os214 gastrointestinal tract imaging final

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Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)

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Gastrointestinal Tract Imaging

Tel, Ther, Joram, Roland of 13Thurs, Feb. 24, 2011

OUTLINE

I. PharynxII. Esophagus III. AbdomenIV. Stomach & DuodenumV. Small IntestinesVI. Large Intestines, including Rectum and Anus VII. Liver, Hepatobiliary Tree & Gall BladderVIII. Pancreas

A mass posterior to the pharynx; streaks of lucency

Disclaimer: Don’t hate us for this trans. This is our first trans on Imaging Modalities and we tried our best to make this at par with our usual transes. If you find any difficulty appreciating the figures, please see Dr. Hizon;s slides. The file’s uploaded in our Scribd account.

PHARYNX

Radiographic Evaluation

1. Plain Radiograph or X-ray most common imaging modality Soft tissues of the neck viewed laterally Neck is positioned in hyperextension Usually x-ray comes from the patient’s right side, film is

at the left Done to evaluate the thickness and osseous structures

of the pharyngeal area; normal pharyngeal airspace: 1-2 cm in thickness

||> This is a lateral view of the neck to image the normal pharynx. The neck should be hyperextended and it is important to instruct the patient not to move. Note the thickness of the soft tissues and check for abnormal indentations

Normal: Homogenous image; air column seen anterior vertebra

2. Fluoroscopy next most common Evaluation of structures in real life time – flexion,

extension and in swallowing In swallowing – soft tissue density of prevertebral

structures can be seen If there’s a foreign body, this can be used have

patient swallow barium so that the defect can be seen. Divided into the nasopharnyx, oropharynx and

hypopharnyx Fluoroscope- consists of an X-ray source and

fluorescent screen Modified barium swallow study - Barium-impregnated

liquids and solids are ingested by the patient. A radiologist records and, with a speech pathologist (a.k.a speech therapist), interprets the resulting images to diagnose oral and pharyngeal swallowing dysfunction. This is also used in studying normal swallow function.

3. Double Contrast Pharyngography Makes use of contrast agent

like Barium, in addition to X-ray.

Allows detection of tumors that are difficult to visualize endoscopically.

Radiographic signs :(1) intraluminal mass- seen as a filling defect (pointed by arrows in the pharyngogram shown on the left), abnormal luminal contour, or focal increased density;(2) mucosal irregularity owing to ulceration or mucosal elevation

(3) asymmetric distensibility caused by infiltrating tumor or extrinsic nodal mass.

4. Computed Tomography Scan (CT-Scan) For a more detailed evaluation For less radiation exposure: request for with multi-

slice ||> May allow better

visualization and evaluation of osseous structures, soft tissues and vascular networks;

Uses contrast agents administered intravenously, takes a longer scanning time, and is more expensive.

5. Magnetic Resonance Imaging (MRI) even better than CT-scan uses a magnetic beam to

visualize tissue Soft tissue appearance is

much better than CT-Scan Metallic implants/objects-

contraindicated titanium, porcelain – MRI

friendly This modality is best for soft

tissues and is only reserved for difficult cases.

MRI provides much greater contrast between the different soft tissues of the body

Pharyngeal Disorders that need imaging:

1. Diverticula Can be anterior, lateral or posterior; congenital or

acquired “Zenker’s Diverticulum”

o Also known Pharyngo-esophageal Diverticulum, o Originates in Laimer’s triangle or Kilian’s dehiscenceo It is a diverticulum of the mucosa of the pharynx, just

above the cricopharyngeal muscle (i.e. above the upper sphincter of the oesophagus)

o Take a look at thickness of prevertebral face

2. Retropharyngeal Abscess

Note the marked swelling of the prevertebral space, which indicates mass infection.

Lucencies: indicate tissue breakdown compatible with tubular abscesses

If with calcifications may be indicative of chronic tuberculosis.

Take note of the thickness w/c is > 2 cm

3. Functional Disorders to detect

impairment of function.

