Professional Documents
Culture Documents
Anatomy
Date:
Title:
4.8 Radiology of the Abdomen
Lecturer:
Dr. Nakpil
Sem/ A.Y.:
Transcribers: Arce J., Arquiza A., Arriba H., Avenir M., Azarraga C., Balberia J.
Trans Subject Head: Chong, Cheryl; (uerm2018a.anatomy@gmail.com)
I.
OUTLINE
I.Outline
II. Objectives
III.Radiology of the abdomen
A. Imaging Modalities
B. Stomach and Bowel Patterns
C. Indications for Abdominal Radiographs
D. Pharynx
E. Esophagus
F. Stomach
G. Small Intestines
H. Colon
I.
Accessory Organs
J. Urinary System
IV. Review Questions
V. References
II. OBJECTIVES
At the end of the lecture, the student should be able to:
1.
Identify anatomic structures that may be seen in different
imaging modalities
2.
Recognize typical imaging manifestations of some common
diseases involving the gastrointestinal and urinary tracts
III.
A. IMAGING M ODALITIES
The most common modality for studying the abdomen is the plain
abdominal radiograph / flat plate of the abdomen.
Radiographic Densities
1. Air - radiolucent/ black
2. Fat - radiolucent
3. Fluid-containing structures/soft-tissue masses - radioopaque/ white
4. Bone radio-opaque
5. Metalradio-opaque, used when administering contrast
Intravenous: Iodine
Oral: Barium
Abdominal radiograph
o
Used to determine presence or absence of bowel obstruction
Upright Abdominal Film
o
used to look at the presence or absence of obstruction
o
Free air would collect beneath the diaphragm
o
Take a look at air-fluid levels
2.
2018-A
2 /A.Y. 2014-2015
o
To evaluate for swallowing disorder
o
To evaluate for suspected lesions of pharynx and esophagus
BARIUM SWALLOW/ESOPHAGOGRAM
1OF14
Air will appear like a frame; will be framing the rest of the
abdomen.
Small bowel: at the center
C.
Note: Plain abdominal radiographs are always done before any other
contrast techniques in order to differentiate the contrast material such
as barium from calcification on subsequent radiographs.
D.
PHARYNX
3 regions:
o
Nasopharynx
STOMACH
Figure 4.Stomach
Figure 2.Parts of the pharynx and structures: NP (nasopharynx), OP
(oropharynx), HP (hypopharynx), V (vallecula), P (piriform fossa), HB
(hyoid bone), white arrow on picture B (epiglottic cartilage)
E.
ESOPHAGUS
2018-A
2OF14
Hiatal Hernia
Protrusion of stomach to the mediastinum throuh the esophageal
hiatus (T10)
Usually see in middle-aged patients
Types:
o
Paraesophageal Hernia
Most common
2018-A
Figure 10. Ultrasound of pylorus showing a donut sign. Left thick arrow
pointing to the right- hypoechoic (dark gray) part represents the
hypertrophic pyloric muscle; right thick arrow pointing upward-- internal
echogenic (light) part represents thickened mucosa of pyloric canal
3OF14
3.
SMALL INTESTINE
DUODENUM
Figure 11. Duodenum and its four parts: duodenal bulb, descending
part, horizontal part and its ascending part.
2.
JEJUNUM
Entirely intraperitoneal
ILEUM
2018-A
4OF14
Ileum
Figure 14 & 15.Normal small bowel follow-through. (A) Prone
abdominal radiograph. The small bowel is demonstrated on an UGIS by
having the patient ingest additional barium and by taking additional
radiographs to document its passage through the small bowel into the
colon. (B) Spot compression view of the terminal ileum. The spot
compression provides separation of bowel loops in the RLQ to optimally
demonstrate the terminal ileum (TI)
Meckels Diverticulum
CLINICAL CORRELATION
1.
Ulcer
Ulcers are GI lesions that extend through the muscularis mucosae
and are remitting, relapsing lesions. (Erosions affect only the
superficial epithelium.)
May occur in the stomach, but most occur in the first part of the
duodenum (Netters Clinical Anatomy)
The mucosa, submucosa, and some muscularis externa have already
been eaten by the ulcer. There appears to be an outpouching but what
you can see is the crater on the wall. (Nakpil, 2014)
Figure 19. Malrotation. The jejunum is on the right side. There should
be a C-loop formed by the duodenum with the duodenojejunal flexure
prominent. But in this image, the flexure is not distinguishable. Fundus
(F), body of stomach (B), antrum (A), duodenal bulb (DB), jejunum (J).
2.
3.
