Gastrointestinal Imaging

22

PLAIN ABDOMINAL FILMSPLAIN ABDOMINAL FILMS

• The supine abdominal film• The erect chest film• The horizontal-ray abdominal film:

- Erect

- Left lateral decubitus

33

The supine abdomen filmThe supine abdomen film

- The diaphragm to the hernial orifices- The preperitoneal fat line: Blurring of the preperitoneal fat line e.g. inflammatory- The psoas outlines: Obliteration of psoas outlines e.g. fluid/inflammatory

exudate- Distribution of gas- The calibre of bowel : N: Calibre of small bowel is 2.5 cm & colon is 5 cm.- Displacement of bowel by soft-tissue masses.- Calculus

44

The erect chest filmThe erect chest film

The erect chest film can assess :• Small pneumoperitoneum.• Chest conditions may mimic an acute

abdomen. • Acute abdominal conditions may be

complicated by chest pathology,

e.g. pleural effusion frequently complicate

acute pancreatitis, etc.

55

The erect chest filmThe erect chest film

• Erect• The patients should be in position for

10 min before the film is taken.• Radiological findings:

- free gas beneath the diaphragm

- chest abnormality

66

The horizontal-ray abdominal filmThe horizontal-ray abdominal film

• Erect & left lateral decubitus.• The patients should be in position for

10 min before the film is taken.• Radiological findings:

fluid levels & free gas

77

ACUTE ABDOMENACUTE ABDOMEN• Perforation• Intestinal obstruction• Paralytic ileus• Acute colitis• Intraperitoneal fluid• Inflammatory conditions• Intramural gas• Calcification associated with acute abdominal

conditions

88

PERFORATION PERFORATION → → PNEUMOPERITONEUMPNEUMOPERITONEUM

● Require emergency surgery!

● Small pneumoperitoneum (I ml of free gas) → erect chest/LLD abdominal films.

99

Small pneumoperitoneumSmall pneumoperitoneum

1010

PNEUMOPERITONEUMPNEUMOPERITONEUM

● Radiological appearances:

Plain abdominal film: - Oval/linear collection of gas: ♠ Subhepatic space ♠ Morison’s pouch ♠ Beneath the diaphragm (the cupola sign) ♠ In the centre of the abdomen over a fluid collection (the football sign) ♠ Fissure for ligamentum teres

1111

-- Small triangular collections of gas betweenSmall triangular collections of gas between loops of bowel. loops of bowel.

- Visualisation of the outer as well as the - Visualisation of the outer as well as the inner wall of a loop of bowel ( inner wall of a loop of bowel (Rigler’s signRigler’s sign).).

CT:CT: Free gas over the liver, anteriorly in the mid Free gas over the liver, anteriorly in the mid abdomen, & in the peritoneal recesses. abdomen, & in the peritoneal recesses.

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PneumoperitoneumPneumoperitoneum

1313


Rigler’s signFissure for ligamentum teres

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SUSPECTED PERFORATIONSUSPECTED PERFORATION• Severe upper abdominal pain.• No free gas is seen on plain films.

• Contrast media: ♠ 100 ml air is injected down the tube (NGT)→LLD→ film is taken after 10 min.

♠ 50 ml of non-ionic contrast medium (orally) → placed on the right side → film is taken after 5 min.

1616

INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION= Dilated loops of bowel proximally with non-dilated/collapsed bowel distal to the

presumed point of obstruction.

Gastric Dilatation:Etiology:- Mechanical gastric outlet obstruction- Paralytic ileus- Gastric volvulus- Air swallowing

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Gastric DilatationGastric Dilatation

1818

Small-Bowel Obstruction:Small-Bowel Obstruction:

♠ ♠ EtiologyEtiology:: - Adhesions due to previous surgery - Adhesions due to previous surgery - Strangulated hernias - Strangulated hernias - Volvulus - Volvulus - Gallstone ileus - Gallstone ileus - Intussusception - Intussusception - Neoplastic, etc. - Neoplastic, etc.

1919

♠ ♠ Radiological appearancesRadiological appearances:: ♥ ♥ Plain filmPlain film changes appear after 3-5 h changes appear after 3-5 h (marked after 12 h) (complete obstruction). (marked after 12 h) (complete obstruction).

♥ ♥ Supine filmSupine film:: - - Small-bowel dilatation with accumulationSmall-bowel dilatation with accumulation of both gas & fluid. of both gas & fluid. - A reduction in calibre of the large bowel. - A reduction in calibre of the large bowel.