May be caused by spasm due to: A. Neuromuscular Dysfunction

Reproduction and Hormonal Regulation

Augustina D. Abelardo, MD, FPSP, MIAC

Patho 1

Digestion and Excretion

Vicente Francisco R. Hizon, M.D. FPCR, FPROS, FUSP, FESTRO, FPSO 2

http://en.wikipedia.org/wiki/Diverticulum

http://en.wikipedia.org/wiki/Oesophagus

http://en.wikipedia.org/wiki/Sphincter

http://en.wikipedia.org/wiki/Cricopharyngeal_muscle

http://en.wikipedia.org/wiki/Pharynx

http://en.wikipedia.org/wiki/Mucosa

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CNS Disease Muscle Disease Myasthenia Gravis Peripheral Nerve Disease

B. Abnormalities in the crico-pharnygeal sphincter Achalasia, Myotonic Dystrophy, Familial

Dysautonomia (Riley-Day Syndrome)

C. Malignant Epithelial Neoplasms (Tumors) Nasopharynx – more common for Filipinos

better diagnosed with CT-Scan or MRI Oropharynx Hypopharynx

ESOPHAGUS

A. Radiographic EvaluationB. CT-Scan – can be used for a dynamic study C. MRI


1. Contrast Esophagography Usually done because the esophagus collapses Ask patient to hold the contrast medium in his/her mouth

and swallow it slowly Single Contrast

- Employs the most usual contrasts- Use of Barium (non water-soluble) or other

Water-soluble contrasts

Double Contrast- Other liquid media such as Sprite® or 7-Up®

can be added to the contrast medium normally a part of upper GI series look for mucosal irregularities look for abnormal filling defects, areas of narrowing or

dilatation seen in segments due to normal persistalsis of the

esophagus 1st step: Drink contrast then hold in mouth

2nd step: Swallow then contrast is traced

A. AP view. B. Lateral view. Look at where the esophagus is resting. The esophagus is not usually seen since it usually collapsed when empty. C. Done under fluoroscopic guidance. Check for filling defects and mucosal irregularities. D. Esophagogram of a normal esophagus as it enters the esophageal hiatus. Observe the smoothness of the mucosal surface.

B. Esophageal Disorders that warrant imaging studies

Only a small amount of contrast or light barium is used because there is always the danger of aspiration and obstruction of the respiratory tree.

In cases of aspiration (which can cause pneumonitis), the patient should be immediately hydrated by nebulization and administered with expectorants. This won’t work if thick contrast media is used. Water-soluble media are also not used in this procedure because it may lead to pulmonary edema.

1. Chemical Esophagitis

Ingestion of corrosive material Perforations indicate spillage

2. Motility Disorders

PRIMARY Achalasia: most common indication for

esophagogram Cardiospasm Deficiency of the ganglion cells of

Auerbach’s plexus Failure of relaxation of the Lower

Esophageal Sphincter (LES) Mecholyl Test Usually 30-50 yrs.

A. Take note of the nasograstic tube and the lucent area compatible with achalasia. B. Dilated terminal part of the esophagus. Balloon-like dilatation is always ABNORMAL.

Diffuse Esophageal Spasm Presbyoesophagus Chalasia Idiopathic Pseudo-obstruction –constriction of

esophagus

SECONDARY

Connective Tissue Disorders (i.e. Scleroderma, SLE, etc.)

Reflux Esophagitis Metabolic & Endocrine Disorders (i.e. DM, Alcoholism,

etc.) Neuromuscular Disease Can be secondary to radiographic treatment

3. Congenital Anomalies esophageal contrast study is usually indicated *Note: If there’s suspicion of tracheoesophageal

reflux -> ALERT RADIOLOGIST due to possibility of aspiration

Atresia and TracheoEsophageal Fistula (TEF): most common cause: Iatrogenic due to chemicals

Types: A: Atresia with Distal TEF B: Atresia without TEF

There is a filling defect in the image (blind pouch) compatible with complete obstruction. In this case, no TEF is observed.

