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ABDOMEN

• Plain films allow one to view the entire abdomen before proceeding to a more specific investigation. Indications:

Abdominal distention

Abdominal pain

Vomiting

Diarrhea

Abdominal trauma

*The presence of a palpable abdominal mass

warrants imaging by CT Scan or Ultrasound.

*The plain film is most efficacious when obtained for patients who have significant abdominal tenderness or who are strongly suspected of having bowel obstruction, or perforation, urinary calculi or ischemia.

*The plain film examination is least effective as screening study in patients with mild or nonspecific symptoms.

*The major value of NORMAL findings from a plain film exam is that they exclude bowel obstruction or large perforation.

***Films of the abdomen in erect and supine positions are obtained to complete the “perforation series.”

NORMAL BOWEL GAS PATTERN

Intestinal tract of adults - <200ml of gas

3 sources of intestinal gas:

a. swallowed air

b. bacterial production

c. diffusion from the blood

Gas rises and accumulates in the anteriorly placed segments of intestine, including the body of the stomach, transverse colon, and sigmoid colon.

Gas tends to accumulate in the stomach and colon bec of the slower exit of fluid and gas from these structures. The gas-filled small intestine tends to occupy the central portion of the abdomen and has a smaller caliber than the colon.

*Recognition of mucosal features:

- Haustra of the colon = 2-3cm wide, occur at intervals of 1 cm.-Plicae circulares of small bowel = 1-2mm wide, occur at intervals of 1mm.

*however, the differentiation of colon from small bowel is difficult without a positive contrast study.*Intestinal gas should be considered a natural contrast agent in the interpretation of abdominal plain films.

ABNORMAL BOWEL GAS PATTERNS

Mechanical Small Intestine Obstruction

Mechanical Colon Obstruction

Paralytic (Adynamic) Ileus

Gastric Outlet Obstruction

Mechanical Small intestinal obstruction

Abdominal pain, distention, vomiting.

hx of previous abdl surgery.

Common Causes in Adults: adhesions, hernia, malignancy, inflammatory

bowel disease, Misc.(Crohn’s dse, volvulus, appendiceal abscess, and gallstone ileus)

Radiographic findings:

w/in 3-5 hrs after the onset of obstruction, gas and fluid accumulate proximally.

In upright film, distended bowel loops w/ air-fluid levels are present (non- specific).

Degree of small bowel dilatation is greater in pxs w/ true mechanical obstruction than w/ adynamic ileus.

As the loops fill w/ air, they may assume a “STEPLADDER” configuration.

Air may be resorbed through the intestinal wall as fluid accumulates in the bowel lumen – “GASLESS” abdomen.

STRING OF PEARLS” sign – small amounts of air trapped bet the plicae circulares (upright position).

Mechanical colon obstruction

Usually caused by cancer or diverticulitis.

Other causes: volvulus, hernia, fecal impaction.

Obstruction usu occurs in the sigmoid colon (narrower caliber and stool is more solid).

Carcinomas of the cecum & ascending colon are less likely to cause obstruction bec of wider caliber and more liquid content of the stool.

Plain film findings:

Dilated, gas-filled loops of colon proximal to the site of obstruction and a paucity or absence of gas in the distal colon and rectum.

Competent ileocecal valve – the cecum may become markedly dilated and little if any gas may be seen in the small bowel (risk of perforation).

CLOSED LOOP OBSTRUCTION

Incompetent ileocecal valve – allows gas to reflux proximally into the small bowel, producing plain film findings that can mimic small bowel obstruction. Close search for colonic gas is required.

Sigmoid Volvulus – two parallel gas- distended colonic loops rising out of the pelvis (dilated loop of sigmoid colon that has an inverted U configuration and absent haustra).

Cecal Volvulus – dilated, air-filled cecum in an ectopic location, usu w/ the cecal apex in the left upper quadrant.

***When plain films suggest colonic obstruction, it should be confirmed by endoscopy or barium enema.

PARALYTIC (ADYNAMIC) ILEUS

Causes: laparotomy and other types of trauma, sepsis.

Other causes: hypothyroidism, drugs that inhibit intestinal motility, hypokalemia.

Plain films usually show a PROPORTIONATE DISTENTION of small and large bowel

Colonic ileus may also result in cecal perforation, so, cecal diameters in the range of 12 cm are reason for concern.

GASTRIC OUTLET OBSTRUCTION

Antrum or pyloric region is the usual site of GOO

Most common causes: edema and spasm resulting from an acute pyloric channel ulcer and antral scarring caused by previous ulcers.

Other causes: scirrhous gastric CA and scarring from previous ingestion of a caustic substance.

Plain film: GOO -dilated air-filled or fluid-filled stomach in the left upper quadrant with displacement of the transverse colon inferiorly.-can mimic ascites or hepatomegaly (but a small amount of air is almost always present w/in the stomach).- contrast studies are often performed to confirm the presence of GOO.

PNEUMOPERITONEUM

A natural consequence of surgical exploration of the abdomen.

Usually indicates bowel perforation.

Upright plain films or cross-table decubitus films can detect small quantities of peritoneal gas.

Radiographic signs:

Serosal or Rigler’s sign – gas outlining both sides of the bowel wall; the bowel wall appears as thin white stripe (supine).

Increased lucency in the right upper quadrant – air accumulating superiorly in the free space between the anterior aspect of the liver and the abdominal wall.

Visualization of the undersurface of the diaphragm.

Air in the Morison’s pouch (posterior hepatorenal space) – linear or triangular collection of gas in the right upper quadrant.

Outline of the normal peritoneal ligaments – visualization of the falciform ligament in the upper abdomen, the lateral umbilical ligaments (inverted V sign) in the lower abdomen and the urachus.

“FOOTBALL SIGN” – indicates a large amount of free air filling the oval- shaped peritoneal cavity, mimicking an American football (infants).

Air in the lesser sac of the peritoneal cavity – ill-defined lucency above the lesser curvature of the stomach.

Conditions that may mimic pneumoperitoneum

Chilaiditi syndrome – bowel, usu the colon becomes interposed bet liver & diaphragm; common in elderly & pxs w/ obstructive airway disease.

Subdiaphragmatic fat – fatty (linear) lucency lies lateral to the apex of the hemidiaphragm; occasionally seen in obese pxs.

Extraperitoneal gas

Subphrenic abscess

Atelectasis of the lower lobes

Pneumatosis coli – intramural gas

PNEUMOBILIA

Gas in the bile ducts

Characterized radiographically by thin, branched, tubular areas of lucency in the central portion of the liver.

Results from some type of communication between the bile duct and the intestine.

Common causes: surgical creation of a biliary-enteric fistula such as a choledochoduodenostomy, choledochojejunostomy, or cholecystoenterostomy.

