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Anatomy 4.

Radiologic Correlation- Abdomen

November 29, 2011


Dr. Lino Santiago Pabillo

OUTLINE
I. Imaging Modalities
II. Plain Abdomen
III. Contrast Study
IV. Ultrasound
V. Nuclear Scantigraphy
VI. CT scan
VII. Clinical Cases

I. IMAGING MODALITY
X-ray (tomography)
CT scan
Nuclear Scintigraphy
o Requires injection of radioisotope to the patient and the
machine detects where the isotope concentrates
Ultrasound
MRI
o Ultrasound and MRI are the most used for imaging the
abdominal cavity, as compared to thoracic cavity wherein the
X-ray is most used.

STRENGTH OF MODALITIES
Survey or preliminary study of the abdomen
o Plain X-Ray
SOLID structures/organs
o Ultrasound first choice
Cheap
does not use ionizing radiation
o CT
o MRI (open-type)
Alimentary Tract
o X-Ray (Contrast study)
But now it has been replaced by endoscopy

Figure 1. X-Ray of the Abdomen

III. CONTRAST STUDY


In studying the abdomen, barium sulfate suspension is used
o Ingested by the patient
o To contrast between the foreground and background
Important because it would emphasize the different structures by
looking at their boundaries (black lines)
What gives contrast? Black is air/fat.
o For psoas, contrast can be seen because of fat in the fascia
surrounding it. (same with liver and kidney)

CLINICAL CORRELATION
Densities on Plain Radiograph (x-ray)
Substances with higher atomic number are more white,
therefore, plain calcium is more white than bone
Why is contrast important?
-It is used for seeing the border or boundaries of the structures,
thus, it enlargement or atrophy can be detected

II. PLAIN ABDOMEN


Look at the bones, soft tissues, retroperitoneal and
intraperitoneal, intestinal tract patterns
o you can see triangular structure: Psoas
Look at x-ray images as if you are facing the patient.
For a cross-sectional image, look as if the patient is lying supine
and you are standing from the foot
o Posterior: down
o Anterior: up
o Right: right
o Left: left
*based on your point of view
RG, Sopie, Keifer, Tasie, Fille, Jana

Figure 2. X-ray of colon with contrast

Significance
o If you have a severely malnourished patient without
body fat, you might not be able to see these
structures.
o Clearly seen in obese because of the abundant fat
present in the fascia

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INTESTINAL PATTERNS
Presence of gas
o swallowed air
o from bacterial fermentation in colon
In pediatrics, gas would be absent in the alimentary tract
because it is filled with fluid. There would only be gas once
the baby starts to cry. The gas would stay there in 24 hours
before it reaches the rectum.
In normal adults, gas seen in the stomach and colon only
but not in the small intestine (SI) because peristalsis is
faster in the SI.
o If you see gas in the SI, it could mean that
peristalsis has stopped
there is blockage that prevents the passage of air to
the colon

Duodenal C-Loop
o Inside the C-loop, youll find the Pancreatic Head

Figure 5. Small intestines: Small bowel series.

Enteroclysis/Small bowel series


o fluoroscopic x-ray of the small intestines

Figure 3. Esophagogram (Esophagus)

Figure 6. Colon: Lower GI series.

Barium enema insert a tube at the rectum and inject contrast


material to visualize the colon and appendix

Figure 4. Stomach

Lesser curvature
o straight
o Magenstrasse (German: main street)
directs the flow of gastric acids gastric acids would be at
the lesser curvature, at the area of pyloric antrum
Peptic ulcer (rapture): Pyloric antrum (lesser curvature
aspect raptures air in the stomach escapes air goes to
the lesser peritoneal cavity since the lesser sac is posterior to
the stomach
Greater curvature
o Mucosal pattern: whirl pattern (?)
RG, Sopie, Keifer, Tasie, Fille, Jana

Figure 7. Biliary tree:


Endoscopic Retograde Pancreatico Cholangiopraphy (ERC)

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Endoscopic Retograde Pancreatico Cholangiopraphy (ERC)


o insert through the mouth move the scope to the area of the
duodenum look for the Ampulla of Vater (medial portion of
nd
the 2 part of the duodenum) inject the contrast medium
o outlines of the biliary tree, common bile duct, common hepatic
duct, etc.
Oral cholecystogram
o not used anymore because the contrast solution used is no
longer available

Figure 10. A few vascular structures of the Abdomen.

