PENGANTAR GASTROINTESTINAL IMAGINGZainuddin Moh

IMAGING STUDY

A. X RAY :

1. PLAIN FILM /BOF

2. ABDOMEN 2/3 POSISI

3. Intraluminal Kontras study

B. USG

C. CT / MRI SUPINE

Plain abdominal x-ray

Systemic approach :

1. Identity

2. Posotiton and condition

3. Study of abdominal wall,Solid organs, hollow organs and

bones

Solid organs

1. Liver

2. Spleen

3. Kidneys

4. Psoas Muscles

5. Bladder

6. Uterus

7. Prostate

Hollow organs

1. Stomach –

2. Small Bowel –

– Gas will be seen in polygonal shapes due to perstalsis.

– Normal small bowel is 2.5 to 3.0 cm in diameter.

– Valvulae may be seen crossing the entire lumen.

– Often little small bowel is seen on a plain film.

3. Appendix - Occasionally an appendicolith is seen.

4. Colon –

– It may be filled with air or faeces.

– Shape may altered by redundant bowel.

– The colon is in the periphery of the

abdomen

Normal Calcification

1. Costal cartilage

2. Mesenteric lymph nodes

3. Pelvic vein phleboliths

4. Prostate gland

Abnormal intraluminal gas

Abnormal gas can be :

(a) intraluminal, in the stomach, duodenum,

and intestine, or

(b) extraluminal

Large bowel obstruction and paralytic ileus

• diameter of more than 5 cm suggests a large bowel obstruction

• the appearance of a "cut off" point on the radiograph (fig 1). is indicative of a mechanical large bowel obstruction.

( lihat slide 1)

Small bowel obstruction

• dilated small bowel loops are seen centrally on the radiograph

• diameter is greater than 3 cm but usually less than 5 cm.

• no gas should be seen within the large bowel

• An erect film tends to show multiple small fluid levels, a "stepladder" appearance (slide 2).

Comparison of large and small bowel obstruction features

Feature Small bowel Large bowel

Bowel diameter (cm) >3 and < 5 >5

Position of loops Central Peripheral

Number of loops Many Few

Fluid levelsMany, short Few, long

(on erect film)

Bowel markings Valvaulae Haustra

( all the way across) (partially across)

Large bowel gas No Yes

Volvulus

• twisting of bowel about its mesentery

• The two most common sites are the sigmoid and the caecum.

• With a sigmoid volvulus=> look like a coffee bean

• In caecal volvulus =>"empty caecum"

Toxic megacolon

• grossly dilated large bowel, typically the transverse colon, with "thumb printing" evident .

Duodenal obstruction, congenital or acquired

- appearance of two gas bubbles =>"double bubble" sign.

Meteorism (excessive swallowed air)

• prominent bowel loops,

• there is no cut off point: the bowel has been likened to crazy paving (slide 3)

INTRALUMINAL KONTRAS STUDIES

• Esophagogram

• Omd/oesophagus,magh,duodenum

• Ba.follow through.

• Colon in loop

Three types of barium x-ray procedures, including the following:

1. barium enema (also called lower GI series)

Barium enemas are performed in two ways

single-contrast image - when the entire large intestine is filled with barium liquid. Single-contrast images show

prominent abnormalities in the large intestine.

double-contrast image - when a smaller quantity of thicker barium liquid is introduced to the large intestine,

followed by air.

2. barium small-bowel enema (also called enteroclysis)

3. barium swallow (also called upper GI series)

Barium Swallow: the hypopharynx esophagus –Duodenum.

• Pemeriksaan pharynk – oesophagus-magh-duodenum.

• Tujuan pemeriksaan :

evaluate digestive function and to detect:

1. ulcers

2. Tumors

3. inflammation of the esophagus, stomach

and duodenum

4. hiatal hernias

5. scarring

6. blockages

7. abnormalities of the muscular wall of

gastrointestinal tissues.

Indikasi

1.difficulty swallowing

2.chest and abdominal pain

3. reflux (a backward flow of partially digested food

and digestive juices)

4.unexplained vomiting

5.severe indigestion

6.blood in the stool (indicating internal GI bleeding

Benefits

– extremely safe, noninvasive procedure.

– accurate analysis of the esophagus, stomach and duodenum.

– allergic reactions are rare.

– No radiation remains in a patient's body after an x-ray examination.

– X-rays usually have no side effects.

Risks

1. There is always a slight chance of cancer from radiation

2. The effective radiation dose from this procedure is about 2 mSv, =which is about the same as the average person

receives from background radiation in eight months.

3. may be allergic to the flavoring added to some brands of barium.

4. some barium could be retained, => blockage of the digestive system..

Normal Swallowing Physiology

Normal swallowing physiology is dependent upon:

1. rapid neuromuscular coordination of 26 muscles,

2. 6 cranial nerves (V, VII, IX, X, XI, XII),

3. 3 cervical nerves.

Swallowing can be subdivided into four sequential phases:

1. oral preparatory,

2. oral,

3. pharyngeal, and

4. esophageal.