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Small-Bowel ObstructionSmall-Bowel Obstructiondue to adhesiondue to adhesion

2121

Small-Bowel ObstructionSmall-Bowel Obstructiondue to gallstone ileusdue to gallstone ileus

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Small-Bowel ObstructionSmall-Bowel Obstructiondue to Intussusceptiondue to Intussusception

A crescent of air at the apex of an intussusception

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♥ ♥ Erect filmErect film:: - Multiple fluid levels ( - Multiple fluid levels (Stepladder patternStepladder pattern)).. - ‘ - ‘String of beadsString of beads’ ’ signsign = small bubbles of gas may be trapped = small bubbles of gas may be trapped in rows between the valvulae conniventes. in rows between the valvulae conniventes.

♥ ♥ Oral dose of 100 ml of non-ionic contrast mediumOral dose of 100 ml of non-ionic contrast medium:: The contrast hasn’t reached the caecum at 4 h The contrast hasn’t reached the caecum at 4 h → → surgery is required!surgery is required!

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Stepladder patternStepladder pattern in mechanical in mechanical obstruction of the small bowelobstruction of the small bowel

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Small-Bowel Obstruction:Small-Bowel Obstruction:String of beads signString of beads sign

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♥ ♥ UltrasoundUltrasound:: - Dilated fluid-filled loops of small-bowel - Dilated fluid-filled loops of small-bowel obstruction. obstruction. - Assessment of the peristaltic activity. - Assessment of the peristaltic activity.

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♥ ♥ CTCT:: * CT should be performed whenever * CT should be performed whenever there is a history of previous abd. there is a history of previous abd. malignancy. malignancy.

* * Radiological appearancesRadiological appearances:: - Bowel calibre change - Bowel calibre change - Fluid-filled loops - Fluid-filled loops - The level of obstruction - The level of obstruction - Peritoneal adhesions - Peritoneal adhesions

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Small-Bowel ObstructionSmall-Bowel Obstruction

Fluid-filled loops Bowel calibre change

2929

LARGE-BOWEL OBSTRUCTIONLARGE-BOWEL OBSTRUCTION

• Etiology:

- Neoplastic (benign & malignant)

- Volvulus (caecal & sigmoid), etc.

• Radiological appearances:

Depends on the state of competence

of the ileocaecal valve:

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Type IA : The ileocaecal valve is competentType IA : The ileocaecal valve is competentDistended large bowel, particularly ascending colon Distended large bowel, particularly ascending colon & caecum. No distention of small- bowel.& caecum. No distention of small- bowel.

Type IB:Type IB:Caecal distension & small-bowel distension.Caecal distension & small-bowel distension.

Type II:The ileocaecal valve is incompetentType II:The ileocaecal valve is incompetentNo distension of caecum & ascending colon but No distension of caecum & ascending colon but distension of small-bowel.distension of small-bowel.

3131

LARGE-BOWEL OBSTRUCTIONLARGE-BOWEL OBSTRUCTION

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LARGE-BOWEL OBSTRUCTIONLARGE-BOWEL OBSTRUCTION due to Sigmoid Volvulus due to Sigmoid Volvulus

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LARGE-BOWEL OBSTRUCTIONLARGE-BOWEL OBSTRUCTION due to Caecal Volvulus due to Caecal Volvulus

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PARALYTIC ILEUSPARALYTIC ILEUSGeneralised paralytic ileusGeneralised paralytic ileus::●●EtiologyEtiology:: - Peritonitis- Peritonitis - Post-operative - Post-operative - Hypokalaemia- Hypokalaemia - General debility or infection - General debility or infection - Drugs: morphine- Drugs: morphine - Congestive cardiac failure, renal colic, etc.- Congestive cardiac failure, renal colic, etc.

●●Radiological appearancesRadiological appearances:: - Both small & large-bowel dilatation - Both small & large-bowel dilatation - Horizontal-ray films: multiple fluid levels - Horizontal-ray films: multiple fluid levels

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PARALYTIC ILEUSPARALYTIC ILEUS

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Localised ileusLocalised ileus::● ● EtiologyEtiology:: - Local inflammatory processes: - Local inflammatory processes: pancreatitis, cholecystitis, appendicitis, salpingitis pancreatitis, cholecystitis, appendicitis, salpingitis - Trauma: - Trauma: spine, ribs, hip, retroperitoneum spine, ribs, hip, retroperitoneum - Renal colic, etc. - Renal colic, etc.

●●Radiological appearancesRadiological appearances:: - Non specific (Mimic small/large-bowel obstruction). - Non specific (Mimic small/large-bowel obstruction). - Dilatation of one/two adjacent loops of bowel. - Dilatation of one/two adjacent loops of bowel.

