Kuliah Gastro Dr-BM(Jan 2013)

Bachtiar MurtalaDept.of Radiology Medical Faculty Hasanuddin University General Objective To provide basic understanding about the role of radiological imaging in diagnosing gastroenterohepatologic diseases Specific objectives Imaging modalities and techniques/examination procedures Radiological appearances of some GIT and hepatobiliary diseases Organs scope  Plain Abdomen  Esophagus-rectum  Liver  Biliary tract  Pancreas In general  Plain abdominal radiography  Conventional radiography with contrast media  Imaging (US, CT-Scan, MRI, Nuclear medicine) peritonitis. Erect 2. blunt or penetrating trauma. LLD ( left lateral decubitus) 4. ileus (dynamic or adynamic).etc  Usually needed 3 standard positions : 1.Plain abdominal radiography  Commonly used in emergency cases such as . free-air/fluid. Cross table ( optional ) . Supine 3. colon carcinoma .Diverticulitis .Volvulus .Large bowel obstruction  Less commonly than small bowel obstruction  Three main causes : . . . Colon cancer . Small bowel obstruction . Radiological signs  Bowel distended filled by gas++  Lack gas in the distal part  Air fluid level (“step ladder appearance”)  Valvula conniventes appears as herring bone (“herring bone appearance”) . . . . . . . . invaginasi . . . Necrotizing enterocolitis ( NEC)  Pneumatosis intestinalis ( Gas within bowel wall ) . Peritonitis Bowel wall thickening Properitoneal fat line disappear/ obliterate Paralytic ileus sign . Adynamic or paralytic ileus Bowel distended until distal part Air fluid levels (+) . longer Herringbone appearance(-) . . Radiography with contrast  Barium Sulphate (BaSO4) suspension  Iodine . Sialography .Salivary glands : Consist of : .Plain Foto .Submandibular glands Indications : Stones.MRI . neoplasm Technique : .Parotic glands .CT . inflamation. 5 ml contrast medium (water soluble/lipiodol) injected slowly & then taking a series pictures  Give a few drops of lemon juice  make an “after lemon” film 10’ later to evaluate the remaining contrast Abnormalities :  Chronic obstructive Sialectasis .5 – 1.Sialography :  Duct orifice. is located & intubated by a blunt needle/abbocath  0.strictures  Chronic non-obstructive Sialectasis (chronic inflamation)  Tumours (mostly mixed salivary type) .stone . . . Haematemesis/melena .Esophagus : It should be visualized with contrast media (Barium Sulfat)  Esophagography Indications : .Dysphagia .Dyspepsia .Congenital anomalies ? Technique of Examination : • The patient is asked to swallow a thick Barium Sulphate (1:1) or Iodine ( for baby) and followed by fluoroscopy & taking radiography . Duplication Traumatic Disorders  rupture Abnormalities in density  foreign bodies Abnormalities in Size (length & diameter) Abnormalities in architecture .Esophageal atresia .B. Abnormalities : Congenital malformation .Short esophagus with a thoracic stomach (Brachy-esophagus) . Left atrium .AP .Left Anterior Oblique projection (LAO) .Spot Film (optional) Radiological Signs : A.Right Anterior Oblique projection (RAO) .Hiatus hernia .Knob aorta .Left main bronchus .• Radiography positions : . Normal Indentations : . . . Esophageal atresia . . commonly seen in cirrhosis hepatis “cobble stone appearance” .Esophageal varices Caused by portal hypertension. . Esophageal stricture Narrowing and irregularity due to corrosive materials (corrosive stricture) . . Benign : • Filling defect with smooth border • Forked stream appearance (Fluoroscopy) .Malignant : • Filling defect with irregular border • Spasticity .Tumours : . . . . . .ACHALASIA  Aganglionic of the distal part of esophagus  Distal smooth narrowing with