C: TEF without Atresia(H-type)

D: Atresia with Proximal TEF E: Atresia with Double TEF

Duplication

BronchoEsophageal Fistulas



Patho 1



A B C D

AB

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4. Esophageal Tumors Squamous: most common in the upper 2/3 Gastric: distal 3rd Esophagogram can reveal tumors well, provided that it

is not yet fully obstructed If with complete obstruction: length cannot be

determined so need to request CT-scan Diagnosed nowadays by Esophagoscopy and

Endoscopy

Malignant Neoplasms Carcinomas (Squamous, Adenocarcinoma, Carcinoid)

A. The image shows complete obstruction. B. Partial obstruction secondary to tumor mass. Take note of the irregularities in the esophageal mucosa suggesting multi-focus type of esophageal cancer. C. This is a classical picture of “shouldering defect” in esophageal carcinoma (Concentric carcinoma): irregular outline of esophagus.

Sarcomas (Leiomyosarcoma, Fibrosarcoma, etc.) Metastasis

Benign Neoplasms

Mucosal (Papilloma or Adenoma) Submucosal (Neurofibroma, Leiomyoma,

Hemangioma, Lipoma, Fibroma, Myeloblastoma, etc.)

Non-neoplastic

Polyps Hematoma Varices Hamartoma Cysts Chemical Esophagitis Focal Infection Foreign Body

5. Foreign body - Ingested coin

ABDOMEN

A. Radiographic EvaluationB. Contrast Study (barium enema, upper GI seriesC. CT-ScanD. MRIE. UltrasoundF. Nuclear (Radioisotope) Scanning


1. Plain Abdomen X-ray Patient in supine position. (X-ray beam above, X-ray

plate below) Plain abdominal X-ray: upper limit should include the

diaphragm; primarily for visualization of Upper GI Tract KUB studies: film should extend down the pubis and

cover the whole pelvis

What to Examine: o Gas Pattern – look at distribution of bowel gaso Extraluminal Airo Soft Tissue Masses

o Calcifications – especially in the area of the gallbladder and the kidneys and urinary tract

o Psoas Muscles & Flank stripeso Liver, Spleen & Bladder (esp. visible when

distended)o Osseous structures

Normal Gas Pattern :o Stomach: Always present (gastric bubble)o Small Bowel: 2 or 3 loops of non-distended

bowel; finer lucencieso Rectum or Sigmoid: Almost always present

Normal Fluid Levels: Stomach: Always present (except in supine film) Small Bowel: Possibly present in 2 or 3 levels (few) Large Bowel: None normally because water is

absorbed

Small vs. Large Bowel

Small Bowelo Centralo Valvulae conniventes (mucosal foldings of the small

intestines) extend across lumeno Has a maximum diameter of 2 in. (dilated if > 2)

Large Bowel

o Peripheralo Haustral markings

(sacculations in the wall of the large intestines) don’t extend from wall-to-wall

Complete Abdomen: Obstruction Series(Abdominal X-ray positions)

Supine – this is done first for economic reasons: radiologist recommends whether to proceed with the obstruction series or not

Prone □ Look for:

Gas in Rectum/Sigmoid



Patho 1



A B C

Roland Angeles, 02/24/11,

Circumferential obstruction Irregular outline ( MUCOSAL IRREGULARITIES


Usually dapat non-differential If there’s a differential fluid segment ( obstruction


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Gas in Ascending and Descending Colon□ Alternative: Lateral Rectum if patient cannot lie

prone Erect

□ Look for: Free Air/bowel gas Air under the diaphragm

(pneumoperitoneum) Air-fluid leveling

□ Alternative: Left Lateral Decubitus – if unable to sit up or stand up

Chest-Erect □ Look for:

Changes in the pleural cavity

Blunting of the costophrenic sulci

Free Air Pneumonia at bases Pleural effusions

□ Alternative: Chest-Supine if unable to sit/stand

*Collateral Findings: basal pneumonitis, blunting of the costophrenic sulci etc.