Other causes: (non-surgical) choledochoduodenal fistula sec to penetrating duodenal ulcer, cholecystoduodenal fistula sec to a gallstone that erodes into the duodenum.

Rigler’s Triad:

*Air in the biliary tree, small bowel obstruction, ectopic gallstone (diagnostic of GALLSTONE ILEUS).

Intramural gas or intestinal wall gas (pneumatosis)

Collection of gas in the bowel wall.

Radiographic patterns: bubbly appearance

thin, linear streaks

Can be seen in adult patients w/ bowel infarction.

ABDOMINAL CALCIFICATIONS

APPENDICITIS APPENDICOLITH – 10% of pxs w/ acute AP

- round or oval calcified densities, laminated.

- from 1-2cm in size, maybe as large as 4cm.

- located in RLQ, pelvis, RUQ, LUQ

- its presence often indicates appendicitis

complicated by perforation and abscess formation.

Abnormal bowel gas pattern – 25% of pxs

- adynamic ileus, partial or complete SI obstr’n

Abnormal cecum and ascending colon – thickening of the cecal wall, widening of the haustra, air-fluid level in upright position

Extraluminal soft tissue mass – found in up to 1/3 of pxs w/ perforation; may be caused by a combination of edema,

fluid, and fluid-filled loops of small bowel in the RLQ

Gas in the appendix – has been described as acute AP but an air-filled appendix may be a normal finding and simply reflects the position of the appendix in relation to the cecum

Free peritoneal air – may be seen in ruptured appendix

Obliteration of normal fat planes – inflammation and edema may alter the water content of surrounding fat and obscure normal fat planes of psoas muscle or flank stripes

Scoliosis of the lumbar spine – as a result of splinting (non-specific and can be related to positioning)

ORGANOMEGALY IN PLAIN FILM

Hepatomegaly

Splenomegaly

Renal enlargement

HEPATOMEGALY (PLAIN FILM)

Generalized hepatic enlargement tends to displace the hepatic flexure and transverse colon inferiorly and the stomach to the left

Other signs:

a. displacement of inferior edge of liver beyond

the right margin of the psoas muscle

b. displacement of the duodenal bulb below the

L2 vertebral body or to the left of the midline c. inferior displacement of the right kidney

d. enlargement or marked rounding of the hepatic angle

e. elevation of the right hemidiaphragm with with decreased motion on normal respiration

f. inferior displacement of the gastric fundus away from the diaphragm w/ left lobe enlargement

g. anterior displacement of the duodenal bulb on lateral films with caudate lobe enlargement

Reidel’s lobe

downward extension or elongation of the right lobe of the liver in the absence of hepatic disease.

normal variant found in about 4-14% of population, more common in females

this lobe may extend caudally below the iliac crest and does not indicate hepatomegaly.

downward extension or elongation of the right lobe of the liver in the absence of hepatic disease.

normal variant found in about 4-14% of population, more common in females

this lobe may extend caudally below the iliac crest and does not indicate hepatomegaly.

SPLENOMEGALY(PLAIN FILM)

Tip of the spleen extends inferiorly below the 12th rib.

Displacement of the splenic flexure of the colon – uncommon finding bec the

splenic flexure usually lies anterior to the spleen.

Marked splenomegaly may also displace the stomach medially.

Elevation of the left hemidiaphragm

RENAL ENLARGEMENT (PLAIN FILM)

Bec of surrounding fat, the renal outlines are visible on the majority of abdominal films taken in supine position.

An enlarged kidney does not displace intra-abdominal organs bec of its retroperitoneal location, except in extreme cases.

ASCITES

Obliteration of the inferior edge of the liver

Widening of the distance between the flank stripe and the ascending colon – this distance is normally 2-3mm, but it may increase as fluid fills the paracolic gutter.

Medial displacement of the lateral edge of the liver (Hellmer’s sign) – more common w/ malignant ascites than w/ cirrhosis

Fluid accumulation in the pelvis

Separation of bowel loops

Centrally located bowel loops with bulging flanks – w/ large amounts of ascites, the bowel loops may float to the highest central portion of the abdomen.Ground-glass appearance – in large amounts of ascites.

GASTROINTESTINAL SYSTEM

Liver, Biliary Tract, Pancreas

To review the gross anatomy of the liver To know the segmental anatomy of the liver A basic imaging correla<on of the segmental anatomy of the liver

Surface anatomy

Shaped like a wedge

Base against the R abd. wall and <p poin<ng to the spleen

Extends from the 5 th ICS in the MCL to the R costal margin

12 to 15 cm coronally

15 to 20 cm transversely

covered by a fibrous capsule (of Glisson)

capsular peritoneum reflects at the diaphragm – con<nues as parietal

reflec<ons forms – coronary, R & L triangular ligaments, and falciform ligament

round lig. – free edge of falc. l. – obliterated umbilical vein

Anatomic variants

Important to recognize variants to avoid labeling them as pathologies

incomplete accessory fissures

o

invagina<on of the diaphragm

o

one or more

o

common variant

o

commonly seen at the R lobe superiorly

LeS lateral segment

o

leSward extension of and projects posteriorly to wrap around the spleen

o

may be mistaken for pathology of the stomach/spleen

CONGENITAL ANOMALIES

true hepa<c congenital defects are rare

either defec<ve or excessive development

Riedel’s lobe

o

most common anomaly/ more common in women

o

due excessive dev’t

o

Sessile accessory lobe extending caudally from the inferior aspect of the R lobe oSen with bulbous configura<on

CONGENITAL ANOMALIES

Defec<ve dev’t of hepa<c lobe/segment

Typically affect an en<re lobe, rarely segmental

 

o

Absence (agenesis)

o

Small size with NORMAL structure (hypoplasia)

o

Small size with ABNORMAL structure (aplasia)

Must be dis<nguished from lobar atrophy secondary to vascular/biliary disease

LIVER

dual blood supply

 

o

portal venous system - 75%

o

hepa<c artery - 25%

hepa<c vein ’ inferior vena cava DIFFUSE HEPATIC DISEASE

cirrhosis

hepa<<s

faby infiltra<on

Budd-Chiari Syndrome

iron deposi<on FOCAL LIVER LESIONS

hemangioma

hepa<c cyst

pyogenic abscess

amebic abscess

echinococcal disease

fungal abscess

hepa<c adenoma

focal nodular hyperplasia

focal fat infiltra<on or sparing

hepatocellular carcinoma

metasta<c disease

HEMANGIOMA

cavernous hemangioma - most common benign hepa<c lesion

single or mul<ple (10%)