dilatation of the proximal segmen--“mouse tail app”. MOUSE TAIL APPEARANCE . GASTRODUODENOGRAPHY (= Maag Duodenum/MD Foto) Is a radiographic evaluation of the stomach & duodenum by introducing contrast media inside [Barium sulfat (+) & air/gas (-) Indication : - Dyspepsia - Epigastric pain - Vomiting - Haematemesis/melaena Procedure Of Examination 1. Prone. Usually in Supine. Erect. Prone oblique. The patient swallows contrast Barium Sulfat (& air) followed by fluoroscopy and taking radiography in various position 3. Spot-Film Compression (recommended) . Preparation : fasting ± 4-6 hours 2. Normal Anatomic Radiography . Radiographic Abnormalities of Gastroduodenal Disease. enrlargement/widening. It can be classified as changes in :  Position  Size (redundancy. narrowing/shrinkage)  Contour  Rugae abnormalities  Filling defect  Function . . 28-14.Fig. Left lateral erect film of the stomach . Pyloric stenosis = Infantile Hypertrophic Pyloric Stenosis . Protrution of mucosa and submucosal outward .Additional shadow .DIVERTICLE . Gastritis  Mucosal atrophy  Mucosal hypertrophy-hypersecretion “ three level density” . . En profile (lateral view)—additional shadow . globular shape (active ulcer).Peptic ulcer Mostly seen in pyloric antrum and duodenal bulbus Primary Signs : . conus (inactive) .En face (frontal view)—barium spot with halo (active ulcer) and star sign ( inactive) . . Secondary signs  Contralateral/opposite spastic insicura  Hypersecretion  Bulb deformity . . . . . TUMOR BENIGN Filling defect with smooth border Polip . Exophytic ( fungating type ) .Annular ( infiltrating type ) .Malignant Types : 1. filling defect + ulcer . Early gastric cancer Limited in mucosa/submucosa mimicking ulcer 2. Advance gastric cancer Filling defect – irregular border .Linitis plastica ( schirrus type) .Ulcer type. . . .DUODENUM  Congenital : Stenosis post bulbar  duodenal atresia “Two bubbles app”. . SMALL INTESTINE (JEJENUM & ILEUM)  Normal size: .2. 1.5 cm (jejenum).± 20 feets (length) .75 cm (ileum) in diameter  Indications: Anemia (unclear origin) Persistent diarrhoe Abdominal pain Palpable mass Excessive protein loss Malabsorbtion . followed by taking pictures 30-60 minutes interval until contrast seen in caecum . Plain abdominal radiography 2. Follow Through Patient is asked to swallow 200-300 cc Barium sulfat (1:2-3 water). Contraindication: Obstruction signs Perforation Paralytic ileus Peritonitis  Technique of Examination 1.  Abnormalities Crohn’s Disease = Regional ileitis Adhesion Fistula . COLON Indication : • Haematochesia • Persistent diarrhea • Abdominal mass • Obstructive symptoms • Congenital abnormalities Contraindication : • Ileus (Paralytic) • Suspect Bowel Perforation • Peritonitis . .Picture taken in many positions/ views.Technique of Examination : • Barium enema (colon inloop) • Mostly Double-Contrast method Preparation is the most important to remove faecal material from the colon Colon inloop : .Contrast should fill colon entirely (rectum-caecum) . 2 L .Using a thin Barium sulfat (1:3-6) aprox. Kongenital 1. Atresia Ani (Imperforate anus) . Foto polos abdomen terbalik (Invertogram) 2.COLON A. Hirschsprung’s disease ( megacolon congenitum ) . Atresi ani Radiographically : Technique of examination for atresia ani: • Inverted or Wangesteen position • Knee-chest position Aim : to identify the lowest end of air in colorectal . Lower level High level . mostly males  Abscent of ganglion cells in the mesenteric plexus in the narrowing segment (mostly sigmoid colon.Barium enema/colon inloop  . Radiographically : .Hirschsprung’s disease (megacolon congenital) Disease of