Imaging of Gastrointestinal

System
Dewi Asih
Dept. of Radiology
Cipto Mangunkusumo Hospital
University of Indonesia

tanggal upload : 20 April 2009

Plain Photo

EUS

Fluoros copy

Nuclear Medicine

US G

MR I
C T S can

Digestive system:
Digestive tracts:
- Oral cavity

- Pharyng.
- Oesophagus.
- Stomach.
- Small bowel.
- Large bowel (Colon).
- Rectum.

Accessories organs:
- Parotis.
- Liver.
- Billiary.
- Pancreas.

1. Oral cavity : Salivary glands

Parotid gland:
behind the angle of mandible, single duct (Stensons) opening on
the papila on the buccal mucosa opposite the 2nd upper molar
tooth.

Submandibular gland
the mandible with a single submandibular duct (Whartons)
opening on a papilla at the side of the frenulum beneath the
tongue.

Radiology examination: sialography

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Technique of sialography
The duct is intubated by a blunt
metal cannula or a fine thin
walled polythene catheter with
a tapered and connected to a 2ml glass syringe.
Approximately 0.5-1.5 ml of
contrast medium is slowly
injected until the duct system is
filled.
A few drops of lemon juice
stimulate salivation

Submandibular gland

Stensons

DSA

Normal overfilling

Sialalitiasis

Filling defect: stone

Sialadenitis
Inflammation salivary gland:
-akut (viral, bacterial)
-chronic (stricture,stone,tumor)

stone
5 minutes
Intermittent parotid swelling
distended duct with stricture

sialodochitis
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Sialadenitis and sialodochitis

MRI:T2 sagital

MRI:T2W

Sjogren syndrom: dilated duct, multiple stenosis, poor parenchymal filling

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CT of parotid glands
Low attenuation
structure, pre auricular
region

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Parotitis

Chronic change of Stensons duct improve with balloon

dilatation

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2. Oesophagus, Stomach, Duodenum

Radiology modality :

Plain photo
Contrast study
CT scan
MRI
Nuclear medicine
Esophagus atresia

Duodenal atresia

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OMD :
Patient preparation :
Fasting at least 8 hours except
oesophagography doesnt need preparation
Abstain from smoking
Laxative for 2 night before examination
Women : pregnant ?
Radiographic equipment :
Conventional fluoroscopy
Remote-control fluoroscopy
Cine-radiography and video-fluorography
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Radiographic technique :
Single contrast barium meal
Barium suspension only
Observation of peristaltic and well demonstrated of
fistulae and obstruction

Double contrast barium meal

Barium suspension and distention by gas
producing agent
Demonstrate : fine mucosal detail
Operator skill and experienced is important
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Diffuse esophageal spasm:

corkscrew oesophagus
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Foreign body
Mimicking tumor

Intralumen filling defect

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Gastric wall filling defect

Gastric carcinoma

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Linitis plastica

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Additional shadow

Duodenum diverticulosis

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3. Small Intestines
Barium follow through (SC)
Enteroclysis (DC)

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Barium Follow Through

Patient fasting
Single contrast : 200 500 cc of barium
suspension is given to drink
Followed by fluoroscopic or conventional xray.
Taken serial photo : 5 , 10, 20 etc.
Examination must be stop when barium filling
the caecum.
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Enteroclysis = small bowel enema

Inserted the NGT (12F Bilbao-Dotter tube

135 cm long).
Maneuver catheter tip to the anthrum
passing pylorus placed and fixation
catheter tip in duodenal 3rd parts.
Contrast irrigation (+ methylcellulose) or
air insufflating
Filming
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Normal follow through

Enteroclysis - normal small

bowel mucosa

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ascariasis in small intestine

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Infection : Crohns dss.