Causes of Abnormal Gas Patterns Functional Ileus (medical)

□ Localized (Sentinel Loops) One or two persistently dilated loops of large or

small bowels There should always be gas in rectum or

sigmoid no gas = obstruction Seen in Gastroenteritis Pitfall: may resemble early mechanical SBO

□ Generalized Adynamic Ileus

Gas in dilated small bowel and large bowel to rectum

Long air-fluid levels Only post-op patients have Generalized Ileus Can be caused by surgery or medications that

affect GI motility

Mechanical Obstruction

□ Small Bowel Obstruction (SBO)

Dilated small bowel Fighting loops: dilating loops are very

prominent; walls are thickened Little gas in colon, esp. rectum

Differential air-fluid levels: may indicate obstruction

Key: Disproportionate dilatation of the small bowel

Causes: Adhesions Hernia* Volvulus** Gallstone Ileus* -

obstruction of the ileus by a gallstone from the biliary tree

Intussusception****may be visible on plain film**Medical emergencies;

Most common emergency procedures

Pitfall: Early SBO may resemble localized Ileus (get follow up abdominal x-ray after 24 hours to see if it progresses)

□ Large Bowel Obstruction (LBO)

Dilated colon proximal to point of obstruction Little or no air in rectum/sigmoid Little or no gas in small bowel, if…

Ileocecal valve remains competent

If incompetent, then small bowel air is seen

Causes: Tumor Volvulus Hernia Diverticulitis Intussusception

Pitfalls: Incompetent Ileocecal Valve Large bowel decompresses into small

bowel May look like SBO Get Barium Enema or F/O



Patho 1



Supine Prone

Supine Erect

No gas in the rectumThickening of bowel wallsIn upright –there is air fluid levelling in areas proximal

No air-fluid levelling; Presence of gas in the rectum; Diameter is about 2 inches

No presence of differential air-fluid level (2 air-fluid interfaces in 1 bowel);

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Table 1.

Air in Rectum or Sigmoid

Air in Small Bowel

Air in Large Bowel

Localized ileus

Yes2-3 distended

loopsAir in rectum or sigmoid

Generalized ileus

YesMultiple

Distended loopsYes

(Distended)

SBO NoMultiple Dilated

loopsNo

LBO NoNone (unless

ileocecal valve is incompetent)

Yes(Dilated)

||> Gallstone Ileus

Occurs when the gallstone obstructs the lumen between the Ileum and the Cecum

May cause transient obstruction

||> Volvulus

Bean-shaped structure/Inverted U-loop structure in a radiograph is indicative of volvulus

A radiologic emergency Golden period for correcting volvulus: 72 hours to 1

week (if 1 week: proceed with caution!) Be careful during palpation because volvulus may rupture In this case, a Barium enema would both be

diagnostic and therapeutic. In the figures below, take note of the different air-fluid

levels

||> I ntraperitoneal Calcification

For Higher Learning: The radiological detection of peritoneal calcification is rare but potentially of major clinical importance because such findings have been associated with

□ primary and secondary peritoneal malignancies;□ benign causes:

Sclerosing peritonitis due to peritoneal dialysis

Peritoneal tuberculosis Prior meconium peritonitis Hyperparathyroidism Pneumocystis carinii infection Postsurgical heterotopic ossification.

||> Intussusception

An emergency situation a part of the intestine has invaginated into another

section of intestine Intussuscepiens (R)

□ The “receiver”□ The part of the bowel into which another part is

invaginated in; □ The portion of the bowel containing the

intussusceptum Intussusceptum (I)

□ The “invaginator”□ The portion of the bowel that has been

invaginated within another part

||> Extraluminal Air: Free Intraperitoneal Air

Signs of Free Air (Pneumoperitoneum):□ Air beneath diaphragm□ Falciform Ligament Sign□ Air on both sides of bowel wall – Rigler’s Sign

Rigler's sign (also, double wall sign), is seen on an X-ray of the abdomen when air is present on both sides of the intestine; a Rigler's sign is present when air is present on the inside (lumenal side) and the outside (peritoneal side).

