M-2 Lecture

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GASTROINTESTINAL IMAGING
M-2 Lecture Dr. F. Neuffer 2014
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GI TRACT

• Anatomy
• imaging
• Pathology
• Patients

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OBJECTIVES

• Vascular supply and effect on pathology location.
  
• Age and site considerations in four major disease
  groups.
• Familiarity with imaging findings in Neoplastic,
  Inflammatory,
• Vascular and Traumatic diseases relative to
  the GI Tract.
• Modality choices based on pathology
  considerations.

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UPPER GI ORAL BARIUM CONTRAST
STOMACH
WITHOUT CONTRAST
COLON
BARIUM ENEMA - RECTAL BARIUM CONTRAST
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AIR UNDER THE DIAPHRAGM
NORMAL GAS PATTERN
Perforation of GI tract leads to
pneumoperitoneumperitonitis..bleeding Air
collecting under the diaphragm on upright x-ray.
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ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR
UNDER THE DIAPHRAGM.
UPRIGHT
DECUBITUS
Left lateral decubitus (left side dependent)
shows air along liver margin. This is the
preferred x-ray if the patient cannot stand.
Air visible under diaphragm
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RADIOLOGY DIAGRAM

Pathology image
X-ray image
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BARIUM FILLED ESOPHAGUS
AORTIC IMPRESSION
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Pediatric patient
Coin often is at site of Aortic impression.
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ASPIRATION
NORMAL SWALLOW
ASPIRATION
Risk with patients with altered neurological
status -post CVA -intoxicated
Contrast tracks anteriorly into trachea with
aspiration.
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ZENKERS DIVERTICULUM source for
aspiration
Disordered contraction of cricopharyngeus
with swallowing leads to diverticulum formation
elderly patients
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NORMAL ESOPHAGUS
HIATAL HERNIA
Note distended distal esophagus with herniation
of gastric fundus into chest through esophageal
hiatus.
DIAPHRAGM
DIAPHRAGM
This allows reflux of gastric contents into
esophagus.
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ESOPHAGEAL CANCER
Distal malignancy may be adenocarcinoma due to
Barretts esophagus, a dysplastic change caused
by chronic reflux of gastric contents.
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ESOPHAGEAL CANCER
Typical squamous cell carcinoma Poor prognosis
from local extension into critical mediastinal
structures. (esophagus lacks a serosa) .
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TRACHEO-ESOPHAGEAL FISTULA / ATRESIA
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• Diffuse
• Esophageal spasm
• sometimes referred to as
• PRESBYESOPHAGUS
• Elderly patient
• Disordered contraction
• Chest pain
• Cardiac mimic

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CANDIDA ESOPHAGITIS

• Extensive nodular filling defects in the
  esophagus in an immunocompromised patient are
  typical for Candida esophagitis.

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ACHALASIA

• Distended esophagus with distal
  stricture.-Chronic process
• Little symptoms. Halitosis
• Failure of distal sphincter to relax
• Nerve damage to sphincter
• leads to obstruction.
• Stricture due to CANCER / REFLUX has to be
  considered first.

Barium filled esophagus
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LOOK ALIKES

• Scleroderma-smooth muscle
• -- Skin findings
• Chagas Disease -Trypanosome infection
• --Central America

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ESOPHAGEAL VARICES
Linear tubular filling defects represent
distended veins from shunting due to cirrhosis
and portal hypertension.
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MALLORY-WEISS TEAR
Esophagus shows a linear tear of the distal
esophageal mucosa due to vomiting. Barium
is seen tracking into the wall. Full thickness
tear or rupture (Boerhaaves syndrome) can lead
to mediastinitis and death.
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Boerhaaves Syndrome
Post emesis Perforation esophagus into
mediastinum Edema, Effusion and Pneumomediastin
um
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ESOPHAGEAL DISEASE

• HIATAL HERNIA / ESOPHAGEAL CANCER
• CANDIDA / SPASM / VARICES
• MALLORY WEISS TEAR / BOERHAAVES SYNDROME
• ACHALASIA / SCLERODERMA / CHAGAS
• TE FISTULA / ZENKERS DIVERTICULUM
• SIGNS / SYMPTOMS
• CHEST PAIN
• DIFFICULTY SWALLOWING
• HOARSENESS

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FUNDUS
NORMAL GASTRIC ANATOMY
DUODENUM
BODY
ANTRUM
JEJUNUM
C-LOOP
Single AP radiograph showing filling of distal
esophagus, stomach and proximal small bowel
without mass, obstruction or filling defect.
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GASTRIC ULCER
Barium collects in ulcer crater
Endoscopic view of ulcer
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ULCER CAN PERFORATE INTO PANCREAS AND LEAD TO
PANCREATITIS
Silva, A. C. et al. Radiographics 200424677-687
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GASTRIC CARCINOMA
PYLORIC STENOSIS
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PYLORIC STENOSIS
Narrowed pyloric channel
Thickened pylorus
ULTRASOUND
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GASTROPARESIS DIABETIC NEUROPATHY EFFECT
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GASTRIC DISEASE