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4. Large bowel = colon

Radiology modality :
Plain abdominal radiographs
Barium enema = colon in loop
EUS = endoscopic ultrasonography
CT scan, virtual colonography
MRI
Nuclear medicine
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Plain abdominal x-ray

Technique :

AP Supine
AP Erect
LLD
Semi recumbent
CXR

Indication :

Acute abdomen

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What to Examine ??
Plain abdominal photo

abdominal wall
(preperitoneal fat
line)
psoas line
bowel gas
soft tissue mass
ascites
renal contour
opaque stone /
calcification / foreign
body
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plain abdominal x-ray

radioopaque stone

soft tissue mass29

Erect chest x-ray

Sub diaphragm free air

Bowel perforation

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Mechanical bowel obstruction

plain abdominal x-ray : 3 position

AP-semi
recumbent

LLD, horizontal

AP-supine : vertical ray

-small bowel dilatation

-thickening of bowel wall
-herring bone appearance
-colon gas (-)
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Plain abdominal x-ray

AP-Supine position

Ileo-cecal valve
incompetent
small and large
bowel distention

Mechanical bowel
obstruction
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Mechanical large bowel

obstruction
Colon dilatation

obstruction.

Barium enema
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volvulus of sigmoid colon

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Plain abdominal x-ray

air in portal vein

NEC
= necrotizing
entero-colitis
pneumatosis intestinalis

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Barium Enema
= Colon in Loop
Definition: radiological examination of the colon with
barium suspension through rectum
The routine examination of the colon

2 method :
Single Contrast : barium suspension
Double Contrast : barium susp.+ air
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Technique :
SINGLE
CONTRAST
Simple and easier
technique
Motility study.

DOUBLE
CONTRAST
Mucosa study.
Technique more
difficult.

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Barium enema
Hirschsprung dss:
Fecal retention in rectum and dilatation of
proximal bowel.

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Intussusception

Barium enema

Plain abdomen photo

CDFI

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C olon R adiology Anatomy

Caecum - colon - rectum

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Indication
Single contrast barium enema :

Intussusceptions
Diverticle dss/diverticulosis/diverticulitis
Colonic polyps
Colon and rectal carcinoma
Crohns dss
Hirschprungs dss
Fatique / very old patient / serious illness
Suspected pelvic metastasis

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Indication
Double contrast barium enema :

Melena / bloody stool

Chronic diarrhea
Pain & abdominal discomfort
IBD (inflamatory bowel dss)
Diverticulosis
Suspected colonic carcinoma
Suspected colonic polyp / familial polyposis
Family history of colonic ca / polyp
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Contraindication

Suspect bowel perforation

Toxic megacolon
After colonic biopsi
After snare polypectomy

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Complication

Gas pain
Colonic perforation or colonic ruptur
Water intoxication
Colonic intramural barium
Rectal laserasion
Bacteri contamination
Allergy / hipersensitivitas of barium or
glukagon/buscopan

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Preparation
Patient preparation

Low residue diet

Increased fluid intake
Rectal or oral laxative (if needed)
Antispasmodic agent :
1. Glucagon : intravenous : 0,5 1 mg.
2. Buscopan (hyoscine N-butylbromide) : iv or
im : 1 ampul (20 mg/mL)
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Contrast preparation

Barium sulphate suspension :

Single contrast : 12% - 25% w/v

Double contrast : 70% - 100 % w/v

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Irigator preparation

Plastic irigator :
1. enema tip
2. enema tube
3. enema reservoir bag
4. retention balloon with its
inflator.

1
4
2

4
2
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Fluoroscopy x-ray

1. Undertable tube
2. Tabletop
3. Lead drape

4. Image-intensifier tower
5. Spot film cassette slot
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Technique & positioning

A.
Left lateral position :
contrast filling
rectum and
rectosigmoid

B.
Left posterior
oblique (LPO):
contrast filling
sigmoid

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C.
Left lateral with 15o
Trendelenberg position :
contrast flow to descendent
colon and lienalis flexure

Posisi lateral, enema

tip dicabut.

D.
Clockwise to prone position:
contrast filling transversal
colon
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E.
Clockwise to right lateral
with 15o Trendelenberg
position : contrast filling the
hepatic flexure

F.
From E, turn left to supine
position : contrast filling
hepatic flexure and
ascendant colon
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G.
Turn to left posterior oblique
(LPO) to filling the
ascendants colon

H.
From G position, turn
clockwise to supine
position: contrast filling the
caecum
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Record / filming
Plain abdominal photo
Spot photo
Overhead whole abdomen

Plain abdominal photo53

B arium
E nema
S ingle
C ontrast
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Spot film : Single contrast

Rectum (left lateral)

Hepatic flexure

Sigmoid

Lienalis flexure

Caecum

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Whole abdomen : single contrast

