GASTROINTESTINAL

IMAGING
DEPARTMENT OF RADIOLOGY
FACULTY OF MEDICINE, UNIVERSITY OF PADJADJARAN /
HASAN SADIKIN HOSPITAL
BANDUNG

Anatomy

- Plain

Without
Contrast

GI
Imagin
g

photo
- 3 way
abdomen
series
-

Esophagograhy
-MaagWith
Contrast

Duodenography
- Barium Follow
Through
- Colon in Loop

First thing to do
Establish the name, sex, age and clinical
diagnosis of the patient
Establish the projection of the film
See the marker : Right / Left

Diseases You Should Know

Mechanical Ileus
Localized / Generalized Ileus
Peritonitis
Ulcerative Colitis
Diverculitis
Colonic Carcinoma

Abdominal Images
What to Examine

Gas pattern
Extraluminal air
Soft tissue masses
Calcifications

Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen

Large vs. Small Bowel

Large Bowel
Peripheral
Haustral markings don't
extend from wall to wall

Small Bowel
Central
Valvulae extend across
lumen
Maximum diameter of 2"

3 Way Abdomen Series

Supine
Prone or lateral rectum
Erect or left decubitus
Chest - erect or supine

Supine
Looking for
Scout film for gas
pattern
Calcifications
Soft tissue
masses

Substitute none

Prone
Looking for
Gas in rectum/sigmoid
Gas in ascending and
descending colon

Substitute lateral
rectum

Erect
Looking for
Free air
Air-fluid levels

Substitute left lateral

decubitus

Erect Chest
Looking for
Free air
Pneumonia at bases
Pleural effusions

Substitute supine
chest

Abnormal Gas Patterns

Localized ileus
Generalized ileus
Mechanical SBO
Mechanical LBO

Important Points
Look for air in the rectum/sigmoid first
Identify the most dilated loops-are they large bowel or
small bowel?
Sentinel loops are 1-2 dilated loops of small bowel
Generalized adynamic ileus almost always occurs in
immediate post-op patients
Always correlate the clinical findings with imaging
findings

Localized Ileus
One or two persistently dilated loops of
large or small bowel
Gas in rectum or sigmoid

Supine

Sentinel Loops

Prone

Sentinel Loops
Cholecystitis

Pancreatitis
Ulcer

Appendicitis

Diverticulitis
Ulcer
Ureteral calculus

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

Supine

Erect

Generalized Adynamic Ileus

Mechanical SBO

Dilated small bowel

Fighting loops
Little gas in colon, especially rectum
Key: disproportionate dilatation of SB

Mechanical SBO
Causes

Adhesions
Hernia*
Volvulus
Gallstone ileus*
Intussusception

*Cause may be visible on plain film

SBO

Mechanical SBO
Pitfalls

Early SBO may

resemble localized
ileus -get F/O

Mechanical LBO
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

Incompetent ileocecal valve

Large bowel decompresses into small

bowel
May look like SBO
Get BE or follow-up

Mechanical LBO
Causes

Tumor
Volvulus
Hernia
Diverticulitis
Intussusception

Supine

Prone

Carcinoma of Sigmoid LBO Decompressed into

SB

Distinction between SBO and LBO

Haustra
Valvula conniventes
Number of loops
Distribution of loops
Radius of curvature of loop
Diameter of loop
Solid faeces

Small bowel

Large bowel

Absent

Present

Present in
jejenum

Absent

Many
Central
Small
30-50 mm

Few
Peripheral
Large
50 mm+
May be present

absent

Greinger,Allison. Diagnostic Radiology

PERITONITIS
Radiological findings :
Generalized ileus
Ascites
Pneumoperitoneum
No pre-peritoneal fat

COLON IN LOOP
Indikasi :
Kelainan motilitas
Kelainan pada mukosa (ulkus), divertikel, inflamasi)
Keganasan
Degeneratif
Kelainan kongenital
Kelainan obstruktif
Kontraindikasi
Perforasi dari saluran cerna, ulkus yang mengalami
perforasi
Alergi bahan kontras media
Obstruksi total dari saluran cerna

SINGLE
CONTRAST STUDY

DOUBLE
CONTRAST
STUDY

Ulcerative Colitis

Ulcerative Colitis

Chrons Diseases
Crohn's disease is a disorder of unknown
aetiology that is characterised pathologically by
involvement of all bowel wall layers in a chronic
inflammatory
process
with non-caseating
granulomas. The granulomatous inflammation
most frequently affects the terminal ileum but it
may affect any part of the gastrointestinal tract
and frequently affected areas are in discontinuity.
There is a tendency to form fistulae.

Chrons Diseases
skip lesions - discontinuous sites of pathology along
the gastrointestinal tract
cobblestone ulceration; a result of apthous
ulceration progressing to oedema and nodular
thickening
lead pipe thickening - thickened, stiff bowel
narrowed lumen
strictures
'rose-thorn' narrow-mouthed ulcers which lead to
fistulae

Skip lessions

This lower abdominal X-ray shows narrowing (stenosis) of the end of the small
intestine (ileum)with loss of mucosal pattern and bowel wall thickening. Crohn's
disease typically affects the small intestine. A solution containing a dye (barium), was
swallowed by the patient. When it passed into the small intestines, this X-ray was
taken (lower GI series).

Colonic
Diverticulitis

Radiographic findings : Colonic Diverticulosis

1.

Multiple round or oval outpouchings of barium projecting beyond the lumen on

profile view (white arrow), barium collection (white arrowhead) or ring-like lesion
(black arrowhead) on en-face view

Radiographic findings : Colonic Diverticulosis

COLONIC CARCINOMA

Identify the Types of

Abnormal Gas Patterns

What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

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What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

Go Back

What abnormality is represented here?

Focal Ileus
Generalized Ileus
SBO
LBO

Go Back

Correct
There are multiple aircontaining and dilated loops
of small bowel with little or no
gas in the colon. The findings
are those of a mechanical
small bowel obstruction. The
patient had undergone prior
surgery and the cause of this
obstruction was adhesions
form the prior surgery.

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Correct
There is a dilated colon to
the splenic flexure/ Little
or no gas is seen in the
rectum or in the small
bowel. The findings are
those of a mechanical
large bowel obstruction.
The cause was an annular
constricting carcinoma at
the splenic flexure.

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Correct
There are several air-containing
and slightly dilated loops of
small bowel in the LLQ. These
were persistent. The findings
are those of a localized ileus
(sentinel loops) and their
location would suggest
diverticulitis. The patient had
appendicitis. The sentinel loops
do not always correspond to the
area of inflammation.

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Correct
All of the bowel is dilated.
There is air in the rectum. The
patient was post-op
abdominal surgery and the
bowel sounds were absent.
This is a generalized adynamic
ileus as is seen sometimes
after abdominal surgery.

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Wrong
Look Again

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Congratulations, You Graduate

You
know
your
bowel gas