Surgical Pathology & X-rays

for

Medical Students
2008

GIT-3
Small intestine Colon Rectum & anal canal

Abnormal gas patterns in plain X-ray abdomen

GIT 3

The intestinal tract of normal adults generally contains less than 200 cc of gas
Five gases make up greater than 99% of gas passed per rectum. These are N2, O2, CO2, H2, and CH4

There are three sources of intestinal gas

Air swallowing
depends upon the position of the patient and the level of anxiety of the patient Bedridden patients, for example, may be unable to eructate swallowed air, thus allowing it to pass distally into the GIT
3

Bacterial production
Bacterial metabolism is the source of hydrogen and methane production Certain foodstuffs, (e.g.beans) deliver nonabsorbable carbohydrates to the colon where bacterial metabolism produces both hydrogen and methane.

Diffusion from the blood

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Normal plain X-ray film of the abdomen, demonstrating soft tissue densities
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Normal plain X-ray film of the abdomen demonstrating the bowel gas pattern
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The radiographic evaluation of intestinal gas should include the following points: what segment of bowel contains the gas Identify gut mucosa outlined by the gas Most distal point the gas has passed in the intestine Dimension of the air-filled gut
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In the supine position:

Gas normally accumulates in the anteriorly placed segments of intestine: the distal stomach, transverse colon, and sigmoid colon.
Gas within the remainder of the colon, particularly the rectum, is not uncommon

The gas-filled gut that in the most superior portion of the abdomen on the
supine film is usually the stomach The transverse colon lies immediately inferior Ascending and descending portions of the colon occupy the right and left lateral most portions of the abdominal cavity Air in the sigmoid colon tends to occupy a lower mid-line position, but because of variations in the length of the sigmoid mesocolon may extend into the upper mid-abdomen as well

Rectal air occupies a mid-line pelvic position

Small intestinal gas tends to accumulate in the mid-abdomen, framed by the colon
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Gas in stomach

Gas in a few loops of small bowel

Stomach: Always Small Bowel: Two or three loops of non-distended bowel

Normal diameter = 2.5 cm = 1 US quarter

Gas in rectum or sigmoid

Large Bowel: In rectum or sigmoid almost always

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Normal Gas Pattern

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Always air/fluid level in stomach

A few air in small bowel

Erect Abdomen
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The distinction between colon and small bowel

The position of the bowel is helpful. Small bowel is central while colon is peripheral (frame)
The gas may outline the colonic haustra or intestinal plicae circulares. Haustra tend to be two to three millimeters wide, and occur at centimeter intervals. Plicae circulares are approximately one millimeter wide and occur at millimeter intervals.
Extension of either of these soft tissue lines across the entire width of the lumen is not the only helpful point of distinction. The width of the lines, spacing, and location of the bowel loop are felt to be more helpful

Occasionally the distinction between colon and small bowel cannot be determined and a contrast study is necessary
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Normal Bowel Gas Pattern:

Air is seen in nondilated loops of small and large bowel. Small loops are centrally located, and colon is distributed peripherally like a picture frame.
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Plain X-ray supine : Small intestinal obstruction Small bowel loops are distributed centrally in the abdomen and have mucosal folds that cross the entire lumen of the bowel. These folds are called valvulae conniventes or plica circularis and are visible in gas-filled loops
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The colon gas pattern is usually distributed like a picture frame around the periphery of the abdomen. Colonic loops contain haustrations which do not extend all the way across the lumen of the bowel
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Large vs. Small Bowel

Large Bowel

Peripheral Haustral markings don't extend from wall to wall Central Valvulae extend across lumen Maximum diameter of 2"

Small Bowel

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This is a normal plain X-ray abdomen in the supine position In supine X-rays of the abdomen we look for: Free air Air-fluid levels

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Abnormal Gas Patterns

Functional Ileus

Localized (Sentinel Loops)

Generalized adynamic ileus

Mechanical Obstruction

SBO LBO

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Plain X-ray Abdomen - Postoperative adynamic ileus