□ Air in Lesser Sac (the most anterior part of the peritoneum) – since mataas

□ Football Sign and the Falciform ligament sign – seen bulging to the right The Football Sign appears as a large oval

radiolucency reminiscent of an American football seen on supine radiographs of the abdomen. The football sign is most frequently seen in infants with spontaneous or iatrogenic or iatrogenic gastric perforation causing pneumoperitoneum.



Patho 1



R

I

R

I

Supine Prone

1st: dilated bowel loop2nd: differential levelling limited to large gut

‘Barium enema: incomplete filling of cecum


http://en.wikipedia.org/wiki/Pneumoperitoneum

http://en.wikipedia.org/wiki/Gastric_perforation

http://en.wikipedia.org/wiki/Gastric_perforation

http://en.wikipedia.org/wiki/Iatrogenic

http://en.wikipedia.org/wiki/Infant

http://en.wikipedia.org/wiki/Radiograph

http://en.wikipedia.org/wiki/Football_(ball)#American_and_Canadian_football

http://en.wikipedia.org/wiki/Intestine

http://en.wikipedia.org/wiki/X-ray


http://en.wikipedia.org/wiki/Invaginated

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Falciform ligament sign: seen bulging to the right; linked to the football sign seen as the football’s seam

Causes of Free Air:

□ Rupture of a hollow viscus (an internal organ; singular form of viscera) Perforated Ulcer Perforated Diverticulitis Perforated Carcinoma Trauma or Instrumentation

□ 5-7 days Post-op□ NOT caused by a perforated Appendix

Because the Appendix is retroperitoneum; and therefore, outside the peritoneum

||> Chilaiditi Syndrome

Normal findings Loop of large colon insinuates between diaphragm

and liver (hepatic flexure) asymptomatic Transposition of a loop of large intestine (usu. the

Transverse colon) in between the Liver and the Right Diaphragm, causing extreme abdominal pain, volvulus and shortness of breath

Manifests in the abdominal X-ray as Chilaiditi’s Sign – presence of gas in the right Colic angle between the Liver and Right Diaphragm

||> Bochdaleck’s Hernia One of two forms of a Congenital Diaphragmatic

Hernia Posterior and lateral in location Heart is displace dot the rught

Bochdalek Foramen is found on the left posterolateral portion of the diaphragm.

Congenital abnormality wherein an opening that exists in the infant’s diaphragm allows intra-abdominally located organs (i.e. stomach and intestines) to protrude into the thoracic cavity

Has the potential to be life-threatening – can cause deformities in the lungs that can lead to its compression

Differential: Morgagni’s Hernia: medial in position

STOMACH & DUODENUM

RADIOLOGIC STUDIES

1. Plain Abdomen X-Ray

Look for abnormal gas pattern, calcification, outline of liver, psoas shadow

2. Upper GastroIntestinal Series

||> Components: Esophagogram (refer to previous figures) Gastric Series

Gastric series: Check for the rugal patterns as well as the patency of the Gastro-Duodenal junction. Normal gastric folds: Parallel to each other; Usually smooth



Patho 1



Free Air

Falciform Ligament Sign


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Duodenal Series

Duodenal series: Loperamide or Buscopan are administered for the relaxation of the Duodenum- look for mucosal irregularities- reading: spastic duodenum – refuses to relaxBuscopan – will dilate duodenum

Small Intestinal Series (will be tackled later)

3. CT-Scan – will not be able to see the small intestine well – due to collapse; useful for locating nodes in malignancies