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ACUTE COLITISACUTE COLITIS

• Acute inflammatory colitisAcute inflammatory colitis

• Toxic megacolonToxic megacolon

• Pseudomembranous colitisPseudomembranous colitis

• Ischaemic colitisIschaemic colitis

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Acute inflammatory colitisAcute inflammatory colitis• Plain film can assess :

♠ the extent of the colitis

♠ the state of mucosa:

It can be assessed from :

- the faecal residue:

In left-sided disease, the proximal limit of

faecal residue will indicate the extent of

active mucosal lesion.

- the width of the bowel lumen

- the mucosal edge

- the haustral pattern

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* The mucosal edge is smooth & the haustral * The mucosal edge is smooth & the haustral clefts are sharp clefts are sharp → no mucosal change.→ no mucosal change.

* Fuzzy mucosal edges, widened clefts/absent * Fuzzy mucosal edges, widened clefts/absent haustrations → active disease. haustrations → active disease.

* Coarse irregularity of the mucosal * Coarse irregularity of the mucosal edge & edge & absent haustrations → marked ulceration. absent haustrations → marked ulceration.

* Extensive mucosal destruction → * Extensive mucosal destruction → mucosal islandsmucosal islands or or pseudopolypspseudopolyps → toxic dilatation → toxic dilatation → → indication for surgery!indication for surgery!

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♠ ♠ The depth of the ulcerationThe depth of the ulceration♠ ♠ The presence/absence of megacolon and/or The presence/absence of megacolon and/or perforation. perforation.

SSevere disease processevere disease process::- - The presence of large amounts of faeces The presence of large amounts of faeces in the caecum & ascending colon in the caecum & ascending colon - A gasless colon- A gasless colon

Urgent surgeryUrgent surgery::- Ulceration penetrate the muscle layer- Ulceration penetrate the muscle layer

- Dilated bowel - Dilated bowel › 5.5 cm› 5.5 cm

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Toxic megacolonToxic megacolon

• A fulminating form of colitis with transmural inflammation, extensive & deep ulceration & neuromuscular degeneration.

• Involve the transverse colon• Ro. Findings:

Mucosal islands (=pseudopolyps) & dilatation (8 cm)• Common complication:

Perforation in the sigmoid & peritonitis

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Toxic megacolonToxic megacolon

4343

Pseudomembranous colitisPseudomembranous colitis

• Etiology: Clostridium difficile• Involve the whole of the colon• Radiological appearances: Plain films: - Thumb-printing - Thickened haustra in left half - Abnormal mucosa - Dilated bowel in the right half - Ascites

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Ischaemic colitisIschaemic colitis• Etiology: Vascular insufficiency & bleeding into the wall of the colon.• Sudden onset of severe abd.pain in the early

hours of the morning, followed by bloody diarrhoea.

• In middle-aged & elderly patients.• The wall of splenic flexure & descending colon is

greatly thickened→ thumb printing (plain films).• The right side of colon is frequently distended.

4545

Ischaemic colitisIschaemic colitis

thumb printing

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INTRAPERITONEAL FLUIDINTRAPERITONEAL FLUID

• Fluid within the peritoneal cavity is commonly present in acute abdominal conditions.

• Ro findings: - The earliest signs: Fluid density within the pelvis, visualised superiorly & laterally to the bladder/rectal gas shadows. - Displace colon medially from the flank fat stripes.

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- Huge amounts of fluid:- Huge amounts of fluid: ♠ ♠ A generalised haze over the abdomen &A generalised haze over the abdomen & poor visualisation of normal structures, e.g. poor visualisation of normal structures, e.g. psoas & renal outlines. psoas & renal outlines. ♠ Separation of bowel loops.♠ Separation of bowel loops. ♠ Thinning of the flank stripes laterally. ♠ Thinning of the flank stripes laterally.

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INFLAMMATORY CONDITIONSINFLAMMATORY CONDITIONS

• Intraabdominal abscesses

• Appendicitis

• Acute cholecystitis

• Emphysematous cholecystitis

• Acute pancreatitis

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Intra-abdominal abscessesIntra-abdominal abscesses

• Displacement of adjacent structures.• Loss of visualisation of normal fat lines.• One/several tiny bubble-like lucencies.• Long air-fluid levels on horizontal-ray films• Pelvis is the most common site of residual

abscess

formation following generalised peritonitis.