Whole colon :
overhead film

Overhead film

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B arium
E nema
D ouble
C ontrast
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Spot film : double contrast

Rectum & sigmoid :

Lateral position

Supine position

Prone position
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Spot film : double contrast

Sigmoid :
posterior oblique

Distal descendant colon

Proximal
descendant colon
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Spot film : double contrast

Lienalis flexure
(RPO)

Transverse colon
Erect position

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Spot film : double contrast

Ascendant colon

Hepatic flexure

Erect position

Erect position, LPO

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Spot film : double contrast

Caecum & appendix

caecum & terminal ileum

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Overhead film :
whole colon

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Others position (if needed)

Right lateral decubitus (RLD)

- Decubitus to right side

(RLD)
- Horizontal ray
- Redundant colon
- Clearly evaluated :
lateral of descendant
and medial of
ascendant colon
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Others position (if needed)

Left lateral decubitus (LLD)

Decubitus to left side

Horizontal beam
Redundant colon
Clearly evaluated : lateral of
ascendant and medial of
descendant colon

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Polyp

Bubble

Filling defect

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Pedunculated Polyp

Sessile Polyp

Mexican hat sign sombrero

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Malignant polyp : villous type

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Apple core sign

Shoulder sign

Ca colon : anular type

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Colonic diverticulitis

Colonic diverticulosis
Multiple additional shadow
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IBD : ulcerative colitis

Continuous ascendering lesion

Segmental colitis

Pancolitis

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Crohns dss
Discontinuous skip lesion

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Colitis TB

Rectal carcinoma
Overhanging edges / shouldering
Annular constriction
Irregularity border
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Colonic polyp
Filling defect on single contrast

Soft tissue mass on double contrast

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Extraluminal tumor

ileocaecal intussusceptions
(Coiled spring appearance)
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Sekundary tumor :
metastatic of breast
cancer

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US G
C T s can
MR I
Nuklir
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US (Ultrasonography):

USG in CM hospital : Aloka

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Ultrasonography :
detection of hepatic metastases (primary
role).
Metastases lesions :
always multiple.
hyperechoic or hypoechoic lesions.

US has a detection rate of 70-90% for

hepatic metastases.

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USG : Liver metastases

Hyperechoic lesions

Hypoechoic lesions

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US finding :
A colonic carcinoma appear as :
a target sign,
irregular colonic wall thickening,
irregular contour,
absence of the normal layer of the colonic
wall.

usually cannot detect colonic tumors

smaller than 2 cm.
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CT Scanning

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CT Scanner in CM hospital: Siemens

Annular colonic carcinoma. Concentric

thickening of the bowel wall and
narrowing of the lumen.

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Early carcinoma :
intraluminal
polypoid mass,
limited to
submucosa,
no thickening of
bowel wall,
no pericolic fat
invasion.

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Advance carcinoma

Colonic carcinoma. Thickening of the bowel wall,

narrowing of the lumen, infiltration of the pericolic
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fat and invade the anterior abdominal wall.

Invasion of the
bladder base

Cervical mass

Stranding of
perirectal
fat

Cervical cancer. Invasion to the bladder

base and stranding to the perirectal fat.
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Liver metastases :
well-defined rounded areas of low density following
intravenous contrast medium.

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CT Colonography = virtual colonoscopy

Using MDCT / MS Helical CT
3-D computer reconstruction.

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Virtual CT colonography : flying through

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CT Colonography = virtual colonoscopy

Introduced by Vining in 1996

Adequate colon preparation, distending colon with air.
3-D computer reconstruction.

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Sigmoid tumor

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Tumor of the caecum

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Rectal tumor

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MRI

MRI in CM hospital : Bruker Tomikon 0.5T

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MRI Findings:
greater contrast between soft tissues.
colonic tumors :
T1 : medium signal intensity, contrast
enhancement
T2 : high-signal intensity.
Fat suppression

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Degree of Confidence :
MRI : sensitivity and specificity : in T
staging.
MRI : sensitivity and specificity in
detecting local recurrence.
MRI = CT : accuracy in N and M
staging.

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Nevertheless,
most centers tend to use CT rather than MRI
for staging and follow-up because of their
much longer experience with and the wider
availability of CT.
spiral CT (and the newer multislice CT) can
assess the whole abdomen and pelvis in a
much shorter time than MRI.

This is likely to change in the near future.

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