MEDICINE

GIT RADIOLOGY AND IMAGING

Lecturer: Dr. Renato M. Carlos| Date: 09-25-09 Transcriber(s): Kat S.

OUTLINE Air fluid levels – step ladder sign

I. Introduction
- Distended jejunum appears as stack
II. Imaging Modalities
A. Plain Abdominal Radiograph of coins, mucosal folds are more
B. Contrast examinations adherent to each other
1. Barium swallow / esophagogram -ileum when distended mucosal folds
2. UGIS are effaced
3. SBS -Obstruction is more distal somewhere
4. Barium enema in the ileum
C. Ultrasound
D. CT Scan
E. MRI
F. ERCP
T tube Cholangiogram
IOC
III. Interventional radiology
A. Angiogram and embolization
B. Abscess drainage
C. CT guide biopsy
Pneumoperitoneum – in ruptured viscous. Air escapes into the
INTRODUCTION peritoneal cavity, Double wall sign – translucent inner wall
(mucosa) and outer wall (serosa). Boarder of the liver and
DENSITIES diaphragm is also seen, as air insinuates in between. Rigler’s
sign – upright position,air goes up, inner and outer wall of the
AIR FAT WATER SOFT BONE stomach is seen.
TISSUES
2 Basic: B. CONTRAST EXAMINATIONS
1. Black – radiolucent (air and fat) 1. Barrium swallow / esophagogram
2. White – radioopaque (include bones, metals and Barium sulfate- contrast medium used, an inert
contrast medium) substance, radioopaque
Intermediate density – gray color – water and soft tissues or Indications:
organ structures. - esophageal motility disorders
Intestines- contain air. - atresia and tracheoesophageal fistula
- duplication
IMAGING MODALITIES - esophageal diverticula
- foreign bodies
A. PLAIN ABDOMINAL RADIOGRAPH - esophageal perforation
- Used to show calculi, calcifications, stones, tumors - hiatal hernia
-Take note of the pattern of calcifications. If its - esophagitis
toothlike – think of teratoma or cyst; vascular - rings, webs and strictures
calcification – hemangiomas that appears as ring-like - esophageal varices
Indications: - esophageal tumors
1. Abdominal pain
Achalasia – severe narrowing in the
2. Abdominal distention – obstruction, ileus, atresia gastroesophageal junction, proximal is
3. Vomiting dilated and distal is constricted
4. Diarrhea -in advance cases esophagus may
5. Trauma – intraabdominal bleeding and ruptured viscous appear sigmoid
→ pneumoperitoneum - terminal part shows a beak-like
Things to look at narrowing representing an nonrelaxing
1. Intestinal Gas Pattern LES.
2. Osseous Structures
3. Abnormal Calcifications
4. Abnormal Soft Tissue Densities
5. Renal Shadow
6. Psoas Shadow
Calcifications and psoas
shadow - psoas muscles
bounded by fat thus appears
translucent and is enlarged
in the presence of tumors
and abscesses. Kidneys lie Enlarging mass in the Diverticulosis - outpouching
along the lumbar area and lower neck.
is also bounded by fat - renal
shadow 2. Upper GI series
a. Duodenal atresia – - px on NPO, ingest barrium and effervescent
double bubble sign, tablet
shows an enlarged Indications
stomach and proximal ◦ Hematemesis
duodenal distention, ◦ Melena
absence of distal gas ◦ Hernia
(colonic gas) ◦ subacute or chronic nausea and vomiting
b. Jejunal atresia – ◦ palpable mass in the upper abdomen
a. b. triple bubble sign.
absence of distal gas
(colonic gas) Page 1 of 4
 (Symptoms related to peptic ulcer disease or lesions - Used to study the colon
involving the stomach and duodenum) - Px on NPO, laxative given to cleanse to bowel,
catheter inserted into the anus, barium is injected
Double contrast and pushed with air.
exam – barium Indications
is radio opaque a. hematochezia
and b. rectal bleeding
effervescent is c. change in stool caliber
translucent. d. constipation
Take note of e. weight loss
the mucosal f. severe anemia
patterns of the (Symptoms related to Colon Cancer or Inflammatory
small intestine, Bowel Disease)
more adherent
unlike the
haustra of the Haustral patterns is 2-
colon. 3cm apart
Appendix is 2-3 haustras
apart beyond the
ileocecal valve that is
like a lip.
Widening of C loop Tumors cause narrowing
of the lumen
on SBS
-doudenal loop in
relation with the
pancreas Diverticulosis – multiple diverticles or
outpouchings taking up the medium. Causes
- Enlarging
severe bleeding, can become infected-
pancreatic mass diverticulitis- when ruptured produces
intramural abscess or localized peritonitis.
Also diagnosed with CT scan
String sign
-hypertrophic
pyloric stenosis
- narrowing of the Colon cancer
lumen of the pylorus -apple core deformity
(but is now directly -tumors are usually
dx by the use of circumferential, produce
UTS) narrowing of the lumen
- Adenocarcinoma
Peptic Ulcer
-seen outpouching or mound which corresponds to the
edematous base around the ulceration, it has to be big for
it to be seen in UGIS. Colitis
– not anymore used for its diagnosis -thumbprinting