4% to 20% of the popula<on

women > men

asymptoma<c; discovered incidentally

most common in the posterior segment, right lobe

oSen subcapsular or peripheral

ultrasound (US) - well-defined, round, homogeneous hyperechoic lesion

large lesions - may be heterogeneous with areas of degenera<on

on noncontrast-enhanced CT (NECT) - well- circumscribed and of low density

on contrast-enhanced CT (CECT) - ini<al peripheral nodular enhancement with near- complete filling-in on delayed images

retain contrast for 20 to 30 minutes

nuclear single photon emission computed tomography (SPECT) - with techne<um

labelled RBC - decreased ac<vity in early images and increased ac<vity on delayed

magne<c resonance imaging (MRI) - useful for lesions < 2 cm.; well-defined, homogeneous and markedly hyperintense on T2-weighted images; peripheral to central enhancement on gadolinium- contrast

HEPATIC CYST

Ø second most common benign lesion

Ø single or mul<ple

Ø 2.5% to 10% of the popula<on

Ø women > men

liver is accessed by Entamoeba histoly/ca via the portal vein

symptoms similar to pyogenic abscess

US and CT appearance similar to pyogenic abscess

oSen located peripherally

on aspira<on, fluid classically “anchovy paste”

treatment - metronidazole

may take months to resolve

ECHINOCOCCAL DISEASE

§ caused by Echinococcus granulosis

§ symptoms similar to pyogenic abscess

Ø usually asymptoma<c

§ common in the right lobe, may be mul<ple,

§ grow slowly and cyst-like in appearance

Ø seen in 40% of pa<ents with polycys<c kidney disease; 60% of pa<ents with

Ø US - anechoic (no internal echoes), sharp

and may involve the chest

mul<ple hepa<c cystc have polycys<c

§ US and CT

kidneys

o

double line sign, water lily sign, racemose cyst wall

margins, impercep<ble wall, increased through transmission; US has 95% to 99% accuracy

o

double-layer cyst wall with inner germinal layer which gives rise to “daughter cysts”

Ø CT - sharply-defined, water density with no percep<ble wall and no contrast enhancement

o

daughter cysts are visualized within the parent cyst in 70% of cases

Ø CT - delayed images show no contrast enhancement

o

50% have shell-like calcifica<ons

Ø MRI - homogeneous low-signal intensity on

FUNGAL ABSCESS

T1-weighted images and high -signal

1.

immunocompromised pa<ents

intensity on T2-weighted images

2.

usually Candida

PYOGENIC ABSCESS

3.

with other organisms like Pneumocys/s carinii , cytomegalovirus, mycobacteria

may be bacterial, parasi<c, fungal

4.

have concomitant hepa<c involvement with

85% to 90% are bacterial or pyogenic

Kaposi’s sarcoma, lymphoma

bacteria access the liver via the biliary tree or portal vein

associated with biliary obstruc<on, diver<culi<s, trauma, inflammatory bowel disease, iatrogenic

pain, fever, diarrhea, leukocytosis, abnormal liver func<on tests

most commonly in the right lobe

US : heterogeneous, round, hypoechoic collec<on with irregular thick walls

: internal echoes, fluid-fluid levels, internal debris

: acous<c shadowing indicate gas within the abscess

CT : heterogeneous lesion with irregular margins

: peripheral contrast enhancement

: internal septa<ons common

: 20% may contain air

Differen<al diagnoses

cys<c or necro<c metastases

amebic abscess

hyda<d, echinococcal cysts

AMOEBIC ABSCESS

HEPATIC ADENOMA

ü seen exclusively in women of childbearing age (in 98%)

ü linked to oral contracep<ves, anabolic steroids, glycogen storage disease

ü composed of atypical hepatocytes and increased fat and glycogen

ü usually asymptoma<c; pain if with hemorrhage

ü slight malignant transforma<on poten<al

ü US - well defined with variable echogenicity; indis<nguishable from focal nodular hyperplasia

ü CT: discrete, low-density lesion, mean size of 10 cm.

ü mul<ple in 30% of pa<ents

ü may have dense enhancement

ü 50% heterogeneous because of hemorrhage

or necrosis MRI : inhomogeneous on all pulse sequences; increased signal on T1-weighted images Nuclear scan : cold lesion on sulfur colloid scan

FOCAL NODULAR HYPERPLASIA

Ø nonencapsulated

Ø common in women

Ø usually asymptoma<c

Ø CECT - enhancement during hepa<c arterial phase

Ø MRI

Ø composed of normal hepatocytes, Kupffer cells and bile ducts in an unusual

o

decreased signal intensity on T1 weighted images

arrangement

o

increased signal on T2 weighted

Ø usually less than 5 cm diameter

images

Ø

rarely mul<ple

Ø

nuclear scan

Ø common in the periphery of the right lobe

o

cold defect on sulfur colloid scan

Ø classic appearance - solitary, well- circumscribed with central stellate scar of fibrosis (central scar seen in 20%)

METASTASIS

o

increased ac<vity on gallium scan

Ø US - variable echogenicity

o

the most common malignant lesion of the

metastasis is 20% more common than

Ø CT - may be seen only on the hepa<c arterial phase of enhancement

Ø MRI - the central scar is high-signal intensity

o

liver

primary HCC

on T2-weighted (versus low-signal intensity in fibrolamellar carcinoma)

o

common primary source - colon, stomach, lung, breast, pancreas

o

abnormal liver func<on test, hepatomegaly

FOCAL FAT INFILTRATION OR SPARING

o

typically mul<ple, involve both lobes

§ common in right lobe of the liver

o

solitary metastasis in 30% to 40%

§ associated with obesity, alcohol abuse, use

o

may be calcified

of steroids, hyperalimenta<on

o

may be solid, necro<c, cys<c or calcified

§ US

o

can mimic any other lesion on CT and MRI

 

o

lobar or segmental distribu<on

o

should be considered in pa<ents >50 years

o

margins are angulated

old and in those with known primary

o

no mass effect on adjacent vessels

§ CT

LIVER TRAUMA

 

o

patchy or focal area of decreased abenua<on

Ø second most frequently injures intra- abdominal organ aSer the spleen

o

typically adjacent to the falciform ligament or gallbladder fossa

Ø commonly the posterior segment of the right lobe

§ sparing characteris<cally involve the caudate lobe, periportal region and adjacent to gallbladder fossa

HEPATOCELLULAR CARCINOMA (HCC)

Ø most common visceral malignancy

Ø most common risk factor - hepa<<s B (in the U.S., alcoholic cirrhosis is the most common risk factor)

Ø other risk factors - hemochromatosis, Wilson’s disease, glycogen storage disease

Ø common in men

Ø

Three paberns:

Ø best evaluated by CECT

Ø contusions, lacera<ons, intrahepa<c and subcapsular hematomas

BILIARY TRACT

ü abdominal plain film / radiograph - gas or

calcium

ü oral cholecystography - not done anymore

ü ultrasound

ü hepatobiliary scan / cholescin<graphy

ü percutaneous cholangiography / ERCP

ü opera<ve cholangiography

ü

CT, MRI

o

solitary mass (50%)

o

mul<focal involvement

CHOLELITHIASIS

o

diffuse infiltra<on

Ø most common disease of the gallbladder

Ø 80% of pa<ents have underlying cirrhosis

Ø invasion of portal vein seen in 30% to 60%

Ø increased alpha feto protein, elevated liver func<on tests, weight loss, RUQ pain, ascites, hepatomegaly

Ø poor prognosis; average survival = 6 months

Ø US - variable appearance; discrete hypoechoic mass; or tumor may be undetectable because of diffuse infiltra<on of the parenchyma

Ø NECT - hypodense mass with areas of increased density

Ø 10% of the popula<on have gallstones

Ø most gallstones are cholesterol stones

Ø 95% detected by US

Ø ultrasound

o

echogenic, shadowing foci

o

move when pa<ent changes posi<on

o

non-mobile echoes may be due to bile sludge, cholesterol or adenomatous polyps, adenomyomatosis, gallbladder carcinoma

Ø CT

o less sensi<ve than US

ACUTE CHOLECYSTITIS

ü increasing frequency with HIV; cryptosporidia and cytomegalovirus are the pathogens

v

most commonly due to cys<c duct obstruc<on by cholelithiasis

ü thickening of the walls of the bile ducts and gallbladder

v

5% to 10% are acalculous

ü intrahepa<c findings of sclerosing

v

US - cholelithiasis, thickening of the GB wall,

cholangi<s

Murphy’s sign

ü papillary stenosis

v

cholescin<graphy - non-visualiza<on of GB by 1 hour (normally in 30 minutes)

RECURRENT PYOGENIC CHOLANGITIS (ORIENTAL CHOLANGIOHEPATITIS)

CHRONIC CHOLECYSTITIS

v

endemic in Asia

Ø gallbladder is oSen contracted

v

acute abdominal pain, recurrent jaundice,

intra- and extrahepa<c bile ducst are

Ø gallstones, chronic inflamma<on, recurrent colic

v

fever, chills

Ø cholescin<graphy - delayed visualiza<on in 1-4 hours

dilated and contain soS pigmented stones and infec<on

BILIARY DILATATION

NEOPLASMS OF THE GALLBLADDER

v

not necessarily due to biliary obstruc<on

ü adenomas, fibromas, papillomas,

v

common bile duct > 0.8 cm.

cystadenomas

v

gallbladder diameter > 4 cm.

ü adenocarcinoma - oSen with gallstones

v

must determine presence, level and cause

(70% to 80%)

of obstruc<on

ü may be masked by gallstones, hence late diagnosis

BILIARY OBSTRUCTION

Ø common causes

o

gallstones

o

tumor

o

stricture

o

pancrea<<s

o

Mirizzi’s syndrome

Ø malignant cause of obstruc<on produces abrupt termina<on of the extrahepa<c biliary duct

o

pancrea<c carcinoma

o

ampullary carcinoma

o

cholangiocarcinoma

SCLEROSING CHOLANGITIS

Ø primary sclerosing cholangi<s is associated with ulcera<ve coli<s and Crohn’s disease

Ø secondary sclerosing cholangi<s are caused by chronic low-grade obstruc<on or infec<on

Ø intermibent jaundice

Ø alterna<ng areas of stricture and dilata<on = beaded appearance

Ø complica<ons

o

cholangiocarcinoma

o

cirrhosis

o

portal hypertension

ASCENDING CHOLANGITIS

ü acute infec<on of the biliary tree

ü secondary to par<al or complete obstruc<on

ü Escherichia coli is the frequent organism responsible

CHOLANGIOCARCINOMA

§ slow growing carcinoma of the bile ducts

§ Klatskin’s tumor = cholangiocarcinoma at the junc<on of the right and leS hepa<c ducts

§ predisposing factors: sclerosing cholangi<s, hepatolithiasis, liver flukes (Clonorchis sinensis and Opistorchis viverrini ; Caroli’s disease, choledochal cysts, familial polyposis

PANCREAS

§ Lies transversely in the upper abdomen at L1-L2 level

§ Head and body are retroperitoneal, tail is intraperitoneal lying in the splenorenal lig

§ Pancrea<c size is variable but normal maximum adult AP measurement is 3.5 cm for the head, body and tail

§ Imaging Modali<es

§ plain abdominal radiograph - pancreas is not seen; calcifica<ons or gas within pancrea<c abscesses only

§ Chest film – demonstrates pleural effusion, basal atelectasis, elevated diaphragm

§ Ultrasound – homogeneous echopabern of slightly higher echogenicity than the liver

§ US can evaluate pancrea<c head and body

§ CT is best modality

§ CT scan – more helpful than ultrasound in assessing pancrea<c outline and tail, peripancrea<c <ssues and blood vessels

§ ERCP (Endoscopic Retrograde Cholangiopancreatography)

 

o

Endoscopic assessment of UGIT and ampulla

 

o

pancrea<c pseudocyst - encapsulated collec<on of fluid

o

Contrast assessment of pancrea<c

 

and debris

 

and bile ducts

 

o

portal and splenic vein thrombosis

 

o

Most effec<ve method for imaging pancrea<c duct

o

pancrea<c necrosis

o

Therapeu<c and diagnos<c

CHRONIC PANCREATITIS

 

procedures may be done

v

repeated bouts of acute pancrea<<s

§

E.g. sphincterotomy, biopsy, stone extrac<on, balloon dilata<on, stent

v

pancrea<c calcifica<ons; irregularity of the ducts with beading and saccular dilata<on of the branches

 

inser<on, cyst drainage

v

cause is almost always alcohol abuse or

§

MRI specifically MRCP- can demonstrate

gallstones

common, cys<c and pancrea<c ducts

v

calcifica<on suggest alcohol abuse

v

Plain film, barium studies, US, CT scan, ERCP

ACUTE PANCREATITIS

ü alcohol abuse, choledocholithiasis; trauma,

ü diagnosis is clinical; imaging is used for

PANCREATIC ADENOCARCINOMA

drugs (steroid, INH, sulfonamides), pep<c

v

95% of all malignant tumors of the pancreas

ulcer disease, viruses (mumps, coxsackie,

v

poor prognosis

hepa<<s)

v

hypoechoic/ low-density mass; usually head or uncinate process (60% to 70%)

prognos<ca<on and iden<fy complica<ons

v

jaundice

ü Chest film changes

 

v

atrophy of the distal gland

o

LeS pleural effusion, basal

v

smooth dilata<on of the pancrea<c duct

atelectasis, elevated hemidiaphragm

v

dilata<on of the main pancrea<c duct and the bile duct (double-duct sign)