Food Impactions & Foreign Bodies in the Esophagus

• Gastric antrum (patient LPO)

• Gastric body, inferior portion (patient supine,

AP)

• Fundus (patient right lateral)

• Gastric body, superior portion (patient RPO)

• LPO position

• AP (supine)

• RPO

• right anterior oblique (RAO) position

• Gastric antrum (patient LPO)

• Gastric antrum/body (patient LPO or AP)

• upper g.i. tract biphasic-contrast exam

Lower GI.Tract X-ray (Barium Enema "BE")

• Pemeriksaan x ray usus besar /colon.

• Tujuan to detect:

1. ulcers

2. benign tumors (such as polyps)

3. cancer

4. signs of other intestinal illnesses.

Indikasi colon in loop

1. chronic diarrhea

2. blood in stools

3. constipation

4. irritable bowel syndrome

5. unexplained weight loss

6. a change in bowel habits

7. suspected blood loss.

Benefits

1. X-ray imaging of the lower GI tract is a minimally invasive procedure with rare complications.

2. Radiology examinations such as the lower GI can often provide enough information to avoid more invasive

procedures such as colonoscopy.

3. Because barium is not absorbed into the blood, allergic reactions are rare.

4. No radiation remains in a patient's body after an x-ray examination.

5. X-rays usually have no side effects.

Risks

1. There is always a slight chance of cancer from radiation.

2. The effective radiation dose from this procedure is about 4 mSv, which is about the same as the average person

receives from background radiation in 16 months.

3. the barium could leak through an undetected hole in the lower GI tract => inflammation in surrounding tissues.

4. the barium can cause an obstruction in the gastrointestinal tract, called barium impaction.

5. Teratogenic for pregnant Women.

Types of Enema

Indications for double contrast (air contrast) barium enema :

1. Rectal bleeding - gross or occult

2. Polyps or carcinoma - suspected or known Inflammatory bowel disease - suspected or

3. Patient over 40 years of age who can cooperate and turn over without assistance

Indications for single contrast barium enema :

1. Patient under 40 years of age with abdominal signs or symptoms not suggestive for polyps, colitis, or bleeding (i.e.,

pain only, bloating only) 

2. Suspected diverticulitis   

3. Bowel not prepared but limited exam requested to verify or exclude obstruction, volvulus, appendicitis, fistula,

etc.   

4. Uncooperative, disabled, very old, or very ill patient unable to tolerate or perform the maneuvers required for a

double contrast study

Contraindications to barium enema of any type :

1. Suspected acute perforation 

2. Acute, fulminating colitis

3. Immediately after biopsy

Double Contrast (Air Contrast) Barium Enema

Indications

1. Rectal bleeding - gross or occult

2. Polyps or carcinoma - suspected or known

3. Inflammatory bowel disease - suspected or known

4. Patient over 40 years of age who can cooperate and turn over without assistance

Contraindications

1. Suspected acute perforation

2. Acute, fulminating colitis

3. Immediately after biopsy

Defecography (Evacuation Proctography)

Indications

1. Obstipation

2. Unexplained rectal bleeding or mucous discharge

3. Suspected rectal intussusception or prolapse

4. Feeling of incomplete evacuation or anal blockage

5. Rectal tenesmus (painful, long-continued, and ineffective straining at stool)

6. Necessity of special maneuvers, such as self-digitation, to obtain rectal evacuation

7. Fecal incontinence or soiling

8. Solitary rectal ulcer

9. Comparative evaluation of anorectal function before and after medical treatment (biofeedback) or surgery

(rectopexy, post-anal repair)

KELAINAN KONTRAS STUDY

1. Filling defect.

2. Addiitional defect.

3. Pelebaran.

4. Penyempitan.

KELAINAN ESOPHAGUS

• Diverticle

• Achalasia

• Hiatal hernia

• Reflux esophagitis

• Tu sphagus

• Varices

• Extrinsic Mass

KELAINAN GASRODUODENAL

• Pendesakan mass extrinsic

• Volvolus

• Kelainan struktur (hps,diverticle)

• Peptic Ulcer

• Gastritis

• Tu gaster

Small Intestine Abn

• Congenital (diverticle,cyst).

• Inflamasi ( tbc ,chron disease).

• Neoplasma.

• Small bowl obstruction.

KELAINAN PD COLON

Kelainan conginetal

– Anorectal anomali (aresia )

– Microcolon.

– Hirschprung disease.

– Idopatic megacolon

Inflamasi colon:

1. Colitis

2. Ulceratif colitis

3. Chron disease

4. Ischemic colitis

B. Diverticle

C. Tu.colon (benign vs malignant )

Ultrasound - Abdomen

Performed to evaluate the:

1. Kidneys and adrenal

2. liver

3. gallbladder

4. pancreas

5. spleen

6. Peritonium/retroperitonium (aorta )

7. GIT

Diagnose a variety of conditions, such as:

1. abdominal pains

2. inflamed appendix

3. enlarged abdominal organ

4. stones in the gallbladder or kidney

5. an aneurysm in the aorta

CT-

Scan

• Bisa menilai kondisi intralumnal maupun extraluminal.

• Organ sekitar dan organ lain dapat dinilai

• Staging penyakit lebih detail.(penyebaran lokal maupun jauh terdeteksi )