Supine Erect

Multiple loops of minimally dilated small bowel with air fluid levels at different levels within the same loop of intestine on the upright (103-2) film. There is a GIT 3 16 small amount of gas in the right colon

Plain X-ray abdomen (erect

position)

Multiple fluid levels

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Plain X-ray abdomen (erect

position)

Multiple fluid levels

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Mechanical Small bowl obstruction (supine position)

Dilated small bowel Frequent audible intestinal sounds (Fighting loops) 19 Little gas in colon, especially rectum
Key: disproportionate dilatation of SB

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Plain X-ray- Small bowel obstruction secondary to adhesions

Supine
The supine view of the abdomen demonstrate dilated small bowel without 20 any air in the colon

Erect
Erect Film shows a large amount of fluid within the small bowel. There are multiple
in 3 small pockets of air arranged in a line noted GITthe left lower quadrant (residual colonic gas)

Small intestinal illius Plain abdominal radiograph: Inverted Ushaped, gaseous, dilated small bowel loops can be observed above one another (arrows) in the middle of the abdomen. The double arrow points to an air-fluid level in the intestines

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Mechanical SBO
Causes

Adhesions Hernia* Volvulus Gallstone ileus* Intussusception

*Cause may be visible on plain film

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Mechanical LBO
Key Features

Dilated colon to point of obstruction

Little or no air in rectum/sigmoid

Little or no gas in small bowel, if

Ileocecal valve remains competent

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Mechanical large bowel obstruction

Dilated colon to point of obstruction Little or no air in rectum/sigmoid

(according to the site of obstruction)

Little or no gas in small bowel, if 24 Ileocecal valve remains competent

Tumor (CA colon) Volvulus (Sigmoid) Hernia (strangulated) Intussusception

Diverticulitis
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Sigmoid carcinoma causing colon obstruction

Supine

Erect

Multiple dilated loops of bowel with scattered air fluid levels on the upright film. The caliber and location of the bowel loops suggest that the air is within the colon. There is some small intestinal gas noted 3 in GIT 25 the right mid abdomen, but the preponderance of air is in the colon. There is little rectal gas present

Barium enema of the same patient shows an abrupt obstruction at the level of the sigmoid colon

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Large bowl obstruction (supine position)

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History: Elderly man with new onset of abdominal pain Physical exam: distended, tympanitic abdomen

Diagnosis: Sigmoid Volvulus In sigmoid volulus, the colon appears as a dilated, inverted U-shaped loop which extends from the pelvis into the mid-upper abdomen. (coffee bean sign)

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Sigmoid Volvulus Most common colonic volvulus Water soluble enema confirms distal obstruction

If discovered early, colonoscopic decompression is usually effective

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Volvulous of the sigmoid colon

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Volvulous of the sigmoid colon

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Generalized adynamic ileus

Supine

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Generalized Adynamic Ileus

Gas in dilated small bowel and large bowel to rectum Long air-fluid levels 33 Only post-op patients have generalized ileus

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Plain X-ray abdomen

Supine Both mucosal and serosal surfaces of bowel wall are outlined by gas indicating that there must be free gas in the peritoneal cavity Pneumoperitoneum
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Pneumoperitoneum
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Intestinal obstruction
Dynamic
Peristalsis is working against mechanical obstruction

Adynamic
Absent peristalsis Paralytic ileus

Intraluminal

Impacted faeces Foreign body Malignant or inflammatory stricture Peritoneal bands Strangulated hernia Volvulus, Intussusception Nonpropulsive peristalsis Mesenteric vascular occlusion

Intramural Extramural

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Dynamic obstruction
Symptoms of intestinal obstruction
Abdominal pain Distension Vomiting Absolute constipation

These symptoms will vary according to the site of obstruction

Clinical types of obstruction

Small bowel obstruction
High Early profuse vomiting (Rapid dehydration) Minimal distension Minimal fluid levels in37 abdominal X-ray Low Vomiting is delayed Distension is early & marked