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Subphrenic abscessSubphrenic abscess• Appear in the post-operative period, perforated Appear in the post-operative period, perforated peptic ulcer, appendicitis, diverticulitis, perforations peptic ulcer, appendicitis, diverticulitis, perforations of the GIT, or penetrating abdominal injuries.of the GIT, or penetrating abdominal injuries.

• Ro.findingsRo.findings:: - A raised hemidiaphragm- A raised hemidiaphragm - Basal consolidation- Basal consolidation - Pleural effusion (unilateral)- Pleural effusion (unilateral) - Decreased diaphragmatic movement- Decreased diaphragmatic movement - Generalised/localised paralytic ileus- Generalised/localised paralytic ileus - Scoliosis toward the lesion- Scoliosis toward the lesion - Decreased organ morbility- Decreased organ morbility

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Subphrenic abscessSubphrenic abscess

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Intra-abdominal sepsisIntra-abdominal sepsis

• Plain films: - Small gas bubbles, unchanged in position on consecutive films. - Displacement of organs & bowel. - Effacement of fat lines

• CT: - A mass with an attenuation value of 15-35HU. - Ring enhancement after i.v. contrast medium.

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AppendicitisAppendicitis

• Signs of acute appendicitis:

- Appendix calculus (0.5-6cm)

- Localised paralytic ileus in RLQ

- Sentinel loop-dilated atonic ileum containing

a fluid level

- Widening of the preperitoneal fat line

- Blurring of the preperitoneal fat line

- Blurring of the right psoas outline-unreliable

cont…

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AppendicitisAppendicitis

- Scoliosis concave to the right

- Dilated caecum

- Right lower quadrant (RLQ) mass identing

the caecum on its medial border (abscess

formation)

- RLQ haze due to fluid & oedema

- Gas in the appendix-rare, unreliable.

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Small bowel obstruction due to Small bowel obstruction due to Appendix abscessAppendix abscess

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• • Ultrasound signsUltrasound signs of acute appendicitis of acute appendicitis : : - Blind-ending tubular structure at the point - Blind-ending tubular structure at the point of tenderness: of tenderness: Non-compressible Non-compressible Diameter Diameter ≥≥ 7 mm 7 mm No peristalsis No peristalsis - Appendicolith casting acoustic shadow - Appendicolith casting acoustic shadow - High echogenicity non-compressible - High echogenicity non-compressible surrounding fat surrounding fat - Surrounding fluid/abscess - Surrounding fluid/abscess - Oedema of caecal pole - Oedema of caecal pole

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Acute appendicitisAcute appendicitis

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Acute appendicitisAcute appendicitis

Acute appendicitis with appendicolith. Abscess formation & appendicolith.

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Acute cholecystitisAcute cholecystitis

• Plain abdominal film: - Gallstones seen in 20% - Duodenal ileus - Ileus of hepatic flexure of colon - Right hypochondrial mass due to enlarged gallbladder - Gas within the biliary system - Normal plain films in two-thirds of cases

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• Ultrasound imagingUltrasound imaging:: - A circumferential halo of low echogenicity - A circumferential halo of low echogenicity with thickening of the gallbladder wall with thickening of the gallbladder wall ( (Ø8-10mm) in fasting state.Ø8-10mm) in fasting state. - Indistinct contour to the gallbladder wall- Indistinct contour to the gallbladder wall - Fluid around the fundus of the gallbladder - Fluid around the fundus of the gallbladder - Gallstones casting acoustic shadow - Gallstones casting acoustic shadow - A distended gallbladder (a stone obstructing - A distended gallbladder (a stone obstructing

the cystic duct) the cystic duct) - Echogenic sediment in the lumen - Echogenic sediment in the lumen - Positive sonographic Murphy sign - Positive sonographic Murphy sign

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Acute cholecystitisAcute cholecystitis

6262

Emphysematous cholecystitisEmphysematous cholecystitis

• Etiology: Clostridium welchii• 30% of cases are diabetic• More common in men• Gas in the wall/lumen of the gallbladder (right

hypochondrium).• Gas in the bileducts in 20%• Obstructed cystic duct → enlarged gallbladder• Small-bowel fluid levels

6363

CHRONIC CHOLECYSTITISCHRONIC CHOLECYSTITIS

• Ultrasound imaging:

- A contracted gallbladder

- Sometimes, obliteration of the lumen

- Thickening of the gallbladder wall & strongly

reflective

- Cholelithiasis

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CHRONIC CHOLECYSTITISCHRONIC CHOLECYSTITIS

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CholangitisCholangitis

• Ultrasound imaging:

- The common bile duct (CBD) is thickened

& dilated, especially in the ampulla of vater

- Cholangitis abscess

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Acute pancreatitisAcute pancreatitis

• Plain chest film: - A left side pleural effusion - Basal parenchymal shadowing - Elevated left hemidiaphragm-unreliable

• Plain abdominal film: - Normal plain films in two-thirds of cases - Duodenal ileus → Gas in a dilated duodenal loop in the LLD - A gasless abdomen due to vomiting

cont…

6767

Acute pancreatitisAcute pancreatitis

- Generalised paralytic ileus

- Dilated loops of bowel (small bowel, terminal

ileum, ascending & transverse colon)

- Loss of the psoas outline

- Multiple small bubbles within the pancreas

(pancreatic abscess)

- Pancreatic calcification-unreliable

6868

• • Ultrasound signsUltrasound signs of a of acute pancreatitiscute pancreatitis:: - Contours: smooth & well delineated- Contours: smooth & well delineated - Enlargement - Enlargement - Echotexture: heterogeneous, hypoechoic to anechoic - Echotexture: heterogeneous, hypoechoic to anechoic & less echogenic than the liver & less echogenic than the liver - Associated signs: venous compression, pleural - Associated signs: venous compression, pleural effusion, ascites, duodenal atony effusion, ascites, duodenal atony

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ACUTE PANCREATITISACUTE PANCREATITIS

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- Complication: ♠ Necrotising pancreatitis → liquid/semiliquid tissue is spreading beyond

organ boundaries to the retroperitoneal,

pararenal space & the lesser sac of

the peritoneum)

♠ Pancreatic pseudocyst → A transonic mass

7171

• • CT signs of acute pancreatitisCT signs of acute pancreatitis: : - Necrosis, haemorrhage, & solid parenchyma that - Necrosis, haemorrhage, & solid parenchyma that enhances with i.v.contrast medium enhances with i.v.contrast medium - Abscess - Abscess - Pancreatic pseudocyst - Pancreatic pseudocyst - Extrapancreatic fluid collection - Extrapancreatic fluid collection - Ascites - Ascites

7272

CHRONIC PANCREATITISCHRONIC PANCREATITIS• Plain abdominal film: - Calcification

• Ultrasound imaging: - Atrophic/subnormal size - Contours irregular - Increased in echogenicity - The pancreatic duct is irregularly dilated (zipperlike pattern) & contains calculi - Complication: pseudocyst or thrombosis of the splenic vein, portal vein, or both.

7373

CHRONIC PANCREATITISCHRONIC PANCREATITIS

7474

INTRAMURAL GASINTRAMURAL GAS• Cystic pneumatosis = pneumatosis cystoides intestinalis

- Cyst-like collections of gas (Ø 0.5-3 cm) in the walls of hollow viscera.

- It is most frequently seen in the GIT (=pneumatosis cystoides intestinalis) in the left half of colon.

- Cysts rupture →pneumoperitoneum without evidence of peritonitis → unnecessary laparotomy!

7575

Pneumatosis cystoides Pneumatosis cystoides intestinalisintestinalis

7676

● ● Interstitial emphysemaInterstitial emphysema

- - Rare conditionRare condition

- Etiology: - Etiology: Gastroscopy, pyloric stenosis, & toxic megacolon Gastroscopy, pyloric stenosis, & toxic megacolon

- In toxic megacolon - In toxic megacolon → it is a sign of impending → it is a sign of impending perforation. perforation.

- Linear gas, in single/double streaks in the bowel - Linear gas, in single/double streaks in the bowel wall, & isn’t associated with infection. wall, & isn’t associated with infection.

7777

● ● Gas-forming infectionsGas-forming infections (gastritis, enterocolitis, cystitis) (gastritis, enterocolitis, cystitis)

Etiology: Etiology: E.coli, Clostridium welchii & Klebsiella aerogenes. E.coli, Clostridium welchii & Klebsiella aerogenes. Emphysematous gastritisEmphysematous gastritis:: - A contracted stomach, with a frothy/mottled - A contracted stomach, with a frothy/mottled radiolucency visible in the left upper abdomen radiolucency visible in the left upper abdomen due to gas within the stomach wall. due to gas within the stomach wall. - High mortality. - High mortality.

7878

Emphysematous enterocolitisEmphysematous enterocolitis:: - Premature babies/adults - Premature babies/adults - In an adult, has a grave prognosis - In an adult, has a grave prognosis

Emphysematous cystitisEmphysematous cystitis:: - More common in diabetics. - More common in diabetics. - Linear gas streaks & gas cysts within - Linear gas streaks & gas cysts within the wall of the urinary bladder. the wall of the urinary bladder. - Associated with gas within the lumen of - Associated with gas within the lumen of the bladder itself. the bladder itself.