4. MRI

ACID-RELATED DISORDERS

1. Gastritis

||> Radiologic Findings Acute

□ Mucosal erosions and shallow ulcers that do not penetrate the gastric mucosa

Chronic□ Mucosal thinning and atrophy which is why in

image below almost everything is contrast markings

Gastric irregularities’ mucosal changes

2. Benign Ulcer Disease

||> Radiologic Findings

Hampton’s Line – represents the edge of the over-hanging gastric mucosa

Ulcer Collar (pointed by arrow in the figure below) Ulcer Niche (adjacent ) Edematous gastric folds radiating towards the ulcer

Mucosal bump at the periphery/ ulcer collar; Turn it en passé --<> Hampton’s line

3. Gastric Ulcer

4. Gastric Diverticulum (may develop from gastric ulcer due to weakening of the walls; not much mucosal changes seen)

GASTRIC CANCER

||> Radiologic Procedures Contrast studies (UGIS): not used so much nowadays Endoscopic Ultrasound CT-Scan (Staging)

||> Radiologic Classification Type I : Polypoid (> 0.5 cm.) Type II : Superficial

□ IIA : elevated (>0.5 cm)□ IIB : flat□ IIC : depressed (erosions not extending beyond

Muscularis Mucosa) Type III: Excavated (Ulceration)

Stomach (Gastric) Cancer: A. Antral Cancer compressing the pylorus; filling defect B. intraluminal mass; C. Note the irregular borders.

||> Examples

Linitis Plastica (Diffuse Infiltrative Carcinoma)



Patho 1



Hamptom’s Sign

Ulcer Collar

Edematous Gastric Folds

Ulcer Niche

A B C




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□ A Diffuse infiltrative Carcinoma of the Stomach□ Also known as Brinton’s Disease or Leather

Bottle Stomach

Irregular mucosa; Cecal shape; Does not expand irregardless of contrast

Gastric Lymphoma

□ The stomach is a very common extranodal site for lymphomas

□ Characterized by mucosal elevations and multiple erosions

□ Extraluminal: gentler curves as compared to an intraluminal mass: distinct border from mass to mucosa

OTHER DISEASES

1. Diaphragmatic Hernia

||> A defect or hole in the diaphragm that allows the abdominal contents to move into the chest cavity

||> Treatment is usually surgical (make sure no part of the hernia is strangulated, it might cause Peritonitis)

Diaphragmatic Hernia: Look for the portion of the stomach outside the hiatus

2. Duodenal Ulcer

||> Also known as Peptic Ulcer Disease (PUD)||> Majority are associated with Helicobacter pylori infections||> Most Peptic Ulcers arise from the Duodenum (rather than

the Stomach)||> Are generally benign

Antrum: ulcer NICHE at the proximal part of the duodenum

Duodenal Ulcer: Note the folds toward the ulcer niche. The walls are edematous.

SMALL INTESTINES

RADIOLOGIC STUDIES

1. Plain X-ray

2. Small Intestinal Series

||> The Ileum has a feathery appearance as compared to the Jejunum

SMALL INTESTINAL DISEASES

1. Crohn’s Disease

Most common non-specific inflammatory disease of the Small Intestines

See thickened folds and mucosal irregularities If chronic – narrowing- string or rat-tail Findings of small fistula Also known as Inflammatory Bowel Disease (IBD)

Radiologic Findings: Thickened intestinal folds Fistulas, Sinuses, and thickening/retraction of the

Mesentery String Sign – tubular narrowing of the lumen of the

small intestines Transmural type of Inflammation (Inflammation may

span the entire thickness of the Intestinal wall): Fine Granular Pattern Nodular Mucosa (Submucosal Edema) Ulceronodular Mucosa Ulcerations



Patho 1



Leather Bottle Sign



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Crohn’s Disease: Note the thickened mucosal folds

2. Ileocecal Koch’s

Also known as Ileocecal Tuberculosis

Difficult to differentiate from Crohn’s Disease

Can be seen as irregularities in the Terminal Ileum

3. Ileocecal TB with Abscess

4. Periappendiceal Abscess

||> Usually results from the perforation of an acutely inflamed appendix

A periappendiceal abscess in a localized area of displacement of the small intestine

5. Small Intestinal Parasite

Adult ascaris in the small intestine: Barium-based contrast agents can irritate the worm and promote its migration in other organs like

the liver. Sometimes, the patient may even expel vomitus with the worm.