-inflammation,
infection or ischemia

C.
3. Small Bowel Series (SBS)
Indications
a. Inflammatory, neoplastic or infectious
diseases which result in mucosal changes or
obstruction of the small bowels.
This shows the
distribution of the small
bowel. Take note of the
differences of the
valvulated patterns,
more prominent in the
jejunum than in ileum
-transit time of the
medium is within 2-3 hrs
ULTRASOUND
Indications
◦ Evaluation of solid organs such as the liver,
pancreas, spleen, kidneys and fluid-filled
structures such as the gallbladder and urinary
bladder
◦ Ability to characterize lesions as solid, cystic
or complex
◦ Of value in evaluating nonpalpable,
intraabdominal and retroperitoneal masses
◦ Small amount of fluid collections in the
peritoneal space are also easily assessed.
- Any enlargement of the structures suspect tumor,
about >2.5 cm
- Gall bladder- pear shaped, wall measures 8mm, if
there’s thickening – cholecystitis

Lymphoma
- Fluids such as Bile appears dark, while
-segmentation and calcifications or stones appears white
distortion of the mucosal (hyperechoic)
folds, characteristic finding
of malabsorption syndrome

4. Barium enema
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 Gall bladder: bile is dark, inside is
multiple small echogenic foci. Due to
calcifiactions/stones, sound waves
can’t penetrate through it and produces
distal acoustic shadowing
– Cholelithiasis
Acute cholecystitis with lithiasis
thickened gall bladder wall with
pericholecystic fluid
- Acoustic shadowing
impacted stone at the gall bladder neck
FAST (Focused
Abdominal Sonography
for Trauma)
Objective:
Detection of free fluid
(leaky fluid / minimal
fluid) secondary to
hHEPATORENAL SPLENORENAL
injury of the abdominal
organs
D. CT SCAN
Indications
a. A powerful imaging technique for evaluating
the abdominal walls, intraperitoneal and
retroperitoneal spaces, all organ systems,
fascial planes and potential spaces
b. May be used to evaluate the entire abdomen
for masses and their extension into
adjacent structures.
c. Can also differentiate between solid and
cystic masses, exudates from transudates,
and can demonstrate calcifications within
masses
- Given contrast medium to enhanced structures-
vessels appear white, fat appear dark.
Advantage over MRI:
-Used in general abdominal cases
-Can detect calcifications, MRI does not
- it takes about 10 sec to scan the entire
abdomen, while MRI takes about 30-45min
-In Sigmoid Ca – advantage of CT over barium enema is
that your able to identify if there’s serosal
involvement or any involvement outside the colon
which is important in staging.
Multi-detectional CT scan
– able to attain different planes or sections
-virtual colonography - able to show the mucosal
linings, can able to detect polypoid lesion and tumor
E. MRI
Advantages over CT: can evaluate pancreas, adrenals
and chemical structures. No use of X-ray
F. ERCP(Endoscopic Retrograde Cholangiopancreatography)
Cholangiography – used to study biliary tree
Indications/Method of Examination
◦ can be used to evaluate the biliary tree to
detect common bile duct stones,
inflammatory or neoplastic duct anomalies
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◦ During ERCP, sphincterotomy, biopsy,
stone extraction, and mucosal brushings
can be done
◦ IOC may be used to visualize nonpalpable
stones during surgery
◦ T-tube cholangiogram is used to detect
retained stones after surgery
Normal T-tube Normal ERCP CBD stone
MRCP advantages over ERCP
(a) is noninvasive
(b) is cheaper
(c) uses no radiation
(d) requires no anesthesia
(e) is less operator dependent
(f) allows better visualization of ducts proximal to an
obstruction
(g) when combined with conventional T1- and T2-weighted
sequences, allows detection of extraductal disease.
IOC
Oral Cholecystogram – showing multiple gall stones
IV. INTERVENTIONAL RADIOLOGY
A. Visceral Angiogram and embolization
Indications
- evaluation and treatment of vascular diseases
- presurgical evaluation of lesions
- Embolization: Endovascular treatment of specific
diseases, e.g. bleeding control, tumor
chemoembolization, pre-operative devascularization…
Technique:
- Patient positioning, sterilization, draping
- Introduction of Needle, Guidewire, Catheter, into
Femoral Artery
Normal hepatic Hepatoma on angiogram
Angiogram
B. Percutaneous Abscess/Fluid Drainage
Indications
- Diagnostic sampling for Laboratory Analysis
- Therapeutic management, removal of fluid for
palliative or therapeutic purposes
C. CT-Guided Biopsy
Indications
- Tissue diagnosis of disease
- Aspiration for microbiologic/cytologic studies
Advantages vs. Surgical Biopsy
1. management planning is immediate, therapy may be
initiated without waiting for the incision to heal
2. minimal trauma, to normal as well as neoplastic tissue,
decreasing the risk of tumor dissemination
3. risks of surgery and general anesthesia are avoided
 -done under local anesthesia
4. failure to obtain a diagnostic specimen does not
preclude a surgical biopsy