ü Abdominal film changes

v

Barium studies

o

Colon cut-off sign transverse colon is dilated but cuts off

o

Widened duodenal loop with fixa<on

abruptly at the splenic flexure

o

Anterior displacement, spicula<on

o

Sen<nel loops

 

of medial mucosal folds

§

DUODENAL ILEUS – MOST

o

Nodular mucosal filling defects

 

SPECIFIC

o

Inverted 3 or Frostberg sign

o

Small bowel ileus

v

Compression and invasion of the second

o

Gasless abdomen due to persistent vomi<ng

por<on of the duodenum with ulcera<on of the inner wall

ü Barium studies

 

v

Reverse 3 sign of Frostberg

o

Widened duodenal loop or C-loop

v

Ultrasound

with compressed medial border

o

Posi<ve findings in 80-90% of cases

o

Ampullary edema

 

§ Early – focal bulge to

o

Thickening of gastric and duodenal

pancrea<c outline

ü CT scan

folds

§ Late – irregular lobulated mass of low or mixed

o

Best imaging technique

echogenicity

o

pancrea<c enlargement, decreased

 

o

Distal chronic pancrea<<s

density due to edema, intrapancrea<c fluid collec<on,

o

Dilated CBD, pancrea<c duct distal to tumor

blurring of the gland margins

o

Signs of spread: liver metastasis,

o

Phlegmon – low density mass

 

portal and peripancrea<c nodes,

o

Hemorrhage – high density mass

invasion of retroperioneal fat,

o

Fluid collec<ons, pancrea<c or peripancrea<c

v

CT scan

venous occlusion

o

Abscess

o

Superior to ultrasound in assessing

ü Free peritonel fluid

 

tumor invasion of peripancrea<c

ü Complica<ons

structures

o

phlegmon - inflammatory mass

 

o

Preferred technique for assessing

o

hemorrhage - from arterial injury

 

operability

o

abscess forma<on

v

CT findings indica<ve of unresectability (Whipple’s procedure)

o liver metastasis

o

ascites

o

local extension (except the duodenum)

o

arterial encasement

o

venous occlusion

o

lymph node enlargement outside the field

ESOPHAGUS, STOMACH. DUODENUM

Methods of Examination of the Upper Gastrointestinal Tract

1. Plain film

2. Upper GI series

1. Examination with an opaque contrast medium

1. Barium sulfate – agent of

choice; inert and isotonic

2. Double contrast method – examination with an opaque contrast medium plus gas producing medications

Rules to follow prior to UGIS

Free passage through colon must be certain

Barium studies in a patient with suspected perforation must be approached with caution. Water soluble contrast materials are useful on some occasions but these agents are hypertonic and should be used with caution in the elderly and dehydrated patients

ESOPHAGUS

l

Straight muscular tube

l

20-24cm long

l

Joins the hypopharynx just above the sternal notch,at the level of C5 or C6 and GE jxn at the level of T11

l

Attaches to the gastric cardia behind the xiphoid process

l

Cricopharyngeus muscle- major element of UES

l

LES- 2-4cm with minimal muscle thickening

l

Divided into proximal,middle and distal

l

Jxn of proximal and middle 3rd is near the aortic arch level

l

Proximal 3-4cm lies in the lower part of the neck, the remainder is intrathoracic behind the heart

Major impressions:

a. Level of aortic arch

b. Left mainstem bronchus

c. Left ventricle

Types of examination

l

Esophagography

l

Flouroscopy

l

Endoscopy

l

Esophageal Manometry

Esophagogram/Barium swallow

l

Ingestion of barium sulfate suspension

l

Types:

Double contrast – demonstrate wall neoplasm and esophagitis

Full column

Mucosal relief – esophageal varices

Fluoroscopic observation and motion recording technique – esophageal motility

Classification of esophageal motility disorders

l

PRIMARY

Achalasia

Diffuse esophageal spasm

Intestinal pseudoobstruction

Hypertensive peristalsis

Presbyesophagus

Congenital tracheoesophageal fistula

Chalasia

l

SECONDARY

Connective tissue

Chemical or physical

Infection

Metabolic

Endocrine

Neurologic

Muscular

Vascular

Neoplasm

Pharmacologic

ACHALASIA

l

Failure of normal lower esophageal sphincter opening produces persistent V configuration of head of the barium column above the sphincter

l

Impairment or absence of Auerbach’s plexus ganglion cells

l

Pseudoachalasia-a constricting annular CA extending from the gastric fundus may cause motor abnormalities in the esophageal body

DIFFUSE ESOPHAGEAL SPASM Clinical syndrome characterized by:

1.symptom of intermittent dysphagia and chest pain

2.forceful,simultaneous repetitive contractions on manometry 3.segmental lumen-obliterating contractions on radiograph 4.thickening of the esophageal wall

l

Peristalsis may occur in the upper esophagus

l

All nonperistaltic movement are observed in the smooth muscle part

TRACHEOESOPHAGEAL FISTULA Type A =esophageal atresia- NO fistula =10% Type B=esophageal atresia-PROX fistula=1% Type C=esophageal atresia-DIST fistula=80% Type D=esophageal atresia-PROX + DIST=1% Type E=H-type fistula-NO atresia=10%

PRESBYESOPHAGUS

l

Curling or corkscrew esophagus

l

Helix configuration suggest possible shortening of the spiral esophageal muscle

ESOPHAGEAL PERFORATION

l

Nearly all perforations are caused by trauma

l

Non-traumatic esophageal perforation is generally caused by caustic ingestion or neoplasm

l

The most frequent sites are adjacent to the cricopharyngeus

1

l

Abnormal radiographic finding include

pneumomediatinum ,mediastinal widening

BARRETT’S ESOPHAGUS

and cervical emphysema

l

Partial lining of the esophagus by columnar

CAUSTIC ESOPHAGITIS

type epithelium reflects an adaptive alteration caused by chronic reflux

l

Alkaline-coagulation necrosis in minutes

esophagitis

l

Acid-more superficial

l

Has a predilection to develop

l

During the 1st 24 hrs,esophagus often

adenocarcinoma

appear normal

l

Generally older than 40y/o

l

Blurred margin,contour irregularity

l

Punch-out esophageal ulcer that resembles

l

Ulceration

gastric ulcer morphology or when an

l

Thickened folds

unexplained stricture of the middle esophagus is observed

HIATAL HERNIA

l

Types:

DIVERTICULAR DISEASE

1)

Axial

I.