7979

CALCIFICATION ASSOCIATED WITH CALCIFICATION ASSOCIATED WITH ACUTE ABDOMINAL CONDITIONSACUTE ABDOMINAL CONDITIONS

Calcification Acute conditionAppendix calculus AppendicitisGallstone Acute cholecystitis

Acute pancreatitisBiliary colicEmpyema of gallbladderGallstones ileus

Calcified gallbladder wall CholecystitisLimy bile CholecystitisCalculus in Meckel's, sigmoid Acute inflammation/perforationor jejunal diverticulumPancreatic calculi PancreatitisCalcified aneurysms RuptureTeeth/bone in ovarian dermoid TorsionUreteric, renal calculus Ureteric, renal colic

8181

BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMA

• The third most common organ injured in the abdomen.

• The need for surgery is determined by the size of the laceration, the amount of hemoperitoneum, & the patient’s clinical status.

• Ultrasound findings: - Laceration (3%) (right lobe > left lobe)

8282

- Intrahepatic hematoma: * Hyperechoic in the first 24 hours * Hypoechoic & sonolucent thereafter

- Subcapsular hematoma: * Unilateral, along the area of laceration * Anechoic, hypoechoic, septated lenticular, or curvelinear (DD/ascitic fluid)

- Capsular disruption

- Intraperitoneal fluid

8383

Ultrasound findingsUltrasound findings

A crescent-shaped hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.

8484

BLUNT HEPATIC TRAUMABLUNT HEPATIC TRAUMACT grading (blunt hepatic trauma)

Grade I Capsular avulsion, superficial laceration (s) (<1 cm deep),subcapsular haematoma (<1 cm thick), isolated periportal blood tracking

Grade II Parenchymal laceration (s) 1-3 cm deep, central/subcapsularhaematoma (s) 1-3 cm

Grade III Laceration (s) > 3 cm deep, central/subcapsular haematoma(s)> 3 cm

Grade IV Massive central/subcapsular haematoma (> 10 cm), lobartissue destruction (maceration) or devascularisation

Grade V Bilobar tissue destruction (maceration) or devascularisation

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8686


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SUBACUTE SUBCAPSULAR SUBACUTE SUBCAPSULAR HAEMATOMA OF THE LIVERHAEMATOMA OF THE LIVER

8888


8989

HEPATIC CONTUSION WITH HEPATIC CONTUSION WITH HAEMATOMAHAEMATOMA

9090

GALLBLADDER INJURYGALLBLADDER INJURY

9191

SPLENIC INJURYSPLENIC INJURY• Most commonly injured• Ultrasound findings: - Splenomegaly, with progressive enlargement - Irregular splenic border - Intrasplenic hematoma take longer - Contusion (splenic inhomogeneity) - Subcapsular and pericapsular fluid collections - Free intraperitoneal blood (disappear 2-4 weeks) - Left pleural effusion - When the spleen returns to normal → small irregular foci /normal parenchyma

9292

SPLENIC INJURYSPLENIC INJURYCT grading (blunt splenic trauma)

Grade I Capsular avulsion, superficial laceration (s) or subcapsularhaematoma < 1 cm

Grade II Parenchymal laceration (s) 1-3 cm deep, central/subcapsularhaematoma(s) < 3 cm

Grade III Laceration (s) > 3 cm deep, central/subcapsular haematoma(s)> 3 cm

Grade IV Fragmentation (> 3 segments), devascularised (non-enhancing)spleen

9393

SPLENIC INJURYSPLENIC INJURY

9494

HAEMOPERITONEUM HAEMOPERITONEUM (FRAGMENTED SPLEEN)(FRAGMENTED SPLEEN)

9595

BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURY

CT grading (blunt pancreatic injury)

Grade I Minor contusion or laceration without duct injury

Grade II Major contusion or laceration without duct injury or tissue loss

Grade III Distal transection or parenchymal injury with duct injury

Grade IV Proximal transection (to the right of mesenteric vein) or parenchymal injury involving ampulla

Grade V Massive disruption of pancreatic head

9696

BLUNT PANCREATIC INJURYBLUNT PANCREATIC INJURY

9898

Stomach and duodenum disorders:Stomach and duodenum disorders:

- Hypertrophic pyloric stenosis - Hypertrophic pyloric stenosis - Gastritis- Gastritis- Peptic ulceration - Peptic ulceration - Miscellaneous conditions (gastric volvulus, - Miscellaneous conditions (gastric volvulus, gastric diverticulum, duodenal diverticulum) gastric diverticulum, duodenal diverticulum) - - Benign tumours and malignant tumoursBenign tumours and malignant tumours- Duodenal atresia- Duodenal atresia- Duodenitis- Duodenitis- Duodenal ulcer- Duodenal ulcer

9999

MaagduodenographyMaagduodenography

100100

Hypertrophic pyloric stenosisHypertrophic pyloric stenosis

• Congenital abnormality of the pyloric musculature.