Large bowel obstruction

Pain is predominant with central distension

Multiple central fluid levels in x-ray

Pain is mild
Vomiting & dehydration are late
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The clinical picture of intestinal obstruction is also influenced by whether the presentation is: Acute
Usually in small bowel obstruction
Sudden onset of severe colicky central abdominal pain & distension Early vomiting & constipation
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Chronic
Usually in large bowel obstruction
Lower abdominal colic & constipation Followed by distension

Acute on chronic
Short history of distension & vomiting on top of background of pain & constipation

Subacute
Incomplete obstruction

Pathophysiology
Above obstruction Distension is due to: Gas produced by overgrowth of organisms Fluid of digestive juices which is not absorbed Obstruction Below obstruction

Proximal peristalsis increases to overcome obstruction (increases intestinal sounds) If obstruction is not relieved, the bowel will dilate, peristalsis will decrease With more dilatation the bowel becomes flaccid & paralyzed
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The bowel has normal peristalsis & absorption until it becomes empty, then becomes immobile
Dehydration & electrolyte loss are due to:

Reduced oral intake

Defective intestinal absorption Vomiting Fluid sequestration in bowel lumen
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Examples of dynamic obstruction

Extramural Peritoneal bands Strangulated hernia

Volvulus, Intussusception

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Peritoneal bands

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Small bowel obstruction secondary to intraperitoneal fibrous band adhesion

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Intestinal Obstruction Small Bowel Infarction secondary to intraperitoneal fibrous band (Late presentation
irreversible intestinal ischemia)

The commonest cause of inrtaperitoneal bands is previous inrtaperitoneal operation. e.g. : appendectomy, exploration,..
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Small bowel obstruction

Central distension of small intestinal loops. Note the metal clips of a previous operation

Erect: Multiple fluid levels

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Strangulated hernia

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Strangulated femoral hernia causing intestinal obstruction

1 3

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Small intestinal strangulation

Strangulated femoral hernia

This loop of intestine was strangulated within a hernia.

How would you know that this loop is viable or not?

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Strangulated para-umbilical hernia

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Small intestinal gangrene

This gangrenous loop of small intestine was strangulated within a hernia.

What was the possible clinical presentation of this patient?

What is the next step in management?
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Intussusception

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Small bowl Intussusception

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More pictures for intussusception will come later

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Small bowel obstruction

Erect: Multiple fluid levels

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Supine:
Central distension of small intestinal loops
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Volvulus

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Sigmoid volvulus

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Sigmoid volvulus

(late irreversible gangrene)

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Small bowl volvulus

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Examples of dynamic obstruction

Intramural

Malignant or inflammatory stricture

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Chronic intestinal obstruction due to CA descending colon

Ba enema shows the shadow of the mass Dilated intestinal loops are seen

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Ba enema:
Dilated bowel loops proximal to the obstruction. Arrow points to the etiology of obstruction
The ilio-cecal valve in this patient is incompetent

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Examples of dynamic obstruction

Intraluminal

Impacted faeces Foreign body

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Fecal impaction
As a result of chronic constipation, the patient is unable to expel stools, it further accumulates into a larger, harder mass that is impossible to pass by normal defecation.

Impaction is most common in inactive elderly people

Symptoms include chronic constipation. There can be fecal incontinence and paradoxical diarrhea as liquid stool passes around the obstruction
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Foreign body
Phyto-bezoar in the jejunum

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Peritonitis:
Generalized Localized
Usually due to spreading inflammation across the wall of an intraabdominal viscus

Primary Infection of the peritoneal fluid without intra-abdominal disease:

Haematogenous spread Lymphatic spread Direct spread: usually associated with CAPD catheters Ascending infection: from the female genital tract

Secondary Inflammation of the peritoneum arising from an intra-abdominal source:

Infectious Non-infectious Blood Ischaemia Bile Chemical Foreign body Perforation

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Patho-physiology of peritonitis
Early: hyperemia & fluid transudate

Normally, the greater omentum changes its position with intestinal peristalsis & abdominal muscles contraction Peritoneal inflammation will suppress peristalsis & abdominal muscles contractions

protein-rich fibrinous exudate The exudate will suppress peristalsis (paralytic ileus), and limits
spread of infection

The greater omentum will adhere to & surround the inflamed organ preventing
further spread of inflammation