• ULCER
• CANCER
• PYLORIC STENOSIS
• GASTROPARESIS
• SIGNS / SYMPTOMS
• PAIN
• ANEMIA
• HEMATEMESIS / MELENA
• EMESIS
• WEIGHT LOSS

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NORMAL SMALL BOWEL
JEJUNUM
Early contrast is predominantly in jejunum and
later predominately in ileum. (note difference
in mucosal fold pattern)
ILEUM
COLON
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SMALL BOWEL OBSTRUCTION
Ng tube
ERECT
Note dilated small bowel centrally placed with
air/fluid levels on upright exam.
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POST OP ADYNAMIC ILEUS
COLON
LARGE AND SMALL BOWEL
SM. BOWEL
SUTURES
Symmetric dilation of large and small bowel is
seen normally as a post operative ileus.
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SMALL BOWEL BARIUM STUDY
HERNIA
CT
Note hernia in right lower quadrant on both
exams accounting for obstruction. Hernia is
likely cause if there is no history of prior
surgery.
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CROHN'S DISEASE
normal
Narrowed distal ileum due to chronic inflammation
is typical for Crohns disease.
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SMALL BOWEL DISEASE

• ULCER
• OBSTRUCTION
• POST-OPERATIVE ILEUS
• CROHNS DISEASE

SIGNS / SYMPTOMS

• PAIN
• HEMATEMESIS
• DISTENTION
• DIARRHEA

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SPLENIC FLEXURE
NORMAL COLON
HEPATIC FLEXURE
TRANSVERSE COLON
DESCENDING COLON
ASCENDING COLON
Normal air contrast barium enema (double
contrast-air and barium per rectum) shows filling
of colon with air and barium retrograde to the
cecum with reflux into the terminal ileum.
TERMINAL ILEUM
CECUM
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COLON DISEASE

• APPENDICITIS / DIVERTICULITIS
• POLYP / CANCER
• VOLVULUS
• GI HEMORRHAGE
• SIGNS / SYMPTOMS
• RIGHT / LEFT LOWER QUADRANT PAIN
• FEVER / ELEVATED WBCs
• DISTENSION / OBSTRUCTION
• WEIGHT LOSS
• HEMOCULT POSITIVE STOOL / ANEMIA
• MELENA / HEMATOCHEZIA

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ACUTE APPENDICITIS
NORMAL
DISTENDED APPENDIX WITH LOCAL INFLAMMATION.
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ABSCESS
Catheter has been placed by radiologist using CT
guidance draining abscess collection.
DRAINAGE
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PEDUNCULATED COLON POLYP
(DESCENDING COLON)
stalk on polyp--pedunculated
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COLON CANCER
Barium enema showing apple-core type
constricting lesion with proximal dilation of
colonAPPLE - CORE constricting lesion
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SMALL BOWEL vs COLON OBSTRUCTION
Ng tube
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COLON
SIGMOID VOLVULUS
Dilated horse-shoe shaped sigmoid colon due to
volvulus.
COFFEE BEAN SIGN
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COLON VOLVULUS
BEAK SIGN
Barium fills to point of obstruction -- twist of
sigmoid colon
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ULCERATIVE COLITIS
Normal
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PSEUDOPOLYPS with ulcerative colitis
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CHROHNS COLITIS Segmental distribution commonly
referred to as skip lesions
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CROHNS VS ULCERATIVE COLITIS
Skip Fistula
Continuous Colon cancer
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DIVERTICULOSIS
Balloon in rectum to Help control barium.
Barium extends from lumen outward into
diverticulum.
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DIVERTICULITIS
Extensive inflammation, wall thickening and
spasm can simulate carcinoma. Colonoscopy
required to confirm.
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PSEUDOMEMBRANOUS COLITIS

• ANTIBIOTIC ASSOCIATED
• CLOSTRIDIUM DIFFICILIS
• PAIN
• DIARRHEA
• FEVER

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GI HEMORRHAGE
Catheter is placed in superior mesenteric artery.
NORMAL
BLEEDING
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NUCLEAR MEDICINE Technetium-labeled RBCs
Labeled red blood cells are imaged over 1 hour
showing extravasation in Rt. colon steadily
increasing indicating active bleeding.
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ISCHEMIC COLITIS
Watershed area-----Splenic flexure Elderly---Embol
ic----Fibrillation Blood in stool----Pain
SMA
IMA
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• MECKELS DIVERTICULUM
• Yolk sac remnant at distal
• small bowel. Usually asymtomatic but can bleed.

Stomach
Technetium 99m labels gastric Mucosa --Ectopic
gastric mucosa
Diverticulum
Bladder
Pediatric patient lt2yrs old
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SUMMARY

• PLAIN X-RAY---BOWEL GAS PATTERN
• BARIUM---OUTLINES LUMEN
• CT---PROBLEM SOLVING
• NUCLEAR MED
• ULTRA SOUND SPECIAL SITUATIONS
• ANGIOGRAPHY
• MR---LITTLE USE

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RADIOLOGY VACATION SPOT
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The end!