LARGE INTESTINES & RECTUM

RADIOGRAPHIC EVALUATION

1. Plain Abdominal X-Ray

2. Barium Enema (Single or Double Contrast)

Also known as Lower Gastrointestinal Series. X-ray pictures are taken while barium sulfate fills the colon via the rectum.

Air may be puffed to provide air contrast into the colon to distend it and provide better images (often called a "double-contrast" exam). There is a risk for hypotension associated with valsalva in the elderly undergoing this procedure.

Double contrast improves visualization of the mucosa||> If there is a suspected bowel perforation, a water-soluble

contrast is used instead of barium.

A and B. Supine image, Arrow points to the insertion of the foley catheter that introduces the contrast until the level of the splenic flexure; C. Lateral Decubitus image. Note the smooth mucosal surface of the colon visualized by Barium Enema.

Post evacuation radiography



Patho 1



A B


If ascaris is not alive – not puti Parasites ( give contrast then after, worms come out Most common cause of

http://en.wikipedia.org/wiki/Radiocontrast

http://en.wikipedia.org/wiki/Bowel_perforation

http://en.wikipedia.org/wiki/Barium_sulfate



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Redundant rectosigmoid colon condition where extra loops form, resulting in a longer

than normal colon; a mass is felt and then disappears/changes place; presents with constipation

3. Defecography Also known as Defecating Proctogram An imaging study in which the mechanics of a patient’s

defecation are visualized real-time, with the use of a fluoroscope

Not done anymore

4. Ultrasound

5. Abdominal CT-Scan

6. Rice-Wangensteen Radiograph||> The Rice-Wangensteen radiographic technique is an

inverted lateral radiograph of an infant||> It is performed when the baby is at least 6 hours old||> The baby is turned upside down in a lateral position with

the hips flexed||> Mainly used for the assessment of an Imperforate Anus

Wangensteen-Rice radiograph: The infant is held in invert position. Triangular metallic marker identifies the anal dimple. The arrow points to the occlusion on the lateral view. Additional UTZ examination helps to decide the real extent of the rectal atresia. The distal blind pouch plugged with meconium (outlined) disturbs the judgment of the exact level of atresia.

DISEASES OF THE COLON AND RECTUM

1. Congenital Disorders

||> Hirschsprung’s Disease Also known as Aganglionic Megacolon Enlargement of the colon secondary to bowel

obstruction caused by the persistent contraction of a part of the colon with absent enteric nerves (hence the term ‘aganglionic’) for relaxation

||> Congenital Rectal Atresia||> Imperforate Anus

2. Diverticula

Dangerous if spiculed: May rupture

3. Inflammatory Diseases

||>Ulcerative Colitis

Radiologic Findings: □ Acute

Fine granulations Stippled appearance

of the mucosa Failure of the colonic

walls to collapse on post-evacuation study

□ Chronic Loss of haustral markings Coarse granulations (due to multiple

ulcerations which increase in size and number) affecting the entire length of the colon

Accompanied by polypoid changes

Secondary Changes: □ Foreshortening of the

Colon□ Lack of haustrations

markings and tubular narrowing (Stove-pipe or Garden-hose sign)

□ Increase in Presacral space (> 1 cm)

□ Fibrosis or strictures may develop

□ Increase in presacral space

CECAL ABSCESS:

||> Granulomatous Colitis

i.e. Crohn’s Disease



Patho 1



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||> Infectious Colitis Examples:

□ Cecal Abscess:appears almost the same as a malignant mass

□ Ileocecal Tuberculosis with Abscess: mucosal irregularities indicate inflammation

4. Polyps - there’s a filling defect

||> Morphologic Types Sessile

□ Broad base□ With mound-like protuberances or flattened

plaques Pedunculated

□ With stalks

5. Malignancies

||> Radiographic Patterns

Annular Constricting□ Apple-core appearance (mass is black part beside the core)

Polypoid

Infiltrating or Stenosing

Ulcerative

6. Others

||> Redundant RectoSigmoid Colon

||> Rectal Foreign Body



Patho 1



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You don’t call this the bottle sign. This film shows an actual bottle claimed to be seated upon “accidentally”

||> Large and Small Intestine Fistula

- usually iatrogenic

||> Cecal Cancer

Manifests with the String Sign

Filling defect in the cecum.