Clinically: Early: Guarding, rebound tenderness, decreased or absent intestinal sounds 63

Ileus --- fluid accumulates within the intestine + intraperitoneal exudate --- decreased intravascular volume --- hyopvolemia
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The most common cause of generalized peritonitis is perforation of an intraabdominal viscus

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Generalized peritonitis with fibrinous exudate

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Infarction:
Aetiology of infarction

Area of ischemic necrosis caused by impaired arterial supply or venous drainage

Occlusive
Arterial: Embolism Thrombosis Extrinsic compression Venous: Thrombosis Extrinsic compression

Non-occlusive
Shock: Hypovolaemia Cardiogenic Sepsis 66 Vasoconstrictor drugs

Arterial mesenteric vascular occlusion

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Infarction of small intestine

Compare the dark red to grey infarcted bowel with the pale pink normal bowel at the bottom. Some organs such as bowel with anastomosing blood supplies, or liver with a dual blood supply, are hard to infarct. This bowel was caught in a hernia and the mesenteric blood supply was constricted by the small opening to the hernia sac.
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What other causes can result in such massive intestinal infarction?

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Mesenteric vascular occlusion

Irreversible small bowl ischemia

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Mesenteric ischaemia

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Intussusception

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Intussusception (Ileo-ileal)

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Intussusception (Ileo-ileal)

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Intussusception (Ileo-ileal) - postmortum

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Intussusception

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Intussusception (Ileo-ileal)
Redcurrent jelly stools

What are the early clinical features of a child presenting with intussusception?
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A child of about 6 months old, develops sudden onset of screaming with drawing of the legs. The attacks are recurrent. Vommiting may occure early, stools may be normal first, then the child GIT 3 passes blood & mucous

Intussusception of ileum into the colon

The leading proximal, small bowel segment (intussusceptum) telescopes into the distal, colon segment (intussuscipens).
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The small intestine (blue arrow) is going into the large intestine (green arrow)

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Intussusception (Ileo-colic)

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Barium enema with rectal instillation under fluoroscopy is the gold standard for both diagnosing and reducing childhood ileo-colic or colocolic intussusception
Transverse colon

Barium enema showing intussusception Passing from the rectum, the barium fills the colon untill a mass is noted (the 78 intussusception)

Barium enema is used for reduction of the intussusception It is about to be completely reduced (note the barium is going GIT 3 into the small intestine)

Barium enema for diagnosis & reduction of intussusception

Head of intussusception is at hepatic flexure

Partial reduction

Free flow of contrast into distal small bowel indicates complete reduction
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Barium enema Intussusception (Claw sign)

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The rectally administered contrast material draws around the head of the intussusception (arrow) (Claw sign)

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Barium enema

Intussusception (Claw sign)

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Barium enema
Intussusception (Claw sign)

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Small Intestine
Other pathological conditions

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Meckels diverticulum

Inflamed

Remember the complications of Meckels diverticulum

Infection & obstruction (as the
appendix)
May contain gastric, colonic or pancreatic tissue usually at the diverticulum mouth Peptic ulceration with severe bleeding Intussusception 86 Intestinal obstruction (band between umbalicus & diverticulum)
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Meckels diverticulum

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Meckels diverticulum

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Crohns Disease

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Regional enteritis

Remember that symptoms & signs of acute Crohns resemble acute appendicitis Chronic Crohns can cause enteric 90 strictures & fistulae
GIT 3 Deep linear mucosal ulcerations, with edema of the mucosa between the ulcers

The Appendix

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Normal appendix (postmortem)

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Acute appendicitis with gangrenous tip

Various positions of appendix in order of frequency: 1. Retrocecal 74% 2. Pelvic 21% 3. Paracecal 2% 4. Subcecal 1.5% 5. Preileal 1% 6. Postileal 0.5% 7. Sub-hepatic
8. Lt. iliac fossa in situs invertus

How can different positions alter the classical clinical 93 picture?