Malrotation
Duodenum normally sweeps across midline and end on the left
side of the vertebrae, level of the ligament of Treitz where it will
become the jejunum
Malrotation occurs when the duodenum fails to cross the midline,
occupying the right lower quadrant (RLQ) and pushing the cecum
to the right upper quadrant (RUQ).
2018-A
5OF14
2.
Figure 20. Child with intestinal malrotation indicated by the low position
of the duodenojejunal junction (arrowhead) overlying the spine rather
than the normal position to the left of the spine at the level of the
duodenal bulb.
4.
Used not to evaluate the mucosa but to evaluate the extent of the
lesion
Figure 21. String of pearls sign in an abdominal x-ray.
H.
COLON
Ascending colon
Sigmoid colon
Descending colon
Appendix
Cecum
Transverse colon
Imaging methods to evaluate the large intestines
1.
Barium enema
An X-ray examination of the large intestine (colon and rectum).
To make the intestine visible on X-ray,
o
Colon is filled with a contrast material which contains
barium through a tube inserted into the anus.
o
The barium in the contrast material then blocks X-rays,
causing the colon to show up clearly on the X-ray.
Two types of barium enema examination
o
Single contrast
2018-A
3. CT (virtual) Colonography
Also a CT scan, a machine can take a look inside the lumen of the
colon. Image is reformatted by software.
1.
Diverticulosis
Very common in elderly patients but they are usually benign/not
neoplastic findings
Usually occurs in the sigmoid and descending colon
6OF14
2.
Colonic Carcinoma
The most common type of gastrointestinal cancer. It is a
multifactorial disease process, with etiology encompassing genetic
factors, environmental exposures (including diet), and inflammatory
conditions of the digestive tract.
At the level of hepatic flexure, the colonic wall has started to
disappear and thelumen is very narrow. The mass is located on the
areas where there is no barium.
Common in the retrosigmoid region
Apple core sign in radiograph
Sigmoid Volvulus
2018-A
7OF14
Appendicitis
Is an inflammation of the appendix, a 3 1/2-inch-long tube of
tissue that extends from the large intestines.
Diameter is > 1 cm (10 mm), it is already considered
appendicitis
Figure 34.Area of the Lesser sac. LS= Lesser sac. Ghl= Gastrohepatic
ligament.
2018-A
8OF14
I.
ACCESSORY ORGANS
1.
2.
SPLEEN
RA
A
Ascites
Excess fluid in the peritoneal cavity which can be a result of:
mechanical injury, portal hypertension, widespread metastasis of
cancer cell to abdominal viscera.
2018-A
Splenomegaly
Abnormal enlargement of the spleen
Can enlarge up to 10 or more times its normal size
Splenic length greater than 14cm
Inferior tip of spleen is below the inferior pole of kidney
Inferior tip of spleen is below the inferior tip of the liver
If its lower edge can be detected when palpating below the left
costal margin at the end of inspiration, it is enlarged about three
times its normal size.
Possible causes:
o
Portalhypertension
o
AIDS
o
Leukemia
o
Lymphoma
o
Infectious Mononucleosis
9OF14
Transient Pseudomasses
Would sometimes appear in multi-detector/multi-facet CT
examination
Due to differences in the passage of contrast in the white pulp and
red pulp
In more delayed images, the normal homogenous appearance of
the spleen would be demonstrated.
Anterior Segment:
Segment VIII Superior
Segment V Inferior
PosteriorSegment:
Segment VII Superior
Segment VI Inferior
o
The Left Lobe has medial and lateral segments. It is also
divided into superior and inferior segments by the portal vein.
Lateral Segment:
Segment II Superior
Segment III Inferior
Medial Segment:
Segment IVa Superior
Segment IVb Inferior
Quadrate Lobe: part of right and left lobe
Caudate Lobe: Segment 1 is between the fissure for the
ligamentum venosum, and anteriorly and superiorly the inferior
vena cava. Not included in the right and left lobe.
Hepatic segments are important because it used in describing
lesions for pre-operative planning.
LIVER
IVC tributaries include left, middle and right hepatic veins = form
the longitudinal plane
Figure 42.CT Scan of the Liver. Superiorly taken at a plane above the
portal vein (LEFT) and inferiorly taken at a plane below the portal vein
(RIGHT).
Imaging Techniques to Evaluate the Biliary Tree
1.
2.
With aging the common bile duct usually dilates. If the patient is
around 60 years old or around 70 years old, a CBD measuring of
around 6mm or 7mm still acceptable.
Middle hepatic vein divides the liver into left lobe and right lobe.
Specifically between the anterior segment of the right lobe and the
2018-A
10OF14
3.