LIVER, HEPATOBILIARY TREE & GALLBLADDER

RADIOGRAPHIC TECHNIQUES

1. Ultrasonography procedure of choice2. ERCP (Endoscopic Retrograde Cholangiopancreatography)3. CT-Scan4. MRI5. MRS (Magnetic Resonance Spectroscopy)6. Nuclear Medicine (Radionuclide Scanning)

LIVER

||> Radiologic Evaluation:

1. CT-Scan – more expensive&detailed; not used for

screening, just for diagnostic purposes

2. MRI

3. Ultrasound

Ultrasound with Doppler – flow can be visualized

4. Angiography

Done in the Operating Room usually for checking/screening for Hemangiomas and other tumors

Transfemoral catheter through femoral artery then abdominal aorta then organ of choice

5. Nuclear (Radioisotope) Scanning For ‘hotspots’i.e. Ultrasound with Doppler

Radiologic Evaluation of the Liver. A. CT-Scan; B. MRI; C. Ultrasound, Normal liver is clear; D. Angiography; and E. Nuclear (Radioisotope) Scanning (Blue Areas = arterial system and red areas = venous system)

||> Diseases of the Liver:

1. Tuberculosis of the Liver

The Liver is large with calcifications

2. Subcapsular Hematoma

If dark mostly fluid; If something becomes bight malignancy; if a lot of vessels hemangioma

3. Fatty Liver- liver brighter than kidneys cholesterol deposits

A sonogram of a fatty liver showing increased echotexture compared with the adjacent kidney (bright liver). The white round structures on the right sonogram correspond to fats.



Patho 1



C D

C

E

D

BA

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GALLBLADDER

||> Unseen in normal radiographs; unless it is distended or stone-containing


1. Plain Abdomen X-ray

2. Ultrasound

The normal gallbladder (gb) is seen as a cystic structure with echo-free contents. The walls of the gallbladder are smooth. Normal liver parenchyma (L) is seen to the left of the gallbladder.

3. Oral Cholecystography

A normal cholecystogram. (left) In the initial phase the contrast medium is seen evenly filling the gal/bladder, the walls of which are smooth. (right) After a fatty meal, the gallbladder has contracted. Now both the fundus and the neck of the gallbladder, as well as the cystic duct is filled with contrast medium and the common bile duct is demonstrated (arrows).

Gallstones

Gallstones are usually moving in contrast to malignant growths.

HEPATOBILIARY TREE


1. T-Tube Cholangiography

If it is done poorly air bubbles will be misinterpreted as gall stones

A fluoroscopic procedure in which contrast medium is injected through a T-tube into the patient’s Biliary tree

The T-tube (a tubular device in the shape of the letter T) is most commonly inserted during a cholecystectomy operation when there is a possibility of having residual gallstones within the Biliary tree

2. ERCP (Endoscopic Retrograde Cholangiopancreatography)- to view pancreatic and biliary tree

||> Diseases of the Biliary Tree:

1. Biliary Ascariasis

If still alive, a white line is seen inside since the parasite is still swallowing.

2. Retained Biliary Stone/Sludge

PANCREAS

RADIOGRAPHIC TECHNIQUES

1. Ultrasonography

2. CT-Scan



Patho 1



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DISEASES OF THE PANCREAS

1. Pancreatitis

||> Irregularities and swelling in the Pancreas are observed here

2. Pancreatic Mass



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