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Acute Appendicitis

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Acute Appendicitis

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Acute Appendicitis
Note flakes of pus

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Acute Appendicitis
Opened to show fecalith inside

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Regarding appendicitis a. The risk of developing the illness is greatest in childhood b. Mortality increases with age and is greatest in the elderly c. 20% of appendices are extraperitoneal in a retrocaecal position d. Faecoliths are present in 75-80% of resected specimens e. Appendicitis is a possible diagnosis in the absence of abdominal tenderness
All answers are correct. Pelvic appendicitic can present with few abdominal symptoms & signs. Rectal examination is t he key to diagnosis. GIT 3 98

Acute peritonitis
The loops of bowel are plastered together with yellowish fibrinous exudate containing a large number of neutrophils. What are the factors that favor the development of diffuse peritonitis?

When this process heals, what complications may develop?

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Subphrenic abscess
A pocket of infection has developed beneath the diaphragm elevating it as seen on the chest x-ray

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Colon

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Diverticular disease of the colon

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Sigmoid Colon Most Common Site Diverticula are small (0.5 to 1.0 cm in diameter) outpouchings of the colon that occur in rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric taeniae. At the sites of most diverticula, the muscular layer is absent (see Figure 1). Technically, such lesions are really pseudodiverticula; true diverticula (which are much less common than pseudodiverticula) involve all layers of the bowel wall. Nevertheless, both pseudodiverticula and true diverticula are generally referred to as diverticula Diverticula are located at sites where blood vessels enter the colonic wall The sigmoid colon is the most common site of diverticula: in 90% of patients with diverticulosis, the sigmoid colon is involved. If a diverticulum becomes inflamed as a result of obstruction by feces or hardened mucus or of mucosal erosion, a localized perforation (microperforation) may occur -a process known as diverticulitis. The incidence of diverticulitis is about 10% to 25% in patients with colonic diverticula

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Which of the following statements regarding colonic diverticula are true? (Tick all those that apply) a)They are true diverticula which contain all the layers of the colonic wall. b)The sigmoid and rectum are the commonest site, as faeces are most solid here and require higher pressure to propel c)Their presence stimulates hypertrophy of the circular muscle layer of the large bowel. d)They tend to arise at weak point where blood vessels penetrate the submucosa of the large bowel.

Colonic diverticula are outpouchings of the mucosal layer of the large bowel through the submucosa and circular muscle layer of the bowel. Colonic diverticula are virtually restricted to the sigmoid colon only; the rectum is spared as its complete longitudinal muscle coat protects against their development. Diverticula stimulate marked hypertrophy of the circular muscle layer of the muscle coat. They tend to arise at weak points where blood vessels penetrate the submucosa

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Profuse Bleeding in Complicated Diverticulitis Usually Ceases Spontaneously In complicated diverticulitis, the disease process has progressed to obstruction, abscess or fistula formation, or free perforation. Complicated diverticulitis may be particularly challenging to manage,[1] especially because patients may have no known history of diverticular disease.[2] Gastrointestinal bleeding is a complication of diverticular disease in 30% to 50% of cases; in fact, diverticula are the most common colonic cause of lower GI bleeding. Approximately 50% of diverticular bleeding originates in the right colon, despite the low incidence of diverticula in this segment of the colon. Patients tend to be elderly[1] and to have cardiovascular disease and hypertension. Although patients may lose 1 to 2 units of blood, the bleeding usually ceases spontaneously, and expeditious operative treatment generally is not necessary.

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Barium enema- double contrast Diverticular disease of colon

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Barium enema

Diverticular disease of colon

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Barium enema - Diverticular disease of colon

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Ba. EnemaDiverticulitis An area of eccentric narrowing is present in the sigmoid colon (arrows). Within this area diverticula are seen

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Barium enema

Diverticular disease of colon late stage

The radiograph taken several days after the examination, remains of contrast material in the diverticula demonstrate extended diverticulosis involving the 111 entire colon

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78 year old man is complaining of blood in the feces. This is the air-contrast barium enema showing the sigmoid & descending colon Does the X ray explain the clinical presentation? Explain. What is the next step?
The film demonstrates several small projections extending out of the colon. The appearance is typical of diverticulosis