PTBD(Percutaneous transhepatic biliary drainage)

- used when surgical intervention and ERCP to place
a stent to bypass bile obstruction fails.
- under UTS and colonoscopy guidance, needle is
inserted into the biliary system and tube is placed
from the hepatic duct to the duodenum
- it does not cure the site of obstruction but it only
drains the bile that is retained from obstruction

REFERENCE
1. Lecture ppt and recording
2. Wala masyado sa Harrisons 

SHOUTOUTS! ^_^
Thanks to Gail for the recording and kay Grace S. thank
you na rin sa effort to send it, to Angel for the Harrison’s
and jollibee breakfast.. To Alvin for the powerpoint.. 
And we must not forget to thank God for keeping us alive…
continue to pray for our safety in all the calamities that
may come..
Goodluck to all of us.. esp sa exams, sana maging
“physically, mentally, and emotionally ready tayo” (-Carlo
Sancha)
Hope you enjoyed our early sembreak.. hehe!

KEY POINTS
1– Plain Abdominal Radiograph – shows calcifications.
Stones and tumor
2. Patterns of calcification: Toothlike – teratoma or cyst;
Ring-like - hemangiomas
3. Psoas shadow and renal shadow – bounded by fat thus
appears translucent
4. in small bowel obstruction/ atresia – absence of colonic
or distal gas
Duodenal atresia – double bubble sign; Jejunal
atresia – triple bubble sign; Step ladder sign – air fluid
levels
5. Pneumoperitoneum: Double wall sign, Rigler’s sign
6. Achalasia – shows beak-like in barium swalow
7. Upper GI series: Double contrast exam
Pancreatic mass – widening of C loop (duodenal loop)
Hypertrophic pyloric stenosis – String sign
8. Lymphoma-segmentation and distortion of the mucosal
folds, characteristic finding of malabsorption syndrome
9. Diverticulosis – multiple diverticles or outpouchings
10. Colon cancer (adenoCa) -apple core deformity
11. Colitis -thumbprinting
12. Cholelithiasis - multiple small echogenic foci,
calcifiactions/stones, distal acoustic shadowing; if with
gall bladder wall thickening - cholecystitis
13. FAST – detects free fluid
14. T-tube cholangiogram is used to detect retained
stones after surgery
15. MRCP advantages over ERCP- allows detection of
extraductal disease.

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