• Radiological findings: - Contrast studies: * Tit sign * Shoulder sign * String sign * Railroad track * Umbrella sign

101101


1.Tit sign, 2. shoulder sign, 3. string sign, 4. railroad track, 5. umbrella sign

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103103


- Ultrasound imaging: * A hypertrophied muscle layer (width of > 2 mm) is

hypoechoic to the adjacent liver, with a double line

of hyperechoic mucosa seen centrally.

* No transit of gastric contents into the duodenum

was observed

104104


Normal pylorusPyloric stenosis

105105

GastritisGastritis

• Classified into:

1. Superficial gastritis

2. Atrophic gastritis

3. Hypertrophic gastritis

• Radiographic appearances:

1. Superficial gastritis (involve mucosa):

- No detectable alteration

- Severe irregularity of the gastric folds

106106

2. Atrophic gastritis:2. Atrophic gastritis: - The stomach is usually rather long & tubular - The stomach is usually rather long & tubular - Fundus of the stomach appears like a small dome. - Fundus of the stomach appears like a small dome. - Mucosal folds in the fundus/body of the stomach - Mucosal folds in the fundus/body of the stomach are very thin (tissue paper folds) are very thin (tissue paper folds) - A very thin gastric wall - A very thin gastric wall - The greater curvature of the stomach is remarkably - The greater curvature of the stomach is remarkably smooth smooth

107107

3. Hypertrophic gastritis :3. Hypertrophic gastritis : - Marked enlargement of the mucosal fold - Marked enlargement of the mucosal fold (up to 1 cm in width) (up to 1 cm in width) - Irregularity of the greater curvature - Irregularity of the greater curvature - Marked thickening of the gastric wall - Marked thickening of the gastric wall - Peculiar reticular pattern of barium which - Peculiar reticular pattern of barium which mixes poorly with large amounts of mucus mixes poorly with large amounts of mucus - Gastric emptying is delayed - Gastric emptying is delayed

108108

Atrophic gastritisAtrophic gastritis

109109

Gastric ulcerationGastric ulceration

• Discontinuity in the mucous membrane of

the stomach with inflammatoory base.

• Roentgen signs of a benign ulcer:

1. Location: lesser curvature & adjacent part of the

posterior wall

2. Multiple

3. 4% of benign ulcers greater in diameter than 4 cm

4. Ulcer niche/’fleck’/spot

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5. Cartwheel configuration5. Cartwheel configuration = folds radiate from the ulcer like the spokes = folds radiate from the ulcer like the spokes on a wheel on a wheel

6. An incicura on the greater curvature opposite6. An incicura on the greater curvature opposite a gastric ulcer. a gastric ulcer.

7. The ulcer protrudes beyond the line of the lumen.7. The ulcer protrudes beyond the line of the lumen.

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112112

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8. Edematous ridge leads to the ulcer & surrounds8. Edematous ridge leads to the ulcer & surrounds it at its base: it at its base: - Hampton’s line - Hampton’s line - Ulcer collar - Ulcer collar - Ulcer mound - Ulcer mound

9. The association of a gastric ulcer with a duodenal ulcer9. The association of a gastric ulcer with a duodenal ulcer

10. 10. ± ± 80% heal within 4 weeks (rapid healing)80% heal within 4 weeks (rapid healing)

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Roentgen signs of a malignant ulcerRoentgen signs of a malignant ulcer::

1. Location: upper part of the greater curvature 1. Location: upper part of the greater curvature 2. Ulcer edges irregular 2. Ulcer edges irregular 3. Doesn’t protrude beyond the line of the lumen 3. Doesn’t protrude beyond the line of the lumen 4. Ulcer within a polypoid mass 4. Ulcer within a polypoid mass 5. Shallow ulcer surrounded by thick rigid fold 5. Shallow ulcer surrounded by thick rigid fold

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6. 6. The Carman-Kirklin meniscus signThe Carman-Kirklin meniscus sign:: Large ulcer niche ( Large ulcer niche (Ø Ø 3 to 8 cm) with an elevated 3 to 8 cm) with an elevated rolled margin: rolled margin: - In antrum: crater is crescentic toward lumen of - In antrum: crater is crescentic toward lumen of stomach stomach

- In body: crater is crescentic & curves away - In body: crater is crescentic & curves away from lumen of stomach from lumen of stomach

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Gastric ulcerationGastric ulceration

Benign ulcer Malignant ulcer

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Gastric diverticulumGastric diverticulum

• Protrusions of the mucosa & submucosa through

a congenitally weakened muscular coat.