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Selective AngiographyActive bleeding from right-sided colonic diverticulum This early film shows a focus of extravasation (arrow) arising from a division of the right colic branch of the superior mesenteric artery
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The later film demonstrates persistent extravasation in this area with filling of an adjacent diverticular-like structure

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Adenomatous polyp (colon)

A polyp is any outgrowth of a mucosal surface (as compared to a papilloma, which is an outgrowth from squamous or transitional epithelium). Polyps are particularly common in the colon. This one is on a long stalk (pedunculated). Polyps of the colon sometimes become malignant so that microscopic examination is important. The term adenoma is also used since they are tumors of glandular origin. How might a patient know that he had a polyp? (What is the possible clinical presentation?)
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Polyps of large intestine

Inflamatory Metaplastic Hamartomatous

Neoplastic

Adenoma
Tubular adenoma Villous adenoma

Adenocarcinoma
Solitary adenomas are usually found during investigations of colonic bleeding Villous adenomas usually cause diarrhea, mucous discharge & occasionally
hypokalemia

The risk of malignant transformation in an adenomatous polyp is related to GIT 3 116 its size.

Adenomatous polyp of the colon

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Colon polyp longitudinal section - wall layers are preserved (purly mucosal)

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Familial adenomatous polyposis

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Familial adenomatous polyposis

Multiple adenomatous polyps of the cecum are seen here in a case of familial adenomatous polyposis, a genetic syndrome in which an abnormal genetic mutation leads to GIT 3 120 development of multiple neoplasms in the colon.

Multiple colonic adenomatous polyps in familial adenomatous polyposis

This is an autosomal dominant familial disease. Why should members of affected families be regularly screened starting from the age of 10? When those patients undergo total colectomy , they will GIT 3 need regular follow-up. Why?

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Barium enema Familial polyposis of the colon

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Barium enema Familial polyposis of the colon

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Familial adenomatous polyposis

Importance of screening program

Large bowl carcinoma occurs 10 20 years after the onset of polyposis

Operative options:

Colectomy with ilio-rectal anastomosis (needs regular follow-up for recurrent polps in the rectal stump. Treated by fulgration Proctocolectomy with restorative ilio-anal anastomosis
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Proctocolectomy with iliostomy

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Cancer colon

What are the different macroscopic types?

cecum

What are the possible clinical presentations?

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Common macroscopic varieties of colon carcinoma:

1. Annular
2. Tubular 3. Ulcer

4. Cauliflower

Possible clinical presentations:

Recent alteration in bowl habbits with constipation needing more laxatives

Emergency presentation with intestinal obstruction

Colonic bleeding or progressive anemia
Segmoid carcinoma may cause tenesmus

Palpable mass
Caecal carcinoma may be accidentally discovered during operation for appendicitis or appendicular abscess Metastasis (usually liver) & ascitis
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Cancer cecum
Remember the different clinical presentations of cancer cecum
Terminal ileum

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Malignant ulcer of the colon. Everted edge & necrotic floor

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Resected segment of colon from a 70 year old man with iron deficiency anemia

What condition does this patient have? Why is he anemic?

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Colon Carcinoma
Causing luminal stenosis

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Cancer sigmoid colon

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Barium enema CA cecum

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Barium enema CA cecum

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Barium enema
Apple-core type lesion in the sigmoid colon, typical of a carcinoma

Air contrast barium film

Diverticulosis in the colon, in the middle of which is found a small applecore lesion typical of a carcinoma
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Barium enema: A 6 cm long section of the recto-sigmoid region has irregular contour, narrowed lumen (1 cm) and filling defect (arrow)

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Ba. EnemaCarcinoma of sigmoid colon causing complete retrograde obstruction

An irregular mass encroaches on the lumen, which ultimately narrows to a thin distorted wisp of barium. The mass involves both the superior and inferior margins of the sigmoid colon, and is therefore circumferential. Diverticula are present distal to the obstructing mass. They represent an GIT 3 137 incidental finding

Barium enema

CA ascending colon

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Barium enema

CA ascending colon

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Barium enema

CA ascending colon

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Barium enema CA hepatic flexure

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Barium enema CA sigmoid colon

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Rectum & Anal Canal

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Thrombosed, infected piles

What are the symptoms of piles?