Cirrhosis of Liver
Usually seen in alcoholics or those with chronic hepatitis D & E
Appears nodular with irregular margin
Hepatocyte parenchyma are destroyed and replaced by fibrous
septa: producing regenerative nodules
The nodules impede circulation (primary: portal vein) of blood
through the liverLiver becomes firm; causes portal hypertension
(see below); manifested on the skin as caput medusae
regenerating nodules on cirrhosis needs biopsy
Determines whether it is regenerating or a cause of cancer
On ultrasound, liver looks heterogeneous with coarse parenchyma;
very large compared to the kidneys
Most common cause of portal hypertension
Obstructive jaundice
occurs when the essential flow of bile to the intestine is blocked
and remains in the bloodstream.
might be due to blocked bile ducts caused by gallstones, or
tumours of the bile duct which can block the area where the bile
duct meets the duodenum
Portal Hypertension
Obstruction of portal vein > pressure rises
Enlarged varicose vein (caput medusae) at sites of anastomoses
between portal systemic veins.
Postacaval anastomoses or portosystemic shunt
Communication between
o Portal Vein and IVC
o Splenic and Left Renal Veins
Divert blood from the portal venous system to the systemic venous
system is just obstruction in the portal vein causing increase in
pressure.
Gall Stones
Most commonly seen on plain abdominal radiograph and even on
ultrasound
Concretions in the gallbladder whch may cause biliary colic or
cholecystitis (inflammation of the gall bladder)
Risk factors (FFF):Fat, Female, Forty
Only operated on when it causes pain
Distal end of hepatopancreatic ampulla
Narrowest part of the biliary passages
o Common site for impaction of gallstone
Usually found in the fundus of gallbladder, or obstructing the neck,
or towards the bile duct /cystic duct
On Ultrasound
o Gallbladder is usually filled with anechoic bile
o In the presence of gall stones, you will see intense echoes with
posterior shadowing
On CT Scan
o Gallstones would appear as calcifications
o Thickened gall bladder walls sign of cholecystitis
2018-A
11OF14
Choledocholithiasis
Seen as the presence of structures in the region of the common
bile duct
Hepatic ducts dilated beyond the area of the stricture
On MRCP (MR Cholangiopancreatography)
o Seen as filling defects in the common bile duct
PANCREAS
Unencapsulated
Tongue-shaped
Tail ending in the splenic hilum
Mainly retroperitoneal, except its tail
Pancreatitis
Since the pancreas is unencapsualted, the pancreatic juices would
easily spread to the surrounding tissues.
Would appear normal if imaged early
Seen as fluid collections surrounding the pancreas.
Pancreatic Cancer
Can cause extrahepatic obstruction of the biliary ducts and
jaundice
Can also cause obstruction of the portal vein or the IVC
On UTZ:
o Ill-defined hypoechoic structure
o If an anechoic structure is seen, it could be a dilated pancreatic
duct
Criteria for resectability: If SMA becomes encased by tumor, the
cancer is already non-resectable
o Resectable: Definite fat planes surrounding the Superior
Mesenteric Artery
o Non-Resectable: Tumor is seen surrounding the SMA
Figure 50. Normal CT of the pancreas showing the neck (n), body (b),
and tail (t) of the pancreas.
Figure 53. Pancreatic Carcinoma (black arrow) Resectable. The
superior mesenteric artery and vein (white arrows) are spared of
involvement.
3.
2018-A
12OF14
KIDNEYS
J. URINARY SYSTEM
Minor Calyx will join to form Major Calyx
Major Calyx will join to form your renal pelvis Ureter Urinary
Bladder
URETERS
URETHRA
(Important Note from Dr. Nakpil) According to the lecture, you should
not be able to see the ureter in its entirety because it should always be
obstructed by peristalsis. Thus, you might see it opening at different
levels each time. However, if you can see the whole length of the ureter
you can suspect an obstruction because it means that has vessel is a
state of dilation.
3.
4.
5.
6.
7.
2018-A
13OF14
CLINICAL CORRELATION
1.
GUIDE QUESTIONS
2018-A
REFERENCES
2017A Transcription.
th
Brant, W., Helms, C. (2012). Fundamentals of Diagnostic Radiology, 4 ed.
Philadelphia: Lippincott Williams and Wilkins.
Gourtsoyianni, H. (ed.) (2002). Radiological Imaging of the Small Intestine.
Germany: Springer-Verlag Berlin Heidelberg.
nd
Hansen, J. (2010). Netters Clinical Anatomy, 2 ed. Philadelphia:
Saunders-Elsevier.
14OF14