Pulsion diverticulum mucosal herniations thru

2)

Paraesophageal

muscular wall

3)

Mixed

- Related to esophageal motility disorders

l

Relevant landmarks:

- Oval or rounded or smooth

1)

Diaphragmatic hiatus

a. Zenker’s diverticulum – along the posterior

2)

Esophagogastric jxn

wall of the upper end of esophagus at its

3)

LES segment

junction with the pharynx

4)

Loculus of herniated stomach

b. Epinephric – lower third of esophagus just

SLIDING HIATAL HERNIA

above the diaphragm II.Traction – due to extrinsic inflammatory

l

part of the stomach moves through the diaphragm so that it is positioned outside of the abdomen and in the chest.

involvement of esophagus; mid-esophageal III.Intramural pseudodiverticulosis multiple small outpuchings in the wall

l

lower esophageal sphincter (LES) often

moves up above its normal location in the

FOREIGN BODY

opening of the diaphragm.

l

In the esophagus flat objects such as coins

l

Most people have no symptoms, and it is

are oriented in the coronal plane

often diagnosed when a person is being evaluated for other health concerns.

l

In contrast,flat foreign body in the trachea is oriented in the sagittal plane

l

If the LES moves above the diaphragm, it

may not close well and stomach acid and

ESOPHAGEAL VARICES

juices may go back into the esophagus (acid reflux) commonly known as heartburn.

l

Changeable fold thickening or serpigenous and polypoid defects in the lower esophagus

 

l

Best shown by mucosal relief technique

PARAESOPHAGEAL HERNIA

l

Stomach bulges up through the opening in

ESOPHAGEAL RINGS

the diaphragm (hiatus) alongside the esophagus (upside-down stomach).

l

Schatzki’s ring-asymptomatic, mucosal fold at the esophagogastric jxn

l

LES remains in its normal location inside the opening of the diaphragm.

l

Exaggeration of the normal transverse mucosal fold-thickened to 4-5mm in width

l

This type of hernia most commonly occurs

causing narrowing of the luminal aperture

when there is a large opening in the

l

Steak house syndrome

diaphragm next to the esophagus.

l

Rings<12mm always accompanied by

l

The stomach and, rarely, other abdominal

dysphagia

organs (such as the intestine, spleen, and colon) may also bulge into the chest

l

Rings >12-20mm may or may not cause symptoms

MIXED HERNIA

ESOPHAGEAL STRICTURES

The LES is above the diaphragm as in a sliding hiatal hernia, and the stomach is alongside the

l

Any persistent intrinsic esophageal narrowing > 1cm

esophagus as in a paraesophageal hiatal hernia.

l

Fibrosis-most common cause

l

Benign strictures-”hourglass” appearance

ESOPHAGITIS

l

Malignant strictures-irregular luminal contour

l

Irregularity of luminal contour

often demonstrating ulceration or tumor

l

Granular mucosal pattern

nodules

l

Discrete ulceration

l

Reflux peptic esophagitis-strictures of the

l

Transverse esophageal folds

distal 2/3

l

Esophageal wall thickening

l

Segmental narrowing

ESOPHAGEAL CARCINOMA

l

Finding of transverse esophageal ridging or fold- felinization

Polypoid – filling defect in the barium filled lumen

2

- Edges of the lesion are sharply demarcated producing sharp angle or overhanging edges

Fluid-filled, appears as pseudotumor

Infiltrating – annular constricting filling defect or narrowing of the lumen

 

Mucosal folds are characteristically absent or sparse, stomach appears

-

Stenotic area is irregular and mucosal folds

smooth

are absent

l

In older children, stomach appears same

l

About 90%are squamous cell in origin

as in adults.

LEIOMYOMA

l

The most common benign tumor of the esophagus

l

35 y/o-mean age

l

Solitary mass in the distal 3rd

l

Cxr-soft tissue mediastinal density,mediastinal widening,or a calcified mass

l

Esophagograms-smooth filling defect

l

Seen face on-splitting of barium column, splaying of longitudinal folds,segmental widening of esophageal dm

STOMACH

Examination technique using barium sulfate:

1. Single contrast

a. Compression – demonstrate lesions and structural details including erosions and area gatrica

b. Mucosal relief – radiographs of the stomach in prone and supine position with small amount of barium

c. Distension with barium suspension

2. Double contrast – provides the greatest mucosal detail

Anatomically divided into 3 parts:

a. Fundus- lies above the transverse line drawn thru the EGJ

b. Body- lies between the gastric fundus, and line transecting the stomach at incisura angularis

c. Antrum- extends from incisura angularis to

pyloric canal Rugae longitudinal folds parallel to long axis of the stomach Area gastricae – small tufts of gastric mucosa 1-3mm in size

CONGENITAL AND DEVELOPMENTAL ANOMALIES Gastric diverticulum – located near EGJ Antral web diaphragm composed of mucosal and submucosal tissues - constriction proximal to pyloric canal Hypertrophic pyloric stenosis – elongated, narrow pyloric canal surrounded by muscle mass impinging

on the base of the distal gastric antrum and duodenal bulb Duodenal diverticulum – common at the medial aspect of 2nd portion in proximity to the papilla of Vater NORMAL CONFIGURATION

l In infants

Gas-filled, overdistended and erroneously suggests obstruction.

HYPERTROPHIC PYLORIC STENOSIS

l

Precise etiology is unknown

l

Hypotheses:

Nerve cells in the myenteric plexus of the pylorus are abnormal in number and function

Prolonged spasm of the antropyloric muscle leading to hypertrophy

l Secondary to hyperacidity

which is common in the immediate postnatal period. UGIS shows contrast material passing through the mucosal interstices of the canal, forming a “double track sign.” Mass impression on the gastric antrum

best seen during peristaltic activity is termed “the shoulder sign”.

l Diagnosis has been relegated to ultrasound

Ultrasound Classic appearance:

l

Elongation of the pyloric canal

l

Persistent spasm of the pyloric canal with little, if any, fluid passing into the duodenum

l

Persistent thickening of the circular muscle in the elongated canal

l

Sonolucent donut (thickened muscle) on cross-section

l

Ultrasound

* Muscle thickness of 4 mm or greater

* Length of pyloric canal: 1.2 cm or longer

Double Track sign” results from compressed mucosa showing numerous linear fluid accumulations within

Longitudinal sonogram shows anterior thickened muscle. Double layer of rounded and redundant mucosa fills the channel and protrudes into fluid filled antrum. (D) fluid filled duodenal cap.

Cross sectional sonogram shows circumferential muscular thickening surrounding the central channel filled with mucosa.