1.Bright red painless bleeding. 3.Prolapsed piles
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2.Mucous discharge 4.Pain only with prolapse

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What are the complications of piles?

Complications of piles:
1. Bleeding 2. Strangulation (prolapsed & gripped by the external sphincter impairing venous return) 3. Thrombosis of strangulated piles will follow if not reduced within an hour or two 4. Ulceration of the mucous membrane 5. Gangrene if strangulation occludes arterial supply 6. Suppuration if infection is superadded 7. Portal pyaemia
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Cancer rectum
Malignant ulcer
Rectum

What are the organs that may be involved due to local spread of CA rectum?

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Rectal cancer well within the reach of an examiner's finger

Malignant ulcer in the rectum

Anal canal

Autopsy Picture

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The Colon

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Normal Barium enema

The first two films are of an air contrast barium enema. There is both barium and air within the colon. By changing the position of the patient, different areas are well outlined with the air. When the patient is lying on his right side, the air accumulates on the left and vice-versa The 3rd film is a single contrast barium enema where only barium is instilled in the colon. The complete colon is well demonstrated. The colonic haustra GIT 3 150 are well seen. The terminal ileum and appendix are also filled

Hirschsprungs disease

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Hirschsprungs disease
Barium enema:

The contrast material outlines a bowel segment without ganglions (arrows), above which prestenotic dilatation is visible

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Barium enema
Hirschsprungs disease

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Barium enema
Hirschsprungs disease

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Ba enema Ulcerative cholitis

The colon is short, with smooth haustration and narrow lumen. Filling excesses (caused by ulceration) and filling defects (caused by mucosal regeneration) give a typical picture

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Ba. Follow-throughTuberculous enterocolitis The cecum and ascending colon are markedly narrowed, nodular, and shortened. The ileocecal valve is gaping, and the terminal ileum is narrowed and nodular

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Ba. Follow-throughIschemic colitis segmental narrowing of the entire transverse colon. Within the narrowed segment, there are multiple nodular indentations, many of which have the appearance of thumbprinting

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Ba. Follow-throughAdvanced Crohn's disease of the colon Diffuse narrowing of the ascending colon and cecum, associated with extensive deep ulceration seen in profile. Similar changes are present in the upper descending colon. The terminal ileum is narrowed and has a nodular mucosal pattern

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Invertogram
An invertogram may be used to investigate the extent of the defect in anal or rectal atresia. The anus is marked with a radiopaque marker, and the baby inverted. A lateral radiograph is taken. The air in the rectum will rise to the highest point, giving an indication of the extent of the atresia

159

GIT 3

160

GIT 3

Plain X-ray abdomen

(erect position)

Duodenal atresia

161

GIT 3

Plain X-ray abdomen

(erect position)

Duodenal atresia

162

GIT 3

Ba. Meal follow-through- Small bowel obstruction by an adhesive band (Lt. lateral position).
The film shows complete interruption of the lumen of the jejunum. Stretched circular mucosal folds without distortion or nodularity extend to the site of the lumen interruption. The absence of fold distortion or of nodularity is against a malignant cause for the obstruction. When it is possible to observe peristaltic activity changing the outline of the obstructed segment (this best seen in the single contrast phase), a diagnosis of non-malignant obstruction can be confidently made even when there is a history of abdominal surgery for malignancy. The patient gave a history of abdominal surgery done several years before. Palpation during fluoroscopy shows fixation of the site of obstruction, usually to the anterior GIT 3 163 abdominal wall.

Ba follow-throughLow grade obstruction by a single band adhesion

Dilatation of the proximal jejunum terminating at a sharply demarcated, short and narrow segment (arrow); a normal fold pattern in an underfilled lumen is seen beyond the narrowed segment. The patient had abdominal surgery 164 several years before

GIT 3

Free air under diaphragm Perforated viscera

Both sides of the bowel wall are outlined by the 165 arrows in the supine film

GIT 3