Tube Cholangiography, Durante operatif ,
Post operatif
- Nuclear Medicine
Gallstones/cholelithiasis
- Soliter / multiple
- Echogenic/hyperechoic structure dengan
acoustic shadowing
Acute Cholecystitis

* Gallbladder wall thickening > 3 mm

* Sludge
CIRRHOSIS HEPATIS
- Liver atrophy
- Increasing echogenecity,
fibrotic.
- Irregular of the surface
- Portal hypertention
- Splenomegaly
- Ascites.
HEPATOCELLULAR CARCINOMA/HCC HEPATOMA
USG : Iso  hipo or hiperechoic mass
Ill-defined

TUMOR METASTASIS
 Noduler” bull-eye”, usually multiple,
 Well defined
Liver abscess
• Hypoechoic mass
• Irregular and thicken wall

Liver cyst
• Free-echoic mass, well defined,
• Solitary or multiple
Biliary obstruction
Causes :
- Stone
- Tumor intra/extraluminer.
such as Panreatic cancer,
cholangiocarcinoma
- Strictur cholangitis, etc
Biliary obstruction due to cancer of caput pancreas
Acute pancreatitis