GASTRIC ULCERS

Epidemiology/Pathogenesis

l

Helicobacter pylori

l

NSAIDs

l

Steroids

l

Tobacco,alcohol, and coffee

l

Stress

l

Gastroduodenal reflux of bile and delayed gastric emptying

l

Hereditary factors

Helicobacter pylori

l gram(-), spiral-shaped bacillus

3

l

responsible for almost all ulcers, 60-80%

HYPERPLASTIC

(gastric), 95-100%(duodenal)

l

up to 90% of all gastric polyps

l

increased secretion of gastrin with high basal and peak acid outputs

l

elongated, branching, cystically dilated glandular structures

l

eradication of H. pylori accelerates ulcer

l

rare malignant potential

healing and decreases recurrence rate

l

<1cm,sessile

Radiographic findings

l

often multiple

l

Presence of an ulcer crater or niche

ADENOMATOUS

l

views obtained en face and in profile

l

less than 20% of all gastric polyps

l

En face: presence of dense ovoid collection

l

dysplastic epithelium

of barium within the crater

l

malignant transformation in 50%

l

In profile: barium filled projection extending

l

>1cm, sessile, pedunculated, or lobulated

from the lumen

l

often solitary

l

barium coating the rim of the unfilled ulcer crater produces the “ring sign”

LEIOMYOMA

Complications

l

40% of all benign gastric tumors

l

gastric outlet obstruction(20%)

l

consist of intersecting bundles of spindle-

l

penetration to contiguous organs

shaped cells in a characterisitc whorling

l

perforation(7%)

pattern

l

fistula(duodenum,small bowel,colon)

l

endogastric(80%), exogastric(15%),

l

hemorrhage(20%)

“dumbbell”-shaped(5%)

 

l

mostly solitary lesions, <3cm

BENIGN VERSUS MALIGNANT

l

epigastric pain, UGIB, palpable mass

BENIGN

Radiographic findings:

l

Project beyond the lumen

l

discrete submucosal masses

l

more likely to be deep

l

tumors larger than 2 cm frequently contain

l

surrounding mucosa is smooth

areas of ulceration

l

Edematous mound is symmetrical and

l

may contain calcification

smooth

Management:

l

radiating folds are smooth and distinct from

l

small, asymptomatic masses ® follow-up

each other

l

>2cm ® resected

MALIGNANT

l

Extends into the lumen

l

more likely to be shallow

l

surrounding mucosa has a nodular or irregular component

l

Infiltrating tumor is usually asymmetrical and maybe distinctly masslike

l

radiating folds may be irregular, nodular, variable in thickness, and may merge

BENIGN TUMORS OF THE STOMACH

l

85-90% of all neoplasms in the stomach and duodenum are benign

l

50% mucosal

l

50% submucosal

MUCOSAL LESIONS

l

Polyps (hyperplastic,adenomatous)

l

Villous tumors

l

Polyposis syndromes

(familial adenomatous polyposis, Peutz- Jeghers, Cronkhite-Canada) SUBMUCOSAL LESIONS

l

Leiomyoma

l

Lipoma

l

Neurofibroma

POLYPS (HYERPLASTIC/ADENOMATOUS)

l

50% of all benign gastric tumors

l

mostly asymptomatic, may cause upper GI bleeding or gastric outlet obstruction

l

some adenomatous polyps undergo malignant degeneration

l

need for endoscopic biopsy and removal of polyps is related to size and appearance

LIPOMA

l

2-3% of benign gastric tumors

l

mature fat cells surrounded by a fibrous capsule

l

no malignant potential

l

usually asymptomatic, may cause upper GI bleeding or gastric outlet obstuction

l

solitary lesions, frequently in the antrum

Radiographic findings:

l

CT has proved to be a valuable technique ® well-circumscribed areas of uniform fatty

density with an attenuation of -80 to -120 Hounsfield units

l

soft consistency ® change in size and shape with peristalsis or palpation at fluoroscopy

POLYPOSIS SYNDROMES

l

Familial adenomatous polyposis ® detection of adenomatous polyps in stomach or duodenum is important ® periodic surveillance of the UGI tract

l

Peutz-Jeghers syndrome ® hamartomatous polyps

l

Cronkhite-Canada syndrome ® gastrointestinal polyposis with nail and hair changes ® innumerable benign sessile polyps with distinctive “whiskering” effect

TUMORS

l Vast majority are malignant epithelial neoplasm

4

l

Most are detected by direct visual or endoscopic technique

l

Primary radiologic manifestation are – inraluminal mass and/or deformity caused by tumor infiltration with loss of normal distensibility

DUODENUM

- C-shaped curve extending from the pyloric canal to the junction of the duodenum and jejunum at the junction of the ligament of Treitz

- Four segments:

- Duodenal bulb – usually devoid of mucosal folds

- Descending limb – contains major and minor papillae

- Transverse limb – extends across SMA

- Limb ascending to ligament of Treitz

DUODENAL ATRESIA AND STENOSIS

l Plain Film: Supine frontal radiograph of the abdomen shows the “Double bubble sign”. An enlarged stomach and duodenum with absence of gas in the distal bowel loops.

BRUNNER’S GLAND ADENOMA

l

Small protuberant lesions covered by duodenal mucosa

l

Smoothly demarcated filling defects with a dm varying from several mm to approximately 1cm

l

If multiple lesions occur this is generally called hyperplasia of Brunner’s gland

ADENOCARCINOMA OF THE DUODENUM, POLYPOID FORM

l

Barium study. a. Overview of the duodenum, and (b) spot view of the lower part. There are multiple rounded and oval sharply delineated filling defects in the second and third portion of the duodenum revealing polypoid surface of the tumour.

l

Most common malignant duodenal tumor

LEIOMYOSARCOMA OF THE DUODENUM

l

Second most common malignant duodenal tumor

l

May mimic polypoid adenocarcinoma

l

The presence of a sinus or fistula suggest leiomyosarcoma

l

Thickened folds or constrictive lesion

1

SMALL AND LARGE INTESTINES

Indications for the examination of the small intestines

1. presence of an abdominal mass

2. suspicion of small bowel obstruction

3. unexplained diarrhea

4. malabsorption

tenacious meconium in

the distal small bowel

Complications:

Ischemia-induced ileal atresia or stenosis

Ileoperforation

Meconium peritonitis (most common)

 

5. unexplained intestinal

6. abdominal pain or tenderness

S/S:

bleeding

vomiting (bile

stained)

Basic anatomy

Abdominal

-

duodenum is fixed

distention

jejunum and ileum are not fixed = mesenteric small intestine

-

Failure to pass meconium

- mucosal folds (valvulae conniventes) normally 1-2 mm in width and are regularly spaced

- jejunum may be 3 cm in diameter

- ileum may be 2.5 cm in diameter

Basic physiology

- digestion and absorption

- reabsorption of bile salts and water - ileum

- motility = quiescent and active phase

- active phase = churning phase and propulsive phase

- contractile activity = myogenic,

neural, and biochemical controls Methods of examination

1. plain film of the abdomen - supine and upright views

2. upper gastrointestinal series (UGIS)

3. enteroclysis

4. peroral small bowel examination with pneumocolon

5. water-soluble contrast studies

Congenital anomalies

1. tubulation defects - atresia and stenosis

2. rotation anomalies - nonrotation, midgut volvulus

3. duplication cysts and diverticula - Meckel’s diverticulum

ABNORMALITIES OF THE SMALL BOWEL

1. Meconium Ileus

Obstruction results from impaction of thick,

Plain Film:

Low small bowel obstruction with numerous air-filled loops of small bowel

Air fluid levels usually are absent

Absence of gas in the rectal vault

Soap bubble e fect” of gas mixed with meconium

Ultrasound shows dilated intestinal loops containing echogenic material representing calcified meconium.