childhood. ± 40%)  Marked dilatation above the area of aganglionosis.Dilatation/Distension : .Idiopathic symptomatic megacolon (older age) .Plain abdominal films  veriable degrees of distension of GIT above the obstruction . might be associated with irregularity/sawtoothing/ulcerative Colitis Narrowing of the Colonic Lumen : ..Colon in loop : • Narrowing along the site of aganglionosis • Dilatation above the narrowing. Obstruction of colon Obstruction to the flow of Barium can be caused by :  Spasm  Annular Carcinoma  Intusussception  Volvulus  Diverticulitis . . Tumor Carcinoma of Colon 3 types : • Fungating type • Polypoid type • Annular type . . Complication: Bleeding. fistula Polypoid type : . Ascending Colon.usually medullary Ca. .Sites: Caecum.Fungating type : .Complications: Intussusception . Rectum .Sites: usually Descending Colon . . Descending Colon.Sites: Sigmoid.10% mucoid adeno Ca.Annular type : . obstruction Pathology : .20% fibro Ca.50 – 75% adeno Ca. Metastasis : Liver or regional nodes Radiographically : Filling defect with Obstruction signs . . flexures .Complication: Fistula. “Coiled spring “ or “cupping sign” -proximal bowel dilatation -absence of gas in dist segment .Intussusception = Invagination A proximal segment of bowel (intussusceptum) into lumen of a distal segment (intussuscepiens) Location : Ileoileal > ileocolic > colocolic Radiographic sign : . Cupping sign Coiled spring . US findings : -Target sign.pseudokidney sign ( longitudinal scan) . doughnut sign or bull’s eye sign (transverse scan ) . Crohn’s Disease .Ulcerative colitis .Inflammation : . Saw-toothing/ulceration .“Stringiness/String sign” .• Ulcerative Colitis .Contracted.Loss of haustra .shortened & small calibre . . Diverticle . physical examination & laboratory studies. (↑) to 5% in small children & elderly. Helical CT scan & graded compression US – powerful imaging methods in appendicitis . Mortality rate in developing countries : ± 1%. Imaging is useful and advisable in patients with atypical symptoms. Diagnosis – clinical history.Acute appendicitis  Acute appendicitis – acute appendiceal inflammation due        to luminal obstruction and superimposed infection Most common abdominal surgical emergency. Surgical aim – to operate early before complications such as appendiceal rupture & peritonitis developed. IMAGING IN APPENDICITIS  ABDOMINAL PLAIN FILMS  APPENDICOGRAPHY  ULTRASOUND  CT SCAN  MRI (MAGNETIC RESONANCE IMAGING) . . HEPATOBILIER & PANCREAS  Imaging modalities : .Nuclear Medicine . Durante operatif .CT scan : Computerized Tomography .T-Tube Cholangiography.MRCP : MRI for Cholangiopancreatography. Post operatif .PTC(D) : Percutaneus Transhepatic Cholangiography ( Drainage ) .MRI : Magnetic Resonance Imaging .USG : Ultrasonografi / Ultrasound . . Gallstones/cholelithiasis .Echogenic/hyperechoic structure dengan acoustic shadowing .Soliter / multiple . Acute Cholecystitis * Gallbladder wall thickening > 3 mm * Sludge . Cholangitis . Cholangiocarcinoma . Increasing echogenecity.Portal hypertention . .Liver atrophy . .Splenomegaly .CIRRHOSIS HEPATIS .Irregular of the surface . fibrotic.Ascites. .  Well defined .HEPATOCELLULAR CARCINOMA/HCC HEPATOMA  USG : Iso  hipo or hiperechoic mass  Ill-defined TUMOR METASTASIS  Noduler” bull-eye”. usually multiple. . . . well defined.Liver abscess • Hypoechoic mass • Irregular and thicken wall Liver cyst • Free-echoic mass. • Solitary or multiple . . Strictur cholangitis.Biliary obstruction Causes : . cholangiocarcinoma . such as Panreatic cancer. etc .Stone .Tumor intra/extraluminer. Biliary obstruction due to cancer of caput pancreas .