• Location:

- posterior wall of fundus of the stomach (common)

- prepyloric (rare)

• Radiographic appearances (barium study):

- Size: few mm – 8 cm

- Single or multiple

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- Pocketlike structure attached to the inner- Pocketlike structure attached to the inner wall with a smooth outline wall with a smooth outline - The lining mucosa may show an area - The lining mucosa may show an area gastricae pattern gastricae pattern

• • ComplicationsComplications:: - Inflammation - Inflammation - Ulceration - Ulceration - Perforation - Perforation - Malignant degeneration - Malignant degeneration

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Gastric diverticulumGastric diverticulum

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Tumours of the stomach

• Benign tumours of the stomach: - Adenoma - Leiomyoma - Lipoma - Abberant pancreas - Inflammatory polyps, etc

Location: - pyloric portion (75%) - body (20%) - fundus & cardia (5%)

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Radiographic appearancesRadiographic appearances:: - A sharply circumscribed filling defect - A sharply circumscribed filling defect projecting within the lumen projecting within the lumen

• • Malignant tumours of the stomachMalignant tumours of the stomach:: Gross morphologic typesGross morphologic types:: - Ulcerative (28%) - Ulcerative (28%) - Fungating/polypod (22%) - Fungating/polypod (22%) - Spreading/infiltrating (13%) - Spreading/infiltrating (13%) - Remainder unclassifiable - Remainder unclassifiable

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Usual Usual histologic patternhistologic pattern: well-differentiated adenoca: well-differentiated adenoca

LocationLocation: pyloric & prepyloric regions: pyloric & prepyloric regions

Radiographic appearancesRadiographic appearances::1. Irregular filling defect.1. Irregular filling defect.2. Malignant ulcer within the filling defect.2. Malignant ulcer within the filling defect.3. A ‘leather bottle’ type stomach suggesting scirrhous ca.3. A ‘leather bottle’ type stomach suggesting scirrhous ca.

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Duodenal atresiaDuodenal atresia


* Plain film: ‘double bubble’ sign with an absence

of distal air

* Barium study: complete obstruction

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Duodenal atresiaDuodenal atresia

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DuodenitisDuodenitis


- A coarsening of the duodenal folds

- Erosions (en face): Dots of barium with/without

a radiolucent halo

- A ‘cobblestone’ appearance to the duodenal cap

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DuodenitisDuodenitis

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Duodenal ulcerDuodenal ulcer• 70% of peptic ulcers are in duodenum• 62% in the duodenal bulb• Occurs in 4% of gastrointestinal disturbances.• 75% in males• Radiographic appearances: - Single (80%)/multiple (20%) - Niche/fleck - Edematous mucosa - Fragmentation of bulb on compression - Bulbar deformity & irritability - Eccentric pylorus with widened rugae - Cartwheel rugae

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Duodenal ulcerDuodenal ulcer

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Duodenal diverticulumDuodenal diverticulum• Mucosal herniations through the muscle coat of the

duodenum

• Location: Periampullary, the third & fourth parts of the duodenum.

• Radiographic appearance: - Pocketlike structure attached to the inner

wall with a smooth outline - Often multiple

• Complications: haemorrhage, diverticulitis & perforation.

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Duodenal diverticulumDuodenal diverticulum

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Tumours of the duodenumTumours of the duodenum

• Benign tumours of the duodenum:

- Very rare

- Adenoma, papilloma, lipoma, fibroma, etc.

- Radiographic appearance:

Single smooth filling defect within duodenum

• Malignant tumours of the duodenum:

- Rare

- Carcinoma, malignant carcinoid, leiomyosarcoma

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Ulcerating leiomyomaUlcerating leiomyoma

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Chronic duodenal obstruction of the proximal portion of Chronic duodenal obstruction of the proximal portion of the fourth part of the duodenum due to the fourth part of the duodenum due to

a carcinoma of the duodenuma carcinoma of the duodenum

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Gastrointestinal Imaging

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