Contrast Enema

- Aqueous contrast ( hyperosmolar)

agents diluted 3:1 with normal saline

- When contrast is refluxed into the

small intestine, the enema becomes diagnostic and at the same time therapeutic

- Filling of the terminal colon should be attempted in all cases, even though occasional perforation can occur.

STAGES OF INTESTINAL ROTATION

A. The duodenum has rotated 90 counterclockwise to lie to the right of the SMA The distal large bowel also rotates 90 counterclockwise.

B. The duodenum has rotated another 90 counterclockwise.

C. The duodenum has rotated to its final 90 counterclockwise with the duodenojejunal flexure lying to the left of midline. The cecum continues to rotate.

D. The normal rotated bowel is depicted.

2

ROTATIONAL ABNORMALITIES AND MIDGUT VOLVULUS

Types of Rotational abnormalities

1. Non-rotation

2. Malrotation

3. Reversed rotation

NON-ROTATION

1. Usually asymptomatic

2. Small bowel lies on the right and

colon on the left

3. Bowel is not mobile

4. Volvulus is not common

UGIS shows the small intestine on the right side of the abdomen. UGIS of the same patient shows the colon and cecum on the left side of the abdomen. The ileum is seen crossing the midline from right to left. Small intestine on the right side of the abdomen; colon on the left

MALROTATION

Final positioning is somewhere between the normal and complete non- rotation

Cecum and terminal ileum are displaced upward and medially

If duodenal bands and midgut volvulus are present:

A. Beaked deformity of the obstructed duodenum and spiraling of the small intestine

B. Obstructed duodenum ends at a point medial to the left vertebral bony pedicle

MIDGUT VOLVULUS UGIS demonstratres the “corkscrew appearance” of the proximal small bowel as it twist around the SMA

INTUSSUSCEPTION

Common between the ages of 6 months and 4 years

Neonatal intussusception is rare.

Associated with lead points:

o Meckel’s diverticula, polyps, lymphoma, appendix

S/S:

o Crampy abdominal pain

o Vomiting

o Bloody (currant jelly) stool

o Palpable abdominal mass

Types:

Hypermobile cecum

o

Ileocolic (most common)

Small bowel mesenteric

o

Ileo-ileo

attachment is lost

o

Ileo-ileocolic

Poorly fixed small bowel is

Duodenal bands (Ladd’s

Plain Film:

floppy and predominantly lies

-

depends on the duration of symptoms

1. Normal abdominal gas pattern

on the right

band) and absence of the ligament of treitz are

and presence or absence of complications

common

2. Small bowel obstruction with paucity

Volvulus is common.

On BE, the intestine occupies an intermediate position between that of non rotation and the normal post natal position. The cecum and terminal ileum are displaced upward and medially.

REVERSED ROTATION

Hepatic flexure and left transverse colon lie behind the descending duodenum and SMA.

Cecum is malrotated and medially placed

Small bowel is more on the right side.

of gas in the right.

3. Soft tissue mass within the right side

of the colon

4. “Target Sign” (Ring like area of

lucency within the mass 5. “Interrupted air column sign

The mass causes cut o f of the air column in the transverse colon

6. “Meniscus sign

- Rounded soft tissue mass

(intussusceptum) protruding into the gas-filled transverse colon

ULTRASOUND - sensitivity of 100% and specificity of 88%

Axial UTZ shows the “Doughnut Sign”.

3

- Hyperechoic outer ring represents the intussuscipiens

- Hypoechoic outer ring formed by the everted limb of the intussusceptum

- Center varies with the section level, represents the central limb of the intussusceptum

UTZ obtained at the base of the intussusceptum shows the “ Crescent- in-doughnut sign”. -a hyperechoic, crescent shape center -occurs when the mesentery encloses the central limb of the intussusceptum.

Longitudinal Scan shows the “Sandwich Sign”. -Outer hypoechoic bands represents the everted limb of the intussusceptum beside the intussuscipiens. -Two hyperechoic bands represent the mesentery -Central hypoechoic band represents the central limb of the intussusceptum

Reduction:

Barium reduction:

40-45% Success rate

Air contrast (Enema and ultrasound) and Ultrasound-guided

reduction (air or aqueous contrast)

80-90% success rate

Three or four tries

If no progression of reduction occurs within 4 to 5 minutes at any one

location, reduction is less likely to occur.

Air reduction:

 

Pressures of at least 60 mmHg

Pressure beyond 120 mmHg should be avoided

Barium reduction:

Elevate the reservoir to 3.5 feet

Diluted aqueous contrast agents

Elevate the reservoir to 5 feet

MECKEL’S DIVERTICULUM

Persistence of the omphalomesenteric duct

May be a site of volvulus or intussusception with resultant SBO

•May contain acid-secreting cells that may cause ulceration of the sensitive ileal mucosa and subsequent hemorrhageEnteroclysis; Technetium studies are helpful in patients who are bleeding and have ectopic gastric mucosa in the diverticulum

SMALL INTESTINES INFECTIONS/ INFESTATION

Tuberculosis- commonly at ileocecal area

Yersinia enterocolitica

parasites - ascaris, tapeworms. Campylobacter and Giardia, Strongyloides

TUBERCULOSIS -coning of cecum with mucosal ulcerations and stricture of ileum

ASCARIASIS – worms GIARDIASIS

- jejunal folds are thick and irregular

SMALL INTESTINES: PARALYTIC ILEUS

- most common motility disorder

- small bowel and colon dilate with gas, and transport is inhibited

- equal distension of small bowel and colon

- air-fluid level occur only if the process persists 5-7 days

- usually self limited

SMALL INTESTINES: HERNIA

greater tendency for right than left inguinal herniation

diaphragmatic hernia

internal hernia

ADHESIONS

most common cause of small bowel obstruction in the adult

following laparotomy g intraperitoneal fixed adhesions vs. mobile bowel

small bowel is distended

air-fluid levels seen proximal to the site

usually little or no gas in the colon

COLON

4

Indications for the examination of the colon

carcinoma - hematochezia or occult blood in stool

inflammatory bowel disease - diarrhea

other symptoms - change in