Figure 8. Biliary tree: Percutaneous Transhepatic Cholangiogram

Percutaneous Transhepatic Cholangiography (PTCA)


o inject a long needle into the liver inject contrast medium
hoping that you would hit a branch of the biliary tree.
o Some inject it 4 or more times

Celiac trunk
o Only vascular structure that forms the letter T
Superior mesenteric artery 1 cm below Celiac trunk
o anterior: pancreas
o curves downwards
Inferior mesenteric artery
Splenic vein
o With inferior mesenteric vein forms the portal vein
o The only vein that moves from R to L
Portal vein part of the portal triad
o Anterior: common bile duct or main bile duct (in
ultrasound)
Portal triad (extrahepatic)
o Portal vein
o Hepatic artery
o Common bile duct
Duodenum
st
o duodenal bulb 1 part
o Descending
rd
o Horizontal/transverse 3 part
passes between aorta and superior mesenteric
artery
passes between IVC and Superior mesenteric vein
o Ascending

Figure 9. Magnetic Resonance Cholangiography (MRCP)

Magnetic Resonance Cholangiography (MRCP)


o Less invasive but very expensive

LANDMARKS
Useful in identifying different structures of the abdomen
Vascular structures are the most reliable ones (know them by
heart!)

RG, Sopie, Keifer, Tasie, Fille, Jana

In US or CT
To identify the common hepatic duct:
Look for portal vein (big structure)
o Anterior: main bile duct it is called as such
because you cant differentiate the common
hepatic duct and common bile duct
o Cystic duct is the boundary of common bile duct
and common hepatic duct
o To identify cystic duct: look for spiral valves of
Heister
Pancreas anterior to splenic vein (?)

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IV. ULTRASOUND
ABDOMINAL AORTA

It predominantly flows up the right paracolic gutter which is


deeper and wider than the left and is partially cleared by the
subphrenic lymphatics.

Figure 12.Peritoneal Compartments

There are watershed regions in the peritoneal cavity that are areas of
fluid stasis:
Ileocolic region
Root of the sigmoid mesentery
Pouch of Douglas

Figure 11. Ultrasound of the Aorta


*The images here were taken from the lectures ppt. It takes a lot of
practice to see vessel in an ultrasound. Imagine niyo na lang guys.

2 branches close to aorta:


o celiac trunk (superiorly)
o superior mesenteric artery (just below celiac trunk)
All fluid containing structures would appear as black.
Left renal vein
o only branch of IVC that goes between the aorta and superior
mesenteric artery
Right renal artery
o branch of the aorta that goes behind the IVC

CLINICAL CORRELATION
When you are staging a patient for gastrointestinal malignancy
you have to look for disease in these areas of stasis.
Clearly the surgeons do better in finding subtle disease in these
areas.
Peritoneal metastasis usually occurs in the RLQ because of the
normal circulation of the peritoneal fluid from left to right side
of the abdomen.

V. NUCLEAR SCINTIGRAPHY
Differs because here, you inject the radioactive isotope into the
patient.
The machine records the location where the isotopes would
concentrate (BLACK SPOTS)
GAMMA Camera

PERITONEAL CAVITY
3 Important Structures:
Transverse Mesocolon
Sigmoid Mesocolon
Root of Mesentery

Peritoneal circulation
Compartments enable the peritoneal cavity to have a
normal circulation for peritoneal fluid.
The normal abdomen without intraperitoneal disease, a
small amount of peritoneal fluid continuously circulates.
Fluid in the peritoneal cavity is normal, it is not static and
circulates in the cavity.
Movement of fluid in this circulatory pathway is produced
by the movement of the diaphragm and peristalsis of
bowel.

RG, Sopie, Keifer, Tasie, Fille, Jana

Figure 13. Scintigraphy scan of the abdomen

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Densities in X-ray
Depends on how black or how white the image is
What is responsible in making the image black or white?
o ATOMIC NUMBER
High Z atoms would appear white.
Bone can be seen in the x-ray since it contains Ca.
However it is not as white as barium sulfate, since the
bone is composed of Ca (not purely made) in proteinrich matrix.
Black substances that allow x-ray to pass through and
interact with the film

Computerized Axial Tomography


a sensitive method for diagnosis of abdominal diseases.
It is used frequently to determine stage of cancer and to
follow progress.
A useful test to investigate acute abdominal pain.

VI. CT SCAN
Figure 15. Diaphragmatic Hernia

Figure 14. CT scan of the Peritoneal Cavity

VII. CLINICAL CASES


DIAPHRAGMATIC HERNIA

Bochdalek type 3Ls


o Left
o Lateral
o Likod (posterior)

Morgagni type (MARgagni)


o Median
o Anterior
o Right

RG, Sopie, Keifer, Tasie, Fille, Jana

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